GLOMERULAR FILTRATE

• Water
• Substances with mol. Wt < 70,000
• Crystalloids
• Urea
• Uric acid
• Sugar
• Proteins with low mol. Wt. e.g. Hb, myoHb, BJ proteins
• Albumin, Globulin, fibrinogen cannot pass through
glomerular filtrate
Renal tubules modify glomerular filtrate

• Reabsorption of high threshold substances

Water, Glu, AA, VitC, Na, K, Mg, Cl

• Diffusion of low threshold substances

Urea, uric acid, creatinine, sulphates, PO4

• Secretion
NH3, Creatinine
 INDICATIONS OF URINE EXAMINATION

• Routine investigation
• Diagnosis
• Urinary tract diseases
• Jaundice
• Pregnancy
• Endocrine disorders- DM,Hormonal problems
• Genetic abnormalities- cystinuria,phenylketonuria
• Parasitic infections-S.hematobium,T.vaginalis
• Drug overdose
• Carrier of enteric fever
• Neoplastic diseases-multiple myeloma,neuroblastoma

• Physical fitness
COLLECTION OF URINE
1. SINGLE SPECIMEN
• Random specimen - Routine analysis
- Qualitative chemical tests
• First morning specimen – concentrated
Low pH – preserves formed elements
• M/E – pus, cellular elements
• Nitrites
• Proteins
• Pregnancy
• Fasting glucose levels

• 3-4 hours after meals: Metabolic disorders, albumin,

glucose
• Post-prandial specimen : Glucose, Urobilinogen,
creatinine
COLLECTION OF URINE

2. 24 HOUR COLLECTION
Essential for quantitative studies.
Used for estimation of :
– Urobilinogen
– 24 hrs protein
– 24 hrs glucose
– Inborn errors of metabolism
COLLECTION OF URINE

3. BACTERIOLOGICAL EXAMINATION

• Container: Sterile bottle

• Indication: UTI, enteric fever
• Method:
A ‘mid stream’ clean catch sample is collected
in a sterile test tube & subjected to cultural
studies immediately. Do not add
preservatives. Bacterial, viral, fungal culture
 Changes in composition of urine stored at
room temperature:

• Lysis of red blood cells by hypotonic urine

• Decomposition of casts
• Bacterial multiplication
• Decrease in glucose level, due to bacterial
growth
• Formation of ammonia from urea by the action
of bacteria (and the pH of urine changes to
alkaline)
• Precipitation of urates & Phosphates
 URINE PRESERVATIVES

Preservative Concentration Comments

Toluene 2ml / 100ml urine Forms a thin layer on the

surface of urine. Interferes with
protein exam
Formaldehyde 1-2 drop/ounce Good for sediments. May
precipitate proteins

Thymol 0.1 g/100 ml of Preserves sediment well. May

urine interfere with tests for sugar &
acetone
Conc. HCl Estimation of Ca & Na
URINE EXAMINATION

• Physical
• Chemical
• Microscopic
• Microbiological
• Cytological
 PHYSICAL EXAMINATION

• Appearance
• Colour
• Volume
• Odour
• Specific gravity
PHYSICAL EXAMINATION

1. Appearance
• Clear – Normal

• Cloudy – ppt of amorphous phosphates

(alkaline urine), urate ppts on cooling urine
(acidic urine)

• Fecal contamination – fistula

• Turbid – pus cells, RBC, bacteria, spermatozoa

 2. Colour

• Normal pale yellow : urochromes

• Yellow/ yellowish green: bile pigments, vit B complex, carotene

• Red/ brown: Hb, beet, aniline dyes, hematuria, menstrual blood

• Smoky red/ brown: blood, senna

• Milky: large amounts of pus, bacteria, fat or chyle

• Black: melanin, homogentesic acid

3. Volume

• Adult -Normal average 24 hrs volume of urine is about 1500ml

(a) Polyuria - > 2,500 ml/24 hrs

• Increased salt, water & protein intake, Caffeine, thiazides,

diuretics
• Cold weather, rainy season
• DM, DI, Chronic Pyelonephritis, renal failure

(b) Oliguria - < 500 ml/24 hrs

• Acute & chronic glomerulonephritis, CCF, Shock

• Dehydration – water deprivation, hot weather, vomiting,
diarrhea, febrile states
(c) Anuria - Renal ischemia (CCF, HTN), Crush injuries, surgical
shock, mismatched transfusion
 PHYSICAL EXAMINATION

4. Odour

Normal - aromatic/uriniferous d/t volatile aromatic acids

Sweet or fruity - ketone bodies

Ammonical - decomposition from stasis in bladder

Musty - phenylketonuria

Putrid - infection
 PHYSICAL EXAMINATION
5. Reaction & pH

• Freshly voided normal urine is slightly acidic with a pH of 6.

• On standing pH becomes alkaline d/t release of NH3 from urea
• Acidic urine: high protein intake, Diabetic ketoacidosis,
respiratory & metabolic acidosis, UTI by Escherichia Coli

Alkaline urine: alkalinization of urine, high citrus fruits intake,

respiratory & metabolic alkalosis, UTI by Proteus &
pseudomonas

• Method- Litmus paper

pH electrode
Reagent strip
6. Specific gravity

• Ratio of the weight of a volume of urine to the weight of

same volume of distilled water.
• Sp.gr. depends on – Amount of solute, volume of solution
• Normal range for a 24 hr urine specimen is 1.016 to 1.022

• Increase S.G (hypersthenuria) - Decreased fluid intake,

fever, vomiting, diarrhea, CCF, DM,proteinuria

• Decrease S.G (hyposthenuria) - Diuretics, hypothermia,

glomerulonephritis, Diabetes insipidus

• Fixed S.G (isosthenuria)- CRF 1.010

Specific gravity

METHODS
• Urinometer
• Refractometer
• Falling drop method
• Reagent strip
CHEMICAL EXAMINATION

• Protein
• Glucose
• Ketone bodies
• Blood
• Bile pigments
• Bile salts
• Urobilinogen
PROTEIN

I. Qualitative estimation – ppt of proteins by

heat/chemical agents
• Heat coagulation test
• Sulfosalycilic acid test
• Heller’s nitric acid test
• Reagent strips- detects only albumin

II. Quantitative estimation –

• Esbach’s albuminometer

III. Test for Bence jones proteins

1. Heat coagulation test/ Heat & acetic acid test:
• Fill a test tube ¾ full with clear urine & gently heat the
upper portion & boil for 1-2 minutes. If turbidity appears,
it could be due to phosphates, carbonates or proteins.
• Add 1% acetic acid 1- 3 drops to the urine - cloudiness
due to phosphates & carbonates disappears. It persists if
proteins are present.

2. Sulfosalicylic acid test:

Mix equal volumes of clear urine & 3-5% sulfosalicylic
acid. Cloudiness indicates presence of proteins d/t heavy
precipitation.

3. Heller’s test:
White ring at the point of contact of conc. nitric acid &
urine indicates presence of albumin
Bence-Jones proteins:

• Light chain Ig

• Secreted by neoplatic plasma cells & is found in the

urine of 35-65% cases of multiple myeloma

• Also seen in Metastatic carcinoma of bone, communited

fractures & senile osteomalacia, leukemia, carcinoma of
stomach & kidney, inactive pulmonary tuberculosis &
primary amyloidosis

• Heat coagulable, precipitate at temperatures between 40-

60°c & redissolve again near 100°c

• Diagnosis of multiple myeloma: combined serum & urine

electrophoresis for B-J protein
 Causes of proteinuria

I. Renal:
Glomerulonephritis (NS), nephrosclerosis, diabetic
glomerulosclerosis, nephrotic syndrome & Pyelonephritis

II. Prerenal:
• Alimentary tract due to excessive ingestion of proteins
• Following heavy exercise (functional proteinuria)
• Congestive cardiac failure
• Postural/ orthostatic albuminuria

III. Post-renal:
Infections/ lesions in renal pelvis & lower urinary tract, - derived
from leukocytic blood, mucus, vaginal discharge.
• Urinary Microproteins - Microalbuminuria:

– Excretion of albumin in urine in minor quantity,

normal value < 200 mg/24 hours

– Values >400 mg/24 hours indicate irreversible

damage

– Earliest indication of renal vascular damage in

Diabetic nephropathy, benign hypertension
B. SUGAR
Reagent strip: Glucose oxidase reacts with glucose in the
urine to form gluconic acid & hydrogen peroxide. The
hydrogen peroxide, in the presence of peroxidase oxidizes
to form orthotoluidine (blue colour)
Copper reduction test (Benedict’s test): Glucose & other
reducing sugars reduce cupric ions of copper sulphate to
cuprous form in an alkaline medium

Interpretation
green Colour - trace - 0.25 gm%
green ppt. - 1+ - 0.50 gm%
yellow ppt. - 2+ - 0.75 gm%
orange ppt. - 3+ - 1.00 gm%
brick red. - 4+ - 2.00 gm%
 Glycosuria
• I. Diabetic : in DM
• II. Non-diabetic:

– Alimentary glycosuria – partial gastrectomy,

excessive sugar ingestion

– Renal glycosuria - low renal threshold,

pregnancy, after anaesthesia

– Endocrine- hyperthyroidism, pancreatitis,

acromegaly, Cushing syndrome

– Liver disease

– Intracranial injury

– Starvation
C. KETONE bodies

• Ketone bodies are intermediate products of fat

metabolism & include acetone, acetoacetic acid
& β hydroxyl butyric acid
• Ketonuria - diabetic ketoacidosis, starvation,
glycogen storage diseases, eclampsia, severe
dehydration states, febrile states & after general
anaesthesia.
• Tests: 1. Rothera’s- acetone, acetoacetic acid
2. Gerhardt’s – acetoacetic acid
D. BILE SALTS

Hay’s test:

Principle: Bile acid lowers the surface tension

of fluids in which they are contained.
E. BILE PIGMENTS

• Principle: Bile pigments are oxidized by acids

forming a series of coloured derivatives of
bilirubin. eg biliverdin (green), bilicyanin (blue),
& choletelin (yellow).

• Gmelin’s Test
• Harrison Fouchet test
BILE SALTS AND BILE PIGMENTS

BILE PIGMENT UROBILINOGEN

OBSTRUCTIVE
JAUNDICE + –
HEPATOCELULLAR
JAUNDICE + +

HEMOLYTIC
JAUNDICE – +
F. BLOOD

• Presence of blood may be in the form of intact

RBC’s (hematuria) or hemoglobin
(hemoglobinuria).
• Benzedine test:
Urine is centrifuged . The sediment is mixed
with equal volumes of the reagent (saturated
solution of benzedine in glacial acetic acid to
which equal quantitiy of hydrogen peroxide is
added)
Result: Blue color indicates a positive test
 Hematuria:

• Pyelonephritis
• Urinary calculi
• Renal tuberculosis
• Tumours of kidney & urinary tract
• Sulfonamides & salicylates

Bleeding can occur high in the kidney & renal pelvis

( urine appears smoky brown due to hematin) or in lower
urinary tract (bright red urine).
 Hemoglobinuria:

Disintegration of RBC’s within the circulation with

excessive liberation of Hb
When free hemoglobin d/t hemolysis is >150mg% in
plasma, it is excreted by the kidneys
(i) black water fever , clostridial infection
(ii) severe burns
(iii) hemolytic transfusion reaction
(iv) autoimmune hemolytic anemia
(v) PNH
(vi) sulfonamide & phenacetin administration
 MICROSCOPIC EXAMINATION

1. Cells
(a). Pus cells
• Normal range is 2-5/HPF
• Pyogenic infection of
urinary tract and genital
tract
• Glomerulonephritis
• Kidney infarct
MICROSCOPIC EXAMINATION

(b). Red cells:

Pale yellow refractile
discs, & disintegrate on
addition of 2% acetic acid
Normally an occasional
red cell may be present.
Significant numbers
indicate hematuria.
MICROSCOPIC EXAMINATION

(c). Epithelial cells:

Originate from any site in

the genitourinary tract
Normally 3 – 5/ H.P.F.

(a) tubular
(b) transitional
(c) squamous cells
CASTS
• Cylindrical structures with parallel edges, formed by
precipitation of proteins (Tamm Honsefall protein) within
DCT & collecting tubules
• Associated with pathological change in kidney

a) Hyaline - fever, anaesthesia, GN, nephrosclerosis,

exercise
b) Epithelial – acute GN, kidney infarct
c) Granular – chronic GN, nephrosclerosis
d) Waxy - chronic nephritis, NS, Anuria, prolonged oliguria
e) RBC & WBC cast – pus cell cast
f) Pigment – blood, hemosiderin, bile, melanin
 CRYSTALS IN URINE
Normal 1-3 per lph

Crystals in acid urine

Uric acid crystals
Urate crystals
Calcium oxalate
 CRYSTALS IN URINE (Cont.)

Crystals in alkaline urine

Ammonium magnesium phosphates
Calcium carbonate
Ammonium biurate
CRYSTALS IN URINE (Cont.)

3. Abnormal crystals
(a) cysteine
(b) leucine
(c) Tyrosine
PARASITES IN URINE

Trichomonas vaginalis

Microfilaria in chylous urine

Ova of schistosoma hematobium

Hooklets or Scolices of E.granulosus

BACERIOLOGICAL EXAMINATION

For pyogenic organisms

For M. tuberculosis
 SPECIAL TESTS

CYTOLOGICAL EXAMINATION FOR CANCER

HORMONES IN URINE

 Diseases of ovary, adrenals and pituitary

 Diagnosis of pregnancy (HCG level )

 Hydatiform mole and choriocarcinoma (HCG level)

DIP STICKS/ REAGENT
STRIPS

Commercially available
strips impregnated with
various reagents, for
easy & rapid testing of
various abnormal
constituents of urine.
 URINE REPORT

Name: Regd no:

Age: Sex: Time of collection:

Chief complaints:

PHYSICAL EXAMINATION
Appearance-Colour,clarity :
Odor :
Volume :
Specific gravity :
CHEMICAL EXAMINATION
Reaction :
Proteins :
Sugar :
Ketone bodies :
Bile salts and pigments :
Urobilinogen :

MICROSCOPY
RBCS :
PUS CELLS :
EPITHELIAL CELL :
CASTS :
CRYSTALS :
OTHER FINDINGS :

IMPRESSION