Penyakit saluran kencing

GANGGUAN SISTEM PERKEMIHAN
dr A. Yuda Handaya SpB,FInAC,FMAS
Bagian Bedah RSUD Kabupaten Malang

UROLOGI
Tractus urinarius ♀
Tractus genitourinarius ♂
The Urinary System consists :
kidneys
ureters
bladder
urethra

RUANG LINGKUP
Kelainan Bawaan / Kongenital
Trauma
Radang / Infeksi
Batu Saluran Kemih
Obstruksi Saluran Kemih
Emergency Urologi (non trauma)
Infertilitas pada pria
Disfungsi Ereksi (DE)
Andropause (Male aging)
Keganasan

Urinary tract consist of

Anatomi Fisiologi

Embryology
Pronephros
Mesonephros
Metanephros
Renal parenchyma
Pelvicalyceal system
ureter
Ureteric bud

Pronephros
Mesonephros
Metanephros
Mesonepric duct
Ureter bud
Epididimis-vas deferens

Kelainan Bawaan / Kongenital

Anomalies of the Upper Urinary Tract

Anomalies of Number

Ascent of Kidney

Anomalies of Ascent
Ectopic kidney
Pelvic kidney
Thoracic kidney

Anomalies of Form and Fusion
Crossed ectopic with or without fusion:
(1) Unilateral Fussed kidney,
(2) Sigmoid kidney, dan
(3) Lump kidney
Horseshoe kidney

Anomalies of Structure (polycystic kidney)
Bilateral kidney
Cyst in another organ
2 types:
Infant and adult type
Progressive renal failure
Tx: renal transplantation

Anomalies of Structure (Simple Cyst)
Tx marsupialitation if:
Bleeding
Infection
Very huge cyst will obstruct PCS

Anomalies of Pelvio-ureteric System

Normal Ureteral Bud and Metanephric Development

Anomalies of pelvio-ureteric system

Embryology of incomplete double system

Incomplete double system
Y-type ureter:
Asymptomatic
Yo-yo phenomena
V-type ureter:
Asymptomatic
VUR

Embryology of complete double system

Complete double system
Weighert-Meyer’s Law:
Upper pole ureter more distal than lower pole
Normal orificium ureter
Ectopic ureter

Ureterocele with ectopic ureteric
A big ureterocele will obstruct bladder neck
Filling defect on cystogram phase of IVP.

Pieloureteric Junction Obstruction
Aberrant vessel obstruct UPJ
UPJ stenosis

TRAUMA

GINJAL
Paling sering
Trauma tumpul, tajam / tembak
Langsung
Tak langsung (deselerasi)
Mudah cideraginjal patologis
Hidronefrosis
Kista ginjal
Tumor ginjal
TBC ginjal

MEKANISME TRAUMA GINJAL
Dikutip dari Smith’s General Urology

GRADE TRAUMA GINJAL

DIAGNOSIS
Trauma
Hematuria
Jejas/Massa pada pinggang
Nyeri
Tanda perdarahan/syok
PENCITRAAN
USG
IVU
CT-scan

PENANGANAN
Tusuk/tembak Eksplorasi laparotomi
Tumpul :
Konservatif
Operatif
Renorafi
Partial/total nefrektomi
Penyambungan vaskuler

KOMPLIKASI
SEGERA: Perdarahan, Ekstravasasi urin
Urinoma
Abses perirenal
Fistula renokutan
Sepsis
LAMBAT:
Hipertensi
Hidronefrosis
AV Shunt
Batu
PNC

URETER
IATROGENIK
Op. Endourologi
Op. Kebidanan
Op. Digestive
Terjerat
Crushing  robek/putus
Devaskularisasi nekrosis
DISTAL

Diagnosis
Durante operationum
Pasca bedah
Pencitraan
Retrogade pyelografi
IVU

Stab wound of right ureter

TINDAKAN
Lepas jeratan
Anastomosis end to end
Neoimplantasi/Boari flap
Trans uretero – Ureterostomi
Nefrostomi
Ureterocutaneoustomi
Nefrektomi

KANDUNG KEMIH
JENIS TRAUMA:
IATROGENIK
TUR terutama buli-buli
Litotripsi
TAJAM : Tembak, tusuk
TUMPUL : Fr. Pelvis (90%)
SPONTAN: Patologis
RISIKO : - VU penuh
- patologis

MEKANISME

KLASIFIKASI
KONTUSIO
RUPTUR
Intra peritoneal 25 – 45%
Ekstra peritonel 45 – 60%
Intra & ekstra 2 – 12%

KLINIS
Trauma Abdomen bawah
Nyeri
Hematuria/miksi(-)
Tanda Fr. Os pubis
Tanda-tanda cairan bebas
Peritonismus
Cidera organ yang lain

DIAGNOSIS
KLINIS
RÖ : SISTOGRAFI
PERIVESIKAL DI SELA-SELA USUS
EKSTRAPERITONEUM INTRAPERITONEUM
NEGATIF PALSU
Robekan kecil
TEST BULI-BULI
SISTOSKOPI

Extraperitoneal bladder rupture
Intraperitoneal bladder rupture

PENANGANAN
KONTUSIO : Kateter 7 – 10 hari
INTRAPERITONEUM : Laparotomi/eksplorasi
Jahit
Pasang drain
Sistostomi
Kateter uretra
EKSTRAPERITONEUM :
Kateterisasi
Jahit – pasang kateter

KOMPLIKASI
SEPSIS
ABSES PERIVESIKAL
KELUHAN MIKSI
PERITONITIS

URETRA

Trauma Urethra
Trauma urethra posterior
Urethra pars prostatika
Urethra pars membranosa
Trauma urethra anterior
Urethra pars bulbosa
Urethra pars pendulosa

Uretra Anterior
IATROGENIK
STRADDLE INJURY
KLINIS :
Trauma
Perdarahan per uretram
Miksi (+)/(-)
Hematoma
Perineum  seperti kupu-kupu
Scrotum/penis
DIAGNOSIS :
Klinis
Uretrografi
Ekstravasasi kontras

STRADDLE INJURY

Ruptur bulbar (anterior) urethra following straddle injury

PENANGANAN
KONTUSIO :
Terapi (-)
Follow up 4 – 6 bulan
GOLDEN PERIOD ( < 6 – 8 jam)
HEMATOMA MINIMAL
Primary repair : pasang kateter dan sistostomi
HEMATOMA LUAS :
Multipel insisi
Sistostomi
Late repair

KOMPLIKASI
STRIKTURA URETRA
FISTULA URETEROKUTAN

Uretra Posterior
FR. PELVIS / SIMFISIS PUBIS MERUSAK PELVIC RING
ROBEKAN URETRA POSTERIOR
Ligan Prostatomembranacea robek
Hematoma yang luas dalam cavum ret2ii
VU dan Prostat terdorong ke cranial
“ FLOATING PROSTATE”

INJURY OF POSTERIOR URETHRAL

KLASIFIKASI (Colapinto – McCollum)
Uretra posterior utuh, stretching
Uretrogram : memanjang, ekstravasasi(-)
Uretra posterior putus, diafragma uretra anterior utuh
Uretrogram : ekstravasasi kontras terbatas
di atas diafragma uretra anterior
Uretra posterior, diafragma uretra anterior, dan uretra pars bulbosa bag. proksimal rusak
Uretrogram : ekstravasasi yang luas

Ruptur prostatomembranous urethra

KLINIS
TRAUMA
TANDA-TANDA PERDARAHAN/SYOK
PERDARAHAN PER URETRAM
RETENSI URIN
HEMATOMA SUPRAPUBIK
TANDA-TANDA FR. PELVIS
RT : “FLOATING PROSTATE”
DIAGNOSIS:
KLINIS
RÖ : URETROGRAFI

Repair of urethral injury

PENANGANAN
ATASI SYOK
SISTOSTOMI TERBUKA
LATE REPAIR
P.E.R
KOMPLIKASI
STRIKTUR
GANGGUAN EREKSI
INKONTINENTIA
Catatan:
Pada setiap kecurigaan ruptur uretra
TIDAK BOLEH dilakukan kateterisasi !!

PENIS
TRAUMA TUMPUL
TRAUMA TAJAM (AMPUTASI PENIS / REPLANTASI)
FRAKTUR PENIS
Robekan T. Albuginea
dalam keadaan ereksi
bengkok dan hematoma
STRANGULASI/TERJERAT
Karet
Cincin Logam

SCROTUM
TRAUMA TAJAM
TRAUMA TUMPUL
LUKA BAKAR
CRUSHING
AVULSI

Infeksi Saluran Kemih

What are the causes the UTI ?
Normal urine : sterile, contains fluid,
salt, waste product,
free of bacteria,
viruses, fungi.

DEFINISI
Infeksi Saluran Kemih atau bakteriuria adalah didapatkannya mikro-organisme sebanyak 102 CFU/mL -> 104 CFU/mL
Kriteria bakteriuria: ≥ 104 CFU/mL

Infection
when microorganisms, usually bacteria from the digestive tract, to the opening of the urethra and begin multiply. (Escherichia coli)
first bacteria growing in the urethra  Urethritis bacteria move to thebladderCystitis, bacteria go up the ureters  Ureteritis  infect the kidney  Pyelonephritis

Chlamydia and Mycoplasma UTI in
male and female, limited in the
urethra and reproductive
system, sexually transmitted,
require treatment both partner

Common urinary bacterial pathogens
(Escherichia Coli, Streptococcus
Faecalis, Proteus spp,
Pseudomonas spp, Klebsiella spp)

Who is at risk ?
abnormality of urinary tract,  obstructs the flow of urine (kidney stone)
enlarged prostate gland  slow the flow of urine
from catheter ( urinary retention, unconscious, critically ill, nervous system disorder / lost bladder control

Diabetes
changes in immune system, disorder suppresses the immune system infant,
infant, born with abnomalities urinary tract (corrected by surgery)
rarely seen in young men and boys
in women UTIs gradually increases by age

women more UTIs then men (the urethra is short, bacteria quick access to the bladder, near the anus and vagina /sources bacteria, sexual intercourse)
women use a diaphragm more develop UTIs than other forms of birth control
women whose partners use condom with spermicidal foam

What are the symptoms of UTI ?
not everyone with UTI has
symptoms
symptoms (frequent urge to urinate
and painful, burning in the area
bladder and urethra during urination,
feel uncomfortable pressure ebove
the pubic bone, fullness in the
rectum)

despite the urge  small amount
of urine is passed
the urine look milky, cloudy, even
reddish if blood is present
nausea, vomiting and pain in the
back / side below the ribs 
kidney infection

UTIs in children is not
characteristic : irritable, is not
eating normally, unexplained
fever, incontinence, loose bowel,
is not thriving
change in urinary pattern

Features of UTIs
UTIs in adults is common, particularly in women
Cystistis produces symptoms, frequency, dysuria, urgency
Pyelonephritis typically present with loin pain, fever, malaise
UTIs less common in men  urethral extra length  prevent colony bacteria the bladder

How is UTI diagnosis ?
urine test for bacteria or pus
(midstream urine in sterile container)
urinalysis test is examined for white, and red blood cells and
Chlamydia, Mycoplasma can detected by special bacterial cultures

If an infection does not clear up with treatment  order IVP ( gives images the bladder, ureters, kidneys
Recurrent UTI  recommend USG internal organ, cystoscopy (see the bladder by cystoscope from the urethra)

How is UTI treated ?
with antibacterial drugs (the chois and the length of treatment depend urine test, the offending bacteria)

Quinolones : ofloxacin (Floxin), norfloxacin (Noroxin), ciprofloxacin
(Cipro ) and trovafloxin (Trovan)
UTI can be cured 1 – 2 days
treatment  doctor ask to take antibiotics for a week or two week  to ensure the infection has been cured
Single dose treatment is not recommended (kidney infection, diabetes, structural anatomy, prostate infections)

infection caused by Mycoplasma, Chlamydia, longer treatment is also needed treated with (tetracycline, trimethroprin, sulfamethoxazole / TMP,SMZ, doxocycline)
urinalysis help to confirm  UT is infection free
note : symptoms may disappear, before the infections is fully cleared

severe ill patients (kidney
infections  hospitalized) until they can take fluid and drugs on their own
2 weeks theraphy with TMP/SMZ as effective 6 weeks, on kidney infections
various drugs is available to relieve the pain in UTI

a heating pad also help
drinking water helps cleanse the urinary tract from bacteria
ovoid drinking coffee, alcohol, spicy foods
Uncomplicated urinary infections usually responds to 3 days course of antibiotic

EPIDEMIOLOGI UTI OK KATETERISASI
Lebih dari 25% pasien yang dirawat di RS menggunakan kateter
Risiko bakteriuria pd kateterisasi tunggal (single catheterization) adalah 1 – 2%
(Sedor & Mulholland, 1999)
Penggunaan kateter menetap (indwelling catheter) kemungkinan terjadinya bakteriuria adalah 3 – 10% (dengan rerata 5%) -> setelah 30 hari

Faktor Risiko Timbulnya ISK Karena Kateterisasi
(dikutip dari Maki & Tambyah, 2001)

Etiopatogenesis dan Perjalanan Penyakit
Kateterisasi
Bakteriuria
Bakteriemia
Sepsis
Kematian
(dikutip dari Saint & Lipsky,1999)
< 4%
≥ 30%
12,3%

Cara Mikro-organisme Memasuki Saluran Kemih pada Pemakaian Kateter Menetap
(dikutip dari Maki & Tambyah, 2001)

Pencegahan ISK yang Berhubungan dengan Kateterisasi
Indikasi pemasangan kateter menetap pada pasien yang menjalani rawat inap di rumah sakit

Pencegahan
Pemasangan kateter sistostomi (suprapubik) pada pria
Penggunaan kateter kondom
Antibiotika (??)
Higiene pada saat memasang dan selama kateter terpasang
Sistem pengaliran tertutup (closed drainage system)

Morbiditas Kateterisasi
Faktor risiko berkembangnya bakteriuria menjadi bakteriemia

Rangkuman
Pemakaian kateter ISK/Bakteriuria
Bakteriuria akan berkembang menjadi bakteriemia, yang menyebabkan morbiditas maupun mortalitas
Pembentukan biofilm kuman sulit diberantas dengan antibiotika

Profile
Dr Yuda Handaya SpB FInaCS,FMAS
Contact Person
Jl. Bromo 98-100 Kepanjen,Kabupaten
Malang,JawaTimur,Indonesia
Phn/sms/mms 0341-7304141; 08175404141 ; 08122966805
Fax 0341-394979
email : yudahandaya@yahoo.com
PROFESSIONAL QUALIFICATIONS
Specialist of General Surgery, University of GadjahMada, Indonesia
PROFESSIONAL LICENSURE
Indonesian Medical Council No : 34.1.1.101.1.06.005789

Thank You

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Penyakit saluran kencing

by Yuda Handaya on May 09, 2010

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