URINE EXAMINATION
Examination of urine is important for diagnosis and assistance in the diagnosis of various diseases.
Routine examination of urine is discussed under four headings:
A. Adequacy of specimen
B. Physical/gross examination
[Link] examination
D. Microscopic examination
ADEQUACY OF SPECIMEN
1. Specimen collection
2. Methods of Preservation of Urine
Urine should be examined fresh or within one hour of voiding. But if it has to be delayed then following
preservation procedures can be followed which prevent its decomposition
i. Refrigeration at 4°C.
ii. Toluene: Toluene is used 1 ml per 50 ml of urine. It acts by forming a surface layer and if
preserves the chemical constituents of urine.
iii. Formalin: 6-8 drops of 40% formalin per 100 ml of urine is used. It preserves RBCs and pus
cells. However, its use has the disadvantage that it gives false-positive test for sugar.
iv. Thymol. It is a good preservative; 1% solution of thymol is used. Its use has the disadvantage
that it gives false- positive test for proteins.
V. Acids: Hydrochloric acid, sulfuric acid and boric acid can also be used as a preservative.
PHYSICAL EXAMINATION
Physical examination of urine consists of volume, colour, odour, reaction/pH and specific gravity.
Volume
Normally, 700-2500 ml (average 1200 ml) of urine is passed in 24 hours and most of it is passed during
day time.
i) Nocturia It means when urine is passed in excess of 500 ml during night. This is a sign of early renal
failure.
ii) Polyuria As the name indicates, polyuria is excess passing of urine in 24 hours (>2500 ml). Polyuria can
be physiological due to excess water intake, may be seasonal (e.g. in winter), or can be pathological (e.g.
in diabetes insipidus, diabetes mellitus).
iii) Oliguria This term is used when less than 500 ml of urine is passed in 24 hours. Oliguria can be due to
less intake of water, dehydration, or renal ischaemia.
iv) Anuria When there is almost complete suppression of urine (<150 ml) in 24 hours, it is termed anuria.
It can be due to renal stones, tumours, or renal ischaemia.
Colour
Normally urine is clear, pale or straw-coloured due to pigment urochrome. Various colour changes in
urine may be as under:
[Link] in diabetes mellitus, diabetes insipidus, excess intake of water.
ii. Deep amber colour due to good muscular exercise, high gread fever.
iii) Orange colour due to increased urobilinogen, concen- treated urine.
iv) Smoky urine due to administration of vitamin B12, aniline dye.
v) Red due to haematuria, haemoglobinuria.
vi) Brown due to bile.
vii) Milky due to pus, fat.
viii) Green due to putrefied sample, phenol poisoning.
Odour
Normally urine has faint aromatic odour. It may have following abnormal odours:
i) Pungent due to ammonia produced by bacterial contamination.
ii) Putrid due to UTI.
iii) Fruity due to ketoacidosis.
iv) Mousy due to phenylketonuria
Reaction/pH
It reflects ability of the kidney to maintain H+ ion concentration in extracellular fluid and plasma. It
can be measured by pH indicator or by electronic pH meter.
Freshly voided normal urine is slightly acidic and its pH ranges from (average 6.0). Abnormalities in
pH may be as under:
Acidic urine i.e. pH may be lower than normal due to following conditions:
i. High protein intake, e.g. meat.
[Link] of acidic fruits.
iii. Respiratory and metabolic acidosis.
iv. UTI by E. coli.
Alkaline urine i.e. pH more than 7 may occur due to following:
i. Citrus fruits, certain vegetables.
[Link] and metabolic alkalosis.
iii. UTI by Proteus, Pseudomonas.
Specific Gravity
This is the ratio of weight of 1 ml volume of urine to that of weight of 1 ml of distilled water. It depends
upon the concentration of various particles/solutes in the urine. Specific gravity is used to measure the
concentrating and diluting power of the kidneys. It can be measured by -
1. Urinometer
2. Refractometer
3. Reagent strips.
Significance of Specific Gravity
The normal specific gravity of urine is 1.003 to 1.030.
Low specific gravity urine occurs in:
i. Excess water intake
ii. Diabetes insipidus
High specific gravity urine is seen in:
ii. Albuminuria
iii. Glycosuria.
Fixed specific gravity (1.010) of urine is seen in:
i. ADH deficiency
ii. Chronic kidney disease (CKD).
CHEMICAL EXAMINATION
Chemical constituents frequently tested in urine are glucose, ketones, bile derivatives and blood.
Proteinuria
If urine is not clear, it should be filtered or centrifuge testing for Urine may be tested for pro qualitative
tests and quantitative methods.
Qualitative method Quantitative method
Heat and acetic acid test Esbach’s albuminometer method
Sulphosalicylic acid test Turbidimetric method
Heller’s test
Reagent strip method
Causes of Proteinuria -
Normally, there is a very scanty amount of protein in urin which cannot be detected by usual tests (<
150 mg/day).
Heavy proteinuria (> 3 gm/day) occurs due to:
i. Nephrotic syndrome
ii. Renal vein thrombosis
iii. Diabetes mellitus
iv SLE
Moderate proteinuria (1-3 gm/day) is seen in:
i. Nephritic syndrome
ii. Nephrosclerosis
iii. Multiple myeloma
iv. Pyelonephritis
Mild proteinuria (< 1.0 gm/day) occurs in:
i. Hypertension
ii. Polycystic kidney iii. Chronic pyelonephritis
iv. UTI
v. Fever.
Glucosuria
Glucose is by far the most important of the sugars which may appear in urine. Normally, approximately
130 mg of glucose per 24 hours is passed in urine which is undetectable routine qualitative tests.
Tests for glucosuria may be qualitative or quantitative.
Qualitative Tests
These are as under:
[Link]'s test
2. Reagent strip test
Benedict's Test
In this test cupric ion is reduced by glucose to cuprous oxide and a coloured precipitate is formed.
Interpretation -
No change of blue colour = Negative
Greenish colour = traces (<0.5 g/dl)
Green/cloudy green ppt =1 (0.5-1 g/dl)
Yellow ppt = +2 (1-1.5 g/dl)
Orange ppt = +3 (1.5-2 g/dl)
Brick red ppt =+4(>2 g/dl)
Causes of Glucosuria
i. Diabetes mellitus
ii. Renal glucosuria
iii. Alimentary glucosuria
[Link] causes (hyperthyroidism, hyperpituitarism, hyperadrenalism)
[Link] of corticosteroids.
[Link] burns
viii. Severe sepsis , Pregnancy.
Ketonuria
Ketones are products of incomplete fat metabolism. The three ketone bodies excreted in urine are:
acetoacetic acid (20%), acetone (2%), and B-hydroxybutyric acid (78%).
Tests for Ketonuria
1. Rothera's test
2. Gerhardt's test
3. Reagent strip test
1. Rothera's Test - Principle Ketone bodies (acetone and acetoacetic acid) combine with alkaline solution
of sodium nitroprusside forming purple complex.
Interpretation Appearance of purple or permanganate coloured ring at the junction indicates presence
of ketone.
Causes of Ketonuria
i. Diabetic ketoacidosis
ii. Dehydration
iii. Hyperemesis gravidarum
iv. Fever
V. Cachexia
vi. After general anesthesia.
Bile Derivatives in Urine
Three bile derivatives excreted in urine are: urobilinogen bile salts and bile pigments. While urobilinogen
is normally excreted in urine in small amounts, bile salts and bile pigments appear in urine in liver
diseases.
Tests for Bile Salts
Bile salts excreted in urine are cholic acid and chenodeox cholic acid.
Tests for bile salts are Hay's test and strip method.
1. Hay's Test - Principle If bile salts are present in urine, they lower t surface tension of the urine.
Interpretation if bile salts are present in the urine, sulphur powder sinks, otherwise it floats.
Causation – obstructive jaundice
Microscopic examination
[Link] of sample
B. Preparation of sediment
C. Examination of sediment
D. Automation
Collection of sample -
Early morning sample is the best specimen. It provides an acidic and concentrated sample
which preserves the formed elements (rbcs, wbcs and casts) which otherwise tend to lyse in a hypotonic
or alkaline urine. The specimen should be examined fresh or within 1-2 hours of collection.
Preparation of sediment
Take 5-10 ml of urine in a centrifuge tube. Centrifuge for 5 minutes at 3000 rpm.
Discard the supernatant.
Resuspend the deposit in 0.5-1 ml of urine left. Place a drop of this on a clean glass slide.
Place a coverslip over it and examine it under the microscope.
Examination of sediment
Urine is an unstained preparation and its microscopic examination is routinely done under reduced light
using the light microscope.
Following constituents observe in urine –
Cells –RBC ,WBC ,Epithelial cells
Casts
Crystals
Miscellaneous structure.
[Link] – Significance Normally 0-2 RBCs/HPF may be passed urine. RBCs in excess of this number are
seen in urine in the following conditions:
Physiological -
i. Following severe exercise
ii. Smoking
iii. In menstruating females
Pathological -
i. Renal stones
ii. Kidney tumors
[Link]
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2. WBC –
Significance Normally 0-4 WBCs/HPF may be present in females. WBCs are seen in urine in following
conditions:
i. UTI
ii. Cystitis iii. Prostatitis
iv. Chronic pyelonephritis
v. Renal stones
vi. Renal tumour
3. Epithelial Cells -
These are round to polygonal cells with a round to oval, small to large nucleus. Epithelial cells in urine
can be squamous epithelial cells, tubular cells and transitional cells i.e. they can be from lower or upper
urinary tract, and sometimes, it is difficult to distinguish between different types of these cells. At times,
these cells can be confused with cancer cells.
When these cells are present in large number along with WBCs, they are indicative of inflammation.
Casts –
Depending upon content following types –
e.g.
[Link] casts - CKD ,fever
[Link] casts –fat necrosis
[Link] casts
[Link] casts – CRF
Crystals –
e.g.
Calcium oxalate ,uric acid , cysteine , tyrosin etc.
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