spotlight

Urinalysis: analysing urine and

interpreting the results
Urinalysis is a fundamental component of the holistic and symptom assessment of any individual in
poor health. Urinalysis can disclose evidence of diseases, even some that have not caused significant
signs or symptoms. Susan Foxley explains in this article how urine should best be collected so that test
results can be used to screen, diagnose and manage diseases—including those affecting the kidneys.

n urinalysis n urine characteristics n urine collection n reagent dipstick testing

rinalysis is a relatively straightforward

U procedure, both due to the usually

effortless way in which a urine
specimen can be collected and the
availability of reagent testing strips in health-
care settings. Urinalysis subsequently provides
information not available in any other way nor
obtained as quickly. Changes in the composition of
urine are sometimes the first and only indication
of genuine or imminent renal disease. In addition,
urinalysis is often the only feasible way of making
a diagnosis of a metabolic disorder or of drug
overdose.
In 1797, Dr Carl Gartner identified the need for an
easier way of testing urine to exclude the presence of
disease (Hohenberger and Kimling, 2008). However,
it was not until the 1950s that urine testing strips
were made commercially, becoming widely available
in most health-care settings.
Research undertaken by the North East Valley
Division of General Practice (2006) revealed that
15–30% of men and 25–50% of women in nursing
Box 1. Disorders urinalysis
may help reveal
n Renal disease
n Bilary disease
n Renal stones
n Glomerulonephritis
n Pyelonephritis
n Cystitis
n Urinary tract infection
n Liver disease/failure
n Diabetes mellitus
n Hypertension
n Pre-eclampsia
n Malignancy
n Osteoporosis
* Specific diseases pertinent to renal disease are in bold
Table 1. Reasons for urinalysis
Screening
Diagnosis
For disease, both renal and systemic
Confirms or excludes a suspected
disease process especially in the
renal and urinary tract
Management Monitors the progress of an
established disease either by the
health professional or by the
patient
Source: Getliffe and Dolman (2003)
homes had an abnormal urine test but no urinary
tract infection. The researchers concluded that there
was no role for the urine dipstick test as a screening
test. However, Khallid and Haddad (1999) concluded
from research they undertook with university
candidates that routine urinalysis was desirable for
disease surveillance. On the whole, the reliability of
dipstick urinalysis is recognized for different patient
populations, e.g, those presenting with a possible
new illness and more importantly monitoring those
with chronic health problems. Recently, a new rapid
urine test for the early detection of kidney disease
was reported by Vishal et al (2009). He and his
colleagues developed a highly sensitive and specific
urinary biomarker that helps detect kidney disease or
injury within 15 minutes of testing.
Urine may undergo several changes as an
individual becomes unwell. Routine urinalysis can
therefore be performed for several reasons, falling
into three main groups (Table 1).
Urinalysis will be performed to help diagnose
many specific disorders (Box 1).
Susan Foxley
n Consultant Nurse, Continence Care, Kings College Hospital NHS Foundation Trust,
London UK n Susan.Foxley@kch.nhs.uk

journal of renal nursing vol 2 no 3 May 2010 137

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 spotlight
Usually these tests include urine samples taken
over specific time periods, for example the 24-hour
urine collection. The reliability of urine analysis is
dependent on the quality of the specimen, which is
best collected at the beginning of the day and should
always be fresh. A first-morning specimen provides
valuable information concerning renal function and
genitourinary disease. Investigations such as urine
culture and urinalysis may also help identify causes
of bladder dysfunction (Parsons and Cardozo, 2004).
How the kidneys work
The kidneys are a pair of vital organs that perform
fundamental functions so that the human body can
remain chemically balanced and healthy. Urine is
formed by the kidneys, and is the medium by which
water and solutes in excess of body requirements are
excreted, together with end-products of the body’s
metabolism and foreign substances including drugs.
Drugs and food can influence the colour of urine.
For example, red-coloured urine may be caused by
the patient consuming beetroot or anticoagulant
medication. In women, menstruation can turn urine
red in colour. Orange coloured urine may be due to
the patient taking rifampicin medication, consuming
paprika or rhubarb, or simply being dehydrated.
Noticeably yellow urine may be linked to diseases of
the kidney but may also be caused by consumption
of carrots or the following medication:
n Nitrofurantoin
n Riboflavine
n Senna
n Sulphonamides
n Chloroquine.
Table 2. Physical characteristics of urine
Colour Normally urine should be straw coloured—the colour is due to
urochrome a pigment derived from the destruction of haemoglobin
in the body
Fluid balance, diet, medicines, infections and diseases affect colour
The darkness or lightness of the colour will indicate the water content
Acute mental illness can darken urine colour
Odour Fresh urine usually does not smell strong
Urine left standing for a period of time can have a smell of ammonia
Infected urine may have a ‘fishy’ smell or an offensive smell
Urine from anorexic patients may have a sweet odour
Diabetic ketoacidosis causes a fruity or sweet odour
Clarity Cloudiness and debris may indicate the presence of disease
Vaginal discharge can make the urine cloudy as well as the presence of
mucus
Patients who have undergone bladder surgery may have cloudy urine due
to colonization of bacteria within the bladder
Volume Urine volume is dependent on the person’s physical health and fluid intake
Sources: Jones, 1906; Anon, 1999; Simerville et al, 2005; Zaykoski, 2009
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Walker (1990) suggested that the kidney has certain
management mechanisms to guarantee that, in
health, the composition of urine is appropriate to
maintain the accurate content of water, sodium,
potassium, calcium and phosphate in the body.
Interpretation of urinalysis
‘Urinalysis is relatively simple to do, but do we
know how to interpret the findings?’ Indeed
Wells (2007) advocated that ‘urine should not be
tested indiscriminately, but within the context of
the patient’s illness or as a screening procedure’
Heimann et al (1976) suggested that abnormal
routine urinalysis results are often overlooked by the
attending medical personnel.
Many of the tests undertaken can be influenced
by the collection method of the urine. Reine and
Langston (2005) therefore suggested that it is
essential that the results are interpreted accordingly.
For example, exposure of unpreserved urine at room
temperature for long periods of time may result in
an increase in microorganisms in the urine and a
change in pH. For this reason, Simerville et al (2005)
suggested that a midstream clean collection of urine
is best in most situations. However, if a catheter
specimen is required it should never be taken from
the catheter bag (as urine in it may have been
standing for several hours) but from the coloured
cuff found on the tubing of the catheter bag (Anon,
1999).
To obtain accurate readings, all urine specimens
should be examined within one to two hours
of collection (Heimann et al 1976; Khallid and
Haddad 1999; Devillé et al, 2004; and Steggal,
2007). Higgins (2008) went further by advocating
that urine should be ‘as fresh as possible as ongoing
bacterial multiplication can occur’ and Gould (2010)
recommended ‘a clean-catch specimen of urine’ for
any microscopic tests.
Routine urinalysis falls into three testing groups:
n Physical characteristics (Table 2)
n Biochemical tests (Table 3)
n Microscopic evaluation undertaken in a
laboratory.
Urine specimens examined under a microscope may
determine whether it contains blood cells, crystals or
small pieces of fibrous material known as casts.
Safe urine testing with
reagent dipsticks
Urinalysis is valued as a highly complex, skilled
activity. Testing urine with reagent dipsticks
provides an instant diagnostic test that can influence
immediate interventions. The health professional
undertaking this test needs to respond immediately
when abnormal dipstick test results are revealed,
journal of renal nursing vol 2 no 3 May 2010

explaining possible causes and offering appropriate
interventions after gaining the patient’s consent.
Considering normal results is just as important as
considering abnormal ones in forming a clinical
picture and giving feedback to the patient.
The health professional needs to be able to
demonstrate clinical competence when undertaking
a urinalysis and interpreting the results. Table 4
outlines some of these competencies.
Possible additional implications
for the renal patient
In those patients with renal disorders, signs and
symptoms may be nonspecific, only manifesting
themselves when possible life-threatening problems
exist. Urologists in the US (Ford, 2008) indicated
that global warming may result in an increase in
kidney stone incidence.
Typically changes in urine production may be the
first to appear and in those patients who present
with urinary incontinence, a urine dipstick is
mandatory component in the continence assessment
process. The National Institute for Health and
Clinical Excellence (NICE) (2006) recommended a
urine dipstick test for all women presenting with
urinary incontinence to detect any abnormality.
When problems are detected, further investigations
to evaluate kidney function are recommended. These
include glomerular filtration rate and creatinine
clearance tests. Anderson et al (1984) carried out a
study in three different hospitals, looking at
68 patients presenting with acute renal failure. Urine
tests helped differentiate the cause of renal failure.
Conclusions
Urine testing by reagent dipstick is a fundamental
component of the holistic and symptom assessment
of any individual in poor health.
Urinalysis is a highly complex skilled activity
which needs to be undertaken by a competent
health practitioner. Testing urine with reagent
dipsticks provides an instant diagnostic test that can
influence immediate interventions for the patient’s
ongoing management.
References
Anderson RJ, Gabow PA, Gross PA (1984) Urinary chloride in acute
renal failure. Miner Electrolyte Metab 10: 92–7
Anon (1999) Urine testing. Quick reference guide 8. Nursing Standard
13(50)
Devillé WL, Yzermans JC, van Duijn NP, Bezemer PD, van der Windt
DA, Bouter LM (2004) The urine dipstick test useful to rule out
infections. A meta-analysis of the accuracy. BMC Urol 4:4
Dougherty L, Lister S (2004) The Royal Marsden Hospital Manual of
Clinical Nursing Procedures. Blackwell Publishing, Oxford
Ford S (2008) Global warming will lead to more kidney stones. www.
nursingtimes.net/nursing-practice-clinical-research/global-warming-will-
lead-to-more-kidney-stones/1732609.article (assessed 27 April 2010)
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spotlight
Table 3.Ten biochemical tests of reagent strips
Note: the accuracy of any result on dipstick testing may be questioned (Devillé et al, 2004).
pH A reflection of the acid or base levels in the urine (Kennedy, 2010)
Normal ranges are 5.0–9.0 (Zaykoski, 2009)
Metabolic processes and diet can change pH (Dougherty and Lister, 2004).
Vomiting and bacterial infections can make the pH alkaline
Determination of pH is useful in the management and treatment of
urinary tract infections and renal calculi (Simerville et al, 2005)
Glucose in the urine may reduce the pH value as a result of
metabolism of glucose by organisms present in the urine
Alkaline urine may show false positive results in the presence of protein
The most common cause of high pH readings is stale urine specimens
Specific A measure of the concentration of dissolved substances in the urine
gravity that reflects on the ability of the kidneys to concentrate the urine
Normal values can vary within the range of 1.002–1.035
High values can be seen in those patients with diabetes mellitus and
by those who use multiple medications
Low values are seen in those patients with diabetes insipidus
In renal failure the specific gravity remains equal to that of blood
plasma (1.008–1.010)
Blood Blood can enter the urine from the kidney right down to the external
urethral meatus
Menstruating women will also have blood detected in their urine
Blood in the urine can be associated with diseases of the kidney or
urinary tract and should always be investigated
Blood can be macroscopic and therefore obvious to the naked eye
Microscopic blood in the urine is detectable only by chemical tests
Exercise may cause haematuria (blood in the urine) which normally
resolves quickly (Rainford, 1990)
Causes of haematuria include bleeding disorders, trauma, malignancy,
bladder diverticulum, urethral stricture, renal infarction and infection
Glucose Glucose is normally filtered by the glomerulus in the kidney, then
almost completely reabsorbed in the proximal tubule
Glucose presence in the urine occurs when renal absorption is
compromised
Causes of glycosuria include diabetes mellitus, liver disease and
Cushing’s syndrome
Ketones Presence in the urine may indicate starvation or excessive dieting
Found in diabetic patients whose diabetes is poorly controlled
(Wells, 2007)
Found in patients on carbohydrate-free diets (Simerville et al, 2005)
Bilirubin Found typically in patients with obstructive jaundice (Lloyd, 1993)
Urobilinogen May indicate blood disorders, e.g sickle cell anaemia or thalassaemia
Causes include hepatic irregularity and red cell breakdown
Protein A trace in the urine can be caused by contamination of the sample
Its presence can determine whether there is a problem with the urinary
tract, indicating advanced kidney problems where albumin is detected
Causes may include hypertension, pre-eclampsia, glomerulonephritis,
infection and diabetes
Nitrites May indicate bacteria present in significant numbers
Devillé et al (2004) suggested that the sensitivity of the urine dipstick for
nitrites was low, the highest accuracy was found in pregnant women,
urology patients and the older adult
Leukocytes A positive result can indicate the presence of white cells in the urine
possibly indicating infection
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Table 4. Competencies needed for urinalysis
Be aware that patients may have different cultural attitudes to the handling and
collection of body fluids
Maintain the patient’s privacy and dignity at all times
Give the patient full written and verbal instructions and obtain consent before sample
is taken
Obtain, check suitability of and store urine dipsticks correctly according to
manufacturer’s instructions
Use dipsticks according to manufacturer’s instructions, check expiry date
Obtain dipstick, test, interpret, document, act on, and dispose of the urine specimen
appropriately
Be aware of any ‘false readings’ on dipstick reading
Minimize handling and prevent cross-infection when handling urine
Have clear protocols and onward referral pathways for abnormal results
Identify clear rationale for repeat urine testing
Implement safe pathways of care for those patients who self-monitor their urine either
for diabetes or urinary tract infections
Test urine as part of any continence assessment
Key points
n Urinalysis—tests performed on urine—helps to screen, diagnose and manage a
number of different diseases
n Changes in the urine may be the first and only indication of imminent renal disease.
n The quality of the urine collected may impact on the reliability of the urinalysis
n There are different methods and time intervals for collecting urine
n Physical characteristics—colour, odour, clarity and smell—give clues to evidence of
disease
n Biochemical tests with reagent dipsticks reveal the presence of pH, specific gravity,
blood, glucose, ketones, bilirubin, urobilinogen, protein, nitrite and leukocytes
n Urinalysis is a complex and skilled activity which requires clinical competence
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