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British Journal of Sports Medicine

Runners with red pee = red alert?…The answer to MOOC’s question of the week

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This week’s question: What are the possible causes for first time gross hematuria in a female runner who experiences some abdominal pain during running?

The scenario presented occurs rarely, and most sports physicians would only see a few cases in their career. Haematuria is frightening for the athlete, so most present promptly for advice.

The history, duration, frequency and type of exercise is important. Lots of downhill running provokes cell break down in the quadriceps due to eccentric loading, and this may result in myoglobinuria. Old shoes with poor cushioning have less shock absorption and can lead to foot strike haemolysis. Anit-inflammatory medications can reduce renal blood flow, and studies on hyponatremia have found increased creatinine in the serum. However, we know these medications are commonly used by distance runners with relatively few suffering severe complications.

On physical examination, the athlete’s general condition is usually well unless there is a rare case of rhabdomyolysis. In collision sports, flank tenderness may be present. In the vast majority of cases, the diagnosis is Runners’ Haematuria, which was initially termed “10,000 metres haematuria” by the urologist Blacklock back in the 1970s. It is caused by abrasions of the bladder wall against the trigone, analogous to caecal slap in the gut. The only routine investigation necessary is a simple urinalysis to look for RBC and casts, plus protein.

Although the vast majority of cases are Runner’s haematuria, physicians still need to ensure the less common possibilities from the differential diagnosis are ruled out based on history, physical and investigations:

  1. Renal or ureteric stone will cause pain. The condition is uncommon in young athletes, but the first episode can occur in youth. A detailed metabolic work up is required if this condition is diagnosed.
  2. Foot strike haemolysis with haemaglobin pigment causing red urine. This is common when old or worn shoes are used, and the running occurs on a concrete surface.
  3. Urinary tract infections classically presents with dysuria and frequency rather than severe abdominal pain. Haematuria is uncommon in UTI.
  4. In a female athlete, the bleeding may actually be coming from the reproductive tract, i.e. uterus or cervix, but admixed with urine. Most women will be able to distinguish the two sources, but a pelvic examination may be required to clarify things in some circumstances.
  5. Myoglobinuria from damaged muscle can also change the colour of urine and appear similar to hematuria. This usually occurs after unaccustomed eccentric exercise and was originally termed the ‘squat jump syndrome’ within military settings. This condition can cause rhabdomyolysis and this would require an emergency work-up if suspected.
  6. Malignancy in the renal tract classically presents with painless haematuria. It is rare in young people, but should not be forgotten.
  7. In repeated cases of haematuria, a cystoscopy may help identify sites of bleeding, but these are usually just abrasions in the bladder wall opposite the trigone.

If the history and physical condition suggest any of the more serious differential diagnoses, further investigations are warranted. The only condition that needs urgent work up is rhabdomyolysis, which presents very differently from Runners Haematuria and needs hospital admission because an associated hyperkalemia can be life threatening, and an associated acute compartment syndrome can be limb threatening. If rhabdomyolysis is suspected, then the investigations should include a CBC, CRP, creatinine, electrolytes, plus ECG (to look for peaked T waves as a sign of hyperkalaemia). Thomas and Ibels summarised the recommendations for management of rhabdomyolysis in the 1980s and it has not been improved upon. They advocate:

  • A- aggressive fluid replacement 4-11 litres in the first 24 hrs
  • B-resonium ion exchange resins to correct significant hyperkalaemia. Dialysis may be required in some circumstances
  • C-compartment pressure testing if there is suspicion of acute compartment syndrome, and decompressive surgery when required.

Management of Haematuria in a Runner

For a first episode where history and physical examination do not suggest any of the differential diagnoses, the physician should manage the patient as a case of runners’ haematuria ie bladder wall abrasions. Apart from the basic investigations mentioned above, the athlete should rest from exercise until the haematuria clears, and then resume exercise. Some authorities advise the athlete to exercise with the bladder partly full, with the idea that this will reduce the contact between the trigone and the opposing bladder wall. Practically, this can be difficult to achieve! Athletes should also be advised to minimise NSAID use prior to races and long training runs, particularly in the heat. When there are recurrent episodes of exercise related haematuria, the patient should be referred to a renal physician or urologist. The referral route will be determined by the clinical picture and local or regional availability of services. Cystoscopy may be required to identify the source of bleeding

In summary, Runners’ Haematuria is uncommon, but sports physicians need to know how to deal with it. In most cases, the cause is relatively benign, but be aware of the occasional serious cause, and refer those people for prompt further management.

Other Readings:

Thomas MA, Ibels LS. Rhabdomyolysis and acute renal failure. Aust N Z J Med 1985;15(5):623-628.

Mercieri A. Exercise-induced hematuria. Up to date Oct 14 2015, http://www.uptodate.com/contents/exercise-induced-hematuria?source=machineLearning&search=runners+haematuria&selectedTitle=1~150§ionRank=1&anchor=H138038#H138038 Siegel AJ, Hennekens CH, Solomon HS, Van Boeckel B.. Exercise-related hematuria. Findings in a group of marathon runners. JAMA 1979;241:391-392.

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Dr Chris Milne is a Sports and Exercise Physician based in Hamilton New Zealand. He has particular interest in exercise related renal and GI issues. He has been Team Physician to several NZ Olympic Teams, and is Chair of the Medical Commission for Oceania National Olympic Committees.

British Journal of Sports Medicine

Is it safe to run a marathon after heart surgery (valve replacement)?

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Q: I used to be a marathon runner currently has 2+ mitral regurgitation and had past heart surgery including tricuspid valve repair. I am not asking your medical opinion (and I appreciate you cannot give me medical advice on a blog) but I wonder what principles underpin a cardiologist’s advice to runners who have had surgery and wonder if it will ever be safe to run a marathon again? (Underscore – this is an example for discussion, it is NOT medical advice for one person.

Answer by Associate Professor André La Gerche, MBBS, PhD, FRACP, FCSANZ, FESC. Sports Cardiologist, Cardiology Department, St Vincent’s Hospital, Melbourne, Australia (Click to read Dr La Gerche’s key paper on right heart problems (members & library access) in high volume exercisers or listen to him chat (free) to Dr Michael Turner).

Note: Legal caveat. BJSM underscores that this is not ‘patient advice’ but discussion of a general question.

There are many different ways a heart valve may not be working well. Each has its own particular challenges that would influence recommendations for exercise, as well as personal history of previous heart surgery and other past medical or surgery history. However, there are some basic principles that are usually followed.

First, we want to avoid any factors that may exacerbate the condition and increase the chance of needing re-do surgery. The complexity of re-do surgery is always greater.

An important consideration is the distinction between “structural valve disease” such as problems with the valve leaflets or the papillary muscles that tether the valve in place as opposed to “functional” mitral valve regurgitation where the leakiness arises from dilation of the heart structures around the valve, but the valve itself is ok. There are some settings in which structural heart disease, such as severe mitral valve prolapse, may be exacerbated by strenuous exercise.

In general, in the absence of significant abnormalities with the valve structure and in the absence of left ventricular dilation or heart failure then it may be possible to exercise at any level and compete in all sports.

The American Heart Association Guidelines (Bonow et al. Circulation 2015) (OPEN ACCESS) suggest:

1. Patients with mild to moderate mitral regurgitation with normal heart size, function and pressures can participate in all competitive sports at all levels. This would include marathon running.

If there are 1) abnormalities in valve structure or 2) significant left ventricular dilation or dysfunction, then a thorough patient history, physical and investigations are required before advising patients on what might be considered a safe amount of exercise or intensity.

What are the benefits of exercise on cognition/memory?

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Worldwide, the incidence of dementia and related cognitive disorders is estimated to affect 44 million people (CDC 2014) so, the question of exercise related benefits is not only interesting but essential to health care. The short answer is that the benefits of exercise for this population far outweigh the risks, despite the person’s level of cognitive impairment, and the type of exercise best suited to improve cognitive processing is aerobics and resistance training or a consistent active lifestyle. If you are interested in the science, read on!

Dementia is characterized by impaired cognitive processing, memory disorders and personality changes. The most common cause is aging compounded by vascular impairment. Therefore, since we know that exercise has been found to reduce the incidence of hypertension, coronary artery disease and strokes; the benefits of exercise should also include reduction of vascular aging in the brain tissue. Anatomically, Colcombe et al (PNAS, 2004) studied MRI scans in older adults who walked 3 x week for 6 months and found significant increases in gray and white matter volumes . Physiologically, Lui-Ambrose et al (Arch Int Med 2010) studied functional MRI in older adults who participated in resistance training twice weekly and found significant improvement in brain functions which actually persisted for 12 months after training had stopped. These changes include memory recall, time duration for cognitive response and ability to follow instructions.

What about the personality and mood changes that occur with cognitive decline? Behrman et al (Practioner, 2014) took a similar approach extrapolating the known benefits of exercise on adult depression symptoms and studied the effect of exercise on older adults of various ages. They found that with increased activity including walking and dancing, patients with mild to moderate depressive symptoms associated with dementia improved their feelings of self-esteem and mood while decreasing negative distracting thoughts. They compared the gains to pharmacology treatment and found that exercise was as effective and often reduced the need for medication with potential side effects.

In a 2010 meta-analysis conducted by Sofi et al (J. Int Med 2011) the authors reviewed studies that enrolled adults without dementia symptoms and monitored cognitive function versus anatomical presence of disease to see if the risk of cognitive decline changes in exercising adults. 15 prospective studies were found on mid-age adults participating consistently in an active lifestyle. The overall analysis followed over 30,000 subjects for 1-12 years and found that there was a 38% reduced risk of cognitive decline in subjects with high levels of physical activity and 35% reduction risk in low-to-moderate levels of activity compared to sedentary subjects.

In my attempt to present balanced research, I did a literature scan of adverse effects on cognitive function in exercising older adults. The result only unearthed a few logical warnings…start low and go slow to avoid musculoskeletal strain, maintain good energy input when exercising the older adult and ensure supervision and instructions for new training techniques. The main finding was that cognitive function does not worsen with exercise and that is a critical take-home message.

In summary of the research to date, (and my experience as a clinician at Toronto Rehab) the protective effect of physical activity on cognitive function is related to maintaining good cerebrovascular supply to the brain through blood flow and oxygen. Through the positive effects of exercise on cardiovascular risk reduction, the incidence of associated cerebrovascular events from diabetes, hypertension, obesity and dyslipidemia is greatly reduced and thus reduces disease induced cognitive decline. In the aging adult, there is a role for prevention of cognitive decline through an active lifestyle that seems to have a protective mechanism and potentially be related to the stimulation of neurotrophins that may actually promote neural growth and survival. Lastly, there is ongoing research suggesting that through exercise there is a reduction in stress related cortisol levels which may also be a positive factor in preserving cognitive function.

All science aside, I recall a public campaign years ago that proudly announced the slogan, “Be Smart, Exercise your Heart” … I think the underlying meaning is finally coming of age, no pun intended !

Author: Dr. Julia M.K. Alleyne MD
Toronto Rehab, MSK Lead Outpatients
Associate Clinical Professor, University of Toronto
Enhanced Skills Director, Department of Family and Community Medicine CEO, MSK Course of Canada

References

  • Stanley J. Colcombe et al; Cardiovascular Fitness, Cortical Plasticity, and Aging Proceedings of the National Academy of Sciences of the United States of America Vol. 101, No. 9 (Mar. 2, 2004), pp. 3316-3321
  • Liu-Ambrose T et al, Resistance training and executive functions: a 12-month randomized controlled trial, Arch Intern Med. 2010 Jan 25;170(2): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3448565/
  • Behrman S, Ebmeier KP.Can exercise prevent cognitive decline? Practitioner. 2014 Jan;258(1767):17-21, 2-3.
  • Sofi et al, Physical activity and risk of cognitive decline: a meta-analysis of prospective studies, Journal of Internal Medicine,Volume 269, Issue 1, pages 107–117, January 2011

British Journal of Sports Medicine

This week’s answer to MOOC question: Professor Louise Burke on fitness, weight loss and abnormal menstrual periods

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Q: I have been working hard in gym over the last 6 months. I got cool muscles and I look very fit. I also like that instead of losing weight I gained 3 kg extra (muscles). I eat well. But what worries me is the absence of a menstrual period. I wonder if amenorrhea can be caused by just hard training (without weight loss)?

A: Answer by Professor Louise Burke, PhD & Sports Nutritionist. Australia’s multi-Olympic games sports nutritionist, lead Nutritionist at the Australian Institute of Sport and author of the definitive Clinical Sports Nutrition. Member of the IOC Consensus Statement group that described RED-S: the Relative Energy Deficiency Syndrome (read on).

Louise writes…”Being too thin or training too hard were some of the early suspects in our understanding of amenorrhea in athletes. The first version of the Female Athlete Triad syndrome added further confusion with its rigid definition of the co-existence of amenorrhea with eating disorders and osteoporosis. Over the last decade, however, an appreciation of the real dietary problem – low energy availability – has emerged. This new term helps to tie a number of issues and observations together, and provides a new perspective on why amenorrhea occurs, who is at risk, and why you should care. The answer to these questions lies in an understanding of how the body handles energy.

Energy balance just considers the difference between energy intake from food and daily energy expenditure/requirement. When daily energy intake and expenditure is roughly equal, you’re said to be in neutral energy balance (or just “energy balance”). Energy balance can be changed by changing your intake, changing your expenditure, or changing both. If this change results in an energy intake that is less than expenditure (negative energy balance), there is a general expectation that body energy stores in the form of body fat and muscle are sacrificed to bridge the deficit.

Meanwhile, energy availability focuses on energy requirements, breaking them into two components: energy for exercise and energy for health and maintenance. In an ideal world, where you want to be in top shape and top function, your energy intake would cover both components. However, if we upset this equation by reducing our energy intake, increasing the energy we commit to exercise or a mixture of both, the result is a shortfall in the energy specifically available to support other body functions. Some of these functions are critical for keeping you alive while other functions are “nice to have” but can be turned off or turned down in an emergency. This situation is termed low energy availability.

Although we’ve said that negative energy balance causes you to break down fat and muscle to contribute these energy stores to the energy deficit and try to address the low energy availability, your body is smart enough to know that this isn’t a good long-term solution. After all, you will eventually disappear if you keep sacrificing your body tissues! Your body’s solution to low energy availability is to turn down or turn off some of the less essential health and maintenance functions to save its energy costs and try to restore energy balance. The good news is that you are now more economical at being you, expending fewer Calories/kilojoules to get through the day. The bad news is that you are no longer maintaining your health and function at its top level. Loss of the menstrual cycle is one of the common casualties of the energy adjustments.

Honing back in on the MOOC question & periods stopping…

This concept raises three important findings of relevance to the current case. First, low energy availability can be associated with negative energy balance and weight loss, but not always. In some situations or some individuals, the body’s priority response to low energy availability is to adjust energy expenditure to restore energy balance at a lower energy intake. Thus, low energy availability can exist without the typical presentation of weight loss or becoming very thin.

The second update is the recognition the energy mismatch that causes low energy availability can occur in a variety of scenarios:

  • Disordered eating and eating disorders
  • Over-enthusiastic and/or misguided weight loss campaigns. Some athletes set unrealistic targets for weight/body fat loss; others have reasonable targets, but try to reach them way too quickly.
  • A high training volume or strenuous competition schedule – particularly when this represents a sudden increase in usual patterns. It can be difficult to get a handle on just how much more energy is needed to support the new exercise program, and your appetite may be blunted by fatigue rather than directing you to eat more
  • An environment in which access to food is difficult and prevents an athlete from finding food at the right time in the right amounts – tight finances, travel, boarding in residences with small windows for meal times, a hectic schedule that means always being on the run. In other words, different types of factors can be represented in the development of low energy availability ranging from psychological problems to lack of knowledge or simply being in the wrong place at the wrong time in terms of food availability. We need to increase our recognition of the different types of athletes in which low energy availability can occur (including males!) and we need to have different solutions to fit the problem.

The third update on this syndrome belongs in the “why should you care” basket. Although amenorrhea is a common outcome of low energy availability adjustments, it is not universal (think of male athletes or post-menopausal athletes) and may not be recognised or considered problematic by some athletes. However, we now know that many other body systems are impaired by low energy availability, with casualties including poor bones and cardiovascular health, an increased risk of injury and illness, and impaired training adaptations and performance.

There are many incentives to tackle the problems of low energy availability. Indeed, many experts in sports science/medicine have identified the need to re-badge the syndrome so that it casts a wider net on the populations at risk and the problems it causes, as well as focusing attention on the underlying problem. The result is coining of the term “RED-S” (Relative Energy Deficiency in Sport) as a larger umbrella and spotlight on a common problem among athletes. RED-S promotes our new insights and provides a platform for a new approach to recognise, treat and prevent this issue.”

Links:

Listen to Dr Margo Mountjoy, MD, PhD, sports physician & MOOC lecturer – outline Relative Energy Deficiency Syndrome (RED-S) in this BJSM podcast http://ow.ly/Z5UgW

Author: Karim Khan

References

  • Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A, Ackerman K. The IOC relative energy deficiency in sport clinical assessment tool (RED-S CAT). Br J Sports Med. 2015;49(21):1354.
  • Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A. Authors’ 2015 additions to the IOC consensus statement: Relative Energy Deficiency in Sport(RED-S).
  • Br J Sports Med. 2015;49(7):417-20.
  • Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A. The IOC consensus statement: beyond the Female Athlete Triad–Relative Energy Deficiency inSport (RED-S). Br J Sports Med. 2014;48(7):491-7