• Hematuria may originate at any site along the urinary tract.
• Factitious causes, urine appears bloody, but there is no hematuria.

• Myoglobin
• Hemoglobin
• Bile pigments
• Urate crystals (“pink diaper” syndrome)

• Food and beverage dyes
• Drugs that cause urinary discoloration
  • Phenazopyridine (Pyridium)
  • Deferoxamine
  • Rifampin
  • Sulfa

• Strenuous exercise
• Acute post-infectious glomerulonephritides
• IGA nephropathy
• Thin basement membrane disease (benign familial hematuria)

• Membranoproliferative glomerulophritis
• Nephritis of systemic disease (Henoch-Schönlein or systemic lupus)
• Alport syndrome, hereditary nephritis

• Hypercalciuria/nephrolithiasis
• Renal trauma (contusion)
• Hemoglobinopathies [sickle cell (SC) disease, SC trait, SC disease]
• Ureteropelvic junction obstruction

• Drug-induced interstitial nephritis (penicillins, cephalosporins, NSAIDs, phenytoin)
• Cystic disease
• Neoplasm
• Coagulopathy
• Vascular thrombosis

• Cystitis (bacterial, viral, occasionally chemical)
• Meatal stenosis in males
• “Terminal hematuria” syndrome (trigonitis)
• Perineal trauma or irritation

• Bladder tumor
• Polyp
• Foreign body in bladder or urethra

• Menstrual contamination
• Diaper rash

Question: Prior episodes of any gross hematuria, or abnormal urinalyses?
Significance: Chronic versus acute process

Question: Medications and diet?
Significance: Food or drug pigment, drug nephrotoxicity. Excessive calcium intake.

Question: Antecedent infection or concurrent infection?
Significance: Antecedent suggests post-infections glomerulonephritis (GN). Concurrent suggests IgA nephropathy, basement membrane disease.

Question: Any precipitating factors (trauma, exercise)?
Significance: Renal contusion, exercise hematuria, or myoglobinuria

Question: Voiding symptoms?
Significance: Suggests lower tract source

Question: Renal colic or other pain?
Significance: Suggests stones

Question: Fever, rash, arthritis?
Significance: Signs or symptoms of systemic illness

Question: Bleeding from any other source?
Significance: Suggests coagulopathy

Question: Hematuria in family members?
Significance: Familial benign hematuria or Alport syndrome

Question: SC disease in family members?
Significance: Sickle nephropathy or hemoglobinuria

Question: Renal stone disease in family members?
Significance: Hypercalciuria or metabolic disease

Question: Cystic kidney disease in family members?
Significance: Autosomal recessive or dominant polycystic kidney disease

Question: Premature deafness in family members?
Significance: Suggestive of Alport syndrome

Question: Anyone in family with kidney failure or identified kidney disease?
Significance: Suggestive of hereditary nephritis, cystic disease or stones

Finding: Cardiovascular exam
Significance: Hypertension in glomerulonephritis, renal failure, tachycardia, murmur on gallop in volume overload

Finding: Abdominal exam
Significance: Volume overload ascites, organomegaly, tenderness, or masses

Finding: Genital exam
Significance: External source of bleeding or infection

Finding: Extremities
Significance: Edema or joint swelling

Finding: Skin and mucosal exam
Significance: Petechial, vasculitic rash, ulcerations

Test: Gross and microscopic analyses of fresh urine specimen
Significance: Urinalysis should guide additional evaluation

Test: Screening of the family members for occult hematuria
Significance: Baseline test for child with isolated asymptomatic hematuria

Test: Screening the child for hypercalciuria (random urine calcium:creatinine ratio, 0.2)
Significance: Hypercalcemia causes hematuria

Test: Serum creatinine
Significance: Renal function

Test: Renal ultrasound
Significance: To rule out obvious structural etiology of the hematuria

Test: SC preparation should be considered
Significance:

Test: Evaluation for glomerulonephritis
Significance: Hematuria occurring in combination with proteinuria, edema, hypertension, or signs or symptoms suggestive of a systemic illness

Test: CBC with platelets
Significance: May suggest clotting problem

Test: Serum electrolytes
Significance: Renal function

Test: BUN and creatinine
Significance: Renal function

Test: Streptococcal serology
Significance: Acute GN

Test: Complement studies
Significance: Immune complex disease

Test: Anti-nuclear antibody titer
Significance: Collagen disease (lupus)

Test: Quantitation of proteinuria
Significance: A low C3 complement suggests postinfectious glomerulonephritis or the nephritis of systemic lupus

Test: Urine culture
Significance: Voiding symptoms, fever, and concurrent pyuria

Test: Trauma to the perineum should be avoided and periodic reassessment
Significance: Symptomless “terminal” hematuria, indicating trigonitis

Test: Radiographic evaluation of lower urinary tract
Significance:

• The majority of children with asymptomatic isolated microscopic hematuria detected on a well-child examination will not be found to have serious underlying pathology and will simply require longitudinal follow-up.
• Children with asymptomatic microscopic or gross hematuria combined with proteinuria have a high likelihood of significant pathology.
• For children with either microscopic or gross hematuria associated with findings suggestive of glomerulonephritis (proteinuria, systemic symptoms), the prognosis will depend on the type of glomerulonephritis identified.

• Uncontrollable bleeding—can be seen in SC disease with papillary necrosis or unlocalized source.
• Bleeding after trauma may expose a congenital anomaly such as uretero-pelvic obstruction.
• Bleeding secondary to coagulopathy
• Bleeding and proteinuria

• Hematuria may be gross or microscopic, symptomless, or associated with a constellation of other complaints and physical findings.
• Asymptomatic microscopic hematuria may be found in 1% to 4% of all healthy school-aged children.
• The complaint of gross hematuria may account for 0.1% to 0.15% of pediatric acute care walk-in visits.
• The majority of children with asymptomatic hematuria will be healthy, and no serious underlying cause will be found.

Ahn JH, Morey AF, McAninch JW. Workup and management of traumatic hematuria. Emerg Med Clin North Am 1998;16(1):145–164.

Feld LG, Meyers KE, Kaplan BS, Stapleton FB. Limited evaluation of microscopic hematuria in pediatrics. Pediatrics 1998;102(4):E42.

Feld LG, Waz WR, Perez LM, Joseph DB. Hematuria. An integrated medical and surgical approach. Pediatr Clin North Am 1997;44(5):1191–1210.

Grasso SN, Keller MS. Diagnostic imaging in pediatric trauma. Curr Opin Pediatr 1998;10(3):299–302.

Mahan JD, Turman MA, Mentser MI. Evaluation of hematuria, proteinuria, and hypertension in adolescents. Pediatr Clin North Am 1997;44(6):1573–1589.

Piqueras AI, White RH, Raafat F, Moghal N, Milford DV. Renal biopsy diagnosis in children presenting with haematuria. Pediatr Nephrol 1998;12(5):386–391.

Roy S 3rd. Hematuria. Pediatr Rev 1998;19(6):209–212;quiz 213.

Ward JF, Kaplan GW, Mevorach R, Stock JA, Cilento BG Jr. Refined microscopic urinalysis for red blood cell morphology in the evaluation of asymptomatic microscopic hematuria in a pediatric population. J Urol 1998;160(4):1492–1495.