Patient education: Blood in the urine (hematuria) in children (Beyond the Basics)

BLOOD IN THE URINE OVERVIEW — Hematuria is the medical term for blood in the urine. Blood in the urine can come from the kidney (where urine is made) or anywhere in the urinary tract (figure 1). The urinary tract includes the ureters (the tubes from the kidneys to the bladder), the bladder (where urine is stored), and the urethra (the tube from the bladder to the outside of the body).

Although seeing blood in the urine can be very frightening, most of the time hematuria in children is not life threatening.

TYPES OF HEMATURIA — There are two main types of hematuria:

●Gross hematuria – Gross hematuria means that blood can be seen in the urine with the naked eye because it turns the urine pink, red, or tea-colored. If you see blood in your child's urine, you should call your child's health care provider.

●Microscopic – Microscopic hematuria means that the urine is normal in color, but it has an increased number of red blood cells (blood) as seen with a microscope. Commonly, in office settings, urine specimens are screened for microscopic hematuria by urine dipstick (not by microscopy). If your child's urine dipstick shows blood in the urine, the urine should be examined with a microscope to confirm that blood is present. A positive finding on dipstick may not always be correct, so the presence or absence of blood needs to be confirmed by urine microscopic examination. (See 'What tests will be done?' below.)

HEMATURIA CAUSES — Some common causes of blood in the urine include the following. However, many of these conditions will have other presenting symptoms (see 'Symptoms of conditions associated with hematuria' below):

●Benign familial hematuria, which runs in families and does not cause any long-term kidney problems

●Kidney or bladder (also called urinary tract) infections. Infections that are localized only to the bladder are also referred to cystitis.

●Kidney stones

●Irritation of the urethra (the area where the urine exits the body), which can occur during bladder catheter insertion.

●Trauma (for example, after falling off a bike and bruising a kidney)

●Vigorous exercise

●Kidney diseases

●Sickle cell disease or trait

Less common causes of blood in the urine include inherited kidney diseases and other underlying medical problems. Cancers of kidney or urinary tract that cause hematuria in adults are very rare in children.

Other causes not due to blood — Sometimes, the urine appears to have blood in it because other red substances are contained in the urine. This can be seen when children eat an excessive amount of beets (called beeturia), food dyes, or with certain medications (such as phenazopyridine/Pyridium). Even highly concentrated urine may sometimes be confused with cola-colored urine.

Urine may also look red due to the presence of hemoglobin or myoglobin caused by an excessive breakdown of red blood cells or muscles, respectively.

SYMPTOMS OF CONDITIONS ASSOCIATED WITH HEMATURIA — Hematuria may not cause any symptoms. This section will describe the symptoms of some of the most common reasons for hematuria.

●Infections

•Bladder infections – Infants with bladder infections may have fever, be irritable, and feed poorly. Older children may have fever, pain and burning while urinating, urgency, and lower belly pain. (See "Patient education: Urinary tract infections in children (Beyond the Basics)".)

•Kidney infections – Children with kidney infections may have fever, chills, and flank pain (pain in one side of the back).

●Kidney stones – Children with kidney stones may have severe belly or flank pain. (See "Patient education: Kidney stones in children (Beyond the Basics)".)

●Kidney diseases – Children with kidney diseases may not have any symptoms, or they can have a variety of symptoms, such as weakness, high blood pressure, puffiness around the eyes, joint swelling, abdominal pain, pale skin, skin rashes, or seizures.

●Depending upon the amount of bleeding, a clot may form in the bladder, which may cause obstruction to the flow of urine.

●Sickle cell anemia – Patients have anemia, painful crisis, and other complications associated with sickle cell anemia. (See "Patient education: Sickle cell disease (The Basics)" and "Patient education: Sickle cell trait (The Basics)".)

WHAT TESTS WILL BE DONE? — The evaluation of a child with hematuria depends upon the type of hematuria (microscopic or gross) and the child's history, symptoms, and physical examination.

●If the child has microscopic hematuria, but has no symptoms (pain, fever, recent trauma) and no protein in the urine, a urine test will be repeated several times over a few months to determine if the blood persists. No further testing is needed. Urine calcium may also be checked to see if there is an increased amount of calcium in the urine. If the microscopic hematuria does not resolve, and your child continues to have no symptoms and no protein in the urine, the child will be monitored over time. The child may be referred to a pediatric nephrologist (kidney specialist) if hematuria persists.

●If the child has hematuria and has symptoms of a bladder or kidney infection, testing will be done to confirm the diagnosis. This usually includes a urine culture.

●If the child has hematuria and symptoms suggestive of a kidney stone, testing with an ultrasound or computed tomography (CT) scan of the kidney is performed to confirm the presence and location of a kidney stone. A urine sample will be collected over 24 hours to measure substances that cause kidney stones.

●If the child has had a recent injury, an imaging test may be recommended to examine the kidneys, ureters, and bladder.

●If the child has hematuria and protein in the urine, further testing will be done. This includes blood and urine tests to evaluate the child's kidney function. The child's blood pressure will also be measured because high blood pressure is a common finding in children with kidney problems. The child may be referred to a pediatric nephrologist if the tests are abnormal.

Family members of children with persistent hematuria may also be tested. Familial hematuria, which has no serious long-term effects, is the most common cause of persistent microscopic hematuria in children.

HEMATURIA TREATMENT — There is no specific treatment for hematuria. Rather, treatment is aimed at the underlying cause, if a cause can be determined. Treatment of specific causes of hematuria is discussed separately. (See "Patient education: Urinary tract infections in children (Beyond the Basics)" and "Patient education: Kidney stones in children (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION — Your child's health care provider is the best source of information for questions and concerns related to your child's medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Blood in the urine (hematuria) in children (The Basics)
Patient education: Blood in the urine (hematuria) in adults (The Basics)
Patient education: Glomerular disease (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Urinary tract infections in children (Beyond the Basics)
Patient education: Kidney stones in children (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Acute infectious cystitis: Clinical features and diagnosis in children older than two years and adolescents
Kidney stones in children: Clinical features and diagnosis
Urinary tract infections in infants and children older than one month: Clinical features and diagnosis
Evaluation of gross hematuria in children
Evaluation of microscopic hematuria in children

The following organizations also provide reliable health information.

●National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

●The Centers for Disease Control and Prevention

(www.cdc.gov/)

●The American Academy of Pediatrics

(www.aap.org)

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