MED TECH DEPT-U&BF PHYSICAL EXAMINATION OF URINE Dr.H.Khouja

PHYSICAL EXAMINATION OF THE URINE

Physical examination of urine involves checking the urine specimen for physical characteristics including: volume; colour; appearance, specific gravity and odour.

Any urine specimen received in the lab must be examined physically For accurate description of physical characteristics, the urine sample must be fresh and analyzed

immediately on receipt. Delay in analysis will cause many changes in various parameters including colour; appearance,

specific gravity and odour. Indicate on the result form time of receipt and time of examination. The specimen container

should have the collection time written on its label. The section of the lab in which this examination is carried out must have abundant light for

proper investigation (colour; appearance) Physical findings are suggestive which may require chemical and/or microscopic examinations Abnormal findings can either be pathological or non-pathological Pathological findings are usually consistent and continue with the duration of the disease Non-pathological findings are transient and temporary occurring only once or twice, eg abnormal

colour which is due to medications or diet Physical findings are not diagnostic and must be confirmed by blood and other investigation as

well as chemical and microscopic examinations of the urine.

Volume of urine.

Volume of each sample received in the lab must be measured and recorded This is used as evidence of the volume and for purpose of standardization Under normal state of hydration, random adult urine volume ~50-200mL Adult Normal broad range (750-2000mL/24hrs) Normal narrow range under normal state of hydration (1200-1500mL/24hrs) In normal adults, under normal state of hydration, day time vol is higher than night time vol Day time vol (750-1200mL) night time vol (300-500mL)

MED TECH DEPT-U&BF PHYSICAL EXAMINATION OF URINE Dr.H.Khouja

Increased urine volume (Polyurea)Pathological Non-pathological

Diabetes mellitus-excessive thirst, excessive intake of water-excessive excretion of glucose requires more water to excrete sugar loadDiabetes insipidus-inadequate output of ADH-decreased response of tubules to ADHChronic renal disease: loss of ability to concentrate urine

-Excessive intake of fluids-Diuretic medications-Diuretic fluids : coffee, tea, alcohol-Stress, nervousness, anxiety-COLD TEMPERATURE (cold climates)-tight underwear (pants)

Decreased urine volume (oilgurea, anurea)Pathological Non-pathological

Obstruction:-acute glomerular nephritis with blockage of glomerular tufts-precipitation of crystal in kidney stonesTransfusion reaction:-anurea due to renal ischemia

-dehydration:-vomiting, diarrhea, sweating-decreased fluid intake

URINE COLOUR Colour of the urine is due to the presence of pigments that is present in urine Normal urine colour is yellow Yellow colour of urine is due to; urochrome (a derivative of urobilin which is a degradation of

bilirubin), urobilin & uroerythrin Direct relationship between colour and concentration ; i.e darker colour more concentrated urine Also colour darkens upon standing at room temperature due to oxidation The lab should have standardized reference colour system to relate urine colour to it Colour observation should be done together with specimen appearance. Refer to proper colour observation procedure in the lab for accurate colour description Abnormal colour must be categorized as pathological or non-pathological Pathological finding must be confirmed by chemical and microscopic analysis and/or blood tests REFER TO TABLE FOR VARIOUS COLOURS OF URINE AND POSSIBLE INTERPERTATION

MED TECH DEPT-U&BF PHYSICAL EXAMINATION OF URINE Dr.H.Khouja

Urine Colours and Interpertation.

colour Pathological causes Non-pathological causesColourlessVery light yellowLight yellow

Polyurea due to; Diabetes mellitus (high Sp Gr)(+ve glucose) Diabetes insipidus (low Sp Gr) Chronic renal failure (low Sp Gr)

Recent fluid consumption Large volume of fluid intake Stress, anxiety, nervousness

yellow Normal fresh urine under normal state of hydrationDark yellow Bilirubin (orange foam on shaking the tube)(+ve

bilirubin)-Liver disease Normal concentrated urine (first morning) After strenuous exercise old normal urine dehydration Carrots, vit A (colour soluble in petroleum ether) Acriflavin (-ve bile tests)(green fluorsence) Pyridium (UTI drug, orange foam, turbid urine) Nitrofurantoin (UTI antibiotic)

amberorange

Yellow greenYellow-brown

-bilirubin oxidized to biliveridin (coloured foam on shaking tube in acidic urine)(-ve bilirubin)

Rhubarb in acidic urine

GreenBlue-green

Pseudomonas infection (+ve urine culture) Amitryptyline (antidepressant); methocarbmol (muscle relaxant); clorets (chewing gum); indicant (dye); methylene blue (indicator); oxidized phenol

Pink-to-red -RBCs (+ve blood)(cloudy urine when in high numbers)(RBCs seen in microscopic examination)-Hemoglobin (+ve blood)(clear urine)(red plasma)(hemolytic anemia, in vitro hemolysis)-myoglobin (+ve blood)(clear urine)(clear normal colour plasma) (burns)-porphyrins -porphobilin (-ve blood)(prophyrin disorders, renal diseases)

-beet (alkaline urine of genetically susceptible people)-rhubarb (alkaline urine)-menstrual contamination (cloudy specimen with clots, mucus, epithelial cells)-phenolsulfonphthalein (PSP)(alkaline urine after administration in renal tubular secretion test)- phenindione (anticoagulant)

Dark red -myoglobin (+ve blood)(clear urine)(clear plasma)-porphyrins -porphobilin (-ve blood)

MED TECH DEPT-U&BF PHYSICAL EXAMINATION OF URINE Dr.H.Khouja

Red-purple -porphyrins -porphobilin (-ve blood)

Brown-black -RBCs oxidized to methemoglobin (+ve blood)#after standing in acidic urine -myoglobin (+ve blood) -Homogentisic acid(alkaptouria)(-ve blood)# alkaline urine after standing-melanin (melanoma) #colour darkens from brown-black upon standing

-phenol derivatives-argyrol (antiseptic)(colour disappears with ferric chloride)-methyldopa, levodopa (antihypertensive drugs) -metronidazole (flagyl)(darkens on standing)

MED TECH DEPT-U&BF PHYSICAL EXAMINATION OF URINE Dr.H.Khouja

MED TECH DEPT-U&BF PHYSICAL EXAMINATION OF URINE Dr.H.Khouja

Urine Appearance (Transparency) Appearance is a subjective examination with grading description including; CLEAR, HAZY, SLIGHTLY CLOUDY, CLOUDY, TURBID & MILKY Normal urine is clear The presence of high amounts or concentrations of certain relatively large size particles (crystals, precipitates) or cells may result in an

unclear urine Unclear urine is a strong case for microscopic examination. The causative factor must be known to establish its clinical significance. The lab must standardize its procedure for reporting appearance results Proper appearance determination procedure must be followed to obtain accurate results Identification of some turbidity causative agents

Causative factor Solubility characteristics -amorphous urates & uric acid soluble at 60oC

-RBCs, amorphous phosphates and carbonates soluble in dilute acetic acid

-lipids, chyle, lymphatic fluid soluble in ether

-WBCs, Bacteria, Yeasts, sperms Insoluble in dilute acetic acid

appearance Pathological Causes Non-pathological Causes

clear -dilute urine (colourless, v light yellow, light yellow)-presence of small amounts of RBCs, WBCs, Epithelial Cells …etc-presence of relatively small size substances such as; glucose, hemoglobin, myoglobin, porphyrin

Normal appearance of fresh yellow urine-presence of relatively small size substances such as; drugs metabolites, vitamin metabolites, food pigments

-hazy-Slightly cloudy-cloudy-turbid

Appearance depends on the amount of substances or elements present

Pus (WBCs) (pyurea) (infection, UTI, Cystitis, Pyelonepheritis) RBCs (glomerulonepheritis) Epithelial cells (columnar tubular)

-mucus-amorphous phosphates (alkaline urine)-amorphous carbonate (alkaline urine)-amorphous urates (acidic urine)-oxalate crystals (acidic urine)

MED TECH DEPT-U&BF PHYSICAL EXAMINATION OF URINE Dr.H.Khouja

-milky Bacteria (fresh urine) Casts Crystals (abnormal crystals such as; cholesterol, cysteine) Protein (large size white foam on shaking) Lipids (opalescent) Chyle (milky urine) Yeast (fresh urine)(turbid urine)

-uric acid crystals (acidic urine)-bacteria (contamination, old urine)-talcum powder-X-ray contrast material-fecal material contamination-serum /plasma contamination-menstrual cycle contamination (blood, mucus, menstrual discharge)-yeast (old urine)-sperms -fiber threads (from clothes or tissues)-dust from air contamination

SPECIFIC GRAVITY (SG) (Sp Gr) The higher the concentration (amount) of substances in urine the higher is the Sp Gr Sp Gr depends on the number and size of dissolved particles in urine but not on the nature or type of molecules Sp Gr of the glomerular filterate =1.007-1.010 Sp Gr measurement must be performed on fresh urine sample Random Sp Gr does not have any clinical significance and ranges (1.003-1.035) depending on the state of hydration In normal adults, under normal state of hydration, day time Sp Gr is lower than night time Sp Gr Day time Sp Gr (1.010-1.020) night time Sp Gr (1.020-1.035) 24hr Sp Gr (1.015-1.025) For assessment of the renal concentrating ability, controlled fluid intake or timed urine specimen is required Concentrating limit of the kidneys for ordinary normal constituents result in urine of Sp Gr=1.035 Sp Gr> 1.035 is due to the presence of abnormal solutes (glucose, protein, dextran…etc) or dyes (X-ray contrast material) In such cases, the true concentrating ability of the renal system may be required and therefore correction for such particles Correction for glucose (using the refractometer) : subtract 0.004 from refractometer reading for each 10g/L (55.6 mmol/L) glucose Correction for protein (using the refractometer) : subtract 0.003 from refractometer reading for each 10g/L protein Example: o a urine sample Sp Gr = 1.032. However, the urine was found to contain 2g/dL protein and 10g/L glucose. What is the corrected Sp Gr for

the sample. Changes due to protein and glucose= (2X0.003) +(0.004) = 0.010

MED TECH DEPT-U&BF PHYSICAL EXAMINATION OF URINE Dr.H.Khouja

Corrected Sp Gr = 1.032-0.010 = 1.022

Hyposthenuria (<1.010) & Isosthenuria (=1.010) Hypersthenuria (>1.010)Pathological Non-pathological Pathological Non-pathological-collagen disease-pyelonepheritis-hypertension-polydipsia-diabetes insipidus

-excessive intake of fluids-diuretic fluids (coffee, tea, alcohol)-diuretic medications-nervousness, stress, anxiety-cold climate

-proteinurea-glycosurea-eclampsia-lipid nepherosis-dehydration

-low intake of fluids-presence of high density compounds;-dextran, X-ray contrast material, renal dyes, metabolites of some drugs and medications-old urine-refrigerated urine

Urine Odour Not of clinical significance unless noticeable (does not form part of physical examination unless noticeable in fresh urine) Observe method for smelling of urine (use face mask, position from nose) Fresh urine must be used Hereditary metabolic disorder urine usually have distinctive odour due to unusual metabolites in urine (mother may notice the

smell during changing of diapers or when the child urinate)

odour Interpretation odour InterpretationPungent aromatic Normal fresh urine fruity Presence of ketone bodiesAmmonical Old urine -presence of urea splitting bacteria syrup Maple syrup diseaseFoul -Fecal Infection of the renal system (pyelonepheritis, cystitis, UTI) mousy phenylketoureasweet Presence of glucose

VARIOUS URINE COLOUR STANDARD SCHEME

Color-less

V L Yellow

Lightyelow

yellow Dark yellow

amber orange Yellow green

Yellow brown

green Blue-green

pink red Dark red

Purple red

brown

black

MED TECH DEPT-U&BF PHYSICAL EXAMINATION OF URINE Dr.H.Khouja

VARIOUS URINE COLOUR STANDARD SCHEME

Colourless V L Yellow

Lightyelow

yellow Dark yellow

amber orange Yellow green

Yellow brown

green Blue-green

pink red Dark red

Purple red

brown black

VARIOUS URINE COLOUR STANDARD SCHEME

Colourless V L Yellow

Lightyelow

yellow Dark yellow

amber orange Yellow green

Yellow brown

green Blue-green

pink red Dark red

Purple red

brown black