What is the treatment approach for a teenager presenting with hematuria?

Treatment Approach for Hematuria in a Teenager

The treatment of hematuria in a teenager is determined entirely by the underlying cause identified through systematic evaluation—there is no treatment for "hematuria" itself, only for the specific disease causing it. 1

Initial Diagnostic Evaluation to Guide Treatment

The first critical step is determining whether the hematuria is glomerular or non-glomerular, as this fundamentally directs all subsequent management decisions. 1

Confirm True Hematuria

• Verify microscopic hematuria with ≥3 red blood cells per high-power field on urinalysis with microscopic examination, as dipstick alone has only 65-99% specificity and can produce false positives. 1, 2
• Exclude pseudohematuria from menstruation, vigorous exercise, or food substances that don't contain actual red blood cells. 2

Distinguish Glomerular from Non-Glomerular Causes

Glomerular indicators (require nephrology referral):

• Tea-colored or cola-colored urine with proteinuria >2+ on dipstick 1, 2
• Dysmorphic red blood cells >80% on phase contrast microscopy 1
• Red blood cell casts (pathognomonic for glomerular disease) 1
• Elevated serum creatinine or declining renal function 1
• Hypertension accompanying hematuria 3, 1

Non-glomerular indicators (require urologic evaluation):

• Bright red blood with minimal or no proteinuria 2
• Normal-appearing red blood cells >80% 1
• Dysuria, frequency, urgency, or fever suggesting urinary tract infection 3, 1
• Flank pain suggesting urolithiasis 2

Treatment Based on Specific Causes

For Urinary Tract Infection

• Obtain urine culture before starting antibiotics (clean-catch or catheterization, not bag collection due to high false-positive rates). 3
• Treat with appropriate antibiotics based on culture results. 3
• All teenagers with first febrile UTI require renal ultrasound after confirming infection to detect congenital or acquired abnormalities. 3

For Glomerular Disease (Post-Infectious Glomerulonephritis, IgA Nephropathy)

• Immediate nephrology referral for persistent significant proteinuria, red cell casts, or declining renal function. 1
• Obtain blood urea nitrogen, serum creatinine, complete blood count, and complement levels (C3, C4) if glomerular disease suspected. 3, 1
• Investigate recent streptococcal infection if post-infectious glomerulonephritis suspected. 3
• Monitor for long-term complications including hypertension and chronic kidney disease. 3
• Renal biopsy may be necessary for definitive diagnosis of IgA nephropathy, Alport syndrome, or other glomerular diseases. 2

For Urolithiasis

• Renal and bladder ultrasound as first-line imaging for painful hematuria. 1
• Evaluate spot urine calcium-to-creatinine ratio to assess for hypercalciuria. 3, 1
• Plain radiography may detect calcifications and radiopaque stones. 3, 1
• CT may be useful if ultrasound negative but high clinical suspicion persists. 1

For Trauma-Related Hematuria

• Contrast-enhanced CT of abdomen and pelvis for macroscopic hematuria following trauma. 1
• Blood at urethral meatus with pelvic fractures requires investigation of urethra and bladder (50% incidence of genitourinary injury). 1
• Minor trauma to an anomalous kidney can cause major clinical consequences. 1

For Isolated Microscopic Hematuria in Otherwise Well Teenager

• No imaging or further workup is required for isolated microscopic hematuria without proteinuria or dysmorphic red blood cells, as these patients are unlikely to have clinically significant renal disease. 1
• A large study of 325 pediatric patients with microscopic hematuria found no clinically significant findings on imaging, supporting conservative management. 1
• Clinical follow-up at six-month intervals is appropriate for isolated glomerular hematuria. 2

For Macroscopic (Gross) Hematuria

• Ultrasound of kidneys and bladder is the initial imaging modality to screen for structural lesions, anatomic abnormalities, nephrolithiasis, and rarely renal or bladder tumors. 1
• Plain radiography may be performed concurrently to detect stones. 1

Critical Red Flags Requiring Urgent Evaluation

Abdominal Mass with Hematuria

• Urgent ultrasound evaluation is mandatory as this raises concern for Wilms tumor, fundamentally changing management from isolated hematuria. 1
• Ultrasound confirms renal origin, assesses contralateral kidney, evaluates inferior vena cava involvement, and determines tumor size. 1
• After ultrasound confirms renal mass, proceed urgently to chest CT for staging and consider contrast-enhanced abdominal CT or MRI. 1

Systemic Symptoms

• Rash, arthritis, or soft-tissue edema suggests systemic disease requiring immediate evaluation. 3, 1
• Fever with costovertebral angle tenderness suggests pyelonephritis. 3

Key Historical Elements That Direct Treatment

• Recent streptococcal infection suggests post-infectious glomerulonephritis. 3, 1
• Family history of renal disease, hearing loss (Alport syndrome), or sickle cell disease. 3, 1
• Recent trauma or strenuous exercise may cause transient hematuria requiring no treatment. 3, 1
• Medications that may cause hematuria should be reviewed. 1

Common Pitfalls to Avoid

• Never perform advanced imaging (CT, MRI, VCUG) for isolated, transient microscopic hematuria in an otherwise well teenager—this exposes the child to unnecessary risk. 1
• Isolated microscopic hematuria is very rarely the presenting scenario of Wilms tumor; brief, self-limited findings should not trigger oncologic concerns. 1
• Delaying imaging when an abdominal mass is present by assuming isolated hematuria requires no workup is a critical error. 1
• Do not ignore gross hematuria even if self-limited, as it requires urologic evaluation. 2, 4

Follow-Up for Negative Initial Evaluation

• If initial workup negative but hematuria persists, repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring. 1, 2
• Immediate re-evaluation warranted if gross hematuria develops, significant increase in microscopic hematuria occurs, new urologic symptoms appear, or development of hypertension/proteinuria. 1, 2