What is the appropriate evaluation and treatment for a 2-year-old patient with hematuria (presence of blood in urine) and urinary sediment?

Evaluation and Management of Sediment in Urine in a 2-Year-Old

Immediate Clinical Assessment

Begin with a focused history targeting specific red flags: recent streptococcal infection (suggests post-infectious glomerulonephritis), family history of renal disease or hearing loss (Alport syndrome), recent trauma or strenuous exercise, dysuria, frequency, fever, and any medications. 1, 2

Key physical examination findings to assess:

• Fever, rash, arthritis, or soft-tissue edema (suggests systemic disease like Henoch-Schönlein purpura or lupus) 1
• Abdominal mass (critical red flag requiring urgent imaging for possible Wilms tumor) 3, 2
• Hypertension (indicates glomerular disease) 1, 3
• Costovertebral angle tenderness (suggests pyelonephritis) 1, 3
• Height and weight (indicators of chronic disease) 1, 2

Urinalysis with Microscopic Examination - The Critical First Step

Perform thorough urinalysis with microscopic examination within 24 hours to differentiate between urinary tract infection and glomerular disease. 3, 2

Glomerular vs. Non-Glomerular Hematuria

Tea-colored urine with proteinuria (>2+ by dipstick), red blood cell casts, and dysmorphic red blood cells (best seen with phase contrast microscopy) indicate glomerular disease such as glomerulonephritis. 1, 2

The presence of white blood cells and microorganisms confirms urinary tract infection. 1, 3, 2

Additional Laboratory Testing

If glomerular disease is suspected:

• Blood urea nitrogen, serum creatinine, and complete blood count with platelets 1, 2
• Spot urine calcium-to-creatinine ratio to evaluate for hypercalciuria 1, 2
• Urine culture (obtain before starting antibiotics if infection suspected) 3, 2

Imaging Strategy Based on Clinical Scenario

For Isolated Microscopic Hematuria (Nonpainful, Nontraumatic)

If the child has isolated microscopic hematuria without proteinuria or dysmorphic red blood cells, NO imaging is indicated. 1, 2 A large study of 325 pediatric patients found that 87% underwent renal ultrasound and 24% had voiding cystourethrography, yet no clinically significant findings were identified. 1 Patients without proteinuria or dysmorphic red blood cells are unlikely to have clinically significant renal disease. 1, 2

For Macroscopic (Gross) Hematuria

Renal and bladder ultrasound is the first-line imaging modality to exclude nephrolithiasis, anatomic abnormalities, and rarely renal or bladder tumors. 2 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

For Painful Hematuria (Suspected Urolithiasis)

Ultrasound of the kidneys and bladder is first-line imaging, though it has limited sensitivity for ureteral stones. 2 If ultrasound is negative but clinical suspicion remains high, CT may be considered, particularly if stone detection would impact treatment. 2

Critical Exception: Hematuria with Abdominal Mass

If an abdominal mass is palpable, urgent ultrasound evaluation is required immediately, as this raises concern for Wilms tumor. 3, 2 This fundamentally changes the clinical scenario from isolated hematuria. 2

After 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

For Traumatic Hematuria

Macroscopic hematuria following trauma requires contrast-enhanced CT of the abdomen and pelvis. 1, 2 All CT scans must be performed with intravenous contrast unless specifically contraindicated. 1, 2

Isolated microscopic hematuria without clinical or laboratory findings of visceral trauma or concerning mechanism does not need emergency investigation. 1, 2 Radiologic evaluation is indicated when ≥50 red blood cells are present on urinalysis, when the patient is hypotensive on presentation, or based on mechanism of injury. 1, 2

Management Based on Findings

If UTI is Confirmed

Obtain urine culture before starting antibiotics. 3, 2 All children under 6 years with first febrile UTI require renal ultrasound after confirming infection to detect congenital or acquired abnormalities. 3

If Glomerular Disease is Suspected

Nephrology referral is indicated for persistent significant proteinuria, presence of red cell casts or >80% dysmorphic RBCs, elevated creatinine or declining renal function, or hypertension with hematuria and proteinuria. 1

If Alport syndrome is suspected, obtain audiogram and slit lamp examination. 1, 2

Critical Pitfalls to Avoid

• Never assume isolated microscopic hematuria requires extensive imaging in an otherwise well child - this exposes the child to unnecessary risk 2
• Do not delay imaging when an abdominal mass is present - this is a critical red flag 3, 2
• Do not perform advanced imaging (CT, MRI, VCUG) for isolated, transient microscopic hematuria in an otherwise well child 2
• Hypotension is an unreliable clinical indicator for prompting imaging in children 1, 2
• Blood at the urethral meatus with pelvic fractures requires investigation of the urethra and bladder (50% incidence of genitourinary injury) 1, 2

Follow-Up Considerations

Monitor for long-term complications including hypertension and chronic kidney disease. 3 Many patients with isolated microscopic hematuria who are otherwise asymptomatic are followed clinically without more extensive workup. 1