Penyakit saluran kencing
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GANGGUAN SISTEM
PERKEMIHAN
dr A. Yuda Handaya SpB,FInAC,FMASBagian Bedah RSUD Kabupaten Malang
UROLOGI Tractus urinarius ♀ Tractus genitourinarius ♂
The Urinary System consists :• kidneys• ureters• bladder• urethra
RUANG LINGKUPKelainan Bawaan / KongenitalTraumaRadang / InfeksiBatu Saluran KemihObstruksi Saluran KemihEmergency Urologi (non trauma)Infertilitas pada priaDisfungsi Ereksi (DE)Andropause (Male aging) Keganasan
Urinary tract consist of
Kidney: parenchyma pelvicaliceal
Ureter Bladder urethra
Anatomi Fisiologi
Embryology
PronephrosMesonephrosMetanephros
Ureteric bud
Renal parenchyma
Pelvicalyceal systemureter
Pronephros
Mesonephros
Metanephros
Mesonepric duct Ureter bud
Epididimis-vas deferens
Renal parenchymal
Pelvicalyceal systemUreter
Kelainan Bawaan / Kongenital
dr A. Yuda Handaya SpB,FInAC,FMASBagian Bedah RSUD Kabupaten Malang
Anomalies of the Upper Urinary TractAnomalies of Number A. Agenesis (bilateral or unilateral)
B. Supernumerary Kidney
Anomalies of volume and structure
A. HypoplasiaB. Multicystic kidney C. Polycystic kidney
Anomalies of Ascent A. Ectopic kidneyB. Pelvic kidneyC. Thoracic kidney
Anomalies of Form and Fusion
A. Crossed ectopic with or without fusion: (1) Unilateral Fussed kidney, (2) Sigmoid kidney, dan (3) Lump kidney
B. Horseshoe kidney
Anomalies of Rotation A. IncompleteB. ReverseC. Excesive
Anomalies of Renal vasculature
A. Accessory, aberant,a or multiple vesselsB. Renal artery aneurismC. Arteriovenous fistula
A.Agenesis (bilateral or unilateral)B. Supernumerary Kidney
Anomalies of Number
Ascent of Kidney
Anomalies of Ascent A.Ectopic kidneyB.Pelvic kidneyC.Thoracic 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 kidneyCyst in another organ2 types:Infant and adult typeProgressive renal failureTx: renal transplantation
Anomalies of volume and structure
A.HypoplasiaB.Multicystic kidney C.Polycystic kidney
Anomalies of Structure (Simple Cyst)
Tx marsupialitation if:• Bleeding• Infection• Very huge cyst will
obstruct PCS
Anomalies of volume and structure
A.HypoplasiaB.Multicystic kidney C.Polycystic kidney
Anomalies of Pelvio-ureteric System
Normal Ureteral Bud and Metanephric Development
Anomalies of pelvio-ureteric systemAnomalies of Termination Ectopic ureter
Anomalies of Number Duplication Complete or incomplete
Anomalies of Structure Ureterocele
Obstruction Pelvio-ureteric junction.
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
Ectopic ureter
Normal orificium ureter
Weighert-Meyer’s Law:Upper pole ureter more distal than lower pole
Ureterocele with ectopic
ureteric
A big ureterocele will obstruct bladder neckFilling defect on cystogram phase of IVP.
Pieloureteric Junction Obstruction
UPJ stenosisAberrant vessel obstruct UPJ
TRAUMA
dr A. Yuda Handaya SpB,FInAC,FMASBagian Bedah RSUD Kabupaten Malang
GINJALPaling sering
Trauma tumpul, tajam / tembak Langsung Tak langsung (deselerasi)
Mudah cidera ginjal patologis Hidronefrosis Kista ginjal Tumor ginjal TBC ginjal
MEKANISME TRAUMA GINJAL
Dikutip dari Smith’s General Urology
GRADE TRAUMA GINJAL
• DIAGNOSISTraumaHematuriaJejas/Massa pada pinggangNyeriTanda 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 :HipertensiHidronefrosisAV ShuntBatuPNC
URETERIATROGENIK
»Op. Endourologi»Op. Kebidanan»Op. Digestive
» Terjerat» Crushing robek/putus» Devaskularisasi nekrosis
DISTAL
• Diagnosis– Durante operationum– Pasca bedah
• Pencitraan– Retrogade pyelografi– IVU
Dikutip dari Smith’s General Urology
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
Dikutip dari Smith’s General Urology
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
Dikutip dari Smith’s General Urology
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
Dikutip dari Smith’s General Urology
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
Dikutip dari Smith’s General Urology
Dikutip dari Smith’s General Urology
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
Dikutip dari Smith’s General Urology
KLASIFIKASI (Colapinto – McCollum)
1) Uretra posterior utuh, stretchingo Uretrogram : memanjang, ekstravasasi(-)
2) Uretra posterior putus, diafragma uretra anterior utuho Uretrogram : ekstravasasi kontras terbatas
di atas diafragma uretra anterior
3) Uretra posterior, diafragma uretra anterior, dan uretra pars bulbosa bag. proksimal rusako Uretrogram : ekstravasasi yang luas
Dikutip dari Smith’s General Urology
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
Dikutip dari Smith’s General Urology
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
dr A. Yuda Handaya SpB,FInAC,FMASBagian Bedah RSUD Kabupaten Malang
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 the bladderCystitis, 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
Faktor Risiko relatifLama kateterisasi > 6 hari 5,1-6,8
Wanita 2,5-3,7
Pemasangan kateter di luar kamar operasi 2,0-5,3
Tindakan urologi 2,0-4,0
Terdapat infeksi di tempat lain 2,3-2,4
Diabetes 2,2-2,3
Malnutrisi 2,4
Azotemia (kreatinin > 2,0 mg/dl) 2,1-2,6
Kateter ureter 2,5
Monitor produksi urine 2,0
Terapi antimikroba 0,1-0,4
(dikutip dari Maki & Tambyah, 2001)
Etiopatogenesis dan Perjalanan Penyakit
≥ 30%
< 4%
Kateterisasi
Bakteriuria
Bakteriemia
Sepsis
Kematian(dikutip dari Saint &
Lipsky,1999)
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
Obstruksi infravesikal (Bladder outlet obstruction) Pemasangan sementara untuk mengatasi retensi urine Dipasang dalam jangka waktu lama karena terdapat kontraindikasi tindakan pembedahan
Inkontinensia urine tanpa obstruksi Terdapat luka pada daerah perineum dan sakral Permintaan pasien
Monitor produksi urine Pada pasien kritis Pasien tidak mampu mengumpulkan urine
Selama pembedahan yang lama dengan pembiusan umum atau regional
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
Pria
Infeksi yang disebabkan oleh Serratia marcescens
Penyakit traktus urinarius lain yang tidak terinfeksi (nefrolitiasis, BPH)
Terdapat kateter uretra menetap
Rangkuman
• Pemakaian kateter ISK/Bakteriuria
• Bakteriuria akan berkembang menjadi bakteriemia, yang menyebabkan morbiditas maupun mortalitas
• Pembentukan biofilm kuman sulit diberantas dengan antibiotika
ProfileDr Yuda Handaya SpB FInaCS,FMAS
Contact Person Jl. Bromo 98-100 Kepanjen,KabupatenMalang,Jawa Timur,IndonesiaPhn/sms/mms 0341-7304141; 08175404141 ; 08122966805 Fax 0341-394979 email : [email protected]
PROFESSIONAL QUALIFICATIONSSpecialist of General Surgery, University of Gadjah Mada, IndonesiaPROFESSIONAL LICENSUREIndonesian Medical Council No : 34.1.1.101.1.06.005789