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Manual for Student CSL

UROGENITALIA SYSTEM

LEARNING GUIDE FOR STUDENT

CLINICAL SKILL UROGENITAL SYSTEM

Given to 4th Semester Undergraduate’s Medical Faculty of Hasanuddin University

MEDICAL FACULTY HASANUDDIN UNIVERSITY 2011
Even Semester 2010/2011 FK-UNHAS

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Manual for Student CSL

UROGENITALIA SYSTEM

LEARNING GUIDE FOR STUDENT

CLINICAL SKILL UROGENITAL SYSTEM

CONTENT LIST
TITLE No. 1. History taking & Physical Examination of Urogenital System Method of Taking the directly taken 2. 3. Specimen & Urethra’s Discharge Transport Method of Catheter’s Application in 4. Men & Women (Per urethra 5. 6. Catheterization Technique) 7. Method of Prostate Examination through Rectal Touché Method of Circumcision Method of Evaluating BNO-IVP photo Suprapubic Aspiration
Even Semester 2010/2011 FK-UNHAS

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Manual for Student CSL

UROGENITALIA SYSTEM

LEARNING GUIDE FOR STUDENT
HISTORY TAKING & PHYSICAL EXAMINATION OF UROGENITAL SYSTEM

Given to 4th Semester Undergraduate’s Medical Faculty Of Hasanuddin University

UROGENITAL SYSTEM MEDICAL FACULTY HASANUDDIN UNIVERSITY 2011

Even Semester 2010/2011 FK-UNHAS

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OBJECTIVES 1. Used to be a standard service in ensuring perfect service for the patient. 4. However. Besides. Complaints from the patient that assessed carefully would help the doctor to make a diagnosis. b. catheterization. and imaging test should be carried out to enable diagnosis confirmation. c. Summarize the clinical problem of the patient. Helping the doctor to pursue the next step for the patient.Manual for Student CSL UROGENITALIA SYSTEM HISTORY TAKING AND PHYSICAL EXAMINATION UROGENITAL SYSTEM History taking is a communication activity between the doctor as an examiner and the patient which is purposing to obtain information about the disease and other associated information so that it will lead to making a diagnosis. Obtaining comprehensive information from the patient. Systematical history taking. Even Semester 2010/2011 FK-UNHAS 4 . Concluding presume of system/organs that involved in. Creating good connection between the doctor and the patient. d. their complaints not always associated with abnormality of genital and urinary tract. a. urethral discharge examination. There are many kinds of complaints from the patient who has the health problem of Urogenital system. 3. diagnostic procedures such us rectal examination (Rectal Touché). 2. Knowing about the progress of therapy for the patient. so that we need to be patience in the process of history taking from the patient.

. Can perform the physical examination in the right procedures 8. imaging test orderly. 6. . .Manual for Student CSL UROGENITALIA SYSTEM Learning Objectives General Aim : After participating in this activity. Spesific Aim : After participating in this activity.The mannequin for Rectal Touché and Catheterization (male/female). 3.The list of learning guide about the history taking and physical examination of urology. Can perform an assessment of several result of radiological examination esp. Media and Learning Instrument : . 7. pen.Patient status. the student: 1. and can differentiate normal and abnormal condition of the system. 2. napkin. Even Semester 2010/2011 FK-UNHAS 5 . the students can perform complete history taking and physical examination such as rectal touché. handscoen (sterile hand gloves). urethral discharge examination. in urogenital case. Can perform history taking to the patient completely. Can do the procedures of “taking and transport of urethral discharge” correctly and efficiently. Can perform rectal examination of the prostate correctly and efficiently.Jelly. Can perform catheterization procedures correctly. 5. . Can prepare the patient for the physical examination. catheter. and wastafel (flow water) for hand washing stimulation.Audio-visual. catheterization. 4. soap. Can recognize various the abnormality of the urogenital system.

Each student should practice. Active participation in skill lab. one becomes the doctor and the other becomes the patient. 4. 2. first act as the doctor and the other one as the patient. 4. They will give an example of how to perform complete history taking.Manual for Student CSL UROGENITALIA SYSTEM Learning Methods : 1. Introduction 2. Arrange the sitting position of the student. Discussion. Evaluation through check list with scoring system. 5. Role Play with feedback 100 minutes 1. The student could attend and ask about anything that they not understand and the instructor should help the student. The students required to pay attention. and then will be asked by the doctor. 5. Even Semester 2010/2011 FK-UNHAS 6 . Students is paired into groups contain 2 persons. Activity Description Activity 1. The specific theme or the main complaint of the patient will be given by the instructor. Lecture. Two Instructors. 3. 2. (Minimal once). The activity is followed by perform physical examination to the mannequin. 3. An instructor needs to supervise 2 groups. 3. Give the opportunity for the students to ask and the instructor will give an explanation about the important aspect. 3. The instructor will supervise the students according to the learning guide 5. 4. (Simulation). Every group plays the role. Question and Answer session Time 5 minutes 10 minutes Introduction Description 1. 2. Demonstration that suitable with the list of learning guide.

Total of times 150 minutes Even Semester 2010/2011 FK-UNHAS 7 .Manual for Student CSL 4. The Instructor concludes and answers the last question and explains unclear statements. What should be done by the doctor to ensure the patient feel comfortable? 2. Brain storming/discussion about: Anything considered easy or difficult? How the student feels after acting as the patient or the doctor. Brain Storming / Discussion 15 minutes UROGENITALIA SYSTEM 1.

right abdominal tenderness. 4. non verbal languages that easy to understand. age. 6. HISTORY TAKING No. LANGKAH KLINIK Greetings. occupation. 5. Asking other complaints complaint. address. Mentioning patient’s name every asking question. Ask : Onset and duration of the main complaint: since when? The morphology (shape). Performing history taking that associated with the system. 3. sand’s urine. Creating comfortable situation. 1. hip pain. Enquire history of past illness which is connected: with oligouria/ genital wound/ abdominal and facial swelling/ right abdominal pain. abdominal discomfort. 7. that associated with chief Kasus 9. Asking the patient to sit opposite each other. Speaking clearly and using verbal. Personal habit: eating jengkol-fruit/bowels. haematuria. dysuria. 10. 8.Manual for Student CSL UROGENITALIA SYSTEM LEARNING GUIDE OF UROGENITAL SYSTEM A. color and quantities of urine. 2. Asking the main complaint: oligouria/ genital wound/ facial or abdominal swelling/ right abdominal pain and taking the history of present Illness. Asking the identity of the patient: name. associating stone. facial edema (since when?) Associating symptoms: nausea. using nonEven Semester 2010/2011 FK-UNHAS 8 . the doctor stands up and offer handshake.

Manual for Student CSL UROGENITALIA SYSTEM steroid drugs. 11. 12. Cross-checking 13. History taking of previous therapy. Family history: disease that suffered and causing difficulty in passing urine. anti inflammation. Concluding the case from history taking to establish differential diagnosis. medicinal herbs consumer. antibiotic. Even Semester 2010/2011 FK-UNHAS 9 .

Baedah Madjid. Firdaus Hamid dr.MK dr. Ph.Manual for Student CSL UROGENITALIA SYSTEM LEARNING GUIDE FOR STUDENT METHOD OF TAKING THE DIRECTLY TAKEN SPECIMEN & URETHRA’S DISCHARGE TRANSPORT Given to 4th Semester Undergraduate’s Medical Faculty Of Hasanuddin University Arranged by : dr. Nasrum Massi.D. UROGENITAL SYSTEM MEDICAL FACULTY HASANUDDIN UNIVERSITY 2010 Even Semester 2010/2011 FK-UNHAS 10 . Sp.

Medical garbage . 7. 6. 5. 4. how to perform it. for example the patient’s right to refuse the method that the doctor will do without loosing his/her right to be served.Manual for Student CSL UROGENITALIA SYSTEM METHOD OF TAKING & PREPARING THE DIRECTLY TAKEN SPECIMEN AND THE TRANSPORT OF URETHRAL DISCHARGE GENERAL INTRUCTIONAL OBJECTIVE The students will be able to take and transport urethral discharge correctly and efficiently. Sterile cotton sticks (3-4 sticks) Cotton with alcohol 70 % Slide glass . and take it off after working. what are advantages. the students are able to: 1. Perform the “transport of the specimen” process correctly and efficiently. towel or tissue Spiritus lamp/bunsen Sterile hand glove Basin filled with chlorine 0. Perform the preparation of the instrument/materials correctly. 3.5 % solution 5 ml of sterile physiologic NaCl in reaction tube. standard method and also asepsis method correctly. the instruments that are used.Non-medical garbage Even Semester 2010/2011 FK-UNHAS 11 . Perform the “taking urethral discharge” process correctly. Perform hand washing. Give explanation to the patient or his/her family about the patient’s rights. Give explanation to the patient or his/her family about what the doctor will do. PREPARING THE INSTRUMENT Flow water Liquid soap Antiseptic solution Napkin. 2. and the guarantee from safety aspect and the confidentiality of patients identity. Use sterile hand gloves correctly.Stuart medium . SPESIFIC INTRUCTIONAL OBJECTIVE After perform this skill practice.

because that area is an unsterile area and usually contaminated with microbes. Worker’s hand should be washed aseptically and used sterile hand gloves. Especially for Chlamydia trachomatis culturing. Transportation Method After fixing. the cotton sticks must be pressed while rotated at urethral mucosa. The instrument (cotton sticks) cannot be disinfected with chemical method. FORM Informed Consent The objective of taking the specimen (examination material): to investigate the causes of disease correctly. The instruments such as cotton sticks.SISTEM UROGENITALIA INDICATION Patient suspected with urethritis or prostatitis. Procedures The distal area of urethral have to be cleaned before taking the specimen. Using this method of transportation is making the existing microbes remain alive without allowing them to reproduce. gonorrhea. FK-UNHAS Semester Akhir 2010/2011 12 . because chemical residue could kill the microorganism. This specimen cannot be kept at the cold temperature (refrigerator) because cold temperature could kill the N. similar with the microbes found in glands penis area. Procedures: all procedures must be performing in sterile environment and using sterile instrument. the swab specimen is safe to be transported in a tissue pack (so that it would not be scratch or missing) and ready for sending with the labeled envelope at the room temperature. physiologic NaCl must be sterile. therefore it can lead to false negative result. so that it can be determine the appropriate treatment.

Give the opportunity for the students to ask and the instructor will give an explanation about the important aspect.SISTEM UROGENITALIA Activity Description Activity 1. The instructor will supervise the students according to the learning guide 10. The Instructor concludes and answers the FK-UNHAS Semester Akhir 2010/2011 13 . Students is paired into groups contain 2 persons. one becomes the doctor and the other becomes the patient. Brain storming/discussion about: Anything considered easy or difficult? How the student feels after acting as the patient or the doctor. Every group plays the role. Brain Storming / Discussion 15 minutes 3. The specific theme or the main complaint of the patient will be given by the instructor. and then will be asked by the doctor. 8. 8. Each student should practice. (Minimal once). give example of how to take and prepare specimen directly and transport of urethral discharge. 7. 4. What should be done by the doctor to ensure the patient feel comfortable? 4. The students attend the demonstration by using the learning guide. An instructor needs to supervise 2 groups. 3. Two Instructors. 9. Question and Answer session Time 2 minutes 30 minutes Introduction Description 6. 7. Introduction 2. Role Play with feedback 100 minutes 6. Arrange the sitting position of the student.

but are not efficiently performed. Give general information to the patient or his/her family about the procedures of taking the specimen. STEPS / ACTIVITIES PREPARING THE PATIENT 1. NS Not Suitable: The procedures need not to be performed because it is not suitable with the situation. Need Improvement: the procedures are done incorrectly or done but didn’t suitable with the arrangements. PREPARING THE DIRECTLY TAKEN SPECIMEN AND THE TRANSPORT OF URETHRAL DISCHARGE (Used by the student) Give the score for each clinical procedure by using these criteria: 1. Please the patient to sit. PREPARING THE DIRECTLY SPECIMEN AND THE TRANSPORT OF URETHRAL DISCHARGE NO. Able: the procedures are done correctly and suitable with the arrangement. Greet the patient or his/her family nicely and introduce yourself.SISTEM UROGENITALIA last question and explains unclear statements. 2. 4. 3. 2. Total of times 150 minutes LEARNING GUIDE METHOD OF TAKING. and ask the patient condition. or there are unperformed procedures. LEARNING GUIDE METHOD OF TAKING. 3. Skillful: the procedures are done correctly and suitable with the arrangement and efficiently performed. Give the guarantee to the patient or his/her family about the safety of the procedures. the objectives and the advantages for the patient’s condition. Give the guarantee to the patient or his/her family about the FK-UNHAS Semester Akhir 2010/2011 1 CASES 2 3 14 .

Enter the cotton sticks into the transport medium until all of the cotton part completely soaks into the medium. 21. 15. and then throw the gauze into the medical waste bin. 10. pull the preputium towards to the end. Using tweezers clean the penis glans area and using sterile gauze that pour with physiologic NaCl. Then put it on the table until the specimen dry. horizontally. Then break the stick by burning it using Bunsen fire. Do the routinely hand washing. Ask the patient to take off his/her trousers/skirt which using to close the genital organ and ask the patient it lying horizontally. 19. Put the side glass on a table. Wearing the sterile hand gloves. 6. for example about patient’s rights to refuse the procedures taking the urethral discharge without losing the right to be serve. Insert the second cotton sticks that soaked by sterile physiologic NaCl slowly into the urethra until approximately 2-3 cm while rotating it towards clockwise. Write down the patient identity with permanent marker on the side glass (patient’s name & registration number). Insert the third cotton stick into the urethra until approximately 2-3 cm while rotating it toward clockwise. 17. Throw the second cotton stick into medical garbage. Ask the patient agreement to do the procedures of taking urethral discharge. pull the cotton sticks slowly. must be put into the basin filled with chlorine 0. Throw this cotton stick to the medical garbage. 5. PREPARING THE INSTRUMENT AND METERIALS 7. Clean the slide glass with alcohol cotton and do the sterilization by running it through spiritus flame. 22. 9. 16. Put all the instrument and material that require in the reachable place. Insert the cotton sticks that soaked by sterile physiologic NaCl into approximately 1 cm while rotating it to clean the external urethra orificium and distal area of the urethra. 12. Wiped circularly this cotton stick at the middle space of slide glass surface that had been prepared.5% solution. FK-UNHAS Semester Akhir 2010/2011 1 2 3 1 2 3 1 2 3 15 . and then while rotating. Explain to the patient or his/her family about their rights.SISTEM UROGENITALIA confidentiality of the patient’s identity. 20. The tweezers that has been used. If the patient hasn’t been circumcised. 18. PREPARING OURSELVES TO TAKING THE SPECIMEN 11. 8. 23. Stand in Right side of the patient. 13. TAKING THE URETHRAL DISCHARGE 14. Close the transport medium’s tube tightly and seal it.

address. Fixated the swab specimen after it dry. Put your hand which still using the hand gloves into a basin contain 0. 25. TRANSPORT OF THE SPECIMEN 29. age.SISTEM UROGENITALIA Give the label that content patient’s identity in the transport medium’s tube. c. 33. AFTER FINISHING TAKING THE SPECIMEN 26. Do the aseptic hand washing. Sender identity e. sex. content: a. 5% chlorine. Type of specimen (urethra secretion) f. rub both hand to wipe away urethral discharge that might attach on the hand glove. 28. Clinical description 30. Pack the swab specimen that had been fixated into the tissue. 1 2 3 1 2 3 16 . Take off the gloves and throw it to the medical garbage. Bring the transport medium tube and swab specimen to laboratory in room temperature. Laboratory examination that needed g. Media transport/ preservative use h. 27. Put the transport medium tube to the other tube 32. Write the reference letter of laboratory examination completely. number medical record) d. Date of transport b. FK-UNHAS Semester Akhir 2010/2011 24. and enter it to the envelope with patient’s identity. Date and time of specimen taking. Patients identity (name. Write to the label of the transport medium: Patient’s identity Date of specimen taking 31.

Sp. dr. Muhammad Yunus Amran UROGENITAL SYSTEM MEDICAL FACULTY HASANUDDIN UNIVERSITY 2010 FK-UNHAS Semester Akhir 2010/2011 17 . Baedah Madjid.SISTEM UROGENITALIA LEARNING GUIDE FOR STUDENT METHOD OF CATHETER’S APPLICATION IN MEN & WOMEN (PER URETHRA CATHETERIZATION TECHNIQUE) Given to 4th Semester Undergraduate’s Medical Faculty Of Hasanuddin University Arranged by : Prof.. Achmad Makkarausu P.MK dr. Sp.B (K-BU) dr. Irfan Idris Edited by : dr.

Urine collection for diagnostic purpose 5. To prepare the tools for the catheterization properly 3. Be able to use sterile hands-on properly 5. To know when is the right time to fill the catheter’s balloon 12. To hold the catheter properly 7. For low UG tract imaging 7. The condition where we have to monitor urine output in trauma or critical patients 4. To be in the right position for the action 6. Urine retention 2. To perform the proper fixation of the catheter Indication 1. To prepare the patient properly 2. To check if the catheter has reach the target 11. To perform proper hand washing 4. Nerve-related bladder dysfunction. To perform the catheter insertion properly 10. spinal trauma 6.g. Urethra obstruction cause by anatomical changes: prostate hypertrophy. prostate cancer. or urethral stricture 3. To hold the genital organ properly 8. e. To hold the clamp (if needed) properly 9. the students are hope to able: 1. After an operation FK-UNHAS Semester Akhir 2010/2011 18 .SISTEM UROGENITALIA CATHETER INSERTION TECHNIQUE (PERURETHTRA CATHETERIRATION TEHNIQUE) General Instruction Target (GIT) Students are able to perform catheterization Specify Instructional Target (SIT) After the lesson.

Getting Off: Start with sucking out the water or air from the catheter balloon with 10-20 ml spoit. LippincottRaven. 4th edition. Emergency Medicine : Concepts and Clinical Practise. Emergency Medicine. The catheter ballon filling in urethrae can cause pain of urethrae rupture (bleeding). Cover the area with sterile cloth after Disinfect the OUE and the surrounding area Getting Started Give xylocain jelly to the OUE or lubricate the jelly on the catheter. the balloon is blown with spoit fill with sterile water 10-20 ml. When the catheter reach the bladder (usually shown when the urine flows out the tube). Precautions: Be careful when you fill the catheter’s balloon with water or air before knowing the right position of the catheter ( whether its already in the bladder or not). Aghababian R. References 1. Mosby-Year Book. Barkin R. Then insert the catheter into the patient which was in lying position (lithotomic position for female). May HL. 1997 FK-UNHAS Semester Akhir 2010/2011 19 . then pull out the catheter. 2nd. Fleisher GR. then fix the urine bag at the end of the catheter and fix the catheter at the base of patient hip. Rosen P. to prevent the catheter to loose. danzi DF et al.SISTEM UROGENITALIA Introduction Preparation: Clean the genital area before catheterization. 1992 2.

5% chlorin Sterile metal catheter which fix with the urethrae size jelly or xylocain jelly 2% (if possible) pincers or sterile artery clamp sterile pinset for cleaning one 20 ml spoitt for inserting the jelly into the urethrae and to fill the catheter’s balloon sterile gauze sterile NaCl fluid to fill the ballon savlon fluid sterile handscoon sterile doek lobang antibiotic plaster sterile gauze analgetic/ sedative drugs washbasin contains water small towel FK-UNHAS Semester Akhir 2010/2011 20 .SISTEM UROGENITALIA THE STUFF liquid soap antiseptic flowing water clean towel or tissue medical dustbin non-medical dustbin instrument washbasin contain 0.

SISTEM UROGENITALIA ACTIVITIES DESCRIPTION Activities 1 . 4. An instructor is needed to check every step done by each pair. 2. Positioning the students 2. 3. Each pair of students will practice doing every step of catheterization. 3. Students are given a chance to ask and the instructors to explain about the important aspects. 4. Role Play 100 minutes 1. Discussion 15 minute 1. The instructor will ask questions and feed back to each pair. Stimulation 2 minutes 30 minutes Time Briefing Description 1. 3. Discussion: What do you 21 FK-UNHAS Semester Akhir 2010/2011 . Students are divided into pairs. Two instructors will show how to do the catheterizations. The instructor will observe and supervise using checklist.Introduction 2. Students will check and learn the stimulation.

Instructor will do the summary after answering the last question and explain whatever issues that the student didn’t understand. Total Time 150 minute 22 FK-UNHAS Semester Akhir 2010/2011 .SISTEM UROGENITALIA think is the easiest? What is the hardest? Asking how does the student feel while during catheterization? What can a doctor do to make their patient comfortable? 2.

Approach the client or the family and introduce yourself while asking about his/her condition Give general information to the client or family about the procedure and the benefits of catheterization for the patient 3. CATHETHERIZATION IN MAN STEPS / ACTIVITY 1 CASES 2 3 MEDICAL CONSENT 1. 3. Not appropriate : steps are unnecessary to be done because not appropriate with current circumstances.SISTEM UROGENITALIA STUDY GUIDANCE SKILL OF NONIRON CATHETHERIZATION IN MAN (used by Participant) Marks will be given for each step by using certain criteria which is: 1. STUDY GUIDANCE SKILL OF NON-IRON NO. 2. FK-UNHAS Semester Akhir 2010/2011 23 . but assure the patient that the risk is minimal because you are qualified to do the technique and you are using sterile equipment. 2. Explain to the patient using understandable language to the client or family about: the type of catheter that will be used Where the catheter will be put on How to put on the catheter Explain the risk that might happen. according to the order and efficiently. Need Improvement : there are steps which is done incorrectly and/or not according to the order or steps which is undone. . Capable : Steps are done correctly and appropriate order but not efficiently. Expert : steps are done correctly.

Check all the equipments SELF PREPARATION 8. TOOL AND EQUIPMENT PREPARATION 7. (Swap the betadine on the whole area of the penis.SISTEM UROGENITALIA 4. 13. CATHETHERIZATION 14. so that the patient wont feel any pain during the catheterization insertion. OUE and around mons pubis). 12. 9. then fill a syringe with xylocaine jelly and insert about 20cc into the urethrae. Cover the genital area with sterile doek until the only area that 1 2 3 needed expose for the catheterization area. Open the OUE with your thumb and index finger and pull the penis upward to stretch the urethrae. With the help of your partner. 18. Ask for the inform consent from the patients. Clamp the tip of the urethrae using a pin set with your right hand. Do asepsis hand washing Put on the sterile handscoon on both hands Stand on the patients right side 1 2 3 PREPARATION OF THE PATIENT 11. 5. while the base of the catheter is hold using between the FK-UNHAS Semester Akhir 2010/2011 1 2 3 24 . 1 2 3 6. 17. 10. Hold the penis with your left hand where your thumb is at one side and your index and middle finger at the other side. clean and disinfect the genital area with betadine. (if the penis is slippery. Ask the patient to lie down with both extremities are straight. Wait for about 5 minutes. 15. you can hold it with a sterile gauze). Ensure secrecy to the patient and the family Explain about the patient’s right or family that they have the right to refuse the catheterization. Swap xylocaine jelly on the catheter. 16.

Wash your hand Bid farewell towards the patient. 20. 28. When using self retaining catheter. Fix the catheter on the cranial of the hip until the waist. When using non-self retaining catheter. 25. 19. insert the catheter until the marked line.9%. The urine is put in a proper place. 23 24. Fill the catheter’s balloon with sterile water/NaCl 0. from blood or any secrete of the body. 29. Take off the doek Place the end of the catheter in a bottle which had been fill with 50 cc of antiseptic (formaldehyde) or urine bag. pull out the catheter slowly until the urine stop flowing. Take off the handscoon and throw it in a medical dustbin.SISTEM UROGENITALIA fourth and fifth finger (see picture). after the urine flows out. then pull put the catheter until it is stuck at the balloon. 21. for 5-20 cc depends on the balloon capacity. AFTER THE PROCEDURE IS FINISHED 26. after the urine flows out. Insert the catheter slowly into the urethra with the smallest pressure as possible until the urine flows out. Give antibiotic on the OUR and cover it with sterile gauze to 1 2 3 prevent infection and change it every 12 hours. This is important to avoid filling the balloon while the tip of the catheter is still in 22. the urathrae which can cause rupture of the urethrae. then insert the catheter back in until the urine flows again and fix the catheter on the penis with a plaster. Do the decontamination by washing your hand (the handscoon still on) in a basin containing chloride 5% to clean your hands 27. FK-UNHAS Semester Akhir 2010/2011 25 .

according to the order and efficiently. 3. Not appropriate : steps are unnecessary to be done because not appropriate with current circumstances. Approach the client or the family and introduce yourself while asking about his/her condition 2. but assure the patient that the risk is minimal because FK-UNHAS Semester Akhir 2010/2011 26 . 2. . Give general information to the client or family about the procedure and the benefits of catheterization for the patient Explain to the patient using understandable language to the client or family about: the type of catheter that will be used Where the catheter will be put on How to put on the catheter Explain the risk that might happen. CATHETHERIZATION IN MAN STEPS / ACTIVITY 1 CASES 2 3 MEDICAL CONSENT 1. Capable : Steps are done correctly and appropriate order but not efficiently. STUDY GUIDANCE SKILL OF NON-IRON NO. Expert : steps are done correctly. 3.SISTEM UROGENITALIA STUDY GUIDANCE SKILL OF NON-IRON CATHETHERIZATION IN WOMAN (used by Participant) Marks will be given for each step by using certain criteria which is: 1. Need Improvement : there are steps which is done incorrectly and/or not according to the order or steps which is undone.

If using non-self retaining cathether. Ask for the inform consent from the patients. should be accompanied with a nurse if the operator is a male. Swap betadine around OUE. Push the cathether in until the urine comes out/flows out. 1 2 3 TOOL AND EQUIPMENT PREPARATION 7. 6. after urine flows out (by placing the tip hole of the cathether above the bladder neck ) then fixation the cathether with two plester on the hip FK-UNHAS Semester Akhir 2010/2011 1 2 3 1 2 3 16. Check all the equipments SELF PREPARATION 8. 10. The operator ( doctor ) stands on the right side of the patient. CATHETHERIZATION 14. 9. are using sterile equipment. 5. vulva and mons veneris. 27 . Ensure secrecy to the patient and the family Explain about the patient’s right or family that they have the right to refuse the catheterization. 15. Hold the cathether between thumb and pointing-finger and insert it into the OUE. Patient lie down with both legs in flexion position both hip are in abduction position ( Lithotomi) Cover the genital area with sterile doek until the only area that needed expose for the catheterization area. Do asepsis hand washing Put on the sterile handscoon on both hands Stand on the patients right side 1 2 3 PREPARATION OF THE PATIENT 11. Sterilize external genitalia with betadine. 17. 13. 12.SISTEM UROGENITALIA you are qualified to do the technique and you 4.

Fixation the cathether on the cranial part of hip and waist 1 2 3 (SIAS). Take off handscoen and throw it to medical garbage bin. 23. 25. Dry your hands with napkin. 29. 18. 20. 27.5%. let some part still on the hand before put off the other glove. Put gloving-hands into a bowl filled with chlorine 0. Take off the doek Place the cathether and connect it with a urine bag or a bottle filled with 50cc antiseptic. 28. Do not open until the handscoen is full-open. after urine flows out push the cathether in until near the branch of cathether. Fill the cathether balloon with water/ NaCl 0. This is important to prevent the filling of the balloon while cathether is still inside the 19. 28 FK-UNHAS Semester Akhir 2010/2011 . urethra because can cause rupture of the urethra. 24. AFTER THE PROCEDURE IS FINISHED 22. When both handscoen almost reach the tip of the fingers. 26.SISTEM UROGENITALIA and button. Then hold the other handscoen on its fold then pull it until the inside part of the handscoen is in the outside. Hold one of the handscoen on its fold and then pull it until the inside part of the handscoen is in the outside.9% about 5-20cc depends on the balloon capacity. Urine that flowing out are put in the urine bag. If using non-self retaining cathether. 21. put off both handscoen together. Wash hand with antiseptic. then pull the cathether out until it restrain on the balloon.cc Do the farewell to the patient. 30. rub both hands to wash the dirt on the gloves.

MK dr. Sp. Irfan Idris Edited dy : dr. Muhammad Yunus Amran UROGENITAL SYSTEM MEDICAL FACULTY HASANUDDIN UNIVERSITY 2011 FK-UNHAS Semester Akhir 2010/2011 29 . Aidah Juliaty Baso dr.SISTEM UROGENITALIA LEARNING GUIDE FOR STUDENT METHOD OF PROSTATE EXAMINATION THROUGH RECTAL TOUCHÉ Given to 4th Semester Undergraduate’s Medical Faculty Of Hasanuddin University Arranged by : dr. Baedah Madjid.

Can prepare the tools and materials correctly 3. dribbling. 8. Can prepare the patient correctly. Can inspects prostate gland correctly. noctury. such as about will disable action can do for him. Can explain to the patient and him family bout examine prosedures. Can wash hand and asepsis wash hand correctly 6. how to do. 5. 2. 4. Inspects to evaluate gastrointestinalis tractus ( rectal toucher ) FK-UNHAS Semester Akhir 2010/2011 30 . properly and efficient. Can inspects rectal toucher correctly. Can explain to the patient and him family about the secret action and patient rights. Decrease urine flow. the student: 1. Urine retention 2. SPECIFY INSTRUCTION TARGETS (SIT) After done this skill training.SISTEM UROGENITALIA METHOD OF PROSTATE EXAMINATION THROUGH RECTAL TOUCHÉ GENERAL INSTRUCTION TARGETS (GIT) The Student can be able to perform rectal toucher correctly. ttools. INDICATION 1. 3. Can to wear the steril handschoen with properly and released after finishing. 7. benefits and posible risk.

inelastic and very sencitive from the pressure (pressure pain). hard. and then keep the ventral side of point finger facing anteriol wall of rectal. Degown RL and Brown DD: DeGowin’s Diagnostic Examination 7th edition . grown up.SISTEM UROGENITALIA REFERENCES Preparation : ask the patient to pee. Prosedure: Inspects the perineum with separating both gluteus maximal muscles with left hand. Insert point finger to anal orificium slowly and press gently to relaxating external anal sphincter. REFERENCES 1. Evaluate the skin around perineum like inflamation. In Benigna Prostate Hipertophy (BPH) ussualy has billaterally grown up. On carcinoma has touched bumps like stone and nodulsly and unillaterally grown up. For the next. the consistency (elastic. and then wear the handschoen and apply lubricant to the point finger side. sizes (normals. sensitivable from the pressure (normals or abnormals). 2000 FK-UNHAS Semester Akhir 2010/2011 31 . If the point finger moving up. Arrange the patient position with lithotomy side. push the point finger until reach rectal ampulla and evaluating all part of rectal to trace for any sign of mass or compression. Feel the prostate surfaces (smooth or nodulsly). mobility or ficsationed. McGraw-Hill. so that vesica seminalis can be reach in the every midline side when the normally condition could not touched. atrophy). catheterisation can be applied if the patient can not do it. After finishing. In acute prostatytis the glands grown up and softly. pylonidal cynus. anal fistle. releasing finger and taking tissue for the patient to clean himself. elastic like rubber and slippery surface on mucosa rectum. Push the point finger forwards 12 ‘clock direction and fell the medial line that separate two prostate glands and continue until point finger reching the pole of prostate when the median line began to dissapear. smooth). rectal prolaps and hemorhoid. that’s form.

SISTEM UROGENITALIA 2. History and Examination. TOOLS AND MATERIALS PREPARATION Liquid soap Water flow Antiseptic Tissue or mop Steril handschoen PATIENT PREPARATION Empty the urine bladder Steril cotton wool A pile of water Small towl or tissue Chlorin 0. 5th edition. Swartz MH : Textbook of Physical Diagnosis. 2006.5% in bowl Nonmedic bin Medic bin Male patient ussualy lying flat in lithotomic position FK-UNHAS Semester Akhir 2010/2011 32 . Elsevier.

Introduce yourself and ask about current conditions 2 Give the general information to the patient and him family about prostate inspection. 5. benefits and risk for patients condition. Rectal toucher Preparation 8. Get permission from the patient to rectal toucher inspects. 4. If could not do alone. targets. The Patient is lithotomy position ( according inspection technique review the picture ) 11. procedurally and efficient. Inspect perineum and anal area. Wash hands routine 9. GUIDE LEARNING METHOD OF PROSTATE EXAMINATION THROUGH RECTAL TOUCHÉ NO STEPS/ METHODS Medical Consent 1. Explain to the patient about patient rights and him family. Need improvement : the steps are incomplete and incorrectly. Capable : the steps are done correctly and appropriate but inefficiently. such as about the right for unagree the rectal toucher inspections. Patient and tools/ materials Preparation 6. 3. 3. Ask the patient for pee. Expert : the steps are done correctly. Wear the DDT handschoen Rectal Toucher Inspection 10. Check and arrange supporting tools 7. trace for any sign of FK-UNHAS Semester Akhir 2010/2011 1 CASE 2 3 1 2 3 1 2 3 1 2 3 33 .SISTEM UROGENITALIA GUIDE LEARNING METHOD OF PROSTATE EXAMINATION THROUGH RECTAL TOUCHÉ (used by Participant) Valuates for every clinical steps using the criteria below: 1. And then help him to be lithotomy position. Inappropriate : unnecessary step because different conditions. 2. Talk to the patient or him family friendly and pleased to sit. doing catheterization. Make guaranty to the patient or him family about unexposed action and checked report.

and check again there any blood.5% bowls. and then. Clean the handschoen with flowing water. or into the medic bin. hemorrhoid or urethral stone (pars prostates) 15. 12. mucus and feces on handschoen. rub hand to clean bloods pock or other body dilution on handschoen . Another hand on the suprapubic and press to vesica urinaria direction ( if the vesica urinaria was empty. Do aseptic Wash hand 20. Ask the patient to breath normally. Push the point finger into the anal and feel the ampulla and rectal wall. Apply jelly to the point finger that wears handschoen 13. trace for any sign of tumor. 3) The consistency: rubbery. hardly. Feel the mass and evaluate below: 1) That’s surface or rectal mucosa at prostate. open the handschoen bring into the chlorin 0. anal fistel (fisura ani) or surgical scars. so that both finger can feel touched. Release the finger with forming the fingertip. Insert the point finger into anal. 14. or softly 4) Symmetric or not 5) Bumping or not 6) Fissionable or not 7) Pain pressure or not 8) Crepitating or not 17. to grope prostates gland in lithotomic position. Be farewell with patient FK-UNHAS Semester Akhir 2010/2011 1 2 3 34 . 19. touch the anal spinchter slowly. Place the point finger in 12’clock direction. 2) Deformation up: high pole can/ did not can touched and nodules into the rectum. Release the handschoen 18.SISTEM UROGENITALIA hemourhoid or noduls. being evaluate the tonus spinkter. (prostate gland can grope in 12’clock position) 16.

B (K-BU) Edited by : dr.SISTEM UROGENITALIA LEARNING GUIDE FOR STUDENT METHOD OF CIRCUMCISION Given to 4th Semester Undergraduate’s Medical Faculty Of Hasanuddin University Arranged by : Prof. Sp. Muhammad Yunus Amran UROGENITAL SYSTEM MEDICAL FACULTY HASANUDDIN UNIVERSITY 2011 FK-UNHAS Semester Akhir 2010/2011 35 . Baedah Madjid. Achmad Makkarausu P.MK dr. dr.. Sp.

Wear sterile gloves and then dispose them correctly 6. Prepare the patient 2. Circumcise correctly FK-UNHAS Semester Akhir 2010/2011 36 .SISTEM UROGENITALIA METHOD OF CIRCUMCISION AIM Of COURSE General Aim : Students are able to carry out the techniques of circumcision that is correct. students are able to: 1. Place the patient in the correct position 7. how it will be done. lege artis and efficient. Wash hands correctly 5. Spesific Aim : After completion of the course. Ready the tools 3. the advantages and the risks 4. the tools involve. Explain to the patient or his family of the process.

Sterile gloves 9. Sterile 5cc spoit 6. Procain/xylocain 1-2% 5. Sofratule Preparation of the patient · · Note · Children under 5 years of age are usually put under general anesthesia in the operating thatre · Children above 5 years of age are given local anesthesia Clean the outer area of the groin Place the patient in supine position FK-UNHAS Semester Akhir 2010/2011 37 . Sterile kasa 8. Sterile minor surgery set 2.SISTEM UROGENITALIA Tools 1. Adrenalin & deladryl injection/cortizon 11. Betadine + korentang 4. Plaster 10. Sterile dock with a small hole 7. Cat gut chronic 3/0 with the needle 3.

advantages and risks Ask for the patient’s consent to continue with the process Wash hands correctly to get rid of all bacteria Put on the gloves Disinfect the groin area with betadine Put the dock on the groin with the genitals uncovered Anesthetize the tip of the penis and mucosa of the coronaries sulcus with 4cc of xylocain 2% 38 2. NS Not Suitable: The procedures no need to be done because it wasn’t suitable with the situation. 6.SISTEM UROGENITALIA LEARNING GUIDE METHOD OF CIRCUMCISION (Used by the student) Give the score for each clinical procedure by using this criteria: 4. FK-UNHAS Semester Akhir 2010/2011 . or there’s a procedures step didn’t done. Skillful: the procedures done correctly. but didn’t efficient. and suitable with the arrangement and efficiently. Able: the procedures done correctly and suitable with the arrangement. 4. 5. 6. STEP / ACTIVITY 1 CASES 2 3 1. especially the reason. NO. Need Improvement: the procedures done incorrectly or done but didn’t suitable with the arrangements. 5. 3. MEDICAL CONSENT Introduce yourself to the patient and his family Inform them of the whole circumcision process.

3 Pull the preputium towards the tip of the penis until the coronaries sulcus is exposed B.7 Skin and mucosa are sewn one by one or continuously using cat gut 3/0 B. perform dorsumcision until 1cm from coronaries sulcus A.verban C GUILLOTINE TYPE CIRCUMCISION C.verban B B.SISTEM UROGENITALIA 7. 6 Note the penis symmetry – make sure it doesn’t twist A.8 Sofratule . 7 Sofratule . Mucosa and the skin are sewn one by one or continuously using cat gut 3/0 A.4 Incise 1-2cm around the mucosa of the corona glandis B. A.5 Excise the preputium from the subcutaneous tissue B. 2 Make sure the area is free from smegma and the mucosa sticking to the penis gland is free A.6 Control the bleeding B.1 The operator should be on the right side of the patient VARIOUS TECHNIQUES OF CIRCUMCISION DORSAL SLIT CIRCUMCISION Firstly. 5 Control the bleeding. 4 The skin and mucosa are cut circularly to the ventral until the frenulum and mucosa remains 1cm in the coronaries sulcus A.1 Clamp the mid part of the ventral and dorsal part of the preputium FK-UNHAS Semester Akhir 2010/2011 39 . A. 3 The mucosa and skin at the end of the dorsumcision is sewn together A.1 SLEEVE TYPE CIRCUMCISION Place the penis in the normal position B.2 Incise the skin following the corona glandis of the penis circularly until the frenulum B. 8.

3 Cut the preputium below the clamp with a scalpel. verban Dispose the gloves 10.4 Control the bleeding C.2 Use the straight clamp to clamp the preputium from dorsal to ventral at the end of the penis gland sideways to the proximal of dorsal C. Wash hands correctly FK-UNHAS Semester Akhir 2010/2011 40 .SISTEM UROGENITALIA and pull it back C. C. Use fingers by pressing the gleands to protect it C.6 Skin and mucosa are sewn one by one or continuously using cat gut 3/0 C.7 Sofratule 9.5 Leave only 1cm of mucosa at the corona glandis.

Parafimosis is a condition where Tumor prevention. at the perineum II. Medical i. Religion b. smegma is carcinogenic iv. iii. Penoscrotal. INDICATION a.SISTEM UROGENITALIA CIRCUMCISION THEORY INTRODUCTION Circumcision means complete or partial removal of the penis preputium. at the penis itself c. Social c. Absolute I. Hipospadia is a condition which the opening of the urethra (meatus urethrae external) is at the wrong place. Hemophilia Condiloma acuminate v. between the penis and scrotum d. Scrotal. This usually causes the penis glans to be trapped by the inflamed preputium. at the frenulum b. at the scrotum e. disorders CONTRAINDICATION A. because Other preputium the preputium could not be pulled forward (distal). Frenal. According to the location: a. inflammation (balanopostitis). The position is along the ventral of penis until the perineum. Sometimes the hole at the end of the preputium is only as big as a needle which makes it hard to urinate. ii. Conditions which can cause fimosis are congenital. Fimosis is a condition which the preputium could not be pulled backwards (proximal). Penil. FK-UNHAS Semester Akhir 2010/2011 41 . Perineal.

Kutis (mtegumentum commune}. B. b. Korpus kavernosum penis. Vena dorsalis penis kutaneus. General infection III. Meat us uretra eltstemus. F. d. Diabetes mellitus ANATOMY A. Frenulum prepusii. k. Rafepenis. Septum penis. Korona glandis. e. Nervus tbrsalts penis. wraps corpus cavernosum and corpus spongiosum and the internal structures a. under the fasia Buck Fasia Buck. g. Blood discrasia B. Perhalik'nn posisi hsin Buck {fasia penis). FK-UNHAS Semester Akhir 2010/2011 42 . Fasia penis ffssia Buck). n. Korpus kavernasuiit. f. h. g. d. Arteri profunda penis. Local infection on the penis and the surrounding II. c. h. m. Arteri tiorsalis penis. L Korpus spongiosum. Vena dorsnlis penis. Koryus spongiosum uretra. D. t. Fnsai Buck. f. E. Muskulus iskkiokavemosus. vein and nervus dorsalis penis. Verm^vena profunda penis. Kutis (integumentum commune). k. Arteri bulbus uretra. Diafragrna uregenihtl. o. p. Glaus penis. Tttnika albugmea. a. b. c. TunHcaalbugmeci. n. Rjrtnus superior Osispttbis. POTONGAN SAGITAL PENIS DAW SEK1TARNYA.SISTEM UROGENITALIA III. Relative I. I. j. 2 corpus cavernosum at the dorsal of the penis 1 corpus spongiosa. Butbus uretra. C. at the ventral Uretra pars spongiosa along the inside of corpus spongiosum Tunika albuginea wraps both corpus cavernosum Artery. Uretra parsspongiosa. Verm-vena profunda pmi$. Prepusiam. m. l.

Straight kocher clamp f. Circumcision equipment a. Anatomical pinset g. Use antiseptic such as Salvon and Hibiscrub to cleanse hands d. Patient a. Operator should be on the right side of the patient B. Ether. Non-irritative antiseptic such as betadine. pikrat acid 1-2%. Needle to sew the skin FK-UNHAS Semester Akhir 2010/2011 43 . Operator wears clean clothes. cleanse the area repeatedly by: i.3 l. Put on sterile gloves e. Tissue pinset h. Check if the patient has any kind of allergies When everything is done. Blade no. calm the patient so that the everything goes on smoothly d. Operator a. Clean the area around penis with soap c. before the circumcision. surgical gowns if possible b. For children. Wears cap and mask c.SISTEM UROGENITALIA PREPARATION A. Straight pean clamp d. Shave hair around the penis b. Needle holder b.to dispose of skin lipid properties ii. Do not use Iodium because the skin around the penis is very sensitive iii. Knife holder no. Thread scissor j. Curve mosquito clamp c. 10 k. Ethanol 70% EQUIPMENT I. Curved halstead clamp e. Straight major scissors or Busch scissor i.

awake patient i.5% v. Additional equipment a. vomiting) rarely happens iii. Local. Lidocain i. Effective concentration 0.5% v. Infiltration 0. Patients Agitated allergic to local anesthesia iii. patients b.2-0(00) or-0(000) ANESTHESIA a. ii. epidural and its modifications ii. Spinal. 2 pairs of sterile rubber gloves c.5-2% iii. Active time 15-30 minutes ii. Effective concentration 0. Active time 30-60 minutes ii.Manual for Student CSL UROGENITALIA SYSTEM II. Maximum dose 1000mg iv. Procain i. Nerve block 1-2% III. Sterile kasa d. Infiltration 0. Combination of dorsal penis block and infiltration Of all the above. For nerve block 1-2% b. General anesthesia i.25-0. Uncooperative children ii. Sterile cloth with hole in the middle b. Maximum dose 500mg iv. Relatively easy to perform Combination of general anesthesia (nausea. Plain cat gut no. Local anesthesia a. combination of nerve block and infiltration is most favored due to: i. Cheaper This method can be done by combination of Dorsal penis nerve block Even Semester 2010/2011 FK-UNHAS 44 .5-5% iii. Antiseptic e.

inject the anesthesia. ii. usually doesn’t need aspiration Infiltration at the corpus penis or ring block at the corpus penis Inject the needle from the distal to the proximal subcutaneous lean towards dorsal and ventral. Inject whilst pulling out the needle. It has to be done carefully as it can injure the glans penis. CIRCUMCISION TECHNIQUE Circumcision is usually done by 2 techniques: A.5-2ml. Dorsumcision a. RELEASING PREPUTIUM To release the preputium can be done by i. it with clamp. However this technique is harder for the inexperienced. Releasing the preputium with kasa. use the mosquito clamp. This type of anesthesia is done usually if the patient still feels the pain.Manual for Student CSL UROGENITALIA SYSTEM The injection is done at the end of the penis perpendicular to the corpus penis through the fasia Buck then lean the needle laterally to aspirate the blood. If it’s not in the blood vessels inject 1-3ml of anesthesia Infiltration of the penis frenulum Penis is flipped back then inject at the medioventral distal to the frenulum proximal to the penis. Often smegma can be found after the release. Inject anesthesia 0. inject to the left and right. betadine). This technique is safer because the probability of injuring the penis is smaller compared when using the clamps. b. Benefits Excessive skin-mucose can be managed No excessive mucosal incision The odds of injuring the penis glands and preputium frenulum are little Release Even Semester 2010/2011 FK-UNHAS 45 . Whilst pulling out the needle. apply some antiseptic around that area (Lysol. along the penis towards the proximal (dorsal slit) then cut to the left and right around the sulkus coronaries glands. Boundaries This technique is done by cutting the preputium at 12o’clock. After releasing it.

Antibiotics: broad spectrum such as tetrasyclin. then cutting it. The technique is more difficult If inexperience. Anti-inflammatory: serapeptase (danzen).Manual for Student CSL UROGENITALIA SYSTEM - Easier to manage bleeding c. Disadvantages B. mefenamic acid (ponstan) and acetilsallicylic acid (aspirin) c. Boundaries This is done by clamping the preputium horizontally along the penis length. the incision is not smooth The duration is longer Classic (Guillotine) a.5-1cc/IM Even Semester 2010/2011 FK-UNHAS 46 . tripsin+kimotripsin (chymomed) d. Benefits Relatively simple Produces smooth incision The duration is shorter c. Disadvantages Inexperience operators can cause excessive mucosa and re-incision is needed The mucosa-skin length could not be determined The possibility of injuring the penis glands and excessive frenulum incision is larger Bleeding is usually more compared to dorsumcision CARE A. b. Analgetics: non-arcotic analgesic such as antalgin. The incision can be done at the proximal or distal of the clamp. Pharmacology a. pankreatin + proctase. Anti-tetanus: purified tetanus toxoid 0. ampicillin and amoxicillin b. Roborantia: B complex vitamin and high dose C vitamin to help the healing process e.

loosen it a little. the penis will lean towards the painful side and the patient will feel extreme pain. find the source of the bleeding. the analgetics can be given via injection such as xylomidon b. edema Pain and pus In severe conditions. high dose of vitamin E. Others Even Semester 2010/2011 FK-UNHAS 47 . The treatment are among others radiation. If the patient is bleeding heavily. Large haematom If it happens at the time of circumcision. Due to tissue fibrosis of one of the corpus cavernosum. Edema This usually happens on the second day onwards. Explain to the patient and his family that edema often occurs and is not life-threatening c. Complications & How to overcome a. operation to remove the scar tissue but with unsatisfactory result C. If the bandage is too tight. If need be. If the patient feels unbearable pain. Bleeding If the bandage is wet. open the suture. Pain Give the patient analgetics before carrying out the operation. it is better to remove the haematom as it can slow the healing process f. If the condition improves. Infection Signs: Red penis. apply suitable cream g. Peyronie disease Late complication that arises from infection. change it as it can be a media for bacteria. give haemostatic medication such as karbazokrom (Adona) or tranexamic acid (transamine) d. if need be. Small haematom Not a problem as it will be reabsorped by the body e. patient will be feverish Give antibiotics and treat the symptoms and compress the penis with betadine or rivanol.Manual for Student CSL UROGENITALIA SYSTEM B. During erection.

Even Semester 2010/2011 FK-UNHAS 48 .Manual for Student CSL UROGENITALIA SYSTEM a. Food Advice the patient to eat food with high protein to speed the healing process b. It is best that on the first day after. Others Patient wears loose pants so as not to pressure the penis. the patient rest to prevent possible trauma and bleeding. Keep the penis dry until the wound heals and bandage removed.

Manual for Student CSL

UROGENITALIA SYSTEM

LEARNING GUIDE FOR STUDENT
METHOD OF EVALUATING BNO-IVP PHOTO

Given to 4th Semester Undergraduate’s Medical Faculty Of Hasanuddin University

Arranged by :
dr. Sri Asriani, Sp.Rad.

Edited by :
dr. Baedah Madjid, Sp.MK dr. Muhammad Yunus Amran

UROGENITAL SYSTEM MEDICAL FACULTY HASANUDDIN UNIVERSITY 2011

Even Semester 2010/2011 FK-UNHAS

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Manual for Student CSL

UROGENITALIA SYSTEM

METHOD OF EVALUATING BNO-IVP PHOTO
(Used by the student) Give the score for each clinical procedure by using this criteria: 1. Need Improvement: the procedures done incorrectly or done but didn’t suitable with the arrangements, or there’s a procedures step didn’t done. 2. Able: the procedures done correctly and suitable with the arrangement, but didn’t efficient. 3. Skillful: the procedures done correctly, and suitable with the arrangement and efficiently. NS Not Suitable: The procedures no need to be done because it wasn’t suitable with the situation.

GENERAL INSTRUCTIONAL AIM

Students are expected to be able to make assessment in a few radiological examinations in genitourinary system cases.

SPESIFIC INSTRUCTIONAL AIM

After this clinical practice, students are expected to be able to : 1. Read and evaluate BNO film 2. Read and evaluate IVP film

INDICATION

1. When there are abnormalities in kidney, ureter, and urinary vesicel 2. Finding accurately disturbance in urine flow in uropoitic tractus 3. Stone in urinary tractus as the most frequent cause 4. Evaluating function of kidney NEEDED INSTRUMENTS

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Manual for Student CSL

UROGENITALIA SYSTEM

1. An unit of x-ray machine 2. Contrast (dye) 3. Infuse set

METHOD/PROCEDURE Preparation: clear the abdomen with laxative or use enema to remove fecal mass from stomach. Patients are required to fast 8-12 hours before this test procedure examination. Procedure: For BNO film, after the preparation, patients are brought directly to the xray room to be taken abdominal x-ray/ plain film of abdomen In IVP, patient in line supine and media contrast is infuseose via the veins of the arm. Photos are taken at 0,5 minute, 10 minute, and 20 minute. Interval 0 is the time when contrast media is given intravenoury. The test is completed, when after 20 minute the radiology picture of kidney, urethra, and urinary vesicle bilateral. References : 1. Peacock WF. Urologic stone disease. In: Tintinalli JE, Krome RL, Ruiz E, eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. McGraw-Hill; 1995:549-53. 2. Schneider RE. Genitourinary procedures. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 3rd ed. WB Saunders Co; 1998:978

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The instructor observes students and supervises using a checklist. 3. An instructor gives examples of how to do an examinated and evaluation BNO-IVP photos. 1. Students are device into pairs to pairs. 4.Manual for Student CSL UROGENITALIA SYSTEM JOB DESCRIPTION times 2 minute 30 minute description Introduce 1. What is felt to be easy? What was hard? 2. 1. 2. Discussion/ opinion share 15 minute Total time 150 minute Even Semester 2010/2011 FK-UNHAS . An instructor will evaluate 3 pairs. Practice to inspect with feedback 100 minute 4. Student watch the demonstration and using the modules 3. arrange Position sit students 2. Introduction 2. The instructor concludes the session by answering any last question and explaining unclear issue 52 1. Role playing : question and answer 3. Give change for students to ask questions and instructor to give explanation on the more important aspects. The instructor give specific feed back to each students. Pairs will practice evaluate the roentgen photos one by are.

Fasten the photo to the light box 2. and size of ureter and are the signs of obstruction 12. Able: the procedures done correctly and suitable with the arrangement. Write down the result from identification READING AND EVALUATING IVP PHOTOS 8. 9. or there’s a procedures step didn’t done. NS Not Suitable: The procedures no need to be done because it wasn’t suitable with the situation. Need Improvement: the procedures done incorrectly or done but didn’t suitable with the arrangements. 8. but didn’t efficient. Check the condition of the photo: Include T12. Check for markers (R/L. Check the patients identity (name/age) on the photo 3. Report the result of your invention Even Semester 2010/2011 FK-UNHAS 1 CASES 2 3 1 2 3 53 . Evaluate the excretion and secretion function of both kidney’s 10 Evaluate the pelviocalyceal system of both kidney’s ( are there signs of obstruction or not) 11 Evaluate shape. size and position of kidney’s 9. Skillful: the procedures done correctly. and suitable with the arrangement and efficiently. Evaluate the Vesica Urinary 13. psoas line.symphisis or pubis Check for faecal mass ( in connection with patient preparation) READING AND EVALUATING BNO PHOTOS 5 Do identification the contour of kidney.Manual for Student CSL UROGENITALIA SYSTEM LEARNING GUIDE METHOD OF EVALUATING BNO-IVP PHOTO (Used by students) Give the score for each clinical procedure by using this criteria: 7. Evaluate shape. and bones 6. NO. STEPS/ACTIVITY PREPARATION 1. Do identification by for radioopage structure along the urinary tractus. 7. D/S) on the photo 4.

these stones are fragile in response to ESWL. Stasis or anatomic factors can also contribute to the development of stone disease. They demonstrate intermediate fragility to extracorporeal shock wave lithotripsy (ESWL). dotted. The greater the degree of supersaturation. which leads to supersaturation of the crystallizing salt. autosomal dominant polycystic kidney disease. Calyceal diverticula. in rare cases. Calcium stones account for 75-85% of urinary stones. Pathophysiology: In patients with stone disease. is also associated with stone disease. The pathologic process in medullary sponge kidney is renal tubular ectasia. horseshoe or ectopic kidney. more than 1 of 3 general mechanisms is likely to be active.” Medullary sponge kidney is another common anatomic cause of renal calculi. These include ureteropelvic junction (UPJ) obstruction. Approximately three eighths of calcium stones are formed of only calcium oxalate dihydrate. Increased absorption in individuals after a normal diet causes an elevation of serum calcium levels and a suppression Even Semester 2010/2011 FK-UNHAS 54 . the least responsive to ESWL. These stones are the densest and. stones are present. The pain may be some of the most severe pain that humans experience. death. These range from a few large calculi to many tiny seed calculi and to the microscopic “milk of calcium. These may be spiculated. Usually. or jackstone in appearance. Calcium stones have numerous causes.Manual for Student CSL UROGENITALIA SYSTEM NEPHROLITHIASIS Background: Passage of a urinary stone is the most common cause of acute ureteral obstruction and affects as many as 12% of the population. Calculi form in approximately 50% of patients. the greater the rate of growth of the calculi. and complications of stone disease may result in severe infection. Most causes of hypercalciuria are absorptive. In 10-40% of calyceal diverticula. and (3) a possible excessive excretion or concentration of salts in the urine. or. The calcifications form in the medulla but frequently pass into the collecting system. mulberry. consequently. (2) a possible relative lack of substances to inhibit crystal formation. Idiopathic hypercalciuria occurs in more than one half of patients with calcium oxalate stones. renal failure. and vesicoureteral reflux. Approximately one half of calcium stones are composed of a mixture of calcium oxalate and calcium phosphate. pyramidal clusters of calculi within the dilated tubules classically become obscured or appear enlarged after contrast material surrounds them in the dilated tubules. Approximately 85% of calcium stones are idiopathic. or primary. On intravenous urography (IVU). but they may also be unilateral or segmental. The remaining one eighth of stones are composed of calcium phosphate (apatite) or calcium monohydrate. They are usually bilateral and diffuse. These include the following: (1) the possible presence or abundance of substances that promote crystal and stone formation. the result of anomalous budding of the calyceal system.

Type IV RTA commonly is seen in medical renal disease and does not predispose patients to stone formation. Nephrocalcinosis or urolithiasis is seen in as many as 70% of patients with type I RTA. hypercalciuria. These stones are lucent but complex with calcium phosphate. and hyperphosphaturia. therefore. use of steroids. Conversely. The injured distal tubule loses the ability to maintain the hydrogen-ion gradient. However. Magnesium ammonium phosphate (struvite) stones account for approximately 10-20% of urinary stones. Uric acid stones account for 5-10% of urinary stones. as many as one half of patients have an underlying metabolic cause for stone disease. they result from hyperparathyroidism. paraneoplastic phenomenon. Most commonly. who may develop stones within weeks to months of immobilization. the presence of infection. and multiple myeloma.Manual for Student CSL UROGENITALIA SYSTEM of parathyroid function as an abnormal response to vitamin D. less common. Cushing syndrome. potentially. Patients with the stones are treated with surgical removal of the parathyroid adenoma or hyperplasia. Although they fragment easily. The inability of the kidney to conserve calcium results in low serum calcium concentrations. Other secondary causes include milk-alkali syndrome. hypervitaminosis D. hypercalcemia and increased absorption lead to hypercalciuria. On occasion. and this is an important mechanism in patients with spinal cord injury. In this situation. Klebsiella. In type I (distal) RTA. patients with these stones usually are treated with percutaneous fragmentation and extraction because of the large size of the stones and. which helps keep stones from forming. type II (proximal) RTA is associated with increased bicarbonate loss. Approximately 10% of cases of primary hypercalciuria are renal in origin. secondary cause of calcium stone formation and most often results from inflammatory bowel disease. or renal failure. Immobilization of an individual causes rapid mobilization of the calcium in bones. which is found in 5-10% of patients with stones. Combined obstruction and infection frequently cause renal destruction and. usually. Renal tubular acidosis (RTA) is an additional fairly common secondary cause of calcium stones. Calcium stones can also occur in approximately 15% of patients with sarcoidosis in whom the production of activated vitamin D by macrophages is abnormal. Hyperoxaluria is another. The remaining 15% of calcium stones are secondary to some discernible etiology. bowel surgery. which stimulate parathormone secretion. causes alkaline urine. in turn. and Pseudomonas species. metabolic evaluation is indicated. renal failure if both kidneys are affected. which may be primary or secondary to a variety of renal injuries. they enlarge and branch (staghorn). Struvite stones are caused by urea-splitting bacteria such as Proteus. Primary hyperoxaluria is a rare autosomal recessive disease. kidneys have a decreased ability to lower urine pH levels. vitamin C overdose. These small smooth Even Semester 2010/2011 FK-UNHAS 55 . This.

salicylates. The prevalence of urinary lithiasis is as high as 2-3% in the general population. Internationally: A slightly lower prevalence of urinary stones is found in less developed countries. When this occurs. However. even on CT scans. Predisposing factors include acidic concentrated urine. This can be intermittent or persistent and microscopic or gross. pressure in the collecting system and renal blood flow acutely increase. sulfa drugs. less opaque. possibly because of diets lower in protein. followed by decreased blood flow after 1-2 hours. Treatment and prevention for these stones is alkalinization and dilution of the urine. and cell lysis (eg. resulting from treatment of leukemia or from starvation). Some patients with renal calculi may have no symptoms at all. Frequency: · In the US: Renal calculi occur in 5-12% of the American population. and they are bilateral in 10-15% of patients. triamterene ephedrine).Manual for Student CSL UROGENITALIA SYSTEM stones usually appear radiolucent on conventional radiographs but opaque on CT scans. Acute ureteral obstruction by stone causes severe. especially if they are smooth. which result from cystinuria (a rare autosomal recessive metabolic disorder). may cause stones that appear lucent on CT scans. gout. are homogeneous. recurrent infection may result in pyelonephritis or · · Even Semester 2010/2011 FK-UNHAS 56 . Inspissation of indinavir. colicky (intermittent) flank pain that can radiate throughout the groin. small-bowel disease or resection. · Mortality/Morbidity: · Passage of a renal stone is the most common cause of acute ureteral obstruction. Matrix stones formed from inspissated mucoproteins in patients with a chronic Proteus infection may demonstrate soft tissue attenuation on CT scans. Stones that are 4-6 mm pass in approximately 50% of patients. These ground-glass stones. as many as 10% of patients with acute stones may not have hematuria. Stones smaller than 4 mm pass spontaneously in approximately 80% of patients. an antiretroviral protease inhibitor used to treat HIV infection. Hematuria usually occurs. Cystine stones account for only approximately 1% of urinary stones. back. Several other less common forms of urolithiasis may produce stones that appear relatively lucent. excess urinary uric acid. and less fragile than other stones. Stones can also be caused by metabolic byproducts and drugs (eg. testicles. Occasionally. or periumbilical region. whereas stones larger than 8 mm pass in only approximately 20% of patients.

The peak age for development is in persons aged 40-60 years. damage. possibly as a result of a higher protein diet. stones recur within 1 year. confirm stone passage. recurrent infection may result in pyelonephritis or abscess. This percentage increases to 50% within 10 years. conventional or digital radiography should be used to monitor the Even Semester 2010/2011 FK-UNHAS 57 . When acute flank pain suggests the passage of a urinary stone. Hematuria usually occurs. Radiographs can also be used to monitor the passage of visible stones. Race: Urinary stones occur more often in white populations than in black populations. Preferred Examination: The goals of imaging are to determine the presence of stones within the urinary tract. back. with a male-to-female ratio of 3:1 (except for struvite stones and in black populations). estimate the likelihood of stone passage. and renal failure. Occasionally. or even renal failure if they are bilateral. many methods of examination can be used. Almost all studies conducted to date show that IVU provides no additional clinically important information after nonenhanced CT is performed. They are also more prevalent in highly developed countries. Stones can result in renal scarring. conventional radiography is initially used to screen for stones. Age: Stones are uncommon but not unknown in children. Stones can cause renal scarring. damage. Some patients with renal calculi may have no symptoms at all. However. assess the stone burden. All of these methods have become less useful with the advent of more sensitive and specific nonenhanced CT scanning. and evaluate disease activity. Ultrasonography (US) is useful in young or pregnant patients and in patients allergic to iodinated contrast material. Often. When CT is available. In 10% of patients. IVU (excretory urography) provides important physiologic information regarding the degree of obstruction. US is also helpful in problem solving. evaluate for complications. As a result of the higher radiation dose of CT. Clinical Details: Acute ureteral obstruction by stone causes severe colicky (intermittent) flank pain that can radiate throughout the groin. or free intraabdominal air.Manual for Student CSL UROGENITALIA SYSTEM abscess. Sex: Males are at a greater risk than females. testicles. bowel abnormalities. it is now considered the examination of choice for the detection and localization of urinary stones. as many as 10% of patients with acute stones may not have hematuria. and periumbilical region. It can be intermittent or persistent and microscopic or gross.

US has limited sensitivity for smaller stones. In some cases. The radiation dose is generally smaller than that of CT. It should be used mainly in patients who are young. Pregnant or pediatric patients may be imaged with US first to avoid radiation exposure. but it is of the same order of magnitude. conventional or digital radiography should be used to monitor the passage of stones if radiographic follow-up is believed to be indicated and if the stone is visible on conventional radiographs. Limitations of Techniques: Because of the higher radiation dose with CT. IVU is the traditional examination for the assessment of urinary stone disease.Manual for Student CSL UROGENITALIA SYSTEM passage of stones if radiographic follow-up studies are indicated and if the stone is visible on conventional radiographs. Ulcers Epididymitis Gastric Ulcer Gout Meckel Diverticulum Midgut Volvulus Nephrocalcinosis Obstructive Uropathy. with resultant risks of an allergic reaction or nephrotoxicity. Acute Cholelithiasis Colon. and it does provide physiologic information related to the degree of obstruction. IVU is less sensitive than CT. I DIFFERENTIALS Section 3 of 11 CBack Top Next J Appendicitis Cholecystitis. Acute Pancreatitis. The rare falsenegative finding is usually due to reader error or a protease-inhibitor CTlucent stone. especially for small or nonobstructing stones. Chronic Papillary Necrosis Pelvic Inflammatory Disease/Tubo-ovarian Abscess Renal Cell Carcinoma Renal Vein Thrombosis Even Semester 2010/2011 FK-UNHAS 58 . intravenous contrast material may be needed to opacify the ureter. Diverticulitis Crohn Disease Duodenum. False-positive results are usually due to phleboliths adjacent to the ureter. and does not depict the ureters well. or those undergoing multiple examinations (eg. Intravenous contrast is required. Acute Ovarian Torsion Ovarian Vein Thrombosis Pancreatitis. patients with spine injury). those who are pregnant.

Manual for Student CSL UROGENITALIA SYSTEM Retroperitoneal Fibrosis Testicular Torsion Transitional Cell Carcinoma Tuberculosis. and. 2 images are required. Congenital Vesicoureteral Reflux Wilms Tumor Xanthogranulomatous Pyelonephritis Other Problems to be Considered: Blood clot Fungus ball Calcifications in tumors such as renal cell carcinoma Complicated renal cysts Infection Abscess Infarcts Hematoma Malakoplakia Atherosclerotic calcification Biliary colic Ulcer disease Diverticulitis X-RAY Section 4 of 11 tBack Top Next J Findings: Conventional radiography Conventional radiography is often performed as a preliminary examination in patients with abdominal pain possibly resulting from urinary calculi. Conventional radiographs should include the entire urinary tract. · Stones are often found at key points of narrowing such as the UPJ. the ureterovesical junction (UVJ). and the point at which the ureter Even Semester 2010/2011 FK-UNHAS 59 . Genitourinary Tract Ureterocele Ureteropelvic Junction Obstruction. These images should be obtained before contrast material is administered to prevent obscuring calcifications within the collecting system or calyceal diverticula. often.

they are often difficult to distinguish from ureteral calculi. The nephrogram of acute obstruction is usually homogeneous. but uric acid stones are usually not seen unless they have become calcified. Because stones are more visible with a lower peak kilovoltage (kVp). the use of compression has been associated with forniceal rupture. When a stone causes acute obstruction. Preinjection renal tomography may depict additional stones. scouting the entire urinary tract prior to their administration is critical. Even Semester 2010/2011 FK-UNHAS 60 . an obstructive nephrogram may be present. but they overlap with the ureter. In rare cases. UPJ obstruction. retrocaval ureter.Manual for Student CSL UROGENITALIA SYSTEM crossing the iliac vessels. and it can be used to confirm the relationship of stones to the kidneys. Larger patients may require a higher peak kilovoltage for acceptable exposure and scatter. Phleboliths in the pelvis are usually located lower than and lateral to the ureter. calyceal diverticula. maintaining a maximum of 60-80 kVp is best. However. A caveat is that the contralateral kidney may have an abnormality that requires ureteric compression for adequate examination. Mild bowel preparation may be helpful for increasing the sensitivity of conventional radiography for small stones in patients undergoing screening or follow-up observation for stones. duplication. This view can also depict calcifications that are projected over the sacrum or transverse processes on the frontal view. phleboliths are round or oval. with increasing opacity over time. and others that may predispose patients to stone formation or alter therapy. Cystine stones as small as 3-4 mm may be depicted. and they may demonstrate a central lucency. An addition site is on the right side where the ureter passes through the root of the mesentery. In this situation. Because gonadal veins parallel the upper ureters. Calcium stones as small as 1-2 mm can be seen. contrast enhancement may be needed to opacify the ureter and demonstrate the extraurinary location of phleboliths in the gonadal veins. Because contrast agents can obscure stones in the collecting system. An erect or posterior oblique radiograph obtained on the side of the calcification may help in distinguishing urinary stones from extraurinary calcifications. When an acute urinary stone is the primary consideration. Typically. This may be prolonged and hyperopaque. Intravenous urography IVU is useful for confirming the exact location of a stone within the urinary tract. if possible. IVU depicts anatomic abnormalities such as dilated calyces. compression may not be used to increase sensitivity for detection of low-grade obstruction. compression of the abdomen and collimation is critical.

False Positives/Negatives: Occasionally. Extravasation of urine at the fornices may result in pyelosinus or pyelolymphatic extravasation. but using gravity to position the more opaque and more distal contrast material–laden-urine is also possible by placing the patient in a prone or erect position. Greater extravasation may outline the collecting system. CAT SCAN Section 5 of 11 CBack Top Next] Findings: With a sensitivity of 94-97% and a specificity of 96-100%. Degree of Confidence: Although 90% of urinary calculi are opaque on abdominal radiographs.Manual for Student CSL UROGENITALIA SYSTEM but may also be striated or occasionally not visible on radiographs. if the urine is not infected. pure matrix stones may demonstrate soft-tissue opacity on CT scans. In addition. which may depict only a filling defect). US and CT are effective tools in making this distinction. however. which is often first indicated by blurring of the calyceal fornices. Immediately after the passage of a stone. false-positive findings result from extrarenal calcification. dilatation to the point of obstruction. However. Helical CT scans frequently depict nonobstructing stones that are missed on IVU. but these are usually correctly identified with IVU. Delayed images may be needed to opacify to the point of the obstruction. and the specificity is only approximately 70%. helical CT is the most sensitive radiologic examination for the detection. Approximately 10% of stones are radiolucent on conventional radiographs. helical CT is considerably more effective than IVU. this is usually clinically insignificant. in most studies. and indinavir stones appear lucent. much of the ureter cannot be visualized with US. and the contrast may dissect into the perinephric space. however. and characterization of urinary calcifications. or blunting of the calyceal fornices. residual mild obstruction or edema can be detected at the UVJ. helical CT is better than US or IVU in detecting other causes of abdominal pain. CT is faster and no contrast agent is needed in most patients. therefore. all other stones appear opaque Even Semester 2010/2011 FK-UNHAS 61 . but they are not distinguished from non–stone-filling defects such as transitional cell carcinomas or blood clots. localization. CT easily differentiates between non-opaque stones and blood clots or tumors (compared with IVU. Lucent stones appear as filling defects on IVU. Other signs include delayed excretion. In fact. Rarely. IVU added little or no information. the sensitivity for the prospective identification of individual stones is only 50-60%.

After 3-5 minutes. nonenhanced CT is usually performed. routine abdominal and/or pelvic CT should be performed.0046 Gy for nonenhanced CT.5 mSv for a 3-image IVU. When contrast-enhanced scans are required to evaluate pain not related to stones. Stones that have already passed into the bladder will drop into a dependent location. although some radiologists choose to use a pitch of as much as 2:1. 94% specific) Perinephric fluid (82% sensitive. and a 5-mm helical CT scan is obtained with a pitch of 1.3-1.5:1. In this situation. The kidneys and. a 5-mm helical scan is obtained through the area of concern. this finding differentiates it from a calculus. Stones at the UVJ may be difficult to distinguish from stones that have already passed into the bladder. CT findings CT may depict the following: · · · · Stones in the ureter Enlarged kidneys Hydronephrosis (83% sensitive. if possible. phleboliths do not have radiolucent centers.5 mSv compared with 1. At the authors' institution. the uterine dose is approximately 0. A phlebolith may have a comet tail of soft tissue extending from it.5:1 or less is preferred. a repeat scan through the UVJ in the prone position may be helpful. 93% specific) Even Semester 2010/2011 FK-UNHAS 62 .8-4. approximately 12% (10-20%) of patients who undergo nonenhanced CT for possible urinary stones receive intravenous contrast material for further evaluation.Manual for Student CSL UROGENITALIA SYSTEM on CT scans. Patient selection determines the number of examinations needed. the entire abdomen should be scanned during a single breath hold to prevent section misregistration. Fewer contrast-enhanced studies are needed with increasing experience. Soft tissue around the rim of a calculus can differentiate it from a phlebolith. A fairly high level of noise as a result of the inherently high contrast levels is tolerable in most patients. Technique Because stones in the collecting system may be obscured by contrast material. 100-150 mL of a low-osmolar oral and rectal contrast agent is used.006 Gy for 4image IVU compared with 0. Reported radiation doses for CT are 2. However. minimizing the radiation dose is critical. Helical CT is important to avoid missing stones because of section misregistration. Because patients with stones are often young and because stone disease may recur. On CT scans. as often seen on plain radiographs. If the distinction changes therapy. A 5-mm helical technique with a pitch of 1. To discern between phleboliths and urinary stones. 50 mL of low-osmolar contrast agent should be administered.

CT scans often suggest an alternative or additional Even Semester 2010/2011 FK-UNHAS 63 . If contrast material is administered. If kidney. and as with the obstruction. Almost no stones with attenuation values of less than 200 HU are visible. CT may be needed to follow its passage. For this reason. ureter. and bladder radiographs fail to depict the stone. and repeat CT scans are usually required if passage of the stone is to be followed. Conventional radiography may be helpful in visualizing larger stones. Normal hyperattenuating renal pyramids sometimes are seen. Considerable overlap exists in the CT attenuation values of calcium stones. the usefulness of IVU is limited. 93% specific) Soft-tissue rim sign (good positive predictive value with a positive odds ratio of 31:1) The amount of perinephric fluid is correlated with the degree of obstruction seen on IVU. Approximately 40-55% of stones are not visible on abdominal radiographs. Degree of Confidence: Individual CT signs are associated with varying degrees of confidence. False-negative results are primarily due to indinavir radiolucent stones and error. as noted in CT findings above. to provide a baseline to follow passage of the stone. a delayed or hyperattenuating nephrogram may also be visible on CT scans if the ureter has an obstruction. this finding has been seen with proven ureteral calculi and is often absent in patients without stones. These indicate that significant obstruction is not present. However. Cystine and urate stones have an attenuation of 100-500 HU. once they are identified on CT scans. False Positives/Negatives: False-positive results are almost exclusively the result of a phlebolith adjacent to the ureter.Manual for Student CSL UROGENITALIA SYSTEM · · Ureteral dilatation (90% sensitive. the amount of fluid is correlated with the likelihood of stone passage. calcium stones usually demonstrate attenuation higher than 700 HU.

Manual for Student CSL UROGENITALIA SYSTEM LEARNING GUIDE FOR STUDENT SUPRAPUBIC ASPIRATION Given to 4th Semester Undergraduate’s Medical Faculty Of Hasanuddin University UROGENITAL SYSTEM MEDICAL FACULTY HASANUDDIN UNIVERSITY 2011 Even Semester 2010/2011 FK-UNHAS 64 .

· Give explanation to the patient or his/her family about the patient’s rights. and take it off after working. Preparing the instrument/materials correctly Give explanation to the patient or his/her family about what the doctor will do. SPESIFIC INTRUCTIONAL OBJECTIVE After Perform this skill practice. Use sterile hand glove correctly. Definition Suprapubic aspiration is the technique for taking urinary sample through the abdominal wall at the suprapbic area. For urinalysis or urine culture in neonate and child. that uncapable to collect the urine by midstream. 3. 4. and the guarantee from safety aspect and the secret of patients identity. what its advantages. that is one of the contraindication for inserting the urethral catheter. Perform suprapubic aspiration properly. how to perform it. 2. the students able to : 1. · · · Perform hand washing. For establish the diagnosis of urinary tract infection in children but the urine specimen from sterile catheter can’t be done or the urine sample from the cathteter already contaminated. · Preparing the patient properly.Manual for Student CSL UROGENITALIA SYSTEM SUPRAPUBIC ASPIRATION GENERAL INTRUCTIONAL OBJECTIVE The students able to perform suprapubic aspiration technique correctly and efficiently. 2. Phymosis 6. Urethral obstruction 5. The patient with widely urethral trauma. Urethritis dan paraurethritis Even Semester 2010/2011 FK-UNHAS 65 . the instruments that used. This method could be perform if you can’t collect the urine directly or by catheter. standard method and also asepsis method correctly. for example the patient’s right to refuse the method that the doctor will do without loosing his/her right to be serve. Indication 1.

2. Cover the area with sterile doek after disinfect the suprapubic and the surrounding area Procedure : The child lay down on supine position. Aspirate as much urine as you can.5 – 1 cm above the suprapubic. Caution : While doing the aspiration. stop insert the needle. bag collector urine to anticipate the Even Semester 2010/2011 FK-UNHAS 66 . Disinfect the supra pubic area and if it neccesary we can do local anaesthesia. Empty or unpalpable bladder. Put the urine in a sterile bottle. Make sure that the bladder in a full condition. Unknown bladder tumour REFERENCE Preparation : Clean the suprapubic area before aspiration. we can use spontanous micturation. Aspirate the bladder 3 cm depth with 23 G neddle and insert the needle in 10-20 degree angle. If the urine already in the syringe. Mark the puncture point at 0. after that pull out the needle and cover the insertion area with sterile gauze.Manual for Student CSL UROGENITALIA SYSTEM Contra Indication : 1. Scar cause by post operative in lower abdominal 3. Insert the needle gently and aspirate the urine.

Two Instructor. Minimally required 1 instructor to supervise each procedures that done by each pair of student. 12.Sterile doek with small hole . Give the opportunity for the students to ask and the The Students paired into groups contain 2 person. first act as the doctor and the other one as the patient. 13. Total waktu 150 menit Even Semester 2010/2011 FK-UNHAS 67 . Each pair practice do the procedures of suprapubic aspiration. 14.Brain storming/discussion about: Anything considered easy or difficult? How the feel of the student acting as a patient? What should done by the doctor to ensure the patient feel comfortable? 6. Brain Storming / Discussion 15 minute 5.5% chlorin .Antiseptic solution .23 G needle Local anaestesia with 1% lidocain Betadine Sterile operation clothes Washbasin contain 0. instructor will give an explanation about the important aspect. Introduction # 2. 11. They will give an example how to do the suprapubic aspiration .Sterile gauze + bandage Activity Description Activity # 1. # 3. The Instructor concludes and answers the last question and explains unclear statements. The istructure will supervise the student according to the learning guide.Sterile bottle .Question and answer session Time 2 minute 30 minute Description Introduction 9.Manual for Student CSL UROGENITALIA SYSTEM TOOLS AND MATERIALS PREPARATION - Sterile hand gloves 22 G. 10. Arrange the sitting position of the student. Role Play with feedback 100 minute 11. The students required to pay attention. The instructor give question and feedback to each pair of student. # 4.10 ml syringe .

STEPS / ACTIVITY MEDICAL CONSENT 1. Need Improvement : there are steps which is done incorrectly and/or not according to the order or steps which is undone. 3. 5. Ensure secrecy to the patient and the family Explain about the patient’s right or family that they have the right to refuse the suprapubic aspiration. Expert : steps are done correctly.Manual for Student CSL UROGENITALIA SYSTEM STUDY GUIDANCE SUPRAPUBIC ASPIRATION TECHNIQUE (used by Participant) Marks will be given for each step by using certain criteria which is: 1. Check all the equipments SELF PREPARATION Even Semester 2010/2011 FK-UNHAS 1 1 2 2 68 3 3 . Ask for the inform consent from the patients. Capable : Steps are done correctly and appropriate order but not efficiently. TOOL AND EQUIPMENT PREPARATION 7. according to the order and efficiently. Give general information to the client or family about the procedure and the benefits of suprapubic aspiration for the patient 3. equipment. Explain to the patient using understandable language to the client or family about: the type of needle that will be used the location of aspiration the technique of suprapubic aspiration Explain the risk that might happen. Approach the client or the family and introduce yourself while asking about his/her condition 2. 2. but assure the ASPIRATION TECHNIQUE CASES 1 2 3 patient that the risk is minimal because you are qualified to do the technique and you are using sterile 4. . Not appropriate : steps are unnecessary to be done because not appropriate with current circumstances. 6. STUDY GUIDANCE SUPRAPUBIC NO.

PTT. at the same time do the aspiration. 21. Mark the point area for aspiration. Do the decontamination by washing your hand (the handscoon still on) in a washbasin containing chloride 5% to clean your hands from blood or any secrete of the body. (if the position of the needle in the bladder. 24.. Inset the needle gently. 20. Put on the urine bag collector to anticipate the spontaneous micturation 16. Insert the needle 3 cm and the position of the needle 10-20 degree angle. AFTER FINISHING THE ASPIRATION 26. pull out the needle and press the insertion area with sterile gauze menekan tempat tusukan dengan kasa steril. If necessary use local anaesthesia on aspiration area with topical cream anaesthesia.Manual for Student CSL UROGENITALIA SYSTEM 8. 1 2 3 69 . the urine will come out in the syringe). When the needle reach the subcutaneous tissue.5 – 1 cm above the simpisis pubis 19. Put on the sterile handscoon on both hands 10. Put the urine in the sterile bottle for urine examination. Wash your hand 29. PT. 27. Do asepsis hand washing 9. Take off the handscoon and throw it in a medical trash can 28. 25. Wait for 5 minute so the patient can’t feel the pain. 15. stop the aspiration. Clean and disinfect the suprapubic area with betadine 17. 14. If the amount of the urine is enough. bleeding time) 12. Cover the suprapubic area with sterile doek SUPRAPUBIC ASPIRATION 18. Stand on the patients right side PREPARATION OF THE PATIENT 11. Before aspiration ask the patient to drink as much as he/she can. Ask the patient to lie down. Open the sterile doek. Use 23 G needle for aspiration. at midline 0. Make sure the bladder is full by percussion at suprapubic area or USG (if available). pull out the syringe plunger for making negative pressure in the syringe 22. Be farewell with patient Even Semester 2010/2011 FK-UNHAS 1 2 3 13. 1 2 3 23. If the urine already come out. It’s better to check routine blood before suprpubic aspiration (platelet count.

1. 4. Using sterile handscoon. 6. 13. Stand in right side of the patient Ask the patient to drink as much as possible Ask the patient to lay down Do the percussion on the suprapubic area Put on the urine bag collector Disinfect the suprapubic area Cover with sterile doek the suprapubic area Determine the point area for aspiration Suprapubic aspiration technique Put the urine in the sterile bottle Decontaminating the handschoon and open it Do the aseptic hand wash Jumlah Makassar. 12. 15. Washing hands correctly. 8. 16. 14. 2 3. Score : 0 it’s undone 1 it’s done but unsatisfied 2 it’s done correctly NO. EVALUATED ASPECT 0 Give inform consent Preparing the tools and equipment. 5. 11. VALUE 1 2 2010 SCORE = TOTAL X 100 % 32 Instructure coordinator ( ) Even Semester 2010/2011 FK-UNHAS 70 . 9.Manual for Student CSL UROGENITALIA SYSTEM CHECK LIST SUPRAPUBIC ASPIRATION TECHNIQUE Direction : Check ( ) into the suitable box. 7. 10.

Manual for Student CSL UROGENITALIA SYSTEM Even Semester 2010/2011 FK-UNHAS 71 .