Microscopic Urine Examination

Genesis G. Gamurot, AHI(AMT), RMT, MLS(ASCPi)CM

Preparation and Examination of Urine
Sediment
 Specimen volume
 Usually between 10-15 mL
 12 mL is frequently used

 Centrifugation
 400 RCF for 5 minutes
 Vol. of sediment after decantation = 0.5-1.0 mL
 Vol. of sediment examined = 20 uL
 Reporting:
 RBC/WBC, RTE Cells & Oval fat bodies = Ave. No. /10 HPF
 Casts = Ave. No. /10 LPF
 Epithelial cells, crystals and others = 0/1+/2+/3+/4+ or neg, rare, few,
moderate, many

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Techniques for Microscopy

Bright field microscope

 Object appears dark in

light background

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Techniques for Microscopy
Phase-Contrast
Microscope

 Works by retardation of
light rays diffused by the
object in focus, a halo
effect is produced around
the element, thereby
producing better image
reinforcement

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Techniques for Microscopy

Polarizing Microscope

 Aids in identification of
crystals & lipids

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Techniques for Microscopy

Interference Contrast

 Provides three-
dimensional image
showing very fine
structural detail by
splitting the light ray so
that the beams pass
through different areas of
the specimen

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Techniques for Microscopy

Dark Field Microscope

 Aids in identification of
T. pallidum

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Techniques for Microscopy

Fluorescence Microscope

 Allows visualization of
naturally fluorescent
microorganisms or those
stained by fluorescent dye

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Microscopic Sediment Stains
Stain Action Function

Sternheimer-Malbin Delineates structures and dconsists of crystal violet and

contrasting colors of the nucleus safranin O. used to identify WBCs,
and cytoplasm epi. Cells and casts
Toluidine blue Enhances nuclear stain – differentiates WBCs and RTE
cells
Lipid stains: Stains triglycerides and neutral fats identifies free fat droplets and lipid
Oil Red O (ORO) & Sudan III ORANGE RED containing cells and casts

Gram stain Differentiates gram (-) & (+) – identifies bacterial casts
bactaria
Hansel stain Stains eosinophilic granules contains methylene blue and eosin
Y in methanol, identifies urinary
eosinophils in drug-induced
interstitial nephritis
Prussian blue Stains structures containing iron – identifies yellow brown granules
of hemosiderin in cells and casts
- Presence of hemosiderin
indicates intravascular hemolysis

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Sternheimer-Malbin Stain

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Toluidine Blue stain

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Lipid Stain

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Gram Stain

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Hansel Stain

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Prussian Blue Stain

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Classification of Urinary Sediment
 Organized Urine Sediments

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I. RBCs
 colorless disks without nucleus, 7 microns in
diameter
 frequently confused with yeast cells, air bubbles,
calcium oxalate and oil droplets
 NV: 0-2/HPF
 Clinical significance:
 glomerular membrane damage
(glomerulonephritis)
 vascular injury within the genitourinary tract
 renal calculi

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II. WBCs/Pus Cells
 Appear as granular spheres, about 12 microns in
diameter, usually neutrophils
 Usually distinguished from RBC by the addition of 2-%10%
HAc
 NV: 0-5/HPF
 Clinical significance:
 Bacterial infection (pyelonephritis, cystitis, prostitis,
urethritis)
 Non bacterial (glomerulonephritis, SLE, interstitial nephritis,
tumors)

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II. WBCs/Pus Cells
 Glitter cells
 pale blue leukocytes exhibiting “Brownian movement” in their
cytoplasm usually producing a “sparkling appearance”; in dilute or
hypotonic urine

 Eosinophils
 associated with drug induced interstitial nephritis (UTI and renal
transplant)

 Mononuclear cells
 indicates inflammatory process or renal transplantation rejection

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Glitter Cells

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III. Epithelial Cells
 Squamous Cells
 Most frequently seen and least significant of epithelial cells
 Derived from vaginal lining and lower portions of male and
female urethra

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Squamous Cell

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Clue Cells

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Oval Fat Bodies

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Bubble Cells
 RTE cells containing large, non-lipid filled vacuoles

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III. Epithelial Cells
 Transitional Epithelial Cells/Urothelial/Caudate
 Originate from lining of renal pelvis, bladder, upper urethra
 Increase of transitional cell in singly, pairs, clump (syncytia) –
present if invasive urologic procedures such as catheterization
and no clinical significance
 increase of transitional cells in abnormal morphology
(vacuoles/irregular nuclei) – malignancy or viral infection

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III. Epithelial Cells
 Renal Tubular Epithelial Cells (RTECs)
 Usually round slightly larger than WBC, with single round
eccentrically located nucleus
 Clinical Significance:
 tubular damage
 Pyelonephritis
 toxic reactions
 viral infections
 allograft rejection
 secondary effects of glomerulonephritis

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Renal Tubular Epithelial Cells

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IV. Casts
 Formed primarily within the “Lumen of DCT and
Collecting duct
 Cylindrical with parallel slides an rounded ends
 Gels (forms) during urine flow stasis, acidity and presence of
sodium and calcium

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Formation of Urinary Casts
 cellular cast – granular:coarsely – finely – waxy (final
degenerative form

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IV. Casts
 Types of Casts
 Hyaline Cast
 NV: 0-2/LPF
 colorless, homogenous and has same refractive index as urine ; most
difficult to detect under microscope
 Clinical Significance:
 non-pathogenic: strenuous exercise, dehydration, heat exposure, emotional
stress
 pathogenic: acute glomerulonephritis, pyelonephritis, chronic renal disease,
congestive heart failure

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Hyaline Casts
 Hyaline casts are formed in
the absence of cells in the
renal tubular lumen.
 Have a smooth texture and a
refractive index very close to
that of the surrounding fluid
 Hyaline casts are not always
indicative of clinically
significant disease
 Greater numbers of hyaline
casts may be seen associated
with proteinuria of renal (eg.,
glomerular disease) or extra-
renal (eg., overflow proteinuria
as in myeloma) origin

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IV. Casts
 Types of Casts
 RBC Casts
 Indicates hemorrhage in the renal tubules – “active acute nephritis
 Indicative of “serious renal disease”

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IV. Casts
 Types of Casts
 WBC Casts
 Presence signifies “infection and inflammation” within the nephron
 White blood cell casts are most typical for acute pyelonephritis, but
they may also be present with glomerulonephritis. Their presence
indicates inflammation of the kidney, because such casts will not form
except in the kidney

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IV. Casts
 Types of Casts
 Granular Casts
 Usually seen accompanying hyaline casts following periods of stress
and strenuous exercise
 Fine or coarse granular casts may be considered:
 pathologic or non-pathologic

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IV. Casts
 Types of Casts
 Epithelial Cell Casts
 Observed in conjunction with RBC and WBC cast in
glomerulonephritis and pyelonephritis

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IV. Casts
 Types of Casts
 Waxy Casts
 Refractile with rigid texture, which causes them to be fragmented as
they pass through the tubules
 Waxy casts have a smooth consistency but are more refractile and
therefore easier to see compared to hyaline casts.
 Waxy casts are found especially in chronic renal diseases, and are
associated with chronic renal failure; they occur in diabetic
nephropathy, malignant hypertension and glomerulonephritis

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Waxy Casts

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IV. Casts
 Types of Casts
 Fatty Casts
 Seen in conjunction with Oval Fat Bodies in disorders causing
“lipiduria” such as Nephrotic Syndrome
 Fatty casts are identified by the presence of refractile lipid droplets

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Fatty Casts

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IV. Casts
 Types of Casts
 Broad Cast
 All types of cast may be broad – common are granular and waxy
 Much larger than other casts
 Indicates “Grave Prognosis”

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V. Mucus Threads
 Protein constituent produced by glands and epithelial
cells in GUT and RTE cells
 Not clinically significant

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VI. Bacteria
 Not normally present in urine especially if freshly voided
 Presence is indicative of lower or upper UTI
 Usually Enterics, Staphylococcus

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VII. Yeast Cells
 Easily confused with RBCs, observed with budding forms
 Clinical significance
 DM,
 Vaginal monoliasis
 Immunocompromised patients

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VIII. Parasites
 T. vaginalis
 S. haematobium
 E. granulosus
 W. bancrofti

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IX. Spermatozoa
 Found in urine after sexual intercourse, nocturnal
emissions or masturbation
 (+) CHON reagent strip in increase amount of semen

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X. Artifacts

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X. Artifacts

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 Unorganized Urine Sediments

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I. Crystals
 Formed by the precipitation of urine solutes such as:
 Inorganic salts
 Organic compounds
 medications
 Reported as
 Rare/HPF
 Few/HPF
 Moderate/HPF
 Many/HPF
 Abnormal crystals may be averaged and reported per LPF

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I. Crystals
 Normal Crystals in Acidic Urine
 Amorphous urates
 Also seen in neutral specimen
 Macroscopic pink color upon refrigeration
 Microscopic brick red or yellow brown in color

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I. Crystals
 Normal Crystals in Acidic
Urine
 Uric acid
 Associated with “gout
arthritis”, “Lesch-Nyhan
Syndrome” and Leukemia
patient receiving
chemotherapy
 Occur at a very low pH of 5-
5.5

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I. Crystals
 Normal Crystals in Acidic Urine
 Sodium urates
 Slender prisms usually colorless or sometimes yellow; arranged in fan
or sheaf-like structures

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I. Crystals
 Normal Crystals in Acidic Urine
 Calcium sulfates
 Elongated prismatic table/ cigarette-butt looking / star-like looking
crystals

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I. Crystals
 Normal Crystals in Acidic Urine
 Calcium oxalate
 Mostly appear as envelope or dumbbell shape or ovoid
 Derived from various food notably spinach, rhubarb, berries and
tomatoes
 Also seen in Neutral / Slight Alkaline Urine

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I. Crystals
 Normal Crystals in Acidic Urine
 Hippuric Acid
 May also be seen in Neutral/ Sl. Alkaline Urine
 Colorless prisms or plates often conglomerated into masses
 Soluble in HAc

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I. Crystals
 Normal Crystals in Alkaline Urine
 Amorphous phosphate
 Dissolved by HAc but not by heat
 Granular, similar to amorphous urates
 Macroscopic white turbidity

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I. Crystals
 Normal Crystals in Alkaline Urine
 Calcium carbonate
 Also seen in neutral urine
 Colorless granules larger than amorphous phosphates

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I. Crystals
 Normal Crystals in Alkaline Urine
 Ammonium biurate
 Converts to uric acid crystal when glacial acetic acid is added
 Dissolved with HAc and heat (60C)

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I. Crystals
 Normal Crystals in Alkaline Urine
 Calcium phosphate
 Colorless, flat rectangular plates on thin prisms often in rosette
formation

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I. Crystals
 Normal Crystals in Alkaline Urine
 Triple phosphate
 Seen in highly alkaline urine associated with presence of urea-splitting
bacteria
 Common shapes: colorless, 3 to 6 sided prisms with oblique ends
(coffin lid crystals)
 Less often: flat fern leaf form, sheets and flakes

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I. Crystals
 Abnormal Crystals in Acidic Urine
 Cystine
 Hexagonal plates, colorless, highly refractile and thick/thin
 Often mistaken with uric acid but dissolves in dilute HCl
(uric acid does not)

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I. Crystals
 Abnormal Crystals in Acidic Urine
 Cholesterol crystal
 Large flat plates with one or more corners cut-off; notched plates

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I. Crystals
 Abnormal Crystals in Acidic Urine
 Leucine crystals
 Yellow or brown spheres resembling fat globules with delicate radiating
and concentric striations

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I. Crystals
 Abnormal Crystals in Acidic Urine
 Tyrosine
 Colorless fine needles grouped in clusters (may appear black in the
center), rosettes or sheaves crossing at various angles

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I. Crystals
 Abnormal Crystals in Acidic Urine
 Bilirubin crystals
 Yellow-rhombic/ruby red crystals/clumped needles or granules with
characteristic yellow

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I. Crystals
 Abnormal Crystals in Acidic Urine
 Sulfonamide crystals
 Cause of formation: inadequate patient hydration; green color, soluble in
acetone
 Less encountered: needles, rhombic, whetstones, sheaves of wheat,
rosettes with colors ranging from colorless to yellow brown
 Clin sig: tubular damage

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I. Crystals
 Abnormal Crystals in Acidic Urine
 Ampicillin crystals
 Appear as colorless needles that tent to form bundles following
refrigeration

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I. Crystals
 Abnormal Crystals in Acidic Urine
 Radiographic dye
 Similar to cholesterol crystal and highly birefringent
 Dissolved in 10% KOH

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Urine Crystals

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Urine Crystals

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Urine Crystals

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End of Presentation

“You can’t expect to have

A deep relationship
With a shallow person.”

~Sir G.

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