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Genitourinary Disease in the Athlete

Genitourinary Disease in the Athlete . Benjamin J Ingram, MD Sports Medicine Fellow Tri-Services Sports Medicine Fellowship Uniformed Services University Bethesda, Maryland. Literature Review. Pub Med June 19, 2011 Hematuria Proteinuria Acute Renal Failure

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Genitourinary Disease in the Athlete

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  1. Genitourinary Disease in the Athlete Benjamin J Ingram, MD Sports Medicine Fellow Tri-Services Sports Medicine Fellowship Uniformed Services University Bethesda, Maryland

  2. Literature Review • Pub Med • June 19, 2011 • Hematuria • Proteinuria • Acute Renal Failure • Current Sports Medicine Reports • British Journal Sports Medicine • Clinical Journal Sports Medicine • Un-cited Material • material from the Book Chapter by Gebke • Just the Facts unpublished update by Dr. Sean Martin

  3. Overview • Overview • Hematuria • Proteinuria • Acute Renal Failure • Trauma • Cycling Unique Injuries • Other Pearls • Probably Useless for Boards but Interesting Anyways

  4. Hematuria

  5. Exercise Induced Hematuria • Happens to an athlete • And • And • And • Resolves 24-72 hours after decreased physical activity • And the common sense • No other obvious reason like trauma

  6. Exercise Induced Hematuria • AKA • Athletic Pseudonephritis • Sports Hematuria • Stress Hematuria • 10,000 meter Hematuria • Bongo Drum Hematuria • Ohio State Med J. 1974 Mar;70(3):169-71 • Gross or • Microscopic • Defined as > or = 3 RBC’s/high powered field (American Urological Association)

  7. Prevalence • Normal folks • 13-15% • Athletes • Swimmers • 80% • Football • 55% • Rowers • 55% • Boxers • 73% • Middle Distance Track • 45%

  8. Should I be screening? No “routine screening of all adults for microscopic hematuria with dipstick testing currently is not recommended…” Kane S. Evaluation of the Asymptomatic Athlete with Hepatic and Urinalysis Abnormalities. Curr Sports Med Rep , 2009

  9. Overload or Duration? • Conflicting answers • Depends on the sports demands • Sprinters vs marathon runners

  10. Pathophysiology • Many Causes • Many pathophysiologies

  11. Renal Pathophysiology • Not Well Understood • Non-traumatic • Decreased afferent flow proportional to intensity of exercise • Shunting to the muscles • Hypoxic renal damage • Increased glomerularpermeability • Renal vasoconstriction in the efferent arteriole • Increased filtration pressure • Increased passage of RBC into the urine • Traumatic Holmes, Renal Injury in Sport, Curr Sports Med Rep, 2003

  12. Bladder Pathophysiology • Traumatic • Blacklock performed cystoscopy in long distance runners >10,000m • Mirrorlesions in 2 sites • Flaccid posterior wall • Thick rigid trigone • Repetitive impact lesions • Empty bladder injury • Bladder with residual urine protective? Holmes, Renal Injury in Sport, Curr Sports Med Rep, 2003; Bernard, Renal Trauma: Evaluation, Management, and Return to Play, Curr Sports Med Rep 2009

  13. Prostate and Urethra Pathophysiology • Traumatic • Usually Cyclists

  14. Friendly Neighborhood Urine Dipstick • Rememeber… Heme positive = • Hemoglobin, or • Myoglobin, or • Erythrocytes

  15. Globinuria • Hemoglobinuria • + dipstick for heme • May be from mechanical damage to RBC in hands and feet (runner’s/martial arts) • Myoglobinuria • + dipstick for heme • Possible rhabdo badness

  16. Other Pathophysiology • Footstrikehemolysis • Hemoglobin overload • No erythrocytes seen in urine • Bongo Drum Hematuria

  17. Exercised Induced Hematuria Differential • Again, definition of Exercise Induced Hematuria • Athlete • Urine quickly returns to normal after exercises is stopped

  18. Exercised Induced Hematuria Differential • Trauma • Bike Seats on the prostate? • False positives • Menses in the female • Masturbation in the male • Sickle Cell • Drugs and medications • PCN, cephasporins, thiazides, allopurinol, NSAIDs, ASA, lasix, OCP’s, phenytoin, macrobid, septra, rifampin • Supplements • Rhabdo • Infection • Urgency? • Dysuria? • Penile Discharge? • Recent Strep Infection? • Nephrolitiasis • Intrinsic renal disease • Generalized Swelling? • Beets, berries, and food coloring • Bleeding disorders • Menses • Cancer Risk (tobacco, chemical exposure, age >40, h/o radiation) • Family History • Recent Digital Rectal • Sexual Intercourse Holmes, Renal Injury in Sport, Curr Sports Med Rep, 2003

  19. Gross Hematuria • Times gives clues to location • Continuous • Terminal • Initial • Color • Dark Brown- Upper • Pink or Red- Lower

  20. Exercise Induced Hematuria • Work Up • <40, recheck UA in 24-48 hours • If normal, then exercise induced hematuria • no further work up • If >40, persistent, recurrent, or other associated symptoms, continue the work up • Long Term • No long term consequences • Assuming the diagnosis is correct • And assuming the diagnosis didn’t change Gebke, Primary Care Sports Medicine Chapter 16

  21. Exercise Induced Hematuria Especially if > 40 Gebke, Primary Care Sports Medicine Chapter 16

  22. More Busy and Complicated Version of the Same Holmes, Renal Injury in Sport, Curr Sports Med Rep, 2003

  23. Return to Play Asymptomatic ResolvedHematuria attributed to exerciseonly

  24. Proteinuria

  25. Proteinuria • Severe, strenuous or prolonged exertion • Degree of proteinuria is linear to severity of workout • Prevalence 18-100% • Begins 30 min after starting workout • Maximum excretion 20-30 min after workout session • Clears 24-48 hours later • If it doesn’t, need more work up

  26. Proteinuria So, What is the Right Amount? • Normal urine protein 30-45mg/24 hours • 2+ to 3+ urine dipstick (300-500mg) • 100-300mg/24 hours • Commonly associated with: • Hemoglobinuria • Hematuria • Myoglobinuria

  27. What is the Right Amount? • Martin’s Article for Just the Facts: • 150mg/24 hours • Bernard • 100mg/24 hours • Gebke • 100-300mg/24 hours • Patel • 100mg/m2 in pediatric population • Kane • 150mg/24 hours

  28. Proteinuria

  29. Exercise Induced Proteinuria Differential Diagnosis • Orthostatic proteinuria • Common in pediatric population • Uncommon in adults >30 • Glomerulonephritis • Nephrotic syndrome • Multiple myeloma • Drugs • NSAIDs, NSAIDs, NSAIDs • Diabetes • Lupus • Hepatitis • Polycystic Kidney Disease

  30. Orthostatic Proteinuria • 10% of kids ages 8-15 years test + for proteins on urine dipstick • 60% of pediatric proteinuria is orthostatic • AKA Postural Orthostatis • Uncommon in adults >30 • Diagnosis: • Empty bladder completely before bed • Sleep recumbent • Protein: Creatinine Ratio with 1st morning void • <0.2 = orthostatic proteinuria • >0.2 = persistent proteinuria • This requires work up • Orthostatic protein will be 10X higher standing than supine Kane, Evaluation of the Asymptomatic Athlete with Hepatic and Urinalysis Abnormalities. Curr Sports Med Rep. 2009 Patel, Kidneys and Sports. AdolescMed2005

  31. Return to Play Asymptomatic ResolvedHematuria attributed to exerciseonly

  32. Acute Renal Failure • Rare in Athletes • Usually related to a non-kidney problem • Rhabdomyolysis • Hyerpyrexia • Volume depletion • NSAIDs • FENA can differentiate between pre-renal azotemia and acute tubular necrosis (ATN)

  33. Trauma

  34. Renal Truama • Presents as: • Flank Pain • And • Hematuria • Kidneys normally well protected • Ribs • Muscles • Pericapsular fat

  35. Renal Trauma • Children and anomalous kidneys are not as protected • Larger kidneys to body size • Less rib protection • Decreased perirenal fat • Weaker abdominal musculature • 90% pediatric renal injury is blunt trauma

  36. Renal Truama • Direct blow • Football Helmet to Flank • Contrecoup • After high speed collision • Puncture • Rib fractures, javelin, archery

  37. Work Up • Good High Quality History and Physical • Sport • Injury • Symptoms • ? Gross Hematuria • Labs • UA, CBC, CMP, amylase, lipase HCG • Imaging • KUB • CT • IVP

  38. Normal UA and Normal KUB • Low Suspicion • Normal UA, normal KUB? • HCG in females • Observation only and serial UA • High Suspicion • Normal UA, normal KUB? • Perform CT or IVP • Why? Because 5% of renal trauma will have a normal UA • And normal KUB doesn’t mean much

  39. Renal Trauma Observation, bed rest, serial UA’s May Go Either Way Present in Shock • 5 Classes • Contusion • 85% sports injuries to kidney • Hematuria + with neg IVP • Management: observation, hydration, rest, serial UA • RTP 2-3 weeks (possibly 6-12 weeks) • Superficial Cortical Laceration • Loss of psoas shadow on KUB • IVP with extravasations • RTP 2-3 weeks (possibly 6-12weeks) • Deep Cortical Laceration (>1cm) • Cortex and Calices Laceration • Intrarenal hemorrhage with disrupted calices • Possible IVP without extravasations, • Observation with possible surgery • V. Vascular Pedicle Injury/Complete Renal Fracture • Rare in sports • Most likely present in shock Martin S, Johnson M. Genitourinary. Just the Facts. (In Press)

  40. Psoas Sign? Carry over from the 1960-70’s that doesn’t seem to be overly relied upon. The lateral margin of the psoas muscle, contrasted by adjacent fat, is usually visualized on supine abdominal radiographs. Failure to visualize all of the lateral margin or segments of it, has been cited as a sign of retroperitoneal pathology Williams, The Psoas Sign: A Re-Evaluation, Radiographics, 1985

  41. Psoas Sign Expanding Right Psoas sign with loss of L2 spinous process Missing Left Psoas Sign Pictures taken from the internet without regard to credit

  42. Return to Play Consensus is Inconsistent 2 weeks? 6-8 weeks? 12 weeks? 6-12 months?

  43. Return to Play Protection kidney pads (kick plates) flack jackets (rib protectors)

  44. Single Kidney? • Adults? • Kids?

  45. Single Kidney? • Johnson et al. • National Pediatric Trauma Registry 1995-2001 • 49,651 peds traumas analyzed • 0 kidneys lost due to sports • Wan et al. • National Pediatric Trauma Registry 1990-1999 • 81,923 peds traumas analyzed • 0 kidneys lost due to sports Bernard, Renal Trauma: Evaluation, Management, and Return to Play, Curr Sports Med Rep 2009

  46. Ureter Trauma= Massive Trauma Probably not your only problem

  47. Bladder Trauma • Usually protected by the pelvis • Full bladders clear pelvic brim • Most prone to trauma • Martial arts • 2 types • Contusion • Small injury, lots of blood • Rupture • Usually associated with pelvic fracture • Recommend to pee before competition to help prevent injury

  48. Don’t completely empty the bladder if you’re running a long way. Empty your Bladder if you’re planning to get kicked in the bladder

  49. Incontinance • It happens

  50. Genital Trauma • Women • Vulvar trauma • Balance beams • Water skiing falls • Forced water douche • Miscarriage • Salpingitis • Rubber pants

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