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Fisiologi Dan Patofisiologi Proses Berkemih: Dr. Bobby Hery Yudhanto, Spu
Fisiologi Dan Patofisiologi Proses Berkemih: Dr. Bobby Hery Yudhanto, Spu
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
L1 S2
S3
L2
Pelvic nerve S4
L3
Sympathetic
chain
Somatic
Hypogastric nerve supply
ganglion S2
S3
Hypogastric S4
nerve Urethra Pudendal nerve
External sphincter
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
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 injury’s
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)
• Beta-adrenergic agents
• Botulinum toxin
Imipramine, methylephedrine
• Botulinum toxin