CASE PRESENTATION

By :
Nadila Ayu Putri, S.Ked
Supervisor :
dr. H. Martha Hendry, Sp.U
Medical Faculty Sriwijaya University
Surgery Department
RSUP DR. Mohammad Hoesin Palembang
2015

BACKGROUND

BACKGROUND
OBSTRUCTION
IN
THE URINARY
SYSTEM
UPPER
URINARY TRACT
KIDNEY

URETER

ANURIA

COLIC PAIN

LOWER
URINARY
TRACT
BLADDER

URETHR
A

URINARY
RETENTION

BACKGROUND
URINARY
RETENTION

URETHRAL
STRICTURE

BACKGROUND
Urethral stricture is a relatively common
disease in men with an associated prevalence
of 229-627 per 100,000 males, who are
typically older men.
Stricture incidence increases gradually with
increasing age, particularly for those older
than 55 yo

CLINICAL
PRESENTATION

IDENTIFICATION
Name
Age/Date of Birth :
Sex
:
Marital Status
Religion
:
Nation
Address
:
Occupation
:
Date of Admission
Med. Record

: Usman bin Muhim

80 yo/19th November 1935
Males
: Married
Islam
: Indonesia
Karang Agung, OKI
Retiree
: 19th May 2015
: 828316

ANAMNESIS

CHIEF
COMPLAINT

UNABLE
TO URINATE
SINCE 2
DAYS AGO

ANAMNESIS
Patient complained difficulty while urinating.
Straining while starting to pass the urine (+),
intermittency (+), decreased force and size of the
1,5 years stream of urine (+), dribbling of urine for a while
after going to toilet to pass the urine (+), feeling
Before of incomplete emptying bladder (+), needing to
admission pass urine more often than normal (+), nocturia
(-), cant hold to pass urine (-). Day by day, the
complained got worse. The patient went to doctor
got diagnosed BPH and had TURP on August 2014.
The patient had been hospitalized for two weeks
and after that he wasnt regularly control to
hospital because of financial reasons.

ANAMNESIS
Patient re-complained difficulty while urinate. Straining
while starting to pass the urine (+), intermittency (+),
decreased force and size of the stream of urine (+),
dribbling of urine for a while after going to toilet to pass
the urine (+), feeling of incomplete emptying bladder
(+), needing to pass urine more often than normal
(+), nocturia (-), cant hold to pass urine (-), mild pain
on passing urine (-), pus in urine (-), fever (-), flank pain
(-), bloody urine (-), intermitten pain (-). These
complains got worse. Patient also said that he got fall
from the bed right after he woke up, on last November
2014. Bloody discharge (-), bloody urine (-). And then
on December 2014, he complained unable to urinate at
all, he was referred to RSMH Palembang to undergo
cystostomy. And then on January 2015, he had surgery
for bladder. The patient had been hospitalized for two
weeks and after that he wasnt regularly control to
hospital because of financial reasons.

ANAMNESIS

2 Days
Before
admissio
n

Patient complained unable to urinate. There was

straining to start urinate. After that, he felt his
bladder was full, on suprapubic region pain when
palpable (+), fever (-), flank pain (-), bloody urine
(-), pus in urine (-), bloody discharge (-), stone or
sandy urine (-), intermitten pain (-), trauma (-)

HISTORY
History of Past and Chronic Illness :
Diabetes Mellitus (-)
Trauma on vertebral (-)
Stroke (-)
Urinary Tract Infection (-)
History of Medication :
Had been cathetherized twice before because
urine
retention
History of Surgery :
Had been BPH and took TURP surgery, Aug 2014
Open Cystostomy ec Retensio urine, Dec 2014
BNI ec BNC + Sachse, January 2015

PHYSICAL
EXAMINATION
GENERAL STATE :
General Condition
Sensorium
Blood Pressure
Respiratory Rate
Pulse Rate
Temperature

: Moderately Ill
: Compos Mentis
: 130/80 mmHg
: 19x/ m
: 72x/m
: 36,6 0C

PHYSICAL
EXAMINATION
SPECIFIC STATUS :
A.Head
: Normal
B.Eye
: Normal
C.Neck
: Normal
D.Thorax:
a. Cor
: I : Ictus cordis not seen
P : Ictus cordis not palpable
P : Within normal limits
A: Heart Sound I-II normal, gallop(-),
murmur(-)
b. Lungs:
I
: Static and dynamic symmetric
P
: Stem Fremitus same in both lung field
P
: Resonant in both lung field
A
: Vesicular (+) Normal, Ro (-), Wheezing (-)

PHYSICAL
EXAMINATION
Abdomen
: Normal
Extremities:
Superior
: Normal
Inferior
: Normal
External Genitalia :
I
: Discharge (-), had been circumcised,
diameter externa urethra meatus look
normal, hematom (-), edema (-)
P
: Pain (-), palpable mass (-).

LOCAL EXAMINATION
Costovertebral Angle Region:
I
: Bulging (-)
P
: tenderness (-)
Suprapubic region:
I
: Bulging (+), scar post surgery (+)
P
: tenderness (+)
Rectal Toucher
Anal sphincter tone
: good
Rectal mucosa
: smooth
No enlargement of prostate
Hand gloves
: blood (-), mucus (-), feses (+)
Bulbo-Cavernosus Reflex : (+)

LABORATORY FINDINGS
Hematology
Hemoglobin
:12,5mg/dl(12.6-17.4 mg/dl)
Leucocytes
: 9,7mg/dl (4.5-11.0 /mm3)
Hematocrits
: 44% (43-49%)
Platelet
: 372 /ul (150-450/ul)
Blood Chemistry Screen
Glucose
: 95 mg/dl

Electrolytes
Sodium (Na)
: 134 (135-155 mEq/L)
Potassium (K)
: 4,2 (3.5-5.5 mEq/L)
Kidney Function Test
Ureum
: 46 (16.6-48.5 mg/dl)
Uric Acid
: 5.10 (<8.4 mg/dl)
Creatinine
: 0,9 (0.70-1.2 mg/dl)

RADIOLOGY

Impression Bipolar Urethrogram:

There is stricture urethra pars
bulbosa

DIAGNOSIS
Working Diagnosis
Urine Retention ec Urethral Stricture pars
Bulbosa
Differential Diagnosis
Urethral Stricture
Benign Prostatic Hyperplasia
Bladder Neck Contracture
Urethrolitiasis
Complication
Urinary Tract Infection
Hydronefrosis
Renal Failure

TREATMENT
IVFD RL gtt xx/m
Inj. Ceftriaxon 1 gr/12 h
Inj. Ketorolac 30 mg/8 h
Pro Cystostomy CITO
Pro Sachse

OVERVIEW

ANATOMY

DEFINITION
Urethral stricture is a narrowing of the urethra caused
by scarring, which functionally has the effect of
obstructing the lower urinary tract. This scar is due to
fibrosis to the lumen of urethra and to a more severe
level the fibrosis will occur at corpus spongiosum.
Epidemiology :
Urethral stricture is a relatively common disease
in
men with an associated prevalence of 229-627
per 100,000 males, who are typically older men.

ETIOLOGY
Divided into two :
Congenital
Acquired : Trauma, infection, iatrogenic,
neoplasma.
Based on location of the stricture, the etiology :
Location Uretra
Pars membranasea

Possible Cause
Pelvic Trauma, false route

Pars bulbosa

catheter.

Meatus

Straddle Injury, uretritis.

Balanitis,
instrumentation.

rough

PATHOPHYSIOLO
GY

STAGE OF
STRICTURE

HOW TO DIAGNOSE ?
Anamnesis :
-Straining to start micturition/Hesitancy
-Decreased flow of the urine
-Frequency
-Terminal Dribbling
-Intermittency
-Sensation of incomplete bladder emptying
-Urine Retention (very serious)
Risk Factors :
-Have had Urinary Tract Infection
-Have used catheter

Physical Examination :
-Decreased of the urine flow
-Bulging on the suprapubic region
-Palpable mass on the ventral penis (if there is
spongiofibrosis)
Another Examination :
1. Uroflowmetry
2. Radiology
- Urethrogram
3. Laboratorium : To know the occurence of infection
and kidney function

TREATMENT
Dilatation
Interna Urethrotomy
Externa Uretrotomy
Urethroplasty

ANALYSIS

A Male, 80 yo,
Unable to urinate since 2
days ago
Urine
Retention
Weakness
Incoordinated

Detrussor
Muscle

Urethra
Obstruction

Bloody urine
Congeni (-)
Age
tal
Bloody
Circumsi
discharge (-) zed
Fimos
Trauma in
BNC
is
past few
Meatal
Para
days
(-)
Stenosi Ruptu
Blood fimos
re
sPost.
clot (-)
is
Urethr
a
valve

urethr
a

detrussor muscleuretra

Dysuria (+)
Flank Pain (-)
Hemathuria (-)
Sandy or stone
urine (-)

Ureth
ral
Strict
ure

enlargement
of the prostate
(-)
Nodul
(-)

Urethroliti
asis

Ca

BP
H

A Male,
80 yo,
with
chief
complai
nt
Unable
to
urinate

From
Autoanamnesis:
Straining/Hesitanc
y
Terminal Dribbling
Intermittens
Decreased forced
and size of urine
stream
Dysuria
History:
Frequent
Had been cathetherized
TURP
Suprapubic Cystostomy
BNI + Sachse
Physical Examination :
General Examination Normal
Suprapubic Region : Bulging
( +),scar post surgery (+),
tenderness (+)

Lower Urinary Tract

Symptoms (LUTS)

Obstructiv
e

Irritative

Laboratorium Findings within normal

limits
Bipolar Urethrogram : Urethral Stricture

Urine
Retentio
n ec
Urethral
Stricture
Pars
Bulbosa

CONGENITA
L
ETIOLOGY
ACQUIRED

INFECTIO
N
TRAUMA
IATROGENI
C

Post TUR-P
Catheterized
BNI +Sachse

It is important to know the location, length, stage of narrowing of

the stricture :
BIPOLAR
URETHROGRA
M
CLINICAL
PRESENTATION
S

LOCATION

Pars
bulbosa

LENGTH

2cm

Stage of
narrowing

Severe

Urethrotom
y Interna
using
Sachse

COMPLICATION

PREVENTIO
N
Avoid trauma to the urethra and pelvic
Transurethral act with caution, like
catheterization.
Avoid direct contact to patients infected with
sexually transmitted diseases such as gonorrhea,
using condoms.
Early treatment of urethral strictures can avoid
complications such as infection and renal failure

FOLLOW-UP
After surgery, catheter must be installed for 1 month.
Once the patient is discharged, the patient must control :
- every week during the first month
- two weeks for 6 months
- every 6 months for life
At the time of the control, do uroflowmetry examination,
when the stream of the urin <10 ml/sec do the dilatation
To prevent recurrence, patients often have to undergo several
measures, such:
(1) periodic dilatation with bougie
(2) periodic self clean catheterization or CIC (Clean
Intermittent
Catheterization) in which patients are
encouraged to conduct periodic catheterization on a certain
time with a clean catheter (not necessarily sterile) in order to

PROGNOSIS
Quo ad Vitam : Dubia
Quo ad Functionam : Dubia

THANK YOU

ANY QUESTIONS?
AIDA: -As a GP, what should we do?
-Differences between urethrotomy and urethroplasty?
RAHMAN: Education for prevention urethral stricture?
YULIAN: Any medication available for this patients?
MILA: How to prevent recurrency of urethral stricture?
IQBAL: What is the point of avoiding STD? Relation between
STD and
urethral stricture?

ANY
QUESTIONS?
ANDRE: How to differentiate between BNC and urethral stricture?
LIA MAHDI: What the infection of urethra that can cause urethral
stricture?
AYU RATNA: Why after the surgery had done on this patients, the
urethral
stricture can still recur?
TIARA: How did the first catetherization in this patient?
YOLA: Any complications in urethral stricture?
VINDY: How and why history of BPH can cause urethral stricture?

ANY
QUESTIONS?
AYU ARIES: How much is the max limits that we can taking
sache procedure?
ALI ZAINAL: Complication for internal urethrotomy?
ANUGRAH: Other treatment except surgical procedure?
ANGEL: How to differentiate staging of urethral stricture?