EMERGENCIES IN UROLOGY

PRESENTING SYMPTOMS OF UROLOGICAL

EMERGENCIES
1. Flank Pain
Causes :
a. Pain on either side
- Urological causes : ureteric stones, renal stones, renal or ureteric
tumours, renal infection (pyelonephritis, perinephric abcess,
pyonephrosis), pelvic ureteric junction obstruction.
- Medical Causes : Myocardial infarction, pneumonia, rib fracture,
malaria, pulmonary embolus
- Gynecological and obstetric disease : twisted ovarian cyst, ectopic
pregnancy, salpingitis
- Other non urological causes : pancreatitis, diverticulitis, inflammatory
bowel disease, peptic ulcer disease, gastritis
b. Right-side flank pain :
Billiary colic, cholecystitis, hepatitis, appendicitis
Flank pain urological origin occurs as aconsequences of the renal
capsule by inflammatory or neoplastic disease (pain of constant
intensity) or as a consequence of obstruction to the kidney (pain of
fluctuating intensity)
2. Haematuria
Alarming symptom may cause patient to present to the Emergency Department
a. Microscopic Haematuria : >3 red blood cells/ hpf
b. Macroscopic/ Gross Haematuria : may be seen with the naked eye
Causes :
a. Nephrological ( Medical) : glomerular and non glomerular
- Glomerular hematuria dysmorphic erythrocyte, red blood cell cast, proteinuria (+)
- Non Glomerular : circular erythrocyte, erythrocyte cast (-), proteinuria (-)
b. Surgical / Urological : renal tumours, urothelial tumours ( bladder, ureteric, renal,
collecting system, prostate cancer, bleeding from vascular BPE, trauma, renal or ureteric
stones, UTI
characterized by circular erythrocytes, proteinuria (-), cast (-)
Haematuria :
a. Painless
b. Painfull
c. Occur at the beginning of the urinary stream urethral or
prostatic pathology
d. Occur at the end of the urinary stream prostatic urethra, bladder
neck pathology
e. Occur at the throughout the stream renal or bladder pathology
3. Oliguria, Anuria and Inability to pass Urine
a. Anuria complete absence of urine production usually indicates
Urinary Tract Obstruction.
b. Oliguria scanty urine production urine production < 400 ml/
day in adults and < 1 mg/ kg body weight/ hour in children
Causa : pre renal, renal, post renal
4. Suprapubic Pain
Causa : overdistention of the bladder, inflammatory, infective and
neoplasma of the bladder.
Emergency condition : Urinary retention
5. Scrotal Pain and Swelling
Scrotal Pain :
- Pathology within scrotum itself : torsion of the testicles or its appendages, epididymo-orchitis
- Referred from disease elsewhere : referred pain from ureteric colic

6. Priapism
A painful persistent prolonged erection not related to sexual stimulation
Categories :
a. Low flow priapism most common, essentially due to haematological disease, malignant infiltration of
the corpora cavernosa with malignant disease, or drugs. Painful because ischemia of the erectile tissue
b. High flow priapism due to : perineal trauma, which creates an arteriovenous fistula. Painless
Diagnosis : obvious from the history and examination of the erect, tender penis ( in low flow priapism).
Characteristically the corpora cavernosa are rigis and the glans is flaccid. Examine the abdomen evidence of
malignancy, DRE to examine the prostate and anal tone
7. Back pain and Urological Symptoms
Occasionally patients with urological disease present with associated back pain.
2 broad categories of disease that may present with back pain and urological symptoms :
- Neurological conditions
- Malignancy of urological or non urological origin

8. Neurological Disease
Presentation : both back pain and disturbed lower urinary tract, disturbed bowel and disturbed
sexual function.
e.g : spinal cord and cauda equine tumors, HNP.
Back pain is the most common early presenting symptom gradual in onset and progress slowly.
Associated symptom : pins and needles in the hands or feet, weakness in the arm or legs, urinary
symptoms : hesitancy, poor urinary flow, constipation, loss of erection, loss of sensation of orgasm
or absent ejaculation, urinary retention.
9. Malignant Disease
Malignant tumours metastasize to the vertebral column
compress the spinal cord or nerve roots comprise the cauda equine.
The pain of the vertebral metastases may be localized to the area of the
involved vertebra but may also involve adjacent spinal nerve roots,
causing radicular pain
LOWER URINARY TRACT
EMERGENCIES
1. Acute Urinary Retention
Painful inability to void, with relief of pain following drainage of the bladder by catheterization.
Initial urine volume :
- < 500 ml should lead one to question the diagnosis
- 500 800 ml typical
- > 800 ml acute on chronic retention
Pathophysiology :
- Increased urethral resistance : BOO
- Low bladder pressure : impaired bladder contractility
- Interruption of sensory or motor innervation of the bladder
a. Causes in Men
- BPE due to BPH leading to BOO
- Malignant enlargement of the prostate
- Urethral stricture
- Prostatic abcess
It could be spontaneous or precipitated by an event.
- Precipitated retention : anaesthetics and other drugs ( anticholinergics, sympathomimetic agents e.g :
ephedrine), non prostatic abdominal or perineal surgery, immobility following surgical procedures, e.g : Total
Hip Replacement.
- Spontaneous retention : recur after TWOC require definitive treatment, e.g : TURP
Pediatric
Sistitis/post operative
Overdistension
Congenital Obstruction
( post uretral valve/urethral polip /
hydrometrocolpos )
Acquired Obstruction ( Blood
clot/post surgical obstruction )
Neurogenic bladder
Trauma/abses ( app-perianal )
Tumour ( sarcoma btoryoides )
hipermagnesia
Female
Cystitis/post operative
Extrinsic Compression
( constipation/ovarial cyst/
gynaecological tumour/ uterine
prolaps/ hymen
imperforata+hematocolpos/ skenes
gland abcess )
Intrinsic Obstruction ( meatal
stenosis/ urethral carcinoma/
urethral diverticula/ caruncula/
Fowlers syndrome )
Neurogenic ( DM/ spinal
compression )
Psikogenic-histeria
Risk Factors for Postoperative Retention
Precipitated by : instrumentation of the lower urinary tract, surgery to the perineum or anorectum,
gynaecological surgery, bladder overdistention, reduced sensation of bladder fullness, preexisting prostatic
obstruction, epidural anaesthesia

Initial Management :
Urethral catheterization if failed : suprapubic catheterization.
Record the volume drained :
- < 800 ml acute retention
- > 800 ml acute on chronic retention
When the patient have a high retention volume (> 1000 cc) :
- Serum creatinine
- Renal USG : hydronephrosis
Anticipate that a post obstructive diuresis is going occur
TRAUMATIC UROLOGICAL
EMERGENCIES
1. RENAL INJURIES
The kidneys retroperitoneal structures surrounded by perirenal fat,
posteriorly are situated the vertebral column, associated spinal muscles
and the lower ribs, and anteriorly the content of the abdomen relatively
protecyed from traumatic injuries.
1-5% of all trauma cases.
Kidneys most common injured genitourinary organ
Male : female = 3 : 1
Mechanisms and Cause
Mode of Injury :
- Blunt injuries : as a result of direct blow to the kidney or rapid acceleration
or rapid deceleration (or combination of two or all three)
- Penetrating injuries : stab or gunshoot
 Classification System
The American Association for the Surgery of Trauma (AAST)
GRADE DESCRIPTION OF INJURY
1 Contusion or non-expanding subcapsular haematom
No laceration

2 Non expanding perirenal haematom

Critical laceration < 1 cm deep without extravasation
3 Critical laceration > 1 cm without urinary extravasation
4 Laceration : through corticomedullary junction into collecting system
Or
Vascular, segmental renal artery or vein injury with contracted
haematoma, or partial vessel laceration, or vessel thrombosis

5 Laceration : Shattered Kidney

Or
Vascular, renal pedicle or avulsin
 Diagnostic Evaluation :
a. Patient History and Physical Examination

b. Laboratory Findings
Suspect a renal injury and arrange renal imaging in trauma cases with :
Macroscopic haematuria
Penetrating chest, flank, abdominal wounds (knives, bullet)
Microscopic hematuria (>5 RBCs/hpf) or a dipstick haematuria in
ahypotensive patient ( systolic BP < 90 mmHg recorded at any time
since the injury)
Haematuria is not always present in cases of renal injury, nor does the
degree of haematuria correlate with the degree of renal injury.
In renal vascular injuries or ureter or pelvireteric junction avulsion
haematuria (-)
c. Imaging :
- Contrast-enhanced CT Scan gold standard
- IVU has been replaced by CT-scan
- One shoot IVU
- Renal USG in evaluation of renal injuries.
Renal US establish the presence of two kidneys, retroperitoneal
hematoms, and with Doppler can identify the presence of the blood
flow in the renal vessel, but cannot accurately identify parenchymal
tears, collecting system injuries or extravasation of urine until a later
stage
Intravenous Urography for Renal Imaging
If the patient should be transferred immediately to the operating
theatre without having a CT scan and retroperitoneal hematoma is
found, a single-shot IVU taken 10 minutes after contrast
administration (2 ml/kg of contrast). If the patient is hypotensive,
take the image at between 20 and 30 minutes.
Very useful in determining the presence of a normally functioning
contralateral kidney.
Management :
- Conservative
- Surgical
 Blunt Renal Injuries Management ` guidelineEAU2010

Blunt Abdominal Unstable

Stable Haemodinamic Trauma Hemodinamic
c/ Renal Injuries

Gross Microscopic Cito Laparotomy +

Haematuria Hematuria one-shot IVU

Rapid deceleration Observation

injury / major Normal IVU
associated injury

Gr. 1 - 2 Retroperitoneal
Stable
Renal Imaging Haematom
Gr. 5
Gr. 3 - 4 Pulsatile/Expanding

Associated
Observation :
injuries Renal Exploration
bed rest, serial
requiring Abnormal IVU
Ht, Antibiotic
laparotomy
 Penetrating Renal Injuries guidelineEAU2010

Penetrating
Stable Hemodinamic Unstabe Hemodinami
Abdominal Trauma
c/ Renal injuries

Renal Imaging Cito Laparotomy +

one-shot IVU

Gr. 3 - 4 Gr. 1 - 2 Observation

Normal IVU

Retroperitoneal
Stable
Observation : Haematom
bed rest,
serial Ht, Gr. 5
Antibiotic Pulsatile/Expanding

Associated
injuries
requiring Renal Exploration
Abnormal IVU
laparotomy
Follow Up
2. URETERAL TRAUMA
Relatively rare
1-2.5% of urinary tract trauma
Iatrogenic trauma commonest cause
It is seen in open, laparascopic or endoscopic surgery and often
missed intraoperatively.
 Clinical Diagnosis
- External ureteral trauma : accompanies by severe abdominal
and pelvic injuries.
- Penetrating trauma associated with vascular and intestinal
injury
- Blunt trauma damage to the pelvic bones and lumbosacral
spine injury.
- Haematuria poor indicator
- Sign of delayed diagnosis : flank pain, urinary incontinence,
vagina or drain leakage, haematuria, fever, uraemia, urinoma
 Radiological Diagnosis
- Extravasation of contrast medium in CT scan hallmark sign
- Hyrdronephrosis, ascites, urinoma, or mild ureteral dilatation often
the only sign.
- If CT scan is not available retrograde or antegrade urography is the
gold standard
- IVU especially one shoot IVU unrealiable diagnosis, negative
results up to 60% of patients
 Management
3. BLADDER TRAUMA
 Diagnostic Evaluation
Haematuria : Cardinal Sign
 Signs of External Intraperitoneal Bladder Trauma : extravasation of urine,
visible laceration, clear fluid in the surgical field, appearance of the bladder
catheter, blood and/or gas in the urine bag during laparaoscopy.
Signs of Internal Intraperitoneal Bladder trauma : cystoscopic identification
: fatty tissue, dark space between detrusor-muscle fibres, or the
visualization of bowel. Sign of major perforation : inability to distend the
bladder, low return of irrigation fluid, abdominal distention
IBT not recognized during surgery haematuria, abdominal pain,
abdominal distension, ileus, peritonitis, sepsis, urine leakage from the
wound, decreased urine output, increased serum creatinine
Symptoms of an intravesil foreign body : dysuria, recurrent UTI, frequency,
urgency, hematuria, perineal/ pelvic pain
 Supplement Evaluation
- Cystography : plain and CT cystography
- Cystoscopy
- Excretory phase of CT or IVU
- Ultrasound
Ruptur Buli

Management of urolgical emergencies

Cp.7 : Lower Urinary tract trauma- Kiaran J OMalley and anthony R Mundy
Cp.15.6 Bladder Trauma N.L.Turkeri
Emergencies in Urology Hohenfellner

kartiko.ppds1uro-jan2009
 Statistik
10% of all trauma patients
manifest genitourinary
involvement (Schneider 1993)
among abdominal injuries that
require surgical repair, 2% involve
the bladder (Carlin and Resnick
1995)
Penyebab
Trauma
- Tumpul ( 67 86 % )
- Tusuk / Crush Injury ( 14 33 % )
Ruptur Spontan
Iatrogenik
- SC ( insisi MLSU : Pfanennstiel = 7 : 1 )
- Laparoskopi : 2 10 x konvensional
Klasifikasi Ruptur Buli
Intraperitoneal ( 34 % )
Extraperitoneal ( 58 % )
Combined ( 8 % )
Cedera terkait
85 % terkait dg trauma tumpul
( 15 % dg trauma tusuk )
89 % terkait dg fr. Pelvis (
sebaliknya hanya 5 10 % Fr
pelvis berakibat ruptur buli )
10 20 % bersama adanya ruptur
uretra ( sebaliknya 15 30 %
trauma uretra post terdapat
ruptur buli )
Mekanisme
Extraperitoneal : hampir pasti terkait adanya Fr. Pelvis
daya tarik akibat pergerakan fraktur ( shearing force ) shg pelvic ring
kehilangan efek proteksi buli robek pd titik insersi ligamentnya
Lacerasi akibat robekan fragmen fraktur ( < 40 % )
Bursting type
Intraperitoneal direct blow
Bursting type : sudden increase in pressure in a full bladder ruptur
Dome : dinding paling tipis saat buli penuh ( susunan serat otot yg lebar )
Laserasi oleh fragmen pd high fracture of pelvic ring ( 25 % )
Anak
Insiden ruptur intraperitoneal lebih tinggi
Sebab anatomi buli letak abdominal baru akan mencapai letak
pelvis pd saat pubertas
Klinis
Gross Hematuria ( 86 95 % )
Microscopis 25 200 eri/lbp
20 /lbp 25 % missed
Suprapubic Tenderness ( 62 % )
Jejas / nyeri suprapubik
Distensi abdomen
Gangguan Miksi / Tdk bisa Miksi
Extravasasi urin ke perineum,
scrotum / dinding depan
abdomen
Durante laparoskopi
Banayak cairan jernih di lap.
Operasi
Gas pd urin bag
Imejing
Sistografi ( immediately unless
life-threatening )
Akurasi 85 100%
Standar 5 film pd retrogard-
sistografi
Pelvis AP plain
Pelvis AP + 100cc kontras
Pelvis AP / Lat + 400cc
Pelvis AP post miksi
Pd anak
Instilasi kontras 60cc +
30cc/tahun s/d max 400cc
Manajemen
Extraperitoneal
Trauma tunggal : pasang kateter uretra 10 14 hari sistografi
ulang kateter aff / prolong
Dg Trauma uretra : sistostomi sistografi antegard / BUS
Open jika dinding buli terjepit fragmen fraktur atau ada fragment
fraktur intrabuli atau ada cedera pd bladder neck, prostat atau
rektum
Ada Laparotomi : sekaligus pro eksplorasi repair buli
Buka dome : Repair ruptur dari intravesica dg chromic 3.0 kontinu
Debridement buli secukupnya : Hematome pelvis jgn dimanipulasi
Evaluasi : bladder neck, ureter distal, prostat, rectum, vagina
Jika ada cedera pd organ diatas harus langsung direpair cegah mjd fistula,
abses pelvis, BNS, inkontinen
Pasang kateter No. 18 -22 selama 10 -14 hari k/p + pasang sistostomi
( preventif re-open jika kateter uretra tdk adekuat )
Manajemen
Intraperitoneal + Trauma Tusuk
Pro Open Eksplorasi + Repair Buli cito
Midline insisi : memudahkan evaluasi pd organ intra abdomen
Buka buli dg melebarkan insisi dari laserasi
Evaluasi : bladder neck, ureter distal, prostat, rectum, vagina
Pastikan urin keluar dari ke-2 ureter jet
Jika ada cedera pd organ diatas harus langsung direpair cegah mjd fistula,
abses pelvis, BNS, inkontinen
Jahit laserasi 2 lapis scr kontinu dg chromic 3.0 / serosa dg Dexon 3.0
Pasang kateter No. 22 selama 10 -14 hari k/p + pasang sistostomi (
preventif re-open jika kateter uretra tdk adekuat )
 Rupture Uretra
Management of urolgical emergencies
Cp.7 : Lower Urinary tract trauma- Kiaran J OMalley and anthony R Mundy
Emergencies in Urology Hohenfellner
Cp. 15.9 : Urethral Trauma L Martinez-Pinieiro
EAU Guideline 2010 ed

kartiko.ppds1uro-jan2009
Ruptur Uretra Posterior

Terkait dg Fr. Pelvis

3.5%19% pd pria dan 0%6% pd wanita
10 20 % pd pria tjd bersama ruptur buli
17 39 % intraperitoneal dan 56 78 % retro
Cedera prostatomembranesa
25 % streching, 25 % partial dan 50 % ruptur total
Biomekanika :
Severe shearing forces necessary to fracture the pelvis are
transmitted to the prostatomembranous junction,
resulting in disruption of the prostate from its connection
to the anterior urethra at the prostatic apex
. ruptur uretra post

Urethral Injuries in Children

straddle pelvic fractures, Malgaignes fractures, or the
association of straddle plus sacroiliac joint fracture are
more common in children than in adults
Robekan sering pd uretra pars prostatika, karena scr
alamiah prostat anak belum berkembang. Robekan sering
total ( 69% vs 42% )
Urethral Injuries in Women
Biasanya ruptur partial pd dinding anterior
Fr. Pelvis
Stable
a mechanically stable pelvis is defined as one that can
withstand normal physiological forces without abnormal
deformation ( Tile and Pennal 1980 )
Fr. Ramus pubis ( straddle fracture)
Biomekanika :
Benturan pd Os Pubis : Fr. rami pubis : butterfly fragment
mendorong prostat ke arah posterior, dimana seharusnya fixed dg
pubis uretral disruption
.. fr. pelvis
Unstable
Fraktur melibatkan pubic ring sisi anterior + sacroilliaca
joint, os illium atau sacrum
Biomekanika : robekan langsung oleh fragmen tulang atau
yg lebih sering akibat adanya distorsi pd tulang pelvis
Anteroposterior compression / Vertical shearing / Fr. Malgaigne :
Fr. Rami pubis bilateral + disruption posterior ( sacrum/sacroilliac
joint/illium )
Lateral shearing : lig puboprostatikum dan uretra membranesa
terdorong pd arah yg berlawanan
Ruptur Uretra
Anterior
Diagnosis
Blood at the meatus
37%93% pd pasien dg cedera uretra posterior
Setidaknya 75 % pd cedera uretra anterior
Blood at the vaginal introitus
more than 80% of female patients with pelvic fractures
Hematuria
Although nonspecific, hematuria on a first voided specimen
may indicate urethral injury
Pain on urination or inability to void
. diagnosis
Hematoma or swelling
Extravasasi urin/darah pd batang penis fascia Buck utuh
Butterfly pattern fascia Buck robek, extravasasi dibatasi
oleh fascia Colles ( extended superior s/d f.coracoclavicula
dan inferior s/d f. lata )
High Riding Prostat
Tidak mjd parameter penting krn sulit ditemukan pd fase
akut sebab adanya hematom akibat Fr. pelvis
Rectal examination is more important as a tool to screen for
rectal injuries, which can be associated with pelvic fractures
Imejing
Retrograde urethrography merupakan Golden
Standar utk evaluasi cedera pd uretra
12/14-F di fossa navicularis dg balon 12ml 2030ml
kontras di injeksikan : film diambil dg posisi oblique 30
BUS : setelah 1 mg pro PER atau 3 bulan jika delay
repair
Jika uretra proksimal tdk dpt dinilai pd BUS
sistoskopi ( rigid + fleksibel ) melalui sistostomi
Saat sheat ada di daerah defek kmd dilakukan pengambilan
foto
Manajemen > Trauma / Iatrogenik > Blunt / Open>
Male / Female > Ant / Posterior

Anterior Urethral Injuries : Blunt Injuries

Sistostomi 4 mg BUS : PER / aff / Delay Repair
Early Uretroplasty TIDAK indikasi : e.c tdp kontusi spongiosa
shg sulit utk evaluasi batas debridemant
Komplikasi awal ruptur : striktur dan infeksi Sequele
infeksi : fistel, divertikel atau Forniers
Delay Repair ( 3 6 bln )
Striktur < 1 cm : Sachse
Striktur > 1 cm : E to E
Striktur panjang : Garft-Flap uretroplasti ( jika E to E akan
terbentuk chorde )
 Open Injuries : Male Urethral Injuries
Stab wounds, gunshot wounds, and dog bites to the
urethra often involve the penis and testes, necessitating
immediate exploration
Defek 1 cm : Degloving sub corona jahit primer E to E
scr water-tight+tension-free repair dg Vicryl 6.0 +
overclosure c.spongiosa
Defek > 1 cm : marsupialisasi + sistostomi delay

Female Urethral Injuries

Sering bersamaan ruptur buli : eksplorasi bladder neck +
uretra proksimal defek jahit primer
Uretra distal di-repair trans vagina
Manajemen Cedera Uretra Iatrogenik
Curiga Ruptur Uretra
e.c kateterisasi

False Route uretroskopi

Pre-existing Stenosis

Uretroskopi +
Guide wire Striktur Sistostomi

No Striktur
Pendek Tipis Panjang Tebal

Follow Up

Sachse Uretroplasti
Manajemen Cedera Uretra pd Wanita
Hematuria / Darah pd
Introitus Vagina

Curiga Ruptur Uretra

Cedera pd Bladder Tidak ada lesi

Uretroskopi
Neck / uretra

Evaluasi Upper tract

Tdk stabil Stabil

sistostomi Uretra
Proksimal / Retropubik repair
Bladder neck
Delay repair
Trans-vagina
Uretra Distal
repair
Posterior Urethral Injuries

20 60 % pasien cedera uretra posterior akan

mengalami disfungsi ereksi
Faktor terkait : usia, panjang defek dan tipe fraktur
Fr. Rami pubis bilateral mrp penyebab tersering cedera
neurogenik : kerusakan pd nervus cavernosus bilateral
( dibelakang simpisis pubis pd uretra rostatomembranasea )
Spontaneous return of potency may occur up to 2 years after
injury / improved sexual function after 18 months in 21% of
patients
 ruptur uretra post

Partial Urethral Rupture

Sistostomi 2 4 mg BUS : aff / Delay
Complete Urethral Rupture
Primary Open Realignment
pro eksplorasi cito jika ada cedera bladder neck / ruptur uretra /
cedera pd rectum
realignment uretra dg kateter sbg stenting
Primary Endoscopic Realignment
syarat : bisa posisi litotomi + dikerjakan dalam 2 mg pertama
pasca trauma
 Kegawatan Genitalia
Eksterna
Penile Trauma : Mumtaz F, Management of Urological Emergencies
Scrotal Emergencies, Sullivan E.M, Management of Urological Emergencies
Scrotal Emergencies, V Master. Emergencies in Urology-Hohenfellner
Injuries of External Genitalia, Morey A.f, Rozanski T.A, Campbell-Walsh 9th ed
EAU guideline 2010 ed

kartiko.ppds1uro-jan2009
Cedera / kegawatan Penis
Tumpul ( 80 % )
Fraktur Penis
Tajam / Penetrating
Amputasi
Human / animal Bites
Missil / Zipper injuries
Iskemia
Priapismus
Protese / Injeksi
Diabetik / HD kronik
Injury Severity Scale for the Penis
EAU guide line 2010 ed

1. Kontusio / laserasi kulit

2. Laserasi fascia Bucks tanpa tissue loss
3. Avulsi kulit / laserasi hingga gland-meatus-
cavernosa atau adanya defek pd uretra < 2 cm
4. Defek pd cavernosa / uretra > 2 cm atau partial
penectomy
5. Total penectomy
Fraktur Penis :
ruptur corpus cavernosa akibat robeknya tunika albuginea
Biomekanika :
occurs during vigorous sexual intercourse rigid penis slips
out of the vagina and strikes the perineum or pubic bone
Patofisiologi
Ereksi : tekanan intracavernosa > 1500 mmHg
Tunika albuginea menipis dari 2 mm 0.25 mm
Tunika yg tipis beresiko tjd Fr. penis
Robekan Tunika, pd umumnya :
Transversal : 1 2 cm
di sisi ventral / lateral ( biasanya unilateral )
Distal ligamentum Suspensorium penis
 . Fraktur penis
Klinis :
Cracking / Popping Sound + Nyeri + Rapid Detumescence
Bengkak + deformitas + ekimosis ( aubergine sign )
Rolling sign : clot at fracture site a firm, mobile, discrete,
tender swelling over which the penile skin can be rolled
Hematom : shaft penis butterfly ( tgt f. bucks )
Penunjang : jarang dilakukan ( Dx Klinis cukup )
Cavernosografi : invasif + resiko infeksi
USG : >> false negatif
MRI : akurat tp mahal, perlu waktu
Uretrografi : 3 20 % fr. Penis dg cedera uretra
( 10 -22 % : Hohenfellner )
 . Fraktur penis
Manajemen :
should be promptly explored and surgically repaired
( previously : konservatif dg splint penis / bebat )
Insisi scr : - Degloving ( best access )
- Direct longitudinal incision
- Midline high scrotal raphe
Identifikasi lokasi : Pasang kateter atau injeksi saline intra
corpora ( evaluasi kebocoran )
Hindari ligasi vascular intra corpora / debridement berlebihan
Jahit terputus dg benang absorbable 2.0 / 3.0
Ruptur uretra jahit scr tension-free ( baca cedera uretra )
k/p sirkumsisi ( cegah komplikasi edem post ops )
k/p anti androgen utk cegah ereksi ( not routine )
Abstinensia 1 bulan
 . Fraktur penis
Komplikasi :
Fibrosis pd daerah fraktur Peyronies
Konservatif > explorasi
Penile curvature ( 10 % )
Abses / Timbul plaque ( 25 30 % )
LOS perawatan panjang
Disfungsi ereksi
Waktu antara trauma s/d operasi : di-operasi dlm 8 jam sejak
cedera mpy outcome lebih baik ( dp yg delay s/d 36 jam )
Luka Tembakan ( Gunshot wound ) :
77 80 % terkait cedera lain ( cedera organ abd-pelvis )
15 50 % tdp cedera uretra Dx dg Uretrografi
Klinis suspek : high velocity missile, meatal bleeding, tampak
luka dekat uretra, gangguan miksi atau dg injeksi metilen
blue intra operasi
Repair uretra scr primer uretroplasti
Prinsip terapi : eksplorasi cito
Irigasi + angkat benda asing
Antibiotik propilaksis
Jahit tutup luka
Luka Gigit ( animal / human bites ) :
Animal Bites ( mostly : dog bites )
Initial management : copious irrigation, dbridement, and
immediate primary closure
20 25 % gigitan anjing / kucing tdp bakteri Pasteurellla
multocida Prophylactic broad-spectrum antibiotics
Penicilin V 4 x 500 mg atau amoksisilin 3 X 500 mg
cloramfenicol 50 mg/kgBB/hr selama 10 hari atau
ATS + anti rabies
Human Bites animal bites kecuali
produce potentially contaminated wounds that often should
not be closed primarily
Amputasi Penis : usually the result of genital self-mutilation 65 87 %
mrp penderta psikosis

Kirim ke rujukan dg fasilitas microsurgery :

Amputat cuci dg NaCl 0.9 % bungkus dg kasa lembab NaCL 0.9 %
masukkan dlm kantong plastik steril masukkan lg dlm kantong plastik dg
es
Reimplantasi masih mungkin dilakukan pd 16 jam utk cold ischemia dan 6
jam utk warm ischemia
Komplikasi : Striktur uretra - Skin loss - Sensasi abnormal
Teknik Operasi :
2 lapisan uretra jahit dg benang absorbable 5.0 ( dg kateter )
Diseksi minimal disekitar neurovasculer evaluasi
Jahit tunika albuginea dg absorbable 3.0
Anastomose mikro a. dorsalis / vena / epineural n. dorsalis dg nylon 11.0 /
9.0 / 10.0
Pasang sistostomi
Priapism : prolong ereksi 4 jam tanpa adanya stimulasi / hasrat seksual
40 % idiopatik + sekunder e.c berbagai sebab
Prinsip Causa : Iskemik dan Non Iskemik
Puncak insiden
Usia 5 10 th : terkait dg kelainan hematologi / sickle sel
Usia 20 50 th : penyebab tdk diketahui
Banyak tjd pd malam hari / pasca aktivitas seksual
Tipe Priapism:
Low-Flow / Iskemik / Venous : akut, kronik dan rekuren/stutter
High-Flow / Non Iskemik / Arteriel
Klinis :
Full length of cavernosa with
Corpora spongiosa + glands remain flaccid
Penyebab Priapism
Primer
Sekunder
Hematologi : sickle sel, leukimia, talasemia, limfoma
Neurogenik : spinal cod injury, cauda equina
compression
Neoplastik : renal, bladder, prostat, lung, melanoma
Trauma : genital, perineal
Iatrogeik : inj papaverin ( 5 % ), pgE1 ( < 1 % )
Infeksi : malaria, rabies, scorpion bites
Medikasi
Antipsikostik : cpz, haldol, trifulperazine, thioridazine
Antidepresan : fluoxetine, sertraline, trazodone
Antikoagulan : heparin
Recreational drugs : cocaine, alkohol
Total Parenteral Nutrisi : intralipid
Iskemik Priapism ..priapism : patofisiologi
Prolong oklusi vena + release
neurotransmiter
Non Iskemik Priapism
Anoxia otot polos cavernosa

Trauma perineal /
Failure of smooth muscle
sebab lain
contraction
Kerusakan arteri
Persisten Ereksi cavernosa

Anoxia berlanjut Fistula Arteriolacunar

Nekrosis otot polos

High Uncontrolled
arteriel Inflow into
Fibrosis otot polos cavernosa sinusoid

Obstruksi Blood Flow

Manajemen Priapism
Tujuan : rapid detumesence + relief pain + preservasi potensi
Diagnosis
Klinis : history of cause + rigiditas + pain on erection
Penunjang : Blood Gas Cavernosa + USG Doppler
Low Flow vs High Flow
Low Flow High Flow
Frekuensi Sering Jarang
Etiologi Multi Trauma
Patofisiologi Obst. Corpora blood flow Arteriolacunar fistula
Simptom Painful Mild discomort
Aspirasi Thick + dark Bright red
Low PO2 PO2 12kPa
pH asam pH 7.4
Doppler Low / no flow High flow
Treatment Urgent deferred
Manajemen iskemik priapism
 Dx : Klinis Causa Sickle Cell
Low Flow -Rehidrasi IV
BGA + USG Iskemik
Doppler - alkalinisasi Priapism
- transfusi
Konservatif
Analgetik narkotik Aspirasi 20 50 cc
Hipotensive agent dg butterfly needle 19 21 G Resolusi
Ketamine i.v + irigasi dg salin heparin

persisten

Inj -adrenergic agonist intracorpora

Tourniquet base of penis + one of :
Resolusi
- Phenylephrine 2.5 mg / 2.5 mL
- Lidocain cum 0.5 % - 1 % 1 ml ( k/p ulang 1x )
- Ephedrin 15 mg / 0.5 mL ( k/p ulang 1x )

persisten Operasi shunting

- Cavernosa-Glandular ( winter / El-ghourab )
- Cavernosa-Spongiosa ( Quackels )
- Cavernosa-Saphenous ( Grayhack / Barry )
Non iskemik priapism
 High Flow Evaluasi Klinis

Dx : BGA + USG
Doppler Non Iskemik
Priapism
Konservatif dg
Resolusi
Es

persisten

Embolisasi fistula dg
- Autolog blood clot
- polyvinyl alkohol Resolusi
- N-butylcyanocyalate

Open Ligasi
persisten
arteri
Manajemen priapism rekuren ( stuttering )
pd umumnya resolusi spontan kadang perlu medikasi, dpt digunakan salah satu
dibawah ini :

Cyproterone acetate : 100 mg nocte

Flutamide
LH-RH analog ( zoladex )
Procylidine
Phenylepherine ( self-injected )
Terbutaline
Etilefrine (-adrenoceptor agonist )
Kegawatan Scrotum
Cedera Testis : 75 % blunt trauma 1.5 % bilateral
25 % penetrating 30 % bilateral
Dx : Klinis + USG inhomogen parenkim testis + robekan pd
tunika albuginea
Tx : Early exploration and repair of testis injury orchidectomi post
konservatif : 3 8 x lipat dp early eksplorasi
Torsio Testis
Peak insiden : 12 18 th ( 1 : 4000 < 25 th )
Torsio testis kiri : kanan = 6 : 4 ( funiculus kiri > panjang )
Insiden bilateral < 1 %
Tipe :
Extravaginal : 75 % pre-natal + 25 % neonatus
jaringan penunjang antara tunika skrotum bersifat
longgar testis + tunika resiko torsio
Intravaginal : dewasa
insersi tunika letak tinggi bell clapper deformity
54 100 % anomali tjd bilateral ( reasoning to orchidopexy )
>> puberty e.c peningkatan volume testis 5 6 x lipat
Extravagina
Dx : berbagai gambaran klinis
Monorchia / Vanishing Testis
Syndrome ( tjd prenatal )
Abdominal crisis ( neonatus )
Massa keras pd skrotum
Durante ops :
Skrotum edema + eritema
Testis hitam dg reaksi inflamasi di
sekitarnya
Fibrosis sekitar testis
Tx : Orchidectomy + Orchidopexy
kontra lateral
3-point fiksasi dg benang
monofilamen non absorbable
atau
Buka tunika vaginalis : pexy testis pd
sub dartos tanpa jahitan
. torsio testis
Intravagina
Dx
- Sudden pain + swelling
- Skrotum eritema
- Non tender epididimis letak anterior
- Elevasi tetis + Horisontal + Phren
test ( - )
- No fever + urin analisa N
- USG Doppler : no flow / <
Tx : Explorasi cito + Detorsi +
orchidopexy kontralateral
- Manual detorsi ( anticlockwise )
- Pastikan vitalitas testis k/p
orchidektomi
- Prognosis baik jika explore 4 6 jam
 . dd. torsio testis
Torsio Apendix Testis
Sisa ductus mullerian : Palpasi torsio pd pole atas testis ( jika blm edema )
blue dot Klinis lanjut torsio testis
Tx : bed rest + analgetik explorasi cito : apendextomi testis
Epididimitis Akut : Inflamasi, nyeri dan bengkak pd epididimis yg tjd < 6 mg
Peak insiden 20 29 th ( 1 : 350 pd > 18 th ) / kanan = kiri
Penyebab : < 35 th STD ( N. Go C.trachomatis ) dan pd anak / usia tua
kuman tr. Urinarius ( E. colli / E. colli-32 %, Pseudomonas-14 %, Proteus-4 % )
Dx :
Demam ( 75 % ), disuria ( 30 % ), bengkak dari tail epididmis epididmis +
testis s/d funiculus spermaticus, Orchitis 58 % : eritema skrotum 62 % : +
prostatitis 8 %
Leukositosis ( 64 % ) Px meatal discharge + urin analisa : gram (-)
Chlamydia trachomatis ( 2/3 kasus )
Tx : bed rest + analgetik + antibiotik + elevasi skrotum
Bakteriuria : AB empiris broad spektrum ( cipro ) 10 hari
Uretristis : single dose Penisilin V + Doxyciclin 10 hari
Algoritma acute
scrotal swelling
pd anak
Fourniers Gangrene

Polymicrobial necrotizing
fasciitis of the perineum
and genitalia
Most common in oldermen
(peak incidence in the 5th
and 6th decades)
incidence of 1/7,500, and
accounting for only 1%2%
of urologic hospital
admissions
10% of cases occur in
females
Penyebab Fourniers
 Anatomi relevan
The pelvic outlet can be divided into
anterior and posterior triangles by
drawing a line between the ischial
tuberosities with the symphysis pubis
and coccyx being the apices
Urogenital causes of Fourniers
gangrene lead to initial involvement
of the anterior triangle
Anorectal causes primarily involve the
posterior triangle
The five fascial planes that can be
affected are:
Colles fascia, Dartos fascia, Bucks
fascia, Scarpas fascia and Campers
fascia
 anatomi relevan

Colles fascia
is the fascia of the anterior triangle of the perineum. Laterally it is
attached to the pubic rami and fascia lata, posteriorly it fuses with the
perineal membrane and perineal body, and anterosuperiorly it is
continuous with Scarpas fascia
It prevents the spread of infection in a posterior or lateral direction,
but provides no resistance to spread in an anterosuperior direction
towards the abdominal wall
The dartos fascia
is the continuation of Colles fascia over the scrotum and penis.
Bucks fascia
lies deep to the dartos fascia, covering the penile corpora. It fuses
distally with the corona ofthe glans and proximally with the suspensory
ligament and crura of the penis
 anatomi relevan

Campers fascia
is the loose areolar fascial layer deep to the skin of the abdominal
wall, but superficial to Scarpas fascia. Together with Scarpas fascia it is
continuous with Colles fascia inferomedially.
Scarpas fascia
lies deep to Campers fascia, covering the muscles of the anterior
abdominal wall and thorax.
It terminates at the level of the clavicles.
The perineal membrane
lies deep to Colles fascia. It is triangular in shape and lies between the
pubic rami from the symphysis pubis to the ischial tuberosities.
It has a distinct posterior border, with the central perineal tendon in
the midline.
Colles fascia terminates in this posterior border.
 anatomi relevan
The central perineal tendon (or perineal body)
lies between the anus and bulbar urethra.
It serves as an attachment for the various perineal muscles and helps to
maintain the integrity of the pelvic floor.
Via the internal and external fascial layers of the spermatic cord,
the perineal fascia is continuous with the retroperitoneal fascia
This is a potential path for the spread of infection from the perineum to
the perivesical and retroperitoneal areas, and vice versa
Spread of infection along the fascial planes will follow the path of
least resistance
Infection in the anterior perineal triangle will spread preferentially in an
anterosuperior direction along Scarpas fascia,
lateral spread will be limited by fusion of Colles fascia to the ischiopubic
rami,
Posterior spread to the anal region will be limited by the termination of
Colles fascia in the posterior edge of the perineal membrane
 anatomi relevan
Infection from the perianal region may sometimes penetrate Colles
fascia, which is fenestrated at the level of the bulbocavernosusmuscle,
leading to spread of infection to the anterior triangle
Anterior triangle infection rarely spreads to the posterior triangle
it is possible for infection to spread from the posterior to the anterior
triangle and then to the anterior abdominal wall
Blood supply to the testis, bladder, and rectum
Originates directly from the aorta and not from the perineal
vasculature, and for this reason they are rarely affected in Fourniers
gangrene.
If the testes are affected, it may be from specific testicular pathology
such as epididymo-orchitis, or from a retroperitoneal infection
spreading along the spermatic fascia, causing thrombosis of the
testicular arteries.
Mikroba penyebab
Fourniers
Patofisiologi Fourniers : polymicroba

Gr (-) endotoksin Aktivasi makrofag sitokin

AEROB Agregrasi platelet Syok septik

Intravaskuler koagulasi

Hipoksia jaringan Radikal bebas

Nekrosis jaringan Sel rusak

Krepitasi
A Sub Kutan
Clearence toksin
N
A Produksi gas
E Suasana anaerob
R + Lecitinase
NEKROSIS
FASCIA
O Proliferasi Bakteri Kolagenase Digesti fascia
B ANAEROB hyaluronidase
Diagnosis Fourniers
It is usually preceded by prodromal symptoms such as fever, prostration,
nausea and vomiting, perineal discomfort, and poor glucose control in
diabetics, for a period ranging from 2 to 9 days
Genital and perineal discomfort worsens, leading to pain, itching, burning
sensation, erythema, swelling, and eventual skin necrosis. There may be a
purulent discharge with a feculent odor. The pain may subside as neural
damage develops
Once there is necrosis of the skin, the underlying fascia has already
undergone extensive necrosis
Special investigations to be done include a full blood count, clotting profile,
urea, creatinine and electrolytes, liver function tests, blood glucose, blood
gases, group and screen, HIV and VDRL
Blood and urine cultures, together with wound swabs and tissue specimens
for bacterial culture are very important
Manajemen Fourniers

The main goals in the management of Fourniers gangrene :

aggressive resuscitation of the patient,
administrationof broad-spectrum antibiotics, and
Debridement of infected and necrotic tissue
Initial and Preoperative Management
The cause of the infection should be established
Aggressive fluid resuscitation with crystalloid or colloid fluids is
essential to optimize the hemodynamic status
A mean arterial pressure over 65 mmHg and a central venous pressure
(CVP) of 812 cm H2O should bemaintained
Anemia should be corrected to a hemoglobin greater than 10 g/dl
Keep oxygen saturation above 90% using an oxygen mask
High-dose, broad-spectrum parenteral antibiotics covering Gram-
positive and Gram-negative aerobe as well as anaerobe organisms
should be used
 ..manajemen Fourniers
Surgery Management
Early and aggressive surgical debridement is essential, because it
significantly decreases morbidity and mortality
The patient should be placed in a dorsal lithotomy position
A midline perineal and scrotal incision usually gives the best initial
exposure
if it is not possible to pass a transurethral catheter easily, a suprapubic
catheter should be inserted
Colostomy is indicated if the anal sphincter is involved, if rectal or
colon perforation is present, in immunocompromised patients with
fecal incontinence, and if there is extensive involvement of the
posterior perineal triangle
During scrotectomy, all necrotic tissues except the testes and
spermatic cords should be debrided
The testes, because of their nonperineal blood supply, are rarely
affected, and orchidectomy is required in only 10%20% of cases, if
there is extensive involvementor a testicular cause for the infection
..manajemen Fourniers
The testis can be buried in a lateral thigh pouch or in a subcutaneous
abdominal pouch, depending on the extent of the debridement. This
should not be done during the initial debridement
Postoperative Management
The wound should be inspected daily
Bacterial culture results should be checked to make sure that
appropriate antibiotic therapy is given
Maintaining a blood glucose level of 46 mmol/l (74110 mg/dl)
The caloric needs of 2535 kcal/kg per day and protein of 1.52 g/kg
per day should be met
Nosocomial infections should be prevented as far as possible
common complications in the acutely ill patient, the development of
ileus, stress ulcers, and translocation of gut flora
Gut integrity can be maintained by starting early with gastrointestinal
feeding and by using enteral rather than parenteral nutrition
Stress ulcers can be prevented by giving sucralfate (1 g every 68 h)
Late Complication & Prognosis Fourniers

Late Complication
Chordee, painful erections, and erectile dysfunction
Infertility as a result of burying the testes in thigh pouches (high
temperature)
Squamous cell carcinoma in the scar tissue
Contractures due to prolonged immobilization
Depression secondary to dysmorphic body changes
Loss of income and disruption of family life due to prolonged
hospitalization
Lymphodema of the legs secondary to pelvic debridement and
subsequent thrombophlebitis
Prognosis
mortality of Fourniers gangrene ranges from 0% to 70%, with an
average of 20%30%
 Diagnotic Evaluation
 TRAUMA
Causa : - iatrogenic trauma
- external trauma