At a Glance

Why It's Ordered
Screening for urinary tract infection, evaluation of ketoacidosis, and the first look at dark or bloody urine (myoglobin or true hematuria) and at kidney function in the ED, ICU and transport. Results are a screen; culture, serum β-hydroxybutyrate and creatine kinase (CK) confirm.
Check First
Glucose and ketones (DKA), blood with few or no RBCs (myoglobin: check CK), leukocyte esterase and nitrite with pyuria (infection), and specific gravity (hydration and concentrating ability).
Critical Values
Ketonuria ≥2+ with glucose ≥200 mg/dL or known diabetes · Heme-positive dipstick with few or no RBCs on microscopy (check CK) · Pyuria or bacteriuria with fever or hypotension (urinary-source sepsis)
Don't Miss
A dipstick ketone test detects acetoacetate, not β-hydroxybutyrate, the main ketoacid in DKA, so a weak or negative result does not exclude DKA. Measure serum β-hydroxybutyrate, pH and bicarbonate. Heme-positive urine with few RBCs is myoglobinuria until proven otherwise.
Field & Transport
A urine dipstick is not a standard prehospital test; use one only where local protocol provides it. Obtain a clean-catch or catheter specimen per protocol and send it with the patient. Ask the sending facility for prior urine, culture, glucose and creatinine results, and note SGLT2 inhibitor use.

Panel Overview

The urinalysis is a physical, chemical and microscopic examination of urine. This panel covers 10 components: appearance, specific gravity, pH, dipstick protein, glucose, ketones, blood, leukocyte esterase and nitrite, plus microscopic sediment. Dipstick bilirubin and urobilinogen are not covered on this page. It is the fastest test for urinary tract infection, ketoacidosis and myoglobinuria, and a first screen for kidney disease.

It is a sibling of the Renal Function Panel and CMP, which measure the blood side of kidney function (creatinine, BUN, eGFR, electrolytes). Read urine and blood results together. A dipstick result is a screen. The urine albumin-creatinine ratio, serum β-hydroxybutyrate and culture confirm.

When to Order:
  • Sepsis or fever: suspected urinary source, with pyuria, nitrite or bacteria. Collect before antibiotics.
  • DKA or hyperglycemic crisis: glucose ≥200 mg/dL or known diabetes with suspected ketosis or acidosis.
  • Dark or cola-colored urine: after crush injury, prolonged immobility, seizure or heavy exertion.
  • Altered mental status or unexplained acute kidney injury: protein and microscopy for casts.
  • Flank pain with hematuria: stones and other urologic causes.
  • Pregnancy with hypertension: proteinuria screening, with a urine protein-creatinine ratio to confirm, per obstetric protocol.

Physical & Concentration

Appearance & Clarity

Normal: pale yellow to amber, clear

Color and clarity. Dark, red or cola-colored urine needs a dipstick and microscopy to separate blood from myoglobin. Bilirubin and drug coloring are not tested on this page.

Specific Gravity

Normal: 1.005–1.030

Urine concentration. High values suggest dehydration; low values suggest dilute urine or impaired concentrating ability, as in chronic kidney disease.

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Urine pH

Normal: 4.5–8.0

Urine acid–base handling. Interpret with serum bicarbonate. Persistently alkaline urine with infection raises concern for urease-producing bacteria.

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Dipstick Chemistry

Urine Protein

Normal: Negative

Dipstick detects mainly albumin and misses low-grade albuminuria. Confirm persistent proteinuria with a urine albumin-creatinine ratio.

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Urine Glucose

Normal: Negative

Glucosuria reflects blood glucose above the renal threshold. SGLT2 inhibitors lower that threshold, so glucose can be positive with a normal blood glucose.

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Urine Ketones

Normal: Negative

Nitroprusside test detects acetoacetate, not β-hydroxybutyrate, so it can underestimate early and overestimate late DKA. Use serum β-hydroxybutyrate for diagnosis and monitoring.

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Urine Blood

Normal: Negative

Detects heme from RBCs, hemoglobin or myoglobin. Confirm hematuria by microscopy. Heme-positive urine with few or no RBCs points to myoglobinuria or hemoglobinuria; check CK.

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Leukocyte Esterase

Normal: Negative

Enzyme from neutrophils and a sensitive marker of pyuria. Vaginal contamination and sexually transmitted infection can also cause a positive result.

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Urine Nitrites

Normal: Negative

Positive when bacteria reduce urinary nitrate, which needs urine to dwell in the bladder. A negative result does not exclude infection.

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Microscopic Examination

Urine Microscopy

Normal: WBC ≤5/HPF; RBC 0–2/HPF (3 or more: evaluate per AUA/SUFU); hyaline casts 0–2/LPF

Sediment: cells, casts, crystals and bacteria. RBC casts suggest glomerular injury; WBC casts suggest pyelonephritis; muddy-brown granular casts suggest tubular injury. Calcium oxalate crystals are not specific, but ethylene glycol poisoning is one cause.

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Common Add-Ons

Urine Culture

Normal: No significant growth

Confirms bacteriuria and identifies the organism for targeted therapy. Collect before the first antibiotic dose.

Urine Albumin-Creatinine Ratio

Normal: <30 mg/g

Quantifies albuminuria when the dipstick is negative or trace but kidney disease is suspected. Used for CKD staging.

Urine hCG

Normal: Negative

Pregnancy test in urine. A positive result changes drug choice and imaging decisions in the ED.

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Urine Drug Screen

Normal: Negative (presumptive)

Immunoassay screen for common drug classes. Cannot exclude many substances; confirmatory testing is needed for a definitive result.

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Urine Electrolytes (Na⁺, FENa)

Expected: no universal normal (prerenal FENa under 1%)

Spot urine Na⁺, osmolality and FENa separate prerenal from intrinsic kidney injury and help sort out hyponatremia. A diuretic before the sample makes FENa read high.

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Reference Ranges & Critical Values
TestAdult Normal (conventional)SI UnitsCritical LowCritical HighNotes
Appearance
Pale yellow to amber, clear
—
—
—
Color and clarity; see microscopy
Specific gravity
1.005–1.030
No SI unit (ratio)
—
—
Dilute or concentrated urine
pH
4.5–8.0
—
—
—
Diet and infection shift it
Protein (dipstick)
Negative
Negative
—
—
Insensitive; quantify with ACR
Glucose (dipstick)
Negative
Negative
—
—
SGLT2 inhibitors cause glucosuria
Ketones (dipstick)
Negative
Negative
—
≥2+ with glucose ≥200 mg/dL or known diabetes
Detects acetoacetate, not β-hydroxybutyrate
Blood (heme)
Negative
Negative
—
Few or no RBCs: check CK
Confirm with microscopy
Leukocyte esterase
Negative
Negative
—
—
Pyuria marker
Nitrite
Negative
Negative
—
—
Negative does not exclude UTI
Microscopy (sediment)
WBC ≤5/HPF; RBC 0–2/HPF (3 or more: evaluate per AUA/SUFU); hyaline casts 0–2/LPF
Per HPF or LPF (no SI unit)
—
—
Casts and crystals need context
Note: Every lab sets its own intervals and its own critical list. The analyzer and the assay change the numbers too. Use your lab's reported interval and its critical-call policy.

Systematic Interpretation
  1. Appearance and volume: Dark, red or cola-colored urine: think blood, myoglobin, bilirubin or drug coloring. Dipstick and microscopy split blood from myoglobin. Bilirubin and drug coloring are not tested on this page.
  2. Specific gravity: A high value suggests dehydration. A low value suggests dilute urine or impaired concentrating ability. Chronic kidney disease and diuretic effect are two examples.
  3. Ketones and glucose: Ketonuria ≥2+ with glucose ≥200 mg/dL or known diabetes meets the DKA ketone and glucose criteria. Confirm it with serum β-hydroxybutyrate, pH and bicarbonate. The trap: DKA can occur with glucose below 200 mg/dL. Glucose-positive urine with a normal blood glucose points to an SGLT2 inhibitor.
  4. Blood: Confirm RBCs on microscopy. Heme-positive urine with few or no RBCs suggests myoglobin or hemoglobin. Check CK, potassium and creatinine.
  5. Leukocyte esterase and nitrite: Pyuria and bacteria together support urinary infection. Neither test is diagnostic alone, and a negative nitrite still does not exclude UTI.
  6. Protein: A positive dipstick calls for a urine albumin-creatinine ratio. Persistent albuminuria matters for CKD staging.
  7. Microscopy: WBCs, RBCs, casts, crystals and bacteria. Read the sediment against the dipstick and the clinical picture.
Worked Example: A 34-year-old with type 1 diabetes and 1 day of vomiting. Glucose is 412 mg/dL, urine ketones are large (≥2+), serum β-hydroxybutyrate is 4.2 mmol/L, venous pH is 7.18 and bicarbonate is 12 mEq/L. That meets DKA criteria. Severity is moderate: β-hydroxybutyrate up to 6.0 mmol/L, pH 7.0–7.25, bicarbonate 10 to <15 mEq/L.

Patterns & Differential

One urine result seldom tells the whole story. Read the dipstick and microscopy against the glucose, the creatinine and the clinical picture.

PatternKey FindingsCommon CausesNext Step
Cystitis or pyelonephritis
Leukocyte esterase and nitrite positive; pyuria; bacteria
Uropathogens such as E. coli
Urine culture before antibiotics; sepsis screen if febrile
Asymptomatic bacteriuria
Bacteriuria without urinary symptoms
Common in older adults and people with diabetes
Do not treat without symptoms, except in pregnancy and before some urologic procedures
DKA
Glucose ≥200 mg/dL or known diabetes; ketonuria ≥2+ or β-hydroxybutyrate ≥3.0 mmol/L; pH <7.3 and/or bicarbonate <18 mEq/L
Insulin deficiency with illness or missed insulin
Serum β-hydroxybutyrate, venous pH, bicarbonate, K⁺; insulin protocol
Euglycemic DKA
Ketosis with acidosis and glucose below 200 mg/dL (known diabetes still meets the glucose criterion)
SGLT2 inhibitor, pregnancy, fasting, alcohol, liver failure
Serum β-hydroxybutyrate; insulin with dextrose; hold the SGLT2 inhibitor
Myoglobinuria (rhabdomyolysis)
Heme-positive urine with few or no RBCs; dark urine
Crush injury, exertion, prolonged immobility, seizure, drug toxicity
CK, potassium, creatinine; IV fluids per protocol
True hematuria
RBCs on microscopy
Stones, infection, glomerular disease, malignancy
Microscopy, imaging per clinical picture; urology or nephrology per severity
Nephrotic pattern
Heavy proteinuria; few RBCs; edema
Glomerular disease, diabetic kidney disease
Quantify protein; nephrology referral
Nephritic pattern
RBC casts; hematuria; hypertension
Glomerulonephritis
Serum creatinine, nephrology referral

Serial Testing & Kinetics
AnalyteRises or DetectablePeaksRepeat IntervalMonitoring Target
Serum β-hydroxybutyrate
With insulin deficiency; preferred DKA marker
Not applicable
Every 4 h until DKA resolves, per the 2024 consensus
Falling β-hydroxybutyrate with rising bicarbonate; resolution means ketonemia is suppressed (anion gap normalization is a surrogate if BHB is unavailable)
Urine ketones
Lags early in DKA
Can overestimate late in DKA
Not used to track DKA
Do not use alone to judge response
Creatine kinase (CK)
After muscle injury
Per protocol
Repeat until falling, interval per protocol
Falling CK with stable creatinine and potassium
Creatinine and potassium
Rise in AKI and hyperkalemia risk
Per clinical course
Per protocol
Urine output and potassium during fluid therapy

Critical Findings & Emergency Actions

Diabetic Ketoacidosis (DKA)

Recognize: Glucose ≥200 mg/dL or known diabetes, with ketonuria ≥2+ or serum β-hydroxybutyrate ≥3.0 mmol/L, and pH <7.3 and/or bicarbonate <18 mEq/L. DKA can occur with glucose below 200 mg/dL (euglycemic DKA).

  1. Confirm and draw labs: serum β-hydroxybutyrate, venous pH, bicarbonate, potassium and creatinine, per local protocol (Paramedic/RN).
  2. Fluids: isotonic saline or balanced crystalloid, about 500–1000 mL/hr for the first 2–4 h, per protocol. Use smaller boluses in older adults, heart failure or end-stage kidney disease (RN/CCT).
  3. Check potassium before insulin: if K⁺ is below 3.5 mEq/L, replace potassium first (about 10 mEq/h) and delay insulin until K⁺ is above 3.5 mEq/L. If K⁺ is 3.5–5.0 mEq/L, add potassium to fluids per protocol to keep K⁺ at 4–5 mEq/L. If K⁺ is above 5.0 mEq/L, withhold potassium. Repeat electrolytes about every 4 h (RN/CCT).
  4. High-alert Insulin: regular insulin IV infusion at 0.1 units/kg/hr, no bolus. If IV access is delayed, the insulin route and timing follow local protocol (see insulin). Check capillary glucose every 1–2 h. Add 5–10% dextrose when glucose falls below 250 mg/dL and continue insulin; some protocols also reduce the rate (for example to 0.05 units/kg/hr), per protocol (RN/CCT).
  5. Transport: severe DKA, low pH, or altered mental status needs ICU-level care; keep glucose, potassium and β-hydroxybutyrate checks per protocol (CCT).

Urinary-source sepsis

Recognize: Fever, hypotension or altered mental status with a urinary source (pyuria, nitrite, or bacteria on the dipstick or microscopy).

  1. Culture first if it does not delay treatment: urine culture, and blood cultures per protocol (Paramedic/RN).
  2. Antibiotics: give immediately, ideally within 1 hour of recognition of possible septic shock or high likelihood of sepsis, and within 3 hours for possible sepsis without shock; choose the agent per local antibiogram and protocol (see ceftriaxone) (RN/CCT).
  3. Fluids: SSC 2021 suggests at least 30 mL/kg IV crystalloid within the first 3 hours for sepsis-induced hypoperfusion or septic shock (a weak recommendation); give per protocol with reassessment (Paramedic/RN).
  4. Transport: notify the receiving facility of a suspected urinary source and bring the specimen and the time it was collected (CCT).

Rhabdomyolysis

Recognize: Dark or cola-colored urine, heme-positive dipstick with few or no RBCs, after crush injury, exertion, immobility, seizure or drug toxicity.

  1. Labs: CK, potassium, creatinine, and a 12-lead ECG for hyperkalemia risk, per protocol (Paramedic/RN).
  2. Fluids: IV isotonic crystalloid per protocol, titrated to urine output and volume status (RN/CCT).
  3. Potassium: treat hyperkalemia per protocol (see potassium) (Paramedic/RN).
  4. Transport: report suspected rhabdomyolysis with CK and potassium results; monitor urine output en route (CCT).
Pitfall: A heme-positive dipstick is not hematuria until microscopy shows RBCs. Do not stop at the dipstick when the picture suggests muscle injury. Send CK.

Prehospital & Transport Considerations

Point-of-Care Testing

Device / MethodAnalytesSpecimenLimitations
Urine dipstick (reagent strip)
Specific gravity, pH, protein, glucose, ketones, blood, leukocyte esterase, nitrite
Clean-catch urine
Screen only; not a substitute for microscopy or culture; availability per protocol
Capillary β-hydroxybutyrate meter
β-hydroxybutyrate
Capillary blood
Where stocked; confirm with laboratory results when possible

Interfacility Transfer & Handoff

  • Send with the patient: the specimen with the collection time, prior urinalysis, culture, glucose and creatinine results.
  • Note medications: SGLT2 inhibitors (glucosuria and euglycemic DKA), antibiotics started, and any drug that changes urine color.
  • Repeat en route: glucose and K⁺ in DKA; urine output and CK in suspected rhabdomyolysis; mental status in suspected urinary-source sepsis.

Scope Notes

  • Catheter specimen collection is a skilled procedure. Work inside agency scope and protocol.
  • Antibiotic and fluid volumes on this page depend on protocol, the agency and the receiving facility.

Special Populations

Pediatrics

Pediatric reference intervals for dipstick chemistry are set by each lab. Use the lab's pediatric intervals, not adult cutoffs. A urine culture from a young child needs clean technique or a catheter specimen. Bag specimens are unreliable for culture. Pediatric DKA insulin dosing and fluid volumes are not the adult numbers. See the insulin page and weight-based dosing. Pediatric DKA runs on pediatric protocols.

Pregnancy

  • Asymptomatic bacteriuria: Screen and treat in pregnancy, going by the IDSA 2019 guideline.
  • Euglycemic DKA: Pregnancy is a recognized cause. When glucose is normal and ketones are positive, check β-hydroxybutyrate.

Older Adults

  • Asymptomatic bacteriuria: Don't screen or treat functionally impaired, community-dwelling older adults without symptoms, per the IDSA 2019 guideline.
  • Delirium: Look for other causes before treating bacteriuria alone. If fever or hemodynamic instability suggests sepsis, start broad therapy.

CKD and Dialysis

  • Albuminuria staging: Stage it with the urine albumin-creatinine ratio, not the dipstick alone, per the KDIGO 2024 guideline.
  • Anuric patients: You may not get a urinalysis at all. Specific gravity and protein stop meaning anything.

Specimen Collection & Interfering Factors
  • Specimen and container: Clean-catch midstream urine in a sterile container. Catheter specimen per protocol. Container colour and additive depend on the institution.
  • Handling: Analyze promptly or refrigerate, per lab policy. Waiting at room temperature changes bacterial counts and chemistry.
  • Culture: Collect before the first antibiotic dose. A contaminated specimen can't be interpreted.
Error or InterferentEffect on ResultsPrevention
Vaginal or menstrual contamination
False pyuria, false-positive blood or leukocyte esterase
Clean-catch technique; catheter specimen if contaminated
Delayed processing at room temperature
Bacterial overgrowth, falling glucose, alkaline pH
Analyze promptly or refrigerate per policy
SGLT2 inhibitors
Glucosuria with normal blood glucose
Record the medication on the requisition
Drugs that color urine
Visual color read is misleading
Record the medication; use the dipstick and microscopy

Clinical Pearls
Ketones are not β-hydroxybutyrate: The urine nitroprusside test sees acetoacetate. For DKA, diagnose and track with serum or capillary β-hydroxybutyrate.
Glucose-positive urine with a normal glucose: An SGLT2 inhibitor is the likely cause. Check for ketosis, since euglycemic DKA occurs with these drugs.
Heme-positive, RBC-poor urine: Think myoglobin. Before you dismiss the dipstick, send CK, potassium and creatinine.
A negative nitrite does not rule out infection: Some organisms don't reduce nitrate, and a short bladder dwell time does the same. Both give false negatives. Read leukocyte esterase, pyuria and symptoms together.
Asymptomatic bacteriuria: Don't screen for it or treat it without symptoms in people with diabetes, functionally impaired community-dwelling older adults, catheterized patients, people with spinal cord injury, or solid organ transplant recipients (kidney transplant after the first month). In pregnancy, screen and treat.
Collect urine before antibiotics: A culture taken before the first dose won't delay treatment, as long as the specimen is collected when the infection is recognized.
Pitfall (field and transport): A specimen left at room temperature can't be trusted. Bacteria multiply and glucose drops. Analyze promptly or refrigerate per policy. Label the collection time.
Pitfall (critical care): Potassium comes before insulin. If K⁺ is below 3.5 mEq/L, replace potassium first and delay insulin until K⁺ is above 3.5 mEq/L.

Related

References
  1. Umpierrez GE, Davis GM, ElSayed NA, Fadini GP, Galindo RJ, Hirsch IB, et al. Hyperglycaemic crises in adults with diabetes: a consensus report. Diabetologia. 2024;67(8):1455–1479. https://doi.org/10.1007/s00125-024-06183-8
  2. Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019;68(10):e83–e110. https://doi.org/10.1093/cid/ciy1121
  3. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117–S314. https://pubmed.ncbi.nlm.nih.gov/38490803/
  4. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181–1247. https://pubmed.ncbi.nlm.nih.gov/34599691/
  5. Society of Critical Care Medicine. Surviving Sepsis Campaign: adult guidelines (2026 update). Accessed October 2026. https://www.sccm.org/survivingsepsiscampaign/guidelines-and-resources/surviving-sepsis-campaign-adult-guidelines

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  • For Educational Purposes Only: This content is intended for educational reference and should not be used for clinical decision-making.
  • Not a Substitute for Professional Judgment: Always consult your local protocols, institutional guidelines, and supervising physicians.
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