These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.


To guide Emergency Department (ED) staff with the assessment and management of haematuria.


  • Small numbers of red cells are normally excreted in urine.
  • Blood in the urine can originate at any site in the urinary tract, but in contrast to adults, lower tract haematuria is relatively uncommon in children.
  • Blood in urine may come from somewhere other than the urinary tract (e.g. vaginal haemorrhage, rectal fissure).

Causes of red urine1

Not everything staining the urine pink, brown or red is haematuria.

  • Urine dipsticks for haematuria are very sensitive and will also be positive in the presence of haemaglobinuria and myoglobinuria.
  • Dyes and foodstuffs (e.g. beetroot, blackberries) can colour the urine pink / red.
  • Urates in the urine of neonates may also stain the nappy pink.
  • Drugs (e.g. rifampicin, nitrofurantoin, phenolphthalein).
  • Porphyria.

Features of Upper Tract Haematuria may include2:

  • Brown urine.
  • Protein is often present.

Features of Lower Tract Haematuria may include2:

  • Blood towards the end of the urine stream.
  • Often pink or red in colour.
  • Red blood cells are of normal shape.
  • No proteinuria.


  • Microscopic haematuria in the setting of an acute febrile illness can be normal.
  • Asymptomatic micro-haematuria in children without other signs of renal disease (hypertension, oedema, proteinuria, urinary casts, poor growth or renal impairment) is relatively common.
  • Consider immune thrombocytopenic purpura (ITP), Henoch Schonlein Purpure (HSP) and coagulation disorders
  • Trauma, irritation to meatus or perineum.

Glomerular haematuria verses Non-glomerular haematuria2

Glomerular haematuria Non-glomerular haematuria
  • Glomerulonephritis
  • Familial Nephritis (Alport Syndrome)
  • Thin Basement Membrane Disease
  • IgA Nephropathy
  • Urinary tract infection
  • Idiopathic hypercalciuria
  • Stones
  • Anatomical abnormalities
  • Tumours
  • Trauma
  • Sickle Cell Disease (in relevant ethnic groups)'
  • Urethritis


Investigations in the Emergency Department

  • Patient history
  • Blood pressure 
  • Urine microscopy (abnormal RBC morphology + casts)
  • Urine culture
  • Urinalysis for protein
  • Plasma urea, creatinine and electrolytes
  • Full blood count
  • Coagulation screen
  • Plasma calcium, PO4, albumin.

Investigations to consider

  • Urine calcium: creatinine ratio
  • Urine protein: creatinine ratio
  • Streptococcal serology
  • C3, C4
  • Anti-Nuclear Factor (ANF) / Anti-Nuclear Antibody (ANA)
  • Abdominal X-ray
  • Renal ultrasound
  • Sickle cell electrophoresis.


All cases of haematuria should be followed up by the family doctor, a paediatrician or paediatric nephrologist.


  1. Gillion Boyer O. Evaluation of Gross Haematuria in Children. UpToDate 2022. Last Update: April 2020. Cited 1 Sept 2022. Available from: Evaluation of gross hematuria in children - UpToDate (health.wa.gov.au)
  2. The approach to the child with haematuria. Paediatric Nephrology. L Rees, D Bockenhauer, et al (eds). 2019.Oxford University Press.

Endorsed by:  Nurse Co-director, Surgical Services  Date: Sep 2022

 Review date:  Jul 2025

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