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Pemicu 2 – Blok Urogenital

“Derita waktu berkemih”


Adrian Pratma – 405100018
Urinary tract obstruction
  infection & stone formation >>; unrelieved  permanent renal
atrophy

 Etiology
 Congenital anomalies: posterior urethral valves and urethral strictures,
meatal stenosis, bladder neck obstruction; ureteropelvic junction narrowing
or obstruction; severe vesicoureteral reflux
 Urinary calculi
 Benign prostatic hypertrophy
 Tumors: carcinoma of the prostate, bladder tumors, contiguous malignant
disease (retroperitoneal lymphoma), carcinoma of the cervix or uterus
 Inflammation: prostatitis, ureteritis, urethritis, retroperitoneal fibrosis
 Sloughed papillae or blood clots
 Pregnancy
 Uterine prolapse and cystocele
 Functional disorders: neurogenic (spinal cord damage or diabetic
nephropathy) and other functional abnormalities of the ureter or bladder
(often termed dysfunctional obstruction)
Clinical features
 Acute obstruction
  distention of the collecting system or renal capsule  pain
 Calculi lodged in the ureters  renal colic
 prostatic enlargements  bladder symptoms
 Unilateral complete or partial hydronephrosis may remain silent
for long periods
 bilateral partial obstruction
 inability to concentrate the urine  polyuria & nocturia
 distal tubular acidosis, renal salt wasting, secondary renal calculi, and
a typical picture of chronic tubulointerstitial nephritis
 hypertension
 Complete bilateral obstruction
 oliguria or anuria
 relief  postobstructive diuresis
Diagnosis
Examination
 A history of difficulty in voiding, pain, infection, or change
in urinary volume is common
 Evidence for distention of the kidney or urinary bladder
can often be obtained by palpation and percussion of the
abdomen
 rectal examination may reveal enlargement or nodularity
of the prostate, abnormal rectal sphincter tone, or a rectal
or pelvic mass
 Penis  meatal stenosis or phimosis
 vaginal, uterine, and rectal lesions responsible for UTO are
usually revealed by inspection and palpation
 Urinalysis may reveal hematuria, pyuria, and bacteriuria
 urine sediment is often normal, even when obstruction leads
to marked azotemia and extensive structural damage
 abdominal scout film may detect nephrocalcinosis or a
radiopaque stone
 Ultrasonography is approximately 90% specific and
sensitive for detection of hydronephrosis
Treatment
 relief of obstruction as soon as possible
 Drainage (nephrostomy, ureterostomy, or ureteral, urethral,
or suprapubic catheterization)
 When infection is not present, immediate surgery often is
not required
 Benign prostatic hypertrophy  alpha adrenergic blockers
and 5α-reductase inhibitors
 Functional obstruction secondary to neurogenic bladder 
frequent voiding and cholinergic drugs
Prognosis
 Relief of obstruction  return of renal function depends
largely on whether irreversible renal damage has occurred
 Obstruction not relief  obstruction is complete or
incomplete and bilateral or unilateral; whether or not
urinary tract infection is also present
 Complete obstruction with infection  total destruction of
kidney
 Partial return of glomerular filtration rate may follow
relief of complete obstruction of 1 and 2 weeks' duration,
but after 8 weeks of obstruction, recovery is unlikely
LO 1
 Menjelaskan batu saluran kemih
Nephrolithiasis
 one of the most common urological problems
 ~13% of men and 7% of women will develop a kidney
stone during their lifetime, and the prevalence is increasing
throughout the industrialized world (United States)
Etiology & type of stones
Manifestations of stones
 Asymptomatic until the stones reach the ureter
 Stone passage
 traverse the ureter without symptoms, but passage usually
produces pain and bleeding
 Pain  gradually, usually in the flank; increases over the next
20–60 min to become so severe  spread downward and
anteriorly toward the ipsilateral loin, testis, or vulva
 stone in the portion of the ureter within the bladder 
frequency, urgency, and dysuria
 Examinations  USG, CT, IVP, abdominal x rays
 Other syndromes
 Staghorn calculi
 Struvite, cystine, and uric acid stones  grow too large  fill the renal
pelvis and may extend to the calyces themselves  eventual loss of kidney
function
 Nephrocalcinosis
 Calcium stones grow on the papillae  break lose & cause colic / remain
stay in place (nephrocalcinosis)
 e/ hereditary distal renal tubular acidosis (RTA)
 Infection
 can occur after instrumentation and surgery of the urinary tract
(treatment of stone disease)
 due to bacteria that possess the enzyme urease can cause stones
composed of struvite
 Activity of stone disease
 New stones are forming / preformed stones are growing
Pathogenesis
 Supersaturation
 Excessive supersaturation is common in stone formation
 ex: calcium oxalate crystals will grow in size when it is put in the water with
calcium & oxalate ions
 Factors: dehydration, overxcretion (of calcium, oxalate, phosphate,
cystine, or uric acid), urine pH
 Crystallization
 Cell debris and other crystals present in the urinary tract can serve as
templates for crystal formation  multiple crystals  aggregated 
kidney stone
 ex: overgrowth of apatite plaque (Randall’s plaque)  calcium oxalate
crystallization
 Inhibitors of crystal formation
 Inorganic pyrophosphate inhibits calcium phospate formation;
 Citrate inhibits crystal growth and nucleation;
 glycoproteins inhibit calcium oxalate crystallization
Evaluation
 chemical analyses of serum and urine
 24-h urine collections, with a corresponding blood sample 
measurements of serum and urine
 calcium,
 uric acid,
 electrolytes
 creatinine,
 urine pH,
 volume,
 oxalate,
 citrate
Treatment
 avoid dehydration and to drink copious amounts of water
 Oral α1-adrenergic blockers  relax ureteral muscle
 general, severe obstruction, infection, intractable pain, and
serious bleeding  removal
 Extracorporeal lithotripsy  shock wave
 Percutaneous nephrolithotomy  cystoscope-like instrument
into the renal pelvis through a small incision in the flank 
ultrasound manuver or holmium laser
 Ureteroscopy  holmium laser
 Calcium oxalate stone
 Hypercalcemia & hypercalciuria (hyperparathyroidism, diffuse
bone disease, sarcoidosis, and other hypercalcemic states) 
5%
 Hypercalciuria without hypercalcemia  55%
 Pathogenesis
 hyperabsorption of calcium from the intestine (absorptive hypercalciuria)
 an intrinsic impairment in renal tubular reabsorption of calcium (renal
hypercalciuria)
 idiopathic fasting hypercalciuria with normal parathyroid function
 Uric acid secretion > (hyperuricosuric calcium nephrolithiasis),
with or without hypercalciuria  20%
 Hyperoxaluria  5%
 Hypocitraturia, associated with acidosis and chronic diarrhea of
unknown cause
 Treatment (hypercalciuria)
 Low-sodium and low-protein diets
 Thiazide diuretics lower urine calcium
 Thiazide-induced hypokalemia should be treated, hypokalemia will reduce urine
citrate  formation of stone

 Treatment (hyperoxaluria)
 diet low in oxalate and with a normal intake of calcium and magnesium to
reduce oxalate absorption
 Enteric hyperoxaluria  low-fat, low-oxalate diet and calcium
supplements, given with meals, to bind oxalate in the gut lumen
 oxalate-binding resin cholestyramine at a dose of 8–16 g/d  additional
 high fluid intake, neutral phosphate, and pyridoxine (25–200 mg/d) 
primary
 Citrate suplementation
 Magnesium ammonium phospate stones ~ struvite stones
 formed largely after infections by bacteria (e.g., Proteus and
some staphylococci)  convert urea -> ammonia
 Alkaline urine  precipitation magnesium ammonium phospate
salts  largest stone (staghorn calculi)

 Treatment
 Percutaneous nephrolithotomy
 extracorporeal lithotripsy
 Irrigation of the renal pelvis and calyces with hemiacidrin
 Antimicrobial treatment
 acetohydroxamic acid (many side effects  limit), an inhibitor of
urease
 Uric acid stones
 common in individuals with hyperuricemia (gout, diseases
involving rapid cell turnover, such as the leukemias)
 hyperuricemia nor increased urinary excretion of uric acid  half
of patients
 Urine pH , 5,5  predisposing factors
 Radiolucent stones

 Treatment
 Supplemental alkali, 1–3 mmol/kg (3-4 divided dose, one given at
bedtime)
 A low-purine diet
 Cystine stones
 genetic defects in the renal reabsorption of amino acids
(cysteine, lysine, arginine, and ornithine)  cystinuria
 Form at low urine pH

 Treatment
 High fluid intake, even at night; Daily urine volume should exceed 3 L
 Raising urine pH with alkali
 A low-salt diet (100 mmol/d)
 penicillamine and tiopronin (use only when fluid loading, salt reduction,
and alkali therapy are ineffective)
LO 2
 Menjelaskan infeksi saluran kemih
Definiton
 growth of >=105 organisms/ml from a properly collected
midstream "clean-catch" urine sample
 fewer bacteria (102–104/mL) may signify infection
 Suprapubic aspiration  colony counts of 102–104/mL 
infection

 Dysuria, frequency, urgency + significant bateriuria  acute


urethral syndrome

 Classifications
 lower tract infection (urethritis and cystitis)  superficial / mucosal
infection
 upper tract infection (acute pyelonephritis, prostatitis, and intrarenal
and perinephric abscesses)  tissue invasion
Epidemiology
 Acute community-acquired UTIs  7 million office visits
annually in the United States
 female population, these infections occur in 1–3% of
schoolgirls
 UTIs are unusual in male patients under the age of 50
 common among women between 20 and 50
 Asymptomatic bacteriuria is more common among elderly
men and women  40-50%
 acute uncomplicated pyelonephritis among community-
dwelling women (18–49 yo)  28 cases per 10,000
women
Etiology
 Most common  gram-negative bacilli
 E. coli (~80%),

 Proteus spp. (through the production of urease)


 Klebsiella spp. (through the production of extracellular slime and
polysaccharides)
  stone formation; isolated more frequently from patients with calculi

 + Serratia spp. & Pseudomonas spp.  recurrent infections,


urologic manipulation, calculi, or obstruction, nosocomial,
catheter-associated infections
 Lesser  Gram-positive cocci
 Staphylococcus saprophyticus (novobiocin-resistant, coagulase-
negative species)  10–15% of acute symptomatic UTIs in
young female patients
 Enterococci  acute uncomplicated cystitis in women
 enterococci + Staphylococcus aureus  infections in patients with
renal stones or with previous instrumentation or surgery
 Staphylococcus epidermidis  catheter-associated UTI
 Chlamydia trachomatis, Neisseria gonorrhoeae, herpes simplex
virus  most frequently in young, sexually active women with
new sexual partners
 Ureaplasma urealyticum  patients with acute dysuria and
frequency but is also found in specimens from many patients
without urinary symptoms
 Ureaplasmas and Mycoplasma genitalium  urethritis and
cystitis
 U. urealyticum and Mycoplasma hominis  acute prostatitis and
pyelonephritis
 Colonization of the urine of catheterized or diabetic patients by
Candida
 Mycobacterial infection
Pathogenesis
 vaginal introitus and distal urethra are normally colonized
by diphtheroids, streptococcal species, lactobacilli, and
staphylococcal species
 In female  enteric gram-negative organisms colonize the
introitus, the periurethral skin, and the distal urethra 
episodes of bacteriuria  cystitis
 Predisposing factors: alteration of the normal vaginal flora by
antibiotics, other genital infections, or contraceptives
 Ex: E. coli invades bladder epithelium  intracellular colonies
(biofilms)  persist & source of reccurent infections

 Infection ensues depends on strain pathogenicity & local


and systemic host defense mechanisms
Conditions affecting pathogenesis
 Gender & sexual activity
 Female most (short length of urethra; its proximity to anus)
 Use of spermicidal compounds with a diaphragm or cervical cap or
use of spermicide-coated condoms  alters normal flora  increases
in vaginal colonization with E. coli  cystitis & acute pyelonephritis >

 Male  prostatic hypertrophy, Insertive rectal intercourse  cystitis

 Men (and women) who are infected with HIV and who have CD4+ T
cell counts of <200/microL  UTI risk >>
 lack of circumcision has been identified as a risk factor for UTI in both
male neonates and young men
 Pregnancy
 detected in 2–8% of pregnant women
 20–30% of pregnant women with asymptomatic bacteriuria
subsequently develop pyelonephritis
 Predisposing fx
 decreased ureteral tone,
 decreased ureteral peristalsis,
 temporary incompetence of the vesicoureteral valves
  low birth weight, premature delivery, and neonatal death
result from UTIs
 Obstruction
 tumor, stricture, stone, or prostatic hypertrophy 
hydronephrosis  UTI >>
 lead to rapid destruction of renal tissue

 Neurogenic bladder dysfunction


 spinal cord injury, multiple sclerosis, diabetes, and other diseases
 UTI
 may be initiated by the use of catheters for bladder drainage
 demineralization due to immobilization  hypercalciuria,
calculus formation, and obstructive uropathy
 Vesicoureteral reflux
 common among children with anatomic abnormalities of the
urinary tract / anatomically normal but infected urinary tracts
 some retrograde movement of bacteria probably takes place
during infection but is not detected by radiologic techniques
 Reflux  unexplained failure of renal growth or with renal
scarring
 Genetic factors
 Ex: P fimbriae mediate attachment of E. coli to P-positive
erythrocytes and are found on nearly all strains causing acute
uncomplicated pyelonephritis
 Mutations in host genes integral to the immune response (e.g.,
Toll-like receptors, interferon receptors) may also affect
susceptibility to UTI
 Bacterial virulence factors
 Uropathogenic E.coli (serogroup O, K, H)
 Bacterial adherence to uroepithelial cells
 fimbriae (hairlike proteinaceous surface appendages) mediate
bacterial attachment to specific receptors on epithelial cells 
 secretion of IL-6 and IL-8 (with subsequent chemotaxis of leukocytes to the
bladder mucosa)
 Apoptosis and epithelial cell desquamation
 produce cytotoxins, hemolysin, and aerobactin (a siderophore for
scavenging iron) and are resistant to the bactericidal action of human
serum

  acute pyelonephritis and most of those causing acute cystitis


Clinical presentation
 Cystitis
 dysuria, frequency, urgency, and suprapubic pain

 Physical exam
 tenderness of the urethra or the suprapubic area
 Genital lesion / vaginal discharge + <105 bacteria/ml urine 
urethritis, vaginitis, or cervicitis (e.g., C. trachomatis, N. gonorrhoeae,
Trichomonas, Candida, and HSV)
 temperature of >38.3°C (>101°F), nausea, and vomiting
 costovertebral angle tenderness

 Urine  grossly cloudy and malodorous and is bloody (~30%)


 some women with cystitis  102–104 bacteria/ml urine
 Acute pyelonephritis
 fever, shaking chills, nausea, vomiting, abdominal pain, and diarrhea
 develop rapidly over a few hours or a day

 Physical exam
 fever, tachycardia, and generalized muscle tenderness
 tenderness on deep pressure in one or both costovertebral angles or on
deep abdominal palpation

 significant leukocytosis and bacteria detectable in Gram-stained


unspun urine
 Leukocyte casts; bacteriuria; pyuria
 Hematuria  acute phase; persist  a stone, a tumor, or tuberculosis
should be considered
 Respond to appropriate therapy (48–72 h) if papillary necrosis,
abscess formation, or urinary obstruction not found
 Urethritis
 acute dysuria, frequency, and pyuria
 midstream urine cultures with either no growth or insignificant
bacterial growth (~30%)
 sexually transmitted pathogens (e.g., C. trachomatis, N. gonorrhoeae, or
HSV)
 gradual onset of illness, no hematuria, no suprapubic pain, and >7 days of
symptoms
 sex-partner change
 low-count E. coli or S. saprophyticus infection of the urethra and bladder
 Gross hematuria, suprapubic pain, an abrupt onset of illness, a duration of
illness of <3 days, and a history of UTIs
 Catheter-Associated UTIs
 E. coli, Proteus, Pseudomonas, Klebsiella, Serratia, staphylococci,
enterococci, and Candida
 Risk factors  female sex, prolonged catheterization, severe
underlying illness, disconnection of the catheter and drainage
tube, lack of systemic antimicrobial therapy
 Infection reach bladder with 2 routes
 migration through the column of urine in the catheter lumen (intraluminal
route)
 up the mucous sheath outside the catheter (periurethral route)
 minimal symptoms without fever and often resolve after
withdrawal of the catheter
Diagnostic testing
 bacteria are usually present in the urine in large numbers
(>=105/mL)
 samples of urine from the ureters or renal pelvis may
contain <105 bacteria/ml
 the presence of bacteriuria of any degree in suprapubic
aspirates
 >=102 bacteria per milliliter of urine obtained by
catheterization

 Pyuria in the absence of bacteriuria (sterile pyuria)  C.


trachomatis, U. urealyticum, or Mycobacterium tuberculosis
or with fungi
Approaches
 treatment is initiated solely on the basis of a typical history
and/or typical findings on physical examination
 women with symptoms and signs of acute cystitis and
without complicating factors are managed with urinary
microscopy
  positive result for pyuria and/or bacteriuria  treat the
patient without culture
 Culture  when a woman's symptoms and urine-
examination findings leave the diagnosis of cystitis in
question
Treatment
 Acute urethritis
 Chlamydial inf  azithromycin (1 g in a single oral dose) or
doxycycline (100 mg twice daily by mouth for 7 days)
 Asymptomatic bacteriuria
 Removal of the catheter in conjunction with a short course of
antibiotics
 antimicrobial therapy is unnecessary, except neutropenia, renal
transplants, obstruction, or other complicating conditions has
arrised  7 days therapy
 If bacteriuria persists  monitored without further treatment in
most patients; Longer-term therapy (4–6 weeks) may be
necessary in high-risk patients with persistent asymptomatic
bacteriuria
 Treatment during pregnancy
 7 days of treatment with amoxicillin, nitrofurantoin, or a
cephalosporin
 should be screened for asymptomatic bacteriuria during the first
trimester  if bacteriuric  treated  culture (ensure cure)
repeated monthly until delivery

 Acute pyelonephritis in pregnancy  hospitalization and


parenteral antibiotic therapy, generally with a cephalosporin or
an extended-spectrum penicillin
 Continuous low-dose prophylaxis with nitrofurantoin should be
given to women who have recurrent infections during pregnancy
Prognosis
 uncomplicated cystitis or pyelonephritis, treatment
ordinarily results in complete resolution of symptoms
 Cystitis may also result in upper tract infection or in
bacteriemia
 repeated episodes of cystitis occur  commonly
reinfections
 Acute uncomplicated pyelonephritis in adults rarely
progresses to renal functional impairment and chronic renal
disease
 Repeated upper tract infections often represent relapse
rather than reinfection; renal calculi or an underlying
urologic abnormality should be vigorously sought 
neither is found  6 weeks of therapy
 Asymptomatic bacteriuria in these groups as well as in
adults without urologic disease or obstruction predisposes
to increased numbers of episodes of symptomatic infection
but does not result in renal impairment in most instan
Prevention
 Women who experience frequent symptomatic UTIs (>=3 per
year on average) are candidates for long-term administration
of low-dose antibiotics directed at preventing recurrences +
advised to avoid spermicide  Daily or thrice-weekly
administration of a single dose of TMP-SMX (80/400 mg), TMP
alone (100 mg), or nitrofurantoin (50 mg)
 Fluoroquinolones have also been used for prophylaxis
 initiated only after bacteriuria has been eradicated with a full-
dose treatment regimen
 Postmenopausal women who are not taking oral estrogen
replacement therapy can effectively manage recurrent UTIs with
topical intravaginal estrogen cream
Prostatitis
 various inflammatory conditions affecting the prostate
References
 Fauci. Braunwald. Dkk. Harrison’s Principles of Internal
Medicine. 17th edition. United State: The McGraw-Hills;
2008
 Robbin’s pathology

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