A 17-year-old girl is brought to the office due to bright red blood in the urine for 2 days. She has also had dysuria but no trauma, fever, or flank pain. The patient has no history of serious illness and takes no medications. She has regular menstrual periods, and her last period was 2 weeks ago. Temperature is 37.2 C (99 F). Examination shows no abnormalities. Laboratory results are as follows:
| Urinalysis | |
| Protein | none |
| Blood | 3+ |
| Leukocyte esterase | positive |
| Nitrites | negative |
| White blood cells | 20-30/hpf |
| Red blood cells | 100+/hpf |
Which of the following is the best next step in management of this patient?
Show Explanatory Sources
In addition to hematuria, this patient has dysuria and pyuria (white blood cells ≥5/hpf), which are findings consistent with a urinary tract infection (UTI). UTI is one of the most common causes of transient hematuria due to leaky blood vessels associated with urinary tract inflammation. Additional signs and symptoms of UTI that may not always be present include fever, urinary urgency and frequency, and the presence of nitrites and/or leukocyte esterase in the urine.
The next step in management of a patient who has characteristic UTI symptoms and/or urinalysis findings is to begin empiric antibiotic therapy (eg, cefdinir). A urine culture should also be obtained, and bacterial growth (most commonly Escherichia coli) confirms the diagnosis. Notably, although sexually active adolescents with dysuria and pyuria should undergo screening for gonorrhea and chlamydia, gross hematuria is atypical.
Urinalysis should be repeated a few weeks after completion of antibiotics for patients initially presenting with blood in the urine to ensure resolution of hematuria after UTI treatment; a UTI without initial hematuria can typically be followed clinically for resolution of symptoms (Choice G).
(Choice A) A 24-hour urine protein measurement is part of the evaluation for proteinuria, not hematuria.
(Choice C) CT scan of the abdomen is indicated to identify the source of bleeding in patients with hematuria and a history of trauma, which is not seen here.
(Choice D) Cystoscopy may be used to evaluate for bladder cancer, which is rare in children and adolescents and presents with painless hematuria. In addition, white blood cells would not be expected on urinalysis.
(Choice E) Kidney biopsy may be performed to diagnose glomerulonephritis (eg, IgA nephropathy) in a patient with persistent hematuria plus proteinuria, hypertension, or elevated creatinine. This patient's characteristic UTI symptoms and urinalysis with lack of proteinuria make invasive testing unnecessary.
(Choice F) Renal ultrasound is the preferred imaging study in children to assess for nephrolithiasis, which can present with hematuria and dysuria but also typically causes flank or abdominal pain. Renal ultrasound may also be indicated to assess for complications of pyelonephritis in a patient with a UTI that does not respond to antibiotic treatment. Empiric antibiotic therapy is the priority in this patient.
Educational objective:
Hematuria accompanied by dysuria and pyuria is most likely due to a urinary tract infection, and the first step in management is antibiotic therapy. Resolution of hematuria is expected after treatment of infection.