Runners with red pee = red alert?…The answer to MOOC’s question of the week

Each week students in Professor Ian Shrier’s (@McGillU) Massive Open Online Course (MOOC) ask questions. We call on our ‘world expert panel’ for the answers, and profile select responses on the BJSM blog.  

This week’s question: What are the possible causes for first time gross hematuria in a female runner who experiences some abdominal pain during running?

The scenario presented occurs rarely, and most sports physicians would only see a few cases in their career. Haematuria is frightening for the athlete, so most present promptly for advice.

red runnerThe history, duration, frequency and type of exercise is important. Lots of downhill running provokes cell break down in the quadriceps due to eccentric loading, and this may result in myoglobinuria. Old shoes with poor cushioning have less shock absorption and can lead to foot strike haemolysis.
Anit-inflammatory medications can reduce renal blood flow, and studies on hyponatremia have found increased creatinine in the serum. However, we know these medications are commonly used by distance runners with relatively few suffering severe complications.

On physical examination, the athlete’s general condition is usually well unless there is a rare case of rhabdomyolysis. In collision sports, flank tenderness may be present. In the vast majority of cases, the diagnosis is Runners’ Haematuria, which was initially termed “10,000 metres haematuria” by the urologist Blacklock back in the 1970s. It is caused by abrasions of the bladder wall against the trigone, analogous to caecal slap in the gut. The only routine investigation necessary is a simple urinalysis to look for RBC and casts, plus protein.

Although the vast majority of cases are Runner’s haematuria, physicians still need to ensure the less common possibilities from the differential diagnosis are ruled out based on history, physical and investigations:

  1. Renal or ureteric stone will cause pain. The condition is uncommon in young athletes, but the first episode can occur in youth. A detailed metabolic work up is required if this condition is diagnosed.
  2. Foot strike haemolysis with haemaglobin pigment causing red urine. This is common when old or worn shoes are used, and the running occurs on a concrete surface.
  3. Urinary tract infections classically presents with dysuria and frequency rather than severe abdominal  pain. Haematuria is uncommon in UTI.
  4. In a female athlete, the bleeding may actually be coming from the reproductive tract, i.e. uterus or cervix, but admixed with urine. Most women will be able to distinguish the two sources, but a pelvic examination may be required to clarify things in some circumstances.
  5. Myoglobinuria from damaged muscle can also change the colour of urine and appear similar to hematuria. This usually occurs after unaccustomed eccentric exercise and was originally termed the ‘squat jump syndrome’ within military settings. This condition can cause rhabdomyolysis and this would require an emergency work-up if suspected.
  6. Malignancy in the renal tract classically presents with painless haematuria. It is rare in young people, but should not be forgotten.
  7. In repeated cases of haematuria, a cystoscopy may help identify sites of bleeding, but these are usually just abrasions in the bladder wall opposite the trigone.

If the history and physical condition suggest any of the more serious differential diagnoses, further investigations are warranted. The only condition that needs urgent work up is rhabdomyolysis, which presents very differently from Runners Haematuria and needs hospital admission because an associated hyperkalemia can be life threatening, and an associated acute compartment syndrome can be limb threatening. If rhabdomyolysis is suspected, then the investigations should include a CBC, CRP, creatinine, electrolytes, plus ECG (to look for peaked T waves as a sign of hyperkalaemia). Thomas and Ibels summarised the recommendations for management of rhabdomyolysis in the 1980s and it has not been improved upon. They advocate:

  • A- aggressive fluid replacement 4-11 litres in the first 24 hrs
  • B-resonium ion exchange resins to correct  significant hyperkalaemia. Dialysis may be required in some circumstances
  • C-compartment pressure testing if there is suspicion of acute compartment syndrome, and decompressive surgery when required.

Management of Haematuria in a Runner

For a first episode where history and physical examination do not suggest any of the differential diagnoses, the physician should manage the patient as a case of runners’ haematuria ie bladder wall abrasions. Apart from the basic investigations mentioned above, the athlete should rest from exercise until the haematuria clears, and then resume exercise. Some authorities advise the athlete to exercise with the bladder partly full, with the idea that this will reduce the contact between the trigone and the opposing bladder wall. Practically, this can be difficult to achieve! Athletes should also be advised to minimise NSAID use prior to races and long training runs, particularly in the heat. When there are recurrent episodes of exercise related haematuria, the patient should be referred to a renal physician or urologist. The referral route will be determined by the clinical picture  and local or regional availability of services. Cystoscopy may be required to identify the source of bleeding

In summary, Runners’ Haematuria is uncommon, but sports physicians need to know how to deal with it. In most cases, the cause is relatively benign, but be aware of the occasional serious cause, and refer those people for prompt further management.

Other Readings:
Thomas MA, Ibels LS. Rhabdomyolysis and acute renal failure. Aust N Z J Med 1985;15(5):623-628.

Mercieri A. Exercise-induced hematuria. Up to date Oct 14 2015,
Siegel AJ, Hennekens CH, Solomon HS, Van Boeckel B.. Exercise-related hematuria. Findings in a group of marathon runners. JAMA 1979;241:391-392.


Dr Chris Milne is a Sports and Exercise Physician based in Hamilton New Zealand. He has particular interest in exercise related renal and GI issues. He has been Team Physician to several NZ Olympic Teams, and is Chair of the Medical Commission for Oceania National Olympic Committees.

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