CHAPTER 27 • GENITOURINARY 161- The athlete in acute renal failure often presents with
nonspecific complaints, such as malaise, weakness,
loss of appetite, nausea, anuria or oliguria, and symp-
toms of dehydration.
DIFFERENTIAL DIAGNOSIS AND TREATMENT
- Kidney failure in athletes is most often caused by
renal hypoperfusion or ATN. Obstructive uropathy is
rarely a source of renal failure. - Serum laboratory tests include a complete blood
count, blood urea nitrogen (BUN), creatinine, and
basic chemistry panel. Urine tests include osmolality,
sodium, and creatinine. With this data, a fractional
excretion of sodium(FENa) can be calculated to differ-
entiate between prerenal azotemia and ATN as the
cause of kidney failure.
•Treatment of prerenal azotemia involves rapid and
aggressive volume replacement. - Identification of the endogenous nephrotoxin such as
myoglobin in rhabdomyolysis or the exogenous
nephrotoxin as in NSAID-induced renal failure is cru-
cial. All reversible causes must be sought and treated.
•Treatment involves appropriate intravenous fluid
hydration, electrolyte management, and cardiovascu-
lar monitoring. Diuretics are only indicated in fluid
overload states. Indications for dialysis include the
need for ultrafiltration of a volume-overloaded state or
the need for solute clearance.
GENITOURINARY TRAUMA
RENAL
- The kidneys are normally well protected by surround-
ing muscles, ribs, and pericapsular fat. A blow to the
flank or abdomen produces a coup or countercoup
mechanism of injury. Abnormally located or anom-
alous kidneys are more prone to injury. - Flank pain and hematuria are the most common pre-
senting complaint. - Kidney injuries are divided into 5 classes based on
severity and type of injury:
Class I: Contusion—most common renal sports injury
Class II: Cortical laceration
Class III: Caliceal laceration
Class IV: Complete renal fracture—rare sports injury
Class V: Vascular pedicle injury—again, rare in sports - Flank pain or gross hematuria after blunt trauma in an
athlete requires consideration of possible renal injury.
Physical examination may reveal flank echymosis and
tenderness. Gross or microscopic hematuria is present
in greater than 95% of renal trauma.- Athletes with severe renal injuries (Class IV and V)
often present in hypovolemic shock. Aggressive
intravascular volume replacement, transfusion, and
surgical exploration to control life-threatening bleed-
ing are required for these injuries.
•Evaluation of renal injuries in hemodynamically stable
athletes may use intravenous pyelogram(IVP), com-
puted tomography, or magnetic resonance imaging.
Treatment of Class I–III injuries involve observation,
bed rest, and repeat urinalysis to assess for resolution
of hematuria. The athlete is restricted from contact
sports and a repeat IVP is obtained at 3 months.
- Athletes with severe renal injuries (Class IV and V)
URETERS- Ureteral injury is associated with severe trauma, such as
pelvic fractures and lower lumbar vertebrae fractures.
•Trauma to flank or pelvis raises the possibility of
ureteral injury. Hematuria is present in 90% of
ureteral trauma. The diagnosis is best established uti-
lizing IVP and retrograde pyelogram.
•Treatment is accomplished with placement of a
ureteral stent in a partially intact ureter or, as is often
the case, open surgical repair.
BLADDER- Injury often occurs with blunt trauma to a distended
bladder resulting in contusion or rupture. Patients with
bladder contusion present with a history of trauma,
suprapubic pain, guarding, hematuria, and possibly
dysuria. - Bladder rupture may be intra- or extra-peritoneal and
is usually associated with pelvic fracture. - Biker’s bladderis a complication of aggressive bicy-
cling and presents with abrupt onset of urinary fre-
quency, diminished urinary stream, nocturia, and
terminal dribbling. - Cystography is the definitive study for the diagnosis of
bladder rupture. If bladder rupture is present, assess-
ment for pelvic fracture is mandatory. Bladder contu-
sions are treated with catheter drainage for a few days.
Bladder rupture is surgically repaired (Sagalowsky and
Peters, 1998).
GENITALIA- Genital trauma may occur in any sport, though it’s
often seen in gymnastics, cycling, martial arts, and
contact sports.
•Testicular injuries result from direct trauma and
include contusion, torsion, or fracture.