A 6-year-old boy is brought to the office due to bright red blood in the urine for the past day. He has had no dysuria, urgency, frequency, or pain. There is no history of trauma. He has no chronic medical conditions or recent infections and takes no medications. Temperature is 98.6 F (37 C), pulse is 80/min, blood pressure is 100/65 mm Hg, and respirations are 20/min. Examination shows normal cardiopulmonary, abdominal, and genital examinations. There is no flank or suprapubic tenderness. There is no edema. Laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

Question

A 6-year-old boy is brought to the office due to bright red blood in the urine for the past day.  He has had no dysuria, urgency, frequency, or pain.  There is no history of trauma.  He has no chronic medical conditions or recent infections and takes no medications.  Temperature is 98.6 F (37 C), pulse is 80/min, blood pressure is 100/65 mm Hg, and respirations are 20/min.  Examination shows normal cardiopulmonary, abdominal, and genital examinations.  There is no flank or suprapubic tenderness.  There is no edema.  Laboratory results are as follows:  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d5f3_46ee_bc81_3baff662caf2_MD0003_00 This patient has acute onset of asymptomatic gross hematuria with no history of trauma, signs/symptoms of infection (eg, dysuria, pyuria, leukocyte esterase), or evidence of glomerular disease (eg, casts, proteinuria, hypertension). Common conditions associated with isolated gross hematuria in children include meatal irritation, which is usually painful and may be visible on external examination, and nephrolithiasis. Classic symptoms of nephrolithiasis (eg, flank/abdominal pain) commonly occur in older children and adults as the stone passes through the urinary tract and obstructs the ureter. However, young children are more likely to have stones located in the kidney, which are painless and cause an atypical presentation of gross hematuria alone, as seen in this patient. Apart from confirming hematuria (eg, positive blood, presence of red blood cells), urinalysis may be otherwise unrevealing because characteristic crystals are not always present. A major risk factor for nephrolithiasis is hypercalciuria, which may be suspected by a previous history of microscopic hematuria and confirmed with an elevated spot urine calcium/creatinine ratio. The preferred imaging study for evaluation of nephrolithiasis in children is a renal and bladder ultrasound, which can detect some stones and ureteral obstruction while avoiding radiation exposure. CT scan of the abdomen without contrast is more sensitive, particularly for identifying small calculi, and may be required if the ultrasound is nondiagnostic (Choice B). (Choices A and D) Glomerular disease can present with gross hematuria, and evaluation may include 24-hour urine protein or diagnostic kidney biopsy. However, additional signs of glomerulonephritis include hypertension, edema, proteinuria, and red blood cell casts, which are not seen in this patient. Moreover, brown urine is typical of glomerulonephritis, and bright red urine (as seen in this patient) usually indicates a nonglomerular source of bleeding. (Choice C) Cystoscopy is typically performed in adults to evaluate for bladder cancer, which is a very rare cause of painless gross hematuria in children. In addition, evaluation with bladder ultrasound would precede an invasive procedure. Educational objective: Young children may have an atypical presentation of nephrolithiasis with isolated gross hematuria in the absence of abdominal or flank pain. Due to radiation exposure associated with CT scans, renal and bladder ultrasound is the preferred imaging study in children to detect stones. References: Nephrolithiasis in children. (http://www.ncbi.nlm.nih.gov/pubmed/21896379)

A 6-Year-Old Boy Is Brought to the Office Due to Bright