Exercise Hematuria

I have done some research and I am feeling better. I have been having blood in my urine intermittently for a couple of months. (see here and here). Saturday after my race, I started having problems again and throughout Sunday (visible clots of blood in my urine).

In February, I had a full work-up by a Urologist including ultrasound and Cystoscopy. Nothing was found.

After this weekend, I have done some more web research. The first piece of news is that my problem is probably urethral and not renal. A renal cause, including cancer or kidney disease would present with dispersed blood and not a clot. The clots definitely indicate blood entering late in the process.

I also had a full body massage on Saturday after the race and I had no specific pain in my lower back or flank area that would indicate renal disease or damage. This is consistent with the other incidents in December and January. The doctors poked and prodded, but there were no tender areas.

I then discovered the term: "exercise hematuria." Dr. Andy Bosch writes:

The most common reason for haematuria is a result of impact of the walls of the bladder while running. Repeated many times over a prolonged period such as during a marathon, each of these minor impacts causes more severe damage until eventually there is sufficient trauma to cause bleeding. The damage sustained to the bladder walls can be viewed through an instrument called a cystoscope, which is how the nature of the "injury" was first determined and which has also been used to show that healing occurs within a couple of days. [link]

Dr. Tim Noakes discusses this in his book: Lore of Running. He calls it common in runners that don't drink enough.

Now, both my GP and Urologist had mentioned running could cause bleeding, but gave me a clear impression that it was marathon distance or beyond necessary to cause those problems. I found a case study by Froukje L. Ubels, Gabe G. van Essen, Paul E. de Jong and Coen A. Stegeman of Department of Internal Medicine, University Hospital, Groningen, The Netherlands. In their review of extant literature they note:

Macroscopic haematuria was found mainly in long-distance runners (>10 km) and appears usually to be asymptomatic. It is usually most pronounced in the first urine voiding after exercise, normalizes often within 72 h after running and seems to be independent of the exercise intensity [1,3,5]. Link

Robert Campbell in "American Family Physician" (1996) refers to it as "10,000-meter hematuria":

Hematuria in athletes has been known by several other names, including "sports hematuria," "stress hematuria," "bongo drum hematuria," "athletic pseudonephritis" and "10,000-meter hematuria."(2) The condition was first reported in 1700, although it may have been recognized as early as the first century A.D.(5) [link]

I realize that my Saturday run, for example, was at the low end of this range (11K total), and not the marathon or more that my doctors are used to seeing with this condition. My wife Paige added a key point: I am a "clydesdale" (runner over 220#) and carry a lot of weight still in the front of my intestinal area. I have also lost significant weight in the last 9 months and the remaining skin and fat in that area are less firm than at my high weight point. This would cause extra pressure and bounce on my lower intestinal region including the bladder. I guess that most of the studies on exercise hematuria do not take into account my weight, and I had healed sufficiently before my February cystoscope that no irritation was found in the walls of my bladder.

So what does this mean? The symptoms (dehydration, emptying bladder before run, distances of 10K or more, symptoms that go away in 48 to 72 hours, etc.) are consistent with what I experience.

The good news is there is no need for serious concern. Dr. Bosch concludes:

If testing reveals no apparent cause, then future episodes can be ignored. Generally, however, a runner need not be too perturbed if they pass a bloody urine after a marathon.

Treatment includes drinking more fluids and not "emptying" my bladder right before a race. Dr Bosch writes:

Since the damage is due to impact of the bladder walls, the chance of developing haematuria is greatest when running with an empty bladder. Therefore, if you develop haematuria, avoid urinating immediately before the start of a marathon and see if that helps. The presence of some urine in the bladder will help prevent the bladder walls from making contact with each other.

Dr Ubels, et al agree:

We concluded it was postrenal, exercise-related macroscopic haematuria and found no reason for further urological examinations. We advised her to not completely empty the bladder prior to exercise. She restarted running and haematuria did not reappear.

So I will recover from this in a day or so, and then I will address changes in future habits to minimize the problems. I will also bounce a copy of this off my GP and other doctor types before I completely relax. But not before I put a few miles on tonight!

Carpe Viam.

Edit: I almost forgot. I also found two web references that ibuprofen acts a blood thinner and can contribute to gross hematuria. That is also consistent with this weekend's event.