3 glass technique For detection of prostatic infection

1. 1st portion of voided urine

2. Middle portion of voided urine: Serves as control for kidney and bladder
infection
-If (+), result for #3 is considered invalid
3. Urine after prostatic massage
Compare WBC and Bacteria of specimen 1 and 3
Prostatic infection: 1 < 3 (10x)
Pediatric specimen Wee bag
Drug Specimen Collection Chain of custody: step by step documentation of handling and testing of legal
specimen
Required amount: 30-45 mL
Temperature (urine): 32.5-35.7’C (w/in 4 mins)
Blueing agent  Toilet bowl (to prevent adulteration)
Types of Urine Specimen
Occasional/Single/Random Routine
Qualitative UA
24 hr 1st voided urine  discarded
w/ preservative
Ex. 8AM  8AM
12 hr Ex. 8AM  8PM
u k
Addis count: measure of formed elements in the urine using hemacytometer
o .
le.c
Afternoon (2PM-4PM) Urobilinogen (alkaline tide)
4 hr
t e s
NO3  NO2 = (+) UTIa
Nitrite determination (1st morning/4 hr)

1st morning N o
Pregnancy test (hCG)
o m 4 3
Ideal specimen for routine UA
f r f
i e w e 2 o
Most concentrated and most acidic = preservation of cells and casts
Fasting/2nd morning
P r e v P a g
Glucose determination
2nd voided urine after a period of fasting
Changes in Unpreserved Urine
Decreased
Clarity Bacterial multiplication
Precipitation of AU/AP
Glucose Glycolysis
Ketones Volatilization
Bilirubin Photooxidation
Urobilinogen Oxidized to urobilin
RBC/WBC Disintegrate in alkaline urine
Increased
pH Urea ---(Urease)---> NH3
Bacteria Multiplication
Odor Urea ---(Urease)---> NH3
Nitrite Bacterial multiplication
Differentiate contamination Contamination:  Bacteria
from true infection True infection:  Bacteria and WBCs
Preservation
Refrigeration 2-8’C
 SG (hydrometer/urinometer)
Precipitate AU/AP
Formalin Addis count
Boric acid Urine culture
lec.mt 04 |Page | 135
Red/Purple/Burgundy red/ Porphyria
purplish red/Portwine (Lead poisoning: normal color)
Brown/black Methemoglobin (acid urine)
Homogentisic acid: Alkaptonuria
-Urine darkens after a period of standing
-(-) Homogentisic acid oxidase
Urine Color Changes w/ Commonly Used Drugs
Cola-colored Levodopa (Tx: Parkinsonism)
Red  Brown (alkaline)
Yellow Mepacrine/Atabrine (Tx: Malaria, Giardiasis)
Red to brown Metronidazole/Flagyl (Tx: Trichomoniasis, Amoebiasis, Giardiasis)
Methyldopa/Aldomet (Antihypertensive)
Orange-red (acid) Phenazopyridine/pyridium (Tx: UTI)
Bright orange-red (acid) Rifampin (Tx: TB) = all body fluids are red
Bright yellow Riboflavin (Multivitamins)
Nubecula Faint cloud in urine after a period of standing
WBCs, epithelial cells and mucus
Bilifuscin (Dipyrrole) Hemoglobin Köln = unstable
Red-brown urine
Clarity/Transparency/Turbidity
Clear Transparent, no visible particulates
Hazy
.
Few particulates, print easily seen through urine
o u k
Cloudy
Turbid
s
Print cannot be seen through urine
e le.c
Many particulates, print blurred through urine
a
Milky
Bacteria o t
May precipitate or clot
N
Uniform turbidity NOT cleared by acidification or filtration
Chyluria
f r o m f 4 3
Lymph fluid in urine

i e w Filariasis
e 4 o
P r e
Radiographic contrast
v
Squamous epithelial cells
a g
 females
P
 SG by refractometer (>1.040)
media Rgt strip: not affected by RCM
Vaginal cream Tx: Candida
Pseudochyluria
Laboratory Correlations in Urine Turbidity
Acidic urine AU
RCM
Alkaline urine AP
Carbonates
Soluble w/ heat AU
Uric acid
Soluble w/ dilute acetic RBCs
acid AP
Carbonates
Insoluble in dilute acetic WBCs
acid Yeasts
Spermatozoa
Bacteria
Soluble in ether Lipids
Lymph fluid
Chyle

lec.mt 04 |Page | 137

 Specific Gravity
SG Density of solution compared w/ density of similar volume of distilled H2O at a
similar temperature
NV = 1.003-1.035 (random)
SG <1.003 = not a urine except DI
Refractometer (TS meter) Based on refractive index:
RI = _light velocity in air_
light velocity in soln
Compensated to temperature (15-38’C)
Corrections:
a. 1g/dL glucose: (-0.004)
b. 1g/dL protein: (-0.003)
Calibrations:
a. Distilled H2O = 1.000
b. 5% NaCl = 1.022 ± 0.001
c. 9% Sucrose = 1.034 ± 0.001
Urinometer Requires temperature correction
a.  3’C calibration temperature (20’C) = (+0.001)
b.  3’C calibration temperature (20’C) = (-0.001)
Requires correction for glucose and protein (Rf/U)
Rf < U by 0.002 Refractometer reading is lower than the urinometer reading by 0.002
Urinometer calibration K2SO4 solution: 1L H2O + 20.29g K2SO4
o . u k
le.c
SG = 1.015
Isosthenuria
Hyposthenuria SG < 1.010
t e a
SG = 1.010 (Glomerular filtrate)
s
Hypersthenuria SG > 1.010N o
f r o m f 4 3Urine Odor
Aromatic/Odorless
i e wNormal
e 5 o
Ammoniacal
P r e v P a g
Urea ---(Urease)---> NH3
Ex. UTI (Proteus:  urease)
Fruity, sweet DM (Ketones)
Rotten fish/Galunggong Trimethylaminuria
Sweaty feet Isovaleric acidemia
Mousy Phenylketonuria
Cabbage Methionine malabsorption
Caramelized sugar, curry MSUD
Bleach Contamination
Sulfur Cystine disorder

Chemical Examination of Urine

Specific Gravity
Principle (Rgt Strip) pKa dissociation constant
 concentration =  H+
Indicator: Bromthymol blue = () Blue  Green  Yellow ()
Other info. Not affected by glucose, protein and RCM
Harmonic Oscillation Frequency of soundwave entering a solution will change in proportion to the
Densitometry density (SG) of the solution
-Yellow IRIS (Automated): International Remote Imaging System
pH
Normal Random = 4.5-8.0
1st morning = 5.0-6.0
pH 9.0 = Unpreserved urine
lec.mt 04 |Page | 138
 ID: yellow-brown granules of hemosiderin in cells and casts
Sediment Constituents
RBCs NV = 0-2 or 0-3/hpf
Hypertonic: crenated, shrink
Hypotonic: Ghost cells, swell, hemolyzed
Dysmorphic: glomerular membrane damage, w/ projections, fragmented

Sources of error:
-Yeasts
-Oil droplets
-Air bubbles
-CaOx crystals
♫ Remedy: add 2% acetic acid
-RBCs: lysed
-Other cells: intact
WBCs NV = 0-5 or 0-8/hpf
Glitter cells (Hypotonic urine)
-Granules swell
-Brownian movement
>1% eosinophils: significant
- Drug-induced allergic reaction
- Inflammation of renal interstitium
o . u k
le.c
Addis count Quantitative measure of formed elements of urine using hemacytometer

t e a
Specimen: 12 hr urine
s
Preservative: Formalin
NV:
N o 3
f r o m o f 4
a. RBCs: 0-500,000/12 hr urine

v i e w e 1 2
b. WBCs: 0-1,800,000/12 hr urine
c. Hyaline Casts: 0-5000/ hr urine

P r e
Squamous epithelial cells
P a g
Largest cell in the urine sediment
From linings of vagina, female urethra and lower male urethra
♫ Variation: Clue cells:
-EC w/c are studded w/ bacteria (bacterial vaginosis)
-Whiff/Sniff test: vaginal discharge + 10% KOH  Fishy amine-like odor
-Culture: G. vaginalis = HBT medium
Transitional epithelial cells Spherical, polyhedral, or caudate w/ centrally located nucleus
(Urothelial cells) Derived from the linings of the renal pelvis, ureter, urinary bladder, male
urethra (upper portion)
Not clinically significant in small numbers
Renal tubular epithelial Rectangular, polyhedral, cuboidal or columnar w/ an eccentriac nucleus,
cells possibly bilirubin stained or hemosiderin laden
From nephron:
-PCT: rectangular, columnar/convoluted
-DCT: round/oval
>2 RTE/hpf: tubular injury
Oval fat body Lipid containing RTE cells
Lipiduria (Ex. nephrotic syndrome)
Cholesterol: Maltese cross
Bubble cells RTE cells w/ nonlipid containing vacuoles
Acute tubular necrosis
Yeast C. albicans (DM, vaginal moniliasis)
T. vaginalis Flagellate w/ jerky motility

lec.mt 04 |Page | 145

 Hartnup disease: “Blue diaper syndrome”
Obermayer’s test: FeCl3  (+) Violet w/ chloroform
Argentaffinoma Carcinoid tumor involving argentaffin cells
 5-HIAA: metabolite of serotonin
FeCl3  (+) Blue-green (PKU)
Nitrosonaphthol  (+) Violet w/ HNO3
Be sure patient should avoid banana, pineapple, tomatoes (serotonin-rich)
Cystine Disorders
Cystinuria (Renal type) Defect in renal tubular transport of:
-Cystine (least soluble  urine)
-Ornithine
-Lysine
-Arginine
Cystinosis Inborn error of metabolism
Cystine deposits in many areas of the body
Cyanide-nitroprusside  (+) Red-purple
Homocystinuria Defect in the metabolism of homocystine
Silver nitroprusside  (+) Red-purple
Brand’s modification of Rxn: Cyanide-nitroprusside  (+) Red-purple
Legal’s nitroprusside
Mucopolysaccharide Disorders
MPS Dermatan SO4
o . u k
le.c
Keratan SO4

Clinical significance
Heparan SO4
t e s
Alder-Reilly syndromea
N o
Hurler syndrome = MPS  cornea of the eye
3
o m f 4
Hunter syndrome = Sex-linked recessive
f r o
CTAB
v i e w e 8
Sanfilippo syndrome = Mental retardation only
1
(+) White turbidity
P r e P a g Purine Disorders
Lesch-Nyhan disease  Urinary uric acid crystals
Porphyrias
D-ALA Glycine + Succinyl CoA ----(ALA synthetase)----> D-ALA
Porphobilinogen D-ALA ----(ALA synthetase)----> Porphobilinogen
Lead poisoning: inhibits ALA synthase
Uroporphyrinogen Porphobilinogen -----(Uroporphyrinogen synthase/
Uroporphyrinogen cosynthase)----> Uroporphyrinogen
Acute intermittent porphyria: (-) Uroporphyrinogen synthase
Congenital erythropoietic porphyria: (-) Uroporphyrinogen cosynthase
Coproporphyrinogen Uroporphyrinogen ---------(Uroporphyrinogen
decarboxylase)---------------> Coproporphyrinogen
Porphyria cutanea tarda: (-) Uroporphyrinogen decarboxylase
Protoporphyrinogen Coproporphyrinogen ---------(Coproporphyrinogen
oxidase)-------------------> Protoporphyrinogen
Hereditary coproporphyria: (-) Coproporphyrinogen oxidase
Protoporphyrin IX Protoporphyrinogen ---(Protoporphyrinogen oxidase)---> Protoporphyrin IX
Variegate porphyria: (-) Protoporphyrinogen oxidase
Heme Protoporphyrin IX + Fe2+ ----(Ferrocheletase)--------------> Heme
Lead poisoning: inhibits Ferrocheletase
Porphyrias Vampire disease
Disorders of porphyrin metabolism

lec.mt 04 |Page | 151

 Access to procedure manuals
Competency of personnel performing the tests
Microscopic Quantitations
EC (lpf) Crystals (hpf) Bacteria (hpf) Mucous threads
None 0 0 0 -
Rare 0-5 0-2 0-10 0-1
Few 5-20 2-5 10-50 1-3
Moderate 20-100 5-20 50-200 3-10
Many >100 >20 >200 >10
Casts (lpf) None = 0
Numerical ranges = 0-2/2-5/5-10/>10
RBCs (hpf) None = 0
Numerical ranges = 0-2/2-5/5-10/10-25/25-50/50-100/>100
WBCs (hpf) None = 0
Numerical ranges = 0-2/2-5/5-10/10-25/25-50/50-100/>100
Quality Assurance Errors
Preanalytical Patient misidentification
Wrong test ordered
Incorrect urine specimen type collected
Insufficient urine volume
Delayed transport of urine to the laboratory
Incorrect storage or preservation of urine
o . u k
Analytical Sample misidentification

e s a
Erroneous instrument calibration le.c
o t
Reagent deterioration
N
Poor testing technique
r o m f
Instrument malfunction
f 4 3
w 3 o
Interfering substances present
e 2
r e v i g e
Misinterpretation of quality control data
a
Postanalytical
P P
Patient misidentification
Poor handwriting
Transcription error
Poor quality of instrument printer
Failure to send report
Failure to call critical values
Inability to identify interfering substances
TQM Based on a team concept involving personnel at all levels working together to
achieve a final outcome of customer satisfaction through implementation
CQI Improving patient outcomes by providing continual quality care in a constantly
changing health-care environment
PDCA Plan-Do-Check-Act
PDSA Plan-Do-Study-Act

lec.mt 04 |Page | 156

 (+) Pink = HbF
(-) Yellow brown = Maternal Hgb
Diarrhea Acute: <4 weeks
Chronic: >4 weeks
Secretory diarrhea  solute secreted by the intestine
Endotoxins
Osmotic diarrhea  amounts of osmotically active solutes in the lumen (maldigestion)
 CHO in stool
Intestinal hypermotility Secretory and osmotic diarrhea
Laxatives
Emotions/stress
Cardiovascular drugs
Fecal enzymes 1. Trypsin
= X-ray paper
= Trypsin deficiency (CF): inability to digest gelatin on the X-ray paper
2. Chymotrypsin
3. Elastase I = pancreas specificity
Fecal CHO Stool pH = 7.0-8.0
pH 5.5 = CHO disorders (lactose intolerance)
Clinitest: >0.5 g/dL = CHO intolerance
Follow up tests:
a. D-xylose: malabsorption
o . u k
le.c
b. Lactose intolerance test: maldigestion
Fecal Leukocytes Primarily neutrophils
 Neutrophils:
t e s a
-Salmonella
N o 3
o m
-Shigella
f r o f 4
v i e w
-Yersinia
e 0
-Campylobacter
4
P r e P
-EIECa g
(-) Fecal leukocytes:
-Parasites
-Viruses
-S. aureus
-Vibrio spp
Methylene blue For wet preparation
Faster procedure than Wright’s and GS (for dry smears) but may be more
difficult to interpret
Lactoferrin Latex Sensitive in refrigerated and frozen specimens
agglutination test
 amounts of striated Biliary obstruction
fibers Gastrocolic fistulas
Fecal fats NV = 1-6 g/day
Qualitative Fecal fat test Sudan III = most routinely used
Sudan IV
Oil red O
Split fat stain Free fatty acids and fatty acids from hydrolysis of soaps and neutral fats
NV = 100 droplets (<4 μm)
Slightly increased = 100 droplets (1-8 μm)
Increased = 100 droplets (6-75 μm)
Quantitative Fecal fat test Confirmative test for steatorrhea
3 day specimen

lec.mt 04 |Page | 173