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CONTENT LISTTITLE No. 1. History taking & Physical Examination of Urogenital System Method of Taking the directly taken 2. 3. Specimen & Urethras Discharge Transport Method of Catheters Application in 4. Men & Women (Per urethra 5. 6. Catheterization Technique) 7. Method of Prostate Examination through Rectal Touch Method of Circumcision Method of Evaluating BNO-IVP photo Suprapubic AspirationEven Semester 2010/2011 FK-UNHAS
Learning Objectives General Aim : After participating in this activity, the students can perform complete history taking and physical examination such as rectal touch, catheterization, urethral discharge examination, imaging test orderly, and can differentiate normal and abnormal condition of the system. Spesific Aim : After participating in this activity, the student: 1. Can perform history taking to the patient completely. 2. Can prepare the patient for the physical examination. 3. Can perform rectal examination of the prostate correctly and efficiently. 4. Can perform catheterization procedures correctly. 5. Can do the procedures of taking and transport of urethral discharge correctly and efficiently. 6. Can perform an assessment of several result of radiological examination esp. in urogenital case. 7. Can perform the physical examination in the right procedures 8. Can recognize various the abnormality of the urogenital system. Media and Learning Instrument : - The list of learning guide about the history taking and physical examination of urology. - The mannequin for Rectal Touch and Catheterization (male/female), catheter, handscoen (sterile hand gloves). - Jelly, napkin, soap, and wastafel (flow water) for hand washing stimulation. - Patient status, pen. - Audio-visual.
Learning Methods : 1. Demonstration that suitable with the list of learning guide. 2. Lecture. 3. Discussion. 4. Active participation in skill lab. (Simulation). 5. Evaluation through check list with scoring system. Activity Description Activity1. Introduction 2. Question and Answer session
Time5 minutes 10 minutes Introduction
1. Arrange the sitting position of the student. 2. Two Instructors, first act as the doctor and the other one as the patient. They will give an example of how to perform complete history taking. The students required to pay attention. 3. Give the opportunity for the students to ask and the instructor will give an explanation about the important aspect. 4. The activity is followed by perform physical examination to the mannequin. 5. The student could attend and ask about anything that they not understand and the instructor should help the student.
100 minutes
1. Students is paired into groups contain 2 persons. An instructor needs to supervise 2 groups. 2. Every group plays the role, one becomes the doctor and the other becomes the patient. 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. 4. The instructor will supervise the students according to the learning guide 5. Each student should practice. (Minimal once).
UROGENITALIA SYSTEM 1. Brain storming/discussion about: Anything considered easy or difficult? How the student feels after acting as the patient or the doctor. What should be done by the doctor to ensure the patient feel comfortable? 2. The Instructor concludes and answers the last question and explains unclear statements.
Total of times
150 minutes
A. HISTORY TAKING No. 1. 2. 3. 4. 5. 6. 7. LANGKAH KLINIK Greetings, the doctor stands up and offer handshake. Asking the patient to sit opposite each other. Creating comfortable situation. Speaking clearly and using verbal, non verbal languages that easy to understand. Asking the identity of the patient: name, age, address, occupation. Mentioning patients name every asking question. Asking the main complaint: oligouria/ genital wound/ facial or abdominal swelling/ right abdominal pain and taking the history of present Illness. Ask : Onset and duration of the main complaint: since when? The morphology (shape), color and quantities of urine, associating stone, sands urine, haematuria, facial edema (since when?) Associating symptoms: nausea, hip pain, dysuria, 8. abdominal discomfort, right abdominal tenderness. Asking other complaints complaint. that associated with chief Kasus
9. 10.
Performing history taking that associated with the system. Enquire history of past illness which is connected: with oligouria/ genital wound/ abdominal and facial swelling/ right abdominal pain. Personal habit: eating jengkol-fruit/bowels, using nonEven Semester 2010/2011 FK-UNHAS
steroid drugs, antibiotic, anti inflammation, medicinal herbs consumer. Family history: disease that suffered and causing difficulty in passing urine. 11. History taking of previous therapy. 12. Cross-checking 13. Concluding the case from history taking to establish differential diagnosis.Even Semester 2010/2011 FK-UNHAS
Arranged by :dr. Baedah Madjid, Sp.MK dr. Firdaus Hamid dr. Nasrum Massi, Ph.D.
GENERAL INTRUCTIONAL OBJECTIVE The students will be able to take and transport urethral discharge correctly and efficiently. SPESIFIC INTRUCTIONAL OBJECTIVE After perform this skill practice, the students are able to: 1. Perform the preparation of the instrument/materials correctly. 2. Give explanation to the patient or his/her family about what the doctor will do, the instruments that are used, how to perform it, what are advantages, and the guarantee from safety aspect and the confidentiality of patients identity. 3. Give explanation to the patient or his/her family about the patients rights, for example the patients right to refuse the method that the doctor will do without loosing his/her right to be served. 4. Perform hand washing, standard method and also asepsis method correctly. 5. Use sterile hand gloves correctly, and take it off after working. 6. Perform the taking urethral discharge process correctly. 7. Perform the transport of the specimen process correctly and efficiently. PREPARING THE INSTRUMENT Flow water Liquid soap Antiseptic solution Napkin, towel or tissue Spiritus lamp/bunsen Sterile hand glove Basin filled with chlorine 0,5 % solution 5 ml of sterile physiologic NaCl in reaction tube. Sterile cotton sticks (3-4 sticks) Cotton with alcohol 70 % Slide glass - Stuart medium - Medical garbage - Non-medical garbage
INDICATION Patient suspected with urethritis or prostatitis. FORM Informed Consent The objective of taking the specimen (examination material): to investigate the causes of disease correctly, so that it can be determine the appropriate treatment. Procedures: all procedures must be performing in sterile environment and using sterile instrument. Workers hand should be washed aseptically and used sterile hand gloves. The instruments such as cotton sticks, physiologic NaCl must be sterile. Procedures The distal area of urethral have to be cleaned before taking the specimen, because that area is an unsterile area and usually contaminated with microbes, similar with the microbes found in glands penis area. The instrument (cotton sticks) cannot be disinfected with chemical method, because chemical residue could kill the microorganism, therefore it can lead to false negative result. Especially for Chlamydia trachomatis culturing, the cotton sticks must be pressed while rotated at urethral mucosa. Transportation Method After fixing, 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. Using this method of transportation is making the existing microbes remain alive without allowing them to reproduce. This specimen cannot be kept at the cold temperature (refrigerator) because cold temperature could kill the N. gonorrhea.
Time2 minutes 30 minutes Introduction
6. Arrange the sitting position of the student. 7. Two Instructors, give example of how to take and prepare specimen directly and transport of urethral discharge. The students attend the demonstration by using the learning guide. 8. Give the opportunity for the students to ask and the instructor will give an explanation about the important aspect.
6. Students is paired into groups contain 2 persons. An instructor needs to supervise 2 groups. 7. Every group plays the role, one becomes the doctor and the other becomes the patient. 8. The specific theme or the main complaint of the patient will be given by the instructor, and then will be asked by the doctor. 9. The instructor will supervise the students according to the learning guide 10. Each student should practice. (Minimal once).
15 minutes
3. Brain storming/discussion about: Anything considered easy or difficult? How the student feels after acting as the patient or the doctor. What should be done by the doctor to ensure the patient feel comfortable? 4. The Instructor concludes and answers the
last question and explains unclear statements. Total of times 150 minutes
LEARNING GUIDEMETHOD OF TAKING, 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. Need Improvement: the procedures are done incorrectly or done but didnt suitable with the arrangements, or there are unperformed procedures. 2. Able: the procedures are done correctly and suitable with the arrangement, but are not efficiently performed. 3. Skillful: the procedures are done correctly and suitable with the arrangement and efficiently performed. NS Not Suitable: The procedures need not to be performed because it is not suitable with the situation.
LEARNING GUIDE METHOD OF TAKING, PREPARING THE DIRECTLY SPECIMEN AND THE TRANSPORT OF URETHRAL DISCHARGENO. STEPS / ACTIVITIES PREPARING THE PATIENT 1. Greet the patient or his/her family nicely and introduce yourself, and ask the patient condition. Please the patient to sit. 2. Give general information to the patient or his/her family about the procedures of taking the specimen, the objectives and the advantages for the patients condition. 3. Give the guarantee to the patient or his/her family about the safety of the procedures. 4. Give the guarantee to the patient or his/her family about theFK-UNHAS Semester Akhir 2010/2011
confidentiality of the patients identity. 5. Explain to the patient or his/her family about their rights, for example about patients rights to refuse the procedures taking the urethral discharge without losing the right to be serve. 6. Ask the patient agreement to do the procedures of taking urethral discharge. PREPARING THE INSTRUMENT AND METERIALS 7. Put all the instrument and material that require in the reachable place. 8. Clean the slide glass with alcohol cotton and do the sterilization by running it through spiritus flame. 9. Write down the patient identity with permanent marker on the side glass (patients name & registration number). 10. Put the side glass on a table, horizontally. PREPARING OURSELVES TO TAKING THE SPECIMEN 11. Do the routinely hand washing. 12. Wearing the sterile hand gloves. 13. Stand in Right side of the patient. TAKING THE URETHRAL DISCHARGE 14. Ask the patient to take off his/her trousers/skirt which using to close the genital organ and ask the patient it lying horizontally. 15. If the patient hasnt been circumcised, pull the preputium towards to the end. 16. Using tweezers clean the penis glans area and using sterile gauze that pour with physiologic NaCl, and then throw the gauze into the medical waste bin. The tweezers that has been used, must be put into the basin filled with chlorine 0,5% solution. 17. 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. Throw this cotton stick to the medical garbage. 18. 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, and then while rotating, pull the cotton sticks slowly. 19. Wiped circularly this cotton stick at the middle space of slide glass surface that had been prepared. Then put it on the table until the specimen dry. 20. Throw the second cotton stick into medical garbage. 21. Insert the third cotton stick into the urethra until approximately 2-3 cm while rotating it toward clockwise. 22. Enter the cotton sticks into the transport medium until all of the cotton part completely soaks into the medium. Then break the stick by burning it using Bunsen fire. 23. Close the transport mediums tube tightly and seal it.FK-UNHAS Semester Akhir 2010/2011
Give the label that content patients identity in the transport mediums tube. 25. Fixated the swab specimen after it dry. AFTER FINISHING TAKING THE SPECIMEN 26. Put your hand which still using the hand gloves into a basin contain 0, 5% chlorine, rub both hand to wipe away urethral discharge that might attach on the hand glove. 27. Take off the gloves and throw it to the medical garbage. 28. Do the aseptic hand washing. TRANSPORT OF THE SPECIMEN 29. Write the reference letter of laboratory examination completely, content: a. Date of transport b. Date and time of specimen taking. c. Patients identity (name, age, sex, address, number medical record) d. Sender identity e. Type of specimen (urethra secretion) f. Laboratory examination that needed g. Media transport/ preservative use h. Clinical description 30. Write to the label of the transport medium: Patients identity Date of specimen taking 31. Put the transport medium tube to the other tube 32. Pack the swab specimen that had been fixated into the tissue, and enter it to the envelope with patients identity. 33. Bring the transport medium tube and swab specimen to laboratory in room temperature.FK-UNHAS Semester Akhir 2010/2011
Arranged by :Prof. dr. Achmad Makkarausu P., Sp.B (K-BU) dr. Irfan Idris
Edited by :dr. Baedah Madjid, Sp.MK dr. Muhammad Yunus Amran
Introduction Preparation: Clean the genital area before catheterization. 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. Then insert the catheter into the patient which was in lying position (lithotomic position for female). When the catheter reach the bladder (usually shown when the urine flows out the tube), the balloon is blown with spoit fill with sterile water 10-20 ml, to prevent the catheter to loose, then fix the urine bag at the end of the catheter and fix the catheter at the base of patient hip. Getting Off: Start with sucking out the water or air from the catheter balloon with 10-20 ml spoit, then pull out the catheter. Precautions: Be careful when you fill the catheters balloon with water or air before knowing the right position of the catheter ( whether its already in the bladder or not). The catheter ballon filling in urethrae can cause pain of urethrae rupture (bleeding). References 1. Aghababian R, May HL, Fleisher GR. Emergency Medicine, 2nd. LippincottRaven; 1992 2. Rosen P, Barkin R, danzi DF et al, Emergency Medicine : Concepts and Clinical Practise, 4th edition, Mosby-Year Book; 1997
THE STUFF liquid soap antiseptic flowing water clean towel or tissue medical dustbin non-medical dustbin instrument washbasin contain 0,5% 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 catheters 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
Time Briefing
1. Positioning the students 2. Two instructors will show how to do the catheterizations. Students will check and learn the stimulation. 3. Students are given a chance to ask and the instructors to explain about the important aspects.
3. Role Play
1. Students are divided into pairs. An instructor is needed to check every step done by each pair. 2. Each pair of students will practice doing every step of catheterization. 3. The instructor will observe and supervise using checklist. 4. The instructor will ask questions and feed back to each pair.
4. Discussion
15 minute
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. Instructor will do the summary after answering the last question and explain whatever issues that the student didnt understand. Total Time 150 minute22
MEDICAL CONSENT 1. 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. 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, but assure
the patient that the risk is minimal because you are qualified to do the technique and you are using sterile equipment.FK-UNHAS Semester Akhir 2010/2011
4. 5.
Ensure secrecy to the patient and the family Explain about the patients right or family that they have the right to refuse the catheterization. Ask for the inform consent from the patients. 1 2 3
SELF PREPARATION 8. 9. 10. Do asepsis hand washing Put on the sterile handscoon on both hands Stand on the patients right side
PREPARATION OF THE PATIENT 11. 12. Ask the patient to lie down with both extremities are straight. With the help of your partner, clean and disinfect the genital area with betadine. (Swap the betadine on the whole area of the penis, OUE and around mons pubis). 13. Cover the genital area with sterile doek until the only area that
needed expose for the catheterization area. CATHETHERIZATION 14. 15. 16. Swap xylocaine jelly on the catheter, then fill a syringe with xylocaine jelly and insert about 20cc into the urethrae. Wait for about 5 minutes, so that the patient wont feel any pain during the catheterization insertion. Hold the penis with your left hand where your thumb is at one side and your index and middle finger at the other side. (if the penis is slippery, you can hold it with a sterile gauze). 17. 18. Open the OUE with your thumb and index finger and pull the penis upward to stretch the urethrae. Clamp the tip of the urethrae using a pin set with your right hand, while the base of the catheter is hold using between theFK-UNHAS Semester Akhir 2010/2011
fourth and fifth finger (see picture). 19. Insert the catheter slowly into the urethra with the smallest pressure as possible until the urine flows out. 20. When using non-self retaining catheter, after the urine flows out, pull out the catheter slowly until the urine stop flowing, then insert the catheter back in until the urine flows again and fix the catheter on the penis with a plaster. 21. When using self retaining catheter, after the urine flows out, insert the catheter until the marked line. The urine is put in a proper place. Fill the catheters balloon with sterile water/NaCl 0,9%, for 5-20 cc depends on the balloon capacity, then pull put the catheter until it is stuck at the balloon. This is important to avoid filling the balloon while the tip of the catheter is still in 22. 23 24. 25. the urathrae which can cause rupture of the urethrae. 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. Fix the catheter on the cranial of the hip until the waist. Give antibiotic on the OUR and cover it with sterile gauze to 1 2 3
prevent infection and change it every 12 hours. AFTER THE PROCEDURE IS FINISHED 26. Do the decontamination by washing your hand (the handscoon still on) in a basin containing chloride 5% to clean your hands 27. 28. 29. from blood or any secrete of the body. Take off the handscoon and throw it in a medical dustbin. Wash your hand Bid farewell towards the patient.
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. 2. Capable : Steps are done correctly and appropriate order but not efficiently. 3. . Expert : steps are done correctly, according to the order and efficiently. Not appropriate : steps are unnecessary to be done because not appropriate with current circumstances.
MEDICAL CONSENT 1. Approach the client or the family and introduce yourself while asking about his/her condition 2. 3. 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, but assure
you are qualified to do the technique and you 4. 5. 6. are using sterile equipment. Ensure secrecy to the patient and the family Explain about the patients right or family that they have the right to refuse the catheterization. Ask for the inform consent from the patients. 1 2 3
PREPARATION OF THE PATIENT 11. Sterilize external genitalia with betadine. Swap betadine around OUE, vulva and mons veneris. 12. 13. 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. CATHETHERIZATION 14. The operator ( doctor ) stands on the right side of the patient, should be accompanied with a nurse if the operator is a male. 15. Hold the cathether between thumb and pointing-finger and insert it into the OUE. Push the cathether in until the urine comes out/flows out. If using non-self retaining cathether, 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 hipFK-UNHAS Semester Akhir 2010/2011
16. 17.
and button. 18. If using non-self retaining cathether, after urine flows out push the cathether in until near the branch of cathether. Urine that flowing out are put in the urine bag. Fill the cathether balloon with water/ NaCl 0,9% about 5-20cc depends on the balloon capacity, then pull the cathether out until it restrain on the balloon. This is important to prevent the filling of the balloon while cathether is still inside the 19. 20. 21. urethra because can cause rupture of the urethra. Take off the doek Place the cathether and connect it with a urine bag or a bottle filled with 50cc antiseptic. Fixation the cathether on the cranial part of hip and waist 1 2 3 (SIAS). AFTER THE PROCEDURE IS FINISHED 22. Put gloving-hands into a bowl filled with chlorine 0,5%, rub both hands to wash the dirt on the gloves. 23. Hold one of the handscoen on its fold and then pull it until the inside part of the handscoen is in the outside. 24. 25. 26. 27. 28. 29. 30. Do not open until the handscoen is full-open, let some part still on the hand before put off the other glove. Then hold the other handscoen on its fold then pull it until the inside part of the handscoen is in the outside. When both handscoen almost reach the tip of the fingers, put off both handscoen together. Take off handscoen and throw it to medical garbage bin. Wash hand with antiseptic. Dry your hands with napkin.cc Do the farewell to the patient.28
Arranged by :dr. Aidah Juliaty Baso dr. Irfan Idris
Edited dy :dr. Baedah Madjid, Sp.MK dr. Muhammad Yunus Amran
GENERAL INSTRUCTION TARGETS (GIT) The Student can be able to perform rectal toucher correctly, properly and efficient. SPECIFY INSTRUCTION TARGETS (SIT) After done this skill training, the student: 1. Can prepare the patient correctly. 2. Can prepare the tools and materials correctly 3. Can explain to the patient and him family bout examine prosedures, ttools, how to do, benefits and posible risk. 4. Can explain to the patient and him family about the secret action and patient rights, such as about will disable action can do for him. 5. Can wash hand and asepsis wash hand correctly 6. Can to wear the steril handschoen with properly and released after finishing. 7. Can inspects rectal toucher correctly. 8. Can inspects prostate gland correctly. INDICATION 1. Urine retention 2. Decrease urine flow, noctury, dribbling. 3. Inspects to evaluate gastrointestinalis tractus ( rectal toucher )
REFERENCES Preparation : ask the patient to pee, catheterisation can be applied if the patient can not do it. Arrange the patient position with lithotomy side, and then wear the handschoen and apply lubricant to the point finger side. Prosedure: Inspects the perineum with separating both gluteus maximal muscles with left hand. Evaluate the skin around perineum like inflamation, pylonidal cynus, anal fistle, rectal prolaps and hemorhoid. Insert point finger to anal orificium slowly and press gently to relaxating external anal sphincter. For the next, push the point finger until reach rectal ampulla and evaluating all part of rectal to trace for any sign of mass or compression, and then keep the ventral side of point finger facing anteriol wall of rectal. 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. If the point finger moving up, so that vesica seminalis can be reach in the every midline side when the normally condition could not touched. Feel the prostate surfaces (smooth or nodulsly), the consistency (elastic, hard, smooth), thats form, sizes (normals, grown up, atrophy), sensitivable from the pressure (normals or abnormals), mobility or ficsationed. After finishing, releasing finger and taking tissue for the patient to clean himself. In Benigna Prostate Hipertophy (BPH) ussualy has billaterally grown up, elastic like rubber and slippery surface on mucosa rectum. On carcinoma has touched bumps like stone and nodulsly and unillaterally grown up. In acute prostatytis the glands grown up and softly, inelastic and very sencitive from the pressure (pressure pain).
REFERENCES 1. Degown RL and Brown DD: DeGowins Diagnostic Examination 7th edition . McGraw-Hill, 2000
2. Swartz MH : Textbook of Physical Diagnosis, History and Examination, 5th edition, Elsevier, 2006. 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 0,5% in bowl Nonmedic bin Medic bin
GUIDE LEARNINGMETHOD OF PROSTATE EXAMINATION THROUGH RECTAL TOUCH (used by Participant) Valuates for every clinical steps using the criteria below: 1. Need improvement : the steps are incomplete and incorrectly. 2. Capable : the steps are done correctly and appropriate but inefficiently. 3. Expert : the steps are done correctly, procedurally and efficient. Inappropriate : unnecessary step because different conditions.
NO STEPS/ METHODS Medical Consent 1. Talk to the patient or him family friendly and pleased to sit. Introduce yourself and ask about current conditions 2 Give the general information to the patient and him family about prostate inspection, targets, benefits and risk for patients condition. 3. Make guaranty to the patient or him family about unexposed action and checked report. 4. Explain to the patient about patient rights and him family, such as about the right for unagree the rectal toucher inspections. 5. Get permission from the patient to rectal toucher inspects. Patient and tools/ materials Preparation 6. Check and arrange supporting tools 7. Ask the patient for pee. If could not do alone, doing catheterization. And then help him to be lithotomy position. Rectal toucher Preparation 8. Wash hands routine 9. Wear the DDT handschoen Rectal Toucher Inspection 10. The Patient is lithotomy position ( according inspection technique review the picture ) 11. Inspect perineum and anal area, trace for any sign ofFK-UNHAS Semester Akhir 2010/2011
hemourhoid or noduls, anal fistel (fisura ani) or surgical scars. 12. Apply jelly to the point finger that wears handschoen 13. Insert the point finger into anal, touch the anal spinchter slowly. Ask the patient to breath normally, being evaluate the tonus spinkter. Another hand on the suprapubic and press to vesica urinaria direction ( if the vesica urinaria was empty, so that both finger can feel touched. 14. Push the point finger into the anal and feel the ampulla and rectal wall, trace for any sign of tumor, hemorrhoid or urethral stone (pars prostates) 15. Place the point finger in 12clock direction, to grope prostates gland in lithotomic position. (prostate gland can grope in 12clock position) 16. Feel the mass and evaluate below: 1) Thats surface or rectal mucosa at prostate, 2) Deformation up: high pole can/ did not can touched and nodules into the rectum. 3) The consistency: rubbery, hardly, or softly 4) Symmetric or not 5) Bumping or not 6) Fissionable or not 7) Pain pressure or not 8) Crepitating or not 17. Release the finger with forming the fingertip, and check again there any blood, mucus and feces on handschoen. Release the handschoen 18. Clean the handschoen with flowing water, rub hand to clean bloods pock or other body dilution on handschoen . and then, open the handschoen bring into the chlorin 0,5% bowls, or into the medic bin. 19. Do aseptic Wash hand 20. Be farewell with patientFK-UNHAS Semester Akhir 2010/2011
Arranged by :Prof. dr. Achmad Makkarausu P., Sp.B (K-BU)
METHOD OF CIRCUMCISIONAIM Of COURSE General Aim : Students are able to carry out the techniques of circumcision that is correct, lege artis and efficient. Spesific Aim : After completion of the course, students are able to: 1. Prepare the patient 2. Ready the tools 3. Explain to the patient or his family of the process, the tools involve, how it will be done, the advantages and the risks 4. Wash hands correctly 5. Wear sterile gloves and then dispose them correctly 6. Place the patient in the correct position 7. Circumcise correctly
Tools 1. Sterile minor surgery set 2. Cat gut chronic 3/0 with the needle 3. Betadine + korentang 4. Procain/xylocain 1-2% 5. Sterile 5cc spoit 6. Sterile dock with a small hole 7. Sterile kasa 8. Sterile gloves 9. Plaster 10. Adrenalin & deladryl injection/cortizon 11. 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
MEDICAL CONSENT Introduce yourself to the patient and his family Inform them of the whole circumcision process, especially the reason, advantages and risks Ask for the patients 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. 3. 4. 5. 6.
The operator should be on the right side of the patient VARIOUS TECHNIQUES OF CIRCUMCISION DORSAL SLIT CIRCUMCISION Firstly, perform dorsumcision until 1cm from coronaries sulcus
A. 2 Make sure the area is free from smegma and the mucosa sticking to the penis gland is free A. 3 The mucosa and skin at the end of the dorsumcision is sewn together A. 4 The skin and mucosa are cut circularly to the ventral until the frenulum and mucosa remains 1cm in the coronaries sulcus A. 5 Control the bleeding. Mucosa and the skin are sewn one by one or continuously using cat gut 3/0 A. 6 Note the penis symmetry make sure it doesnt twist A. 7 Sofratule - verban B B.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.3 Pull the preputium towards the tip of the penis until the coronaries sulcus is exposed B.4 Incise 1-2cm around the mucosa of the corona glandis B.5 Excise the preputium from the subcutaneous tissue B.6 Control the bleeding B.7 Skin and mucosa are sewn one by one or continuously using cat gut 3/0 B.8 Sofratule - verban C GUILLOTINE TYPE CIRCUMCISION C.1 Clamp the mid part of the ventral and dorsal part of the preputiumFK-UNHAS Semester Akhir 2010/2011
and pull it back 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.3 Cut the preputium below the clamp with a scalpel. Use fingers by pressing the gleands to protect it C.4 Control the bleeding C.5 Leave only 1cm of mucosa at the corona glandis. C.6 Skin and mucosa are sewn one by one or continuously using cat gut 3/0 C.7 Sofratule 9. verban
CIRCUMCISION THEORYINTRODUCTION Circumcision means complete or partial removal of the penis preputium. INDICATION a. Religion b. Social c. Medical i. Fimosis is a condition which the preputium could not be pulled backwards (proximal). Sometimes the hole at the end of the preputium is only as big as a needle which makes it hard to urinate. Conditions which can cause fimosis are congenital, inflammation (balanopostitis). ii. Parafimosis is a condition where Tumor prevention, because Other preputium the preputium could not be pulled forward (distal). This usually causes the penis glans to be trapped by the inflamed preputium. iii. smegma is carcinogenic iv. disorders CONTRAINDICATION A. Absolute I. Hipospadia is a condition which the opening of the urethra (meatus urethrae external) is at the wrong place. The position is along the ventral of penis until the perineum. According to the location: a. Frenal, at the frenulum b. Penil, at the penis itself c. Penoscrotal, between the penis and scrotum d. Scrotal, at the scrotum e. Perineal, at the perineum II. Hemophilia Condiloma acuminate v.
III. Blood discrasia B. Relative I. Local infection on the penis and the surrounding II. General infection III. Diabetes mellitus ANATOMY A. B. C. D. E. F. 2 corpus cavernosum at the dorsal of the penis 1 corpus spongiosa, at the ventral Uretra pars spongiosa along the inside of corpus spongiosum Tunika albuginea wraps both corpus cavernosum Artery, vein and nervus dorsalis penis, under the fasia Buck Fasia Buck, wraps corpus cavernosum and corpus spongiosum and the internal structures
a. Vena dorsalis penis kutaneus. b. Vena dorsnlis penis. c. Kutis (integumentum commune). d. Nervus tbrsalts penis. e. Arteri tiorsalis penis. f. TunHcaalbugmeci. g. Arteri profunda penis, h. Korpus kavernasuiit. L Korpus spongiosum. j. Septum penis. k. Fnsai Buck. t. Verm-vena profunda pmi$. m. Uretra parsspongiosa. n. Arteri bulbus uretra.
a. Meat us uretra eltstemus. b. Korona glandis. c. Glaus penis. d. Prepusiam. l. Frenulum prepusii, f. Kutis (mtegumentum commune}. g. Rafepenis. h. Fasia penis ffssia Buck). Korpus kavernosum penis. Verm^vena profunda penis. k. Tttnika albugmea. I. Koryus spongiosum uretra. m. Rjrtnus superior Osispttbis. n. Muskulus iskkiokavemosus. o. Butbus uretra. p. Diafragrna uregenihtl.
POTONGAN SAGITAL PENIS DAW SEK1TARNYA. Perhalik'nn posisi hsin Buck {fasia penis).
PREPARATION A. Operator a. Operator wears clean clothes, surgical gowns if possible b. Wears cap and mask c. Use antiseptic such as Salvon and Hibiscrub to cleanse hands d. Put on sterile gloves e. Operator should be on the right side of the patient B. Patient a. Shave hair around the penis b. Clean the area around penis with soap c. For children, before the circumcision, calm the patient so that the everything goes on smoothly d. Check if the patient has any kind of allergies When everything is done, cleanse the area repeatedly by: i. Ether,to dispose of skin lipid properties ii. Non-irritative antiseptic such as betadine, pikrat acid 1-2%. Do not use Iodium because the skin around the penis is very sensitive iii. Ethanol 70% EQUIPMENT I. Circumcision equipment a. Needle holder b. Curve mosquito clamp c. Straight pean clamp d. Curved halstead clamp e. Straight kocher clamp f. Anatomical pinset g. Tissue pinset h. Straight major scissors or Busch scissor i. Thread scissor j. Blade no. 10 k. Knife holder no.3 l. Needle to sew the skin
II. Local anesthesia a. Procain i. Active time 15-30 minutes ii. Effective concentration 0.5-2% iii. Maximum dose 1000mg iv. Infiltration 0.25-0.5% v. For nerve block 1-2% b. Lidocain i. Active time 30-60 minutes ii. Effective concentration 0.5-5% iii. Maximum dose 500mg iv. Infiltration 0.5% v. Nerve block 1-2% III. Additional equipment a. Sterile cloth with hole in the middle b. 2 pairs of sterile rubber gloves c. Sterile kasa d. Antiseptic e. Plain cat gut no.2-0(00) or-0(000) ANESTHESIA a. General anesthesia i. Uncooperative children ii. Patients Agitated
and infiltration Of all the above, combination of nerve block and infiltration is most favored due to: i. ii. Relatively easy to perform
Cheaper This method can be done by combination of Dorsal penis nerve block
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 its 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. Inject whilst pulling out the needle. Inject anesthesia 0.5-2ml. usually doesnt 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. Whilst pulling out the needle, inject the anesthesia, inject to the left and right. This type of anesthesia is done usually if the patient still feels the pain. RELEASING PREPUTIUM To release the preputium can be done by i. it with clamp. It has to be done carefully as it can injure the glans penis. After releasing it, apply some antiseptic around that area (Lysol, betadine). Often smegma can be found after the release, use the mosquito clamp. ii. Releasing the preputium with kasa. This technique is safer because the probability of injuring the penis is smaller compared when using the clamps. However this technique is harder for the inexperienced. CIRCUMCISION TECHNIQUE Circumcision is usually done by 2 techniques: A. Dorsumcision a. Boundaries This technique is done by cutting the preputium at 12oclock, along the penis towards the proximal (dorsal slit) then cut to the left and right around the sulkus coronaries glands. 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
c. Disadvantages B. The technique is more difficult If inexperience, the incision is not smooth The duration is longer
Classic (Guillotine) a. Boundaries This is done by clamping the preputium horizontally along the penis length, then cutting it. The incision can be done at the proximal or distal of the clamp. b. 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. Pharmacology a. Antibiotics: broad spectrum such as tetrasyclin, ampicillin and amoxicillin b. Analgetics: non-arcotic analgesic such as antalgin, mefenamic acid (ponstan) and acetilsallicylic acid (aspirin) c. Anti-inflammatory: serapeptase (danzen), pankreatin + proctase, tripsin+kimotripsin (chymomed) d. Roborantia: B complex vitamin and high dose C vitamin to help the healing process e. Anti-tetanus: purified tetanus toxoid 0.5-1cc/IM
Complications & How to overcome a. Pain Give the patient analgetics before carrying out the operation. If the patient feels unbearable pain, the analgetics can be given via injection such as xylomidon b. Edema This usually happens on the second day onwards. If the bandage is too tight, loosen it a little. Explain to the patient and his family that edema often occurs and is not life-threatening c. Bleeding If the bandage is wet, change it as it can be a media for bacteria. If the patient is bleeding heavily, find the source of the bleeding, if need be, open the suture. If need be, give haemostatic medication such as karbazokrom (Adona) or tranexamic acid (transamine) d. Small haematom Not a problem as it will be reabsorped by the body e. Large haematom If it happens at the time of circumcision, it is better to remove the haematom as it can slow the healing process f. Infection Signs: Red penis, edema Pain and pus In severe conditions, patient will be feverish Give antibiotics
and treat the symptoms and compress the penis with betadine or rivanol. If the condition improves, apply suitable cream g. Peyronie disease Late complication that arises from infection. Due to tissue fibrosis of one of the corpus cavernosum. During erection, the penis will lean towards the painful side and the patient will feel extreme pain. The treatment are among others radiation, high dose of vitamin E, operation to remove the scar tissue but with unsatisfactory result C. Others
a. Food Advice the patient to eat food with high protein to speed the healing process b. Others Patient wears loose pants so as not to pressure the penis. It is best that on the first day after, the patient rest to prevent possible trauma and bleeding. Keep the penis dry until the wound heals and bandage removed.
Arranged by :dr. Sri Asriani, Sp.Rad.
Students are expected to be able to make assessment in a few radiological examinations in genitourinary system cases.
After this clinical practice, students are expected to be able to : 1. Read and evaluate BNO film 2. Read and evaluate IVP film
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
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
JOB DESCRIPTION times 2 minute 30 minute description Introduce 1. arrange Position sit students 2. An instructor gives examples of how to do an examinated and evaluation BNO-IVP photos. Student watch the demonstration and using the modules 3. Give change for students to ask questions and instructor to give explanation on the more important aspects. 1. Students are device into pairs to pairs. An instructor will evaluate 3 pairs. 2. Pairs will practice evaluate the roentgen photos one by are. 3. The instructor observes students and supervises using a checklist. 4. The instructor give specific feed back to each students. 1. What is felt to be easy? What was hard? 2. The instructor concludes the session by answering any last question and explaining unclear issue 52
100 minute
4. Discussion/ opinion
Total time
150 minute
NO. STEPS/ACTIVITY PREPARATION 1. Fasten the photo to the light box 2. Check the patients identity (name/age) on the photo 3. Check for markers (R/L, D/S) on the photo 4. Check the condition of the photo: Include T12- symphisis or pubis Check for faecal mass ( in connection with patient preparation) READING AND EVALUATING BNO PHOTOS 5 Do identification the contour of kidney, psoas line, and bones 6. Do identification by for radioopage structure along the urinary tractus. 7. Write down the result from identification READING AND EVALUATING IVP PHOTOS 8. Evaluate shape, size and position of kidneys 9. Evaluate the excretion and secretion function of both kidneys 10 Evaluate the pelviocalyceal system of both kidneys ( are there signs of obstruction or not) 11 Evaluate shape, and size of ureter and are the signs of obstruction 12. Evaluate the Vesica Urinary 13. Report the result of your inventionEven Semester 2010/2011 FK-UNHAS
NEPHROLITHIASISBackground: Passage of a urinary stone is the most common cause of acute ureteral obstruction and affects as many as 12% of the population. The pain may be some of the most severe pain that humans experience, and complications of stone disease may result in severe infection; renal failure; or, in rare cases, death. Pathophysiology: In patients with stone disease, more than 1 of 3 general mechanisms is likely to be active. These include the following: (1) the possible presence or abundance of substances that promote crystal and stone formation; (2) a possible relative lack of substances to inhibit crystal formation; and (3) a possible excessive excretion or concentration of salts in the urine, which leads to supersaturation of the crystallizing salt. The greater the degree of supersaturation, the greater the rate of growth of the calculi. Stasis or anatomic factors can also contribute to the development of stone disease. These include ureteropelvic junction (UPJ) obstruction, horseshoe or ectopic kidney, autosomal dominant polycystic kidney disease, and vesicoureteral reflux. Calyceal diverticula, the result of anomalous budding of the calyceal system, is also associated with stone disease. In 10-40% of calyceal diverticula, stones are present. These range from a few large calculi to many tiny seed calculi and to the microscopic milk of calcium. Medullary sponge kidney is another common anatomic cause of renal calculi. The pathologic process in medullary sponge kidney is renal tubular ectasia. Calculi form in approximately 50% of patients. The calcifications form in the medulla but frequently pass into the collecting system. They are usually bilateral and diffuse, but they may also be unilateral or segmental. On intravenous urography (IVU), pyramidal clusters of calculi within the dilated tubules classically become obscured or appear enlarged after contrast material surrounds them in the dilated tubules. Calcium stones account for 75-85% of urinary stones. Approximately one half of calcium stones are composed of a mixture of calcium oxalate and calcium phosphate. They demonstrate intermediate fragility to extracorporeal shock wave lithotripsy (ESWL). Approximately three eighths of calcium stones are formed of only calcium oxalate dihydrate. These may be spiculated, dotted, mulberry, or jackstone in appearance. Usually, these stones are fragile in response to ESWL. The remaining one eighth of stones are composed of calcium phosphate (apatite) or calcium monohydrate. These stones are the densest and, consequently, the least responsive to ESWL. Calcium stones have numerous causes. Approximately 85% of calcium stones are idiopathic, or primary. Idiopathic hypercalciuria occurs in more than one half of patients with calcium oxalate stones. Most causes of hypercalciuria are absorptive. Increased absorption in individuals after a normal diet causes an elevation of serum calcium levels and a suppressionEven Semester 2010/2011 FK-UNHAS
of parathyroid function as an abnormal response to vitamin D. Approximately 10% of cases of primary hypercalciuria are renal in origin. The inability of the kidney to conserve calcium results in low serum calcium concentrations, which stimulate parathormone secretion. The remaining 15% of calcium stones are secondary to some discernible etiology. Most commonly, they result from hyperparathyroidism, which is found in 5-10% of patients with stones. In this situation, hypercalcemia and increased absorption lead to hypercalciuria. Patients with the stones are treated with surgical removal of the parathyroid adenoma or hyperplasia. Calcium stones can also occur in approximately 15% of patients with sarcoidosis in whom the production of activated vitamin D by macrophages is abnormal. Renal tubular acidosis (RTA) is an additional fairly common secondary cause of calcium stones. In type I (distal) RTA, kidneys have a decreased ability to lower urine pH levels, which may be primary or secondary to a variety of renal injuries. The injured distal tubule loses the ability to maintain the hydrogen-ion gradient. This, in turn, causes alkaline urine, hypercalciuria, and hyperphosphaturia. Nephrocalcinosis or urolithiasis is seen in as many as 70% of patients with type I RTA. Conversely, type II (proximal) RTA is associated with increased bicarbonate loss, which helps keep stones from forming. Type IV RTA commonly is seen in medical renal disease and does not predispose patients to stone formation. Immobilization of an individual causes rapid mobilization of the calcium in bones, and this is an important mechanism in patients with spinal cord injury, who may develop stones within weeks to months of immobilization. Hyperoxaluria is another, less common, secondary cause of calcium stone formation and most often results from inflammatory bowel disease, bowel surgery, vitamin C overdose, or renal failure. Primary hyperoxaluria is a rare autosomal recessive disease. Other secondary causes include milk-alkali syndrome, use of steroids, Cushing syndrome, hypervitaminosis D, paraneoplastic phenomenon, and multiple myeloma. Magnesium ammonium phosphate (struvite) stones account for approximately 10-20% of urinary stones. These stones are lucent but complex with calcium phosphate. On occasion, they enlarge and branch (staghorn). Although they fragment easily, patients with these stones usually are treated with percutaneous fragmentation and extraction because of the large size of the stones and, usually, the presence of infection. Struvite stones are caused by urea-splitting bacteria such as Proteus, Klebsiella, and Pseudomonas species. However, as many as one half of patients have an underlying metabolic cause for stone disease; therefore, metabolic evaluation is indicated. Combined obstruction and infection frequently cause renal destruction and, potentially, renal failure if both kidneys are affected. Uric acid stones account for 5-10% of urinary stones. These small smooth
stones usually appear radiolucent on conventional radiographs but opaque on CT scans. Predisposing factors include acidic concentrated urine, excess urinary uric acid, small-bowel disease or resection, gout, and cell lysis (eg, resulting from treatment of leukemia or from starvation). Treatment and prevention for these stones is alkalinization and dilution of the urine. Cystine stones account for only approximately 1% of urinary stones. These ground-glass stones, which result from cystinuria (a rare autosomal recessive metabolic disorder), are homogeneous; less opaque; and less fragile than other stones, especially if they are smooth. Several other less common forms of urolithiasis may produce stones that appear relatively lucent, even on CT scans. Inspissation of indinavir, an antiretroviral protease inhibitor used to treat HIV infection, may cause stones that appear lucent on CT scans. Matrix stones formed from inspissated mucoproteins in patients with a chronic Proteus infection may demonstrate soft tissue attenuation on CT scans. Stones can also be caused by metabolic byproducts and drugs (eg, sulfa drugs, salicylates, triamterene ephedrine). Frequency: In the US: Renal calculi occur in 5-12% of the American population, and they are bilateral in 10-15% of patients. 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, possibly because of diets lower in protein.
Mortality/Morbidity: Passage of a renal stone is the most common cause of acute ureteral obstruction. When this occurs, pressure in the collecting system and renal blood flow acutely increase, followed by decreased blood flow after 1-2 hours. Hematuria usually occurs. This can be intermittent or persistent and microscopic or gross. However, as many as 10% of patients with acute stones may not have hematuria. Acute ureteral obstruction by stone causes severe, colicky (intermittent) flank pain that can radiate throughout the groin, testicles, back, or periumbilical region. Some patients with renal calculi may have no symptoms at all. Stones smaller than 4 mm pass spontaneously in approximately 80% of patients. Stones that are 4-6 mm pass in approximately 50% of patients, whereas stones larger than 8 mm pass in only approximately 20% of patients. Occasionally, recurrent infection may result in pyelonephritis or
abscess. Stones can cause renal scarring, damage, or even renal failure if they are bilateral. In 10% of patients, stones recur within 1 year. This percentage increases to 50% within 10 years. Race: Urinary stones occur more often in white populations than in black populations. They are also more prevalent in highly developed countries, possibly as a result of a higher protein diet. Sex: Males are at a greater risk than females, with a male-to-female ratio of 3:1 (except for struvite stones and in black populations). Age: Stones are uncommon but not unknown in children. The peak age for development is in persons aged 40-60 years. Clinical Details: Acute ureteral obstruction by stone causes severe colicky (intermittent) flank pain that can radiate throughout the groin, testicles, back, and periumbilical region. Some patients with renal calculi may have no symptoms at all. Hematuria usually occurs. It can be intermittent or persistent and microscopic or gross. However, as many as 10% of patients with acute stones may not have hematuria. Occasionally, recurrent infection may result in pyelonephritis or abscess. Stones can result in renal scarring, damage, and renal failure. Preferred Examination: The goals of imaging are to determine the presence of stones within the urinary tract, evaluate for complications, estimate the likelihood of stone passage, confirm stone passage, assess the stone burden, and evaluate disease activity. When acute flank pain suggests the passage of a urinary stone, many methods of examination can be used. Often, conventional radiography is initially used to screen for stones, bowel abnormalities, or free intraabdominal air. Radiographs can also be used to monitor the passage of visible stones. IVU (excretory urography) provides important physiologic information regarding the degree of obstruction. Ultrasonography (US) is useful in young or pregnant patients and in patients allergic to iodinated contrast material. US is also helpful in problem solving. All of these methods have become less useful with the advent of more sensitive and specific nonenhanced CT scanning. When CT is available, it is now considered the examination of choice for the detection and localization of urinary stones. Almost all studies conducted to date show that IVU provides no additional clinically important information after nonenhanced CT is performed. As a result of the higher radiation dose of CT, conventional or digital radiography should be used to monitor the
passage of stones if radiographic follow-up studies are indicated and if the stone is visible on conventional radiographs. Limitations of Techniques: Because of the higher radiation dose with CT, 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. Pregnant or pediatric patients may be imaged with US first to avoid radiation exposure. The rare falsenegative finding is usually due to reader error or a protease-inhibitor CTlucent stone. False-positive results are usually due to phleboliths adjacent to the ureter. In some cases, intravenous contrast material may be needed to opacify the ureter. US has limited sensitivity for smaller stones, and does not depict the ureters well. It should be used mainly in patients who are young, those who are pregnant, or those undergoing multiple examinations (eg, patients with spine injury). IVU is the traditional examination for the assessment of urinary stone disease, and it does provide physiologic information related to the degree of obstruction. The radiation dose is generally smaller than that of CT, but it is of the same order of magnitude. Intravenous contrast is required, with resultant risks of an allergic reaction or nephrotoxicity. IVU is less sensitive than CT, especially for small or nonobstructing stones.
Section 3 of 11
Appendicitis Cholecystitis, Acute Cholelithiasis Colon, Diverticulitis Crohn Disease Duodenum, Ulcers Epididymitis Gastric Ulcer Gout Meckel Diverticulum Midgut Volvulus Nephrocalcinosis Obstructive Uropathy, Acute Ovarian Torsion Ovarian Vein Thrombosis Pancreatitis, Acute Pancreatitis, Chronic Papillary Necrosis Pelvic Inflammatory Disease/Tubo-ovarian Abscess Renal Cell Carcinoma Renal Vein Thrombosis
Retroperitoneal Fibrosis Testicular Torsion Transitional Cell Carcinoma Tuberculosis, Genitourinary Tract Ureterocele Ureteropelvic Junction Obstruction, 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
Findings: Conventional radiography Conventional radiography is often performed as a preliminary examination in patients with abdominal pain possibly resulting from urinary calculi. These images should be obtained before contrast material is administered to prevent obscuring calcifications within the collecting system or calyceal diverticula. Conventional radiographs should include the entire urinary tract, and, often, 2 images are required. Stones are often found at key points of narrowing such as the UPJ, the ureterovesical junction (UVJ), and the point at which the ureter
crossing the iliac vessels. An addition site is on the right side where the ureter passes through the root of the mesentery. Calcium stones as small as 1-2 mm can be seen. Cystine stones as small as 3-4 mm may be depicted, but uric acid stones are usually not seen unless they have become calcified. An erect or posterior oblique radiograph obtained on the side of the calcification may help in distinguishing urinary stones from extraurinary calcifications. This view can also depict calcifications that are projected over the sacrum or transverse processes on the frontal view. Preinjection renal tomography may depict additional stones, and it can be used to confirm the relationship of stones to the kidneys. Because stones are more visible with a lower peak kilovoltage (kVp), maintaining a maximum of 60-80 kVp is best, if possible. Larger patients may require a higher peak kilovoltage for acceptable exposure and scatter. In this situation, compression of the abdomen and collimation is critical. 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. Typically, phleboliths are round or oval, and they may demonstrate a central lucency. However, they are often difficult to distinguish from ureteral calculi. Phleboliths in the pelvis are usually located lower than and lateral to the ureter, but they overlap with the ureter. Because gonadal veins parallel the upper ureters, contrast enhancement may be needed to opacify the ureter and demonstrate the extraurinary location of phleboliths in the gonadal veins.
Intravenous urography IVU is useful for confirming the exact location of a stone within the urinary tract. IVU depicts anatomic abnormalities such as dilated calyces, calyceal diverticula, duplication, UPJ obstruction, retrocaval ureter, and others that may predispose patients to stone formation or alter therapy. Because contrast agents can obscure stones in the collecting system, scouting the entire urinary tract prior to their administration is critical. When an acute urinary stone is the primary consideration, compression may not be used to increase sensitivity for detection of low-grade obstruction. A caveat is that the contralateral kidney may have an abnormality that requires ureteric compression for adequate examination. In rare cases, the use of compression has been associated with forniceal rupture. When a stone causes acute obstruction, an obstructive nephrogram may be present. This may be prolonged and hyperopaque, with increasing opacity over time. The nephrogram of acute obstruction is usually homogeneous,
but may also be striated or occasionally not visible on radiographs. Other signs include delayed excretion, dilatation to the point of obstruction, or blunting of the calyceal fornices. Immediately after the passage of a stone, residual mild obstruction or edema can be detected at the UVJ. Delayed images may be needed to opacify to the point of the obstruction, but using gravity to position the more opaque and more distal contrast materialladen-urine is also possible by placing the patient in a prone or erect position. Extravasation of urine at the fornices may result in pyelosinus or pyelolymphatic extravasation, which is often first indicated by blurring of the calyceal fornices. Greater extravasation may outline the collecting system, and the contrast may dissect into the perinephric space; however, if the urine is not infected, this is usually clinically insignificant. Degree of Confidence: Although 90% of urinary calculi are opaque on abdominal radiographs, the sensitivity for the prospective identification of individual stones is only 50-60%, and the specificity is only approximately 70%. Approximately 10% of stones are radiolucent on conventional radiographs. False Positives/Negatives: Occasionally, false-positive findings result from extrarenal calcification, but these are usually correctly identified with IVU. Lucent stones appear as filling defects on IVU, but they are not distinguished from nonstone-filling defects such as transitional cell carcinomas or blood clots. US and CT are effective tools in making this distinction; however, much of the ureter cannot be visualized with US.
Findings: With a sensitivity of 94-97% and a specificity of 96-100%, helical CT is the most sensitive radiologic examination for the detection, localization, and characterization of urinary calcifications; therefore, helical CT is considerably more effective than IVU. Helical CT scans frequently depict nonobstructing stones that are missed on IVU. CT is faster and no contrast agent is needed in most patients. CT easily differentiates between non-opaque stones and blood clots or tumors (compared with IVU, which may depict only a filling defect). In addition, helical CT is better than US or IVU in detecting other causes of abdominal pain. In fact, in most studies, IVU added little or no information. Rarely, pure matrix stones may demonstrate soft-tissue opacity on CT scans, and indinavir stones appear lucent. However, all other stones appear opaque
on CT scans. Technique Because stones in the collecting system may be obscured by contrast material, nonenhanced CT is usually performed. Helical CT is important to avoid missing stones because of section misregistration. A 5-mm helical technique with a pitch of 1.5:1 or less is preferred, although some radiologists choose to use a pitch of as much as 2:1. The kidneys and, if possible, the entire abdomen should be scanned during a single breath hold to prevent section misregistration. Because patients with stones are often young and because stone disease may recur, minimizing the radiation dose is critical. A fairly high level of noise as a result of the inherently high contrast levels is tolerable in most patients. Reported radiation doses for CT are 2.8-4.5 mSv compared with 1.3-1.5 mSv for a 3-image IVU. However, the uterine dose is approximately 0.006 Gy for 4image IVU compared with 0.0046 Gy for nonenhanced CT. At the authors' institution, approximately 12% (10-20%) of patients who undergo nonenhanced CT for possible urinary stones receive intravenous contrast material for further evaluation. To discern between phleboliths and urinary stones, 50 mL of low-osmolar contrast agent should be administered. After 3-5 minutes, a 5-mm helical scan is obtained through the area of concern. Fewer contrast-enhanced studies are needed with increasing experience. Soft tissue around the rim of a calculus can differentiate it from a phlebolith. A phlebolith may have a comet tail of soft tissue extending from it; this finding differentiates it from a calculus. On CT scans, phleboliths do not have radiolucent centers, as often seen on plain radiographs. When contrast-enhanced scans are required to evaluate pain not related to stones, routine abdominal and/or pelvic CT should be performed. In this situation, 100-150 mL of a low-osmolar oral and rectal contrast agent is used, and a 5-mm helical CT scan is obtained with a pitch of 1.5:1. Patient selection determines the number of examinations needed. Stones at the UVJ may be difficult to distinguish from stones that have already passed into the bladder. If the distinction changes therapy, a repeat scan through the UVJ in the prone position may be helpful. Stones that have already passed into the bladder will drop into a dependent location. CT findings CT may depict the following: Stones in the ureter Enlarged kidneys Hydronephrosis (83% sensitive, 94% specific) Perinephric fluid (82% sensitive, 93% specific)
Ureteral dilatation (90% sensitive, 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, and as with the obstruction, the amount of fluid is correlated with the likelihood of stone passage. Normal hyperattenuating renal pyramids sometimes are seen. These indicate that significant obstruction is not present. However, this finding has been seen with proven ureteral calculi and is often absent in patients without stones. For this reason, the usefulness of IVU is limited. If contrast material is administered, a delayed or hyperattenuating nephrogram may also be visible on CT scans if the ureter has an obstruction. Conventional radiography may be helpful in visualizing larger stones, once they are identified on CT scans, to provide a baseline to follow passage of the stone. If kidney, ureter, and bladder radiographs fail to depict the stone, CT may be needed to follow its passage. Approximately 40-55% of stones are not visible on abdominal radiographs. Almost no stones with attenuation values of less than 200 HU are visible, and repeat CT scans are usually required if passage of the stone is to be followed. Cystine and urate stones have an attenuation of 100-500 HU; calcium stones usually demonstrate attenuation higher than 700 HU. Considerable overlap exists in the CT attenuation values of calcium stones. Degree of Confidence: Individual CT signs are associated with varying degrees of confidence, as noted in CT findings above. False Positives/Negatives: False-positive results are almost exclusively the result of a phlebolith adjacent to the ureter. False-negative results are primarily due to indinavir radiolucent stones and error. CT scans often suggest an alternative or additional
SUPRAPUBIC ASPIRATIONGENERAL INTRUCTIONAL OBJECTIVE The students able to perform suprapubic aspiration technique correctly and efficiently.
SPESIFIC INTRUCTIONAL OBJECTIVE After Perform this skill practice, the students able to : 1. 2.
Preparing the patient properly. Preparing the instrument/materials correctly Give explanation to the patient or his/her family about what the doctor will do, the instruments that used, how to perform it, what its advantages, and the guarantee from safety aspect and the secret of patients identity.
Give explanation to the patient or his/her family about the patients rights, for example the patients right to refuse the method that the doctor will do without loosing his/her right to be serve.
Perform hand washing, standard method and also asepsis method correctly. Use sterile hand glove correctly, and take it off after working. Perform suprapubic aspiration properly.
Definition Suprapubic aspiration is the technique for taking urinary sample through the abdominal wall at the suprapbic area. This method could be perform if you cant collect the urine directly or by catheter. Indication 1. For establish the diagnosis of urinary tract infection in children but the urine specimen from sterile catheter cant be done or the urine sample from the cathteter already contaminated. 2. The patient with widely urethral trauma, that is one of the contraindication for inserting the urethral catheter. 3. For urinalysis or urine culture in neonate and child, that uncapable to collect the urine by midstream. 4. Urethral obstruction 5. Phymosis 6. Urethritis dan paraurethritisEven Semester 2010/2011 FK-UNHAS
Contra Indication : 1. Empty or unpalpable bladder. 2. Scar cause by post operative in lower abdominal 3. Unknown bladder tumour
REFERENCE Preparation : Clean the suprapubic area before aspiration. Cover the area with sterile doek after disinfect the suprapubic and the surrounding area Procedure : The child lay down on supine position. Mark the puncture point at 0,5 1 cm above the suprapubic. Make sure that the bladder in a full condition. Disinfect the supra pubic area and if it neccesary we can do local anaesthesia. Aspirate the bladder 3 cm depth with 23 G neddle and insert the needle in 10-20 degree angle. Insert the needle gently and aspirate the urine. If the urine already in the syringe, stop insert the needle. Aspirate as much urine as you can, after that pull out the needle and cover the insertion area with sterile gauze. Put the urine in a sterile bottle. Caution : While doing the aspiration, we can use spontanous micturation. bag collector urine to anticipate the
Sterile hand gloves 22 G- 23 G needle Local anaestesia with 1% lidocain Betadine Sterile operation clothes Washbasin contain 0,5% chlorin
- Sterile doek with small hole - 10 ml syringe - Antiseptic solution - Sterile bottle - Sterile gauze + bandage
Activity DescriptionActivity # 1. Introduction # 2.Question and answer session
Description Introduction9. Arrange the sitting position of the student. 10. Two Instructor, first act as the doctor and the other one as the patient. They will give an example how to do the suprapubic aspiration . The students required to pay attention. 11. Give the opportunity for the students to ask and the The Students paired into groups contain 2 person. instructor will give an explanation about the important aspect.
Minimally required 1 instructor to supervise each procedures that done by each pair of student. 12. Each pair practice do the procedures of suprapubic
the learning guide. 14. The instructor give question and feedback to each pair of student. # 4. Brain Storming / Discussion
Total waktu
150 menit
STUDY GUIDANCESUPRAPUBIC ASPIRATION TECHNIQUE(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. 2. Capable : Steps are done correctly and appropriate order but not efficiently. 3. . Expert : steps are done correctly, according to the order and efficiently. Not appropriate : steps are unnecessary to be done because not appropriate with current circumstances.
patient that the risk is minimal because you are qualified to do the technique and you are using sterile 4. 5. equipment. Ensure secrecy to the patient and the family Explain about the patients right or family that they have the
right to refuse the suprapubic aspiration. 6. Ask for the inform consent from the patients. TOOL AND EQUIPMENT PREPARATION 7. Check all the equipments SELF PREPARATIONEven Semester 2010/2011 FK-UNHAS
1 1
2 2 68
3 3
8. Do asepsis hand washing 9. Put on the sterile handscoon on both hands 10. Stand on the patients right side PREPARATION OF THE PATIENT 11. Its better to check routine blood before suprpubic aspiration (platelet count, PT, PTT, bleeding time) 12. Before aspiration ask the patient to drink as much as he/she can. Ask the patient to lie down. Make sure the bladder is full by percussion at suprapubic area or USG (if available). 15. Put on the urine bag collector to anticipate the spontaneous micturation 16. Clean and disinfect the suprapubic area with betadine 17. Cover the suprapubic area with sterile doek SUPRAPUBIC ASPIRATION 18. Mark the point area for aspiration, at midline 0,5 1 cm above the simpisis pubis 19.. If necessary use local anaesthesia on aspiration area with topical cream anaesthesia. Wait for 5 minute so the patient cant feel the pain. 20. Use 23 G needle for aspiration. Insert the needle 3 cm and the position of the needle 10-20 degree angle. 21. When the needle reach the subcutaneous tissue, pull out the syringe plunger for making negative pressure in the syringe 22. Inset the needle gently, at the same time do the aspiration. (if the position of the needle in the bladder, the urine will come out in the syringe). If the urine already come out, stop the aspiration. If the amount of the urine is enough, pull out the needle and press the insertion area with sterile gauze menekan tempat tusukan dengan kasa steril. 24. Open the sterile doek. 25. Put the urine in the sterile bottle for urine examination. AFTER FINISHING THE ASPIRATION 26. 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. 27. Take off the handscoon and throw it in a medical trash can 28. Wash your hand 29. Be farewell with patientEven Semester 2010/2011 FK-UNHAS
13. 14.
EVALUATED ASPECT0 Give inform consent Preparing the tools and equipment. Washing hands correctly. Using sterile handscoon. 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,
Instructure coordinator


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