How should I evaluate and manage a 6‑year‑old child presenting with gross hematuria?

Evaluation and Management of Gross Hematuria in a 6-Year-Old Child

Immediate Clinical Assessment

Begin with a focused history targeting specific red flags: recent streptococcal infection (within 1–3 weeks), family history of kidney disease or hearing loss, sickle cell disease, recent trauma (even minor), strenuous exercise, medications, dysuria, flank pain, frequency, bloody diarrhea, joint pains, rash, and any history of foreign body insertion. 1

On physical examination, specifically assess for fever, arthritis, rashes, soft-tissue edema, nephromegaly, abdominal masses, genital or anal bleeding (concerning for abuse), costovertebral angle tenderness, and measure height and weight as indicators of chronic disease. 1

Laboratory Confirmation and Differentiation

Perform urinalysis with microscopic examination immediately to confirm true hematuria (≥3 RBCs per high-power field) and differentiate glomerular from non-glomerular causes—this single test fundamentally determines your entire diagnostic pathway. 1

Glomerular indicators (require nephrology referral):

• Tea-colored urine with proteinuria (>2+ on dipstick) 1
• Dysmorphic red blood cells (>80%) on phase contrast microscopy 1
• Red blood cell casts (pathognomonic for glomerulonephritis) 1
• Elevated serum creatinine or blood urea nitrogen 1

Non-glomerular indicators (require urologic evaluation):

• Bright red blood with normal-shaped RBCs 1
• White cells and microorganisms (suggests UTI) 1
• Absence of proteinuria or only trace amounts 1

Obtain a spot urine calcium-to-creatinine ratio to evaluate for hypercalciuria, one of the most common causes of pediatric hematuria. 1, 2

Imaging Strategy Based on Clinical Scenario

For isolated gross hematuria WITHOUT a palpable mass:

Renal and bladder ultrasound is your first-line imaging modality—it effectively displays kidney anatomy, screens for structural lesions, stones, cysts, and ureteropelvic junction obstruction without radiation exposure. 1, 3

Plain radiography may be performed concurrently to detect radiopaque stones and calcifications. 1

Critical exception—palpable abdominal mass:

If you palpate an abdominal mass, this is NOT isolated hematuria—proceed urgently to renal ultrasound to confirm renal origin, assess the contralateral kidney, evaluate for inferior vena cava involvement, and determine tumor size. 1

After ultrasound confirms a renal mass, urgently obtain chest CT for staging and consider contrast-enhanced abdominal CT or MRI to define local extent and vascular invasion (Wilms tumor protocol). 1

For traumatic hematuria:

Any history of abdominal or flank trauma—even minor trauma to an anomalous kidney—warrants contrast-enhanced CT of the abdomen and pelvis when gross hematuria is present. 4

Blood at the urethral meatus with pelvic fractures requires retrograde urethrography before catheter placement. 4

Common Etiologies in This Age Group

The most frequent causes in a 6-year-old are urinary tract infection (14%), congenital urologic anomalies (13%), hypercalciuria, post-infectious glomerulonephritis, and benign urethrorrhagia (19% in boys). 3, 5, 2

Urolithiasis accounts for approximately 5% of cases, while malignancy (Wilms tumor, bladder transitional cell carcinoma) is exceedingly rare (<1%) but must be excluded. 3, 6, 2

In 34% of cases, no etiology is found after complete evaluation—these children can be managed with clinical observation. 3

What NOT to Do

Do not order CT, MRI, or voiding cystourethrography for isolated microscopic hematuria in an otherwise well child—a large study of 325 pediatric patients found no clinically significant findings, and these modalities expose the child to unnecessary risk. 1

Do not assume isolated microscopic hematuria requires extensive workup; patients without proteinuria or dysmorphic RBCs are unlikely to have clinically significant renal disease. 1

Cystoscopy should be reserved for the minority in whom hematuria persists after negative imaging or those with ambiguous findings—it is not part of the initial evaluation. 3, 7

When to Refer

Refer to nephrology if you identify tea-colored urine, proteinuria >2+, dysmorphic RBCs >80%, red cell casts, elevated creatinine, hypertension, or family history of kidney disease with hearing loss (Alport syndrome). 1, 5

Refer to urology urgently if ultrasound reveals a mass, persistent unexplained gross hematuria after negative initial workup, or structural anomalies requiring surgical intervention. 1, 7

Follow-Up for Negative Initial Workup

If the complete evaluation is negative but isolated microscopic hematuria persists, perform serial urinalysis at 6,12,24, and 36 months—after two consecutive negative annual urinalyses, no further testing is necessary. 1