What are the common causes of hematuria with dysuria and flank pain?

Blood in Urine with Burning and Back Pain: Common Causes

The combination of hematuria (blood in urine), dysuria (burning), and flank/back pain most commonly indicates either urinary tract infection with pyelonephritis or urolithiasis (kidney stones), both of which require prompt evaluation to prevent serious complications including sepsis, renal scarring, or obstructive uropathy. 1, 2

Primary Differential Diagnoses

Acute Pyelonephritis (Kidney Infection)

This is a severe upper urinary tract infection that presents with the classic triad you describe:

• Fever ≥38°C (100.4°F) with systemic symptoms including chills, nausea, and vomiting 1, 2, 3
• Flank pain or costovertebral angle tenderness that distinguishes it from simple bladder infections 1, 2, 3
• Dysuria (burning urination) along with urinary frequency, though dysuria can be absent in up to 20% of cases 3
• Hematuria with pyuria (white blood cells) and bacteriuria on urinalysis 1, 2

Critical point: Pyelonephritis can rapidly progress to sepsis and requires immediate antibiotic therapy, as 95% of patients become afebrile within 48 hours of appropriate treatment 2. If fever persists beyond 72 hours, imaging with contrast-enhanced CT is mandatory to exclude complications like renal abscess 1, 2.

Urolithiasis (Kidney or Ureteral Stones)

This presents with:

• Acute severe flank pain from ureteral hyperperistalsis, often described as colicky and radiating to the groin 1
• Hematuria from irritation and trauma to the ureter, present in approximately 77-85% of cases with ureteral stones 1, 4
• Dysuria may occur if the stone is in the lower ureter near the bladder 1
• Important caveat: Absence of hematuria does NOT exclude stones—15-23% of confirmed stone cases have no blood in urine 4

Immediate Evaluation Algorithm

Step 1: Assess Severity and Need for Emergency Referral

Refer immediately to emergency department if: 5

• Severe pain requiring evaluation within 30 minutes
• Fever with signs of systemic infection or shock
• Inability to tolerate oral intake
• Age >60 years (to exclude vascular emergencies like leaking aortic aneurysm)
• Pregnancy (to exclude ectopic pregnancy or complicated pyelonephritis)

Step 2: Obtain Diagnostic Studies

Mandatory initial tests: 1, 2

• Urinalysis with microscopy looking for pyuria, bacteriuria, white blood cells, red blood cells, and nitrites
• Urine culture with antimicrobial susceptibility testing in all suspected pyelonephritis cases
• Blood cultures if patient appears systemically ill or has high fever

Step 3: Risk Stratification for Imaging

Imaging is NOT initially indicated for uncomplicated pyelonephritis 1, 2. However, obtain contrast-enhanced CT abdomen/pelvis if: 1, 2

• No clinical improvement within 48-72 hours of antibiotics
• High-risk features present: diabetes, immunocompromise, anatomic urinary abnormalities, transplant recipient, indwelling catheter
• History of kidney stones suggesting possible obstructive pyelonephritis

For suspected urolithiasis: Non-contrast CT is the gold standard diagnostic tool and should be performed when stone disease is suspected based on the pain pattern 1, 4.

Less Common but Important Causes

Glomerulonephritis

Consider if: 1

• Tea-colored urine with proteinuria (>2+ on dipstick)
• Red blood cell casts on microscopy
• Recent streptococcal infection, rash, or joint pains
• Absence of white cells or organisms in urine

Urinary Tract Malignancy

Gross hematuria carries >10% risk of malignancy and warrants urgent urologic referral 1. However, this typically presents as painless hematuria, making it less likely with your symptom complex of pain and burning 1.

Urinary Tract Infection (Lower Tract/Cystitis)

Simple cystitis causes dysuria and hematuria but typically lacks flank pain and fever 1. The presence of back pain suggests upper tract involvement (pyelonephritis) rather than isolated bladder infection.

Critical Management Pitfalls to Avoid

• Do NOT delay antibiotic treatment while awaiting culture results in suspected pyelonephritis—empiric therapy should begin immediately 2, 3
• Do NOT assume anticoagulation explains hematuria—pursue full evaluation even in patients on blood thinners 1
• Do NOT rely on absence of hematuria to exclude stones—up to 23% of confirmed stones have no microscopic hematuria 4
• Do NOT obtain screening urinalysis or urinary cytology for cancer detection in the initial workup of symptomatic hematuria 1
• Do NOT dismiss symptoms in elderly patients—maintain high suspicion for serious pathology including vascular emergencies 5