Urinalysis Prepared by Hamad ALAssaf alassaf_h@yahoo.com

Urine Examination 1- Physical Examination 2- Chemical Examination 3- Microscopic Examination

URINE ANALYSIS Physical Examination 1- Volume 2- Specific Gravity 3- Apperance 4- Color 5- Odor 6- Deposit 7- Reaction (pH)

URINE ANALYSIS Physical Examination   1- Volume: Normal urine volume in 24 hours is 600-2000 ml A- Urine volume increases (Polyuria) in the following conditions: Physiological: Increased fluid intake Diuretic Pathological: Diabetes mellitus Diabetes insipidus Chronic renal failure B- Urine volume decreases (Oliguria or anuria) in the following conditions: Dehydration Acute renal failure Obstruction

URINE ANALYSIS Physical Examination 2- Specific gravity (SG): Specific gravity measures solute concentration (urea and sodium). Normally the specific gravity ranges between 1.015-1.025. A- Increased in Dehydration (with oliguria) Diabetes Mellitus (with polyuria) Acute renal failure (with oliguria) B- Decreased in Diabetes insipidus (with polyuria)  

URINE ANALYSIS Physical Examination 3- Appearance: - Normal fresh urine: clear (transparent) - Abnormal : Cloudy urine Indicates possible abnormal constituents such as: White blood cells Epithelial cells Crystals Bacteria N.B. Stored urine with no preservative & no cooling may turn clear urine samples into cloudy urine.

URINE ANALYSIS Physical Examination 4- Color:   - Normal color: pale yellow (amber yellow) due to the presence of pigments of urobilin or urobilinogen - Abnormal colors of urine: Colorless Orange Greenish yellow Red Black Smoky

Urine Colour Left to right: (Straw, clear) (yellow, clear) (yellow, hazy) (yellow, clear) (red-orange, clear) (brown, hazy)

URINE ANALYSIS Physical Examination Color (cont.) 1- Colorless Urine: Chronic renal failure Diabetes insipidus. 2- Orange Urine: Ingestion of large amount of carotenoids (vitamin A) 3- Yellowish - brown urine: due to presence of billirubin in cases of : Obstructive Jaundice Hepatic Jaundice

URINE ANALYSIS Physical Examination Color (cont.)  4- Red urine: due to presence of blood, hemoglobin & RBCs.   5- Black urine: Methemoglobin Homogentisic acid in alkaptonuria Malignant malaria (black water fever due to Malaria falciparum). Melanin (melanoma) 6- Smoky urine: presence RBCs. in the urine, in cases of acute glomerulonephritis

URINE ANALYSIS Physical Examination 5- Odor:  Normal Urineferous odor: The normal odor of fresh voided urine sample Abnormal Odors: 1- Fruity odor: due to presence of acetone in the urine as in diabetic ketoacidosis 2- Ammonia odor: due to release of ammonia as result of: - the bacterial action on urea in the contaminated urine - or long standing exposed urine samples.

URINE ANALYSIS Physical Examination 6- Deposits: Normally the urine is devoid of deposits. The presence of deposits is mainly due to various types of crystals, salts and cells.

URINE ANALYSIS Physical Examination 7- Reaction (pH):   Normally: The pH of urine varies from 4.6 - 8.0  1- Acidic urine: Large intake of meat & certain fruits (cranberries) Metabolic & respiratory acidosis 2- Alkaline urine: Vegetarians Metabolic & respiratory alkalosis Urinary tract infection by urea splitting bacteria which split urea to ammonia (alkaline)

URINE ANALYSIS Chemical Examination The presence of normal and abnormal chemical elements in the urine are detected using dry reagent strips. These plastic strips contain absorbent pads with various chemical reagents for determining a specific substance. When the test strip is put in urine the reagents are activated and a chemical reaction occurs. The chemical reaction results in a specific color change.

URINE ANALYSIS Chemical Examination Used in the LAB for routine urine analysis (10 Chemical Tests) Used in Emergency Room (ER) for diagnosis of Diabetic Ketoacidosis (DKA) (3 chemical tests: Glucose, Ketones & protein)

URINE ANALYSIS Chemical Examination Glucose Protein Specific Gravity pH primarily detects glucose (sugar); important indicator of diabetes mellitus primarily detects protein called albumin; important indicator in the detection of renal disease state of kidney and hydration status of patient partial assessment of acid base status; alkaline pH indicates old sample or urinary tract infection

URINE ANALYSIS Chemical Examination Urobilinogen Bilirubin Ketone Blood another by-product of red cell breakdown; increased amounts seen in fever, dehydration, hemolytic anemia and liver disease detects bilirubin (a product of red cell breakdown); indicator of liver function normal product of fat metabolism; increased amounts seen in diabetes or starvation (extreme dieting) red blood cells, hemoglobin, or myoglobin (muscle hemoglobin); sensitive early indicator of renal disease

URINE ANALYSIS Chemical Examination Ascorbic Acid Leukocyte Esterase Nitrite Ascorbic acid (vitamin C) is known to interfere with the oxidation reaction of the blood and glucose pad on common urine test strips. detects esterase enzyme present in certain white blood cells (e.g, neutrophils, monocytes); indicator of urinary tract infection certain bacteria convert normal urine nitrate to nitrite; indicator of urinary tract infection

URINE ANALYSIS Chemical Examination Abnormal Constituents of Urine 1- Proteins (proteinuria) 2- Sugars (glucosuria, fructosuria & galactosuria) 3- ketone Bodies (ketonuria) 4- Billirubin (billirubinuria) & Bile Salts 5- Nitrites  

URINE ANALYSIS Chemical Examination 1- Proteins: (proteinuria) Proteinuria is divided into prerenal, renal and postrenal proteinuria.   1-Prerenal proteinuria: Bence-Jones protein: This abnormal gamma globulin (light chains only) is synthesized by malignant plasma cells (multiple myeloma). It precipitates at 60oC, redissolves at 100oC and reprecipitates on cooling. 2-Renal proteinuria: Severe muscular exercise After prolonged standing Acute glomerulonephritis Nephrotic syndrome 3- Postrenal proteinuria: Lower urinary tract inflammation, tumors or stones.

URINE ANALYSIS Chemical Examination   2- Glucose: (glycosuria) Presence of detectable amount of glucose in urine which occurs in the following conditions: Uncontrolled Diabetes Mellitus (DM) Renal glucosuria with lowering of renal threshold : e.g. during pregnancy (gestational diabetes). - Fructose (Fructosuria) Presence of fructose in urine & may be due to: - Alimentary causes following the ingestion of large amounts of fructose - Fructosemia & hereditary fructose intolerance (Metabolic disorders of fructose). - Galactose (Galactosuria): Presence of galactose in urine& may be due to: - Alimentary causes following the ingestion of large amount of galactose. - Galactossemia

URINE ANALYSIS Chemical Examination 3- Ketone Bodies (Ketonuria): Presence of acetone, acetoacetic acid & β hydroxybutyric acid in urine due to: Diabetic ketoacidosis (uncontrolled DM) Starvation Unbalanced diet: high fat & low carbohydrates diet.

URINE ANALYSIS Chemical Examination 4- Bilirubin (bilirubinuria) Billirubin appears in urine in cases of: Hepatocellular Jaundice: as in viral hepatitis Obstructive Jaundice as any cause of obstruction of bile duct 5- Nitrites: In bacteruria in urine (in cases of Urinary Tract Infection, UTI)

URINE ANALYSIS Microscopic Examination The urine specimen is centrifuged and the liquid portion is poured off.

URINE ANALYSIS Microscopic Examination The concentrated cellular sediment, is then placed on a microscope slide, covered with a coverslip and read under microscope.

URINE ANALYSIS Microscopic Examination A variety of normal and abnormal cellular elements may be seen in urine sediment such as: Casts Crystals Amorphus Microorganisms Pus cells RBCs Epithelial cells Mucus

URINE ANALYSIS Microscopic Examination RBCs 40x objective - presence of a few is normal (2 – 5 cells/HPF) - higher numbers are indicator of renal disease - result of bleeding at any point in urinary system

URINE ANALYSIS Microscopic Examination Pus cells 40x objective a few are normal (2 – 4 cells /HPF) high numbers indicate inflammation or infection somewhere along the urinary or genital tract.

URINE ANALYSIS Microscopic Examination Mucus 40x objective look like long, ribbon-like threads common finding in urine sediment secreted by glands in the lower urinary tract. Become more with UTI, ulcerative colitis, kidney stones

URINE ANALYSIS Microscopic Examination Epithelial Cells 40x objective cells are large and flat normal cells that line the urinary and genital tract or renal tubules

URINE ANALYSIS Microscopic Examination

URINE ANALYSIS Microscopic Examination Crystals of calcium oxalate colorless octahedron found in acid urine Crystals of triple phosphate colorless, “coffin-lid” prism common finding; no clinically significant

URINE ANALYSIS Microscopic Examination

URINE ANALYSIS Microscopic Examination (Casts)

URINE ANALYSIS Microscopic Examination Amorphous urate (Acidic urine) Amorphous phosphate (alkaline urine)

URINE ANALYSIS Microscopic Examination Bacteria Yeast

URINE ANALYSIS Microscopic Examination (Parasites) schistosoma haematobium Trichomonas vaginalis Characterized by Central spin It is not Urinary system protozoa, it’s vagina protozoa

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