Hematuria Clinical Presentation

Updated: Jun 26, 2017
  • Author: Sanjeev Gulati, MD, MBBS, DNB(Peds), DM, DNB(Neph), FIPN(Australia), FICN, FRCPC(Canada); Chief Editor: Craig B Langman, MD  more...
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Presentation

History

The first step in the evaluation of hematuria is a detailed review of the history and a thorough physical examination.

The presence or absence of hypertension or proteinuria helps to decide how extensively to pursue the diagnostic evaluation. The initial evaluation should be directed toward important and potentially life-threatening causes of hematuria in any child who has any of the following in addition to hematuria: hypertension, edema oliguria, significant proteinuria (more than 500 mg per 24 hours), or RBC casts. An attempt should be made to distinguish glomerular causes of hematuria from extraglomerular ones, as this helps in prioritizing the investigations.

  • A history of passage of clots in urine suggests an extraglomerular cause of hematuria.
  • A history of fever, abdominal pain, dysuria, frequency, and recent enuresis in older children may point to a urinary tract infection as the cause of hematuria.
  • A history of recent trauma to the abdomen may be indicative of hydronephrosis.
  • A history of early-morning periorbital puffiness, weight gain, oliguria, the presence of dark-colored urine, and the presence of edema or hypertension suggests a glomerular cause.
  • Hematuria due to glomerular causes is painless.
  • A history of a recent throat or skin infection may suggest postinfectious glomerulonephritis.
  • A history of joint pains, skin rashes, and prolonged fever in adolescents suggests a collagen vascular disorder.
  • The presence of anemia cannot be accounted for by hematuria alone, and, in a patient with hematuria and pallor, other conditions such as systemic lupus erythematosus and bleeding diathesis should be considered.
  • Skin rashes and arthritis can occur in Henoch-Schönlein purpura and systemic lupus erythematosus.
  • Information regarding exercise, menstruation, recent bladder catheterization, intake of certain drugs or toxic substances, or passage of a calculus may also assist in the differential diagnoses.
  • Because certain diseases that present with hematuria are inherited or familial, asking for a family history that is suggestive of Alport syndrome, collagen vascular diseases, urolithiasis, or polycystic kidney disease is important.
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Physical

In the general physical examination, the most important step is to measure the blood pressure (with an appropriate-sized cuff) and evaluate for the presence of periorbital puffiness or peripheral edema. [5, 6]

  • A detailed skin examination is necessary to look for purpura.
  • An abdominal examination is indicated to look for palpable kidneys (Wilms tumor or hydronephrotic kidneys).
  • A careful examination of the genitalia is also important.
  • A detailed ophthalmological evaluation is helpful in familial hematurias.
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Causes

Hematuria can be of glomerular or nonglomerular origin. Brown-colored urine, RBC casts, and dysmorphic (small deformed, misshapen, sometimes fragmented) RBCs and proteinuria are suggestive of glomerular hematuria. Reddish or pink urine, passage of blood clots, and eumorphic (normal sized, biconcavely shaped) erythrocytes are suggestive of a nonglomerular bleeding site.

Potential causes of hematuria in children include the following:

  • Glomerular hematuria
  • Nonglomerular hematuria
    • Fever
    • Strenuous exercise
    • Mechanical trauma (masturbation)
    • Menstruation
    • Foreign bodies
    • Urinary tract infection
    • Hypercalciuria/urolithiasis
    • Sickle cell disease/trait
    • Coagulopathy
    • Tumors
    • Drugs/toxins (nonsteroidal anti-inflammatory drugs [NSAIDs], anticoagulants, cyclophosphamide, ritonavir, indinavir)
    • Anatomic abnormalities (hydronephrosis, polycystic kidney disease, vascular malformations)
    • Hyperuricosuria
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