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Urinalysis Dipstick Interpretation

Cheryl S. Sine, DVM; Paula Krimer, DVM, DVSc; Perry J. Bain, DVM, PhD; and
Kenneth S. Latimer, DVM, PhD
Class of 2003 (Sine) and Department of Pathology (Krimer, Bain, Latimer), College of Veterinary Medicine,
The University of Georgia, Athens, GA 30602-7388

University of Georgia – Veterinary Clinical Pathology Clerkship Program

[Link]

Introduction

Urinalysis is an important tool in disease detection, as well as monitoring and screening

animal health. Abnormalities can be indicative of diseases of the urinary system as well
as other organ systems, including liver function, acid-base status, and carbohydrate
metabolism.1 Complete urinalysis involves both macroscopic and microscopic
assessment. This is typically performed by gross visual assessment of the urine,
microscopic examination, and chemical evaluation. Several chemical parameters can be
measured using a commercially available in house dipstick test. This test is relatively
inexpensive, and takes less than 5 minutes to complete. Typical dipstick strips include
the following tests: bilirubin, blood, glucose, ketones, pH, protein specific gravity, and
urobilinogen. Some dipsticks also include leukocytes and nitrite analyses.

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Figure 1: Example of commercially

available Bayer® reagent strips for
urinalysis.

Sample Collection

Urine should be collected in a clean, dry container that is free of any disinfecting or
cleaning chemicals. Samples may be collected by free catch of voided sample, manual
bladder expression, catheterization, or cystocentesis.2

Voided samples are the easiest and least invasive samples to collect. However, voided
samples may have contaminants that include bacteria, epithelial cells, and white blood
cells.1 Red blood cells should not be found in normal voided samples. Voided samples
should be collected midstream to lessen contaminants from the vagina or prepuce.3,4
Collection of samples from surfaces such as floors, cages, and litter boxes should be
avoided, since these will introduce environmental contaminants.

Manual expression of the bladder is another technique used in urine collection. In this
method, the patient’s bladder is gently squeezed until urine is expressed. This technique
may lead to bladder trauma resulting in hematuria, and in some instances (such as
urethral obstruction) may result in a ruptured bladder.5 This method may have the same
cellular contaminants as a voided sample.

Catheterization is performed by placing a small hollow tube into the urethra to the level
of the bladder. Urine is then withdrawn from the bladder using a syringe. Catheterized
samples have less contamination from the distal urogenital tract; however,
contamination from the urethra may still occur. Contaminants include epithelial cells or
red blood cells. Poor catheterization technique may lead to trauma or, less commonly,
infection.3,4,5

Cystocentesis samples are collected by inserting a sterile needle through the body wall
into the bladder. Urine is withdrawn from the bladder using a syringe. A lateral or ventral

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approach to the bladder may be made without causing severe trauma to any vital region
of the bladder. Clipping or surgical preparation of the area along the body wall is not
necessary prior to sample collection. Often a 1 inch or 1.5 inch 22 gauge needle is used
attached to a 6 or 12 cc syringe. The bladder is manually immobilized and the needle is
inserted through the abdominal wall into the bladder, and the urine is withdrawn. It is
important to stop aspirating prior to withdrawing the needle as this may lead to aspiration
of blood cells or epithelium from the bladder wall. Animals often tolerate cystocentesis
very well and little restraint is needed. Contaminants that may be found include
iatrogenically introduced red blood cells. 3,4,5 Rarely, enterocentesis may occur which
results in a sample containing bacteria, intestinal villi and other intestinal contents.

Sample Handling

In order to obtain accurate results, the urine collection, storage and handling must be
sterile and follow standard procedures. The dipstick analysis should be performed as
soon after collection as possible (ideally within 30 minutes of collection) and the sample
should be well mixed prior to testing. If for some reason the test cannot be performed
immediately, the sample may be covered and refrigerated. It should be allowed to return
to room temperature prior to testing. The dipsticks should be stored in the original airtight
container to maintain reagent reactivity.5,6

Testing Methods

Dipsticks may be removed from the air tight, light sealed containers. It is important not to
touch the reagent areas of the strip as this may alter test results. Each reagent area
should be immersed in urine by dipping. The excess urine should be removed to prevent
dilution of reagents or mixing of reagents between pads. This can be achieved by tilting
the strip and allowing the urine to run off the edges (Figure 2). While blotting excess
urine, ensure the chemicals from the different tests do not mix.6

Figure 2: Removal of excess urine horizontally will

prevent the mixing of chemicals from different reagent
pads.

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The reagent pads should be read at the specified times. These times are different for
each test and also vary between dipstick manufacturers. Compare the blocks to the
corresponding color chart provided by the test strip's manufacturer.6

Urine discoloration may create difficulty in visually interpreting the test results. Color
changes may be masked, or read as false positive test results. If the urine is noticeably
discolored, the sample may be centrifuged and the supernatant used for analysis.
Common causes of altered urine color include hemoglobin, myoglobin, bilirubin, and
drugs (phosphoenolpyruvate).

Interpretation of Test Results

Dipsticks commonly include tests for specific gravity, pH, glucose, protein, blood,
bilirubin, ketones, urobilinogen, nitrite, and leukocytes.

Specific Gravity

Urine specific gravity is based on the ratio of weight of urine to weight of an equivalent
volume of pure water. This test is used to measure tubular function. The dipstick
measures specific gravity by measuring the change in pKa of polyelectrolytes in relation
to ionic concentration5.

Although dipstick strips do have a method of approximating specific gravity, this

measurement is best made with a refractometer.1

Urine specific gravity measured by the dipstick can be falsely elevated by moderate to
high concentrations of protein. Low reading may occur if the urine is alkaline.6 High lipid
content in urine may also alter the results by either raising or lowering the specific gravity
measurement.

pH

The pH of urine can vary depending on an animal’s diet as well as its acid-base status.
For example, animals that primarily eat high protein meat-based diets will have acidic
urine. On the other hand, animals that eat more vegetable-based diets will have an
alkaline urine.1,5

Dipsticks measure pH using methyl red, bromthymol blue or phenolphathalein indicator

dyes. These reagents react rapidly and result in a color change. pH can be
approximated within 0.5 units using a dipstick. The urine sample should be fresh as
urine becomes more alkaline on standing due to the conversion of urea to ammonia by
bacteria (if present), and loss of CO2.1

Causes of acidic urine include: meat diet, systemic acidosis, hypochloridemia, and
administration of acidifying agents such as d,l-methionine or NH4Cl. 4,5 Urine with high
concentrations of glucose may have a lower pH.6 This is due to bacterial metabolism of
glucose and and production of ammonia which lowers pH.1

Causes of alkaline urine include: vegetable based diet, bacterial infection of urease-
producing bacteria, systemic alkalosis, urine exposed to room air for an extended time
(loss of CO2), and administration of alkalinizing agents including citrate or NaHCO3.1,4,5

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Urine pH also may provide good predictive assessment of crystal and stone morphology
as certain crystals and stones form in either acidic or alkaline environments. Uric acid,
cystine, and calcium oxalate crystals are found in acidic urine. On the other hand,
struvite, calcium carbonate, calcium phosphate, ammonium biurate, and amorphous
phosphate crystals are found in alkaline urine.5

For a more accurate assessment of urine pH, a pH meter may be used. However, for
most routine veterinary analyses a dipstick pH reading is sufficient.5

Glucose

Glucose is not detectable in the urine of healthy dogs or cats. In a healthy animal,
glucose passes freely through the glomerular filter and is resorbed by the proximal
tubules. If glucosuria is present, it is due to either an excess amount of glucose reaching
the tubules that cannot be resorbed or, less commonly, decreased tubular resorptive
function.4

Reagent strips measure glucose levels using the glucose oxidase method.1 This method
is a sequential enzymatic reaction. Glucose reacts with glucose oxidase to produce
hydrogen peroxide, which oxidizes the indicator chemical to produce a color change.
The color change is related to the amount of glucose present in the urine sample (Figure
3).

Figure 3: Example of marked glucosuria with Bayer®

reagent strips.

Glucosuria may be either persistent or transient and multiple tests may be needed for
differentiation of these conditions. Persistent causes of glucosuria include: diabetes
mellitus, administration of glucose containing fluids, chronic disease that is not related to
the kidneys such as hyperadrenocorticism, hyperpituitarism, or acromegaly. Other
diseases that may result in transient hyperglycemias leading to glucosuria include:

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hyperthyroidism, acute pancreatitis, stress (especially in cats), postprandial, and
administration of certain drugs. Rarely, a Fanconi-like syndrome may lead to
glucosuria.1,4

False positive test results may be caused by contamination of the sample with oxidants
such as hydrogen peroxide, bleach (sodium hypochlorite), or occasionally
pseudoglucose in obstructed cats.1,5

False negative test results may be due to high concentrations of ascorbic acid (Vitamin
C) in the urine. Moderately high concentrations of ketones also may cause false
negative test results if the amount of glucose is only slightly elevated. The glucose test
also becomes less reactive as urine specific gravity increases or as temperature
decreases. Cold urine (refrigerated specimens) or expired reagent strips may also result
in false negative test results.1,5,6

Protein

Dogs and cats normally have small proteins that pass through the glomerular filter,
however a majority of these proteins are resorbed by the renal tubules. The renal
nephron does excrete a small amount of Tamm Horsfall protein. Thus, only a very small
amount of protein is normally excreted in the urine, which is not usually clinically
detectable.1,5

The protein portion of the dipstick reagent strip measures the protein based on a pH dye
indicator method using bromphenol blue. Due to the negative charge of albumin, if
protein (albumin) is present in urine, the pH increases, and a positive test result occurs.
This test is primarily sensitive to albumin is relatively insensitive for the detection of
globulins and Bence-Jones proteins (see Figure 4).1

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Figure 4: Example of marked proteinuria with

Bayer® reagent strips.

Positive protein results must be evaluated in relationship to the patient’s history, physical
examination, method of urine collection, urine specific gravity, and microscopic sediment
examination. Proteinuria may be due to hemorrhage, infection, intravascular hemolysis,
or renal disease. Hemorrhage is confirmed by a positive occult blood reaction on the
dipstick and the presence of red blood cells in the sediment. A urinary infection or cystitis
can be confirmed by observing bacteria and white blood cells on sediment examination.
Cases of intravascular hemolysis have hemoglobinuria leading to a positive occult blood
test.1,4,5

Proteinuria of renal disease may be due to glomerular and/or tubular lesions. If the
proteinuria is due to renal disease, the occult blood test will be negative and the
sediment may or may not contain casts. Determination of the urine protein/urine
creatinine ratio is helpful in confirming renal proteinuria.1

Protein results must be analyzed with the urine specific gravity. Trace proteinuria may
represent significant protein loss with low specific gravity, but not with high specific
gravity.1,4

False positive protein reactions may occur with alkaline urine or if a disinfectant residue
is in the urine, possibly from improper cleaning of the collection container.6 Samples
containing urease-producing bacteria may have an elevated pH resulting in a false
positive test result.

False negative test results may occur in dilute or acidic urine.6

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If the urine protein dipstick is positive for protein, the sample should be further analyzed
with a quantitative method at an outside laboratory.

Blood

The occult blood test will react positively in the presence of red blood cells, free
hemoglobin or free myoglobin (see Figure 5). Hemoglobin usually is bound and is too
large to pass through the glomerular filter. If the renal threshold is exceeded, the
hemoglobin can pass into the urine. Myoglobin on the other hand, is not bound and
freely passes through the glomerular filter. Myoglobin can be detected in urine before a
change in plasma color is apparent. The presence of free red blood cells results in a
positive test when blood cells lyse and hemoglobin is released. Healthy animals should
have negative test results.1,5

This test is based on a pseudoperoxidase reaction, which is more sensitive to

hemoglobin and myoglobin than intact red blood cells.5 This test is also more sensitive to
hemoglobin than the urine protein dipstick tests.1

Figure 5: Example of trace hematuria and marked

hematuria or hemoglobinuria with Bayer® reagent strips.

A positive occult blood test indicates hematuria, hemoglobinuria, or myoglobinuria.

Further evaluation of the urine sediment is needed if a positive test result is found. Most
commonly, hematuria is the cause of the positive test result while myoglobinuria is rare.1

Hematuria can be caused by trauma, infection, inflammation, infarction, calculi,

neoplasia or a coagulopathy anywhere along the urinary tract.5 In cases of hematuria,
the urine is red and cloudy, but will clear if centrifuged. Microscopic evaluation of the
urine sediment will reveal red blood cells.1

Hemoglobinuria, on the other hand, will have reddish brown urine that does not become
clear after centrifugation. The microscopic evaluation of urine sediment will not reveal

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red blood cells. With intravascular hemolysis, plasma will have a reddish tint due to
hemoglobinemia that is detectable prior to hemoglobinuria. The patient usually will be
clinically anemic.1

A false positive test result may occur if the urine is contaminated with bleach, or contains
large amounts of iodide or bromide. If a voided sample is collected from a bitch in heat, a
false positive test may also occur. In this case a cystocentesis sample is preferred for
analysis. Microbial peroxidase that is present in some urinary tract infections, can also
lead to false positive test results.5,6

False negative test results may occur if the urine is not well mixed prior to evaluation.
This is due to the fact that red blood cells often sediment quickly.5

Bilirubin

Bilirubin is produced from the breakdown of hemoglobin, transported to the liver bound
to albumin, and conjugated with carbohydrates by hepatocytes. Only conjugated bilirubin
is found in urine. Excess bilirubin may be produced when red blood cells are destroyed,
or in liver disease, including bile duct obstruction. Conjugated bilirubin is detected in
urine if the renal threshold is exceeded. The renal threshold in dogs, especially males, is
lower than that of other species.1

Reagent strips measure levels of conjugated bilirubin with the diazotization method. This
occurs by coupling bilirubin with diazotized dichloroaniline in an acidic environment.6
Bilirubin is very unstable when exposed to room air and light. Thus, urine specimens
should be tested soon after collection (see Figure 6).6

Figure 6: Example of marked bilirubinuria with Bayer®

reagent strips.

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Positive test results may be observed in concentrated urine of healthy dogs. In dogs, the
renal threshold for bilirubin is low and renal tubules are able to break down heme and
produce some renal bilirubin, therefore slight bilirubinuria can be a normal finding in
dogs with concentrated urine.4 However, bilirubinuria is always abnormal in cats.
Bilirubinuria may indicate: liver disease, bile duct obstruction, starvation, hemolysis, or
pyrexia. Bilirubinuria in bile duct obstruction is often more severe than that of
hepatocellular disease.1,5

False positive test results may occur if high doses of chlorpromazine, which lowers urine
pH, have been given. A metabolite of etodolac (Lodine), also produces false positive test
results.6

False negative test results may occur in urine samples with high ascorbic acid or nitrite
concentration.5

Ketones

Acetone, acetoacetic acid, and beta-hydroxybutyric acid are ketones. Glomeruli freely
filter ketones and the tubules then resorb them completely. If the tubular resorptive
capacity is saturated, then the ketones are incompletely resorbed, resulting in ketonuria.
Ketonuria occurs quickly in younger animals and is more easily detected than
ketonemia. Ketonuria does not signify renal disease, but rather excessive lipid or
defective carbohydrate metabolism.1

Dipstick tests are semiquantitative and only detect acetone and acetoacetic acid.
Reagent strips contain nitroprusside that does not react with beta-hydroxybutyric acid.1,5

Ketonuria may be caused by starvation, insulinoma, diabetic ketoacidosis, persistent

hypoglycemia, high fat low carbohydrate diets, and glycogen storage disease1,5.

False positive test results may occur if urine is pigmented, or has high concentrations of
levodopa metabolites.5,6

False negative test results are uncommon in fresh urine, but may occur if urine samples
are old. Ketones are very volatile and can evaporate quickly.5,6

Urobilinogen

Urobilinogen is formed by intestinal bacteria from the breakdown of conjugated bilirubin.

Urobilinogen is usually excreted in feces, however a small amount may be reabsorbed
and excreted in urine. This test is not of significant value in animals.1,5

The dipstick method measures urobilinogen by reacting with p-

diethylaminobenzaldehyde in an acid environment.6

A positive test response indicates normal enterohepatic circulation of biliary pigments.

High concentrations of biliary pigments may occur in hemolytic crisis, or cases of hepatic
or intestinal dysfunction.1

A false positive test result may occur if the temperature of the reagent strip is elevated.6

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A false negative test result may occur if there is formalin residue in the collection
container, or if the sample is old, because urobilinogen is very unstable when exposed to
light and air.6

Nitrite

The nitrite portion of the dipstick analysis has limited value in veterinary medicine. This is
due to the high number of false negative test results in small animals. Nitrites occur in
urine during some bacterial infections. In order to achieve an accurate positive test
result, the urine must have been retained in the bladder at least 4 hours. Therefore, it is
best to collect a (first) morning sample or ensure the patient has not urinated in at least 4
hours.1,5

A positive test indicates a bacterial infection. Gram negative rods are more likely
produce a positive test response.6

Negative test results do not exclude infection. The urinary tract infection may involve
organisms that do not convert nitrites, or the urine may not have been held in the
bladder greater than 4 hours.6

Leukocytes

The leukocyte test detects the presence of white blood cells or partial cells in the urine.
In dogs, this test is indicative of pyuria but false negative test results often occur.5

Leukocytes are measured by a reaction of the esterases in leukocytes that catalyze

reaction of pyrrole amino acid ester to release 3-hydroxy-5-phenol pyrrole.5,6

False positive test results often occur in cats, and this test is clinically unreliable.5 False
positive test results also may occur in the event of fecal contamination.

False negative test results may develop if the patient has been treated with high doses
of tetracycline or other antibiotics. Glucosuria or increased urine specific gravity may
cause false negative test results.6 False negative test results may be observed with
voided urine samples obtained from animals with pyometra or prostatitis.

Conclusion

The dipstick portion of urinalysis is an important diagnostic and monitoring laboratory

test system. There are certain techniques of sample collection, handling and testing that
should be followed closely to ensure accurate results. The causes of false positive and
negative test results also should be considered when evaluating urine dipstick results.
Because the dipstick test is easy to perform and economical, all veterinary practices
should be able to perform this test in house rather than submitting samples to an outside
laboratory. In house laboratory analysis also provides more accurate results and
prevents age-induced artifacts that may lead to false positive and false negative test
results.

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Table 1. Potential causes of error when evaluating urine via dipstick method5

• Refrigerated urine sample not returned to room temperature prior to testing

• Urine contaminated with disinfectant – from skin or cleaning prior to collection
• Expired reagent strips
• Improper storage with exposure to air or light
• Leakage of reagent chemical from one test to another if the test is read vertically
rather than horizontally
• Tests read at inappropriate times
• Highly pigmented urine
• Failure to use control urine to check accuracy of strip

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Table 2. Summary of Dipstick Analysis

Parameter Expected Interpretation of Results Causes of False Causes of False

Results Positives (or Negatives (or
Increase) Decrease)

Specific 1.005 to moderate to high alkaline urine

Gravity 1.065 levels of protein

pH 5.0 to 6.0 Acidic: meat diet; acidosis; low glucose in urine

chloride; acidifying agents
Alkaline: vegetable based diet;
bacterial infection; alkalosis;
urine exposed to air for
extended times; administration
of alkalinizing agents;
postprandial tide

Glucose Negative Positive: Chronic or transient hydrogen peroxide; ascorbic acid;

to Trace hyperglycemia; post bleach ketones; increased
administration of certain drugs; specific gravity;
rarely-fanconi-like syndrome cold urine; expired
reagent strips

Protein Negative hemorrhage; urinary infection; alkaline urine; dilute or acidic urine
to Trace intravascular hemolysis; renal disinfectant residue
disease

Blood Negative Positive: hematuria: trauma, bleach poorly mixed urine

infection, inflammation, contamination; high
infarction, calculi, neoplasia, or levels of bromide or
coagulopathy hemoglobinuria: iodide; bitch in heat
myoglobinuria

Bilirubin Negative Positive: can be normal in high doses of ascorbic acid;

dogs; ALWAYS abnormal in chlorpromazine; nitrates
cats; indicates liver disease, etodolac
bile duct obstruction, starvation; metabolites
hemolysis; pyrexia

Ketones Negative Positive: starvation; insulinoma; pigmented urine old urine sample
diabetes mellitus; persistent
hypoglycemia; high fat low
carbohydrate diets; glycogen
storage disease

Urobilinogen 0.2 to 1.0 Positive: hemolytic crisis; elevated reagent old urine sample,
mg/dL intestinal or hepatic dysfunction strip temperature formalin residue in
collection container

Nitrite Negative bacterial infection common in small

animals

Leukocytes Negative pyuria common in cats, often occurs;

and if fecal tetracycline; high
contamination glucose; high
specific gravity;
voided sample in
animal with
pyometra or
prostatitis

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Bibliography

1. Duncan, J.R., Prasse, K.W., & Mahaffey, E.A.. Veterinary Laboratory Medicine:
Clinical Pathology.3rd ed. Iowa State University Press, Ames, 1994. pp 162-183.

2. Ling, G.V.. Techniques of urine collection and handleing. In: Ling [Link] Urinary
Tract Diseases of Dogs and Cats. St. Louis, Mosby, 1995. pp 23-28.

3. Zinkl, J.G. in Cowell, R.L., Tyler, R.D., & Meinkoth, J.H.. Urinary Sediment and
Cytology of the Urinary Tract. in Diagnostic Cytology and Hematology of the Dog and
Cat. 2nd ed. Mosby, Inc, St. Louis, 1999. pp 211-229.

4. Osborne, C.A., Low, D.G., & Finco, D.R.. Canine and Feline Urology. [Link]
Co., Philadelphia, 1972. pp 25-61.

5. Chew, D.J & DiBartola, S.P.. Interpretation of Canine and Feline Urinalysis. Ralston
Purina Co., St Louis, 1998. pp1-21.

6. Package insert for BAYER Multistix® 10SG · Multistix® 9 · Multistix® 9 SG · Multistix® 8

SG · Multistix® 7 · N-Multistix® SG · Multistix® 9 · N-Multistix® · Multistix® SG · Multistix® ·
Bili-Labstix® Reagent Strips. Bayer Corporation, Elkhart, 1992.

7. Package Insert fro Ictotest® Reagent Tablets for Urinalysis. Bayer Corporation,
Elkhart, 1995.

8. Package Insert for Acetest® Reagent Tablets. Miles, Inc, 1980

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