Background <p>The prevalence of pediatric nephrolithiasis has been rising globally, with hematuria being one of its most frequent diagnostic markers. However, the relationship between stone characteristics and the presence or severity of hematuria in children remains unclear. This study aimed to assess this association in a pediatric population.</p> Methods <p>This observational study included children aged one month to 18&#xa0;years diagnosed with nephrolithiasis or nephrocalcinosis. Exclusion criteria included patients with systemic diseases, active urinary tract infections, genitourinary anomalies, familial hematuria, recent trauma or fever, urinary tract tumors, or recent episodes of kidney colic. Data on demographics, stones characteristics, urinalysis, and metabolic parameters were analyzed using SPSS v25. Associations with hematuria were assessed using Chi-square and Kruskal–Wallis tests (p &lt; 0.05 significant).</p> Results <p>A total of 260 patients (mean age 5.03 ± 4.57&#xa0;years; 54.6% male) were included. Hematuria was observed in 40% of cases. Stones located in the ureters and bladder were significantly associated with hematuria (p &lt; 0.05), while lower calyceal stones were linked to lower rates. No significant association was found between stone size or number and hematuria severity.</p> Conclusions <p>Over half of the pediatric patients with nephrolithiasis lacked hematuria, highlighting its limited role as a diagnostic marker. This finding emphasizes the shortcomings of relying solely on urinalysis and supports the need for imaging in the diagnostic work-up of children with suspected nephrolithiasis.</p> Graphical abstract <p></p>