Osteopathic Approach to the Renal Patient Flashcards
Imaging study of choice for suspected nephrolithiasis
Non-contrast CT
Most common stones causing nephrolithiasis
Calcium oxalate
Calcium phosphate
Signs and symptoms of interstitial cystitis
Pain in pelvis or between vagina and anus in women, or between scrotum and anus in men
Chronic pelvic pain, persistent urgent need to urinate, frequent urination of small amounts, pain or discomfort while bladder fills with relief after urinating, pain during sexual intercourse
Signs/symptoms of renal failure
Decreased urine output Fluid retention, causing swelling in legs, ankles, or feet Shortness of breath Fatigue Confusion Nausea Weakness Irregular heartbeat Chest pain or pressure Seizures or coma in severe cases
Incontinence characterized by dribbling of urine due to a bladder that doesn’t empty completely
A. Stress B. Urge C. Overflow D. Functional E. Mixed
C. Overflow
Incontinence characterized by leakage with pressure, i.e., cough, sneeze
A. Stress B. Urge C. Overflow D. Functional E. Mixed
A. Stress
Incontinence characterized by physical or mental impairment making it difficult to get to the toilet in time
A. Stress B. Urge C. Overflow D. Functional E. Mixed
D. Functional
Incontinence characterized by sudden, intense need to urinate, followed by involuntary loss of urine
A. Stress B. Urge C. Overflow D. Functional E. Mixed
B. Urge
Biomechanical considerations in a renal patient involve the fact that the kidneys are paired retroperitoneal organs, the uppor poles lie opposite the _____ vertebra, and lower pole lies opposite the ______ vertebra
The renal hila move by approx. ____ with breathing
T12; L3
3cm
Anatomic relationships to kidneys when considering biomechanical model
Right kidney: liver, duodenum, ascending colon anteriorly
Left kidney: spleen, pancreas, stomach, descending colon anteriorly
Posteriorly, both kidneys are adjacent to muscles and nerves of the posterior abdomen as well as diaphragm, pleura, and lungs
Note relationship between bladder, pelvis, sacrum, pelvic floor, and other organs
Sympathetic and parasympathetic innervation of kidneys - for consideration of neurologic model
Sympathetic:
T10-11
Lesser splanchnic nn.
Superior mesenteric ganglion
Parasympathetic:
Vagus n. (CN X)
Sympathetic and parasympathetic innervation of lower ureters, bladder, and pelvic organs - for consideration of neurologic model
Sympathetic:
T12-L2
Least/Lumbar splanchnic nn.
Inferior mesenteric ganglion
Parasympathetic:
Sacral (pelvic)
Splanchnic (S2-4)
Tx for collateral ganglia found to have fullness, bogginess, or increased tissue texture abnormalities
Direct inhibitory pressure with finger pads to feather’s edge of discomfort is maintained until release is observed
- Instruct pt to breath into your finger pads
- Follow the tissue release
Excessive distension of the ureter or spasm of its muscle may be caused by a stone and provokes severe pain (ureteric colic) that is spasmodic and agonizing. It is referred to cutaneous areas innervated from spinal segments which supply the ureter, mainly _______, and shoots down and towards groin, scrotum, or labium majus; it may extend into the proximal anterior aspect of the thigh by projection to the genitofemoral n.
T11-L2
Anterior Chapman’s reflexes associated with urinary system (adrenals, kidneys/ureters, bladder, and urethra)
Adrenals: 2-2.5” above and 1” lateral to umbilicus
Kidney/ureters: 1” above and 1” lateral to umbilicus
Bladder: periumbilical or umbilical
Urethra: inner edge of the pubic ramus near the symphysis
Posterior chapmans points associated with the urinary system: adrenals, kidneys, ureters, bladder, and urethra
Adrenals: intertransverse spaces between T11-12
Kidneys: intertransverse spaces between T12-L1
Ureters: intertransverse spaces between L1 and L2
Bladder and urethra: superior edge of L2 transverse process
Primary respiratory circulatory consideration for renal patients
Lymphatic drainage
[lymph vessels by the cortical radial arteries —> arcuate arteries —> interlobar arteries —> intrarenal plexi —> lateral aortic nodes —> thoracic duct: cysterna chyli to left subclavian vein]
Start at thoracic inlet, especially left. Examine and tx thoracoabdominal diaphragm. Examine and tx lower ribs to remove mechanical restrictions to lymph drainage. Examine and tx pelvic diaphragm. Pedal pump, if tolerated.
Primary metabolic/energetic consideration in a renal pt
Treat the gut to treat the bladder!
Constipation can cause bladder to have spasms on not empty completely; bladder sx may include day and night wetting, UTIs, frequency, urgency, and dysuria. It is very important to tx a child’s constipation so that bladder sx improve
Behavioral model management of a pt with cystitis
Increased fluid intake, take abx as directed
Behavioral model management of a pt with nephrolithiasis
Increased fluid intake, diet modifications as prescribed
Behavioral model management of a pt with interstitial cystitis
Diet modification, medications as directed
Behavioral model management of a pt with renal failure
Diet modification
Behavioral model management of a pt with incontinence
Bladder training, double voiding, scheduled toilet trips, fluid and diet management
Pelvic floor muscle exercises
Contraindications to OMT in renal pt
Pt is unable to tolerate OMT secondary to pain or positioning
Delaying more definitive care
A pt has a stone in the ureter. Which SD would you expect to find related to the biomechanical model?
A. T11 ERS L B. Iliopsoas hypertonicity C. OA E RrSl D. Anterior thoracic 9 TP E. Right diaphragm restriction
B. Iliopsoas hypertonicity
A pt has a stone in the ureter and is dx with iliopsoas hypertonicity. How would performing CS to the pt’s psoas help his condition?
A. Improve lymphatic flow and decrease stasis to help clear infection
B. Allow for decreased tone in L3-4 and allow for relaxation and passage of stone
C. ER and flexion of the femur allows for decreased psoas tone and ureter tone aiding in passage of stone
D. By touching the pt there is a placebo effect
C. ER and flexion of the femur allows for decreased psoas tone and ureter tone aiding in passage of stone
What is the best explanation for the finding “tender congested nodule noted 1 inch above and 1 inch to the right of the umbilicus?
A. Anterior thoracic TP B. Somatovisceral reflex C. Myofascial trigger point D. Reflex related to lymphatic and autonomic interactions E. Points related to venous congestion
D. Reflex related to lymphatic and autonomic interactions
Which of the following nerves is responsible for the referred pain in a patient with kidney stones?
A. Obturator B. Genitofemoral C. Lateral femoral cutaneous D. Femoral E. Cluneal
B. Genitofemoral
A nephrolithiasis pt passes a stone. You recommend he drink plenty of water and avoid soft drinks and tea. This is using what osteopathic model?
A. Biomechanical B. Resp-Circ C. Met-En D. Neurologic E. Behavioral
E. Behavioral
What technique most directly addresses a nephrolithiasis pt from a neurologic perspective?
A. Treating T8 with MET B. Treating inhaled first rib on the right C. Doming the diaphragm D. Treating T10-L2 with ST E. Treating quadratus lumborum spasm
D. Treating T10-L2 with ST
Which of the following accurately describes the mechanism of a viscerosomatic reflex?
A. Nociceptive signals carried by spinal motor neurons
B. The signal is carried by the vagus n. to the brain where there is a synapse with the motor cortex
C. Localized visceral stimuli produce a reflex response in segmentally related visceral structures
D. Irritation of a somatic structure causes facilitation of the spinal segment and thereby irritates a visceral structure of similar innervation
E. Nociceptors carry impulses via sympathetic nerve fibers that synapse with spinal interneurons that interact with spinal motor neurons
E. Nociceptors carry impulses via sympathetic nerve fibers that synapse with spinal interneurons that interact with spinal motor neurons
When prescribing antibiotics for a bladder infection, what osteopathic model are you focusing on?
A. Biomechanical B. Behavioral C. Metabolic energetic D. Resp. Circ. E. Neurologic
C. Metabolic energetic
Which of the following techniques will improve lymphatic drainage from the kidney and bladder?
A. Ischiorectal fossa release
B. MET for a pubic shear
C. CS for anterior thoracic 10
D. MET to L4
A. Ischiorectal fossa release
Which of the following techniques will address the bladder from a biomechanical perspective?
A. Doming the diaphragm
B. MET for pubic shear
C. Counterstrain to AT10
D. MET to L4
B. MET for pubic shear
Where would you expect to find a posterior Chapman’s reflex related to a bladder infection?
A. Upper edge of transverse process of L2
B. Triangular region located posteriorly near L2-4
C. Tip of rib 12
D. Inferior border of T12
A. Upper edge of transverse process of L2
You are treating a 33 y/o female for a bladder infection. On PE, you find decreased diaphragmatic excursion, increased lumbar lordosis, suprapubic tenderness, and left CVA tenderness. What technique most directly addresses her tx from a respiratory-circulatory perspective?
A. Treating L4 with MET B. Treating inhaled first rib on the L C. Treating inferior pubic shear on the L D. Treating T10-L2 with ST E. Treating her right scalenes
B. Treating inhaled first rib on the left
