Fisiologi dan Patofisiologi

Proses Berkemih
dr. Bobby Hery Yudhanto, SpU

Anatomi traktus
urinarius laki-laki

Anatomy and relations of the bladder, urethra,

uterus and ovary, vagina, and rectum

Sistem Persarafan Traktus

Urinarius dan Traktus
Digestivus

Physiology
Main function of bladder :
1. Urine storage
2. Urine voiding
Ada 2 faktor yang berpengaruh dalam proses
miksi :
1. Buli buli (kandung kemih) sebagai
pompa
2. Saluran kemih bagian bawah, meliputi
bladder neck, prostat, sphincter urethra
externa dan urethra sebagai jalan keluar
urine

Neuroanatomy and
Neurophysiology of micturition

A. Peripheral :
1. Sympathetic : Filling /storage
2. Parasympathetic : voiding /emptying
3. Somatic : external sphincter
B. Central : four loops in Brain, Brainstem, Spinal cord

Peripheral innervation :
1.

2.

Afferents :
from detrusor stretch receptors, sphincter,
perineum, genitalia
Efferents:
a. Parasympathetic S2 S4
Receptors : Cholinergic muscarinic ( at body of the
bladder )
b. Sympathetic : T11 L2
Receptors : Alpha adrenergic ( at sphincter)
Beta adrenergic ( at body of the
bladder)

Central Innervation :
1.

2.

Loop I : Corticopontine-mesencephalic nuclei

From frontal lobe
Exerts inhibitory influence on parasympathetic
Sacral Micturition Center (SMS)
bladder storage
Lesions here
detrusor hyperreflexia
Loop II : Pontine-mesencephalic-sacral nuclei
Pontine Micturition Center (PMC)
To coordinate efficient detrusor and sphincter
interaction
Lesions here and down
DSD

Central
innervartion..
3. Loop III : Pelvic-Pudendal nuclei :
Sacral Micturition Center (SMC)
Lesions here
areflexic / atonic
bladder
4. Loop IV : Motor Cortex to pudendal nuclei
Responsible for the voluntary control of the
external sphincter

Innervation of Lower Urinary

Tract
Bladder- cholinergic
parasympathetic- contraction; betaadrenergic & NO relaxation
Bladder neck alpha-adrenergiccontration
Urethral muscles- cholinergic
parasympathetic, NO, cholinergic
somatic nerves

Innervation of the
Sympathetic nerve
bladder
Parasympathetic
supply

nerve supply

L1

S2
S3

L2

Pelvic nerve

L3

S4

Sympathetic
chain
Hypogastric
ganglion
Hypogastric
nerve

Urethra
External

Somatic
nerve
supply S2
S3
S4
Pudendal nerve

BLADDER FILLING

Physiology of Urine Storage

First sensation of filling

Fullness sensation
Urge sensation
Premicturition urge sensation- phasic
detrusor contraction
Increased activity of urethral
sphincter during filling

Fase Pengisian Buli

Terjadi relaksasi dari buli-buli dan kontraksi dari
bladder neck (dipengaruhi oleh saraf simpatis)
Volume buli pada usia dewasa muda sekitar 500cc.
Pada volume sekitar 150cc sudah ada rangsangan
untuk berkemih
Pada volume 300cc rangsangan untuk berkemih
semakin kuat yang disertai pembukaan bladder
neck secara spontan.
Proses miksi masih bisa ditahan melalui sphincter
urethra externa (bisa diatur secara sadar/voluntary)

BLADDER EMPTYING

Fase Pengosongan Buli

(berkemih)
Dipengaruhi oleh sistem saraf parasimpatis
Terjadi relaksasi dari otot sphincter urethra externa
dan bladder neck. Kemudian diikuti oleh kontraksi
otot-otot detrusor Buli.
Terjadi pengosongan buli sehingga volume urine di
dalam buli-buli tidak tersisa atau residu urine
kurang dari 50cc

Bladder filling and urine storage require:

1. Accommodation of increasing volumes of urine at a low
intravesical
2. A bladder outlet that is closed at rest and remains so
during increases pressure and with appropriate sensation in
intra-abdominal pressure
3. Absence of involuntary bladder contractions.
Bladder emptying requires:
1. A coordinated contraction of the bladder smooth
musculature of adequate magnitude
2. A concomitant lowering of resistance at the level of the
smooth and striated sphincter.
3. Absence of anatomic (as opposed to functional)
obstruction.

Micturition detrusor pressuredepends on urethral resistance

High voiding pressure indicates a greater urethral
resistance
Low voiding pressure indicates a lower urethral
resistance or a low detrusor contractility
Efficient bladder empty depends on a sustained
detrusor contraction

Efficient Bladder Empty

Hypersensitive bladder- low detrusor contractility
Inadequate contractility in elderly
Bladder outlet obstruction- Bladder neck
dysfunction, Prostatic enlargement, Urethral
stricture, Cystocele, External sphincter
dyssynergia

Abnormalities of micturition
1.Atonic bladder
This is due to destruction of sensory nerve fibers
from urinary from the bladder. When the dorsal
sacral roots are interrupted by diseases of the
dorsal roots such as tabes dorsalis or when there is
crush injury to sacral segments of spinal cord,
person looses bladder control (abolition of reflex
contractions of the bladder). Bladder muscle looses
the tone (hypotonic) and becomes flaccid). Bladder
fills to the capacity and overflows few drops at a
time through the urethra (overflow incontinence or
overflow dribbling).

2. Automatic bladder (Spastic

neurogenic bladder)
During spinal shock after complete transection of
spinal cord above sacral centres of micturition, the
urinary bladder looses its tone and becomes flaccid
and unresponsive. So, the bladder is completely
filled, and later urine overflows by dribbling. After
the spinal shock has passed, the voiding reflex
returns although there is no voluntary and higher
centre control.
Whenever, the bladder is filled with some amount
of urine, there is automatic evacuation of the
bladder.

Spinal Cord injury

Abnormality in micturition cycle depend spinal
cord injurys level :
Above brain stem
detrusor
hyperreflexia
Above S2 segment
detrusor
hyperreflexia with detrusor external sphincter
dyssynergia (DESD)
Below S2 segment
detrusor areflexia
with fixed sphincter urethral external tone

3. Uninhibited neurogenic bladder

Due to a lesion in some parts of brain stem
(interrupting mst
of the inhibitory signals), there is continuous
excitation of
spinal micturition centres by the higher centres.
There is
uncontrollable micturition. Even a small quantity
of urine
collected in bladder will elicit the micturition
reflex increasing
the frequency of micturition.

4. Nocturnal micturition (Bed

wetting)
This is normal in infants and children below 3 years.
It occurs due to incomplete myelination of motor
nerve fibers of the bladder resulting loss of
voluntary control of micturition .

Traktus Urinarius Bawah

Gejala Iritatif
Frekuensi

Frekuensi normal miksi orang dewasa sebanyak 5-6x/hari

dengan setiap miksi sebanyak 300cc
Penyebab :
1. penurunan kapasitas buli-buli termasuk bladder outlet
obstruction dengan penurunan daya regang buli, peningkatan
residu urine, dan/atau penurunan kapasitas fungsional buli
karena iritasi
2. neurogenic bladder dengan peningkatan sensitivitas dan
penurunan daya regang buli
3. penekanan dari luar
4. anxietas.

Disuria : nyeri pada saat kencing yang disebabkan

oleh proses inflamasi
Nokturia : merupakan frekuensi yang terjadi malam
hari

Normal : orang dewasa tidak terbangun lebih dari 2x semalam

untuk miksi
Produksi urine pada penderita geriatri meningkat pada malam
hari

Gejala Obstruksi
1.

Penurunan pancaran kencing

Merupakan akibat dari bladder outlet obstruction

(biasanya oleh BPH atau striktur urethra).

Karena prosesnya berjalan perlahan-lahan maka

seringkali tidak dikeluhkan oleh penderita.

2.

Hesitansi : memerlukan waktu yang lama untuk memulai

miksi

3.

Intermittensi : proses miksi terputus-putus

4.

Post void dribbling : keluarnya urine setelah akhir proses

miksi

5.

Straining : harus mengejan untuk memulai proses miksi

Penyakit-penyakit lain yang dapat menimbulkan keluhan

iritatif :
Penyakit neurologis (contoh : cerebrovascular accidents,
diabetes mellitus dan Parkinson's)
Karsinoma buli-buli in situ

Inkontinensia Urine
Definisi : Keluarnya urine tanpa disadari (involunter)
a. Continuous Incontinence
Penyebab : fistula traktus urinarius, ektopik
ureter
b. Stress Incontinence
Stress incontinence merujuk pada keluarnya
urine secara tiba-tiba pada saat batuk, bersin
olahraga atau aktivitas lain yang
meningkatkan tekanan intra-abdominal.
c. Urgency Incontinence
Merupakan keluarnya urine yang disebab
dorongan kuat yang mendadak untuk
berkemih.
Biasanya terjadi pada penderita sistitis,
neurogenic bladder atau obstruksi bladder
outlet berat dengan hilangnya daya regang

d. Overflow Urinary Incontinence /Inkontinensia

paradoksal
Merupakan efek sekunder dari retensio urine dan volume
residual urine yang tinggi. (terjadi distensi buli secara kronis
dan tidak dapat mengosongkan kandung kemih secara tuntas)

e. Enuresis
Merupakan inkontinensia urine yang terjadi pada waktu tidur.
Secara normal terjadi pada anak-anak hingga usia 3 tahun,
tetapi tetap ada pada 15% anak usia 5 tahun dan 1 % pada
usia hingga 15 tahun ( Forsythe and Redmond, 1974 ).
Setiap anak berusia diatas 6 tahun dengan enuresis harus
dilakukan pemeriksaan urologis

Pharmacology of MicturitionIncrease storage efficiency

Reduce detrusor overactivity
Anticholinergic agents- oxybutynine, flavoxate,
imipramine
Ganglion blocker- bentyl
Beta-adrenergic agents
Botulinum toxin
Vanilloid receptor blockers- capsaicin, resiniferatoxin

Pharmacology of MicturitionIncrease empty efficiency

Parasympathomimetic agent- Urecholine
Adrenergic blockers- inhibition of detrusor
relaxation (?)

Pharmacology of MicturitionIncrease outlet resistance

Increase smooth muscle tone
Imipramine, methylephedrine
Increase striated muscle tone
Nitric oxide synthase inhibitor
Pelvic floor muscle training

Pharmacology of MicturitionDecrease outlet resistance

Decrease bladder neck & urethral resistance
Alpha-adrenergic blockers- dibenyline, terazosin,
tamsulosin, doxazosin
Nitric oxide donors
Botulinum toxin
Polysynaptic blocker baclofen, diazepam