BAB 2 Literatures Review 2.1.

Anatomy anf Physiology of Urology System Urology system is the system that process screening of blood, so that the blood free from substances which is not to be used by body and permeate substances which is used by body. Subtances which is not to be used again, dissolved by body and realease in urene form. The urology system consist of : 1. Two kidneys 2. Two ureters 3. One bladder 4. One urethera

2.1.1. Kidney Is a gland. It lies in wall behind of kavum abdominalis and behind the peritonium, at both side of third vertebra lumbalis. The form of kidney is like a nut. There are two kidneys, left and right. Right kidney is few lower than left kidney, caused by big dexter hepatitis lobus. The functioning unit of the kidney is the neprhon. Each kidney contains more than one million of these units. Each kidney divided into three major areas; the cortex, medulah, and pelvis. The kidney has many function : a. Be a part important in expendituring of bodys toxin b. Maintance balance of liquid c. Keep balance acid and basa in the body

d. Release the finish result of metabolism from protein ureum, ammonia and creatinin.

Formation of Urine Urine is form in the nephron by three process : filtration, reabsorbstion, secretion. Filtration is the passage of the liquid through a filtering membrane as the result af the pressure differential. In the kidney, this take place in the glomerolus. Marking of normal urine : a. Mean in one day 1-2 liter, but different each other as according to amount of dilution which enter. b. Its color of transparant orange without sediment c. Its aroma sharply d. Its reactoin a little acid to litmys with mean pH 4.5-8.

2.1.2. Ureter Consists of two pipes, each duct is connected from kidney to vesika urinaria. Each ureter has definite elastic characteristic and is made of three

issue layer : (1) an inner mucosa (transitional ephithelial membrane) lining the lumen; (2) a muscular layer; and (3) a fibrous outer layer. The chief function of the ureter is to transport urine form the renal pelvis to the bladder.

2.1.3.

Bladder or Vesica Urinaria Works as relocation of urine. Its located behind the symphysis pubica in

flank cavity. Vesica Urinaria can shrink like a rubber balloon. Micturition, also called urination and voiding, is the act of emptying the bladder. As the bladder fills and the muscle fibers expand, stretch reseptors in the bladder wall are stimulated. The impulses initiating reflex are also sent to the cerebral cortex after a period of succesfully toilet training in early, childhood, the external sphincter usually under voluntary control. 2.1.4. Urethra and Meatus The Urethra is tube that starts at the base of the bladder and extends to the surface of the body. Lenght at men about 13.7 - 16.2 cm Urethra consist of : 1) Prostatica urethra 2) Membranosa urethra 3) Spongiosa urethra Lenght of womans urethra is about 3.7 - 6.2 cm (Taylor) or 3 5 cm (Lewis). Spichter urethra located in upside vagina, among vagina and clitoris and uretrha here only as channel of excretion. Wall of urethra consist of : a. Artless muscle coat, representing artless muscle continuation of bladder. b. Coat submucous c. Coat of mucous The act of micrurition, the female urethra empties by gravity, whereas the male urethra empties by several contraction of the bulbocarvenosus muscle. The uretrha ends in the meatus, which under voluntary control in adult. When

voiding is not appropriate, the external sphincter contracts, holding back the flow of urine until the reflex stimulation caeses. 2.2. Definition of Urinary Tract Infections Urinary Tract Infection (UTI) is an inflamantory response of the urothelium to bacterial invasion. Bacteriuria is a commonly used term that means bacteria in the urine. It has been assumed to be a valid indicator of either bacterial colonization or bacterial infection of the urinary tract. Althought this is ussualy true, studies in animals and humans have indicated that bacteria may colonize the urothelium without causing bacteriuria. Pyuria , the presence of white blood cells (WBCs) in the urine, is generally, indicative of infection and a significant inflamantory response of the urothelium to the bactherium. Bactheriura in the absence of pyuria is genrally indicative of bactherial colonization without infection of the urinary tract. UTI maybe defined as the presence of pathogens in the urinary tract. They are among the most common of bacterial infections ad are frequent causes of morbidity and mortality. As the second most common reason for the prescription of empirical antobiotics, UTIs are also major drivers of antibiotic usage and antibiotic resistance. It is therefore essential that we understand the pathogenesis of these conditions so that they can be managed appropriately, not only for the benefit of the individual patient but also in order to control the spread of multidrug-resistance organism. Infections are often defined by their presumed site of origin. Cystitis describes a clinical syndrome associated with dysuria, frequency, urgency,and occasionally suprabubic pain. These symptoms,althougt generally indicative of cystitis, may also be associated with infection of the urethra or vagina or noninfection condition such as interstitial cystitis, bladder carsinoma, or calculi. Conversely, patients may be asymptomatic and have infection of the bladder and possibly the upper urinary tract. The pressumed source of bachteria that causes the infection can be used to further define infections. Domiciolary infection, or outpatient-acquired infections,

occur in individuals who are not institutionalized at the time they incur the infection. Nosocomical infections, or health care-associated infections, occur in individuals who are hospitalized ar institutionalized and often in those who are catheterized. Domicialiry infections are ussualy caused by common fecal bacteria (i.e Enterobacteriacceae) and generally susceptible to most antimocrobial therapy, whereas nosocomical infections are frequently caused by Pseudomonas and other more antimicrobial-resistant strains. 2.3. Urinary Tract Infections Etiology The microbial etiology of urinary infections has been regarded as well established and reasonably consistent. Escherichia coli remains the predominant uropathogen (80%) isolated in acute community-acquired uncomplicated infections, followed by Staphylococcus saprophyticus (10% to 15%). Klebsiella, Enterobacter, and Proteus species, and enterococci infrequently cause

uncomplicated cystitis and pyelonephritis. The pathogens traditionally associated with UTI are changing many of their features, particularly because of antimicrobial resistance. The etiology of UTI is also affected by underlying host factors that complicate UTI, such as age, diabetes, spinal cord injury, or catheterization. Consequently, complicated UTI has a more diverse etiology than uncomplicated UTI, and organisms that rarely cause disease in healthy patients can cause significant disease in hosts with anatomic, metabolic, or immunologic underlying disease. The majority of community-acquired symptomatic UTIs in elderly women are caused by E coli. However, gram-positive organisms are common, and polymicrobial infections account for up to 1 in 3 infections in the elderly. In comparison, the most common organisms isolated in children with uncomplicated UTI are Enterobacteriaceae. Etiologic pathogens associated with UTI among patients with diabetes include Klebsiella spp., Group B streptococci, and Enterococcus spp., as well as E coli. Patients with spinal cord injuries commonly have E coli infections. Other common uropathogens include Pseudomonas and Proteus mirabilis.Recent advances in molecular biology may facilitate the identification of new etiologic agents for UTI. The need for accurate and updated population surveillance data is apparent, particularly in light of

concerns regarding antimicrobial resistance. This information will directly affect selection of empiric therapy for UTI. 2.4. Urinary Tract Infections Phathophysiology The pathophysiology of urinary tract infection involves the infection of urinary tract organs such as the urethra, bladder, ureters, and kidneys. Although different microorganisms can cause UTI, the pathophysiology of urinary tract infection is similar for each organism. Normal urine is sterile, but when bacterial urinary infection occurs, microorganisms enter through the urethra and may travel up or ascend to other parts of the urinary system. It is important to treat UTI to avoid complications. In all cases, the pathophysiology of urinary tract infection begins with the entry of microorganisms through the outermost part of the urinary system called the urethra. Normal urine is acidic and resistant to bacterial growth, and urine flow is always toward the external environment. Other protective mechanisms against bacterial urinary infection include bladder emptying, the presence of contracting muscles called sphincters, and the availability of immune cells and antibodies in the urinary mucosa. In men, secretions of the prostate gland minimize bacterial growth. Bacterial agents, such as Escherichia coli (E. coli), may be transferred from the anus to the urethral opening, leading to urethral infection. E. coli is an organism that lives in the colon and is passed out in the stools during defecation. The relationship between the anus and the urethra explains why UTI occurs more frequently in women than in men. In women, the anal and urethral openings are closer to each other, and the urethral length is shorter. This leads to easier bacterial translocation and ascension to the upper parts of the urinary tract. UTI symptoms differ according to what part of the urinary tract is infected. The symptoms of urethra infection or urethritis may be limited to increased frequency of urination as well as burning pain while urinating, called dysuria. With bladder infection or cystitis, there may be additional symptoms of pain over the abdominal and pubic regions, and also a low-grade fever. Kidney

infection, or pyelonephritis systemic, symptoms include high fever, chills, nausea, and vomiting. In some cases, blood in the urine and loss of appetite may be experienced. Different risk factors contribute to the pathophysiology of urinary tract infection. Congenital anatomical abnormalities and acquired diseases, such as kidney stones, can predispose a person to getting UTI. Among sexually active people, the frequency of intercourse and the mode of intercourse increase UTI risk. In elderly men, enlargement of the prostate gland impedes urine flow, leading to increased risk of infection. Immunocompromised states, such as diabetes, contribute to an increased UTI risk because the immune cells of the body are not able to fight against the infection. Treatment of UTI usually involves antibiotics, such as co-trimoxazole. It is important to follow the full antibiotic course recommended by the doctor. This is needed to avoid complications such as scarring of the urethra, strictures, and destruction of the kidney parenchyma. 2.5. Urinary Tract Infections Clinical Manifestation Urethritis most of the cases of purulent urethritis without cystitis are sexually transmitted and will be discussed later. The inflammation and infection is limited to the urethra. It is usually a sexually transmitted disease. Pathogens such as Chlamydia trachomatis, Neisseria gonorrhoeae, Ureaplasma urealyticumor or Trichomonas vaginalis are the common causes of urethritis. The disease is present in men and women. Complaints include discomfort during voiding, but there are usually no symptoms of postvoid suprapubic pain or urinary frequency. Cystitis results from an irritation of the lower urinary tract mucosa. This infection as such is not invasive. Frequently, one will see (symptoms 1-4 are sometimes called irritative voiding symptoms.): 1. Dysuria (painful urination) 2. Urgency (the need to urinate without delay) 3. Increased frequency of urination

4. Suprapubic tenderness, pelvic discomfort especially pre- and immediately postvoid. Occurs in 20% of women with uncomplicated UTI. 5. Small volume voiding. 6. Increased number of white blood cells in the urine (pyuria) Hemorrhagic cystitis is characterized by large quantities of visible blood in the urine. It can be caused by an infection (bacterial or adenovirus types 1-47) or as a result of radiation, cancer chemotherapy, or immunosuppressive medication. Clinical presentation usually depends on its origin. All causes result in irritative voiding symptoms typically. When infectious in origin, signs and symptoms of infection may also be encountered. Adenovirus is a common cause and is selflimiting in nature. Hemorrhagic cystitis is often confused with glomerulonephritis, but hypertension and abnormal renal function are absent in hemorrhagic cystitis. Hemorrhagic cystitis may develop months after cessation of radiation therapy. Pyelonephritis this infection usually results from ascension of the bacteria to the kidney from the lower urinary tract, but also can arise by hematogenous spread (e.g., from lungs in patients with pneumonia). In contrast to cystitis, pyelonephritis is an invasive disease. Blood cultures are positive in up to 20% of women who have this infection. The patient will experience many of the symptoms of cystitis as well as: 1. Suprapubic tenderness 2. Urinary urgency and frequency may be present or absent. 3. Fever 4. Flank pain and tenderness (back pain) 5. Costovertebral angle tenderness (CVA tenderness) 6. Nausea and vomiting 7. Peripheral leukocytosis 8. Urine contains white blood cell casts- elongated structures composed of cells that were tightly packed in the tubules and excreted in a proteinaceous matrix.

2.6. Urinary Track Infections Diagnostic

1.

Analyzing a urine sample. Your doctor may ask for a urine sample for lab analysis to look for white blood cells, red blood cells or bacteria. To avoid potential contamination of the sample, you may be instructed to first wipe your genital area with an antiseptic pad and to collect the urine midstream.

2.

Growing urinary tract bacteria in a lab. Lab analysis of the urine is sometimes followed by a urine culture a test that uses your urine sample to grow bacteria in a lab. This test tells your doctor what bacteria are causing your infection and which medications will be most effective.

3.

Creating images of your urinary tract. If your doctor suspects that an abnormality in your urinary tract causes frequent infections, you may have an ultrasound or a computerized tomography (CT) scan to create images of your urinary tract. In certain situations, your doctor may also use a contrast dye to highlight structures in your urinary tract. Another test, called an intravenous pyelogram (IVP), uses X-rays with contrast dye to create images. Historically, doctors used this test for urinary tract imaging, but it's being replaced more often by ultrasound or CT scan.

4.

Using a scope to see inside your bladder. If you have recurrent UTIs, your doctor may perform a cystoscopy, using a long, thin tube with a lens (cystoscope) to see inside your urethra and bladder. The cystoscope is inserted in your urethra and passed through to your bladder.

2.7. Urinary Track Infections Treatment Antibiotics are the main treatment for all UTIs. A variety of antibiotics are available, and choices depend on many factors, including whether the infection is complicated or uncomplicated or primary or recurrent. Treatment decisions are also based on the type of patient (man or woman, a pregnant or nonpregnant
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woman, child, hospitalized or nonhospitalized patient, person with diabetes). Treatment should not necessarily be based on the actual bacteria count. For example, if a woman has symptoms, even if bacterial count is low or normal, infection is probably present, and the doctor should consider antibiotic treatment.

2.7.1.

TREATMENT FOR UNCOMPLICATED UTIS

UTIs in low-risk women can often be successfully treated over the phone. In such cases, a health professional provides the patients with 3-day antibiotic regimens without requiring an office urine test. This course is recommended only for women at low risk for recurrent infection, who do not have symptoms (such as vaginitis) suggesting other problems. Antibiotic Regimen . Oral antibiotic treatment cures 94% of uncomplicated urinary tract infections, although the rate of recurrence remains high. The following antibiotics are commonly used for uncomplicated UTIs:
a.

The standard regimen has traditionally been a 3-day course of trimethoprim-sulfamethoxazole, commonly called TMP-SMX (Bactrim, Cotrim, Septra). TMP-SMX combines an antibiotic with a sulfa drug. A single dose of TMP-SMX is sometimes prescribed in mild cases, but cure rates are generally lower than with 3-day regimens. Allergies to sulfa are common and may be serious.

b.

Fluoroquinolone antibiotics, also called quinolones, have usually been a second choice. However, in geographic areas that have a high resistance to TMP-SMX, quinolones are now the first-line treatment for UTIs. Ciprofloxacin (Cipro) is the quinolone antibiotic most commonly prescribed. Quinolones are usually given over a 3-day period. Pregnant women should not take these drugs.

c.

Nitrofurantoin (Furadantin, Macrodantin) is a third option. This drug must be given for longer than 3 days.

d.

Fosfomycin (Monurol) is not as effective as other antibiotics but may be used during pregnancy. Resistance rates to this drug are very low.

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e.

Other antibiotics may also be used, including amoxicillin (with or without clavulanate) and cephalosporins. Doxycycline is often effective but cannot be given to children or pregnant women.

After a week of antibiotic treatment, most patients are free of infection. If the symptoms do not clear up within the first few days of therapy, doctors generally suggest that women discontinue their antibiotic and provide a urine sample for culturing in order to identify the specific organism causing the condition. Treatment for Relapsing Infection . A relapsing infection (caused by treatment failure) occurs within 3 weeks in about 10% of women. Relapse is treated similarly to a first infection, but the antibiotics are usually continued for 7 - 14 days. (Relapsing infections may be due to structural abnormalities, abscesses, or other problems that may require surgery, and such conditions should be ruled out.)

2.7.2.

TREATMENT FOR RECURRENT INFECTIONS Women who have two or more symptomatic UTIs within 6 months or

three or more over the course of a year may need preventive antibiotics. A woman's own perception of discomfort can generally guide her decisions on whether or not to use preventive antibiotics. All women should use lifestyle measures to prevent recurrences. Intermittent Self Treatment . Many, if not most, women with recurrent UTIs can effectively self-treat recurrent UTIs without going to a doctor. In general, this requires the following steps:
a.

As soon as the patient develops symptoms, she takes the antibiotic. Infections that occur less than twice a year are usually treated as if they were an initial attack, with single-dose or 3-day antibiotic regimens.

b.

In some cases, she also performs a clean-catch urine test before starting antibiotics and sends it to the doctor for culturing to confirm the infection.

A woman should consult a doctor under the following circumstances:

a. b.

If symptoms have not gone away within 48 hours If there is a change in symptoms

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c. d.

If the patient suspects that she is pregnant If the patient has more than four infections a year

Women who are not good candidates for self-treatment are those with impaired immune systems, previous kidney infections, structural abnormalities of the urinary tract, or a history of infection with antibiotic-resistant bacteria. Postcoital Antibiotics . If recurrent infections are clearly related to sexual activity and episodes recur more than two times within a 6-month period, a single preventive dose taken immediately after intercourse is effective. Antibiotics for such cases include TMP-SMX, nitrofurantoin, cephalexin, or a fluoroquinolone (such as ciprofloxacin). (Fluoroquinolones are not appropriate during pregnancy.) Continuous Preventive Antibiotics (Prophylaxis) . Continuous preventive (prophylactic) antibiotics are an option for some women who do not respond to other measures. With this approach, low-dose antibiotics are taken continuously for 6 months or longer.

2.7.3.

TREATMENT FOR KIDNEY INFECTIONS (PYELONEPHRITIS) Patients with uncomplicated kidney infections (pyelonephritis) may be

treated at home with oral antibiotics. Patients with moderate-to-severe acute kidney infection and those with severe symptoms or other complications may need to be hospitalized. In such cases, antibiotics are usually given intravenously for several days. Chronic pyelonephritis may require longterm antibiotic treatment.

2.7.4.

TREATMENTS FOR SPECIFIC POPULATIONS Treating Pregnant Women . Pregnant women should be screened for UTIs,

since they are at high risk for UTIs and their complications. The antibiotics used during pregnancy include amoxicillin, ampicillin, nitrofurantoin, and

cephalosporin. Fosfomycin (Monurol) is not as effective as others but may be used during pregnancy. Pregnant women should not take fluoroquinolones. Pregnant women with asymptomatic bacteriuria (evidence of infection but no symptoms) have a 30% risk for acute pyelonephritis in their second or third
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trimester. They need screening and treatment for this condition. In such cases, they should be treated with a short course of antibiotics (3 - 5 days). For an uncomplicated UTI, pregnant women may need longer-term antibiotics (7 - 10 days). Treating Children with UTIs . Children with UTIs are generally treated with TMP-SMX, cephalexin (Keflex) and other cephalosporins, amoxicillin,or amoxicillin/clavulanic acid (Augmentin). These drugs are usually taken by mouth in either liquid or pill form. Doctors sometimes give them as a shot or IV. Children usually respond to treatment within a few days. Vesicoureteral reflux (VUR) is a concern for children with UTIs. (See "Risk Factors" section.) VUR can lead to kidney infection (pyelonephritis), which can cause kidney damage. The two treatment options for children with VUR are long-term antibiotics to prevent infections or surgery to correct the condition. However, there is debate as to the benefit of these approaches. Recent studies indicate that preventive treatment with antibiotics may not be much help for preventing recurrent urinary tract infections in children, and that VUR itself may not substantially increase the risk for recurrent UTIs. Children with acute kidney infection are treated with oral cefixime (Suprax) or a short course (2 - 4 days) of an intravenous (IV) antibiotic (typically gentamicin, given in one daily dose). An oral antibiotic then follows the IV.

2.7.5.

MANAGEMENT OF CATHETER-INDUCED URINARY TRACT INFECTIONS Catheter-induced urinary tract infections are very common, and preventive

measures are extremely important. Catheters should not be used unless absolutely necessary, and they should be removed as soon as possible. Reducing the risk for infections during long-term catheter use, however, remains problematic. Intermittent Use of Catheters . If a catheter is required for long periods, it is best to use it intermittently if possible (as opposed to an indwelling catheter). Some doctors recommend replacing it every 2 weeks to reduce the risk of infection and irrigating the bladder with antibiotics between replacements.

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Daily Hygiene . A typical catheter is one that has been preconnected and sealed and uses a drainage bag system. To prevent infection, some of the following tips may be helpful:
a. b. c.

Drink plenty of fluids, including 3 glasses of cranberry juice a day. The catheter tube should be free of any knots or kinks. Clean the catheter and the area around the urethra with soap and water daily and after each bowel movement. (Women should be sure to clean front to back.)

d. e.

Wash hands before touching the catheter or surrounding area. Never disconnect the catheter from the drainage bag without careful instructions from a health professional on strict methods for preventing infection.

f. g.

Keep the drainage bag off the floor. Stabilize the bag against the leg using tape or some other system. Antibiotics for Catheter-Induced Infections . Patients using catheters who

develop UTIs with symptoms should be treated for each episode with antibiotics and the catheter should be removed, if possible, or changed. A major problem in treating catheter-related UTIs is that the organisms involved are constantly changing. Because there are likely to be multiple species of bacteria, doctors generally recommend an antibiotic that is effective against a wide variety of microorganisms. Although high bacteria counts in the urine (bacteriuria) occur in most catheterized patients, administering antibiotics to prevent a UTI is rarely recommended. Many catheterized patients do not develop symptomatic urinary tract infections even with high bacteria counts. If bacteriuria occurs without symptoms, antibiotic therapy has little benefit if the catheter is to remain in place for a long period. 2.8. Urinary Track Infections Complications
1.

Life-threatening blood infection (sepsis) - risk is greater among the young, very old adults, and those whose bodies cannot fight infections (for example, due to HIV or cancer chemotherapy)

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2. 3.

Kidney damage or scarring Kidney infection

2.9. Urinary Track Infections Outlook A urinary tract infection is uncomfortable, but treatment is usually successful. Symptoms of a bladder infection usually disappear within 24 - 48 hours after treatment begins. If you have a kidney infection, it may take 1 week or longer for your symptoms to go away.

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BAB III CASE STUDY AND ROLE PLAY A female college student, Ms.K 20 years old came to Airlangga clinic, complain about her experiancing pain in her lower abdomen and difficultly to urinate. Everytime she urinate, she feel burn sensation around her perineal area. From anamnesa the nurse know that Ms.K has habit to delay her urinate for this past 3 weeks due to KKN BBM. She told nurse that she hesitated to urinate in KKN BBM area because the hygiene of the bathroom is lack. Ms.K also feel cold, the temperature observation reveal 38,5 C. 3.1. Nursing Diagnosis No. 1. Supporting Data Subjective : patient said that the pain in her lower abdomen and difficultly to urinate Difficultly of Objective : lower of abdomen has Tenderness of lower abdomen Experiencing pain when urinate urinate Etiology Bathroom lack of hygiene Diagnosis Acute pain related to agent injury

examination tenderness

patient

2.

Subjective : pateint said feel burn sensation around her

Bacterium have to entered to the body Urinary tract infection Antibody

Hypertermia related to urinary tract infection

perineal area and feel cold Objective : temperature

observation reveal 38,5 .

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activated in the body Burn sensation is raising Patient have termoregulation 3.2. Intervention No. 1. Diagnosis Intervention Rational

Acute pain related to agent injury 1. Do assessment 1. To know level Nursing Out Comes : 1. Patient can show relaxation techniques effectivelly for achieve comfort 2. Patient can maintain the level of pain in lower abdomen 3. Patient will be describe a comfort of physical and psychological of pain include : location, and location

pain the patient

characteristics, 2. To decrease or duration, lose pain

frequency, and 3. To release pain quality 2. Give patient 4. To decrease

patient respons for pain uncomfort

analgesic 3. Teach relaxation

Result : a. Physically and psicological Pleased b. The amount of pain indicated and reported

techniques and music therapy 4. Involve patient the for

decrease pain, if possible

2.

Hypertermia related to urinary tract infection Nursing Out Comes : 1. Patient can show the right

1. Teach or

patient to

1. To

prevent

family

hypertermia 2. To teach the patient the

calculate temperature

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method for measure the temperature 2. Patient will be describe to avoid or decrease temperature 3. Patient can report the sign and symptom hypertermis

for avoid and identification hyperthermia 2. Temperature regulation (NIC) : educate the exhausted to

exhausted indication 3. 4 , 5 To the

decrease high

temperature

Result : a. The equality between burn increase and burn loss

education

the patient and emergency intervention as needed 3. Use wascloth arround femur 4. suggest fluid intake 5. Use fan in the patient room oral cold

3.3. Role Play 1. Good morning Mrs. K, how are you feeling today ? 2. How much do you drink this morning ? 3. how about your urine Mrs. K ? 4. Do you feel better after urinate ? 5. Do you have habit to delay urinate ? why you do that ? 6. Is there any pain ? where ? how does it feel ? since when ? 7. Do you have a fever ?

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Daftar Pustaka Hanno PM et al.2001.Clinical manual of Urology york:Mcgraw-hill. Naber KG, Bergman B, Bishop MC, Johansen TEB, Botto H, Lobel B (ed). 2001.European Association of Urology : Guidelines on Urinary and Male Genital Tract Infections. Nursalam. 2010. English for Nursing-Midwefery Science and Technology. Jakarta: Salemba Medika. Page 48-57 3rd edition. New

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