See also

Henoch-schonlein purpura

Key points

1. The majority of children have isolated asymptomatic microscopic haematuria and do not need immediate investigation, but require follow up with repeat urinalysis
2. Haematuria associated with pain, oedema, hypertension or proteinuria needs investigation

Background

• Microscopic haematuria (>10 RBC/microlitre) can only be detected by urinalysis as urine colour remains normal
• Persistent microscopic haematuriais 3 positive separate samples that occur ≥1 week apart, without prior exercise nor during menstruation
• Isolated asymptomatic microscopic haematuria is the presence of microscopic haematuria without clinical symptoms or any other abnormalities in the urine eg proteinuria
• Macroscopic haematuria is when blood is visible in urine without microscopy, and is more likely to come from the bladder or urethra rather than the kidney
• Red or brown urine does not always indicate haematuria (may also be haemoglobinuria, myoglobinuria, medication, and food) and requires microscopy to differentiate
• Urate crystals are commonly present in the urine of newborn babies. They can produce a red discolouration of the nappy ("brick dust" appearance) which is sometimes mistaken for blood
• Blood in the urine may come from sources other than the urinary tract (eg vaginal bleeding, rectal fissure)
• Common causes include isolated asymptomatic microscopic haematuria, viral infections, UTI, trauma, HSP, hypercalciuria and inherited abnormalities of the glomerular basement membrane

Assessment

History

• Previous history of haematuria
• Symptoms of urinary infection: dysuria, frequency, pain, fever
• Systemic symptoms such as fatigue, oedema, rash, arthralgia, or coryza
• Recent surgery or trauma including non-accidental injury
• Family history of haematuria, renal disease/ stones or hearing loss
• History of underlying bleeding disorder or immunodeficiency
• Medication history (eg NSAIDs, rifampicin, metronidazole, nitrofurantoin, cyclophosphamide)
• Food intake (beetroot and berries can colour urine to pink or red)
• Exercise

Examination and investigations

• Urinalysis
• Weight
• Physical exam particularly reviewing for eyes, skin, genitalia, joint tenderness or swelling, and signs of oedema or organomegaly
• Blood pressure (see Hypertension)

Red flags

Haematuria AND any of:

• Proteinuria
• Hypertension
• Fluid overload: oedema, ascites
• Flank/abdominal pain
• Immunocompromise

Management

Management of children presenting with haematuria

Further investigations

Microscopic haematuria

• In children with isolated asymptomatic microscopic haematuria and no other abnormal findings:
• Send to GP for review and urinalysis on 2 further occasions, at least 1 week apart, ensuring the urine sample is not collected during menstruation and there has been no exercise that day
• No other investigations are necessary in the interim
• Commonly resolves spontaneously

• In children with isolated persistent microscopic haematuria:
• Urine microscopy
• Urine protein:creatinine and calcium:creatinine ratios
• Urinalysis of immediate family

Macroscopic haematuria

• Urine microscopy and culture
• Urine protein:creatinine and calcium:creatinine ratios
• FBE, UEC, LFT, coagulation profile, CMP
• If painless, glomerulonephritis screen as per flowchart
• Renal ultrasound

Consider consultation with local paediatric team when

• Child is systemically unwell
• Haematuria is present with any red flag
• Microscopic haematuria has not resolved following three consecutive tests
• Clinical features of nephritis (consider consultation with nephrology team)
• Haemolytic uraemic syndrome (consider consultation with nephrology team)
• Abdominal mass (consider consultation with surgical or urology team)

Consider transfer when

Child requiring care beyond the comfort level of the hospital
For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.

Consider discharge when

An appropriate follow up plan is in place, see flowchart for details

Last updated April 2021