Sugeng Rawuh…………..

1. Sugeng Rawuh…………..

2. Seminar “Clinical Updates 2011” simposiumsatelitTema : Dysuria Hari/Tanggal : Minggu, 16 Januari 2011Tempat : Auditorium II FK UGM

3. Semangat !! • 100% • Tambah Pintar, Sehat, Hebat ! Bisa !! • Jam • HP

4. Mengesankan!!

5. Daftar penyakit dikelompokkan menurut sistem, organ dan tahapan usia. Berikut ini tingkat kemampuan yang diharapkan akan dicapai di akhir pendidikan. Tingkat kemampuan yang diharapkan dicapai pada akhir pendidikan dokter

6. Soal 1 Tingkat kemampuan 4 berarti: • Level ini mengindikasikan overview level. Bila menghadapi pasien dengan gambaran klinik ini dan menduga penyakitnya, Dokter segera merujuk. • Dokter mampu merujuk pasien secepatnya ke spesialis yang relevan dan mampu menindaklanjuti sesudahnya • Dokter dapat memutuskan dan mampu menangani problem itu secara mandiri hingga tuntas. • Dokter dapat memutuskan dan memberi terapi pendahuluan, serta merujuk ke spesialis yang relevan (bukan kasus gawat darurat). • Dokter dapat memutuskan dan memberi terapi pendahuluan, serta merujuk ke spesialis yang relevan (kasus gawat darurat).

7. Soal 2 Yang termasuk Tingkat kemampuan 4 dibidangNefrologi: • Urinary tract infection • Acute tubular necrosis • Horse shoe kidney • Uncomplicated Pyelonephritis • BatuGinjal

8. Kidney • Cortical adenoma 1 • Renal cell carcinoma 2 • Wilm's tumor 1 Nefrourologi • Acute renal failure 2 • Chronic renal failure 2 • Nephrotic syndrome 2 • Acute glomerulonephritis 3A • Chronic glomerulonephritis 3A • Interstitial nephritis 1 • Renal colic 3A • Urinary stone diseases or urinary calculi without colic 3A • Polycystic kidneys symptomatic 2 • Urinary tract infection 4 • Acute tubular necrosis 2 • Horse shoe kidney 2 • Uncomplicated Pyelonephritis 4 • Urinary incontinence 2 • Nocturnal and diurnal enuresis 2 • Prostatitis 3A

9. Soal 3. Pengelolaan Disuria: • Dibedakan kelompok Anak dengan yang lain. • Dibedakan kelompok Geriatri dengan yang lain. • Dibedakan kelompok Laki-laki dan perempuan. • Terapi dibedakan kelompok ISK atas dan ISK bawah. • Dibedakan kelompok Penyakit Penyerta.

10. Dysuria Yes Child, geriatric patient, adult male No Yes Vaginal complaints UA No Yes Signs or symptoms of pyelonephritis Pelvic exam Evidence of UTI: pyuria, hematuria, nitrete-positive No Yes No Yes Risk factors of occult pyelonephritis UA Culture urine and investigate non-UTI causes of dysuria Culture urine No Yes Recent Hx recurrent UTI Evidence of UTI pyuria, hematuria, nitrate Localize site of infection No Yes No Yes Treat uncomplicated lower tract infection Culture urine Culture and investigate non-UTI causes of dysuria Culture urine Lower tract Upper tract Treat Treat recurrent lower tract infection Treat upper tract infection Figure 28.1 Algorithm for the management of dysuria

11. Dysuria: Causes and associated

14. L = 7,61 P = 8,64

17. Algoritme Disuria

18. Differential Diagnosis of Dysuria in Otherwise Healthy Women of Reproductive Age *May be more common in college health centers and reproductive health clinics UTI, urinary tract infection.

19. Key Elements of the History and Physical Examination for Dysuria

20. Guiding Questions UTIs • How has the epidemiology of urinary tract infections (UTIs) changed? • What are the differences between asymptomatic bacteriuria, cystitis, and pyelonephritis? • What distinguishes an uncomplicated UTI from a complicated UTI and how do treatments vary?

21. Guiding Questions UTIs 4. Are particular patient populations at increased risk for UTI and are adverse outcomes a concern? 5. What is the pathogenesis of UTI? 6. What impact does bacterial antibiotic resistance have on UTI? 7. What are two important types of complicated renal infections?

22. KEY POINTSUrinary Tract Infection • Infections in different locations within the urinary tract present with similar symptoms. • Fever in a patient with LM means tissue invasive infection. • The duration of therapy and the pathogens responsible for UTT are different in uncom­plicated and complicated UIT. • Infection of the urinary tract with Staphylococcus aureusrequires evaluation for a hematogenoussource of infection.

23. KEY POINTSRisk Factor for and pathogenesis of UTI • Patient-specific risk factors for UTI can be modified to decrease the incidence of infection. • Pathogen-specific virulence factors are not the cause of antibiotic resistence.

24. Soal 4 Penyebab Terbanyak ISK • E. coli • Proteus • Klebsiella, enterobacter • Enterococcus • Pseudomonas

25. Frequency of bacteria causing UTI

26. Characteristics of Urine Tests for Primary Care Patients with Dysuria1

27. KEY POINTSDiagnosis of Urinary Tract Infection • For an uncomplicated patient, a history consistent with UTI and pyuria on urinalysis establishes the diagnosis. • For a complicated patient, a culture and sensitivity must be performed.

28. Soal 4. PrinsipPengelolaanDisuriaWanita • Terapi jangka pendek • Evaluasi 4-7 paska terapi • Urinalisis baik, tanpa terapi antibiotika. • Urinalisis jelek, kultur negatif: terapi Chlamydia • Antibiotika sesuai Kultur, sensitivitas dan angka kuman.

29. WHO PRESENT WITH COMPLAINTS OF DYSURIA AND FREQUENCY Treat with short-course therapy Follow-up 4-7 days later Asymptomati Asymptomati Urinalysis urine culture No further intervention Both negative Pyuria, no bacteriuria Bacteriuria with or without Observe, treat with urinary analgesia Treat for Chlamydia trachomatis Treat with extended course Figure 15-1.Clinical approach to the woman with dysuria and frequency. (Modified from Tolkoff-Rubin NE, Wilson ME, Zuromskis P, et al: Single-dose amoxicillin therapy of acute uncomplicated urinary tract infections in women. Antimcrob Agents Chemother 25:626, 1984.)

30. KEY POINTSAntibiotics for the Treatment of UTI • Antimicrobial-resistant bacteria are more common, therefore, broad-spectrum empiric coverage with a quinolone is appropriate. • In order to avoid inducing further antibiotic resistance, once culture and sensitivity result are available, antibiotic therapy is changed to the narrowest possible spectrum.

31. Soal 5. “Red Flags”for a Complicated UTI • Male gender • Prepubertal or geriatric age • Symptoms for more than 7 days • An immunosuppressing condition E. An episode of acute pyelonephritis within the past year

32. “Red Flags” for a Complicated Infection

33. “Red Flags” for a Complicated Infection

34. Factors predisposing to recurrent UTI Local factors • Impaired bladder emptying, e.g. due to prostatic hypertrophy or neuromuscular problems • Bladder or renal calculi • Renal cysts • Anatomical anomaly, e.g. horseshoe kidney • Indwelling urinary catheter or recurrent bladder instrumentation • Postmenopausal vaginal atrophy

35. Factors predisposing to recurrent UTI Systemic factors • Diabetes mellitus • Immunosuppression • Pregnancy

36. Factors Suggesting Occult Pyelonephritis Or Complicated UTI • Diabetes • Pregnancy • Male patient • Childhood UTI • Elderly patient

37. FACTORS SUGGESTING OCCULT PYELONEPHRITIS OR COMPLICATED URINARY TRACT INFECTION 6. Indwelling catheter 7. Immunosupression 8. Urologic anatomic abnormality 9. Symptoms for >7 days 10. Recent urinary tract instrumentation or antibiotics

38. Criteria That Define a Complicated UTI

39. Abbreviations: UTI, urinary tract infection; PKD, polycystic kidney disease; CKD, chronic kidney disease. Modified from Bent, S., Saint, S. Am J Med 113:20S-28S , 2002 with permission.

40. Inherited or Acquired Host Susceptibility Factors for UTI

41. Inherited or Acquired Host Susceptibility Factors for UTI

42. Inherited or Acquired Host Susceptibility Factors for UTI

43. Inherited or Acquired Host Susceptibility Factors for UTI

44. Inherited or Acquired Host Susceptibility Factors for UTI

45. Evidence for Effectiveness of Recommended Therapies

46. Oral Drug Therapy Tract Infection

47. Oral Drug Therapy Tract Infection

48. KEY POINTSPregnant Women • Bacteriuria and UTI have negative consequences on the outcome of pregnancy • All pregnant women must be treated.

49. KEY POINTSThe Spinal Cord Injury Patient • Spinal cord injury patients are at high risk for UTI because of chronic indwelling catheters and loss of coordinated micturition. • Antimicrobial-resistant organisms are common pathogens because SCI patients have multiple antibiotic exposures.

50. Soal 6 Kondisiinimemerlukanpenangananlebihserius: • Pasien Diabetes • PasienHipertensi • PasienBatuginjal • Pasiencangkokginjal • Emphysematous Pyelonephritis