PENGELOLAAN RETENSIO

URIN

OLEH : dr. SUNARDI

PEMBINAAN BIDAN DESA
PUSKESMAS AWANG BESAR, BARABAI
SENIN, 04 MEI 2009
 PENDAHULUAN
Retensio Urin adalah tertahannya urin di
dalam kandung kemih
Bisa mencapai jumlah lebih dari kemampuan
kandung kemih, lebih dari 500cc
Keadaan ini akan menimbulkan keluhan –
keluhan dan rasa sakit
Penyebab bervariasi, bisa terjadi pada kasus
obstetri, misalnya pada kasus kehamilan atau
pasca persalinan, sedang pada kasus
ginekologi bisa pada kasus pra operatif
maupun pasca operatif
 Topografi – anatomi Vesika Urinaria

 Kandung kemih dalam keadaan kosong

kira – kira sebesar telur penyu dan bisa
berisi sampai kira – kira satu liter. Dalam
keadaan normal kandung kemih terisi 400
– 500cc sudah terasa untuk miksi.
 Kandung kemih terletak ventral uterus
dan dorsal simpisis pubis. Apabila terisi
penuh bisa sampai diatas simpisis pubis.
 Definition of Urinary Retention
Acute : Cronic
 Painful, palpable or  Nonpainful bladder
percussable bladder, that remains palpable
associated with the or percussable after
inability to pass urine the patient has passed
 May be nonpainful or attempted to pass
under certain urine
conditions  Postvoid residual
(postoperative, generally > 300 ml
postpartum, bulging
disk, or after regional
anesthesia)
 Etiologies of Urinary Retention
Pharmacologic Neurologic
• Tricyclic antidepressant • Central nervous system lesions
• Anticholinergic agents Multiple sclerosis
• α-Adrenergic agents Cerebrovascular disease
• Ganglion bloking agents
Parkinson’s disease
Normal pressure hydrocephalus
Inflamantory
Brain or spinal cord tumor / injury
• Acute urethritis, cystitis,
Cauda equina or conus medullaris
vulvovaginitis lesions
• Acute anogenitalia infections Spinal steneosis
( herpes simplex ) Tabes dorsalis
• Pelvic floor spams/tension myalgia
Multiple system atrophy (shy-Drager-
Obstructive Syndrome)
• Intrinsic • Periphenal nervous system lesions
Steneosis/fibrosis (ie, Autonomic neurophathy
postradiation) Herpes Zoster
Acute edema of the urethra (ie, Radical pelvic surgery
postoperative) Pelvic radiation
Foreign body
Bladder stone
• Extrinsic Idiopathic
Pelvic mass • Fowler’s syndrome
Fibroid (vaginal, urethral, • Detrusor- sphincter dyssynergia
uterine) • Hypersensitive female urethra
Fecal impaction • Pelvic floor hypertonicity
Entrapped cervix (retroverted Latrogenic
uterus, gravid or nongravid)
• Post – incontinence surgery
Anterior vaginal wall prolapse
• Post – Prolapse surgery
Uterine prolapse
• Post – botulinum toxin or phenol
Female circumcision with injection
subsequent labial fusion
• Post – radical hysterectomy
Psychogenic
• Anxiety
• Depression
• Hysteria
Endocrinologic
• Diabetes
• Hypothyroiditis
 Symptoms of
Voiding Dysfunction
Hesitancy
Slow or weak stream
Straining to avoid
Prolonged stream
Postvoid fullness (incomplete void)
Need for positional change to void
Double voiding
 Signs of Voidin Dysfunction
 Pelvic Examination  Neurologic Examination
Prolapse Mental status
Mass Motor and sensory of
Infection lower limbs
Pelvic floor spasticity Reflexes
Deep tendon reflexes
Proprioception
Clitoral – anal reflex
 Infestigations

 Voiding diary ( frequency – volume chart)

 PVR determination
Transurethral catheterization
Bladder ultrasound
 Imaging studies
 Urodynamics
Cystometry (simple)
Uroflowmetry
Video cystometry
Pressure voiding study
 Neurodiagnostic evaluation
 Urodynamic Features of Retention
 Delayed first sensation
 Peak flow consistency < 15 mL/s and/ or a postvoid
residual of > 50 mL with 150 mL minimum starting
bladder volume
 Increased bladder capacity (acontractile states)
 Detrusor pressure and compliance are generally normal
except in association with fibrosis
 Low or absent detrusor activity (detrusor failure)
 Detrusor pressure > 50 cm H2O (obstruction)
 Upper motor neuron lesion may present with :
Hyperreflexia and reduced bladder capacity
Early First sensation and urgency
Abnormal compliance and end filling detrusor pressures
 Imaging Studies
 CT or MRI
Bulging disk
Spina Bifida
 Voiding Cystourethrography
Ureteral reflux
Bladder diverticulum
 Ultrasound
Noninvasive assessement of postvoid residual volume
 Cystourethroscopy
Trabeculation
Saculation or diverticulum or pseudodiverticulum
 Neurodiagnostic Studies
 Electromyography of the external urethral sphincter
Detrusor – Sphincter dyssynergia
Multiple sclerosis
Spinal cord injury
Nonrelaxing Sphincter
Fowler’s syndrome
Multiple system atrophy
 Treatment Options for
Voiding Dysfunction
Conservative
Intermitted self-catheterization
Pharmacotheraphy
Surgical intervention
 Conservative Therapies
 Prohylactic (acute postprocedural)
Bladder drainage
• Double voiding
• Timed voiding (every 3-4 h)
• Crede maneuver
May be contraindicated in patients with evidence of
ureteral reflux as this may cause high pressures
• Pelvic floor physical therapy
Pelvic floor hypertonic disorders
 Intermittent Self-Catheterization
 Sterileisc
Generally reserved for a hospital setting
 Clean ISC
Performed by the individual or caretaker
 Frequency varies based on goals
Avoid incontinence episodes
Avoid overdistention
 Pharmacotheraphy

o Cholinergic agents
Bethanechol
Distigmine bromide ( anticholinesterase)
o Α-Adrenergic bloking agents
o Intraversial prostaglandin E2 dan F2
o Anxiolytic agents (diazepam)
May be beneficial in postoperative voiding
dysfunction
 Surgical Management
 Urethral dilation
Useful in stenosis (ie, postradiation)
 Bladder diverticulectomy
 Uretheral bulking agents or reimplantation for reflux
conditions
 Intraurethral botulinum toxin A injections in for DSD
(124)
 Chronic indwelling catheter
Transurethral
Suprapubic
 Urinary diversion
 Sacral neuromodulation
 Theory of the Mechanism of
Action for Facilitating Voiding

 Turn off sphincter and urethral guarding reflex

 Inhibition of the sphincter indirectly facilitates
bladder activity
 Help patient to relocalize the pelvic floor and
regain the capability to relax it and intiate
voiding
 Kesimpulan
Tidak mudah untuk mengelola secara tuntas,
memerlukan pemeriksaan fisik maupun penunjang.
Sebagai tindakan pertama adalah mengusahakan urin
bisa keluar.
1. Pemasangan kateter (foley catheter)
2. Apabila terpaksa bisa dengan melakukan pungsi
kandung kemih per abdominal, selanjutnya
dilakukan pemeriksaan – pemeriksaan untuk terapi
sesuai penyebabnya
Kadang – kadang diperlukan penanganan multi
disipliner secara tim.