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Posted by Dr. Monica Wonnacott | September 14, 2016

Hematuria: Blood In The Urine

In follow up to my last post, I thought I’d stick with pee problems. If you’ve ever seen blood in your child’s urine, then you know how alarming that can be. The medical term for blood in the urine is hematuria, and it is not normal. While blood goes into the kidney, only urine comes out. The kidney has a very complex little filter system that prevents it from happening. When blood is in the urine, something has gone wrong.

What causes hematuria in kids?

There are over 100 different causes of hematuria. Sometimes, no cause is ever determined. The most common causes are listed:

  1. Bad UTIs (see URINARY TRACT INFECTIONS: DECODING PEE PROBLEMS) can cause so much inflammation that there is blood in the urine.
  2. Structural problems. If there are problems with how the kidney or other urinary organs are formed or working, you can get blood in the urine. Kidney cysts can be one of those structural problems.
  3. Inherited problems. There are a number of different inherited diseases that cause hematuria (e.g., Alport’s syndrome, Polycystic Kidney Disease, sickle cell disease).
  4. Mineral imbalances. Kids who have high levels of calcium can have hematuria. Often times these kids have family members with kidney stones.
  5. Kidney stones (little overlap from #4).
  6. This can happen with a straddle injury (injuring the urethra) or from bruising a kidney (a blow to the back/side).
  7. Vigorous exercise (causing stress to the kidneys-common in cross country runners).
  8. Encompasses a group of problems where the part of the kidney that does all the filtering (glomeruli) gets inflamed. Some forms of glomerulonephritis are mild and resolve on their own, while others are very severe.

What are the symptoms?

Hematuria can present in countless ways. If it is “gross hematuria” then you can see blood with the naked eye. If it is “microscopic hematuria” than you can’t see the blood in the urine. The blood is only determined from a test, usually a urine dip (but technically it is supposed to be confirmed by a microscope to ensure it isn’t a false positive). Depending on the cause, the other symptoms will vary.  If there is pain with the peeing, then that dictates a group of diagnoses, while painless hematuria dictates others. If is important that when you take your child to the doctor, that you mention every symptom your child has (however, unrelated it may seem).  Things like sore throats, rashes, weight gain/loss, trauma, etc. are all important to know when forming a differential diagnosis (all the different possible reasons).

What should I do if my kid has blood in the urine?

Hematuria warrants a visit to the pediatrician. At the very least, the treatable or worrisome causes of the hematuria should be ruled out. If your child has blood in the urine at 10 o’clock at night, you probably don’t have to rush to the emergency room (unless your child is looking terrible), but you should go the next day to the office. It’s not one of those things I would watch for weeks before doing anything about.

What will the doctor do?

Depending on the story that goes with the symptom of hematuria, you can expect a workup of the hematuria. One or more of the following would be reasonable in a work up of hematuria:

  1. Obtain a careful history (should ask about all the body systems, not just the bloody pee)
  2. Do a thorough physical exam (your doc should look at everything: genitalia for abnormalities/trauma, joints for swelling, skin for rashes, abdomen for kidney swelling, eyes, etc.)
  3. Microscopic urine analysis (maybe even with multiple samples over time), usually looking for blood, protein, calcium, and creatinine. These tests help clue the doctor into what is happening with the kidneys.
  4. Blood pressure (the kidney also helps to regulate blood pressure)
  5. Urine culture-looking for infection
  6. Blood tests-again looking at things like kidney function (e.g., a BUN and creatinine) and blood counts. Sometimes other blood tests are done to rule out other causes.
  7. Depending on findings, imaging studies (e.g. ultrasounds, spiral CT, voiding cystourethrography) may also be done.

Should I see a specialist?

The short answer is: maybe. Whether your child needs to see a specialist entirely depends on what is found/determined to be the cause. If your child has an infection, you probably don’t need to see a specialist. Your child will simply need treatment with antibiotics. If your child has a complex condition, you may end up being referred. Who you get referred to depends on the problem. A kidney specialist is a nephrologist. A specialist on the urinary system is an urologist. Technically an urologist is a trained surgeon, while a nephrologist is not. There is overlap in their knowledge and specialty coverage.


The treatment of hematuria entirely depends on the cause. Your doctor will help walk you through what is the appropriate treatment for your child.