Pemicu 1 – Blok Urogenital

“Oh, tubuhku bengkak”

Adrian Pratama - 405100018
LO 1.1
 Menjelaskan anatomi traktus urinarius
Kidneys
 Primary retroperitoneal structures on the posterior abdominal
wall
 Kidneys’ layers
 Perinephric fat (the perirenal fat capsule)
 renal fascia
 paranephric fat (or the pararenal fat body)
 Relations:
 Superior  diaphragm
 Posterior  quadratus lumborum muscle, subcostal nerve and vessels
and the iliohypogastric and ilioinguinal nerves
 Anterior
 Right kidney  liver, duodenum, and ascending colon
 Left kidney  stomach, spleen, pancreas, jejunum, and descending colon
External & internal appearance of kidneys
Arterial & venous supply
Renal artery  segmental
arteries (anterosuperior,
anteroinferior, superior, inferior,
posterior)  interlobar arteries
 arcuate arteries 
interlobular arteries  afferent
arteriole  glomerulus 
efferent arteriole  peritubule
capillary  fasa recta 
interlobular veins  arcuate veins
 interlobar veins  segmental
veins  renal vein
Ureters & kidneys’ lymph nodes
Nerves
Ureters
 muscular tubes; 25-30 cm long; connect the kidneys to the
urinary bladder
 Pars
 Abdominalis
 Pelvica (As the ureters cross the bifurcation of the common iliac
artery or the beginning of the external iliac artery)
Lymphatic drainage
Arterial supplies & innervations
Urinary bladder
 hollow viscus with strong muscular walls, is characterized by
its distensibility
 lying partially superior to and partially posterior to the
pubic bones, separated from pubic bones by the potential
retropubic space (of Retzius)

 Parts
 apex of the bladder
 fundus of the bladder
 body of the bladder
 neck of the bladder
Position of urinary bladder & its lymph drainage
Arterial supply & innervation
Arterial supply (male)

-. superior vesical
arteries 
anterosuperior parts
of the bladder

-. inferior vesical
arteries  fundus
and neck of the
bladder

Arterial supply (female)

-. vaginal arteries =
the inferior vesical
arteries and send
small branches to
posteroinferior parts
of the bladder
Proximal male urethra
 muscular tube; conveys urine from the internal urethral
orifice of the urinary bladder to the external urethral
orifice
 Arterial supply
 prostatic branches of the inferior vesical and middle rectal
arteries
 Venous & lymphatic drainage
 prostatic venous plexus
 internal iliac lymph nodes (mainly), external iliac lymph nodes
(few)
 Innervations
 derived from the prostatic plexus (mixed sympathetic,
parasympathetic, and visceral afferent fibers); arising as organ-
specific extensions of the inferior hypogastric plexus
Distal male urethra
 The intermediate (membranous) part of the urethra
 surrounded by the external urethral sphincter
 It then penetrates the perineal membrane, ending as the urethra
enters the bulb of the penis
 Posterolateral to this part of the urethra are the small
bulbourethral glands
 The spongy urethra
 it is expanded in the bulb of the penis to form the intrabulbar
fossa and in the glans of the penis to form the navicular fossa
 many minute openings of the ducts of mucus-secreting urethral
glands
 Arterial supply
 from branches of the dorsal artery of the penis
 Venous & lymphatic drainage
 accompany the arteries and have similar names
 Lymphatic vessels from the intermediate part of the urethra drain
mainly into the internal iliac lymph nodes; the spongy urethra pass to
the deep inguinal lymph nodes
 Innervations
 autonomic (efferent) innervation via the prostatic nerve plexus, arising
from the inferior hypogastric plexus
 sympathetic innervation is from the lumbar spinal cord levels via the
lumbar splanchnic nerves, and the parasympathetic innervation is from
the sacral levels via the pelvic splanchnic nerves
 dorsal nerve of the penis, a branch of the pudendal nerve, provides
somatic innervation of the spongy part of the urethra
Scrotum
 cutaneous fibromuscular sac for the testes and associated
structures

 Arterial supply
 Anterior scrotal arteries; posterior scrotal arteries
 Venous & lymphatic drainage
 scrotal veins
 superficial inguinal lymph nodes
 Innervation
 Anterior  lumbar plexus: anterior scrotal nerves, derived from the
ilioinguinal nerve, and the genital branch of the genitofemoral nerve
 Posterior  sacral plexus: posterior scrotal nerves, branches of the
superficial perineal branches of the pudendal nerve, and the perineal
branch of the posterior femoral cutaneous nerve
Penis
 male copulatory organ and, by conveying the urethra, provides
the common outlet for urine and semen
 consists of a root, body, and glans

 Arterial supply
 Dorsal arteries of the penis; Deep arteries of the penis; Arteries of the
bulb of the penis
 Venous & lymphatic drainage
 deep dorsal vein of the penis; superficial dorsal vein
 Lymph from the skin of the penis drains initially to the superficial
inguinal lymph nodes; glans & spongy urethra drain to the deep
inguinal and external iliac nodes; from the cavernous bodies and
proximal spongy urethra drain to the internal iliac nodes
 Innervation
of penis
Female urethra
 approximately 4 cm long and 6 mm in diameter; passes
anteroinferiorly from the internal urethral orifice of the
urinary bladder
 The urethra passes with the vagina through the pelvic
diaphragm, external urethral sphincter, and perineal
membrane
 Urethral glands are present, particularly in the superior
part of the urethra
 One group of glands on each side, the paraurethral
glands, are homologues to the prostate
 Arterial supply
 internal pudendal and vaginal arteries
 Venous & lymphatic drainage
 veins follow the arteries and have similar names
 sacral and internal iliac lymph nodes (mainly); inguinal lymph
nodes (few)
 Innervations
 vesical (nerve) plexus and the pudendal nerve
Female external genitalia
 Arterial supply (vulva)
 internal pudendal artery supplies most of the skin, external
genitalia, and perineal muscles. The labial arteries are branches
of the internal pudendal artery, as are those of the clitoris
 Venous & lymphatic drainage (vulva)
 labial veins are tributaries of the internal pudendal veins
 superficial inguinal lymph nodes
 Innervation (vulva)
 Anterior  lumbar plexus: the anterior labial nerves, derived from the
ilioinguinal nerve, and the genital branch of the genitofemoral nerve
 Posterior  derivatives of the sacral plexus: the perineal branch of
the posterior cutaneous nerve of the thigh laterally and the pudendal
nerve centrally
 posterior labial nerves  labia
 deep and muscular branches of the perineal nerve supply the orifice
of the vagina and superficial perineal muscles
 dorsal nerve of the clitoris supplies deep perineal muscles and
sensation to the clitoris
 The bulb of the vestibule and erectile bodies of the clitoris receive
parasympathetic fibers via cavernous nerves from the uterovaginal
nerve plexus
LO 1.2
 Menjelaskan histologi traktus urinarius
Kidney
Nephrons  The smallest fungsional units of kidney
Blood circulation (Kidney)
Renal Corpuscles & Blood Filtration
Glomerular filtration barrier

Filtration slit  slit diaphragms are a highly

specialized type of intercellular junction in which the
large transmembrane protein nephrin
Mesangial cells in renal corspuscles

Functions: -. Physical support and contraction

-. Phagocytosis
-. Secretion (cytokines, prostaglandins, and other factors
important for immune defense and repair in the glomerulus)
Proximal & distal convulated tubules
Differences
Nephron loop (of henle)
Juxtaglomerular Apparatus

Components:
-. macula densa
-. juxtaglomerular
granular (JG) cells
-. lacis cells
Collecting tubules & ducts
Ureter
Components of urothelium:

-. a single layer of small

basal cells resting on a very
thin basement membrane

-. an intermediate region
containing from one to several
layers of more columnar cells

-. a superficial layer of very

large, polyhedral or bulbous
cells called umbrella cells
which are occasionally bi- or
multinucleated and are highly
differentiated to protect
underlying cells against the
cytotoxic effects of hypertonic
urine (uroplakins on apical
side)
Urinary bladder
Urethra
 In male:
 The prostatic urethra, 3–4 cm
long, extends through the
prostate gland and is lined by
urothelium
 The membranous urethra, a
short segment, passes through an
external sphincter of striated
muscle and is lined by stratified
columnar and pseudostratified
epithelium
 The spongy urethra, 15 cm in
length, is enclosed within erectile
tissue of the penis and is lined
by stratified columnar and
pseudostratified columnar
epithelium, with stratified
squamous distally
LO 1.3
 Menjelaskan fisiologi ginjal & traktus urinarius
Fungsi spesifik ginjal
 Mempertahankan keseimbangan H2O dlm tubuh
 Mengatur jumlah & konsentrasi sebagian besar ion CES
 Memelihara volume plasma yg sesuai
 Membantu memelihara keseimbangan asam basa tubuh
 Memelihara osmolaritas
 Mengekskresikan produk2 sisa dari metabolisme tubuh
 Mengekskresikan banyak senyawa asing
 Mensekresikan eritropoietin
 Mensekresikan renin
 Mengubah vitamin D menjadi bentuk aktif
Nefron sbg satuan fungsional ginjal
Tipe nefron
3 proses dasar ginjal
Filtrasi glomerulus
 3 lapisan pembentuk membran glomerulus
 Dinding kapiler glomerulus
 Lapisan gelatinosa aseluler yg dikenal sbg membran basal
 Lapisan dalam kapsul bowman
Tekanan darah kapiler glomerulus
Faktor lain yg mempengaruhi tekanan
darah kapiler glomerulus (koefisien
filtrasi)
-. Luas permukaan glomerulus yg
tersedia utk filtrasi
-. Permeabilitas membran glomerulus
 Faktor penyebab perubahan tekanan darah kapiler
glomerulus  perubahan tekanan darah kapiler
glomerulus
 Tekanan osmotik koloid plasma & tekanan hidrostatik
kapsul bowman tetap tdk berubah dalam keadaan normal
(kec patologis)

 Perlunya mekanisme kontrol terhadap perubahan GFR

 Kontrol jangka pendek u/ mencegah perubahan spontan GFR
 otoregulasi
 Kontrol jangka panjang tekanan darah arteri  kontrol
simpatis ekstrinsik
Otoregulasi GFR
 Mekanisme miogenik
 Mekanisme umpan balik tubulo-glomerulus
Kontrol simpatis ekstrinsik GFR
Reabsorpsi tubulus
 Cairan filtrasi yg mengandung nutrien, elektrolit, dan zat
lain yg digunakan o/ tubuh & bersifat esensial
dikembalikan ke dalam darah
  proses yg sangat selektif
Transportasi transepitel pada proses reabsorpsi
tubulus
Mekanisme transportasi natrium di bagian tubulus
 Reabsorpsi natrium di tubulus proksimal berperan penting
dalam reabsorpsi glukosa, asam amino, H2O, Cl-, dan
urea
 Reabsorpsi natrium di lengkung Henle bersama dgn
reabsorpsi Cl- berperan penting dalam kemampuan ginjal
menghasilkan urin dgn konsentrasi & volume berbeda2
 Reabsorpsi natrium di bagian distal nefron bersifat
variabel & berada dibawah kontrol hormon, serta
berkaitan dgn sekresi K+ & H+
Proses reabsorpsi natrium
Transpor reabsorpsi glukosa & asam amino
 Transpor glukosa & asam amino menggunakan kotranspor
(proses transpor aktif sekunder)

 Proses reabsorpsi glukosa


Reabsorpsi fosfat & kalsium
 Tubulus mereabsorpsi fosfat sampai konsentrasi plasma
normal, kelebihannya akan segera dikeluarkan melalui urin
= semakin besar fosfat yg dimakan semakin besar yg
akan dikeluarkan tubuh

 Reabsorpsi fosfat & kalsium berada di bawah kontrol

hormon (PTH)
Reabsorpsi klorida
 Reabsorpsi / perpindahan ion klorida berjalan melewati
gradien listrik menuju tubulus
 Jumlah klorida yg direabsorpsi tergantung pada
kecepatan reabsorpsi Na+ & tidak dikontrol langsung o/
ginjal
Reabsorpsi air
 Air secara pasif akan berdifusi melalui osmosis yg terjadi
karena proses reabsorpsi natrium & reabsorpsi zat2
terlarut lainnya

 65% air direabsorpsi di tubulus proksimal

 15% air direabsorpsi secara obligatorik di ansa henle
 20% air direabsorpsi di tubulus distal dibawah pengaruh
hormon ADH
Reabsorpsi urea
Mekanisme kerja aldosteron pd tubulus distal
Sekresi tubulus
 Sekresi ion hidrogen
 Bergantung pada keasaman cairan tubuh

 Sekresi ion kalium

Aldosteron dapat mengubah
kecepatan sekresi K+
Ringkasan transportasi pada tubulus
Kemampuan ginjal mensekresikan urin dgn berbagai
kepekatan
 Countercurrent multiplications
 Countercurrent exchange
 Peran hormon ADH pada tubulus koligentes
Daur ulang urea di medula ginjal
Mikturisi

Saraf simpatis dari plexus hypogastricus tidak berperan langsung

pada proses mikturisi / perkemihan
LO 2
 Menjelaskan kelainan pada ginjal
LO 2.1 Nephritic syndrome
 Glomerular diseases presenting with a nephritic syndrome
are often characterized by inflammation in the glomeruli
 Clinical presentations
 hematuria,
 red cell casts in the urine,
 azotemia,
 oliguria,
 mild to moderate hypertension
 Proteinuria and edema are common, but these are not as severe
as those encountered in the nephrotic syndrome
 may occur in such multisystem diseases as SLE
Acute Poststreptococcal Glomerulonephritis
  acute nephritic syndrome characterized by the sudden onset
of gross hematuria, edema, hypertension, and renal
insufficiency
 most common glomerular causes of gross hematuria in children

 Etiology
 follows infection of the throat or skin by certain "nephritogenic" strains
of group A β-hemolytic streptococci
 Epidemiology
 commonly follows streptococcal pharyngitis during cold weather
months and streptococcal skin infections or pyoderma during warm
weather months
 epidemics of nephritis have been described in association with both
throat (serotype 12) and skin (serotype 49) infections
 Pathology

-. all glomeruli appear enlarged and relatively bloodless and show diffuse mesangial
cell proliferation with an increase in mesangial matrix
-. Polymorphonuclear leukocytes are common in glomeruli during the early stage of
the disease
 Pathogenesis
 Mediated by immune complexes

 Clinical course
 a young child abruptly develops malaise, fever, nausea, oliguria, and
hematuria 1 to 2 weeks after recovery from a sore throat / 3-6 wk
after a streptococcal pyoderma
 red cell casts in the urine, mild proteinuria (usually less than 1
gm/day), periorbital edema, and mild to moderate hypertension
 acute phase generally resolves within 6-8 wk
 urinary protein excretion and hypertension usually normalize by 4-6
wk after onset
 persistent microscopic hematuria may persist for 1-2 yr after the initial
presentation
 Clinical manifestations
 various degrees of edema, hypertension, and oliguria
 Patients may develop encephalopathy and/or heart failure
owing to hypertension or hypervolemia
 malaise, lethargy, abdominal or flank pain, and fever are
common
 Diagnosis
 Urinalysis  red blood cells (RBCs), frequently in association with RBC
casts, proteinuria, and polymorphonuclear leukocytes
 mild normochromic anemia
 low-grade hemolysis
 The serum C3 level is usually reduced in the acute phase
 A positive throat culture
 antistreptolysin O titer is commonly elevated after a pharyngeal
infection
 to document cutaneous streptococcal infection is the
deoxyribonuclease (DNase) B antigen
 renal biopsy is considered when hematuria and proteinuria, diminished
renal function, and/or a low C3 level persist more than 2 mo after
onset
 Complications
 Hypertension is seen in 60% of patients and may be associated
with hypertensive encephalopathy in 10% of cases
 heart failure
 Hyperkalemia
 Hyperphosphatemia
 Hypocalcemia
 Acidosis
 Seizures
 Uremia
 Prevention
 Early systemic antibiotic therapy for streptococcal throat and
skin infections does not eliminate the risk of glomerulonephritis
 Family members of patients with acute glomerulonephritis should
be cultured for group A β-hemolytic streptococci and treated if
culture positive
 Treatment
 a 10-day course of systemic antibiotic therapy with penicillin is
recommended to limit the spread of the nephritogenic organisms
 Hypertension treatment
 Prognosis
 Complete recovery occurs in more than 95% of children
 Mortality in the acute stage can be avoided by appropriate
management of acute renal failure, cardiac failure, and
hypertension
 Infrequently, the acute phase may be severe and lead to
glomerular hyalinization and chronic renal insufficiency
 Recurrences are extremely rare
LO 2.2 Nephrotic syndrome
 Certain glomerular diseases virtually always produce the
nephrotic syndrome

 Pathophysiology
 Manifestations
 Massive proteinuria, with the daily loss of 3.5 gm or more of protein
(less in children)
 Hypoalbuminemia, with plasma albumin levels less than 3 gm/dL
 Generalized edema
 Hyperlipidemia and lipiduria
 Causes
Idiopathic nephrotic syndrome
 Diagnosis
 urinalysis reveals 3+ or 4+ proteinuria
 Microscopic hematuria (20%)
 A spot urine protein:creatinine ratio exceeds 2.0
 urinary protein > 40 mg/m2/hr
 serum albumin level is <2.5 g/dL
 serum cholesterol, triglyceride levels are elevated
 Treatment
 Prednisolone 60 mg/m2/day (maximum daily dose, 80 mg) a
single daily dose for 4-6 consecutive wk prednisone dose should be
tapered to 40 mg/m2/day given every other day as a single daily dose
for at least 4 wk
Secondary nephrotic syndrome
Congenital nephritic syndrome
  nephrotic syndrome manifesting at birth or within the
first 3 mo of life
 Other genetic causes
LO 2.3 Acute renal failure
  rapid decline in glomerular filtration rate (GFR) over hours
to days
 usually asymptomatic and diagnosed when biochemical
monitoring of hospitalized patients reveals a new increase in
blood urea and serum creatinine concentrations

 Categories
 that cause renal hypoperfusion, resulting in decreased function without
frank parenchymal damage (prerenal ARF, or azotemia) (~55%)
 diseases that directly involve the renal parenchyma (intrinsic ARF)
(~40%)
 diseases associated with urinary tract obstruction (postrenal ARF)
(~5%)
Prerenal ARF (Prerenal Azotemia)
 Etiology
 Pathophysiology
 Hypovolemia leads to a fall in mean systemic arterial pressure
 detected as reduced stretch by arterial (e.g., carotid sinus) and
cardiac baroreceptors
 activation of the sympathetic nervous system and renin-angiotensin-
aldosterone system
 salt loss through sweat glands is inhibited, and thirst and salt appetite
are stimulated. Renal salt and water retention also occur
 In response to the reduction in perfusion pressure, stretch receptors in
afferent arterioles trigger afferent arteriolar vasodilatation through a
local myogenic reflex
 constriction of efferent arterioles
 GFR is preserved  more severe hypovolemia  AFR
Intrinsic ARF
 Etiology
Postrenal ARF
 Etiology
Clinical assesment
 Prerenal ARF
 Intrinsic ARF
 Complication
 Expansion of extracellular fluid volume  hypoosmolality and
hyponatremia  lead to neurologic abnormalities, including
seizures
 Hyperkalemia
 metabolic acidosis
 Hyperphosphatemia
 Anemia
 uremic syndrome
 A vigorous diuresis can occur during the recovery phase of ARF
 Prevention
 Adjusting drug dosage (estimate the GFR using the Cockcroft-
Gault formula)

 Diuretics, NSAIDs, ACE inhibitors, ARBs, and vasodilators should

be used with caution in patients with suspected true or
"effective" hypovolemia or renovascular disease
 Treatment
 Causative treatment
 Indications for dialysis in ARF include the following:
 Volume overload with evidence of hypertension and/or
pulmonary edema refractory to diuretic therapy
 Persistent hyperkalemia
 Severe metabolic acidosis unresponsive to medical management
 Neurologic symptoms (altered mental status, seizures)
 Blood urea nitrogen greater than 100-150 mg/dL (or lower if
rapidly rising)
 Calcium/phosphorus imbalance, with hypocalcemic tetany
LO 2.4 Chronic kidney disease
 Chronic renal failure (CRF) is defined as an irreversible
reduction in GFR

 Etiology
 result of congenital, acquired, inherited, or metabolic renal disease
 children younger than 5 yr is most commonly a result of congenital
abnormalities such as renal hypoplasia, dysplasia, and/or obstructive
uropathy
 After 5 yr of age, acquired diseases (various forms of
glomerulonephritis) and inherited disorders (familial juvenile
nephronophthisis, Alport syndrome) predominate
 related to metabolic disorders (cystinosis, hyperoxaluria) and certain
inherited disorders (polycystic kidney disease) may present throughout
the childhood years
 Classification
 Mild chronic renal insufficiency: GFR 50-75 mL/min/l.73 m2
 Moderate chronic renal insufficiency: GFR 25-50 mL/min/l.73
m2
 Chronic renal failure (CRF): GFR 10-25 mL/min/l.73 m2
 End stage renal disease (ESRD): GFR < 10 mL/min/l.73 m2
 Clinical Manifestations
 Anemia in patients with CRF is primarily the result of inadequate
erythropoietin production by the failing kidneys and usually
becomes manifest at a GFR less than 35 mL/min/1.73 m2
 The term renal osteodystrophy is used to indicate a spectrum of
bone disorders seen in patients with CRF.
 The most common condition seen in children is high-turnover
bone disease caused by secondary hyperparathyroidism
 Acidosis  maintain the serum bicarbonate level above 22
mEq/L sodium bicarbonate tablets (650 mg equals 8 mEq of
base)
 Children with high blood pressure, edema, or heart failure 
sodium restriction and diuretic therapy
 Hyperkalemia  restriction of dietary potassium intake,
administration of oral alkalinizing agents, and/or treatment with
Kayexalate.
 Nutritions
 Dietary phosphorus, potassium, and sodium should be restricted
according to the individual patient's laboratory studies and fluid
balance.
 Protein intake should be 2.5 g/kg/24 hr and should consist of
proteins of high biologic value that are metabolized primarily
to usable amino acids rather than to nitrogenous wastes. The
proteins of highest biologic value are those of eggs and milk,
followed by meat, fish, and fowl.
 Tatalaksana
 replacing absent/ diminished renal functions, which
progressively increase in parallel with the progressive loss of
GFR,
 slowing the progression of renal dysfunction
Daftar pustaka
 Dalley, Arthur F. Keith L Moore. Clinically Oriented
Anatomy. 5th edition. Lippincott Williams & Wilcins; 2006
 Nelson Textbook of Pediatric, 19th edition
 Sherwood,Lauralee. Fisiologi Manusia dari Sel ke Sistem.
Cetakan pertama edisi 2. Jakarta: EGC; 2001
 Fauci. Braunwald. Dkk. Harrison’s Principles of Internal
Medicine. 17th edition. United State: The McGraw-Hills;
2008
 Guyton and Hall medical physiology