Overview in Body Fluids

By: ROSE
+970568936993
 Urinalysis Sample Collection & Physical Examination

 Osmolarity: Concentration of particle per liter of solution.

 Osmolality: Concentration of particle per kilogram of solution.

**Urine specific gravity measures the kidneys’ ability to excrete or conserve water
 Composition of Urine

 It is a very complex fluid, composed of 95% water and 5% solids.

 an average urinary out put of 1-1.5 L per day.
 Urine consists of thousands of dissolved substances although the three principle constituents are
water, urea, chloride and sodium.
 Only substances that can be dissolved in water are present in the urine.
 The major constituent of urine is the urea, a protein waste product produced in liver as a result
of protein metabolism and breakdown.

z 
 1st : Specimen Collection

Sample containers:
 Capacity of the container is 50 mL, which allows 12 mL of specimen needed for
microscopic analysis, additional specimen for repeat analysis. and enough room for
the specimen to be mixed by swirling the container.
 The specimen must be delivered to the lab within 1 hr

 If you expect the specimen to stay for a long time, it should be :

Refrigerated or have an appropriate chemical preservative added.
eg. (Toluene, thymol, formalin or boric acid).

 The most routinely used method of preservation is refrigeration at 2C to 8C, which

decreases bacterial growth and metabolism.
 Changes in unpreserved urine:
 Transformation of urea to ammonia which increase pH.

 Decrease glucose due to glycolysis and bacterial utilization.

 Decrease ketones because of volatilization.
 Decrease bilirubin from exposure to light.
 Decrease urobilinogen as it oxidized to urobilin.
 Increase bacterial number.
 Increase turbidity caused by bacteria & amorphous.
 Increase nitrite due to bacterial reduction of nitrate.
 Disintegration of RBCs casts, particularly in diluted alkaline urine.
 Changes in color due to oxidation or reduction of metabolic.
 TYPES OF SPECIMEN
 Random specimen (at any time).
 First morning specimen
 24 hr’s collection***kidney function**.
 2 hour Post. Prandial** It taken at specified time after specific meal to know the normal
excretion
 Clean catch sample (midstream urine) **bacteriological work

 Catheterized urineCollected form pediatric or adult that can’t give urine.

 Supra – pubic needle aspiration For bacteriological samples and taken from pediatric
mainly
Routine Urinalysis
1. Acceptability of urine specimen
2. Physical examination
3. Chemical examination
4. Microscopic examination
 Acceptability of urine specimen

 Proper specimen labeling: reject improperly labeled specimens.

 Properly filled request form: reject improperly filled request.
 If there is any sign of contamination: reject and request new specimen.
 If there is any delay in transporting: reject and request new specimen.
 Types of Analysis

 Macroscopic Examination (Physical)

 Chemical Analysis (Urine Dipstick)

 Microscopic Examination

 Culture (not covered)

 Cytological Examination (not covered)

 Macroscopic Examination

1. Color

2. Clarity

3. Odor

4. Volume

5. Specific gravity

6. PH
 Color
 Urine gets its yellow color from a pigment called urochrome, trace of
urobilin and uroerythrin.

The color is affected By :

 Concentration of urine, pH, Metabolic activity, Diet intake and Some
Drugs (Rifampicine)
 Abnormalities in color
 1. Colorless or pale yellow
 High fluid intake
 Using of diuretic.
 Diabetes Mellitus.
 Diabetes Insipidus (Low level of antidiuretic hormone).
 2. Dark yellow, Amber, orange
 Low fluid intake.
 Excessive sweating
 Carrots or vitamin (A)
 Dehydration (burns, fever).
 Pyridium and nitrofurantoin (drugs).
3. Brownish yellow
 Bilirubin :on shaking yellow foam will appear.
 Urobilin: on shaking the foam has no color.

4. Yellow – green
 Biliverdin (greenish) just in abnormal cases when there is liver cirrhosis

5. Blue – Green
 Pseudomonas Infection
5. Pink – Red
 Due to the presence of fresh blood or Hb.
 Calculi
 Urinary tract infection
 Menstrual contamination.
6. Dark brown
 Methemoglobin if bloody sample long standed, Hb will be oxidized.
7. Black Urine
 Alkaptonurea, a disease of tyrosine metabolism.
 Clarity (Transparency)
 Normal urine clear or transparent, any turbidity will indicate.
 WBCs (pus) RBCs
 Epithelial cells Bacteria
 Yeast Casts
 Crystals Lymph
 Semen Lipids
 Odor

 Fresh normal urine has a faint aromatic odor due to the

presence of some volatile acids.

 Fruity odor is due to..................Diabetic urine acetone.

 Ammonia odor .........................urine standing long time
 Volume

Adult urine volume = 600 – 2500 ml /24hr.

Children urine volume = 200 – 400ml /24hr. (4ml / kg / hr).
Volume of urine depends on
1. Water intake
2. External temperature.
3. Mental and physical state.
4. Intake of fluid and diuretics (Drugs, alcohol – tea).
 Abnormalities in volume

 Oligouria: Marked decrease in urine flow < 400 ml.

 Polyuria : Marked increase in urine flow > 2500 ml.
 Anuria: complete stoppage of urine flow.
 Nocturia: excessive urination during night.
Specific Gravity (spg)

 Specific gravity measures urine density, or the ability of the kidney to concentrate or
dilute the urine over that of plasma.

 It is directly proportional to urine osmolality which measures solute concentration.

 It’s a measure of number and size of molecules.

Specific gravity between 1.002 and 1.035 on a random sample should be considered normal if
kidney function is normal.
 Notes:
❑ Dark yellow urine is usually associated with high specific gravity.
❑ Pale/light urine is usually associated with low specific gravity.

Low specific gravity 

 Diabetes Insipidus
 Glomerulonephritis

 High specific gravity

 Diabetes mellitus.
 Nephrosis
Measurement of spg

 1.Urinometer
 2. Refractometer

3. Reagent strip:

Which contain polyelectrolyte, when ions increase in urine, more
acidic groups are released, the change in pH will take place
which change the color of bromothymol blue indicator.
The indicator changes from blue (1.000 [alkaline]), through
shades of green, to yellow (1.030 [acid]).
 PH
 In cases of alkalosis, urinary pH will be alkaline by stop H+
excretion. A healthy individual usually produces a first morning
specimen with a slightly acidic pH of 5.0 to 6.0

 Normal random urine pH is (4.5 – 8.0).

 Even in abnormal conditions, urine pH mustn’t reach 9, if so or more

this will indicate that urine is stand for along time & must be rejected.
Precipitation of crystals to from stone requires specific pH for each type. Hence,
pH control may inhibit the formation of these stones by control diet.
 High protein will give acidic urine.
 High vegetable will give alkaline urine
 some drugs can control pH.
 Crystals found in alkaline urine: Ca carbonate, Ca phosphate, Mg phosphate,
and amorphous phosphate.
 Crystals found in acidic urine: Ca oxalate, Uric acid, Cystine, Xanthine and
amorphous urate.
 Test for PH
 Reagent strip which has two indicators (methyl red) – bromothymol blue indicator) or
other indicators.

 Methyl red produces a color change from red to yellow in the pH range 4 to 6.
 Bromthymol blue turns from yellow to blue in the range of 6 to 9.

Alkaline urine is found in:

Patient with alkalemia, UTI, diets high with citrus fruits or vegetables.
Acidic urine is found in:
Patient with acidemia, starvation, dehydration, high diets with meat products
 Glucose
 Under normal conditions, almost all of glucose filtered by glomerulus is reabsorbed in
the proximal convoluted tubule, by an active process to maintain the plasma
concentration of glucose.

 If the blood glucose concentration is increased, reabsorption of glucose ceases &

glucose appears in urine.

 Glycosuria (excess sugar in urine) generally means diabetes mellitus

 The threshold of glucose is 160 to 180 mg / dl.

1. Diagnosis and control of diabetes mellitus.
2. Normal blood glucose level with glucosuria is usually associated with renal tubular
dysfunction

Principle of Glucose test

1.Enzymatic method

a.glucose oxidase

Method used on urine dipstick

 Principle of Glucose test

2. Reference method

b.Hexokinase

3.clinetest tablet
. For glucose and other reducing sugar.
. principle pendicet's copper reduction
test.
 Ketones
 Ketones are products of incomplete fat metabolism and their presence is
indicative of acidosis.

 Ketonuria: the presence of measurable amount of ketones in urine.

 Ketonemia: the presence of measurable amount of ketones in blood.
 Ketonuria occur in:
 Diabetes acidosis
 Starvation, vomiting
 Excessive Carbohydrate loss
 Weight reduction programs
 Ketone test is used to manage and monitor diabetics.
 Test principle

Negative

Trace (5 mg/dL)

+ (15 mg/dL)

++ (40 mg/dL)

+++ (80 mg/dL)

++++ (160+ mg/dL)

.Confirmatory test: Acetest

 Protein
 Urinary protein determination is still the most common indicative of renal diseases/failure.

 A small amount of protein (100 mg / 24 hrs) appears daily in the normal urine, or less than 10
mg/dl in any single specimen which not appear in routine urinalysis procedure.

 ≥ 30 mg/dL or (300 mg/day) is defined as Clinical Proteinuria

 Albumin 40%
Clinical significance of urinary protein

 Glomerular renal diseases.

 Tubular renal diseases.
Postural proteinuria (Orthostatic proteinuria).
 Pre-eclampsia.
 Multiple myeloma.
 All positive protein reagent strip specimens should be confirmed with
confirmatory protein tests.

Sulfosalicylic acid test is a more sensitive precipitation test as it can detect

albumin, globulins, and Bence-Jones protein at low concentrations.

3% Sulfosalicylic acid:(semiquantitave)
Combined use of dipstick and sulfosalicylic
acid

Sulfosalicylic Dipstick interpretation

+ve +ve Proteinuria

no pathologic concentration of protein

Negative +ve
Bence Jones protein or one of the heavy chain
+ve Negative proteins

Bence Jones protein appears in urine of multiple myeloma patients.

 Blood, Hemoglobin & Myoglobin
 Normally, there is no blood or Hb in normal urine.
 The finding of abnormal number of intact red blood cells in urine is known hematuria.
(relatively common), cloudy red urine.
 Hemoglobinuria: means the presence of Hb pigment in urine (un common), clear red urine.
 Myoglobinouria : means the presence of myoglobin pigment in urine (rare).
 The finding of a positive reagent strip test result for blood indicates the presence of red blood
cells, hemoglobin, or myoglobin.
If hematuria, cast and proteinuria are present then the origin of problem is kidney.

Causes ofHaematuria

Bleeding
Lower Urinary disorders&amp;am
Kidneyproblems p;amp;amp;amp;a
tract problem
mp;amp;blood
disease

Renal disease Infection Leukemia

Renal calculi Tumor Hemophilia
Renal tumor Calculi Thrombocytopenia
Trauma Sickle cell trait
Trauma
toxins that damage Catheterization
the glomeruli
 Bilirubin
 Bilirubin derived from Hb, is conjugated in the liver and excreted in the bile.

Presence of bilirubin in urine is bilirubinuria.

This indicates hepatic or post-hepatic defects (liver disease) includes:
1. Hepatitis
2. Cirrhosis
3. Biliary obstruction (gallstones, carcinoma)
Principle of Bilirubin test
1. Reagent strip reaction

2.Confirmatory tets:
 Urobilinogen
 Bilirubin in intestine is converted to urobilinogen and stercobilinogen.

 A small amount of urobilinogen—less than 1 mg/dL or Ehrlich unit—is normally found in

the urine.

 Increased urine urobilinogen (greater than 1 mg/dL) is seen in liver disease and hemolytic
disorders.
p-dimethyl aminobenzaldehyde (Ehrlich’s reagent) 
 Nitrite
Clinical significance
 A positive nitrite test indicates that bacteria may be present in significant numbers in urine.
Gram negative rods such as E. coli are more likely to give a positive test.

Test principle Greiss Reactions: 

 Leukocyte Esterase
 A positive leukocyte esterase test results from the presence of WBCs either as whole cells
or as lysed cells.
 Detects the presence of esterase in the granulocytes and monocytes.
 Pyuria can be detected even if the urine sample contains damaged or lysed WBC's.
 Microscopic exam and/or urine culture needed to rule out significant bacteriuria.
 1. Red Blood Cells 0-5/HPF
 2. White Blood Cells: (< 4 /HPF )
 3. Epithelial Cells
 4.Casts (They form via precipitation of Tamm-Horsfall mucoprotein which is secreted
by renal tubule cells.)
 casts
Hyaline cast: (0-2) / LPF
 The most frequently seen casts is the hyaline type, which consist almost
entirely of Tamm–Horsfall protein and may appear as a result of
strenuous exercise, fever, dehydration and stress and

Red blood cell cast:

• Acute glomerulonephritis.

White Blood Cells Cast:

The presence of WBC’s indicates the presence of infection or inflammation within the
nephron(pyuria)
&Pylonephritis
Granular Casts
▪ Disintegration of cellular cast

Broad Casts:
▪ All casts forms can occur in the broad from which is formed in the collecting ducts &
called renal failure casts

Fatty Casts:
▪ Casts contain fat droplets (bodies), refractive formed of oval fat bodies & integrated fats
attached to casts matrix to for Fatty casts in lipiduria as (nephrotic)

Waxy cast

.From degeneration of granular casts

.Disease association: Chronic renal failure
 Bacteria
 Bacteria are common in urine specimens because of the abundant normal microbial
flora of the vagina or external urethral.

 A colony count may also be done to see if significant numbers of bacteria are present.
Generally, more than 100,000/ml of one organism reflects significant bacteriuria.

Yeast
 Yeast cells may be contaminants or represent a true yeast infection. They are
often difficult to distinguish from red cells and amorphous crystals but are
distinguished by their tendency to bud.

 Most often they are Candida, which may colonize bladder, urethra, or vagina
 Miscellaneous

▪ Spermatozoa can sometimes be seen rarely.

▪ Trichomonas vaginalis (Contaminated from vaginal secretion), pinworm
ova may contaminate the urine.
▪ In Egypt, ova from bladder infestations with schistosomiasis may be seen
 Crystal
▪ Crystal are frequently found in urine, although they are seldom of clinical significance,
▪ Crystals are formed by the precipitation of urine salts subjected to changes in pH,
temperature or concentration, which affect their solubility.
▪ The most valuable aid in crystal identification is knowledge of urine pH, because this will
type the chemicals precipitated hence crystal are categorized as well as crystals in acidic
or alkaline urine.
1. Uric acid
2. Amorphous Urate yellow brown granules if present in large amount may give urine pink
color.

3. Calcium oxalate color less octahedral resembles envelopes.

▪ They are associated with high oxalic acid and with chemical toxicity and are seen in
genetically susceptible person following large doses of ascorbic acid.
 alkaline urine
▪ Phosphates are the most common crystals found in alkaline urine.

1. Triple phosphate
2. 2. Amorphous phosphate (granules). If present in large amounts the produce white turbidity
in urine.
3. Calcium phosphate:
When found in neutral urine they may be confused with abnormal sulfonamide crystal,
however calcium phosphate crystals are soluble in dilute acetic acid and sulfonamide are not.
▪ 4.Ammonium biurate
▪ 5.Calcium Carbonate
 Difference between amorphous urate & phosphate
The distinction between amorphous urates and amorphous phosphates is often made on the
urinary pH basis but the following can help in differentiation:

Examination of the centrifuge pellet

 The precipitate of phosphate is white
 The precipitate of amorphous urate is pink (known as brick dust).
Precipitation
 Amorphous urates are precipitated by cooling (refrigeration)
 Amorphous phosphate are precipitated by heating.
Solubility
 Amorphous phosphate is soluble in acetic acid
 Amorphous urates are insoluble in acetic acid (by acidification it converts to uric acid
 Semen analysis
 A semen analysis measures the amount of semen a man produces and determines the
number and quality of sperm in the semen sample.

 Clearly, a semen analysis should not be performed immediately following sample

production. The sample should be mixed well in the original container by swirling for
several seconds prior to removing the lid. Do not invert the container.

 Masturbation (the method of choice for all seminal fluid tests).

 The sample should be clearly labeled

 TIMING OF ANALYSIS
 Semen is placed in a 37° C gently shaking incubator for 30 minutes.
 The semen sample should be examined, Ideally within 30 mins
 Absolutely within 1 hour of collection.
 Motility decreases significantly after 2 hours

 Hypospermia - small semen volume

 Aspermia - complete lack of semen

 Examination of seminal fluid
✓ Appearance(white gray-yellow opalescent fluid)
✓ Odor(musty odor)
✓ Liquefaction (gradually liquefies 10-20 min)
✓ Volume ((2-5 milliliters).
✓ viscosity
✓ pH (slightly alkaline (7.2- 8.0) but increases with time)
✓ sperm die at pH < 6.9.
✓ sperm count (concentration)
✓ motility
✓ morphology.
 sperm concentration and sperm count:

 Several terms are used to describe both sperm concentration and sperm count:
 Azoospermia describe a total absence of spermatozoa in semen. (After centrifuge sperm count
is zero/HPF).
 Oligozoospermia refers to a reduced number of spermatozoa in semen and is usually used to
describe a sperm concentration of less than 20 million/ml. Sperm count 5-10 sperm/HPF.
 Severe oligospermia, sperm count 1-2 sperm/HPF.
 Polyzoospermia denotes an increased number of spermatozoa in semen and is usually refers
to a sperm concentration in excess of 350 million/ml.
Semen biochemistry

 Acid phosphatase: marker for prostatic function

 Citric acid: can indicate prostatic function – low levels may

indicate dysfunction or a prostatic duct obstruction

 Zinc: marker for prostatic function – colorimetric assay (WHO)

 Fructose: marker for seminal vesicle function, and is a substrate

for sperm metabolism – spectrophotometric assay (WHO)
 Serous fluids

 Serous fluids are fluids within the closed cavities of the body.
 The cavities are the:
 Pleural (around the lungs),
 Pericardial (around the heart), and
 Peritoneal (around the abdominal and pelvic organs).
 Synovial fluid, often referred to as “joint fluid,” is a viscous liquid found in the
cavities of the movable joints

 The amniotic fluid, commonly called a pregnant woman's water , is the protective
liquid contained by the amniotic sac of a pregnant female. Amniotic fluid is present
in the amnion, a membranous sac that surrounds the fetus.
 Cerebrospinal fluid (CSF) is a major fluid of the body.

 CSF is a clear, colorless liquid fills the cavities of the brain and
the spinal cord, surrounding them and acts as a lubricant and a
mechanical barrier against shock.

 Part of extracellular fluid (ECF).

 CSF Properties
 Has a slightly alkaline chemical composition, similar to blood.
 It contains no RBCs, and low amounts of protein and lipids in comparison to blood, it is about
99 % water.
 Specific Gravity: 1.005
 Volume:
 There are about 100 to 150 ml of CSF in the normal adult body.
 10 to 60 ml in neonates.
Tube of Collection
 Sample Storage

 Ideally, tests are performed on a STAT basis. If it is not possible:

 CSF specimens for chemical and serological tests should be frozen,
 Hematology tubes are refrigerated, and
 Microbiology tubes remain at room temperature.
 Total volume
◌ Adult = 100-150 ml / Neonates = 10 -60 ml.
 Appearance
Normal CSF is crystal clear and the consistency of water.

❑ Specific gravity: 1.005 – 1.008

pH : Alkaline
.
 Clarity
➢ Normal CSF is crystal clear and the consistency of water.
➢ Cloudy, turbid or milk
1. WBCs (over 200 cells/µl)
2. RBCs (over 400 cells/µl)
3. Microorganisms (bacteria, fungi, amebas)
4. aspiration of epidural fat during lumber puncture
 CSF Color
 Color:
 Clear and colorless as Distilled water
 Normal
 Encephalitis and Meningitis associated with viral infections.
 Bright Red
 Puncture of blood vessels
 Old hemorrhage (yellow supernatant)

 Yellow

 Xanthochromic : bilirubin from disintergration of RBC in subarchnoid space from

old hemorrhage
 Excess bilirubin in plasma.
Xanthochromic
Is a term used to describe CSF supernatant that is pink, orange or yellow
1. Oxyhemoglobin:
2. Bilirubin
3. CSF protein levels
4. Contamination of CSF
5. Melanin
 Biochemical Tests
▪ CSF is formed by filtration of the plasma, so the same chemicals in the plasma as are
found in the CSF.
▪ However, normal values of CSF chemicals aren’t the same as the plasma values (Selective
Filtration)
 Proteins determination

◌ The most frequently performed chemical test on CSF.

◌ Normal CSF contains a very small amount of protein.
◌ Normal CSF protein conc. (mg/dl) is less than 1% of serum protein concentration (g/dl) and
usually listed as 15 to 45 mg/dl with slightly higher values found in infants and elderly
people.
◌ In normal situations, albumin is the only protein fraction found.
  Glucose Determination

◌ Glucose enters the CSF by active transport across the blood-brain barrier.
◌ CSF glucose conc. is slightly lower than that plasma and usually between 60–70 % of
plasma glucose concentration. (2/3),
◌ Normal CSF Glucose: 50-80 mg/dl
 Clinical significance

❑ Low CSF glucose values can be of considerable diagnostic value in determining the
causative agents in meningitis.
❑ Decreased CSF glucose accompanied by:
❑ An increased WBC's count and a large percentage of Neutrophil is most indicative of
bacterial meningitis.
❑ WBC's count and a large percentage of Lymphocytes is most indicative of tubercular
meningitis.

Note:
❑ If a normal CSF glucose value is found with an increased number of lymphocytes, the
diagnosis would favor viral meningitis.
Differential Diagnosis of Meningitis by
Laboratory Results
Bacterial Viral Tubercular Fungal
Increased WBC count Increased WBC count Increased WBC count Increased WBC count

Neutrophils Lymphs Lymps & Monos Lymphs & Monos

Marked ↑ protein Mod. ↑ protein Mod-Marked ↑ protein Mod-Marked ↑ protein

Marked ↓ glucose ↔ normal glucose ↓ glucose Normal to ↓ glucose

Lactate > 35 mg/dL Lactate normal Lactate >25 mg/dL Lactate > 25 mg/dL

+ gram stains Pellicle formation + India ink with

Cryptococcus
neoformans

+ bacterial antigen tests + immunological test for

C. neo.