Rhabdomyolosis, renal failure, and bladder flap.... blood in the urine of the ultra runner.

It was my second time running the SpeedGoat 50k and shortly after starting the last and final decent from the tram at Snowbird, it happened again -- a repeated and almost painful desire to urinate with little more than a few drops of success.  I could barely run, if not barely walk fast.  Every time I would jostle the bladder, the urge would return.  Not just return as in I need to find a bathroom, but return as in the kidney stone pushing its razor edges into the lining of the Urethra.  I was less than ten miles from the finish, and my pace slowed almost to a crawl...  I guess it was better than the guy who ran past me the wrong direction from confusion and dilution thinking the course went the other direction.

The Speed Goat 50k is touted by many to be the hardest 50k in the US if not the world.  30.8 miles and 12000ft of vertical with painfully difficult climb after climb, after climb, followed by equally painful decent after decent.  A race that I am always determined to DNF, yet have somehow finished every time.  Even Killian Jornet have shown up for this sufferfest before.  Based on my observation, as many people DNF in this race as in the Wasatch 100.  For me, it wasn't new, and it wasn't going any better.  The previous year the exact same thing happened, and I had no idea the cause.  This year I was sure it was dehydration, but I just couldn't bring myself to down that last 10 oz of water.  By the time I reached the finish line I was not just going crazy from the bladder pain, but also borderline suffering from heat exhaustion.  After dousing myself with water, downing a coke or two, and a lot of water things started to come back to normal.  I figured it was the crazyness of the race and lack of training for ridiculous downhill sections that jostle the insides.  That was back in 2009.

Fast forward to 2015 and a friend and I are running just under 50 miles of the North Country Trail in flat Michigan.  34 miles in I got the same problem.  Unfortunately the trail was totally flat, the temperature was moderate, and the running was easy.  At least I knew what was coming and I quickly degenerated to walking and pounding water.

SO this time I had to ask myself what causes this problem since I can't seem to fix it on my own?  Is it dehydration, over hydration, electrolyte deficiency, or excessive electrolytes.  I figured it MUST be one of these things.  As always, the internet has lots to say, and so do runners... most of which had no real medical advice on dealing with the issue.  Here are the facts, as much as I can tell as a NOT doctor.

Symptoms:  Desire to Urinate often with little to no success, discoloration in the Urine caused by either blood or  myoglobin often describes as 'coca-cola' urine, possible pain in the lower back.

Diagnosis:  From best to worst, 1.) empty bladder (bladder flap) 2.) Rhabdomyolysis 3.)Renal Failure.

1.) Trauma to the bladder (I like bladder flap) caused by not having enough liquid in the bladder is one possible cause.  It appears to be mostly harmless, with some corrective action and verification from a physician it is actually the cause.  Dr. Bill Roberts recommendations are as follows: to relieve this form of hematuria is to void [the bladder] 20-30 minutes before your run so there is some urine in the bladder to soften the slap."  Unfortunately, when my run is longer than an hour or so, I'll be voiding a lot more times during a run.²

2.) Rhabdomyolysis is the rapid destruction of skeletal muscle resulting in leakage into the urine of the muscle protein myoglobin. ¹ Myoglobin is a protein that is contained in muscle cells, and if enough is spilled into the blood stream, it can clog the kidney's filtering system and lead to kidney failure and a variety of other serious medical consequences and complications. While muscles routinely get sore after physical activity, rhabdomyolysis takes that muscle injury to a higher level.

3.) Renal failure in our case is cased by Rhabdomyolysis progressing to the point of completely blocking the kidney.³  This is a life threatening.  Some sources show as high as 33-50 percent of cases of Rhabdomyolysis lead to renal failure.  Unlike non-exercise-induced rhabdomyolysis (crush injuries, infections, drugs and toxins, for example) where the progression from rhabdomyolysis to acute renal failure is between 17 – 40 percent of cases, exercise-induced rhabdomyolysis only very rarely progresses to acute renal failure.⁴

So if your like me, it can be pretty upsetting when I get into the 'coca cola' Urine state.  Remember the color of the Urine in actually caused by Myoglobin, not blood in the Urine, so if you can clearly identify blood, you are not suffering from Rhabdomyolysis.

A recent article in Ultrarunning magazine has this recommendation from Tamara Hew-Butler DPM, PhD and Marty Hoffman MD:⁴

Because the incidence of rhabdomyolysis and renal failure seems to be increasing disproportionately in ultramarathon circles, the four basic questions and answers below are ones you should understand and share with your crew:

1) How dangerous is rhabdomyolysis? Exercise-associated rhabdomyolysis in and of itself is not dangerous nor is it an uncommon biochemical finding in runners competing in an ultramarathon race. In fact, it’s more normal than abnormal! In the rare instances where rhabdomyolysis progresses to renal failure in athletes, the “perfect storm” of additional factors must be present.

2) What are the warning signs that rhabdomyolysis is harming my kidneys? When urine output becomes sparse and very dark, it is a good idea to start monitoring fluid intake and output carefully. In many cases, runners will urinate a reddish brown urine which resolves itself over the course of a race. However, if “coca cola” urine continues or gets worse, urinating becomes more difficult, you begin to feel “bloated”, or you develop lower back pain in addition to severe muscular pain, then you need to seek the advice of a medical professional immediately – on or off the course.



3) What are some factors that put me more at risk for developing renal failure associated with rhabdomyolysis? Excessive heat, severe dehydration, NSAID and/ or analgesic usage, and prior viral or bacterial infection are well-documented risk factors for developing exercise-associated rhabdomyolysis leading to renal failure. We have found in a recent analysis that development of hyponatremia during the run, under-training (especially if an injury limited training time), and being a relatively younger and faster male runner pushing through pain to finish the race, may be additional risk factors for developing renal failure associated with rhabdomyolysis.

4) How can I prevent developing rhabdomyolysis-induced renal failure during an ultramarathon?
■ Avoid taking NSAIDs (Advil, Motrin, Aleve, Celebrex, et al.) and/or analgesics during an ultramarathon race
■ Do NOT race if you had a recent viral or bacterial infection
■ Do NOT over- or under-hydrate
■ Train properly for the event; if you get injured, race only when you have regained proper fitness
■ Listen to your body; if you have any of the above-mentioned warning signs, seek medical attention immediately!

Be safe, Run far, and hydrate properly.

KP

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^{1. [http://www.medicinenet.com/rhabdomyolysis/article.htm]↩}

^{2. [http://www.runnersworld.com/ask-the-sports-doc/why-do-i-have-blood-in-my-urine-after-running ]↩}

^{3. [http://www.ncbi.nlm.nih.gov/pubmed/18711286]↩}

^{4. [http://www.ultrarunning.com/features/running-rhabdomyolosis-and-renal-failure-whos-at-risk/]↩}