Exertional hematuria: definition, epidemiology, diagnostic and clinical considerations

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.