Hematuria (peds)

This page is for pediatric patients. For adult patients, see: hematuria

Background

Macroscopic Hematuria algorithm

• Hematuria in children can be gross (visible) or microscopic (detected only on urinalysis)
• Defined as >5 RBCs per HPF on microscopy
• Confirm true hematuria — rule out myoglobin (e.g. from rhabdomyolysis) or hemoglobin in urine; also rule out bleeding from non-urinary source (vaginal, rectal)
• Common in pediatrics; most cases are benign (viral illness, exercise, minor trauma)
• Key EM concerns: post-infectious glomerulonephritis (most common nephritic cause), hemolytic uremic syndrome (HUS), trauma, and urologic emergencies

Common Causes by Age

• Neonates/Infants: UTI, congenital anomalies, renal vein thrombosis, birth trauma
• Young children: UTI, glomerulonephritis, Wilms tumor, trauma
• School age: post-streptococcal GN, IgA nephropathy, UTI, nephrolithiasis, trauma
• Adolescents: UTI, nephrolithiasis, IgA nephropathy, exercise-induced

Clinical Features

History

• Color of urine: bright red/pink (lower tract or gross hematuria), cola/tea-colored (glomerular source)
• Timing: at beginning of stream (urethral), throughout (bladder/upper tract), at end (bladder neck)
• Pain: dysuria (UTI), colicky flank pain (stone), painless (glomerulonephritis, tumor)
• Recent illness: preceding pharyngitis/skin infection 1-3 weeks prior (post-streptococcal GN)
• Recent bloody diarrhea (HUS — typically E. coli O157:H7)
• Trauma history
• Family history: sickle cell disease/trait, Alport syndrome, polycystic kidney disease, kidney stones
• Medications: anticoagulants, cyclophosphamide
• Exercise history (exercise-induced hematuria — benign, resolves in 24-72 hours)

Types of hematuria

• Initial hematuria
  • Blood at beginning of micturition with subsequent clearing
  • Suggests urethral disease
• Intervoid hematuria
  • Blood between voiding only (voided urine is clear)
  • Suggests lesions at distal urethra or meatus
• Total hematuria
  • Blood visible throughout micturition
  • Suggests disease of kidneys, ureters, or bladder
• Terminal hematuria
  • Blood seen at end of micturition after initial voiding of clear urine
  • Suggests disease at bladder neck or prostatic urethra
• Gross hematuria
  • Indicates lower tract cause
• Microscopic hematuria
  • Tends to occur with kidney disease
• Brown urine with RBC casts and proteinuria
  • Suggests glomerular source
• Clotted blood
  • Indicates source below kidneys

Physical Exam

• Vital signs including blood pressure (hypertension suggests glomerulonephritis)
• Edema (facial, periorbital, pedal — nephritic or nephrotic syndrome)
• Abdominal exam: flank tenderness, masses (Wilms tumor)
• Genital exam: rule out non-urinary source
• Skin: purpura (IgA vasculitis/HSP), petechiae (HUS/TTP), impetigo (post-strep GN)
• Throat exam (recent pharyngitis)

Red Flags

• Hypertension + edema + cola-colored urine (acute glomerulonephritis)
• Bloody diarrhea followed by hematuria + oliguria + pallor (HUS)
• Abdominal mass (Wilms tumor — do NOT palpate vigorously)
• Gross hematuria with hemodynamic instability (trauma, renal injury)
• Anuria or significant oliguria

Differential Diagnosis

Pediatric Hematuria

Macroscopic Hematuria	Transient Microhematuria	Persistent Microhematuria
Blunt abdominal trauma	Strenuous exercise	Benign familial hematuria
Urinary tract infection	Congenital anomalies	Idiopathic hypercalciuria
Nephrolithiasis	Trauma	Immunoglobulin A nephropathy
Infections	Menstruation
Poststreptococcal glomerulonephritis	Bladder catheterization	Alport syndrome
	High fever	Sickle cell trait or anemia
Immunoglobulin A nephropathy		Henoch-Schonlein purpura
Hypercalciuria		Drugs and toxins
Sickle cell disease		Lupus nephritis

Look-Alikes

• Foods or medications
  • For example beets, rifampin, multivitamins, pyridium
• Uric acid crystalluria
• Gastrointestinal bleeding (peds)
• Vaginal bleeding
  • Prepubertal vaginal bleeding
• Other causes of abnormally colored urine

Evaluation

Initial

• Urinalysis with microscopy: RBCs, RBC casts (glomerular), WBCs (infection), protein
• Urine culture if UTI suspected
• BMP: creatinine, BUN, electrolytes (renal function)
• CBC with smear: anemia, thrombocytopenia (HUS), schistocytes
• Blood pressure measurement (critical — hypertension suggests renal parenchymal disease)

Glomerular Hematuria Suspected (Cola-Colored, RBC Casts, Proteinuria)

• Complement levels: C3 low in post-streptococcal GN; C3 and C4 low in lupus nephritis
• ASO titer and anti-DNase B (post-streptococcal)
• Serum albumin (nephrotic features)
• ANA if lupus suspected
• Consider renal ultrasound

HUS Suspected

• CBC with peripheral smear (schistocytes, thrombocytopenia, anemia)
• Reticulocyte count, LDH, haptoglobin
• Stool culture and STEC testing
• BMP (renal function, potassium)
• Coagulation studies (PT, PTT — typically normal in HUS, abnormal in DIC)

Trauma

• Imaging per FAST exam and trauma protocol
• CT abdomen/pelvis with contrast if renal injury suspected

Imaging

• Renal/bladder ultrasound: hydronephrosis, stones, masses, structural anomalies
• CT without contrast if nephrolithiasis strongly suspected (less commonly needed in pediatrics)
• CT with contrast for trauma evaluation

Management

General

• Treat underlying cause
• Monitor blood pressure closely
• Fluid management based on etiology

Condition-Specific

• UTI: antibiotics appropriate for age (see UTI (peds))
• Post-streptococcal GN: supportive care, sodium restriction, antihypertensives for BP control, diuretics for fluid overload; typically self-limited
• HUS: supportive care, aggressive fluid management, transfusions as needed, dialysis if oliguric/anuric; do NOT give antibiotics for STEC-HUS (may worsen course); nephrology and hematology consultation
• Nephrolithiasis: IV fluids, analgesia (ibuprofen + acetaminophen), urology follow-up
• Wilms tumor: surgical oncology consultation
• IgA vasculitis (HSP): supportive care; nephrology if renal involvement

Disposition

Admit

• Hemolytic uremic syndrome
• Acute glomerulonephritis with hypertension, edema, or renal insufficiency
• Significant renal trauma
• Abdominal mass concerning for malignancy
• Hemodynamic instability
• Anuria or severe oliguria
• Hyperkalemia or other significant electrolyte derangements

Discharge with Follow-Up

• Isolated microscopic hematuria with normal BP, normal renal function, and normal exam: pediatric nephrology referral within 1-2 weeks
• Mild post-streptococcal GN with controlled BP and stable renal function: close follow-up in 24-48 hours
• Exercise-induced hematuria: reassurance, recheck UA after rest
• Return precautions: decreased urine output, swelling (face, legs), worsening blood in urine, headache, visual changes (hypertensive emergency), vomiting

See Also

• Hematuria (adult)
• Glomerulonephritis
• Hemolytic uremic syndrome
• UTI (peds)
• IgA vasculitis