Urine

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Yazan Daaboul, M.D. Synonyms and keywords: Urinary findings; Urinary abnormalities; Findings on urine exam; Urine; Urine composition; Urine output

Overview

Urine is a fluid produced by humans through the kidney, collected in the bladder, and excreted through the genital urethra. Urine formation helps to maintain the balance of minerals and other substances in the body. Urinary findings may be qualitative or quantitative. Qualitative urinary findings are often analyzed on urinalysis and urine culture. Quantitative urinary findings depends on urine output.

Composition of Urine

Urea structure

The following is a list of normal urine constituents:

• Non-organic substances: bicarbonate, chloride, phosphorus, sulphur, bromide, fluoride, iodide, rhodanide, potassium, natron, calcium, magnesium, iron, copper, zinc, cobalt, selenium, arsenium, lead, and mercury.
• Nitrogenous substances: nitrogen, urea, creatine, creatinine, guanidine, choline, carnitine, piperidine, spermidine, dopamine, epinephrine, norepinephrine, serotonin, tryptamine, levulinique amino-acid, and bilirubin
• Non-nitrogenous organic acids
• Amino acids: alanine, carnosine, glycine, histidine, leucine, lysine, methionine, phenylalanine, serine, tyrosine, valine, hydroxyloproline, galactosylhydroxylyzine, xylosylserine, and others.
• Proteins: albumin, haptoglobin, transferrin, immunoglobulins IgG, IgA, IgM, and others.
• Enzymes: lactadehydrogenase, gamma-glutamyl transferase, alpha amylase, uropepsinogene, lysozyme, beta-N-acetylglucosaminidase, urokinase, protease, and others.
• Carbohydrates: arabinose, xyloseribose, fucose, rhammose, ketopentose, glucose, galactose, mannose, fructose, lactose, sucrose, fucosylglucose, raffinose, and others.
• Vitamins: thiamine (vitamin B1), riboflavin (vitamin B2), vitamin B6, 4-pyridoxique acid, nicotinic acid, vitamin B12, biopterine, ascorbic acid (vitamin C) and others.
• Hormones: gonadotropin, corticotropin, prolactin, lactogeniques hormones, oxytocin, vasopressin, thyroxine, catecholamines (epinephrine, norepinephrine, dopamine), insulin, erythropoietin, corticosteroids (aldosterone, corticosterone, cortisone), testosterone, progesterone, estrogen and others.
• Agglutinins and precipitines: neutralizing action on the polio virus and other viruses.
• Antineoplaston: selectively prevents the development of cancer cells without affecting healthy cells that
• Allantoin: nitrogen crystalline substance that promotes healing, from the oxidation of uric acid. It is used in the manufacture of many skin creams.
• DHEA (dehydroepiandrosterone): steroid secreted by the adrenal glands, present in large quantities in male urine. It prevents obesity, prolongs the life of animals and is a possible treatment against anemia, diabetes and breast cancer. DHEA stimulates the development of the bone marrow and increases its production of red blood cells, monocytes, macrophages and lymphocytes. A low level of DHEA seems to be associated with aging.
• Gastric antisecretory products: prevent the onset and development of stomach ulcers.
• Glucoronic acid: produced by the liver, kidneys and intestines, it has a major secretory function.
• H-11: inhibits the growth of cancer cells and reduces the existing tumors without disrupting the recovery process.
• H.U.D. HUD (Human’s urine derivative): demonstrates remarkable anticancer properties.
• Interleukin-1: a positive influence on the auxiliary and inhibitory substances. Can send a signal to the hypothalamus to trigger fever.
• Trimethyl-glyoxal: destroys cancer cells.
• Prostaglandine: a hormonal substance that dilates the blood vessels, lowers tension, relaxes the muscle walls of the bronchi, stimulates contractions during labor, and many metabolic functions.
• Proteoglobulines: plasma proteins containing anti-bodies against certain allergens, they are identical to the proteins of immoglobulines blood serum.
• Prosteoses: immunological products assets allergic reactions.

Alogithm of Common Urinary Findings

Urinary Findings

Quality (Composition)

Quantity (Volume)

Urinalysis

Urine culture

Urine output

High urine output

Low urine output

Urine odor

Urine color and turbidity

Specific gravity/osmolality

Urinary pH

Hematuria

Pyuria

Proteinuria

Cells

Casts and Crystals

Other

Polyuria

Oliguria

Anuria

Urine Odor

Urine is usually odorless but can produce pungent smells following the consumption of certain foods (e.g. asparagus)

Urine Color and Turbidity

Color

Below is a list of common urine discolorations and their associated diseases.

• Clear or light yellow
  • Normal urine color (caused by the pigment urochrome and degradation of bilirubin and urobilin products)
• Dark yellow
  • Dehydration
• Greenish yellow color
  • Vitamin B ingestion
• Orange color
  • Excess urinary losses of vitamin B
  • Medication-induced: rifampin and pyridium
• Dark red color
  • Hematuria
  • Myoglobinuria
  • Ingestion of certain foods: berries, colored candy, and beets
• Brown color
  • Hematuria
  • Myoglobinuria
  • Porphyria
  • Hyperbilirubinemia
• Black (melanuria)
  • Sarcoma
  • Alkaptonuria

Turbidity

• Normal urine is usually clear
• Turbid urine may be a manifestation of urinary bacterial infection, hematuria, proteinuria, pyuria, or presence of crystals and casts.

Urine Specific Gravity and Osmolality

Urine Specific Gravity

• Normal urine specific gravity (density) ranges between 1.003 and 1.035 g.cm^-3.
• Specific gravity outside the normal range may sometimes be associated with urinary disorders.

Urine Osmolality

• In healthy individuals with restricted fluid intake, urine osmolality should be > than 800mOsm/kg.
• 24-hour urine osmolality normally ranges between 500 and 800 mOsm/kg.
• Random urine osmolality normally ranges between 50 and 1400 mOsm/kg.

Increased urine osmolality

• Acidosis
• Addison's Disease
• Congestive Heart Failure
• Hepatic cirrhosis
• Hypernatremia
• Shock
• Syndrome of Inappropriate Anti Diuretic Hormone (SIADH)

Decreased urine osmolality

• Aldosteronism
• Amyloidosis
• Chronic Interstitial Nephritis
• Chronic pyelonephritis
• Diabetes Insipidus
• Primary polydypsia
• Glomerulonephritis
• Hypercalcemia
• Hypokalemia
• Lithium nephrotoxicity
• Nephrogenic diabetes insipidus
• Polycystic kidneys
• Renal Tubular Necrosis

Urinary pH

• The pH of urine is normally close to neutral pH=6-7 (Range: 4.5 to 8.2).
• Strongly acidic or alkaline urine may be manifestations of the following:

Renal and urologic diseases

• Urinary tract infection
• Acute kidney injury
• Chronic kindey disease
• Renal tubular acidosis

Systemic diseases

• Diabetes Mellitus
• Diarrhea
• Vomiting
• Fanconi's Syndrome
• Increased protein catabolism
• Lupus erythematosus
• Metabolic/respiratory alkalosis or acidosis
• Protein rich diet

Drug administration

• Acetazolamide
• Aldosteronism
• Amyloidosis
• Antibiotics
• Sodium acetate
• Sodium bicarbonate
• Sodium lactate

Hematuria

• Microscopic hematuria
• Gross hematuria

Pyuria

• Microscopic pyuria
• Gross pyuria

Proteinuria

• Albuminuria
  • Microalbuminuria
  • Macroalbuminuria
• Paraproteinuria

Cells

• Benign
• Malignant

Casts and Crystals

Casts

Acellular casts

• Hyaline casts
• Granular casts
• Waxy casts
• Fatty casts
• Pigment casts
• Crystal casts

Cellular casts

• RBC casts
• WBC casts
• Bacterial casts
• Epithelial cell casts

Crystals

• Struvite crystals (magnesium-ammonium-phosphate)
• Bilirubin crystals
• Calcium carbonate crystals
• Amorphous crystals
• Calcium oxalate dihydrate crystals
• Cystine crystals

Other

Dissolved electrolytes or heavy metals

Calciuria (urinary calcium) differential diagnosis:

• Bone metastases
• Diets low in calcium
• Hypervitaminosis
• Idiopathic hypercalciuria
• Increased calcium intake
• Multiple Myeloma
• Paget's Disease
• Primary hyperparathyroidism
• Prolonged immobilization
• Pseudoparahypothyroidism
• Renal Tubular Acidosis
• Renal osteodystrophy
• Sarcoidosis
• Steroids
• Vitamin D deficiency
• Vitamin D resistant ricketts

Catecholamines

Parameter	Upper reference range in the urine per 24 hours
Norepinephrine	23-105 micrograms/24 hours
Dopamine	190-450 micrograms/24 hours
Metanephrine	74-297 micrograms/24 hours
Normetanephrine	105-354 micrograms/24 hours
Vanillic acid	3.3-6.5 mg/24 hours
Vanillyl mandelic acid	17-33 micromol/liter (3.3-6.5 mg/24 hour)

Differential Diagnosis of urinary catecholamines

• Medication-induced
• Ganglioma
• Multiple endocrine neoplasia type 2
• Neuroblastoma
• Pheochromocytoma
• Stress

Urine Culture

Normal urine is sterile. Presence of microorganisms in urine may be associated with urinary infections.

• Fungi
• Bacteria

Urine Quantity (Volume)

• The amount of urine produced depends on hydration (volume of fluid intake), physical activity, environmental factors, body surface area, and general health condition.
• In adult humans, the average urine production is approximately 1 L to 2 L per 24 hours.

High Output

• Polyuria: Excessive urinary production > 2.5 L per 24 hours

Low Output

• Oliguria: Urine production < 400 mL / 24 hours
• Anuria: Urine production < 100 mL / 24 hours

References

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