SELAMAT PAGI

KEDARURATAN UROLOGI

Dr. H. Suharjendro, SpU

SMF Bedah Urologi
RSU Prov NTB, Mataram

DEFINISI
Kead.

kasus darurat urologi

Tidak mendapat
terapi yg cepat &

tepat

Morbiditas
Mortalitas
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Darurat

Urologi
Trauma

Non Trauma

 DARURAT

UROLOGI
TRAUMA : -

Ginjal

- Ureter
- Buli-Buli
- Urethra

NON TRAUMA :

Urosepsis
Hematuria
Kolik
Retensi Urin
Torsio Testis
Dll

- Genitalia
- Fraktur Penis

KEDARURATAN UROLOGI NON

TRAUMA

Dr. Suharjendro H.,SpU.

Divisi Urologi Bagian / SMF Ilmu Bedah
FK UNUD / RS Sanglah Denpasar

ACUTE OF UPPER URINARY

TRACT DISORDER
COMMON

CAUSE OF
URINARY TRACT
DISORDER :
Ureteral Or Renal Colic
Obstructions
Acute Pyelonephritis /
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ACUTE OF UPPER URINARY

TRACT DISORDER

URETERAL OR
RENAL COLIC
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ACUTE OF UPPER URINARY TRACT

DISORDER

The Nature, severity, and periodicity of pain

underlying cause

Colic : if there are pain free , intervals

that reflect intermittent smooth muscle
contractions

Colicy pain is usually promptly alleviated by

Analgetics

The Clinician familiar with Pathophysiology

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& Silient features of the common cause

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Ureteral Or Renal Colic

Renal Pain :
Etiology

: Capsular distension,
Inflammation or Distention of the Renal
Collecting System

Renal

pain : dull, aching area CVA; pain

or colic in the area of the flank;
radiation around the abdomen, into the
groin,
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ipsilateral testicle or labium

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Ureteral Or Renal Colic

Ureteral Pain :
Etiology

: The most common : Sudden

Obstruction and Ureteral distension;

Upper

Ureteral pain is similar that Renal

pain : dull, aching area CVA; pain or colic
in the area of the flank; radiation around
the abdomen, into the groin, ipsilateral
testicle or labium
Lower Ureteral pain , derived the lower
uereter suprapubic area, bladder, penis
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or the urethra

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Treatment
Analgesic

adequate

Pemeriksaan

Penunjang :

Lab : UL , RFT
2. Imaging : USG, BOF, CT Scan
1.

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OBSTRUKSI SALURAN KEMIH

BAGIAN ATAS
Batasan

:
Terhambatnya aliran urin secara
parsial/total dari proksimal ke
arah distal
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Klasifikasi :
Etiologi
Kelainan bawaan(UPJ stenosis,pimosis)
Kelainan dapatan(Batu,tumor sal.kemih)
Kejadian(duration)
Akut(kejadian < 1 minggu)
Kronis(kejadian > 1 minggu)
Derajat(degree)
Parsial
Total
Tingginya(level)
Sal.kemih atas(sistem pelvio-kaliksureter)
Sal.kemih Bawah(kand.kemih-uretra)
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PATOFISIOLOGI
Tek.hidrostatik

intraluminer meningkat :

Delatasi/penipisan dinding proks.obst.

Reflux

Hipertensi

Obst.akut unilateral(sistem angiotensin)

Obst.kronis bilateral(retensi

air,garam,azotemia)
Asites

urin :

Inhibisi urin(forniks ginjal-rongga.perit)

Rasio kreatinin
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Patofisiologi
Refleks

anuria :

Obstr.sesaat
Odema mukosa ureter(tind.medis)
Neurogenik

Kolik ureter(batu ureter)

GFR menurun + 20%(obst.unilat)

Produksi urin menurun +

28%Obst.unilat)
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Patofisiologi
Diuresis

pasca obst.:

Obstr.ureter bilat.
Obst.ureter pd.ginjal soliter
Self-limiting dan fisiologis

Air dan Na yg.berlebih dikeluarkan

Reabsorsi

Air dan Na Kurang

Solut diuresis(urea dan glukosa dlm.urin)

Tek.osmotik cairan dan bahan yg larut

dlm.urin> plasma
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Patofisiologi
Ginjal hipertropi :
Obst.ureter kronis unilat Ginjal kontralat

hip.
Klerens kreatinin meningkat(kontralat.obst.)

Reversibilitas

obst.

fungsi ginjal pasca releas

Berat kerusakan akibat obstr.

ISK (ada/tidak)
Drainase dg.ureter kat.pada obst.ureter akut
GFR mencapai normal dlm.2 jam
Hipertropi kontralat.obst.(-)

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DIAGNOSIS
Anamnesis

:
Hematuria makroskopis
Keluhan traktus GI(mual,muntah)
Panas badan/menggigil
Urin keruh

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DIAGNOSIS
Pem.fisis

:
Sal.kemih atas
Inspeksi : Benjolan masa
daerah
pinggang/perut(kurus
Palpasi
: Terapa ginjal
membesar,nyeri
Perkusi
: Nyeri Ketok +
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DIAGNOSIS
Pem.penunjang
Laboratorium

Anemia
ISK,GGK

Lekositosis
Infeksi akut

Eritrosituria/hematuria mikroskopis
Batu
Tumor
ISK

RFT(BUN,SC) meningkat
GGA / AKD
GGK / CKD
GGT
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DIAGNOSIS
Pem.penunjang
Radiologi :
BOF/BNO
IVP(nefrogram,ureterogram dan sistogram)

Ultrasonografi(USG)
CT.Scan
Renogram

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TERAPI
Terapi darurat :
Release obstruksi

Hidronefrosis Nefrostomi / Terapi Difinitif ( kondisi )

Antibiotika profilaksis/terapiutik
Diuresis pasca releas obstruksi
Normal beberapa jam s/d 4 hari
Terapi cairan(NaCl 0,9%/RL) 50-60% cairan
yg.keluar

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KOMPLIKASI
ISK
Batu

sal.kemih
Pyonephrosis
Gagal ginjal

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INFECTIONS
Pyelonephritis
Perinephric Abscess
Renal Abscess
Urosepsis

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Acute Pyelonephritis
General

Considerations :

Ascending type of infection (axcept :

presence : stasis, foreign bodies, trauma

etc.)
Pathogenic organism reach kidney from

bladder ; UVJ incompetent

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Acute Pyelonephritis
Clinical

Findings
A. Symptoms And Sign : chills, fever, flank pain

Frequency, urgency, dysuria

B. Laboratory Findings :

Pyuria, bacteriuria, Leucocytosis

C. Imaging Study :
USG ; BNO-IVP ; CT Scan
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Acute Pyelonephritis
Complications

Missed diagnosis in acute stage chronics

Both ( acute and chronics ) progressive renal

damage

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Acute Pyelonephritis
Treatment

1) Specific antibiotic : 4-5 days

2) Symptomatic treatment
3) Adequate fluid assure optimum urinary

output
4) Identify and treat predisposing factors (e.g.
Obsrtuctions )

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Perinephric Abscess

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Etiology & Pathogenesis

Rupture of intrarenal abscess
Organism = cause intrarenal :

Staphyllococci
o Gram negt : E. Coli, Klebsiella, Proteus,
Pseudomonas
o Gram postf, fungi, M. Tbc

Gerotas fascia perinephric space

retroperitoneum
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Clinical Findings
A.

Symptoms & Sign

a.
b.

c.
d.
e.

Symptomatic 2 3 weeks
Fever ; flank + CVA pain; tenderness (with or
without palpable mass)
Pleuretic chest pain
Scoliosis spasm of psoas muscle
Painfull flank bulge erytheme & edema

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Clinical Findings
B.

Laboratory Findings
a.
b.
c.

Blood test : leucocytosis

Urine : pyuria & proteinuria
( 30% : Urinalysis normal , 40% Urine culture
sterile, 40% positife blood culture)

Imaging
a.
b.
c.
d.

BOF + Thorax : BNO IVP :

US
CT Scan

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Treatment
Treatment
a.
b.
c.
d.
e.

Antimicrobial alone inadequate

combined with drainage
Recently : percutaneous drainage by US / CT control
Open incision & drainage abscess
Antimicrobial until results culture & senstivity

MORTALITY IS DIRECTLY ASSOCIATED WITH

DELAYED IN DIAGNOSIS & PROPER
THERAPHY
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Perinephric Abscess
Antimicrobial Choices
Trimethoprim/sulfamethoxazole

(TMP/SMX)

Fluoroquinolones

(ciprofloxacin, ofloxacin, levofloxacin, norfloxacin)

Aminoglycosides

(gentamicin, tobramycin, amikacin)

Third-generation cephalosporins

(ceftriaxone, cefotaxime, ceftazidime)

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UROSEPSIS
Batasan

Septiksemia
Invasi akut mikroorg.ke-dlm.sirkulasi
darah
Keadaan serius,progresif,lifetreatening
infection
Mungkin berasal dari infeksi lokal pada :
Trakt.resp/GI/UG/kulit

Urosepsis
Septisemia dg.mikroorg.berasal dari
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trakt.UG

ETIOLOGI
Obstruksi

sal.kemih atas/bawah
Manipulasi urologi
Pemasangan/pelepasan kateter

urethra
Tindakan endoskopi urologi
Pembedahan urologi

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Faktor resiko

Umur : > 65 th atau < 6 bln.

Diabetes
Uremia
Immunesuppression :
AIDS,Chemotherapy,organ
trasplant,concurren infection
Prolong antibiotica therapy
Instrumentasi
Endotrachealintubation,Vasc/Urinary catheter
Pebedahan
GI,UG,Obs/Gyn
Trauma
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DIAGNOSIS
Anamnesis

Panas/kedinginan

Pem.Fisis

Temp.>380C atau <360C, Nadi

>90x/mnt Resp.>20x/mnt.
Pem.Penunjang
WBC >12 juta atau <4 juta,

PaCO2<32
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CONSENSUS CONFERENCE CRITERIA DEFINING SEPS

State

Criteria

SIRS

Any or two of the following :

Temp. : >38 0 C or <360 C ; Heart rate :90x/mnt
Resp.rate: >20x/mntor PaCO2<32
WBC
: >12x106/mm3 0r <4x106/mm3 or > 10% band forms

Sepsis

SIRS plus clinical evidence of infection

Severe sepsis

Sepsis plus hypotension(SBP<90 mmHg or organ disfuction or

hypoperfution

Septic Shock

Sepsis plus hypotension despite adequate fluid resucitation

plus hypoperfution
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TERAPI
Resusitasi cairan :
RL/RD
Monitor T/N,prod.urin,JPVCVP
Antibiotika spektrum luas :
Ampicillin+Gentamicin atau
Sefalosporin G III atau
Quinolone/cyprofloxacin atau
Sesuai dg.biakan kuman dlm.urin
Mencari/menghilangkan sumber

infeksi
Nutrisi/oksigenasi/perbaiki perfusi jaringan
Hemodialisis
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Terapi
Mencari/menghilangkan
Drainase (Terapi darurat)

sumber infeksi

Obst.sal.kemih bawah : Sistostomi/kateter

peruretra
Obst.sal.kemih atas
: Nefrostomi
Abses/jar.nekrosis
: Insisi/nekrotomi

Terapi definitif

Menghilangkan obstruksi

Nutrisi/oksigenasi/perbaiki

jaringan
Hemodialisis

perfusi

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Terapi
Nutrisi/Oksigenasi/perbaiki

perfusi

jaringan
Nutrisio oral/sonde/enteral
Nutrisi parenteral parsial/total
Oksigen sungkup/respirator

Hemodialisis
Odem paru
Asidosis
Hiperkalemia
Gagal ginjal
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KOMPLIKASI

Syok

septik
Gagal fungsi organ

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