Urinalysis (Urine Test)

  • Medical Author:
    Siamak N. Nabili, MD, MPH

    Dr. Nabili received his undergraduate degree from the University of California, San Diego (UCSD), majoring in chemistry and biochemistry. He then completed his graduate degree at the University of California, Los Angeles (UCLA). His graduate training included a specialized fellowship in public health where his research focused on environmental health and health-care delivery and management.

  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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What is a urinalysis?

A urinalysis is simply an analysis of the urine. It is a very common test that can be performed in many health-care settings, including doctors' offices, urgent-care facilities, laboratories, and hospitals.

A urinalysis test is performed by collecting a urine sample from the patient in a specimen cup. Usually only small amounts (30-60 mLs) may be required for urinalysis testing. The sample can be either analyzed in the medical clinic or sent to a laboratory to perform the tests. Urinalysis is abbreviated UA.

Picture of urine dip stick and color box instructions
Picture of urine dipstick and color box instructions

UA is in general easily available and relatively inexpensive. It is also a simple test and can provide many useful information about various diseases and conditions. Some physicians refer to urinalysis as "a poor man's kidney biopsy" because of the plethora of information that can be obtained about the health of the kidney or other internal diseases by this simple test.

Urine can be evaluated by its physical appearance (color, cloudiness, odor, clarity), or macroscopic analysis. It can be also analyzed based on its chemical and molecular properties or microscopic assessment.

Urinalysis is ordered by doctors for a number of reasons, including the following:

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UTI Diagnosis

Urinalysis (Urine Test)

A doctor may simply perform a urine dipstick test in the office. Only a few minutes are needed to obtain results. Your health-care provider may also send a urine sample to the lab for culture testing (see below). These results take a few days to come back. This tells the doctor the exact bacteria causing the infection and to which antibiotics these bacteria have resistance or sensitivity. The culture is usually sent for special populations, including men, because they are less likely to get UTIs. It is not necessary to send a culture for everyone because the majority of UTIs are caused by the same bacteria.

  • The single most important lab test is urinalysis. A urine sample will be tested for signs of infection, such as the presence of white blood cells and bacteria.

What can urinalysis results show?

Urinalysis can disclose evidence of diseases, even some that have not caused significant signs or symptoms. Therefore, a urinalysis is commonly a part of routine health screening.

Urinalysis is commonly used to diagnose a urinary tract or kidney infection, to evaluate causes of kidney failure, to screen for progression of some chronic conditions such as diabetes mellitus and high blood pressure (hypertension).

It also may be used in combination with other tests to diagnose some diseases. Additional tests and clinical assessment are often required to further investigate findings of urinalysis and ultimately diagnose the causes or specific features of underlying problems. For example, urine infection is generally diagnosed based on results of urinalysis. However, urine culture is often ordered as a follow-up test to identify the bacteria that may be causing the infection. Other examples include kidney stones, inflammation or the kidneys (glomerulonephritis), or muscle breakdown (rhabdomyolysis).

Who is involved in the interpretation of urinalysis?

Interpretation of urinalysis is generally based on reviewing all the components of the test and correlating it with the clinical signs and symptoms of the patient and the physical examination. The results are reviewed and interpreted by the doctor who ordered the test.

What types of doctors perform urinalysis?

Many types of doctors may order a urinalysis in their practice. Because of easy availability, relatively nominal cost, simplicity of performing the test, and quick turnaround time, UA is done in many settings by variety of doctors. Most frequently, UA is ordered by internists, family practitioners, emergency-room physicians, obstetricians and gynecologists, nephrologists (kidney specialists), urologists, rheumatologists, and possibly less often by many other specialists.

What does urinalysis involve?

Urinalysis is done by collecting a urine sample from a patient. The optimal sample tends to be an early morning urine sample because it is frequently the most concentrated urine produced in the day. Typically, no fasting is required before the collection of urine sample and routine medications can be taken before the test, unless otherwise instructed by the ordering physician.

Methods of collection are slightly different for female and male patient.

  • For females, the patient is asked to clean the area around the urethra with a special cleansing wipe, by spreading the labia of the external genitals and cleaning from front to back (toward the anus).
  • For men, the tip of the penis may be wiped with a cleansing pad prior to collection.
  • The urine is then collected in a clean urine specimen cup while the patient is urinating. It is best to avoid collecting the initial stream of urine. After the initial part of urine is disposed of in the toilet, then the urine is collected in the urine container provided. Once about 30 to 60 ml (roughly 3 to 5 tablespoons) are collected in the container for testing, the remainder of the urine may be voided in the toilet again. This is called the clean catch or the midstream urine collection.

The collected urine sample should be taken to the laboratory for analysis, typically within one hour of collection. If transportation to the lab could take more than one hour, then the sample may be refrigerated.

In some patients who are unable to void spontaneously or those who are not able to follow instructions other methods may be used, such as placing a catheter (a small rubber tube) through the outside opening to the bladder (urethra) to collect the sample directly from the bladder.

What is macroscopic urinalysis?

Macroscopic urinalysis is the direct visual observation of the urine, noting its quantity, color, clarity or cloudiness, etc.

Normal urine is typically light yellow and clear without any cloudiness. Obvious abnormalities in the color, clarity, and cloudiness may suggest possibility of:

Certain medications may also change the color of urine. Very foamy urine may represent large amounts of protein in the urine (proteinuria).

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What is urine dipstick chemical analysis?

Urine dipstick is a narrow plastic strip which has several squares of different colors attached to it. Each small square represents a component of the test used to interpret urinalysis. The entire test strip is dipped in the urine sample and color changes in each square are noted. The color change takes place after several seconds to a few minutes from dipping the strip. If read too early or too long after the urinalysis strip is dipped, the results may not be accurate.

Each color change on a particular square may indicate specific abnormalities in the urine sample caused by a certain chemical reaction. The reference for color changes is posted on the plastic bottle container of the urine test strips. This makes for easy and quick interpretation of the urinalysis results by placing the strip next to the container and comparing its color changes to the reference provided.

The squares on the dipstick represent the following components in the urine:

  • specific gravity (concentration of urine),
  • acidity of the urine (pH),
  • protein in the urine (mainly albumin),
  • glucose in the urine (sugar),
  • ketones (products of fat metabolism),
  • blood in the urine,
  • leukocyte esterase (suggestive of white blood cells in urine),
  • nitrite (suggestive of bacteria in urine),
  • bilirubin (possible liver disease or red blood cell breakdown), and
  • urobilinogen (possible liver disease).

Presence or absence of each of these color changes on the strip provides important information for clinical decisions.

After the UA test strip is dipped in urine briefly and completely, the reading is done within a few minutes. Each one of the squares on the box has next to it the time which is recommended for its interpretation (for example, whether these is a change in color on the square). The squares are placed in similar order on the box, from the ones requiring the shortest time to read of 30 seconds to the ones with the longest time to read of two minutes. This arrangement is based on result time and makes it easier to quickly read and interpret any color changes by simply scanning the strip from the shortest (glucose) to the longest (leukocytes).

What are the pros and cons of dip sticks?

The main advantage of dipsticks is that they are convenient, easy to interpret, and cost-effective. They can be analyzed within minutes of urine collection in the doctor's office or in the emergency room to provide valuable information.

However, what can be learned from a dipstick is limited by the design of the dipstick. The main disadvantage is that the information may not be very accurate, as the test is time-sensitive. It also provides limited information about the urine, as it is qualitative test and not a quantitative test (for example, it does not give a precise measure of the quantity of abnormality). Therefore, normal and abnormal values are not reported as part of urinalysis results.

What is microscopic urinalysis?

The microscopic urinalysis is the study of the urine sample under a microscope. It requires only a relatively inexpensive light microscope. Cells and cellular debris, bacteria, and crystals in the urine can be detected by this examination to provide further clinical clues.

How is microscopic urinalysis done?

Microscopic urinalysis is done simply pouring the urine sample into a test tube and centrifuging it (spinning it down in a machine) for a few minutes. The top liquid part (the supernatant) is discarded. The solid part left in the bottom of the test tube (the urine sediment) is mixed with the remaining drop of urine in the test tube and one drop is analyzed under a microscope.

The sediment is examined through the microscope under low-power to identify what are called casts, crystals, squamous (flat) cells, and other large objects.

Examination is then performed through the microscope at higher power to further identify any cells, bacteria and clumps of cells or debris called casts.

What kind of cells can be detected?

Epithelial (flat cells), red and white blood cells may be seen in the urine.

Sometimes cells, cellular debris, and casts are seen in the microscopic urinalysis. Epithelial cells (cells in the lining of the bladder or urethra) may suggest inflammation within the bladder, but they also may originate from the skin and could be contamination.

Casts and cellular debris originate from higher up in the urinary tract, such as in the kidneys. These are material shed from kidney cell lining due to injury or inflammation and travel down through the urinary tubes. These usually suggest an injury to the kidney from an inflammation or lack of blood flow to the kidneys. Rarely, tumor cells can be in the urine suggesting a urinary tract cancer.

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What can the presence of red blood cells in the urine mean?

Red blood cells can enter the urine from the vagina in menstruation or from the trauma of bladder catheterization.

A high count of red blood cells in the urine can indicate infection, trauma, tumors, or kidney stones. If red blood cells seen under microscopy look distorted, they suggest kidney as the possible source and may arise due to kidney inflammation (glomerulonephritis). Small amounts of red blood cells in the urine are sometimes seen young healthy people and usually are not indicative of any disease.

What can the presence of white blood cells in the urine mean?

Urine is a generally thought of as a sterile body fluid, therefore, evidence of white blood cells or bacteria in the urine is considered abnormal and may suggest a urinary tract infection such as, bladder infection (cystitis), infection of kidney (pyelonephritis). White blood cells (WBCs) may be detected in the urine through a microscopic examination (pyuria or leukocytes in the blood). They can be seen under high power field and the number of cells are recorded (quantitative) as "rare,""few,""moderate," or "many."

White cells from the vagina or the opening of the urethra (in males, too) can contaminate a urine sample. Such contamination aside, the presence of abnormal numbers of white blood cells in the urine is significant.

Other than urinalysis, what are other common urine tests available?

Other commonly performed urine tests are drug tests, pregnancy tests, specific chemicals and proteins in the body, which are not a part of routine urinalysis.

Urine drug screen is done routinely to check for drugs or their byproducts in the urine. There are many purposes for these tests including athletic screening, emergency rooms settings, drug detoxification programs, school and employment screening. This test detects the presence of commonly used drugs such as:

Urine pregnancy test is very common and it measures a hormone in the urine associated with pregnancy (beta-HCG or beta- human chorionic gonadotropin). This test can be done in medical settings, but numerous kits are available for home use.

Other urine tests can also be used in evaluation of many medical conditions. Examples include:

  • urine culture (in determining the bacterial cause of urine infection)
  • urine creatinine (in assessing kidney disease)
  • urine total protein and albumin (in assessing kidney disease and protein loss from kidney)
  • urine cytology (in evaluating for possible bladder or other urinary tumors)
  • urine calcium (in evaluating elevated blood calcium levels)
  • 24-hour urine collection for proteins (in diagnosing causes of kidney impairment, diabetic related kidney disease, lupus related kidney disease)
  • 24-hour urine collection for protein electrophoresis (for measuring different components of proteins in urine in evaluating multiple myeloma, kidney inflammation with increased protein loss)
  • 24-hour urine collection of catecholamine metabolites (in evaluating adrenal gland disease, difficult to treat high blood pressure)

REFERENCE:

Kasper, D.L., et al., eds. Harrison's Principles of Internal Medicine, 19th Ed. United States: McGraw-Hill Education, 2015.

Last Editorial Review: 7/13/2016

Reviewed on 7/13/2016
References
REFERENCE:

Kasper, D.L., et al., eds. Harrison's Principles of Internal Medicine, 19th Ed. United States: McGraw-Hill Education, 2015.

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