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Hematuria

Hematuria

• Hematuria is the excretion of abnormal amounts of red blood cells (RBCs) into the
urine. Normal individuals excrete about 1 million RBCs per day in their urine.
When translated to the sediment of a spun urine specimen, this equates to about 1
to 3 RBCs per high-power field (HPF). Therefore excretion of more than 3 RBCs
per HPF is abnormal and may warrant further evaluation.
• Asymptomatic “microscopic hematuria” is very common ; it may be detected in up
to 13% of adults.
• Routine screening of healthy individuals for the presence of hematuria is not
recommended by the U.S. Preventive Services Task Force.
• Gross hematuria may first be detected by a change in urine color. Microscopic
hematuria can be detected by dipstick methods, microscopic examination, or both.
• Dipstick methods may be applied as diagnostic tests in patients with known kidney
disease or as screening tools in healthy or high-risk individuals.
• The U.S. Preventive Services Task no longer recommends screening for occult
hematuria in the general population.
• Even when the urine is red, or when a dipstick screening test result is positive, the
sediment should be examined to deter mine whether red cells are present. The
presence of other pigments such as free hemoglobin and myoglobin can
masquerade as hematuria
• When such testing reveals hematuria, the person’s age, gender, race, medical
history, and physical findings should be considered in deciding whether to
further evaluate this finding and, if so, in determining the most appropriate
diagnostic studies and the sequence in which they should be performed.
• Asymptomatic microscopic hematuria should be confirmed in at least two
of three midstream clean - catch voiding's.
• If microscopic hematuria spontaneously resolves, evaluation decisions are
strongly influenced by the clinician’s index of suspicion.
Hematuria

• Gross hematuria, especially if clots are passed, usually indicates a urologic source
of bleeding.
• Even a single episode of gross hematuria mandates evaluation.
• The most common cause of gross hematuria in young women (<40 years of age) is
urinary tract infection (UTI).
• Malignancy must be strongly considered and ruled out by appropriate studies in
older patients.
• Brown, “Coca-Cola”–colored, or smoky urine with RBCs present on micros-copy
is very suggestive of a glomerular source of bleeding.
• Three major factors influencing the workup are the patient’s gender, race, and age. The common causes of
hematuria in children and young adults are much different than those in older individuals.

• Hematuria in adults older than 40 years (some experts propose an age cutoff of older than 50 years) must
be considered a sign of malignancy.

• Hypercalciuria , and less commonly hyperuricosuria, cause hematuria frequently in children but less
commonly in adults.

• Hematuria due to UTI is much more common in women , whereas older men may bleed from the prostate.
History and Review of Systems

• The combination of hematuria with fever, dysuria, or flank pain, or a prior history
of these symptoms raises the likelihood of infection, stones, or malignancy.

• When a patient with hematuria has family members with renal failure, polycystic
kidney disease. A very common cause of otherwise unexplained asymptomatic
familial hematuria is thin basement membrane disease.
• Hematuria sometimes occurs after vigorous exercise or participation in contact or
noncontact sports .
• Travel history may be very important as, for example, when hematuria develops in
patients who have traveled to areas where Schistosoma haematobium infection or
tuberculosis is endemic.

• Bleeding disorders and anticoagulants will cause any pathologic GU structures such
as malignancies to bleed more readily. This is especially common in older patients.

• ofA history of cigarette smoking (or second-hand smoke exposure) increases the risk
bladder cancer twofold to four fold.
• Occupational exposure to aniline dyes and aromatic amines and amides; treatment
with some chemotherapeutic agents such as cyclophosphamide and mitotane; and
radiation to the pelvis increase the risk for uroepithelial cancers.

• Aglomerulonephritis
recent history of pharyngitisfol lowed by hematuria raises the possibility of
with synpharyngitic bleeding. Chronic glomerulonephritis, most
commonly immunoglobulin A (IgA) nephropathy, is often exacerbated by an upper
respiratory tract infection and may result in gross hematuria. This is distinct from
post streptococcal glomerulonephritis, which occurs 2 to 6 weeks following the
infection.
• With gross hematuria, a history of initiation hematuria suggests a urethral
source, whereas termination hematuria is suggestive of bladder neck or
prostatic urethra pathology.

• Blood clots in some the urine usually denote structural urologic pathology.
Physical examination
• Evaluation of blood pressure and volume status is especially important when
glomerulonephritis is a consideration.
• Ifexist.palpation of the abdomen reveals a mass, a renal tumor or hydronephrosis may
• A palpable bladder after voiding indicates obstruction or retention.
• Atrial fibrillation raises the possibility of renal embolic infarction, especially if the
patient has flank pain.
• nephrolithiasis,
Costovertebral angle tenderness is also suggestive of pyelonephritis,
or ureteropelvic junction obstruction.
• A bruit over the kidney suggests a vascular cause.
• Careful genital and rectal examination is necessary to diagnose prostatitis,
prostate cancer, epididymitis, meatal stenosis, and other structural causes of
hematuria .
Laboratory test
• A diagnosis of gross hematuria is suggested by red or brown urine. Only
about 1 mL of blood causes 1 L of urine to become red. However, many
substances other than RBCs can produce. red or brown urine. Many
chemicals, medications, and food metabolites can produce a spectrum of
urine colors.
Laboratory test
• A chemical test for hemoglobin is very helpful in distinguishing among these possibilities.

• The most commonly used method of testing the urine for blood is the urine test strip or
dipstick, which utilizes the peroxidase-like activity of hemoglobin to generate a color change.

• The test strip does not react with most nonhemoglobin pigments that can color the urine.

• In addition to detecting the hemoglobin within RBCs, however, the test reaction yields a positive
result with free hemoglobin and myoglobin.
Laboratory test
• It is crucial to separate hematuria caused by glomerular abnormalities from bleeding
due to other pathologic kidney conditions (tumors or cysts) or pathologic processes
distal to the glomerulus (interstitial disease, stones, or tumors, or other processes
affecting the renal pelvis, ureters, bladder, urethra, prostate, or other lower GU
system structures). When blood originates from glomeruli, the RBCs pass through
the length of the renal tubules, where they are subjected to marked changes in
osmolality, ionic strength, pH, and other forces. Compression of the RBCs together
with urine proteins creates RBC casts and identification of these casts on
microscopic examination is excellent evidence of glomerular bleeding. Although
quite specific, RBC casts often are not seen even with definite glomerular bleeding.
Laboratory test
• A more common helpful finding in glomerular bleeding is the identification
of dysmorphic RBCs of varying shape and sizes with blebs, budding, and
especially the vesicle-shaped protrusions that characterize acanthocytes. For
dysmorphic RBCs to be an excellent indicator of glomerular bleeding, most
of the urine RBCs should be affected.

• Acanthocytes are quite specific, however, and if they represent more than
5% of the RBCs, this is very a suggestive sign of glomerular bleeding.
Laboratory test
• Another indication that bleeding is more likely of glomerular origin is coexistent
significant proteinuria (>0.5 g/day or >0.5 g protein per gram of creatinine). The
presence of pyuria with hematuria suggests inflammation or infection and warrants
a urine culture.

• Urine cytologic analysis is indicated when otherwise unexplained hematuria is


documented. It has good specificity when results are positive and a sensitivity of
about 80% for bladder cancer but a much lower sensitivity for upper tract
malignancy.
Imaging
• When hematuria is not believed to be of glomerular origin, then computed
tomography (CT) with and without intravenous (IV ) contrast is currently the
preferred initial imaging modality to evaluate microscopic and gross hematuria and
has largely replaced intravenous pyelography (IVP).

• CT urography has excellent sensitivity for stones, identifies most kidney tumors,
and reveals other non–GU tract abdominal pathologic processes. The major
downside of a CT scan is the need for IV contrast and the significant radiation
exposure.
• If CT cannot be done, then renal ultrasonography is the next best initial
imaging test. If the explanation for hematuria is not evident on the initial
study, the next diagnostic imaging test to perform is cystoscopy.
Urinary Incontinence
• Pasien Geriatri  jika terserang kondisi
akut :

GERIATRIC GIANTS :

SINDROM DELIRIUM
DEPRESI
JATUH / INSTABILITAS POSTURAL
INKONTINENSIA
IMOBILISASI
GEJALA DEKONDISI
Anatomi saluran
kemih

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PROSES
BERKEMIH

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Persarafan Saluran
Kemih Bagian
Otak Bawah

T10–L2 Otot Polos


Detrusor

Internal sphincter
smooth muscle

S2–S4 Intramural skeletal muscle


Extramural
skeletal muscle

Urethral smooth muscle

Adapted from Wein AJ. Exp Opin Invest Drugs. 2001:10:65-83.


BASICS MECHANISMS

Three basic mechanisms serves as “final


common pathways” in nearly all causes
of incontinence :
• Urge incontinence
 Hyperactive / irritable bladdder
• Stress incontinence
 Urethral incompetence
• Overflow bladder
INKONTINENSIA
URGENSI

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INKONTINENSIA
STRESS

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INKONTINENSIA
STRESS

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OVERACTIVE BLADDER

Gejala OAB :
• Urgency, dengan atau tanpa urge inkontinensia biasanya dengan frekuensi dan nocturia.
• Gejala ini merupakan akibat dari otot detrusor yang overaktif (secara urodinamik terdapat
kontraksi yang tidak terkendali dari otot detrusor).
• Istilah OAB dipakai apabila tidak terbukti ada infeksi atau patologi yang lain.

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OVERACTIVE BLADDER

• Urgency adalah keluhan keinginan berkemih yang kuat yang datang secara
mendadak, dan sulit ditahan.
• Frekwensi berkemih meningkat yang dikeluhan oleh pasien pada siang hari ( setara
dengan polyuria)
• Nocturia adalah keluhan dimana terbangun dari tidur malam untuk berkemih lebih
dari 1 x.

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Causes of Reversible Urinary Incontinence
D Delirium
I Infection
A Atrophic vaginitis
P Pharmaceutical
P Physiological disorders
E Endocrine disorders
R Restricted mobility
S Stool impaction
Diagnosis
• Anamnesis
• Pemeriksaan Fisik
• Melakukan pemeriksaan umum, abdomen (palpasi buli-buli), dan pemeriksaan neurologi
• Melakukan pemeriksaan panggul dan dubur pada wanita dan pemeriksaan dubur pada laki-laki
• Mengobservasi keluarnya urine padastress (misalnya batuk, valsava, dll)
• Melakukan pemeriksaan residu urine apabila diduga ada obstruksi bagian bawah (kesulitan
berkemih, BPH, operasi daerah panggul sebelumnya)

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Diagnosis

• Pemeriksaan Laboratorium
• Urinalysis
- untuk melihat adanya hematuria, pyuria, bacteria, glucosuria, proteinuria
• Pemeriksaan darah bila diperlukan
- Glucose
- PSA (laki-laki di atas 50 tahun)
- Lain-lain

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• Obat-obatan yang mungkin berpengaruh terhadap fungsi
berkemih
• Diuretik • Narkotika
• Antidepresan • Sedatif
• Antihipertensi • obat tidur dan
demam
• Hipnotik
• Antipsikotik
• Analgesik
Diferensial Diagnosis

~ BPH ~ Interstitial cystitis


~ Prolapse ~ Diabetes
~ Atrophic vaginitis ~ Urinary tract infection
~ Pelvic floor dysfunction ~ Urinary tract infection

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Inkontinensia urgensi
Terapi non medikamentosa
• Modifikasi asupan cairan, hindari kafein, obati setiap penyebab (infeksi,tumor, batu),
latihan berkemih, antikolinergik/relaksan otot polos(oksibutin, tolterdin).
Terapi bedah
• Terapi pembedahanSistoskopi (cystoscopy) adalah prosedur pemeriksaan dengan
sebuah tabung fleksibel berlensa yang dimasukkan melalui uretra ke dalam kandung
kemih dan kemudian untuk mempelajari kelainan dalam kandung kemih dan saluran
kemih bawah.
Inkontinensia Stres
• Terapi non medikamentosa
Latihan otot otot dasar panggul, estrogen untuk vaginitis atrofik
• Terapi Pembedahan
Uretropeksi retroubik atau endoskopik, perbaikan vagina, sfinger buatan
Inkontinensia overflow
• Jika terdapat obstruksi : obati penyebab obstruksi, misalnya TURP.
• Jika tidak terdapat obstruksi : drainase jangka pendek dengan kateter untuk
memungkinkan otot detrusorpulih dari peregangan berlebihan, kemudian
penggunaan stimulan ototdetrusor jangka pendek (bethanekol ; distigmin).
Jika semuanya gagal,katerisasi interminten yang dilakukan sendiri
(inkontensia overflowneurogenik).
Medikamentosa
Alfa Adrenergik
• Agonis otot leher vesika dan uretha proksimal megandung alfa adrenoseptor yang
menghasilkan kontraksi otot polos dan peningkatan tekanan penutupan urethra
Efedrin
• Efek langsung merangsang alfa sebaik beta-adrenoseptor dan juga melepaskan noradrenalin
dari saraf terminal.
Phenylpropanololamine
• PPA (Phenylpropanololamine) efek stimulasi perifer sebanding dengan efedrin, akan tetapi
dengan efek CNS yang terkecil. PPA adalah komponen utama obat influensa dalam
kombinasi dengan antihistamin dan anthikholinergik.
Tampon
• Tampon dapat membantu pada inkontinensia stres terutama bila kebocoran
hanya terjadi intermitten misal pada waktu latihan. Penggunaan terus
menerus dapat menyebabkan vagina kering atau luka
Bonnas Device
• Terbuat dari bahan lateks yang dapat ditiup. Bila ditiup dapat mengangkat
sambungan urethrovesikal dan urethra proksimal
Penatalaksanaan stres inkontinensia urine secara operatif dapat dilakukan dengan beberapa cara meliputi :
• Kolporafi anterior
• Uretropeksi retropubik
• Prosedur jarum
• Prosedur sling pu
• Periuretral bulking agent
• Tension vaginal tape (TVT)
• Tindakan operatif sangat membutuhkan informed consent yang cermatdan baik pada penderita dan
keluarganya karena angka kegagalan maupunrekurensi tindakan ini tetap ada

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