What is the appropriate management for hematuria in a 5-year-old boy?

Management of Hematuria in a 5-Year-Old Boy

The appropriate management depends entirely on the clinical presentation: isolated microscopic hematuria without proteinuria or dysmorphic red blood cells requires no imaging and only clinical follow-up, while macroscopic hematuria or any hematuria with a palpable abdominal mass demands urgent ultrasound evaluation. 1, 2

Initial Clinical Assessment

Begin by obtaining specific historical red flags that determine the diagnostic pathway:

• Recent streptococcal infection (suggests post-infectious glomerulonephritis) 2
• Family history of renal disease, hearing loss, or hematuria (suggests hereditary nephropathy including Alport syndrome or thin basement membrane disease) 1, 2
• Recent trauma or strenuous exercise (may cause transient hematuria) 2
• Dysuria, frequency, or fever (suggests urinary tract infection) 2
• Flank pain (suggests urolithiasis) 2
• Bloody diarrhea, joint pains, or rash (suggests Henoch-Schönlein purpura or systemic disease) 2

Physical examination must assess for:

• Palpable abdominal mass (fundamentally changes management—see below) 2, 3
• Hypertension (indicates glomerular disease) 2
• Rashes, arthritis, or soft-tissue edema (suggests systemic disease) 2
• Costovertebral angle tenderness (suggests pyelonephritis or urolithiasis) 2
• Height and weight (chronic disease indicators) 2

Laboratory Evaluation

Perform urinalysis with microscopic examination to differentiate glomerular from non-glomerular causes:

• Dysmorphic red blood cells, red cell casts, or tea-colored urine with proteinuria indicate glomerular disease requiring nephrology referral 1, 2
• White cells and microorganisms indicate urinary tract infection 2
• Spot urine calcium-to-creatinine ratio to evaluate for hypercalciuria (common cause of pediatric hematuria) 2
• Blood urea nitrogen, serum creatinine, and complete blood count if chronic kidney disease is suspected 1, 2

Management Algorithm by Clinical Scenario

Isolated Microscopic Hematuria Without Proteinuria

No imaging is indicated. 1, 2

• Patients without proteinuria or dysmorphic red blood cells are unlikely to have clinically significant renal disease 1
• A study of 325 pediatric patients with microscopic hematuria found no clinically significant findings on renal ultrasound (87% underwent imaging) or voiding cystourethrography (24% underwent imaging) 1, 2
• Clinical follow-up alone is appropriate for isolated, transient microscopic hematuria in an otherwise well child 1, 2
• Screen family members' urine if hematuria persists, as benign familial hematuria (including thin basement membrane nephropathy) is common 1

Isolated Macroscopic (Gross) Hematuria Without Pain or Trauma

Ultrasound of kidneys and bladder is the initial imaging modality. 1, 2

• Macroscopic hematuria is usually due to benign processes such as hypercalciuria or IgA nephropathy but requires imaging to exclude nephrolithiasis, urologic abnormalities, and rarely renal or bladder tumors 1
• Ultrasound effectively displays kidney anatomy, size, and position and screens for structural lesions 1, 2
• Plain radiography may be performed concurrently to detect calcifications and radiopaque stones 2, 3

Painful Hematuria (Suspected Urolithiasis)

Ultrasound of kidneys and bladder is first-line imaging. 2

• Ultrasound has limited sensitivity for ureteral stones 2
• CT may be particularly useful if ultrasound is negative and clinical suspicion for urolithiasis remains high, especially if detection would impact treatment 2
• CT has sensitivity and specificity both well above 90% for stone detection with proper low-dose techniques 2

Hematuria with Palpable Abdominal Mass

This is a medical emergency requiring urgent ultrasound evaluation. 2, 4, 3

This presentation raises concern for Wilms tumor (bilateral involvement occurs in 5-10% of cases) or other renal masses including neuroblastoma, renal cell carcinoma, or mesoblastic nephroma 3

Sequential diagnostic algorithm:

1. Immediate ultrasound of kidneys and bladder to confirm renal origin of mass, assess the contralateral kidney, evaluate for inferior vena cava involvement, and determine tumor size and extent 2, 4, 3
2. Plain radiography concurrently to assess for calcifications 2, 3
3. If ultrasound confirms a renal mass, proceed urgently to chest CT for staging and consider contrast-enhanced abdominal CT or MRI to define local extent and vascular invasion 2, 4, 3

Post-Traumatic Hematuria

Macroscopic hematuria following trauma necessitates contrast-enhanced CT of abdomen and pelvis. 2

• All CT scans must be performed with intravenous contrast unless specifically contraindicated 2
• Radiologic evaluation for renal injury is indicated when ≥50 red blood cells are present on urinalysis, when the patient is hypotensive on presentation, or based on mechanism of injury 2
• Isolated microscopic hematuria without clinical or laboratory findings of visceral trauma does not need emergency investigation 2
• Blood in the urethral meatus with pelvic fractures should prompt investigation of urethra and bladder (50% incidence of genitourinary injury) 2

Critical Pitfalls to Avoid

• Do not perform advanced imaging (CT, MRI, VCUG) for isolated, transient microscopic hematuria in an otherwise well child—this exposes the child to unnecessary risk without clinical benefit 2
• Do not delay imaging when an abdominal mass is palpable by assuming isolated hematuria requires no workup—this fundamentally changes the clinical scenario and delays diagnosis of potentially life-threatening conditions like Wilms tumor 2, 3
• Do not proceed directly to CT without ultrasound confirmation of renal origin when evaluating an abdominal mass—ultrasound may reveal the mass is not renal in origin, changing the diagnostic approach 3
• Isolated microscopic hematuria is very rarely the presenting scenario of Wilms tumor—brief, self-limited findings should not trigger oncologic concerns 1, 2
• CT is not appropriate for initial evaluation of isolated nonpainful, nontraumatic hematuria without proteinuria 1