Indian J Pediatr
DOI 10.1007/s12098-017-2448-4
REVIEW ARTICLE
Child with Dysuria and/or Hematuria
Ankit Mehta 1 & Vijai Williams 1 & Biraj Parajuli 1
Received: 25 May 2017 / Accepted: 31 July 2017
# Dr. K C Chaudhuri Foundation 2017
Abstract Dysuria and/or hematuria are common and worri-
some symptoms for most parents. Dysuria results from exces-
sive bladder muscle contraction and peristaltic activity of the
edematous and inflamed urethral mucosa. Though urinary
tract infection remains the commonest cause for dysuria,
non-infectious causes should also be kept in mind. Equating
all cases of dysuria to urinary infection is not incorrect.
Hematuria can be both macroscopic and microscopic and an
important sign of genitourinary tract disease. However, sys-
temic causes like bleeding disorder or malignancy can also
present with hematuria. A thorough history and physical ex-
amination is important for arriving at a diagnosis. The inves-
tigations for both the symptoms and the urgency with which
the tests are required are dictated by the patient’s clinical
presentation.
Keywords Dysuria, UTI, Hematuria, Glomerular, Children.
Dysuria
Introduction
Dysuria is a symptom of pain with or without burning during
micturition. Dysuria is not synonymous with urinary tract in-
fection (UTI), as it is caused by a wide range of infectious and
non-infectious causes. Empiric treatment with antibiotics for
* Ankit Mehta
ankitvijay.mehta@gmail.com
1
Advanced Pediatric Centre, Post Graduate Institute of Medical
Education and Research, Chandigarh 160012, India
every case of dysuria may therefore be inappropriate. Dysuria
occurs when excessive bladder muscular contraction or peri-
staltic activity of the urethra stimulate the pain fibres of the
edematous and inflamed mucosa. A thorough history and
physical examination should be performed in all children,
with careful attention to the presence of systemic signs, such
as fever, conjunctivitis, rash, arthritis, genital lesions and dis-
charge, local exposure, trauma, and in adolescents, sexual
activity. ‘Urethral syndrome’ which commonly occurs in ad-
olescents and adults is characterized by triad of urinary fre-
quency, dysuria, and suprapubic discomfort without any ob-
jective finding of urological abnormalities.
Classification
Depending on the area involved, dysuria can be due to:
1. Pyelonephritis: Infection of the upper genitourinary tract,
usually manifests with high grade fever, flank pain or
tenderness. Neonates however, can manifest with nonspe-
cific symptoms such as poor feeding, irritability, jaundice
and weight loss [1].
2. Lower urinary tract: Cystitis or lower urinary tract infec-
tion (UTI) often presents with suprapubic pain or tenderness,
with or without fever, which, if present, is usually low grade.
3. Urethritis: It is a more localized infection associated with
discharge. In adolescents, Neisseria gonorrhoeae and
Chlamydia trachomatis are the most commonly isolated
pathogens. Herpes simplex should be considered if vesi-
cles and/or ulcers are found on examination. A sexually
transmitted etiology in pre-pubertal children should raise
suspicion of sexual abuse.
4. Balanitis and balanoposthitis: Younger boys may devel-
op a nonspecific bacterial infection of the distal penis with

involvement of the glans (balanitis) or, if uncircumcised,
both the glans and the prepuce (balanoposthitis).
5. Vaginitis: It may cause dysuria in both pre-pubertal girls and
adolescents. Sexually transmitted pathogens and Candida
albicans are frequently isolated in postpubertal girls. In
younger girls, one must also consider non-sexually transmit-
ted agents, such as Group A Streptococcus and Shigella
species. Physical examination may reveal scant discharge
(nonspecific vaginitis), thick and green (gonorrhoea), or
white and cheesy (Candida) [2].
6. Cervicitis: In sexually transmitted diseases (STDs) clinic,
infectious urethritis and/or cervicitis was a cause for iso-
lated dysuria in up to 30% of adolescent girls.
7. Pelvic inflammatory disease: Asymptomatic infections
of the lower genitourinary tract by Neisseria gonorrhoeae
and Chlamydia trachomatis may lead to pelvic inflamma-
tory disease (PID) in post pubertal females. Although PID
may be accompanied by dysuria, fever and abdominal/
pelvic pain are usually the chief complaints.
Etiology
Infectious Causes
Infection is the most common cause of dysuria and can involve
different areas of urogenital tract as described above. Most
infections are ascending, arising from fecal flora colonizing
around perineum and going to urethra. Rarely, they can spread
hematogenously, causing pyelonephritis and urosepsis. About
75–90% of culture-proven UTI’s are caused by Escherichia
coli followed by Proteus mirabilis (10%) and Klebsiella
species (3%) in girls [1]. Few series report Proteus as common
as E.coli in boys >1 y [3]. Other infrequent pathogens include
Staphylococcus saprophyticus, Staphylococcus aureus and
Enterococcus species. Abnormalities in urinary anatomy (di-
verticula, renal cysts, urethral strictures) or function (neurogen-
ic bladder) are high risk for recurrent or persistent UTI with
Proteus, Klebsiella, or Enterobacter species. Chlamydia
trachomatis, Urea plasmaurealyticum, Mycoplasma
genitalium, Trichomonas vaginalis, viruses like adenovirus,
herpes virus, mumps virus, and the tropical parasite
Schistosoma haematobium can rarely cause UTI. The non-
infectious causes for dysuria have been elucidated in Table 1.
History
Important history related to systemic symptoms, fever, local
exposures, trauma, and sexual activity is needed to arrive at a
specific diagnosis [4]
& Fever points towards pyelonephritis, or PID, none of
which is likely to present with dysuria alone.
Indian J Pediatr
& Local exposures and trauma: A negative history for
injury may be inaccurate, because most trauma is not
recalled by young patients. Furthermore this history
may not be forthcoming in cases of masturbation or
sexual abuse.
& Systemic symptoms: History of conjunctival erythema,
oral lesions, joint pain or swelling, and/or a generalized
rash suggests systemic inflammatory or infectious condi-
tions, such as reactive arthritis or Behçet’s syndrome.
& Sexual activity: STDs are a common cause of dysuria in
adolescents; this can be ascertained by a detailed history
about the nature and extent of sexual activity; a denial of
sexual activity does not exclude this possibility.
& The timing, frequency, severity, and location of dysuria
are important. Pain at the onset of urination is usually
caused by urethral inflammation, but post voiding
suprapubic pain is suggestive of bladder inflammation or
infection. Longer duration and more gradual onset of
symptoms may suggest C. trachomatis infection, whereas
sudden onset of symptoms and hematuria suggests bacte-
rial infection.
Red Flag Signs for Immediate Referral to ED
& High grade fever
& Toxic look
& Suspicion of systemic disease
& Suspicion of child abuse
& Severe low back pain
Investigations
The investigations should be targeted, based on the find-
ings of history and physical examination. Urine analysis
and urine culture are valuable tools in children with
dysuria.
& Urine testing: Best specimen for culture is got by
suprapubic aspiration. Clean catch specimens may be
analysed in those who are toilet-trained. In pre-pubertal
children, a positive dipstick (leukocyte esterase test),
pyuria (more than 5 to 10 white blood cells per high-
power field in spun urine), or enhanced urinalysis with
≥10 WBC/mm3 on urinalysis increases the likelihood
of bacterial infection (urethritis, cystitis, or pyelone-
phritis) [5]. The diagnosis must be confirmed by cul-
ture. Pyuria may also be observed in inflammatory con-
ditions, such as chemical urethritis, and nonbacterial
infections. Conversely, UTI may occasionally occur
in children in the absence of pyuria on routine urinaly-
sis [6].
Indian J Pediatr
Table 1 Non-infectious causes for dysuria
Causes
Irritants: detergents, fabric softeners, perfumed soaps, and bubble baths
Trauma: normal self-exploratory sexual play, masturbation
(older children and adolescents), or sexual abuse
Urinary stones: anatomic abnormalities, idiopathic hypercalciuria and
hyperuricosuria
Genital ulcers:
•Virginal vaginal ulcers (Lipschutz ulcers)
•Behçet’s syndrome
Lichen sclerosis
Urethral strictures
Psychogenic
Labial adhesions
Juvenile spondylo-arthritis
& Gram stain: A Gram stain of urethral or vaginal discharge
showing gram-negative intracellular diplococci in pre-
pubertal girls or boys of any age suggests gonorrhoea.
This further warrants evaluation for sexual abuse.
Sometimes non-pathogenic vaginal colonisers can mimic
N. gonorrhoeae, as a result of which this test may be
unreliable in teenage girls.
& Other cultures: As many as 10% of infants <1 y of age
with UTI who are highly febrile (>39 °C) may have bac-
teremia. Hence it is preferable to obtain a blood culture in
infants ≤6 mo of age with UTI who have fever >39 °C.
& USG KUB may be of benefit in diagnosis of cystitis or
pyelonephritis [7].
& Nucleic acid amplification tests: Urine can be tested for
the presence of C. trachomatis and N. gonorrhoeae using
nucleic acid amplification tests (NAATs), which are an
accurate screening tool for STDs in absence of culture of
cervix or urethra (males).
& Direct fluorescent antibody and viral culture: For her-
pes simplex, a scraping for direct fluorescent antibody
(DFA) testing gives rapid result, though culture is more
definitive.
Management
All children with red flags should be referred to emergency
department for further management. Children with suspected
pyelonephritis must be started on intravenous cephalosporin
and gentamicin pending cultures. Children who are non-toxic
or suspected to have lower UTI can be treated with oral 3rd
generation cephalosporin or nitrofurantoin. Children suspected
to have STD should be referred to a gynaecologist and a
Physical examination
None to mild erythema
Unremarkable
Flank tenderness
Clustered vesicles which resemble herpes simplex
Recurrent oral ulcers, ocular pan-uveitis, vasculitis and genital
ulcers
Perineal pruritic rash, hourglass shape depigmentation around
the vagina and anus
Unremarkable
None
Mostly asymptomatic
Triad of conjunctivitis, arthritis, and urethritis
counselling centre. An algorithmic approach to management
of child with dysuria has been depicted in Fig. 1.
Hematuria
Hematuria can originate from the renal tissue or from the
urinary tract; majority originating from the lower urinary
tract whereas <10% originating from the glomerular pa-
thology [8]. Hematuria is basically classified as macro-
scopic or microscopic. The causes of hematuria are as
shown in Table 2.
Microscopic hematuria can be seen in renal or non-renal
etiologies. Most common cause identified is hypercalciuria
(22%–30%) and sickle cell trait. A variety of non-renal con-
ditions like viral or bacterial respiratory infections, any febrile
illness and exercise can cause hematuria.
Gross hematuria on the other hand is usually a sign of
serious underlying disorder, most common cause being immu-
noglobulin A (IgA) nephropathy [9]. Common causes for
non- glomerular gross hematuria are hypercalciuria,
urethrorrhagia and hemorrhagic cystitis.
Transient hematuria can be secondary to trauma, strenuous
exercise, drugs, or infection. Since hematuria is directly relat-
ed to the primary illness it will disappear once the primary
illness is taken care of and these children may not need de-
tailed evaluation.
One must remember that urine may also occasionally get
contaminated by blood from external genitalia, or urethral
meatus. Sometimes, discoloration of urine may mimic hema-
turia when in actual fact it may be due to hemoglobinuria,
myoglobinuria, drugs/toxins or pink discoloration of diapers
in infants due to excretion of urate crystals.
 Indian J Pediatr

Fig. 1 Algorithmic approach to a Child with dysuria

child with dysuria

Absent Assess for systemic features Present

Present
SJS
Local examination Behcet syndrome
Reiter syndrome

Vesicles Ulcers Irritation of glans Discharge present

HSV Chancroid Balanitis Male

Fever / pyuria
Balanoposthitis Urethritis

Prostatitis

Absent
Viral cystitis
Chemicals
Local trauma
Urethral stricture
Smear examination and
Dysfunctional voiding
Assess site appropriate antibiotics

Red flag signs that need urgent referral

At meatus Suprapubic pain Flanks
Hematuria
Urethritis cystitis Pyelonephritis High grade fever
Rectal bleeding
Severe low back pain
Suspicion of child abuse
HSV Herpes simplex virus; SJS Steven Johnson syndrome

Table 2 Common causes of

hematuria Site of Causes
hematuria

Glomerular •Recurrent gross hematuria (IgA nephropathy, benign familial hematuria, Alport’s syndrome)
•Acute post streptococcal glomerulonephritis
•Membranoproliferative glomerulonephritis
•Systemic lupus erythematosus
•Membranous nephropathy
•Henoch-Schönlein purpura
•Good Pasture’s disease
Interstitial •Acute pyelonephritis
•Acute interstitial nephritis
•Hematologic (sickle cell disease, Von Willebrand’s disease, renal vein thrombosis,
thrombocytopenia)
Urinary tract •Bacterial or viral (adenovirus) infection-related
•Nephrolithiasis and hypercalciuria
•Congenital structural anomalies, polycystic kidney disease
•Trauma
•Tumors
•Exercise
•Medications (aminoglycosides, amitriptyline, anticonvulsants, aspirin, chlorpromazine,
warfarin, cyclophosphamide, diuretics, penicillin)
Indian J Pediatr
Table 3 Clues on history and
physical examination
DIC Disseminated intravascular coagulation; SLE Systemic lupus erythematosus
Definitions [10]
1. Hematuria: Hematuria is the presence of five or more
RBCs per high-power (400×) field in three consecutive
fresh centrifuged urine samples.
2. Gross hematuria: Blood in the urine visible to naked eye.
History
Fever Urinary tract infection
Sepsis with DIC
Dengue hemorrhagic fever,
Systemic lupus erythematosus
IgA nephropathy
Oliguria Post infective glomerulonephritis, Renal vein thrombosis
Hemolytic-uremic syndrome
Nephrotic syndrome
Trauma Recent bladder catheterization
Blunt abdominal trauma
Bleeding from other sites Coagulation and platelet abnormalities
History of sore throat, skin infections Post infective glomerulonephritis
Diarrhea (± bloody) Hemolytic uremic syndrome
Viral illness – conjunctivitis, pharyngitis Hemorrhagic cystitis
Pain during micturition UTI
Loin to groin pain Urolithiasis
Costo-vertebral angle pain Pyelonephritis, Urolithiasis
Urine
Discolored at initiation Urethritis, Meatal trauma
Discolored throughout Glomerular hematuria
Discolored at termination of micturition Cystitis
Urine color
a) Brown, tea or cola colored Glomerular hematuria
b) Bright red, clots in urine UTI, Urolithiasis, Hypercalciuria, Bleeding diathesis
Rash, arthralgia, muscle pain, abdominal pain Henoch-Schönlein purpura, SLE
History of drug intake Cyclophosphamide, warfarin, amitriptyline, aspirin,
diuretics, anticonvulsants
Family history of hematuria Hypercalciuria, urolithiasis, autosomal dominant polycystic
kidney disease, IgA nephropathy
Physical Examination
Hypertension Glomerulonephritis
Dehydration Renal vein thrombosis
Edema Glomerulonephritis
Nephrotic syndrome
Pallor Hemolytic uremic syndrome
Rash Henoch-Schönlein purpura (HSP), SLE
Dengue hemorrhagic fever
Costo-vertebral angle tenderness Pyelonephritis
Renal mass Wilms tumor, Polycystic kidney disease, Hydronephrosis
Arthritis SLE, HSP
Eye, ear abnormalities Alport syndrome
3. Microscopic hematuria: RBC’s only on microscopic ex-
amination of urine; RBC’s > 5/ul in a fresh un-centrifuged
midstream urine sample or >3 RBC/hpf in centrifuged
sediment from 10 ml of freshly voided midstream urine.
4. Symptomatic hematuria: Occurs in association with
other urinary symptoms or hypertension, and edema.
 Indian J Pediatr

Always indicates underlying renal disease and needs de- Investigations

tailed evaluation.
5. Asymptomatic (Isolated) hematuria: It is usually micro-
scopic and may be the sole abnormality with neither histo-
ry nor physical examination indicating a systemic, renal or
urological disorder. Long term follow-up is necessary to
identify a benign or a slowly progressive disease process.
Evaluation
Step wise approach for evaluation of hematuria is the most
important step in urgent care facility [11, 12]
Glomerular Hematuria: Further investigations to determine
specific glomerular etiology include:
1. Complete blood count along with peripheral smear
to look for microangiopathic hemolysis and throm-
bocytopenia (hemolytic-uremic syndrome).
2. Throat culture, streptozyme panel (ASO/Anti DNAse B)
and serum C3, C4 concentration (acute post-streptococcal
glomerulonephritis).
3. Renal function test, electrolyte panel
4. Renal ultrasound for all macroscopic hematuria

1. Focused history and examination Non-glomerular: Common causes of non-glomerular gross

2. Confirm and classify gross/microscopic hematuria
3. Identify red flags for immediate referral to emergency
department
hematuria in children include UTI (commonly cystitis) and
hypercalciuria. Presence of fever, dysuria and suprapubic pain
suggests UTI, while the absence of fever with significant family
history of renal stones may point towards hypercalciuria or
urolithiasis. The initial evaluation in such children should be

Focused History and Examination 1. Complete hemogram

2. Coagulogram
Important clues can be obtained by focused history and thor- 3. Urine culture and sensitivity
ough physical examination (Table 3). 4. Renal ultrasound

Confirm and Classify Hematuria
The next step in the evaluation of hematuria is to determine if
it is true, false positive or false negative. Urine dipstick
followed by urine microscopy should be done in all patients.
The site of bleed is localized as glomerular or non-glomerular
with the help of history, clinical examination and urine analy-
sis (Table 4).
If the above-mentioned investigations are not suggestive of
any etiology, spot urine calcium-creatinine ratio and 24-h
urine collection for calcium should be obtained to rule out
hypercalciuria.
Traumatic: Hematuria due to bladder catheterization
resolves by 6 h post procedure. In children with history
of abdominal trauma and hematuria, urgent CT scan of
abdomen and pelvis must be obtained, following which

Table 4 Difference between

glomerular and non-glomerular Features Glomerular Non-glomerular
hematuria [13]
History
Dysuria Absent Present in urethritis and cystitis
Systemic complaints Edema, fever, pharyngitis, rash, arthralgia Fever with UTI, pain with calculi
Family history Deafness (Alport’s syndrome) Positive with calculi/hypercalciuria
Physical examination
Hypertension, Edema Usually present Less common
Abdominal mass Absent Wilm’s tumor, Obstructive uropathy
Rash, Arthritis SLE, HSP Absent or drug induced nephritis
Urinalysis
Color Brown, tea, cola Bright red, clots may be present
Proteinuria 2+ or more Less than 2+
Dysmorphic RBCs More than 20% Not common, less than 15%
RBC casts Common Absent
Crystals Absent Positive in few

HSP Henoch-Schönlein purpura; RBC Red blood cells; SLE Systemic lupus erythematosus; UTI Urinary tract infection
Indian J Pediatr
urology opinion must be taken [14]. Hematuria following
trivial trauma suggests an underlying structural renal ab-
normality (cystic kidney disease/ tumor), which requires
imaging (ultrasound/CT) [15].
Red Flags for Referral to Emergency Department [16]
1. Hypertension
2. Edema
3. Oliguria
4. High grade fever
5. Bleeding from other sites
6. History of trauma
7. Infants with hematuria
Management
Management depends upon specific etiology. One needs to
address the hemodynamic stability upfront before going into
specific etiology [17]. If the evaluation does not yield a diag-
nosis, which often occurs with isolated hematuria, the parents
are counselled and children are kept under close follow-up to
monitor for evolution of new signs like hypertension or pro-
teinuria. In a child with glomerular pathology, blood pressure
and urine output must be monitored frequently.
Conclusions
To summarize infection remains the most common cause
for dysuria; Non-infectious causes must be kept in mind
while evaluating a child with dysuria; Hematuria can
have local as well as systemic cause; Hematuria can have
local as well as systemic causes; Step wise approach
helps in differentiating glomerular from extra glomerular
causes of hematuria; Children with ‘red flags’ should be
referred for detailed evaluation and management.
Contributions VW and BP had done the literature search and drafted
the manuscript. AM had guided the framework of the manuscript and had
done a critical review and had approved the version to be published. Dr.
Muralidharan Jayashree will act as guarantor for this paper.
Compliance with Ethical Standards
Conflict of Interest None.
Source of Funding None.
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