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Hematuria is a common sign of urinary tract disease but also occurs in otherwise healthy children.1,2 Hematuria can present as either discolored red, brown, or tea-colored urine (eFig. 467.1), or it can present as yellow urine with a positive dipstick for blood. Clues to the diagnosis may be obtained from a history focused on whether the hematuria is painless, intermittent, or persistent, or microscopic or gross. A family history of hematuria or renal disease is important. Brown or tea-colored urine is common in glomerulonephritis, whereas red or obviously bloody urine suggests postglomerular bleeding. Glomerulonephritis is commonly associated with other abnormalities of the urine such as proteinuria and cellular casts as well as hypertension, edema, and reduced renal function. Table 468-1 provides a simple mnemonic for the causes of hematuria throughout the urinary tract. A diagnostic approach and differential diagnosis for discolored urine and microscopic hematuria are shown in Figure 468-1.

Table Graphic Jump Location
Table 468-1. A Mnemonic for the Causes of Hematuria
Figure 468-1.
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Algorithm for the evaluation of the child with hematuria.


Microscopic hematuria, defined as the presence of a positive urine dipstick for blood and more than five RBCs/hpf on centrifuged urine, occurs in approximately 1% of school-age children on at least one urine sample. About 0.5% will continue to have hematuria on two of three samples, and a third have hematuria on three samples.1,2 Fewer than one third of patients diagnosed with hematuria demonstrate hematuria 1 year later. Only a very small number of children with microscopic hematuria had significant renal or urological disease. Microscopic hematuria can occur following vigorous exercise; thus, it is common in school-age children and in the majority of cases is benign.


Hypercalciuria, defined as more than 4 mg urinary calcium/kg per day, has been found in significant numbers of children with microscopic hematuria.3 This association is even stronger if there is a family history of stone disease or the occurrence of gross hematuria. The calcium-to-creatinine ratio can be used to screen for hypercalciuria; for children or adolescents, a urinary Ca/Cr ratio greater than 0.2 is abnormal.4


The value of urinary tract imaging in children with microscopic hematuria is controversial. The yield of routine IVP or ultrasound is low, and reported findings are frequently of little clinical significance. When microscopic hematuria persists for several months, decisions on the need for urinary tract imaging are made based on other concerns. Voiding cystourethrograms and cystoscopy are rarely helpful and are not indicated for the routine evaluation of ...

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