Dr. Rose Dinda Martini, SpPD Inkontinensia Urin Dr. Rose Dinda Martini, SpPD

Geriatric Giant Immobility Instability Incontinence (urinary & alvi) Intellectual impairment (MCI, Dementia) Infection (Pneumonia, etc) Impairment of hearing & vision Impaction (constipation) Isolation (depression) Inanition (malnutrition) Impecunity (poverty) Iatrogenesis Insomnia Immune deficiency Impotence Kane, Ouslander Abrass. (from Solomon 1988), Essentials of Clinical Geriatrics.2004 . p.13-14.

Pasien Geriatri  jika terserang kondisi akut : GERIATRIC GIANTS : SINDROM DELIRIUM DEPRESI JATUH / INSTABILITAS POSTURAL INKONTINENSIA IMOBILISASI GEJALA DEKONDISI

In the US the problem has become so severe we have even modified our freeway signs to help those who suffer Urinary Incontinence

Urodynamics Made Easy – third edition ANATOMI SALURAN KEMIH Urodynamics Made Easy – third edition

Urodynamics Made Easy – third edition PROSES BERKEMIH Urodynamics Made Easy – third edition

Persarafan Saluran Kemih Bagian Bawah Sympathetic hypogastric nerve Otak T10–L2 Otot Polos Detrusor Parasympathetic pelvic nerve To understand the components that contribute to the profile of an antimuscarinic agent, it is important to understand the 3 motor (or effector) components of the nervous system that are involved in normal lower urinary tract (LUT) function. These are the somatic, sympathetic, and parasympathetic nervous systems Each has a specialized function. The somatic nervous system is involved primarily in regulating voluntary contractions of skeletal muscle. The sympathetic and parasympathetic nervous systems make up the autonomic nervous system and are involuntary systems. They affect the body as a whole and are never completely inactive The central nervous system (CNS) controls micturition through both inhibitory and stimulatory signals that it receives from (afferent) and sends to (efferent) the bladder via the peripheral nervous system Sensory afferent nerves carry signals from the bladder to the T10–L2 area of the spinal cord. These signals are then relayed to the brain to indicate bladder fullness Voluntary voiding involves signaling from the brain to activate the parasympathetic pathways and to inhibit the sympathetic and somatic pathways For voiding to occur, parasympathetic stimulation of the bladder detrusor muscle must be activated, resulting in contraction of the detrusor muscle, while coordinated afferent and efferent signaling (through sympathetic and somatic pudendal nerves) to the smooth muscle of the bladder neck and urethra inhibits contraction Internal sphincter smooth muscle S2–S4 Somatic pudendal nerve Intramural skeletal muscle Extramural skeletal muscle Urethral smooth muscle Adapted from Wein AJ. Exp Opin Invest Drugs. 2001:10:65-83.

Persarafan Parasimpatik dan Reseptor Transmiter: acetylcholine Reseptor Muskarinik - kontraksi Saraf Pelvis Kontraksi This slide shows the parasympathetic arm of the micturition reflex Neurons located in the sacral spinal cord send signals to the bladder via the pelvic nerves. Postganglionic neurons in the bladder release the neurotransmitter acetylcholine Peripheral cholinergic (ie, muscarinic) receptors in the detrusor muscle bind acetylcholine, which initiates a cascade of intracellular events that results in contraction of the detrusor muscle

Urinary Incontinence chronic Acute • Stress UI • Overflow UI • Urgency UI --- OAB • Functional UI • Mixed UI

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 Urodynamics Made Easy – third edition

Urodynamics Made Easy – third edition INKONTINENSIA STRESS Urodynamics Made Easy – third edition

Urodynamics Made Easy – third edition INKONTINENSIA STRESS Urodynamics Made Easy – third edition

OVERACTIVE BLADDER Overactive baldder (OAB) adalah gejala Syndrom : 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. - Diagnosis OAB sekarang dapat dibuat atas dasar symptom tidak diperlukan pembuktian dengan urodinamik. Abrams P et al. Neurourol Urodyn. 2002;21:167-178

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. Abrams P et al. Neurourol Urodyn 2002;21:167-178

Causes of Reversible Urinary Incontinence D Delirium D Delirium I Infection R Restricted mobility, retention A Atrophic vaginitis I Infection, inflammation, impaction P Pharmaceutical P Polyuria, pharmacutical P Physiological disorders E Endocrine disorders R Restricted mobility S Stool impaction 16

Complication of Urinary Incontinence Skin infections Pressure ulcers Falls Fractures Depression Decreased libido and sexual dysfunction Acute hospitalization Social isolation Caregiver stress Reduced feeling of well-being Institutionalization Increased health-care costs

Diagnosis 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) Fantl JA al. Agency for Healthcare Policy and Research 1996;AHCPR Publication No. 96-0686

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 Fantl JA al. Agency for Healthcare Policy and Research 1996;AHCPR Publication No. 96-0686

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

Diagnosis Deferensia diagnosis ~ BPH ~ Interstitial cystitis ~ Prolapse ~ Diabetes ~ Atrophic vaginitis ~ Urinary tract infection ~ Pelvic floor dysfunction ~ Urinary tract infection

Daily Bladder Diary Buku Catatan Kandung Kemih Buku catatan ini akan membantu anda dan tim kesehatan anda. Buku Nama : Erna Catatan berkemih membantu melihat penyebab dari gangguan kontrol kemih. Tgl : 17 Maret 2007 Contoh dibawah memperlihatkan bagaimana cara menggunakan buku catatan ini Waktu Minum Berkemih Kebocoran/ngompol Merasakan ingin berkemih (anyang-anyangan) Apa yang sedang dikerjakan Jenis Jumlah Berapa sering Jumlah (sedikit,sedang,banyak) Olah raga,tertawa,bersin,dll contoh kopi 2 cangkir 12 Banyak Ya tertawa 06 - 07 07 - 08 08 - 09 10 - 11 11 - 12 12 - 13 13 - 14 14 - 15 15 - 16 16 - 17

SITI SETIATI, Geriatri IPD FKUI/RSUPN-CM, 2003 Instabilitas Jatuh Inkontinensia urin Infeksi Fraktur Kesadaran  Hipotermia Imobilisasi Depresi Gangguan Ulkus tidur Trombosis vena Pneumonia ISK Dehidrasi konstipasi Atrofi otot Asupan makanan Malnutrisi Obat Asupan cairan 

Inkontinensia Alvi

Klinis Feces cair/belum terbentuk, keluar merembes Keluarnya feces yang sudah terbentuk, 1 x atau 2 x perhari di pakaian atau di tempat tidur

Penyebab IA akibat konstipasi IA simtomatik, berkaitan dg penyakit usus besar IA neurogenik IA karena hilangnya refleks anal

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