EVALUASI FUNGSI

BERKEMIH DAN
DEFIKASI
Oleh : Lisa Emilda
Pembimbing : dr. Ira Mistivani, Sp.KFR-K
 Comprehensive evaluation of voiding dysfunction
Urology assessment of the upper and lower urinary
tract
Neuroanatomy and neurophysiology
Peripheral Pathways:
Afferent fiber : Pelvic Nerve
Efferent fiber :
Somatic System : pudendal nerve (S2-S4)
Autonomic System : Sympathetic Nerves (T10-L2)
Parasympathetic Nerves (S2-S4)

Central Pathway:
Corticopontine-mesencephalic nuclei
Pontine-mesencephalic-sacral (Pontine micturition center)
Pelvic and pudendal nuclei (sacral micturition center)
Motor cortex to pudendal nucleus
 Physiology of Micturition
A) Urinary Storage

Storage = Sympathetic

1. Stimulus: Urine filling until tension in wall of bladder rises above

threshold
2. Receptor: Stretch receptors in bladder wall
3. Afferent: Pelvic nerve
4. Center: S2-S4
5. Efferent: Hypogastric sympathetic (T10-L2)
6. Effectors:
Detrusor muscle: relaxation
internal urethral sphincter : contraction
B) Micturition Reflex

Voiding = Parasympathetic

1. Stimulus: Volume of urine that initiates micturition reflex

2. Receptor: Stretch receptors in bladder wall
3. Afferent: Pelvic nerve
4. Centre: S2S4
5. Efferent: Pelvic parasympathetic
6. Effectors:
Derusor muscle: contraction
Internal urethral sphincter : relaxation
 Voiding Dysfunction

Classifications have been based on:

Neurologic lesion
Urodynamic findings
Functional classification
Wein classification is useful for deciding on treatment
option
Combination of bladder and urethral function based on
urodynamics
Weins classification.

based on a clinical problem

(incontinence or retention)
Comprehensive Evaluation of Voiding Dysfunction

Anamnesa:
Neurourologic History:
Voiding complaints : urgency, frequency, incontinence,
dysuria
Previous voiding history
Previous surgery : abdominal, pelvic, transurethral
Medication : sedative, anticholinergic, adrenergic, ca-
channel blocker
Other medical problem : stroke, endocrine disorder, UTI
Restricted mobility
Physical Examination:
Motoric examination
Sensory examination
Deep tendon reflexes
Cutaneous reflexes:
Cremasteric (L1 to L2), Bulbocavernosus (S2 to S4),
and Anal reflex (S2 to S4)
Pathologic reflexes
Prostat examination
 Urologic Assessment:

Indications for Testing

the disease process
the patients clinical course
any preexisting urologic problems needing further follow-up
Upper Tract Studies:
1. Ultrasonography : to detect anatomical changes
2. Plain Radiography
3. Computed Tomography
4. Intravenous Pyelogram (IPV) : evaluates both function
and anatomy
5. Creatinine Clearance Time
6. Quantitative MAG 3 radioisotope renal scan : to
monitor renal function and drainage
 Lower Tract Studies

1. Urinalysis, Culture, and Sensitivity Testing.

2. Postvoid Residual.
3. Cystography.
4. Cystometrography.
5. Urethral Pressure Profiles.
6. Sphincter Electromyography.
7. Videourodynamics
8. Cystoscopy
Evaluation of Bladder Filling (Storage Phase)

Bedside cystometrogram
This test can be used to evaluate:
Sensation (aware of the bladder being filled)
Stability (there is a rise in the column of water signifying a
bladder contraction)
Capacity (the volume at which the bladder contraction
occurs).
Screening test to determine if an SCI patient has come out
of spinal shock
 Evaluation of Bladder Emptying
Postvoid Residual:
can be determined with catheterization or bladder
ultrasound
elderly person with no voiding symptoms may have a
postvoid residual of 100 to 150 mL
A normal postvoid residual does not rule out a voiding
problem
as a result of a compensatory increase in the strength
of detrusor contractions or of absent bladder contractions in
the presence of increasing intra- abdominal pressure
(Valsalva maneuver)
 Urodynamics
Provides objective information on voiding function
information about filling phase, emptying phase, or both
phases of micturition.
Bladder wall inflammation is likely to cause the bladder to
lose some of its compliance, resulting in a smaller bladder
capacity than normal and also likely to trigger uninhibited
contractions and cause the bladder to be more overactive
than usual
Indications for an urodynamics evaluation:
Recurrent UTIs in a patient with neurogenic bladder
Urinary incontinence
Urinary frequency
Large postvoid residuals (i.e., retention)
Deterioration of the upper tracts
Monitoring of voiding pressures
Evaluation and monitoring of pharmacotherapy
Multichannel Water-fill Urodynamic Study
Filling (storage) phase water is being
infused into the bladder

Can be evaluated:
bladder sensation,
bladder capacity,
bladder wall compliance,
bladder stability
 Empty bladder no sensation
First sensation a person has of having a full bladder (first
sensation of fullness) usually occurs with 100 to 200 mL.
The sensation of fullness occurs around 300 to 400 mL
onset of urgency occurs between 400 and 500 mL
Voiding (emptying) phase begin when a
person is told to void
Evaluated:
opening or leak-point pressure (bladder pressure at voiding
begins),
maximum voiding pressure,
urethral sphincter activity (EMG or actual pressure),
Flow rate,
voided volume,
postvoid residual.
During the voiding phase:
Detrusor pressures < 30 cm H2O (women), 30-50 cmH2O
(men)
The flow usually has a bell-shaped curve, progressively
increasing to its maximum rate and then decreasing
should be no postvoid residual catheterized or
ultrasound
 The type of voiding dysfunction
with an urodynamics evaluation
Voiding Dysfunctions Found in Neurologic
Disordes

Suprapontine Lesions
The expected urodynamic finding is detrusor hyperreflexia
without detrusor-sphincter dyssynergia
Urinary incontinence is the most common urologic problem
following an acute CVA
Detrusor overactivity with uninhibited bladder contractions
is the most common urodynamic finding
The release of the spinal micturition reflexes from the
inhibitory higher centers
Parkinsons Disease
Detrusor overactivity has been the most common urodynamic
finding
loss of the inhibitory input from the basal ganglia on the
micturition reflexes
Suprasacral Spinal Cord Lesions
Expected to have detrusor hyperreflexia with detrusor-
sphincter dyssynergia
Traumatic suprasacral SCI results in an initial period of spinal
shock hyporeflexia of the somatic system below the level
of injury and detrusor areflexia.
During this phase, the bladder has no contractions, even
with various maneuvers such as water filling, bethanechol
supersensitivity testing, or suprapubic tapping.
Decreased activity of the external urethral sphincter during
acute spinal shock
Sacral Lesions
Damage to the sacral cord or roots results in a highly compliant
acontractile bladder
The external sphincter is not affected to the same extent as the
detrusor. This is because the pelvic nerve innervation to the
bladder usually arises one segment higher than the pudendal
nerve innervation to the sphincter
The nuclei also are located in different portions of the sacral
cord, with the detrusor nuclei located in the intermediolateral cell
column and the pudendal nuclei located in the ventral gray
matter.
This combination of detrusor areflexia and an intact sphincter
helps contribute to bladder overdistention and decompensation
Autonomic Dysreflexia
can occur in those with injuries at thoracic level 6 (T6) and
above
sudden severe elevation in blood pressure
sweating, flushing, goose bumps,headache, and bradycardia
any noxious stimuli, various urologic problems, such as
bladder distention, UTIs, epididymitis, and urologic
instrumentation, may provoke its onset
Peripheral Lesions
peripheral neuropathy secondary to diabetes mellitus A
sensory neuropathy
Urodynamic findings, including decreased bladder sensation,
chronic bladder overdistention, increased postvoid residuals,
and possible bladder decompensation, may result from bladder
overdistention secondary to decreased sensation of fullness
Voiding dysfunctions resulting from pelvic surgery or pelvic
trauma usually involve both motor and sensory innervation of
the bladder
TERIMA KASIH