ROUTINE EXAMINATION

ROUTINE EXAMINATION OF
OF URINE
URINE
AND
AND
IT’S INTERPRETATION
IT’S INTERPRETATION
 Exam of Urine
Volume 600-2500ml/24 hrs
Osmolality 500-800 m Osn/Kg water
pH 4.6-8

Polyuria
Increase of urine output (>3000ml/day)
• Physiological
• Diabetes mellitus
• Diabetes insipidus
• Chronic renal failure
• Diuretics
• IV Saline
• During elimination of oedema fluid
• Addison’s disease
Oliguria
<300 ml excretion in 24 hrs
Anuria <50 ml or no excretion
Renal : ATN
AGN
Prerenal : Dehydration from vomiting, diarrhoea
excessive sweating, shock, cardiac failure, severe
haemorrhage, extensive burn
Postrenal : Stone in ureter
Ureter involvement by ca cervix, prostate
Proteinuria/albuminuria
Passage of protein/albumin in urine
Normal range-upto 20mg/24hrs

Causes of Proteinuria
Renal :
Nephrotic syndrome
Nephritic syndrome
AGN
Chronic glomerulonephritis
Lupus nephritis
Pyelonephritis, Tuberculosis
Mulliple myeloma
Toxaemia of Pg
Haematuria
Postrenal:
Infections in ureter, urinary bladder, urethra,
prostate
Haematuria due to any cause

Pre renal:
Fever
Convulsive disorder
Congestive cardiac failure
Postural/orthostatic proteinuria
Micro albuminuria
Incearse in urinary albumin excretion but not
detectable by conventional methods.
Range 30-300mg/day.

Importance
Diabetic nephropathy
Organ damage in HTN
Associated with cardio vascular disease
Glycosuria with hyperglycaemia
Diabetes mellitus
Other endocrine disorders like
Acromegaly, Cushing’s syndrome
hyperthyroidism
Pancreatic disease like cystic fibrosis
Chr pancreatitis
Severe burn
Uraemia
Sepsis
Advanced liver disease
Glycosuria without hyperglycaemia
Renal glycosuria
Alimentary glycosuria
 Haematura (Passage of blood in urine Macroscopic &
microscpic)
Renal
Acute glomerulonephritis
Chroni glomerulonephritis
Pyelonephritis
Goodpasture’s syndrome
Trauma
Calculi
Malignancy
Pre renal
Bleeding diathesis eg ITP, Aplastic anaemia, Acute
leukaemia, Haemophilia, Anticoagulant therapy
Post renal
Infection eg urethritis, cystitis
Trauma
Calculi
Malignancy
Ketonuria (Passage of ketone bodies in urine)
Diabetic ketoacidosis
Acute febrile state
Toxic states with vomiting and diarrhoea, severe
exercise
 24 hour Urine
• Protein
• VMA (Vanillyl mandelic acid) for
phaechromocytoma
• 5 HIAA (5-Hydroxy Indole Hcetic Acid) for
Argentaffinoma
• 17 Ketosteroids-Adrenal gland disorder
• Uninary creatinine
Preservatives
HCl
Toluol
Thymol
Formaline
Na aside for protein
No preservative for urea, creatinine, Na, K
to be kept in 2-8◦c
 ROUTINE URINE ANALYSIS PROCEDURE

 10 –15 ml of well mixed urine specimen into a

disposable centrifuge tube.
 Perform physical examination and reagent strip
chemical exam
 Centrifuge urine at 3000 rpm for 5 minutes
 Carefully remove and save the supernatant
 A drop of sediment is placed on a glass slide
and covered with cover slip
 Examine with low- and high-power objectives.
R/E
Physical:
Quantity
600-2500 ml. avg-1200ml
Polyuria →An increase in output
Oliguria → Decrease in output-less than 300ml in
24 hrs
Anuria → less than 50 ml/day or no urine in 24 hrs
• Colour
Straw due to urochrome, urobilinogen
Yellow due to bilirubin or exccess urobilinogen
Red due to RBC and Hb
Milky due to chyluria
Pinkish due to Rifampicin
Coca colla colour due to altered Hb
Black due to Alkaptonuria
Appearance:
Clear and transparent
Smoky due to presence of blood
Hazy due to presence of pus

2. Chemical exam
 CHEMICAL EXAM :
Urine pH: Normal--- acidic
range 4.6--- 8 Average ---6

Method:
1. Reagent strip: Indicators—methyl red and bromothymol blue
If pH rises---color changes to orange, green and blue colors
permitting estimation of pH values within the ranges of 5 to 9.
2. pH electrode: In patients with disturbances of acid-base
balance, urinary pH may be accurately measured with a pH
meter with a glass electrode.
3. Titrable acidity of urine: This may be used together with
urinary ammonia determination in patients with chronic
acidosis of obscure origin.
ACID URINE:

 Diet high in meat-protein

 Some fruits e.g. cranberries
 Some chemicals
ammonium chloride
methionine
 Metabolic and respiratory acidosis
 Diabetic ketoacidosis
 E. Coli infection
ALKALINE URINE:
 Diet high in fruits & vegetables especially

citrus fruits
 Chemicals: Na-bicarbonate, K-citrate

 Acetazolamide

 Metabolic and respiratory alkalosis

Paradoxical aciduria:
Acidic urine in presence of alkalosis.
PROTEIN IN URINE :

Normal range: 20-30 mg /24 hrs

Detectable, when >300 mg/day by conventional
method.
Types of protein passed
 Albumin----------- 1/3 rd [Mol wt 69000, so
filtration through glomerular memb is very small]
 Tamm-Horsfall protein ---- -1/3 rd or more
 (secreted by the distal tubular cells and cells of
the ascending loop of Henle)
 Others:  ,, -globulins
Retinol binding
2 -microglobulin
Immunoglobulin light chains
Lysozyme
Secretory IgA
Enzyme & protein
Importance of Tamm-Horsfall protein-
formation of cast

Microproteinuria – 30-300 mg/day

Macroproteinuria – >300 mg/day

Methods used to test Protein in urine:

1. Reagent strip
2. Heat coagulation test (Heat and Acetic acid test)-
mainly detects albumin
3. Sulfosalicylic acid test – detect both albumin &
globulin
HEAT COAGULATION TEST: (Heat and Acetic
acid test)
Reagent: 5% Acetic acid
Method:
1. A test tube is taken & 2/3 rd is filled with urine

2. Upper top inch is heated till boiling starts, turbidity

may appear due to presence of protein, phosphate or
carbonate
3. a few drops of 5 % acetic acid is added & the area
re-heated
4. Persistence of turbidity indicates proteinuria.
 REPORT:
No cloudiness (–)

Cloudiness barely visible (± ) 0.01 % or less

Definite cloudiness, but no ( +) 0.01—0.05 %

granularity and No flocculation

Granular Cloudiness but no ( ++) 0.05—0.2 %

flocculation

Dense opaque cloud clearly (+++) 0.2—0.5 %

flocculated

Very thick precipitation almost solid (++++) 0.5 % or higher percent of

albumin
* 3 % albumin boils solid.
 CAUSES OF PROTEINURIA:
Prerenal Renal Post-renal

1.Febrile illness 1. Nephrotic 1. Severe urinary

2.CHF syndrome tract infection-----
3. Systemic disorder 2.Nephritic •Pyogenic
associated syndrome •Tuberculosis
with haematuria. 3. CGN •Schistosomiasis
4. PET 4. Infection—
5. Shock due to any Pyelonephritis 2. Haematuria due to
cause Tuberculosis calculi
5. Toxaemia of tumour
preg.
6. Haematuria, e.g.
Calculi
Tumour
Nephrotic syndrome –is a clinical complex
characterized by a number of renal &
extrarenal features, most prominent of which
massive proteinuria (>3.5 g/d),
hypoalbuminaemia,generalised oedema,
hyperlipidaemia & lipiduria.
Acute Nephritic syndrome- It is the clinical
correlate of AGN. It is characterized by
haematuria,generalised oedema,hypertension
& oliguria.
 PROTEINURIA QUANTIFICATION:
Heavy proteinuria (>4 gm/day)

 Nephrotic syndrome
 Acute, rapidly progressive glomerulonephritis
 CGN (Severe)
 DM
 SLE
 Toxaemia of pregnancy
 Malaria
 Malignant hypertension
 Heavy metals (gold, Mercury)
 Drugs: Penicillamine
 Neoplasia
 Amyloidosis
 Sickle cell disease
 Renal transplant rejection.
Moderate proteinuria (1—4 gm/day)
1. All causes of heavy proteinuria
2. Nephrosclerosis
3. Multiple myeloma
4. Toxic nephropathies
5. Degenerative, malignant, and inflammatory
conditions of lower urinary tract
6. Irritative conditions-presence of calculi.
 Minimal proteinuria (< 1 gm /day)
1. Chr. Pyelonephritis
2. Nephrosclerosis
3. Chr. Interstitial nephritis
4. Cong. Disease: Polycystic disease,
Medullary cystic disease
5. Renal tubular disease
6. Postural Proteinuria
7. Transient proteinuria
8. HTN
9. Fever
10. Lower UTI
 Bence Jones Protein:
 Bence Jones Protein: is an abnormal low
molecular wt. globulin consisting of monoclonal
free light chain of immunoglobin.It is found in
Multiple myeloma, Macroglobulinaemia,
lymphoma etc.

 Method: Heat precipitation test

Protein Electrophoresis------ Best
Bence Jones protein precipitates at temperatures
between 400C and 600 C and redissolves near
1000 C.
 Procedure:
o filter the urine, if cloudy. If alkaline, make it acid to
litmus with 5% acetic acid
o place 5 ml urine in a test tube
o place the tube in a water-bath and raise the temp.
gradually.
o Bence Jones protein begins to appear below 600 C.
o Heating is continued up to boiling point. Bence Jones
protein re-dissolves. A precipitate will form in the
filtrate on cooling.
Normal serum protein coagulates at a temp. over 600 C .
If albumin is present, it should be removed by filtering
the urine hot.
Microalbuminuria: It is defined as the presence of albumin
in urine above the normal level but below the detectable range
of conventional Urine Dipstick method.
Urine albumin level range----20 t0 200 mg/L

This is an indicator of early and possibly reversible glomerular

damage. In diabetic patients microalbuminuria is associated
with a 4 to 6 fold increase in cardiovascular mortality and is an
independent risk factor for renal mortality.
It is also more prevalent in hypertensive subjects.
Methods: ELISA
RIA (radioimmunoassay)
Dye- binding chemical test strips
Nephelometry
 TESTS FOR REDUCING SUBSTANCES

Sugars: Glucose, Lactose, Pentose,

Fructose, Galactose
Non-sugars: Homogentisic acid
(present in alkaptonuria), Nalidixic
acid, Cephalosporin, Ascorbic acid,
or Aspirin.

Method:
1. Glucose reagent strip test
2. Benedict’s test
 Glucose reagent strip test:
Based on specific Glucose oxidase and peroxidase
method ,---- a double sequential enzyme reaction,
reagent strips differ only in the chromogen used.
It is specific for glucose, does not react with Lactose,
Pentose, Fructose, Galactose or reducing
metabolites of drugs.
It gives semi quantitative result (reported as g/dl)
Chemistry:
glucose oxidase
 Glucose + O2 -----------------»Gluconic acid+ H2O2

peroxidase
H2O2 + chromogen-------------»oxidised chromogen
+ H2O
 Copper reduction test
 Strip test
 Benedict test

Benedict’s test:
Principle: Glucose contains an aldehyde
group that reduces the blue coloured cupric
ions of copper sulphate to the yellow red
insoluble cuprous oxide. This test will detect
glucose and others reducing substances
present and urine also give positive
reaction.
Procedure
Reagent: Benedict’s qualitative solution

5 ml of Benedict’s qualitative solution is taken in

a test tube
8 drops (0.5 ml) of urine is added
boiled for 2 minutes in a bare flame or by placing
in a boiling water bath—for 5 minutes.
allowed to cool.
this method is sensitive to detect glucose as low
as 0.2%

 Test for Galactose, Sucrose, Lactose, Pentose=>

Thin layer chromatography
 REPORT:
Appearance Sugar concentration

Blue ( no color change) Nil

Green < 0.5 %

Greenish yellow 0.5 %

Yellow 1.0 %

Orange 1.5 %

Red 2.0 %

Brick red > 2.0 %

 GLYCOSURIA WITH HYPERGLYCAEMIA

1. DM
2. Other endocrine causes : Acromegaly, Cushings
syndrome, Hyperthyroidism, Phaechromocytoma
3. Pancreatic disease with loss of functioning Islet
cells: carcinoma, pancreatitis , cystic fibrosis.
4. CNS dysfunction: Brain tumour, Haemorrhage,
Asphyxia, Hypothalamic disease.
5. Drug induced: Corticosteroid, Thiazide, Oral
contraceptives
6. Others: severe burn, uraemia, advanced liver
disease.
 KETONE BODIES
1. Acetone (2%)
2. Acetoacetic acid (20%)
3. β-hydroxybutyric acid (78%)
Acetone, aceto-acetic acid---detected by Rothera’s test
(Nitropriusside strip and Tablet test)
β-hydroxybutyric acid----commonly not detectable.
 Methods:

1. Rothera’s test
2 Reagent strip
1. Rothera’s test :
Reagents:
Ammonium sulphate
Powdered sodium nitroprusside
Liquor ammon fort
Procedure:
saturate a few ml of fresh urine with ammonium sulphate.
Add a few granules of powdered sodium nitroprusside
Add liqor ammon fort by the side of the test tube .
* * a permanganate coloured ring at the junction of two
fluids indicates the presence of acetone bodies.
BILIRUBIN:
Methods:

1. Fouchet’s test
2. Reagent strip

UROBILINOGEN:
Methods: 1. Ehrlich’s Aldehyde test
2. Reagent strip test
BILE SALTS:
Hay's test—Sprinkle finely powdered sulphar on the surface of the urine in a
wide container.
In the normal urine the sulphar floats but it sinks in the presence of bile salts.

BLOOD: Orthotoludene test

Reagent strip test
CHYLE: 1) True chyle—
I) Filariasis
II) Diabetes mellitus causing lipaemia
III)
IV) Fracture of long bones
2) Pseudochyle—It is a lecithin compound of globulin
found when there is a great excess of globulin in urine.
Method of detection -- Ether test

ALKAPTONURIA
is an inborn error of metabolism characterized by a failure to
oxidise completely tyrosine and phenylealanine and the
resulting excretion in the urine of homogentisic acid.
 MICROSCOPIC EXAM OF URINARY
SEDIMENT:
 CELLS:
Pus cell/WBC: Round, granular.
 Normal range 0--4/HPF
 Female---may have higher quantity
 >6/HPF----suggests Acute infections.
 Increased no. of Leukocytes: (principally
Neutrophils): in the urine termed pyuria and
indicates the presence of infection or
inflammation in urinary tract.
Bacteruria without pyuria may occur in early
UTI, DM., Enteric fever, and sub-acute
bacterial endocarditis

Epithelial cell: have a single round nucleus.

1. Renal tubular epithelial cell

2. Transitional (urothelial ) epithelial cell

3. Squamous epithelial cells:

 Red blood cell: Normal range: 0 /HPF
appears as pale, disc, non granular refractile
in nature , may show
crenated margin. RBC may be confused with
oil droplets or yeast cells.
 Oil droplets
 Yeast cell
 HAEMATURIA(BLOOD IN URINE)

May indicate a variety of urinary tract and systemic condition

These include:
Renal disease:
1. Glomerulonephritis
2. Lupus nephritis
3. Interstitial nephritis associated with drug reactions
4. Calculus
5. Tumour
6. Acute retention
7. Tuberculosis
Lower urinary tract disease:
1. acute and chronic infection

2. calculus

3. tumour

4. stricture

5. haemorrhagic cystitis following

cyclophosphamide therapy
Extrarenal disease:
1. acute appendicitis
2. salpingitis
3. diverculitis
4. acute febrile episodes
5. malaria,sub-acute bacterial endocarditis
6. poly arteritis nodosa
7. malignant hypertension
8. blood dyscrasias
9. scurvy
 Toxic reaction to drugs:
1. Sulphonomides
2. Salicyletes
3. Methenamine
4. Anticoagulant therapy
 Physiologic causes: exercise
N.B. When increase no. of erythrocytes are found in
the urine in conjunction with erythrocyte casts,
bleeding may be assumed to be renal in origin.
 INCREASED NUMBER OF LEUKOCYTES:
Infection either bacterial or non-bacterial
pyelonephritis
cystitis
prostatitis
urethritis
balanitis
Other urinary tract diseases:
Glomerulonephritis
SLE
Interstitial nephritis
Calculus disease at any level:
Bladder tumour
In women acute urethral syndrome (Dysuria pyuria syndrome)
Gross pyuria may reflect rupture of renal or urinary tract abscess
Transiently increased --- Fever
Following strenuous exercise
Cast : are the cylindrical structures with parallel sides
and blunt rounded ends that are formed due to
precipitation of protein
 CASTS
are the only formed elements of urine that have the
kidney as their sole site of origin. Tamm-Horsfall
protein forms the matrix of all casts. The proteins
forms a meshwork of fibrils that can potentially trap
any elements present in the tubular filtrate including
cells, cell fragments or granular materials.
In normal person----few casts are seen in urinary
sediment
In kidney disease---casts may appear in large numbers
and in many forms
After strenuous exercise—large no. of casts is seen in
healthy person
Casts can be quite variable in their appearance, size,
shape and stability, casts typically have parallel sides
and blunt ends, but with age they may begin to
disintegrate and show thinning and irregularities.
Tails and tapering ends can be seen and these
disintegrating forms are referred to as Cylindroids.
Cast formation increases
 with lower pH
 increase ionic concentration,
 when there is stasis or obstruction of the
nephron by cells or cell debris.
 when larger than normal amounts of
plasma proteins enter the tubules.
 Classification of cast:
1. Matrix casts: 3. Inclusion casts:
a) Hyaline casts a) Granular casts
b) Waxy casts b) Fatty casts
c) Crystal casts
2. Cellular casts :
a) Erythrocyte(RBC) 4. Pigment casts:
casts a) Haemoglobin casts (Blood)
b) Leukocytes (WBC) b) Haemosiderin casts
casts c) Myoglobin casts
c) Renal tubular d) Biliribin casts
epithelial cell casts e) Drug casts
d) Mixed cellular casts
 CRYSTALS:
Crystals form by the precipitation of urinary
salts when alteration in multiple factors affect
their solubilities. These include changes in pH,
temperature & concentration. The precipitate
can appear in the urine in the form of either
true crystals or amorphous material.
Crystals seen in normal acid urine
Ca-oxalate: Refractile, octahedral envelope
Uric Acid: yellow or red brown irregular/ rhomboids
 Crystal seen in normal alkaline urine.
 Amorphous phosphates: Fine precipitation
 Triple phosphate: colorless 3-6 sided prism
 Ca-phosphate: Stellate prism
 Ammonium biurate: yellow brown sphere –
Thorn apple.
 Crystal seen in abnormal urine
Cystine: Colorless refractile, hexagonal plate, occur in patients
with cystinuria and may be associated with cystine calculi.

Tyrosine: Fine needles arranged in sheaves/clumps.---

occasionally seen in Severe liver disease.

Leucine: Yellow, oily appearing spheres..--- -occasionally seen

in severe liver disease.

Sulphonomide (sulphadiazine): yellow brown sheaves of wheat

with central bindings, striated sheaves with eccentric bindings,
rosettes, Arrow heads, petals needles and round forms with
radial striations, Occasionally colorless
Bacteria:
 If bacteria are identified with Gram’s stain in an
uncentrifused urine specimen under an oil-
immersion lens, it suggests that >100,000
organisms/ml are present. (significant
bacteriuria).
 Acid-fast bacilli may be seen in urine sediment
Fungus:
 Yeasts (most commonly Candida species)
 May be seen in UTI e.g. in DM but yeasts are also
common contaminants from the skin, female
genital tract and the air
 Parasites:
Parasites and parasitic ova may be seen as a result of
faecal or vaginal contamination.
Trichomonus vaginalis may come from vagina in
urethral /bladder infection
Motility of the organisms is helpful for identification.

 Spermatozoa: generally present in urine of man

after nocturnal emission.

 Mucus: mucus originates from the mucus lining

of the urinary tract.---it’s presence in urine is of
no importance
 CAUSES OF PROTEINURIA:
Prerenal Renal Post-renal

1.Febrile illness 1. Nephrotic 1. Severe urinary

2.CHF syndrome tract infection-----
3. Systemicdisorder 2.Nephritic •Pyogenic
associated syndrome •Tuberculosis
with haematuria. 3. CGN •Schistosomiasis
4. PET 4. Infection—
5. Shock due to any Pyelonephritis 2. Haematuria due to
cause Tuberculosis calculi
5. Toxaemia of tumour
preg.
6. Haematuria, e.g.
Calculi
Tumour
* Sugar (Reducing substance)
glucose, lactose, fructose, galactose
Non sugars: Ascorbic acid, Nalidixic acid, aspirin
cephalosporin
Benedict test
Reagent Strip
3. M/E
Organised
Deposit-
Unorganised
Organised
Cell: Epithelial cell
WBC/Pus cell
RBC

Cast : are the cylindrical structures with parallel sides

and blunt rounded ends that are formed due to
precipitation of protein