Immediate Management of Exercise-Induced Gross Hematuria in a Young Woman
This is almost certainly benign exercise-induced (exertional) hematuria that will resolve spontaneously within 24-48 hours with rest and rehydration, and does not require urgent urologic evaluation unless it persists beyond 72 hours. 1
Immediate Actions
Reassure the patient and initiate oral rehydration immediately. The combination of vigorous exercise (walking for an hour in heat), dehydration, and an empty bladder are classic precipitating factors for exertional hematuria. 1, 2
Rehydration Protocol
- Administer 5-10 mL/kg of water over 2-4 hours for slow rehydration (avoid rapid fluid intake). 3
- Use readily available fluids: water, 4-9% carbohydrate-electrolyte drinks (sports beverages), or skim/low-fat milk are all acceptable. 3
- Target sodium intake of 20-30 mmol/L and potassium 2-5 mmol/L, achievable through sports beverages or water with salty snacks. 3
- Continue modest fluid intake (0.4-0.8 L/hour) until well-hydrated. 3
Diagnostic Approach
Confirm True Hematuria
- Obtain microscopic urinalysis to confirm ≥3 red blood cells per high-power field (do not rely on dipstick alone). 4
- Examine for dysmorphic RBCs, red cell casts, proteinuria, white blood cells, or bacteria. 5, 4
Rule Out Infection
- Obtain urine culture if urinalysis shows leukocytes or bacteria. 4
- If infection confirmed, treat and repeat urinalysis 6 weeks post-treatment to confirm resolution. 4
Assess for Glomerular Disease
- Check serum creatinine to assess renal function. 5
- Glomerular source is unlikely given the clinical context, but would be suggested by: significant proteinuria (>500 mg/24 hours), dysmorphic RBCs (>80%), red cell casts, or elevated creatinine. 5, 4
Expected Clinical Course
Exertional hematuria should resolve completely within 24-48 hours with rest alone. 1, 2 The pathophysiology involves increased vascular resistance during exercise, bladder trauma from repeated impact on an empty bladder, renal ischemia, and increased glomerular permeability—all exacerbated by dehydration. 1, 2
When to Pursue Further Evaluation
Urgent Urologic Referral Required If:
- Hematuria persists beyond 72 hours 1
- Hematuria recurs without temporal association to exercise 1
- Patient has risk factors: age >40 years, smoking history, occupational chemical exposure, irritative voiding symptoms, or history of pelvic irradiation 4
Follow-Up Plan
- Repeat urinalysis in 48-72 hours to document resolution. 4, 1
- If hematuria clears as expected, no further workup is needed for this isolated episode in a low-risk 26-year-old. 1, 2
- Counsel patient to maintain adequate hydration before and during exercise, avoid exercising on an empty bladder, and report any recurrence. 1
Critical Pitfalls to Avoid
Do not order CT urography or refer to urology for an isolated episode of exertional hematuria in a young, low-risk patient that resolves within 72 hours. 1 This would represent overutilization of resources for a benign, self-limited condition.
Do not dismiss persistent hematuria (>72 hours) as exercise-related. At that point, standard hematuria evaluation with imaging and possible cystoscopy becomes necessary to exclude urinary tract malignancy or other pathology. 5, 6, 1
Do not attribute hematuria to dehydration alone without confirming resolution. While dehydration is a contributing factor, persistent hematuria requires investigation for underlying genitourinary disease. 1