How should a 7-year-old girl presenting with gross hematuria be evaluated and managed?

Evaluation of a 7-Year-Old Girl with Blood in Urine

Start with renal and bladder ultrasound as the first-line imaging study for this child with gross hematuria, after obtaining a thorough history, physical examination, and complete urinalysis with microscopy. 1, 2

Initial Clinical Assessment

Critical History Elements to Obtain

• Recent streptococcal infection (pharyngitis or impetigo within 1-3 weeks suggests post-infectious glomerulonephritis) 2
• Family history of renal disease, hearing loss (Alport syndrome), or hematuria (thin basement membrane nephropathy) 2
• Recent trauma (even minor trauma to an anomalous kidney can cause significant bleeding) 1, 2
• Dysuria, frequency, urgency, or fever (suggests urinary tract infection) 3, 2
• Flank or abdominal pain (raises concern for stones or obstruction) 2
• Recent strenuous exercise (can cause transient hematuria) 2
• Medications that may cause hematuria 2
• Rash, joint pain, or bloody diarrhea (suggests systemic disease like Henoch-Schönlein purpura) 2

Physical Examination Priorities

• Blood pressure measurement (hypertension suggests glomerulonephritis) 2
• Assess for edema (periorbital or peripheral edema indicates nephritic syndrome) 2
• Examine for rash (purpura suggests Henoch-Schönlein purpura) 2
• Palpate abdomen for masses (Wilms tumor, though rare, must be excluded) 2
• Check for costovertebral angle tenderness (suggests pyelonephritis or obstruction) 2
• Assess growth parameters (height and weight as indicators of chronic disease) 2

Essential Laboratory Evaluation

Urinalysis with Microscopy (Most Critical Test)

Complete urinalysis with microscopic examination is the only test uniformly required for all children with hematuria. 4

• Confirm true hematuria with ≥3 RBCs per high-power field on microscopic examination 2
• Examine for dysmorphic RBCs (>80% indicates glomerular source) 2
• Look for red blood cell casts (pathognomonic for glomerulonephritis) 2
• Assess proteinuria using dipstick; if ≥2+, obtain spot urine protein-to-creatinine ratio 2
• Check for white blood cells and bacteria (indicates urinary tract infection) 2

Additional Laboratory Tests Based on Urinalysis Findings

If glomerular features are present (dysmorphic RBCs, casts, or significant proteinuria):

• Serum creatinine and BUN to assess renal function 2
• Complete blood count 2
• Complement levels (C3, C4) if post-infectious glomerulonephritis suspected 2

If non-glomerular hematuria (normal-shaped RBCs, no proteinuria):

• Spot urine calcium-to-creatinine ratio to evaluate for hypercalciuria 2
• Urine culture if infection suspected 3, 2

Imaging Strategy

First-Line Imaging: Renal and Bladder Ultrasound

Ultrasound is the appropriate first-line imaging for gross hematuria in children because it avoids radiation, effectively displays kidney anatomy, and screens for structural lesions. 1, 2

Ultrasound will detect:

• Kidney stones (though sensitivity for ureteral stones is limited to 38%) 1
• Anatomic abnormalities (ureteropelvic junction obstruction, ureterocele, duplicated collecting systems) 5
• Renal masses (Wilms tumor, though extremely rare as a cause of isolated hematuria) 2
• Hydronephrosis 2
• Bladder abnormalities 2

When CT Is NOT Appropriate

CT is not appropriate in the initial evaluation of isolated nonpainful, nontraumatic hematuria in children. 1, 2 Reserve CT for:

• Painful hematuria with high suspicion for stones after negative ultrasound 1
• Traumatic hematuria with concerning mechanism or multiorgan injury 1

When Additional Imaging May Be Needed

• Plain radiography can be performed concurrently with ultrasound to detect radiopaque stones 2
• Voiding cystourethrography (VCUG) is indicated only if ultrasound shows suspicious findings, recurrent UTIs, or voiding symptoms—not for isolated hematuria 5

Management Based on Findings

If Isolated Microscopic Hematuria (Incidental Finding)

No imaging or further workup is required for isolated microscopic hematuria without proteinuria or dysmorphic RBCs, as these children are unlikely to have clinically significant renal disease. 2 A large study of 325 pediatric patients found no clinically significant findings on imaging in this scenario. 2

If Gross Hematuria with Normal Ultrasound and Urinalysis

If ultrasound and urinalysis are normal and the child is otherwise well, observation with repeat urinalysis is appropriate. 4, 6 Studies show that nearly half of children with nonglomerular gross hematuria have no identifiable cause, and their long-term prognosis is excellent. 6

If Glomerular Features Present

Immediate nephrology referral is indicated when any of the following are present:

• Dysmorphic RBCs >80% or red blood cell casts 2
• Protein-to-creatinine ratio >0.5 g/g 2
• Elevated serum creatinine 2
• Hypertension with hematuria 2

If Urinary Tract Infection Confirmed

Obtain urine culture before antibiotics, treat appropriately for 3-5 days with nitrofurantoin or cephalexin, and repeat urinalysis 6 weeks after treatment. 3 If hematuria resolves, no further workup is needed. 3 If hematuria persists, proceed with imaging. 3

If Hypercalciuria Identified

Hypercalciuria is one of the most common causes of nonglomerular gross hematuria in children. 6 Management includes increased fluid intake and dietary modification; nephrology referral may be warranted for persistent cases. 2

Common Pitfalls to Avoid

• Do not order CT as the initial imaging study for isolated hematuria—ultrasound is first-line and avoids radiation exposure 1, 2
• Do not skip microscopic urinalysis—dipstick alone is insufficient to guide management 2, 4
• Do not assume isolated microscopic hematuria requires extensive workup—most cases are benign and require only observation 2
• Do not delay nephrology referral when glomerular features are present (proteinuria, casts, dysmorphic RBCs, or elevated creatinine) 2
• Do not forget to check blood pressure—hypertension is a key indicator of glomerular disease 2
• Do not overlook family history—screening first-degree relatives' urine can diagnose thin basement membrane nephropathy or Alport syndrome 2

When to Refer to Pediatric Nephrology

• Persistent proteinuria (protein-to-creatinine ratio >0.2 g/g on three specimens) 3
• Dysmorphic RBCs >80% or red blood cell casts 2
• Elevated or rising serum creatinine 2
• Hypertension accompanying hematuria 2
• Family history of hereditary nephritis 2

When to Refer to Pediatric Urology

Urologic referral is more limited in children and includes: 4

• Stones >5 mm or that do not pass spontaneously 4
• Anatomic abnormalities detected on ultrasound 4, 5
• Gross hematuria that appears to originate from the urinary tract without an identified cause after complete evaluation 4
• Recurrent hematuria with negative nephrology workup 4