Hi Dr. Roberts –
Is it normal to have blood in the urine after running? This happened to me last year (during a 6-mile run which was normal for me). I had a whole series of tests afterward which were all normal and the urologist said it was common for runners. But, is it common? This happened again recently after a 7-mile run over the weekend and a 3-mile run this morning. My base runs are 3 miles 4-5 days a week with a long run the weekend.
Is it normal for runners or perhaps I should dig deeper?
Thanks! Have a great day.
Blood in the urine is not normal, but does happen occasionally in some runners. There are two types of hematuria (blood in the urine) – macroscopic where you can see it and microscopic where we see it under a microscope. The usual causes of hematuria are infection, trauma, kidney stones, cancer, blood cell disorders, medications, and strenuous exercise. We do not know why strenuous exercise can cause blood leaking in the urinary tract, but it could have to do with fluid balance (dehydration), blood cell breakdown, or bladder trauma.
You did the right thing by getting evaluated after the first episode. I am guessing that you had a study of your kidneys like an ultrasound and a cystoscopy where the urologist could directly visualize your bladder. If those two tests and others for abnormal blood cells are normal, and you did not have an infection, you likely have a running-induced blood leak. It is important to have all the causes, especially bladder cancer, ruled out before you assume the blood loss is due to exercise. Exercise-related hematuria is a diagnosis of exclusion.
If the leak is in the bladder, there may be a strategy to reduce the problem. Some runners get blood loss if they void immediately before the run, and the hypothesis is that the bladder walls slap together causing traumatic blood loss. The usual recommendation to relieve this form of hematuria is to void 20-30 minutes before your run so there is some urine in the bladder to “soften” the slap.
I hope this helps.
Have a question for the Sports Doc? Email him at [email protected] NOTE: Due to the volume of mail, we regret that Dr. Roberts cannot answer every email.
- Blood in the Urine After Workouts
- Exercise-induced proteinuria?
- Mayo Clinic Q and A: Blood in urine should not be ignored
- Bloody Urine After Injury Rarely Cause For Alarm, but Check It Out Anyway – 01/03/2011
- What is Bladder Trauma?
- Intraperitoneal Rupture
- Extraperitoneal Rupture
- Penetrating Injuries
- What is Hematuria?
- Repeat Urine Testing
- If Testing Shows Blood and Protein
- If Testing Shows Blood but No Protein
- What Increases the Risk of Finding Cancer?
- Issues that Increase the Chance of Cancer
Blood in the Urine After Workouts
I started having blood in my urine two days ago after strenuous weight lifting and aerobic workouts for cardiac rehabilitation, three times a week. Also, my left side hurts. It is not a lot of blood, and it starts and stops.
— Betty, Illinois
Seeing blood in the urine can be very upsetting. There are a multitude of potential causes, some benign, others more significant. Discovering the cause is based almost entirely on your medical history: Was there any trauma, are you taking any drugs, what is the nature of the blood — small amounts, even tiny, or are there clots? — and do you have any associated symptoms? The long list of potential causes includes kidney stones, which are usually associated with significant pain; primary kidney problems, including diseases that cause inflammation, such as glomerulonephritis; trauma, such as a car accident; and medications that interfere with clotting, such as warfarin. Abnormal growths, including cancer, can also be the source of blood in the urine.
Strenuous exercise, including both weight lifting and aerobic training, can cause blood to appear in the urine. There is a specific condition known as march hematuria, which was originally described after soldiers experienced blood in their urine following long marches. Patients who are part of a cardiac rehabilitation program may also be on medications that “thin” the blood and may lead to blood in the urine.
The typical workup for blood in the urine includes tests to check clotting (particularly if the patient is on any medications that may interfere with this process), radiology exams such as CT urography, and cystoscopy — a look into the bladder with an endoscope.
Learn more in the Everyday Health Fitness Center.
• Rely on a spot urine microalbumin-to-creatinine or protein-to-creatinine ratio to accurately assess proteinuria. B
• Repeat testing if routine urinalysis detects proteinuria—especially if the patient reports having exercised in the previous 24 hours. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE As part of a routine physical examination, urinalysis reveals that a patient new to your practice is excreting an excessive level of protein. The patient is physically fit and shared during the history taking that he is an avid runner. The physical examination and other laboratory values were unremarkable. How concerned should you be about the finding of proteinuria?
Exercise-induced proteinuria is generally benign and a function of the intensity—rather than the duration—of exercise.1 It occurs most often among athletes participating in such sports as running, swimming, rowing, football, or boxing.2 It’s also transient—lasting 24 to 48 hours.1 Recognizing exercise-induced proteinuria is fairly straightforward—once you know what to look for.
But first, a word about the processes at work.
Diverse processes that work alone—or together
The normal range of protein excretion in healthy individuals is 150 to 200 mg of protein per day, of which albumin constitutes 10 to 20 mg.3 Individuals with proteinuria persistently higher than this level need further evaluation.
Diverse processes leading to proteinuria—working alone or concomitantly—occur at the level of the nephron.3
Glomerular proteinuria results from increased filtration of macromolecules such as albumin across the glomerular capillary barrier. This type of proteinuria can occur with different glomerulopathies, upright posture, or exercise.4
Researchers have not identified the mechanisms leading to postexercise proteinuria, but there are several theories. (For more on this, see “Why does exercise increase protein excretion?”.)
Tubular proteinuria is due to a deranged tubular apparatus with an intact glomerulus. This results in the escape of β2-microglobulin and immunoglobulin light chains from proximal tubular reabsorption. It is often missed on dipstick testing, which detects only albumin. This type of proteinuria is usually seen in tubulointerstitial diseases or in patients with idiopathic nephrotic syndrome.5
Overflow proteinuria occurs when small molecular light chains escape the glomerular filtration barrier and overwhelm the tubular reabsorptive capacity. This type of proteinuria can be seen in multiple myeloma, and is detectable by protein-to-creatinine ratio or urine protein electrophoresis.
Why does exercise increase protein excretion?
The root cause of exercise-induced proteinuria is unclear, but the renin-angiotensin system (RAS) and prostaglandins are thought to play a major role. The plasma concentration of angiotensin II increases during exercise, leading to filtration of protein through the glomerular membrane.30 And angiotensin-converting enzyme (ACE) inhibitors have been shown to significantly diminish exercise-induced proteinuria, thus supporting this theory.31,32
Also, strenuous exercise increases sympathetic nervous system activity as well as blood levels of catecholamines, thereby increasing permeability of the glomerular capillary membrane.33 Furthermore, lactate increases with strenuous exercise and causes conformational changes in serum proteins that, when coupled with glomerular barrier changes, can lead to increased permeability and protein excretion.
The surest means of detecting proteinuria
Albumin excretion >300 mg/d is called macroalbuminuria, overt proteinuria, or dipstick-positive proteinuria. Albumin persistently excreted in the urine between 30 and 300 mg/d is referred to as microalbuminuria.
Because microalbuminuria is not detectable by a standard urine dipstick test, some providers routinely screen for protein with the microalbumin-to-creatinine ratio. A first-voided morning urine specimen is recommended, but random urine samples are an acceptable alternative.6 The microalbumin-to-creatinine ratio is recommended as a screen for early diabetic nephropathy and other kidney diseases. And a positive test result may also suggest increased risk of cardiovascular disease.6 Microalbuminuria is defined as persistent albumin excretion between 30 and 300 mg/d.7
When exercise is a factor, here’s what to look for
As noted earlier, exercise-induced proteinuria is a function of the intensity of the exercise. Moderate and strenuous (vigorous) exercise are the 2 types of exercise that come into play when discussing proteinuria. Differentiating them is not precise, but is often defined by maximal oxygen consumption (vigorous=60% of VO2max; moderate <60% VO2max); metabolic equivalents (vigorous=6 METS; moderate <6 METS); walking/running speeds (various); and heart rate reserve (vigorous=60% HRR; moderate <60% HRR).8
Moderate exercise produces glomerular proteinuria, with an increase in macromolecular (albumin) filtration across the glomerular barrier. Strenuous exercise increases glomerular filtration of low-molecular-weight proteins (β2-microglobulin), which overwhelm the reabsorbing capacity of the tubular apparatus, causing temporary dysfunction and tubular proteinuria.9 Thus, the pathophysiology is mixed, with a major contribution from glomerular proteinuria.10
Strenuous exercise can cause protein excretion to exceed 1.5 mg/min.11 However, it seldom rises beyond 1 to 2 g/d,4 and this increase usually reverts to normal physiologic levels within 24 to 48 hours after exercise.12
Mayo Clinic Q and A: Blood in urine should not be ignored
DEAR MAYO CLINIC: What could be causing a small amount of blood to show up in urine? I am in my 70s.
ANSWER: Blood in the urine — hematuria — can be alarming. Although some causes of hematuria can be serious, others are fairly harmless and may clear up with little or no treatment. Either way, it definitely should be evaluated by a health care provider.
Blood in the urine that’s clearly visible is called gross hematuria. Blood in the urine that isn’t clearly visible is called microscopic hematuria. With gross hematuria, urine may be red or pink, or similar in color to cola, tea or rust. Gross hematuria often occurs without other symptoms. It takes little blood to discolor urine, so you’re probably not losing as much blood as it may appear. However, heavier bleeding that involves passing blood clots is an urgent issue that can be painful and puts you at risk of having a blocked bladder outlet and inability to pass urine.
The first step is to determine if the discoloration is blood. Urine can become discolored in other ways, such as by blood proteins (hemoglobin or myoglobin); from eating beets; or taking certain medications, including some used to treat urinary tract infections. Occasionally, vaginal bleeding can be mistaken for hematuria and vice versa. Hematuria in older adults nearly always indicates the need for an evaluation to determine the cause of bleeding.
To determine what is causing the hematuria, your health care provider may first order a urine test to determine if bleeding is caused by a urinary tract or kidney infection. Symptoms of an infection may include a frequent urge to urinate, burning with urination, and abdominal pain or pressure. More severe symptoms, such as a fever, chills, and back or side pain, may indicate a kidney infection. Even if you don’t have symptoms, urine tests are almost always performed to check for an infection.
Urine tests and tests on the blood in the urine often can indicate if bleeding is coming from within the kidneys, which could indicate kidney disease or kidney cysts. A family or personal health history that includes a kidney disease or urinary stones can provide important clues.
The risk of hematuria being an indicator of cancer somewhere in the urinary tract increases after age 40. And, in most cases, it’s the first symptom. If suspected, testing for cancer may include looking for kidney, bladder, prostate or other potential cancers. A history of smoking, working with chemicals or dyes, radiation to the pelvic area, and other factors heighten the risk of urinary tract cancer.
In addition to infection, kidney disease and cancer as possible causes of hematuria, there’s a long list of other possibilities, with some being more common than others. Possible causes that are temporary and generally not worrisome, or are easily addressed, include strenuous exercise (particularly running), a blow to the kidney area, or various medications, such as the cancer drug cyclophosphamide or anticlotting drugs ranging from aspirin to warfarin (Coumadin) to clopidogrel (Plavix).
Other possible causes may include an enlarged prostate, kidney or bladder stones, or a number of inherited kidney diseases, such as polycystic kidney disease or Alport syndrome. For those of African descent, sickle cell anemia can be a cause.
It’s fairly common for no cause of hematuria to be found. For older adults with hematuria of undetermined cause, follow-up testing usually is recommended. One goal is to determine if the hematuria was temporary, persistent or intermittent. Another goal may be to remain watchful — or take an additional diagnostic look — for cancer or another disease that wasn’t previously detected. (adapted from Mayo Clinic Health Letter) — Dr. Mitchell Humphreys, Urology, Mayo Clinic, Phoenix
Bloody Urine After Injury Rarely Cause For Alarm, but Check It Out Anyway – 01/03/2011
Few things are more startling to parents than the sight of a child’s bright red-colored urine. Yet, blood in the urine — especially microscopic blood found during routine well-child visits — is fairly common, usually temporary and rarely a cause for concern, say experts at the Johns Hopkins Children’s Center.
An abdominal injury during sledding, a hit to the back during football practice, or being in a minor car accident can all bruise kidneys and cause them to spill small amounts of blood in the urine.
“Many triggers, including heavy exercise or a slightly bruised kidney from trauma, can set off a ‘red-pee’ alarm, and most cases resolve on their own with rest,” says Hopkins Children’s pediatric urologist Ming-Hsien Wang, M.D. Some children may even have tiny amounts of blood in the urine without any reason at all, she adds, noting that pediatricians should rule out common causes like urinary tract infections and kidney stones, an increasingly common problem in children.
One scenario that warrants special attention is bloody urine after a minor fall, a slight bump to the belly or other such seemingly innocuous injury, Wang says, because it could be the first sign of a urinary tract anomaly in an otherwise healthy child. One such condition is a “pelvic” kidney or a kidney that is abnormally positioned in the lower abdomen rather than higher and toward the back. The condition, Wang explains, is quite rare and occurs during fetal development when one or both kidneys fail to ascend into the back of the abdominal cavity and instead remain in the lower abdomen, their “original home” during early fetal development.
Pelvic kidneys are more vulnerable to damage because they are not as well shielded by fat, ribs and cartilage as normally positioned kidneys. Even minor falls or bumps to the abdomen can damage them, leading to bloody urine.
In addition to being more vulnerable to physical trauma, the ureters — the “drainage pipes” carrying fluid from the kidneys to the bladder — are often misshapen and squished by surrounding organs and cannot drain fluid properly. This can cause slow but progressive kidney damage over time. Timely diagnosis and surgery to restore shape and flow can save a pelvic kidney and its function, but because the condition rarely causes symptoms in early life, all too often it is discovered only after substantial kidney damage has occurred.
“For a child with a pelvic kidney, an injury that causes blood in the urine can be a blessing in disguise,” Wang says.
Blood in the urine always requires medical attention and, at a minimum, a urine analysis and blood work to check the kidney function, Wang says.
Blood in the urine that doesn’t go away after a day or two or comes and goes — whether visible or detected during microscopic urine analysis — should always prompt further evaluation, including a noninvasive ultrasound of the kidneys to check their position and structure.
What is Bladder Trauma?
The treatment for bladder trauma depends on the type of damage.
Blunt injury is damage caused by blows to the bladder. This bruises the bladder.
Penetrating injury is damage caused by something piercing through the bladder. This tears the bladder.
Most of the time, the bladder wall doesn’t tear and is only bruised. The only sign will be bloody urine. Your health care provider may just leave a wide catheter in the bladder so clots can pass. Once the urine becomes clear, the catheter will be taken out if there aren’t any other reasons to leave it in.
If the tear is on the top of the bladder, the hole will usually open to the part of the abdomen that holds the liver, spleen, and bowel. Urine leaking into the abdomen is a serious problem. This tear can be sewn closed with surgery. A catheter is left in the bladder for up to 2 weeks after surgery to allow the bladder to rest. The tube will either come out through the urethra or out through the skin below the belly button.
If the tear is at the bottom or side of the bladder, the urine will leak into the tissues around the bladder instead of the abdominal cavity. Complex injuries of this type should be repaired with surgery. But often it can be treated by simply placing a wide catheter into the bladder to keep it empty. The urine and blood drain into a collection bag. It usually takes at least 10 days for the bladder to heal. The catheter is left in the bladder until an X-ray shows that the leak has sealed. If the catheter doesn’t drain properly, surgery is needed.
Injury to the bladder from a bullet or other penetrating object is usually fixed with surgery. Most of the time, other organs in the area will be injured and need repair as well. After surgery, a catheter is left in the bladder to drain the urine and blood until the bladder heals.
Not sure if you’ve realized, but you and peeing are in an extremely committed relationship. You’ve been doing it since you were born, after all, which means you have a solid idea of what your pee should look like. Seeing blood in your urine doesn’t exactly make the cut.
“Blood in your urine can be alarming,” Jennifer Linehan, M.D., urologist and associate professor of urologic oncology at the John Wayne Cancer Institute at Providence Saint John’s Health Center in Santa Monica, California, tells SELF. Gross hematuria, which is blood that you can see in your urine, might make your pee look pink, red, or like you dumped some Coke into the toilet, according to the Mayo Clinic. Microscopic hematuria is blood in your pee that’s only visible under a microscope. None of this is ideal, but some causes of bloody urine are more serious than others. Here’s what could be behind your bloody pee.
1. You ate something hella red.
Let’s start with the least worrisome cause: You might not actually be seeing blood at all. Foods with deep red hues such as beets, rhubarb, and berries can make your pee look red, according to the Mayo Clinic. This will typically go away within a few days, but it’s smart to see your doctor anyway just to be certain your red pee is, in fact, food-related.
2. You have a bladder infection.
A bladder infection is a type of urinary tract infection that happens when bacteria gets into your body through your urethra (the small opening through which you pee). There, the bacteria can multiply, causing symptoms like a constant urge to pee, pain and burning when you do manage to squirt any out, and pelvic pressure, the Mayo Clinic explains.
This kind of UTI can inflame the lining of your bladder enough for it to bleed and result in bloody urine, Tom Guzzo, M.D., chief of urology at Penn Medicine, tells SELF. “It’s almost like having tiny cuts or a rash on the inside of the bladder,” Dr. Linehan adds.
See your doctor if you have any symptoms of a bladder infection. They’ll likely test your urine and, if you do have an infection, prescribe antibiotics to help get rid of it, according to the U.S. National Library of Medicine. Without prompt treatment, your bladder infection can progress to a kidney infection, so don’t try to push through it.
3. You have a kidney infection.
Speaking of bladder infections progressing, a kidney infection is a type of UTI that starts in your bladder and moves up to one or both of your kidneys, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) says. (Your kidneys filter your blood and remove waste and extra water, which become urine, the U.S. National Library of Medicine explains.)
Kidney infections share a few symptoms with bladder infections, including frequent, painful peeing and bloody urine (like a bladder infection, this is due to irritation and inflammation in your urinary tract, Doreen Chung, M.D., a urologist at NewYork-Presbyterian/Columbia University Irving Medical Center, tells SELF). They can also cause chills, fever, nausea, vomiting, and back, side, or groin pain, the NIDDK says.
If you suspect you have a kidney infection, see your doctor ASAP. They’ll likely want to put you on antibiotics. If your case is severe, you may need to be hospitalized so you can receive IV antibiotics and fluids, the Mayo Clinic says. Like a bladder infection, you don’t want to wait this out: A kidney infection can permanently damage your kidneys, or in severe cases, the bacteria can spread to your bloodstream and cause a life-threatening infection, the Mayo Clinic says.
4. You have a bladder or kidney stone.
Fun fact about your pee: It contains minerals. But if your urine is too concentrated, those minerals can form crystals on the walls of your kidneys or bladder, the Mayo Clinic says, and eventually transform into small, hard stones. You can have bladder or kidney stones that you might not even know about because they don’t cause symptoms. Or they can lead to a ton of pain, along with red flags like bloody pee.
What is Hematuria?
Repeat Urine Testing
The next step when microscopic blood is found is to repeat your urine test. This checks that the first finding was correct. You will need to get a mid-stream sample of urine. You will be told to collect your sample only after you have started to pass urine. Uncircumcised men will need to retract their foreskin to get a proper sample. Women will need to spread their labia and clean the opening of the urethra to get a clean sample.
Your health care provider will ask you questions about your health history. They will want to know about any infection, menstruation (period), kidney stones, drugs, or recent kidney injury. Simply repeating the urine test might be all that is needed if no further blood is found.
Cystoscopy Medical Illustration Copyright © 2015 Nucleus Medical Media, All rights reserved
If Testing Shows Blood and Protein
If protein is also found in the urine along with blood, then more urine tests and blood tests are needed. These tests are done to find out if kidney disease is the cause. Sometimes a kidney biopsy (putting a needle into the kidney) is done to find out if drugs are needed. Many of these health issues do not need treatment.
If Testing Shows Blood but No Protein
If a repeat urine test still shows blood and no protein is found, the next step would involve:
- blood test for kidney function
- cystoscopy (a procedure to look inside the bladder)
- imaging test such as CT scan, MRI or ultrasound to look at the inner and outer parts of the kidney, ureters and bladder.
Most often no specific cause for blood in the urine is found. You will be asked to do another urine test 1 and 2 years later. If no further blood is found, then no further testing is needed. If you still have blood in your urine, these tests will likely be repeated.
What Increases the Risk of Finding Cancer?
Cancers are not often the cause of microscopic blood in the urine. But there are many health issues that increase the chance that a bladder or kidney tumor is the cause. Seeing blood yourself in the urine (“gross hematuria”) is the most worrisome. A history of smoking or current smoking will increase your health care provider’s concern about finding cancer.
Issues that Increase the Chance of Cancer
- Age over 35 years
- Prior visible “gross” blood in the urine
- Cigarette smoking (past or current)
- Chemicals in the workplace
- Prior pelvic radiation for cancer
- Prior urological disorder or disease
- Irritative voiding symptoms (pain, infection)
- Chronic urinary tract infection