INFEKSI SALURAN

KEMIH
Ayu Prawesti Priambodo, M.Kep

The urinary system

The urinary system is one of the excretory
systems of the body. It consists of the
following structures:
2 kidneys,
2 ureters, which convey the urine from the kidneys
to
the urinary bladder
1 urinary bladder where urine collects and is
temporarily stored
1 urethra through which the urine is discharged from
the urinary bladder to the exterior.

The main functions of the

kidneys are:
formation and secretion of urine
production and secretion of
erythropoietin, the
hormone responsible for controlling the
rate of
formation of red blood cells
production and secretion of renin, an
important
enzyme in the control of blood pressure .

MICTURATION

INFECTIONS OF THE
URINARY TRACT

Infeksi Saluran Kemih (ISK) adalah suatu keadaan adanya

infeksi bakteri pada saluran kemih. (Enggram, Barbara, 1998)

The kidney are susceptible to

inflammation caused by bacterial
infection, altered immune response,
drugs and other chemicals toxin, and
radiation.

Inflammation may be acute or chronic

UTI are among the most common

infections affecting humans
throughout their life span.

Urinary Tract Infection

Lower
urethritis
cystitis
prostatitis
Upper
pyelonephritis
intrarenal and perinephric abscess

Etiology
Most common is Gram neg. bacteria

E. coli = 80% of uncomp. acute UTI

Proteus assoc. with stones
Klebsiella assoc. with stones
Enterobacter
Serratia
Pseudomonas

Etiology
Gram pos. cocci

Staphylococcus saprophyticus 10-15 %

acute sx UTI in young females
Enterococci occas. in acute uncomp.
cystitis
Staphylococcus aureus assoc. with renal
stones, instrumentation, increased susp. of
bacteremic kidney infection

Etiology

Urethritis from chlamydia, gonorrhea,

HSV acute sx female with sterile pyuria
Ureaplasma urealyticum
Candida or other fungal species
commonly assoc. with cath. or DM
Mycobacteria

Pathophysiology

Ascending infection from the urethra

Hematogenous spread.( Tuberculosis, renal abses)
Lymphatogenous spread
Direct extension from another organ : this occurs
from intra peritoneal abses, especially those
associated wit inflammatory bowel disease,
fulminant pelvic inflammatory disease in women,
genitourynary tract fistula
Structural and functional abnormalities of the
urinary trac, obstruction of urine flow, and impaired
bladder innervation increase the risk for UTI

MICTURATION

What is a urinary tract

infection?
is the system that makes urine and carries it
out of your body. It includes your bladder
and kidneys and the tubes that connect
them. When germs get into this system,
they can cause an infection.

ETIOLOGI
Nonspesifik disebabkan
- Batang gram (-) aerob : E coli, P
mirabilis
- Kokus gram (+) : Stafilokok, Enterokus
- Anaerob obligate : Bakterioides.
- Lain-lain: Chlamidia trachomatis,
Ureaplasma
Spesifik
Disebabkan mikroorganisme spesifik yang
memberikan gejala yang khas
Misal: Tuberkulosis, Gonorrhea,
Actinomycosis

Patofisiologi :

Ginjal : sepasang organ saluran kemih yang

mengatur keseimbangan cairan tubuh dan
elektrolit dalam tubuh, dan sebagai
pengatur volume dan komposisi kimia
darah dengan mengeksresikan air yang
dikeluarkan dalam bentuk urine apabila
berlebih. Diteruskan dengan ureter yang
menyalurkan urine ke kandung kemih.
Saluran kemih atau urine bebas dari
mikroorganisme atau steril.

Penyebaran endogen yaitu kontak

langsung dari tempat infeksi
terdekat (ascending)
Hematogen
Limfogen
Eksogen sebagai akibat pemakaian
berupa kateter

Jalur Utama ISK

Hematogen

Ascending

Kuman penyebab ISK pada umumnya adalah

kuman yang berasal dari flora normal usus. Dan
hidup secara komensal di dalam introitus
vagina, prepusium penis, kulit perineum, dan di
sekitar
anus.
Mikroorganisme
memasuki
saluran kemih melalui uretra prostate vas
deferens testis (pada pria) buli-buli ureter,
dan sampai ke ginjal

Ascending
Masuknya
kuman
secara ascending ke
dalam saluran kemih,
(1) Kolonisasi kuman di
sekitar
uretra,
(2)
masuknya
kuman
melalui uretra ke bulibuli, (3) penempelan
kuman pada dinding
buli-buli, (4) masuknya
kuman melalui ureter
ke ginjal.(2)

ASENDING
masuknya
A
N
I
M
A
S
I

mikroorganisme dalm
kandung kemih, antara lain: factor
anatomi
dimana
pada
wanita
memiliki uretra yang lebih pendek
daripada laki-laki sehingga insiden
terjadinya ISK lebih tinggi, factor
tekanan
urine
saat
miksi,
kontaminasi fekal, pemasangan alat
ke
dalam
traktus
urinarius
(pemeriksaan
sistoskopik,
pemakaian
kateter),
adanya
dekubitus yang terinfeksi.

HEMATOGEN
system

imunnya rendah sehingga

mempermudah penyebaran infeksi
secara hematogen Ada beberapa hal
yang mempengaruhi struktur dan
fungsi
ginjal
sehingga
mempermudah
penyebaran
hematogen,
yaitu:
adanya
bendungan
total
urine
yang
mengakibatkan distensi kandung
kemih, bendungan intrarenal akibat
jaringan parut

Etiologi
Mikroorganisme yang paling sering ditemukan adalah
jenis bakteri aerob. Virus dan jamur. Penyebab
terbanyak adalah Gram-negatif : Escherichia coli
adanya
gangguan
keseimbangan
antar
mikroorganisme penyebab infeksi sebagai agent dan
epitel saluran kemih sebagai host.
Kemampuan host untuk menahan mikroorganisme
masuk ke dalam saluran kemih disebabkan oleh
beberapa faktor, antara lain adalah :
1. pertahanan lokal dari host
2. peranan dari sistem kekebalan tubuh yang terdiri
atas kekebalan humoral maupun imunitas seluler.

Etiology
Most common is Gram neg. bacteria
E. coli = 80% of uncomp. acute UTI
Proteus assoc. with stones
Klebsiella assoc. with stones
Enterobacter
Serratia
Pseudomonas

FAKTOR-FAKTOR YANG MEMPENGARUHI

TIMBULNYA I.S.K.
1. Faktor virulensi bakteri
2. Faktor kepekaan ekstrinsik
2.1. Pada wanita
2.1.1. Introitus
2.1.2. Urethra pendek
2.2. Pada pria Prostat mensekresi zat anti
bakteri bila /(-) Bacterial prostatitis
3. Faktor kepekaan intrinsik
Neurogenic bladder, rest urine, batu
memudahkan infeksi.
, urinary antibody, PH urine.

4. Faktor ureter & ginjal

Adanya Vesicoureteral reflux, kualitas
pristaltik ureter & kepekaan medula
ginjal terhadap infeksi
Obstructive uropathy, renal blood
flow & adanya benda asing me
(+) kepekaan terhadap infeksi.

OBSTRUCTIVE
DISORDER

Faktor Risiko
Perempuan
Sexual intercouse, pregnancy, penggunaan diagfragma dan
spermicides,DM, menunda bak postcoital

Pria
Lack of circumcision, Prostatic hypertrophy, Immunodefisiensi,
Homosexcual activity, oral sex

Keduanya
Obstruksi aliran urin (congenital, batu ginjal, oklusi pd uretra),
vesicouretral refluk, residual urine in bladder (neurogenic
bladder, striktur uretra), instrumentalia in trak urinary
(inwelling cateter,intermitten catheter)

GEJALA KLINIS
ISK bagian bawah,
rasa sakit/nyeri pada daerah suprapubik,
disuria (rasa terbakar/nyeri pada waktu
berkemih), frekuensi (sering kencing),
polakisuria (anyang-anyangen), nokturia,
(kencing di malam hari >1x), hematuria
(adanya darah dalam urin/urin berwarna
merah), urin berwarna keruh. Presentasi
klinis SUA (SindromUretra Akut) sulit
dibedakan dengan sistitis. Presentasi klinis
SUA sangat sedikit (hanya disuria dan
sering kencing) disertai bakteriuria <105
cfu/ml
urin,
sering
disebut
sistitis
abakterialis.

Pada ISK bagian atas

ditemukan gejala sakit kepala, malaise,
mual, muntah, demam, menggigil, rasa
tidak enak, atau nyeri di pinggang.

SPESIFIK
TRAK.URINARIUS

NON SPESIFIK
- Ginjal

INFEKSI

- Ureter
- Buli
- Urethra
TRAK. GENITALIS - Prostat
Epididymis
- Testis

INFEKSI NON SPESIFIK

Akut

GINJAL - Pielonefritis
Kronis
- Abses ginjal
- Abses perirenal
- Interstitial nephritis
URETER - Ureteritis
BULI - Sistitis - Akut
- Berulang
URETHRA - urethritis - Akut
- kronis

Ureteritis
Inflammation of a ureter is usually due to the
upward
spread of infection in cystitis.

Acute cystitis

This is inflammation of the bladder and may be

due to:
spread of microbes that are commensals of the
bowel (Escherichia coli and Streptococcus
faecalis) from the perineum, especially in
women because of the short wide urethra, its
proximity to the anus and the moist perineal
conditions
a mixed infection of coliform and other
organisms which may follow the passage of a
urinary catheter or other instrument

The effects are inflammation, with oedema and

small haemorrhages of the mucosa, which may
be accompanied by haematuria. There is
hypersensitivity of the sensory nerve endings in
the bladder wall, which are stimulated before
the bladder has filled leading to frequency of
micturition
and
dysuria
(a
burning
sensation on micturition). The urine may
appear cloudy and have an unpleasant smell.
Lower abdominal pain often accompanies
cystitis.

Predisposing factors.
factors are coli form microbes in the perineal
region and stasis of urine in the bladder.
During sexual intercourse there may be
trauma to the urethra and transfer of microbes
from the perineum, especially in the
female.Hormones associated with pregnancy
cause relaxation of perineal muscle and
relaxation and kinking of the ureters. Towards
the end of pregnancy pressure caused by the
fetus may obstruct the outflow of urine. In the
male, prostatitis provides a focus of local
infection or an enlarged prostate gland may
cause progressive urethral obstruction.

Urethritis
This is inflammation of the urethra. A common
cause is Neisseria gonorrhoeae (gonococcus)
spread by sexual intercourse directly to the
urethra in the male and indirectly from the
perineum in the female. Many cases of
urethritis have no known cause, i.e. non-specific
urethritis

OBSTRUCTIVE
DISORDER

Renal calculi
Calculi (stones) form in the kidneys and bladder when
urinary constituents normally in solution are
precipitated.
The solutes involved are oxalates, phosphates, urates
and uric acid, and stones usually consist of more
than one substance, deposited in layers. They are
more common in males and after 30 years of age.
Most originate in collecting tubules or in renal
papillae. They then pass into the renal pelvis where
they may increase in size. Some become too large to
pass through the ureter and may obstruct the outflow
of urine causing renal failure.

Hydronephrosis
This is dilatation of the renal pelvis and

calyces caused by accumulation of urine.

Obstruction of any part of the urinary

system from the uretra to the kidney

generates backflow of urrine and pressure
on the renal tubules, causing tubular
dysfunction.
When there is an abnormality of the

bladder or urethra both kidneys are

affected whereas an obstruction above the
bladder is more common and affects only

Complete sustained obstruction

The most common causes are a large calculus or
tumour. The outcome depends on whether one
or both kidneys are involved (homeostasis can
be maintained by one kidney)
Partial or intermittent obstruction
a succession of renal calculi in a ureter,
eventuallymoved onwards by peristalsis
a calculus that partially blocks the ureter
constriction of a ureter or the urethra by fibrous
tissue, following epithelial inflammation caused
by the passage of a stone or by infection
a tumour in the urinary tract or in the
abdominal or pelvic cavity

Tumours of the bladder

The causes of both types arenot known but
predisposing factors include cigarette
smoking, taking high doses of analgesics
over a long period and exposure to
chemicals used in some industries, e.g.
manufacture of aniline dyes, rubber
industry, benzidine-based industries.
Papillomas
These tumours arise from transitional
epithelium and are usually benign.

Solid tumours
These are all malignant to some degree. At an
early stage the more malignant and solid
tumours rapidly invade the bladder wall and
spread in lymph and blood to other parts of the
body. If the surface ulcerates there may be
haemorrhage and necrosis.

Acute pyelonephritis
Is an infection of the upper urinary tract

that involves both, the parenchima and

kidney pelvis.
It is one of the leading causes of infections
in the bood )
May be acute and chronic (permanently
destroy renal tissue)
Manifest : chills, fever, malaise, flank pain,
costovertebral angle tendernes,
leukocytosis, urynalisis (white blood cells,
cast, bacteria), hypertension, increase BUN,
decreased creatinin clearance.

Ascending infection
Upward spread of microbes from the bladder is
the most common cause of this condition.
Reflux of infected urine into the ureters when
the bladder contracts during micturition
predisposes to upward spread of infection to the
renal pelves and kidney substance.
Blood-borne infection
The source of microbes may be from septicaemia
or elsewhere in the body, e.g. respiratory tract
infections,
infected wounds or abscesses. When the
infection spreads into the kidney tissue it
causes suppuration and destruction of

Urosepsis
Can occur in anyone, but the risk greatest

in immunocomprimised indiviuals(older
women, patient with DM, severe UTI,
indwelling chateters, kidney stone)
Gram negative (E Coli), are most commonly

responsible for urosepsis. Bactery migrate

to the bloodstream from , genitourynary
tract, where they release endotoxin that
damage cells. Damage cells release
proinflammatory cytokines and set
complement cascade into motion.
Manifest : altered mental status, fever or

Pemeriksaan Lab dan

Penunjang
Analisa Urin (urinalisis)
Pemeriksaan bakteri (bakteriologis)
Pemeriksaan kimia
Pemeriksaan penunjang lain meliputi:
radiologis (rontgen), IVP (pielografi intra
vena), USG dan Scanning. Pemeriksaan
penunjang ini dimaksudkan untuk
mengetahui ada tidaknya batu atau
kelaianan lainnya.

Analisa Urin (urinalisis)

Leukosuria (ditemukannya leukosit dalam urin).
Dinyatakan positif jika terdapat 5
atau lebih leukosit (sel darah putih) per lapangan
pandang dalam sedimen urine.
Hematuria (ditemukannya eritrosit dalam urin).
Merupakan petunjuk adanya ISK
jika ditemukan eritrosit (sel darah merah) 5-10 per
lapangan pandang sedimen urin.
Hemeturia bisa juga karena adanya kelainan atau
penyakit lain, misalnya batu
ginjal dan penyakit ginjal lainnya.

Pemeriksaan bakteri (bakteriologis)

Pemeriksaan ini meliputi pemeriksaan secara mikroskopis dan
biakan bakteri.
Mikroskopis. Bahan: urin segar (tanpa diputar, tanpa
pewarnaan). Positif jika
ditemukan 1 bakteri per lapangan pandang.
Biakan bakteri. Ditujukan untuk memastikan diagnosa ISK.
Pemeriksaan
Tes Dip slide (tes plat-celup)
Berguna untuk menentukan jumlah bakteri per cc urin.
Kelemahan cara ini tidak mampu
mengetahui jenis bakteri

Pengobatan ISK

Tujuan pengobatan ISK adalah mencegah

dan menghilangkan gejala, mencegah dan
mengobati bakteriemia, mencegah dan
mengurangi risiko kerusakan jaringan ginjal
Pada ISK yang tidak memberikan gejala
klinis tidak perlu pemberian terapi
bila sudah terjadi keluhan harus segera
dapat diberikan antibiotika. Antibiotika
yang diberikan berdasarkan atas kultur
kuman dan test kepekaan antibiotika.

Prinsip pengobatan adalah memberantas

(eradikasi) bakteri dengan antibiotika dan
koreksi terhadap kelainan organ.
Tujuan pengobatan:
Menghilangkan bakteri penyebab ISK
Menanggulangi keluhan (gejala)
Mencegah kemungkinan gangguan organ
(terutama ginjal)

Cara Pengobatan

*pengobatan
*pengobatan
*pengobatan
*pengobatan
*pengobatan

dosis tunggal
jangka pendek (10-14 hari)
jangka panjang (4-6 minggu)
profilaksis dosis rendah
supresif

COntoh Obat
Amoksisilin 3 gram
Kotrimoksazol 320-1600 mg
Trimetoprim 400 mg
Kanamisin 500 mg injeksi
(intramuskuler)
Gentamisin 120 mg injeksi
(intramuskuler)

Upaya preventive

Large urine
volume
Free urine flow
Complete the
empying of
bladder to
prevent urinary
stasis

Dianjurkan untuk tidak sering

menahan BAK

Konsumsi cairan ltr/hari

Diet : vit c, canberry, batasi caffein,

alkohol,makanan pedas

Cara membersihkan area perineum

Dianjurkan utk BAK setelah coitus

Estrogen terapi

Pemasangan kateter dilakukan bila

ada indikasi

ISK Rekurent
Reinfeksi

umumnya episode infeksi > 6

minggu
dengan
mikroorganisme
yang berlainan.

Relapsing

setiap kali infeksi disebabkan

mikroorganisme
yang
sama,
dikarenakan sumber infeksi tidak
mendapat terapi yang adekuat

KOMPLIKASI ISK
tipe sederhana

non-obstruksi dan bukan wanita

hamil merupakan penyakit ringan
dan tidak mengakibatkan akibat
lanjut jangka lama

tipe berkomplikasi

meliputi ISK selama kehamilan

dan ISK pada Diabetes Melitus

bakteriemia, sepsis, dan syok.

Penyebab kuman pada ISK
complicated adalah
Pseudomonas, Proteus, dan
Klebsiela.

ISK KEHAMILAN

ISK selama kehamilan dengan kondisi

Basiluria Asimtomatik yang tidak diobati
merupakan risiko potensial untuk
terjadinya pielonefritis, lahirnya bayi
prematur, anemia, dan pregnancyinduced hypertension. ISK selama
trimester III memiliki risiko potensial
untuk terjadinya retardasi mental pada
bayi, pertumbuhan lambat pada bayi,
Cerebral Palsy, dan fetal death.

ISK PADA DM

pada DM dapat terjadi komplikasi

pielonefritis emfisematosa yang
disebabkan mikroorganisme pembentuk
gas seperti E. coli, Candida spp dan
Klostridium, disertai syok septik dan
nefropati akut vasomotor. Abses
perinefrik merupakan komplikasi ISK
pada pasien DM (47%), nefrolitiasis
(41%) dan obstruksi ureter (20%)

Congenitally abnormal
ureter
Reflux of urine from
bladder to kidney
Infection, renal scarring,
pyelonephritis

Caused By Bacteria, Fungal

and Parasite

Vesicoureteral Reflux

UTI

Cystitis

Pyleonephritis
Virulence of Uropathogens

Host Defense Mechanisms

Acute

Most Common Site for

UTI
Bacterial Attaches to
Uroepithelium

Causes: E. Coli, Klebsiella,

Pseudomonas, Staph

Periurethral Mucus
Secreting Gland
Bacteria Form
Biofilm

Sphincter Mechanisms
Chronic

Body Immune System

(Bladder Wall)

Common Causes:
Kidney Stones
Vesicoureteral Reflux
Pregnancy
Neurogenic Bladder
Instrumentation
Female Sexual Trauma

Infection initiates inflammatory

response

Tumors
Association:
Tobacco Use, Obesity, Long-term Analgesic
use

Bladder Tumors
Renal Adenoma

Benign Tumors
Located near cortex of
kidney

Renal Cell Carcinoma

Most common renal

neoplasm
Proximal tubule
epithelial cells

Primary
Associated with mutation
of gene P53

Increase Risk

Smokers (men)

Workers exposed to
chemicals, rubber, &
in textile industry

Secondary

Result of invasion of
cancer from bordering
organs

Nursing management
Health history :
keluhan utama. Presdiposisi faktor, riwayat
UTI
Physical examination :
peningkatan suhu, urin analisis dan kultur,
abdominal dan costovertebral tenderness,

Nursing Diagnosis

Gangguan pola
eliminasi b/d
infeksi/ proses
inflamasi pada
sistem urinari
(kandung kemih,
uretra)

Kolaborasi pemberian antibiotik

Anjurkan untuk intake cairan liter

per hari

Anjurkan untuk mengkonsumsi vit

c/canberry

Berikan penkes mengenai

management pencegahan uti

Kaji keluhan pasien

Observasi pola eliminasi

Observasi hasil urin analisis

Nursing diagnosis

Gangguan pola
tidur b/d nyeri
akut ditandai oleh
tenderness pada
area kandung
kemih, disuria

Management cairan

Pemberian obat analgesik

(acetaminophen, ibupropen,
phenazophyridine)

Lakukan kompres hangat pada

abdomen bagian bawah

Rendam hangat pada area genital

dan abdomen bag bawah

Anjurkan untuk tidak mengkonsumsi

alkohol dan kaffein

Pemasangan kateter bila ada indikasi

Kaji keluhan pasien