Skip to content
Licensed Unlicensed Requires Authentication Published by De Gruyter June 11, 2019

Exertional hematuria: definition, epidemiology, diagnostic and clinical considerations

  • Giuseppe Lippi EMAIL logo and Fabian Sanchis-Gomar


Exertional hematuria can be considered a subcategory of exercise-induced hematuria, characterized by painless appearance of erythrocytes in urine after recent physical exercise, not directly attributable to external traumatic injuries to the genitourinary system, and spontaneously resolving with rest. Although its frequency has enormous heterogeneity, depending on the athlete population, duration and intensity of exercise, technique used for identifying or quantifying hematuria and relative diagnostic thresholds, what clearly emerges from the scientific literature is that a certain degree of hematuria is commonplace after non-contact sports, especially running. This exertional hematuria, which appears self-limiting, may be attributable to some frequently concomitant causes, involving organs of the genitourinary system, and mostly encompassing bladder or urethral injuries. Renal injuries caused by internal movements, vascular spasm and ischemia are also potential causes of increased glomerular permeability to erythrocytes, whilst the presence of preexisting genitourinary diseases cannot be ruled out, especially when post-exercise hematuria is recurrent or endures. Therefore, whenever hematuria is observed in a random urine specimen, recent sports performance (especially running) should be investigated and urinalyses scheduled for the following days. When no temporal association of hematuria with exercise can be found, when genitourinary traumas have been excluded or hematuria persists for >72 h, specific diagnostic investigations should be planned to identify possible genitourinary diseases.

Corresponding author: Prof. Giuseppe Lippi, Section of Clinical Biochemistry, University of Verona, Piazzale LA Scuro, 37134 Verona, Italy

  1. Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

  2. Research funding: None declared.

  3. Employment or leadership: None declared.

  4. Honorarium: None declared.

  5. Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.


1. Davis R, Jones JS, Barocas DA, Castle EP, Lang EK, Leveillee RJ, et al. Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults: AUA guideline. J Urol 2012;188:2473–81.10.1016/j.juro.2012.09.078Search in Google Scholar

2. Linder BJ, Bass EJ, Mostafid H, Boorjian SA. Guideline of guidelines: asymptomatic microscopic haematuria. BJU Int 2018;121:176–83.10.1111/bju.14016Search in Google Scholar

3. Kirkpatrick WG. Hematuria. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Boston, MA: Butterworths; 1990. Chapter 184. Available from: in Google Scholar

4. Bolenz C, Schröppel B, Eisenhardt A, Schmitz-Dräger BJ, Grimm MO. The investigation of hematuria. Dtsch Arztebl Int 2018;115:801–7.10.3238/arztebl.2018.0801Search in Google Scholar

5. Oyaert M, Delanghe J. Progress in automated urinalysis. Ann Lab Med 2019;39:15–22.10.3343/alm.2019.39.1.15Search in Google Scholar

6. Becker GJ, Garigali G, Fogazzi GB. Advances in urine microscopy. Am J Kidney Dis 2016;67:954–64.10.1053/j.ajkd.2015.11.011Search in Google Scholar

7. Mariani AJ, Luangphinith S, Loo S, Scottolini A, Hodges CV.Dipstick chemical urinalysis: an accurate cost-effective screening test. J Urol 1984;132:64–6.10.1016/S0022-5347(17)49465-1Search in Google Scholar

8. Froom P, Gross M, Froom J, Caine Y, Margaliot S, Benbassat J. Factors associated with microhematuria in asymptomatic young men. Clin Chem 1986;32:2013–5.10.1093/clinchem/32.11.2013Search in Google Scholar

9. Mariani AJ, Mariani MC, Macchioni C, Stams UK, Hariharan A, Moriera A. The significance of adult hematuria: 1000 hematuria evaluations including a risk-benefit and cost-effectiveness analysis. J Urol 1989;141:350–5.10.1016/S0022-5347(17)40763-4Search in Google Scholar

10. Britton JP, Dowell AC, Whelan P. Dipstick haematuria and bladder cancer in men over 60: results of a community study. Br Med J 1989;299:1010–2.10.1136/bmj.299.6706.1010Search in Google Scholar PubMed PubMed Central

11. Woo KT, Chan CM, Wong KS, Choong HL, Tan HK, Foo MW, et al. National Health Survey on the prevalence of urinary abnormalities in the population: then and now (1975 to 2012). Ann Acad Med Singapore 2012;41:339–46.10.47102/annals-acadmedsg.V41N8p339Search in Google Scholar

12. Bruyninckx R, Buntinx F, Aertgeerts B, Van Casteren V. The diagnostic value of macroscopic haematuria for the diagnosis of urological cancer in general practice. Br J Gen Pract 2003;53:31–5.Search in Google Scholar

13. Topham PS, Jethwa A, Watkins M, Rees Y, Feehally J. The value of urine screening in a young adult population. Fam Pract 2004;21:18–21.10.1093/fampra/cmh105Search in Google Scholar PubMed

14. Ingelfinger JR, Davis AE, Grupe WE. Frequency and etiology of gross hematuria in a general pediatric setting. Pediatrics 1977;59:557–61.10.1542/peds.59.4.557Search in Google Scholar

15. Topaktaş R, Altın S, Aydın C, Akkoç A, Yılmaz Y. Retrospective evaluation of urological admissions to emergency service of a training and research hospital. Turk J Urol 2014;40:216–20.10.5152/tud.2014.77861Search in Google Scholar

16. Talreja S, Banerjee I, Teli R, Agarwal N, Vyas N, Priyadarshi S, et al. A spectrum of urological emergency reported at a tertiary care teaching hospital: an experience. J Clin Diagn Res 2015;9:PC12–5.10.7860/JCDR/2015/15793.6821Search in Google Scholar

17. Khadra MH, Pickard RS, Charlton M, Powell PH, Neal DE. A prospective analysis of 1930 patients with hematuria to evaluate current diagnostic practice. J Urol 2000;163:524–7.10.1016/S0022-5347(05)67916-5Search in Google Scholar

18. Edwards TJ, Dickinson AJ, Natale S, Gosling J, McGrath JS. A prospective analysis of the diagnostic yield resulting from the attendance of 4020 patients at a protocol-driven haematuria clinic. BJU Int 2006;97:301–5.10.1111/j.1464-410X.2006.05976.xSearch in Google Scholar PubMed

19. Jung H, Gleason JM, Loo RK, Patel HS, Slezak JM, Jacobsen SJ. Association of hematuria on microscopic urinalysis and risk of urinary tract cancer. J Urol 2011;185:1698–703.10.1016/j.juro.2010.12.093Search in Google Scholar PubMed

20. Loo RK, Lieberman SF, Slezak JM, Landa HM, Mariani AJ, Nicolaisen G, et al. Stratifying risk of urinary tract malignant tumors in patients with asymptomatic microscopic hematuria. Mayo Clin Proc 2013;88:129–38.10.1016/j.mayocp.2012.10.004Search in Google Scholar PubMed

21. Yafi FA, Aprikian AG, Tanguay S, Kassouf W. Patients with microscopic and gross hematuria: practice and referral patterns among primary care physicians in a universal health care system. Can Urol Assoc J 2011;5:97–101.10.5489/cuaj.10059Search in Google Scholar PubMed PubMed Central

22. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep 1985;100:126–31.Search in Google Scholar

23. Lippi G, Favaloro EJ, Sanchis-Gomar F. Sudden cardiac and noncardiac death in sports: epidemiology, causes, pathogenesis, and prevention. Semin Thromb Hemost 2018;44:780–6.10.1055/s-0038-1661334Search in Google Scholar PubMed

24. Adams MJ, Fell JW. Hemostasis in exercise and the athlete. Semin Thromb Hemost 2018;44:707–9.10.1055/s-0038-1675169Search in Google Scholar PubMed

25. Pedersen BK, Saltin B. Exercise as medicine – evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports 2015;25(Suppl 3):1–72.10.1111/sms.12581Search in Google Scholar PubMed

26. Rees-Punia E, Evans EM, Schmidt MD, Gay JL, Matthews CE, Gapstur SM, et al. Mortality risk reductions for replacing sedentary time with physical activities. Am J Prev Med 2019;56:736–41.10.1016/j.amepre.2018.12.006Search in Google Scholar PubMed PubMed Central

27. Ljungqvist A, Jenoure P, Engebretsen L, Alonso JM, Bahr R, Clough A, et al. The International Olympic Committee (IOC) Consensus Statement on periodic health evaluation of elite athletes March 2009. Br J Sports Med 2009;43:631–43.10.1136/bjsm.2009.064394Search in Google Scholar PubMed

28. Jones GR, Newhouse I. Sport-related hematuria: a review. Clin J Sport Med 1997;7:119–25.10.1097/00042752-199704000-00008Search in Google Scholar PubMed

29. Sacco E, Marangi F, Pinto F, D’Addessi A, Racioppi M, Gulino G, et al. Sports and genitourinary traumas. Urologia 2010;77:112–25.10.1177/039156031007700208Search in Google Scholar

30. Lippi G, Schena F, Ceriotti F. Diagnostic biomarkers of muscle injury and exertional rhabdomyolysis. Clin Chem Lab Med 2018;57:175–82.10.1515/cclm-2018-0656Search in Google Scholar PubMed

31. Lippi G, Schena F, Salvagno GL, Aloe R, Banfi G, Guidi GC. Foot-strike haemolysis after a 60-km ultramarathon. Blood Transfus 2012;10:377–83.Search in Google Scholar

32. Trivedi DJ, Kulkarni SP, Mudaraddi R. Primary myoglobinuria: differentiate myoglobinuria from hemoglobinuria. Indian J Clin Biochem 2017;32:367–9.10.1007/s12291-016-0607-4Search in Google Scholar PubMed PubMed Central

33. Barach JH. Physiological and pathological effects of severe exertion (the marathon race) on the circulatory and renal systems. Arch Intern Med (Chic) 1910;V(4):382–405.10.1001/archinte.1910.00050260059006Search in Google Scholar

34. Akiboye RD, Sharma DM. Haematuria in sport: a review. Eur Urol Focus. 2018 Feb 27. DOI: 10.1016/j.euf.2018.02.008 [Epub ahead of print].10.1016/j.euf.2018.02.008Search in Google Scholar PubMed

35. Gilligan DR, Altschule MD, Katersky EM. Physiological intravascular hemolysis of exercise. Hemoglobinemia and hemoglobinuria following cross-country runs. J Clin Invest 1943;22:859–69.10.1172/JCI101460Search in Google Scholar PubMed PubMed Central

36. Alyea EP, Parish HH Jr. Renal response to exercise: urinary findings. J Am Med Assoc 1958;167:807–13.10.1001/jama.1958.02990240007002Search in Google Scholar

37. Kachadorian WA, Johnson RE. Athletic pseudonephritis in relation to rate of exercise. Lancet 1970;1:472.10.1016/S0140-6736(70)90867-6Search in Google Scholar

38. Kachadorian WA, Johnson RE, Buffington RE, Lawler L, Serbin JJ, Woodall T. The regularity of “athletic pseudonephritis” after heavy exercise. Med Sci Sports 1970;2:142–5.10.1249/00005768-197023000-00008Search in Google Scholar

39. Siegel AJ, Hennekens CH, Solomon HS, Van Boeckel B. Exercise-related hematuria. Findings in a group of marathon runners. J Am Med Assoc 1979;241:391–2.10.1001/jama.241.4.391Search in Google Scholar

40. Boileau M, Fuchs E, Barry JM, Hodges CV. Stress hematuria: athletic pseudonephritis in marathoners. Urology 1980;15: 471–4.10.1016/0090-4295(80)90007-2Search in Google Scholar

41. Fassett RG, Owen JE, Fairley J, Birch DF, Fairley KF. Urinary red-cell morphology during exercise. Br Med J (Clin Res Ed) 1982;285:1455–7.10.1136/bmj.285.6353.1455Search in Google Scholar PubMed PubMed Central

42. Gilli P, De Paoli Vitali E, Tataranni G, Farinelli A. Exercise-induced urinary abnormalities in long-distance runners. Int J Sports Med 1984;5:237–40.10.1055/s-2008-1025912Search in Google Scholar PubMed

43. Reid RI, Hosking DH, Ramsey EW. Haematuria following a marathon run: source and significance. Br J Urol 1987;59:133–6.10.1111/j.1464-410X.1987.tb04803.xSearch in Google Scholar

44. Alvarez C, Mir J, Obaya S, Fragoso M. Hematuria and microalbuminuria after a 100 kilometer race. Am J Sports Med 1987;15:609–11.10.1177/036354658701500615Search in Google Scholar PubMed

45. Kallmeyer JC, Miller NM. Urinary changes in ultra long-distance marathon runners. Nephron 1993;64:119–21.10.1159/000187290Search in Google Scholar PubMed

46. Gür H, Küçükoğlu S, Sürmen E, Müftüoğlu A. Effects of age, training background and duration of running on abnormal urinary findings after a half-marathon race. Br J Sports Med 1994;28:61–2.10.1136/bjsm.28.1.61Search in Google Scholar PubMed PubMed Central

47. McInnis MD, Newhouse IJ, von Duvillard SP, Thayer R. The effect of exercise intensity on hematuria in healthy male runners. Eur J Appl Physiol Occup Physiol 1998;79:99–105.10.1007/s004210050480Search in Google Scholar PubMed

48. Jones GR, Newhouse IJ, Jakobi JM, LaVoie NL, Thayer R. The incidence of hematuria in middle distance track running. Can J Appl Physiol 2001;26:336–49.10.1139/h01-021Search in Google Scholar PubMed

49. Babalhavaeji H, Mosavi Bahar SH, Imami F, Amir Zargar MA. Evaluation of post-exercise test hematuria in Hamadan, Iran. Iran Heart J 2007;8:32–5.Search in Google Scholar

50. Mousavi M, Sanavi S, Afshar R. Effects of continuous and intermittent trainings on exercise-induced hematuria and proteinuria in untrained adult females. NDT Plus 2011;4:217–8.10.1093/ndtplus/sfr011Search in Google Scholar PubMed PubMed Central

51. Khodayari B, Saiiari A. The effect of empty bladder and not emptying the bladder on hematuria rate in student speed and endurance runners. Procedia Soc Behav Sci 2012;46:5745–9.10.1016/j.sbspro.2012.06.509Search in Google Scholar

52. Kohanpour MA, Sanavi S, Peeri M, Zare AH, Mirsepasi M. Effect of submaximal aerobic exercise in hypoxic conditions on proteinuria and hematuria in physically trained young men. Iran J Kidney Dis 2012;6:192–7.Search in Google Scholar

53. Varma PP, Sengupta P, Nair RK. Post exertional hematuria. Ren Fail 2014;36:701–3.10.3109/0886022X.2014.890011Search in Google Scholar PubMed

54. Chiu YH, Lai JI, Wang SH, How CK, Li LH, Kao WF, et al. Early changes of the anemia phenomenon in male 100-km ultramarathoners. J Chin Med Assoc 2015;78:108–13.10.1016/j.jcma.2014.09.004Search in Google Scholar PubMed

55. Kao WF, Hou SK, Chiu YH, Chou SL, Kuo FC, Wang SH, et al. Effects of 100-km ultramarathon on acute kidney injury. Clin J Sport Med 2015;25:49–54.10.1097/JSM.0000000000000116Search in Google Scholar PubMed

56. Mansour SG, Verma G, Pata RW, Martin TG, Perazella MA, Parikh CR. Kidney injury and repair biomarkers in marathon runners. Am J Kidney Dis 2017;70:252–61.10.1053/j.ajkd.2017.01.045Search in Google Scholar PubMed PubMed Central

57. O’Brien CJ, Hopkinson JM, Bastable JR. Haematuria after strenuous exercise. Br J Urol 1987;59:478.10.1111/j.1464-410X.1987.tb04850.xSearch in Google Scholar PubMed

58. Eichner ER. Hematuria – A diagnostic challenge. Phys Sportsmed 1990;18:52–63.10.1080/00913847.1990.11710173Search in Google Scholar PubMed

59. Ubels FL, van Essen GG, de Jong PE, Stegeman CA. Exercise induced macroscopic haematuria: run for a diagnosis? Nephrol Dial Transplant 1999;14:2030–1.10.1093/ndt/14.8.2030Search in Google Scholar PubMed

60. Polito C, Andreoli S. Sport hematuria in boys: a provocative test. Pediatr Nephrol 2005;20:1171–3.10.1007/s00467-005-1981-ySearch in Google Scholar PubMed

61. Lüthje P, Nurmi I. Recurrent macroscopic haematuria due to bladder blood vessels after exercise induced haematuria. Br J Sports Med 2004;38:e4.10.1136/bjsm.2003.007278Search in Google Scholar PubMed PubMed Central

62. Sanchis-Gomar F, Alis R, Rodríguez-Vicente G, Lucia A, Casajús JA, Garatachea N. Blood and urinary abnormalities induced during and after 24-hour continuous running: a case report. Clin J Sport Med 2016;26:e100–2.10.1097/JSM.0000000000000222Search in Google Scholar PubMed

63. Nichols TW Jr. Bicycle-seat hematuria. N Engl J Med 1984;311:1128.10.1056/NEJM198410253111720Search in Google Scholar

64. Salcedo JR. Huffy-bike hematuria. N Engl J Med 1986;315:768.10.1056/NEJM198609183151220Search in Google Scholar PubMed

65. Algazy KM. Spinner’s hematuria. N Engl J Med 2002;346:1676.10.1056/NEJM200205233462120Search in Google Scholar PubMed

66. Albersen M, Mortelmans LJ, Baert JA. Mountainbiker’s hematuria: a case report. Eur J Emerg Med 2006;13:236–7.10.1097/01.mej.0000206197.69824.f9Search in Google Scholar PubMed

67. LaSalle M, Salimpour P, Adelstein M, Mourtzinos A, Wen C, Renzulli J, et al. Sexual and urinary tract dysfunction in female bicyclists. J Urol 1999;161(4 Suppl):269.10.1097/00005392-199904020-00079Search in Google Scholar

68. Blacklock NJ. Bladder trauma in the long-distance runner: “10,000 metres haematuria”. Br J Urol 1977;49:129–32.10.1111/j.1464-410X.1977.tb04084.xSearch in Google Scholar

69. Fred HL, Natelson EA. Grossly bloody urine of runners. South Med J 1977;70:1394–6.10.1097/00007611-197712000-00005Search in Google Scholar

70. Bellinghieri G, Savica V, Santoro D. Renal alterations during exercise. J Ren Nutr 2008;18:158–64.10.1053/j.jrn.2007.10.031Search in Google Scholar

71. Bernard JJ. Renal trauma: evaluation, management, and return to play. Curr Sports Med Rep 2009;8:98–103.10.1249/JSR.0b013e31819e2e52Search in Google Scholar

72. Lippi G, Sanchis-Gomar F, Salvagno GL, Aloe R, Schena F, Guidi GC. Variation of serum and urinary neutrophil gelatinase associated lipocalin (NGAL) after strenuous physical exercise. Clin Chem Lab Med 2012;50:1585–9.10.1515/cclm-2011-0954Search in Google Scholar

73. Hodgson LE, Walter E, Venn RM, Galloway R, Pitsiladis Y, Sardat F, et al. Acute kidney injury associated with endurance events-is it a cause for concern? A systematic review. Br Med J Open Sport Exerc Med 2017;3:e000093.10.1136/bmjsem-2015-000093Search in Google Scholar

74. Poortmans JR. Exercise and renal function. Sports Med 1984;1:125–53.10.2165/00007256-198401020-00003Search in Google Scholar

75. Abarbanel J, Benet AE, Lask D, Kimche D. Sports hematuria. J Urol 1990;143:887–90.10.1016/S0022-5347(17)40125-XSearch in Google Scholar

76. Hanna HE, Santella RN, Zawada Jr ET, Masterson TE. Nutcracker syndrome: an underdiagnosed cause for hematuria? S D J Med 1997;50:429–36.Search in Google Scholar

77. LeRoy JB. Banana-seat hematuria. N Engl J Med 1972;287:311.10.1056/NEJM197208102870623Search in Google Scholar PubMed

78. Lippi G, Corgnati A, Salvagno G, Schena F, Franchini M, Guidi G. Total and free PSA serum concentrations are not influenced by extensive physical exercise and bicycle riding. Int J Sports Med 2005;26:79–81.10.1055/s-2004-830450Search in Google Scholar PubMed

79. Malmström PU. Time to abandon testing for microscopic haematuria in adults? Br Med J 2003;326:813–5.10.1136/bmj.326.7393.813Search in Google Scholar PubMed PubMed Central

80. Statista. Running & Jogging – Statistics & Facts. Available at: Last accessed April 30, 2019.Search in Google Scholar

81. Mueller EJ, Thompson IM. Bladder carcinoma presenting as exercise-induced hematuria. Postgrad Med 1988;84:173–6.10.1080/00325481.1988.11700519Search in Google Scholar PubMed

82. Sanchis-Gomar F, Lippi G. Physical activity – an important preanalytical variable. Biochem Med (Zagreb) 2014;24:68–79.10.11613/BM.2014.009Search in Google Scholar PubMed PubMed Central

Received: 2019-04-30
Accepted: 2019-05-01
Published Online: 2019-06-11
Published in Print: 2019-11-26

©2019 Walter de Gruyter GmbH, Berlin/Boston

Downloaded on 29.2.2024 from
Scroll to top button