Hematuria

Ann Salerno, MD

Hematuria - BASICS

Hematuria - description

Hematuria is defined as >5 RBCs per high-power field (hpf), using a standard urinalysis technique on a centrifuged sample. This correlates with a urine dipstick reaction of ≥1+.

Hematuria - epidemiology

Hematuria - prevalence

• Asymptomatic microscopic hematuria: 0.5–2% of school-aged children
• Gross hematuria is more commonly observed in boys.

Hematuria - risk factors

Hematuria - genetics

Hematuria, hypercalciuria, nephrolithiasis, and nephritis can be inherited.

Hematuria - pathophysiology

Bleeding can occur from anywhere along the urinary tract or kidney. In glomerular hematuria, RBCs cross the glomerular basement membrane (GBM) into the urinary space.

Hematuria - DIAGNOSIS

General goals:

• Phase 1: Determine if the pigment in urine is from blood or another source. Are RBCs present?
• Phase 2: Determine the source of bleeding: Glomerular or nonglomerular, kidney or urinary tract?
• Phase 3: Select those who will require referral versus those who will simply require follow-up.

Hematuria - signs & symptoms

Hematuria - history

• Prior episodes of gross hematuria or abnormal urinalyses: Chronic versus acute process
• Antecedent infection, concurrent infection, streptococcal pharyngitis, or impetigo: Antecedent suggests postinfectious glomerulonephritis (GN). Concurrent upper respiratory infection (URI) or gastroenteritis suggests IgA nephropathy.
• Any precipitating factors (trauma, exercise): Renal contusion, exercise hematuria, or myoglobinuria
• Voiding symptoms, dysuria, urgency, frequency: Suggests bacterial or viral (adenovirus) hemorrhagic cystitis
  • Drops of blood or spotting in underwear after or between voiding in prepubertal boys: Urethrorrhagia
• Renal colic or other pain: Suggests stones
• Fever, rash, arthritis: Signs or symptoms of systemic illness or immune-mediated process
• Bleeding from any other source (i.e., gums, GI tract): Suggests coagulopathy
• Symptomless “terminal” hematuria: Trigonitis, hemorrhagic cystitis
• Medications and diet: Food or drug pigment, drug nephrotoxicity
• Family history:
  • Hematuria in family members: Familial hematuria or Alport syndrome: Premature deafness in family members:
  • Suggests Alport syndrome
  • Sickle cell disease in family members: Suggests sickle nephropathy, papillary necrosis, or hemoglobinuria
  • Renal stone disease in family members: Suggests stones, hypercalciuria, or metabolic disease
  • Cystic kidney disease in family members: Autosomal-recessive or -dominant polycystic kidney disease
  • Kidney failure or identified kidney disease/nephritis in family members: Suggests hereditary nephritis, cystic disease

Hematuria - physical exam

• Head, ears, eyes, nose, throat (HEENT) exam (periorbital edema): GN, renal failure, volume overload
• Cardiovascular exam (hypertension, tachycardia, murmur, gallop): GN, renal failure, volume overload
• Abdominal exam (ascites, organomegaly, tenderness, or masses): Volume overload, tumor, polycystic kidneys, venous thrombosis
• Back exam (flank tenderness): Pyelonephritis, renal calculi, large cysts
• Genital exam (blood at urethral meatus): Urethral trauma
• Perineal exam (skin breakdown, irritation): External source of bleeding or infection
• Extremities (pretibial edema, arthritis): GN, volume overload, systemic illness
• Skin and mucosal exam (petechial, vasculitic rash, ulcerations): Systemic illness (lupus, Henoch-Schönlein purpura [HSP])

Hematuria - tests

Positive test for blood on urine dipstick may be myoglobin or hemoglobin. If the urinary sediment does not show RBCs, investigate for problems such as rhabdomyolysis (elevated creatinine phosphokinase [CPK]) or hemolysis.

Hematuria - lab

• Repeated urinalysis to confirm persistent microscopic hematuria:
  • Patient should be told not to exercise before the urine collection.
  • 2 of 3 positive specimens over 2–3 weeks should be documented in an otherwise well child before diagnostics evaluating hematuria.
• Gross and microscopic analyses of fresh urine specimen:
  • Absence of RBCs suggests factitious hematuria.
  • RBC casts: Diagnostic for GN
  • WBCs suggest cystitis.
  • WBC casts suggest pyelonephritis.
• Screening of the family members for occult hematuria: Familial benign hematuria or Alport syndrome
• Screening for hypercalciuria (random urine calcium/creatinine ratio >0.2 in children >6 years; >0.6 in children 6–12 months; >0.8 in children <6 months). If elevated, 24-hour urine calcium collection >4 mg/kg/d in children >2 years of age: Hypercalciuria
• Culture: Bacterial, viral: Cystitis, Serratia marcescens, adenovirus
• Serum electrolytes, BUN, and creatinine levels: Impaired renal function suggests inflammation, infection, or obstruction.
• Evaluation for GN:
  • Hematuria with RBC casts in combination with proteinuria, edema, hypertension, and/or impaired renal function
  • Streptococcal serology ([ASOT], streptozyme): Acute postinfectious GN
  • Complement studies (C3, C4): Hypoccomplementemic GN: immune complex-mediated (lupus nephritis, postinfectious GN, membranoproliferative GN)
  • Antinuclear antibody (ANA) titer or anti–double-stranded DNA if hypocomplementemic: Vasculitis (lupus)
  • Quantitation of proteinuria and serum albumin concentration:
    • 3–4+ proteinuria, urine protein/creatinine ratio >2, and hypoalbuminemia suggest glomerular disease/nephrosis.
    • 24-hour urine protein ≥1 g/day
• CBC with platelets, coagulation times: May suggest hemolysis, clotting disorder, or systemic illness
• Hemoglobin electrophoresis should be considered in black patients: Sickle cell disease or sickle trait may cause hematuria.

Hematuria - imaging

Every child with gross hematuria should have imaging of the kidneys and urinary tract. It may or may not be indicated in children with microscopic hematuria:

• Ultrasound of kidneys and bladder: Urinary tract obstruction, congenital malformation, cysts, stones, nephrocalcinosis, malignancy
• Abdominal CT scan: After trauma if there are >50 RBCs/hpf or if microscopic hematuria persists for several weeks
• Helical CT without contrast: Study of choice for the visualization of stones

Hematuria - diag proced-surgery

• Rarely, additional studies such as cystourethrogram, renal angiography, cystoscopy, or renal biopsy will be required with an appropriate referral to urology or nephrology.
• Audiometry may be indicated if hereditary (Alport) nephritis is suspected; should be performed on boys with familial hematuria.

Hematuria - differencial diagnosis

Hematuria may originate at any site along the urinary tract.

• Factitious cause: Urine appears bloody, but no RBCs are present.
  • Factious cause: Endogenous pigments
    • Myoglobin (rhabdomyolysis)
    • Hemoglobin
    • Bile pigments
    • Urate crystals (pink diaper syndrome)
    • Beets, blackberries
  • Factious cause: Exogenous pigments:
    • Food and beverage dyes
    • Drugs that cause urinary discoloration:
    • Phenazopyridine (Pyridium)
    • Deferoxamine
    • Rifampin
    • Sulfa
    • Others
  • Serratia marcescens
• Glomerular causes:
  • Common:
    • Strenuous exercise
    • Acute postinfectious glomerulonephritides
    • IgA nephropathy
    • Thin basement membrane disease (benign familial hematuria)
  • Uncommon:
    • Alport syndrome, hereditary nephritis
    • Membranoproliferative GN
    • Nephritis of systemic disease (Henoch-Schönlein or systemic lupus)
• Nonglomerular (interstitial) renal causes:
  • Common:
    • Pyelonephritis
    • Hypercalciuria/nephrolithiasis/nephrocalcinosis
    • Renal trauma (contusion), particularly in hydronephrotic or cystic kidneys
    • Hemoglobinopathies (sickle cell disease, sickle cell trait)
    • Ureteropelvic junction obstruction
  • Uncommon:
    • Drug-induced interstitial nephritis (penicillins, cephalosporins, NSAIDs, phenytoin)
    • Cystic disease (simple cyst, polycystic kidney disease)
    • Neoplasm: Wilms tumor
    • Coagulopathy
    • Renal venous thrombosis, renal arterial thrombosis
• Urinary tract causes:
  • Common:
    • Bladder catheterization, Foley catheter
    • Cystitis (bacterial, viral, occasionally chemical)
    • Urethrorrhagia
    • Meatal stenosis
    • Urethritis
    • “Terminal hematuria” syndrome (trigonitis)
    • Perineal trauma or irritation
  • Uncommon:
    • Bladder tumor
    • Polyp
    • Urethral or bladder trauma
    • Foreign body in bladder or urethra
    • Schistosomiasis
    • “Nutcracker” phenomenon
• External causes of “hematuria:”
  • Menstrual contamination
  • Diaper rash, perineal irritation
  • No identifiable cause is found in the majority (up to 80%) of children with asymptomatic microscopic hematuria and in up to 30% of children with a single episode of gross hematuria.

Hematuria - TREATMENT

Hematuria - general measures

• For children with microscopic hematuria, in the absence of other clinical, laboratory, or imaging findings, no specific treatment is indicated besides routine longitudinal follow-up.
• For children with glomerular hematuria, treatment depends on the histopathological diagnosis, clinical features, renal function, and degree of proteinuria.

Hematuria - FOLLOW UP

Hematuria - disposition

Hematuria - issues for referral

• Nephrology: Recurrent gross hematuria, proteinuria, RBC casts, nephrosis, edema, hypocomplementemia, hypertension, azotemia, cysts, hypercalciuria, family history of hereditary nephritis, deafness, or cystic kidney disease
• Urology: Congenital anomaly of urinary tract, uncontrollable bleeding after trauma, recurrent, painful or large stones, recurrent urinary infections
• Bleeding secondary to coagulopathy or sickle cell disease papillary necrosis

Hematuria - prognosis

• Most children with asymptomatic isolated microscopic hematuria detected on a well-child examination, without proteinuria, hypertension, or azotemia, will not be found to have serious underlying pathology and will simply require longitudinal follow-up.
• Many children will not have an identifiable cause.
• Children with asymptomatic microscopic or gross hematuria combined with proteinuria have a high likelihood of glomerular disease.
• Children with a history of stones or hypercalciuria are at increased risk of developing renal stones in the future.
• Familial hematuria secondary to thin GBM disease is a diagnosis of exclusion. Although it often has a benign prognosis, in some families it can progress to chronic kidney disease. Children should be examined yearly for the development of proteinuria or hypertension.

Hematuria - patient monitoring

The well child with asymptomatic isolated hematuria and a negative workup should be reassessed annually with a complete physical examination, measurement of BP, and urinalysis. If hematuria is persistent, periodic assessment of renal function should also be performed. The development of significant proteinuria, hypertension, elevated creatinine, or other concerns should prompt evaluation by a pediatric nephrologist.

Hematuria - bibliography

1. Bergstein JB, Leiser J, Andreoli S. The clinical significance of asymptomatic gross hematuria and microscopic hematuria in children. Arch Pediatr Adolesc Med. 2005;159(4):353–355.
2. Carasi C, Van’t Hoff WG, Rees L, et al. Childhood thin GBM disease: Review of 22 children with family studies and long-term follow-up. Pediatr Nephrol. 2005;20:1098–1105.
3. Cohen RA, Brown RS. Clinical practice: Microscopic hematuria. N Engl J Med. 2003;348:2330–2338.
4. Feld LG, Meyers KE, Kaplan BS, et al. Limited evaluation of microscopic hematuria in pediatrics. Pediatrics. 1998;102:E42.
5. Meglic A, Cavic M, Hren-Vencelj H, et al. Chlamydial infection of the urinary tract in children and adolescents with hematuria. Pediatr Nephrol. 2000;15:132–133.
6. Patel HP, Bissler JJ. Hematuria in children. Pediatr Clin North Am. 2001;48:1519–1537.
7. Youn T, Trachtman H, Gauthier B. Clinical spectrum of gross hematuria in pediatric patients. Clin Pediatr. 2006;45(2):135–141.

Hematuria - CODES

Hematuria - icd9

599.7 Hematuria

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

Other Book Chapters Related to Blood in urine

Read excerpts from these other book chapters related to Blood in urine:

Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Williams & Wilkins.

More About Causes of Blood in urine

• Back to symptom: Blood in urine: Introduction (review 391 causes)
• Next Book Extract About Blood in urine: Urinary Tract Infection (The 5-Minute Pediatric Consult)
• All Book Extracts: All Online Book Extracts for Blood in urine

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

 » Next page: Urinary Tract Infection (The 5-Minute Pediatric Consult)

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

• Urinary Tract Infection (The 5-Minute Pediatric Consult)
• Urinary Tract Infections (Pediatric Infectious Disease)
• Medications causing Blood in urine
• Videos relating to Blood in urine
• Drug interactions causing Blood in urine

Tools & Services:

• Bookmark this page
• Take a survey relating to Blood in urine
• Symptom Search
• Symptom Checker
• Medical Dictionary
• Give your feedback

Medical Articles:

• Disease & Treatments Search
• Misdiagnosis Center
• Full list of interesting articles

Forums & Message Boards

• Ask or answer a question at the Boards:
• I cannot get a diagnosis. Please help.
• Tell us your medical story.
• Share your misdiagnosis story.
• What is the best treatment for my condition?
• See all the Boards.

Enter your search terms Submit search form
Search The Web Search wrongdiagnosis.com

Common Health Mistakes

Symptom
Checker

Search Specialists by State and City