By: dr.

Yoavita
Moderator: dr. Anik Widijanti, Sp.PK (K)
URINE
URINE
The final product of:
1. Glomerular filtration
2. Tubular reabsorption
3. Tubular secretion
FORMATION: Glomerular Filtration
FORMATION: Tubular Reabsorption
FORMATION: Tubular Secretion
COMPOSITION
Urine

95% water 5% solutes

Organic Inorganic

• Urea • NaCl
• Creatinine • K+
• Uric acid • SO42-
• Hippuric • PO43-
acid • NH4+
• Other • Mg2+
substances • Ca2+
VOLUME
• Normal daily urine output: 1200 – 1500 mL
• Influenced by:
– Fluid intake & Fluid loss from non-renal sources
– Variations in secretion of ADH
– Need to excrete increased amounts of dissolved solids

Term Urine Volume

Oligouria < 400 mL/day
Anuria Cessation of urine production
Polyuria > 2.5 L/day
URINE SPECIMEN
SPECIMEN COLLECTION
• Container
– clean, dry, leak-proof
– disposable containers are recommended
– wide mouth, wide & flat bottom
– made of a clear material
– recommended capacity: 50 mL
• Gloves
SPECIMEN COLLECTION
• Proper labelling
– patient’s name & age, identification number
– the date & time of collection
– physician’s name & location
Labels must be attached to container, not to the lid
• A requisition form
Must match the information on the specimen label
SPECIMEN HANDLING
• Following collection:
– delivered to laboratory promptly
– tested within 2 hours
If not  refrigerated / add chemical preservative
• Ideal preservative
 bactericidal
 inhibit urease
 preserve formed elements in the sediment
 not interfere with chemical tests
PRESERVATIVES
Preservatives Advantages Disadvantages Additional Info.
Refrigeration Doesn’t interfere with Raises specific gravity Prevents bacterial
chemical tests by hydrometer growth 24 h
Precipitates amorphous
phosphates and urates
Thymol Preserve glucose and Interferes with acid
sediments well precipitation tests for
protein
Boric acid Preserve protein and May precipitate crystals Keeps pH at
formed elements well when used in large about 6.0
Doesn’t interfere with amounts Bacteriostatic at
routine analyses 18g/L; can use for
other than pH culture transport
Interferes with
drug & hormone
analysis
PRESERVATIVES
Preservatives Advantages Disadvantages Additional Info.
Formalin Excellent sediment Interfere chemical tests Rinse specimen
preservative for glucose, blood, container with
leukocyte esterase, formalin to
copper reduction preserve cells &
casts
Toluene Doesn’t interfere with Floats on surface of
routine tests specimens & clings to
pipettes and testing
materials
Sodium Prevent glycolysis Inhibit reagent strip For reagent strip
fluoride A good preservative tests for glucose, blood, test: use sodium
for drug analyses and leukocytes benzoate
Phenol Doesn’t interfere with Causes an odor change 1 drop/ounce of
routine tests specimen
TYPES OF URINE SPECIMENS
Types Purpose
Random Routine screening
First morning Routine screening
Pregnancy tests
Orthostatic protein
Fasting (2nd morning) Diabetic screening/monitoring
2-h postprandial Diabetic monitoring
Glucose tolerance test Optional with blood samples in glucose tolerance tests
24-h (or timed) Quantitative chemical tests
Catheterized Bacterial culture
Midstream clean-catch Routine screening; Bacterial culture
Suprapubic aspiration Bladde urine for bacterial culture; Cytology
3-glass collection Prostatic infection
TYPES OF URINE SPECIMENS
• Random Specimen
May be collected at any time
• First Morning Specimen
Collected immediately on arising
• Fasting Specimen (Second Morning)
2nd voided specimen after a period of fasting
TYPES OF URINE SPECIMENS
• 2-Hour Postprandial Specimen
Void shortly before consuming a routine meal
 collect specimen 2 hours after eating
• Glucose Tolerance Specimen
The number of specimens varies with the length of the test
TYPES OF URINE SPECIMENS
• 24-Hour (or Timed) Specimen
Day 1: 7 am  voids and discards specimen; collects all urine for
the next 24 hours
Day 2: 7 am  voids & adds this urine to previously collected
urine
• Catheterized Specimen
By passing a catheter through urethra into the bladder
TYPES OF URINE SPECIMENS
• Midstream Clean-Catch Specimen
– wash hands before collecting
– ♂: clean the glans; withdraw foreskin, if necessary
♀: separate the labia, clean urinary meatus & surrounding
area
– void first into the toilet
 collect urine in the sterile container
 finish voiding into the toilet
TYPES OF URINE SPECIMENS
• Suprapubic Aspiration
By external introduction of a needle through the abdomen into
the bladder
• 3-glass Collection
– 1st urine  sterile container
– midstream portion  another sterile container
– Massage the prostate >> prostate fluid + remaining urine
 3rd sterile container
PHYSICAL EXAMINATION
OF URINE
COLOR & CLARITY
• Use well mixed specimen
• View through a clear container
• View against a white background
• Maintain adequate room lighting
• Evaluate a consistent volume of specimen
COLOR
• Normal: colorless – pale yellow

Color Causes
Colorless Recent fluid consumption
Pale Yellow Polyuria or Diabetes Insipidus, Diabetes Mellitus, Dilute
random specimen
Dark yellow Concentrated specimen
Amber Dehydration
Orange Bilirubin, Acrifalvine, Phenazopyridine, Nitrofurantoin,
Phenindione
Yellow-green
Bilirubin oxidized to biliverdin
Yellow-brown
COLOR
Color Causes
Green Pseudomonas infection
Blue-green Amitriptyline, Methocarbamol, Clorets, Indican, Methylene Blue,
Phenol
Pink RBCs
Red Hb, Myoglobin, Porphyrins, Beets, Rifampin, Menstrual
contamination
Brown RBCs oxidized to methemoglobin, Methemoglobin, Alkaptonuria,
Black Melanin/melanogen, Phenol derivatives, Argyrol, Methyl-
/levodopa, Metronidazole
Orange Bilirubin, Acrifalvine, Phenazopyridine, Nitrofurantoin, Phenindione
CLARITY
• Normal: Clear

Clarity Term
Clear No visible particulates, transparent
Hazy Few particulates, print easily seen through urine
Cloudy Many particulates, print blured through urine
Turbid Print cannot be seen through urine
Milky May precipitated or be clotted
CLARITY
Causes of Turbidity
Nonpathologic Pathologic
• Squamous epithelial cells • RBCs
• Mucus • WBCs
• Amorphorous phosphates, • Bacteria
carbonates, urates • Yeast
• Semen, spermatozoa • Nonsquamous epithelial cells
• Fecal contamination • Abnormal crystals
• Radiographic contrast media • Lymph fluid
• Talcum powder • Lipids
• Vaginal cream
SPECIFIC GRAVITY
• The density of a solution compared with the density of a
similar volume of distilled water at a similar temperature
• Assessed to evaluate the kidney’s reabsorption ability
• Depends on patient’s amount of hydration
• Normal: 1.003 – 1.035
Term Specific Garavity
Hypersthenuric > 1.010
Isosthenuric 1.010
Hyposthenuric < 1.010
SPECIFIC GRAVITY
Urinometer
• Correction needed for temperature
• Correction must be calculated if large amounts of
glucose/protein are present

Harmonic
Oscillation
Densitometry
SPECIFIC GRAVITY
Refractometer
ODOR
• Normal: Aromatic odor

Odor Causes
Foul, ammonia-like Bacterial decomposition, urinary tract infection
Fruity, sweet Ketones (diabetes mellitus, starvation, vomiting)
Maple syrup Maple syrup urine disease
Mousy Phenylketonuria
Rancid Tyrosinemia
Sweaty feet Isovaleric acidemia
Cabbage Methionine malabsorption
Bleach Contamination
CHEMICAL EXAMINATION
OF URINE
SEMI-QUANTITATIVE
Substances Tests
Protein Sulfosalicylic Acid
Heat & Acetic Acid
Glucose Benedict’s
Ketone Rothera’s
Gerhardt’s
Bilirubin Harrison’s
Urobilin Schlesinger’s
PROTEIN: Sulfosalicylic Acid
8 drops of 20% sulfosalicylic acid
 mix

Compare the 1st &

@ 2 mL of urine 2nd tube

• 1st tube = 2nd tube: (-)

• 1st tube more cloudy than 2nd tube: warm the 1st tube until boils,
cool with running water  still cloudy until cold: (+)
PROTEIN: Heat & Acetic Acid
Fill with urine until 2/3 full

Boil the upper

portion of the tube Add 3 – 5 drops of
± 30 seconds 6% acetic acid

• After the addition of 6% acetic acid  cloudiness remains or

increased: (+)
PROTEIN: Interpretation
- No cloudiness
Trace Cloudiness is just perceptible against a black background
1+ Cloudiness is distinct but not granular
2+ Cloudiness is distinct and granular
3+ Cloudiness is heavy with distinct clumping
4+ Cloud is dense with large clumps that may solidify
GLUCOSE: Benedict’s
Add 5 mL of Benedict’s
reagent
Place in boiling
Add 5 – 8 drops of water bath for 5
urine  mix minutes

- Clear blue colour, blue precipitate may form trace-bluish-green color

1+ Green color, green or yellow precipitate
2+ Yellow to green color, yellow precipitate
3+ Yellow-orange color, yellow-orange precipitate
4+ Reddish –yellow color, brick red or red precipitate
KETONE: Rothera’s
Add 5 mL of urine

Overlay with 1 mL of
Add 1 g of Rothera’s concentrated
reagent  mix ammonium hydroxide

- No ring or a brown ring

1+ Narrow lavender-purple ring
2+ Narrow dark purple ring
3+ Wide dark purple ring
KETONE: Gerhardt’s
Add 5 mL of urine

Add 10% of ferric chloride

solution drop by drop until all Add a slight excess of
phosphates are precipitated ferric chloride

• Bordeaux red color: (+)

• To confirm the presence of diacetic acid  boil another portion of
urine for 15 minutes  repeat the test on boiled sample
– (+): color is from an interfering substances
– (-): color was due to acetic acid
BILIRUBIN:Harrison’s
Add 5 mL of shaked urine

Spread the precipitate

Add 5 mL of 10% Barium out on another filter
chloride solution paper, allow to dry
Mixed well & filter to remove ↓
the precipitate Add 2 – 3 drops
Fouchet’s reagent

• Green or Blue-green color: (+)

UROBILIN: Schlesinger’s
Add 5 mL of urine filtrate

Fluorescence (-)  add 2 – 4 Add 5 mL of

drops of Lugol Schlesinger’s reagent
Mix & wait for 5 minutes Mix & filter

• Green fluorescence: (1+ / 2+)

REAGENT STRIP
Chemical-impregnated absorbent pads
Urine
attached to a plastic strip

A color-producing chemical reaction

Color produced on the pad is compared

with the supplied chart
REAGENT STRIP TECHNIQUE
1. Dip the reagent strip briefly into a well-mixed
uncentrifuged urine specimen at room temperature
2. Remove excess urine by touching the edge of the strip to
the container as the strip is withdrawn
3. Blot the edge of the strip on a disposable absorbent pad
4. Wait the specified amount of time for the reaction to
occur
5. Compare the color reaction of the strip pads to the
manufacturer’s color chart in good lighting
PRINCIPLES: pH

Reagents Methyl red, bromthymol blue

Sensitivity 5–9
Interference No know substances; runover from adjacent
pads; old specimens
Correlations with other tests Nitrite, leukocytes, microscopic
PRINCIPLES: Specific Gravity

Reagents Poly (methyl vinyl ether/maleic anhydride)

bromthymol blue
Sensitivity 1.000 – 1.030
Correlations with other tests False (+): Protein >>>
False (-): Alkaline urines (>6.5)
PRINCIPLES: Protein

Reagents Tetrabromphenol blue

Sensitivity 15 – 30 mg/dL albumin
Interference False (+): buffered alkaline urine >>, pigmented
specimens, detergents, antiseptics, loss of buffer,
specific gravity >>
False (-): other proteins, microalbuminuria
Correlations with other tests Blood, nitrite, leukocytes, microscopic
PRINCIPLES: Glucose

Reagents Glucose oxidase, peroxidase, potassium iodide

Sensitivity 75 – 125 mg/dL
Interference False (+): contamination by oxidizing agents &
detergents
False (-): ascorbic acid , ketones , specific gravity
>>, low temp., improperly preserved specimens
Correlations with other tests Ketones, protein
PRINCIPLES: Ketones

Reagents Sodium nitroprusside

Sensitivity 5 – 10 mg/dL acetoacetic acid
Interference False (+): phtalein dyes, pigmented red urine >>,
levodopa, medications containing free sulfhydryl
groups
False (-): improperly preserved specimens
Correlations with other tests Glucose
PRINCIPLES: Nitrite
PRINCIPLES: Nitrite
Reagents P-arsanilic acid, tetrahydrobenzo(h)-quinolin-3-ol
Sensitivity 0.06 – 0.1 mg/dL nitrite ion
Interference False (+): improperly preserved specimens,
pigmented urine >>
False (-): nonreductase-containing bacteria,
insufficient contact time between bactery and
urinary nitrate, lack of urinary nitrate, large
quantities of bacteria converting nitrite to
nitrogen, presence of antibiotics, ascorbic acid
>>, specific gravity >>
Correlations with other tests Protein, leukocytes, microscopic
PRINCIPLES: Bilirubin

Reagents 2,4-dichloroaniline diazonium salt

Sensitivity 0.4 – 0.8 mg/dL bilirubin
Interference False (+): pigmented urines >>, phenazopyridine,
indican, metabolites of lodine
False (-): specimen exposure to light, ascorbic
acid > 25 mg/dL, nitrites concentration >>
Correlations with other tests Urobilinogen
PRINCIPLES: Urobilinogen

Reagents P-dimethylaminobenzaldehyde
Sensitivity 0.2 mg/dL urobilinogen
Interference False (+): porphobilinogen, indican, p-
aminosalicylic acid, sulfonamides, methyldopa,
procaine, chlorpromazine, pigmented urine >>
False (-): old specimens, preservation in formalin,
nitrate concentration >>
Correlations with other tests Bilirubin
PRINCIPLES: Blood

Reagents Diisopropylbenzene dehydroperoxide

tetramethylbenzidine
Sensitivity 5 – 20 RBCs/mL, 0.015 – 0.062 mg/dL Hb
Interference False (+): strong oxidizing agents, bacterial
peroxidases, menstrual contamination
False (-): specific gravity /crenated cells >>,
formalin, captopril, nitrite concentration >>,
ascorbic acid > 25 mg/dL, unmixed specimens
Correlations with other tests Protein, microscopic
PRINCIPLES: Leukocyte Esterase

Reagents Derivatized pyrrole amino acid ester, diazonium salt

Sensitivity 5 – 15 WBC/hpf
Interference False (+): strong oxidizing agents, formalin,
pigmented urine >>, nitrofurantoin
False (-): protein, glucose, oxalic acid, ascorbic acid,
gentamicin, cephalosporins, tetracyclines,
inaccurate timing
Correlations with other tests Protein, nitrite, microscopic
CAST
FORMATION
• Formed within the lumens of distal convoluted tubules &
collecting ducts
 Microscopic view of conditions within the nephron
• Cast’s shape = representative of the tubular lumen
• Composition:
– Tamm-Horsfall Protein (major constituent)
– Albumin & Immunoglobulin
– Any elements present in tubular filtrate: cells, bacteria,
granules, pigments, crystals
FORMATION
Formation of the Tamm-Horsfall Protein Matrix:
Aggregation of Tamm-Horsfall protein into individual protein fibrils

Interweaving of protein fibrils  a loose fibrillar network

Further interweaving  solid structure

Possible attachment of urinary constituent to the solid matrix

Detachment of protein fibrils from the epithelial cells

Excretion of the cast

TYPE OF CASTS

Hyaline cast Convoluted hyaline cast

Hyaline cast with occasional granules

TYPE OF CASTS

RBC cast Disintegrating WBC cast

RTE cell cast

TYPE OF CASTS

Fatty cast Granular cast

KOVA-stained waxy cast

REFERENCE
1. Strasinger SK, Di Lorenzo MS. Urinalysis and Body Fluids.
5th ed. Philadelphia: FA Davis. 2008.
2. Gandasoebrata R. Penuntun Laboratorium Klinik. Jakarta:
Dian Rakyat. 2004.
THANK YOU