Urine analysis

Urine analysis in dentistry

1. URINE ANALYSIS IN DENTISTRY ASHISH RANGHANI PG PART 2 GDCH, AHMEDABAD UNDER GUIDANCE OF DR. J.S SHAH PROFESSOR AND HEAD ORAL MEDICINE AND RADIOLOGY GDCH DATE- 28/07/2016

2. CONTENTS Processes of Urine Formation Why urinalysis ? Collection of urine specimens Types of urine sample Components of urine Urinalysis Physical Examination Volume ,Color, Odor, Turbidity, Reaction ( pH), Specific gravity 8. Biochemical Examination Proteins, Sugers , Ketone bodies, Bile salts , Bile Pigments, Blood 9 . Microscopic Tests Cells, Crystals ,Casts, Microorganism 10. Urinary changes in Dental Diseases

3. Essentials of Medical Physiology Sixth Edition, Sembulingam

4. Processes of Urine Formation Essentials of Medical Physiology Sixth Edition, Sembulingam

5. Why urinalysis?

6. Collection of urine specimens Improper collection- - may invalidate the results Containers for collection of urine should be wide, clean and dry. Analysed within 2 hours of collection else requires refrigeration. All specimens must be properly labeled The patient’s name The patient’s identification number The date The time of collection The type of specimen The attending physician’s name The label should be affixed on the container , not the lid.

7. Types of urine sample Sample type Sampling Purpose Random specimen No specific time most common, taken anytime of day Routine screening Morning sample First urine in the morning, most concentrated Pregnancy test, microscopic test Clean catch midstream Discard first few ml, collect the rest Culture 24 hours All the urine passed during the day and night and next day 1 st sample is collected. used for quantitative and qualitative analysis of substances Postprandial 2 hours after meal Determine glucose in diabetic monitoring Supra-pubic aspired Needle aspiration Obtaining sterile urine

8. Components of urine textbook of routine urinalysis and body fluids

9. URINALYSIS Volume Color Odor Turbidity Reaction (pH). Specific gravity . 1 . Proteins. 2. Sugers . 3. Ketone bodies. 4. Bile salts. 5. Bile Pigments. 6. Blood. 1. Cells. 2. Crystals. 3. Casts. 4. Microorganism 5. Parasites. 6.Contamination A. Physical Examination B. Biochemical Examination C. Microscopic Tests

10. PHYSICAL EXAMINATION Volume – Normal – 1- 1.5 L /day.

11. APPEARANCE COLOUR Normal - amber yellow due to the presence of Urobilin Uroerythrin Urochromes Colorless - Very dilute urine Diabetes Polyuria Yellow orange (high colored ) Concentrated urine Excess urobilin Bile pigments Intake of carrots Red/ smoky RBC Myoglobin Aniline dyes Menstrual contamination

12. . - Cloudy - Phosphates & Carbonates, Urates & Uric acid, Pus cells, Bacteria, Spermatozoa bacteria, Yeast, Spermatozoa .

13. Specific Gravity It is directly proportional to the concentration of solute & inversely proportional to the volume Ranges between 1.003 to 1.030

14. LOW SPECIFIC GRAVITY HYPOSTHENURIA :indicates dilute urine, which may be caused by Diabetes insipidus ( can be as low as 1.001) Drinking excessive amounts of liquid. Pyelonephritis, glomerulonephritis Use of diuretics. HYPERSTHENURIA : indicates very concentrated urine, which may be caused by Dehydration Diabetes mellitus Adrenal insufficiency. Toximea of pregnancy (protein in the urine). HIGH SPECIFIC GRAVITY

15. TURBIDITY

16. ODOUR OF URINE Normal odour Fresh urine has aromatic odor

17. pH Normal pH for urine ranges from 4.5 – 8.0 (average pH 6) Some foods (such as citrus fruits and dairy products) and medications (such as antacids) can affect urine pH. In a diet high in protein the urine is more acidic, while a diet high in vegetable material a urine that is more alkaline. Tested by: litmus paper pH paper dipsticks

18. pH CAUSES OF ACIDIC URINE Acidosis Uncontrolled diabetes Diarrhea Starvation and dehydration Respiratory Acidosis CAUSES OF ALKALINE URINE UTI with urease producing org After Meal Salicylate intoxication Urinary retention due to obstruction Chronic renal failure Respiratory alkalosis Renal tubular acidosis

19. Chemical examination Proteins Sugars Ketone bodies Bilirubin Bile salts Urobilinogen Blood Text book of practicle pathology & microbiology V.H. Talib

20. Tests for proteins Principle -proteins are denatured & coagulated on heating to give white cloud precipitate. Method -take 2/3 of test tube with urine, heat only the upper part keeping lower part as control. Presence of phosphates, carbonates, proteins gives a white cloud formation. Add acetic acid 1-2 drops, if the cloud persists it indicates it is protein(acetic acid dissolves the carbonates/phosphates) HEAT COAGULATION TEST Text book of practicle pathology & microbiology V.H. Talib

21. Other tests SULPHOSALICYLIC ACID TEST Mix equal volume of clear urine & 3 to 5% acid Cloudiness indicate presence of proteins HELLER’S NITRIC ACID TEST White ring at the point of contact of conc. HNO 3 and urine indicate presence of albumin Text book of practicle pathology & microbiology v.H . Talib

22. Causes of proteinuria Normally there is a very scanty amount of protein in urine (< 150mg/day) Pathology practicle book, harsh mohan

23. Bence Jones proteins These are light chain globulins seen in multiple myeloma & lymphoma. Test- Thermal method( waterbath ): Proteins has unusual property of precipitating at 40 -60 c & then dissolving when the urine is brought to boiling(100 c) & reappears when the urine is cooled. Text book of practicle pathology & microbiology V.H. Talib

24. Test for sugar Blue-green = negative Yellow-green=+(<0.5%) Greenish yellow=++(0.5-1%) Yellow=+++(1-2%) Brick red=++++(>2%) Text book of practicle pathology & microbiology V.H. Talib Test -BENEDICT’S TEST( semiquantitative ) Principle -benedict’s reagent contains cuso4.In the presence of reducing sugars cupric ions are converted to cuprous oxide which is hastened by heating, to give the color. Method- take 5ml of benedict’s reagent in a test tube, add 8drops of urine. Boil the mixture.

25. Benedict’s test Detects all reducing substances like glucose, fructose, & other reducing sustances. To confirm it is glucose, dipsticks can be used (glucose oxidase)

26. Causes of glycosuria Glycosuria with hyperglycaemia - Diabetes, Acromegaly, Cushing’s Disease, Hyperthyroidism, Drugs Like Corti costeroids . Glycosuria without hyperglycaemia - Renal tubular dysfunction Text book of practicle pathology & microbiology v.H . Talib

27. KETONE BODIES 3 types Acetone Acetoacetic acid β-hydroxy butyric acid They are products of fat metabolism

28. Rothera’s test Principle-acetone & acetoacetic acid react with sodium nitroprusside in the presence of alkali to produce purple colour . Method- take 5ml of urine in a test tube & saturate it with ammonium sulphate . Then add one crystal of sodium nitroprusside. Then gently add 0.5ml of Strong ammonium hydroxide along the sides of the test tube . Appearance permanganate colored ring at the junction of the two fluids indicates a positive test Text book of practicle pathology & microbiology V.H. Talib

29. Causes of ketonuria Diabetes Non-diabetic causes- High Fever, Starvation, Severe Vomiting/Diarrhea After General Anaesthesia Text book of practicle pathology & microbiology v.H . Talib

30. Blood in urine Test - BENZIDINE TEST Method - mix 2ml of benzidine solution with 2ml of hydrogen peroxide in a test tube. Take 2ml of urine & add 2ml of above mixture. A blue color indicates + reaction Text book of practicle pathology & microbiology v.H . Talib

31. Text book of practicle pathology & microbiology v.H . Talib

32. BILE SALTS Hay’s test The test depends on the surface activity of bilirubin as it lowers the surface tension of urine. Sprinkle a little of precipitated sulfur powder on the surface of 2 ml urine. If bilirubin is present, sulfur powder will sink to the bottom of urine. If bile is absent, sulfur will remain on the surface of urine. Text book of practicle pathology & microbiology v.H . Talib

33. Bilirubin Test - fouchet’s test. Causes Liver diseases- injury,hepatitis Obstruction to biliary tract

34. Urobilinogen Test- ehrlich test 5ml fresh urine + 0.5 ml Ehrilch's reagent, allow to stand for 5 min → pink color on cold → normal trace. red color on cold → increased amounts. red color after heating → normal traces. Causes-hemolytic anemia's Cause- obstruction to bile flow (obstructive jaundice)

35. Microscopic examination of urine A sample of well-mixed urine (usually 10-15 ml) is centrifuged in a test tube at relatively low speed (about 2000-3,000 rpm) for 5-10 minutes which produces a concentration of sediment (cellular matter) at the bottom of the tube. A drop of sediment is poured onto a glass slide, a coverslip is place over it & observed under microscope Urinalysis : a comprehensive review ,

36. A variety of normal and abnormal cellular elements may be seen in urine sediment such as Red blood cells White blood cells Mucus Various epithelial cells Various crystals Bacteria Casts

37. Hematuria is the presence of abnormal numbers of red cells in urine due to any of several possible causes Renal stone Kidney tumors kidney trauma, Upper and lower urinary tract infections, Polycystic kidney WBC in high numbers indicate inflammation or infection somewhere along the urinary or genital tract UTI Prostatitis Chronic pyelonephritis Renal stone Renal tumours Cystitis

38. The most common type of cast- hyaline casts Seen in fever, exercise, damage to the glomerular capillary. Red blood cells may stick together and form red blood cell casts. Such casts are indicative of glomerulonephritis, with leakage of RBC's from glomeruli, or severe tubular damage White blood cell casts Their presence indicates inflammation of the kidney. TYPES OF CAST

39. Crystals & amorphous materials

40. URINE ANALYSIS IN DIABETES Diabetes mellitus (DM) also known as a group of metabolic diseases in which there are high blood sugar levels over a prolonged period. This high blood sugar produces the symptoms of frequent urination, increased thirst, and increased hunger. Untreated, diabetes can cause many complications. Acute complications include diabetic ketoacidosis and nonketotic hyper osmolar coma. Serious long-term complications include heart disease, stroke, kidney failure, foot ulcers and damage to the eyes A study on abnormal constituents of urine in diabetic patients

41. In diabetes mellitus mainly glucose and ketone bodies are elevated Glucosuria occurs in mainly during diabetis mellitus and renal diabetes . These ketone bodies are present in the urine this may be due to diabetic ketoacidosis It occurs when the body cannot use sugar (glucose) as a fuel source because there is little or no insulin. Fat is used for fuel instead

42. Diagnosis of Multiple Myeloma Two of the 4 following criteria are generally required for diagnosis of multiple myeloma: Radiographic evidence of osteolytic bone lesions >20% plasma cells in bone marrow aspirates or biopsy specimens. Demonstration of monoclonal or biclonal gammopathy with serum electrophoresis Demonstration of Bence -Jones proteinuria Systemic Lupus Erythematosus Heavy proteinuria (> 3gm/day) Pathology practicle book, harsh mohan

43. Mercury concentrations in urine Urine levels of mercury less than 20 ng/mL are considered safe. The mercury body burden of dental personnel is normally higher than in the general population. This increased body burden is attributed to dental personnel mixing and applying dental amalgam and removing amalgam restorations

44. References Text book of practicle pathology & microbiology v.H . Talib Pathology practicle book, harsh mohan Urinalysis in clinical practice, sekhar chakraborty Graff’s textbook of routine urinalysis and body fluids Salma mahaboob , madan mohan rao m, a study on abnormal constituents of urine in diabetic patients, ujmds 2014, page 64-67 Urinalysis : a comprehensive review , jeff Simerville , m.D ., Georgetown university school of medicine , washington , d.C Essentials of Medical Physiology Sixth Edition, Sembulingam