From the Guidelines
Painless hematuria in a child with a normal CT scan requires further evaluation despite the reassuring imaging, and I recommend a comprehensive urinalysis, urine culture, and referral to a pediatric nephrologist or urologist for specialized assessment. The most common causes of painless hematuria in children include urinary tract infection, hypercalciuria, glomerulonephritis, and nutcracker syndrome 1. Initial management should include a 24-hour urine collection to check for calcium and protein excretion, as hypercalciuria is a frequent cause of pediatric hematuria 1. Blood tests including complete blood count, renal function tests, and complement levels (C3, C4) should be performed to screen for systemic conditions.
While the normal CT scan rules out urinary tract stones and structural abnormalities, conditions affecting the glomerular filtration barrier may not be visible on imaging 1. If hematuria persists beyond 2 weeks or is accompanied by proteinuria, a renal biopsy may be necessary. Parents should monitor the child's urine color, record episodes of hematuria, ensure adequate hydration (approximately 1-2 liters daily depending on age and weight), and avoid excessive salt intake. The prognosis is generally good for isolated hematuria, but persistent cases require long-term follow-up to monitor for progressive kidney disease.
Some key points to consider in the evaluation of painless hematuria in children include:
- The role of imaging in the initial evaluation, with ultrasound of the kidneys and bladder being the preferred initial imaging modality 1
- The importance of screening for systemic conditions, such as glomerulonephritis and hypercalciuria 1
- The need for long-term follow-up to monitor for progressive kidney disease in cases of persistent hematuria 1
- The importance of parental education on monitoring urine color, recording episodes of hematuria, and ensuring adequate hydration and avoiding excessive salt intake.
From the Research
Evaluation of Painless Hematuria in Children
- Painless hematuria in children can be caused by various conditions, including urinary tract infections, urethral/bladder irritation, and glomerular disease 2
- The diagnostic workup for hematuria in children often reveals no clear underlying cause, but common causes of persistent microscopic hematuria include thin basement membrane nephropathy, immunoglobulin A nephropathy, and idiopathic hypercalciuria 2
- A normal CT scan does not rule out the possibility of hematuria, as CT urography is a more comprehensive evaluation that includes an unenhanced scan, nephrographic phase, and excretory phase to detect various causes of hematuria 3
Role of CT Scan in Evaluating Hematuria
- CT urography is a useful diagnostic tool for evaluating hematuria, as it can detect various causes, including calculus, trauma, tumors, vascular, and miscellaneous causes 3
- A normal CT scan may not detect all causes of hematuria, and further evaluation may be necessary to determine the underlying cause 4
- CT urography's protocol permits evaluations of hematuria through a single examination, making it a valuable diagnostic tool 3
Approach to Evaluating Hematuria in Children
- The evaluation of hematuria in children should include a thorough medical history, physical examination, and laboratory tests, including urine analysis and imaging studies 5, 6
- Pediatricians should be aware of screening indications and the evaluation and management of a child with hematuria and/or proteinuria 6
- The diagnostic approach to hematuria in children should be systematic and thorough to ensure that serious conditions are not overlooked 5, 2