Urinalysis and Body Fluids - Introduction to Urinalysis PDF

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3920_Ch02_027-038 23/01/14 10:08 AM Page 27 3920_Ch02_027-038 23/01/14 10:08 AM Page 28 28 Part One | Background CHAPTER 2 History and Importance Analyzing urine was actually the beginning of laboratory med- icine. References to the study of urine can be found in the drawings of cavemen and in Egyptian hieroglyphics, such as Introduction to Urinalysis the Edwin Smith Surgical Papyrus. Pictures of early physicians commonly showed them examining a bladder-shaped flask of urine (Fig. 2–1). Often these physicians never saw the patient, only the patient’s urine. Although these physicians lacked the sophisticated testing mechanisms now available, they were able to obtain diagnostic information from such basic obser- vations as color, turbidity, odor, volume, viscosity, and even LEARNING OBJECTIVES sweetness (by noting that certain specimens attracted ants or tasted sweet). These same urine characteristics are still Upon completing this chapter, the reader will be able to: reported by laboratory personnel. However, modern urinalysis 2-1 List three major organic and three major inorganic 2-8 Discuss the actions of bacteria on an unpreserved urine has expanded beyond physical examination of urine to chemical constituents of urine. specimen. include chemical analysis and microscopic examination of urinary sediment. 2-2 Describe a method for determining whether a 2-9 Briefly discuss five methods for preserving urine speci- Many well-known names in the history of medicine are questionable fluid is urine. mens, including their advantages and disadvantages. associated with the study of urine, including Hippocrates, who, 2-3 Recognize normal and abnormal daily urine volumes. 2-10 Instruct a patient in the correct procedure for collect- in the 5th century BCE, wrote a book on “uroscopy.” During ing the following specimens: random, first morning, the Middle Ages, physicians concentrated their efforts very in- 2-4 Describe the characteristics of the recommended urine 24-hour timed, catheterized, midstream clean-catch, tensively on the art of uroscopy, receiving instruction in urine specimen containers. suprapubic aspiration, three-glass collection, and examination as part of their training (Fig. 2–2). By 1140 CE, 2-5 Describe the correct methodology for labeling urine pediatric. Identify a diagnostic use for each collection color charts had been developed that described the significance specimens. technique. of 20 different colors (Fig. 2–3). Chemical testing progressed from “ant testing” and “taste testing” for glucose to Frederik 2-6 State four possible reasons a laboratory would reject a 2-11 Describe the type of specimen needed for optimal Dekkers’ discovery in 1694 of albuminuria by boiling urine.1 urine specimen. results when a specific urinalysis procedure is requested. 2-7 List 10 changes that may take place in a urine speci- men that remains at room temperature for more than 2 hours. Figure 2–2 Instruction in urine examination. (Courtesy of National Library of Medicine.) The credibility of urinalysis became compromised when charlatans without medical credentials began offering their pre- dictions to the public for a healthy fee. These charlatans, called “pisse prophets,” became the subject of a book published by Thomas Bryant in 1627. The revelations in this book inspired the passing of the first medical licensure laws in England— another contribution of urinalysis to the field of medicine. The invention of the microscope in the 17th century led to the examination of urinary sediment and to the development by Thomas Addis of methods for quantitating the microscopic sediment. Richard Bright introduced the concept of urinalysis as part of a doctor’s routine patient examination in 1827. By KEY TERMS the 1930s, however, the number and complexity of the tests Albuminuria First morning specimen Polyuria performed in a urinalysis had reached a point of impracticality, and urinalysis began to disappear from routine examinations. Anuria Midstream clean-catch specimen Suprapubic aspiration Fortunately, development of modern testing techniques res- Catheterized specimen Nocturia Timed specimen cued routine urinalysis, which has remained an integral part Chain of custody (COC) Oliguria of the patient examination. Two unique characteristics of a urine specimen account for this continued popularity: Figure 2–1 Physician examines urine flask. (Courtesy of National Li- 1. Urine is a readily available and easily collected brary of Medicine.) specimen. 3920_Ch02_027-038 23/01/14 10:08 AM Page 29 3920_Ch02_027-038 23/01/14 10:08 AM Page 30 Chapter 2 | Introduction to Urinalysis 29 30 Part One | Background Urea, a metabolic waste product produced in the liver from hydration. Factors that influence urine volume include fluid diabetes mellitus has a high specific gravity because of the in- the breakdown of protein and amino acids, accounts for nearly intake, fluid loss from nonrenal sources, variations in the se- creased glucose content. half of the total dissolved solids in urine. Other organic sub- cretion of antidiuretic hormone, and need to excrete increased Diabetes insipidus results from a decrease in the produc- stances include primarily creatinine and uric acid. The major in- amounts of dissolved solids, such as glucose or salts. Taking tion or function of antidiuretic hormone (ADH); thus, the organic solid dissolved in urine is chloride, followed by sodium these factors into consideration, although the normal daily water necessary for adequate body hydration is not reabsorbed and potassium. Small or trace amounts of many additional in- urine output is usually 1200 to 1500 mL, a range of 600 to from the plasma filtrate. In this condition, the urine is truly di- organic chemicals are also present in urine (Table 2–1). Dietary 2000 mL is considered normal. lute and has a low specific gravity. Fluid loss in both diseases intake greatly influences the concentrations of these inorganic Oliguria, a decrease in urine output (which is less is compensated by increased ingestion of water (polydipsia), compounds, making it difficult to establish normal levels. Other than 1 mL/kg/hr in infants, less than 0.5 mL/kg/hr in producing an even greater urine volume. Polyuria accompa- substances found in urine include hormones, vitamins, and children, and less than 400 mL/day in adults), is commonly nied by increased fluid intake is often the first symptom of medications. Although not a part of the original plasma filtrate, seen when the body enters a state of dehydration as a result either disease. the urine also may contain formed elements, such as cells, casts, of excessive water loss from vomiting, diarrhea, perspiration, crystals, mucus, and bacteria. Increased amounts of these formed or severe burns. elements are often indicative of disease. Oliguria leading to anuria, cessation of urine flow, may Specimen Collection result from any serious damage to the kidneys or from a As discussed in Chapter 1, urine is a biohazardous substance Urine Volume decrease in the flow of blood to the kidneys. The kidneys excrete two to three times more urine during that requires the observance of Standard Precautions. Gloves should be worn at all times when in contact with Urine volume depends on the amount of water that the kidneys the day than during the night. An increase in the nocturnal ex- the specimen. excrete. Water is a major body constituent; therefore, the cretion of urine is termed nocturia. Polyuria, an increase in amount excreted is usually determined by the body’s state of daily urine volume (greater than 2.5 L/day in adults and 2.5 Containers to 3 mL/kg/day in children), is often associated with diabetes mellitus and diabetes insipidus; however, it may be artificially Specimens must be collected in clean, dry, leak-proof contain- Figure 2–3 A chart used for urine analysis. (Courtesy of National ers. Disposable containers should be used because they elimi- Library of Medicine.) TECHNICAL TIP Should it be necessary to determine induced by diuretics, caffeine, or alcohol, all of which suppress the secretion of antidiuretic hormone. nate the chance of contamination owing to improper washing. whether a particular fluid is urine, the specimen can be Diabetes mellitus and diabetes insipidus produce polyuria These disposable containers are available in a variety of sizes tested for its urea and creatinine content. Because both for different reasons, and analysis of the urine is an important and shapes, including bags with adhesive for the collection of 2. Urine contains information, which can be obtained by these substances are present in much higher concentra- step in the differential diagnosis (Fig. 2–4). Diabetes mellitus pediatric specimens and large containers for 24-hour speci- inexpensive laboratory tests, about many of the body’s tions in urine than in other body fluids, a high urea and is caused by a defect either in the pancreatic production of in- mens. Properly applied screw-top lids are less likely to leak major metabolic functions. creatinine content can identify a fluid as urine. sulin or in the function of insulin, which results in an increased than are snap-on lids. These characteristics fit in well with the current trends body glucose concentration. The kidneys do not reabsorb ex- Containers for routine urinalysis should have a wide toward preventive medicine and lower medical costs. In fact, cess glucose, necessitating excretion of increased amounts of mouth to facilitate collections from female patients and a wide, the Clinical and Laboratory Standards Institute (CLSI) de- Table 2–1 Primary Components in Normal Urine3 water to remove the dissolved glucose from the body. Although flat bottom to prevent overturning. They should be made of a fines urinalysis as “the testing of urine with procedures com- appearing to be dilute, a urine specimen from a patient with clear material to allow for determination of color and clarity. monly performed in an expeditious, reliable, accurate, safe, Component Comment The recommended capacity of the container is 50 mL, which and cost-effective manner.” Reasons for performing urinalysis allows 12 mL of specimen needed for microscopic analysis, Urea Primary organic component. Product identified by CLSI include aiding in the diagnosis of disease, Polydipsia additional specimen for repeat analysis, and enough room for of protein and amino acid screening asymptomatic populations for undetected disor- the specimen to be mixed by swirling the container. metabolism ders, and monitoring the progress of disease and the effec- Individually packaged sterile containers with secure Creatinine Product of creatine metabolism by Polyuria closures should be used for microbiologic urine studies. Sterile tiveness of therapy.2 muscles containers are also suggested if more than 2 hours elapse Uric acid Product of nucleic acid breakdown in between specimen collection and analysis.2 Urine Formation food and cells Specific gravity Specially designed sterile containers are available that Chloride Primary inorganic component. Found have a lid with a transfer device that can be assessed with a The kidneys continuously form urine as an ultrafiltrate of device called a transfer straw. The transfer straw has a needle in combination with sodium (table plasma. Reabsorption of water and filtered substances essential Decreased SG Increased SG and an evacuated tube holder. Urine can be sterilely trans- salt) and many other inorganic to body function converts approximately 170,000 mL of ferred to tubes containing preservatives for microbiology test- substances filtered plasma to the average daily urine output of 1200 mL. ing and tubes with conical bottoms for sediment analysis or Sodium Primarily from salt, varies by intake Decreased production Decreased insulin (Refer to Chapter 3.) or or round bottoms for automated reagent strip testing.4 Additional Potassium Combined with chloride and other Function of ADH Decreased function information and pictures can be found at http//www. salts of insulin Urine Composition Phosphate Combines with sodium to buffer the bd.com/ds/productCenter/. In general, urine consists of urea and other organic and inor- blood Diabetes insipidus Increased glucose Labels ganic chemicals dissolved in water. Urine is normally 95% Ammonium Regulates blood and tissue fluid All specimens must be labeled properly with the patient’s name water and 5% solutes, although considerable variations in the acidity and identification number, the date and time of collection, and Diabetes mellitus concentrations of these solutes can occur owing to the influ- Calcium Combines with chloride, sulfate, and additional information such as the patient’s age and location ence of factors such as dietary intake, physical activity, body phosphate Figure 2–4 Differentiation between diabetes mellitus and diabetes and the healthcare provider’s name, as required by institutional metabolism, and endocrine functions. insipidus. protocol. Labels must be attached to the container, not to the 3920_Ch02_027-038 23/01/14 10:08 AM Page 31 3920_Ch02_027-038 23/01/14 10:08 AM Page 32 Chapter 2 | Introduction to Urinalysis 31 32 Part One | Background lid, and should not become detached if the container is refrig- erated or frozen. Specimen Handling TECHNICAL TIP Specimens must be returned to room Types of Specimens The fact that a urine specimen is so readily available and easily temperature before chemical testing by reagent strips To obtain a specimen that is representative of a patient’s meta- Requisitions collected often leads to laxity in the treatment of the specimen because the enzyme reactions on the strips perform best bolic state, regulation of certain aspects of specimen collection after its collection. Changes in urine composition take place at room temperature. is often necessary. These special conditions may include time, A requisition form (manual or computerized) must accompany specimens delivered to the laboratory. The information on the not only in vivo but also in vitro, thus requiring correct han- length, and method of collection and the patient’s dietary and form must match the information on the specimen label. dling procedures. medicinal intake. It is important to instruct patients when they same time, the preservative should not interfere with chemical Additional information on the form can include method of col- must follow special collection procedures. Frequently encoun- Specimen Integrity tests. Unfortunately, as can be seen in Table 2–3, the ideal lection or type of specimen, possible interfering medications, tered specimens are listed in Table 2–4. preservative does not exist; therefore, a preservative that best and the patient’s clinical information. The time the specimen Following collection, specimens should be delivered to the lab- suits the needs of the required analysis should be chosen. is received in the laboratory should be recorded on the form. oratory promptly and tested within 2 hours. A specimen that Random Specimen cannot be delivered and tested within 2 hours should be re- This is the most commonly received specimen because of Specimen Rejection frigerated or have an appropriate chemical preservative added. Table 2–2 describes the 11 most significant changes that may TECHNICAL TIP When preserving samples that will be its ease of collection and convenience for the patient. The transported to another laboratory, be sure to check with random specimen may be collected at any time, but the ac- Improperly labeled and collected specimens should be re- occur in a specimen allowed to remain unpreserved at room that laboratory concerning the appropriate preservative. tual time of voiding should be recorded on the container.2 jected by the laboratory, and appropriate personnel should temperature for longer than 2 hours. Notice that most of the The random specimen is useful for routine screening tests to be notified to collect a new specimen. Unacceptable situa- changes are related to the presence and growth of bacteria. tions include: These variations are discussed again under the individual test procedures. At this point it is important to realize that improper Table 2–3 Urine Preservatives 1. Specimens in unlabeled containers preservation can seriously affect the results of a routine urinalysis. Preservatives Advantages Disadvantages Additional Information 2.Nonmatching labels and requisition forms 3.Specimens contaminated with feces or toilet paper Specimen Preservation Refrigeration Does not interfere with Precipitates amorphous Prevents bacterial growth 4.Containers with contaminated exteriors chemical tests phosphates and urates for 24 hours2 The most routinely used method of preservation is refrigeration 5.Specimens of insufficient quantity at 2°C to 8°C, which decreases bacterial growth and metabo- Boric acid Prevents bacterial growth and Interferes with drug and Keeps pH at about 6.0 lism. If the urine is to be cultured, it should be refrigerated metabolism hormone analyses Can be used for urine 6.Specimens that have been improperly transported culture transport during transit and kept refrigerated until cultured up to Laboratories should have a written policy detailing their Formalin (formaldehyde) Excellent sediment preservative Acts as a reducing agent, Rinse specimen container 24 hours.2 The specimen must return to room temperature conditions for specimen rejection. interfering with chemical with formalin to preserve before chemical testing by reagent strips. When a specimen must be transported over a long dis- tests for glucose, blood, cells and casts tance and refrigeration is impossible, chemical preservatives leukocyte esterase, and TECHNICAL TIP Never discard a specimen before may be added. Commercially prepared transport tubes are copper reduction checking with a supervisor. available. The ideal preservative should be bactericidal, inhibit Sodium fluoride Is a good preservative for drug Inhibits reagent strip tests urease, and preserve formed elements in the sediment. At the analyses for glucose, blood, and leukocytes Commercial preservative Convenient when refrigeration Check tablet composition Table 2–2 Changes in Unpreserved Urine tablets not possible to determine possible Have controlled concentration effects on desired tests Analyte Change Cause to minimize interference Color Modified/darkened Oxidation or reduction of metabolites Urine Collection Kits4 Contains collection cup, Clarity Decreased Bacterial growth and precipitation of amorphous material (Becton, Dickinson, transfer straw, culture and Odor Increased Bacterial multiplication causing breakdown of urea to ammonia Rutherford, NJ) sensitivity (C&S) preserva- tive tube, or UA tube pH Increased Breakdown of urea to ammonia by urease-producing bacteria/loss of CO2 Light gray and gray C&S Sample stable at room tempera- Do not use if urine is below Preservative is boric acid, tube ture (RT) for 48 hours; pre- minimum fill line sodium borate and Glucose Decreased Glycolysis and bacterial use vents bacterial growth and sodium formate. Ketones Decreased Volatilization and bacterial metabolism metabolism Keeps pH at about 6.0 Bilirubin Decreased Exposure to light/photo oxidation to biliverdin Yellow UA Plus tube Use on automated instruments Must refrigerate within Round or conical bottom, Urobilinogen Decreased Oxidation to urobilin 2 hours no preservative Nitrite Increased Multiplication of nitrate-reducing bacteria Cherry red/yellow Stable for 72 hours at RT; in- Must be filled to minimum Preservative is sodium pro- Red and white blood Decreased Disintegration in dilute alkaline urine Preservative Plus tube strument-compatible fill line. pionate, ethyl paraben, cells and casts Bilirubin and urobilinogen and chlorhexidine; may be decreased if round or conical bottoms Bacteria Increased Multiplication specimen is exposed to Trichomonas Decreased Loss of motility, death light and left at RT 3920_Ch02_027-038 23/01/14 10:08 AM Page 33 3920_Ch02_027-038 23/01/14 10:08 AM Page 34 Chapter 2 | Introduction to Urinalysis 33 34 Part One | Background Table 2–4 Types of Urine Specimens 24-Hour (or Timed) Specimen preservative. The preservative chosen must be nontoxic to the PROCEDURE 2-2 patient and should not interfere with the tests to be performed. Type of Specimen Purpose Measuring the exact amount of a urine chemical is often Appropriate collection information is included with test pro- necessary instead of just reporting its presence or absence. A Clean-Catch Specimen Collection: Female cedures and should be read before issuing a container and Random Routine screening carefully timed specimen must be used to produce accurate instructions to the patient. Cleansing Procedure2 First morning Routine screening quantitative results. Many solutes exhibit diurnal variations 1. Wash hands. Pregnancy tests such as catecholamines, 17-hydroxysteroids, and electrolytes Catheterized Specimen 2. Remove the lid from the container without touching in which the lowest concentration is in the early morning and the inside of the container or lid. Orthostatic protein This specimen is collected under sterile conditions by passing the highest concentration occurs in the afternoon.2 When the 24-hour (or timed) Quantitative chemical tests a hollow tube (catheter) through the urethra into the bladder. 3. Separate the skin folds (labia). concentration of the substance to be measured changes with The most commonly requested test on a catheterized speci- 4. Cleanse from front to back on either side of the Catheterized Bacterial culture diurnal variations and with daily activities such as exercise, men is a bacterial culture. urinary opening with an antiseptic towelette, using Midstream clean-catch Routine screening meals, and body metabolism, 24-hour collection is required. a clean one for each side. Bacterial culture If the concentration of a particular substance remains constant, Midstream Clean-Catch Specimen the specimen may be collected over a shorter period. Care 5. Hold the skin folds apart and begin to void into the Suprapubic aspiration Bladder urine for bacterial must be taken, however, to keep the patient adequately As an alternative to the catheterized specimen, the midstream toilet. culture hydrated during short collection periods. Patients must be clean-catch specimen provides a safer, less traumatic method 6. Bring the urine container into the stream of urine and Cytology instructed on the procedure for collecting a timed specimen. for obtaining urine for bacterial culture and routine urinalysis. collect an adequate amount of urine. Do not touch To obtain an accurate timed specimen, the patient must It provides a specimen that is less contaminated by epithelial Three-glass collection Prostatic infection the inside of the container or allow the container to begin and end the collection period with an empty bladder. The cells and bacteria and, therefore, is more representative of the touch the genital area. concentration of a substance in a particular period must be actual urine than the routinely voided specimen. Patients must be provided with appropriate cleansing materials, a sterile 7. Finish voiding into the toilet. calculated from the urine volume produced during that time. detect obvious abnormalities. However, it may also show On its arrival in the laboratory, a 24-hour specimen must container, and instructions for cleansing and voiding. Strong 8. Cover the specimen with the lid. Touch only the erroneous results resulting from dietary intake or physical be thoroughly mixed and the volume accurately measured and bacterial agents, such as hexachlorophene or povidone-iodine, outside of the lid and container. activity just before collection. The patient will then be recorded. If only an aliquot is needed for testing, the amount should not be used as cleansing agents. Mild antiseptic tow- 9. Label the container with the name and time of requested to collect an additional specimen under more saved must be adequate to permit repeat or additional testing. elettes are recommended. Some urine collection transfer kits collection and place in the specified area or follow controlled conditions. If a specimen is collected in two containers, the contents of contain Castile Soap Towelettes. institutional policy. the containers should be combined and thoroughly mixed First Morning Specimen before aliquoting. Consideration also must be given to the Suprapubic Aspiration Although it may require the patient to make an additional preservation of specimens collected over extended periods. Occasionally urine may be collected by external introduction trip to the laboratory, this is the ideal screening specimen. It All specimens should be refrigerated or kept on ice during the of a needle through the abdomen into the bladder. Because the is also essential for preventing false-negative pregnancy tests collection period and may also require addition of a chemical bladder is sterile under normal conditions, suprapubic aspi- PROCEDURE 2-3 and for evaluating orthostatic proteinuria. The first morn- ration provides a sample for bacterial culture that is completely ing specimen is a concentrated specimen, thereby assuring free of extraneous contamination. The specimen can also be Clean-Catch Specimen Collection: Male detection of chemicals and formed elements that may not be used for cytologic examination. Cleansing Procedure2 PROCEDURE 2-1 present in a dilute random specimen. The patient should be 1. Wash hands. instructed to collect the specimen immediately on arising Sample 24-Hour (Timed) Specimen Collection Prostatitis Specimen 2. Remove the lid from the sterile container without and to deliver it to the laboratory within 2 hours or keep it Procedure Several methods are available to detect the presence of prostatitis. touching the inside of the container or lid. refrigerated. Provide the patient with written instructions, and explain 3. Cleanse the tip of the penis with antiseptic Three-Glass Collection the collection procedure. towelette and let dry. Retract the foreskin if Provide the patient with the proper collection container Prior to collection the area is cleansed using the male mid- uncircumcised. HISTORICAL NOTE and preservative. stream clean-catch procedure. Then instead of discarding the 4. Void into the toilet. Hold back foreskin if Day 1: 7 a.m.: patient voids and discards specimen; first urine passed, it is collected in a sterile container. Next, the necessary. Glucose Tolerance Specimens collects all urine for the next 24 hours. midstream portion is collected in another sterile container. The 5. Bring the sterile urine container into the stream of Day 2: 7 a.m.: patient voids and adds this urine to prostate is then massaged so that prostate fluid will be passed Glucose tolerance specimens are sometimes collected urine and collect an adequate amount of urine. Do previously collected urine. with the remaining urine into a third sterile container. Quan- to correspond with the blood samples drawn during a not touch the inside of the container or allow the On arrival at laboratory, the entire 24-hour specimen is titative cultures are performed on all specimens, and the first glucose tolerance test (GTT). The number of specimens container to touch the genital area. thoroughly mixed, and the volume is measured and varies with the length of the test. GTTs may include 6. Finish voiding into the toilet. recorded. fasting, half-hour, 1-hour, 2-hour, and 3-hour specimens, TECHNICAL TIP When both a routine urinalysis and a 7. Cover the specimen with the lid. Touch only the and possibly 4-hour, 5-hour, and 6-hour specimens. The culture are requested on a catheterized or midstream outside of the lid and container. urine is tested for glucose and ketones, and the results are collection, the culture should be performed first to prevent 8. Label the container with the name and time of reported along with the blood test results as an aid to inter- contamination of the specimen. A collection transfer kit collection and place in the specified area or follow preting the patient’s ability to metabolize a measured TECHNICAL TIP Addition of urine formed before the can also be used. institutional policy. amount of glucose and are correlated with the renal start of the collection period will falsely elevate results and threshold for glucose. Collection of these specimens is an failure to include urine produced at the end of the collec- institutional option.5 tion period will falsely decrease results. 3920_Ch02_027-038 23/01/14 10:08 AM Page 35 3920_Ch02_027-038 23/01/14 10:08 AM Page 36 Chapter 2 | Introduction to Urinalysis 35 36 Part One | Background and third specimens are examined microscopically. In prostatic TECHNICAL TIP Check the applied bags approximately PROCEDURE 2-4 infection, the third specimen will have a white blood cell/ high-power field count and a bacterial count 10 times that of every 15 minutes until the needed amount of sample has been collected. Urine Drug Specimen Collection Procedure records the in-range temperature on the COC form the first specimen. Macrophages containing lipids may also be (COC step 2). If the specimen temperature is out of present. The second specimen is used as a control for bladder 1. The collector washes hands and wears gloves. range or the specimen is suspected of having been and kidney infection. If it is positive, the results from the third 2. The collector adds bluing agent (dye) to the toilet diluted or adulterated, a new specimen must be specimen are invalid because infected urine has contaminated water reservoir to prevent an adulterated specimen. Drug Specimen Collection collected and a supervisor notified. the specimen.6 3. The collector eliminates any source of water other 12. The specimen must remain in the sight of the donor and Urine specimen collection is the most vulnerable part of than toilet by taping the toilet lid and faucet handles. Pre- and Post-Massage Test collector at all times. a drug-testing program. Correct collection procedures and 4. The donor provides photo identification or positive In the pre- and post-massage test (PPMT), a clean-catch mid- documentation are necessary to ensure that the results are 13. With the donor watching, the collector peels off the identification from employer representative. stream urine specimen is collected. A second urine sample is those of the specific individual submitting the specimen. The specimen identification strips from the COC form (COC 5. The collector completes step 1 of the chain-of-custody step 3) and puts them on the capped bottle, covering collected after the prostate is massaged. A positive result is sig- chain of custody (COC) is the process that provides this doc- (COC) form and has the donor sign the form. nificant bacteriuria in the post-massage specimen of greater umentation of proper sample identification from the time of both sides of the cap. than 10 times the premassage count.7 collection to the receipt of laboratory results. The COC is a 6. The donor leaves his or her coat, briefcase, and/or 14. The donor initials the specimen bottle seals. standardized form that must document and accompany every purse outside the collection area to avoid the possibil- 15. The date and time are written on the seals. Pediatric Specimens step of drug testing, from collector to courier to laboratory to ity of concealed substances contaminating the urine. 16. The donor completes step 4 on the COC form. Collection of pediatric specimens can present a challenge. Soft, medical review officer to employer. 7. The donor washes his or her hands and receives a For urine specimens to withstand legal scrutiny, it is specimen cup. 17. The collector completes step 5 on the COC form. clear plastic bags with hypoallergenic skin adhesive to attach to the genital area of both boys and girls are available for col- necessary to prove that no tampering of the specimen oc- 8. The collector remains in the restroom but outside the 18. Each time the specimen is handled, transferred, lecting routine specimens. Sterile specimens may be obtained curred, such as substitution, adulteration, or dilution. All stall, listening for unauthorized water use, unless a or placed in storage, every individual must be by catheterization or by suprapubic aspiration. Care must be personnel handling the specimen must be noted. The spec- witnessed collection is requested. identified and the date and purpose of the change taken not to touch the inside of the bag when applying it. imen must be handled securely, with a guarantee that no recorded. 9. The donor hands specimen cup to the collector. For routine specimen analysis ensure the area is free of unauthorized access to the specimen was possible. Proper Transfer is documented. 19. The collector follows laboratory-specific instructions for contamination. Attach the bag firmly over the genital area identification of the individual whose information is indi- packaging the specimen bottles and laboratory copies of cated on the label is required. Either photo identification or 10. The collector checks the urine for abnormal color and avoiding the anus. When enough specimen has been collected, the COC form. positive identification by an employer representative with for the required amount (30 to 45 mL). remove the bag and label it or pour the specimen into con- 20. The collector distributes the COC copies to appropriate tainer and label the container following institutional policy. photo ID is acceptable. 11. The collector checks that the temperature strip on the personnel. For microbiology specimens clean the area with soap and Urine specimen collections may be “witnessed” or “un- specimen cup reads 32.5°C to 37.7°C. The collector water and sterilely dry the area, removing any residual soap witnessed.” The decision to obtain a witnessed collection is residue. Firmly apply a sterile bag. Sterilely transfer collected indicated when it is suspected that the donor may alter or specimen into a sterile container and label the container.2 substitute the specimen or it is the policy of the client order- ing the test. If a witnessed specimen collection is ordered, a Log on to 3. Torora, GJ, and Anagnostakos, NP: Principles of Anatomy same-gender collector will observe the collection of 30 to www.fadavis.com/strasinger and Physiology, ed 6, Harper & Row, New York, 1990, HISTORICAL NOTE 45 mL of urine. Witnessed and unwitnessed collections for additional content related p. 51. to this chapter. 4. Becton, Dickinson and Company: BD Vacutainer Urine Products should be immediately handed to the collector. for collection, storage, and transport of urine specimens. Product Stamey-Mears Test for Prostatitis The urine temperature must be taken within 4 minutes References Circular, 2011. from the time of collection to confirm the specimen has not 5. Baer, DM: Glucose tolerance test: Tips from the clinical experts. 1. Herman, JR: Urology: A View Through the Retrospectroscope. Medical Laboratory Observer, Sept. 2003. The four-glass method consists of bacterial cultures of the been adulterated. The temperature should read within the Harper & Row, Hagerstown, MD, 1973. 6. Rous, SN: The Prostate Book. Consumers Union, Mt. Vernon, initial voided urine (VB1), midstream urine (VB2), ex- range of 32.5°C to 37.7°C. If the specimen temperature is 2. Clinical and Laboratory Standards Institute (formerly NCCLS), NY, 1988. pressed prostatic secretions (EPS), and a post-prostatic not within range, the temperature should be recorded and Approved Guideline GP16-A3: Urinalysis and Collection, 7. Stevermer, JJ, and Easley, SK: Treatment of prostatitis. Am Fam massage urine specimen (VB3). Urethral infection or in- the supervisor or employer contacted immediately. Urine Transportation, and Preservation of Urine Specimens; Approved Physician 61(10), 2000. flammation is tested for by the VB1, and the VB2 tests for temperatures outside of the recommended range may indicate Guideline—ed 3, CLSI, Wayne, PA, 2009. urinary bladder infection. The prostatic secretions are cul- specimen contamination. Recollection of a second specimen tured and examined for white blood cells. Having more as soon as possible will be necessary. The urine color is than 10 to 20 white blood cells per high-power field is also inspected to identify any signs of contaminants. The considered abnormal.7 specimen is labeled, packaged, and transported following Study Questions laboratory-specific instructions. 1. The average daily output of urine is: 2. An unidentified fluid is received in the laboratory with a A. 200 mL request to determine whether the fluid is urine or another body fluid. Using routine laboratory tests, what tests B. 500 mL would determine that the fluid is most probably urine? C. 1200 mL A. Glucose and ketones D. 2500 mL B. Urea and creatinine C. Uric acid and amino acids D. Protein and amino acids