UROLOGY SYSTEM

LABORATORY ANATOMY

MEDICAL FACULTY

MUHAMMADIYAH UNIVERSITY OFPURWOKERTO

2017
Editors tim :

1. Bayu Aji Wicaksono (1313010033)

2. Nila Munaya (1313010022)

3. Faradilla Nur Muliana (1313010047)

4. Almira Meida (1313010039)

5. Afra Brygest Tamia (1313010020)

6. Riska Siela S (1313010041)

7. Cita Dianita Zealand (1313010026)

8. Rosela Alfi Sahara (1313010040)

9. Zaky Rabbani M (1313010016)

10. Mukhammad Arifin (1313010025)

 Urinary System consist of :

A. Ren / Kidney

B. Ureter

C. Vesicaurinaria

D. Urethra

A. REN

B.

a.

Picture Structure of the kidney

a. Quantity : 2 (dextra et sinistra)

b. Position : Regio lumbal C.

c. Skeletopi

a) Dextra : Vertebrae L2-L4

b) Sinistra : Vertebrae T12-L3

 d. Margo : medial et lateral

e. Facies : anterior et posterior

f. Segments : anterius (superius et inferius), posterius,

superius,inferius

g. Layers of tissue (outer to inside )

a) fascia renalis,

b) capsulaadiposa,

c) capsulafibrosa,

d) corpus adipose

h. Segment of the kidney :

a) Cortex renalis

b) Medulla renalis

c) Pyramidesrenales

d) Papillae renales

e) Columnaerenalis

f) Calyx renalis major

g) Calyx renalis minor

h) Pelvis renalis

Tabel Sinus dan Hilum Renalis

Sinus Renalis Hilum Renalis

Vassa (arteri& vena) renalis Vassa (arteri& vena) renalis
Limferenalis Limferenalis
Nervus Nervus
Pelvisrenalis Ureter
i. Blood vessel of the kidneys :

a) Aa. / vv. Interlobares

b) Aa. / vv. Arcuata

c) Aa. / vv. Interlobulares

d) Aa. Segmentales

Picture Vascularization of the kidney

 Picture Flowchart of Renal Circulation

j. Nephron : the smallest structures that can carry out all the
functions of a system

a) Glomerulus

b) Proximal convoluted tubule

c) Distal convoluted tubule

d) Ansahenle / loop of henle

e) Collectives duct
Picture Structure of nephron
C. URETER

Are a pair of muscular tubes that extend from thekidneys to the

urinary bladder (Vesica urinaria)

a. Distance : 10-12 inchi (25-30 cm)

b. Pars : abdominalis et pelvicalis
c. Constringency
a) Junctura Pelvic ureterica
b) Crossed in front of a. iliaca
c) Junctura uretero vesicae

D. VESICA URINARIA / URINARY BLADDER

The urinary bladder is a hollow, muscular organ that serves as a

temporary reservoir for urine

a. Position
a) Male : anterior rectum, superior glandula prostat
b) Female : anterior uterus
b. Layers : musculus detrusor vesicae
c. Ostium
a) Ostium ureteris dextra et sinistra (from ureter)
b) Ostium urethrae internum(to urethra)

The triangular area bounded by the openings of the ureters and the
entrance to the urethra makes up a region called the trigoneof the urinary
bladder.
 d. Ligamentum
a) Ligamentum umbilicalis medialis
b) Ligamentum umbilicalis mediana

Ligamentum umbilicale
medianum Apex vesicae

Tunica
muscularis
Ostium ureteris
dextra et sinistra

Trigonum vesicae

Ostium urethrae
internum Urethra masculina

pars prostatica

Picture.Vesica Urinaria

E. URETRA

The urethra extends from the neck of the urinary bladder and
transports urine to the exterior of the body.

a. Ostium : Ostium urethrae internum et externum

b. The males urethrae consistsof :

a) Urethra pars intramural

b) Urethra pars prostatica

c) Urethra pars membranacea

d) Urethra pars bulbourethralis

e) Ur e th ra p a rs sp o n g i osa

Picture The males urethrae

 Tabel Differentiation between urethra masculine et feminine

Differ Masculine Feminine

ence

Dista 18 20 cm 3-5 cm
nce

Funct Excretion of Excretion

ion urine and of urine
reproduction

Pars 5 -

Clinical application

1. Glomerulonephritis

2. Cystitis

3. Ren Failure

4. Hydronephrosis

5. Kidney stones/ ureter/ vesica urinaria

6. BPH Image 19 Urinary System

F. URINE PATHWAY

Ren
(Glomerulus Proximal convoluted tubule ansa henle / loop henle
Distal convoluted tubule collectives duct papillae renales
calyx minor calyx major pelvis renalis)

Ureter

Osteum Utreteris et Osteum Urethrae

Sinistra Vesica Urinaria
Internum

Ostium urethrae
internum Urethrae Ostium Urethrae Externum
Masculina Reproduction Organ

Picture Masculina reproduction organs

Tabel Masculina reproduction organs

A. PARS INTERNA
1. Ductuli
a. Testis
Location : inside the scrotum
Left/sinistra testis lower than right/dextra testis
Testis divided into lobule-lobule (lobuli testis)
Inside the testis, there is tubuli seminiferus which is winding tubuli
Tubuli seminiferus orifice in rete testis
Ductuli efferent connecting rete testis with the top of epididymis
Travel of sperm:
Tubulus seminiferus tubulus rectus rete testis ductus efferent epididymis
ductus deferens (Vas deferens + ductus vesicula seminalis) ductus ejaculatorius
urethrae ostium urethrae externa (OUE)

Picture Organs of masculines genitalia

b. Epididymis
Structure:
Caput epididymis
Corpus epididymis
Cauda epididymis

c. Ductus deferens/vas deferens

Lining mature sperm from epididymis to ductus ejaculatoriusand urethrae. Ampulla
ductus deferens is the part that much bigger

d. Ductus ejaculatorius
Flow cement to urethrae

e. Urethrae masculina
Divided into 5 parts:
Urethtrae pars intramural
Urethrae pars prostatica
Urethrae pars membranancea
Urethrae pars bulbourethralis
Urethrae pars spongiosa

2. Funiculus spermaticus

a. Consist of nervus, artery, vein, lymphatic vessel

b. It is from annulus inguinalis profundus canalis inguinalis annulus inguinalis
superficialis

3. Accessory Gland

a. Vesicula seminalis
b. Glandula prostat
c. Glandula bulbourethralis
Clinical application :
1. Vasectomy
2. BPH (Benigna Prostat Hyperplasia)
3. Hernia Inguinalis

Vas deferens

1. Vasectomi

Bilateral vasectomy is a simple operation performed to produce infertility.

Under local anesthesia, a small incision is made in the upper part of the scrotal wall,
and the vas deferens is divided between ligatures. Spermatozoa may be present in the
first few postoperative ejaculations, but that is simply an emptying process.

B. PARS EXTERNA

1. Scrotum : testis pack that consist of several layers, that are:

a. Cutis
b. M. Dartos
c. Fascia spermatica interna
d. Fascia cremasterica
e. M. Cremaster
f. Fascia spermatica interna
g. Tunica vaginalis testis lamina parietalis (periorchium)
h. Cavum scrotalis
i. Tunica vaginalis testis lamina visceralis (epiorchium)
j. Tunica albuginea
Picture 15. Scrotal layers
2. Penis

Consist of 2 parts:

a. Pars fixata/afixa

1) Crus penis
2) Bulbus penis
b. Pars libera

1) Corpora cavernosa (a. centralis inside there)

2) Corpus spongiosum (urethrae inside there)

Consist of 3 parts:

a. Radix penis
b. Corpus penis
c. Glans penis

The Bulbourethral glands

1. Infection

The bulbourethral glands are the common sites for chronic venereal infection
(e.g., gonorrhoea). The organisms reach the gland by ascending from the bulbous part
of the urethra along the duct of the gland.
Scrotum

1. Hydrocele

This is an accumulation of fluid within the tunica vaginalis. Most hydroceles are
idiopathic, but some may be caused by spread of infection from the testis or
epididymis.
Penis

1. Circumcision

Circumcision is the operation of removing the greater part of the prepuce, or

foreskin. In many newborn males, the prepuce cannot be retracted over the glans. This
can result in infection of the secretions beneath the prepuce, leading to inflammation,
swelling, and fibrosis of the prepuce. Repeated inflammation leads to

3. Vascularisation of Penis

a. Nervus dorsalis penis

b. Arteri dorsalis penis
c. Vena dorsalis superficialis penis
d. Vena dorsalis penis
e. Arteri profunda penis

Picture 16. Vasculrisation of Penis

 Clinical application:
1. Circumcision
2. Cremaster reflex
3. Constriction of the orifice of the prepuce (phimosis) with obstruction to
urination.
4. Urethra infection
5. Trauma
6. Congenital anomalies

Homologue Genital Organs

Tabel 2. Homologue genital organs

Disease related masculina reproductive system:

1. Varicocele
A varicocele is a condition in which the veins of the pampiniform plexus are
elongated and dilated. This is thought to be because the right testicular vein joins the
low-pressure inferior vena cava, whereas the left vein joins the left renal vein, in
which the venous pressure is higher.
2. Malignant tumor of the testis
A malignant tumor of the testis spreads upward via the lymph vessels to the
lumbar (paraaortic) lymph nodes at the level of the first lumbar vertebra. It is only
later, when the tumor spreads locally to involve the tissues and skin of the scrotum,
that the superficial inguinal lymph nodes are involved.
3. Beningn enlargment of the prostate

The cause is possibly an imbalance in the hormonal control of the gland. The
median lobe of the gland enlarges upward and encroaches within the sphincter
vesicae, located at the neck of the bladder. The leakage of urine into the prostatic
urethra causes an intense reflex desire to micturate.
The enlargement of the median and lateral lobes of the gland produces
elongation and lateral compression and distortion of the urethra so that the patient
experiences difficulty in passing urine and the stream is weak. Backpressure effects
on the ureters and both kidneys are a common complication. The enlargement of the
uvula vesicae (owing to the enlarged median lobe) results in the formation of a pouch
of stagnant urine behind the urethral orifice within the bladder.

4. Prostate cancer and the prostatic venous plexus

Many connections between the prostatic venous plexus and the vertebral veins
exist. During coughing and sneezing or abdominal straining, it is possible for prostatic
venous blood to flow in a reverse direction and enter the vertebral veins. This explains
the frequent occurrence of skeletal metastases in the lower vertebral column and
pelvic bones of patients with carcinoma of the prostate. Cancer cells enter the skull
via this route by floating up the valveless prostatic and vertebral veins.

5. Urinary stone disease

a. Nephrolithiasis and Ureterolithiasis
Nephrolithiasis specifically refers to calculi in the kidneys, but renal calculi
and ureteral calculi (ureterolithiasis) are often discussed in conjunction. The
majority of renal calculi contain calcium. The pain generated by renal colic is
primarily caused by dilation, stretching, and spasm because of the acute ureteral
obstruction.
The classic presentation for a patient with acute renal colic is the sudden onset
of severe pain originating in the flank and radiating inferiorly and anteriorly; at
least 50% of patients will also have nausea and vomiting. Patients with urinary
calculi may report pain, infection, or hematuria. Patients with small,
nonobstructing stones or those with staghorn calculi may be asymptomatic or
experience moderate and easily controlled symptoms.
 The location and characteristics of pain in nephrolithiasis include the
following:

1) Stones obstructing ureteropelvic junction: Mild to severe deep flank pain

without radiation to the groin; irritative voiding symptoms (eg, frequency,
dysuria); suprapubic pain, urinary frequency/urgency, dysuria, stranguria,
bowel symptoms
2) Stones within ureter: Abrupt, severe, colicky pain in the flank and
ipsilateral lower abdomen; radiation to testicles or vulvar area; intense
nausea with or without vomiting (Turk C et al., 2016).

b. Urethrolithiasis
Urethral calculi are reported to be fairly common in people developing
countries, particularly in the Middle and Far East. They are thought to be
relatively common in childhood in developing countries because of the high
prevalence of bladder calculi, and to occur rarely in women. Most urethral stones
in patients in developing countries are thought to consist of struvite and uric acid,
and of calcium oxalate or cystine in those in developed communities. The anterior
and the posterior urethra are reported as the more common sites of urethral stones
(Kamal et al., 2004).
There are various opinions about the frequency of acute retention of urine
caused by urethral calculi, ranging from very frequent, to infrequent, to not at all.
Some authors consider that urethral stones are usually radiolucent and that a
uroradiographic diagnosis is made in only 40% of cases. There seems to be a
consensus that treatment is essentially based on the size, shape and location of
urethral stones, and on the associated anatomical pathology of the urethra (Kamal
et al., 2004).
(Kamal et al., 2004)
 (Akhtar et al., 2012)

c. Vesicolithiasis
Urinary lithiasis affects about 5% of the Western population. The calculi are
formed of calcium in 70% of cases, of uric acid in 20%, of magnesium
ammonium phosphate (struvite) in 10% and of cystine and less than 1%. Urine is
a stable solution and any variation in the degree of saturation, of the urinary pH
and of the concentration of crystallization inhibitors can alter the existing
equilibrium and result in urolithiasis. Bladder stones are rare in developed
countries and in adults they are most commonly associated with bladder outlet
obstruction, chronic infection or the presence of an intravesical foreign body.
They can occur in childhood and are related to malnutrition, especially in a
protein-poor diet. Regarding the clinical presentation, bladder stones may be
asymptomatic. However, symptoms such as suprapubic pain, dysuria, hematuria,
weak and choppy urine stream, hesitancy, frequency, urgency and pain in the
glans may occur in over 50% of patients (Torricelli et al., 2012).
Pathogenesis of bladder stones
1) Adults
Outlet obstruction is the main etiological factor in over 75% of cases of
bladder lithiasis, which provides stasis and infection, change in urinary
pH, urine supersaturation and heterogeneous nucleation, with calculus
formation. This condition usually affects men over 50 years, the benign
 prostatic hyperplasia (BPH) being the most common cause, followed by
urethral stricture and adenocarcinoma of the prostate. These calculi are
made of uric acid, calcium oxalate or magnesium ammonium phosphate
(struvite). The latter is associated with infection by bacteria breakers of
urea. Generally, the calculi are unique, but they may be multiple in 25-
30% of cases. Urinary tract infection can be associated with the
pathogenesis of bladder lithiasis in 22-34% of cases, and Proteus sp. is the
most commonly isolated microorganism from urine cultures. Proteus and
some strains of Pseudomonas and E. coli produce urease, which
hydrolyzes urea, resulting in ammonia and carbon dioxide, raising the pH
and promoting urinary supersaturation and precipitation of crystals of
magnesium ammonium phosphate (Torricelli et al., 2012).
2) Children
Nutritional deficiency of vitamin A, magnesium, phosphate and
vitamin B6, associated with low intake of protein and a carbohydrate-rich
diet are implicated in the pathogenesis of pediatric bladder lithiasis.
Furthermore, dehydration, diarrhea, fever and infection may reduce urine
output and increase crystallization. These conditions acidify the urine and
contribute to the formation of bladder stones. The children endemic
vesical lithiasis is commonly associated with uric acid stones, isolated or
associated with calcium oxalate. Nonetheless, calcium phosphate may be
present (Torricelli et al., 2012).
 (Cervera and Peri, 2012)

6. Infection
a. Pyelonephritis
Acute pyelonephritis is a potentially organ- and/or life-threatening
infection that often leads to renal scarring. Acute pyelonephritis results from
bacterial invasion of the renal parenchyma. Bacteria usually reach the kidney
by ascending from the lower urinary tract. Bacteria may also reach the kidney
via the bloodstream. Signs and symptoms The classic presentation in patients
with acute pyelonephritis is as follows:
 1) Fever - This is not always present, but when it is, it is not unusual
for the temperature to exceed 103F (39.4C)
2) Costovertebral angle pain - Pain may be mild, moderate, or severe;
flank or costovertebral angle tenderness is most commonly
unilateral over the involved kidney, although bilateral discomfort
may be present
3) Nausea and/or vomiting - These vary in frequency and intensity,
from absent to severe; anorexia is common in patients with acute
pyelonephritis
4) Gross hematuria (hemorrhagic cystitis), unusual in males with
pyelonephritis, occurs in 30-40% of females, most often young
women, with the disorder.
Symptoms of acute pyelonephritis usually develop over hours or over
the course of a day but may not occur at the same time. If the patient is male,
elderly, or a child or has had symptoms for more than 7 days, the infection
should be considered complicated until proven otherwise. The classic
manifestations of acute pyelonephritis observed in adults are often absent in
children, particularly neonates and infants. In children aged 2 years or
younger, the most common signs and symptoms of urinary tract infection
(UTI) are as follows:

1) Failure to thrive
2) Feeding difficulty
3) Fever
4) Vomiting
Elderly patients may present with typical manifestations of
pyelonephritis, or they may experience the following:

1) Fever
2) Mental status change
3) Decompensation in another organ system
4) Generalized deterioration (Gupta, 2011).
b. Urethritis
Urethritis is defined as infection-induced inflammation of the urethra.
The term is typically reserved to describe urethral inflammation caused by an
STD, and the condition is normally categorized into either gonococcal
urethritis (GU) or nongonococcal urethritis (NGU).Signs and symptoms
Many patients with urethritis, including approximately 25% of those
with NGU, are asymptomatic and present to a clinician following partner
screening. Up to 75% of women with Chlamydia trachomatis infection are
asymptomatic. Signs and symptoms in patients with urethritis may include the
following:
1) Urethral discharge: May be yellow, green, brown, or tinged with
blood; production unrelated to sexual activity
2) Dysuria (in men): Usually localized to the meatus or distal penis,
worst during the first morning void, and made worse by alcohol
consumption; typically not present are urinary frequency and
urgency
3) Itching: Sensation of urethral itching or irritation between voids
4) Orchalgia: Heaviness in the male genitals
5) Worsens during menstrual cycle (occasionally).
6) Systemic symptoms (eg, fever, chills, sweats, nausea): Typically
absent (Gillespie CW, 2013).

c. Cystitis
Common acute or chronic inflammation of the urinary bladder. The
disease occurs primarily in young women and frequently results from bacterial
invasion of the urethra from the adjacent rectum, most commonly with
normally occurring intestinal bacteria such as E. coli. It is also common in
menopausal women; in them, the bacteria is transmitted from a vagina left
more susceptible to bacterial overgrowth by changes in estrogen levels. In men
cystitis rarely occurs without some other urinary tract disorder, such as kidney
stones or, especially in older men, an enlarged prostate gland. Other
predisposing factors are pregnancy, diabetes, and various systemic disorders.
Symptoms and signs of UTI in the adult are as follows:
 1) Dysuria
2) Urinary urgency and frequency
3) A sensation of bladder fullness or lower abdominal discomfort
4) Suprapubic tenderness
5) Flank pain and costovertebral angle tenderness (may be present in
cystitis but suggest upper UTI)
6) Bloody urine
7) Fevers, chills, and malaise (may be noted in patients with cystitis,
but more frequently associated with upper UTI) (P.Lagasse, 2016).

d. Prostatitis
Prostatitis is an infection or inflammation of the prostate gland that
presents as several syndromes with varying clinical features. The term
prostatitis is defined as microscopic inflammation of the tissue of the prostate
gland and is a diagnosis that spans a broad range of clinical conditions.
The National Institutes of Health (NIH) has recognized and defined a
classification system for prostatitis in 1999.The 4 syndromes of prostatitis are
as follows:

1) I - Acute bacterial prostatitis

2) II - Chronic bacterial prostatitis
3) III - Chronic prostatitis and chronic pelvic pain syndrome (CPPS;
further classified as inflammatory or noninflammatory)
4) IV - Asymptomatic inflammatory prostatitis

Acute prostatitis and chronic bacterial prostatitis are defined by

documented bacterial infections of the prostate and are treated with antibiotic
therapy and supportive care (see Treatment).

CPPS is characterized primarily by urological pain complaints in the

absence of urinary tract infection. This syndrome excludes the presence of
active urethritis, urogenital cancer, urinary tract disease, significant urethral
stricture, or neurological disease affecting the bladder. It is subdivided into
inflammatory and noninflammatory subtypes. Inflammatory CPPS is defined
by the presence of white blood cells in the semen, expressed prostatic
 secretions, or voided bladder urine after prostatic massage (see Workup).
Noninflammatory CPPS is defined by the absence of white blood cells.

Asymptomatic inflammatory prostatitis is characterized by the

incidental discovery of prostatic inflammation without genitourinary
complaints. This condition is diagnosed during a workup for infertility or
elevated prostate-specific antigen (PSA) level. This disease entity can produce
elevated white blood cells in the ejaculate (leukocytospermia) and can cause
male infertility but is usually otherwise left untreated (Charles, 2010).

7. Trauma
a. Renal injury
 (Morey, 2014)
b. Baldder trauma
1) Bladder Contusion
Bladder contusion is an incomplete or partial-thickness tear of the
bladder. This produces a hematoma within the bladder at the location of
injury. Bladder contusion commonly results from blunt trama or extreme
physical activity (eg, long-distance running). Patients typically present
with gross hematuria. On cystography, the bladder usually appears
normal, or it may have a teardrop shape secondary to compression by the
hematoma.
Bladder contusion is relatively benign. It is self-limiting and requires
no specific therapy, except for rest until hematuria resolves. Nevertheless,
it should remain a diagnosis of exclusion. Persistent hematuria or
unexplained lower abdominal pain requires further investigation.
2) Extraperitoneal Bladder Rupture
Traumatic extraperitoneal rupture is usually (89%-100%) associated
with pelvic fracture. Previously, the mechanism of injury was believed to
be direct perforation by bony fragment or disruption of the pelvic girdle. It
is now thought that pelvic fracture is likely coincidental and that bladder
rupture most often is a direct result of deceleration injury and fluid inertia
coupled with the shearing force created by pelvic ring deformation.
Extraperitoneal rupture is usually associated with fracture of the
anterior pubic arch. When this occurs, the anterolateral aspect of the
bladder is typically perforated by bony spicules. Forceful disruption of the
bony pelvis or the puboprostatic ligaments also tears the bladder wall. In
such instances, the degree of bladder injury is directly related to the
severity of the fracture.
A mechanism similar to intraperitoneal bladder rupture is thought to
underly some extraperitoneal bladder injuries. Specifically, this is the
combination of trauma with bladder overdistention, leading to a burst
injury.
The classic cystographic finding is contrast extravasation around the
base of the bladder, confined to the perivesical space. Often, areas of
contrast extravasation shaped like flames, feathers, or starbursts are noted
adjacent to the bladder. Additionally, the bladder may assume a teardrop
shape secondary to compression from a pelvic hematoma.
With a more complex injury, contrast material can extend to the thigh,
penis, perineum, or into the anterior abdominal wall. Extravasation will
reach the scrotum when the superior fascia of the urogenital diaphragm, or
the urogenital diaphragm itself, becomes disrupted.
If the inferior fascia of the urogenital diaphragm is violated, contrast
material will reach the thigh and penis within the confines of the Colles
fascia. Rarely, contrast may extravasate into the thigh through the
obturator foramen or into the anterior abdominal wall through contiguous
tissue planes. Sometimes, extravasation of contrast through the inguinal
canal and into the scrotum or labia majora can occur. See the image
below.
Picture CT scan of extraperitoneal bladder rupture. The contrast extravasates from the
bladder into the prevesical space.

3) Intraperitoneal Bladder Rupture

Classic intraperitoneal rupture is described as large horizontal tears in

the bladder dome. This is the least supported area of the bladder and only
portion of the organ covered by peritoneum. In such cases, the mechanism
of injury is a sudden large increase in intravesical fluid pressure that
overcomes the mechanical strength of the bladder wall. This is more likey
to occur at greater bladder volumes, as the detrusor muscle fibers are more
widely separated along the thinned and stretched bladder wall, offering a
lower resistance to spikes in intravesical fluid pressure.

Intraperitoneal bladder rupture generally occurs as the result of a direct

blow to a distended urinary bladder. Deceleration injuries can also cause
such phenomena. This type of injury is most common in alcoholics and
victims of seatbelt or steering wheel trauma. Otherwise, it is more
common in children due to the relative intraabdominal bladder position
that persists until approximately 20 years of age.

Since urine will generally continue to drain into the abdomen through
the open bladder wall defect, intraperitoneal ruptures may go undiagnosed
for variable lengths of time. Metabolic and electrolyte abnormalities (eg,
hyperkalemia, hypernatremia, uremia, acidosis) may occur as urine is
reabsorbed through the peritoneal cavity. Additionally, such patients may
appear anuric.

The diagnosis is established when urinary ascites are recovered during

paracentesis or the leak is confirmed on imaging. Intraperitoneal rupture
demonstrates contrast extravasation into the peritoneal cavity. The
contrast media will often outline loops of bowel, fill the paracolic gutters,
and pool under the diaphragm. See the image below.
 Picture Cystogram of intraperitoneal bladder rupture. The contrast enters the
intraperitoneal cavity and outlines loops of bowel.

4) Combination of Intraperitoneal and Extraperitoneal Ruptures

Diagnostic imaging with cystogram will reveal contrast outlining

the abdominal viscera and perivesical space. Oftentimes this may be
observed in penetrating trauma, where the bladder is traversed by a high-
velocity bullet, impaled by a knife, or penetrated by another foreign body.
This through-and-through injury creates a combined intraperitoneal and
extraperitoneal bladder rupture. See the image below.

Picture. Cystogram of extraperitoneal bladder rupture. Note the fractured pelvis and
contrast extravasation into the space of Retzius.

The high incidence of associated abdominal visceral and vascular

injury mandates surgical exploration in virtually every case of combined
intraperitoneal and extraperitoneal rupture. Cystography can be falsely
negative in penetrating bladder injuries secondary to small-caliber wounds,
 although the capabilities of cross-sectional imaging with computed
tomographic cystography have improved recently. For full discussion, see
Bladder Trauma Imaging. However, it is often not the suspected bladder injury
alone that drives the consideration for operative intervention. As a result, the
diagnosis of such injuries is commonly made during exploratory laparotomy
(Srinivasa, 2009).

c. Priapism
Priapism is an involuntary, prolonged erection unrelated to sexual
stimulation and unrelieved by ejaculation. This condition is a true urologic
emergency, and early intervention allows the best chance for functional
recovery (Al-Qudah, 2016).

Picture 2. Priapism (Al-Qudah, 2016).

Signs and symptoms (Al-Qudah, 2016)

1. Low-flow priapism
This condition is generally painful, although the pain may disappear
 with prolonged priapism. Characteristics of low-flow priapism include
the following:
1) Rigid erection
2) Ischemic corpora: As indicated by dark blood upon corporeal
aspiration
3) No evidence of trauma
2. High-flow priapism
This type of priapism is generally not painful and may manifest in an
episodic manner. Characteristics of high-flow priapism include the
following:
1) Adequate arterial flow
2) Well-oxygenated corpora
3) Evidence of trauma: Blunt or penetrating injury to the penis or
perineum (straddle injury is usually the initiating event)

d. Testicular Torsion
Testicular torsion refers to the torsion of the spermatic cord structures
and subsequent loss of the blood supply to the ipsilateral testicle. This is a
urological emergency; early diagnosis and treatment are vital to saving the
testicle and preserving future fertility. The rate of testicular viability decreases
significantly after 6 hours from onset of symptoms (Ogunyemi, 2016).
Testicular torsion is primarily a disease of adolescents and neonates. It
is the most common cause of testicular loss in these age groups. However,
torsion may occasionally occur in men 40-50 years old (Ogunyemi, 2016).
Surgical treatment may prevent further ischemic damage to the testis.
Rarely, observation is appropriate, depending on the pathology. Diagnosis of
testicular torsion is clinical, and diagnostic testing should not delay treatment
(Ogunyemi, 2016).
Testicular torsion is caused by twisting of the spermatic cord and the
blood supply to the testicle (see the image below). With mature attachments,
the tunica vaginalis is attached securely to the posterior lateral aspect of the
testicle, and, within it, the spermatic cord is not very mobile. If the attachment
of the tunica vaginalis to the testicle is inappropriately high, the spermatic
cord can rotate within it, which can lead to intravaginal torsion. This defect is
referred to as the bell clapper deformity. This occurs in about 17% of males
and is bilateral in 40% (Ogunyemi, 2016).
Intravaginal torsion most commonly occurs in adolescents. It is
thought that the increased weight of the testicle after puberty, as well as
sudden contraction of the cremasteric muscles (which inserts in a spiral
fashion into the spermatic cord), is the impetus for acute torsion (Ogunyemi,
2016).
By contrast, neonates more often have extravaginal torsion. This
occurs because the tunica vaginalis is not yet secured to the gubernaculum
and, therefore, the spermatic cord, as well as the tunica vaginalis, undergo
torsion as a unit. Extravaginal torsion is not associated with bell clapper
deformity. This can occur up to months prior to birth and, therefore, is
managed differently depending on presentation. Of course, neonates can have
intravaginal torsion and this should be managed in the same manner as
adolescents (Ogunyemi, 2016).
Testicular torsion is associated with testicular malignancy, especially
in adults; one study found a 64% association of testicular torsion with
testicular malignancy. This is thought to be secondary to a relative increase in
the broadness of the affected testicle compared with its blood supply.
However, in a review of 32 patients who had been diagnosed with testicular
torsion, testicular cancer was found in 2 of the 20 patients who had undergone
orchiectomy, a rate of 6.4% (Ogunyemi, 2016).
Picture Testicular torsion: (A) extravaginal; (B) intravaginal (Ogunyemi, 2016).

e. Penile fracture
Penile fracture is the traumatic rupture of the corpus cavernosum.
Traumatic rupture of the penis is relatively uncommon and is considered a
urologic emergency. Sudden blunt trauma or abrupt lateral bending of the
penis in an erect state can break the markedly thinned and stiff tunica
albuginea, resulting in a fractured penis. One or both corpora may be involved,
and concomitant injury to the penile urethra may occur. Urethral trauma is
more common when both corpora cavernosa are injured. Penile rupture can
usually be diagnosed based solely on history and physical examination
findings; however, in equivocal cases, diagnostic cavernosography or MRI
should be performed. Concomitant urethral injury must be considered;
therefore, preoperative retrograde urethrographic studies should generally be
performed. Contraindications to surgical therapy include intolerance to general
anesthesia and a history of penile trauma but completely normal physical
examination findings. In patients with polytrauma, life-threatening injuries
must be prioritized; delayed penile repair can be considered when the patient
becomes medically stable. Patients with penile trauma require fluid
resuscitation prior to operative intervention (Santucci, 2015).
 Picture 1. Severe penile fracture (Santucci, 2015).

f. Urethral injuries
Result in long-term morbidity and most commonly result from trauma.
The male urethra is much more commonly injured than the female urethra and
is the focus of this article.

Clinical presentation

In the setting of trauma, the classic triad of blood of the external

urethral meatus or vaginal introitus may be seen but is an unreliable sign, as is
haematuria. Inability to void may be seen in complete urethral disruption.
Examination may reveal blood on digital rectal exam and perineal
ecchymossis.

Dysuria, urinary urgency and suprapubic discomfort can ensue in the

chronic stages of incomplete urethral injury due to complicating strictures.

Pathology

Male urethral injuries are divided into anterior (penile/bulbar) and

posterior (membranous/prostatic) urethral injuries. Injuries, of course, may be
partial or complete (Ingram, 2008). There are a variety of causes:

1) Blunt trauma: due to shearing or straddle injuries:

 usually affects prostatic or membranous urethra
associated with pelvic fractures (occurs in ~10%)
often associated with bladder injury
2) Penetrating trauma: e.g. stab wounds, gunshot wounds, dog bites
3) Iatrogenic

catheterisation, Foley catheter removal without balloon

deflation, cystoscopy
post-surgical (e.g. surgery for benign prostatic hyperplasia) (Morey,
2014).

g. Ureteric injuries
Ureteric injury is a relatively uncommon, but severe event, which may
result in serious complications as a diagnosis is often delayed.

Clinical presentation

Ureteric injuries unreliably demonstrate macro- or micro-scopic

5, 6
haematuria as it may be absent in up to 25% of patients . Classic clinical
symptoms and signs may also be absent but patients may present with
abdominal/flank pain, renal failure and/or urine leaking from the vagina 5.

The diagnosis is often based on a high index of clinical suspicion. The

detection of ureteric injuries is delayed after days or weeks in approximately
two-thirds of patients.

Pathology

There is a wide-range of injury:

injury to the mucosa of the ureter post lithotripsy

perforation and false passage
partial or complete ureteric transection
complete ureteric avulsion
loss of ureteric segment
 ligation
dissection

Etiology
1) Iatrogenic
rate of injury is ~2% (range 0.5-3%) for laparoscopic
procedures
most commonly injured after gynaecological procedures
traumatic
uncommon; represents <1% of all urological trauma
direct trauma from penetrating injury is a more common cause
than blunt injury (Butler, 2012).

8. Congenital anomaly
a. Hydrocele
Hydrocele is defined as a collection of fluid between the parietal and visceral
layers of tunica vaginalis. Pathogenesis of primary hydrocele is based on patency
of processus vaginalis in contrast with secondary hydrocele. Incomplete
obliteration of the processus vaginalis peritonei results in formation of various
types of communicating hydrocele; a large open processus vaginalis allowing
passage of abdominal viscera results in clinical hernia. The exact time of
spontaneous closure of the processus vaginalis is not known. It persists in
approximately 80-94% of newborns and in 20% of adults. If complete obliteration
of the processus vaginalis occurs with patency of midportion, a hydrocele of the
cord occurs. Scrotal hydroceles without associated patency of the processus
vaginalis are encountered in newborns also. Non-communicating hydroceles,
based on an imbalance between the secretion and reabsorption of this fluid, are
found secondary to minor trauma, testicular torsion, epididymitis, varicocele
operation or may appear as a recurrence after primary repair of a communicating
or non-communicating hydrocele.
b. Hypospadias
Risk factors associated with hypospadias are likely to be genetic, placental
and/or environmental. Interactions between genetic and environmental factors
may help explain non-replication in genetic studies of hypospadias. Single
 nucleotide polymorphisms seemed to influence hypospadias risk only in exposed
cases.
- An additional member with hypospadias is found in 7% of families.
- Endocrine disorders can be detected in rare cases.
- Babies of young or old mothers and babies with a low birth weight have a
higher risk of hypospadias.
- A significant increase in the incidence of hypospadias over the last 20 years
suggests a role for environmental factors (hormonal disruptors and pesticides)
[136-139]. Though this information has been questioned recently.
- The use of oral contraceptives prior to pregnancy has not been associated with
an increased risk of hypospadias in the offspring.
A Dutch case-control study confirmed that genetic predisposition
possibly plays a role in anterior and middle hypospadias, in contrast, the
posterior phenotype was more often associated with pregnancy-related factors,
such as primiparity, preterm delivery, and being small for gestational age.
Hormone-containing contraceptive use after conception increased the risk of
middle and posterior hypospadias, while multiple pregnancies were associated
with the posterior form in particular.
Classification systems
Hypospadias are usually classified based on the anatomical location of
the proximally displaced urethral orifice:
- Distal-anterior hypospadias (located on the glans or distal shaft of the penis
and the most common type of hypospadias)
- Intermediate-middle (penile)
- Proximal-posterior (penoscrotal, scrotal, perineal).
- The pathology may be much more severe after skin release (Europeon Society
of Pediatric Urology, 2015)

c. Renal Agenesis
Renal agenesis is a condition in which a newborn is missing one or both
kidneys. Unilateral renal agenesis (URA) is the absence of one kidney. Bilateral
renal agenesis (BRA) is the absence of both kidneys. The cause of renal agenesis
is not known, though some cases result from inherited mutated genes. Babies with
one kidney can live normally with ongoing tests and treatment. Those with no
 kidneys need long-term dialysis to survive. Renal agenesis is typically found
during routine prenatal ultrasounds. If your doctor identifies BRA in your child,
they can use a prenatal MRI to confirm the absence of both kidneys
(Vanderheyden, 2011).

d. Pelvic Kidney
A fetal pelvic kidney is a condition that results when the kidneys fail to ascend
to their normal position above the waist and remain in the pelvis because they are
blocked by blood vessels in the aorta. A fetal pelvic kidney or horseshoe kidney
is generally diagnosed by ultrasound (sonogram) examination before birth.
Evaluation of the kidneys is part of the routine ultrasound examination done by
many obstetricians as part of their prenatal care around the 20th week of
pregnancy.

e. Horseshoe Kidney
Horseshoe kidney, as the kidneys of the fetus rise from the pelvic area, they
become attached (fuse) together at the lower end or base. By fusing, they form
 into a U shape, like a horseshoe. This is thought to happen more often in males than
in females.

f. Ureteral Duplication
Partial or complete duplication of one or both ureters may occur with
duplication of the ipsilateral renal pelvis. In complete duplication, the ureter from
the upper pole of the kidney opens at a more caudal location than the orifice of
the lower pole ureter. As a result, the lower pole tends to reflux and the upper
pole tends to obstruct when pathology is present. Ectopia or stenosis of one or
both orifices, vesicoureteral reflux into the lower ureter or both ureters,
and ureterocele may occur. Surgery may be necessary if there is obstruction,
vesicoureteral reflux, or urinary incontinence. Incomplete duplication is rarely of
clinical significance.
g. Ureterocele
A ureterocele is a cystic out-pouching of the distal ureter into the urinary
bladder. It is one of the more challenging urologic anomalies facing pediatric and
adult urologists. Ureteroceles may pose a diagnostic and therapeutic dilemma
with perplexing clinical symptoms resulting from a spectrum of abnormal
embryogenesis associate with anomalous development from the intravesical
ureter, the kidney, and the collecting system.

h. Ureteral Pelvic Junction (UPJ) Obstruction

Ureteropelvic junction (UPJ) obstruction is defined as an obstruction of the
flow of urine from the renal pelvis to the proximal ureter.
 i. Vesicoureteral Reflux
Vesicoureteral reflux (VUR), or the retrograde flow of urine from the bladder
into the ureter, is an anatomic and functional disorder that can result in substantial
morbidity, both from acute infection and from the sequelae of reflux nephropathy.

(Anderson CB, 2011)

 Reference
Akhtar, J., Ahmed, S., and Zamir, N. (2012) Management of Impacted Urethral Stones in
Children. Journal of the College of Physicians and Surgeon Pakistan, 22 (8), 510-
513. Available from: https://jcpsp.pk/archive/2012/Aug2012/08.pdf [Accessed April
21, 2017].
Al-Qudah, H. S. 2016. Priapsm. Medscape Reference. Department of General Surgery, Saad
Specialist Hospital Saudi Arabia. Available from:
http://emedicine.medscape.com/article/437237-overview (Accessed 21 April 2017)
Anderson CB, Tanaka ST, Pope JC 4th, Adams MC, Brock JW 3rd, Thomas JC. Acute pain
crisis as a presentation of primary megaureter in children. J Pediatr Urol. 2011
Butler P, Mitchell A, Healy JC. Applied Radiological Anatomy. Cambridge University Press.
(2012) ISBN:0521766664
Cervera, C., and Peri, L. (2012) Bladder Stone. The New England Journal of Medicine.
Available from: http://www.nejm.org/doi/pdf/10.1056/NEJM icm1104023
[Accessed April 20, 2017].
Charles R. Powell, MD, Indiana University School of Medicine, Indianapolis, Indian. Am
Fam Physician. 2010 Aug 15;82(4):397-406.
Europeon Society of Paediatric Urology. (2015) Guidelines on Pediatric Urology. Europeon
Assocoation of Urology. https://uroweb.org/wp-content/uploads/23-Paediatric-
Urology_LR_full.pdf [diakses tanggal 21 April 2017]
Gillespie CW, Manhart LE, Lowens MS, Golden MR. Asymptomatic urethritis is common
and is associated with characteristics that suggest sexually transmitted etiology. Sex
Transm Dis. 2013 Mar. 40(3):271-4
Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, et al. International clinical
practice guidelines for the treatment of acute uncomplicated cystitis and
pyelonephritis in women: A 2010 update by the Infectious Diseases Society of
America and the European Society for Microbiology and Infectious Diseases. Clin
Infect Dis. 2011 Mar 1. 52(5):e103-20.
Ingram MD, Watson SG, Skippage PL et-al. Urethral injuries after pelvic trauma: evaluation
with urethrography. Radiographics. 2008;28 (6): 1631-43. doi:10.1148/rg.286085501
Kamal, B. A., Anikwe, R. M., Darawani, H., Hashish, M., and Taha, S. A. (2004) Urethral
Calculi: Presentation and Management. BJU International, 93, 549-552. Available
from: doi:10.1111/j.1464-410X.2004.04660.x [Accessed April 21, 2017].
Lagasse, & Columbia University, The Columbia encyclopedia (6th ed.). New York, NY:
Columbia University Press. Retrieved from
https://search.credoreference.com/content/entry/columency/cystitis/0
Morey AF, Brandes S, Dugi DD 3rd, Armstrong JH, Breyer BN, Broghammer JA, et al.
Urotrauma: AUA guideline. J Urol. 2014 Aug. 192(2):327-35.
Ogunyemi, O. I. 2016. Testicular Torsion. Medscape Reference. University of Wisconsin
Hospitals and Clinics. Available from:
http://emedicine.medscape.com/article/2036003-overview (Accessed 21 April 2017)
Santucci, R. A. 2015. Penile Fracture and Trauma. Medscape Reference. Michigan State
University College of Medicine. Available from:
http://emedicine.medscape.com/article/456305-overview#showall (Accessed 21 April
2017)
Srinivasa RN, Akbar SA, Jafri SZ, Howells GA. Genitourinary trauma: a pictorial
essay. Emerg Radiol. 2009 Jan. 16(1):21-33
Torricelli, F. C. M., Mazzucchi, E., Danilovis, A., Coelho, R. F., and Srougi, M. (2012)
Surgical Management of Bladder Stone: Literature Review. Rev. Col. Bras. Cir., 40
(3), 227-233. Available from: http://www.scielo.br/pdf/rcbc/v40n3/en_11.pdf
[Accessed April 21, 2017].
Turk C, Knoll T, Petrik A, Sarica K, Skolarikos A, Straub M, et al. Guidelines on urolithiasis.
European Association of Urology. Available at http://uroweb.org/wp-
content/uploads/EAU-Guidelines-Urolithiasis-2015-v2.pdf. 2015; Accessed: May
16, 2016.
Vanderheyden T, Kumar S, Fisk NM, et al. Fetal renal impairment. Semin Neonatol. 2003
Aug. 8(4):279-89