Last reviewed: March 2026
Contents
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Hematuria — UTI
Child presents with painful hematuria, dysuria, and urinary frequency. Urinalysis positive for leukocyte esterase and nitrites with pyuria and bacteriuria. Hematuria visible throughout micturition consistent with bladder mucosal inflammation.
History and exam not consistent with glomerulonephritis, nephrolithiasis, coagulopathy, trauma, or malignancy. No hypertension, edema, or oliguria. Creatinine within normal limits.[1]
Plan: Outpatient antibiotic therapy. Discharge with PCP follow-up in 1-2 weeks for reassessment and repeat urinalysis. Outpatient renal ultrasound if recurrent UTI or atypical features. Return for flank pain, fever, vomiting, or inability to void.
Hematuria — Glomerulonephritis Concern
Child presents with dark brown (“cola-colored”) urine, periorbital and/or lower extremity edema, and hypertension. History notable for pharyngitis or skin infection 1-3 weeks prior. Urinalysis shows hematuria with proteinuria and RBC casts.
Presentation concerning for acute post-streptococcal glomerulonephritis. Differential also includes IgA nephropathy, membranoproliferative GN, lupus nephritis, and HUS. Not consistent with simple UTI, nephrolithiasis, or benign hematuria given the constellation of hypertension, edema, and nephritic sediment.[2]
Plan: Pediatric nephrology consulted. Admit for blood pressure management, fluid restriction, and monitoring of renal function.
Hematuria — Benign / Outpatient
Child presents with microscopic hematuria found incidentally on urinalysis. Asymptomatic with normal blood pressure, no edema, no proteinuria, and normal creatinine. No recent illness, trauma, or medication changes.
History and exam not consistent with glomerulonephritis, UTI, nephrolithiasis, malignancy, or coagulopathy. Isolated microscopic hematuria in a well child is most commonly benign (idiopathic, thin basement membrane disease, hypercalciuria, exercise-induced).[1]
Plan: Discharge with PCP follow-up for repeat urinalysis in 1-2 weeks. Outpatient renal ultrasound and urine calcium-to-creatinine ratio. Return for gross hematuria, flank pain, swelling, or decreased urine output.
Clinical Education
DDx by Presentation
Painful hematuria suggests lower urinary tract: UTI (most common), nephrolithiasis, trauma, hemorrhagic cystitis (adenovirus, cyclophosphamide).[1]
Painless hematuria suggests glomerular or upper tract: PSGN, IgA nephropathy, Alport syndrome, thin basement membrane disease, Wilms tumor, polycystic kidney disease. Cola-colored or brown urine = glomerular origin. Bright red = lower tract.
Post-Strep Glomerulonephritis
PSGN is the most common glomerulonephritis in children and the one you cannot miss in the ED. Occurs 1-3 weeks after GAS pharyngitis or 3-6 weeks after GAS skin infection. Classic triad: hematuria, hypertension, edema.[2]
Complement levels are key: Low C3 with normal C4 is classic for PSGN. If both C3 and C4 are low, think lupus or MPGN. ASO titers confirm recent strep pharyngitis; anti-DNase B is more sensitive for skin infection.
Prognosis is excellent in children. >95% recover completely. Hypertension and edema resolve within 1-2 weeks. Microscopic hematuria may persist for up to 1-2 years.
Nephrotic vs Nephritic Syndrome
| Feature | Nephrotic | Nephritic |
| Proteinuria | Massive (>3.5 g/day) | Moderate |
| Hematuria | Minimal | Prominent (RBC casts) |
| Edema | Severe (anasarca) | Mild-moderate |
| Hypertension | Less common | Common |
| Key example | Minimal change disease | PSGN, IgA, lupus |
Not Blood Mimics
Not everything that looks red is blood. Beets, blackberries, and food dyes turn urine red but are dipstick-negative for blood. Rifampin turns urine orange-red. Myoglobinuria (rhabdomyolysis) is dipstick-positive for blood but has no RBCs on microscopy. Urate crystals in newborn diapers create an orange-pink stain (“brick dust”) that parents mistake for blood.[3]
When to Worry
Hypertension is the most important vital sign to check. Use age/sex/height-appropriate percentiles. Hypertension with hematuria = glomerulonephritis until proven otherwise.
Other red flags: oliguria or anuria, significant proteinuria, rising creatinine, edema, RBC casts on microscopy, and systemic symptoms (fever, weight loss, rash suggesting vasculitis or malignancy).
Disposition
Admit: Hypertension requiring management. Suspected glomerulonephritis. Oliguria or rising creatinine. Concern for HUS (hematuria + thrombocytopenia + AKI after bloody diarrhea).
Discharge: Simple UTI with hematuria. Isolated microscopic hematuria with normal BP, no proteinuria, and normal creatinine. PCP follow-up for repeat UA and outpatient nephrology referral if persistent.
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