Hematuria (peds)
This page is for pediatric patients. For adult patients, see: hematuria
Background
- Hematuria in children can be gross (visible) or microscopic (detected only on urinalysis)[1][2]
- 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
- Uric acid crystalluria
- Gastrointestinal bleeding (peds)
- 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