Osteopathic Approach in Genitourinary Patient Lecture - Treffer

Question 1

What 5 things can diaphragmatic dysfunction caused by?

Answer 1

• Lower thoracics
• Ribs
• Quadratus lumborum spasm
• Hyperlordosis of lumbar spine
• Phrenic nerve dysfunction (C3-5)

Question 2

What do the L/R kidney contact, anatomically?

Answer 2

Right
- Anterior surface covered by liver.
- Contacted by descending duodenum
Left
- Anterior surface covered by stomach
- Spleen, colon, jejunum

Question 3

What group of muscles can affect the ureter, and why?

Answer 3

HIP FLEXORS can affect the ureter because the ureter travels across the anterior aspect of the PSOAS FASCIA.

Question 4

Describe the female urethra.

Answer 4

4cm, approximates the anterior vaginal wall, passes THROUGH the UROGENITAL DIAPHRAGM, exist just above the vagina.

Question 5

Describe the male urethra.

Answer 5

20 cm, three parts:

1) Prostatic part - just distal to bladder, prostate surrounds
2) Pars membranacea part - through the urogenital diaphragm
3) Pars spongiosa part

Question 6

What SNS and PSNS levels affect sphincter, trigone, and urethral orifice (bladder)? Where do the sympathetics synapse?

Answer 6

• Activated by SNS (T12-L2)&raquo_space; synapse at inferior mesenteric G
• Inhibited by PSNS (S2-S3)

Question 7

Does SNS and PSNS activate or inhibit the bladder wall?

Answer 7

SNS inhibits.

PSNS activates.

Question 8

What plexus controls blood flow to the kidney?

Answer 8

The celiac plexus - afferent SNS fibers to renal artery.

Question 9

What plexus supplies the ureters?

What level do stones affect?

Answer 9

Ureteric plexus - SNS afferent and efferent.

Stones affect the afferents to the ureter - T10-L1

Question 10

Sympathetics to the kidney and upper ureter are at what levels and synapse where?

Answer 10

T10-L1

Synapse in superior mesenteric G.

Question 11

Describe PSNS control of micturition.

Answer 11

• Pelvic splanchnic nerve, S2-S4

- Activation CONTRACTS the bladder&raquo_space; EMPTIES

Question 12

Describe SNS control of micturition.

Answer 12

• Hypogastric plexus, T10-L2

- Activation RELAXES the bladder, causing RETENTION.

Question 13

SNS aspects of micturition: Alpha and B2 adrenergic do what?

Answer 13

Cause retention
Alpha - detrusor relaxes
B2 - closes internal urethral sphincter

Question 14

Describe somatic control of micturition.

Answer 14

• Pudendal nerves, S2-S4. Voluntary contraction closes the External Urethral Sphincter.

Question 15

Voiding is the result of what 4 things?

Answer 15

1) PSNS activation&raquo_space; detrusor contracts
2) SNS relaxes IUS
3) Abdominal pressure increases
4) Passive pressure open EUS

Question 16

What are the four central pathways that control micturition?

Answer 16

1) Corticopontine - mesencephalic
2) Pontine mesencephalic sacral
3) Pelvic and pudendal nuclei
4) Metor cortex to pudendal center&raquo_space; voluntary control of EUS

Question 17

What role does corticopontine - mesencephalic play in micturition control? Injury results in what?

Answer 17

• Frontal lobe inhibition of PSNS.

- Injury ABOVE pontine center reduces inhibition&raquo_space; low bladder volume&raquo_space; hyperreflexic bladder

Question 18

What role does pontine mesencephalic sacral play in micturition control?
Injury results in what?

Answer 18

• Coordinates detrusor and sphincter interaction.
• Injury BELOW pontine center results in contraction of both detrusor and sphincters&raquo_space; “detrusor- sphincter dyssyneriga”

Question 19

What role does pelvic and pudendal nuclei play in micturition control?
Injury results in what?

Answer 19

• Mediates sacral PSNS reflex (full bladder stimulates PSNS to contract detrusor and void)
• Injury results in areflexic bladder and urinary retention

Question 20

What role does motor cortex to pudendal center play in micturition control?

Answer 20

Mediates voluntary EUS control.

Question 21

PSNS innervation to

1) the kidney and proximal ureter.
2) distal ureter and bladder

Answer 21

1) vagus

2) Pelvic splanchnic nerves, S2-S4

Question 22

What does the vagus supply?

Answer 22

Exits the jugular foramen and innervates down to mid transverse colon.

Question 23

What do lymphatics do during ureteral obstruction?

Answer 23

Dilate to help preserve renal function. Help kidney concentrate urine. With lymphatic congestion = increase in oncotic pressure in interstitium = decrease flow between plasma and interstitium.

Question 24

*** Five lymphatic tx of urologic dysfunction.

Answer 24

• **Thoracic inlet and diaphragms
• Pelvic diaphragm
• **Rib raising
• **Lymphatic pump
• Cervicothoracic junction (scalenes and first rib)

Question 25

*** Three PSNS tx plans for urologic dysfunction.

Answer 25

• OA/AA&raquo_space; correct here to affect VAGUS
• OM suture
• Sacrum/pelvis&raquo_space; Pelvic splanchnic nerve&raquo_space; correct at S2-S4

Question 26

Ureters are 1/2 1/2 of what two PSNS nerves?

Answer 26

Vagus and Pelvic splanchnic/S2-S4

Question 27

*** Three SNS tx plans for urologic dysfunction.

Answer 27

• **Rib raising
• **T10-L2&raquo_space; reduces stim to renal aa (dec HTN), relax bladder (complete emptying), reduce ureterospasm of IUS (urinary retention)
• **Inferior Mesenteric Ganglion
• Superior cervical ganglion&raquo_space; correct dysfunction at C2-C3

Question 28

*** In people with BPH, most common dysfunctions found at what levels?

Answer 28

T11-12, L1

Question 29

*** In people with nephrolithiasis (and pyelonephritis), most common dysfunctions found at what levels?
If ureter is involved, consider what type of spasm?

Answer 29

T12-L2
S2-S4
Consider possible psoas spasm.

Question 30

Differences in pain referral of ureteral stone if obstruction is in proximal v. distal half.

Answer 30

Proximal half - referral to flank, costovertebral areas

Distal half - referral to groin, testicle, labia