ANALYSIS OF URINE AND BODY FLUIDS (LECTURE)

4. Sediment Examination (microscopic; serve as

- Urinalysis is the testing of urine with procedures the gold standard)
commonly performed in an expeditious, reliable,
accurate, safe, and cost-effective manner (CLSI).
- Manual procedure: 30 minutes
- Automated procedure: 6 minutes

HISTORY OF URINALYSIS
- Analyzing urine was actually the beginning of
laboratory medicine.
- References to the study of urine can be found in
the drawings of cavemen and in Egyptian
hieroglyphics, such as the Edwin Smith Surgical
Papyrus.
- They were able to obtain diagnostic information
from such basic observations as color, turbidity,
odor, volume, viscosity, and even sweetness - Converts approximately 170,000 mL of filtered
plasma to 1,200 mL to 1,500 mL of average daily
History urine output
• 5th BC: Hippocrates wrote a book on “Uroscopy”
• Middle Ages: Physicians were trained on the
“Art of Uroscopy”
• 1140 AD: Color charts were developed to
describe significance of 20 different colors
• 1627: Thomas Bryant published a book on
charlatans called “pisse prophets”
o Pisse prophets – prediction about health
without proper medical educational
background (quack doctors)
- 95% water + 5% solutes
o 1st medical licensure laws in England
- Variation in solute concentration may be due to:
• 1694: Frederik Dekker discovered albuminuria
o Dietary intake (ex. high sodium and
(white precipitates) by boiling urine.
glucose level)
• 17th century: invention of the microscope by o Physical activity (ex. high physical
Anton Van Leeuwenhoek; Thomas Addis activity → high metabolic processes)
developed quantifying the microscopic sediment o Body’s metabolism (results to high waste
(Addis count – quantitation of formed elements products)
in the urine) o Endocrine functions (ex. problem in
• 1827: Richard Bright introduced urinalysis as antidiuretic hormone)
part of a doctor’s routine patient examination o Body’s position (prolonged standing can
cause increase protein, orthostatic or
IMPORTANCE OF URINALYSIS postural proteinuria)
- Unique Characteristics of Urine:
o Readily available & easily collected SOLUTES
o Contains information which can be ➢ Organic Solutes
obtained by inexpensive lab tests about o Urea – major metabolic waste product
the body’s major metabolic functions ▪ Produced by the liver due to
breakdown of protein and
REASONS FOR PERFORMING URINALYSIS amino acids
- Aiding in diagnosis of disease ▪ The amount of urea accounts
- Screening asymptomatic population for nearly half of the total dissolved
undetected disorders (especially for metabolic solids in urine
diseases) ▪ Highest
- Monitoring the progress of disease & o Creatinine: product of muscular
effectiveness of therapy metabolism
o Uric acid: product of purine metabolism
4 PARTS OF ROUTINE URINALYSIS ➢ Inorganic Solutes: chloride (major inorganic solid
dissolved in urine), sodium, and potassium
1. Specimen Evaluation (accept or reject the
➢ Other substances present: hormones, vitamins,
specimen)
and medications
2. Physical Examination (check for the physical
➢ Formed elements present: Increased amounts
characteristic of the urine)
of formed elements, such as cells, casts, crystals,
3. Chemical Examination (detect the presence of
mucus, and bacteria, are often indicative of
different analytes and serves as a confirmatory
disease
for the physical examination)
 ANALYSIS OF URINE AND BODY FLUIDS (LECTURE)

COMPOSITION OF URINE SPECIMEN PRESERVATION

COLLECTED FOR 24 HOURS - Most routinely used method of preservation:
Organic
Amount Remark
o Refrigeration (2⁰C to 8⁰C)
Component o Decreases bacterial growth and
60%–90% of nitrogenous material;
25.0 to metabolism
Urea derived from metabolism of amino
35.0 g
acids into ammonia
Derived from creatine, nitrogenous
Creatinine 1.5 g
substance in muscle tissue
Common component of kidney stones;
0.4 to
Uric acid derived from catabolism of nucleic
1.0 g
acid in food and cell destruction
Benzoic acid is eliminated from the
Hippuric
0.7 g body in this form; increases with
acid
highvegetable diets
Carbohydrates, pigments, fatty acids,
Other
2.9 g mucin, enzymes, hormones;
substances
depending on diet and health

Inorganic
Amount Remark
Component
Prevents enzyme enolase
Sodium
15.0 g Principal salt; varies with intake
chloride (NaCl)
Occurs as chloride, sulfate, and
Potassium (K) 3.3 g
phosphate salts
Sulfate (SO4 2) 2.5 g Derived from amino acids
Occurs primarily as sodium
Phosphate
2.5 g compounds that serve as buffers
(PO4 3)
in the blood
Derived from protein metabolism
Ammonium and glutamine in kidneys; amount
0.7 g
(NH4) varies depending on blood and
tissue fluid acidity
Magnesium Occurs as chloride, sulfate,
0.1 g
(Mg2) phosphate salts
Composed of 50% ethanol
Occurs as chloride, sulfate, and 2% carbowax
Calcium (Ca2) 0.3 g
phosphate salts
Commercial Urine Transport Tubes
with Preservatives
- urine specimen is so readily available and easily
collected often leads to laxity in the treatment of
the specimen after its collection.
- Changes in urine composition take place not only
in vivo but also in vitro
o requiring correct handling procedures

SPECIMEN INTEGRITY
- specimens should tested within 2 hours
- A specimen that cannot be delivered and tested • Urine (biohazardous substance) Standard
within 2 hours should be refrigerated or have an Precautions
appropriate chemical preservative added. • Clean, dry, leak-proof, disposable containers
- Notice that most of the changes are related to
• Sterile containers for culture and sensitivity
the presence and growth of bacteria
• Properly applied screw-top lids
• Wide mouth (4 to 5 cm), flat bottom
SPECIMEN INTEGRITY • Clear plastic (50 mL to 100 mL capacity)
o 12 mL microscopic
o repeat analysis
o there should be room for swirling

SPECIMEN LABEL
• Patient’s name
• Identification number
• Date and time of collection
• Patient’s age and location
• Physician’s name
o Others (as required by institutional
protocol)
o Attached to the container, not to the lid
o Should not become detached if the
container is refrigerated or frozen
 ANALYSIS OF URINE AND BODY FLUIDS (LECTURE)

REQUISITION FORM GLUCOSE TOLERANCE SPECIMENS

• Requisition form (manual or computerized) - The urine is tested for glucose and ketones, and
• Match the information on the specimen label the results are reported along with the blood test
• Additional information on the form: results as an aid to interpreting the patient’s
o Method of collection ability to metabolize a measured amount of
o Type of specimen glucose and are correlated with the renal
o Interfering medications threshold for glucose.
o Patient’s clinical information - Renal threshold for glucose: 160-180 mg/dL
o Time specimen is received in the - Collection of these specimens is an institutional
laboratory option.
- Usually performed for pregnant women
SPECIMEN REJECTION - The number of specimen varies with the length
• Unlabeled containers of test for GTT includes:
o 1-hour postprandial
• Nonmatching labels and requisition forms
o 2-hour postprandial
• Contaminated with feces or toilet paper
o 3-hour postprandial
• Containers with contaminated exteriors
• Specimens of insufficient quantity (12 or 10-15
mL is enough to do the testing) TIMED SPECIMEN
- Example of timed specimen includes:
URINE CONFIRMATION o 24-hour: to quantitate amount of solute
➢ Specific Gravity: 1.003-1.035 in the urine (creatinine, urea, uric acid)
o Increased if the patient undergoes MRI o 12-hour: usually used for addis count
o Decreased in cases of adulteration (quantitation of formed elements in the
▪ 1.002 is still accepted if the urine)
patient has diabetes insipidus o 4-hour: for nitrite determination to
➢ pH: 4.0-8.0 detect whether the bacteria found in the
➢ Temperature: 32.5°C to 37.5°C urine can convert nitrate to nitrite
➢ Creatinine: Approximately 50x that of plasma ▪ Usually used for patients with
cystitis or infection (UTI)
o afternoon urine: used for urobilinogen
(2pm to 4pm)
RANDOM URINE - Measuring the exact amount of a urine. A
- most commonly received specimen because of carefully timed specimen must be used to
its ease of collection and convenience. produce accurate quantitative results
- may be collected at any time - Required when the concentration of the
- useful for routine screening tests to detect substance to be measured changes with diurnal
obvious abnormalities variations and with daily activities such as
- may also show erroneous results resulting from exercise, meals, and body metabolism.
dietary intake or physical activity
Time Urine Collection Protocol
FIRST MORNING URINE • Provide patient with written instructions and
- ideal screening specimen collection container (with preservative, if
- preventing false-negative pregnancy tests and required)
for evaluating orthostatic proteinuria • At start time (e.g., 7 am on day 1), patient
- concentrated specimen (detection of chemicals empties bladder into toilet; afterward, all
and formed elements that may not be present in subsequent urine throughout timed interval is
a dilute random specimen) collected in the container provided
• At end time (e.g., 7 am on day 2), patient empties
FASTING SPECIMEN (SECOND MORNING) bladder into collection container.
- A fasting specimen differs from a first morning • Specimen is transported to laboratory, where
specimen by being the second voided specimen urine is mixed well and the volume is measured
after a period of fasting. and recorded.
- This specimen will not contain any metabolites • A sufficient volume (approximately 50 mL) is
from food ingested before the beginning of the removed for routine testing and possible repeat
fasting period. or additional testing; the remainder is discarded.
- It is recommended for glucose monitoring
CATHETERIZED SPECIMEN
TWO-HOUR POSTPRANDIAL SPECIMEN - The most commonly requested test on a
- specimen is tested for glucose, and the results catheterized specimen is a bacterial culture.
are used primarily for monitoring insulin therapy - Collected under sterile conditions by passing a
in persons with diabetes mellitus. hollow tube (catheter) through the urethra into
- A more comprehensive evaluation of the the bladder.
patient’s status can be obtained if the results of - Invasive procedure because the urine will flow
the 2-hour postprandial specimen are compared directly from the bladder through the use of
with those of a fasting specimen and catheter
corresponding blood glucose tests.
 ANALYSIS OF URINE AND BODY FLUIDS (LECTURE)

- If a routine urinalysis is also requested, the specimen. Macrophages containing lipids may
culture should be performed first to prevent also be present.
contamination of the specimen. - It uses three glasses: (three urine sample is used)
- A less frequently encountered type of o 1st glass: pre-massage
catheterized specimen measures functions in the ▪ Ex. first morning urine or
individual kidneys. Specimens from the right and random urine
left kidneys are collected separately by passing o 2nd glass: midstream clean-catch
catheters through the ureters of the respective ▪ Serve as control
kidneys. ▪ Increased bacteria or WBC
indicates UTI
2 Types of Catheterized Specimen ▪ Cannot rule out prostatitis
➢ Urethral: collect urine specimen up to the infection if positive (do not
urinary bladder proceed to 3rd specimen)
o Used to check if the patient has cystitis, o 3 glass: post-massage
rd

UTI, or urethral infection ▪ There should be presence of

o Kidney infection is uncertain bacteria and WBC (10x higher
➢ Ureteral: collect urine specimen up to the ureter compared to the first specimen)
o Used to check if the patient has
pyelonephritis (kidney infection) Stamey-Mears four-glass localization method
o To locate whether the infection is on the - To locate the infection
left, right, or both kidneys - Prostatitis: highest in EPS → VB3 → VB1 or VB2
- UTI: highest in VB2 → VB1 → VB3 → EPS
MIDSTREAM CLEAN-CATCH SPECIMEN - It uses four glasses:
- safer, less traumatic method for obtaining urine o Initial voided urine (VB1): for urethral
for bacterial culture and routine urinalysis. infection
- is less contaminated by epithelial cells and o midstream urine (VB2): to detect
bacteria and, therefore, is more representative whether the patient has urinary bladder
of the actual urine than the routinely voided infection (cystitis)
specimen. Patients must be provided with o expressed prostatic secretions (EPS):
appropriate cleansing materials, a sterile can be cultured and examine for white
container blood cells
- Strong bacterial agents, such as o Post-prostatic massage urine specimen
hexachlorophene or povidone-iodine, should not (VB3): pure prostatic secretion (urine
be used as cleansing agents. sample has prostatic secretion)
- Mild antiseptic towelettes are recommended
(Castile Soap Towelettes). Pre- and post-massage test (PPMT)
- A positive result is significant bacteriuria in the
post-massage specimen of greater than 10 times
the pre-massage count
- No need to do the midstream clean-catch

DRUG SPECIMEN COLLECTION

- most vulnerable part of a drug-testing program.
- The chain of custody (COC) is the process that
provides this documentation of proper sample
identification from the time of collection to the
receipt of laboratory results.
- Individuals who undergo drug testing are called
clients
- Should be collected within the facility
SUPRAPUBIC ASPIRATION
o Waterless system collection room
- Most invasive among the collection o Has bluing agent to toilet water
- Introduction of a needle through the abdomen reservoir to avoid tampering of sample
into the bladder. - that no tampering of the specimen occurred,
- Provides a sample for bacterial culture that is such as substitution, adulteration, or dilution
completely free of extraneous contamination. - collection may be witnessed or unwitnessed
- Can also be used for cytologic examination - Volume: 30-45 mL
- Temperature: 32.5 to 37.5°C (near body
PROSTATITIS SPECIMEN temperature)
Three-Glass Collection
- Quantitative cultures are performed on all
specimens, and the first and third specimens are
examined microscopically.
- In prostatic infection, the third specimen will
have a white blood cell/high-power field count
and a bacterial count 10 times that of the first