How should a child with moderate hematuria on urinalysis who is now complaining of pain be evaluated and managed?

Evaluation and Management of Moderate Hematuria with Pain in a Child

A child with moderate hematuria on urinalysis who is now complaining of pain requires immediate renal and bladder ultrasound as first-line imaging to evaluate for urolithiasis, structural abnormalities, or masses, followed by targeted laboratory evaluation including urinalysis with microscopy, urine culture, spot urine calcium-to-creatinine ratio, and basic metabolic panel. 1, 2

Immediate Clinical Assessment

Begin by characterizing the pain and associated symptoms:

• Location and character of pain: Flank pain suggests upper urinary tract pathology (stones, obstruction), while suprapubic pain or dysuria points to lower tract causes (infection, bladder stones) 1
• Fever presence: Fever with hematuria strongly suggests urinary tract infection or pyelonephritis and requires immediate urine culture before antibiotics 1, 3
• Urinary symptoms: Dysuria, frequency, urgency indicate possible UTI; these symptoms require culture confirmation 1, 3
• Recent trauma history: Even minor trauma can cause significant injury in children with congenital renal anomalies (present in 1-4% of population) 1, 2
• Recent streptococcal infection: Suggests post-infectious glomerulonephritis, particularly if accompanied by tea-colored urine 1, 2, 4
• Strenuous exercise: Can cause transient hematuria that resolves with rest 2

Critical physical examination findings:

• Palpate for abdominal mass: Any palpable mass with hematuria requires urgent ultrasound to exclude Wilms tumor, though this is rare (<1% of cases) 1, 2
• Costovertebral angle tenderness: Suggests pyelonephritis or upper tract pathology 1, 3
• Blood pressure measurement: Hypertension suggests glomerular disease 1
• Assess for rash, arthritis, edema: These findings suggest systemic disease like Henoch-Schönlein purpura 1, 2

Laboratory Evaluation

Obtain the following tests immediately:

• Urinalysis with microscopic examination: Confirm true hematuria (≥5 RBCs per high-power field in children), assess for dysmorphic RBCs, red cell casts, and degree of proteinuria 1, 2
• Urine culture: Obtain before antibiotics if infection suspected; presence of white cells and microorganisms confirms UTI 1, 3
• Spot urine calcium-to-creatinine ratio: Hypercalciuria is a common cause of painful hematuria in children and predisposes to stone formation 1, 2
• Serum creatinine, BUN, complete blood count with platelets: Assess renal function and rule out coagulopathy 1

Indicators of glomerular versus non-glomerular bleeding:

• Glomerular features: Tea-colored urine, proteinuria >2+ on dipstick, dysmorphic RBCs >80%, red blood cell casts on phase contrast microscopy 1, 2
• Non-glomerular features: Bright red blood, minimal proteinuria, normal-shaped RBCs, presence of clots 1

Imaging Strategy

For painful hematuria (suspected urolithiasis):

• Renal and bladder ultrasound is the first-line imaging modality to detect stones, hydronephrosis, structural abnormalities, and masses 1, 2
• Plain radiography may be performed concurrently to detect radiopaque stones and calcifications 1, 2
• CT is reserved for cases where ultrasound is negative but clinical suspicion for urolithiasis remains high and detection would change management; use low-dose technique to minimize radiation 1, 2
• CT has >90% sensitivity and specificity for stone detection in adults, with proper low-dose protocols reducing radiation below traditional IVU 1, 2

For traumatic hematuria:

• Macroscopic hematuria after trauma requires contrast-enhanced CT of abdomen and pelvis to assess extent of renal injury 1, 2
• Isolated microscopic hematuria without concerning mechanism, hypotension, or associated injuries does not require emergency imaging 1, 2
• Radiologic evaluation is indicated when ≥50 RBCs are present on urinalysis, patient is hypotensive, or mechanism suggests significant injury 1, 2

Management Based on Etiology

If urinary tract infection is confirmed:

• Treat with appropriate antibiotics based on culture and sensitivity 1, 3
• Repeat urinalysis 6 weeks after treatment completion 3
• If hematuria resolves after infection treatment, no further urologic workup is needed in low-risk children 3
• All children under 6 years with first febrile UTI require renal ultrasound to detect congenital or acquired abnormalities 3

If urolithiasis is identified:

• Manage pain appropriately 1, 2
• Ensure adequate hydration 2
• Most pediatric stones pass spontaneously; urology referral for stones causing obstruction or persistent symptoms 2
• Evaluate for metabolic causes including hypercalciuria and hyperuricosuria 1, 2

If glomerular disease is suspected:

• Immediate nephrology referral is indicated for proteinuria >2+, dysmorphic RBCs >80%, red cell casts, elevated creatinine, or hypertension 1, 2
• Consider post-infectious glomerulonephritis if recent streptococcal infection and low C3 levels (C3 normalizes by 8 weeks) 4
• Renal biopsy may be necessary for definitive diagnosis of IgA nephropathy, Alport syndrome, or other glomerular diseases 1

If isolated microscopic hematuria without proteinuria:

• No imaging is indicated for children with isolated microscopic hematuria without proteinuria or dysmorphic RBCs, as clinically significant renal disease is unlikely 1, 2
• Clinical follow-up with repeat urinalysis is appropriate 1, 2
• Screen family members' urine to identify benign familial hematuria or thin basement membrane nephropathy 1, 2

Critical Pitfalls to Avoid

• Never assume pain with hematuria is benign without imaging: Urolithiasis, obstruction, and structural abnormalities require ultrasound evaluation 1, 2
• Do not delay urine culture if infection is suspected: Obtain culture before starting antibiotics 1, 3
• Do not perform CT as initial imaging for non-traumatic painful hematuria: Ultrasound is first-line; CT is reserved for cases with negative ultrasound and high clinical suspicion 1, 2
• Do not ignore glomerular features: Tea-colored urine, significant proteinuria, dysmorphic RBCs, or red cell casts mandate nephrology referral 1, 2
• Do not attribute hematuria to minor trauma without imaging if macroscopic hematuria is present: Minor trauma to an anomalous kidney can cause major injury 1, 2
• Do not overlook family history: Alport syndrome, thin basement membrane nephropathy, and sickle cell disease have hereditary patterns 1, 2

Follow-Up Protocol

• If initial workup identifies a treatable cause (UTI, stone), treat and reassess 3, 2
• If hematuria persists without identified cause, repeat urinalysis and consider nephrology referral if proteinuria, hypertension, or declining renal function develops 1, 2
• After two consecutive negative urinalyses in asymptomatic children, further testing is generally unnecessary 2