URINALYSIS AND BODY FLUIDS

Presented by
Alyazeed hussein, BSc
 Complete urinalysis
 Urine formed by: filtration, reabsorption, secretion.
 A complete urinalysis is composed of multiple tests, including physical,
chemical, and microscopic analysis.
 Urine volume terminology:
◦ Oliguria: Decrease in urine output,
◦ Anuria: No urine,
◦ Polyuria: Increased daily output.
 Specimen Collection and Handling:
 Use clean, dry container, receive and analyze the sample within 2 hours,
otherwise: pH, nitrites, bacteria, and turbidity will increased,
urobilinogen, glucose and bilirubin will decreased also color change
and destruction of formed elements.
 Refrigeration will decrease bacterial growth but will cause precipitation
of amorphous phosphates/urates.
 Before testing, urine must be brought to room temperature.
Urine specimen types and collection times:
1. Random urine: Most common type, for routine tests.
2. First morning: Concentrated specimen used for routine screening,
pregnancy test.
3. Fasting & 2-Hour postprandial: for DM(insulin monitoring), 2 hours after
eating.
4. 24-Hour: Collected over a period of 24 hours for creatinine clearance, GFR.
5. Midstream clean-catch(MSU): urine
collected in the middle of urination; used for bacterial culture.
6. Catheterized: Collected from a tube placed through the urethra
into the bladder; used for bacterial culture and routine screening.
7. Suprapubic aspiration: Needle inserted into the bladder through
the abdominal wall; used for bacterial culture and cytologic testing.
8. Pediatric collection: Use small, clear plastic bags with adhesive
to adhere to the genital area.
 Physical examination of urine:
 . Color, Appearance and SG
A. color:
1.Pale yellow & yellow: normal color of urine(urochrome: urobilin).
2. Uroerythrin adds a slight pink pigment, mostly apparent following
refrigeration, when the pigment attaches to precipitated amorphous urates.
3. Colorless: may due to dilution, or DM.
4. Dark yellow: may due to dehydration, or First morning( concentrated),
usually with high specific gravity.
5. Orange or dark yellow-amber: Bilirubinemia occurs from liver problems,
such as hepatitis > bilirubinuria, yellow foam forms when urine is shaken
due to the presence of conjugated bilirubin.
6. Red/pink: (RBCs, hemoglobin-brown and myoglobin-muscle).
7. Green/blue: medication or pseudomonas.

Foam test: positive

 B. Appearance and clarity:
.Clear: normal .1
slightly cloudy: May be due to the presence of low numbers of formed .2
.elements
Cloudy: if acidic urine: may be due to amorphous urates (showing a .3
slight pink color) calcium oxalate crystals, or uric acid
,crystals, in alkaline pH: if the sample is white
may be due to amorphous phosphates and
.Carbonates, also due to Chyluria(W.bancrofti, lymphatic filariasis
C. Specific Gravity: determines the kidney's reabsorption ability.
Measured by Refractometer.
 Normal range: 1.005 to 1.035
 Low specific gravity: loss of the kidney's ability to concentrate urine or
presence of disease, such as diabetes insipidus(ADH), glomerulonephritis,
and pyelonephritis. It can also be found normally with large fluid intake.
 High specific gravity may result from adrenal insufficiency, diabetes
mellitus(glycosuria).
 Chemical examination of urine:
 Reagent Strips:
 Strips are chemical-containing absorbent pads that react with urine, producing
a chemical reaction that results in a color change.
 Sources of error: Excess time in the urine, not following specific reaction
times to read results(60 sec), and not testing samples at room temperature.
1. pH: (5.0 to 6.0),
 if < 5.0 High-protein diets, respiratory/metabolic acidosis, uncontrolled
diabetes mellitus.
 > 7.0, increased consumption of vegetables, respiratory/metabolic alkalosis,
and UTIs.
 Note that!!! urine may also be alkaline as a result of delay in testing due to the
action of bacteria on urea to form ammonia.
2. Protein: albumin.
 Indicate renal disease.
3. Glucose:
monitor diabetes mellitus.
 Principle: (glucose oxidase)
 Renal glycosuria: presence of glucose in urine with normal blood glucose level! Due to defect in renal
tubular dysfunction.(>180mg/dl)
 Clinitest: detect the presence of glucose, Benedict’s principle (in alkaline media glucose reduce copper
to cuprous oxide).
4. Ketones: products of fatty acid metabolism: acetone, acetoacetic acid, and beta-hydroxybutyric acid.
 (sodium nitroprusside,rothera test, colorless to purple color), Uncontrolled diabetes mellitus, vomiting,
starvation.
 Confirmatory test: Acetest.
5. blood: detects hematuria(intact RBCs): renal calculi, glomerulonephritis,
and hemoglobinuria(Hb from lysed RBCs): e.g. hemolytic anemia,
6. Bilirubin:
hepatitis, cirrhosis, (direct bilirubin).
 Confirmatory tets: lctotest.
 Note that!! (long exposure of the sample to light, converts bilirubin to biliverdin which does not react
with diazonium salts).
7.Urobilinogen:
Increased urobilinogen, indicate liver disease and hemolytic diseases.
 Reagent: Ehrlich's tets.
8. Nitrite(UTIs):
indicate cystitis (bladder infection) and pyelonephritis, detects the ability of
certain bacteria to reduce nitrate (found in urine normally) to nitrite
(abnormal in urine). Culture is recommended.
9. Leukocytes:
urinary tract infection, or non bacterial(inflammation).
10. Specific gravity:
Monitors hydration and dehydration, loss of renal tubular concentrating
ability, and diabetes insipidus.
 Note that! If urine pH >8.0, add 0.005 to the reading.
Microscopic examination
 Standard rules for microscopies:
1. Examine urine while fresh or when properly preserved.
2. Centrifuged 5 to10 mL, of urine leaving 0.5 mL of sediment for viewing.
3. Report RBCs/WBCs using high-power magnification (i.e., high-power field [hpf]), report
casts and crystals using low-power magnification (i.e., low-power field [lpf]).
4. Normal Urines: Contain 0-4 RBCs (hpf), 0-3 WBCs (hpf), 0-2 hyaline casts (lpf), several
epithelial cells (hpf), some types of crystals, and mucus.
 CELLS:
1.RBCs: associated with infections, renal calculi, renal damage and cancers.
 RBCs can be confused with yeast cells or oil droplets. Diluted acetic acid can be used to lyse
RBCs, leaving only yeast, oil droplets, and WBCs.
 Ghost RBCs: RBCs lost Hb in diluted or hypotonic urine.
2.leukocytes(pyuria): Bacterial infections, pyelonephritis, cystitis, prostatitis, and urethritis,
Nonbacterial pyuria resulting from glomerulonephritis and tumors.
 Neutrophils are the predominant WBC.
 Glitter cells, WBCs swell in dilute alkaline urine, eosinophil present in drug-induced
nephritis.
 3.Epithelial cells:
 A. Squamous epithelial: These cells are very common in the urine and usually not clinically
significant, Squamous epithelial cells line the lower urethra and vagina in women and the
urethra of males. In the presence of a vaginal infection, clue cells may appear; clue cells are
squamous epithelial cells covered with Gardnerella vaginalis, (bacterial vaginosis).
 4.Transitional epithelial: These cells line the renal pelvis, ureters, bladder, and upper
urethra, Smaller than squamous epithelial cells, transitional cells are spherical/caudate and
have a central nucleus, There is no associated pathology, except in large numbers, with
abnormal morphology, including vacuoles and irregular nuclei, which may indicate renal
carcinoma or viral infection.
5.Renal tubular epithelial(RTE):
 Is the most significant epithelial cell in the urine. It has a small eccentric nucleus. Cell size
and shape vary from larger cells in the proximal convoluted tubule (PCT) to cells slightly
larger than a WBC-shaped cuboidal or columnar originating from the collecting duct (CD).
 > 5/hpf are present > Tubular injury is suggested. Can indicate renal cancer, renal tubular
damage, pyelonephritis, toxic and allergic reactions, and viral infection.
 Types of renal tubular cells:
A. Bubble cells: contain large, vacuoles > renal tubular necrosis.
B. Oval fat bodies(macrophages): lipids > nephrotic syndrome.
 Casts(Cylindruria):
 Are unique to the kidney!
 Casts are formed within the lumen of the distal convoluted tubule and
collecting duct, taking on a shape similar to the tubular lumen.
 Casts may have formed elements (such as bacteria, WBCs, RBCs, etc).
 Uromodulin (Tamm-Horsfall glycoprotein) is the major constituent of casts,
made by the renal tubular epithelial cells that line the DCT and upper CD.
 Casts also consist of some albumin.
 Types of casts:
1. Hyaline cast: Most commonly seen, 0-4/lpf normal, normally follow exercise,
dehydration, heat, and emotional stress.
 Disease association: Acute glomerulonephritis, pyelonephritis, chronic renal
disease.
 Appearance: Colorless.
2. RBC cast: Disease association: Bleeding within the nephron, damage to the
glomerulus post-streptococcal infections.
 Appearance: Orange to red color, contains hemoglobin and intact
erythrocytes
3. WBC cast: Infection (pyelonephritis) or inflammation within the nephron.
 Appearance: Primarily contain neutrophils.
4. Bacterial cast: Disease association: Pyelonephritis.
 Appearance: bacteria contained within the cast and bound to the surface; mixed
cast containing bacteria and WBCs may occur.
5. Epithelial cell cast: Disease association: Advanced renal tubular damage; seen in
chemical, or drug toxicity, viral infections, and allograft rejection.
 Appearance: Contain renal tubular epithelial cells.
6. Granular cast: Seen with hyaline casts following stress and exercise,
 Disease association: The granular appearance may result from glomerular
precipitants, such as cells or protein aggregates.
7. Waxy cast: from degeneration of granular casts.
 Disease association: Chronic renal failure.
 colorless to yellow with a smooth appearance; with cracks on the sides.
 8. Fatty cast: Seen with oval fat bodies in disease states that result in lipiduria.
 Disease association: Nephrotic syndrome, toxic tubular necrosis,.
 Appearance: contains yellow-brown fat droplets, positive identification of fatty casts is by
Sudan III stain.
8. Broad cast: Formed in the DCT and CD due to anuria.
Disease association: Suggests renal failure.
 Microorganisms:
1. bacteria.: Lower and upper UTI(bacteria vs amorphus)
2. Yeasts: UTIs, vaginal infections, DM, and in immunocompromised individuals, (yeast vs
RBCs).
3. Parasites: Trichomonas vaginalis, Schistosoma haematobium and Enterobius
vermicularis!
 Others:
1. Mucus: Protein substance produced by the RTE cells and the urogenital glands; not
considered clinically significant.
 Crystals(crystalluria):
 precipitation of urine salts and medications.
 Crystals will appear more frequently if urine stands at room temperature for prolonged time
periods or is refrigerated.
A. acidic urine crystals:
1. Amorphous urates: Small, yellow-to-brown granules usually in large amounts;
may make other urine elements difficult to see.(pinkish urine sediment).
 No clinical significance.
 Also can exist in neutral pH.
2. Uric acid: Seen in gout, Appear yellow to orange/brown but can be colorless.
 Pleomorphic (many) lemon, needle and rosettes. Also synovial fluids can be
tested.
3. Calcium oxalate: Most urine oxalate is from oxalic acid, which is found in
such foods as tomatoes, spinach, and oranges. In addition, oxalic acid is a
metabolite of ascorbic acid.
 Colorless, dihydrate form appears as envelope or monohydrate form appears
as dumbbell or oval shaped.
 These crystals are associated with renal calculi formation.
4. Bilirubin: These crystals are most often seen in liver disease.
appear as fine needles or granules that are yellow, orange to brown in color.
5. Tyrosine: Fine delicate needles, colorless to yellow found in clumps or
rosettes.
 Associated with severe liver disease.
6. Leucine: Yellow to brown, spheres shape may be found with tyrosine
crystals, associated with severe liver disease.
7. Cystine: Colorless, these crystals result from a congenital disorder that
inhibits renal tubular reabsorption of cystine(cystinuria).
 Associated with renal calculi formation.
8. Cholesterol: Clear, flat, plates seen with fatty casts and oval fat bodies.
 Associated with nephrotic syndrome.
 Alkaline urine crystals:
1. Amorphous phosphate: Identical in appearance to amorphous urates and
generally colorless. Not clinically significant.
2. Triple phosphate (ammonium magnesium phosphate), Colorless,
resembling a coffin lid not clinically significant; may be associated with UTI.
 3. Calcium phosphate: Colorless, thin prisms. Not clinically significant; may be associated with
renal calculi formation.
4.Ammonium biurate: Normal crystal commonly seen in old urine samples; converts to uric acid
crystals if acetic acid added and dissolves at 60°C, Yellow to brown spheres with irregular, thorny
projections (thorn apple).
5. Calcium carbonate: Appear as small, colorless crystals having dumbbell or spherical shapes. Not
clinically significant
 Special test:
 Phenylketonuria (PKU): The presence of phenylalanine in the urine indicates defective
metabolic conversion of phenylalanine to tyrosine, which is caused by a gene failure to produce
phenylalanine hydroxylase.
 Maple syrup urine disease: maple syrup smell of the urine, breath and skin, low levels of
Branched-chain α-keto acid dehydrogenase complex (BCKDC); inhibits metabolism of leucine,
isoleucine, and valine.
 dinitrophenylhydrazine (DNPH): to form yellow turbidity or precipitate.
 Bence jones protein: light chain of immunoglobulins in urine(multible myeloma), (heat test).
 URINE SPECIMEN STORAGE AND HANDLING:
 Most common form of preservation, refrigeration at 4°C to 6°C, is suitable for the
majority of specimens. Any urine specimen for microbiological studies should be
refrigerated promptly if it cannot be transported directly to the laboratory, the
specimen remains suitable for culture for up to 24 hours.
 Refrigeration can induce precipitation of amorphous urate andphosphate crystals
that can interfere with the microscopic examination.
 Cerebrospinal Fluid (CSF):
 CSF cushions the brain and spinal cord against trauma. 20 mL of CSF is produced each hour.
 Most CSF analysis is performed in chemistry, hematology, and microbiology.
 The procedure for obtaining CSF is known as a lumbar puncture (between L3 and L4).
 10–20 mL of CSF is collected.
 Should transport to lab immediately, otherwise maintained at room temp. (20-25ºC).
 Appearance of CSF:
 Clear and colorless: Normal.
 Cloudy: Indicates WBCs (pleocytosis), RBCs, protein, or bacteria; seen in meningitis, hemorrhage
disorders of the blood-brain barrier.
 Bloody: This may be due to subarachnoid hemorrhage or traumatic tap.
 Xanthochromic (yellow): Increased hemoglobin, bilirnbin, protein, immature liver in premature infants.
 Chemistry testing: e.g.
 CSF glucose: 60-70% of the patient's plasma glucose (2/3), (X 0.6).
 Hematology testing: cell count, Normal CSF contains 0-5 WBC/μL; lymphocytes (28-96%), monocytes
(16-56%), neutrophils (0-7%).
 Microbiology testing: India inke, Used to detect Cryptococcus neoformans(Capsule), possible
complication of AIDS.
 Meningitis
viral Bacterial test

Clear Turbid Appearance

Normal Low Glucose

High High Protein

Lymphocytes Neutrophils(PM WBC type

Ns)
 Semen analysis
 Semen collection is by masturbation. Collect the entire ejaculate.
 After a 48- to 72-hour of abstinence from sexual activity.
 Specimens should not be collected in a condom,
 If transported from a site distant to the laboratory, it must be kept near body temperature.
 Received in the laboratory within 1 hour after the collection
 Liquefaction occurs within 30–60 minutes.
 Grey, white, light yellow.
 Turbidity indicate leukocytes, reproductive tract infection or inflammation.
 Normal semen volume ranges from 2 to 5 mL.
 Normal sperm concentrations have been reported to range between 20 and 250 million per milliliter.
 Oligospermia is a sperm count less than 20 million per milliliter
 Azoospermia is the complete absence of sperm
 The pH of fresh semen normally ranges from 7.2 to 7.8
 Acid phosphatase for the function of prostate. The presence of ACP in vaginal fluid, skin washings,
or clothing helps establish validity of alleged sexual assault.
 Fructose provides energy for spermatozoa.
Pus cells (dead WBCs)
Clue cells
Caudate cells Oval fat body

Vacuolated cells
 Hyaline cast RBCs cast WBCs cast

Epithelia
Bacterial cast cells cast
Granular cast Waxy cast Fatty cast Broad cast
Bacteria Mucus threads Fungal element
Egg of E.vermicularis Trophozoite of Egg of
T.vaginalis S.hematobium
Uric acid Amorphus urate
 Bilirubin

Calcium oxalate
Tyrosine Leucin
e

Cystine Cholesterol
Calcium phosphate Triple phosphate Amorphus phosphate
Ampicillin crystals
Indian ink: C.neoformans (CSF)
Artifacts and contaminants in urine
Pollen grains
Alterneria spores: drumstick like
fibers
Starch/
talcum
Galss artifact
Air bubbles
Corpora amylacea 
Rotifer

Dust mite
Thanks