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TRAUMA
IN GENITO URINARY
Department of Urology
Saiful Anwar General Hospital / Medical Faculty Brawijaya University
Malang
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STANDARD KOMPETENSI DOKTER INDONESIA
(KKI 2012)
Tingkat kemampuan yang harus dicapai (standard
Kompetensi)
1. Mengenali dan menjelaskan
2. Mendiagnosis dan merujuk
3. Mendiagnosis, melakukan penatalaksanaan awal, dan
merujuk
A.Bukan gawat darurat
B. Gawat darurat
4. Mendiagnosis, melakukan penatalaksanaan secara mandiri
dan tuntas
A. Kompetensi yang dicapai pada saat lulus dokter
B. Profisiensi (kemahiran) yang dicapai setelah selesai internsip
dan/atau Pendidikan Kedokteran Berkelanjutan (PKB)
STANDARD KOMPETENSI DOKTER
INDONESIA
Urogenital trauma
Bladder Genitalia
(41 cases) (11 cases) Ureter
23% 6% (5 cases)
3%
Urethral
(50 cases) Kidney
28% (72 cases)
40%
KIDNEY TRAUMA
Kidney (Renal) trauma
*Ginjal dilindungi oleh kapsul ginjal & organ sekitarnya
Grade IV
Grade III 3%
Grade II 4% Grade V
5% 7%
Grade I
81%
Mode of Injury
Stab wounds
Mechanism of renal Penetrating trauma
In urban:
injury up to 20 %
Gunshot wounds
Rapid deceleration
renal artery occlusion
injuries
Tapi kadang jg gada hematuri
*Ada jejas di daerah flank disertai dengan hematuria (mikroskopis/makroskopis)
bila ada bekuan darah
-Kriteria mikrohematuri: eritrosit >5 pada hapusan
menyumbat di ureter
Diagnosis
Initial Emergency Assessment
Securing of the airway
Controlling any external bleeding
Resuscitation of shock
Serial Haematocrit
indicate blood loss
IVU revealed :
– the presence of contra lateral
Grade 3
kidney
– define the renal parenchyma
– out line the collecting system
Extravasation of contrast
CT Urography
Ginjal kedorong
keatas karena
didesak hematom
Grading and Treatment of Kidney
Trauma
• Goal of management :
– Minimize morbidity
– Preserve renal function
Observation
• T
N
Exploration
Hb
Hematuria
Flank mass
Complication
• Early complication • Late complication
⇛ Urinoma ⇛ Hypertension
⇛ Hypertension Akibat vasospasme
a.renalis ⇛ AV Fistula
⇛ Pseudoaneurysms
URETERAL TRAUMA
Etiology
Iatrogenic: 75%
General surgery: 14% (46 cases)
(340 cases )
CLASSIFICATION OF ASSOCIATED
INJURY
MECHANISM OF INJURY
INJURIES
Blunt pelvic trauma with Pelvic fractures
Extra
laceration by bone fragments(s)
peritoneal (80- Other long bone
Shearing at ligamentous
90%) fractures
attachment(S)
Blunt trauma
High velocity blunt lower High rate of associated
Intraperitoneal abdominal trauma intra-abdominal
(10-20%) High intravesical pressure with rupture injuries
at dome High mortality
Cystography
• Is considered as standard
diagnostic procedure?
• Accuracy rate 85–100%
• Injected contrast identified
outside the bladder
• Instillation of 350 ml
contrast media with gravity
• Exposing film :
Plain film
Filled film
Post drainage film
Female : 0 – 6%
In 10 – 17% associated with bladder rupture
In 8% associated with rectal fistula
Modus of pelvic fracture :
Blunt trauma : 90 %
Traffic accidents (70%)
Fall from a leight (25%)
In 27% as associated with multi organ injuries
DIAGNOSIS
• Triad signs of urethral disruption :
– Blood at the urethral meatus (positive in 37-93%
cases)
– Inability to urinate
– Palpably full bladder
• The signs of pelvic fracture clinically and
radiographically
• High riding prostate (complete urethral
disruption) Lakukan RT cek prostat melayang gk
Urethrography
• Technique :
– A 14-Fr foley catheter is
placed 1-2 cm into the
fossa navicularis
inflate the balloon with 1-2
ml water
– Introduce 10 ml 30% /
anna contrast solution with
catheter tip syringe
– Films taken in the lateral
decubitus position
– Study under fluoroscopy
when available
• Iatrogenic
• Straddle Injury
• Bulbous Urethral
crushed (pressed)
between pubic bone
and hard object
• Butterfly hematoma
Positive causative factor
Urethrography
Management Anterior Urethral Injury
• Blunt Trauma :
– Suprapubic catheter: 4 weeks
urethrography
– Urethral catheterization Dengan endoscopi
– Large haematoma/swelling
multiple incisions
Intrascrotal
• Pain
Acute scrotum
• Swelling
(emergency case)
• Acute onset
Potential for
testicular loss &
Infertility
nyeri mendadak disertai mual muntah & menjalar
This congenital
abnormality is present
in approximately 12% Testis seharusnya terfixir tp ini gk
nempel dinding resiko kplintir
of human male
Bell clapper deformity and testicular
torsion
Extravaginal torsion
• Nausea or vomiting
• Pain duration of less than 24 hours
• High position of the testis
• Abnormal cremasteric reflex
Doppler Ultrasonography
Exploration:
• After sharply entering the scrotum, the tunica
vaginalis opened, the testis detorsed and
wrapped in a warm, moist gauze.
• The contralateral side then undergoes
orchidopexy to prevent torsion on that side.
• The affected testis is reinspected for signs of
improved perfusion (“pinking up”)
Tunica albugenia testis di fiksasi ke tunica dartos biar gk mluntir lagi
• Rare in childhood
• Occurs in association with
urinary tract infection
• Evaluate for possible
urogenital anomaly
(ectopic ureter)
• In the absence of UTI’s,
epididymitis has been
known to occur in boys
with severe voiding
dysfunction
*Terapi;
-dikasih antibiotik golongan quinolon selama 4-6mgg
-scrotal support (pake sempak yg lbi kecil ukurannya agar terfixir mengurangi nyeri)
Cont….
• Usually adolescent, sexually active male
• Symptoms are gradual
• Associated pyuria, dysuria, flank pain, fever
• Sonography is helpful in making the diagnosis
• Causes: Chlamydia trachomatis, Ureoplasma
urealyticum, Neisseria gonorrhea
Doppler Ultrasonography
A
B
Hypervascularization in the epididimis (in acute epididimitis, A) or in
testicular area (in acute orchitis, B)
DIAGNOSIS OF SELECTED CONDITIONS
RESPONSIBLE FOR THE ACUTE SCROTUM
Onset of Cremasteric
Condition Age Tenderness Urinalysis Treatment
symptoms reflex
Testicular Surgical
Acute Early puberty Diffuse Negative Negative
torsion exploration
Positive or
Epididymitis Insidious Adolescence Epididymal Positive Antibiotics
negative
TRAUMA
• Infrequent
• History of direct hit to scrotal area
• May range from normal exam to diffusely
enlarged scrotum with echymoses and loss of
anatomic landmarks
• Many patients presents with torsion after acute
trauma
• Testicular rupture requires immediate exploration
• Hematomas are managed expectantly
Upper Urinary Obstruction
Organs that involve in urinary
Urinary tract consist of
Kidney: parenchyma
pelvicaliceal
Ureter
Bladder
urethra
Pathophysiology Urinary Tract Obstruction (“Symptoms”)
Loin pain
U.T.O
ACUTE CHRONIC
UNEQUIVOCAL
EQUIVOCAL
U.T.O.: Urinary Tract Obstruction
ACUTE OBSTRUCTION
ETIOLOGY
• Stone
• Sloughed renal papillae
• Blood clot
• Acute retroperitoneal pathology
• Accidental ureteric ligation
ACUTE OBSTRUCTION
PATHOPHYSIOLOGY
• Intrarenal pressure
• Tubular function
• Obstructive atrophy
Sumber: Smith & Tanagho’s 18th
Functional changes during and following Upper Urinary Tract
Obstruction
• Asymptomatic (incidental)
• Symptoms:
– Acute or chronic
– Uni or bi-lateral
– In or ex-trinsic
– Complete or partial
– Flank pain
– Nausea, vomiting, fever, chilling, anuria
UPPER TRACT OBSTRUCTION
INVESTIGATION
1. IVP
2. USG
3. RADIONUCLIDE (RENOGRAM)
4. CT
Sumber: Basuki B. Purnomo, Dasar-dasar Urologi, 2011
IVP
USG
RENOGRAM
• Considerations in:
– type of the procedure
• Degree of dilatation
• Patient condition --- positioning
• Local or general/regional anesthesia
• Drainage only or definitive treatment
– timing
UPPER TRACT OBSTRUCTION