Working Diagnosis:
Severe left hydronephrosis due to congenital UPJ obstruction

Treatment:
A urologist placed a pigtail probe with left ureteral stent four weeks after initial presentation. Two weeks later, a urologist from her home region recommended robot-assisted left pyeloplasty due to persistent irritative urination problems and left sided discomfort. She underwent the recommended procedure for decompensated left pyeloureteral junction disease six weeks after initial presentation.

Outcome:
The athlete returned to golf 11 weeks post-surgery and to competition 16 weeks post-surgery as her team's top performer. Her home urologist and team physician continue coordinating post-operative care.

Author's Comments:
Congenital hydronephrosis due to UPJ obstruction incidence is 1 in 2000 and is more common in males. Rapid expansion of the renal collecting system via excessive fluid intake causes abdominal pain and intermittent hydronephrosis. Vague presenting symptoms may be attributed to digestive tract disease and result in delayed diagnosis of UPJ obstruction. The affected kidney often has preserved renal function, as reflected in this patient's normal eGFR, because the obstruction is transient. Surgical treatment is indicated for symptomatic (abdominal pain, recurrent urinary tract infections, hypertension) hydronephrosis associated with UPJ obstruction whereas asymptomatic patients are monitored with imaging. To our knowledge, this is the first published case of an athlete with congenital UPJ obstruction and symptomatic hydronephrosis presenting this late in life without an inciting event of trauma.

Editor's Comments:
This case highlights the sports medicine team’s crucial role of coordinating care and navigating the healthcare system for the athlete, which is especially important for college athletes who may be living away from home for the first time. Although congenital hydronephrosis is most often detected prior to birth with routine prenatal ultrasound scans, an athlete may not be aware of their prenatal or neonatal record, including diagnoses that were asymptomatic at that time. Thus, a congenital malformation should be included in a broad differential diagnosis.

References:
Kohno M, Ogawa T, Kojima Y, Sakoda A, Johnin K, Sugita Y, Nakane A, Noguchi M, Moriya K, Hattori M, Hayashi Y, Kubota M. Pediatric congenital hydronephrosis (ureteropelvic junction obstruction): Medical management guide. Int J Urol. 2020 May;27(5):369-376. doi: 10.1111/iju.14207. Epub 2020 Mar 11. PMID: 32162424.
Gonzalez R, Schimke CM. Ureteropelvic junction obstruction in infants and children. Pediatr Clin North Am. 2001 Dec;48(6):1505-18. doi: 10.1016/s0031-3955(05)70388-6. PMID: 11732127.

Heinlen JE, Manatt CS, Bright BC, Kropp BP, Campbell JB, Frimberger D. Operative versus nonoperative management of ureteropelvic junction obstruction in children. Urology. 2009 Mar;73(3):521-5; discussion 525. doi: 10.1016/j.urology.2008.08.512. Epub 2008 Dec 18. PMID: 19100599.

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