Urinary System I

BUKU TUTOR MINGGU KEDUA BLOK URINARI-1

Contributor Blok: dr. Rahma Triliana, S.Ked. M.Kes, PhD (Candidate)

Minggu kedua memiliki tema sistem genitalia pria. Pada minggu ini mahasiswa akan
mempelajari anatomi, fisiologi, dan histologi sistem genitalia pria pada kegiatan tutorial dan
perkuliahan (kecuali anatomi). Kegiatan perkuliahan dilengkapi dengan materi pemeriksaan
radiologis pada sistem genitourinaria dan materi keanekaragaman hayati yang berperan pada
sistem genitourinaria. Praktikum pada minggu ini adalah praktikum histologi genitalia pria
yang akan berjalan paralel dengan pelatihan keterampilan pemeriksaan sistem urogenital pria
dan sircumsisi. Sebelum pelaksanaan pelatihan keterampilan, mahasiswa akan diberi kuliah
pengantar. Pretes praktikum juga diberlakukan agar mahasiswa sudah mempelajari terlebih
dahulu materi yang akan dipraktikkan. Tidak ada inhal praktikum untuk mahasiswa yang belum
siap praktikum.
Anatomi-histologi

Penis, scrotum, tertis, prostat

Genitalia Pria

Fisiologi

Spermatogenesis
Ereksi dan ejakulasi

Radiologi
Pemeriksaan radiologis pada perkemihan dan genitalia pria

Praktikum pemeriksaan urin lengkap (PK)

Ketrampilan (CSL):
Pemeriksaan fisik sistem perkemihan dan genitalia pria
Circumsisi

Aspek ke-Islam-an
Quran, hadits, dan ijtihad yang berhubungan dengan sistem
perkemihan dan genitalia pria

Efek bahan alam terhadap sistem perkemihan dan genitalia pria

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STRATEGI PEMBELAJARAN MINGGU II

- Sistem Genitalia Pria I
TUJUAN INSTRUKSIONAL KHUSUS
1. Menjelaskan anatomi, histologi, dan fisiologi reproduksi pria
2. Menjelaskan fisiologi spermatogenesis
3. Mengetahui macam-macam penyakit pada sistem reproduksi pria
4. Mengetahui pemeriksaan radiologis pada sistem genitourinaria pria
5. Menjelaskan peran Kehati untuk sistem genitalia pria

SKENARIO --- RHM

YEEEE JONGKOK!!!

An. N, 7 tahun, pulang sekolah dengan menangis dan mengadu pada ibunya karena di-olokolok teman sekelasnya. Ia bercerita bahwa saat istirahat siang, dia dan temannya (An. A,
dan An. F) pergi ke kamar mandi untuk buang air kecil bersama-sama. Sebelum buang air,

An. A, menantang An. F dan An. N untuk jauh-juahan pancaran air seni. Saat mulai
berlomba, pancaran air seni An. A dan An. F hampir sama jauhnya, namun An. N, ternyata
air seninya justru memancar kebawah dan hampir membasahi celananya sendiri sehingga
An. N langsung berjongkok untuk buang air kecil. An. F langsung berteriak Yeeee

jongkok yeeee!!! saat melihat An. N buang air sambil ber-jongkok, dan ia terus
mengejek An. N sampai An. N menangis. Sampai di rumah, Ibu An. N melihat bahwa
lubang air seninya An. N berada tepat di bagian bawah kepala penis.

KATA KUNCI
1. Menangis
2. Berjongkok saat BAK
3. Pancaran air seni menghadap kebawah
4. Air seni terkena celana

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IDENTIFIKASI KATA SULIT

* Tidak ada

DAFTAR MASALAH
1. Mengapa An. N. harus berjongkok saat BAK ?
2. Apakah penyebab pancaran air seni An. N menghadap kebawah ?
3. Bagaimana mekanisme pancaran air seni An. N yang mengarah kebawah ?
4. Apakah An.N boleh disunat / menjalani sirkumsisi dalam kondisinya tersebut ?
5. Bagaimana pandangan Islam terhadap kasus tersebut (adab dan hukum) ?
6. Bagaimana adab bergaul dengan orang yang kita ketahui memiliki kecacatan atau disabilitas
fisik?

BRAINSTORMING
Mengapa An. N. harus berjongkok saat BAK ?
An.N berjongkok saat BAK karena pancaran air seni-nya mengarah ke bawah sehingga secara
refleks berjongkok agar celana-nya tidak basah atau kotor karena terkena najis (air seninya
sendiri).

Apakah penyebab pancaran air seni An. N menghadap kebawah ?

An.N mengalami hipospadia yang terjadi akibat kelainan embriogenesis dari uretrae. Hal ini
akan menyebabkan uretrae lebih pendek daripada corpus cavernosusnya sehingga lubang penis
berada lebih rendah dari gland penis.
Macam & Klasifikasi Hipospadia

Hipospadia glandular,

Hipospadia Penile

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Hipospadia Skrotal

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Bagaimana mekanisme pancaran air seni An. N yang mengarah kebawah ?

Air seni dalam kandung kemih yang penuh akan mengalir melalui meatus uretrae internus
setelah spincter uretreae internus dan externus-nya terbuka. Karena meatus uretrae externus
(MUE)-nya menghadap kebawah (berada di ventral batang penis) maka aliran air seni mengarah
ke bawah dan bukan ke depan seperti bila MUE-nya berada di gland penis.

Apakah An.N boleh disunat / menjalani sirkumsisi dalam kondisinya tersebut ?

An. N sebaiknya tidak dikhitan, karena preputium An. N diperlukan untuk proses repair/
memperbaiki uretrae An.A yang pendek (sebagai penyambung uretrea)

Bagaimana pandangan Islam terhadap kasus tersebut (adab dan hukum)?

Anak laki-laki tidak dikhitan ibadahnya tidak sah krn tidak dalam kondisi bersih. Namun
apabila operasi hipospadia tidak dapat dilakukan sebelum masa baliqh, maka An. N, wajib
diajarkan untuk selalu membersihkan daerah dibawah sulcus penis (sekitar gland penis) agar
smegma tidak terkumpul dibawahnya.

Bagaimana adab bergaul dengan orang yang kita ketahui memiliki kecacatan atau
disabilitas fisik?
Memiliki disabilitas fisik bukanlah keinginan seseorang, oleh sebab itu tidak diperbolehkan
menghina disabilitas orang lain.
Apabila kita mengetahui hal tersebut, maka sebaiknya disimpan rapat dan hanya membuka
apabila memang dibutuhkan untuk urusan yang benar dan memang aib itu perlu dibuka, seperti
wajib simpan rahasia kedokteran.
Sesama muslim tidak diperkenankan menjelek-jelekkan orang lain karena fisik

KONSEP TEORI YANG HARUS DIPELAJARI

Embriogenesis organ genitalia maskulina dan faktor-faktor yang berperan pada embriogenesis
tersebut detail Embriogenesis genitalia maskulina NEA
Anatomi dan histologi sistem genitalia pria NEA
Fisiologi sistem reproduksi pria (Spermatogenesis, Ereksi, Ejakulasi, Pembentukan
smegma) RHM
Macam-macam kelainan pada sistem reproduksi pria REZ
Pemeriksaan radiologi pada sistem reproduksi pria DHA
Keanekaragaman hayati yang berperan pada sistem genitalia pria DHA

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KONTRIBUSI BLOK MINGGU KEDUA-RHM

Fisiologi sistem reproduksi pria RHM
The testis is composed of
up to 900 coiled
seminiferous tubules, in
which the sperm are
formed.
The sperm then empty
into the epididymis. The
epididymis leads into the
vas deferens, which
enlarges into
the ampulla of the vas
deferens
immediately
before the vas enters the
body of the prostate
gland.
Two seminal vesicles,
one on each side of the
prostate, empty into the
prostatic end of the
ampulla, & contents
from both ampulla and
seminal vesicles pass
into an ejaculatory duct
leading through the body
of the prostate gland &
then emptying into the
internal urethra.
Prostatic ducts also
empty from the prostate
gland into the ejaculatory
duct & from there into
the prostatic urethra.
Finally, the urethra is the
last connecting link from
the testis to the exterior.
The urethra is supplied
with mucus
derived
from a large number of
minute urethral glands
located along its entire
extent and even more so
from
bilateral
bulbourethral
glands
(Cowper glands) located
near the origin of the
urethra`

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Anatomy of testis depicting the site of spermatogenesis.

(a) The seminiferous tubules are the sperm-producing portion of the testis. (b) The undifferentiated
germ cells (the spermatogonia) lie in the periphery of the tubule, and the differentiated spermatozoa
are in the lumen, with the various stages of sperm development in between. (c) Note the presence of
the highly differentiated spermatozoa (recognizable by their tails) in the lumen of the seminifer-ous
tubules. (d) Relationship of the Sertoli cells to the developing sperm cells.

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Cell divisions during

spermatogenesis.
During embryonic
development, the
primordial germ cells
migrate to the testis,
where they become
spermatogonia.
At puberty (usually 12
to 14 years after
birth), the
spermatogonia
proliferate rapidly by
mitosis. Some begin
meiosis to become
primary spermatocytes
& continue through
meiotic division I to
become secondary
spermatocytes.
After completion of
meiotic division II, the
secondary
spermatocytes
produce spermatids,
which differentiate to
form spermatozoa

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Regulasi Spermatogenesis oleh Androgen & Hipotalamus/Hipofise Axis

Testosterone production give rise to androgenic effects & spermatogenesis

FUNCTIONS OF TESTOSTERONE
Effects before Birth
Masculinizes the reproductive tract and external genitalia
Promotes descent of the testes into the scrotum
Effects on Sex-Specific Tissues after Birth
Promotes growth and maturation of the reproductive sys-tem at puberty
Is essential for spermatogenesis
Maintains the reproductive tract throughout adulthood
Other Reproduction-Related Effects
Develops the sex drive at puberty
Controls gonadotropin hormone secretion
Effects on Secondary Sexual Characteristics
Induces the male pattern of hair growth (e.g., beard)
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Causes the voice to deepen because of thickening of the vocal folds

Promotes muscle growth responsible for the male body configuration
Nonreproductive Actions
Exerts a protein anabolic effect
Promotes bone growth at puberty
Closes the epiphyseal plates after being converted to estro-gen by aromatase
May induce aggressive behavior

Testosterone level through the ages

The different stages of male sexual function as reflected by average plasma testosterone
concentrations (red line) and sperm production (blue line) at different ages.

Functions of Testosterone During Fetal Development

Male chromosome has the sex-determining region Y (SRY) gene that encodes testis
determining factor (also called the SRY protein). The SRY protein initiates a cascade of gene

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activations that cause the genital ridge cells to differentiate into cells that secrete testosterone
and eventually become the testes
Testosterone secreted first by the genital ridges and later by the fetal testes is responsible for
the development of the male body characteristics, including the formation of a penis, prostate
gland, seminal vesicles, and male genital ducts, while at the same time suppressing the
formation of female genital organs.
Effect of Testosterone to Cause Descent of the Testes.
The testes descend into scrotum during the last 2 to 3 months of gestation stimulus for
descent of the testes is testosterone.
Effect of Testosterone on Development of Adult Primary and Secondary Sexual
Characteristics
Testosterone secretion cause the penis, scrotum, and testes to enlarge about eight fold before
the age of 20 years + secondary sexual characteristics
Effect on the Distribution of Body Hair (1) over the pubis, (2) upward along the linea alba
of the abdomen sometimes to the umbilicus and above, (3) on the face, (4) usually on the chest,
and (5) less often on other regions of the body, such as the back.
Male Pattern Baldness. Testosterone decreases the growth of hair on the top of the head; a
man who does not have functional testes does not become bald.
Effect on the Voice. Testosterone causes hypertrophy of the laryngeal mucosa and enlargement
of the larynx
Increases Thickness of the Skin over the entire body and Contribute to the Development
of Acne the ruggedness of the subcutaneous tissues, increases the rate of secretion by some
or perhaps all of the bodys sebaceous glands which can result in acne.
Increases Protein Formation and Muscle Development development of increasing
musculature after puberty, averaging about a 50 % increase in muscle mass > female
Anabolic function increase protein in muscle and non muscle & build muscle
Increases Bone Matrix and Causes Calcium Retention bones grow thicker and deposit
considerable additional calcium salts increases the total quantity of bone matrix, causes
calcium retention, epiphyses of the long bones to unite with the shafts of the bones at an early
age and affect height.
Specific effect on the pelvis (1) narrow the pelvic outlet, (2) lengthen it, (3) cause a
funnel-like shape instead of the broad ovoid shape of the female pelvis, and (4) greatly increase
the strength of the entire pelvis for load bearing.
Increases Basal Metabolic Rate.--> 10-15% due to anabolism, & increase all cells activities.
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Increases Red Blood Cells. 15 - 20 % due to increased metabolic rate

Effect on Electrolyte and Water Balance steroid hormones increase reabsorption of
sodium in the distal tubules of the kidneys, minor compare to the adrenal mineralocorticoids.

STAGES OF THE MALE SEXUAL ACT

Penile Erection & Lubrication are Parasympathetic Function.

Emission and Ejaculation Are Functions of the Sympathetic Nerves.

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Impulses from tactile receptors on the skin in the genital region (especially the glans penis) and
other parts of the body (erogenous areas) are trans-mitted to the erection center in the sacral
spinal cord (S2S4), which conducts them to parasympathetic neurons of the pelvicsplanchnic
nerves, thereby triggering sexual arousal. Sexual arousal is decisively influenced by stimulatory
or inhibitory impulses from the brain triggered by sensual perceptions, imagination and other
factors. Via nitric oxide, efferent impulses lead to dilatation of deep penile artery branches
(helicine arteries) in the erectile body (corpus cavernosum), while the veins are compressed to
restrict the drainage of blood. The resulting high pressure (1000mmHg) in the erectile body
causes the penis to stiffen and rise (erection).

EJACULATION PROCESS
The ejaculatory center in the spinal cord (L2L3) is activated when arousal reaches a certain
threshhold. Immediately prior to ejaculation, efferent sympathetic impulses trigger the partial
evacuation of the prostate gland and the emission of semen from the vasdeferens to the posterior
part of the urethra.This triggers the ejaculation reflex and is accompanied by orgasm, the apex
of sexual excitement. The ef-fects of orgasm can be felt throughout the entire body, which is
reflected by perspiration and an increase in respiratory rate, heart rate, blood pressure, and
skeletal muscle tone. During ejaculation, the internal sphincter muscle closes off the urinary
bladder while the vas deferens, seminal vesicles and bulbo-cavernous and ischiocavernous
muscles contract rhythmically to propel the semen out of the urethra.

Semen.
The fluid expelled during ejaculation (26mL) contains 35 200 million sperm in a nutrient
fluid (seminal plasma) composed of various substances, such as prostaglandins (from the
prostate) that stimulate uterine contraction. Once semen enters the vagina during intercourse,
the alkaline seminal plasma increase the vaginal pH to increase sperm motility. At least one
sperm cell must reach the ovum for fertilization to occur

Semen Formation
Semen, which is ejaculated during the male sexual act, is composed of the fluid and sperm from
the vas deferens (about 10 percent of the total), fluid from the seminal vesicles (almost 60
percent), fluid from the prostate gland (about 30 percent), and small amounts from the mucous
glands, especially the bulbourethral glands. Thus, the bulk of the semen is seminal vesicle fluid,

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which is the last to be ejaculated and serves to wash the sperm through the ejaculatory duct and
urethra.
The average pH of the combined semen is about 7.5, with the alkaline prostatic fluid having
more than neutralized the mild acidity of the other portions of the semen. The prostatic fluid
gives the semen a milky appearance, and fluid from the seminal vesicles and mucous glands
gives the semen a mucoid consistency. Also, a clotting enzyme from the prostatic fluid causes
the fibrinogen of the seminal vesicle fluid to form a weak fibrin coagulum that holds the semen
in the deeper regions of the vagina where the uterine cervix lies. The coagulum then dis-solves
during the next 15 to 30 minutes because of lysis by fibrinolysin formed from the prostatic
profibrinolysin. In the early minutes after ejaculation, the sperm remain relatively immobile,
possibly because of the viscosity of the coagulum. As the coagulum dissolves, the sperm
simultaneously become highly motile.
Although sperm can live for many weeks in the male genital ducts, once they are ejaculated in
the semen, their maximal life span is only 24 to 48 hours at body temperature. At lowered
temperatures, however, semen can be stored for several weeks, and when frozen at temperatures
below 100C, sperm have been preserved for years.

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FUNCTION OF THE SEMINAL VESICLES

Each seminal vesicle is a tortuous, loculated tube lined with a secretory epithelium that secretes
a mucoid material containing an abundance of fructose, citric acid,and other nutrient
substances, as well as large quantities of prostaglandins and fibrinogen.During the process of
emission and ejaculation, each seminal vesicle empties its contents into the ejaculatory duct
shortly after the vas deferens empties the sperm. This action adds greatly to the bulk of the
ejaculated semen, and the fructose and other substances in the seminal fluid are of considerable
nutrient value for the ejaculated sperm until one of the sperm fertilizes the ovum. Prostaglandins
are believed to aid fertilization in two ways: (1) by reacting with the female cervical mucus to
make it more receptive to sperm movement and (2) by possibly causing backward, reverse
peristaltic contractions in the uterus and fallopian tubes to move the ejaculated sperm toward
the ovaries (a few sperm reach the upper ends of the fallopian tubes within 5 minutes).

FUNCTION OF THE PROSTATE GLAND

The prostate gland secretes a thin, milky fluid that contains calcium, citrate ion, phosphate ion,
a clotting enzyme, and a profibrinolysin. During emission, the capsule of the prostate gland
contracts simultaneously with the contractions of the vas deferens so that the thin, milky fluid
of the prostate gland adds further to the bulk of the semen. A slightly alkaline characteristic of
the prostatic fluid may be quite important for successful fertilization of the ovum because the
fluid of the vas deferens is relatively acidic owing to the presence of citric acid and metabolic
end products of the sperm and, consequently, helps inhibit sperm fertility. Also, the vaginal
secretions of the female are acidic (with a pH of 3.5 to 4.0). Sperm do not become optimally
motile until the pH of the surrounding fluids rises to about 6.0 to 6.5. Consequently, it is
probable that the slightly alkaline prostatic fluid helps neutralize the acidity of the other seminal
fluids during ejaculation and thus enhances the motility and fertility of the sperm
REFERENSI
1. Standring S. 2016. Grays Anatomy The Anatomical Basis of Clinical Practice 41st ed.
London: Elsevier.
2. Eroschenko VP. 2016. diFiores Atlas of Histology With Functional Correlations 12th ed.
Philadelphia: Lippincott Williams & Wilkins.
3. Hall JE. 2016. Guyton and Hall Textbook of Medical Physiology 13th ed. Philadelphia:
Elsevier
4. Desdopaulos, et al, Colour atlas Physiology, 2013

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Minggu 2 : Genitalia Pria (PJ=RHM)

Senin
21.11.2016
Kuliah
Pengantar CSL
08.00
Pemeriksaan sistem
09.40
uroreproduksi pria
(REZ)
Waktu

09.50
11. 30

Rabu
23.11.2016

UM-1
Student Day

MKDU

14.20
16.00
16.00

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Kamis
24.11.2016

Sholat Dhuhur Berjamaah di Masjid Ainul Yaqin

Kuliah
Kuliah
Kehati Sistem
Radiologi Sistem
PLENO
1
Genitourinaria Pria
Genitourinari Pria
(YDA)
(DEW)
Persamaan
Persepsi
1

TUTORIAL 1

Jumat
25.11.2016

Kuliah
Fisiologi Sistem
Genitalia Pria
(DSD)
Kuliah
Histologi Sistem
Genitalia
(YHA)

MKDU

11.30
12.30
14.10

Selasa
22.11.2016

Pretest Praktikum
Histo

Sholat Ashar Berjamaah di Masjid Ainul Yaqin

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TUTORIAL 2

CSL
-Pemeriksaan
Genitourinaria
-Circumsisi
Praktikum
Histologi Genitalia
Pria

Sabtu
26.11.2016