While most causes of haematuria are benign and self-limiting, it is important to distinguish which cases require more urgent assessment and investigation.

Population studies of school-aged children suggest that about 1% of them have two or more dipsticks positive for microscopic haematuria, but this only persists at 6 months in a third of this population.

Haematuria is the presence of red blood cells in the urine.  It can be microscopic or macroscopic.

• Microscopic

– > 5 erythrocytes per high-power field seen on microscopy of centrifuged urine

• Macroscopic (or gross)

– Red or brown (cola-coloured) urine with erythrocytes seen on microscopy

Urine dipsticks are very sensitive and can be positive at <5 RBCs per high power field.

Macroscopic Haematuria

History

  • What is the colour of the urine?

Brown (tea- or cola-): renal or glomerular cause of haematuria.

Red or pink: lower tract origin, particularly if bleeding occurs only with the onset of micturition.

Turbid: presence of cells, seen in glomerular disease or infection.

  • What is the timing of the bleeding?

Onset or end of micturition: Lower tract/Urethra

Throughout: Bladder or upper renal tract

  • Is there pain/dysuria?

May indicate urinary tract infection (UTI)

  • Are there any preceding infections?

Group A Streptococcal infection:  may indicate post-infectious glomerulonephritis

Bloody Diarrhoea (E Coli O157): may indicate haemolytic uraemic syndrome (HUS)

  • Is there any history of trauma?
  • Is the patient menstruating?
  • Does the patient have Sickle Cell Disease

 May indicate pupillary necrosis

  • Is there any history of fever / malaise / weight loss / alopecia / rash / joint pains? May indicate multisystem disease
  • Is there a family history of …?  Haematuria, Renal problems, Hearing loss
  • Is there evidence of faltering growth?

This may indicate underlying chronic kidney disease

Microscopic Haematuria

This is usually an incidental finding and is known to occur with fever, illness, vigorous exercise and cystourethritis secondary to insufficient fluid intake.

History

  • Has there been a preceding or current febrile illness?
  • What is the child’s fluid intake?
  • Has the child complained of any pain – back, suprapubic or vulval?
  • Have there been any episodes of gross haematuria associated with illness? (IgA Nephropathy)
Examination (for microscopic and macroscopic haematuria)

The aim of examination is to assess for any underlying renal problem that may require discussion and referral to a paediatrician.  Particular attention should be paid to:

  • Oedema: Extremities and around the eyes
  • Abdomen: Loin pain, Masses
  • Genitalia: External irritation or trauma (accidental or non accidental)
  • Skin: Rashes, Purpura (HSP)
  • Joints: Swelling, Pain, reduced range of movement

If possible in primary care, the following are useful to record:

  • Blood Pressure
  • Dipstick Urine and send for MC+S

Weight and height (plotted on an appropriate centile chart for age and gender)

The following are considered ‘Red Flags’ for serious illness and warrant same day discussion and assessment in paediatrics:

  • Evidence of oedema: This may indicate protein loss and an underlying renal cause
  • Blurred vision/headaches: This may suggest hypertension and underlying renal cause.
  • Purpura (especially if palpable and lower limb/buttock): may indicate systemic disease or HSP (Henoch-Schonlein Purpura)
  • Oliguria (passing very small amounts of urine): this may suggest renal failure
  • Unexplained genital injury – raises safeguarding concerns.

It is important to establish the presence of true haematuria in the first instance by performing dipstick test AND microscopy:

Dipsticks Red Urine Clear Urine
POSITIVE RBC on microscopy : Macroscopic Haematuria RBC on microscopy : Microscopic haematuria   No RBC : Haemaglobinuria (haemolysis) Myoglubinuria (Rhabdomyolysis)
NEGATIVE Other colouring supernatant (examples below) NORMAL

 

NB: A delay in performing microscopy can lead to red cell lysis and misleading results.

Drugs and foods that can discolour urine to give it the appearance of haematuria:

  • Rifampicin
  • Iron supplements eg, ferrous sulfate
  • Nitrofurantoin
  • Beetroot
  • Blackberries
  • Senna
  • Metronidazole
  • Ketamine (used as recreational drug)
  • Chemotherapy drugs (eg, daunorubicin and doxorubicin).

Macroscopic Haematuria:

This always requires further investigation so needs referral for ongoing investigations/management.  This would usually be same day assessment via the Paediatric Assessment Unit and referrals can be made via switchboard to the on call telephone, or registrar bleep out of hours. 

If UTI is suspected  – manage as per UTI guidance ( See separate guidance on UTI)

Microscopic Haematuria:

If isolated microscopic haematuria is found, please re check and only investigate if there are three positive urines for RBCs, which do not occur following exercise.  If haematuria remains present, please arrange the following:

  • urine microscopy
  • urine calcium:creatinine ratio
  • dipstick urine testing of immediate family

If these are all normal, the family can be reassured and the child can be followed up in 6 months’ time.  If microscopic haematuria persists at 6 months, a referral to General Paediatrics via ERS for further investigation is warranted.

At the 6 month review, it is important to assess:

1.Urine dipstick for protein and blood

2. Blood Pressure

3. Growth (height and weight)

Presence of protein in the urine (early morning sample) should prompt a urine protein:creatinine ratio or urine albumin:creatinine ratio and referral to paediatrics if this is elevated, or if any other concerns of underlying renal pathology.  This should be made to General Paediatrics via ERS.  If you would like to discuss the urgency of referral, please be in touch with us via Kinesis.

In the meantime:

  • If urine MC&S shows a UTI, treat urinary tract infections with an appropriate antimicrobial regimen according to local protocol.
  • Treat skin or throat streptococcal infections with phenoxymethylpenicillin (Penicillin V) following an appropriate swab.

Microscopic haematuria without any other signs and symptoms:

– Often is benign

  • Can be familial (Alport syndrome)

– Resolves spontaneously in many cases (transient haematuria)

Please refer to Paediatrics urgently (same day assessment to PAU via switchboard):

• Macroscopic haematuria

• Other ‘Red Flags’ as described above

In the case of persistent (> 6 months) microscopic haematuria that has been confirmed as genuine in laboratory microscopy, please consider referral to General Paediatrics via ERS. If unsure of need or urgency, please discuss via Advice & Guidance on ERS in the first instance. 

The following will definitely need referral:

  • Associated proteinuria
  • Faltering growth
  • Hypertension (if symptomatic, refer urgently as per ‘Red Flags’)
  • Hearing loss
  • Family history of renal disease or deafness
  • Nephrolithiasis / Renal stones (or Paediatric Urologist)

Refer to a Paediatric Urologist urgently if:

• Obstructive uropathy

• Trauma (usually via ED)

• Suspected Tumours (and discussion with paediatrics).

Please consider using this table to record further urine dipstick results:

Date

Timing of sample

Blood

 Protein

Blood pressure
         
         
         
         
         
         
         

 

https://www.infokid.org.uk/

UTI Guideline on this website

NICE Guidelines: UTI in children. https://cks.nice.org.uk/topics/urinary-tract-infection-children/

NICE Guidelines: When to suspect maltreatment in Under 18s https://www.nice.org.uk/guidance/cg89

15-minute consultation: the management of microscopic haematuria. Archives of Disease in Children: Education and Practice. https://ep.bmj.com/content/102/5/230 (requires membership or open Athens to view)