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Urinalysis is an essential part of the diagnostic evaluation for all urinary and metabolic diseases. It includes evaluation of physical characteristics (color, clarity, and volume) and biochemical parameters (urine pH, blood, glucose, ketones, bilirubin, urobilinogen, and protein) Knowledge of factors that can interfere with the accuracy of some test results can decrease improper interpretation.
Urinalysis is an essential part of the diagnostic evaluation for all urinary and metabolic diseases. It includes evaluation of physical characteristics (color, clarity, and volume) and biochemical parameters (urine pH, blood, glucose, ketones, bilirubin, urobilinogen, and protein) Knowledge of factors that can interfere with the accuracy of some test results can decrease improper interpretation.
Urinalysis is an essential part of the diagnostic evaluation for all urinary and metabolic diseases. It includes evaluation of physical characteristics (color, clarity, and volume) and biochemical parameters (urine pH, blood, glucose, ketones, bilirubin, urobilinogen, and protein) Knowledge of factors that can interfere with the accuracy of some test results can decrease improper interpretation.
Nyssa J. Reine, DVM, Dipl. ACVIM (Internal Medicine), and Cathy E. Langston, DVM, Dipl. ACVIM (Internal Medicine) The urinalysis is an essential part of the diagnostic evaluation for all urinary and many metabolic diseases. Its assessment includes evaluation of physical characteristics (color, clarity, and volume), biochemical parameters (urine pH, blood, glucose, ketones, bilirubin, urobilinogen, and protein) and microscopic sediment evaluation (RBC, WBC, organisms, epithelial cells, crystals, and casts). Many of these parameters are inuenced by collection method and therefore, it is essential to interpret accordingly. Knowledge of factors that can interfere with the accuracy of some test results can decrease improper interpretation. When all of these parameters are evaluated in combination with clinical signs, physical examination, thorough history and other laboratory tests, a diagnosis will often be attained. Clin Tech Small Anim Pract 20:2-10 2005 Elsevier Inc. All rights reserved. KEYWORDS urinalysis, urine sediment, urine collection, fractional excretion of electrolytes I nterpretation of a urinalysis can yield a great deal of infor- mationsome beyond the connes of the urinary system. Through coordination of biochemical testing, urinalysis nd- ings, history, and physical examination, many common dis- orders can be included in or excluded from the differential diagnoses (ie, diabetes mellitus, chronic renal failure, etc.). Urine sediment evaluation can alert the clinician to important problems while the patient is still asymptomatic (ie, ammo- nium biurate crystals, pyuria in a diabetic patient). Also, there are some diseases for which early detection may lead to better survival (ie, protein losing nephropathy). This article will review the basics of urinalysis interpretation and how to glean the maximum amount of information from it. Urine Collection The method of collecting the urine sample may affect the results of analysis. A standardized volume of urine should be obtained each time, to allow comparison of urine sediment examination with subsequent samples. Free-Catch Urine Sampling When collecting a free-catch urine sample, a mid-stream sample is preferred. The initial urine that is voided will con- tain cells, bacteria, and debris from the urethra and vulva or prepuce, and may not be a representative sample. Because female dogs are usually positioned with the vulva close to the ground when urinating, a shallow container (such as a pie pan) may be helpful. The sample container should be clean and free of detergent to avoid interference with the biochem- ical analysis. Samples collected from midstream into a sterile container may have false positive urine culture results from external contaminants (ie, hair on prepuce or hindquarters). Urine samples brought in by owners are rarely suitable for urine culture. Quantitative analysis should be performed on all free-catch samples submitted for bacterial culture. Obtaining a free-catch midstream urine sample from a cat can be a difcult task. Removing the litter from the litter box or replacing it with nonabsorbent material [NoSorb beads (Catco, Inc. Cape Coral, FL), plastic packing material, un- popped popcorn, etc.] may allow collection of a suitable sample. Plastic wrap can be loosely placed over the litter to collect urine fromdeclawed cats. Although these samples will not be appropriate for culture, many other parameters will still be valid. Manual expression of the bladder to facilitate obtaining a free-catch sample is rarely successful in awake animals and may induce vesiculoureteral reux at pressures necessary to induce voiding. If the urine is infected, this introduces the risk of causing ascending pyelonephritis. Urinary Catheterization Male dogs are placed in lateral recumbency for catheteriza- tion. The penis is extruded from the prepuce, and the tip cleaned with dilute chlorhexiderm solution to remove any debris or discharge. Sterile lubricant is placed on the tip of the urinary catheter, which is then placed in the urethral Animal Medical Center, New York, NY. Address reprint requests to Nyssa J. Reine, DVM, Dipl. ACVIM (Internal Medicine), Animal Medical Center, 510 E. 62 nd Street, New York, NY 10021. E-mail: nyssa.reine@amcny.org 2 1096-2867/05/$-see front matter 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.ctsap.2004.12.002 orice and the catheter advanced into the bladder. It is help- ful to create a sleeve from the catheter packaging to maintain sterility while passing the catheter (Fig 1). Some resistance may be met at the pelvic exure region, which can usually be overcome by gentle pressure. While performing catheteriza- tion it is important to observe the ease with which the cath- eter is passed as this may be helpful information for dogs having difculty urinating. Most female dogs need chemical restraint to allow urinary catheterization. Lidocaine gel can be placed in the vaginal vault by syringe (without needle) to facilitate catheter place- ment without chemical restraint in some dogs. Some clini- cians are able to place catheters with the dog in lateral or dorsal recumbency, but most clinicians prefer sternal recum- bency. The dog is placed with the hind legs off the table. Keeping the dog straight will make catheter placement easier. Placing a sandbag or pillow beneath the pelvis may aid in positioning and stabilization. Some clinicians prefer to visu- alize the urethral papilla using a vaginal speculum or ano- scope. Blind, manually guided placement is also readily achievable. Wearing sterile gloves, the urethral papilla is pal- pated. The urethral papilla is located on the oor of the vagina canal, and is recognizable as a subtle deviation on the oor. In my experience, it can usually be palpated just before encountering the vestibulovaginal stenosis present in many dogs. It is also typically located behind the caudal aspect of the pubis, which can be palpated. The lubricated urinary catheter is passed just under the nger on the urethral pa- pilla, which helps direct the catheter down and into the ure- thra (Fig 2). The catheter should pass very smoothly in nor- mal dogs and urine should ow out of the catheter. If the catheter passes easily and no urine ows, the catheter may have been passed into the vagina. As with male dogs, easy of catheterization should be recorded. Both male and female cats usually need chemical restraint to allow urinary catheterization. A male cat should be posi- tioned on his back with his hind legs drawn forward. The penis is exteriorized from the prepuce. Because the penile urethra is normally directed downward, the penis should be retracted and lifted dorsally, to align the urethra parallel to the spine, eliminating the natural curve (Fig 3). A 3.5 to 5 French catheter can then be placed into the bladder. The technique for catheterizing female cats is similar to the tech- nique for female dogs, except that visualization is rarely pos- sible because of size. A 3.5 to 6 French catheter can be used in most female cats. After passing a urinary catheter to obtain a urine sample, the rst few milliliters of urine should be discarded, as that is the portion most likely to have debris from the urethra. A second aliquot can then be obtained for urinalysis and quan- titative culture if desired. The risk of creating a urinary tract infection from catheterization is higher in female dogs com- pared with males. 1 Cystocentesis Cystocentesis is the best method for obtaining urine samples for bacterial culture and can be performed on awake animals. With both cystocentesis and urinary catheterization, there is a risk of iatrogenic hematuria. The patient is usually posi- tioned in dorsal recumbency. Palpating the bladder with one hand helps immobilize it while acquiring the sample. The needle should be angled caudally, toward the pelvic inlet so that as the bladder empties, the needle is still in the lumen of Figure 1 Using urinary catheter to obtain urine sample from male dog. Sleeve of catheter wrapping is being used to maintain sterility of catheter during placement. Figure 2 Blind placement of urinary catheter in female dog. Placing the tip of the nger just past the urethral opening helps guide the urinary catheter down and into the urethra. Figure 3 Contrast urethrogram of male cat showing normal urethral position. Retraction of the penis dorsally and caudally will straighten urethra for placement of urinary catheter. Urinalysis interpretation 3 the bladder. It is also possible to use a lateral or standing approach when the bladder is palpable. A 1 inch, 22-gauge needle is preferred, and for very large or obese dogs, a 1.5 to 2-inch needle may be required. Iatrogenic hematuria can occur if the need is in contact with the opposite bladder wall. If the UA is being performed to monitor hematuria, a free catch sample may be preferable to cystocentesis or catheterization. Other complications in- clude puncture of the colon, laceration of the bladder, and laceration of the major blood vessels dorsal to the bladder. Inadvertent puncture of the colon can cause bacterial con- tamination of the urine sample, and a mixed population of bacteria on the urine culture may result. Urinalysis Procedure Multiple parameters are assessed when performing a urinal- ysis (Fig 4). Results are most accurate if a fresh urine sample is evaluated. If the sample will not be analyzed within 1 to 2 hours of collection, it should be refrigerated. Physical Characteristics Urine Color Normal urine is typically transparent and yellow on visual in- spection. Concentrated urine samples may appear amber col- ored and dilute urine may be a lighter yellow color. However, urine color should NEVER be used to replace USG assessment. There are many exogenous and endogenous pigments that can cause abnormal coloration. When a patient has abnormal urine color, a thorough investigation into diet, medications, and environment should be undertaken. The most com- monly observed abnormal urine colors in dogs and cats are red, brown, and black with hematuria, hemoglobinuria, myoglobinuria, and bilirubinuria being the most common causes. Centrifugation of a discolored urine sample should discern between true hematuria versus myoglobinuria or he- moglobinuria as intact red blood cells should settle into the bottom of the sample, leaving a clear supernatant. The serum color may provide information about the cause of alterations in the urine color. Patients with bilirubinuria will typically have hyperbilirubinemia, although bilirubin- uria without hyperbilirubinemia can occur in normal male dogs. Cats with bilirubinuria in absence of hyperbiliru- binemia should have serial urine and biochemical assessment to monitor for the development of icterus. Patients that have hemoglobinuria are expected to have pink tinged, hemolyzed serum. If normal serum color is present, an ammonium sul- fate test should be performed for myoglobin. 2 Urine Clarity Like color, clarity of urine can be affected by urine concen- tration. A well-concentrated urine sample is more likely to be turbid than a dilute sample. Other things that can increase turbidity include white blood cells (WBC), red blood cells (RBC), crystals, bacteria, mucus, lipid, and contaminating materials. Evaluation of the urine sediment should help to elucidate the cause of increased turbidity. It is best to assess urine clarity immediately after collection as crystals can pre- cipitate during storage, thus inuencing turbidity. 3 Urine Volume The daily volume of urination reported by an owner is an important determinant of which portion of the urinary tract should be investigated. A patient that has disease limited to the lower urinary tract will present with signs of stranguria (difcult urination) or pollakiuria (abnormally frequent uri- nation) that could easily be mistaken for polyuria (excessive volume of urine) by an owner. Diseases of the urinary bladder or urethra alone do not cause polyuria. The presence of poly- uria would imply that either the upper urinary tract is the source of the problem (ie, kidneys) or there is another met- abolic problem causing the excessive urination (ie, diabetes mellitus, Cushings disease, etc.). It is often difcult for own- ers to discern between pollakiuria and polyuria. The easiest way to get around this would be to have the owner quantitate water consumption for a few days. A normal dog should drink 1 oz per pound per day. Urine Specic Gravity (USG) Specic gravity is dened as the ratio of the weight of a volume of liquid to the weight of an equal volume of distilled water. Specic gravity is dependent on particle number, size and weight. This differs from urine osmolality, which is de- pendent only on the number of particles in the solution. Because determination of urine osmolality requires special- ized equipment and urine specic gravity (USG) can be de- termined with a simple refractometer, specic gravity is used Figure 4 Step-by step guide to performing a urinalysis. 4 N.J. Reine and C.E. Langston much more commonly in clinical practice to reect the con- centration of a patients urine. Either of these values reects the kidneys ability to concentrate and dilute urine. 4-7 Recent studies have documented that specic gravity is not affected by storage. 3 Normal USG Healthy animals can have a wide range of USG(1.001-1.065) as water consumption and thus urine concentration can vary based on activity, diet, etc. More commonly, it is accepted that a dog with normal renal function will have a USG 1.030 and a cat 1.035. Hyposthenuria Hyposthenuria is dened as a USG 1.008 and reects that the osmolality of the urine is lower than that of plasma. For dilution of urine, the renal distal convoluted tubule must be intact. The presence of hyposthenuria does very little to dis- tinguish between causes of polyuria (PU) and polydipsia (PD) as it can be caused by central diabetes insipidus, neph- rogenic diabetes insipidus (the cause of PU/PD in Cushings disease, hypercalcemia, pyometra, prostatitis), medullary washout, and psychogenic polydipsia. Patients with renal failure are not able to dilute urine below 1.008. Isosthenuria Isosthenuria is dened as a USG 1.007 to 1.012 and reects that the osmolality of urine is equal to that of plasma. The presence of isosthenuria may be suggestive of primary renal failure, though patients with other causes of PU/PD(ie, Cush- ings disease, diabetes mellitus, hypercalcemia) may also have a urine specic gravity in this range. 8 With renal disease, isosthenuria occurs with greater than 66% damage to the kidney (renal insufciency), whereas azotemia does not oc- cur until greater than 75% damage has been sustained (renal failure). USG Interpretation It is important to interpret USG in relation to hydration sta- tus. The presence of a concentrated USG in the face of dehy- dration virtually eliminates the possibility of renal failure as the cause of dehydration. It is never appropriate for a dehy- drated patient to have a lowUSG. In addition to renal failure, other diseases (ie, ketoacidotic diabetes mellitus, Addisons disease) may cause impaired urine concentrating ability with concurrent dehydration. USG in azotemic patients can dif- ferentiate prerenal causes from renal causes. USG must be evaluated before intravenous uid therapy. Also, patients that are normal can have a urine specic gravity that is isos- thenuria or hyposthenuric. A patient who has unexpected isosthenuria or hyposthenuria should have its water con- sumption quantied to assess for polydipsia that has gone unrecognized. Biochemical Analysis Urine dipstick analysis is a convenient method of assessing several biochemical aspects of urine. Visibly bloody or turbid urine samples should be centrifuged and the supernatant used for dipstick analysis. Urine pH Urine pH can give an indication about renal disease (ie, tu- bular acidosis) or systemic acid-base status, and urine pH affects the solubility of several types of urinary crystals. Urine dipsticks containing methyl red, bromthymol blue, and phe- nolphthalein can detect pH in the range of 5 to 9. Results of urine dipstick pHmeasurements may vary substantially from pH meter measurements. 9 pH paper is not accurate enough for clinical decision making. Portable pHmeters are the most accurate compared with laboratory methods, although regu- lar electrode maintenance and daily calibration is recom- mended to ensure accuracy. 10 Blood, Hemoglobin, and Myoglobin The heme portion of hemoglobin and myoglobin acts as a per- oxidase and can cause a color change on a reagent test strip. The hemoglobin in intact RBC will react to the reagent strip. Small number of intact RBCs will cause spotting of the test pad, whereas hemoglobin, myoglobin, or large numbers of intact RBCs will cause a homogenous color change. Most test strips can detect 5 to 20 RBC/mL or 0.015 to 0.062 mg/dL of free hemo- globin (equivalent to 5-20 RBC/mL). About 0.5 mL blood per liter of urine (approx. 2500 RBC/mL) is necessary for visual detection of hematuria. Up to 5 RBC/mL of urine is considered normal in people. False positive reactions may occur if the sam- ple is contaminated with oxidizing agents in disinfectants. False negative reactions may occur if RBCs have settled to the bottom of the sample, leading to a disparity between the dipstick and sediment evaluation. RBCs will lyse in dilute (USG 1.008) or alkaline urine. Hematuria with intact RBC can indicate disease of the lower urinary or genital tract (urethra, prostate, vagina, pe- nis, bladder) including infection, neoplasia, idiopathic or in- ammatory disease, and upper urinary (kidney, ureter) in- cluding pyelonephritis, protein-losing nephropathy, or neoplasia. Hemoglobinuria can occur if intact RBCs hemolyze in the urine (dilute or alkaline urine), or if hemoglobin levels in the blood are elevated fromhemolysis (ie, immune-mediated he- molytic anemia, toxins, genetic disorders, infectious agents, hypophosphatemia, or physical damage). Myoglobinuria oc- curs fromtrauma, toxic, or ischemic injury or necrosis (rhab- domyolysis). To help distinguish hematuria from hemoglo- binuria or myoglobinuria, inspect the supernatant after centrifuging the urine sample. If it clears, hematuria is present. Dipstick methods cannot differentiate myoglobin- uria from hemoglobinuria, but the presence of icteric or dis- colored plasma suggests hemoglobinuria. An elevated myo- globin level in the blood does not cause a color change in plasma. Glucose Glucosuria is detected by a glucose oxidase enzymatic reac- tion that is specic for glucose. Most urine dipstick methods have a practical lower limit of sensitivity for urine glucose concentrations from about 40 to 80 mg/dL, but they are semiquantitative above that level, with more intense color change reactions indicating higher glucose concentrations up to 2,000 mg/dL. The reagent pads have a limited shelf life and should be protected from sunlight. Refrigerated urine sam- Urinalysis interpretation 5 ples should be warmed to room temperature to avoid false negative results. Ascorbic acid (vitamin C) interferes with the test, leading to false negative results if a high concentration of ascorbic acid and a low concentration of glucose are present in the urine. Formaldehyde (a metabolite of the urinary an- tiseptic methenamine) can also cause false negative results. False positive results may be obtained if the sample is con- taminated with hydrogen peroxide, chlorine, or hypochlorite (bleach). Glucosuria may be caused by hyperglycemia or renal prox- imal tubular damage. The proximal tubule normally reab- sorbs almost all of the ltered glucose. When the blood con- centration and thus the ultraltrate concentration exceeds the capacity of the proximal tubule for reabsorption (about 180 mg/dL for dogs and 300 mg/dL for cats), glucose appears in the urine. Hyperglycemia can occur from diabetes melli- tus, stress or excitement in cats, or dextrose administration. Proximal tubular disorders, such as acute tubular necrosis, pyelonephritis, Fanconis syndrome, or primary renal glucos- uria, can lead to normoglycemic glucosuria. Ketones The primary ketones encountered in small animals are ace- toacetic acid, acetone, and -hydroxybutyric acid. Ketone reagent strips containing sodium nitroprusside react with acetoacetic acid and acetone to cause a purple color change. They are more sensitive to acetoacetic acid compared with acetone (lower limit of detection 5-10 mg/dL vs. 70 mg/dL, respectively). They do not detect -hydroxybutyric acid. The reagents are sensitive to the effects of moisture, heat, and light, so the container should be kept closed when not in use. Large amounts of bilirubin or other substances that discolor urine can cause a false positive reaction. Ketones are produced from fatty acid metabolism. Poorly controlled diabetes mellitus is the most common reason for their development, but starvation, a high protein and low carbohydrate diet, and some drugs can also cause ketonuria. Bilirubin When hemoglobin is degraded, the heme portion is con- verted to bilirubin, which is conjugated in the liver and ex- creted in the bile. Some conjugated bilirubin escapes to the circulation and is ltered by the glomerulus and appears in the urine. The kidney can metabolize hemoglobin to biliru- bin and secrete it in dogs but not in cats. Male dogs have a higher secretory ability compared with female dogs. Dipstick reagent pads use diazoniumsalts to create a color change and are more sensitive to conjugated bilirubin than free bilirubin. False negative reactions may occur with large amounts of ascorbic acid or nitrites. False positive reactions can occur if a large dose of a phenothiazine drug has been administered. The practical sensitivity of bilirubin reagent sticks is re- ported to be 0.4 to 0.8 mg/dL. Small amounts of bilirubin are normal in dogs, but bilirubinuria is never normal in cats. Because conjugated bilirubin is freely ltered, bilirubinuria may precede bilirubinemia. Bilirubinuria tends to be higher with extrahepatic biliary obstruction compared with intrahe- patic disease. Urobilinogen Conjugated bilirubin is excreted into bile then degraded by intestinal bacteria into urobilinogen. Most of the urobilino- gen is then oxidized to urobilin, but a small amount is reab- sorbed and excreted in the urine. Urobilinogen is unstable and stored urine samples yield inaccurate results. Urobilino- gen is a normal nding. Urobilinogen concentration is poorly correlated to hepatobiliary disease and this test has question- able clinical usefulness. Nitrite Some bacteria are able to convert nitrate to nitrite. Although nitrite test pads are available on some dipsticks, nitrite is not a reliable marker of bacteriuria in small animals. Leukocytes The leukocyte esterase reaction detects esterases found in granules of granulocytes (neutrophils, basophils, and eosin- ophils). In dogs, the test is specic, but not sensitive, mean- ing the test fails to detect many cases of pyuria, but a positive test is indicative of pyuria. WBCs may be present from infec- tion or inammation. Because of the high false positive rate in cats, this test is not useful in this species. Protein Urine dipsticks can give a semiquantitative estimate of pro- teinuria. The color indicator (tetrabromophenol blue) is more sensitive to albumin than to globulins, and most urine protein is albumin. Results are reported as trace (10 mg/dL), 1 (30 mg/dL), 2 (100 mg/dL), 3 (300 mg/dL), or 4 (1000 mg/dL). Very alkaline or highly concentrated urine may cause false positive results. The sulfosalicylic acid turbi- dimetric test precipitates protein and can be used to conrm positive dipstick results. A semiquantitative microalbumin- uria dipstick is available to detect 1 to 30 mg/dL of urinary albumin (ERD-HealthScreen, Heska Corp., Fort Collins, CO). It uses ELISA technology specic for canine or feline albumin. Because of minor species differences in albumin, there are different kits for dogs and cats. The microalbumin- uria test can detect lower concentrations of albumin than would be detected with a standard dipstick. Hematuria must be macroscopic to increase the microalbuminuria (or urine protein:creatinine) measurements, although pyuria is vari- ably associated with increased values. 11 A positive dipstick reading for protein may occur in con- centrated urine and still represent normal urine protein ex- cretion. In people, the gold standard is the 24-hour protein excretion, calculated by analyzing an aliquot of all urine pro- duced over a 24-hour period. Collecting a complete 24-hour urine sample is cumbersome in animals. The urine protein: creatinine ratio (UPC) accounts for the variations in urine volume throughout the day by means of the creatinine con- centration. UPC values correlate well to 24 hour urine pro- tein excretion in dogs and cats. 12,13 Values below 0.5 are considered normal in nonazotemic dogs and cats, and values above 0.5 in azotemic dogs and 0.4 in azotemic cats should prompt intervention. 14 Proteinuria can be preglomerular, glomerular, or postglo- merular in origin. Preglomerular causes include fever, stren- uous exercise, seizures, extremes of heat of cold, venous con- 6 N.J. Reine and C.E. Langston gestion, or hyperproteinemia (ie, multiple myeloma). Glomerular proteinuria is caused by damage to the glomer- ular ltration barrier and is the most common and most serious type of proteinuria. Postglomerular proteinuria can be caused by inammation of the bladder or genital tract or by tubular disease (inammation in the tubules or failure to reabsorb the normal small amount of ltered protein). In the presence of pyuria or hematuria, differentiating between glo- merular and postglomerular proteinuria can be difcult. Sediment Evaluation Low speed centrifugation (1,000-1,500 revolutions per minute for 3-5 minutes) minimizes disruption of cellular elements of the urine sediment. After centrifugation, the su- pernatant should be removed and the sediment then resus- pended in the small remaining volume of urine. Ideally, a consistent volume of urine should be utilized for re-suspen- sion of each sample. Once suspended, a drop should be placed on a microscope slide with a coverslip. It is best to examine unstained samples with the condenser low, the mi- croscope light dimmed and the iris diaphragm closed. This will maximize contrast. Alternatively, sediment stains (ie, Se- diStain, Becton-Dickinson, Sparks, MD) can be used to enhance contrast. The sediment should be evaluated under low and high power (Fig 5). 15 RBC Normal urine should contain very few red blood cells. Own- ers may observe macroscopic hematuria but microscopic he- maturia will go undetected without sediment evaluation. He- maturia can result from infection, inammation, neoplasia, bleeding disorders, or trauma (Table 1). Iatrogenic hematuria may result from cystocentesis. If blood contamination is ob- served, particularly as the needle is being withdrawn fromthe Figure 5 Common urine sediment ndings (400magnication). (A) Struvite crystals; (B) Oxalate dihydrate crystals; (C) Unstained urine sediment with RBCs and WBCs; (D) Granular cast; (E) Mixed bacterial infection, Wrights stain. Table 1 Causes of Hematuria by Location Kidney/Ureter Bladder Urethra Genital Tract Extra-Urinary Pyelonephritis Infection Stones Prostatic disease Coagulopathy Nephrolithiasis Stones Infection Vaginal disease Trauma Ureterolithiasis Neoplasia Inammation Vulvar disease Strenuous exercise Neoplasia Drugs (Cytoxan) Neoplasia Uterine disease Benign renal hematuria Idiopathic cystitis Granulomatous urethritis Preputial disease Infarct Parasite Normal estrus Urinalysis interpretation 7 bladder and skin, this should be noted and the results inter- preted accordingly. If it is unclear if hematuria is iatrogenic, a free catch sample performed a few days later can be sub- mitted. WBC The presence of increased WBC indicates the presence of urinary tract inammation. Typically, greater than 5 WBC/ high power eld (HPF) is excessive though individual labo- ratory ranges may vary slightly. The presence of pyuria cer- tainly raises concern of the presence of bacterial urinary tract infection. Sterile inammation associated with urolithiasis and neoplasia can also cause pyuria. Pyuria in a sample ob- tained via cystocentesis may indicate infection or inamma- tion of the kidneys, ureters, urinary bladder, or prostate. For free catch samples, the vaginal cavity or skin may contribute as well. 1 Any patient with pyuria, particularly those with signs referable to the urinary tract (ie, stranguria, pollakiuria, hematuria, polyuria) should have a urine culture and sensi- tivity performed. Patients with diabetes mellitus are predis- posed to urinary tract infection and many times do not have signicant pyuria. 16 Organisms Bacteria Normal urine is sterile. Because bacteria can be found in the distal urethra and genital tract, samples obtained via free- catch or catheterization may have some degree of contami- nation. Cystocentesis is the method of choice for obtaining the urine sample when bacterial urinary tract infection is suspected. Although bacteria can be visualized on micro- scopic examination, it is sometimes difcult to distinguish bacteria from debris. The presence of pyuria in the same sample would support the nding of bacteriuria. Microscopic examination of modied Wrights stained urine samples have been shown to be superior to traditional wet-mounts when attempting to identify bacterial urinary infections in dogs. 17 A bacterial culture and sensitivity should be performed on urine samples with microscopic evidence of bacteriuria. Bacterial urinary tract infections are quite common in dogs. Dogs with recurrent or persistent urinary tract infec- tions will frequently have either a metabolic or structural reason for recurrent infection. It has been documented that dogs with diabetes mellitus and Cushings disease can have urinary tract infections without the presence of stranguria, pollakiuria, or abnormal urine color. In one study, pyuria was found in 60%of dogs with hyperadrenocorticismand/or diabetes mellitus. 18 Based on this information, it is essential that patients with either of these diseases have frequent uri- nalysis and urine cultures performed, regardless of clinical signs. Recurrent bacterial urinary tract infection is also well documented in dogs with recessed or juvenile vulvar confor- mation. Surgical correction has been shown to minimize re- currence. 19 Another patient group to consider frequent uri- nalysis and urine culture testing would be patients with chronic kidney failure. In contrast to dogs, the incidence of bacterial urinary tract infection in cats is quite low, relative to the incidence of lower urinary tract signs (5%). 20 Older cats (10 years) are more likely than younger cats to have urinary tract infection asso- ciated with lower urinary tract signs. 21 As in dogs, cats with diabetes mellitus and kidney failure should have frequent testing of their urine for evidence of infection (pyuria, bacte- ruria, positive urine culture) regardless of clinical signs. Yeast Occasionally, yeast or fungal hyphae may be seen in a urine sample and often represent contamination. In cats, true fun- gal urinary tract infections are most commonly seen associ- ated with prolonged antibiotic and/or glucocorticoid ther- apy, aciduria, and the use of indwelling transurethral catheters. 22 Fungal organisms can also be identied in the urinary bladder of patients with systemic mycoses (ie, blas- tomycosis). Epithelial/Transitional Cells Transitional cells are the epithelial cells lining the mucosa of the renal pelvis, ureter, urinary bladder, and urethra. There are also epithelial cells associated with the prostate, vagina, and uterus. It is normal to have occasional small epithelial cells in a urine sample. The size of the epithelial cells seen may aid in determining where in the urinary tract they come from as cells from the kidney are the smallest; the ureter, bladder and proximal urethra have cells larger than the kid- ney cells; and the cells from the distal urethra, vagina, and prepuce are the largest. Increased numbers of epithelial cells can be seen in association with infection, inammation, irri- tation, and neoplasia. Transitional cells are very reactive cells. It is very difcult to distinguish neoplastic transitional cells from metaplastic changes in transitional cells associated with inammation, infection or mechanical (ie, calculus) or chemical (ie, cyclo- phosphamide) irritation. This explains why urine cytology evaluation is not the ideal method of diagnosing transitional cell carcinoma. 23 Urinary Casts Casts form in the renal tubular lumen and are composed of matrix mucoprotein and varying cell types and numbers. There can be 1 to 2 casts per lowpower eld in normal urine. Tamm-Horsfall mucoprotein (THM) is likely the matrix for cast formation in dogs and cats. Secretion or precipitation of THM is increased in acidic, highly concentrated urine and during times of low tubular ow rate (ie, when there is a decrease in GFR). Increased THM favors increased cast for- mation. Cylindruria (increased number of casts) indicates that there is disease in the kidney, though not necessarily kidney failure. It does not mean that the kidney is the primary organ involved in the disease process. For example, hypoxia associated with hypovolemic shock can result in cylindruria. The presence of casts does not discriminate between glomer- ular, interstitial, and tubular disease. The different types of casts seen are hyaline, cellular, epithelial (white cell, red cell, or granular), waxy, and broad casts. Hyaline Casts There are pure protein precipitates (THM and albumin). They are transparent and can be easily missed in an unstained sample. Using Sedi-Stain will make them pink and more visible. Hyaline casts will be increased in disease processes that favor proteinuria (ie, protein-losing nephropathy, fever, 8 N.J. Reine and C.E. Langston exercise, acute tubular necrosis) but their presence doesnt indicate the source of the protein. Cellular Casts Samples of urine from normal dogs and cats should never have cellular casts. The most common cellular casts are epi- thelial cell casts, white cell casts and red cell casts. Epithelial Cell Casts These contain renal epithelial cells. They form in situations where there is sloughing of the renal tubular epithelium (ie, renal tubular necrosis). These are most commonly associated with acute renal tubular injury (ie, nephrotoxicity or isch- emia). White Cell Casts. It can be difcult to distinguish renal ep- ithelial cells from white blood cells when there has been signicant degeneration. Examination of a fresh sample should minimize the likelihood of degeneration. White cell casts most commonly contain neutrophils. They are seen most commonly in patients with acute bacterial pyelonephri- tis but can be seen with other forms of interstitial nephritis. Red Cell Casts. Red cell casts are rare. They form when red cells aggregate associated with tubular bleeding. Fresh sedi- ment should be evaluated as these casts degenerate easily. Granular Casts. These casts contain debris associated with tubular cell necrosis and degeneration. They are typically coarse initially after damage then progress to ne granular casts. These casts usually indicate tubulointerstitial disease. Waxy Casts. These represent the latest stage of degeneration of granular casts and are more stable than their precursors. They are usually associated with chronic renal disease. Broad Casts. These are wide casts of any type. They are usually formed in the collecting duct or other portions of the distal tubule that are abnormally dilated. These casts can be seen with chronic renal disease or during recovery from an oliguric state. 1 Crystals The presence of crystalluria is inuenced by urine pH, urine specic gravity, urine saturation with precursors, and the presence of crystal promoters or inhibitors. Patients with highly concentrated urine samples, high concentrations of crystallogenic substances in their urine, and low urine ow rates are predisposed to crystal formation. Unfortunately, crystals found in stored samples may have formed after sampling. A recent studies investigating crystal- luria in dogs and cats documented that interpretation of 28% of stored samples positive for crystalluria were false positives. In fact, crystals formed in vitro less frequently in nonrefrig- erated samples compared with those stored in a refrigerator. 3 Urine samples should be analyzed with an hour to increase the likelihood that it is truly representative of what is going on in the patient. Ideally, all samples, particularly serial sam- ples in the same patient, should be interpreted in a timely manner. Crystals (struvite, amorphous phosphates, oxalates) may be seen in samples obtained from patients without signs of lower urinary tract disease. A recent investigation found that 92% of cats without urinary tract signs fed a mixture of wet and dry food had crystalluria on stored urine samples. 24 This may lead to inappropriate use of diets formulated for crystal prevention and potential increased incidence of other crystal types. If fresh urine samples were utilized, only 24% of the cats had crystalluria. Remembering that none of these cats had lower urinary tract signs, the presence of crystalluria found in urine samples from cats should be interpreted with caution, particularly in those fed some amount of dry food. Miscellaneous Urine Tests Fractional excretion is the fraction of a ltered substance that appears in the urine as a result of tubular reabsorption and secretion. It is calculated from the formula: FE (U x /S x ) * (S Cr /U Cr ) * 100, where U is the urine concentration, S is the serumconcentration, x is the electrolyte being measured, and Cr is creatinine. Diurnal variation, diet, and hormonal inu- ences affect fractional excretion, which does not correlate well with 24-hour electrolyte excretion. 25,26 Results should be interpreted in light of the entire clinical picture (Table 2). Veterinary bladder tumor antigen test [VBTA, Alidex Inc. (subsidiary of Polymedco Inc.), Redmond, WA] can be used as a screening test for transitional cell carcinoma. Unfortu- nately, this test is not specic for transitional cell carcinoma, in that dogs with nonneoplastic bladder disease (eg, UTI, polypoid cystitis) frequently have positive test results. On the other hand, a negative test almost rules out neoplasia. 27 This test might be considered for routine screening of dogs pre- disposed to bladder cancer (ie, Scottish Terriers 28 ) who do not have signs of lower urinary tract disease. References 1. Chew DJ, DiBartola SP: Interpretation of canine and feline urinalysis. St. Louis, Ralston Purina Company, 1998 2. Bartges JW: Discolored urine, in Ettinger SJ, Feldman EC (eds): Text- book of veterinary internal medicine (ed 5). Philadelphia, WB Saun- ders, 2000, pp 96-99 3. Albasan H, Lulich JP, Osborne CA, et al: Effects of storage time and temperature on pH, specic gravity, and crystal formation in urine samples from dogs and cats. J Am Vet Med Assoc 222:176-179, 2003 4. Dossin O, Germain C, Braun JP: Comparison of the techniques of evaluation of urine dilution/concentration in the dog. J Vet Med A Physiol Pathol Clin Med 50:322-325, 2003 5. George J: The usefulness and limitations of hand-held refractometers in veterinary laboratory medicine: An historical and technical review. Vet Clin Pathol 30:201-210, 2001 6. Watson A: Urine specic gravity in practice. Aust Vet J 76:392-398, 1998 7. van Vonderen I, Kooistra H, Rijnberk A: Intra-and interindividual vari- ation in urine osmolality and urine specic gravity in healthy pet dogs of various ages. J Vet Intern Med 11:30-35, 1997 8. Brobst D: Urinalysis and associated laboratory procedures. Vet Clin North Am Small Anim Pract 19:929-949, 1989 9. Heuter KJ, Bufngton C, Chew DJ: Agreement between two methods Table 2 Normal Fractional Excretion Values for Dogs and Cats 29 FE (%) Dog Cat Na <1 <1 K <20 <24 Chloride <1 <1.3 Phosphorus <39 <73 Urinalysis interpretation 9 for measuring urine pH in cats and dogs. J Am Vet Med Assoc 213:996-998, 1998 10. Raskin RE, Murray KA, Levy JK: Comparison of home monitoring methods for feline urine pH measurement. Vet Clin Pathol 31:51-55, 2002 11. Vaden SL, Pressler BM, Lappin MR, et al: Effects of urinary tract inam- mation and sample blood contaminationon urine albumin and total protein concentrations in canine urine samples. Vet Clin Pathol 33:14- 19, 2004 12. Adams LG, Polzin DJ, Osborne CA, et al: Correlation of urine protein/ creatinine ratio and twenty-four-hour urinary protein excretion in nor- mal cats and cats with surgically induced chronic renal failure. J Vet Intern Med 6:36-40, 1992 13. Grauer G, Thomas C, Eicker S: Estimation of quantitative proteinuria in the dog, using the urine protein-to-creatinine ratio from a random, voided sample. Am J Vet Res 46:2116-2119, 1985 14. Lees GE, Brown SA, Grauer GF, et al: Assessment and management of proteinuria in dogs and cats: 2004 ACVIM forum consensus statement (small animal) draft: ACVIM, 2004 15. Gregory CR: Urinary system, in Latimer K, Mahaffey E, Prasse K (eds): Veterinary laboratory medicine: Clinical pathology (ed 4). Ames, Iowa State Press, 2003, pp 231-259 16. McGuire NC, Schulman R, Ridgway MD, et al: Detection of occult urinary tract infections in dogs with diabetes mellitus. J AmAnimHosp Assoc 38:541-544, 2002 17. Swenson CL, Boisvert AM, Kruger JM, et al: Evaluation of modied Wright-staining of urine sediment as a method for accurate detection of bacteriuria in dogs. J Am Vet Med Assoc 224:1282-1289, 2004 18. Forrester SD, Gregory C, Dalton M: Retrospective evaluation of urinary tract infection in 42 dogs with hyperadrenocorticism or diabetes mel- litus or both. J Vet Intern Med 13:557-560, 1999 19. Hammel SP, Bjorling D: Results of vulvoplasty for treatment of recessed vulva in dogs. J Am Anim Hosp Assoc 38:79-83, 2002 20. Kruger JM, Osborne CA, Goyal S: Clinical evaluation of cats with lower urinary tract disease. J Am Vet Med Assoc 199:211-216, 1991 21. Lekcharoensuk C, Osborne CA, Lulich JP: Epidemiologic study of risk factors for lower urinary tract diseases in cats. J Am Vet Med Assoc 218:1429-1435, 2001 22. Lulich JP, Osborne CA: Fungal infections of the feline lower urinary tract. Vet Clin North Am Small Anim Pract 26:309-315, 1996 23. Wasmer M, Pinson D: Urine sediments and urothelial carcinoma. Vet Med 92:330-331, 1997 24. Sturgess C, Hesford A, Owen H, et al: An investigation into the effects of storage on the diagnosis of crystalluria in cats. J Feline Med Surg 3:81-85, 2001 25. Finco DR, Brown SA, Barsanti JA, et al: Reliability of using random urine samples for spot determination of fractional excretion of elec- trolytes in cats. Am J Vet Res 58:1184-1187, 1997 26. McKenzie E, Valberg S, Godden S, et al: Comparison of volumetric urine collection versus single-sample urine collection in horses con- suming diets varying in cation-anion balance. Am J Vet Res 64:284- 291, 2003 27. Henry CJ, Tyler J, McEntee MF, et al: Evaluation of a bladder tumor antigen test as a screening test for transitional cell carcinoma of the lower urinary tract in dogs. Am J Vet Res 64:1017-1020, 2003 28. Glickman L, Raghavan M, Knapp DW, et al: Herbicide exposure and the risk of transitional cell carcinoma of the urinary bladder in Scottish Terriers. J Am Vet Med Assoc 224:1290-1297, 2004 29. DiBartola SP: Clinical approach and laboratory evaluation of renal dis- ease, in Ettinger SJ, Feldman EC (eds): Textbook of veterinary internal medicine (ed 5). Philadelphia, WB Saunders, 2000, pp 1600-1614 10 N.J. Reine and C.E. Langston