Urine Examination (T&P) PDF

Dr. Haitham Alhakimi Body Fluid Urine Examination (T&P) 1- Physical Examination 2- Chemical Examination 3- Microscopic Examination 4- Microbiologi...

Dr. Haitham Alhakimi Body Fluid Urine Examination (T&P) 1- Physical Examination 2- Chemical Examination 3- Microscopic Examination 4- Microbiological Examination Collection of Urine for Analysis Precautions For Urine Collection: A preservative (as toluene, chloroform, thymol & formalin) is added to prevent contamination of the urine. Change in pH causes degeneration of cast and cell lysis. If urine is kept for a longer time, then it will get a false positive test, like nitrite will be positive. Keep urine at 2 to 8°C if delayed > 8 hours. keeping urine in refrigerator is greatly advisable especially in hot weather. Urea-producing organisms will degrade urea to ammonia and change the pH to alkaline. Urine is collected over a period of 24 hours. Urine must be analyzed within one hour of collection if held at room temperature. Factors that will interfere with the urine analysis: 1. Certain foods will color the urine, like: 1. Carrots will change their urine color to dark yellow. 2. Beets may cause red color urine. 3. Rhubarb will change its color to red or brown. 2. Asparagus‫ الهيليون‬produces a typical urine odor. 15 ‫ من‬1 ‫الصفحة‬ Dr. Haitham Alhakimi Body Fluid 3. If you keep urine on the table, bacteria will change the urine pH, making it alkaline because of urea-splitting bacteria, and there is the production of ammonia. 4. Effect of the food on the urine pH: 1. Eating citrus fruits, dairy products, and vegetables makes urine alkaline. 2. A high protein diet and some foods (cranberries) make urine acidic. 3. A high protein, a fat diet without the intake of carbohydrates also causes ketonuria. 5. When radiopaque contrast media is given to the patient will give false-positive urine protein for at least 3 days. 6. Females may have contamination from the vaginal secretions and show an increased number of WBCs. 7. Traumatic catheterization may cause hematuria and false RBCs in the urine. 8. False proteinuria is seen when urine is contaminated with vaginal secretions. 9. Urine culture gives false-positive results when contaminated with stool, vaginal secretions, and contaminated test tubes or hands and clothes. 15 ‫ من‬2 ‫الصفحة‬  Dr. Haitham Alhakimi Body Fluid Urine Analysis, Physical Examination 1- Volume 2- Specific Gravity 3- Aspect 4- Color 5- Odor 6- Deposit 7- Reaction (pH) 1- Volume: Normal urine volume in 24 hours is 600-2000 ml. A- Urine volume increases (Polyuria) in the following conditions: Physiological: ▪ Increased fluid intake. ▪ Diuretic. Pathological: ▪ Diabetes mellitus ▪ Diabetes insipidus ▪ Chronic renal failure 15 ‫ من‬3 ‫الصفحة‬  Dr. Haitham Alhakimi Body Fluid B- Urine volume decreases (Oliguria or anuria) in the following conditions: ▪ Dehydration ▪ Acute renal failure ▪ Obstruction 2- Specific gravity (SG): Specific gravity measures solute concentration (urea and sodium). This is the weight of 1 mL of urine in grams divided by 1 mL of water. Normally the specific gravity ranges between 1.010-1.030. Definition of specific gravity: - Urine-specific gravity is the measure of the kidney’s ability to concentrate urine. - The important process of reabsorption by the kidneys is often the first renal function to become impaired. 1. Instruments to determine urinary density. A. Urodensimeter. B. Refractometer.. C. Test strip colors (g/mL). Urine Specific gravity facts: 1. So, the specific gravity will detect dehydration or abnormality in the antidiuretic hormone. 2. Urine is a solution of minerals, salts, and other compounds dissolved in water. 3. Specific gravity = water + dissolved chemicals. 15 ‫ من‬4 ‫الصفحة‬  Dr. Haitham Alhakimi Body Fluid 4. So specific gravity is the measure of the density of dissolved substances in the urine. 5. Specific gravity is the weight of urine compared to distilled water, which has a specific gravity of 1.000. 6. The specific gravity of the plasma entering the glomerulus is 1.010. Types of urine according to the specific gravity: Isosthenuria 1. The urine-specific gravity is fixed and remains constant at around 1.010. 1. It is not influenced by water intake or dehydration. 2. Normal kidneys concentrate the urine in dehydration. 2. It is the urine that has not greater and not less than the protein-free plasma specific gravity. 3. It is urine with a specific gravity of 1.010 (1.008 to 1.012). 4. It suggests renal damage. 5. These patients need medical check-ups and workups. Hyposthenuria 1. Specific gravity is low = 1.010 (1.025 to 1.035). 2. It is seen in the following conditions: 1. Diabetes mellitus. 2. Nephrosis. 3. Increased secretion of ADH. 4. The diuretic effect of stress of the surgical procedure. 5. Excessive loss of water due to dehydration, fever, diarrhea, and vomiting. 6. Toxemia of pregnancy. 7. Cardiac diseases like congestive heart failure. Random sample = 1.003 to 1.035. 1. Most random sample = 1.015 to 1.025. 2. A specific gravity of 1.010 or higher is generally considered normal. 3. Specific gravity >1.035 is usually seen in the renal pyelogram. 4. Specific gravity 20 million/ml ◼ Total count > 40 million ◼ Morphology > 30% normal form ◼ Viability > 75% (50% in other) ◼ WBC< 1million/ml ◼ RBC none Macroscopic Examination: ◼ Semen is viscous, yellow grayish. ◼ Forms gel-like clot immediately. ◼ Liquefication time: Liquefies completely in 5-60 minutes; this must be complete before further testing (mix before further testing). ◼ Appearance: homogenous white-gray opalescence. Brown/red in hematospermia Dense white turbid if inflammation and high WBC ◼ Volume: (2 - 6 ml). in graduated cylinder or centrifuge tube free of contamination. WHO criteria specify that any volume greater than 2.0 mL is normal. Low volume may indicate partial or complete blockage of the seminal vesicles, or that the man was born without seminal vesicles. 13 ‫ من‬3 ‫الصفحة‬  Dr. Haitham Alhakimi Body Fluid ◼ Viscosity: 5ml pipette or plastic pipette normal, more viscous, very viscous ◼ pH: important parameter of motility and viability 7.2-8.0; measured by pH paper. pH is important because sperm die at pH < 6.9 The pH of liquefied semen is normally determined using test strips An acidic pH suggests problems with seminal vesicle function, and is usually found in association with a low volume of the ejaculate and the absence of fructose. Microscopic examination The characteristics assessed are: ◼ Motility. ◼ Sperm aggregation (random clumping): “some” is normal, but large clumps (each with hundreds of sperm) is abnormal. ◼ Sperm agglutination (between specific sites): could suggest the presence of anti-sperm antibodies. ◼ Epithelial cells: usually present in small numbers ◼ Erythrocytes: should not be present ◼ Bacteria and protozoa: presence indicates infection Normal Semen Analysis Semen volume 2ml or more (usually 2-4 milliliters per ejaculation) Semen pH Semen pH of 7.2-8.0 Liquefaction time 20-30 minutes after collection Sperm count 40 million spermatozoa per ejaculate or more Sperm morphology More than 30% of the sperm have normal shape and structure. More than 50% of the sperm show progressive movement or 25% Sperm motility or more with rapid progressive movement. Vitality 75% or more live, i.e., excluding dye White blood cells Fewer than 1 million WBCs/ml Microscopic examination: 1. Concentration: this is a measurement of how many million sperm there are in each milliliter of fluid. Average sperm concentration is more than 20 million per milliliter (20 - 40 million/ml). 2. Total sperm count: is the total number of spermatozoa in the entire ejaculate (40 million per ejaculate). 13 ‫ من‬4 ‫الصفحة‬  Dr. Haitham Alhakimi Body Fluid Methods of measuring sperm concentration: Hemacytometer: Sperm can be counted by make dilution 1:20 in WBC pipette or by automatic pipette (which is more accurate) with a solution containing sodium bicarbonate (5g) and formalin (1ml) (immobilize & preserve the spermatozoa), tap water (100 ml) will suffice as a diluent. Sperm concentration – hemocytometer: The number of squares assessed depends on the number of sperm counted in the first large square: – If < 10 counted, the whole grid is assessed – If 10-40 counted, 10 squares are assessed – If > 40 counted, 5 squares are assessed If the counts of the two chambers are not within 5% of their average discard, remix the sample, and set it up again If the two counts are in agreement, then the sum of the two counts is divided by the correction factor: – If 2 × 25 squares counted, divide their sum by 10 large central square. – If 2 × 10 squares counter, divide their sum by 4 This square is ruled into 25 small squares, each of which is further divided into 16 – If 2 × 5 squares counted, divide their sum by 2 This gives the sperm concentration in millions per ml. Sperm count = concentration × total volume Calculations – Using a 1:20 dilution and four large WBC’s squares counted The sperm concentration/ml = No of sperms counted x 50,000 – Using a 1:20 dilution and five small RBC’s squares counted The sperm concentration /ml = No of sperms counted x 1,000,000 13 ‫ من‬5 ‫الصفحة‬  Dr. Haitham Alhakimi Body Fluid Sperm concentration – interpretation: The WHO Reference values for: Sperm concentration is > 20 × 106 sperm/ml Counts of less than 20 million per milliliter ( 3 Erythrocytes – > 5 Leukocytes – > 2 Renal tubular cells – > 10 Bacteria 2) Per Low Power Field (LPF) (10x) – > 3 Hyaline casts or > 1 granular cast – > 10 Squamous cells (indicative of contaminated specimen) – Any other cast (RBCs, WBCs) 3) Presence of: – Fungal hyphae or yeast, parasite, viral inclusions – Pathological crystals (cystine, leucine, tyrosine) – Large number of uric acid or calcium oxalate crystals 13 ‫ من‬10 ‫الصفحة‬ Dr. Haitham Alhakimi Body Fluid 13 ‫ من‬11 ‫الصفحة‬ Dr. Haitham Alhakimi Body Fluid Causes of common renal calculi formation: - 13 ‫ من‬12 ‫الصفحة‬  Dr. Haitham Alhakimi Body Fluid Quiz: Q1: What are the signs and symptoms of urinary crystals? Q2. How can I avoid urinary crystal formation? Q3. What is the specimen of choice for urinary crystals? Q4. What is the role of refrigeration in urinary crystals? Q5. What are the most common crystals and renal calculi. Q6. What are the artifacts in the urine examination? 1- The common signs and symptoms are Pain Fever Blood in urine Urinary obstructio n Urinary frequency 2- These simple techniques can lower the risk of urinary crystals. Avoid taking medications without a prescription. Drink an adequate amount of fluid Maintain healthy weight Take a moderate amount of proteins Take an average daily intake of vitamin C, calcium, and oxalate. Avoid taking too much salt and sugar. 3- The specimen of choice to evaluate urinary crystals is First/second-morning, midstream, and clean-catch urine sample. Although the first-morning urine is the most concentrated for microscopically examining cells, the second-morning specimen is preferred. Because in the first-morning sample, the cellular elements can be damaged or decomposed. The urine volume should be 6-12 mL. The sample should be fresh and taken within one hour. 4- The refrigeration process will precipitate the formation of the crystals. It is due to the change in solubility of various crystals. 5- Most common crystals are calcium oxalate or calcium phosphate. 6- There is starch, oil droplets, air bubbles, pollen grains, and fecal contaminatio n. 13 ‫ من‬13 ‫الصفحة‬