URINAlysis interpretation

INITIAL ASSESSMENT
COLOR
The color of the urine is the easiest way to determine
someone’s hydration status. Surprisingly, it can indicate other
aspects of health as well.

Amber ORANGE-Red
Amber or Yellow color is considered Could be caused by use of Rifampin or
normal. Pyridium (OTC AZO).

Red or Pink Purple

Usually indicates blood, but could Termed ”Purple Urine Syndrome”, can
indicate rhabdo due to myoglobin in be caused by Methylene blue dye,
the urine. Certain foods/medications medications like amitriptyline, a diet
can also cause red urine. high in Tryptophan, or certain bacteria.

Blue or Green
May be caused by some food dyes, urology dyes, medications like propofol, amitriptyline,
or indomethacin, or a rare condition called familial benign hypercalcemia.
Pseudomonas bacteria can rarely cause green urine as well.

Turbidity Smell
Turbid = Cloudy. Cloudy urine may Strong smelling urine typically indicates
indicate infection, dehydration, or dehydration/concentrated urine. Foul
kidney damage or malodorous urine often indicates
infection. Sweet smelling urine may
indicate hyperglycemia. Feces smelling
urine may indicate a fistula.
 URINAlysis interpretation
DIPSTICK ANALYSIS

Glucose (Normal = none)

Glucose is detected if blood glucose is >180mg/dL. This is usually due to diabetes, but can also
be from acute illness.

Bilirubin (Normal = none)

Can be normal in small amounts, but increased levels may indicate abnormality of bilirubin
production or liver function. Causes include hepatitis, liver disease, gallstones, hemolysis, or
constipation.

(Normal = none)
Ketones
Ketones in the urine indicate excessive fat breakdown for energy. This often occurs in DKA, but
also during starvation, excessive nausea/vomiting, or low-carb diets.

(Normal = none)
Ascorbate
This is Vitamin C. The presence of Vitamin C can lead to false negatives for both Heme, glucose,
leukocyte esterase, and protein.

Normal
Specific Gravity 1.005– 1.030)
Specific gravity tells you how dilate or concentrated the urine is, giving a decent indication of
hydration status. Low specific gravity often indicates renal failure, nephritis, or diabetes (mellitus
and insipidus), whereas high specific gravity indicates dehydration, CHF, or SIADH.
URINAlysis interpretation
DIPSTICK ANALYSIS
Heme (Normal = none)
Positive Heme usually indicates blood, but can also indicate myoglobin from rhabdomyolysis.
Blood is common during UTIs, but not common in urethritis or vaginitis (think STIs).
Vitamin C can also cause false negatives, and recent ejaculation, high alkaline urine, or vaginal
contamination can cause false positives.

PH (Normal = 4.5-8)
pH indicates the acidity of urine. Acid-base disturbances in the blood can be reflected in the
urine, but also certain UTIs and kidney stones can correlate with pH of urine.
Uric acid and cystine stones commonly are formed in acidic urine, whereas Ca oxylate, Ca
Phosphate, and others are formed in alkaline urine.

Proteus and Klebsiella (2 common bacteria found in UTIs) are often associated with a pH of
7.0-7.5.

Protein Normal = None

Protein in the urine, termed proteinuria, can be temporary, or can indicate underlying
glomerular disease of the kidney.

Temporary causes include Fever, strenuous exercise, stress, inflammation, or acute illness.
Glomerular proteinuria is caused by Diabetic nephropathy, lupus nephritis, pre-eclampsia,
various infections, NSAIDs, and more.

Urobilinogen (Normal = .1-1.8 mg/dL)

Urobilinogen is a byproduct of bilirubin production. Elevated levels can indicate malaria,
hemolytic anemia/jaundice, or internal bleeding.
URINAlysis interpretation
DIPSTICK ANALYSIS
(Normal = none)
nitrites
Certain bacteria convert nitrates to nitrites. Positive nitrites in the UA is highly specific to
UTIs, but is not that sensitive so may not be present.

Bacteria likely to cause nitrites are those in the Enterobacteriaceae group: E Coli, Proteus, and
Klebsiella.

Urine may need to dwell in the bladder for 4 hours for this to show up, so urinary frequency
with fully emptying the bladder may lead to a negative result.

Leukocyte Esterase (Normal = none)

Leukocyte esterase is a byproduct of lysed White Blood Cells. When this is present, this is also
termed pyuria (pus in the urine). While this can be nonspecific, it is associated with a bacterial
infection (UTI).

Non-infectious causes include autoimmune disorders, kidney stones, or intra-abdominal

infections.

Excessive protein, glucose, or ascorbic acid can cause false negatives.

Contamination often causes false positives.

 URINAlysis interpretation
MICROSCOPY
Crystals bacteria
Normal: Can be normal Normal: None
Crystallizations within the urine can be The presence of bacteria indicates
normal, as long as they are composed infection or contamination.
of substances normally found in the
urine. Certain UTIs can cause
ammonium phosphate and struvite
crystals.

White Blood Cells Red Blood Cells

Normal: < 2 – 5 WBCs/HPF Normal: < 2 RBC/HPF
Higher levels can indicate infection, The presence of red blood cells
inflammation, or contamination. indicates hematuria.

CASTS
Casts are tube-like protein structures made of various cells. Low urine pH, low urine flow
rate, and high urinary salt concentration promote cast formation

The presence of casts, other than hyaline casts, represents pathology within the kidney
itself (Acute/chronic renal failure, nephrotic syndrome, glomerulonephritis, etc.).

Types of casts include Hyaline casts, RBC casts, WBC casts, “muddy-brown” granular casts,
waxy casts, broad casts, fatty casts, and renal tubular epithelial casts
 URINAlysis interpretation
UTI Quick Guide
The quickest way to tell if there is a bacterial infection of the urine is to
look at the Leukocyte Esterase, as well as the nitrites

1 Symptoms?
The first step is to examine the patient and see if they have any signs or
symptoms of a UTI. Asymptomatic bacteriuria is usually not recommended to
be treated.

2 Leukocyte Esterase
Are any Leukocyte esterase present and how much? If not, you can pretty much
rule out an infection. If it is positive at all, infection IS possible. The larger the
amount, the more convincing it is for infection.

3 Nitrites
If Nitrites are present, you can pretty much BET that there is an infection. However,
just because nitrites are negative this doesn’t mean there isn’t an infection.

4 WBC on microscopy
Always check the urine microscopy to reinforce the diagnosis. UTIs will typically
cause WBC to be 5-10 cells / HPF or more.

5 Epithelial cells
A high amount of epithelial cells on the microscopy indicate possible contamination.
If levels exceed 15-20 cells/HPF, then consider getting another sample (clean catch or
catheterization).

6 Bacteria
The presence of bacteria on the microscopy just reinforces the diagnosis, but is not
necessary. It also may indicate contamination.
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REFERENCES
1.Carroll, M. F., & Temte, J. L. (2000). Proteinuria in adults: A diagnostic approach. American Family
Physician, 62(6), 1333-1340. Retrieved April 1, 2018, from https://www.aafp.org/afp/2000/0915/p1333.html.

2.Fischbach, F. T., & Dunning, M. B., III. (2009). Manual of laboratory and diagnostic tests (8th ed.). Wolters
Kluwer Health.

3.Lerma, E. V. (2015). Urinalysis. Medscape. Retrieved April 1, 2018,

from https://emedicine.medscape.com/article/2074001-overview

4.Meyreir, A. (2022). Sampling and evaluation of voided urine in the diagnosis of urinary tract infection in
adults. In T.W. Post (Ed.), UpToDate. From https://www.uptodate.com/contents/sampling-and-evaluation-of-
voided-urine-in-the-diagnosis-of-urinary-tract-infection-in-adults

5.Tintinalli, J. E., Stapczynski, J. S., Ma, O. J., Cline, D., Meckler, G. D., & Yealy, D. M. (2016). Tintinallis emergency
medicine: A comprehensive study guide (8th ed.). New York: McGraw-Hill Education.

6.Walk, R. W. (2022). Urinalysis in the diagnosis of kidney disease. In T.W. Post (Ed.), UpToDate. Retrieved April
1, 2018, from https://www.uptodate.com/contents/urinalysis-in-the-diagnosis-of-kidney-disease