Urine Examination

Indication
• As part of physical examination.
• Associated diagnostic test in
DM,Jaundice,Derangment of metabolism
• Cultural studies done in enteric fever, and
urinary tract infection
• Helpful in detecting anatomical and functional
abnormalities of kidney and urinary tract.
 Collection
• Midstream
• Rubber catheter
• Indwelling catheter
• Urinary bag
• S/P Puncture
• Cystoscopy
• Ureteric catheter
 Time of collection
• Morning 1st sample is best, must be fresh and should
examine immediately.
• Specimen preservative:
– Boric acid 0.5g/60ml
– 2-4 drops of formaldehyde/30 ml
– Thymol 0.1g/100ml
In Refrigrator
Special preservative: Concentrated HcL for calcium,nitrogen
and bacteriological examination
For Quntitative examination 24 hr sample required.
Bacteriological examination
a)For tubercle bacilli,24 hr sample without
preservative
b)For other organism,in sterile test tube.
c)For pregnancy test midstream sample with prior
instruction to stop drugs.
d)For detection of glycosuria Post prandial
urine,collected after 2hr of lunch
 Routine examination

• Physical Ex
• Chemical Ex
• Microscopic Ex
 Physical Examination
• Total Volume
• Specific Gravity
• Colour
• Odour
• Appearance
 Chemical Examination
• Reaction
• Tests for Protein
• Tests for sugar
• Biles salts,Bile pigments
• Ketone Bodies.
 Microscopic examination
• Cells
• Casts
• Crystals
• Parasites
 Physical Ex: Total volume
• Normal volume 1200-1500ml/day
• Range is from 600-2000ml/24 hr
• More in night,,Also depend on fluid
intake,diet(High protein diet act as diuretics),
Exercise,Environmental temp,Humidity,Body
weight, age etc.
• Children & infants excrete 3-4 times more
urine for their body weight.
• Polyuria : >2500ml/ 24hr
– DM,
– DI,
– early stage of chronic nephritis.
• Oliguria : <600ml /24hr
– Acute & Chronic glomerulonephritis,
– Shock,
– Fever,
– CCF,
– Dehydration from any cause.
• Anuria : <100ml/ 24hr,,
--Supression of urine formation inspite of fluid
intake
– Acute GN, Terminal stage of chronic renal dz,
Crush injury, Mismatched blood transfusion
 Physical Ex : Specific Gravity
• Def : At a constant temp ratio of weight of
volume of urine to the weight of same volume
of distilled water.
• Depends on No of particle & it’s weight in
urine. It reflects concentrating & diluting
power of kidney, Varies with fluid intake.
• Sp gravity α Conc of dissolved solute
volume

• Normal range : for random 1.003-1.035

Urinometer
• Higher(Hypersthenuria)
– Dehydration,Eclampsia,Proteinuria,Lipoid
nephrosis,DM
• Lower(Hyposthenuria) <1.007 constantly
– Kidney dz with concentration problem,
Pyelonephritis, Protein malnutrition, DI,
Hypertension,Diuretics medicine, Alcohol, coffee
• Fixed(Isosthenuria) 1.010 at any sample
indicate poor tubular reabsorption,seen in
chronic glomerulonephritis.
• Correction is needed if temp variation,
Albuminuria, and in case of dilution.
• Urinometer calibrated for 25°c temp,add .001
in recorded sp gravity for every 3°c above it,&
subtract .001 for every 3°c below it.
• Urine in small quantity diluted 1:5 or1:10
multiply last two digits of sp gravity by dilution
factor.
• Each gram of albumin for 100 ml of urine
incresed sp gravity by 0.003
 Physical Ex : colour
• Normally pale yellow, due to urinary pigments
urochrome,urobilinogen,uroerythrin,uroporphyrin
• Concentrated :dark yellow to amber colour
– Fever,Dehydration.
• Red/Brown :Blood, Heamoglobin, rhubarb,
phenolphthalin.
• Hematuria- blood(rbc) in urine.. Haemoglobinuria-
haemoglobin in urine
• Yellow/Yellowish green : Bile
pigments(jaundice),carotene,actiflavin,vitB12,
santonin.
• Portwine : Porphyrine
• Black on standing : Homogentisic acid,
melanine
• Blue : Methylene blue, Thymol
 Physical Ex : Appearance
• Normally : Clear
• Cloudy : Amorhous phosphates in alkaline,
amorphous urates in acidic.
• Cloudy & Turbid :Leucocyte,Epithelial cells
Bacterias.
• Milky : Fat,chyle…..
chyluria- chyle in urine(fat droplets)
• Hazy : Mucus,spermatozoa.
• Turbid & Smoky : Red cells.
 Physical Ex : Odour
• Normal : urinoid (Due to volatile aromatic
acids)
• Abnormalities:
• Fruity :Ketone bodies,DKA
• Pungent/Ammonical :Presence of Bacteria
Cystitis when urine get decomposed in urinary
bladder
• Musty : In infant with phenylketonuria.
 Chemical Ex : Reaction
• Normal urine slightly acidic :4.6-7.0
• Tested by litmus paper
• No diagnostic significance,certain calculi,
microorganism prone at certain PH.
• Acidic urine : Respiratory acidosis,uremia,
diabetic ketosis,starvation,severe diarrhea
– E coli infection more prone.
• Alkaline urine : Respiraotry alkalosis, excessive
vomitting,
– Pseudomonas,proteus infection more prone
 Chemical Ex : Tests for Protein
• Normally <150 mg protein/24 hr not detected
by chemical method
• Test principle is precipitation of protein by
chemical agent or coagulation by heat
•
• 1)Heat and acetic acid test:
• The proteins are precipitated when boiled in an acid
solution.
• If the urine is not clear, centrifuge and use the clear
supernatant
• Take urine up to 2/3 of TT,,boil upper portion, see for
precipitation. Add 1-3 drops of 10% acetic acid and
boil again to differentiate between phosphate and
protein,, Phosphate precipitation will disappear
• The result is recorded as from trace and then
one to four plus(+,++,+++,++++) depending
upon the amount of precipitate.
2)Sulphosalicylic acid test :
Mix equal volume of urine + 5% sulphosalicylic acid in
TT,,see for cloudiness,
Result : grade +,++,+++etc
• 3)Test for Bence-Jones proteins :
• 10ml of fresh clear urine + 2ml of saturated sodium
chloride solution to prevent precipitation of mucin +
3% acetic acid drop by drop to make slightly acidic
PH,, heat urine in water bath controlling the temp,,
if urine become cloudy between 40-50°c, on raising
temp up to 100°c precipitate dissolves completely
and reappears on cooling
• Test is positive in multiple myeloma
– More sensitive method is Electrophoresis.
 Causes of proteinuria(Albuminuria)
• Pre renal :Postural,CCF,Cerebral injury,
Fever,Severe infection.
• Renal:Glomerulonephritis,Nephrosclerosis
Diabetic glomerulosclerosis, Nephrotic
syndrome, pyelonephritis.
• Post renal :Inflammation of kidney,ureter,
bladder.
 Chemical Ex : Tests for sugar
• Normally 2-20mg/dl in fasting urine ,not
detected by chemical method
• Test principle is cupric ions reduced to
cuprous form in presence of sugar in urine,
other reducing substance also can do when
heated.
• Benedict’s test(qualitative):
• Method :Take 5ml of benedict’s reagent+ 8
drops of urine,,boil for 2 mins. Examine after
cooling,see for coloured precipitation.
• positive in presence of sugar and other
reducing substance
colour conclusion Approximate
glucose mg/dl
Blue Sugar: Absent ______

Green ppt Sugar:Present, 250-500

Trace
yellow ppt Sugar:Present 500-750
+ to ++ 500-1000
orange ppt Sugar:Present 1000-1500
+++
Brick red ppt Sugar:Present >1500
++++
Next is to differentiate between sugar & other
reducing substance.
1. Fermentation test with yeast: +ve in glucose &
fructose.
2. Osazone test: +ve in glucose,lactose, pentose
3. Modified Benedict’s test: (Heating the mixture at
25°C)
If all this tests are negative reduction is due to other
substance.
 Reducing substances:
Homogentisicacid,creatinine,uricacid, formaline,
choloroform, drugs like
morphine,aspirine,PAS, penicilline,
methanol,phenol,ascorbic acid…..
--Using enzyme glucose oxidase, it is possible to
indentify glucose specifically
• Normal renal threshold is 150-170mg/dl if glucose
exceeds this can not be reabsorbed by tubules.
• Glycosuria :
• Causes : DM, Hyperthyroidism, Hyperadrenalism,
Hyperpitutarism.
Other :MI,cerebral heamorrage,Brain tumor,
Severe liver disease,disease of pancreas
• Renal glycosuria : Heavy metal poisoning,
fanconi syndrome, Acute renal failure
• Alimentary glycosuria : High carbohydrate
diet, after partial gastrectomy
• Transitory Hyperglycemia : Pregnancy, Stress
& anxiety
 Chemical Ex : Tests for Ketones
• Mostly present when inadequate carbohydrate
diet or defect in metabolism
• Acetone(2-4%),Acetoacetic acid(18-20%), B-
hydroxy-butaric acid(76-78%)
• Causes of Ketonuria : In patient of DM,When
change in insuline dosage, GI
disturbances,Acute infection, Stress, Surgery
Other causes :
Anorexia,Fasting,Starvation,Fever,Prolonged
vomitting
• Rothera’s Test : (Acetone, Aceto-acitic acid)
3ml of urine + 1gm of ammonium sulphate to
saturate + 3 drops of freshly prepared sodium
nitroprusside solution + Liquor ammonia
solution from side of TT,,
If ring at the juction is permangenate in colour,
test is positive.
• Gerhardt’s test : (Aceto-acitic acid)
10 ml fresh urine +few drop of 10% ferric
chloride drop by drop till ppt formed,,filter it
and again add more ferric chloride drop by
drop..If violet colour developes test positive.
To exclude other substance like
phenol,salicylates etc perform test after
boiling volatile acetoacitic acid
Chemical Ex : Bile salts & Bilepigments
• Hay’s sulphur flower test for bile salts : 5ml urine +
Sprinkle sulphur flower on surface,,if bile salts
present,particles sink to the bottom because bile
salts lower the surface tension.
 Tests for bile pigment
• Harrison fouchet’s test : 10ml of urine in TT +
5ml of barium chloride (10%aqueous)
solution, filter with whatman’s paper + add 1-
2 drops of Fouchet’s reagent(25g
trichloracetic acid,100ml water,10 ml 10%
ferric chloride sol) if green or blue colour test
is positive because of oxidation of bilirubin to
biliverdin.
 Gmelin’s test

• 3ml of concentrated nitric acid +equal volume

of urine, shake tube side by side, and note
colour changes.
• If bile pigments are present,there is a play of
colours; yellow, red, violet, blue and green.
• Pre hepatic Causes : Sickle cell disease,
Thalassemia major, Aquired Hemolytic
anemia, Incompatible Blood transfusion.
• Hepatic causes : Hepatitis, Cirrhosis, Injury to
paranchymal cells, chemical intoxication, Drug
reaction
• Post hepatic causes : Gall stones, Carcinoma,
Pancreatitis, Obstruction of duct due to lymph
nodes.
Clinical Bile Bile salts Urobilinoge
condition pigment n

Pre hepatic Abst Abst Very high

Hepatic Prst, Prst Incresed ++

trace to +
+++

Post hepatic Prst,++ Prst Abst or Prst

to ++++
• The reagent tablets or paper strips are now
commercially available for detection of
pathological substances in the urine.
• Tests with them are as reliable as those with
conventaional reagents and they are so much
easier to perform; a tablet is to be added to
the urine or a paper strip dipped.
 Microscoic Ex :
• Method : 15 ml urine,spin at 2000 rpm for 10
mins,sediments suspended in 1-2 drops of
urine,drop on slide and cover with coverslip.
Illumination is adjusted by cutting off the iris
diaphragm
 Microscopy
• 1) Cells
• 2)Cast
• 3)Crystals
• 4)Parasites.
 Microcsopic Ex. : 1) pus cells
2) Epithelial cells
3) RBCS
• 1) Pus cells(Leucocyte) :
Normal 2-5/Hpf,
if >5/hpf significant
Mostly neutrophils.
Causes :
pyuria,Urinary tract Infection , Non Infectious condition
Acute glomerulonephritis, fever, Noninfectious irritation of
ureter,urethra
• 2) Epithelial cells :
Normally 2-3/hpf in male
2-5/hpf in female
>5/hpf significant
Normally 3 types of cells found
Tubular,Transitional,Squamous.
Causes :Pyelonephritis,Acute
tubular necrosis,Salicylate
intoxication,Transplant
rejection.
 3) Red blood cells
Normally Absent.
When present more in no is
significant
Causes :
Traumatic injury, Stone,
Neoplastic lesion, Tubular
damage, Severe pyogenic
infection
 Microscopic Ex : Casts & crystals

• Casts :Formed in • Crystals : significance

tubules,basic matrix is Found in calculus formation,
mucoprotein Tamm-horsfall metabolicdisorders,
protein. medication regulation.
• Hyaline cast • In Acidic urine :Uricacid, cal
• Granular cast oxalate,sodium urate,
• Red cell cast cystine,tyrosine,leucine,
• White cell cast cholesterol,cal sulphate,
sulfa crystal,amorphous
• Epithelial cell cast urate.
• Waxy cast • In Alkaline urine :Triple
• Fatty cast phosphate,cal phosphate
• Cylindroides calcarbonate,ammonium
biurates,amophous
phosphate
• Hyaline cast :
Colourless,transperant,
• homogenous
After physical excersise,
Anesthesia,Dehydration,Mild
renal dz,glomerulonephritis,
nephrosclerosis.
• Cylindroides : in organisation resembles
hyaline cast, Longer than cast,taperring
end,Same significance.
• Granular cast :Granular
material derived from
degenarated epithelial cells
caught in hyaline matrix
Significant renal dz, chronic
glomerulo nephritis.
• Epithelial cast
epithelial cell
desquamated from
tubular lining.
Acute glomerulonephritis,
Infection of kidney,
nephrotoxic agent.
• Red cell cast :RBCs in
protein matrix
Always pathogenic
Acute glomerulonephritis,
severe pyelonephritis, Renal
infarction, Sub acute
bacterial endocarditis.
• White cell cast :Majority
are neutrophil tightly
packed togather.
Renal infection,noninfectious
inflammation,Glomerular
dz, Acute
pyelonephritis,interstitial
nephritis.
• Waxy cast : Homogenous
refractile, dull gray
apperance
Produce by degenerative
changes in epithelium.
Chronic nephritis, Nephrotic
syndrome, pt with anuria,
malignant hypertension,
tubular inflammtion.
• Fatty cast :Free fat
droplets or oval fat
bodies in matrix
material
Fatty degeneration of
tubular
epithelium,nephrotic
syndrome,toxic renal
poisoning.
 Microscopic Ex : Casts & crystals

• Casts :Formed in • Crystals : significance

tubules,basic matrix is Found in calculus formation,
mucoprotein Tamm-horsfall metabolicdisorders,
protein. medication regulation.
• Hyaline cast • In Acidic urine :Uricacid, cal
• Granular cast oxalate,sodium urate,
• Red cell cast cystine,tyrosine,leucine,
• White cell cast cholesterol,cal sulphate,
sulfa crystal,amorphous
• Epithelial cell cast urate.
• Waxy cast • In Alkaline urine :Triple
• Fatty cast phosphate,cal phosphate
• Cylindroides calcarbonate,ammonium
biurates,amophous
phosphate
• Uric acid crystal :
Normally may be present
Gout,ch nephritis,Ac febrile
condition
Shape-Rhombic,Diamond,
Rosette.
Colour-yellow,red brown
 Cal oxalate :

Normally may be present

Derived from various
drugs,foods vitc,spinach
etc,indicate renal calculi
Shape-envelop,Dumbell,
oval,Biconcave.
Colour-colourless.
Cystine :
• congenital cystinosis, cong
cystinuria, calculi
Shape- Refractile hexagonal
plate
Colour- colourless
 Tyrosine :
• Tyrosinosis,
Severe liver dz.
Shape- Refractile needles
in clusters or sheaves
Colour- colourless
Leucine
Severe nephritis , Ac yellow
atrohpy, Maple syrup urine
dz.
Shape- Speroides with radial,
concentric striations.
Colour- yellow or brown
 Cholesterol
• Nephritis, Nephrotic
syndrome,
chyluria,tissue
breakdown
Shape-Large flat plate,
notched corners
Colour- Transperant
• Amorphous urates :
Nonsignificant
Shape- Noncrystalline,
amorphous
Colour-yellow-red granules
• Sodium urate : Nonsignificant
Shape-Amorphous or needles like
crystals.
Colour- colourless to yellowish
• Cal sulphate : Nonsignificant
Shape-Needles or prisms
Colour- colourless
 Sulfa crystals
• sulfa drug
precipitation,In
kidney dz.
Shape-sheaves of
needles
Colour-Clear or brown
• Triple Phosphate :
Normally present may be present
Chronic cystitis,Chronic
pyelitis,Calculi,Enlarged prostate
Shape-prisms,hexagonal
Colour-colourless
• Amorphous Phosphate :
Nonsignificant
Same as phosphate crystals
Shape-amophous granular
form
Colour –
yellowish,brownish.
• Ammonium Biurates :
Significant if found in fresh
urine
Shape-sphericle bodies with
or without spicules
Colour-yellow brown
• Cal Phosphate : Normally may
be present,calculi
Shape-prism,rosettes,needles etc.
Colour-colour less

• Cal carbonate :Nonsignificant

Shape-sphericle, dumbell, granules
Colour-colourless
• Parasite :
Trichomonas vaginalis,
Trichomonas
hominis,schistosoma
heamatobium,Microfilaria

Shape-pear shape
Colour- colourless to greyish,
moving.
• Candida/Yeast :
Nonsignificant,In pt of DM
Shape-ovoid,Branching,
budding
Colour-colourless
• Bacteria :
Contamination,presence
of puscells s/o infection
Shape-Bacilli or cocci
colour-colourless
THE END