Urine Analysis 1- Physical Examination 2- Chemical Examination 3- Microscopic Examination 4- Microbiological Examination

Collection of Urine for Analysis Urine is collected period of 24 hours. Urine is collected over a period of 24 hours. preservative (as toluene, chloroform, thymol & formalin) is added to prevent contamination of the urine A preservative (as toluene, chloroform, thymol & formalin) is added to prevent contamination of the urine keeping urine in refrigerator is greatly advisable especially in hot weather. keeping urine in refrigerator is greatly advisable especially in hot weather. Urine Analysis

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

Volume: 1- Volume: 24 hours Normal urine volume in 24 hours is ml Polyuria 1- Urine volume increases (Polyuria) in the following conditions: Physiological:  Increased fluid intake  DiureticPathological:  Diabetes mellitus  Diabetes mellitus (type-1 & type-2)  Diabetes insipidus  Diabetes insipidus (due to decrease of ADH)  Chronic renal failure Oliguria or anuria 2- Urine volume decreases (Oliguria or anuria) in the following conditions:  Dehydration  Acute renal failure  Obstruction

Specific gravity (SG): 2- Specific gravity (SG): solute concentration Specific gravity measures solute concentration (urea and sodium). Normally the specific gravity ranges between Increased in 1- Increased in Dehydration (with oliguria) Diabetes Mellitus Diabetes Mellitus (with polyuria) Acute renal failure Acute renal failure (with oliguria) Decreased in 2- Decreased in Diabetes insipidus Diabetes insipidus (with polyuria) Physical Examination URINE ANALYSIS Physical Examination

Appearance: 3- Appearance: Normal fresh urine: clear (transparent) Abnormal : Cloudy urine may indicate possible abnormal constituents such as white cells, epithelial cells, crystals and bacteria. N.B. Stored urine with no preservative & no cooling may turn clear urine samples into cloudy. Physical Examination URINE ANALYSIS Physical Examination

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

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

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

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

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

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

Normal Constituents of Urine Normal urine contains about 50g of solids dissolved in about 1.5 liters of water per day. Urine contains organic and inorganic solids. A) Chief Inorganic Solids Sodium, potassium & chlorides Smaller amounts of calcium, magnesium, sulfate & phosphates Traces of iron, copper, zinc and iodine. B) Chief Organic Solids: 1- Non-protein nitrogen: amino acids, ammonia, urea, uric acid, creatine & creatinine 2- Organic acids: lactic acid, citric acid & oxalic acid ketone bodies (few amounts) 3- Sugars: Normally not more than 1g of sugars is excreted in the urine per day. Sugars cannot be detected by ordinary tests. Very small amounts of glucose not exceeding 150 mg of glucose are normally excreted per day. Other sugars present in urine are: pentose and lactose. Lactosuria occurs in infant and in women during the late months of pregnancy and during lactation Chemical Examination URINE ANALYSIS Chemical Examination

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

Proteins: (proteinuria) 1- Proteins: (proteinuria) Proteinuria Presence of more than 150 mg proteins in urine in 24 hours detected by ordinary laboratory means heavy proteinuria heavy proteinuria : ＞ 4 gm/24 hours moderate proteinuria moderate proteinuria: gm/24 hours minimal proteinuria minimal proteinuria: ＜ 1.0 gm/24 hours Chemical Examination URINE ANALYSIS Chemical Examination

Proteins: (proteinuria) 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 multiple myeloma synthesized by malignant plasma cells (multiple myeloma). It precipitates at 60 o C, redidssolves at 100 o C and reprecipitates on cooling. 2-Renal proteinuria: Severe muscular exercise After prolonged standing Acute glomerulonephritis Acute glomerulonephritis Nephrotic syndrome Nephrotic syndrome 3- Postrenal proteinuria: Lower urinary tract inflammation, tumors or stones. Lower urinary tract inflammation, tumors or stones. Chemical Examination URINE ANALYSIS Chemical Examination

Sugars: (glycosuria) 2- Sugars: (glycosuria) Glucose (Glucosuria); 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 & herditary fructose intolerance (Metabolic disorders of fructose). Galactose (Galactosuria): Galactose (Galactosuria): Presence of galactose in urine& may be due to: - Alimentary causes following the ingestion of large amount of galactose. - Galactosemia Chemical Examination URINE ANALYSIS Chemical Examination

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

4- Bilirubin (bilirubinuria) Billirubin appears in urine in cases of: Hepatocellular Jaundice: Hepatocellular Jaundice: as in viral hepatitis as in viral hepatitis Obstructive Jaundice Obstructive Jaundice as any cause of obstruction of bile duct as any cause of obstruction of bile duct Chemical Examination URINE ANALYSIS Chemical Examination

Nitrites 5- Nitrites In bacteruria in urine (in cases of Urinary Tract Infection, UTI) In bacteruria in urine (in cases of Urinary Tract Infection, UTI) Chemical Examination URINE ANALYSIS Chemical Examination

MICROSCOPIC URINE EXAMINATION Specimen of Choice: Specimen of Choice: First morning, midstream, clean catch urine specimen. This specimen is preferred since it is most concentrated and thus small amounts of abnormal constituents are more likely to be detected Procedure: Procedure: 1- By pouring the urine sample into a test tube & centrifuging it (spinning it down in a machine) for a few minutes. 2- The top liquid part (the supernatant) is discarded. 3- The solid part left in the bottom of the test tube (the urine sediment) is mixed with the remaining drop of urine in the test tube and one drop is analyzed under a microscope.

Urine is examined microscopically for: 1- Cells 2- Casts 3- Crystals 4- Parasitic ova. MICROSCOPIC URINE EXAMINATION

MICROSCOPIC URINE EXAMINATION Cells Red Blood Cells (RBCs) Normally: < 3 RBCs / HPF Hematuria is the presence of abnormal numbers of red cells in urine Types of Hematuria: 1- Gross hematuria 1- Gross hematuria Means that the blood can be seen by the naked eye. The urine may look pink, brown or bright red. 2- Microscopic hematuria Means that the urine is clear, but blood cells can be seen when urine is examined under microscope. Causes of hematuria: Glomerular damage : as in acute glomerulonephritis Glomerular damage : as in acute glomerulonephritis Tumors Tumors Urinary tract stones Urinary tract stones Upper & lower urinary tract infections Upper & lower urinary tract infections

MICROSCOPIC URINE EXAMINATION Cells White Blood Cells (WBCs) Normally WBCs: < 5 cells / HPF Normally : WBCs: < 5 cells / HPF Pyuria (Pus in Urine) Refers to the presence of abnormal numbers of WBCs that may appear with: Urinary tract Infection - Urinary tract Infection : upper or lower - Acute glomerulonephritis - Acute pyelonephritis Repeated sterile cultures in presence of pyuria may indicate: antibiotic therapy -The patient is on antibiotic therapy organism that does not grow -The presence of an organism that does not grow on ordinary media as T.B. Non- bacterial -Non- bacterial urethritis or cystitis as viral infection

MICROSCOPIC URINE EXAMINATION Cells Epithelial Cells Renal tubular epithelial cells contain a large round or oval nucleus & normally slough into the urine in small numbers. The number sloughed renal epithelial cells is increased in: The number sloughed renal epithelial cells is increased in: Nephrotic syndrome (Glomerular) - Nephrotic syndrome (Glomerular) Renal tubular degeneration (Tubular) - Renal tubular degeneration (Tubular)

MICROSCOPIC URINE EXAMINATION Casts Acellular casts Hyaline casts Granular casts Waxy casts Fatty casts Pigment casts Crystal casts Cellular casts Red cell casts White cell casts Epithelial cell cast Types of Casts distal convoluted tubule Urinary casts are formed only in the distal convoluted tubule collecting duct (DCT) or the collecting duct.

MICROSCOPIC URINE EXAMINATION Casts Hyaline casts Hyaline casts Hyaline casts composed of a mucoprotein (Tamm- Horsfall protein) tubular cells secreted by tubular cells.

Hyaline casts Hyaline casts cont. The factors which favor protein cast formation are: Low flow rate High salt concentration Low pH All of which favor protein denaturation and precipitation. Protein casts with long thin tails formed at the junction of Henle's loop and the distal convoluted tubule are called cylindroids. H yaline casts are seen in 1- Healthy persons 2- Physiological (as in fever, strenuous exercise) Glomerular 3- Glomerular damage (as in nephrotic syndrome) MICROSCOPIC URINE EXAMINATION Casts Hyaline casts Hyaline casts cont.

Granular casts Granular casts can result either from the breakdown of cellular casts (if persist for long duration in tubules) resulting in appearance of aggregation of contents of cells without the cell membranes Or result from the inclusion of aggregates of plasma proteins (e.g. albumin) or immunoglobulin light chains to a hyaline cast chronic renal disease indicative of chronic renal disease MICROSCOPIC URINE EXAMINATION Casts Granular casts

MICROSCOPIC URINE EXAMINATION Casts Waxy casts Waxy casts renal failure (end stage renal disease) Suggest severe longstanding kidney disease such as renal failure (end stage renal disease) They may appear as an advanced stages of granular casts They may appear as an advanced stages of granular casts

MICROSCOPIC URINE EXAMINATION Casts Fatty casts hyaline casts with fat globule inclusions Formed by the breakdown of lipid-rich epithelial cells, these are hyaline casts with fat globule inclusions They can be present in: Nephrotic syndrome Nephrotic syndrome (due to cholesterol increase in urine) Diabetic or lupus nephropathy Diabetic or lupus nephropathy Acute tubular necrosis Acute tubular necrosis (damage of tubular cells with release of fat contents into hyaline casts)

Red Blood Cells Casts Red blood cells may stick together and form red blood cell casts. RBCs casts are indicative of: 1- Glomerulonephritis 1- Glomerulonephritis with leakage of RBC's from glomeruli Severe tubular damage 2- Severe tubular damage MICROSCOPIC URINE EXAMINATION Casts Red Blood Cells Casts

White blood cell casts kidney Indicate inflammation of the kidney as such casts will not form except in the kidney Acutepyelonephritis (most common cause) 1- Acute pyelonephritis (most common cause) Glomerulonephritis 2- Glomerulonephritis. MICROSCOPIC URINE EXAMINATION Casts White blood cell casts

MICROSCOPIC URINE EXAMINATION Casts Epithelial casts Epithelial casts This cast is formed by inclusion or adhesion of desquamated epithelial cells of the tubule lining the casts These can be seen in Acute tubular necrosis Acute tubular necrosis

MICROSCOPIC URINE EXAMINATION Crystals Crystals in acidic urine  Uric acid  Calcium oxalate  Cystine  Leucine Crystals in alkaline urine  Ammonium magnesium phosphates (triple phosphate crystals)  Calcium carbonate

Uric Acid Crystals Triple Phosphate Crystals Calcium Oxalate Crystals CystineCrystals MICROSCOPIC URINE EXAMINATION Crystals

crystals