Diagnostic Evaluation

A comprehensive health history is used to determine the appropriate laboratory and

diagnostic tests. The following sections review some of the tests that might be used.
Most patients undergoing urologic testing or imaging studies are apprehensive, even
those who have had these tests in the past. Patients frequently feel discomfort and embarrassment
about such a private and personal function as voiding. Voiding in the presence of others can
frequently cause guarding, a natural reflex that inhibits voiding due to situational anxiety.
Because the outcomes of these studies determine the plan of care, the nurse must help the patient
relax by providing as much privacy and explanation about the procedure as possible (Chart 433). In addition, Chart 43-4 provides a plan of care for patients undergoing diagnostic testing.
Urinalysis and Urine Culture
The urinalysis provides important clinical information about kidney function and helps
diagnose other diseases, such as diabetes. The urine culture determines whether bacteria are
present in the urine, as well as their strains and concentration. Urine culture and sensitivity also
identify the antimicrobial therapy that is best suited for the particular strains identified, taking
into consideration the antibiotics that have the best rate of resolution in that particular geographic
region. Appropriate evaluation of any abnormality can assist in detecting serious underlying
diseases.
Components
Urine examination includes the following :

Urine color (Table 43-4)

Urine clarity and odor
Urine pH and specific gravity
Tests to detect protein, glucose, and ketone bodies in the urine (proteinuria, renal

glycosuria, and ketonuria, respectively)

Microscopic examination of the urine sediment after centrifugation to detect
RBCs (hematuria), white blood cells (pyuria), casts (cylindruria), crystals
(crystalluria), and bacteria (bacteriuria)

Researchers are working on additional noninvasive tests that can be performed on urine
to detect conditions such as bladder cancer. For example, urine telomerase activity levels
have been found to be sensitive and specific to detect bladder cancer in men (Sanchini,

Gunelli, Nanni, et al., 2005). More research is needed before these tests are acceptable for
routine use in patients.
Significance of Findings
Several abnormalities, such as hematuria and proteinuria, produce no symptoms but may
be detected during a routine urinalysis using a dipstick. Normally, about 1 million RBCs
pass into the urine daily, which is equivalent to one to three RBCs per high-power field.
Hematuria (more than three RBCs per high-power field) can develop from an
abnormality anywhere along the genitourinary tract and is more common in women than
in men. Common causes include acute infection (cystitis, urethritis, or prostatitis), renal
calculi, and neoplasm. Other causes include systemic disorders, such as bleeding
disorders; malignant lesions; and medications, such as warfarin (Coumadin) and heparin
(Heparin Sodium). Although hematuria may initially be detected using a dipstick test,
further microscopic evaluation is necessary (Tierney & Henderson, 2005).
Proteinuria may be a benign finding, or it may signify serious disease (Burrows-Hudson,
2005). Occasional loss of up to 150 mg/day of protein in the urine, primarily albumin and
Tamm-Horsfall protein (also known as uromodulin), is considered normal and usually
does not require further evaluation. A dipstick examination, which can detect from 30 to
1000 mg/dL of protein, should be used as a screening test only, because urine
concentration, pH, hematuria, and radiocontrast materials all affect the results. Because
dipstick analysis does not detect protein concentrations of less than 30 mg/dL, the test
cannot be used for early detection of diabetic nephropathy. Microalbuminuria (excretion
of 20 to 200 mg/dL of protein in the urine) is an early sign of diabetic nephropathy.
Common benign causes of transient proteinuria are fever, strenuous exercise, and
prolonged standing.
Causes of persistent proteinuria include glomerular diseases, malignancies, collagen
diseases, diabetes mellitus, preeclampsia, hypothyroidism, heart failure, exposure to
heavy metals, and use of medications, such as nonsteroidal anti-inflammatory drugs
(NSAIDs) and angiotensin-converting enzyme (ACE) inhibitors (Karch, 2008).

Specific Gravity
Specific gravity measures the density of a solution compared to the density of water,
which is 1.000. Specific gravity is altered by the presence of blood, protein, and casts in the
urine. The normal range of urine specific gravity is 1.010 to 1.025.
Methods for determination of specific gravity include the following:

Multiple-test dipstick (most common method), with a specific reagent area for

specific gravity
Urinometer (least accurate method), in which urine is placed in a small cylinder
and the urinometer is floated in the urine; a specific gravity reading is obtained at

the meniscus level of the urine

Refractometer, an instrument used in a laboratory setting, which measures
differences in the speed of light passing through air and the urine sample

Urine specific gravity depends largely on hydration status. When fluid intake decreases,
specific gravity normally increases. With high fluid intake, specific gravity decreases. In patients
with kidney disease, urine specific gravity does not vary with fluid intake, and the patients urine
is said to have a fixed specific gravity. Disorders or conditions that cause decreased urine
specific gravity include diabetes insipidus, glomerulonephritis, and severe renal damage. Those
that can cause increased specific gravity include diabetes mellitus, nephritis, and fluid deficit.
Osmolality
Osmolality is the most accurate measurement of the kidneys ability to dilute and
concentrate urine. It measures the number of solute particles in a kilogram of water. Serum and
urine osmolality are measured simultaneously to assess the bodys fluid status. In healthy adults
serum osmolality is 280 to 300 mOsm/kg, and normal urine osmolality is 200 to 800 mOsm/kg
(Goertz, 2006). For a 24-hour urine sample, the normal value is 300 to 900 mOsm/kg.

Renal Function Tests

Renal function tests are used to evaluate the severity of kidney disease and to assess the
status of the patients kidney function. These tests also provide information about the
effectiveness of the kidney in carrying out its excretory function. Renal function test results may
be within normal limits until the GFR is reduced to less than 50% of normal. Renal function can

be assessed most accurately if several tests are performed and their results are analyzed together.
Common tests of renal function include renal concentration tests, creatinine clearance, serum
creatinine and blood urea nitrogen levels.
Diagnostic Imaging
Kidney, Ureter, and Bladder Studies
An x-ray study of the abdomen or kidneys, ureters, and bladder (KUB) may be
performed to delineate the size, shape, and position of the kidneys and to reveal urinary
system abnormalities (Labus, 2008).
General Ultrasonography
Ultrasonography is a noninvasive procedure that uses sound waves passed into the
body through a transducer to detect abnormalities of internal tissues and organs.
Abnormalities such as fluid accumulation, masses, congenital malformations, changes in
organ size, and obstructions can be identified. During the test, the lower abdomen and
genitalia may need to be exposed. Ultrasonography requires a full bladder; therefore,
fluid intake should be encouraged before the procedure. Because of its sensitivity,
ultrasonography has replaced many other tests as the initial diagnostic procedure
(Burrows-Hudson, 2005).
Bladder Ultrasonography
Bladder ultrasonography is a noninvasive method of measuring urine volume in
the bladder. It may be indicated for urinary frequency, inability to void after removal of
an indwelling urinary catheter, measurement of postvoiding residual urine volume,
inability to void postoperatively, or assessment of the need for catheterization during the
initial stages of an intermittent catheterization training program. Portable, batteryoperated devices are available for bedside use. The scan head is placed on the patients
abdomen and directed toward the bladder. the device automatically calculates and
displays urine volume.
Computed Tomography and Magnetic Resonance Imaging

Computed tomography (CT) scans and magnetic resonance imaging (MRI) are
noninvasive techniques that provide excellent cross-sectional views of the anatomy of the
kidney and urinary tract (Labus, 2008). They are used to evaluate genitourinary masses,
nephrolithiasis, chronic renal infections, renal or urinary tract trauma, metastatic disease,
and soft tissue abnormalities. Occasionally, an oral or intravenous (IV) radiopaque
contrast agent is used in CT scanning to enhance visualization.