Presented by –Dr.

Suman Kumari
Moderator- Dr.Nitika Chawla
1. A mid-stream, freshly voided first morning urine specimen is
preferred since it is most concentrated, without any
preservative is ideal for microscopic evaluation.

2. If preservative is required then one crystal of thymol or1

drop of formalin (40%) is added to about 10 ml urine

3. Midstream collection is recommended for females.

4. 2 ml of urine sample is taken in a test tube and centrifuged

at 3000 rpm for 5 minutes.
5. The supernatant is removed and sediment is
used for microscopic evaluation.

6. The microscopic evaluation can be done of unstained urine

preparations. However for better delineation of formed
elements crystal-violet safranin stain is commonly used.
1. CELLS :- erythrocytes
leukocytes
epithelial cells

2. CAST:- cellular cast

non-cellular cast
3. CRYSTALS:- normal acidic urine
normal alkaline urine
abnormal urine

4. ABNORMAL CELLS AND OTHER FORMED

ELEMENTS :- Tumor cells
viral inclusion cells
Platelets
Bacteria
Fungi
Parasites
Appear as pale biconcave discs.
Appear crenated in hypertonic urine.
Appear as ghost cells in dilute urine.
 Normally 0-2 erythrocytes/hpf is seen.
 More than 3 cells/hpf is abnormal.

Causes of increased erythrocytes in urine:-

PHYSIOLOGICAL-
Exercise

PATHOLOGICAL-
1. Renal disease: glomerulonephritis
lupus nephritis
Interstitial nephritis
Renal vein thrombosis
Trauma(renal biopsy)
2. Lower urinary tract disease:
- acute and chronic infection
- calculus
- tumor
- infection
- hemorrhagic cystitis following
cyclophosphamide

3. Extra renal disease:

- appendicitis
-salpingitis
-diverticulitis
-tumors of colon ,rectum,pelvis
Dysmorphic erythrocytes- are red cells with
cellular protrusions or fragmentation. Their
presence of >80% is strongly suggestive of
glomerular bleeding.
Appear as granular sphere of 12 microns in diameter
with multilobated nuclei.
Appear as glitter cells in dilute urine.
 Normally less than 5 leukocytes/hpf are seen
in normal urine.
 >5 leukocytes/hpf is abnormal
 Urinary neutrophil counts>30/hpf is
suggestive of acute infection.

Causes of increased leukocytes in urine:-

PHYSIOLOGICAL-
Strenuos exercise

PATHOLOGICAL-
-Infections like pyelonephritis, cystitis,
prostatitis, balanitis.
-non infectious conditions like:
glomerulonephritis
SLE
interstitial nephritis
calculus disease
bladder tumor
SQUAMOUS EPITHELIAL CELLS:-

Most frequent epithelial cell in normal urine and least significant.

These are large cells, rectangular in shape, flat with abundant
cytoplasm and small central nucleus.
- Presence in large numbers indicate contamination of urine with
vaginal fluid.
TRANSITIONAL EPITHELIAL CELLS-

-Cells are large diamond or pear shaped (caudate cells)

-Few transitional epithelial cells are present in normal urine.
-Presence of large clumps and sheets of cells in the absence
of instrumentation raises suspicion of transitional cell
cancer.
RENAL TUBULAR EPITHELIAL CELLS-

These are polyhedral, columnar or oval with granular

cytoplasm and eccentric nucleus.
Most significant cells in urine because increased
number is indicative of tubular damage.
NON- CELLULAR CASTS:-
1. Hyaline Cast- Most common cast. Homogenous, colourless,
transparent and refractile, cylindrical with parallel sides and
blunt rounded ends.
Composed of Tamm-Horsfall proteins.
Transiently increased in exercise and fever.
Increased number in conditions causing glomerular proteinuria.
2. Granular casts- presence of degenerated cellular (renal
tubular epithelial cells) debris in cast makes it granular in
appearance.
Seen in strenuous muscle exercise, fever, acute
glomerulonephritis, and pyelonephritis.

3. Waxy casts- form when hyaline cast remain in renal tubules

for long time. Homogenous, smooth, glassy appearance,
cracked or serrated margin and irregular broken off ends which
are sharp , light yellow in colour. Seen in end stage renal
failure.
4. Fatty cast- cylindrical stuctures filled with highly refractile fat
globules in protein matrix.
Seen in Nephrotic Syndrome.

5. Broad cast- form in dilated distal tubules.

Seen in chronic renal failure and severe renal tubular
obstruction.
CELLULAR CASTS- To be called as cellular, casts should contain
atleast 3 cells in the matrix. They are named according to the
type of cell entrapped.

1.Red cell cast- cylindrical structures with red cells in protein

matrix. May appear brown in colour due to hemoglobin
pigment. Seen in conditions like acute glomeruonephritis, lupus
nephritis, subacute bacterial endocarditis and renal infarction.
2.White cell casts- cylindrical stucture with white cell embedded
in protein matrix.
Seen in pyelonephritis, interstitial nephritis, lupus nephritis.

3. Renal tubular epithelal cell casts- composed of renal tubular

epithelial cells that have been sloughed off.
Seen in acute tubular necrosis, viral renal disease, heavy metal
poisoning, and acute allograft rejection
TELESCOPED SEDIMENT-
Includes red cells, red cell cast, cellular casts, broad
waxy cast and fatty casts in a simultaneous
occurrence.
-it is due to simultaneous occurrence of elements of
glomerulonephritis and those of nephrotic syndrome
in same specimen.
- Seen in collagen vascular disease( lupus nephritis)
and subacute bacterial endocarditis.
CRYSTALS FOUND IN NORMAL ACIDIC URINE
 Amorphous urates(calcium , magnesium,
sodium and potassium)
 Crystalline urates( sodium, potassium,
ammonium)
 Crystalline uric acid
 Calcium oxalates
CRYSTALS FOUND IN NORMAL ALKALINE URINE
 Amorphous phosphates( calcium and
magnesium)
 Crystalline phosphates
CRYSTALS FOUND IN ABNORMAL URINE
 Cystine
 Tyrosine
 Leucine
 Sulfonamide
 Cholesterol
 Bilirubin
CRYSTALS FOUND IN NORMAL ACID URINE:-
1. Amorphous urates( calcium, Magnesium, sodium, and
potassium )
 microscopically appear as yellow-brown small granules that
can form clumps
2. Crystalline urates ( sodium, Potassium, and Ammonium)
 form small brown spheres or colourless needles in slightly
acidic urine.
Large number of uric acid and urate crystals reflect :
 Increased nucleoprotein turnover, especially during
chemotherapy of leukemia and lymphoma.
 Lesch-Nyhan syndrome

 Urate nephropathy of gout

4. Calcium Oxalates
small colourless octahedron that resembles an envelope.
Large number of oxalate crystals reflect:
 Severe chronic renal disease

 Ethylene glycol or methoxyflurane toxicity

 Small bowel disease and resection

 Crohn’s disease
CRYSTALS FOUND IN NORMAL ALKALINE URINE:-
1. Amorphous phosphates( calcium and magnesium )
have a granular appearance. They form a white lacy
precipitate macroscopically. Clumps and masses can often be
seen by light microscopy.
 Crystalline Phosphates/ triple phosphates( ammonium
magnesium phosphates)
colourless, three to six sided prisms with oblique ends
referred to as coffin lids.
 Have little clinical significance.

 Seen in infected urine.

CRYSTALS FOUND IN ABNORMAL URINE:-
1.Cystine- colourless, refractile, hexagonal plates. Seen in
cystinuria, an inborn error of metabolism.

2. Tyrosine- fine silky needles that may be arranged in sheaves

or clumps, especially after refrigeration. They may be colourless
or yellow. Seen in liver disease and tyrosinemia.
3. Leucine- refractile, yellow or brown, spheres with radial or
concentric striations. They are found with tyrosine in severe
liver disease.

4. Sulfonamide crystals- variably shaped, but usually appear as

sheaves of needles. They occur following sulfonamide therapy.
5. Cholesterol crystals- colourless, refractile, flat rectangular
plates with notched (missing) corners, and appear stacked in a
stair-step arrangement.
Seen in lipiduria, associated with nephrotic syndrome and
hypercholesterolemia.

6. Bilirubin crystals- small (5 microns), brown crystals of

variable shape (square, bead-like, or fine needles).
Seen in severe obstructive liver disease.
TUMOR CELLS-
 Malignant exfoliated cells from renal pelvis,
ureter,bladder wall and urethra.
 Myeloma cells.
VIRAL INCLUSION CELLS
Epithelial cells with inclusion bodies .
Seen in viral infections like herpes, CMV,
Polyoma viruses.

PLATELETS
Demonstrated in urine of patients with
hemolytic uremic syndrome.
FUNGI
-Yeasts( candida spcs.) in diabetic patients.
-Common contaminants from skin, female
genital tract and air.
-often confused with RBCs (distinguished by
presence of budding and pseudohyphae)
PARASITES
-Parasites and ova are commonly seen due to fecal
or vaginal contamination of urine.
-Trichomonas vaginalis may be present in urine
either due to contamination or infection of bladder
and urethra. Pear shaped organisms with flagella.
-Schistosoma hematobium ova is shed in urine along
with red blood cells
Significant bacteriuria exists when there are
>10*5 bacterial colony forming ,units/ml of
urine in a clean catch midstream
sample,>10*4 colony forming units/ml of
urine in catheterized sample ,and >10*3
colony forming units/ml of urine in a
suprapubic aspiration sample.
 In a wet preparation, presence of bacteria should
be reported only when urine is fresh. Bacteria
occur in combination with pus cells. Gram’s stain
smear of uncentrifuged urine showing one or
more bacteria per oil immersion field , suggests
presence of >10*5 bacterial colony forming
units /ml of urine.
 If many squamous cells are present then urine is
probably conatminated with vaginal flora .
 Also presence of only bacteria without pus cells
indicates contamination with vagina or skin flora.
 Bacteria in urine
STARCH GRANULES- from surgical gloves are most
common contaminants.
- Appear bright and faintly striated with irregular
outline and faint central depression.
SPERMATOZOA- can occasionally be present in male
patients.