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Merupakan obstruksi di semua bagian tractus urinarius

Klasifikasi
Obstruksi akut atau kronis
Bilateral atau unilateral
Parsial atau total
Dapat menyebabkan hidronefrosis dan urosepsis
Obstruksi bagian atas menyebabkan kerusakan unilateral
Obstruksi bagian bawah menyebabkan kerusakan bilateral
pada bagian atas
Etiologi
Lower Tract Obstruction
Obstruction Hydrostatic pressure proximal Urethra
dilation Urethral wall become thin Form diverticulum
If urine becomes infected, urine extravasation may occur,
and periurethral abscess may be form
Prostatic ducts may become widely dilated
Midtract Obstruction
Stage of compensation
Bladder musculature hypertrophied in its attempt to force
urine pass the obstruction
Trigonal muscle hypertrophy and prominent interureteric
ridges Increase resistance urine flow Back pressure
Stage of decompensation
Large obstructing gland can be palpated by rectal touche
Another may suffer acute retention and have normal
gland size on touche
Bladder Neck Obstruction
In earliest stage, vesical musculature begin to hypertrophy
Bladder appears to be hypersensitive. As it is distended,
the need to void is felt Urinary urgency
Contraction of detrusor muscle is strong Spasm
Compensation
Hesitancy in urination while bladder develops strong
contraction to overcome resistance
Loss in force and size of urinary stream, stream is slow
Acute decompensation
Tone of vesical muscle is impaired by rapid filling
Increased difficulty in urination with hesitany Very
weak and small stream Termination before empty
Chronic decompensation
Progessive imbalance between the power of vesical
muscle and urethral resistance
More difficult to expel all the urine Progressive urinary
frequency with little stream Residual urine increase
Bladder loses its contraction and incontinence results
Upper Tract Obstruction
Ureter
Intravesical pressure is normal, no back pressure due to
ureterovesical valves
Trigonal hypertrophy Increase resistance Back
pressure Hydroureteronephrosis
Hydroureteronephrosis increased by added stretch
Compensation : Ureteral musculature thickens to push
urine by peristaltic activity
Decompensation : Ureteral wall become attenuated and
loses it contractile power
Kidney (hydronephrosis)
End of calyx become blunt and
rounded Flat Clubbing
Renal parenchyma undergo
atrophy from increased
intrapelvic pressure and
compression of blood vessels
Increased pressure transmitted
to tubules Dilated Atrophy
from ischemia
Perubahan Tekanan Intracalices
Terjadi peningkatan tekanan intraureter dan intrarenal
secara mendadak, kemudian menurun
Penurunan tekanan disebabkan oleh
Dilatasi pelvis renalis karena peningkatan volume urine
Penurunan RBF dan GFR
Aliran balik pielolymphatic dan pielovenous
Perubahan RBF dan GFR
Pada awalnya meningkat secara perlahan karena
vasodilatasi yang dirangsang oleh PGE2
Kemudian akan menurun karena vasokontriksi yang
dirangsang oleh :
Tromboksan A2
Faktor lain pada system renin-angiotensin
Peningkatan aktivitas neuronal
Agonis adrenergic lokal
Penurunan RBF akan menyebabkan penurunan GFR
Perubahan Fungsi DCT
Terjadi penurunan volume cairan karena aliran urine
menjadi lambat
Pembentukan cairan berkurang, reabsorpsi NaCl
bertambah, tubulus tidak responsive terhadap ADH
Penurunan GFR menyebabkan retensi nitrogen
Lower and Midtract
Symptoms Signs
Underlying disease Urethra palpation may
Hesitancy in starting reveal induration
Little stream force and size Rectal touche may show
Terminal dribbling
atony of anal sphincter or
prostate enlargement
Hematuria
Vesical distention may be
Burning on urination
found
Cloudy urine
Urine flow rate < 10 ml/s
Acute urinary retention
Upper Tract
Symptoms Signs
Symptom of urethral Enlarged kidney
stricture of renal stone Renal tenderness if there is
Pain in the flank radiating infection
along the course of ureter Large pelvic mass displace
Gross total hematuria and compress ureters
GI tract symptoms Ascites in children
Chills, fever Bladder and renal fornices
Burning on urination rupture signs
Cloudy urine
Laboratory Findings
Anemia secondary to chronic infection or in advance
bilateral hydronephrosis
Leukocytosis is sign of acute stage of infection
Microscopic hematuria may indicate renal or vesical
infection, tumor, or stone
No large amounts of protein
Elevated urea and creatinine in bilateral hydronephrosis
Pemeriksaan USG
Penebalan parenkim atau penipisan cortex renalis
Dilatasi pelvis, calices, dan ureter proximal
Kista ginjal
Pyelografi
Intravenous pyelography (IVP)
Peningkatan opacity karena gangguan fungsi tubule
Keterlambatan gambaran pyelogram
Menentukan penyebab dan dampak obstruksi
Pyelografi retrograde
Menunjukkan obstruksi dan menentukan letaknya
Cystografi retrograde
Perubahan pada vesica urinaria
Penyebab obstruksi : BPH, cancer