2.

7 Analysis of problems
1. Mr. Billar and Mrs. Kejora brought his 5-year-old son, Fatih, to the RSMP General
Polyclinic to be circumcised. Previously, Fatih had been taken to the village mantri in
the Tulung Selapan area, but the mantri refused because of the difficulty of
circumcising and suggested that he was taken to a doctor. Fatih also complained of
pain during urination accompanied by complaints of fever since 1 week ago without
cough and runny nose, no sore throat and ear pain and no nausea and vomiting.
a) what is the embryology in this case?

Secara Fungsional urogenital terbagi menjadi

2 yaitu system urinary dan system genital
yang dimana kedua duanya berasal dari
mesodermal yaitu bagian mesodermal ridge
(intermediate mesoderm) di sepanjang dinding
posterior cavitas abdomen, dan awalnya,
saluran ekskretoris dari kedua sistem
memasuki rongga umum, kloaka.

Urinary Sistem

System urinary terbagi menjadi 3 bagian yaitu the pronephros, mesonephros, and
metanephros.
Pada mulanya rudimeter dan tidak berfungsi
 Pronefros 7-10 kel sel di servikal vestigial nephrotomes  hilang (akhir mg 4)
 Mesonefros  tubulus eskretorius  memanjang berbentuk S  Bowman’s capsule
o Medial terdapat glomerulus renal corpuscle Bersama mesonefros
o Lateral ductus kolekting longitudinal  mesonephric/ wolffian duct
o Bulan 2 urogenital ridge
o Beberapa bagian mesonefros menetap pada laki-laki yang berfungsi membantu
pembentukan system genital tetapi bagian ini menghilang pada wanita.
 Metanefros
o Minggu 5 permanent kidney

1
Sistem kolektivus (minggu 6- 7)
Mesonephric duct Ureteric bud jar metanephric Tunas berdilatasi pelvis renalis
primitive terbagi cranial dan caudal kaliks mayor kaliks minor
Mesonephric duct Ureteric bud  Collecting tubule  enter the calyx minor  pyramid
form

EXCRETORY SYSTEM
Collecting tubule ditutup di bagian distal oleh metanephric tissue cap
Keberadaan tubulus renal vesicle tubulus kecil + glomerulus nefron/ unit eskretorius
bag proksimal akhir kapsul bowman
Pemanjangan berkelanjutan tubulus kontortus proksimal, Henle’s loop, tubulus kontortus
distal
Nephronya berkembang sampai lahir sampai mencapai 1 miliar nephron di masing2 ginjal.
Urin mulai di produksi pada minggu 12 bersama dengan perkembangan glomelurus yang
dimulai pada minggu 10

Posisi Ginjal
Ginjal mulainya di pelvis  pengurangan kurvatura tubuh dan pertumbuhan daerah lumbal
dan sacral  mengarah ke cranial

2
Vesika Urinaria dan Uretrha
 Mg 4- 7  septum urorektal membagi kloaka anorectal canal dan sinus urogenital
primitive
 Membran kloakal terbagi membrane urogenital dan membrane anal
 Primitif urogenital sinus
o Bag atas VU (Vesica Urinaria) lumen allantois obliterasi urachus lig
umbilicalis mediana
o Pelvic part US prostat dan uretra membranosa
o Definitive US phallic part
 Caudal ductus mesonefrik VU ureter berkembang dari ductus mesonefrik vu
secara terpisah
 Epitel uretra prostatika proliferasi gl prostat perempuan gl uretral dan para
uretral

Sistem urogenital
Meskipun jenis kelamin embrio ditentukan secara genetic pada saat fertilisasi, gonad
melakukannya tidak memperoleh ciri-ciri morfologi jantan atau betina sampai minggu
ketujuh perkembangan, dimana sebelum minggu ke-7 primitiv germ sel terbentuk di epiblast
berjalan menuju gonad hingga minggu ke-7 mereka bertemu maka gonad berubah menjadi
cikal bakal ovarium atau testis
Embriology testis

• Minggu ke 7-8 mulai terbentuk gonad hingga diferensiasi testis di cavum abdomen

• Minggu ke 9 : testis telah memproduksi testosterone

• Minggu ke 15: fase pertama proses penurunan testis  dilatasi canalis inguinalis
untuk jalan testis

• Minggu ke 25: prosesus vaginalis memanjag di dalam gubernakulum menuju skrotum

• Minggu ke 30-35 : testis bergerak turun di dalam prosesus vaginalis

Hormon yang mempengaruhi:

• Hromon HCG plasenta  stimulus sel Leydig

• Testosterone (Sel Leydig)

• Anti Mullerian Hormone (AMH)  sel Sertoli

• Mullerian Inhibiting Substance (MIS)  sel Sertoli

Sadler TW. Embriologi Kedokteran Langman Edisi 14. Jakarta: EGC; 2019.

b) what is anatomy, physiology, and histlogy in this case?

c) What is cause pain during urination in this case?

3
Painful urination (disurya) is usually related to acute inflammation of the bladder, urethra, or
prostate. At times, the pain is described as “burning” on urination, seen from the time of
illness, dysuria that occurs at the beginning of micturition is usually from abnormalities in the
urethra, while at the end of micturition abnormalities in the bladder (Purnomo, 2011).

The causes of dysuria can be divided broadly into two categories, infectious and non-
infectious. Infectious causes include urinary tract infections or urethritis, pyelonephritis,
prostatitis, vaginitis, and sexually transmitted diseases. Non-infectious causes include skin
conditions, foreign body or stone in the urinary tract, trauma, benign prostatic hypertrophy,
and tumors. Also, interstitial cystitis, certain medications, specific anatomic abnormalities,
menopause, reactive arthritis (Reiter's syndrome), and atrophic vaginitis can all cause
dysuria.

One of the most common causes of dysuria is urinary tract infection (UTI) which occurs in
both males and females. 

Michels TC, Sands JE. Dysuria: Evaluation and Differential Diagnosis in Adults. Am Fam
Physician. 2015 Nov 01;92(9):778-86.

Basuki B. Purnomo. 2011. Dasar-Dasar Urologi. Jakarta: CV. Sagung Seto

d) How is the mechanism pain during urination in this case?

e) What is the correlation between age and gender in this case?
f) What is the meaning mantri in the Tulung Selapan area, but the mantri refused
because of the difficulty of circumcising and suggested that he was taken to a
doctor?
g) What is the cause of fever in this case?
h) What is the mechanism of fever in this case?

Risk factors: age and sex, not circumcised and poor local hygiene → accumulation of dirt on
the glans penis and accumulation of smegma → possible infection of the glans penis and
prepuce → scar tissue forming on the preputial orificium → preputium adhere to the glans
penis → phimosis → parts orificium urethra externum narrows → inhibits urine output →
urine retention and urine remains accumulate in the prepuce (urine as an ideal medium for
bacterial growth) → bacteria multiply and spread → infection asending to the bladder (vesica
urinaria)
→ urinary tract infection → a reaction occurs inflammation →stimulates endogenous
pyrogens to release pro-inflammatory mediators (IL-1, IL-6, TNF-α,
and IFN) → arachidonic acid release → converted by COX-1 and COX-2 to prostaglandin E2
→ increased thermostart in the thermoregulatory center in the hypothalamus → increase body
temperature → fever (Tusino & Widyaningsih, 2018).
4
Tusino, A., & Widyaningsih, N. 2018. Karakteristik Infeksi Saluran Kemih Pada Anak Usia
0- 12 Tahun Di Rs X Kebumen Jawa Tengah. Biomedika, 9(2), 39–46.
https://doi.org/10.23917/biomedika.v9i2.5842

i) What is the classification of fever?

j) What is the classification of urinary tract infection?
k) What is the meaning Fatih also complained of pain during urination accompanied
by complaints of fever since 1 week ago without cough and runny nose, no sore
throat and ear pain and no nausea and vomiting?

The meaning pain during urination accompanied by fever since 1 week ago is fatih
probability of experiencing experiencing the inflammation cause by acute infection . The
meaning no cough, runny nose, and no sore throat is eliminated the diagnosis of respiratory
illness. The meaning no ear pain is eliminated fever is not caused by ear infection like otitis
media. The meaning of no nausea and vomiting is eliminated the diagnosis of digestive
illness and urinary upper tract infection.

l) What is the mechanism of miksi?

m)What is the classification of miksi disorder?
n) What is the classification of urine colour?

Normal: light yellow, caused by urine pigment urochrom and urobili, affected by food,
medicine, certain diseases. Factors that affect urine color:

a. Urine concentration: the more concentrated the darker the color

b. Urine acidity: the more alkaline the urine color the darker

c. Abnormal pigments in urine and drugs

Red: blood present, porphobilins, drugs.

Green: there are germs

Brown: bilirubin (like tea water), hematin

Black: blood, drugs

Like milk: pus, prostate sap, chylus (fat), bacteria.

Normal: clear If cloudy, may be caused by bacteria, crystals, phosphates, urate,

erythrocytes, epithelium. Nubecula: urine is clear if allowed to / cooled becomes slightly

5
 cloudy, because there are deposits of mucus, urate, phosphate, epithelium, leukocytes,
bacteria.

Washudi, Tanto H, Kirnantoro. 2016. Praktikum Biomedik Dasar dalam Keperawatan.

Kementrian Kesehatan Republik Indonesia

o) What the complication if not circumcised?

p) What is the indication and contraindication of circumcised?
2. According to his mother, there was residual urine after urinating which has been
dripping in his pants since 1 month ago. Fatih's parents asked the doctor if their child
could be circumcised and if there were any abnormalities in the genital organs. Will
Fatih's disorder affect fertility and masculinity problems later when he grows up?.
The puskesmas doctor gave an explanation about the problems and his parents could
understand it.
a) What is the meaning according to his mother, there was residual urine after
urinating which has been dripping in his pants since 1 mont ago?
b) What is the cause urine has been dripping and his pants?
c) What is the mechanism urine has been dripping inhis pants?

Ruang antar peputium dengan glans penis tidak berkembang dengan baik adhesi preputium
dengan gland penis  fimosis  menutupi OUE  Retensi urine  urin menetes

d) What is the correlation main complaint with additional complaint?

e) What is the possible disease can affect fertility and masculinity problem?

Type of Uti

Uncomplicated cystitis: A bladder infection in a healthy, nonpregnant, premenopausal female

with a normal urinary tract.
Complicated cystitis: A bladder infection associated with factors that either increase the risk
of serious outcomes or decrease the efficacy of treatment. This includes: cystitis plus a
foreign body (such as a catheter or urinary tract stone), recent instrumentation, urinary tract
abnormalities, or vesicoureteral reflux. It also includes cystitis in men, pregnant women, and
patients with renal transplant or other causes of an immunocompromised state, and UTIs due
to atypical organisms or multi-drug resistant bacteria.
Uncomplicated pyelonephritis: A kidney infection that occurs in a healthy nonpregnant
patient with a normal urinary tract.
Complicated pyelonephritis: A kidney infection that occurs during pregnancy or in a patient
with other complicating factors (as noted above, under complicated cystitis), typically
requiring hospital admission.

6
Recurrent UTI: Defined as ≥ 2 UTIs in 6 months, or ≥ 3 UTIs in 12 months.
Asymptomatic bacteriuria (colonization): > 100,000 cfu/mL of bacteria are present on clean
catch urine culture without signs or symptoms of illness.

3. Birth history: Fatih was born with a weight of 2500 grams, preterm and normal
delivery helped by a village birth shaman.
Immunization history: complete immunization at the puskesmas.
History of growth and development: normal.
a) What is the inpretation of birth history?
b)Pada kasus Fatih Kadar normal Interpretasi
N

1 Weight 2500 grams Normal

2500-4000

2 <37 weeks Preterm

37-42

Menurut Rohan (2013) Ciri-ciri bayi baru lahir normal adalah lahir aterm antara 37 – 42
minggu, berat badan 2500 – 4000 gram, panjang lahir 48 – 52 cm. lingkar dada 30 – 38 cm,
lingkar kepala 33 – 35 cm, lingkar lengan 11 – 12 cm, frekuensi denyut jantung 120 – 160
kali/menit, kulit kemerah-merahan dan licin karena jaringan subkutan yang cukup, rambut
lanugo tidak terlihat dan rambut kepala biasanya telah sempurna, kuku agak panjang dan
lemas, nilai APGAR >7, gerakan aktif, bayi langsung menangis kuat, genetalia pada laki-laki
kematangan ditandai dengan testis yang berada pada skrotum dan penis yang berlubang
sedangkan genetalia pada perempuan kematangan ditandai dengan vagina dan uterus yang
berlubang labia mayora menutup labia minora, refleks rooting (mencari putting susu)
terbentuk dengan baik, refleks sucking sudah terbentuk dengan baik, refleks grasping sudah
baik, eliminasi baik, urin dan meconium keluar dalam 24 jam pertama.

Rohan, H & Siyoto, S, 2013, Buku Ajar Kesehatan Reproduksi, Yogyakarta: Nuha Medika.

4. Physical examination:
Awareness: compost mentis
Vital signs: BP 100/70 mmHg, pulse: 90x/minute, RR: 24x/minute, temperature:
38.5°C, weight 18 kg, Height: 110 cm.
General physical examination:

7
 Head: eyes: conjunctiva not anemic, sclera not icteric
Thoracic: symmetrical, no retraction, heart: heart sound I and II are normal, heart
murmur (-), Lung: normal vesicular, no rhonchi
Abdomen: flat, weak, normal bowel sounds, liver and spleen are not palpable,
abdominal tenderness is absent, suprapubic tenderness is present.
Inguinal region: no palpable lump, pain (-), enlarged lymph nodes (-).
Extremities: warm
a) What is the interpretation of physical and general physical examination?
b) How the abnormal mechanism of physical and general physical examination?
5. Specific examination of the external genitalia:
it was found that there was residual urine in the prepuce, the prepuce could not be
opened, the OUE was hyperemic, the scrotal skin was normal, the right and left
testicles were not visible and not palpable in the scrotum.
a) What is the interpretation of specific examination of the external genitalia?

No Pada kasus normal Interpretasi

1 Residual Urine in the Urine retention in
Residual not found
perpuce prepuce (abnormal)

2 Perpuce cannot be
Can be oppened
opened Fimosis (abnormal)

3 Inflammation
OUE Hyperemic Not hyperemic
(abnormal)

4 Testis not palpable and Palpable and Undensus testis

not visible in scrotum visible in scrotum (abnormal)

b) How the abnormal mechanism of specific examination of the external genitalia?

Etiology UNDESENSUS TESTIS / KRIPTORKISMUS

Faktor Genetik

8
  Polimorfisme atau mutasi gen INSL3 (Insulin-Like 3)

 Mutasi reseptor androgen

 Mutasi kromosom 10

Faktor Hormonal

 Insufisiensi androgen

 Hipogonadisme atau hipogonadotropik

 Hiperesterogenisme

 Penurunan sekresi (hCG)

 Defisiensi (GnRH)

Faktor Gestasional dan Maternal

 Bayi berat lahir rendah (< 2500 gram)

 Prematur

 Infeksi intrauterine saat kehamilan

Faktor Lingkungan: penurunan gradien suhu retroskrotal dan paparan suhu panas > 37 C.

Kelainan Kongenital: Kelainan testis, epididimis, dan vas deferens

Leslie SW, Sajjad H, Villanueva CA. Cryptorchidism. In: StatPearls. Treasure Island (FL): StatPearls
Publishing; 2022 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK470270/

6. How to diagnose in this case?

7. What is the differential diagnosis in this case?
8. What is the supporting examination in this case?
9. What is the working diagnosis in this case?

Complicated acute lower UTI ec Phimosis, Undescended Testis

10. What is the treatment in this case?

Tatalaksana ISK antibiotik

ISK bawah/sistitis: selama 5-7 hari per oral

TMP-SMX(kotrimoksazol), ampisilin atau amoksisilin.

9
ISK atas/pielonefritis: 7-10 hari parenteral, sefotaksim atau seftriakson

Tatalaksana kelainan anatomi dan fungsional saluran kemih:

Fimosis  Sirkumsisi

Tatalaksana UDT :

 Observasi hingga usia 6 bulan  masih bisa turun spontan usia 3-6 bulan

 Bila usia 6 bulan belum perbaikan  operasi Orchidopexy (spesialis urologi)

 Terapi hormonal  tidak diperlukan

 Pada kasus sudah berumur 5 tahun berarti Orchidopexy

Edukasi :

Cegah infeksi berulang  jaga hygine, dan tingkatkan gizi

11. What is the complication in this case?

12. What is the prognosis in this case?

ISK bawah akut komplikata:

 Quo ad vitam: bonam

 Quo ad functionam: dubia ad bonam

 Quo ad sanationam: Dubia ad bonam

Fimosis:

 Quo ad vitam: bonam

 Quo ad functionam: dubia ad bonam

 Quo ad sanationam: dubia ad bonam

Undescending testis:

 Quo ad vitam: bonam

 Quo ad functionam: dubia ad bonam

10
 13. What is the SKDU in this case?
14. What is the Islamic value in this case?
a) QS. An-nisa ayat 125
b) HR. Bukhori & Muslim about khitan

Dari Abu Hurairah, Rasulullah SAW bersabda: "(Sunnah) fitrah itu ada lima, berkhitan,
mencukur rambut sekitar kemaluan, mencukur kumis, memotong kuku dan mencabut bulu
ketiak."

Intrepertasi = sesungguhnya rassulullah mengingatkan kita bawha fitrah manusia itu adalah
kebersihan dan ia memerintahkan kita untuk membersihkan diri salah satunya adalah khitan
karena dengan berkhitan maka bersihla diri kita dari kotoran2 yang ada di dalam preputium
kita dan menghindari factor resiko dari penyakit infeksi disana

Cryporchidium

11
12