Pediatric Hematuria

By Philip E. Gleason, MD

 

Hematuria, or blood in the urine, is abnormal. The causes are quite varied. There are literally hundreds of different causes of hematuria. They range from very mild and sometimes unknown to possible life threatening disorders. Unfortunately, the amount or severity of hematuria has no relationship to the potential severity or seriousness of the cause. Hematuria can occur one or be recurrent on multiple occasions, or persist from day to day. Microscopic hematuria, or blood seen only under the microscope, is just as severe in fact as gross hematuria, which is blood in the urine seen with the naked eye. Both are considered signs of potentially serious disorder. Therefore, all hematuria or blood in the urine deserves evaluation.

The goal of evaluation is to identify potentially serious problems in the most efficient and expedient fashion to allow further therapy and management. A practical approach for hematuria evaluation is to consider possible anatomic or structural sources of hematuria. Other considerations include kidney disorders or diseases. Other diagnoses of exclusion include hypercalciuria, benign or idiopathic or familial hematuria, and prostatic menorrhagia.

Anatomic structural sources of hematuria include renal tumors, kidney stones, ureteral pelvic junction (UPJ) obstruction or vesicoureteral reflux (VUR) with UTI's etc. Less common sources include ureteral polyps or posterior urethral valves or meatal stenosis, or arterial venous malformation. Screening anatomic evaluation can include an IVP or possibly a renal US for Structural anatomic and functional evaluation of the kidneys and upper urinary tract. Lower urinary tract evaluation of the bladder and urethra is often accomplished with a VCUG. Further diagnostic procedures can include possible CT scan, arteriograms, or cystoscopy etc. One the primary cause is identified, it can be further treated and managed.

Kidney disorders include IGA nephropathy as well as glomerular nephritis and, particularly, post streptococcal glomerular nephritis or kidney inflammation or infections. Kidney sources of hematuria typically pursue a benign or normal future natural course unless they are related to hypertension, evidence of kidney insufficiency, or significant protein in the urine. If hematuria is associated with any of the above-mentioned related findings, further kidney evaluation including possible kidney biopsy and therapy is warranted.

If anatomic and kidney screening evaluations are benign, further diagnoses of exclusion are considered. These include hypercalciuria in which excessive calcium excretion in the urine can produce hematuria. Although there is theoretic potential for future predisposition to stones, this typically follows a benign or normal future natural course. Another potentially benign condition is idiopathic or unknown hematuria. This can also occur in families and is sometimes called familial hematuria. It is felt to represent possible "leakage" of red blood cells through the kidney with filtration of urine. It again typically follows a future benign natural course. Another possibility is meatal stenosis. All of these diagnoses should be considered diagnoses of exclusion after other more significant problems have been ruled out. One last specific mention of hematuria should include prostatic menorrhagia. This is a fairly specific presentation of hematuria as bloody urethral discharge in a pubertal or peripubertal male. It represents initiation and ongoing growth and development of the prostate at puberty from testosterone hormonal stimulation. This is felt to produce increased vascular congestion and potential menorrhagia from the prostate. Diagnosis is dependent upon a high index of suspicion and exclusion of other more significant pathology. It typically follows a benign natural course although this can occasionally run up to a few years.

Once evaluation and diagnosis of hematuria has occurred, further management is dependent upon the cause. Certainly specific causes are addressed. Non-specific evaluation is followed conservatively. It is recommended to follow annually with routine physical exam to identify any progressive difficulties with hypertension, kidney insufficiency, or protein in the urine as indicative of possible progressive nephrologic disorder. As long as that course is benign, it is typically recommended to pursue follow up serial urologic screening anatomic evaluation every 3 years as long as the hematuria persists. The thought processes includes concern over possibly missing any new problems that may develop or form or occur in the meantime if we just assume the hematuria is benign from a previous evaluation. Therefore, it is recommended to pursue serial evaluation every 3 years to exclude possibly missing interval development of pathology, again with either renal IVP, or US etc.

I hope this is helpful with regard to hematuria evaluation, diagnosis, therapy, and follow up in the pediatric patient.

 

© 2005-2010, Dr. Philip E. Gleason, MD