Osteopathic considerations in the genitourinary patient Flashcards
Functional disorders of the GU patient involve
-poor posture and compromised body mechanics
Flexed posture can
- increase pressure in abdomen and put direct pressure on the liver
- compresses the right kidney
- renal fat pad compromised allowing drooping of kidney
- passive congestion, hydronephrosis, urinary stasis/stones, ureters “kinked”
Kidney position
- paravertebral
- Position standing depends on habits but in supine position they usually lie T12-L3
- right lower than left
- retroperitoneal
- adrenals lie on superor surface–in contact with the diaphragm
- medial border of kidneys contacts psoas
Kidney fascias
- retroperitoneal with associated fatty tissue
- tough, surrounds all sides except inferior pole (diaphragmatic motion)
- lymphatics rely heavily on optimal function of the diaphragm
Diaphragmatic dysfunction caused by
-lower thoracics, ribs, quadrates lumborum spasm, hyperlordosis of lumbar spine, and phrenic nerve dysfunction C3-5
Right kidney
- anterior surface covered by liver
- also contacted by descending duodenum
Left kidney
- anterior surface covered by stomach
- also spleen, colon, jejunum
Kidney function
- controls volume and body fluid composition
- forms urine
- bp control
- RBC production
Ureters
- drain kidney
- to bladder
- travel across psoas fascia
- cross genitofemoral nerve on way to bladder
- psoas contracture or spasm may contribute to ureteral dysfunction or vice versa
Bladder
- 3 orifices
- two incoming–ureteric ostia
- one outgoing–internal urethral orifice
Ureter musculature
- detrusor is most of bladder
- small pubovesical muscle slips descend to bladder neck toward urethra
Female Urethra
- 4 cm
- approximates the anterior vaginal wall
- passes through urogenital diaphragm
- exits just anterior (ventral) to vagina
Male Urethra
20 cm
-3 parts: prostatic, paras membranacea, pars spongiosa
Prostatic urethra
-just distal to bladder, prostate surrounds
Pars membranacea urethra
-passes through urogenital diaphragm
Pars spongiosa urethra
-travels through corpus spongiosum of penis
Bladder
- sphincter, trigone, and urethral orifice
- activated by sympathetics (T12-L2)
- inhibited by parasympathetics (S2-3)
Bladder wall
- activated by parasympathetics
- inhibited by sympathetic
Celiac plexus
- sympathetic fibers to renal artery (renal plexus)
- controls flow of blood to the kidneys
Ureteric plexus
- sympathetic afferent and efferent
- afferent (pain from stones) to T10-L1
- ureters
Sympathetics: kidney and upper ureter
- T10-L1
- synapse in the superior mesenteric ganglion
- fibers for lower ureter synapse in inferior mesenteric ganglion
Sympathetics: Bladder
T12-L2
-synapse at inferior mesenteric ganglion
PNS efferent control of micturation
- pelvic splanchnic–S2-4
- activation of nerves contracts bladder
- causes emptying
SNS efferent control of micturation
- hypogastric plexus–T10-L2
- activation of nerves relaxes bladder
- causes retention
- alpha adrenergic-relaxes detrusor
- beta-2 adrenergic-closes internal urethral sphincter
Somatic Innervation of kidney
- pudendal nerves S2-S4
- striated muscles at external urethral sphincter
- voluntary contraction can maintain closed EUS
- normal state is closed
Voiding is partly:
- Parasympathetic activation–detrusor contracts
- Sympathetics relax IUS
- abdominal pressure increases
- passive pressure opens EUS
Central pathways for micturition control: corticopontine-mesencephalic
- frontal lobe inhibition of parasympathetics
- injury above pontine center reduces inhibition
- low bladder volume–hyperreflexic bladder
Central pathway for micturition control: pontine mesencephalic sacral
- coordinates detrusor and sphincter interaction
- injury below pontine center: both detrusor and sphincters contract
- detrusor–sphincter dyssynergia
Central pathway for micturition control: pelvic and pudendal nuclei
- mediates sacral parasympathetic reflex (full bladder stimulates parasympathetics, which contract detrusor)
- injury leads to areflexic bladder
- urinary retention
Central Pathway for micturition control: motor cortex to pudendal center
mediates voluntary control of EUS
Kidney and proximal ureter PNS
-vagus
Distal ureter and bladder PNS
- pelvic splanchnic nerves
- S2-4
Urinary Lymphatics
- renal capsule and parenchyma–preaortic nodes
- in ureteral obstruction–lymphatics dilate to help preserve renal function
- lymphatics help the kidney concentrate urine
With lymphatic congestion
-increase in oncotic pressure in interstitium=decrease flow between plasma and interstitium
Ambulatory Treatment of urinary organs
- postural considerations
- diaphragm massages kidneys
- L1-L3 diaphragm attachment
- Psoas spasm can decrease lordosis, compress kidneys from flexed posture, restrict ureters
- lower ribs, quadrates lumborum–posterior wall of soma
Urologic Dysfunction treatment of sympathetics
-rib raising
T10-L2 (kidney and bladder)–reduce stimulation to renal arteries (reduce component of HTN); reduce excessive relaxation of bladder (complete emptying); reduce ureterospasm of IUS (urinary retention)
-Inferior mesenteric ganglion
-Correct any dysfunction at C2-C3 (superior cervical ganglion)
Urologic Dysfunction treatment of lymphatics
- thoracic inlet and diaphragms
- rib raising
- lymphatic pump
- pelvic diaphragm
- Cervicothoracic junction–Scalenes, first rib
Urologic dysfunction treatment of parasympathetics
- OA/AA
- OM suture
- Sacrum/pelvis
- S2-S4 (PNS to bladder–pelvic splanchnic nerve)
Benign Prostatic Hypertrophy shows dysfunction at
T11-12
L1
Nephrolithiasis Ureteral stone pain referral
- proximal 1/2-flank, CVA
- distal 1/2-groin, testicle, labia
- prevention is very important concept–hydration, dietary
Nephrolithiasis common ares of dysfunction
- T12-L2
- S2-4
- may consider a psoas spasm affecting hip motion if ureter involved
Pyelonephritis
- same as for nephrolithiasis
- frymann associated cervical dysfunction with renal dysfunction
- OA/AA connections with vagus?
