Dear Sumner:
Sorry to bother you with what may be an insignificant problem, but I’m uncertain as to what steps should be taken at this time. Daniel, a 20 year old man, was hit rather vigorously in his right flank while playing basketball. Shortly thereafter he noticed some blood in his urine, but this was just once. Since then the urine has been totally clear. However, when I saw him in the office today, I found a few red blood cells in both the first and second glasses, which, according to your teaching, indicates that the source of the blood is above the bladder neck, and, given the history of the flank pain, probably from the kidney. (You see, Sumner, I did stay awake during your lecture!)Daniel is no longer experiencing any pain. Should I suggest that Daniel hold off on contact sports for awhile? Do I need to get X-rays of his kidneys and, if so, what kind? What sort of follow-up is advisable?
Dear Craig:
First of all, my thanks for staying awake during my lecture and, even more so, for remembering (and using!) the information of the “3-glass urine.” I agree with you completely that the blood is most likely of renal origin, and since the urine was grossly red on only one occasion he probably experienced only a renal contusion rather than any disruption of the renal collecting system (assuming the bleeding was secondary to the trauma and not from other causes).
There are a variety of approaches for the problem of renal trauma. If Daniel’s urine was microscopically free of red blood cells on follow-up urines, I think it reasonable to obtain just a renal ultrasound study to rule out any obvious perirenal hematoma or space-occupying lesions in the urinary tract. However, if there is persistence of the hematuria and/or Daniel has any return of his back or abdominal pain, I would recommend obtaining a CT scan (with dye) which will give us a more accurate picture of the integrity of the renal collecting system (as well as possibly reveal any problems of other adjacent organs or structures). Happily most of the renal injuries caused by blunt trauma can be treated conservatively. (On the other hand penetrating injuries have a much greater chance for more serious injuries usually requiring surgical intervention).
