Urinalysis

Urinalysis can reveal diseases that have gone unnoticed because they do not produce striking signs or symptoms.  Examples include diabetes mellitus, various forms of glomerulonephritis, and chronic urinary tract infections.

For a complete urinalysis or urine culture, the urine sample should be collected from the midstream urine – in other words not from the first or the last of the urine being passed.

Another important consideration is the time between collection and examination in the laboratory.  The urinalysis may be inaccurate if the sample is over 1 hour old due to changes which occur:

• decreased clarity due to crystallization of solutes
• rising pH (the sample becomes more alkaline)
• loss of ketone bodies
• loss of bilirubin
• dissolution of cells and casts
• overgrowth of contaminating microorganisms

Therefore, be sure to get the urine to the laboratory as quickly as possible.

Function

The most cost-effective device used to screen urine is a paper or plastic dipstick.  This microchemistry system has been available for many years and allows qualitative and semi-quantitative analysis within one minute by simple but careful observation.  The color change occurring on each segment of the strip is compared to a color chart to obtain results.  However, a careless doctor, nurse, or assistant is entirely capable of misreading or misinterpreting the results.  Microscopic urinalysis requires only a relatively inexpensive light microscope.

MACROSCOPIC URINALYSIS
The first part of a urinalysis is direct visual observation.  Normal, fresh urine is pale to dark yellow or amber in color and clear.  Normal urine volume is 750 to 2000ml in a 24-hour period.

Turbidity or cloudiness may be caused by excessive cellular material or protein in the urine or may develop from crystallization or precipitation of salts upon standing at room temperature or in the refrigerator.  Clearing of the specimen after addition of a small amount of acid indicates that precipitation of salts is the probable cause of turbidity.

A red or red-brown (abnormal) color could be from a food dye, eating fresh beets, a drug, or the presence of either hemoglobin or myoglobin.  If the sample contained many red blood cells, it would be cloudy as well as red.

URINE DIPSTICK CHEMICAL ANALYSIS
pH: The glomerular filtrate of blood plasma is usually acidified by renal tubules and collecting ducts from a pH of 7.4 to about 6 in the final urine.  However, depending on the acid-base status, urinary pH may range from as low as 4.5 to as high as 8.0. The change to the acid side of 7.4 is accomplished in the distal convoluted tubule and the collecting duct.

Specific Gravity: Specific gravity (directly proportional to urine osmolality, which measures solute concentration) measures urine density, or the ability of the kidney to concentrate or dilute the urine over that of plasma.  Dipsticks are available that also measure specific gravity in approximations.  Most laboratories measure specific gravity with a refractometer.

Specific gravity between 1.002 and 1.035 on a random sample should be considered normal if kidney function is normal.  Since the specific gravity of the glomerular filtrate in Bowman's space ranges from 1.007 to 1.010, any measurement below this range indicates hydration and any measurement above it indicates relative dehydration.

If the specific gravity is not over 1.022 after a 12 hour period without food or water, renal concentrating ability is impaired and the patient either has generalized renal impairment or nephrogenic diabetes insipidus.  In end-stage renal disease, specific gravity tends to become 1.007 to 1.010.

Any urine having a specific gravity over 1.035 is either contaminated, contains very high levels of glucose, or the patient may have recently received high density radiopaque dyes intravenously for radiographic studies or low molecular weight dextran solutions.  Subtract 0.004 for every 1% glucose to determine non-glucose solute concentration.

Protein: Dipstick screening for protein is done on whole urine, but semi-quantitative tests for urine protein should be performed on the supernatant of centrifuged urine since the cells suspended in normal urine can produce a falsely high estimation of protein.  Normally, only small plasma proteins filtered at the glomerulus are reabsorbed by the renal tubule.  However, a small amount of filtered plasma proteins and protein secreted by the nephron (Tamm-Horsfall protein) can be found in normal urine.  Normal total protein excretion does not usually exceed 150mg/24 hours or 10mg/100ml in any single specimen.  More than 150mg/day is defined as proteinuria.  Proteinuria over 3.5gm/24 hours is severe and known as nephrotic syndrome.

Dipsticks detect protein by production of color with an indicator dye, Bromophenol blue, which is most sensitive to albumin but detects globulins and Bence-Jones protein poorly.  Precipitation by heat is a better semiquantitative method, but overall, it is not a highly sensitive test.  The sulfosalicylic acid test is a more sensitive precipitation test.  It can detect albumin, globulins, and Bence-Jones protein at low concentrations.

In rough terms, trace positive results (which represent a slightly hazy appearance in urine) are equivalent to 10mg/100ml or about 150mg/24 hours (the upper limit of normal).  1+ corresponds to about 200-500mg/24 hours, a 2+ to 0.5-1.5gm/24 hours, a 3+ to 2-5gm/24 hours, and a 4+ represents 7gm/24 hours or greater.

Glucose: Less than 0.1% of glucose normally filtered by the glomerulus appears in urine (below 130mg/24 hours).  Glycosuria (excess sugar in urine) generally means diabetes mellitus.  Dipsticks employing the glucose oxidase reaction for screening are specific for glucose but can miss other reducing sugars such as galactose and fructose.  For this reason, most newborn and infant urines are routinely screened for reducing sugars by methods other than glucose oxidase (such as the Clinitest, a modified Benedict's copper reduction test).

Ketones: Ketones (acetone, acetoacetic acid, beta-hydroxybutyric acid) resulting from either diabetic ketosis or some other form of calorie deprivation (starvation), are easily detected using either dipsticks or test tablets containing sodium nitroprusside.

Nitrite: A positive nitrite test indicates that bacteria may be present in significant numbers in urine.  Gram negative rods such as E. coli are more likely to give a positive test.

Leukocyte Esterase: A positive leukocyte esterase test results from the presence of white blood cells either as whole cells or as lysed cells.  Pyuria can be detected even if the urine sample contains damaged or lysed WBCs.  A negative leukocyte esterase test means that an infection is unlikely and that, without additional evidence of urinary tract infection, microscopic exam and/or urine culture need not be done to rule out significant bacteriuria.

MICROSCOPIC URINALYSIS
A sample of well-mixed urine (usually 10-15ml) is centrifuged in a test tube at relatively low speed (about 2-3,000rpm) for 5-10 minutes until a moderately cohesive button is produced at the bottom of the tube.  The supernate is decanted and a volume of 0.2 to 0.5ml is left inside the tube.  The sediment is resuspended in the remaining supernate by flicking the bottom of the tube several times.  A drop of resuspended sediment is poured onto a glass slide and coverslipped.

The sediment is first examined under low power to identify most crystals, casts, squamous cells, and other large objects.  The numbers of casts seen are usually reported as number of each type found per low power field (LPF).  Example: 5-10 hyaline casts/L casts/LPF.  Since the number of elements found in each field may vary considerably from one field to another, several fields are averaged.  Next, examination is carried out at high power to identify crystals, cells, and bacteria.  The various types of cells are usually described as the number of each type found per average high power field (HPF).  Example: 1-5 WBC/HPF.

Red Blood Cells: Hematuria is the presence of abnormal numbers of red cells in urine due to: glomerular damage, tumors which erode the urinary tract anywhere along its length, kidney trauma, urinary tract stones, renal infarcts, acute tubular necrosis, upper and lower urinary tract infections, nephrotoxins, and physical stress.  Red cells may also contaminate the urine from the vagina in menstruating women or from trauma produced by bladder catheterization.  Theoretically, no red cells should be found, but some find their way into the urine even in very healthy individuals.  However, if one or more red cells can be found in every high power field, and if contamination can be ruled out, the specimen is probably abnormal.

RBCs may appear normally shaped, swollen by dilute urine (in fact, only cell ghosts and free hemoglobin may remain), or crenated by concentrated urine.  Both swollen, partly hemolyzed RBCs and crenated RBCs are sometimes difficult to distinguish from WBCs in the urine.  In addition, red cell ghosts may resemble yeast.  The presence of dysmorphic RBCs in urine suggests a glomerular disease such as a glomerulonephritis.  Dysmorphic RBCs have odd shapes as a consequence of being distorted via passage through the abnormal glomerular structure.

White Blood Cells: Pyuria refers to the presence of abnormal numbers of leukocytes that may appear with infection in either the upper or lower urinary tract or with acute glomerulonephritis.  Usually, the WBCs are granulocytes.  White cells from the vagina, especially in the presence of vaginal and cervical infections, or the external urethral meatus in men and women may contaminate the urine.

If two or more leukocytes per each high power field appear in non-contaminated urine, the specimen is probably abnormal.  Leukocytes have lobed nuclei and granular cytoplasm.

Epithelial Cells: Renal tubular epithelial cells, usually larger than granulocytes, contain a large round or oval nucleus and normally slough into the urine in small numbers.  However, with nephrotic syndrome and in conditions leading to tubular degeneration, the number sloughed is increased.

When lipiduria occurs, these cells contain endogenous fats.  When filled with numerous fat droplets, such cells are called oval fat bodies.  Oval fat bodies exhibit a "Maltese cross" configuration by polarized light microscopy.

Transitional epithelial cells from the renal pelvis, ureter, or bladder have more regular cell borders, larger nuclei, and smaller overall size than squamous epithelium.  Renal tubular epithelial cells are smaller and rounder than transitional epithelium, and their nucleus occupies more of the total cell volume.

Squamous epithelial cells from the skin surface or from the outer urethra can appear in urine.  Their significance is that they represent possible contamination of the specimen with skin flora.

Casts: Urinary casts are formed only in the distal convoluted tubule (DCT) or the collecting duct (distal nephron).  The proximal convoluted tubule (PCT) and loop of Henle are not locations for cast formation.  Hyaline casts are composed primarily of a mucoprotein (Tamm-Horsfall protein) secreted by tubule cells.

Even with glomerular injury causing increased glomerular permeability to plasma proteins with resulting proteinuria, most matrix or "glue" that cements urinary casts together is Tamm-Horsfall mucoprotein, although albumin and some globulins are also incorporated.

The factors which favor protein cast formation are low flow rate, high salt concentration, and low pH, all of which favor protein denaturation and precipitation, particularly that of the Tamm-Horsfall protein.  Protein casts with long, thin tails formed at the junction of Henle's loop and the distal convoluted tubule are called cylindroids.  Hyaline casts can be seen even in healthy patients.

Red blood cells may stick together and form red blood cell casts.  Such casts are indicative of glomerulonephritis, with leakage of RBCs from glomeruli, or severe tubular damage.

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.

When cellular casts remain in the nephron for some time before they are flushed into the bladder urine, the cells may degenerate to become a coarsely granular cast, later a finely granular cast, and ultimately, a waxy cast.  Granular and waxy casts are be believed to derive from renal tubular cell casts.  Broad casts are believed to emanate from damaged and dilated tubules and are therefore seen in end-stage chronic renal disease.

The so-called telescoped urinary sediment is one in which red cells, white cells, oval fat bodies, and all types of casts are found in more or less equal profusion.  The conditions which may lead to a telescoped sediment are: 1) lupus nephritis 2) malignant hypertension 3) diabetic glomerulosclerosis, and 4) rapidly progressive glomerulonephritis.

In end-stage kidney disease of any cause, the urinary sediment often becomes very scant because few remaining nephrons produce dilute urine.

Bacteria: Bacteria are common in urine specimens because of the abundant normal microbial flora of the vagina or external urethral meatus and because of their ability to rapidly multiply in urine standing at room temperature.  Therefore, microbial organisms found in all but the most scrupulously collected urines should be interpreted in view of clinical symptoms.

Diagnosis of bacteriuria in a case of suspected urinary tract infection requires culture.  A colony count may also be done to see if significant numbers of bacteria are present.  Generally, more than 100,000/ml of one organism reflects significant bacteriuria.  Multiple organisms reflect contamination.  However, the presence of any organism in catheterized or suprapubic tap specimens should be considered significant.

Yeast: Yeast cells may be contaminants or represent a true yeast infection.  They are often difficult to distinguish from red cells and amorphous crystals but are distinguished by their tendency to bud.  Most often they are Candida, which may colonize bladder, urethra, or vagina.

Crystals: Common crystals seen even in healthy patients include calcium oxalate, triple phosphate crystals and amorphous phosphates.

Very uncommon crystals include: cystine crystals in urine of neonates with congenital cystinuria or severe liver disease, tyrosine crystals with congenital tyrosinosis or marked liver impairment, or leucine crystals in patients with severe liver disease or with maple syrup urine disease.

Miscellaneous: General "crud" or unidentifiable objects may find their way into a specimen, particularly those that patients bring from home.

Spermatozoa can sometimes be seen.  Rarely, pinworm ova may contaminate the urine.  In Egypt, ova from bladder infestations with schistosomiasis may be seen.

Instructions

Methods of Urine Collection

Random collection taken at any time of day with no precautions regarding contamination.  The sample may be dilute, isotonic, or hypertonic and may contain white cells, bacteria, and squamous epithelium as contaminants.  In females, the specimen may contain vaginal contaminants such as trichomonads, yeast, and during menses, red cells.

Collection of the sample should be early morning before ingestion of any fluid.  This is usually hypertonic and reflects the ability of the kidney to concentrate urine during dehydration which occurs overnight.  If all fluid ingestion has been avoided since 6pm the previous day, the specific gravity usually exceeds 1.022 in healthy individuals.

A period of dehydration may precede urine collection if testing of renal concentration is desired, but any specific gravity over 1.022 measured in a randomly collected specimen indicates adequate renal concentration so long as there are no abnormal solutes in the urine.

Clean-catch, midstream urine specimen collected after cleansing the external urethral meatus.  A cotton sponge soaked with benzalkonium hydrochloride is useful and non-irritating for this purpose.  A midstream urine is one in which the first half of the bladder urine is discarded and the collection vessel is introduced into the urinary stream to catch the last half.  The first half of the stream serves to flush contaminating cells and microbes from the outer urethra prior to collection.

Catheterization of the bladder through the urethra for urine collection is carried out only in special circumstances, i.e., in a comatose or confused patient.  This procedure risks introducing infection and traumatizing the urethra and bladder, thus producing iatrogenic infection or hematuria.

Suprapubic transabdominal needle aspiration of the bladder.  When done under ideal conditions, this provides the purest sampling of bladder urine.  This is a good method for infants and small children.