<title>Macroscopic Urinalysis

Macroscopic Urinalysis


The first part ofa urinalysis is direct visual observation. Normal, fresh urine is pale to dark yellow or amber in color and clear. Normal urine volume is 750 to 2000 ml/24hr.

Turbidity or cloudiness may be caused by excessive cellular material or protein in the urine or may develop from crystallization or precipitation of salts upon standing at room temperature or in the refrigerator. Clearing of the specimen after addition of a small amount of acid indicates that precipitation of salts is the probable cause of tubidity.

A red or red-brown (abnormal) color could be from a food dye, eating fresh beets, a drug, or the presence of either hemoglobin or myoglobin. If the sample contained many red blood cells, it would be cloudy as well as red.

Examples of appearances of urine

Three urine samples are shown. The one at the left shows a red, cloudy appearance. The one in the center is red but clear. The one on the right is yellow, but cloudy.

Methodology

A sample of well-mixed urine (usually 10-15 ml) is centrifuged in a test tube at relatively low speed (about 2-3,000 rpm) for 5-10 minutes until a moderately cohesive button is produced at the bottom of the tube. The supernate is decanted and a volume of 0.2 to 0.5 ml is left inside the tube. The sediment is resuspended in the remaining supernate by flicking the bottom of the tube several times. A drop of resuspended sediment is poured onto a glass slide and coverslipped.

Examination

The sediment is first examined under low power to identify most crystals, casts, squamous cells, and other large objects. The numbers of casts seen are usually reported as number of each type found per low power field (LPF). Example: 5-10 hyaline casts/L casts/LPF. Since the number of elements found in each field may vary considerably from one field to another, several fields are averaged. Next, examination is carried out at high power to identify crystals, cells, and bacteria. The various types of cells are usually described as the number of each type found per average high power field (HPF). Example: 1-5 WBC/HPF.

Red Blood Cells

Hematuria is the presence of abnormal numbers of red cells in urine due to: glomerular damage, tumors which erode the urinary tract anywhere along its length, kidney trauma, urinary tract stones, renal infarcts, acute tubular necrosis, upper and lower uri urinary tract infections, nephrotoxins, and physical stress. Red cells may also contaminate the urine from the vagina in menstruating women or from trauma produced by bladder catherization. Theoretically, no red cells should be found, but some find their way into the urine even in very healthy individuals. However, if one or more red cells can be found in every high power field, and if contamination can be ruled out, the specimen is probably abnormal.

RBC's may appear normally shaped, swollen by dilute urine (in fact, only cell ghosts and free hemoglobin may remain), or crenated by concentrated urine. Both swollen, partly hemolyzed RBC's and crenated RBC's are sometimes difficult to distinguish from WBC's in the urine. In addition, red cell ghosts may simulate yeast. The presence of dysmorphic RBC's in urine suggests a glomerular disease such as a glomerulonephritis. Dysmorphic RBC's have odd shapes as a consequence of being distorted via passage through the abnormal glomerular structure.

Red blood cells in urine

Dysmorphic red blood cells in urine

White Blood Cells

Pyuria refers to the presence of abnormal numbers of leukocytes that may appear with infection in either the upper or lower urinary tract or with acute glomerulonephritis. Usually, the WBC's are granulocytes. White cells from the vagina, especially in the presence of vaginal and cervical infections, or the external urethral meatus in men and women may contaminate the urine.

If two or more leukocytes per each high power field appear in non-contaminated urine, the specimen is probably abnormal. Leukocytes have lobed nuclei and granular cytoplasm.

Whiteblood cells in urine

Epithelial Cells

Renal tubular epithelial cells, usually larger than granulocytes, contain a large round or oval nucleus and normally slough into the urine in small numbers. However, with nephrotic syndrome and in conditions leading to tubular degeneration, the number sloughed is increased.

When lipiduria occurs, these cells contain endogenous fats. When filled with numerous fat droplets, such cells are called oval fat bodies. Oval fat bodies exhibit a "Maltese cross" configuration by polarized light microscopy.

Oval fat bodies in urine

Oval fat bodies in urine, with polarized light

Transitional epithelial cells from the renal pelvis, ureter, or bladder have more regular cell borders, larger nuclei, and smaller overall size than squamous epithelium. Renal tubular epithelial cells are smaller and rounder than transitional epithelium, and their nucleus occupies more of the total cell volume.

Squamous epithelial cells from the skin surface or from the outer urethra can appear in urine.

Their significance is that they represent possible contamination of the specimen with skin flora.

Squamous epithelial cells in urine

Casts

Urinary casts are formed only in the distal convoluted tubule (DCT) or the collecting duct (distal nephron). The proximal convoluted tubule (PCT) and loop of Henle are not locations for cast formation. Hyaline casts are composed primarily of a mucoprotein (Tamm-Horsfall protein) secreted by tubule cells. The Tamm-Horsfall protein secretion (green dots) is illustrated in the diagram below, forming a hyaline cast in the collecting duct:

Even with glomerular injury causing increased glomerular permeability to plasma proteins with resulting proteinuria, most matrix or "glue" that cements urinary casts together is Tamm-Horsfall mucoprotein, although albumin and some globulins are also incorporated. An example of glomerular inflammation with leakage of RBC's to produce a red blood cell cast is shown in the diagram below:

The factors which favor protein cast formation are low flow rate, high salt concentration, and low pH, all of which favor protein denaturation and precipitation, particularly that of the Tamm-Horsfall protein. Protein casts with long, thin tails formed at the junction of Henle's loop and the distal convoluted tubule are called cylindroids. Hyaline casts can be seen even in healthy patients.

Red blood cells may stick together and form red blood cell casts. Such casts are indicative of glomerulonephritis, with leakage of RBC's from glomeruli, or severe tubular damage.

White blood cell casts are most typical for acute pyelonephritis, but they may also be present with glomerulonephritis. Their presence indicates inflammation of the kidney, because such casts will not form except in the kidney.

When cellular casts remain in the nephron for some time before they are flushed into the bladder urine, the cells may degenerate to become a coarsely granular cast, later a finely granular cast, and ultimately, a waxy cast. Granular and waxy casts are be believed to derive from renal tubular cell casts. Broad casts are believed to emanate from damaged and dilated tubules and are therefore seen in end-stage chronic renal disease.

The so-called telescoped urinary sediment is one in which red cells, white cells, oval fat bodies, and all types of casts are found in more or less equal profusion. The conditions which may lead to a telescoped sediment are: 1) lupus nephritis 2) malignant hypertension 3) diabetic glomerulosclerosis, and 4) rapidly progressive glomerulonephritis.

In end-stage kidney disease of any cause, the urinary sediment often becomes very scant because few remaining nephrons produce dilute urine.

Hyaline casts in urine

Red blood cell casts forming in tubules

Red blood cell cast in urine

White blood cell cast in urine

Renal tubular cell cast in urine

Granular casts in urine

Granular cast in urine

Waxy cast in urine

Bile stained hyaline casts in renal tubules

Bacteria

Bacteria are common in urine specimens because of the abundant normal microbial flora of the vagina or external urethral meatus and because of their ability to rapidly multiply in urine standing at room temperature. Therefore, microbial organisms found in all but the most scrupulously collected urines should be interpreted in view of clinical symptoms.

Diagnosis of bacteriuria in a case of suspected urinary tract infection requires culture. A colony count may also be done to see if significant numbers of bacteria are present. Generally, more than 100,000/ml of one organism reflects significant bacteriuria. Multiple organisms reflect contamination. However, the presence of any organism in catheterized or suprapubic tap specimens should be considered significant.

Yeast

Yeast cells may be contaminants or represent a true yeast infection. They are often difficult to distinguish from red cells and amorphous crystals but are distinguished by their tendency to bud. Most often they are Candida, which may colonize bladder, urethra, or vagina.

Crystals

Common crystals seen even in healthy patients include calcium oxalate, triple phosphate crystals and amorphous phosphates.

Very uncommon crystals include: cystine crystals in urine of neonates with congenital cystinuria or severe liver disease, tyrosine crystals with congenital tyrosinosis or marked liver impairment, or leucine crystals in patients with severe liver disease or with maple syrup urine disease.

Oxalate crystals in urine

Triple phosphate crystals in urine

Cystine crystals in urine

Miscellaneous

General "crud" or unidentifiable objects may find their way into a specimen, particularly those that patients bring from home.

Spermatozoa can sometimes be seen. Rarely, pinworm ova may contaminate the urine. In Egypt, ova from bladder infestations with schistosomiasis may be seen.

METHODS OF URINE COLLECTION

1.      Random collection taken at any time of day with no precautions regarding contamination. The sample may be dilute, isotonic, or hypertonic and may contain white cells, bacteria, andsquamous epithelium as contaminants. In females, the specimen may cont contain vaginal contaminants such as trichomonads, yeast, and during menses, red cells.

2.      Early morning collection of the sample before ingestion of any fluid. This is usually hypertonic and reflects the ability of the kidney to concentrate urine during dehydration which occurs overnight. If all fluid ingestion has been avoided since 6 p.m. the previous day, the specific gravity usually exceeds 1.022 in healthy individuals.

3.      Clean-catch, midstream urine specimen collected after cleansing the external urethral meatus. A cotton sponge soaked with benzalkonium hydrochloride is useful and non-irritating for this purpose. A midstream urine is one in which the first half of the bladder urine is discarded and the collection vessel is introduced into the urinary stream to catch the last half. The first half of the stream serves to flush contaminating cells and microbes from the outer urethra prior to collection. This sounds easy, but it isn't (try it yourself before criticizing the patient).

4.      Catherization of the bladder through the urethra for urine collection is carried out only in special circumstances, i.e., in a comatose or confused patient. This procedure risks introducing infection and traumatizing the urethra and bladder, thus producing iatrogenic infection or hematuria.

5.      Suprapubic transabdominal needle aspiration of the bladder. When done under ideal conditions, this provides the purest sampling of bladder urine. This is a good method for infants and small children.

Summary

To summarize, a properly collected clean-catch, midstream urine after cleansing of the urethral meatus is adequate for complete urinalysis. In fact, these specimens generally suffice even for urine culture. A period of dehydration may precede urine collection if testing of renal concentration is desired, but any specific gravity > 1.022 measured in a randomly collected specimen denotes adequate renal concentration so long as there are no abnormal solutes in the urine.

Another important factor is the interval of time which elapses from collection to examination in the laboratory. Changes which occur with time after collection include: 1) decreased clarity due to crystallization of solutes, 2) rising pH, 3) loss of ketonebodies, 4) loss of bilirubin, 5) dissolution of cells and casts, and 6) overgrowth of contaminating microorganisms. Generally, urinalysis may not reflect the findings of absolutely fresh urine if the sample is > 1 hour old. Therefore, get the urine to the laboratory as quickly as possible.

Red blood cells in urine appear as refractile disks. With hypertonicity of the urine, the RBC's begin to have a crenated appearance.

Note the irregular outlines of many of these RBC's, compared to two relatively normal RBC's at the center left of the right panel. These abnormal RBC's are dysmorphic RBC's.

These white blood cells in urine have lobed nuclei and refractile cytoplasmic granules.

Oval fat bodies consist of degenerated tubular cells containing abundant lipid, which appears refractile.

Under polarized light, oval fat bodies demonstrate the "Maltese cross" appearance.

Large polygonal squamous epithelial cells with small nuclei are seen here.

Hyaline casts, which appear very pale and slightly refractile, are common findings in urine.

This histologic section at medium power with trichrome stain highlights red blood cells grouping together in tubules to form casts. The tubular epithelium is also damaged, with a foamy appearance, and is the basis for the appearance of oval fat bodies in urine in this case.

The presence of this red blood cell cast in on urine microscopic analysis suggests a glomerular or renal tubular injury.

This white blood cell cast suggests an acute pyelonephritis.

This renal tubular cell cast suggests injury to the tubular epithelium.

These are granular casts, with a roughly rectangular shape.

Casts which persist may break down, so that the cells forming it are degenerated into granular debris, as has occurred in this granular cast.

This is a broad, waxy cast. Note that the edges are sharp and there are "cracks" in this cast.

This section of renal cortex reveals tubules containing hyaline casts that are bile stained in a patient with hyperbilirubinemia.

These are oxalate crystals, which look like little envelopes (or tetrahedrons, depending upon your point of view). Oxalate crystals are common.

Thesec "triple phosphate" crystals look like rectangles, or coffin lids if you are feeling depressed.

These cystine crystals are shaped like stop signs. Cystine crystals are quite rare.