Penyakit saluran kencing

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Penyakit saluran kencing

  1. 1. GANGGUAN SISTEM PERKEMIHAN<br />dr A. Yuda Handaya SpB,FInAC,FMAS<br />Bagian Bedah RSUD Kabupaten Malang<br />
  2. 2. UROLOGI<br /><ul><li>Tractus urinarius ♀
  3. 3. Tractus genitourinarius ♂</li></ul>The Urinary System consists :<br /><ul><li>kidneys
  4. 4. ureters
  5. 5. bladder
  6. 6. urethra </li></li></ul><li>RUANG LINGKUP<br /><ul><li>Kelainan Bawaan / Kongenital
  7. 7. Trauma
  8. 8. Radang / Infeksi
  9. 9. Batu Saluran Kemih
  10. 10. Obstruksi Saluran Kemih
  11. 11. Emergency Urologi (non trauma)
  12. 12. Infertilitas pada pria
  13. 13. Disfungsi Ereksi (DE)
  14. 14. Andropause (Male aging)
  15. 15. Keganasan</li></li></ul><li>Urinary tract consist of<br />
  16. 16. Anatomi Fisiologi<br />
  17. 17. Embryology <br />Pronephros<br />Mesonephros<br />Metanephros<br />Renal parenchyma<br />Pelvicalyceal system<br />ureter<br />Ureteric bud<br />
  18. 18. Pronephros<br />Mesonephros<br />Metanephros<br />Mesonepric duct<br />Ureter bud<br />Epididimis-vas deferens<br />
  19. 19.
  20. 20. Kelainan Bawaan / Kongenital<br />dr A. Yuda Handaya SpB,FInAC,FMAS<br />Bagian Bedah RSUD Kabupaten Malang<br />
  21. 21. Anomalies of the Upper Urinary Tract<br />
  22. 22. Anomalies of Number<br />
  23. 23. Ascent of Kidney<br />
  24. 24. Anomalies of Ascent<br /><ul><li>Ectopic kidney
  25. 25. Pelvic kidney
  26. 26. Thoracic kidney</li></li></ul><li>Anomalies of Form and Fusion<br /><ul><li>Crossed ectopic with or without fusion: </li></ul>(1) Unilateral Fussed kidney, <br />(2) Sigmoid kidney, dan <br />(3) Lump kidney <br /><ul><li>Horseshoe kidney</li></li></ul><li>Anomalies of Structure (polycystic kidney)<br />Bilateral kidney<br />Cyst in another organ<br />2 types:<br />Infant and adult type<br />Progressive renal failure<br />Tx: renal transplantation<br />
  27. 27. Anomalies of Structure (Simple Cyst)<br />Tx marsupialitation if:<br /><ul><li>Bleeding
  28. 28. Infection
  29. 29. Very huge cyst will obstruct PCS</li></li></ul><li>Anomalies of Pelvio-ureteric System<br />
  30. 30. Normal Ureteral Bud and Metanephric Development<br />
  31. 31. Anomalies of pelvio-ureteric system<br />
  32. 32. Embryology of incomplete double system<br />
  33. 33. Incomplete double system<br />Y-type ureter:<br /><ul><li> Asymptomatic
  34. 34. Yo-yo phenomena</li></ul>V-type ureter:<br /><ul><li> Asymptomatic
  35. 35. VUR</li></li></ul><li>Embryology of complete double system<br />
  36. 36. Complete double system<br />Weighert-Meyer’s Law:<br />Upper pole ureter more distal than lower pole<br />Normal orificium ureter<br />Ectopic ureter<br />
  37. 37. Ureterocele with ectopic ureteric <br />A big ureterocele will obstruct bladder neck<br />Filling defect on cystogram phase of IVP.<br />
  38. 38. Pieloureteric Junction Obstruction<br />Aberrant vessel obstruct UPJ<br />UPJ stenosis<br />
  39. 39. TRAUMA<br />dr A. Yuda Handaya SpB,FInAC,FMAS<br />Bagian Bedah RSUD Kabupaten Malang<br />
  40. 40. GINJAL<br />Paling sering<br />Trauma tumpul, tajam / tembak<br /> Langsung<br /> Tak langsung (deselerasi)<br />Mudah cideraginjal patologis<br /> Hidronefrosis<br /> Kista ginjal<br /> Tumor ginjal<br /> TBC ginjal<br />
  41. 41. MEKANISME TRAUMA GINJAL<br />Dikutip dari Smith’s General Urology<br />
  42. 42. GRADE TRAUMA GINJAL<br />
  43. 43. DIAGNOSIS<br />Trauma<br />Hematuria<br />Jejas/Massa pada pinggang<br />Nyeri<br />Tanda perdarahan/syok<br />PENCITRAAN<br />USG<br />IVU<br />CT-scan<br />
  44. 44. PENANGANAN<br />Tusuk/tembak Eksplorasi laparotomi<br />Tumpul :<br />Konservatif<br />Operatif<br />Renorafi<br />Partial/total nefrektomi<br />Penyambungan vaskuler<br />
  45. 45. KOMPLIKASI<br />SEGERA: Perdarahan, Ekstravasasi urin<br />Urinoma<br />Abses perirenal<br />Fistula renokutan<br />Sepsis<br />LAMBAT:<br /><ul><li>Hipertensi
  46. 46. Hidronefrosis
  47. 47. AV Shunt
  48. 48. Batu
  49. 49. PNC</li></li></ul><li>URETER<br />IATROGENIK<br /><ul><li>Op. Endourologi
  50. 50. Op. Kebidanan
  51. 51. Op. Digestive
  52. 52. Terjerat
  53. 53. Crushing  robek/putus
  54. 54. Devaskularisasi nekrosis</li></ul>DISTAL<br />
  55. 55. Diagnosis<br /> Durante operationum<br /> Pasca bedah<br />Pencitraan<br /> Retrogade pyelografi<br />IVU<br />
  56. 56. Stab wound of right ureter<br />Dikutip dari Smith’s General Urology<br />
  57. 57. TINDAKAN<br /> Lepas jeratan<br /> Anastomosis end to end<br /> Neoimplantasi/Boari flap<br /> Trans uretero – Ureterostomi<br /> Nefrostomi<br /> Ureterocutaneoustomi<br />Nefrektomi<br />
  58. 58. KANDUNG KEMIH<br /><ul><li>JENIS TRAUMA:
  59. 59. IATROGENIK</li></ul> TUR terutama buli-buli<br /> Litotripsi<br /><ul><li> TAJAM : Tembak, tusuk
  60. 60. TUMPUL : Fr. Pelvis (90%)
  61. 61. SPONTAN: Patologis
  62. 62. RISIKO : - VU penuh</li></ul> - patologis<br />
  63. 63. MEKANISME <br />Dikutip dari Smith’s General Urology<br />
  64. 64. KLASIFIKASI<br />KONTUSIO<br />RUPTUR<br />Intra peritoneal 25 – 45%<br /> Ekstra peritonel 45 – 60%<br /> Intra & ekstra 2 – 12%<br />
  65. 65. KLINIS<br /> Trauma Abdomen bawah<br /> Nyeri<br /> Hematuria/miksi(-)<br /> Tanda Fr. Os pubis<br /> Tanda-tanda cairan bebas<br /> Peritonismus<br /> Cidera organ yang lain<br />
  66. 66. DIAGNOSIS<br /> KLINIS<br /> RÖ : SISTOGRAFI <br />PERIVESIKAL DI SELA-SELA USUS<br /> EKSTRAPERITONEUM INTRAPERITONEUM<br /> NEGATIF PALSU<br />Robekan kecil<br /> TEST BULI-BULI<br /> SISTOSKOPI<br />
  67. 67. Extraperitoneal bladder rupture<br />Intraperitoneal bladder rupture<br />Dikutip dari Smith’s General Urology<br />
  68. 68. PENANGANAN<br />KONTUSIO : Kateter 7 – 10 hari<br />INTRAPERITONEUM : Laparotomi/eksplorasi<br /> Jahit<br /> Pasang drain<br /> Sistostomi<br /> Kateter uretra<br />EKSTRAPERITONEUM :<br />Kateterisasi <br />Jahit – pasang kateter<br />
  69. 69. KOMPLIKASI<br />SEPSIS<br /> ABSES PERIVESIKAL<br /> KELUHAN MIKSI<br /> PERITONITIS<br />
  70. 70. URETRA<br />Dikutip dari Smith’s General Urology<br />
  71. 71. Trauma Urethra<br />Trauma urethra posterior<br />Urethra pars prostatika<br />Urethra pars membranosa<br />Trauma urethra anterior<br />Urethra pars bulbosa<br />Urethra pars pendulosa<br />
  72. 72. Uretra Anterior<br /> IATROGENIK<br /> STRADDLE INJURY<br />KLINIS :<br />Trauma<br />Perdarahan per uretram<br />Miksi (+)/(-)<br />Hematoma<br />Perineum  seperti kupu-kupu<br />Scrotum/penis<br />DIAGNOSIS :<br />Klinis<br />Uretrografi<br />Ekstravasasi kontras<br />
  73. 73. STRADDLE INJURY<br />Dikutip dari Smith’s General Urology<br />
  74. 74. Ruptur bulbar (anterior) urethra following straddle injury<br />Dikutip dari Smith’s General Urology<br />
  75. 75. PENANGANAN<br />KONTUSIO :<br />Terapi (-)<br /> Follow up 4 – 6 bulan<br />GOLDEN PERIOD ( < 6 – 8 jam)<br /> HEMATOMA MINIMAL<br />Primary repair : pasang kateter dan sistostomi<br /> HEMATOMA LUAS :<br />Multipel insisi<br />Sistostomi<br />Late repair<br />
  76. 76. KOMPLIKASI<br /> STRIKTURA URETRA<br /> FISTULA URETEROKUTAN<br />
  77. 77. Uretra Posterior<br />FR. PELVIS / SIMFISIS PUBIS MERUSAK PELVIC RING<br />ROBEKAN URETRA POSTERIOR<br />Ligan Prostatomembranacea robek<br /> Hematoma yang luas dalam cavum ret2ii<br /> VU dan Prostat terdorong ke cranial<br /> “ FLOATING PROSTATE”<br />
  78. 78. INJURY OF POSTERIOR URETHRAL<br />Dikutip dari Smith’s General Urology<br />
  79. 79. KLASIFIKASI (Colapinto – McCollum)<br />Uretra posterior utuh, stretching<br /><ul><li>Uretrogram : memanjang, ekstravasasi(-)</li></ul>Uretra posterior putus, diafragma uretra anterior utuh<br /><ul><li>Uretrogram : ekstravasasi kontras terbatas </li></ul> di atas diafragma uretra anterior<br />Uretra posterior, diafragma uretra anterior, dan uretra pars bulbosa bag. proksimal rusak<br /><ul><li>Uretrogram : ekstravasasi yang luas</li></li></ul><li>Ruptur prostatomembranous urethra<br />Dikutip dari Smith’s General Urology<br />
  80. 80. KLINIS<br /> TRAUMA<br /> TANDA-TANDA PERDARAHAN/SYOK<br /> PERDARAHAN PER URETRAM<br /> RETENSI URIN<br /> HEMATOMA SUPRAPUBIK<br /> TANDA-TANDA FR. PELVIS<br /> RT : “FLOATING PROSTATE”<br />DIAGNOSIS:<br /> KLINIS<br /> RÖ : URETROGRAFI<br />
  81. 81. Repair of urethral injury<br />Dikutip dari Smith’s General Urology<br />
  82. 82. PENANGANAN<br />ATASI SYOK<br /> SISTOSTOMI TERBUKA<br /> LATE REPAIR<br /> P.E.R<br />KOMPLIKASI<br /> STRIKTUR<br /> GANGGUAN EREKSI<br /> INKONTINENTIA<br />Catatan:<br />Pada setiap kecurigaan ruptur uretra<br /> TIDAK BOLEH dilakukan kateterisasi !!<br />
  83. 83. PENIS<br />TRAUMA TUMPUL<br />TRAUMA TAJAM (AMPUTASI PENIS / REPLANTASI)<br />FRAKTUR PENIS<br /> Robekan T. Albuginea<br /> dalam keadaan ereksi<br /> bengkok dan hematoma<br />STRANGULASI/TERJERAT<br /> Karet<br /> Cincin Logam<br />
  84. 84. SCROTUM<br />TRAUMA TAJAM <br />TRAUMA TUMPUL <br />LUKA BAKAR<br />CRUSHING<br />AVULSI<br />
  85. 85. Infeksi Saluran Kemih<br />dr A. Yuda Handaya SpB,FInAC,FMAS<br />Bagian Bedah RSUD Kabupaten Malang<br />
  86. 86. What are the causes the UTI ?<br /> Normal urine : sterile, contains fluid, <br /> salt, waste product, <br /> free of bacteria, <br /> viruses, fungi.<br />
  87. 87. DEFINISI<br />Infeksi Saluran Kemih atau bakteriuria adalah didapatkannya mikro-organisme sebanyak 102 CFU/mL -> 104 CFU/mL<br />Kriteria bakteriuria: ≥ 104 CFU/mL <br />
  88. 88. Infection<br />when microorganisms, usually bacteria from the digestive tract, to the opening of the urethra and begin multiply. (Escherichia coli)<br />first bacteria growing in the urethra  Urethritis bacteria move to thebladderCystitis, bacteria go up the ureters  Ureteritis  infect the kidney  Pyelonephritis<br />
  89. 89. Chlamydia and Mycoplasma UTI in <br /> male and female, limited in the <br /> urethra and reproductive <br /> system, sexually transmitted, <br /> require treatment both partner<br />
  90. 90. Common urinary bacterial pathogens<br />(Escherichia Coli, Streptococcus <br /> Faecalis, Proteus spp,<br /> Pseudomonas spp, Klebsiella spp)<br />
  91. 91. Who is at risk ?<br />abnormality of urinary tract,  obstructs the flow of urine (kidney stone)<br />enlarged prostate gland  slow the flow of urine<br />from catheter ( urinary retention, unconscious, critically ill, nervous system disorder / lost bladder control <br />
  92. 92. Diabetes <br />changes in immune system, disorder suppresses the immune system infant, <br />infant, born with abnomalities urinary tract (corrected by surgery)<br />rarely seen in young men and boys<br />in women UTIs gradually increases by age<br />
  93. 93. women more UTIs then men (the urethra is short, bacteria quick access to the bladder, near the anus and vagina /sources bacteria, sexual intercourse)<br />women use a diaphragm more develop UTIs than other forms of birth control<br />women whose partners use condom with spermicidal foam<br />
  94. 94. What are the symptoms of UTI ?<br /> not everyone with UTI has <br /> symptoms<br /> symptoms (frequent urge to urinate <br /> and painful, burning in the area <br /> bladder and urethra during urination, <br /> feel uncomfortable pressure ebove <br /> the pubic bone, fullness in the <br /> rectum)<br />
  95. 95. despite the urge  small amount <br /> of urine is passed<br /> the urine look milky, cloudy, even <br /> reddish if blood is present <br /> nausea, vomiting and pain in the <br /> back / side below the ribs <br /> kidney infection<br />
  96. 96. UTIs in children is not <br /> characteristic : irritable, is not <br /> eating normally, unexplained <br /> fever, incontinence, loose bowel, <br /> is not thriving <br /> change in urinary pattern<br />
  97. 97. Features of UTIs<br />UTIs in adults is common, particularly in women <br />Cystistis produces symptoms, frequency, dysuria, urgency <br />Pyelonephritis typically present with loin pain, fever, malaise<br />UTIs less common in men  urethral extra length  prevent colony bacteria the bladder<br />
  98. 98. How is UTI diagnosis ?<br />urine test for bacteria or pus <br /> (midstream urine in sterile container)<br />urinalysis test is examined for white, and red blood cells and <br />Chlamydia, Mycoplasma can detected by special bacterial cultures<br />
  99. 99. If an infection does not clear up with treatment  order IVP ( gives images the bladder, ureters, kidneys<br />Recurrent UTI  recommend USG internal organ, cystoscopy (see the bladder by cystoscope from the urethra) <br />
  100. 100. How is UTI treated ?<br />with antibacterial drugs (the chois and the length of treatment depend urine test, the offending bacteria)<br />
  101. 101. Quinolones : ofloxacin (Floxin), norfloxacin (Noroxin), ciprofloxacin <br /> (Cipro ) and trovafloxin (Trovan)<br />UTI can be cured 1 – 2 days <br /> treatment  doctor ask to take antibiotics for a week or two week  to ensure the infection has been cured<br />Single dose treatment is not recommended (kidney infection, diabetes, structural anatomy, prostate infections)<br />
  102. 102. infection caused by Mycoplasma, Chlamydia, longer treatment is also needed treated with (tetracycline, trimethroprin, sulfamethoxazole / TMP,SMZ, doxocycline)<br />urinalysis help to confirm  UT is infection free<br />note : symptoms may disappear, before the infections is fully cleared<br />
  103. 103. severe ill patients (kidney <br /> infections  hospitalized) until they can take fluid and drugs on their own<br />2 weeks theraphy with TMP/SMZ as effective 6 weeks, on kidney infections<br />various drugs is available to relieve the pain in UTI<br />
  104. 104. a heating pad also help<br />drinking water helps cleanse the urinary tract from bacteria<br />ovoid drinking coffee, alcohol, spicy foods<br /> Uncomplicated urinary infections usually responds to 3 days course of antibiotic<br />
  105. 105. EPIDEMIOLOGI UTI OK KATETERISASI<br />Lebih dari 25% pasien yang dirawat di RS menggunakan kateter<br />Risiko bakteriuria pd kateterisasi tunggal (single catheterization) adalah 1 – 2% <br /> (Sedor & Mulholland, 1999)<br />Penggunaan kateter menetap (indwelling catheter) kemungkinan terjadinya bakteriuria adalah 3 – 10% (dengan rerata 5%) -> setelah 30 hari<br />
  106. 106. Faktor Risiko Timbulnya ISK Karena Kateterisasi<br />(dikutip dari Maki & Tambyah, 2001)<br />
  107. 107. Etiopatogenesis dan Perjalanan Penyakit<br />Kateterisasi<br />Bakteriuria<br />Bakteriemia<br />Sepsis<br />Kematian<br />(dikutip dari Saint & Lipsky,1999)<br />< 4%<br />≥ 30%<br />12,3%<br />
  108. 108. Cara Mikro-organisme Memasuki Saluran Kemih pada Pemakaian Kateter Menetap<br />(dikutip dari Maki & Tambyah, 2001)<br />
  109. 109. Pencegahan ISK yang Berhubungan dengan Kateterisasi<br />Indikasi pemasangan kateter menetap pada pasien yang menjalani rawat inap di rumah sakit<br />
  110. 110. Pencegahan<br />Pemasangan kateter sistostomi (suprapubik) pada pria<br />Penggunaan kateter kondom<br />Antibiotika (??)<br />Higiene pada saat memasang dan selama kateter terpasang<br />Sistem pengaliran tertutup (closed drainage system)<br />
  111. 111. Morbiditas Kateterisasi<br />Faktor risiko berkembangnya bakteriuria menjadi bakteriemia<br />
  112. 112. Rangkuman<br />Pemakaian kateter ISK/Bakteriuria <br />Bakteriuria akan berkembang menjadi bakteriemia, yang menyebabkan morbiditas maupun mortalitas<br />Pembentukan biofilm kuman sulit diberantas dengan antibiotika<br />
  113. 113. Profile<br />Dr Yuda Handaya SpB FInaCS,FMAS <br />Contact Person <br />Jl.  Bromo 98-100 Kepanjen,Kabupaten<br />Malang,JawaTimur,Indonesia<br />Phn/sms/mms 0341-7304141; 08175404141 ; 08122966805 <br />Fax 0341-394979<br />                     email : yudahandaya@yahoo.com<br />PROFESSIONAL QUALIFICATIONS<br />Specialist of General Surgery, University of GadjahMada, Indonesia<br />PROFESSIONAL  LICENSURE<br />Indonesian Medical Council No : 34.1.1.101.1.06.005789<br />
  114. 114. Thank You<br />

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