Evaluation and Approach to Hematuria (Red Urine) in Children

Clinical History Assessment

Systematic approach to history taking for a child presenting with hematuria (red urine)

Physical Examination Guide

Systematic approach to examining a child with hematuria (red urine)

Diagnostic Approach

Initial Assessment

For a child presenting with hematuria (red urine), the initial assessment should include:

• Detailed history focusing on timing, associated symptoms, and color of urine
• Complete physical examination to identify associated conditions
• Basic laboratory studies to confirm true hematuria
• Assessment of vital signs and hydration status

Definitions and Classification

Understanding the presentation and classification of hematuria:

Classification	Definition	Key Features
Gross Hematuria	Visibly red, pink, or brown urine	Visible to the naked eye, often alarming to parents
Microscopic Hematuria	>5 RBCs per high-power field on microscopic urinalysis	Detected only on urinalysis, may be isolated finding
Isolated Hematuria	Hematuria without proteinuria or other abnormalities	Often benign, may be transient or persistent
Hematuria with Proteinuria	Combined presence of blood and protein in urine	Suggests glomerular pathology, higher risk of renal disease

Differential Diagnosis

System/Category	Conditions	Red Flags
Pseudo-hematuria	- Food dyes (beets, berries) - Medications (rifampin, phenazopyridine) - Porphyria - Myoglobinuria	- Color clears with dilution - No RBCs on microscopy - Recent ingestion of pigmented foods - Recent medication changes
Glomerular	- Post-infectious glomerulonephritis - IgA nephropathy - Alport syndrome - Thin basement membrane nephropathy - Lupus nephritis	- Dysmorphic RBCs - RBC casts - Significant proteinuria - Hypertension - Edema - Recent streptococcal infection
Non-glomerular	- Urinary tract infection - Nephrolithiasis - Hypercalciuria - Trauma - Exercise-induced	- Dysuria, frequency, urgency - Flank or abdominal pain - Isomorphic RBCs - History of trauma - Family history of stones
Structural	- Ureteropelvic junction obstruction - Polycystic kidney disease - Congenital anomalies - Nutcracker syndrome - Renal vascular malformations	- Recurrent gross hematuria - Abdominal mass - Family history of kidney disease - Concomitant urinary tract infections - Flank pain with exercise
Hematologic	- Sickle cell disease/trait - Coagulopathies - Thrombocytopenia - Hemophilia - Von Willebrand disease	- Family history of bleeding disorders - Concurrent bruising - Prolonged bleeding after minor trauma - African or Mediterranean descent
Malignancy	- Wilms' tumor - Rhabdomyosarcoma - Renal cell carcinoma - Transitional cell carcinoma - Leukemia	- Palpable abdominal mass - Painless gross hematuria - Weight loss - Pallor, fatigue - Persistent or recurrent hematuria

Laboratory Studies

Initial evaluation for a child with hematuria:

Investigation	Clinical Utility	When to Consider
Urinalysis	Confirm hematuria, assess for proteinuria, pyuria, casts	All patients with suspected hematuria
Urine Culture	Identify urinary tract infection	Presence of pyuria, nitrites, leukocyte esterase, or symptoms of UTI
Complete Blood Count	Assess for anemia, thrombocytopenia, leukocytosis	All patients with gross hematuria or persistent microscopic hematuria
Renal Function Tests (BUN, Creatinine)	Evaluate kidney function	All patients with persistent hematuria or signs of renal disease
Coagulation Studies (PT, PTT)	Screen for bleeding disorders	Family history of bleeding disorders, persistent hematuria
Serum Complement (C3, C4)	Assess for post-infectious or complementopathies	Suspected glomerulonephritis, family history of nephritis
Urine Calcium/Creatinine Ratio	Evaluate for hypercalciuria	Suspected nephrolithiasis, family history of stones
ASO Titer, Throat Culture	Identify recent streptococcal infection	Suspected post-streptococcal glomerulonephritis

Advanced Studies

Consider these studies based on initial findings:

Investigation	Clinical Utility	When to Consider
Renal Ultrasound	Evaluate kidney structure, detect stones, masses, or anomalies	Persistent hematuria, family history of renal disease, abdominal/flank pain
Voiding Cystourethrogram (VCUG)	Evaluate for vesicoureteral reflux, posterior urethral valves	Recurrent UTIs, suspicion of structural abnormality
CT Scan with Contrast	Detailed imaging of renal structures and vascular anomalies	Suspected tumor, vascular malformation, or trauma
24-hour Urine Collection	Quantify protein, calcium, oxalate, citrate, and other solutes	Suspected nephrolithiasis, persistent proteinuria, recurrent hematuria
Renal Biopsy	Definitive diagnosis of glomerular disease	Persistent hematuria with proteinuria, decreased GFR, or suspected glomerulonephritis
Cystoscopy	Direct visualization of bladder and urethra	Persistent unexplained gross hematuria, suspected structural abnormality
Autoimmune Panels (ANA, Anti-dsDNA)	Screen for lupus and other autoimmune nephritides	Systemic symptoms, female adolescent, family history of autoimmune disease

Diagnostic Algorithm

A stepwise approach to evaluating hematuria in children:

1. Confirm true hematuria with urinalysis, distinguish from pseudohematuria
2. Determine glomerular vs. non-glomerular source based on RBC morphology, presence of casts
3. Evaluate for associated proteinuria - increases likelihood of significant renal disease
4. Screen for UTI with urine culture if pyuria present
5. Assess renal function with BUN, creatinine
6. Evaluate for hypercalciuria with spot calcium/creatinine ratio
7. Consider renal ultrasound for persistent or recurrent hematuria
8. Further testing based on clinical suspicion (complement levels, coagulation studies)
9. Nephrology referral for persistent hematuria with proteinuria, hypertension, or abnormal renal function
10. Consider renal biopsy if progressive disease or diagnosis unclear despite non-invasive workup

Management Strategies

General Approach to Management

Key principles in managing pediatric hematuria:

• Stratify risk: Distinguish between benign causes and those requiring intervention
• Treat underlying causes: Target specific diagnosis when identified
• Monitor appropriately: Follow-up based on severity and etiology
• Parental education: Explain significance, reassure when appropriate, and outline monitoring plan
• Nephrology referral: For complex cases, persistent or concerning presentations

Management by Etiology

Etiology	Management Approach	Follow-up Recommendations
Isolated Microscopic Hematuria	- Reassurance if transient - Routine urinalysis monitoring - Avoidance of excessive contact sports if persistent - Monitoring of blood pressure	- Repeat urinalysis in 2-4 weeks - If persistent >6 months, consider nephrology referral - Annual BP monitoring - Check siblings if familial history
Urinary Tract Infection	- Appropriate antibiotic therapy - Adequate hydration - Evaluation for anatomic abnormalities if recurrent - Culture-directed therapy	- Follow-up urinalysis after completion of antibiotics - Imaging if recurrent or febrile UTI - Consider prophylaxis if structural abnormality - Education on prevention strategies
Post-infectious Glomerulonephritis	- Treat underlying infection if still present - Sodium restriction if edema present - Blood pressure control if hypertensive - Monitor renal function	- Weekly urinalysis until clear - Monitor BP until normalized - Follow complement levels until normalized - Long-term monitoring of renal function
Hypercalciuria	- Increased fluid intake - Dietary sodium restriction - Consider thiazide diuretics if symptomatic - Potassium citrate if hypocitruria present	- Follow-up calcium/creatinine ratio - Periodic ultrasound if history of stones - Annual metabolic evaluation - Family screening if genetic predisposition
IgA Nephropathy	- ACE inhibitors for proteinuria/hypertension - Immunosuppression for progressive disease - Omega-3 fatty acids may be beneficial - Tonsillectomy in selected cases	- Regular monitoring of proteinuria - Frequent BP checks - Renal function tests every 3-6 months - Long-term nephrology follow-up
Alport Syndrome	- ACE inhibitors to reduce proteinuria - Hearing and vision evaluations - Genetic counseling - Consider clinical trials	- Multidisciplinary approach (nephrology, ENT, ophthalmology) - Regular monitoring of renal function - Family screening - Preparation for potential transplantation
Nephrolithiasis	- Pain management - Hydration - Dietary modifications based on stone type - Urological intervention if obstruction	- Strain urine to collect stones for analysis - Follow-up imaging to ensure stone passage - Metabolic evaluation - Prevention strategies based on stone composition
Exercise-induced Hematuria	- Temporary reduction in exercise intensity - Adequate hydration - Exclusion of other causes	- Post-exercise urinalysis - Resolution expected within 24-48 hours - Consider other diagnoses if persistent - No long-term restrictions if isolated

Pharmacological Management

Medication Class	Indications	Considerations in Children
Antibiotics	- Urinary tract infections - Streptococcal infections	- Selection based on local resistance patterns - Age-appropriate dosing - Consider compliance issues - Monitor for adverse effects
ACE Inhibitors	- Proteinuric renal diseases - Hypertension with renal involvement	- Start at low doses - Monitor potassium and renal function - Contraindicated in pregnancy (adolescents) - Watch for cough as side effect
Thiazide Diuretics	- Hypercalciuria - Prevention of calcium stones	- Monitor electrolytes - Start with low doses - Consider potassium supplementation - Evaluate for hypotension
Potassium Citrate	- Hypocitruria - Uric acid stones	- Palatability issues in children - Multiple daily dosing may affect compliance - Monitor serum potassium - Available in multiple formulations
Immunosuppressants	- Lupus nephritis - Rapidly progressive glomerulonephritis - Severe IgA nephropathy	- Reserved for severe disease - Increased infection risk - Growth and development concerns - Specialist management required
Corticosteroids	- Immune-mediated nephritis - Minimal change disease with hematuria	- Growth suppression with prolonged use - Monitor for cushingoid features - Bone density concerns - Consider steroid-sparing agents for chronic use

Procedural/Surgical Interventions

Procedure	Indications	Considerations
Renal Biopsy	- Persistent hematuria with proteinuria - Abnormal renal function - Suspected glomerulonephritis - Family history of progressive renal disease	- Usually performed percutaneously under ultrasound guidance - Requires monitoring for post-procedure bleeding - Consider sedation or anesthesia requirements - Risk-benefit assessment critical
Lithotripsy	- Symptomatic renal stones - Stones unlikely to pass spontaneously - Obstructing stones	- Size and location dependent - Less invasive than surgical approaches - Age and size limitations - Post-procedure stenting may be required
Ureteroscopy	- Stone removal - Evaluation of upper tract hematuria source - Management of ureteral strictures	- Technical challenges in very young children - May require specialized pediatric instruments - Risk of ureteral injury - Stent placement often necessary
Cystoscopy	- Evaluation of bladder pathology - Recurrent unexplained gross hematuria - Suspected lower urinary tract anomaly	- Less invasive than upper tract procedures - Can be diagnostic and therapeutic - Anesthesia requirements - Limited utility for upper tract pathology

Parent and Patient Education

• Understanding hematuria: Explain difference between benign and concerning causes
• Monitoring: Instruct on home urine monitoring if appropriate
• Diet and hydration: Emphasize adequate fluid intake (1-2L/day based on age and weight)
• Activity modifications: Guidance on sports participation with specific conditions
• Red flags: When to seek immediate medical attention
• Genetic counseling: For familial conditions like Alport syndrome
• Long-term outlook: Prognosis and expectations for specific diagnosis

When to Refer

• Nephrology:
  • Persistent hematuria (>6 months)
  • Hematuria with proteinuria
  • Hematuria with hypertension
  • Abnormal renal function
  • Family history of hereditary nephritis
• Urology:
  • Recurrent gross hematuria without glomerular cause
  • Suspected anatomic abnormality
  • Symptomatic nephrolithiasis
  • Trauma with hematuria
• Hematology:
  • Suspected coagulation disorder
  • Thrombocytopenia with hematuria
  • Sickle cell disease with hematuria
• Rheumatology:
  • Hematuria with systemic autoimmune symptoms
  • Suspected lupus nephritis
  • Vasculitis with renal involvement
• Emergency Referral:
  • Gross hematuria with clots and pain
  • Hematuria with acute kidney injury
  • Significant trauma with hematuria
  • Hematuria with severe hypertension

Follow-up and Monitoring

Condition	Monitoring Parameters	Frequency
Isolated Microscopic Hematuria	- Urinalysis - Blood pressure - Urine protein/creatinine ratio	- Initially at 2-4 weeks - If persistent, every 3-6 months - Annual thereafter if stable
Post-infectious Glomerulonephritis	- Urinalysis - Blood pressure - Renal function - Complement levels	- Weekly until improving - Monthly until resolved - Every 3-6 months for 1-2 years
IgA Nephropathy	- Urinalysis - Urine protein/creatinine ratio - Blood pressure - Renal function	- Every 3 months initially - Every 6 months if stable - Lifelong monitoring
Hypercalciuria	- Urine calcium/creatinine ratio - Urinalysis - Renal ultrasound if history of stones	- Every 3-6 months initially - Annually if stable - More frequent during growth spurts
Alport Syndrome	- Urinalysis - Proteinuria quantification - Renal function - Hearing assessment - Ophthalmologic examination	- Nephrology: every 3-6 months - Audiology: annually - Ophthalmology: annually - More frequent with disease progression