Seminar

Clinical Updates 2011

simposium satelit
Tema : Dysuria
Hari/Tanggal : Minggu, 16 Januari 2011
Tempat : Auditorium II FK UGM
Semangat !!
100%
Tambah Pintar, Sehat,
Hebat ! Bisa !!
Jam
HP
Daftar penyakit dikelompokkan menurut sistem, organ
dan tahapan usia.
Berikut ini tingkat kemampuan yang diharapkan akan
dicapai di akhir pendidikan.
Tingkat kemampuan yang diharapkan dicapai
pada akhir pendidikan dokter
Soal 1
Tingkat kemampuan 4 berarti:
A. Level ini mengindikasikan overview level. Bila menghadapi pasien
dengan gambaran klinik ini dan menduga penyakitnya, Dokter segera
merujuk.
B. Dokter mampu merujuk pasien secepatnya ke spesialis yang relevan
dan mampu menindaklanjuti sesudahnya
C. Dokter dapat memutuskan dan mampu menangani problem itu
secara mandiri hingga tuntas.
D. Dokter dapat memutuskan dan memberi terapi pendahuluan, serta
merujuk ke spesialis yang relevan (bukan kasus gawat darurat).
E. Dokter dapat memutuskan dan memberi terapi pendahuluan, serta
merujuk ke spesialis yang relevan (kasus gawat darurat).

Soal 2
Yang termasuk Tingkat kemampuan 4 di bidang
Nefrologi:
A. Urinary tract infection
B. Acute tubular necrosis
C. Horse shoe kidney
D. Uncomplicated Pyelonephritis
E. Batu Ginjal


Kidney
1. Cortical adenoma 1
2. Renal cell carcinoma 2
3. Wilm's tumor 1

Nefrourologi
1. Acute renal failure 2
2. Chronic renal failure 2
3. Nephrotic syndrome 2
4. Acute glomerulonephritis 3A
5. Chronic glomerulonephritis 3A
6. Interstitial nephritis 1
7. Renal colic 3A
8. Urinary stone diseases or urinary calculi without colic 3A
9. Polycystic kidneys symptomatic 2
10.Urinary tract infection 4
11. Acute tubular necrosis 2
12. Horse shoe kidney 2
13.Uncomplicated Pyelonephritis 4
14. Urinary incontinence 2
15. Nocturnal and diurnal enuresis 2
16.Prostatitis 3A
Soal 3. Pengelolaan Disuria:
A. Dibedakan kelompok Anak dengan yang lain.
B. Dibedakan kelompok Geriatri dengan yang
lain.
C. Dibedakan kelompok Laki-laki dan
perempuan.
D. Terapi dibedakan kelompok ISK atas dan ISK
bawah.
E. Dibedakan kelompok Penyakit Penyerta.
Dysuria
Child, geriatric patient, adult
male
Signs or symptoms
of pyelonephritis
UA Vaginal complaints
Culture urine
and investigate
non-UTI causes
of dysuria
Evidence of UTI:
pyuria, hematuria,
nitrete-positive
Pelvic
exam
Culture
urine
Localize site of
infection
Lower tract Upper tract
Treat
Evidence of UTI
pyuria, hematuria,
nitrate
Recent Hx
recurrent UTI
UA
Risk factors of
occult
pyelonephritis
Treat uncomplicated
lower tract infection
Culture
urine
Culture and
investigate non-
UTI causes of
dysuria
Culture
urine
Treat upper
tract infection
Treat recurrent
lower tract
infection
Yes
Yes
Yes
Yes Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Figure 28.1 Algorithm for the management of dysuria
SIGNS &
SYMPTOMS
Major associated signs and symptoms
Common causes
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Appendicitis
Bladder cancer
Cystitis (bacterial)
Cystitis (chronic
interstitial)
Cystitis
(tubercular)
Cystitis (viral)
Diverticulitis
Paraurethral gland
inflammation
Prostatitis (acute)
Prostatitis
(chronic)
Pyelonephritis
(acute)
Reiters syndrome
Urethral syndrome
Urethritis
Urinary
obstruction
Vagiritis
Dysuria: Causes and associated

Algoritme Disuria
Differential Diagnosis of Dysuria in Otherwise
Healthy Women of Reproductive Age
Diagnosis Frequency
1. Lower tract UTI

2. Vaginitis
3. Upper tract UTI
4. Urethritis
5. Perineal trauma
Very common (70% of
women with dysuria)
Common
Uncommon
Uncommon*
Rare
*May be more common in college health centers and reproductive health
clinics
UTI, urinary tract infection.
Key Elements of the History and Physical Examination for Dysuria
Diagnosis Question or Maneuver Sensitivity Specificity LR+ LR-
UTI
Nocturia
0.67 0.62 1.8 0.53
Dysuria
0.80 0.50 1.6 0.40
Urgency
0.39 0.71 1.3 0.86
Frequency
0.87 0.32 1.3 0.41
Offensive odor of urine
0.20 0.85 1.3 0.94
Pyelonephritis
Chills and rigors
0.32 0.87 2.5 0.78
Fever
0.44 0.80 2.2 0.70
Nausea and fomiting
0.24 0.84 1.5 0.90
Flank pain
0.48 0.67 1.5 0.78
UTI, urinary tract infection
Data are from References 75 and 76
Guiding Questions UTIs
1. How has the epidemiology of urinary tract
infections (UTIs) changed?
2. What are the differences between
asymptomatic bacteriuria, cystitis, and
pyelonephritis?
3. What distinguishes an uncomplicated UTI
from a complicated UTI and how do
treatments vary?
Guiding Questions UTIs
4. Are particular patient populations at increased
risk for UTI and are adverse outcomes a
concern?
5. What is the pathogenesis of UTI?
6. What impact does bacterial antibiotic
resistance have on UTI?
7. What are two important types of complicated
renal infections?
KEY POINTS
Urinary Tract Infection
1. Infections in different locations within the urinary
tract present with similar symptoms.
2. Fever in a patient with LM means tissue invasive
infection.
3. The duration of therapy and the pathogens
responsible for UTT are different in uncomplicated
and complicated UIT.
4. Infection of the urinary tract with Staphylococcus
aureus requires evaluation for a hematogenous
source of infection.

KEY POINTS
Risk Factor for and pathogenesis of UTI
1. Patient-specific risk factors for UTI can be
modified to decrease the incidence of
infection.
2. Pathogen-specific virulence factors are not
the cause of antibiotic resistence.
Soal 4 Penyebab Terbanyak ISK
A. E. coli
B. Proteus
C. Klebsiella, enterobacter
D. Enterococcus
E. Pseudomonas

Frequency of bacteria causing UTI
Causative organism % primary
infection
% early relapse % Hospital
acquired
E. coli
Proteus
Klebsiella,
enterobacter
Enterococcus
Staphylococcus
Pseudomonas
Other
70-90%
2%
7.5%
2.5%
5%
-
2.5%
60%
15%
20%
-
-
-
5%
48%
10%
15%
6%
6%
15%
<1%
Characteristics of Urine Tests for Primary Care Patients with Dysuria
1
Test Sensitivity Specificity LR+ LR
Dipstick
Leukocyte esterase (LE)
Nitrite
Either LE or nitrie
0.76
0.49
0.90
0.46
0.85
0.65
1.4
4.4
2.6
0.5
0.6
0.15
Sediment Microscopy
1 bacterium/HPFb
10 bacteria/HPFb
5 WBC/HPFc
10 WBC/HPFb
5 RBC/HPFa
0.95
0.85
0.91
0.82
0.44
0.85
0.99
0.48
0.65
0.88
6.3
85
1.7
2.3
3.7
0.06
0.15
0.19
0.28
0.60
HPF, high power field; RBC, red blood count; WBC, white blood count
1
Baeiley BL. Urinalysis predictive of urine culture results. J Fam Pract 1995;40:45-50.
2
Deville WL , Yzermans JC, van Duijin NP, Bezemer PD, van der Windt DA, Bouter L.M. The urine
dipstick test useful to rule out infections. A meta analysis of the accuracy. BMC Urol. 2004; 4:4.

KEY POINTS
Diagnosis of Urinary Tract Infection
1. For an uncomplicated patient, a
history consistent with UTI and
pyuria on urinalysis establishes the
diagnosis.
2. For a complicated patient, a culture
and sensitivity must be performed.
Soal 4. Prinsip Pengelolaan Disuria
Wanita
A. Terapi jangka pendek
B. Evaluasi 4-7 paska terapi
C. Urinalisis baik, tanpa terapi antibiotika.
D. Urinalisis jelek, kultur negatif: terapi
Chlamydia
E. Antibiotika sesuai Kultur, sensitivitas dan
angka kuman.


WHO PRESENT WITH
COMPLAINTS OF DYSURIA AND
FREQUENCY


Treat with short-course
therapy

Follow-up 4-7 days
later
Bacteriuria
with or
without
Asymptomati
Treat with
extended course
Asymptomati
Pyuria, no
bacteriuria

Both
negative


Urinalysis urine
culture


No further
intervention

Treat for
Chlamydia
trachomatis
Observe, treat
with urinary
analgesia
Figure 15-1. Clinical approach to the woman with dysuria and frequency.
(Modified from Tolkoff-Rubin NE, Wilson ME, Zuromskis P, et al: Single-
dose amoxicillin therapy of acute uncomplicated urinary tract infections in
women. Antimcrob Agents Chemother 25:626, 1984.)
KEY POINTS
Antibiotics for the Treatment of UTI
1. Antimicrobial-resistant bacteria are more
common, therefore, broad-spectrum
empiric coverage with a quinolone is
appropriate.
2. In order to avoid inducing further
antibiotic resistance, once culture and
sensitivity result are available, antibiotic
therapy is changed to the narrowest
possible spectrum.
Soal 5. Red Flags for a Complicated UTI
A.Male gender
B. Prepubertal or geriatric age
C. Symptoms for more than 7 days
D. An immunosuppressing condition
E. An episode of acute pyelonephritis within
the past year
Red Flags for a Complicated Infection
1. Male gender
2. Prepubertal or geriatric age
3. Symptoms for more than 7 days
4. An immunosuppressing condition
5. An episode of acute pyelonephritis
within the past year
Adapted from Johnson JR, Stamm WE. Diagnosis and treatment of acute urinary tract
infections. Infect Dis Clin North Am 1987; (14):773-791.
Red Flags for a Complicated Infection
6. Known anatomic abnormality
7. Diabetes mellitus
8. Fever
9. Flank pain or tenderness
Adapted from Johnson JR, Stamm WE. Diagnosis and treatment of acute urinary tract
infections. Infect Dis Clin North Am 1987; (14):773-791.
Factors predisposing to recurrent UTI
Local factors
1. Impaired bladder emptying, e.g. due to prostatic
hypertrophy or neuromuscular problems
2. Bladder or renal calculi
3. Renal cysts
4. Anatomical anomaly, e.g. horseshoe kidney
5. Indwelling urinary catheter or recurrent bladder
instrumentation
6. Postmenopausal vaginal atrophy
Factors predisposing to recurrent UTI
Systemic factors
1. Diabetes mellitus
2. Immunosuppression
3. Pregnancy
Factors Suggesting Occult Pyelonephritis
Or Complicated UTI

1.Diabetes
2.Pregnancy
3.Male patient
4.Childhood UTI
5.Elderly patient
FACTORS SUGGESTING OCCULT PYELONEPHRITIS
OR COMPLICATED URINARY TRACT INFECTION

6. Indwelling catheter
7. Immunosupression
8. Urologic anatomic abnormality
9. Symptoms for >7 days
10. Recent urinary tract instrumentation or
antibiotics
Criteria That Define a Complicated UTI
1. Documented fever >38C
2. Symptoms of dysuria or urgency present for >7 days
3. Symptoms of vaginitis present (e.g., vaginal discharge
or irritation)
4. Symptoms of abdominal pain, nausea, or vomiting
5. Gross hematuria in patients >50 years Presence of
immunosuppression (e.g., current use of chemotherapy or
transplant immuno suppression)
6. Diabetes mellitus
7. Known pregnancy
8. Chronic renal or urologic abnormalities other than
stress incontinence (e.g., PKD, neurogenic bladder,
CKD)
9. Recent or persistent occurrence of urinary tract
stones
10. Urinary catheterization or other urologic procedure
within 2 weeks
11. Discharge from hospital or nursing home within 2
weeks
12. Treatment for UTI within 2 weeks Recurrent or
symptomatic UTI

Abbreviations: UTI, urinary tract infection; PKD, polycystic kidney
disease; CKD, chronic kidney disease. Modified from Bent, S., Saint, S.
Am J Med 113:20S-28S , 2002 with permission.
Inherited or Acquired Host Susceptibility Factors for UTI
GENETIC BIOLOGIC BEHAVIORAL OTHER
Blood group antigen
Nonsecretor status
Increased adhesion
receptors

Congenital abnormalities

Urinary obstruction
Calculi
Diabetes mellitus
Anatomic abnormalities
Residual urine
Atrophic vaginitis
Urinary incontinence
Prior history of UTI
Maternal history of UTI
Childhood history of UTI
Catheters/stents/ foreign
bodies
Condom catheters
Immunologic abnormalities
(HM
Renal transplant
Sexual intercourse

Use of diaphragm
Use of spermicides
Antimicrobial use

Decreased
mental status

Inherited or Acquired Host Susceptibility Factors for UTI
GENETIC
1. Blood group antigen
2. Nonsecretor status
3. Increased adhesion receptors

Inherited or Acquired Host Susceptibility Factors for UTI
BIOLOGIC
1.Congenital abnormalities
2.Urinary obstruction
3.Calculi
4.Diabetes mellitus
5.Anatomic abnormalities
6.Residual urine
7.Atrophic vaginitis
Inherited or Acquired Host Susceptibility Factors for UTI
BIOLOGIC
8. Urinary incontinence
9. Prior history of UTI
10. Maternal history of UTI
11. Childhood history of UTI
12. Catheters/stents/ foreign bodies
13. Condom catheters
14. Immunologic abnormalities (HM
15. Renal transplant
Inherited or Acquired Host Susceptibility Factors for UTI
BEHAVIORAL OTHER
Sexual intercourse

Use of diaphragm
Use of spermicides
Antimicrobial use

Decreased mental
status

Evidence for Effectiveness of Recommended Therapies
Intervention Strength of Recommendation*
Management of uncomplicated lower tract urinary tract infection (UTI)
Oral antibiotics
Cranberry juice
Increased fluid intake
Management of uncomplicated upper tract UTI
Oral antibiotics (in healthy women)
No need for imaging (in healthy women)
Prevention of UTI
Cranberry juice
Increased fluid intake
Behavioral interventions
*A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented
evidence; C = consensus, disease-oriented evidence, usal practice, expert opinion, or case series. For
information about the SORT evidence rating system, see http://www.aaf.org/afpsort.xml.
Oral Drug Therapy Tract Infection
Drug Indications Dosage
Trimethoprim/sulfametho
xazole (TMP/SMX)
(Septra, Bactrim, others)
Lower or upper tract
infections
Adult: double-strength
formulation bid
Child: 8 mg TMP/40 mg
SMX/kg/day; divided bid
Trimethoprim (Trimpex,
Proloprim, others)
Lower tract
infections
Adult: 100 mg bid
Nitrofurantoin
(Macrodantin, Macrobid,
Furadantin)
Lower tract
infections
Adult: 50-100 mg qid or 100 mg
bid (Macrobid, others)
Child: 5-7 mg/kg/day; divided qid
Cephalexin (Keflex) Lower/Upper tract
infections
Adult: 250-500 mg qid
Child: 25-50 mg/kg/day divided
qid
Cefixime (Suprax) Lower/Upper tract
infections
Adult: 400 mg daily
Child: 8 mg/kg/day divided qid
Oral Drug Therapy Tract Infection
Drug Indications Dosage
Cefpodixime (Vantin) Lower/Upper tract
infections
Adult: 100 mg bid
Child: 10 mg/kg/d divided bid
Ciprofloxacin (Cipro) Lower tract
infections
Upper tract
infections
Adult: 250 mg bid
Adult: 250-500 mg bid
Levofloxacin (Levaquin) Lower tract
infections
Upper tract
infections
Adult: 250 mg qd
Adult: 250 mg qd
Amoxicillin/clavulanate
(Augmentin)
Upper tract
infections (only if
gram-positive
organism suspected)
Adult: 875 mg bid
Child: 45 mg of amoxicillin
component divided bid
Note: Length of treatment of outpatient
Lower tract infection (oral antibiotics): female adult 7-10 days, healthy geriatric female 3 days; all other geriatric patients 7-14, child older than 2 months 7-14 days.
For outpatient with upper tract infection (oral antibiotics): female adult 7-14 days, male adult 14 days; geriatic patient 14 days or child 7-14 days.
For hospitalized patient with upper tract infection and initial IV antibiotics (switch to oral antibiotics when stable): female adult 14 days; male agult, geriatic patient,
21 days or child 7-14 days.
KEY POINTS
Pregnant Women
1. Bacteriuria and UTI have negative
consequences on the outcome of
pregnancy
2. All pregnant women must be treated.
KEY POINTS
The Spinal Cord Injury Patient
1. Spinal cord injury patients are at high risk for
UTI because of chronic indwelling catheters
and loss of coordinated micturition.
2. Antimicrobial-resistant organisms are
common pathogens because SCI patients have
multiple antibiotic exposures.
Soal 6
Kondisi ini memerlukan penanganan lebih
serius:
A. Pasien Diabetes
B. Pasien Hipertensi
C. Pasien Batu ginjal
D. Pasien cangkok ginjal
E. Emphysematous Pyelonephritis

KEY POINTS
Diabetic Patient
1. Diabetic patients are at high risk for developing
complications of UTI.
2. Antimicrobial-resistant pathogens are more common
in diabetic patients.
3. Diabetic are at greater risk for atypical pathogens such
as fungi.
KEY POINTS
Transplant Patient
1. The incidence of UTI during the first three
posttransplant months is 30%.
2. Pyelonephritis in a renal transplant patient can cause
acute renal failure.
3. Treatment for cystitis is extended to 7-10 days and
treatment for pyelonephritis is extended to 4 weeks.
KEY POINTS
Emphysematous Pyelonephritis
1. Emphysematous pyelonephritis occurs most
commonly in patients with diabetes mellitus.
2. Gas-forming organisms such as Escbericbia coli and
Klebsiella pneumoniae are associated with this form of
pyelonephritis.
3. Treatment is based on class of lesion. Antibiotics and
either percutaneous drainage or nephrectomy are
available therapeutic options.
KEY POINTS
Xanthogranulomatous Pyelonephritis
1. Xanthogranulomatous pyelonephritis can masquerade as a
renal malignancy.
2. Gram-negative organisms underlie infection in XGP.
3. Computed tomography scan best demonstrates the extent of
disease, excludes malignancy, and identifies the presence of
renal stones.
4. The histopathology of XGP is characterized by necrotic tissue,
cellular infiltration, and lipid-laden macrophages (xanthoma
cells).
5. Antibiotics and nephrectomy (complete or partial) are required
to treat XGP.

KESIMPULAN
I. Lakukan investigasi penderita
Disuria, kemungkinan I S K

II. Penetapan diagnosis yang sahih

III. Terapi/ pencegahan disesuaikan
keadaan khusus penderita

Soal 7. Kapan pasien disuria dirujuk?
A.Kreatinin klirens > 60
B.Kreatinin serum >2 mg/dL
C.Laju Filtrasi Glomerulus <50 mL/menit
D.Kadar Ca x kadar PO4 < 30
E. ISK dan atau Pielonefritis complicated
PANDUAN 1
Pasien dengan kreatinin serum >2
mg/dL dan atau TKK (Tes Klirens
Kreatinin)/LFG (Laju Filtrasi
Glomerulus) <50 mL/menit mempunyai
faktor prognosis yang buruk sehingga
memerlukan penanganan yang khusus dan
sebaiknya dirujuk ke dokter spesialis
penyakit dalam/konsultan ginjal
hipertensi.
G ula darah terkendali
I nfeksi Saluran kencing diatasi/dihindari
N o, hipertensi
J auhi obat/makanan/minuman racun Ginjal
A ir minum/ air putih secukupnya
L anjutkan perilaku hidup SEHAT

Langkah-langkah pencegahan holistik
Penyakit Ginjal:
Pantun Penutup