Microscopic Urinalysis

Vicki S. Freeman, Ph.D

Clinical Laboratory Methods

General Considerations
The results of the microscopic should
correlate with physical and chemical test
results.
Contamination is common; especially in
voided specimens when no effort is made to
obtain a clean catch specimen.
Results more reliable with concentrated, but
fresh specimen, as cellular elements tend to
lyse in dilute, hypotonic urine or alkaline
urine.

More General Considerations

Urine should be examined within one hour
of collection. If not, specimen should be
refrigerated.
Normal values vary considerably due to
variation in concentration of the specimen
and different methods used to concentrate
the sediment by centrifugation (volume,
speed, etc.)

Sediment Preparation & Procedure

1 Centrifuge 10 ml of well-mixed urine
specimen (1500-2000 rpm) for 5 minutes.
2 Suction or pour off all but 1.0 ml of urine
3 Resuspend sediment and place approximately
.05 ml on a glass slide - add coverslip on top

Sediment Preparation & Procedure

Examine under low power with dimmed
light or with phase contrast microscopy to
estimate urine sediment (casts and crystals).
Report numbers per low power field (LPF).
Examine under high power objective to
estimate #s of RBCs, WBCs, and renal
tubular epithelial cells (RTE); report per
high power field (HPF).

Typical Urine Report

on Normal Male

Specific Gravity 1.020

pH range 4.8 - 7.5
Protein
Negative
Glucose
Negative
Ketones
Negative
Urobilinogen
0.8 EUs
Bilirubin Negative
Occult Blood
Negative
WBC Esterase
Negative
Nitrite
Negative

Color
Straw
Appearance Clear

Microscopic

0-8 WBC/HPF
0-2 RBC/HPF
0-1 Hyaline Cast
Few Bacteria
0-1 RTE/HPF
Few Ca oxalate crystals

Epithelial Cells

Squamous epithelial cells

Transitional epithelial cells
Renal tubular epithelial cells
Oval Fat Bodies
Clue Cells

Squamous Epithelial Cells

30-50 microns
large, flat cells with small nuclei
Appear flat with abundant cytoplasm
Originate from the superficial lining of the
urethra and vagina
Common contaminant; seen in female
voided specimen

Transitional epithelial cells

20 -30 microns
Polyhedral shaped but swell in urine to
spheroidal shape
Have round or pear-shaped contours with
small central nucleus (may be bi-nucleated)
Originate from transitional epithelial lining
of the renal pelvis, ureter, urinary bladder
and proximal urethra
A few are seen in normal urine; large clumps
suggest possible carcinoma.

Renal tubular epithelial cells (RTE)

14 - 60 microns from proximal and distal
convoluted tubules
Single, oblong or egg-shaped cells with
coarsely granular eosinophilic cytoplasm
Nuclei may be multiple but are small with
dense chromatin
Seen in cases of acute tubular necrosis and
drug or heavy metal toxicity

Oval Fat Bodies

Renal tubular cells that have absorbed lipids.
Are highly refractile and produce a
characteristic Maltese cross appearance with
polarized light.
Extremely significant finding. Seen in lipid
nephrosis and terminal kidney disease.

Clue Cells
Squamous epithelial cells covered with
coccobacilli, Gardnerella vaginalis

Blood Cells
Red Blood Cells
White Blood Cells

Red Blood Cells

Normal size 6-8 microns, biconcave discs

Swollen in hypotonic, crenated in hypertonic urine
Empty RBC membranes may be seen from lyzed
cells in alkaline urine

Confusing artifacts
oil droplets, yeast, urates

Red Blood Cells

Normal
Male 1-2 RBC/HPF
Female 3-12 RBC/HPF

Increased RBC seen in

Renal disease such as glomerulonephritis, lupus
nephritis, kidney stones, tumors and trauma
Lower urinary tract disease such acute and
chronic infection, tumors and strictures
Extrarenal disease such as acute appendicitis.

White Blood Cells

10-12 microns, swell to 15 microns in
alkaline or hypotonic urine, nuclei more
distinct in acid urine
Mainly neutrophils and have a granular
cytoplasm and lobed nucleus

White Blood Cells

Normal 0-8 WBC/HPF
Increased in
pyelonephritis, cystitis, urethritis, prostatitis

Glitter cell term used to describe large

WBC seen in hypotonic urine that have
Browian movement of granules in cytoplasm
Clumps of WBCs considered very
significant in indicating an infection

Other Urinary Elements

Bacteria
Yeast
confused with red cells
look for budding,
doubly refractive wall

Trichomonas

confused with white cells

look for undulating
membrane movement

Sperm

Urine Casts

Hyaline Casts
Red Blood Cell Casts
Hemoglobin or Blood Cell Casts
White Blood Cell Casts
Renal tubular epithelial cell casts
Granular casts
Waxy casts
Fatty casts

Urinary Casts
Cylindrical structure which consists of
jelled protein (Tamm-Horsfall mucoprotein)
clumping of the protein or conglutination of material
within the lumen of the renal tubules
Albumin or globulins may be mixed with the mucoprotein

Conditions that increase urine cast formation

Increased concentration of the urine]

Increased acidity of the urine
High protein concentration in the urine
Stasis or obstruction of the nephrons by cells or debris

Hyaline Casts
Formed in the lumen of the distal convoluted
tubules or collecting ducts and serve as the
matrix of all casts
Pale, smooth and usually cylindrical,
homogeneous gel-like forms of low refractive
index. Mainly Tamm-Horsfall mucoprotein
Narrower casts form in the convoluted
tubules while broader casts form in the
collecting ducts.

Red Blood Cell Casts

These casts are always pathologic

Diagnostic of glomerular disease or damage
Classically found in acute glomerulonephritis
RBC outline must be sharply defined in at
least part of the cast

Hemoglobin Cast
An RBC cast in which the red cells have
ruptured and disintegrate
Cast appears reddish-brown due to acid
hematin formation
Diagnostic of glomerular disease or damage
such as acute glomerulonephritis

WBC Cast
Hyaline cast with WBCs embedded in
matrix
Indicate inflammation/infection in kidney
Seen in acute pyelonephritis and other
nephritis conditions

Renal Tubular Epithelial Cast

Hyaline cast with renal tubular epithelial
cells embedded in the hyaline matrix
Form as result of stasis and necrosis of the
tubules
Seen in severe chronic renal disease,
exposure to nephrotoxic agents or viruses
and rejection in kidney transplants

Granular Casts
Results of the degeneration of cellular
components of casts or direct aggregation of
serum proteins into a matrix of TammHorsfall mucoprotein
Usually indicates significant renal disease
Thought to be the result of breakdown of
cellular casts with the progression of
cellular to coarsely to finely granular to
waxy.

Waxy Casts
Smooth, homogeneous, highly refractive
appearance. Typically have blunt, broken
ends and cracked or serrated edges
Seen in patients with severe chronic renal
failure, malignant hypertension, diabetic
nephropathy
May also be seen in acute renal disease and
renal allograft rejection

Fatty Casts
Casts that have incorporated either free fat
droplets or oval fat bodies.
In the fat is cholesterol, the droplets will be
demonstrate a Maltese cross appearance
under polarized light.
Droplets which consist of triglycerides or
neutral fat will not polarize but will stain
with Sudan III or Oil Red O stains for fat.

Crystals seen in Acidic Urine

Calcium oxalate
envelope, dumbbell or ring forms
colorless, do not polarize
Common cause of kidney stones

Uric acid

rhombic plates, rosettes, wedges, needles

polarize to multicolored
found in gout

Amorphous urates
clumps of brownish-yellow granules

Crystals seen in Alkaline Urine

Triple phosphate
Coffin lid crystals
colorless prisms

Ammonium biurate
thorn-apple crystals
yellow-brown, spicule covered spheres

Crystals with Pathogenic

Significance
Cystine

colorless hexagonal plates

do not polarize
associated with inborn errors of metabolism

Cholesterol
rectangular plate with a notched
corner or edge
polarize as multicolored plates
seen in nephritis and nephrosis conditions

Gladys Glomerulus (35 yr old)

Color
Appearance
Specific Gravity
Glucose
Bilirubin
Ketone
Blood
pH
Protein
Urobilinogen
Nitrite
Leukocytes

Pale
Clear
1.035
Neg
Neg
Neg
Neg
5.0
1+
0.2
Neg
Trace

Epi cells
Many
Casts
2-5 Hyaline
RBCs/HPF
0-2
WBCs/HPF
10-25
Crystals 2-5 Triple PO4
Many Amorp Urates
Bacteria Few (10-50)

Tammy Tubule (25 yr old)

Color
Appearance
Specific Gravity
Glucose
Bilirubin
Ketone
Blood
pH
Protein
Urobilinogen
Nitrite
Leukocytes

Yellow
Cloudy
1.003
Neg
Neg
Neg
Neg
8.5
4+
0.2
Neg
Trace

Epi cells
5-20
Casts
None
RBCs/HPF
50-100
WBCs/HPF
0-2
Crystals
Many Amorp Urates
Bacteria
None

Bowman S. Capsule (2 yr old)

Color
Yellow
Appearance Hazy
Specific Gravity 1.011
Glucose
Neg
Bilirubin Neg
Ketone
Neg
Blood
Neg
pH 5.0
Protein
Neg
Urobilinogen
0.2
Nitrite
Pos
Leukocytes Mod

Epi cells Few

Casts
2-5 Hyaline
5-10 Fine gran
>10 Coarse gran
RBCs/HPF
2-5
WBCs/HPF
None
Crystals
Few Amorp Urates
Bacteria None

Ned Nephron (23 yr old)

Color
Appearance
Specific Gravity
Glucose
Bilirubin
Ketone
Blood
pH
Protein
Urobilinogen
Nitrite
Leukocytes

Amber
Clear
1.006
Neg
Neg
Small
Mod
6.0
Neg
1.0
Positive
Mod

Epi cells
>100
Casts
None
RBCs/HPF
None
WBCs/HPF
25-50
Crystals
None
Bacteria Mod (50-200)
Other
Budding yeast

Renal Diseases

Nephrosis
Cystitis
Acute pyelonephritits
Acute glomerulonephritis

Sediment Procedure
Centrifuge 10 ml of well-mixed urine specimen (1500 2000 rpm) for 5 minutes
Pour off all but 1.0 ml of the urine
Resuspend sediment and place approximately 0.05 ml on a
glass slide and add coverslip
Examine under low power with dimmed light to estimate
urine sediment (casts and crystals). Report numbers per
low power field (lpf)
Examine under high power to estimate #s of RBCs, WBCs
and renal tubular epithelial cells; report per high power
field (hpf).