U R I N A LYS I S
U R I N A LYS I S
URINALYSIS
●
A simple test of the urine
●
Used to detect and manage a wide range of disorders, such as urinary
tract infections, kidney diseases and diabetes.
U R I N A LYS I S
T Y P E S O F U R I N A LY S I S
●
DIPSTICK
Reagent urinalysis
●
ROUTINE urinalysis
Adds a microscopic examination of urine sediments to the
reagent strip
U R I N A LYS I S
B A S I C U R I N A LY S I S ǀ C O M P O N E N T S
●
Gross/Physical Examination
●
Chemical Examination
●
Microscopic Examination
U R I N A LYS I S
GROSS/PHYSICAL EXAMINATION
U R I N A LYS I S
COLOR
NORMAL: Yellow color
● Due to pigment urochrome
● Urobilins and uroerythrin (pink pigment) also contribute to urine color
● Color is a rough indicator for hydration and urine concentration
●
U R I N A LYS I S
CLARITY (CHARACTER)
NORMAL: Clear
● TURBID
Precipitation of crystals or nonpathogenic salts, and cellular elements:
■ Alkaline urine: phosphate, ammonium urate, carbonate
■ Acidic urine: uric acid and urates
■ Leukocytes
■ RBC
■ Epithelial cells
■ Others: ( mucus, blood clots, menstrual discharge, fecal material)
●
U R I N A LYS I S
●
NORMAL:
Faint, aromatic odor due to volatile fatty acid
ODOR
U R I N A LYS I S
●
Determined by water intake
●
Average ADULT: 600 - 2000 mL per day
●
Night urine: < 400 mL
●
Average CHILDREN: 1 - 2 mL/kg/hour
URINE VOLUME
U R I N A LYS I S
●
SP ECIFIC GR AV ITY
The ratio of the weight of a given volume of the solution (urine) to the
weight of an equal volume of water
●
Physically determined by refractometry
●
NORMAL (over 24-hour period): 1.016 - 1.022
●
Indicator of hydration status of patient
U R I N A LYS I S
CONDITION
OSMOLALITY
OSMOLALITY
mOsm/kg water
Normal
500 – 850
Dehydration
800 – 1400
Diuresis
40 – 80
U R I N A LYS I S
B A S I C U R I N A LY S I S ǀ C O M P O N E N T S
C H E M I C A L E X A M I N AT I O N
U R I N A LYS I S
USE OF REAGENT STRIPS
U R I N A LYS I S
URINE pH
Measures the acidity or alkalinity of the urine
● Strip contains a mixed indicator which assures a marked change in color
between pH 5 & pH 8.5
● Kidneys and lungs work in concert to maintain acid-base balance
● NORMAL URINE pH: 4.6 – 8
●
5.0
pH
60s
6.0
6.5
7.0
7.5
8.0
8.5
U R I N A LYS I S
PROTEIN
NORMAL: Negative
● Change in color from yellow to green is based on the level of protein
● 150 mg protein excreted in urine daily, average: 2 to 10 mg/dL
● It detects primarily albuminuria and are less sensitive for other forms of
proteinuria (e.g. low molecular weight protein, Bence Jones
protein, gamma globulin)
●
Neg.
Protein
60s
Trace
±
0.3
+
1.0
++
3.0
+++
≥20.0
++++
g/L
U R I N A LYS I S
PROTEIN
FALSE NEGATIVE RESULTS
● Dilute urine = Specific gravity < 1.005 or large volume of urine output
● Disease states in which the predominant protein is not albumin
FALSE POSITIVE RESULTS
● High urinary pH > 7.0
● Highly concentrated urine
● Contamination of urine with blood
● Contamination with antiseptic agents (chlorhexidine, benzalkonium
chloride, hydrogen peroxide)
U R I N A LYS I S
P R O T E I N | D I P S T I C K R E S U LT S
NORMAL: Negative
RESULT
Trace
1+
2+
3+
4+
VALUE
10 - 29 mg/dl
30 - 100 mg/dl
100 - 300 mg/dl
300 - 1000 mg/dl
>1000 mg/dl
INTERPRETATION: Significant if:
> trace (10-29 mg/dl) with sp.gr.< 1.010
1+ or greater with sp.gr.> 1.015
U R I N A LYS I S
●
GLUCOSE
NORMAL: Negative
GLUCOSURIA
Presence of glucose in urine
● Occurs when blood glucose level surpasses the renal tubule capacity for
reabsorption
● Blood glucose >180-200 mg/dL
●
Glucose
30s
Neg.
5
Trace
15
+
30
++
60
+++
110
++++
mmol/L
U R I N A LYS I S
GLUCOSE
FALSE POSITIVE
● Strong oxidizing cleaning agent (i.e. bleach) in urine container
● Low specific gravity
● Hydrogen peroxide
FALSE NEGATIVE
● Sodium fluoride as preservative
● High specific gravity
● Ascorbic acid
U R I N A LYS I S
KETONES
The test strip contains sodium nitroprusside and glycine in an alkaline
medium. The violet color proportional to methylketone is generated.
● Acetoacetic acid: 20%
● Acetone: 2%,
●
● β-hydroxybutyrate: 78%
●
NORMAL: negative
Ketone
40s
Neg.
Trace
0.5
Small
1.5
Large
Moderate
4.0
8.0
16
mmol/L
U R I N A LYS I S
BLOOD
●
The test strip contains organic peroxide and a chromogen. The peroxidase
effect of hemoglobin and myoglobin causes change in color to green.
●
NORMAL: Negative
Blood
60s
Neg.
Non
hemolyzed
10 Trace
Hemolyzed
10 Trace
25
Small
80
Moderate
200
Large
cacells/μL
U R I N A LYS I S
BILIRUBIN
●
The test is based on the coupling of bilirubin with diazonium salt (test
strip) in an acid medium. A pinkish tan color proportional to bilirubin
concentration is generated.
●
Breakdown product of hemoglobin
●
NORMAL: Negative
Bilirubin
30s
Neg.
Small
17
Moderate
50
Large
100
μmol/l
U R I N A LYS I S
BILIRUBIN
FALSE POSITIVE
● Elevated urobilinogen concentrations
FALSE NEGATIVE
● Elevated levels of ascorbic acid and nitrite
● Prolonged exposure of urine to light since bilirubin is light sensitive
U R I N A LYS I S
● Nitrite
● Leukocyte Esterase
INDIRECT TESTS FOR UTI
U R I N A LYS I S
NITRITE
●
Urinary tract pathogens can reduce nitrate to nitrite
●
NORMAL: Negative
Nitrite
60s
Neg.
Positive
Any degree of
uniform pink color
U R I N A LYS I S
NITRITE
FALSE POSITIVE
● Food dyes and therapeutic pigments such as red beets & pyridium
FALSE NEGATIVE
● Some gram positive and non-nitrite producing bacteria
● Low nitrate diet
● Antibiotic therapy
● Strong diuresis
● High levels of ascorbic acid
● Insufficient urinary retention time in the bladder
U R I N A LYS I S
LEUKOCYTE ESTERASE
The test strip contains indoxyl ester and diazonium salt. Granulocyte
esterases react with the strip to generate a violet color.
● Can be indicative of remnants of neutrophil cells that are not visible
microscopically.
● Correlate with significant number of neutrophils, either intact or lysed.
● NORMAL: Negative
●
Leukocytes
120s
Neg.
Trace
15
Small
70
Moderate
125
Large
500
cacells/μl
U R I N A LYS I S
FALSE POSITIVE
Contamination of urine with:
● Vaginal fluid
● Trichomonas
● Eosinophils
● Oxidizing agents
LEUKOCYTE ESTERASE
FALSE NEGATIVE
High concentration of:
● Protein
● Glucose
● Ascorbic acid
U R I N A LYS I S
B A S I C U R I N A LY S I S ǀ C O M P O N E N T S
M I C R O S C O P I C E X A M I N AT I O N
U R I N A LYS I S
U S E O F M I C R O S C O P I C E X A M I N AT I O N
●
Detect cellular and non-cellular elements of urine that do not give distinct
chemical reactions
●
Confirmatory test for erythrocytes, leukocytes and bacteria seen in
dipstick
●
Specimen: Freshly collected with no preservative added
●
Cells and casts begin to lyse within 2 hours of collection
U R I N A LYS I S
●
NORMAL: <5/hpf
●
APPEARANCE: Pale biconcave
disks
●
SIZE: 7 μm in diameter
RED BLOOD CELLS
U R I N A LYS I S
NEUTROPHIL - predominant type
of leukocyte in urine
● APPEARANCE: Granular spheres
● SIZE: 12μm in diameter with
multi-lobulated nuclei
● NORMAL: <5/hpf
● Rapidly lysed in hypotonic or
alkaline urine
● 50% lost following 2 to 3 hours of
standing at room temperature
●
WHITE BLOOD CELLS
U R I N A LYS I S
SQUAMOUS EPITHELIAL CELLS
●
Most frequent epithelial cells
●
Least significant
●
Line the distal one third of the
urethra
EPITHELIAL CELLS
U R I N A LYS I S
Most frequently observed casts, consisting
of Tamm-Horsfall protein
TAMM-HORSFALL PROTEIN
● Glycoprotein secreted by the thick
ascending loop of Henle and early distal
convoluted tubules
● Constitutes 1/3 of total urinary protein
● Forms the matrix of all casts
●
●
●
Very few casts in normal person
NORMAL: 0-2 /lpf
H YA L I N E C A S T
U R I N A LYS I S
C R Y S TA L S I N N O R M A L A C I D U R I N E
AMORPHOUS URATES
● Precipitate upon standing in
concentrated urine of slightly
acid pH
● Dark yellow or brown granules
U R I N A LYS I S
C R Y S TA L S I N N O R M A L A C I D U R I N E
CALCIUM OXALATE CRYSTALS
● Calcium oxalate crystals can be
found in both normal and
abnormal urine, and in a range
of urine pH from acidic to neutral
●
●
DIHYDRATE: envelope-shaped
MONOHYDRATE: oval, dumbbell shaped
DIHYDRATE
FORM
MONOHYDRATE
FORM
U R I N A LYS I S
C R Y S TA L S I N N O R M A L A C I D U R I N E
URIC ACID CRYSTALS
● Various shapes: rhombus,
hexagonal plates, rosettes,
rectangles, irregular shapes
●
Colorless to yellow or brown
U R I N A LYS I S
C RYSTA L S I N N O R M A L A L K A L I N E U R I N E
AMORPHOUS PHOSPHATE
● Precipitate upon prolonged
standing at room temperature
or in refrigerator
●
Amorphous granules
U R I N A LYS I S
C RYSTA L S I N N O R M A L A L K A L I N E U R I N E
AMMONIUM BIURATE
●
Round with thorny projections
●
Dark yellow to brown
U R I N A LYS I S
CALCIUM PHOSPHATE
Flat rectangles
● Prisms
● Rosettes
●
C RYSTA L S I N N O R M A L A L K A L I N E U R I N E
U R I N A LYS I S
C RYSTA L S I N N O R M A L A L K A L I N E U R I N E
TRIPLE PHOSPHATE
● Four to six-sided prisms
resembling coffin lids
● Composed of magnesium,
ammonium & phosphate
● Maybe associated with UTIs
caused by urea- splitting bacteria
(Proteus mirabilis)
U R I N A LYS I S
N O R M A L U R I N A LY S I S ǀ S U M M A R Y
G R O S S E X A M I N AT I O N
COLOR
NORMAL
Yellow
REMARKS May range
CLARITY
Clear
Turbidity
from pale
due to
yellow to
precipitadark yellow tion of
depending on crystals or
hydration
nonand urine
pathogenic
concentrasalts
tion
referred as
amorphous
ODOR
Faint,
Aromatic
Odor
URINE VOLUME
1-2 ml/kg/hr
Average adult
600-2000
ml/day
May vary
depending on
water intake
SPECIFIC GRAVITY
1.016-1.022
(over 24 hr period)
Child: 1.010-1.020
Adult: 1.010-1.030
May vary depending
on the hydration
status
OSMOLALITY
500-850
mOsm/kg
water
May vary
depending on
the hydration
status
U R I N A LYS I S
N O R M A L U R I N A LY S I S ǀ S U M M A R Y
C H E M I C A L E X A M I N AT I O N ( R E A G E N T S T R I P S )
URINE pH
NORMAL 4.6-8
SUBSTANCE
DETECTED/
MEASURED
PROTEIN
Negative
GLUCOSE
KETONES
Negative Negative
Albumin
Acidity or
Less sensitive
alkalinity
Glucose
for other
of urine
proteins
BLOOD
Negative
BILIRUBIN
NITRITE
LEUKOCYTE
ESTERASE
Negative
Negative
Negative
Acetoacetic
acid, acetone, Hemoglobin,
Bilirubin
β-hydroxyMyoglobin
butyrate
Nitrate
reducing
bacteria
Neutrophils
U R I N A LYS I S
N O R M A L U R I N A LY S I S ǀ S U M M A R Y
C H E M I C A L E X A M I N AT I O N ( R E A G E N T S T R I P S )
PROTEIN
FALSE
Dilute urine
NEGATIVE (specific gravity
<1.005)
Disease states
in which
predominant
protein is not
albumin
FALSE
Urine pH >7
POSITIVE Highly concentrated
urine
Contamination with
blood, antiseptic
agents
GLUCOSE
BILIRUBIN
High specific gravity
Ascorbic acid
Sodium fluoride as
preservative
Elevated
ascorbic acid
and nitrite,
Prolonged
exposure of
urine to light
Strong oxidizing
agent (bleach) in
urine container,
low specific gravity,
hydrogen peroxide
Elevated
urobilinogen
LEUKOCYTE
ESTERASE
Non-nitrite producing High concentration
bacteria,
of protein, glucose,
Ascorbic acid,
ascorbic acid
antibiotic therapy,
Insufficient urinary
retention time in
bladder
NITRITE
Food dyes, red beets, Contamination with
vaginal fluid,
pyridium
eosinophils,
oxidizing agents,
Trichomonas
U R I N A LYS I S
N O R M A L U R I N A LY S I S ǀ S U M M A R Y
M I C R O S C O P I C E X A M I N AT I O N
NORMAL
RED BLOOD CELLS
WHITE BLOOD CELLS
<5/hpf
<5/hpf
SQUAMOUS EPITHELIAL CELLS HYALINE CASTS
<3/hpf
0-2/lpf
PHOTO
APPEAR- Pale biconcave disks
ANCE
Granular spheres with multi- Most frequent epithelial cells
lobulated nuclei
Most frequently
seen cast consisting
of Tamm-Horsfall
protein
U R I N A LYS I S
N O R M A L U R I N A LY S I S ǀ S U M M A R Y
C R Y S TA L S I N N O R M A L A C I D U R I N E
AMORPHOUS URATE
Standing in concentrated urine
CALCIUM OXALATE
URIC ACID
Normal and abnormal urine Normal and abnormal urine
Dark yellow or brown granules
Dihydrate-envelope shaped Colorless to yellow or brown
Monohydrate-oval or
Shapes maybe rhombus,
dumbbell shaped
hexagonal plates
PHOTO
APPEARANCE
U R I N A LYS I S
N O R M A L U R I N A LY S I S ǀ S U M M A R Y
C R Y S TA L S I N N O R M A L A L K A L I N E U R I N E
AMORPHOUS PHOSPHATE
Prolonged standing of
urine at room
temperature or in
refrigerator
AMMONIUM BIURATE
CALCIUM PHOSPHATE
TRIPLE PHOSPHATE
Magnesium,
ammonium and
phosphate; normal or
associated with UTI
PHOTO
APPEAR- Amorphous granules
ANCE
Dark yellow to brown
Round with thorny
projections
Flat rectangles, prisms
or rosettes
Colorless rectangular prisms like
coffin lids
U R I N A LYS I S
REFERENCES
1.Kliegman RM, Stanton BF, St. Geme III JW, Schor NF, Behrman RE. (Eds.): Nelson
textbook of pediatrics, 20th ed. Philadelphia, PA: Elsevier, 2016.
2.McPherson RA, Pincus MR (Eds.): Henry’s clinical diagnosis and management by
laboratory methods, 23rd ed. St. Louis, Missouri: Elsevier, 2017.
3.Strasinger SK, Di Lorenzo MS: Urinalysis and body fluids, 6th ed. Philadelphia: F.A. Davis
Company, 2014.
4.Todd JC, Sanford AH, Henry JB, Davidsohn I: Clinical diagnosis and management by
laboratory methods, 17th ed. Philadelphia: W.B. Saunders, 1984.
U R I N A LYS I S
CREDITS
PPS UPEC- PNSP MODULE
CHAIR: Remedios Dee-Chan, MD
CO-CHAIR: Cherry Hontiveros-Lim, MD
MEMBERS
Maria Isabel M. Vilvar, MD
Lourdes Paula R. Resontoc, MD
Roxanne Tamondong - Olfato, MD
SPECIAL ACKNOWLEDGMENT
Rene H. Francisco, MD
PNSP PRESIDENT 2017-2018
Ma. Norma V. Zamora, MD