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.
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.
Onset or end of micturition: Lower tract/Urethra
Throughout: Bladder or upper renal tract
May indicate urinary tract infection (UTI)
Group A Streptococcal infection: may indicate post-infectious glomerulonephritis
Bloody Diarrhoea (E Coli O157): may indicate haemolytic uraemic syndrome (HUS)
May indicate pupillary necrosis
This may indicate underlying chronic kidney disease
This is usually an incidental finding and is known to occur with fever, illness, vigorous exercise and cystourethritis secondary to insufficient fluid intake.
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:
If possible in primary care, the following are useful to record:
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:
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:
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)
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:
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:
Microscopic haematuria without any other signs and symptoms:
– Often is benign
– 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:
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 |
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)
