Laporan Tutorial Kelompok 6 Skenario A Blok 15

TUTORIAL REPORT
SCENARIO CASE A BLOK 15
Group 6
Supervisor: dr. Thia Prameswarie M.Biomed
1. M. Abidinsyah (702016020)
2. Muhammad Kevin Al. Hafidz (702018018)
3. Annisa Dwi Yosita (702018022)
4. Rizka Anisa Nurfadilah (702018028)
5. Nabila Tahiyyah (702018035)
6. Dinda Nafatilana (702018068)
7. Maulidiyah Tasya Salsabillah (702018072)
8. Dewi Fortuna Agustia (702018082)
9. Panianida Parindapa (702018085)
10. Aninda Afrilia Aryani (702018100)
FACULTY MEDICAL
UNIVERSITY MUHAMMADIYAH PALEMBANG
2020
1
FOREWORD
Assalamualaikum Wr.Wb.
Praise our thanks to Allah SWT for all his grace and grace so that we can
finish the tutorial A Blok 15. Sholawat as greetings always pour out to our lord,
the great prophet Muhammad and his family, friends and followers until the end
of the age.
We recognize that this tutorial report is far from perfect therefore we
expect constructive criticism and suggestions, in order to refine the next tasks.
In completing this tutorial task, we have much help, guidance and advice. On this
occasion express the respect and gratitude to:
1. dr. Thia Prameswarie M.Biomed as our supervisor.
2. All Members and related parties in the production of this report.
May Allah SWT give a reward for all the charity given to all those who
have supported us and hopefully this tutorial report useful for us and the
development of science. Hopefully we are always in the protection of Allah SWT.
Amin.
Palembang, November2020
Author
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TABLE OF CONTENTS
Foreword.........................................................................................................................2
Table of contents.............................................................................................................3
CHAPTER I : Introduction
1.1 Background.................................................................................................................4
1.2 Purpose and Objectives...............................................................................................4
CHAPTER II : Discussion
2.1 Tutorial Data...............................................................................................................5
2.2 Case Scenario..............................................................................................................6
2.3 Clarification of Problems............................................................................................7
2.4 Identification of Problems..........................................................................................7
2.5 Priority of Problems....................................................................................................9
2.6 Analysis of Problems..................................................................................................9
2.7 Conclusion.................................................................................................................43
2.8 Conceptual Framework..............................................................................................43
BIBLIOGRAPHY..........................................................................................................44
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CHAPTER I
PRELIMINERY
1.1 Background
The System Urinary and Genetalia Masculina Block is the fifthteen block
in the fiveth semester of the Competency Based Curriculum of Doctor
Education Faculty of Medicine, Muhammadiyah University of Palembang. In
addition, as we know that the learning program in this UMP FK uses KBK
learning system, so it is expected that doctor graduates from FK UMP
become doctors who are able to understand the existing systems in the human
body.
1.2 Purpose and objective

The purpose and objectives of this case study tutorial, namely:
1. As a report task group tutorial that is part of KBK learning system at the
Faculty of Medicine, Muhammadiyah University of Palembang.
2. Can solve the case given in the scenario with the method of analysis and
learning group discussion.
3. Achieving the objectives of the tutorial learning method.
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CHAPTER II
DISCUSSION
2.1 Tutorial Date

Tutor : dr. Thia Prameswarie M. Biomed
Moderator : Muhammad Kevin Al. Hafidz
Desk secretary : Aninda Afrilia Aryani
Time : Thursday, November 2th 2020( 1st stage tutorial)
Saturday, November 4th2020 (2nd Stage Tutorial)
2.2 Rules
1. Switch the phone off or in silent
2. Hold hand when asking question and arguments
3. Ask for permission in advance when going out of the room
4. Each tutor member is expected to wear marker
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2.3 Scenario
“Want to be circumcised”
Mr. Mat Idris took his son, Ibad, 7 years old , to the puskesmas for
circumcision. Ibad complained that the urination was painful and according to
his parents there was leftover urine after urination. According to his parents,
Ibad had fever and his urination had dripped since 1 week ago. Ibad often
complained of pain when urination since 6 months ago but has never been
treated. Mr. Mat Idris asked the doctor whether his child could be
circumcised, and if there were any abnormalities in his genital. Will Ibad's
disorder affect his fertility and masculinity as an adult?The puskesmas doctor
gave an explanation about this and Mr. Mat Idris can understand this
explanation.
Childbirth history: Ibad was born weighing 2500 grams, term and normal
delivery.
Immunization history: complete immunization
History of growth and development: normal
Physical examination:
Awareness: compost mentis
Weight: 22 kg, Height: 120 cm.
Vital signs: BP 100/70 mmHg, pulse: 90x / minute, RR: 24x / minute,
temperature: 38.50C
General physical exam:
Head: eyes: conjunctiva is not anemic, sclera is not icteric
Thoracic: symmetrical, absent retraction, heart: normal heart sounds I and II,
heart noise (-), Lungs: normal vesicular, absent crackles.
Abdomen: flat, normal bowel sounds, the liver and spleen are not palpable,
abdominal tenderness is absent, suprapubic tenderness is present
Inguinal region: no palpable lump, pain (-), enlarged lymph nodes (-).
Extremity: warm
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Specific examination of the external genital organs: there was residual
urine in the prepuce, hyperemic OUE, the prepuce could not be opened,
normal scrotal skin, right and left testis were palpable in the scrotum.
2.4 Clarification of Term

1. Circumcision Removal of all or part of the fold of skin
covering the glands of the penis. (Dorland,
2015)
2. Residual urine Residu of liquidsecrection by kidney that
save in vesica urinaria. (Dorland, 2015)
3. Urination Ekskretion of urine. (Dorland, 2015)
4. Oreskin The fold of skin wish covering the glands of
the penis. (Dorland, 2015)
5. Pain Unconvertable feeling body cused by certain
stimulation. (Dorland, 2015)
6. Scrotum The scrotum is a sac consisting of skin and
muscles that encloses the testicles.(Dorland,
2015)
7. Preuce Thefold of skin covering the gland penis.

(Dorland, 2016)
2.5 Identification of Problem

1. Mr. Mat Idris took his son, Ibad, 7 years old , to the puskesmas for
circumcision. Ibad complained that the urination was painful and
according to his parents there was leftover urine after urination. According
to his parents, Ibad had fever and his urination had dripped since 1 week
ago.
7
2. Ibad often complained of pain when urination since 6 months ago but has
never been treated. Mr. Mat Idris asked the doctor whether his child could
be circumcised, and if there were any abnormalities in his genital. Will
Ibad's disorder affect his fertility and masculinity as an adult?. The
puskesmas doctor gave an explanation about this and Mr. Mat Idris can
understand this explanation.
3. Childbirth history: Ibad was born weighing 2500 grams, term and normal
delivery.
4. Physical examination:
temperature: 38.50C
Thoracic: symmetrical, absent retraction, heart: normal heart sounds I and
II, heart noise (-),Lungs: normal vesicular, absent crackles.
Extremity: warm
5. Specific examination of the external genital organs: there oas residual
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2.6 Priority of Problem
No. 1
Mr. Mat Idris took his son, Ibad, 7 years old , to the puskesmas for
circumcision. Ibad complained that the urination was painful and according to
his parents there was leftover urine after urination. According to his parents,
Ibad had fever and his urination had dripped since 1 week ago.
Because there are main complaints such as pain during urination which must
be immediately above so that it will not cause complications and reduce
mortality and morbidity.
2.7 Analysis of Problem

1. Mr. Mat Idris took his son, Ibad, 7 years old , to the puskesmas for
circumcision. Ibad complained that the urination was painful and
according to his parents there was leftover urine after urination. According
to his parents, Ibad had fever and his urination had dripped since 1 week
ago.
a. What is anatomy, physiology mixtiration in this case?
Answer :
Vesica Urinaria
Picture. Anatomy of Vesica Urinaria

Source: Snell, 2018
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The vesica urinaria lies just behind the pubic os in the pelvic cavity. In
adults, the maximum capacity of the bladder is about 500 m1. Vesica
urinaria has strong muscular walls. The shape and boundaries vary
greatly according to the amount of urine it contains. The empty urinary
vesica in adults lies entirely in the pelvis; When filled, the upper wall
rises until it enters the hypogastrica region. In young children, the
empty vesica urinaria protrudes above the pelvic doorway; then when
the pelvic cavity enlarges, the bladder sinks into the pelvis to occupy a
position as in adults (Snell, 2018).
The empty pyramid-shaped vesica urinaria has an apex, a base, and a
superior facies and two inferolateral facies; also has a column (Snell,
2018).
Picture. Anatomy of Vesica Urinaria

Source: Snell, 2018
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The boundaries of the bladder in men are anterior: symphysis pubica,
retropubic fat, and anterior abdominal wall. Posterior: vesica
rectovesicalis peritonei, ducfus deferens, vesicula seminalis, fascia
rectovesicalis, and rectum. Lateral: above the obturator internal
muscles and below the levator ani muscles. Superior: peritoneal cavity,
ileal arch, and colon sigmoideum. And, inferior: the prostate gland
(Snell, 2018).
The vascularization of the bladder is the superior and inferior vesical
arteries, the branches of the internal iliac artery. Veins form the plexus
venosus vesicalis, below which correspond to the plexus prostaticus;
and empties into the internal iliac vein. Lymph flow to the bladder is
the lymph vessels leading to the internal and external iliac nodes
(Snell, 2018).
The innervation of the bladder originates from the inferior hypogastric
plexus. Sympathetic posganglionic fibers originate from the first and
second lumbar ganglion and travel down to the bladder through the
hypogastric plexus. The sympathetic nerves inhibit contraction of the
detrusor vesicae and stimulate closure of the sphincter vesicae. The
parasympathetic nerves stimulate contraction of the detrusor vesicae
and inhibit the musculus sphincter vesicae (Snell, 2018).
Penis
The penis consists of the radix, corpus, and glans penis. The penis has
a fixed radix and a freely hanging corpus. The radix of the penis is
formed by three masses of erectile tissue called the penis bulb and the
penis crus dextrum and sinistrum (Snell, 2018).
The corpus of the penis is substantially composed of three erectile
tissues covered by a tubular sheath (Buck's fascia). The erectile tissue
is formed by two dorsal corpora cavernosa (which are interconnected
with one another) and one corpus spongiosum which lies on its ventral
surface. In the distal part of the corpus spongiosum widens to form the
glans penis, which includes the distal body of the corpora cavernosa.
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At the end of the glans penis there is a gap which is the mouth of the
urethra called the meatus urethrae externus (Snell, 2018).
The preputium is the scarf-like fold of skin that covers the glans penis.
The prepuce is connected to the glans penis by a fold just below the
mouth of the urethra and is called the frenulum. The prephyium is
formed by the folds of skin that attach to the neck of the penis. The
preputium covers the glans penis variably and the prePutium can be
pulled back from the glans penis (Snell, 2018).
Picture. Anatomy of the Penis

Source: Snell, 2018
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Picture. Anatomy of the Penis
Source: Paulsen F and Waschke J, 2015
The vascularization of the penile artery is the corpora cavernosa of the

penis supplied by the deep artery of the penis. The corpus spongiosum
of the penis is supplied by the bulbous penile artery. In addition there
is the dorsal penile artery. All of the above arteries are internal
pudendal arteries. The vein empties into the pudendal vein (Snell,
2018).
Lymph flowwhich drains penile skin lymph fluid drained into the
medial group of superficial inguinal nodes. The deep structure of the
penis drains the lymph fluid into the internal iliac nodi (Snell, 2018).
Innervation of the penisoriginating from the pudendus nerve and
pelvic plexus (Snell, 2018).
Physiology of Miction
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Picture. Nerve Control During Miction
Source: Snell, 2018
The maximum capacity of an adult bladder is approximately 500 ml.

Miction is a reflex action which in normal adults is controlled by a
higher center. The urinary reflex begins when the urine volume
reaches approximately 300 ml. The stretch receptors in the bladder
wall are stimulated and these impulses are transmitted by the central
nerve and there will be awareness of wanting to clear (Snell, 2018).
Most of the impulses go up through the nervi splanchnici pelvici and
enter the second, third sacral segments. all four spinal cord. Some of
the afferent impulses travel along with the sympathetic nerves that
form the hypogastric plexus and enter the first and second lumbar
segments of the spinal cord. The parasympathetic efferent impulses
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leave the spinal cord from the second, third, and fourth sacral
segments and then travel through the parasympathetic preganglionic
fibers between the pelvic nervi splanchnici and hypogaslric plexus
inferior to the bladder wall (Snell, 2018).
The place where the nerve syncs with the postganglionic neurons.
Through this nerve pathway, the smooth muscle of the bladder wall
(musculus detrusor vesicae) contracts and the nusculus sphincter
vesicae relaxes. Efferent impulses also travel to the sphincter urethrae
through the pudendal nerve and cause relaxation (Snell, 2018).
When urine enters the urethra. Additional afferent impulses travel to
the spinal cord from the urethra and strengthen the reflex. Miction can
be assisted by contraction of the abdominal muscles which increases
intraabdominal pressure and pelvic pressure so that pressure arises
from outside the tone of the bladder wall (Snell, 2018).
b. What is the meaning Mr. Mat Idris took his son, Ibad, 7 years old , to
the puskesmas for circumcision. Ibad complained that the urination
was painful and according to his parents there was leftover urine after
urination?
Answer :
The meaning of that is the Ibad's complaint (painful while urination
and leftover urine after urination) is that the complaint is a symptom of
dysuria and post-micturition (terminal dribbling). This is most likely
due to urinary tract disorders. Ibad's dysuria and terminal dribbling
likely stem from acute inflammation of the urinary tract. These
complaints can occur in urinary tract infections, urinary tract anomaly,
and oncology of urogenitalia (Purnomo, 2016).
Synthesis:
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Dysuriais painful with urination and is mainly due to inflammation of
the bladder and urethra. While,dribbling terminal is a post-micturition
symptom where after taking the patient the urine drops again
(Purnomo, 2016).
Urinary tract infection is inflammation that occurs due to the presence
of bacterial colonies that multiply in the urinary tract to the genital
organs and even the kidneys, the most common symptom is pain when
urinating (Purnomo, 2016).
Urinary tract anomaly is a growth disorder of the urinary tract both the
upper urinary tract such as the kidneys, and the lower urinary tract
such as the ureters, bladder bladder, and urethra. One form of anomaly
that can occur especially in boys is phimosis (Purnomo, 2016).
Phimosis is a condition in which the prepuce of the penis cannot be
fractured (drawn) proximal to the corona glandis, this condition often
occurs in children (Purnomo, 2016).
The meaning of Ibad being brought to the health center for
circumcision shows that the patient has not had the prepuce removed
so that the glans penis is still closed. Where the purpose of
circumcision itself from a medical perspective is to keep the penis
clean from smegma and urine debris and prevent infection of the glans
or prepuce of the penis. So that the possibility of cases causing residual
urine and indications of infection in the penis is indicated by
symptoms of dysuria in the case (Purnomo, 2011).
c. What is the corelation age and gender of the case ?

Answer :
UTI is a disease that is relatively common in children. The incidence
of UTI depends on age and sex. The prevalence of UTI in neonates
ranged from 0.1% to 1%, and increased to 14% in neonates with fever,
and 5.3% in infants. In asymptomatic infants, bacteriuria is present in
0.3 to 0.4%. The risk of UTI in children before puberty is 3-5% in girls
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and 1-2% in boys. In children with fever less than 2 years of age, the
prevalence of UTI is 3-5% (IDAI, 2011).
d. What is the etiology of the chief complain in this case?

Answer :
The etiology in the case is probably Escherichia coli (E.coli) where E.
coli is the most common cause of bacteria (60-80%) in the first attack
of UTI. the frequent ones are Proteus mirabilis, Klebsiella pneumonia,
Klebsiella oxytoca, Proteus vulgaris, Pseudomonas aeroginosa,
Enterobacter aerogenes, and Morganella morganii, Staphylococci, and
Enterococci. In complex UTIs, low virulence germs are often found,
such as Pseudomonas, group B streptococci, Staphylococcus aureus or
epidermidis. Haemophilus influenzae and parainfluenza have been
reported as causes of UTI in children. These germs cannot grow on
standard culture media so they are often not considered a cause of
UTIs. If the cause is Proteus, it is necessary to suspect the possibility
of struvite stones (magnesium ammonium-phosphate) because the
Proteus germ produces urease enzymes which break down ureum into
ammonium, so that the urine pH increases to 8-8.5. In alkaline urine,
some electrolytes such as calcium, magnesium, and phosphate will
easily settle (IDAI, 2011).
Physiological phimosisis common in newborn boys. The preputium is
attached to the gland and it separates over time. There will be many
cases of foreskin retraction in physiological phimosis causing
microtears, infection, and bleeding with secondary scarring and true
phimosis. Poor hygiene and recurrent balanitis (penis gland infection),
posthitis (inflammation of the foreskin), or both can cause difficulty in
removal of the foreskin and consequently true phimosis. Diabetes
mellitus predisposes to this infection because of the high urine glucose
content, which is conducive to bacterial proliferation (Shahid, 2012).
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Pathological phimosisit may also be caused by balan it is
xerosisobliterans (BXO), the genital form of lichen sclerosus et
atrophicus. This condition affects both men and boys. The etiology is
unknown; infectious, inflammatory, and hormonal causes have been
implicated. This may represent a pramalignm condition and can also
occur due to repeated catheter use (Shahid, 2012).
e. What is possible disease of the case ?

Answer :
Ibad's complaints of sisuria and terminal dribbling probably stem from
acute inflammation of the urinary tract. These complaints can occur in
urinary tract infections, urinary tract anomaly, and oncology of
urogenitalia (Purnomo, 2016).
1. Urinary tract infection
a. Pyelonephritis, is an inflammatory reaction due to infection
that occurs in the pyelum and renal parenchyma.
b. Cystisis, is acute inflammation of the bladder mucosa which is
often caused by bacterial infection.
c. Prostatitis, is an inflammatory reaction in the prostate gland
that can be caused by bacteria or non-bacteria.
d. Epididymitis, is an inflammatory reaction that occurs acutely or
chronically in the epididymis due to a bacterial infection.
2. Urinary tract anomaly
a. Phimosis, is the prepuce of the penis which cannot be fractured
proximal to the corona glandis.
b. Paraphimosis, is the prepuce of the penis which is fractured
into the coronary sulcus but cannot be returned to its original
state and there is a loop in the penis behind the coronary sulcus.
c. Balanopostitis, is superficial inflammation of the glans penis
and the prepuce of the penis by bacterial infection.
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d. Testicular torsion, is a twisting of the sprematikus funiculus
which results in disruption of blood flow to the testes.
3. Oncology of urogenitalia
a. Kidney tumor, is a urogenitalia tumor that attacks the renal
parenchyma.
b. Bladder carcinoma, is a malignancy that occurs in the bladder.
c. Prostate carcinoma, is a malignancy that occurs in the prostate
gland in men.
(Purnomo, 2016).
f. What kind of UTI in this case?

Answer:
In this case UTI that ibad experienced is Cystitis
a. Pyelonephritis, is an inflammatory reaction due to infection that
occurs in the pyelum and renal parenchyma.
b. Cystisis, is acute inflammation of the bladder mucosa which is
often caused by bacterial infection.
c. Prostatitis, is an inflammatory reaction in the prostate gland that
can be caused by bacteria or non-bacteria.
d. Epididymitis, is an inflammatory reaction that occurs acutely or
chronically in the epididymis due to a bacterial infection.
There is a urinary tract infection that is simple in nature, so that it is
only an infection of microorganisms. And that is compact, where there
are microorganism infections and anomalies in the structure of the
urinary tract (Purnomo, 2016).
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g. What is the meaning of According to his parents, Ibad had fever and
his urination had dripped since 1 week ago?
Answer :
The meaning ibad had fever and his urination had dripped since 1
week ago is ibadalready had urinary tract infection. from accumulation
fluid inside prepuce and disruption of urin flow during micturition.
Local hyginethat aren’t clean enough can causes urinary tract
infection. because the prepuce was attached with the gland penis
.Phimosis causes distruption urine flow make difficulty urinating and
causes urinary retention. (Purnomo, 2011)
h. How is the pathophysiology in this identification ?
Answer :
Urination was painful :
Risk factors: age and sex + not circumcised → poor local hygiene →
accumulation of dirt on the glans penis + accumulation of smegma →
possible infection of the glans penis and prepuce→chronic (for 6
months)→scar tissue forming on the preputial orificium → preputium
adhere to the glans penis → phimosis → parts orificium urethra
externum narrows → inhibits urine output → urine retention and urine
remains accumulate in the prepuce (urine as an ideal medium for
bacterial growth) → bacteria multiply and spread → infection
asending to the bladder (vesica urinaria) → urinary tract infection → a
reaction occurs inflammation → stimulates pain nociceptors in the
vicinity → stimulates pain centers in the hypothalamus → urination
was painful (Tusino & Widyaningsih, 2018).
Therewasleftover urine afterurination :
months) → scar tissue forming on the preputial orificium → preputium
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externum narrows → inhibits urine output →there was leftover urine
after urination (Shahid, 2012).
Fever since 1 week ago :
reaction occurs inflammation →stimulates endogenous pyrogens to
release pro-inflammatory mediators (IL-1, IL-6, TNF-α, and IFN) →
arachidonic acid release → converted by COX-1 and COX-2 to
prostaglandin E2 → increased thermostart in the thermoregulatory
center in the hypothalamus → increase body temperature → fever
(Tusino & Widyaningsih, 2018).
Hisurination had drippedsince 1 weekago :
externum narrows → inhibits urine output → urine remains
accumulate in the prepuce → his urination had dripped (Shahid, 2012).
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i. How to do the circumcision?
Answer:
Preparation of circumcision equipment:
- 2 pairs of sterile gloves
- Sterile gauze
- Disinfectant fluids, such as povidone iodine
- Clamps for disinfection
- Doek sterile hole
- Sterile 2.5 or 5 cc syringe
- Lidocaine for infiltration anesthesia
- or 3 straight clamps
- or small artery clamps
- Network scissors
- Thread scissors
- Surgical threads that are quickly absorbed, for example plain catgut
3/0 to taste
- Curved cutting sewing needle ½, or better if available with a-
traumatic cutting sewing needle
- Needle holder
- Tweezers
- Crooked
- Plaster
Technics:
a. Washing hands and wearing sterile gloves
b. Perform antiseptic aseptic action by applying sterile gauze that has
been given antiseptic liquid from the middle by rotating outward
c. Narrowing the area of action by covering it with a hollow sterile
cup
d. Performing a local anesthetic injection with infiltration and block
anesthesia techniques.
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e. The infiltration anesthetic technique is performed by injecting
lidocaine subcutaneously by circling the base of the penis. Before
inserting lidocaine solution, do an aspiration first to make sure that
the needle does not enter the blood vessel.
f. Block anesthesia technique is performed by inserting lidocaine
perpendicular to the base of the penis just below the pubic
sympathy until it penetrates Buch's fascia (like through a paper).
Before inserting lidocaine solution, do an aspiration first to make
sure that the needle does not enter the blood vessel.
g. Wait 2 - 3 minutes until the onset of action of the drug is reached
and make sure that the local anesthetic has worked by clamping the
prepuce using tweezers.
h. Remove the adhesions between the prepuce and the glans of the
penis and clean the smegma in the area using bent clamps and / or
sterile gauze.
i. Technique Releasing the adhesion between the prepuce and the
glans of the penis by using a bent clamp is done by pulling the
prepuce towards the proximal then inserting the bent clamp into the
prepuce and then the clamp is opened and closed while being
pushed towards the attachment (such as a scissor motion). Do it
repeatedly towards the proximal and lateral direction until you see
the corona glan and the base of the prepuce mucosa around the
corona glan.
j. Technique Removing the adhesions between the prepuce and the
glans of the penis using sterile gauze is that the perpusium is pulled
with the left hand proximal until adhesions are visible and the right
hand holds sterile gauze to release adhesions gradually towards the
proximal and lateral directions until the corona glan is visible and
the base of the prepuce mucosa around the corona glans
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k. Make an incision / disposal prepusium by:
- Pinch prepusiumdiarah hour 1, 11 and 6 using a straight clamp,
then ask an assistant to pull the clamps towards the distal
- Prepuce in the incision at 12 o'clock between the clamping jaws
with scissors proximal to the direction of the network appeared
the coronary sulcus
- Perform a circular incision towards the frenulum to the right
and left of the end of the first incision
- Take control of bleeding in the frenulum by way ligated with
catgut suture technique using the number 8.
- If there is bleeding in the mucosa perform ligation using artery
clamps and catgut.
l. Sewing the wound by approximating / suturing the skin with the
mucosa at the incision site at 3, 6, 9, 12 o'clock and can be added
as needed.
m. The wound is closed with sterile gauze around the wound and fixed
towards the sympathy pubis
j. What is the contraindication and indication of circumcision ?
Answer:
Indication:
Medical Indication circumcision Is for Phimosis, paraphimosis, and
chronic urinary tract infection. Elective circumcision maybe indicated
in regions with in creased HIV and human papilloma virus (HPV)
(Warees, 2020).
Contraindication:
Circumcision is contraindicated in infants with certain genital structure
abnormalities, such as a misplaced urethra lopening (as in hypo
spadias and epispadias), curvature of the head of the penis (chordee),
or ambiguous genitalia, because the foreskin maybe needed forrecon
structive surgery. Circumcision is contraindicated in premature infant
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sand those who are not clinically stable and in good health (Hay &
Levin, 2012).
k. What the functionof circumcision ?

Answer :
a. Maintain the hygiene of the penis from smegma and urine debris
b. Prevent infection of the glans or prepuce of the penis
c. Prevent penile carcinoma (Basuki Purnomo, 2016).
2. Ibad often complained of pain when urination since 6 months ago but has
never been treated. Mr. Mat Idris asked the doctor whether his child could
be circumcised, and if there were any abnormalities in his genital. Will
Ibad's disorder affect his fertility and masculinity as an adult?. The
puskesmas doctor gave an explanation about this and Mr. Mat Idris can
understand this explanation.
a. What is the meaning Ibad often complained of pain when urination
since 6 months ago but has never been treated?
Answer :
The meaning of complaining of pain when urinating since 6 months
ago is the possibility that Ibad has had a local infection of the glans
penis and foreskin (balanoposthitis) which has been chronic since 6
months ago caused by poor hygiene and chronic inflammation of the
glans penis and foreskin (balanoposthitis chronic), this case occurs
only in boys who are not circumcised which can cause scarring of the
preputial opening causing pathological phimosis and the meaning of
but has neverbeentreated is the infection experienced by ibad has
become chronic and has led to urinary tract infections and phimosis
because it is not treated quickly and appropriately (Morris et al, 2020).
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b. What is the meaning Mr. Mat Idris asked the doctor whether his child
could be circumcised, and if there were any abnormalities in his
genital?
Answer :
The meaning that he asks whether his child can be circumcised
indicates that this condition does not occur due to imperfect
circumcision, which is in accordance with the theory in dejong surgery
books that phimosis is a narrowing of the prepuce due to inflammation
such as balanopositis or after an imperfect circumcision.
c. What is the relation of the complain urination since 6 month ago it this
chief complain?
Answer :
The association between complaints 6 months ago with the main
complaint is the progression of lower urinary tract infections
characterized by untreated dysuria causing increased virulence of
microorganism agents to enter the urinary tract through the urethra -
prostate - vas deferens - testes - bladder. So that activates the body's
immune response to infection in the form of fever which is a
manifestation of upper urinary tract infection (Purnomo, 2016).
d. What is the corelation between complain and his fertility and

masculinity?
Answer :
In this case, fertility and masculinity disorders may occur as a result of
prepuce anomaly (phimosis). Phimosis conditions and infection that
also occurs when it attacks the testes and tubules of the semen will
cause disrupted spermatogenesis and production of the hormone
testosterone and result in impaired fertility and masculinity disorders.
(Purnomo, 2016).
26
e. What are the various kinds of abnormality in the masculine genital
organs?
Answer :
1. Maldesensus testes
The testes are not in the testicular bag, due to the failure of the
testicular desensus testicular process or descending into the scrotal
sac
2. Hydrocele
Is the buildup of excessive fluid between the parientalis layer and
visceral tunica vaginalis.
3. Testicular torsion
It is a twisting of the sprematikus funiculus which results in
disruption of blood flow to the testes.
4. Phimosis
Is the prepuce of the penis that cannot be retracted / retracted
proximal to the corona glandis.
5. Paraphimosis
The prepusium of the penis, which is retracted to the coronary
sulcus, cannot be returned to its original state and an entanglement
occurs in the penis behind the coronary sulcus.
6. Balanopostitis
The state of occurrence of balanitis (inflammation of the
superficial glands of the penis) and postitis (inflammation of the
prepuce of the penis) which occur simultaneously so that it
becomes balanopostitis.
7. Penile adhesions
Is adhesions of the foreskin distal to the glands.
8. Hypospadias
It is a congenital abnormality in the form of a urethral opening
which is located next to the ventral of the penis and proximal to the
tip of the penis.
27
f. What is possible doctor explanation about Mr. Mat idris question?
Answer :
The possible explanation given by the doctor is that this Ibad has a
disruption in his duct in the form of prepucium anomaly, namely
physiological phimosis, which develops into pathological phimosis due
to urinary tract infection due to poor genital hygiene. Phimosis and
urinary tract infections that occur manifest in the form of dysuria,
terminal dribbling and fever. In cases where circumcision can still be
done, this is also highly recommended so that it can restore the
condition of the penis skin properly. If this complaint is not treated
quickly, it will cause chronic infection to cause neoplasms, and can
experience fertility and masculine disorders (Purnomo, 2016).
g. How does doctor patient comunication in this case?

Answer :
Communication between doctor-patient is one of the important aspects
in health care. In this case scenario, the doctor must provide the best
possible explanation so that the family patients can understand our
explanation and prevents miscommunication between doctor-patient.
In this case the doctor must provide an explanation to Mr. Mat Idris
regarding the illness suffered by Ibad which is phimosis with UTI. The
doctor must provide education that Ibad is still undergoing
circumcision but we must wait until Ibad condition is better and not
suffering fever again. Doctors must provide education to patients in
order to maintain the best possible hygiene by keeping the masculine
genital organs clean.
3. Childbirth history: Ibad was born weighing 2500 grams, term and normal
delivery.
28
a. What is the meaning of childbirth history?
Answer :
The meaning of childbirth history is that the birth weight is 2500
grams which is still normal, LBW (low birth weight) only occurs if the
baby weighs less than 2500 grams (Proverewati, 2010).
The labor history also indicates that the complaints that occur in the
case are not caused by embryological or congenital disorders, so that
the phimosis that occurs in the case is most likely formed when Ibad
has been born (non-congenital phimosis). This can also rule out the
differential diagnosis of other urinary tract diseases such as the
maldensensus testis, ectopic ureter, testicular torisio, and cryptokimus
(Purnomo, 2016).
b. What is the meaning of Immunization history?

Answer :
Complete Immunization History, meaning that Ibad has immunity to
the invasion of microorganisms that commonly attack children. At the
age of 7 years, Ibad has already carried out immunizations, especially
BCG, DPT, Polio, Measles, Hepatitis B, and others according to the
immunization schedule (IDAI, 2014).
The meaning is that the imbalance between the infectious
microorganisms (uropathogens) as an agent and the urinary tract
epithelium as a host is not caused by decreased body defenses from the
host, but due to the increased virulence of the agent. It can also rule out
a differential diagnosis of renal TB (Purnomo, 2011).
c. What is the meaning of History of growth and development?

Answer :
Normal growth and development is significant if the Body Mass Index,
Height, Weight, Head Circumference and Normal Nutrition. The
development of children aged 7 years or school age are usually active
29
in learning activities or schooling and sports, there are no
abnormalities in organs such as cardiovascular, and others.
4. Physical examination:
temperature: 38.50C
Thoracic: symmetrical, absent retraction, heart: normal heart sounds I and
II, heart noise (-),Lungs: normal vesicular, absent crackles.
Extremity: warm
a. How is the physical and general physical examination interpretation?
Jawab :
An overview Normal Value Information

Physical Examination
Awareness: compost mentis Normal
compost mentis
Weight: 22 kg Weight: 22 kg Normal
Height: 120 cm Height: 120 cm
Blood Preasure: 100-140 / 70-90 Normal
100/70 mmHg mmHg
Pulse: 90x / minute 60-100 x / minute Normal
Respiratory Rate: 20-24 x / minute Normal
24x / minute
Temperature: 36.5-37.5 Fever (febris)
38.50C
General Physical Examination
Head: Normal
30
eyes: conjunctiva is conjunctiva is not
not anemic, sclera is anemic, sclera is not
not icteric icteric
Thoracic: Normal
symmetrical, absent symmetrical, absent
retraction, heart: retraction, heart:
normal heart sounds normal heart sounds I
I and II, heart noise and II, heart noise (-),
(-), Lungs: normal Lungs: normal
vesicular, absent vesicular, absent
crackles. crackles.
Abdomen:
flat, normal bowel flat, normal bowel Abnormal
sounds, the liver sounds, the liver and (suprapubic
and spleen are not spleen are not tenderness is
palpable, abdominal palpable, abdominal present), an
tenderness is absent, tenderness is absent, indication of a cystic
suprapubic and there is no urinary tract
tenderness is suprapubic tenderness infection
present is present
Inguinal region: Normal

no palpable lump, no palpable lump,
pain (-), enlarged pain (-), enlarged
lymph nodes (-). lymph nodes (-).
Extremity: Normal
warm warm
(Purnomo, 2016).
31
b. What is the abnormal mechanism of physical and general physical
examination?
Answer :
Febris/fever :
possible infection of the glans penis and prepuce → chronic (for 6
reaction occurs inflammation →stimulates endogenous pyrogens to
release pro-inflammatory mediators (IL-1, IL-6, TNF-α, and IFN) →
arachidonic acid release → converted by COX-1 and COX-2 to
prostaglandin E2 → increased thermostart in the thermoregulatory
center in the hypothalamus → increase body temperature → fever
(Tusino & Widyaningsih, 2018).
Suprapubic tenderness :
reaction occurs inflammation → suprapubic tenderness. (Tusino &
Widyaningsih, 2018)
32
5. Specific examination of the external genital organs: there was residual
a. How is the specific examination of the external genital organs
interpretation?
Answer :
There was residual urine in the prepuce, hyperemic OUE, the prepuce
could not be opened.
b. What is the abnormal mechanism ofspecific examination of the

external genital organs?
Answer :
There was residual urine in the prepuce :
chronic (for 6 months) → scar tissue forming on the preputial
orificium → preputium adhere to the glans penis → phimosis → parts
orificium urethra externum narrows → inhibits urine output → there
was residual urine in the prepuce (Shahid, 2012).
Hyperemic OUE :
chronic (for 6 months) →local inflammation occurs → bradykinin and
histamine release → vasodilation and increased capillary permeability
→ hyperemic OUE (Shahid, 2012).
The prepuce could not be opened :
chronic (for 6 months) →local inflammation occurs → accumulation
of inflammatory cells→ the prepuce could not be opened (Shahid,
2012).
33
6. Additional Examination
Leukosit : 25.000 mm3
Hb 13 gr/dl
Platelets 250.000 / mm3
USG: thickening of the bladder wall
Makroskopik: Slightly cloudy yellowish color, specific gravity 1.020
Mikroskopik: Eritorosit: 0-1 / hpf, leukosit: 30-50 / hpf, bacteriuria (+),
nitrite (+), leukocyte esterase (+), ephithelium 10 / hpf, urine cylinder (-)
Urin culture: E.coli> 100.000 cfu (colony forming unit) / ml, sensitive to
contrimoksazol, gentamicin, ceptriaxone, and ampicillin
Answer:
Leukositosis,
Abnormal (thickening of the bladder wall, slightly cloudy yellowish color,
specific gravity 1.020, bacteriuria (+), nitrite (+), leukocyte esterase
(+),E.coli> 100.000 cfu / ml)
Indication of infalmatory tract urinary (cystitis) - thickening of the bladder
wall.
a. How is the additional examination interpretation?
Answer :
Laboratory Normal Interpretation

examination
Hb 13 g/dl 13,0-17,5 Normal
WBC 25.000 4.500-11.000 Leukositosis
Platelets 250.000 150.000-350.000 Normal
Macroscopic:slightly Normal
cloudy yellowish
color, specific gravity
1.020
Normal
erythrocytes 0-1 /lpb
Leukositosis
leukocytes 30-50 /lpb,
34
epithelium 10 /lpb
Normal
urine cylinder (-)
Normal
leukocyte esterase (+)
Abnormal
nitrite (+)
Abnormal
bacteriuria (+).
Abnormal
Urine culture: E. Coli
> 100,000 cfu /
ml,sensitive to Abnormal
cotrimoxazole,
gentamicin,
ceptriaxone, and
ampicillin.
USG TUG: hickening

of the bladder wall.
Abnormal
7. How to diagnose?
Answer :
1. Anamnesis
The history that was carried out was a systematic history which
included the main complaints, additional complaints, history of the
disease that had been experienced by him and his family. and the
patient's current medical history. In the case of complaints that the
35
patient experienced was dysuria, terminal dribbling, and fever since 6
months ago (Purnomo, 2016).
2. Physical examination
Physical examination is one way of objective diagnosis, where in this
case it is known that the patient has fever and suprapubic tenderness
indicating urinary tract infection, especially in the bladder or cystisis.
Specific examination of the genitalia shows residual urine, hyperemic
OUE, and the prepuce that cannot be opened, this indicates an anomaly
in the prepuce, namely phimosis (Purnomo, 2016).
3. Additional examination
Additional examination like imaging and urin test in this
case indication of phimosis and urinanry tract imfection (cystitis)
(Purnomo, 2016).
8. What is the differential diagnose of this case?

Answer :
In this case, prepuce anomaly and complicated urinary tract infections
(because it is accompanied by anatomic or structural disorders of the
urinary tract) are likely to occur (Purnomo, 2016).
1. Phimosis and urinary tract infections (cystysis or urethritis).
2. Paraphimosis and urinary tract infections (cystysis or urethritis).
3. Phostitis and urinary tract infections (cystysis or urethritis).
4. Balanitis and urinary tract infections (cystysis or urethritis).
5. Balanopostitis and urinary tract infections (cystysis or urethritis).
An Case F PF P B BP
overview
Dysuria √ √ √ √ √ √
Dribbling √ √ √ √ √ √
terminal
Fever √ √ √/- √ √ √
OUE √ √ - √ - √
hyperemic
36
Preduce √ √ - - - √
could not
be opened
The Preduc Preduc Preduc Preduc Superfici Superfi
location of e e e e al glands cial
the of the glands
disturbanc penis of the
e penis
and
preduc
e
Description:
F : Phimosis B : Balanitis
PF : Paraphimosis BP : Balanophostitis
P : Phostitis
(Purnomo, 2016).
An overview Case Sistisis Urethritis

Dysuria √ √ √
Dribbling terminal √ √ √
Fever √ √ -
Tenderness √ √ -
suprapubic
(Purnomo, 2016).
9. What is the additional examinationof this case?

Answer :
1. Urinalysis
a. Leukosituria is an indication of the possibility of bacteriuria
b. The nitrite test is an indirect examination of bacteria in the urine.
Under normal circumstances, nitrite is not present in the urine, but
can be found if the nitrate is converted into nitrite by bacteria.
Most of the Gram negative bacteria and some Gram positive germs
37
can convert nitrate to nitrite, so if the nitrite test is positive it means
there are germs in the urine
- Leukocyte esterase
- Protein test
- Blood test
- Neutrophil gelatinase associated urinary lipocalin (uNGAL)
and the ratio of uNGAL to urinary creatinine (uNGAL / Cr) are
signs of a UTI. NGAL is an iron-carrier-protein found in
neutrophil granules and is a component of innate immunity that
responds to bacterial infections. Increased uNGAL and uNGAL
/ Cr ratio> 30 ng / mg are signs of UTI.
- Anti-coated bacteria (ACB) in urine examined by using
- fluorescein-labeled anti-immunoglobulin is a sign of
pyelonephritis in adolescents and young adults, but is not able
to be like in children
2. Blood test
a. Leukocytosis, an increase in the absolute value of neutrophils
b. Increased sedimentation rate (ESR)
c. A positive C-reactive protein (CRP) is a non-specific indicator of
upper UTI.
d. High levels of procalcitonin can be used as a valid predictor of
acute pyelonephritis in children with febrile urinary tract infection
and scar. 8 Consensus of Urinary Tract Infection in Kidney
Children. Cytokines are small proteins that are important in the
inflammatory process. Procalcitonin, and proinflammatory
cytokines (TNF-α; IL-6; IL-1β) are increased in the acute phase of
infection, including in acute pyelonephritis (IDAI, 2011).
38
10. What is the working diagnoseof this case?
Answer :
Pathological phimosis and urinary tract infection (cystitis)
Synthesis:
Phimosis (Phimosis) is a disorder that occurs in the genital organs of male
babies, what is meant by phimosis is a condition in which the foreskin
(prepuce) attaches to the glans and results in blockage of the holes in the
urine, so babies and children have difficulty and pain when urinating
(Purnomo, 2016).
Cystysis is an acute inflammation of the mucosa of the bladder which is
often caused by bacterial infection that enters through the urethra, this is
characterized by redness, edema, hypersensitivity when the bladder is
filled with water and fever (Purnomo, 2016).
11. How is the treatment of this case?

Answer :
Pharmacology
1. Topical steroids
Extensive topical steroid use is recommended in patients with
phimosis, and topical application to the foreskin can allow it to be
withdrawn at an early stage. Typical treatment is 4 to 8 weeks, with
regular attempts at retraction during this time. Given the low risk
associated with short-term use of topical steroids, this can be repeated
if necessary (McPhee, 2020).
Administration of corticosteroid ointment (0.05% betamethasone) 2
times per day, 4-8 weeks in the prepuce area (IDI, 2017).
2. Surgery (circumcision)
An alternative surgical approach such as circumcision can be
performed especially with preputioplasty. Preputioplastyis the medical
term for plastic surgery on the phimotic foreskin. This procedure has a
faster and less painful recovery, less morbidity, less cost, and more
39
preservation of the foreskin and various projectile, sexually sensitive,
and sexual physiological functions (Shahid, 2012).
3. Antibiotics for Urinary Tract Infections
 Antibiotics: amoxicillin 50mg / kgBW divided into 3 doses or
cotrimoxazole 10mg / kgBW
 Antipyretics: Paracetamol 10-15mg / kg
(IDI, 2017).
Non-Pharmacology
1. Education about the causes and risk factors for urinary tract infections,
which can occur due to anal contact or poor hygiene.
2. Education about being alert for signs of upper urinary tract infection
(low back pain), and important for return control.
3. Education about adherence to antibiotic treatment that has been given to
patients.
4. Education about maintaining genital and environmental hygiene
properly.
5. Educate and explain to parents that they or the patient do not overdo the
preputum when cleaning the penis as this can cause scarring.
6. Drink at least 2 liters of water / day if kidney function is normal.
(IDI, 2017).
Reference criteria:
If there are complications from a common tract infection and persistent
symptoms or there is resistance to antibiotics (IDI, 2017).
12. What is the complication of this case?

Answer :
1. Inflammation of the glans penis (Balanitis)
2. Inflammation of the prepuce (postitis)
3. Paraphimosis
40
4. If circumcision is not performed, it can increase the incidence of penile
cancer and chronic infections if accompanied by poor hygiene
(McCance, K. 2019).
13. What is the prognose of this case?

Answer :
Phimosis
Quo ad vitam : Dubia ad bonam
Quo ad sanationam : Dubia ad bonam
Quo ad functionam : Dubia ad bonam
Complicated urinary tract infections (cystisis)
Quo ad vitam : Dubia ad bonam
Quo ad sanationam : Dubia ad bonam
Quo ad functionam : Dubia ad bonam
Synthesis:
The prognosis in phimosis and cystisis patients is relatively good, except
when genital hygiene remains poor and urinary tract infections are
recurrent or chronic (IDI, 2017).
14. What is the doctor's competency standard (SKDU) in this case?
Answer :
4A.
A graduate of general practitioners Able to make clinical diagnosis and
manage the disease independently and completely.
15. What is the islamic view in this case?

Answer :
HR. Bukhari 5889, Muslim 257
‫ الختان واالستحداد وقلم األظافر وقص الشارب ونتف اإلبط‬-‫يعني السنة خمس‬- ‫الفطرة خمس‬
Meaning: "The five sunnah fitrah are circumcision (circumcision), istihdad
(shaving pubic hair), cutting nails, shaving the mustache, and pulling out
armpit hair."
41
In the case: The hadith states that the sunnah fitrah is one of them is
circumcision, we know that circumcision has benefits both from a
religious or medical perspective.
QS An-nisa Verse 125
Meaning: "And who is better in his religion than a person who sincerely
surrenders himself to Allah, while he is doing good, and he follows the
straight Abrahamic religion? And Allah took Ibrahim to be His favorite."
2.8 Conclusion
42
Ibad 7 years old, complained of paiful urination (dysuria), residual urine in
the prepuce, fever, dripping urine and suprapubic tenderness due to phimosis
and urinary tract infection (cystitis).
2.9 Conceptual Framework
Risk Factor
(age, gender, poor hygien, and have not circumsision)
↓
Adhesions of the prepuce and glans penis
↓
Inhibition of urine secretion
↓
The rest of urine is on the prepuce
↓
Medium for bacterial development
↓
Urinary tract infection
↓
Complains in the case
(dysuria, fever, residual urine, dripping urine, and suprapubic tenderness)
43
BIBLIOGRAPHY
Abdullahi abdul wahab ahmed.2013. Techniques of Male Circumcision. March

2013 Journal of Surgical Technique and Case Report 5(1):1-7
DOI:10.4103/2006-8808.118588
Ikatan Dokter Anak Indonesia (IDAI). 2011. Unit Kerja Koordinasi (UKK)
Nefrologi Konsensus Infeksi Saluran Kemih Pada Anak
McPhee, AS., Stormont, G., McKay, AC. 2020. Phimosis. StatPearls Publishing:
University of Nebraska Medical Center
Morris BJ, Krieger JN. 2017. Penile Inflammatory Skin Disorders and the
Preventive Role of Circumcision. Int J Prev Med. 2017;8:32. Published
2017 May 4. doi:10.4103/ijpvm.IJPVM_377_16
Morris, B. J., Matthews, J. G., & Krieger, J. N. (2020). Prevalence of Phimosis in

Males of All Ages: Systematic Review. Urology, 135, 124–132.
https://doi.org/10.1016/j.urology.2019.10.003
Paulsen, F., J. Waschke. 2015. Anatomical Atlas of Sobotta. Volume 2 Edition.

23. EGC Medical Publishers Book
Proverawati, A. 2010. LBW (Low Birth Weight).Yogyakarta: NuhaMedika
Purnomo, BB. 2016. Urology Basics. Edition 3. Malang: Sagung seto
Shahid, SK. 2012. Phimosis in Children. India: ISRN Urology
Snell, Richard S. 2018. Clinical Anatomy: Based on Systems. Jakarta: Book

Medical Publishers EGC
Shahid, S. K. (2012). Phimosis in Children. Japanese Journal of Clinical
Urology, 54(11), 853–855. https://doi.org/10.5402/2012/707329
44
Tusino, A., & Widyaningsih, N. (2018). Karakteristik Infeksi Saluran Kemih
Pada Anak Usia 0- 12 Tahun Di Rs X Kebumen Jawa Tengah. Biomedika,
9(2), 39–46. https://doi.org/10.23917/biomedika.v9i2.5842
Yamaji, R., Friedman, C. R., Rubin, J., Suh, J., Thys, E., McDermott, P., Hung-
Fan, M., & Riley, L. W. (2018). A Population-Based Surveillance Study of
Shared Genotypes of Escherichia coli Isolates from Retail Meat and
Suspected Cases of Urinary Tract Infections . mSphere, 3(4), 1–12.
https://doi.org/10.1128/msphere.00179-18
45

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TUTORIAL REPORT

SCENARIO CASE A BLOK 15

1.2 Purpose and Objectives...............................................................................................4

2.1 Tutorial Data...............................................................................................................5

2.2 Case Scenario..............................................................................................................6

2.3 Clarification of Problems............................................................................................7

2.4 Identification of Problems..........................................................................................7

2.5 Priority of Problems....................................................................................................9

2.6 Analysis of Problems..................................................................................................9

2.8 Conceptual Framework..............................................................................................43

1.2 Purpose and objective

2.1 Tutorial Date

2.4 Clarification of Term

7. Preuce Thefold of skin covering the gland penis.

2.5 Identification of Problem

2.7 Analysis of Problem

Picture. Anatomy of Vesica Urinaria

Picture. Anatomy of Vesica Urinaria

Picture. Anatomy of the Penis

The vascularization of the penile artery is the corpora cavernosa of the

The maximum capacity of an adult bladder is approximately 500 ml.

c. What is the corelation age and gender of the case ?

d. What is the etiology of the chief complain in this case?

e. What is possible disease of the case ?

f. What kind of UTI in this case?

k. What the functionof circumcision ?

d. What is the corelation between complain and his fertility and

g. How does doctor patient comunication in this case?

b. What is the meaning of Immunization history?

c. What is the meaning of History of growth and development?

An overview Normal Value Information

Inguinal region: Normal

b. What is the abnormal mechanism ofspecific examination of the

Laboratory Normal Interpretation

USG TUG: hickening

8. What is the differential diagnose of this case?

An overview Case Sistisis Urethritis

9. What is the additional examinationof this case?

11. How is the treatment of this case?

12. What is the complication of this case?

13. What is the prognose of this case?

15. What is the islamic view in this case?

QS An-nisa Verse 125

2.9 Conceptual Framework

Abdullahi abdul wahab ahmed.2013. Techniques of Male Circumcision. March

Morris, B. J., Matthews, J. G., & Krieger, J. N. (2020). Prevalence of Phimosis in

Paulsen, F., J. Waschke. 2015. Anatomical Atlas of Sobotta. Volume 2 Edition.

Proverawati, A. 2010. LBW (Low Birth Weight).Yogyakarta: NuhaMedika

Purnomo, BB. 2016. Urology Basics. Edition 3. Malang: Sagung seto

Shahid, SK. 2012. Phimosis in Children. India: ISRN Urology

Snell, Richard S. 2018. Clinical Anatomy: Based on Systems. Jakarta: Book

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