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. 

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To guide 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 urine

  • 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, phenothiazines, phenolphthalein).
  • Porphyria.

Features of Upper Tract Haematuria may include:

  • Brown urine.
  • Protein is often present.
  • Red blood cells are often small and misshapen.
  • Red blood cell casts and tubular casts may be seen.

Features of Lower Tract Haematuria may include:

  • 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.


Glomerular haematuria verses Non-glomerular haematuria

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


Investigations in the Emergency Department

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

Investigations to consider


  • Urine calcium : creatinine ratio
  • Urine protein : creatinine ratio
  • Streptococcal serology
  • C3, C4
  • 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. External Review: Frank Willis (Consultant - Department of Nephrology): July 2015
  2. Hematuria in children.Patel HP, Bissler JJ Pediatr Clin North Am. 2001;48(6):1519. 
  3. Gross hematuria in children: a ten-year review. Greenfield SP, Williot P, Kaplan D Urology. 2007;69(1):166. 
  4. The clinical significance of asymptomatic gross and microscopic hematuria in children. Bergstein J, Leiser J, Andreoli S Arch Pediatr Adolesc Med. 2005;159(4):353. 

Endorsed by:  Director, Emergency Department   Date: Feb 2018

 Review date:  Feb 2021

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