Routine

Urinalysis
 What is Urine?
• Urine is a liquid tissue biopsy of the
urinary tract
• Urine refers to an ultrafiltrate
containing waste products excreted by
the kidneys, temporarily stored in the
_________________
Urinary Bladder and excreted
through the urethra
• Urine is composed of 95% water and
5% solutes
 Chloride is the major inorganic
• _____________
component of urine
• Other inorganic components include
sodium, potassium, sulfate, phosphate,
ammonium, magnesium and calcium
Urea is the major organic
• _____________
component of urine
• Other organic components include:
creatinine, uric acid, and hippuric acid
 600-2000 ml/day is normally
• Approximately __________________
excreted daily
Polyuria – refers to increased urine output
• ____________
Oliguria – refers to decreased urine output
• ____________
Anuria – refers to complete cessation of
• ____________
urine flow
Dysuria – refers to painful urination
• ____________
Nocturia – refers to increased excretion of
• ____________
urine at night (>500 ml of urine with a specific
gravity of less than 1.018 at night
• Normal day to night urine ratio is ____________
2:1 to 3:1
• Normal urine is clear, with color ranging from straw
(pale yellow) to amber
• The yellow color of the urine is caused by the presence
of the pigment ______________ Urochrome
• Urochrome excretion is increased during fever,
thyrotoxicosis and starvation
• Other pigments responsible for the urine color includes:
• ______________ , a pink colored pigment, is most
Uroerythrin
evident in specimens that have been refrigerated,
resulting in the precipitation of amorphous urates
• ______________ an oxidation product of the normal
Urobilin
urinary constituent urobilinogen, imparts an orange-
brown color to the urine that is not fresh
 How does Urine Formed?
The Renal/Excretory System
• Components include:
Kidneys, Ureter, Urinary Bladder & urethra
________________________________________
• Kidneys are the main organ of excretory system; also
produces erythropoietin in response to tissue
hypoxia; also produces renin which is responsible for
maintaining blood pressure and aldosterone
production
Urinary Bladder– part of the excretory system
• ________________
that serves as temporary storage of urine
Nephrons – functional unit of the kidney.
• ______________
Each kidney contains around 1 – 1.5 M of it.
• Mechanism of Urine formation involves:
1. _______________
Renal blood flow 2. Glomerular
_________________
filtration
3. Tubular
_______________
reabsorption 4. _________________
Tubular secretion
• Kidneys receive approximately _________
20-25%
cardiac output (blood pumped by the heart)
• Normal adult blood passes through the
kidneys at a rate of _______________
1,200 ml/min
(renal blood flow). Renal plasma flow is
equivalent to ______________
600-700 ml/min
 Urine formation in the nephrons:
• Afferent
________________
arteriole – are arterioles formed from
the renal artery; carry blood towards the
nephrons
Glomerulus – filtering apparatus of the
• ________________
nephrons; produces a filtrate with a constant
specific gravity of_______,
1.010 a pH of 7.4 and an
osmolality similar to plasma
• ________________
Renal tubules – responsible for
concentrating and diluting the urine; includes the
proximal convoluted tubule, Loop of Henle, distal
convoluted tubule, and collecting ducts
• Majority (65-80%) of the reabsorption
PCT
process occurs in the _____________.
This is responsible for reabsorbing glucose,
electrolytes, water and amino acids
Descending Loop of Henle
• _____________________ – is permeable to
water but impermeable to salt
Ascending Loop of Henle
• _____________________ – is permeable to
salt but impermeable to water
DCT
• Anti-diuretic hormone acts in the _____ and
Collecting ducts
_______________ to promote water
reabsorption
 Renal Function Tests
Tests that assess Glomerular Filtration
(Clearance Tests)
Urea Clearance Test
1. _______________________
– One of the earliest and historical method used
to assess GFR
– No longer used because:
Affected by diet
(1)_____________________
Approx. 40% urea is reabsorbed
(2) _________________________________
in the tubules
 Inulin Clearance Test
2. ________________________
• Considered as the gold standard for assessment
of glomerular filtration rate
• Measures substance that is filtered by the
glomerulus but not reabsorbed nor secreted by
the tubules
• Uses an exogenous substance, INULIN (a polymer
ofCreatinine
fructose to measure GFR)
Clearance Test
3. ____________________________
• Most commonly used method to assess GFR
• Used since almost 100 % creatinine passes
through the glomerulus and is not reabsorbed
• Specimen needed for creatinine clearance:
24 hr urine & serum/plasma
____________________________
• The greatest source of error in any clearance
procedure utilizing urine is the use of
Improperly collected urine specimens
________________________________________
• Collection of 24-hr urine:

• Addition of urine formed before the start of the

collection period will falsely elevate results and
failure to include urine produced at the end of
the collection period will falsely decrease results
• Calculated glomerular filtration
estimates include: Cockroft and Gault’s
Formula and Modification of Diet in
Renal Disease (MDRD)
• Other tests to assess GFR: cystatin C,
beta-2-microglobulin, 125I-iothalamate
ml/min
• GFR is reported in ___________
• First step in creatinine clearance:
________________________________
Measure the total volume of the urine
• Creatinine Clearance can be calculated using:
= urine creatinine X urine volume in mL per min X 1.73
Plasma creatinine BSA

• Example: urine creatinine: 60 mg/dl

Plasma creatinine: 1.73 mg/dl
Body surface Area (BSA): 1.20
Urine volume: 2,880 mL/24 hours
• Step 1: Convert urine volume into ml per min

• Step 2: Substitute the given to the equation

 I. Tests that assess Tubular Reabsorption (Concentration Tests)

A. Fishberg Concentration Test and

Mosenthal Concentration Test
Specific gravity – most commonly
B. ________________
used; measured uring urinometer,
refractometer or urine reagent strip; both
the number and the weight of particles
contribute to the specific gravity
 Osmolarity – more sensitive since it is only
C. ______________
affected by the number of particles and not by their
molecular weight; can be measured directly using
osmometers that measure colligative properties:
Boiling point Vapor pressure
Freezing point Osmotic pressure
• Most common principle of osmometers:
Freezing pt where 1 Osm/kg depresses
________________
freezing point by 1.86 below the freezing point of
water
50 – 1400 mOsm
• Normal urine osmolality: ____________________
1:1 to 3:1
• Urine to serum osmolality ratio: ______________
II. Tests that assess Tubular Secretion and Renal Blood Flow

• PAH test (p-aminohippuric acid)

• Phenolsulfonaphthalein
• Titratable acidity
• Urinary ammonia
• Urine pH
 A. Types of Specimen
• Random urine – most commonly received
________________
specimen; can be sufficient for routine urinalysis
First morning urine – also known as the 8-
• ____________________
hour urine specimen; first specimen voided in the
morning; more concentrated; essential for
preventing false negative results in pregnancy
testing
Fasting specimen – also known as the
• ___________________
second morning urine specimen; second voided
urine after a period of fasting; recommended for
glucose monitoring
 2-hr Post Prandial – the patient is
• _____________________
instructed to void shortly before consuming a
routine meal and to collect a specimen 2 hours
after eating; specimen is usually tested for
glucose; used for monitoring insulin therapy in
patients with DM
Glucose tolerance - collected to
• ______________________
correspond with the blood samples drawn
during a GTT; may include fasting, half-hr, 1-hr,
2-hr, and 3-hr specimen, and possibly 4-hr, 5-hr,
and 6-hr specimen. The urine is tested for
glucose and ketones
 Early afternoon - urine specimen
• ____________________
collected at around 2-4 pm; Used for
evaluation of urine urobilinogen levels
Suprapubic aspirate- urine collected
• ____________________
by external introduction of a needle
through the abdomen into the bladder
Catheterized urine specimen collected
• ___________________________-
under sterile conditions by passing a hollow
tube (catheter) through the urethra into
the bladder; can be used for bacterial
culture
• _______________________
Midstream clean-catch - safer, less
traumatic method for obtaining urine for
bacterial culture and routine urinalysis; provides
a specimen that is less contaminated by
epithelial cells and bacteria; patients are
instructed to wash their hands before beginning
the collection and then the external genitalia
prior to voiding; patients are to void first into the
toilet; then collect an adequate amount of urine
in the sterile container, and finish voiding into
the toilet
• 24-hr urine specimen - used when the
_____________________
concentration of the substance to be
measured changes with diurnal variation
and with daily activities such as exercise,
meals, and body metabolism; the patient
must begin and end the collection period
with an empty bladder; all specimens
should be refrigerated or kept on ice during
the collection period and may also require
addition of a chemical preservative
• Prostatitis specimen- usually involves a
____________________
three-glass collection; first urine passed is
collected; midstream portion is collected;
prostate is then massaged and prostatic fluid is
then passed thru the third container. In prostatic
infection, the third specimen will have a white
blood cell/high power-field count and a bacterial
count 10 times that of the first specimen; second
specimen is used as a control for bladder and
kidney iinfection; if it is positive, the results from
the third specimen are invalid because infected
urine has contaminated the specimen
 Drug Testing Urine Specimen
Chain of Custody - is a standardized
• ____________________
form that must document and accompany
every step of drug testing, from collector to
courier to laboratory to medical review
officer to employer
 Urine Drug Specimen Collection procedure
• Bluing Agent - is added to the toilet
__________________
bowl to prevent adulteration of the specimen
• Required volume of urine for drug testing is
30 – 45 ml
_____________
• Urine for drug testing should have
32.5 – 37.7 C
temperature between __________________
• Urine temperature must be taken within
4 minutes from the time of collection
_______________
 Specimen Handling
• Should be placed in a sterile, wide-mouthed
disposable containers with a screw-cap lids;
Must accompany request form
• Recommended capacity of container is
50 ml
__________
10-15 ml is
• For routine urinalysis, ___________
recommended volume for analysis
• Properly labeled with name as well as
time/date of collection
• Following collection, specimens
should be delivered to the laboratory
promptly and tested within
2 hours If could not be tested
________.
within this period, urine should be
refrigerated or have an appropriate
chemical presevative added.
 Specimen Integrity
• Should it be necessary to determine
whether a particular fluid is urine, the
specimen can be tested for its
Creatinine and __________
_______________ Urea
content. Because both these substances
are present in much higher concentrations
in urine than in other body fluids, these
can identify a fluid as urine
 Criteria for Specimen Rejection
• Unlebeled containers; Nonmatching labels
and requisition forms
• Contaminated specimens with feces or
toilet paper; containers with contaminated
exteriors
• Insufficient volume of urine; improperly
transported or preserved specimens
• Delay between time of collection and
receipt in the laboratory
 Changes in unpreserved urine
Analyte Change Cause of Change
Color Modified/darkened Oxidation or reduction of metabolites
Clarity Decreased Bacterial growth and precipitation of
amorphous material
Odor Increased strength Bacterial multiplication/breakdown
of urea into NH3
pH Increased Breakdown of urea into ammonia by
urease-producing bacteria/ loss of
CO2
May be decreased Glucose converted to acids and
alcohols by bacteria and yeast
Glucose Decreased Glycolysis and bacterial use
Ketones Decreased Volatilization and bacterial
metabolism
Bilirubin Decreased Exposure to light/photo-
oxidation to biliverdin and
hydrolysis

Urobilinogen Decreased Oxidation to urobilin

Nitrite Positive Multiplication of nitrate-
reducing bacteria

Negative Nitrite converted to nitrogen,

which evaporates

RBCs, WBCs & casts Decreased Disintegration in dilute and

alkaline urine

Bacteria Increased Multiplication

Trichomonas Decreased Loss of motility, death
 Specimen Preservation
Preservation Comments
Refrigeration - Does not interfere with chemical tests;
prevents bacterial growth up to 24 hours
- Raises specific gravity by hydrometer
- Precipitates amorphous phosphates and
urates

Thymol - Preserves glucose and sediments well

- Interferes with acid precipitation tests for
protein
- Preserves protein and sediments well; keeps
pH at about 6.0
- Does not interfere with routine urinalysis,
except for pH
- May precipitate crystals when used in large
amounts
Boric acid - Is bacteriostatic (not bactericidal) at 18
g/L; can be used for culture transport;
interferes with drug and hormone
analyses

Formalin - Excellent sediment preservative

- Acts as a reducing agent, interfering with
chemical tests for glucose, blood,
leukocyte esterase, and copper reduction
- Rinse specimen container with formalin to
preserve cells and casts
- Does not interfere with routine urinalysis

Toluene - Floats on surface of specimens and clings

to pipets and testing materials
Sodium fluoride - Prevents glycolysis
- Inhibits reagents strip tests for
glucose, blood and leukocytes
- May use sodium benzoate instead
of fluoride for reagent strip testing
- Is a good preservative for drug
analyses

Phenol - Does not interfere with routine tests

- Causes an odor change
- Use 1 drop per ounce of specimen

Saccomano fixative - Preserves cellular elements; used for

cytology studies
HCl - At a pH of 1-2, 30 ml of 6 N HCl
can be used for catecholamines,
VMA or 5-HIAA
- For amino acid analysis, pH of
3.0 is used

Chloroform - Inhibits bacterial growth

- Changes characteristics of the
cellular sediment

Chlorhexidrine - Prevents bacterial growth

- Useful as glucose preservative
 Urinalysis
Routine Urinalysis (Routine-UA):
• It consists of a group of tests performed as part of
physical examination. It involves macroscopic and
microscopic analysis.

Type of analysis:
physical characteristics
• macroscopic analysis:
chemical analysis
• microscopic examination: urine sediment is examined
under microscope to identify the components of the
urinary sediments.
 I- Physical Characteristics:
• direct visual observation.
• Normal fresh urine: Color: pale or dark yellow-amber, clear.

• Physical examination involves:

1.Color
2.Transparency
3.Odor
4.Volume
5.pH
6.Specific gravity
 I. Urine Color
• Many things affect urine color, including fluid balance,
diet, medicines, and diseases.
• Color intensity of urine correlates to concentration.
• Darker color means more concentrated sample.
• Serves as an indicator of how well hydrated a person; it
gives a rough estimate of urine concentration
Red
• Most common abnormal urine color is - ________
Porphyrins
• Port wine or burgundy red urine - _______________
• Color of urine in lead porphyrinuria (lead poisoning)
Normal
-_________
• Red orange urine in patients under treatment for
Rifampin
tuberculosis is caused by intake of ___________
 Laboratory Correlation of Urine Color
Color Cause Clinical/Laboratory Correlations
Colorless Recent fluid Commonly observed with
consumption random specimens
Pale yellow Polyuria or diabetes Increased 24-hour volume
insipidus
Diabetes mellitus Elevated specific gravity and
positive glucose test result
Dilute random Recent fluid consumption
specimen
Dark yellow Concentrated May be normal after strenuous
specimen exercise or in first morning
specimen
Amber Dehydration from fever or burns
Orange Bilirubin Yellow foam when shaken and
positive chemical test result for
bilirubin
Acrifavine Negative bile test results and
possible green fluorescence
Phenazopyridine Drug commonly administered for
(Pyridium) urinary tract infections; may have
orange foam and thick orange
pigment that can obscure or
interfere with reagent strip readings
Nitrofurantoin Antibiotic administered for urinary
tract infections
Phenindione Anticoagulant, orange in alkaline
urine, colorless in acid urine
Yellow-green Bilirubin oxidized to Colored foam in acidic urine and
Yellow-brown biliverdin false-negative chemical test results
for bilirubin
Green Pseudomonas infection Positive urine culture
Blue-green Amitriptyline Antidepressant
Methocarbamol Muscle relaxant, may be green-brown
(Robaxin)
Clorets None
Indican Bacterial infections
Methylene Blue Fistulas
Phenol When oxidized
Pink RBCs Cloudy urine with positive chemical test results for
Red blood and RBCs visible microscopically
Hemoglobin Clear urine with positive chemical test results for
blood; intravascular hemolysis
Myoglobin Clear urine with positive chemical test results for
blood; muscle damage
Porphyrins Negative chemical test results for blood
Detect with Watson-Schwartz screening test or
fluorescence under ultraviolet light
Beets Alkaline urine of genetically susceptible persons
Rifampin Tuberculosis infection
Menstrual Cloudy specimen with RBCs, mucus, and clots
contamination
Brown RBCs oxidized to Seen in acidic urine after
Black methemoglobin standing ;positive chemical test
result for blood
Methemoglobin Denatured hemoglobin
Homogentisic acid Seen in alkaline urine after
(alkaptonuria) standing; specific tests are
available
Melanin or melanogen Urine darkens on standing and
reacts with nitroprusside and
ferric chloride
Phenol derivatives Interfere with copper reduction
tests
Argyrol (antiseptic) Color disappears with ferric
chloride
Methyldopa or levodopa Antihypertensive
Metronidazole (Flagyl) Darkens on standing
 II. Urine Clarity

• Freshly voided urine is usually CLEAR

• Assessment of urine clarity should be
Well-mixed specimen
done using: _______________________,
viewed through a clear container and
viewed against a
White background
________________________
 Reporting Urine Clarity
Description of Urine Report as:
No visible particulates, CLEAR
transparent
Few particulates, print easily HAZY
seen through urine
Many particulates, print blurred CLOUDY
through urine
Print cannot be seen through TURBID
urine
May precipitate or be clotted MILKY
 Causes of Turbidity
Non-pathological Causes Pathologic Causes
- Squamous epithelial cells - RBCs
- Mucus - WBCs
- Amorphous phosphates, - Bacteria
urate, carbonates - Yeasts
- Semen, spermatozoa - Non-squamous
- Fecal contamination epithelial cells
- Radiographic contrast - Abnormal crystals
media - Lymph fluid
- Talcum powder - lipids
- Vaginal cream
 Laboratory Correlations in Urine Turbidity
Acidic Urine Amorphous urates
Radiographic contrast media
Alkaline Urine Amorphous phosphates,
carbonates
Soluble with Heat Amorphous urates, uric acid
crystals
Soluble in Dilute Acetic Acid RBCs
Amorphous phosphates,
carbonates
Insoluble in Dilute Acetic Acid WBCs
Bacteria, yeast
Spermatozoa
Soluble in Ether Lipids
Lymphatic fluid, chyle
• Chyluria – urine that contains lymph
fluid, associated with obstruction of
lymph flow
• Pseudochyluria – occurs with the use of
paraffin-based vaginal creams for
treatment of Candida infections
• Lipiduria – presence of fats (neutral fat or
cholesterol) or fat globules in urine
 III. Foam Formation
• Color of urine foam after vigorous
shaking of urine
• White foam indicates presence of
Increased protein
______________________________
• Yellow foam indicates presence of
Bilirubin, phenazopyridine (Pyridium)
______________________________
 IV. Odor
Odor Possible Causes
Aromatic Normal
Foul, ammonia-like Bacterial decomposition, urinary tract
infection
Fruity, sweet Ketones (diabetes mellitus, starvation,
vomiting)
Maple syrup MSUD
Mousy/musty Phenylketonuria
Rancid Tyrosinemia
Sweaty feet Isovaleric acidemia and glutaric acidemia
Cabbage Methionine malabsorption
Bleach Contamination
Rotting fish Trimethylaminuria
 V. Specific Gravity

• Specific gravity is defined as the density

of a solution compared with the density
of a similar volume of distilled water at a
similar temperature
• Normal random specimens may range
1.003-1.035 most random
from _______________;
1.015-1.025
specimens fall between _____________
 Specific Gravity
• measures the amount of substances dissolved in
urine.
• also indicates how well kidneys are able to adjust
amount of water in urine.
• higher SG: more solid material is dissolved in urine
• When you drink a lot of fluid, your kidneys make
urine with a high amount of water in it which has a
low specific gravity. When you do not drink fluids,
your kidneys make urine with a small amount of
water in it which has a high specific gravity.
 Isosthenuria - urine with specific
• __________________
gravity fixed at 1.010
• Hyposthenuria
__________________ - urine with a specific
gravity below 1.010
• Hypersthenuria
__________________ - urine with a specific
gravity above 1.010
• Specific gravity can be measured using:
urinometer, refractometer, harmonic
oscillation densitometry, urine reagent strip
 Urine Specific Gravity Measurement
Method Principle
Urinometry Density
Refractometry Refractive index
Harmonic Density
oscillation
densitometry
Reagents strip pka changes of a
polyelectrolyte
 a. Falling Drop method
• Direct method for measuring specific gravity
• More accurate than the refractometer, and is
more precise than the urinometer
• Uses a specially designed column filled with
water-immiscible oil
• A measured drop of urine is introduced into the
column, and as this drop falls, it encounters two
beams of light;breaking the first beam starts a
timer, and breaking the second turns it off
• The falling time is measured electronically and is
expressed as a specific gravity
b. Harmonic Oscillation Densitometry
• Is based on the principle that the
frequency of a sound wave entering a
solution changes in proportion to the
density of the solution
 c. Urinometer (Hydrometer)
• Consists of a weighted float attached to a scale
than has been calibrated in terms of urine specific
gravity
• Disadvantage: requires a large volume, 10-15 ml
_______
of specimen
• Urinometers are calibrated to read 1.000 in
distilled water at a particular temperature. The
calibration temperature is printed on the
20 C
instrument and is usually about _______.
• Previously, potassium sulfate can be used to
check accuracy of urinometer
• Other Disadvantage: Requires
temperature, as well as glucose and
protein corrections
– Temperature corrections
• For every 3 C increase in temperature, add
0.001
• For every 3 C decrease in temperature,
subtract 0.001
- Glucose and Protein corrections
• 1 g/dl of protein can increase SG by 0.003
• 1 g/dl of glucose can increase SG by 0.004
 Sample Problem
• A specimen containing 1 g/dl protein and 1
g/dl glucose has a specific gravity reading of
1.030 using urinometer. Calculate the
corrected reading
 d. Refractometer (Total Solids meter)
• Determines the concentration of dissolved
particles in a specimen by measuring
refractive index
• Refractive index is the ratio of the velocity
of light in air to the velocity of light in
solution
• Specific gravity reading on the
0.002
refractometer is lower by _______
compared to the urinometer reading
• Advantages: small volume requirement (1-2
drops)
– No need for temperature corrections –
refractometers are calibrated and compensated
15-38 C
between _________
• Disadvantage: Glucose and protein corrections
are required
• Calibrating solutions for refractometer
• 1.000
Distilled water: _____________
• 1.022 + 0.001
5% NaCl solution: ____________________
• 1.015 + 0.001
3% NaCl: _________________
• 1.034 + 0.001
9% sucrose: _________________