Original Article

Performance Characteristics of Dipstick and

Microscopic Urinalysis for Diagnosis of
Urinary Tract Infection
Ramazan Memişoğulları, Hatice Yüksel, Hayriye Ak Yıldırım, Özlem Yavuz

Düzce University, School of Medicine, De- ABSTRACT

partment of Biochemistry, Düzce, Turkey
Aim: Although the urine culture is used as the reference standard to
Eur J Gen Med 2010;7(2):174-178 determine presence or absence of urinary tract infection, the culture
Received: 12.06.2009 is an expensive and time-consuming method. The objectives of the
study were to compare dipstick urinalysis with microscopic urinalysis
Accepted: 15.09.2009
and to compare dipstick and microscopic urinalysis results with urine
culture results, by calculating performance characteristics of these
tests.
Method: The 250 morning urine specimens were performed by using
dipstick and microscopic urinalysis and cultured. Laboratory urinalysis
included semi-automated dipstick reading by a Miditron-M Reflectance
photometer and microscopic examination.
Result: Thirty-five point six percent (89/250) of patients had urine
cultures with 105 colonies/mL or greater. Sensitivity and specificity
of microscopic urinalysis were 91% and 68%, whereas in dipstick uri-
nalysis they were 80% and 60%, respectively. Negative predictive val-
ues were 84% for urine dipsticks and 93% for microscopic urinalysis.
Positive predictive values were 52% and 61% for dipstick and micro-
scopic urinalysis, respectively.
Conclusion: The study has suggested that both urinalysis methods can
be used for rapid diagnosis. Urine culture is an expensive test for
routine use and should not be applied unless the result of the nitrite,
leukocyte or bloods are positive in dipstick or leukocyte, erythrocyte
or bacteria are positive in microscopic examination.
Key words: Dipstick, urine microscopy, urine culture, sensitivity,
specificity, predictive values

Correspondence: Ramazan Memişoğulları,

Department Of Biochemistry,
Düzce University,
School Of Medicine, 81620 Düzce, Turkey
Fax: +903805421387
Phone: +903805421386
E-mail: [email protected]

European Journal of General Medicine

Performance characteristics of urinalysis

İdrar yolu enfeksiyonu tanısında striple ve mikroskopik idrar analizinin performans özellikleri

Amaç: : İdrar kültürü idrar yolu enfeksiyonunun saptanmasında referans test olarak kabul edilmekle beraber pahalı ve zaman
gerektiren bir testtir. Çalışmamızın amacı, striple idrar analizi ve mikroskopik idrar analizini karşılaştırmak, strip ve mikrosopik
idrar analizi sonuçları ile idrar kültür sonuçları arasındaki ilişkiyi bu testlerin performans özelliklerini ölçerek değerlendirmektir.
Metod: : İkiyüzelli hastadan sabah idrar örneği alındı. Laboratuarımızda idrar analizleri yapılıp kültür için ekimleri yapıldı. Labo-
ratuar idrar analizi Miditron-M Reflektans fotometresi ile otomatik strip okuma ve mikroskopik çalışmayı içeriyordu.
Bulgular:Hastaların %35.6 sı (89/250) idrar kültürleri 105 koloni/mL veya daha fazla organizma içeriyordu. Mikroskopik idrar ana-
lizinin sensitivite ve spesifitesi sırasıyla %91 ve %68, striple idrar analizinin %80 ve %60 idi. Negatif prediktör değer strip için %84,
mikroskopik analiz için %93, pozitif prediktör değer strip ve mikroskopik analiz için sırasıyla %52 ve %61 hesaplandı.
Sonuç: Bu çalışma her iki idrar analiz metodunun hızlı tanı için kullanılabileceğini gösterdi. Bu nedenle, idrar kültürü pahalı bir
test olduğundan stripte nitrit, lökosit, kan testi pozitifliği veya mikroskopik incelemede lökosit, eritrosit veya bakteri pozitifliği
yoksa tüm idrar örneklerinde idrar kültürü öneremeyiz.
Anahtar kelimeler: Strip, idrar mikroskopisi, idrar kültür, sensitive, spesifite, prediktif değer

INTRODUCTION nostic accuracy of the test (2,3). Urine samples were

divided into 3 sterile aliquots, 2 for urinalysis and 1 for
Urine samples constitute a major proportion of the sam-
urine culture.
ples tested in routine diagnostic laboratories. Although
the urine culture is used as the reference standard to Urine Dipstick Chemical Analysis
determine presence or absence of urinary tract infection,
A complete urinalysis included physical, chemical, and
the culture is an expensive and time-consuming method
microscopic examinations. Combur 10-Test M strips
(1). Substituting a urine dipstick test or urine microsco-
on a Miditron-M semi-automated reflectance photom-
py for a hospital laboratory urinalysis may be less time-
eter (Roche Diagnostics GmbH, Mannheim, Germany)
consuming and less expensive, but also some doubts are
have been used in our routine laboratory for chemical
present about that the urinalysis may not be as accurate.
examinations. Our laboratory technician was skilled in
There are still different opinions regarding whether uri-
the dipstick procedure. The technician tested the first
nalysis or urine culture should be a routine. A complete
aliquot immediately using Combur 10 Test M reagent
consensus whether culture should be performed only for
strip (Roche Diagnostics GmbH, Mannheim, Germany)
specific indications has yet not concluded.
for urinalysis from a sealed, air-tight container that had
The objectives of the study were; 1) to compare dipstick been opened within the past 10 days. The strips include
urinalysis with microscopic urinalysis, 2) to compare dip- reagent pads for semiquantitative assessment of nitrite,
stick and microscopic urinalysis results with urine culture leukocyte esterase, pH, specific gravity, protein, glu-
results, by calculating performance characteristics of cose, ketones, urobilinogen, bilirubin, and blood. The
these tests. leukocyte esterase measurement was read after 2 min-
utes and recorded as negative, trace, small (1+), mod-
erate (2+), or large (3+). The nitrite measurement was
MATERIALS AND METHODS read at 60 seconds and recorded as negative or positive.
Collection of the Specimens The blood measurement was also read at 60 seconds and
recorded as negative; (1+), (2+), (3+), (4+). Cutoff val-
The 250 freshly morning urine specimens, collected un- ues for a positive result was (3+) leukocyte esterase, or
der sterile conditions as far as possible were studied. All (3+) blood, or nitrite (+). Day-to-day imprecision was
samples were completely processed within 1–2 h after assessed with control material: Liquichek Urinalysis
arrival, to avoid overgrowth of any contaminating bac- Control Levels 1 and 2 (Bio-Rad). This is stable for 30
teria. Patients who had taken antibiotics in the past 72 days when stored tightly capped at 2–8 °C.
hours, or had indwelling Foley catheters, symptomatic
vaginal discharge, diabetes mellitus, or immunodefi- Microscopic Urinalysis
ciency disorders were excluded. Specimens contain- A 10-mL aliquot of urine was centrifuged at 1500 rpm for
ing squamous epithelial cells were not excluded from 5 minutes. The supernatant was removed and the sedi-
analysis because other investigators have found that the ment was resuspended into solution with 1 mL of super-
presence of squamous cells does not affect the diag- natant. One drop (0.4 mL) of the resuspended sediment

175 Eur J Gen Med 2010;7(2):174-178

 Memişoğulları et al.

Table 1. True/False positivity/negativity of Table 2. True/False positivity/negativity in

microscopic examination, when only WBC or WBC,RBC, dipstick analysis, when only leukocyte esterase
or bacteria take into consideration. or leukocyte esterase, blood, or nitrite takes
into consideration.
Only WBC WBC or RBC or Bacteria
Microscopy TP 77 81
Microscopy TN 115 110 Only LE LE or Blood or Nitrite
Microscopy FP 46 51 Dipstick TP 58 71
Microscopy FN 12 8 Dipstick TN 103 96
TP; true positive, TN; true negative, FP; false positive, FN; false negative Dipstick FP 58 65
Dipstick FN 31 18
LE: leukocyte esterase

was placed onto a microscope slide, covered, and ex- Calculation of sensitivity, specificity, and predictive
amined under ×100 and ×400 magnifications. The results values
as the number of WBCs and RBCs per high-power field
Sensitivity, specificity, and predictive values were cal-
(hpf) and bacteriuria (×400 magnification) were inter-
culated for leukocyte esterase, nitrite, or blood on dip-
preted. Cutoff values for a positive result was more than
stick and for RBCs, WBCs, or bacteria on microscopic
5 WBCs/hpf or more than 3 RBCs/hpf or bacteriuria.
urinalyses. Sensitivity, specificity, and predictive values
Urine Culture were calculated as follows (4):

Of the total of 250 urine samples examined, 89 gave a Sensitivity=True positive/(True positive+False negative)
pure growth of 105 or more organisms per ml (‘culture
Specificity=True negative/(True negative+False positive)
positive’ samples). The remaining 161 samples were re-
ported as ‘culture negative’ samples. If 3 or more dis- Positive Predictive Value= True positive/(True positive +
tinct species of bacteria were present in culture and False positive)
were not considered uropathogens, the culture was Negative Predictive Value= True negative/ (True nega-
considered contaminated and classified as negative (9 tive + False negative)
samples).
Statistical Analysis

Pearson’s correlation test was used to evaluate the cor-

4,0
relation between leukocyte in dipstick and leukocyte
Dipstick

count/hpf in microscopic examination

3,0

2,0

1,0

Table 3. Performance Characteristics of dipstick and

0,0
microscopic urinalysis
Culture negative
L L, E, B LE LE, Bl, N
-1,0 Culture positive
Sensitivity 87% 91% 65% 80%
-10 0 10 20 30 40
Specificity 71% 68% 64% 60%
PPV 63% 61% 50% 52%
Microscopy
NPV 91% 93% 77% 84%
Figure 1. The correlation between leukocyte in dip-
L; leukocyte (>5/hpf), E; erythrocyte (>3/hpf), B; bacteriuria,
stick and leukocyte count/hpf in microscopic examina- LE; leukocyte esterase (3+), Bl; blood (3+), N; nitrite (+)
tion PPV; positive Predictive Value, NPV; negative Predictive Value

Eur J Gen Med 2010;7(2):174-178 176

Performance characteristics of urinalysis

RESULTS diate result. Microscopic examination of urine samples

for leukocytes, erythrocytes or bacteria is considerably
Thirty-five point six percent (89/250) of patients had
more time consuming and labor intensive than the dip-
urine cultures with 105 colonies/mL or greater. The main
stick method (5). But false positive and false-negative
organisms grown from the culture positive cases were
rates are significantly higher as compared with the
Escherichia coli (61), Klebsiella (14), Citrobacter (2),
microscopic examination. In dipstick analysis, urinary
Pseudomonas (3), Enterobacter (5), and Staphylococcus
protein excretions in excess of 500 mg/dL and urinary
(4). Nine cultures were considered contaminated and
glucose excretions in excess of 2 mg/dL may diminish
classified as negative.
the intensity of the reaction color, as can cephalexin
Performance Characteristics and gentamicin if administered in high daily doses, or
Table 1, 2, and 3 shows performance characteristics of boric acid if used as a preservative. The nitrite test de-
microscopic or dipstick urinalysis. When at least one of pends on the conversion of nitrates into nitrites by bac-
the leukocytes esterase, nitrite, or blood in dipstick; teria in the bladder. It requires an incubation period of
one of the leukocyte, erythrocyte, or bacteria in mi- several hours in the bladder and so is best performed
croscopic examination was taken into consideration, using an early morning urine sample. In the study, all
sensitivity and specificity of microscopic urinalysis were specimens were morning urine samples. Unfortunately
91% and 68%, and of dipstick urinalysis were 80% and some organisms, especially gram-positive ones, do not
60%, respectively. Negative predictive values were 84% convert nitrates into nitrites. Previous evaluations of
for urine dipsticks and 93% for microscopic urinalysis. the predictive value of combining leucocyte-esterase
Positive predictive values were 52% and 61% for dipstick and nitrite tests have produced conflicting results (6-
and microscopic urinalysis, respectively. 8), but the present study suggests these tests to be of
value. In the present study, when only leukocyte ester-
Correlation of leukocyte analyses between micros- ase takes into consideration, sensitivity and specificity
copy and dipstick was 65% and 64%, respectively, whereas sensitivity and
A strong correlation was present between leukocyte specificity in microscopic examination, when only leu-
esterase and microscopic leukocyte count/hpf both in kocyte esterase takes into consideration, was 87% and
culture negative group (r=0.57; p<0.001) and in culture 71%, respectively. When leukocyte esterase, or blood,
positive group (r=0.75; p<0.001) (Figure 1). or nitrite takes into consideration, sensitivity increased
to 80% from 65%, however specificity decreased to 60%
from 64% due to increased false positives. In the same
DISCUSSION way, when WBC, or RBC, or bacteria take into consider-
ation, sensitivity increased to 91% from 87%, however
In the present study, dipstick and microscopic urinalysis
specificity decreased to 68% from 71% due to increased
results were compared with urine culture results, which
false positives.
were used as the reference standard to determine pres-
ence or absence of urinary tract infection. The present In the present study, when divided into 2 groups as cul-
study demonstrates that bedside urine dipsticks and mi- ture positive and negative, a strong correlation between
croscopic urinalysis may be substituted for rapid urinal- leukocyte esterase and microscopic leukocyte count/
ysis to diagnose uncomplicated urinary tract infections. hpf was present both in culture positive group and in
Use of dipsticks and microscopic urinalysis instead of culture negative group. Rapid diagnosis or exclusion of
urine culture may decrease patient time and the cost urinary tract infection is valuable both to the general
of testing. practitioner and to the hospital physician. Therefore,
dipstick test may be performed when a very rapid con-
Urine culture has the disadvantage of taking at least 48
clusion was desired. Microscopy of the urine is recom-
hours to give a result. More rapid methods of urinary
mended in textbooks for the diagnosis of urinary tract
tract infection diagnosis are therefore desirable. The
infections (9). However, it is reported that less than a
most widely used rapid tests are dipsticks. Dipstick tests
third of general practitioners had a microscope; this in-
have the advantage of being quick and easy to perform
strument also appears to be rarely found on the modern
and can be carried out in primary care giving an imme-
hospital wards (10,11). In the study, accuracy of micro-

177 Eur J Gen Med 2010;7(2):174-178

 Memişoğulları et al.

scopic examination was higher than those of dipstick 3. Walter FG, Knopp RK. Urine sampling in ambulatory wom-
test. Cutoff values for a positive result was more than 5 en: midstream clean catch versus catheterization. Ann
Emerg Med 1989; 18:166-72.
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4. Güner G. Tanısal Yeterlilik Testleri. In: Taga Y, Aslan D,
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Derneği, 2002: 106-123.
urine culture is an expensive test, nitrite, leukocyte,
5. Whiting P, Westwood M, Watt I, Cooper J, Kleijnen J.
or blood test in dipstick or leukocyte, erythrocyte, or
Rapid tests and urine sampling techniques for the diag-
bacteria in microscopic examination may be guiding nosis of urinary tract infection (UTI) in children under
analytes before culture. five years: a systematic review. BMC Pediatrics 2005, 5:4.
6. Wenk RE, Dutta D, Rudert K, et al. Sediment microscopy,
nitriteuria and leukocyte esteraseuria as predictors of
Acknowledgments significant bacteriuria. J Clin Lab Automation 1982; 2:
117-21.
The authors thank Biolog Erdoğan ŞAHİN and Assoc. Prof. Dr. 7. Wilkins EGL, Ratcliffe JG, Roberts C. Leucocyte-
Tevfik YAVUZ, working in Training and Research Hospital of esterasenitrite screening method for pyuria and bacteri-
Düzce University, Biochemistry and Microbiology Laboratory, uria. J Clin Pathol 1985; 38: 1342-5.

respectively, for their technical assistances. 8. Smalley DL, Dittman AN. Use of leukocyte-esterase-ni-
trate activity as predictive assays of significant bacteri-
uria. J Clin Microbiol 1983; 18: 1256-7.

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