CHAPTER FIVE

Microscopic Examination Of
Urine
 Chapter Objective
At the end of this chapter the students will be able to
describe
Microscopic examination for urine sediment
Normal and abnormal organized urine sediments with
their diagnostic features.

Formation and significance of casts

Normal and abnormal crystals encounter in urine
sediments
Relationship between sediments, chemical, physical
findings in urine
Reporting of urinary sediments
Chapter Outline

5. Microscopic Examination Of Urine

5.1. Procedure for microscopic examination
5.2. Source of errors in the microscopic examination of urine
5.3 Urinary Sediments
5.4 Organized Urinary Sediments
5.5 Parasite, fungus and bacteria in urine
5.6 Non-Organized Urinary Sediments Urine Crystals
5.7 Body cells, crystals, casts, yeasts, bacteria, sperm
5.8 Methods of reporting formed elements
 Introduction

In examining urinary sediment it is necessary to learn the

distinguishing characteristics of elements which have
significance .
If the urine sample is properly collected, the test is
carefully performed, and the person performing the test
is knowledgeable, skillful valuable information can be
obtained from microscopic examination of urine
specimen.
Standardization

Aspects of microscopic examination that

should be standardizes:
1. Volume of urine analyzed
2. Length and force of centrifugal
3. Re-suspending volume and concentration of
sediment
4. Volume and amount of sediment examined
5. Terminology and reporting format
Procedure for Microscopic Examination

Assemble all necessary materials used for the collection,

centrifugation and examination.
Conical centrifuge tubes, or regular test tubes up to
15 ml.
centrifuge.
Pasture pipette with .
Slides and cover slides 20 x 20 mm.
microscope
Procedure for Microscopic Examination
contd
1. Mix the urine specimen
2. Transfer about 10 ml of urine into a labelled centrifuge
tube.
3. Centrifuge the specimen at a medium speed (from 1500
2000 rpm) for 3-5 minutes
4. Discard the supernatant by quick inversion of the tube
5. Re suspend the sediment that is at the bottom of the
tube, by tapping the tube by your fingers
6. Take the sediment by Pasteur pipette from the tube and
transfer a drop into the clean and dry slide.
Procedure for Microscopic Examination

Apply cover slide on the urine sediment that is on the

slide.
Put on the microscope and look under 10x objective of
the microscope.
Then after looking through the low power objective,
change the objective in to 40x objective .
Then report what you get under low power and high
power objective on the laboratory request form of the
patient.
 Source of Errors

Drying of the specimen on the slide.

If the supernatant fluid after centrifugation is not poured
off properly, it may decrease concentration of urine
sediments and false result may be reported
If the whole sediment with supernatant is discarded during
inverting down the tube for long period, the whole
sediments will be discarded and so again false negative
result will be reported.
Thus another sample should be collected and the test
repeated.
Classification of Urinary Sediments

Urine sediments can grossly be categorized into

organized and non-organized sediments based
on the substances they are composed of.
Organized (Formed ) elements
RBCs/HPF
WBCs/HPF

Epithelial cells / LPF

Casts / LPF

Parasites/LPF

Bacteria / HPF

Yeast Cells /`LPF

Mucus trade/LPF

Spermatozoa

Miscellaneous substances
Non-organized (Non-living Material)
Slightly acidic urine
Triple phosphates
Amorphous phosphate
Calcium carbonate
Calcium phosphate
Acidic, Neutral, or slightly alkaline Urine crystal
Calcium Oxalate crystals
Alkaline, Neutral, or Slightly acidic urine
Triple phosphates
Alkaline Urine Crystals
Amorphous phosphate
Calcium carbonate
Calcium phosphate
 Organized Urinary Sediments
RED BLOOD CELLS
Red blood cells are not usually present in normal urine.
Appearance:
Normally RBCs appear in the fresh sample as intact, small
and faint yellowish discs, darker at the edges
Measure 7-8 m
In concentrated urine may be crenated and became small
(5-6 m)
In diluted urine, RBCs may be turgid and increase in size (9-
10 m)
In alkaline urine, they may be small or entirely destroyed
forming massive of brownish granules
In diluted and alkaline urine, the red cell will rupture and
release the hemoglobin, leaving faint colorless cell
membrane, and are known as ghost cells (shadow of
original cells)
 This field contains mostly
RBCs, (hp)
Notice many of them
show biconcavity
Some show variability in
shape
Some times it is easy to
mistake fungi for RBCs
To get rid of RBCs so
that WBCs are more
visible acetic acid is
very helpful, Why?
Microscopic Exam

Red blood cells

presence of a few is
normal
higher numbers are
indicator of renal
disease
result of bleeding at
any point in urinary
system

40x objective
 Clinical significance

When the number of RBCs is found more than their

normal range, usually greater than 5 RBCs/HPF it may
indicate:
Presence of disease conditions in the urinary tract, such
as:
Acute and chronic glomerulonephritis
Tumor that erode any part of the urinary tract
Renal stone
Cystitis
Prostates
Trauma of the kidney
traumatic catheterization
 Substances confusing with RBCs
Yeast cells, leukocytes, and bubbles may confuse with red
blood cells
Differentiate by
Yeast cells:
smaller and are oval in shape flattened.
vary considerably in size with one specimen
have budding at the surface
Bubbles (oil droplets)
vary considerably in size,
are extremely refractive or shiny
Leukocytes
larger and have granular appearance
upon addition of 2-5% acid the red blood cells will
disappear
 These can easily be
mistaken for RBCs
They are budding yeast,
notice the almost cactus
like appearance of those
in the box
They will not rupture in
acetic acid, RBCs will
These may truly be from
the bladder or they may
be a contamination
 This structure, (hp)
marked by the arrow,
could be mistaken
for a RBC
See the next slide
 One of the options in
identifying this
structure is to use
polarizing microscopy
In this case, the
maltese shaped
cross indicates that
this structure is an oil
droplet
 Interfering factors:
Factors that may result falsely in high number of RBCs, i.e.
without the presence of actual renal or other normal
physiological disturbances included:
Menstrual bleeding
Vaginal bleeding
Trauma to peranal area in female patients
Following traumatic cateterization
Some drugs:
Aspirin ingestion or over dose

Anticoagulant therapy over dose

LEUKOCYTES (WBCs)

Normal range: 0-4 WBC/HPF.

Appearance: normally, clear granular disc shaped,
Measure 10-15 m, the nuclei may be visible.
In alkaline urine, they may increase their size and become
irregular.
Predominantly, polymorph nuclear neutrophils are seen.
Sometimes because of predominance of neutrophils and
the occurrence of bacterial cell together with
polymorphonuclear cells, WBCs are called pus cells.
WBCs (pus cells) may be seen in clumps.
Microscopic Exam

White blood cells

a few are normal
high numbers indicate
inflammation or infection
somewhere along the
urinary or genital tract

40x objective
 How to report the result of WBCs

After observing the distribution of leukocytes under 40x

objective, at least 10 fields of microscope
When 0-5 leukocytes / HPF are seen-- normal
5-10 leukocytes / HPF are seen-- few leukocytes /
HPF
10-20 leukocytes/HPF are seen--->moderate
leukocytes/ HPF
20-30 leukocytes /HPF are seen ----> many leukocytes /
HPF
Above 30 leukocytes / HPF / are seen - full/field
 Clinical significance
Increased number of leukocyte urine are seen in case of:
Urinary tract infection such as renal tuberculosis
All renal disease
Bladder tumor
Cystitis
Prostates
Temporarily increased number of leukocytes are also seen
during:
Fever
After strenuous exercise
 EPITHELIAL CELLS

Those coming from renal cells:

Size is small as compared to other epithelial cells
It measures 10 to 18 m in length, i.e., slightly larger
than leukocytes
Very granular
Have refractive and clearly visible nucleus
Usually seen in association with proteins or casts .
EPITHELIAL CELLS (cont)

Cells from pelvis and urethra of the kidney

Size is larger than renal epithelias
Those from pelvis area are granular with sort of tail,
while those from urethra are oval in shape
Most of the time urethral epithelia is seen with together
of leukocytes and filaments (mucus trades and large in
number)
Pelvic epithelias seen usually with no leukocyte and
mucus trade, and are few in number
EPITHELIAL CELLS (cont..)

Bladder cells
Are squamous epithelial cells
Very large in size.
Shape seems rectangular and often with irregular
border.
Have single nucleus.
 These are 2 Squamous
Epithelial cells shown on
high power (hp)
They are usually large, flat,
colorless cells
However, there can be
some granularity to the
cytoplasm & the edges
may be rolled
The nucleus is usually
distinct & centered
Note the much smaller
RBC at the top of the
frame, in the circle
Microscopic Exam

Epithelial cells
cells are large and
flat
normal cells that line
the urinary and
genital tract or renal
tubules
 These Epithelial cells, hp,
are shown with phase
microscopy
Notice how much sharper
the details are on an
unstained cell with a low
refractive index
The edge in the rectangle
appears rolled which
suggests a vaginal origin
 The details of these
Transitional Epithelial cells
(3) are somewhat obscured by
the large number of bacteria
present
Originate in proximal 2/3s of
urethra, the bladder, ureters,
calices & pelvis of the kidney
They are usually round with a
large round nucleus
Notice they are smaller than
the Squamous Epithelial cell
 While these could be
Renal Tubular cells, hp,
they more likely are
Transitional cells
The key here is to notice
that they do not have the
appearance of Squamous
Epithelial & are too large
to be WBCs
In a wet prep you could
compare them to other
cells to help identify
 The cell in the box has
the tail associated with
Transitional cells
Notice this cell is much
larger than a WBC it is
almost as big as the
rolled Squamous
Epithelial
Transitional cells line the
tract from the pelvis to the
upper portions of the
urethra
Clinical significance

Presence of epithelial cells in large number, mostly renal

types may indicate:
Acute tubular damage
Acute glomerulonephritis
Silicate over dose
Note: The presence of large number of epithelial cells with
large number of Leukocytes and mucus trades
(filaments) may indicate Urinary Tract Infections (UTI).
 Reporting of epithelial cells
Epithelial cells distribution reported after looking under 10x
objective of the microscope.
Usually they are reported semi quantitatively by saying
1-3 epithelial cells /LPF
2-4 epithelial / LPF
6-14 epithelial / LPF
15-25 epithelial/ LPF
Full of epithelial cells / LPF when the whole field of 10 x
objective covered by epithelial cells.
Casts

Introduction:
Casts are long cylindrical structures that result from the
solidification of material within the lumen of the kidney
tubules.
Formed by precipitation of proteins, and aggregation of cells
within the renal tubules.
Most of them dissociate in alkaline urine, and diluted urine
(specific gravity 1.010) even in the presence of
Proteinuria.
Most of them are transparent.
Pathological Conditions that favors for the creation of casts
include
The presence of protein constituents in the tubular urine
Increase acidification
increase osmolar concentration
 Casts contd

Most urinary casts are formed either in the distal

convoluted tubules or in the collecting ducts, because
urine more concentrated and maximally acidified here.
But rare conditions such as ,in myeloma, casts may be
found in the proximal convoluted tubules.
Casts formed in the collecting tubules tends to be very
broad, and usually indicates the significant reduction in
the functional capacity of the nephron and indicate
severe renal damage.
 CASTS (cont)

Major casts types:

hyaline
epithelial
white blood cell, and. red blood cell casts
granular (coarse and fine). waxes, Fatty
 Casts in Urinary Sediment

Casts in urinary sediment is an important aid in the

differential diagnosis of renal disease
Pure Hyaline casts may be seen in Proteinuria from a
variety of causes.
Small Hyaline cast seen transiently may occur with
marked exercise or febrile conditions
Casts with inclusions, such as RBCs or WBCs may be
formed without a protein matrix
Casts in Urinary
Sediment
Hyaline Casts
All hyaline cast have a precipitated protein matrix, so
there has to be renal Proteinuria for these to be
formed
The Proteinuria is predominately Tamm-Horsfall
mucoprotein, the later being secreted by cells lining
the distal parts of the nephron
Low pH & increased electrolyte concentration
readily precipitate Tamm-Horsfall protein
 Hyaline cast,
high power
These tend to be
colorless &
almost invisible
unless the
microscope is
optimally
focused
 Hyaline casts,
high power
using phase
microscopy
Same set of
casts as in
previous
frame, made
more visible by
use of phase
 Hyaline cast at
same
magnification as
before
Using an
interference filter
Can you find the
pieces of the
cast?
Clinical Implication

Presence of large number of hyaline casts may show

possible damage of glomerular capillary membrane.
This damage permits leakage of protein through
glomerulus and result in precipitate and gel formation
(i.e. hyaline casts) in the tubule. Thus this may indicate:
Nephritis
Meningitis
Chronic renal disease
Congenital heart failure
Diabetic nephropathy
 Granular cast
More similar in appearance with hyaline casts and in
which homogenous, course granules are seen.
More dense (opaque) than hyaline cast.
Shorter and broader than hyaline casts.
May represent the first stage of epithelial cell cast
degeneration.
Based on the amount and type of granules, divided into:
fine (which may appear grey or pale yellow in color)
course granular casts ( which may appear as darker).
Granular Casts

If cellular casts stay within the tubules of the

nephron due to prolonged stasis, the cells will
begin to degenerate
These casts are referred to as Finely Granular
or Coarsely Granular Casts
Usually the original type of cell entrapped cannot
be determined unless the cells were RBC & hgb
remains
 Granular cast
under brightlight
microscopy
If this were on you
scope you would
want to reduce the
amount of light by
closing the
substage
condenser, this
really shows the
importance of your
lighting!
 Same Granular
cast as in
previous frame,
with phase
microscopy
Notice the
increased detail
missed due to the
poor lighting in the
previous frame!
Should this cast
be classified as
broad,
convoluted, or
narrow?
 This is using
interference filter
& is a frame of
the same
convoluted fine
granular cast
[granules from
degenerated
cells as in frames
6&7
Notice the
beautiful RBC
 Mixed Cellular
Granular Cast,
high power
Notice that the
cells are
degenerating
This would
tend to be a
Course
Granular
 This is the same
cast as in frame
# 18
It is with phase
microscopy
 This is the
same cast as
seen in frame
# 22 & 23
Notice the
coarse
granularity is
very noticeable
 This is the
same cast as in
frame # 22,
using phase
Notice the
coarse
granularity can
be seen
 Coarse
Granular
Cast next to
2 Epithelial
Cells, high
power
 The same cast
as in frame #
25, using
phase
Clinical significance

Granular casts may be seen in:

Acute tubular necrosis
Advanced granulonephritis
Pyelonephrites
Malignant nephrosis
Chronic lead poisoning
In healthy individuals these casts may be seen
after strenuous exercise
Cellular & Other Cast

As the protein concentrates in the distal tubule &

becomes stickier, cells can become entrapped
These become Hyaline Casts with Inclusions
& while the formal name would be for example
Hyaline-WBC Cast, they are frequently simply
referred to as WBC Cast
 Mixed Hyaline-
Cellular Cast,
high power
Protein matrix is
clearly visible
The cells are
probably WBCs
& Renal Tubular
cells but is
difficult to be sure
 This is the same
frame as in #10
using phase
microscopy
The material in
the black box is a
mucous thread,
notice it is dense
& has no light
center or cells in
its center
 This is the
same mixed
hyaline-
cellular cast
found in frame
# 10 & 11
Interference
filter was used
White blood cell casts

formed by aggregates of white blood cells that

trapped in protein matrix in the renal tubular
lumen.
An excess of white blood cells, singly or in
clamps, in the urine may indicate inflammation.
white blood cell casts definitely are renal origin.
They characteristically seen in acute pyelonephrities and
occasionally in glomerulonephirites.
 WBC cast,
high power
Some of the
nuclear lobes
can be seen
 The same
WBC cast as
in #13, using
phase
Notice you
can clearly
see mucous
threads
around the
cast
 Same cast as
seen in # 13 &
14, using
interference filter
Notice the
details of the
mucous threads
are more difficult
to see
Red blood cell casts

- Usually, they found in hematuria. Red blood cell casts

may appear broen to almost colorless and are usually
diagnostic of glomerular diseases.
- Normal range: normally not seen in normal individual
- Appearance
- Formed usually after accumulation of cellular element in
the renal tubules
 RBC cast, high
power
Notice the cell
membranes are
clearly visible, but
there does not
appear to be a
nucleus
Notice how
difficult the
mucous threads
are to see, this
might be improved
by reducing the
light a bit
 With the phase
microscopy it is
easier to see that
these are RBCs in
the cast
One even appears
to be biconcave
The mucous
threads are also
easier to see
 This is the same
cast as in # 18 &
19
Notice the large
nuclei can be
seen using an
interference filter
as it was with
the regular light
& with phase
Waxy Casts (Renal Failure Casts)

Not seen in normal individuals.

Appearance
Shorter and broader than hyaline casts.
Composed of homogeneous, yellowish materials.
Broad waxy casts are from two to six times the width of
ordinary
appear waxy and granular.
Have high retractive index.
May occur from cells (WBC, RBC, or Epithelial) casts,
hyaline casts.
 This is a Waxy
Cast, on high
power
Notice the
crack in the
side of the
cast, which is
frequently seen
in Waxy Casts
 This is the
same Waxy
Cast under
phase
The
thickened
waxy exterior
is more easily
seen
 This is the
same cast as
seen in # 27 &
28, using an
interference
filter
Notice again
the waxyness
of the
appearance
Waxy Casts

Clinical significance
Waxy casts are found in
Chronic renal disease.
Tubular inflammation and degeneration.
Localized nephron obstruction.
malignant hypertension
in diabetic diseases
* The presence of waxy casts indicates severity of renal
disease.
Fatty Casts
-normally not seen in health individuals.
Appearance:
These are casts, which contain fat droplets inside them.
Fat droplets are formed after accumulation of fat in the
tubular vessels, especially tubular epithelial and finally
disintegrated.
Clinical Implication:
The occurrence of fat droplets, oval, fat bodies, or fat
casts is
very important sign of nephritic syndrome.
Chronic renal disease.
Inflammation and degeneration of renal tubules.
lupus and toxic renal poisoning
 This is a cast
containing fat
bodies, high
power
On wet mount
the droplets are
highly refractile
[they bounce the
light back]
 This is the cast
containing fat
bodies under
polarizing light
The fat bodies
have a maltese
cross appearance
in polarized light,
which is one way
of confirming
Confirmation can
also be by fat red
stain
 This is the
cast
containing
fat bodies
under phase
 This is the fatty
cast under
interference filter
Epithelial Casts

Epithelial Casts are composed largely of tubular

epithelial cell desquamated within the tubule.
They often appear as two rows if cells in protein cast
matrix.
Inflammation of the kidney may cause greater sloughing
of renal epithelial cells, so large number of epithelial
casts is indicative of renal parenchymal disease with
tubular damage.
 Renal Tubular Cast,
high power
Can be difficult to
differentiate from
other cellular casts
& at times the
decision must be
made on other cells
in the sample
Notice in this cast
the cells have large
nuclei
Reporting of casts

Casts are examined under 10x objective of the

microscope.
Casts are reported quantitatively by saying:
Few casts / LPF
Moderate casts / LPF and
Many casts / LPF
During the report the, type of cast that is seen should
also be mentioned
Example: few hyaline casts / LPF are seen
PARASITES

Parasites that can be seen in urine microscopy are:

Trichomonas vaginalis
Schistosoma haematobium
Wuchereria bancroftie
* Other parasites such as Entrobious vermicularies
also may occur due to contamination of the urine with
stool.
 Here is another frame
of the Trichomonas
(hp), both of these are
shown with phase
microscopy which
enhances the details
of cells with low
refractive indices
 Trichomonas (hp) is a
small parasite that is very
active in a fresh
specimen
They have multiple
flagella (white pointers)
as well as an undulating
membrane which
contribute to movement
In the absence of
movement they can be
mistaken for other cells
 There are 2 sperm in
this frame
In a fresh specimen,
they are visible due to
their movement
In an older urine
specimen, they may
be difficult to visualize
 This frame contains 2
sperm also, with
phase microscopy (lp)
The phase makes
both the head & tail
more visible
Notice also the WBC
and the mucous
thread
 This structure, (hp)
marked by the arrow,
could be mistaken
for a RBC
See the next slide
 One of the options in
identifying this
structure is to use
polarizing microscopy
In this case, the
maltese shaped
cross indicates that
this structure is an oil
droplet
Schistosoma haematobium Egg
Enterobius vermicularis Eggs
 YEAST CELL

Yeast cells are fungi that are not normally seen in

health individuals.
Appearance
Variable in size
Colorless.
Oval in shape, and usually form budding.
Have high refractive index.
Usually confused with Red Blood Cells.
 These can easily be
mistaken for RBCs
They are budding yeast,
notice the almost cactus
like appearance of those
in the box
They will not rupture in
acetic acid, RBCs will
These may truly be from
the bladder or they may
be a contamination
 These are branching
pseudohyphae of a
fungus
Their main
significance is that
they obscure more
important features of
the specimen & may
indicate that the
specimen is not a
clean catch
Clinical Significance

They are usually of candida species (candida albicans)

and are common in patients with
Urinary tract infection
Vaginites
Diabetic mellitus
Intensive antibiotic or immunosuppressive therapy
Summary

You should be able to describe:

Appearance and clinical significance of RBC and
WBC.
Appearance and clinical significance of three
types of epithelial cells.
Formation, composition and clinical significance
of the different types of urinary casts. types of
crystals, identify them and state clinical
significance of each.
Other formed elements to include: bacteria, fat,
fibers, mucous, parasites, sperm, starch,
trichomonas and yeast.
BACTERIA

Bacteria are commonly found in urine specimen because

of abundant normal microbial flora of the vagina or
external urinary meatus.
Most common cause of UTI dipstick test can give indirect
clue.
Further the observed bacterial cell can be identified by
bacteriological culture
 Clinical Significance

Presence of bacteria may indicate the presence of UTI

or contamination by genital or intestinal microflora.
Report of the Result
Few bacteria / HPF
Moderate bacteria / HPF
Many bacteria / HPF
Full of bacteria / HPF
Learning Objectives: Urinalysis
Upon completion of this unit of instruction and lecture, the
student will be able to:
1. Discuss importance of standardizing the microscopic
exam of urine.
2. Describe microscopic and staining techniques to
enhance visualization of urinary sediment.
3. Describe appearance and clinical significance of RBC
and WBC.
4. Describe appearance and clinical significance of three
types of epithelial cells.
5. Describe formation, composition and clinical
significance of the different types of urinary casts.
Learning Objectives: Urinalysis

6. Identify three factors that favor formation of urinary

crystals.
7. Categorize types of crystals, identify them and state
clinical significance of each.
8. Identify other formed elements to include: bacteria, fat,
fibers, mucous, parasites, sperm, starch, trichomonas
and yeast.
9. Correlate the presence of formed elements in urine with
physical and chemical exam.
10. Explain the proper reporting procedure for casts, cells
and other formed elements.
Crystals in Sediment

Crystals
precipitation of solutes
are not normally present in freshly voided urine
can precipitate on storage
most are not clinically significant
pH critical to differentiating some important
crystals
Contributing factors to Crystal
Formation

Concentration of solute in specimen

Decreased flow of urine through tubules
This enhances precipitation of solutes
Ultrafiltrate can become supersaturated in
tubules
Crystals Correlate With:

pH of urine
solutes differ in solubility
inorganic salts: oxalate, phosphate, calcium,
ammonium & magnesium less soluble in neutral or
alkaline urine
organic solutes: uric acid, bilirubin, & cystine less
soluble in acidic urine
Acidic Urine

All clinically significant crystal are found in acid

urine
Include: cystine, tyrosine, leucine & iatrogenic
crytsals: sulfonamide & ampicillin
Acidic Urine

Amorphous Urates
Non crystalline urate salts of sodium, potassium,
magnesium & calcium
small & yellow-brown granules - - similar to sand
enhanced by refrigeration
can be in acidic or neutral urine
Amorphous Urates

Will dissolve in alkaline or heated to 600C

If add acetic acid, uric acid crystals will
precipitate out
Uroerythrin deposits on urate crystals giving
pink-organish color -- referred to as brick dust
Uric Acid Crystals

Urine pH usually around 5.0 to 5.5

Most common form is diamond shape but may
be cube shaped or cluster in rosettes
Uric Acid Crystals

Diamond shape may cluster in rosettes

Sometimes 6 sided & must be differentiated from
clinically significant cystine
Uric Acid Crystals and
Pathology
Usually yellow to orange-
brown
Are birefringent under
polarizing light
Can appear normally BUT
See large #s in gout &
increased purine
metabolism such as
cytotoxic drugs
Acid Urine: Calcium Oxalate
Crystals

Calcium oxalate
Usually octahedral or
look like envelope
Dihydrate form is 2
pyramids joined at the
basewhen
Squares with lines
intersecting the center
can be seen on the end
Calcium Oxalate Crystals

Monohydrate form - small ovoid or dumb bell

rare & can mistake for RBCs
are birefringent under polarizing light
are colorless & vary in size - usually small and may
be in either neutral or acidic urines
Monohydrate form - small ovoid or dumb bell
oftensee in normal urine, 2nd to ascorbic acid,
ingesting tomatoes, asparagus, spinach & oranges
Bilirubin

Appear as fine needles, granules, or plates

urine is acidic
always yellow-brown
the bile stains the other components of the sediment
presence of the crystals indicate high concentrations
of bilirubin in the urine
Bilirubin Crystals: Abnormal
State

If you suspect bilirubin crystals are present, the

strip reaction must confirm the presence of
bilirubin
Otherwise the identification is incorrect
The presence of the positive bilirubin strip &/or
the crystals indicate a pathologic process - are
always considered an abnormal crystal
May see in liver disease
Cystine: Always Abnormal

Colorless hexagonal
plates
sides may be uneven
Crystals appear layered
tend to clump
primarily seen in acidic urine
Must be counted
Can be confused with uric
acid crystals, must confirm
identification with sodium
cyanide
Cystine: Always Abnormal

Clincally significant, seen in congenital

cystinosis or cystinuria
Deposit out in tubules as calculi/stone causing
damage
Amino Acid Crystals

Tyrosine
fine, delicate needles,
colorless or yellow
frequently in clusters or
sheaves [as in stacks of
wheat]
see singly or in small groups
in acidic urine
less soluble than leucine, so
found more often
Leucine

Highly refractile yellow to brown

spheres in acid urine.
Have concentric/radial
striations on their surface
Can be mistaken for fat
globules [or vice versa]
But will not stain with fat stains
or appear as maltese cross
under polarization
Can be seen in urine containing
tyrosine crystals if use alcohol
to precipitate
Bactrim has similar appearance
check patient history
Amino Acid Crystals and
Pathology

Amino acid crystals are abnormal & seen in

overflow aminoaciduria
can be seen in rare cases of liver disease, more likely
to reflect inherited metabolic disorder
before reporting should be confirmed by confirmatory
tests such as chromatography
Cholesterol
Clear flat rectangular plates with
notched corners
in acidic urine
are soluble in chloroform & in
ether
Rarely seen
Presence indicates both ideal
conditions for precipitation &
supersaturation:
Always see with positive protein
+ fat droplets, fatty casts or oval
fat bodies
Seen in nephrotic syndrome &
other renal damage
Confounding Conditions

Diatrizoate meglumine [radiopaque contrast medium]

can be mistaken for cholesterol
contrast medium will give abnormally high S.G. >1.040
not associated with proteinuria or lipiduria
cholesterol crystals found with normal S.G.
Medications
can be excreted in high concentrations, resulting in precipitation
these crystals are termed iatrogenic
proper identification of drug crystals important in alerting to
potential renal tubular damage
Ampicillin

Appear as long thin

colorless prisms or
needles
May aggregate in small
clusters or if refrigerated
may form large clusters
Appear in acidic urine
Require large dosage for
formation, so rarely seen
Sulfonamides

Highly refractile & birefringent

In acidic urine,
Should be confirmed before
reporting
Closely resemble ammonium
biurate but differentiated on
pH & solubility
chemical confirmatory test
Type varies with form of drug
prescribed
Sulfa drugs have been modified
to be more soluble & so crystals
rarely seen
 Sulfadiazinecrystals
appear yellow to brown
& as bundles of wheat
constriction may be
central or excentric
Sulfamethoxazole
[Bactrim & Septra]
more commonly seen
brown rosettes or
spheres with irregular
striations
Radiographic Contrast Media

Diatrizoate salts are used in IV contrast media

Readily soluble in water & excreted in urine
Diatrizoate meglumine [Renografin]
crystals colorless, long pointed needles, singly or in clusters or
flat elongated rectangular plates
distinguished from cholesterol by large # present & high S.G.
[>1.040]
lack significant proteinuria & lipiduria
diatrizoate appears in acidic urine up to 4 hrs post
injection
can cause false pos. sulfosalicylic acid test
Alkaline Urine Crystals

Ammonium Phosphate
alkaline
or neutral urine
microscopically not distinguishable from amorphous
urates
distinguishable on urine pH & solubility
precipitate white rather than pink-orange of amorphous
urates
are soluble in acid & will not dissolve when heated to 60C
finecolorless grains with tendency to obscure other
more significant sediment
presence enhanced by refrigeration
Triple Phosphate

Colorless & in different

forms
most common are 3 & 6
sided coffin lids
vary greatly in size
may also see a fern leaf
form, feathery
See in normal healthy
individuals but are often
present in formation of
calculi &
are associated with UTI
Calcium Phosphate

In 2 forms dicalcium & calcium

Dicalcium colorless thin prisms in rosettes or
star-shaped stellar phosphates
tend to have 1 tapered or pointed end & the other
squared off
calcium phosphates are irregular granular sheets or
plates - - often resemble degenerating squamous
epithelial cells
Ammonium Biurate

Yellow brown spheres

with striations
Can have irregular
spicules thorny apple
In alkaline or neutral urine
Not significant unless
seen in fresh urine
Usually seen in old
specimens
Dissolve in acetic acid or Just forming
heating to 600C
Calcium Carbonate

Very small granular

crystals
Can be misidentified
as bacteria
Birefringent with
polarizing light
Usually found in pairs
dumbbell shape
Cystine Crystals

Rarely found.
Flat, hexagonal plates with well defined edges.
Colorless, and highly retractile.
Size is 30-60 m.
Found only in fresh urine, because if there is delay,
they are soluble and not seen.
Appeared during cystinosis, which is a hereditary
disease (Wilson disease), or during transient acute
phase of pyelonephritis. Its appearance in the urine is
called cystinuria.
Calcium Sulfate Crystals

Have large prism or flat bladder shaped.

Seen separately or in bundles.
Size 50-100 m.
Can be distinguished from calcium phosphate
crystals by measuring pH of urine.
MISCELLANEOUS

Spermatozoa
Are small structures consisting of a head and
tail, connected by a short middle piece (neck).
Easily recognized especially if they are motile.
Frequently seen in the urine of males.
They may see in the urine of females, when the
urine collected after coitus usually not reported,
unless the physician has special interest in it.
 There are 2 sperm in
this frame
In a fresh specimen,
they are visible due to
their movement
In an older urine
specimen, they may
be difficult to visualize
 This frame contains 2
sperm also, with
phase microscopy (lp)
The phase makes
both the head & tail
more visible
Notice also the WBC
and the mucous
thread
Mucus Trades

Formed by the precipitation of mucoprotein in cooled

urine.
Have fine, fiber like appearance.
Wavy in shape and tapered at ends.
If not examined carefully may confuse with hyaline casts.
Contaminates and Artifact Structure

Muscle fibers
Vegetable cells
Structure from slide or cover slide
Fat droplets (other bubbles)
Oil droplets
Pollen greens
Starch granules
 This structure, (hp)
marked by the arrow,
could be mistaken
for a RBC
See the next slide
 One of the options in
identifying this
structure is to use
polarizing microscopy
In this case, the
maltese shaped
cross indicates that
this structure is an oil
droplet
Methods for Examining Urine Sediments

(1)Unstained Urine Sediment

Bright field microscopy of the unstained urine
sediment
Phase Contrasts (PC)
 Stained Preparation

(a) A crystal violet safranin stain (sternheimer and malbin)

is useful in the identification of cellular elements.
Staining reaction to crystal violet safranin stain:
RBC Purple to dark purple.
WBC Cytoplasm -violet to blue.
Nucleus reddish purple.
Glitter cells blue .
 Stained Preparation (cont)

(b) Methyl blue (Loeffler's stain)

(c) CytoDiachrome stains
Automations in Urinalysis

automations are utilized in urinalysis laboratories.

These machines can be applied for physical, chemical,
and microscopical analysis of urine
Automations in Urinalysis (cont.)

advantages of automations:
the readings are more reproducible and unbiased
help to analyze a great number of specimen in less
time
help to develop standards about the sediments and
give better interpretation about the sediments in close
agreement between laboratories
 Exercise:
Say True or False
1.The number of casts preserved decrease as the pH of the
urine decreases.
2. Presence of RBCs in the urine is always indicative of a
renal
disease.
3.Waxy casts are the end stage in the degeneration of
cellular casts.
4. Pyuria refers to elevated numbers of leucocytes in the
urine.
5.The presence of Bacteria in the Urine is determined
using only
Microscope.
The next chapter will
deal concerning quality
control of urine

What is the importance of keeping

quality control for urinalysis
Quality control in urinalysis.

Quality assurance is a set of activates starting

from specimen collection to issuing test results
that ensure test results are accurate and precise
as possible.
It is the sum of all the activates of the laboratory
that ensures test results are of good quality.
Quality control in urinalysis contd

Quality assurance includes

inside and outside the laboratory performance
standards
good laboratory practice and management skills that
are required by achieving and maintaining a quality
service and that provide for continuing improvement
Quality control in urinalysis (cont)

part of quality assurance, which primarily concern the

control of errors in the performance of tests and
verification of test results.
must be practical, achievable, affordable, and above all
continuous.
The purpose of quality control procedure is to monitor
analytical processes, analytical error and to correct result
of analysis.
two types of quality control programs

A) internal quality control

Is carried out in the laboratory, an intra-lab program.
encompasses all measurements made, technical skills
performed within an individual laboratory.
use control samples, like pooled serum
The purpose of quality control program is to insure
tests are performed reliably and reported correctly.
An effective quality control system detect errors at an
early stage, before they lead to incorrect test results.
B) external quality control.
External quality control is observation of variance in
results when the same material is analyzed in different
laboratories
 Cont..

B) external quality control.

External quality control is observation of variance in
results when the same material is analyzed in
different laboratories
Quality control steps:
Pre analytical steps
Analytical steps
Post analytical steps
Pre analytical Quality control in
urinalysis
read and understand requested paper
guide the patient to bring an appropriate urine sample
labeling the urine container after collecting the sample
cheek the material we are going to use whether they are
properly cleaned or not
ask the patient whether the urine sample has been long
time ,more than two hours, after it is voided.
do not accept contaminated requested paper
cheek the slide, the microscope, and all needed material
before taking the next procedure.
if the urine comes from far place ask or read the
preservative applied
Cot

concentrate and find out an abnormalities that is also

related from chemical and physical apperance.
proper sample preparation is also most important.
reduce possible source of errors
do not open the centrifuge while it is not stopped
proper balance of urine in the centrifuge
analytical Quality control in urinalysis

Small urine sample how to be rejected

follow exactly standard operation procedure (SOP)
Check and read reagent strip chemical test according to
the instruction of the manual of the manufacturer, at the
right time
write the physical appearances properly
use the needed amount of urine for centrifugation
when discarding the supernatant, it has to be quick and
vertical up side down in order not to loss the sediment
examine as quickly as possible
 Post analytical Quality control in
urinalysis

improper written result

incorrect calculation
missing of requesting paper