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Bloody urine is a frequent abnormal finding in the genitourinary system, second only to urinary tract infection. The prevalence of microscopic bloody urine among school-aged children is 0.4-2.1%; however, the presence of hematuria alone is rarely indicative of serious illness bloody urine.
Pathophysiology of Hematuria
Blood in the urine is usually first detected with a dipstick test, which reacts with hemoglobin. A reaction greater than 1+ is considered positive for bloody urine. The dipstick is not a test for red blood cells (RBCs); therefore, the dipstick screen must be followed by microscopic examination of the urine to confirm the presence of RBCs (hematuria).
Microscopic hematuria is defined as six or more RBCs per high-power field in a fresh, urine sediment specimen.
Two significant causes of a positive dipstick and a negative microscopic examination are free hemoglobin from hemolysis and myoglobinuria from rhabdomyolysis. Certain drugs and toxins also can cause red urine, although the urine will be
| Causes of Factitious Bloody Urine |
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Heme-positive
Hemoglobinuria Myoglobinuria |
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Heme-negative
Metabolites Homogentisic acid Porphyrin Melanin Drugs Salicylates Sulfa Chloroquine Nitrofurantoin Methyldopa Metronidazole bloody urine Levodopa |
Clinical Evaluation of Bloody Urine
The history often will suggest a presumptive diagnosis and will usually narrow the differential diagnosis. Persistent microscopic hematuria and recurrent episodes of gross hematuria associated with viral illnesses suggests IgA nephropathy.
Dysuria, back pain or flank pain suggests urinary tract infection, hypercalciuria, or nephrolithiasis.
Hematuria from a glomerular lesion may cause the urine to appear to bebrown, green, or tea-colored.
Associated Symptoms
Upper respiratory tract infection suggests IgA nephropathy.
Sore throat or an impetiginous lesion, preceding bloody urine by 7-21 days, suggests poststreptococcal glomerulonephritis.
Abdominal pain may suggest a urinary tract infection or Henoch-Schönlein purpura (HSP)
Petechial or purpuric rashes of the lower extremity may suggest HSP. A malar rash suggests
Treatment