Working Diagnosis:
Hematuria secondary to blunt force genito-urinary trauma with grade 1 right renal contusion.

Treatment:
IV fluid hydration & PO Norco with urine output and Hb/Hct monitoring. Gross hematuria resolved prior to discharge. Patient was discharged after 24hr hospital stay with instructions to follow up with Urology prior to sport participation. Avoid NSAIDs or antiplatelet/anticoagulants and take Tylenol PRN pain.

Outcome:
Athlete was seen by Urology within 3 days of discharge with instructions detailing no workouts of any type for the first 2 weeks post injury. Then if urine is clear, he may begin modified workouts (i.e. weight lifting and cycling but no running or physical contact) over the following 4 weeks. Afterwards, the patient may be cleared to resume sport activity. He successfully completed this 6 week stepwise progression without complication and rejoined his team for the remainder of the season.

Author's Comments:
The American Urological Association defines microscopic hematuria as more than 3 red blood cells per high-power field in the urinary sediment (2). Thus, one cannot simply rely on a positive dipstick to make this diagnosis. Interestingly, the degree of hematuria has no correlation to the seriousness of the underlying condition (1). Hematuria may also indicate a problem anywhere along the genitourinary tract or signify a non-urologic systemic disease. Therefore, it is critical to develop a comprehensive differential to accommodate for wide-ranging possibilities.

The gold standard for radiographic diagnosis of stable patients with suspected renal injuries is via CT with intravenous contrast (5). A CT can define the location of the injury, identify renal contusions, devitalized segments, and allow visualization of the entire retroperitoneum and abdominal organs (5).

Conservative (nonsurgical) management is the treatment of choice for the majority of renal injuries especially in mild trauma cases (5). One reason to avoid strenuous exercise initially following a renal injury is to provide reassurance of the patient’s recovery by the absence of hematuria, because even rigorous exercise alone in a healthy individual, may induce hematuria. This is particularly evident in distance runners (3).

Editor's Comments:
This case illustrates the importance of a thorough evaluation for any athlete presenting with gross hematuria, especially after trauma involving the chest, back or abdomen. While the differential diagnosis of microscopic hematuria is long, the differential for frank blood in the urine after trauma is much more specific, and potentially life-threatening. Prompt evaluation in an emergency department is indicated for a definitive diagnosis. Renal laceration or fracture, ureteral damage, bladder injury and urethral trauma can all have significant morbidity and even mortality. While the kidneys are well protected in the retroperitoneum by the lower ribs, paraspinal muscles and renal adipose tissue, high energy trauma (e.g. getting hit hard in a football practice) can be sufficient to cause contusion or complete disruption of the renal cortex.
The evidence regarding return to play following renal injury is sparse, and this is typically dictated by the severity of the injury along with urology consultation. Extra protective padding may be of benefit.

References:
1. Evaluation of asymptomatic microscopic hematuria in adults. American Family Physician. 60: 1999; 1143-1152.

2. Hematuria. (n.d.). American Urological Association. Retrieved September 19, 2014, from http://www.auanet.org/education/hematuria.cfm

3. Jones GR, Newhouse I. Sport-related hematuria: a review. Clin J Sport Med 1997; 7:119.

4. Moore, EE, Cogbill TH, Malangoni M, et al. Scaling system for organ specific injuries, Table 19. (n.d.). The American Association for the Surgery of Trauma. Retrieved September 19, 2014, from http://www.aast.org/library/traumatools/injuryscoringscales.aspx

5. Sheth S, Casalino DD, Remer EM, et al. Expert Panel on Urologic Imaging. ACR Appropriateness Criteria® renal trauma. [online publication]. Reston (VA): American College of Radiology (ACR); 2012. 7 p.

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