LAPORAN TUGAS EVIDENCE BASED MEDICINE BLOK REPRODUKSI BARTHOLINITIS

Oleh : Bayu Utaminingtyas (04711017) Adi Kurniawan (04711061) Yulis Boneight (04711064) KELOMPOK 9 TUTOR : dr. H. Syaifuddin AA

FAKULTAS KEDOKTERAN

UNIVERSITAS ISLAM INDONESIA 2007 BARTHOLINITIS

Kasus Pemicu: Ny. A, umur 40 tahun datang ke rumah sakit dengan keluhan terdapat benjolan pada kemaluan bagian luar sebelah kanan. Benjolan terdapat sejak lima hari yang lalu. Benjolan dirasakan mula-mula kecil makin lama makin membesar. Benjolan dirasakan nyeri, terasa panas, perih, keluhan demam tidak ada. Ny. A sudah menikah selama 6 tahun. Menstruasi teratur setiap bulan, siklus 28 hari, lamanya 7 hari. Ny. A tidak pernah menggunakan alat kontrasepsi. Pada pemeriksaan fisik didapatkan adanya benjolan tunggal di labia mayora kanan, diameter 1,5 cm, berwarna merah. Pada perabaan, teraba benjolan berbatas tegas, konsistensi kenyal, nyeri tekan (+), permukaan halus, pada perabaan hangat. Diagnosis Ny. A adalah Bartholinitis dengan pemberian terapi Ciprofloksasin 2x500 mg. Problem pada kasus: Problem Diagnosis: Bagaimana cara menegakkan diagnosis Bartholinitis? Problem terapi: Terapi apa sajakan yang digunakan dalam menangani kasus Bartholinitis? Apakah penggunaan antibiotik merupakan terapi yang paling efektif? Problem harm/efek samping: Bagaimanakah resiko efek samping penggunaan antibiotik dibandingkan dengan tindakan terapi yang lain? Problem Prognosis Berapa besar resiko kekambuhan yang dapat ditimbulkan dalam penggunaan antibiotik? Problem ekonomi Apakah penggunaan antibiotik lebih murah dibandingkan dengan terapi yang lain? Analisis PICO: 1. P (Patient/problem) 2. I (Intervention) 3. C (Comparation) 4. O (Outcome) Pertanyaan klinik: Pada kasus bartholinitis apakah pengunaan antibiotik lebih efektif dibandingkan dengan tindakan insisi? : bartholinitis : Antibiotik, ciprofloksasin. : tindakan Insisi : kesembuhan dan kekambuhan

Penelusuran Evidence Adi kurniawan

melalui website Pubmed : http://www.ncbi.nlm.nih.gov/PubMed menggunakan keyword : bartholinitis didapatkan 55 hits tidak ada yang full text menggunakan keyword bartholin gland didapatkan 482 hits menggunakan keyword bartholin gland inflammation didapatkan 143 hits menggunakan keyword bartholin gland inflammation dengan diberi limit to full text didapatkan 8 hits Dipilih artikel : Office Management of Bartholin Gland Cysts and Abscesses D. ASHLEY HILL, M.D., and JORGE J. LENSE, M.D. Florida Hospital Family Practice Residency Program, Orlando, Florida American Academy of family physicians 1998 Apr 1;57(7):1611-6, 1619-20 Bayu Utami melalui website Pubmed : http://www.ncbi.nlm.nih.gov/PubMed menggunakan keyword : bartholinitis didapatkan 55 hits tidak ada yang full text menggunakan keyword bartholin gland didapatkan 482 hits menggunakan keyword bartholin gland inflammation didapatkan 143 hits Dipilih artikel : Therapy of inflammatory changes in Bartholin's glands menggunakan keyword bartholin gland inflammation dengan diberi limit to full text didapatkan 8 hits Dipilih artikel : Med Pregl. 2000 May-Jun;53(5-6):289-92. Management of bartholins duct cyst and gland abscess AFP 2003, Volume 68: 135-140 Yulis B melalui website Pubmed : http://www.ncbi.nlm.nih.gov/PubMed menggunakan keyword gonorrhoeae dengan limit to free full text didapatkan 2232 hits menggunakan keyword gonorrhoeae and ciprofloxacin didapatkan 127 hits menggunakan keyword gonorrhoeae and ciprofloxacin and comparison didapatkan 11 hits Dipilih artikel : Comparison of Single-Dose Cefuroxime Axetil With Ciprofloxacin in Treatment of Uncomplicated Gonnorhea Caused by Penicillinase Producing and Non-PenicillinaseProducing Neisseria gonorrhoeae Strain EDWIN M. THORPE,JR., JANE R. SCHWEBKE, EDWARD W. HOOK III, ANNE ROMPALO. Antimicrobial Agents And Chemotherapy, Dec. 1996, p. 2775-2780

Resume/Summary Adi kurniawan

Normally, the Bartholin's gland cannot be palpated. Bartholin gland cysts develop from cystic dilation of the duct following blockage of the duct orifice. They are generally 1 to 3 cm in size and are usually asymptomatic. The patient may notice a bulge in the labium majus or the cyst may be found during a routine gynecologic examination. When symptoms occur, the patient may report vulvar pain, dyspareunia, inability to engage in sports and pain during walking or sitting. Bartholin gland cysts tend to grow slowly. Since noninfected cysts are usually sterile, routine antibiotic therapy is not necessary.1 Asymptomatic Bartholin gland cysts in patients under age 40 may not require treatment. As discussed below, some clinicians advocate excision of all Bartholin gland cysts in patients over 40 years of age because of the possibility of cancer.1 Various treatment options are available if a cyst causes cosmetic problems or bothersome symptoms. If a patient has a Bartholin gland cyst that ruptures spontaneously, all she may need is hot sitz baths. Occasionally, use of broad-spectrum antibiotics is indicated if secondary infection develops. Simple lancing and drainage of the Bartholin gland cyst is mentioned here only to discourage its routine use. One author3 reported an 85 percent cure rate using cyst or abscess aspiration in 34 patients after sending the aspirate for culture. We have found, however, that many cysts and most abscesses recur if treated only by aspiration. We often see patients who are referred because multiple incision and drainage procedures have been unsuccessful. Definitive methods of treatment include placing a Word catheter, marsupializing the cyst, performing a "window" procedure, using a carbon dioxide laser, applying silver nitrate to the cyst cavity or excising the entire cyst. Bayu Utami Tujuan dari penelitian ini adalah untuk mengetahui efikasi dari berbagai macam terapi yang digunakan dalam mengatasi peradangan pada glandula Bartholini. Penelitian ini dilakukan dengan analisis retrospektif selama tahun 1993-1996. Penelitian dilakukan di Department of Obstetrics and Gynecology, Clinical Centre, Novi Sad. Sebanyak 129 pasien yang diteliti. Analisis dari hasil terapi yang dilakukan meliputi efikasi dari masing-masing terapi, insidensi kekambuhan, lamanya perawatan di rumah sakit, dan penggunaan antibiotik. Total ada 129 pasien yang dirawat, rata-rata berusia 35,4 tahun. Kasus kista bartholini terdapat 14,7% dan abses bartholini terdapat 85,3% dari kasus.terapi yang digunakan berbeda-beda selama beberapa tahun. Sebagai hasil didapatkan bahwa selama 1993-1994 banyak dilakukan insisi dan ekstirpasi lengkap dan sangat jarang marsupialization. Dapat dilakukan insisi dan ekstirpasi lengkap dikombinasikan dengan silver nitrat (AgNO3). Pada tahun 1995 dan 1996 pada sebagian besar kasus, insisi dilakukan sebagai terapi dikombinasikan dengan AgNO3 (94,3% pada tahun 1995, 64% pada tahun 1996). Pada 1995 ekstirpasi glandula total dilakukan (5,7%) sedangkan pada 1996 dalam 9 kasus (36%) dilakukan insisi. Lamanya perawatan di rumah sakit lebih lama pada tahun-tahun awal, lebih pendek ketika digunakan insisi yang dikombinasikan dengan AgNO3 (3,12,4 hari). Penggunaan antibiotik lebih rendah ketika insisi dan AgNO3 digunakan. Kesimpulan yang diambil adalah bahwa insisi dan penggunaan AgNO3 pada terapi pada peradangan glandula bartholini adalah efisien, aman, simple, dan merupakan metode yang murah, yang dapat diterapkan dengan mudah meskipun

dengan kondisi yang mendesak. Yulis B A randomized, multicenter, investigator-blind trial was conducted to compare the efficacies of cefuroxime axetil and ciprofloxacin for treatment of patients with uncomplicated gonorrhea caused by penicillinase-producing Neisseria gonorrhoeae (PPNG). A total of 832 patients (434 females and 398 males) received a single oral dose of cefuroxime axetil (1,000 mg [417 patients]) or ciprofloxacin (500 mg [415 patients]). N. gonorrhoeae was eradicated from the cervix in 114 of 118 (97%) and 118 of 119 (99%) bacteriologically evaluable females treated with cefuroxime axetil and ciprofloxacin, respectively (P = 0.213; difference, -2%; 95% confidence interval, -6 to 1%), and from the urethra in 154 of 166 (93%) and 171 of 171 (100%) bacteriologically evaluable male patients treated with cefuroxime axetil and ciprofloxacin, respectively (P < 0.001; difference, -7%; 95% confidence interval, -11 to -3%). Both treatments were effective in eradicating N. gonorrhoeae in females with rectal infections (cefuroxime axetil, 29 of 30 [97%]; ciprofloxacin, 25 of 25 [100%]; P = 1.00). In small numbers of patients, cefuroxime axetil was less effective than ciprofloxacin in treating males with pharyngeal infections (eradication in 4 of 10 and in 8 of 8 patients, respectively; P = 0.013). PPNG was eradicated from the cervix in 22 of 23 (96%) and 32 of 32 (100%) bacteriologically evaluable female patients treated with cefuroxime axetil and ciprofloxacin, respectively (P = 0.418; difference, -4%; 95% confidence interval, -13 to 4%), and from the urethra in 35 of 36 (97%) and 34 of 34 (100%) bacteriologically evaluable male patients treated with cefuroxime axetil and ciprofloxacin, respectively (P = 1.00; difference, -3%; 95% confidence interval, -8 to 3%). The incidences of drug-related adverse events were similar for the two study drugs. In summary, treatment with a single oral dose of cefuroxime axetil is as effective as treatment with a single oral dose of ciprofloxacin in eradicating PPNG from males and females with uncomplicated gonorrhea (urethral and endocervical), and both regimens are well-tolerated. However, in the present study, cefuroxime axetil was less effective than ciprofloxacin in treating urethral gonococcal infections in male patients, although both study drugs were highly effective in treating cervical gonococcal infections in female patients. Jawaban Pertanyaan klinik Adi kurniawan Dari jurnal yang didapat disebutkan bahwa penggunaan antibiotik untuk kista bartholini hanya diberikan jika terjadi infeksi. Selain itu juga disebutkan bahwa penatalaksanaan untuk kasus ini tergantung pada umur pasien, besar kista, dan apakah kasusnya recurrent dari terapi sebelumnya. Masih harus dilakukan penelitian lagi secara RCTs untuk mengetahui terapi apakah yang paling tepat untuk bartholinitis.

Bayu Utami Hasil penelitian yang dilakukan belum sepenuhnya dapat menjawab problem terapi pada kasus Ny. A. Hasil penelitian yang ada hanya memberikan wacana bahwa tindakan insisi dirasakan cukup efisien, aman, murah dan mudah digunakan dalam kasus proses peradangan pada glandula bartholini. Hasil penelitian ini tidak menjelaskan dengan pasti efikasi dari penggunaan antibiotik dan membandingkannya

dengan tindakan insisi. Penelitian juga tidak menjelaskan secara rinci kasus yang digunakan sebagai obyek penelitian. Sehingga perlu dilakukan pencarian sumber lain supaya mendapatkan evidence yang lebih baik terutama dalam hal tahun penerbitan, lokasi penelitian yang sama, kesamaan karakteristik penderita dan keamanan hasil tindakan. Yulis B Tidak ada perbedaan antara Ciprofloxacin dengan antibiotik lainnya karena samasama efektif perlu dilakukan pencarian sumber lain supaya mendapatkan evidence yang lebih baik terutama dalam hal tahun penerbitan, lokasi penelitian yang sama, kesamaan karakteristik penderita dan keamanan hasil tindakan. Menentukan Level of Evidence Adi kurniawan Tinjauan pustaka Level III Bayu utami Tinjauan pustaka Level III Yulis B Randomized Control Trial with blind sehingga level evidence IA Critical Appraisal Adi kurniawan WORKSHEET FOR CRITICAL APPRAISAL OF A THERAPY ARTICLE Citaton : Author(s) : D. ASHLEY HILL, M.D., and JORGE J. LENSE, M.D. Short title : Office Management of Bartholin Gland Cysts and Abscesses Yr/Vol/Page : 1998 Apr 1;57(7):1611-6, 1619-20 GUIDE A. ARE THE STUDY VALID? 1. Was the assignment of patients to treatment groups truly randomized? ASSESMENT ( ) yes ( ) no ( ) cant tell 2. Were all patients who entered the study accounted for appropriately at the end? Is the number randomized the same as the result? (try a best case/worse case scenario) Were patients analyzed in the groups they were allocated to at the start of the study? ( ) yes ( ) no ( ) cant tell

3. Were patients, physicians and those ( ) yes doing assessment blind to treatment? ( ) no ( ) cant tell 4. Was the similarity between groups documented? Table of baseline characteristics? Were differences controlled for the analysis? 5. Aside from the intervention, were the groups treated in the same way? ( ) yes ( ) no ( ) cant tell

( ) yes ( ) no ( ) cant tell

B. WHAT WERE THE RESULT? 1. How large was the treatment affect? 2. How precise was the estimate of the treatment effect

Cant tell Cant tell

C. CAN RESULT BE APPLIED TO THE PATIENT BASED QUESTION 1. Can the result be applid to my ( ) yes patient (care) Are the study patient similar to ( ) no your patient? ( ) cant tell 2. Were all clinically important outcomes reported? Were the most important outcomes reported? Were quality of life outcomes used assessment of adverse effect? ( ) yes ( ) no ( ) cant tell

3. Are the likely treatment benefits greater than the potential harms and cost?

( ) yes ( ) no ( ) cant tell

CONCLUSIONS The study are valid

( ) yes ( ) no ( ) cant tell ( ) yes ( ) no ( ) cant tell

Result will help in caring for patient

Bayu utami WORKSHEET FOR CRITICAL APPRAISAL OF A THERAPY ARTICLE Citaton : Author(s) Bulatovi S, Milosevi S, Novakov-Miki A, Rajevi J, Suvakovi Z. Short title : Therapy of inflammatory changes in Bartholin's glands Yr/Vol/Page : 2000 May-Jun;53(5-6):289-92 GUIDE A. ARE THE STUDY VALID? 1. Was the assignment of patients to treatment groups truly randomized? ASSESMENT ( ) yes ( ) no ( ) cant tell 2. Were all patients who entered the study accounted for appropriately at the end? Is the number randomized the same as the result? (try a best case/worse case scenario) Were patients analyzed in the groups they were allocated to at the start of the study? ( ) yes ( ) no ( ) cant tell

3. Were patients, physicians and those ( ) yes doing assessment blind to treatment? ( ) no ( ) cant tell

4. Was the similarity between groups documented? Table of baseline characteristics? Were differences controlled for the analysis? 5. Aside from the intervention, were the groups treated in the same way?

( ) yes ( ) no ( ) cant tell

( ) yes ( ) no ( ) cant tell

B. WHAT WERE THE RESULT? 1. How large was the treatment affect? 2. How precise was the estimate of the treatment effect

Cant tell Cant tell

C. CAN RESULT BE APPLIED TO THE PATIENT BASED QUESTION 1. Can the result be applid to my ( ) yes patient (care) Are the study patient similar to ( ) no your patient? ( ) cant tell 2. Were all clinically important outcomes reported? Were the most important outcomes reported? Were quality of life outcomes used assessment of adverse effect? 3. Are the likely treatment benefits greater than the potential harms and cost? ( ) yes ( ) no ( ) cant tell

( ) yes ( ) no ( ) cant tell

CONCLUSIONS The study are valid

( ) yes ( ) no ( ) cant tell ( ) yes ( ) no ( ) cant tell

Result will help in caring for patient

Yulis B 1a. Was the assingment of patients to treatments randomised? Yes 1b. Was the randomisation list concealed? Yes 1c. Were subjects and clinicians blind to wich treatment was being received? Yes 2a. Were all subjects who entered the trial accounted for at is conclusion? Yes 2b. Were the analysed in the groups to which they were randomised? Yes 3a. Aside from the experimental treatment, were the groups treated equally? Yes 3b. Were the groups similar at the start of the trial? Yes 4. Is this patient so diferent from those in the trial that the result dont apply? Yes 5a. How great would the benefit of therapy be for this particular patient? Yes 5b. What is the event rate in my practice for patients like this one? Yes 6. do I have a clear assessment of the patients values and preferences? Yes 7. Do this intervention and its potential consequences meet them? Yes Penerapan pada praktek Tidak sesuai karena karakteristik pasien pada jurnal tidak sesuai karena karakteristik yang didasarkan atas gonorrheae. Sedangkan pada kasus tidak ditemukan gonorrheae tapi hanya ditemukan adanya benjolan pada vagina dan jurnal yang saya dapat pada kasus bartholinitis sebagian besar ditimbulkan oleh gonorrheae. Kesan dan Pesan Adi kurniawan Untuk kasus bartholinis jarang ada sehingga sulit mencari jurnal yang sesuai.Walau pun ada hanya abstract. Bayu utami Tugas EBM ini sebenarnya sangat bermanfaat tetapi bingung, begitu banyak

tugas pada blok ini yang harus dikerjakan dan semuanya minta dijadikan prioritas utama. Jadilah laporan ini seadanya. Amat sangat sedikit sekali jurnal yang membahas kasus bartholinitis, kemungkinan dikarenakan sedikitnya kasus bartholinitis yang ditemukan. Saat menemukan jurnal yang bagus dan menarik, jadi kecewa karena ternyata harus membayar.

Yulis B Pada kasus ini sangat sulit dan jarang di temukan sehingga untuk mencari jurnal yang benar-benar valid sangat susah