urinalysis [Autosaved].pptx how to interpret

urine
• urine is a liquid waste product of the body secreted by the kidneys by process of filtration from
blood. The average amount of urine excreted in 24 hours is about 1,200 cubic cm and normally,
it contains about 960 parts of water to 40 parts of solid matter.

Urine formation
• Urine is continuously formed by the
kidneys. It is an ultrafiltrate of plasma
from which glucose, amino acids, water,
and other substances essential to body
metabolism have been reabsorbed
•The kidney's ability to clear waste
products selectively from the blood
while maintaining the essential water
and electrolyte balances in the body is
controlled in the nephron by
•Glomerular filtration
• Tubular reabsorption
• Tubular secretion

Filtration
• The first step in urine formation is filtration of blood plasma at the nephrons.
• In the nephrons cells, proteins, and other large molecules are filtered out of the glomerulus by a
process of ultrafiltration, leaving an ultrafiltrate that resembles plasma (except that the
ultrafiltrate has negligible plasma proteins) to enter Bowman's space.

Reabsorption
• In the proximal tubule, 60% to 80% of the ultrafiltrate is reabsorbed
• Tubular reabsorption is the process by which solutes and water are removed from the tubular
fluid and transported into the blood.
• Please note: It is called reabsorption (and not absorption) because these substances have
already been absorbed once (in the intestines)

Secretion
• Tubular secretion is the transfer of materials from peritubular capillaries to renal tubular lumen.
• Tubular secretion is caused mainly by active transport.
• In the distal tubule, secretion is the prominent activity
• Usually only a few substances are secreted. These substances are present in great excess, or
are natural poisons.

urinalysis [Autosaved].pptx how to interpret

Complete urinalysis
• A urinalysis is a group of tests that detect and semi-
quantitatively measure various compounds that are eliminated
in the urine, including the byproducts of normal and abnormal
metabolism as well as cells, and cellular fragments.
• A complete urinalysis consists of three distinct testing
phases:
• Physical examination
• Chemical examination, and
• Microscopic examination

Why is urine analysis done?
• As a general evaluation of health
• To screen for a disease or infection of the urinary tract.
• To monitor the treatment of certain conditions such as diabetes,
kidney stones, a urinary tract infection (UTI), or some types of
kidney or liver disease.
• screening for drug abuse
• Diagnosis of some metabolic and endocrine disturbances in the
body such as DM
• Note: Many disorders can be diagnosed in their early stages
by detecting abnormalities in the urine.

Symptoms and conditions that
required urine test
• Discolored or foul-smelling urine
• Pain during urination
• Blood in the urine (hematuria)
• Frequent urination
• Abdominal pain, or back pain
• Pain during intercross (because of pus in prostatic secretion)
• Pregnant women to chick the risk of pregnancy toxemia

Preparation of patient before test
• Do not eat foods that can discolor the urine, as, beets.
• Do not exercise strenuously before a urine sample is taken.
• Because certain medications can discolor the urine, your doctor
may instruct you to stop taking the medications prior to the test.
• Patients do not have to fast or change their food intake before a
urine test.
• Urinalysis should not be performed while a woman is
menstruating or having a vaginal discharge.
• Note: A woman who must have a urinalysis while she has a vaginal discharge or is having her
period should insert a fresh tampon before beginning the test. She should also hold a piece of
clean material over the entrance to her vagina to avoid contaminating the specimen.

Precautions for urine analysis
• ideally the specimen should be analyzed shortly after collection
(within 1h)
• If examination can not be done directly after collection the
sample must be refrigerated within 1 hour of collection.
• If the specimen is not refrigerated within 1 hour of collection

Changes that occur
• Increased pH from the breakdown of urea to ammonia by urease-
producing bacteria)
• Decreased glucose from glycolysis and bacterial utilization
• Decreased ketones because of volatilization
• Decreased bilirubin from exposure to light
• Decreased urobilinogen as a result of its oxidation to urobilin
• Increased bacteria from bacterial reproduction
• Increased nitrite from bacterial reduction of nitrate
• precipitation of amorphous urate
• Changes in color caused by oxidation or reduction of metabolites
• Increased turbidity caused by bacterial growth and precipitation of
amorphous material
• Disintegration of red blood cells (RBCs) and casts, particularly in
dilute alkaline urine

• Generally, specimens that could lead to false interpretation should
be rejected such as:
• The sample must be of sufficient quantity { The widely accepted
urine volume is about 12 ml}
• Specimens that is contaminated from a woman's menstrual period.
• Not getting urine sample to lab in 2 hour.
• urine sample that is taken in dirty container
• Specimens that is contaminated with stool
• Before rejecting a specimen, we must consider that specimens may be unique and represent a
punctual situation in time and the patient will have to come back in the case of a rejected specimen.

Urine volume
• Urine volume measurements are part of the assessment for
fluid balance and kidney function.
• The normal volume of urine voided by the average adult in a
24-hour period ranges from 600 to 2500 ml; the typical amount
is about 1200 ml.
• The amount voided over any period is directly related to the
individual's fluid intake, the temperature and climate
• Note: The volume of urine produced at night is <700 ml, making
the day-to-night ratio approximately 2:1 to 4:1

urine output can be calculated as
follows:
1.Adult = >0.5 mL/Kg/hour.
2.Child = >1 mL/Kg/hour.
3.Neonate (< 1-year-old) = >2 mL/Kg/hour.

Physiological polyuria causes
• Cold climate
• Altitude diuresis (High-altitude diuresis occurs at altitudes above
10,000 ft)
• After drinking large amounts of fluids (polydipsia)
• during pregnancy (frequent urination)
• High protein diet: end product is urea which cause osmotic
diuresis and decrease reabsorption of water by PCT
• diuretic foods (foods and beverages containing caffeine, such
as chocolate, coffee, tea, and soft drinks; hot spicy foods; juices
high in acid; alcoholic beverages; etc.

Pathological polyuria causes
It occurs when urine amount exceeds 2000 mL/24 hours.
• Metabolic diseases
• diabetes mellitus (glucose in urine cause osmotic diuresis)
• hypercalcaemia (it leads to nephrogenic diabetes inspiidus)
• Renal diseases
• glomerulonephritis (inflammation of the glomeruli, or small blood vessels in the kidneys)
• Fanconi syndrome (a disorder in which the proximal tubular function of the kidney is impaired
resulting in decreased reabsorption of electrolytes and nutrients as glucose it may be inherited or
acquired )
• urinary tract infection Although it more commonly causes frequent passage of small volumes of
urine rather than a large volume
• Cystitis (a urinary bladder disease of unknown cause characterized by urinary frequency
,urgency, and pain in the bladder)

Cont..
• Endocrine diseases
• Diabetes inspidus ( caused by a deficiency of antidiuretic hormone)
• Hyperthyroidism (overproduction of circulating free thyroid hormones
(T4), (T3), leading to polyuria and Polydipsia - excessive thirst -)
• Hyperparathyroidism (causing excessive mobilization of ca+ from bone
so rise in plasma and its filtration in kidney renal tubules increase
causing calcification leads to nephrogenic diabetes inspidus)
• hypoaldosteronism (refers to decreased levels of the hormone
aldosterone leads to increased loss of Na+ into urine with increased
water excretion)
• Cushing's syndrome (also called hyperadrenocorticism and caused by
high levels of cortisol in the blood which sensitize hypothalamic ADH
secreting neurons and thus suppress of ADH secretion)

• Drugs causing Polyuria
• diuretic drugs as thiazides
• high doses of riboflavin (vitamin B2)
• high doses of vitamin C
• side effect of lithium (used in the treatment of psychiatric
disease)
• Note: High volume with High specific gravity may indicate D.mellitus while High volume with
low specific gravity may indicate D.Insipidus .

Physiological oliguria causes
1.It is seen when urine volume is less than 500 mL/ 24 hours.
This is seen in the following conditions.
• Hot climate
• Reduced fluid intake
• Exercise that cause sweating

Pathological oliguria causes
• Pre-renal causes (in response to hypoperfusion of the kidney)
• Dehydration caused by prolonged vomiting, diarrhea, massive bleeding or burns
• Cardiac insufficiency
• Renal causes (due to kidney damage)
• Nephritic syndrome (characterized by proteinuria and hematuria. By contrast, nephrotic
syndrome is characterized by only proteinuria)
• Renal ischemia (is the deficiency of blood in one or both kidneys, , usually due to obstruction of
a blood vessel.)
• Post-renal causes (as a consequence of obstruction of the urine flow)
• Enlarged prostate
• Tumor compression urinary outflow

• Postoperative oliguria
• Patients usually have decrease in urine output after a major operation
that may be a normal physiological response to:
• fluid/ blood loss – decreased glomerular filtration rate secondary to
hypovolemia and/or hypotension
• response of adrenal cortex to stress -increase in aldosterone (Na and
water retention)
• Note: Low volume with High specific gravity may indicate nephritic syndrome

Anuria
Also sometimes called anuresis and it means non passage of urine or no
urine output. But it is practically defined as passage of less than 50 ml of
urine in a day
causes
• Bilateral complete urinary tract obstruction (an enlarged prostate gland is a
common cause of obstructive anuria also urinary Stones is a risk factor)
• acute renal failure
• Hemolytic transfusion reaction
• It may occur with end stage renal disease
• Shock, a life-threatening condition characterized by inadequate tissue
perfusion, can lead to anuria (absence of urine production) through several
mechanisms. Shock can be classified into different types, including
hypovolemic shock, cardiogenic shock, distributive shock, and obstructive
shock

Appearance of
urine
• The turbidity of the urine
sample is gauged subjectively
and reported.
• Normally, fresh urine is clear.
• Note: Pathologic urines are often
turbid or cloudy; however, many
normal types of urine can also
appear cloudy.

Very pale yellow or colorless urine
• Large fluid intake
• Diabetes Insipidus
• Alcohol ingestion (inhibit ADH release)
• caffeine ingestion (increase GFR by dilating afferent arterioles)
• Diuretic therapy

Deep yellow urine
• Dehydration or drinking too few fluids can concentrate
urochrome, making urine much deeper in color.
• Concentrated urine caused by fever, sweating, reduced fluid
intake, or first morning specimen

Orange urine
• Certain medications such as the antibiotic Rifampicin and
pyridium can cause orange urine.
• Large amounts of carotene, the orange pigment in carrots

Red or pink urine
• The presence of red blood cells is the main reason (usually
called smoky urine)
• hemoglobinuria turns urine translucent red
• Beets, and blackberries can turn urine red
• Methyldopa in alkaline urine , antipsychotics drugs such as
chlorpromazine and metronidazole in acidic urine cause urine
to turn red
• Note: in the case of red urine due to drug we can add acid to
urine it will convert to yellow color

Black or dark-colored urine
• Melanuria caused by a melanoma
• Alkaptonuria (is a rare inherited genetic disorder of phenylalanine
and tyrosine metabolism due to a defect in the enzyme
homogentisate which participates in the degradation of tyrosine. As a
result, a toxic tyrosine byproduct called homogentisic acid (or
alkapton) accumulates in the blood and is excreted in urine in large
amounts)
• Urine that darkens on standing may indicate antiparkinsonian agents
such as levodopa
• Note: sickle cell crises produce a characteristic dark brown color
that is become darker on standing or on exposure to sun light due
to increased porphyrins

Leukocytes
• Principle
• Granulocytic leukocytes contain esterase enzyme that catalyze the
hydrolysis of the pyrrole amino acid ester to liberate 3-hydroxy-5-
phenyl pyrrole. This pyrrole then reacts with a diazonium salt to
produce a purple product
• .
Sensitivity
• 100% for >50 WBCs/HPF, 90% for 21 to 50 WBCs, 60% for 12 to 20
WBCs, 44% for 6 to 12 WBCs.

Leukocytes
1.Urinary tract infection. (Pyelonephritis, glomerulonephritis, cystitis,
urethritis, ureteritis)
2.Urinary bladder tumor.
3.The Systemic lupus erythematosus (SLE).
4.Inflammation in the vagina or under the foreskin of the penis.
5.Bacterial infection
6.STIs like chlamydia or gonococcal

Nitrites
• The presence of NITRITES is not normal
• Enterobacteriaceae, cause a urinary tract infection (some gram-
negative bacteria) produce an enzyme (nitrate reductase) that
converts urinary nitrates to nitrites.
• Therefore, presence of nitrites in urine indicates a Typical bacterial
infection.

Proteinuria
• In a healthy renal and urinary tract system, the urine contains no
protein or only traces amounts.
• Normally, more than 99% of the filtered protein is reabsorbed by
pinocytosis in the proximal convoluted tubule.
• Because albumin is filtered more readily than the globulins, it is
usually abundant in pathologic conditions; therefore, the term
albuminuria is often used synonymously with proteinuria.
• Note: If more than a trace of protein is found persistently in the urine,
a quantitative 24-hour evaluation of protein excretion is necessary.

Pre-renal protein
Multiple myeloma
Severe infection and inflammation
Intravascular hemolysis
Muscle injury

Renal proteinuria
Glomerular disorders:
• Amyloidosis
• Immune complex disorders
• Diabetic nephropathy
• Toxic agents
• nephrotic and nephritic
syndrome
• Pre-eclampsia
• Hypertension
• Dehydration
• Orthostatic (postural) proteinuria
Tubular diseases:
1.Severe viral infections
2.Fanconi’s syndrome
3.Heavy metal poisoning
4.Toxic agents injury

Postrenal proteinuria
• Injury and trauma
• Lower urinary tract infections and inflammation
• vaginal secretion
• menstrual contamination
• prostatic fluid
• Contamination by the spermatozoa

The specific gravity of urine:
• Specific gravity is the density of a substance relative to the
density of distilled water.
• The kidneys’ ability to selectively reabsorb essential chemicals
and water from the glomerular filtrate is one of the most
important functions.
The normal range of urine-specific gravity = 1.005 – 1.030.

pH
.The lungs and the kidneys are major regulators of the acid-base
balance of the body.
.These two organs control the pH by absorption of Na+ and
excretion of H+ ions in the form of ammonium ions, hydrogen
phosphate, and weak organic acids.
.These organs can maintain the pH by reabsorption of HCO3–
from the filtrate in the convoluted tubules.

Urine Bilirubin
Where do
bilirubin
come from?
What are the
3 types of
bilirubin?

Urine Bilirubin
• Interpretation:
• Jaundice, also known as icterus is a yellowish discoloration of
the skin, the conjunctival membranes over the sclerae (whites
of the eyes), and other mucous membranes caused by
hyperbilirubinemia (increased levels of bilirubin in the blood)
• Note: Typically, the concentration of bilirubin in the plasma must exceed 1.5 mg/dl, for
the coloration to be easily visible.

Causes of jaundice
• Causes of jaundice
• Jaundice is classified into three categories, depending on which part
of the physiological mechanism the pathology affects.
• The three categories are:
•
Pre-hepatic: The pathology is occurring prior the liver as in
hemolytic anemia
• Hepatic: The pathology is located within the liver as in liver viral
hepatitis A,B or C , Cirrhosis, Liver tumors, Autoimmune
hepatitis, Drug-induced liver injury, Hemochromatosis
• Post-Hepatic: The pathology is located after the conjugation of
bilirubin in the liver as in bile duct obstruction due to stones or
pancreatic head tumor, Bile duct tumors
• Note: only hepatic and post hepatic jaundice cause direct bilirubin to appear in urine

Urine Urobilinogen
• Urobilinogen is a colorless product of bilirubin reduction. It is
formed in the intestines by bacterial action.
• Some urobilinogen is reabsorbed, taken up into the circulation
and excreted by the kidney. This constitutes the normal
"intrahepatic urobilinogen cycle".
• Normally, urobilinogen is present in only trace amounts.

Increased urobilinogen
Urinary urobilinogen is increased by any condition that causes an
increase in the production of bilirubin such as:
Hepatic Jaundice
Hemolytic anemia.
Pernicious (megaloblastic) anemia.
Malarial
Cirrhosis.
Acute hepatitis.
Cholangitis.
Sickle cell anemia

Urine ketone
Ketone bodies are three water-soluble compounds that are produced as by-
products when fatty acids are broken down for energy in the liver and kidney.
They are used as a source of energy in the heart and brain. In the brain, they
are a vital source of energy during fasting.
The three ketone bodies are acetone, acetoacetic acid, and beta-
hydroxybutyric acid

• ketonemia (Ketosis): is a state characterized by elevated levels
of ketone bodies in the blood, occurring when the liver converts fat
into fatty acids and ketone bodies (which can be used by all of the
body for energy as an alternative to glucose).
•
Ketoacidosis: is the accumulation of excessive keto acids in the
blood stream (specifically acetoacetate and beta-hydroxy
butyrate).
•
• Ketonuria: is a medical condition in which ketone bodies are
present in the urine. Ketones will be present in the urine when the
ketones in the blood go above a certain level.

What is the indication for urine ketone
test?
.
Screening for ketonuria in persons with diabetes
• Testing for ketones is indicated in any patient showing elevated urine
and blood sugars (blood sugar levels of 300 mg/dl or higher)
• When treatment is being switched from insulin to oral hypoglycemic
agents, the development of ketonuria within 24 hours after withdrawal of
insulin usually indicates a poor response to the oral hypoglycemic
agents.
• The urine of diabetic patients treated with oral hypoglycemic agents
should be tested regularly for glucose and ketones because oral
hypoglycemic agents, unlike insulin, do not control diabetes when acute
complications such as infection develop.
• Ketone testing is done to differentiate between diabetic coma positive
ketones and insulin shock negative ketones.

What is the indication for urine
ketone test?
Screening for ketonuria in persons with Acidosis:
Ketone testing is used to judge the severity of acidosis and to monitor
the response to treatment

Interpretation:
Metabolic conditions
• Diabetes mellitus (diabetic acidosis)
• Glycogen storage disease (von Gierke's disease)
Dietary conditions
• Starvation, fasting
• High-fat diets
• Prolonged vomiting, diarrhea (cause dehydration)
• Anorexia (poor appetite whatever the cause)
• Low-carbohydrate diet
Increased metabolic states caused by:
• Hyperthyroidism
• Pregnancy or lactation
• strenuous exercise

Glucose
• Glycosuria or glucosuria is an abnormal condition of
osmotic diuresis due to excretion of glucose by the kidneys
into the urine.
• The most common cause of glycosuria is untreated diabetes
mellitus which raises plasma glucose levels far above normal,
and beyond a certain threshold, the excess glucose is
excreted by the kidneys, taking water with it and producing
diuresis.
• The threshold varies somewhat from one individual to
another, with values around (160 - 180 mg/dl)

• Principle
• This test is based on a double sequential enzyme reaction.
One enzyme, glucose oxidase, catalyzes the formation of
gluconic acid and hydrogen peroxide from the oxidation of
glucose.
• A second enzyme, peroxidase, catalyzes the reaction of
hydrogen peroxide with a potassium iodide chromogen to
oxidize the chromogen to colors ranging from green to brown
• Note: These tests are specific for glucose only not other reducing
sugars.

• False positive reactions
• The presence of bacterial peroxidases (e.g. cystitis), will
produce false positive reactions.
• Drugs: Nalidixic acid, cephalosporins, Chloramphenicol,
Isoniazid and penicillin
• testing soon after the administration of intravenous glucose may
all cause false-positive results, most frequently trace reactions.
• False negative reactions
• High concentrations of ascorbic acid (>25 mg/dl) inhibit the
reaction.

• Normal:
• Absent
• Interpretation:
• Glucosuria is the excretion of glucose in the urine which may be due to:
•
Diabetes mellitus
• Chronic hyperglycemia that persists even in fasting states is most commonly
caused by diabetes mellitus
•
Diabetes mellitus type 1 (IDDM, juvenile diabetes)
• Type 1 diabetes is an autoimmune disease that results in destruction of insulin-
producing beta cells of the pancreas. Lack of insulin causes an increase of
fasting blood glucose that begins to appear in the urine above the renal
threshold (about 160-180mg/dl in most people)
•
•

• Diabetes mellitus type 2 (NIDDM, or adult-onset diabetes)
• Is a metabolic disorder that is primarily characterized by
insulin resistance, relative insulin deficiency, and
hyperglycemia.
•
Gestational diabetes
• Gestational diabetes (or gestational diabetes mellitus, GDM)
is a condition in which women without previously diagnosed
diabetes exhibit high blood glucose levels during pregnancy.
•

• Complications:
• Babies born to mothers with gestational diabetes are at
increased risk of problems typically such as being large for
gestational age (which may lead to delivery complications),
low blood sugar, and jaundice.
• Women with gestational diabetes are at increased risk of
developing type 2 diabetes mellitus after pregnancy, while their
offspring are prone to developing childhood obesity, with type 2
diabetes later in life.

Renal glucosuria
• Also known as benign glycosuria, Familial renal
glycosuria, Non-diabetic glycosuria, or Primary renal
glycosuria
• It is a rare condition in which the glucose is excreted in the
urine despite normal or low blood glucose levels (glucose in
the urine without hyperglycemia).
• Note To confirm that the excreted sugar is glucose and to
exclude pentosuria, fructosuria, sucrosuria, maltosuria,
galactosuria, and lactosuria, the glucose oxidase method
should be used for all measurements

Renal glucosuria
• Cause:
• Renal glycosuria is due to improper functioning of the
proximal renal tubules and may be due to:
• Renal disease
• Toxic renal tubular disease (e.g., because of lead, mercury,
tetracycline)
• Inflammatory renal disease (e.g., acute GN, nephrosis)

BLOOD
The positive blood test indicates the presence
of RBCs.
Hematuria:
It is a disorder of renal or genitourinary origin
where the bleeding is due to trauma or damage
to the organs.
The main causes are:
1. glomerulonephritis
2. renal infarction
3.renal cysts
4.gouty kidneys
5.Trauma.
6.Malignancies of the bladder or
kidneys
7.Glomerular diseases
8.Schistosomiasis
9.Renal calculi.
10.Pyelonephritis.

Hemoglobinuria:
This may result from the lysis of RBCs.
There will be mixed hemoglobinuria
There may be lysis of RBCs in the urinary tract in
alkaline urine.
In intravascular hemolysis, no RBCs are seen in
the urine

Myoglobinuria:
1.It is a heme-containing protein found in the muscles. This is
seen in Rhabdomyolysis like :
1.Trauma.
2.Crush syndrome.
3.Convulsions.
4.Muscle-wasting disease.
5.Heroin abuse.
6.Extensive exertion

Microscopy
• Microscopic examination of urine sediment is of great clinical importance and should never be
omitted.
• The sediment should be examined for: Type, and Amount
• Examination of the sediment should always be made shortly after collection so that:
• a. Degeneration and lysis of cellular elements will not occur
• b. Bacteria will not proliferate
•
Classification of Sediment:
• The sediment may be divided into:
• Organized elements unorganized elements
• Epithelial cells crystals
• Leukocytes fat droplets
• Erythrocytes mucus threads
• Casts amorphous
• Bacteria, yeast, fungi, protozoa, parasite ova and sperm

Urine Pus cells
• Leucocytes usually enter tubular lumen through and between
tubular epithelial cells
• An increase in urinary WBCs is called pyuria and indicates the
presence of an infection or inflammation in the genitourinary
system.
• Microscopic examination and chemical testing are used to
determine the presence of leukocytes in the urine.

Urine Pus cells
• Pyuria often is caused by urinary tract infections, and often
significant bacteria can be seen on sediment preps, indicating a
need for bacterial culture.

indication
• Acute urethral syndrome. Includes dysuria and pyuria. Defined as
more than 8 leukocytes/mm3) of uncentrifuged urine or ≈2 to 5
leukocytes/ hpf in centrifuged urine sediment.
• Bacteriuria. The presence of detectable bacteria in the urine. Patients
may be symptomatic or asymptomatic (e.g., geriatric or pregnant
patients)
• Cervicitis. Inflammation of the cervix; it may occur as an acute or a
chronic presentation. Causative agents include sexually transmitted
organisms, such as Neisseria gonorrhoeae and Chlamydia
trachomatis. Symptoms include dysuria, urgency, vaginal discharge,
and low back pain.

• Cystitis. Inflammation of the bladder, presenting as dysuria, urinary
frequency, and urgency. It is often caused by gram-negative bacilli,
such as E. coli, Proteus, and Klebsiella. It occurs more frequently in
women than men. It can also be caused by medication and certain
viruses, such as adenovirus.
• Lower urinary tract infection (L-UTI). A genitourinary (GU) tract
infection limited to the urethra (urethritis), bladder (cystitis) and, in
males, the prostate (prostatitis). These infections generally appear in
adults with dysuria (pain on urination), increased frequency, urgency,
and occasionally suprapubic tenderness.

• Prostatitis. A GU infection in males that involves the prostate; fever is
often present.
• Pyelonephritis. Infection in the kidney. This is often caused by
infection in the lower tract ascending to the kidney. Symptoms
include fever, chills, nausea, vomiting, and lower back tenderness, as
well as dysuria. It can be accompanied by bacteremia.
• Upper urinary tract infection (U-UTI). A GU tract infection limited to
the renal parenchyma (pyelonephritis) or the ureters (ureteritis). It is
often accompanied by L-UTI symptoms in addition to costovertebral
flank pain or tenderness and fever. At times, L-UTI precedes the
appearance of fever and U-UTI by 24 to 48 hours

• Urethritis. Inflammation of the urethra, presenting as dysuria and
discharge. Causative agents include Neisseria gonorrhoeae,
Chlamydia trachomatis, and Ureaplasma urealyticum. Other causes
include trauma, allergic, or chemical factors
• Urinary tract infection (UTI). A spectrum of diseases caused by
microbial invasion of the genitourinary (GU) tract that extends from
the renal cortex of the kidney to the urethral meatus

• Sterile Pyuria
• Sterile pyuria is the presence of elevated numbers of white cells (>10/cubic mm)
in a urine which appears sterile using standard culture techniques
• Causes of sterile pyuria
• A recently (within last 2 weeks) treated urinary tract infection (UTI) or
inadequately treated UTI
• UTI with 'fastidious' organism (an organism that grows only in a specially fortified
artificial culture media under specific culture conditions) e.g. N. gonorrhoea
• Renal tract tuberculosis
• Interstitial nephritis: caused by reaction to medication (such as an analgesic or
antibiotics). Reaction to medications causes 71% to 92% of cases.
• Non bacterial glomerulonephritis
• Prostatitis
• Urinary tract stones
• Urinary tract neoplasm
• Systemic lupus erythematosus (SLE)

Rbc
• Theoretically, no red cells should be found, but some find their
way into the urine even in very healthy individuals.
• Increased red cells in urine above normal level is termed
hematuria
• The presence of increased number of RBCs with casts and
proteinuria suggests bleeding from renal origin

• Microscopic hematuria
• Small amounts of blood, can be seen only by
light microscopy)
• In microscopic hematuria, the urine appears
normal.
• Macroscopic hematuria (or "frank" or "gross")
hematuria
• Gross hematuria is suspected because of the
presence of red or brown urine.
• The color change does not necessarily reflect
the degree of blood loss because as little as 1
ml of blood per liter of urine can induce a
visible color change.

• Typically, microscopic hematuria indicates damage to the upper
urinary tract (kidneys), while visible blood indicates damage to
the lower tract (ureters, bladder, or urethra). But this is not
always the case.

What are the Causes of hematuria?
• Acute post-streptococcal glomerulonephritis.
• It is the commonest cause of haematuria in children above 3 years.
• History of preceding streptococcal pharyngitis is usually obtained.
• Membranoproliferative glomerulortephritis :
• It is a chronic glomerulonephritis caused by deposits in the kidney glomerular basement
membrane (GBM), activating complement and damaging the glomeruli which usually
progresses to chronic renal failure
• It should be suspected in every case of glomerulonephntis above the age of 10 years

What are the Causes of hematuria
• Urolithiasis (Urinary calculi): recurrent attacks of haematuria
(intermittent hematuria) with abdominal pain or dysuria should
suggest the possibility of urinary stones.
• Pyelonephritis
• Renal tuberculosis
• renal cancer.
• Glomerular diseases.
• Trauma.

• Benign familial or recurrent hematuria
• Asymptomatic recurrent macroscopic hematuria, unassociated with
hypertension, proteinuria , edema or anatomical urinary tract
abnormalities.
• The syndrome is characterized by recurrent episodes of hematuria
which often begin at the height of an upper respiratory infection.

• Non-renal Causes
• Strenuous exercise
• Urinary Schistosomiasis
• Ureteritis
• Cystitis: diagnosis is confirmed by the presence of pyuria and
bacteriuria.
• Urethritis
• Prostatitis
• benign prostatic hypertrophy
• tumor in the urinary bladder

• Haematological
disorders
• Thrombocytopenia
• Sickle cell trait can precipitate
large amounts of red blood
cell discharge, but only a
small number of individuals
endure this problem
• Hemophilia
• coagulation defects
• Medications
• Antibiotics (for example,
rifampin)
• Anticoagulant therapy
overdose
• Aspirin overdose

Urine Cast
• Urinary casts are cylindrical
aggregations of particulate
matter that form in the distal
nephron, dislodge, and
eventually pass into the urine.

Factors known to be promoters of cast formation are:
• Increased amount of certain proteins as Albumin, Myoglobin
,and Hemoglobin
• Urinary stasis
• Cellular debris
• Low glomerular filtration rate
• Acid pH

Urine Crystals (Crystalluria)
• A variety of crystals may appear in the urine. They can be
identified by their specific appearance and solubility
characteristics.
• Crystals in the urine may present no symptoms, or they may be
associated with the formation of urinary tract calculi and give
rise to clinical manifestations associated with partial or complete
obstruction of urine flow.

Why are urine crystals formed?
• When the amount of solutes in urine increase (due to
dehydration, dietary intake, or medications) urine
supersaturation occurs and crystals will be formed either while
the urine in the body or after the urine is voided
•

Uric acid crystals
• Uric acid crystals are of varying
sizes and shapes, found in
acidic urine.
• They resemble rhomboids,
parallelograms, and rosettes in
shape and are amber in color.
• Though they are seen in
normal urine, are also an
indicator of disease processes,
such as acute uric acid
nephropathy or urate
nephrolithiasis.

Calcium Oxalate Crystals
• Calcium oxalate crystals are found in
individuals with acidic, neutral or
alkaline urine.
• These crystals are colorless when viewed
microscopically.
• There are two forms of the calcium
oxalate crystal: the monohydrate and
dihydrate form.
• The monohydrate calcium oxalate crystal
is described as the “picket fence” form.
• These dumbbells shaped crystals are
common in ethylene glycol toxicity. The
dihydrate form is octahedral or
“envelope” shaped.

Urine other findings
• Bacteriuria may be found in
• ≤15% of patients who are pregnant
• 15% of patients with diabetes mellitus
• ~50% of patients with dysuria
• 70% of patients with prostatic obstruction
• ≤5% of patients during catheterization
Note: When urine is allowed to remain at room
temperature, the number of bacteria doubles every 30 to
45 minutes.

Yeast
• The presence of yeast may be the
result of a contamination with
vaginal secretion.
• Yeast cells may represent a true
yeast infection most often they are
Candida albicans., which may
colonize bladder, urethra, or
vagina.
• Yeasts are often observed in
specimens that contain sugar. It is
important to be careful with these
specimens because a yeast
infection is a frequent finding with
diabetic patients.
•

Schistosome haematobium
• Habitat
• Pelvic venous plexuses
around the urinary bladder
• Note: recommended time for collection:
between noon and 3 PM
•

Sperm in urine (spermatorroea)
Interpretation
• Urinary spermatozoa are a contamination
arising from sexual activity. With a male
subject, these represent a residual drainage
• They may present in urine of men after
epileptic convulsions or nocturnal emission
• Also may be found in case of prostatitis and
orchitis
• Males sometimes experience retrograde
ejaculation, a disorder in which sperm goes to
the bladder instead out through the urethra.

Trichomonas vaginalis
• Habitat
• If male: urinary bladder, urethra, prostate,
seminal vesicle
• For uncircumcised men, the most common
site for the infection is the tip of the penis.
• If female: vagina, the Skene's glands (of the
urethra) and cervix
• Multiplies when vaginal conditions become
more basic than usual (normal pH is 3.8 to
4.2)
• Diagnosis
• In male
• Trichomoniasis is diagnosed by visually
observing the trophozoite via a microscope in the
following specimen:
• Urine examination
• prostatic secretion examination
• Semen examination
• Urethral discharge examination

• In female
• Trichomoniasis is diagnosed by visually
observing the trophozoite via a microscope in
the following specimen:
• Urine examination
• Vaginal discharge wet mount
• High Vaginal swab [collected by inserting a
speculum into the vagina and then using a
cotton-tipped applicator to collect the sample]

B.V
1.These are a special type of
squamous cell and take their
origin from the vagina. These
are covered by
coccobacilli (Gardnerella
vaginalis) and indicate
bacterial vaginitis.
2.A small number of clue cells
may be present in the urine
sediment.

Question 1
• Results of a urinalysis on a very anemic and jaundiced patient are as
follows: COLOR: Red, CLARITY: Clear, KETONES: - BILIRUBIN: -
NITRITE:- PROTEIN- BLOOD: Large, SP: 1.020, pH: 6.0
• UROBILINOGEN: 12 EU GLUCOSE: Negative LEUKOCYTES: Negative
• a. Would these results be indicative of hematuria or hemoglobinuria?
b. Correlate the patient’s condition with the urobilinogen result.
• c. Why is the urine bilirubin result negative in this jaundiced patient?

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