URINALYSIS

1

Mr. Arian Ray E. Malintad

RSF ’17
Edited by: ALD ‘19


URINE SPECIMEN

o  Referred to as a liquid tissue biopsy of the urinary tract -
painlessly obtained
o  It yields a great deal of information quickly and
economically. But like any other laboratory procedure, it
should be performed and properly controlled.

o  REASONS FOR PERFORMING URINALYSIS:
1.  Diagnosis and management of renal or urinary tract diseases
2.  Detection of metabolic or systemic diseases not directly
related to the kidney
3.  Monitoring the progress of disease and effectiveness of
therapy
 URINE COLLECTION
Always observe universal standard precaution. Wear gloves in
handling urine specimen.

o  Urine sample must be collected in a clean, dry container.
o  Clean catch midstream urine should be obtained to avoid a
significant number of epithelial cells
o  Containers should be a wide mouth to facilitate collection
from a female patient
o  Recommended capacity of a container is 50m, which allows
a 12mL of specimen needed for physical examination,
chemical, and repeat test.
o  If analysis is to be delayed, urine should be refrigerated or
preserved.

URINE COLLECTION

o  Labels
o  Containers must be labeled with
1.  Complete name of patient
2.  Date and time of collection
3.  Age and birth date

o  Labels must be attached to the container, not the
lid and should not get detached if the container is
refrigerated or frozen.
 SPECIMEN REJECTION
o  Improperly labeled and collected specimens should be
rejected by the laboratory and appropriate personnel
should be notified or collect a new specimen.
o  Unacceptable situations are
1.  Specimen in unlabelled container
2.  Non-matching labels and requisition forms
3.  Specimen contaminated with feces or toilet paper
4.  Containers with contaminated exteriors
5.  Specimens of insufficient quantities
6.  Specimens that have been improperly transported
 SPECIMEN HANDLING
o  Changes in urine composition take place not only in vivo
but also in vitro, thus requiring correct handling procedures
o SPECIMEN INTEGRITY
•  Specimens should be delivered to the laboratory and
promptly examined within 2 hours
o SPECIMEN PRESERVATION
•  Refrigerate (2°C-8°C) with decrease bacterial growth
and metabolism
•  Specimen must return to room temperature before
tested
•  If specimen is to be transported, chemical
preservatives are required such as boric acid, formalin,
or sodium fluoride, etc.

 CHEMICAL PRESERVATIVES
1.  Toluene – for preservation of acetone, diacetic acid, reducing substances and protein
2.  Formalin (40%) – for preservation of formed elements
•  An excess will cause precipitation of urea
•  Will cause a false (+) Clinitest and Fehling’s test

3.  Thymol – good preservative for most chemical tests

•  Will cause a false (+) reaction for protein with heat and acetic acid test but does not affect the dipstick
method

4.  Boric acid – delay the decomposition of chemical as well as formed elements but
does not stop the growth of yeast.
•  It will precipitate uric acid

5.  Sodium flouride – preserve glucose in 24 hour collection to inhibit glycolysis, cells
and bacteria
•  It will inhibit the reagent strip for glucose. It is a good preservative for drug analysis.
6.  pH adjustment – a very low pH (< 3) will prevent bacterial growth
and stabilize substances such as catecholamines, VMA, or 5 HIAA
7.  Cytologic preservative – 50% alcohol – for evaluation of tumor cells
8.  Saccomanno’s fixative – preserve cellular elements
•  Used for cytologic studies
9.  Urine C&S transport kit – for U/A and C & S on the same specimen,
decreases pH – preservative is boric acid
10.  Preservative tablet – used for transportation of urine for routine
screening, U/A, preserve glucose and other constituents by releasing
formaldehyde
•  They also contain benzoate and mercury and have an acid reaction.
•  95 mg tablet is used with 20 ml urine. In this concentration, formaldehyde
will not react with the copper reduction tests (Clinitest) and the preservative
properly used does not interfere with common reagent strips.
•  Sp. Gr. will be increased. (0.002/tablet)
 TYPES OF SPECIMEN
o  Random specimen (Qualitative)
•  More convenient for the patient and will be suitable for most
screening purposes
•  The concentration of solutes and formed elements in the urine
varies throughout the patient’s waking hours depending upon
the water intake
o  First morning specimen (Qualitative)
•  Specimen must be collected by the patient upon waking up
and deliver to the laboratory within 2 hours
•  Specimen of choice because it is more concentrated and the
formed elements are more stable in acid urine
•  Essential for preventing false negative pregnancy tests
•  For evaluating orthostatic proteinuria
 TYPES OF SPECIMEN
o  24 hour specimen (Quantitative)
•  Used for the examination of protein, glucose, creatinine
clearance
•  Also for the detection of Schistosoma and Onchocerca
•  Procedure:
Provide the patient with written insurance and explain the
collection procedure. Provide the patient with the proper
collection container and preservative.
•  Day 1: 7am – patient voids and discards specimen; collects
all urine for the next 24 hours
•  Day 2:7am – patient voids and adds this urine to previously
collected
•  On arrival at laboratory, the entire 24 hr specimen is
thoroughly mixed. The volume is measured and recorded.
o  ERRORS IN RESULTS ARE OFTEN RELATED TO
COLLECTION PROBLEMS LIKE:

1.  Loss of voided specimen

2.  Failure to discard first specimen
3.  Poor preservation
4.  Inadequate refrigeration
 COLLECTION FOR MICROBIOLOGIC
EXAMINATION
o  A clean-catch midstream specimen is desirable but
sometimes catheterization or suprapubic aspiration
of the bladder is necessary.
•  Bacterial culture should be done immediately but if not
possible, urine should be refrigerated at 4°C until
cultured.
•  Strong bacterial agents such as hexachlorophene or
povidone iodine should not be used. Mild antiseptic
towelettes are recommended.
SPECIAL COLLECTION TECHNIQUES
o  Suprapubic aspiration – urine is aspirated
with a syringe and needle above the
symphysis pubis through the abdominal wall
into the full bladder.
•  Used for anaerobic cultures, problem culture and
infants
SPECIAL COLLECTION TECHNIQUES
o  3 Glass collection – used to determine prostatic
infection
•  Instead of discarding the 1st urine passed, it is collected in
a sterile container and the midstream in another
container. The prostate is then massaged so that
prostatic fluid will be passed with the remaining urine
into the 3rd bottle.
•  Quantitative cultures are made on each specimen. 1st
and 3rd are examined microscopically. In prostatic
infection, the 3rd specimen will have a WBC/hpf and
bacterial count 10x that of the 1st specimen. The 2nd is
used as control for bladder or kidney infection.
SPECIAL COLLECTION TECHNIQUES
o  Urethral cathetherization
•  Introduce a catheter into the urethra and bladder.
Necessary for patients who are unable to void.
•  Used to differentiate bladder from kidney
infection
•  Ureteral catheters are inserted via a cytoscope
into each ureter. Bladder urine is 1st collected,
then a bladder washout specimen. Urethral urine
specimen are obtained separately from each
kidney pelvis and carefully labelled right and left.
 DIABETIC MONITORING
o  Fasting specimen (2nd morning specimen)
•  2nd voided specimen after a period of fasting.
•  This specimen will not contain any metabolite from
food taken or ingested prior to the beginning of the
fasting period.
o  2 hour postprandial specimen
•  Patient is instructed to void shortly before consuming a
routine meal and to collect a specimen 2 hours after
eating.
•  Specimen is tested for glucose and used primarily for
monitoring insulin therapy in a person with DM.
 DIABETIC MONITORING
o  Glucose Tolerance Test (GTT) specimens
•  Specimens are collected to correspond with
blood sample drawn during a GTT.
•  Most tests include fasting: ½ hour, 1 hour, 2
hours, and 3 hours
•  Tested for glucose and ketones
 DRUG SPECIMEN COLLECTION
o  Urine collection is the most vulnerable part of a
drug testing program. Correct collection procedure
and documentation are necessary to ensure that
drug testing results are those of the specific
individual submitting the specimen.
o  The Chain of Custody (COC) is the process that
provides this documentation of proper sample
identification from time of collection to the receipt
of laboratory results
 DRUG SPECIMEN COLLECTION
o  The COC is a standardized form that must document and
accompany every step of drug testing, from collector, to courier,
to lab, to medical review officer, to employer.
o  Urine specimen collection may be “witnessed” or “un-witnessed.”
o  Collect sample about 30-45 ml. urine.
o  Urine temperature must be taken within 4 minutes of collection to
confirm that the specimen has not been adulterated.
o  Temperature is read between 32.5°C to 37.7°C.
o  Urine odor is inspected to identify any sign of contaminants.
(Toilet lid and faucet acids are taped to eliminate source of water.)
Toilet water reservoir is added with bluing agent (dye) to prevent
adulterated specimen.
 URINE CONTAINERS
1.  Disposable plastic containers,
100 to 200 ml with lids for
routine screening. 12 ml.
capped plastic disposable tubes
are also available.
2.  Rigid brown plastic containers,
3000 ml. with wide mouths and
s c r e w c a p s f o r 2 4 h o u r
collection.
3.  Pediatric urine collectors of
clear pliable polyethylene are
available for male and female
infants.
4.  Sterile containers are used for
cultures.
 TESTS TO IDENTIFY URINE
o  The presence of considerable amounts of urea
nitrogen and creatinine is highly suggestive of
urine, as most other body fluids contain only
small amounts of these substances.
1.  Test for UREA – a value of 600mg/100ml
2.  Test for CREATININE – a value of 50mg/100ml
 COMPONENTS OF ROUTINE
URINALYSIS
I.  Specimen Evaluation
II.  Physical Tests
III.  Chemical Examination
IV.  Sediment Examination

I.  Specimen Evaluation
o  Before doing any testing, the Med-Tech should
evaluate its acceptability.
o  Considerations:
1.  Proper labeling – name, date, time of collection
2.  Proper specimen for the requested test
3.  Proper preservative
4.  Visible signs of contamination
5.  Transportation delays
6.  In specimens submitted for multiple testing,
bacteriologic exam, should be done first.
II.  Physical Tests
1.  Color – normally yellow; however, variations in
color may be caused by diet, medication, and
disease
o  Sometimes provide a clue for the diagnosis of certain
disease
o  Yellow color is due to the pigment urochrome and to
small amounts of urobilin and uroerythrin.
o  Urochrome excretion is increased during fever,
thyrotoxicosis, and starvation.
o  Variation indicates the degree of hydration,
metabolic conditions, physical activity, ingested
material, or pathologic conditions.
 COLOR
Pale urine - seen in a
normal person with high
fluid intake
Darker urine - may be seen
when fluids are withheld
Pale urine of high sp. gr. -
found in diabetes mellitus
and after the use of
radiographic media
Color of urine can be due
to certain food and candy
dyes as well as drugs. Ex.
Red urine – ingestion of
beets
 ABNORMAL URINE COLOR
o  Red urine – most common abnormal color
•  Hematuria – may appear cloudy, smoky, pink, red, or
brown
> Commonly caused by infections (glomerulonephritis),
tumors, trauma (stones and injury), poisoning
•  Hemoglobinuria – clear red, clear red brown, or dark
brown
> Caused by severe burns, incompatible blood
transfusions, fever, snake venom
> Congenital erythropoietic porphyria
> Drugs (ex. Rifampin) and dyes in diagnostic tests (ex.
Phenolsulphthalein)
 ABNORMAL URINE COLOR
RED URINE

CLEAR CLOUDY

HEMOGLOBINURIA MYOGLOBINURIA RED BLOOD CELLS PRESENT
(HEMATURIA)
RED PLASMA CLEAR PLASMA
 ABNORMAL URINE COLOR
o  Dark yellow/ Amber/ Orange
•  Caused by presence of abnormal pigment bilirubin
however this can be confirmed during chemical
examination
•  Suspected if yellow foam appears when the
specimen is shaken
•  May also indicate Hepatitis virus
•  May also be a cause of photo oxidation of excreted
urobilinogen to urobilin also produces a yellow-
orange urine; however, yellow foam does not
appear when the specimen is shaken
 ABNORMAL URINE COLOR
o  Brown/ Black
•  May contain melanin or
homogentisic acid
•  Melanin is an oxidation
product of the colorless
p i g m e n t , m e l a n o g e n ,
produced in excess when a
malignant melanoma is
present.
•  H o m o g e n t i s i c a c i d , a
m e t a b o l i t e o f
phenylalanine, imparts a
black color to alkaline urine
from persons with the
inborn-error of metabolism,
called alkaptonuria
 ABNORMAL URINE COLOR
o  Blue/ Green
•  Pathogenic that are limited to bacterial
infections
•  Includes UTI by Pseudomonas species and
intestinal tract infection
•  Ingestion of breath deodorizers (Clorets) can
result in green urine
•  Medications methocarbamol (Robaxin),
methylene blue, and amitriptyline (Elavil) may
cause blue urine
 CLARITY
o  Presence of particulate matter in unspun urine needs to be
explained microscopically.
o  Cloudy urine may not be pathologic.
o  Leukocytes – form a white cloud similar to phosphates but
cloud remains after the addition of dilute acetic acid.
Confirmed microscopically.
o  Turbidity may be due to the precipitation of crystals or non-
pathologic salts:
•  Amorphous phosphates (occasionally carbonates) in alkaline
urine but redissolve when acetic acid is added
•  Uric acid and urates in acid urine redissolve on warming to
60°C

 NON-PATHOGENIC TURBIDITY
o  Presence of squamous epithelial cells and
mucus, particularly from women patients that
can result to cloudy transparency.
o  Specimens that are allowed to stand or
refrigerated – improper preservation of
specimen
 PATHOGENIC TURBIDITY
o  Bacterial growth – causes a uniform opalescence that is not
removed by acidification or by filtering
•  Ex. E. coli, Proteus, Enterococcus, Yeast, Staphylococcus
(skin contaminant) Increased number of epithelial cells
o  Red Blood Cells (Hematuria) – does not clear on warming.
Confirm microscopically.
o  Spermatozoa and Prostatic fluid
o  Mucous from the urinary passages – increased in inflammatory
states of the lower urinary tract
o  Fecal material in urine
o  Contamination with powders or antiseptics that become opaque
with water (Ex. Phenol)
 PATHOGENIC TURBIDITY
o  Chyluria – may be normal, opalescent, milky
– Urine contains lymph associated with obstruction
to lymph flow and rupture of lymphatic vessels into renal
pelvis, ureter, bladder, or urethra
o  Lipiduria – fat globules appear in the urine
– Nephrotic syndrome and Crush injury (Major
skeletal trauma with one or more fractures to
major long bones or pelvis)
o  Both soluble in ether
URINE CLARITY/ CONSISTENCY
CLEAR No visible particulates, transparent

HAZY Few particulates, print easily seen

CLOUDY Many particulates, print blurred

TURBID Print cannot be seen through urine

MILKY May precipitate or be clotted

 ODOR
o  Freshly voided urine has
a faint aromatic odor
o  Chiefly important in the
r e c o g n i t i o n o f
contaminated specimens
and on standing are
ammoniacal, fetid so
unsuitable for laboratory
examination
o  Urine odors associated
w i t h a m i n o a c i d
disorders

 URINE VOLUME
o  Average daily volume in normal adult: 1200 –
1500 ml
•  Normal range: 600 – 2000 ml
•  Normal pregnancy – causes nocturia and the
excretion of a dilute urine
Ø Nocturia – excretion by an adult of more than
500mL urine with a high specific gravity of
1.018 at night
Ø Polyuria – increase of urine volume of more
than 2000mL within 24 hours
Ø Oliguria – a decrease in the normal daily urine
volume (excretion of less than 500 ml of urine
daily)
•  State of dehydration: vomiting, diarrhea, perspiration
or severe burns
•  Uremia, acute nephritis, kidney stones, tumors
Ø Anuria – complete suppression of urine
formation
•  May result from any serious damage to the kidneys or
from a decrease in the flow of blood to the kidneys
•  Mercury bichloride poisoning and severe acute
nephritis
 HYDROGEN ION CONCENTRATION OF
URINE (pH)
o  Reflection of the ability of the kidney to
maintain normal H+ concentration in the
plasma and ECF
o  2 BASIC METHODS:
1.  Potentiometric Determination (pH meter) –
unsuitable for routine urinary pH measurement
but should be used for quality control
HYDROGEN ION CONCENTRATION OF
URINE (pH)
2.  Indicator Paper Strips – rapid, inexpensive but
still gain useful information
•  Ex. Multistix and Chemstrip brands – make use of a
double-indicator system of Methyl red and
Bromthymol blue
•  Red → yellow (pH 4-6)
•  Yellow → blue (pH 6-9)
 HYDROGEN ION CONCENTRATION OF
URINE (pH)
o  In healthy individuals – first morning specimen (pH 5 – pH
6), after meals – a more alkaline pH (alkaline tide)
Normal random samples – pH 4.5 – 8.0

o  CLINICAL SIGNIFICANCE OF URINE pH:
1.  Respiratory of Metabolic Acidosis/ Ketosis
2.  Respiratory or Metabolic Alkalosis
3.  Defects in renal tubular secretion and reabsorption of acids
and bases – renal tubular acidosis
4.  Renal calculi formation
5.  Treatment of urinary tract infection
6.  Precipitation/ Identification of crystal
7.  Determination of unsatisfactory specimens
 SPECIFIC GRAVITY AND OSMOLALITY
o  A measure of the concentrating and diluting power of the kidney
o  Inability to concentrate and dilute urine is an indication of renal
disease or hormonal deficiency
o  Measurement of both tests should give an indication of the urinary
total solute concentration
o  An additional function, which is to determine whether specimen
concentration is adequate to ensure accuracy of the chemical test
o  Normal random specimens may range from 1.002 to 1.035 depending
on the patient’s amount of hydration
o  Specimens measuring below 1.002 probably are not urine
o  Most random specimens fall between 1.015 and 1.030
 SPECIFIC GRAVITY AND OSMOLALITY
o  Osmolality – depends on the number of solutes in a unit of solution.
•  It is a more exact measurement of urine concentration than specific
gravity
o  Specific gravity – depends on the number of particles present in a solution
and the density of these particles.
•  It is influenced by the size of the molecules such as urea, glucose, and
protein that are not significant in renal concentration.
o  Hyposthenuric urine – urines of low specific gravity (less than 1.010)
o  Isothenuric urine – urine of fixed specific gravity
o  Hypersthenuric urine – urines of high specific gravity (more than 1.010)
o  The specific gravity of the protein-free glomerular filtrate is 1.010
o  Freezing Point Depression Method – commonly employed method for
osmolality determination


 METHODS OF SPECIFIC GRAVITY
MEASUREMENT
A.  Refractometer (TS meter)
•  Determine concentration
•  Measures the refractive index of a solution
•  Advantages:
1.  Temperature compensated between 60°F to 100°F
2.  Requires only 1 drop of urine
•  Calibration:
1.  Distilled water – 1.000
2.  5% NaCl – 1.022 ± .001
3.  9% Sucrose – 1.034 ± .001

 METHODS OF SPECIFIC GRAVITY
MEASUREMENT
B.  Urinometer – a hydrometer
adapted to measure specific
gravity at room temperature
•  Consist of a weighed float with
a calibrated stem
•  The float displaces a volume of
liquid equal to its weight and
has been designed to sink to a
level of 1.000 in distilled water.
•  The additional mass provided
by the dissolved substance
causes the float to displace a
volume of urine smaller than
that of distilled water.
•  Requires a larger volume of
urine
 SOURCES OF ERROR
1.  Temperature differences – most urinometers are
calibrated at 20°C. A difference of 3°C between urine
temperature and calibration temperature requires a
correction of 0.001 to be added if above and
subtracted if below the proper temperature.
2.  Proteinuria – subtract 0.003 for every 1g/100ml
3.  Glycosuria – subtract 0.004 for every 1g/100ml
4.  X-ray contrast media – specific gravity may exceed
1.050
5.  Urinary preservative – preservatives increase the
urinary specific gravity

 METHODS OF SPECIFIC GRAVITY
MEASUREMENT
C.  Reagent Strip Method
* based on the change in pKa (dissociation
constant) of a polyelectrolyte in an alkaline
medium
•  The polyelectrolyte ionizes releasing Hydrogen ions
in proportion to the number of ions in the solution.
•  The higher the concentration of urine, the more
Hydrogen ions are released, thereby lowering the
pH.
•  Indicator Bromthymol blue measures the change in
pH.
 METHODS OF SPECIFIC GRAVITY
MEASUREMENT
D.  Harmonic Oscillation Densitometry
Principle:
•  The frequency of a sound wave entering a solution
will change in proportion to the density of the
solution
•  Used by the Yellow IRIS (International Remote
Imaging Systems)
•  A portion of urine enters a U-shaped tube. A sound
wave of specific frequency is generated at one end
of the tube, and as the sound wave passes through
the urine, its frequency is altered by the density of
the solution.
 METHODS OF SPECIFIC GRAVITY
MEASUREMENT
E.  Falling Drop Method
•  A direct method for measuring specific gravity
•  More accurate than the refractometer and more
precise than the urinometer
•  Utilizes a specially designed column filled with water
– immiscible oil. A measured drop of urine is
introduced into the column, and as the drop falls, it
encounters two beams of light; breaking the first
beam starts the timer, while breaking the second
turns it off. The falling time is measured
electronically and expressed as a specific gravity.