UROLOGY

CASE REPORT Oleh: Nicyela Jillien Harlendea (406182061)

Pembimbing: dr. Yulfitra Sony Sp. U

Koass Ilmu Bedah RSUD Ciawi Periode 11 Maret 2019 – 19 Mei 2019 (FK Untar)
IDENTITAS PASIEN

Nama : Tn. P

Jenis Kelamin : Laki-laki

Umur : 53 tahun

Alamat : Bukit cimanggu citi

Agama : Islam

Pekerjaan : Karyawan
ANAMNESIS

Keluhan • BAK sulit sejak 1 tahun yang lalu

utama:

• BAK tersendat dan pancaran lemah

Keluhan • Nyeri saat BAK
• Nyeri pada perut bagian bawah
tambahan: • Warna kencing kuning agak keruh
RIWAYAT PENYAKIT
SEKARANG
Pasien mengeluh sulit BAK sejak 1 tahun yang lalu. Pasien juga
mengeluhkan BAK tersendat dengan pancaran yang lemah.
Keluhan pasien disertai nyeri saat buang air kecil. Keluhan
dirasakan semakin memberat. Pasien juga mengeluhkan nyeri
pada perut bagian bawah yang hilang timbul. Pada saat BAK
pasien merasakan seperti adanya pasir yang keluar. Keluhan ini
mulai pasien rasakan sejak 2 minggu yang lalu.

Warna kencing kuning tetapi agak keruh, pasir (+), darah (-)

Demam (-), Mual (-), Muntah (-), keluhan BAB (-)

RIWAYAT PENYAKIT DAHULU

Pasien pernah
mengalami keluhan
serupa 4 tahun yang lalu Riwayat penyakit IMS (-),
dan mendapatkan terapi trauma pada area
businasi selangkangan/kelamin
(-), cedera pelvis (-),
HT(-), DM (-)
RIWAYAT PEKERJAAN DAN
KEBIASAAN

Pasien merupakan seorang karyawan

Riwayat Kebiasaan

•Pasien jarang minum air putih dan senang minum kopi kira-kira 2-3x/hari.
•Pasien merupakan seorang perokok
PEMERIKSAAN FISIK

Status Generalis:
• Keadaan umum : Baik
• Kesadaran : Compos mentis
• Tekanan darah : 120/70 mmHg
• Nadi : 74x/menit, reguler
• Pernafasan : 18x/menit
• Suhu : 36,5˚C
STATUS LOKALIS
(AREA ABDOMEN)
Inspeksi : Datar

Auskultasi : Bising usus (+)

Palpasi : Nyeri tekan a/r suprapubis, bimanual tidak teraba

pembesaran ginjal

Perkusi : Timpani pada semua kuadran, pekak hati (+),

nyeri ketok CVA (-)/(-)
STATUS LOKALIS
(AREA GENITALIA EKSTERNA)

Inspeksi : Penis terlihat normal, ulkus (-), benjolan (-)

Palpasi : Tidak teraba indurasi

RECTAL TOUCHE

Tonus sfingter ani normal

Mukosa licin

Ampula tidak kolaps

Prostat tidak teraba membesar

DIAGNOSA BANDING

Striktur Uretra

Batu Saluran Kemih

Infeksi Saluran Kemih

BPH

CA Prostat
PENALARAN KLINIS

Infeksi
Striktur Batu Saluran BPH/CA
Saluran
Uretra Kemih Prostat
Kemih

Sulit BAK BAK tersendat Nyeri saat BAK

BAK tersendat
Nyeri saat BAK
BAK tersendat Nyeri
suprapubik
Pancaran Pancaran
kencing lemah kencing lemah
Nyeri saat BAK Kencing keruh
BAK berpasir
Pancaran
kencing lemah Faktor resiko (+)
PEMERIKSAAN PENUNJANG

Hemoglobin 9,9 g/dL Warna Kuning

Hematokrit 28,4 % Kekeruhan Agak keruh
Lekosit 72000/uL Berat Jenis 1,015 mg/dL
Trombosit 272000/uL pH 5,0
GDS 105 mg/dL Leukosit 3+/POS
Ureum 116 mg/dL Nitrit (-)
Kreatinin 6,08 mg/dL Protein 3+/POS
SGOT 12 u/L Glucose normal
SGPT 10 u/L Keton (-)
Natrium 136 mmol/L Urobilinogen 3,2 mg/dL
Kalium 4,6 mmol/L Bilirubin (-)
Clorida 112 mmol/L Eritrosit 3+/POS
Urethrografi Kontras

prostatika

membranasea

striktur

pendulare bulbosa
RESUME

Telah diperiksa seorang laki-laki usia 53 tahun dengan keluhan sulit

BAK sejak 4 tahun yang lalu. Pasien mengeluhkan BAK tersendat
dengan pancaran yang lemah. Nyeri saat BAK (+). Keluhan dirasakan
semakin memberat. Pasien juga mengeluhkan rasa nyeri pada perut
bagian bawah yang hilang timbul. Pasien mengeluhkan warna
kencing kuning tetapi keruh dengan disertai rasa berpasir, darah (-).
Riwayat penyakit IMS (-), trauma pada area selangkangan/kelamin(-),
cedera pelvis (-).
PF: Nyeri tekan a/r suprapubis

PP: Uretrografi kontras (Tampak gambaran kontras terhenti di daerah pars

bulbar dengan gambaran cupping, curiga obstrusksi pada daerah tersebut)
DIAGNOSA KERJA

Striktur uretra

Batu uretra
TATALAKSANA

Operatif
• Uretroplasti elektif / EPA

Farmakologi
• Ciprofloxacin 500mg tab 1x1
• Dexketoprofen 25mg tab 2x1
• Ranitidin 150mg tab 2x1
PROGNOSIS

Ad Vitam: Dubia ad Bonam

Ad Functionam: Dubia
Ad Sanationam: Dubia ad Malam
TINJAUAN
PUSTAKA

STRIKTUR URETRA
URETHRA
URETHRAL STRICTURE

Urethral stricture
is a narrowing of the urethra that is caused by The most common site
the formation of fibrotic tissue around the of narrowing is the
urethra/periurethra area, which in the advanced bulbar part of the
stage can cause fibrosis of the corpus urethra.
spongiosum.

Prevelance 229-627 per

100,000 of men, or 0.6% total
population, that commonly occur
in men older than 55 years old.
URETHRAL
STRICTURE/STENOSIS

Narrowing a segment of the

urethra which is
Urethral stricture surrounded by corpus
spongiosum (anterior
urethra)
WHO
Narrowing a segment of the
urethra which is not
Urethral stenosis surrounded by corpus
spongiosum (posterior
urethra)
URETHRAL STRICTURE

Urethral
Stricture

Anterior Posterior

Bulbar Penile Membranous Prostatic

Urethra Urethra Urethra Urethra

Most common
ETIOLOGY

Idiopathic

Iatrogenic
URETHRAL STRICTURE
Inflammatory

Traumatic
PATHOPHYSIOLOGY

Stimulus

Fissures develop in epithelium

Extravasation occurs

Fibrosis develops in the corpus spongiosum

Fibrotic plaques coalesce

Stricture
DEGREE OF NARROWING
SYMPTOMS

Decreased
Urinary
Stream

Postvoid Incomplete
Residual Emptying

Symptoms

UTI Dysuria
INVESTIGATIONS

1 2 3 4 5
Complete Urinalysis Uroflowmetry Contrast Urethroscopy
blood count urethrography
UROFLOWMETRY
RETROGRADE
URETHROGRAM (RUG)

Normal Urethral stricture

VOIDING CYSTOURETHROGRAM
(VCUG)
URETHROSCOPY
THERAPY

• Use of a dilator / sound to stretch the

Dilation
scar tissue.

• Excision of the urethral scar tissue with

Urethrotomy
Otis / Sachse blades.

Urethroplasty • Open urethral reconstruction to cut

Gold-standard the fibrous tissue.
DILATION

• It is the oldest and simplest way to treat urethral stricture.

• In this procedure, the spongiofibrosis is streched, thus
producing innumerable microlesions in the scar tissue,
leading to further scarring.
• Can only ever have a temporary effect on the obstruction
and the stricture may be expected to recur after 4 to 6
weeks.
• Recommended in patients with low grade stricture severity,
in patients who refuse surgical treatment, unsuited for
surgery for other reasones (e.g anesthesiological).
• Dilation is done by using a balloon catheter or metal plug
that’s inserted carefully into the urethra to widen the
narrowed area.
DIRECT VISION INTERNAL
URETHROTOMY (DVIU)
• Excision of the urethral scar tissue with Otis /
Sachse blades.
• Otis is done if there is no total urethral stricture,
whereas in more strict strictures, cutting
strictures is done visually using a Sachse knife.
• The short-term success rate of this therapy is
quite high, but within 5 years the recurrence rate
reaches 80%
• In addition to the emergence of new strictures,
internal urethrotomy complications are erectile
bleeding, urinary incontinence, and erectile
dysfunction.
URETHROPLASTY

• Open urethral reconstruction to cut the fibrous

tissue.
• Urethroplasty
• End-to-end anastomotic
• Substitution (with graft)
• Complications are rare, but include erectile and
ejaculatory dysfunction, chordee, wound
infections, UTIs, fistula development,
neuropraxia, and incontinence.
COMPLICATION

DVIU Complication : Urethral Bleeding & Perineal Hematoma

TINJAUAN PUSTAKA

URETHROLITHIASIS
URETHRAL STONE

Urethral calculi usually It is either primary urethral calculi which

originate from the arise proximal to urethral strictures or
bladder and rarely associated with urethral diverticulum
from the upper tracts. and urethrocele. Or secondary from
bladder or renal calculi.

Urethral stone constitute of less

than 2% of all urolithiasis and
considered as a rare disease.
Most urethral stones in men
In female development of urethral
present in the prostatic or bulbar
calculi is very rare due to their
regions and are solitary.
short urethra and a lower
incidence of bladder calculi.
TYPES OF STONE
TYPE OF STONES
FAKTOR RESIKO

Faktor Intrinsik Faktor Ekstrinsik

Geografi
Herediter • Angka kejadian daerah
stone belt lebih tinggi

Umur = 30-50thn Asupan Air

• Kurangnya asupan air =
Insidens ↑
♂>♀
Pekerjaan
SIGN AND SYMPTOMS

Symptoms are similar to bladder calculi

• Intermittent urinary stream
• Terminal hematuria
• Infection
• May present with dribbling or acute urinary retention
• Pain may be severe and, in men, may radiate to the tip of the penis.
INVESTIGATIONS

Complete
Urine Serum Serum uric
blood cell Blood urea RUG/VCUG
analysis creatinine acid
count
TREATMENT

The main lines of management of urethral calculi are

– Retrograde manipulation into the bladder with litholopaxy
– Urethrotomy for associated stricture
– Conservative, waiting for spontaneous passage
– Suprapubic cystolithotomy
URETHRAL STRICTURE AND
STONE
• Co-existence of urethral stone along with urethral stricture is infrequently
known entity.
• Often urethral stones are thought to be result from stasis of urine.
• It usually occurs in the dilated urethra proximal to the stricture segment.
• Isolated stone in the urethra is often secondary to migrated stone from the
upper tract or the bladder.
• One of the risk factors for urethral stones is urethral stricture
DAFTAR PUSTAKA

1. Purnomo BB, 2015. Dasar-dasar Urologi, Edisi Ketiga. Jakarta:CV Sagung Seto
2. Brunicardi, F Charles. Schwartz's principles of surgery, Eleventh edition. New York : McGraw-Hill, [2018]
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110(13): 220−6
4. Smith TG. Current Management of Urethral Stricture Disease. Indian J Urol. 2016 Jan-Mar; 32(1): 27–33.
5. McAninch JW, Lue TF. McAninch J.W., Lue T.F. Eds. Jack W. McAninch, and Tom F. Lue.eds. Smith and Tanagho's General Urology, 18e
6. Sjamsuhidayat R, Wim de Jong. Striktur Uretra, dalam: Buku Ajar Ilmu Bedah Ed.4 Revisi. Penerbit Buku Kedokteran EGC, Jakarta, 2015
7. Latini JM, McAninch JW, Brandes SB, et al. SIU/ICUD Consultation On Urethral Strictures: Epidemiology, etiology, anatomy, and
nomenclature of urethral stenoses, strictures, and pelvic fracture urethral disruption injuries. Urology 2014
8. Wessells H, Angermeier KW, Elliott SP, et al. Male Urethral Stricture. American Urological Association (AUA) Guideline 2016
9. Lee YJ, Kim SW. Current Management of Urethral Stricture. Korean Journal of Urology. 2013; 54: 561-569.
10. Gladys Ng, MD. Male Urethral Stricture Disease: Signs, Symptoms and Treatment. UCLA urologist association. 2018
11. Heyns CF, Steenkamp JW, De Kock ML, et al. Treatment of male urethral strictures: is repeated dilation or internal urethrotomy useful? J
Urol. 2018
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