A 12-year-old boy is assessed on the same day that he passed red-colored urine. The boy had been vigorously wrestling with his older brother in the morning; he passed the abnormal-colored urine after lunch. His mother was worried that his kidneys might have been injured during the wrestling.
The boy was delivered vaginally at term after an uncomplicated pregnancy. He was routinely circumcised as a neonate. He was growing and developing normally. Apart from routine childhood illnesses, his past history was unremarkable.
Specific questioning revealed that the urine was passed without discomfort and was dark brownish red. The boy offered that the urine looked like "Coca-Cola." There was no history of frequency, urgency, or incontinence. He voided one further time before the clinic visit; the color of the urine on that occasion was normal. Several weeks earlier, he had experienced a few days of cold symptoms.
Physical examination revealed a healthy-appearing adolescent in no distress. His blood pressure while seated was 100/70 mm Hg in the right arm. There was no edema. Heart sounds were normal and the chest was clear to auscultation. Kidneys and bladder were normal to palpation. There was no bruising about the boy's flanks or suprapubic area. The urethral meatus looked elliptical, of normal caliber, and was not inflamed. Results of the physical examination were otherwise normal.
The boy was able to void during the clinic visit. The urine looked clear. The dipstick revealed a urine pH of 6 and was negative for blood. Results of a microscopic urinalysis were normal. There were no red blood cells, white blood cells, or bacteria. An occasional calcium oxalate crystal and renal tubular epithelial cell were present.
The passage of painless Coca-Cola-colored urine suggests macroscopic hematuria and a source of the bleeding originating at the level of the kidneys. Coca-Cola-colored, tea-colored, brownish, greenish, or blackish urine suggests that hemolysis has occurred, which implies an upper urinary tract origin of the bleeding. Bleeding from the bladder or urethra is usually bright red or pink.
Painless passage of visible blood in a child also suggests an upper urinary tract source of the bleeding. Visible blood in the urine from a lower urinary tract problem is almost always painful in a child. This is not the case for an adult, in whom a bladder tumor might present with painless macroscopic hematuria. Bladder tumors are rare in childhood.
When the passage of visible blood is associated with pain, the location of the pain usually indicates the source of the bleeding. Flank or low back pain suggests an origin in the kidney; suprapubic pain, an origin in the bladder; and urethral pain, an origin in the urethra.
What Would You Do Now?
A. Reassure the boy and his mother that
because the urine test did not reveal any
blood, there was no need for concern.
B. Prescribe an antibiotic for a presumed
urinary tract infection.
C. Order blood tests to determine the complete
blood cell count and levels of antistreptolysin
O, third component of complement,
creatinine, electrolytes, total protein and
albumin; and perform a throat swab for
group A β-hemolytic streptococci.
D. Order an ultrasonogram of the kidneys and
E. Order a voiding cystourethrogram.
FOR MORE INFORMATION:
Gillespie RS, Stapleton FB. Nephrolithiasis in children. Pediatr Rev. 2004;25: 131-139.