OMM #24
9/24/03 Wed. 1 pm
Dr. Fotopoulos
Theresa Poth for Will SawyerPage
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Osteopathy and GU
I. Case Presentation
A 35-year-old Caucasian female presents with dysuria and urinary urgency and
frequency. She denies flank pain, fever, chills, nausea, and vomiting. She does admit to
some mild suprapubic tenderness
II. Differential Diagnosis
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UTI (urinary tract infection)
Interstitial Cystitis
STD (sexually transmitted disease)
-Gnorrhea, Herpes, Chlamydia, AIDS
Urolithiasis
-Kidney Stones-irritation to the ureters, bladder and urethra
Pubic symphyseal somatic dysfunction
Pelvic floor somatic dysfunction
If male patient- Prostitis, Benign Prostatic Hypertrophy
Learn to ask questions- bowel habits? Incontinence? Abdominal Pain?
III. Work-up
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UA with C & S
-WBCs, sed rate, pH (too alkaline-growth medium for bacteria), leukocyte
esterase
Chemistry
-electrolytes
CBC with Differential
-UTIs can progress to pyelonephritis (kidneys- pt presents with flank pain and +
Lloyd’s sign) and CBC will present with a left shift
imaging (KUB, IVP, US, Spiral CT)
- kidney stones
stone composition
IV. General Tenets of Neurologic Originations
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The bladder and urethra have the same innervations as the systems from which they
were derived embryologically
OMM #24
9/24/03 Wed. 1 pm
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Sphincter, trigone, and ureteral orifices are activated by the sympathetic
innervations of T12-L2 (WILL SEE AGAIN)
The above structures are inhibited by the parasympathetic innervations of S2-S4
-detrusor mm. (WILL SEE AGAIN)
The bladder wall is activated by the parasympathetics and inhibited by the
sympathetics (IMPORTANT!)
V. Sympathetic (IMPORTANT)
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Sympathetics
T10-L1= kidneys, ureters
T12-L2= bladder
Kidneys and upper ureters synapses at the superior mesenteric ganglion
Preganglionic fibers for kidney and upper ureters = superior mesenteric
collateral ganglion
-Technique to use on these will be the ganglionic inhibition to help balance out
the autonomic nervous system
Lower ureters, bladder = inferior mesenteric collateral ganglion
VI. Effects of Increased Sympathetic Tone
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Vasoconstriction of afferent arterioles to the kidneys
Leads to decrease in GFR, and results in decreased urine volume
Causes decreased ureteral peristaltic waves, and may cause ureterospasm
Causes bladder wall relaxation and incomplete emptying – may lead to
vesicoureteral reflux (this can happen to spinal cord injury pts.)
Increased tone to external urinary sphincter
Ureteral stimulation, (ie, ureteral stone) = kidney as target organ for
sympathetic discharge
VII. Effects of Increased Sympathetic Tone
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Facilitates contraction of the trigone muscle
Relaxation of the detrusor muscle
This is necessary to allow expansion of the bladder while it is filling
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9/24/03 Wed. 1 pm
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VIII. Global Effects of Renal Sympathetic Stimulation
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“…experiments show when sympathetic nerves to kidneys are stimulated continuously
for several weeks, renal retention of fluid occurs and causes chronically elevated
arterial pressure as long as the sympathetic stimulation continues. Therefore, it is
possible for nervous stimulation of the kidneys to cause chronic elevation of arterial
pressure.”
 Guyton Textbook of Physiology (This is for all you physiologists out there!!!)
IX. Parasympathetic (Important)
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Vagus
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Kidneys
Proximal Ureters
Pelvic Splanchnic Nerves
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Distal Ureters
Bladder
X. Parasympathetic
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Parasympathetics
Kidney and proximal portion of ureters = Vagus nerve
Distal portion of ureters, bladder = Pelvic Splanchnic Nerves (S2-4)
In ureters they maintain normal peristaltic waves.
XI. Effects of Increased Parasympathetic Tone
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Increases ureteral peristaltic waves
Increases bladder wall tone (detrusor mm.)
Relaxes internal urinary sphincter
Excitatory to the detrusor muscle
Inhibitory to the trigone muscle
This allows voiding to take place
XII. Effects of Decreased Parasympathetic Tone
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Decreases bladder wall tone
Tightens internal urinary sphincter
Notes:
-Next two slides show reference diagrams
OMM #24
9/24/03 Wed. 1 pm
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-Appendix overlies the ureter and with a appendicitis you can get blood in the urine. The
epithelial linings are swollen and allow blood from the appendix to seep through into the
ureter.
XIII. Lymphatics
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Lymphatics
Renal lymphatics flow into the pre-aortic nodes before traveling up the thoracic
duct to the subclavian vein. (Important)
Synchronous motion of the thoracic and pelvic diaphragms is vital to lymphatic
drainage from the urinary system.
-You want to open up the “floodgates”-open up the pelvic diaphragm, abdominal
diaphragm, Sibson’s fascia, and once they are open you can pump the lymphatics.
XIV. Lymphatic Drainage of the Kidneys
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Drain waste products, fluids, electrolytes, infectious products and antibiotic products
to the preaortic nodes before traveling to the thoracic duct and dumping into the
subclavian vein.
During acute ureteral obstruction, lymph flow has been shown to increase by 300%.
XV. Factors Affecting Lymphatic Flow
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Dependent upon the synchronous motion of the thoracic (active) and pelvic (passive)
diaphragms
Therefore, proper respiratory mechanics (ribs, thoracic spine, diaphragm excursion,
unrestricted Sibson’s fascia) is vital
XVI. Treatment Plan For Case Presentation
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Facilitated segments of kidneys and ureters (T10-L1) and bladder (T12-L2)
Balance the parasympathetics by treating the sacrum (S2 – S4) and innominates
and the vagus
Treat the thoracics, rib cage, respiratory diaphragm, and pelvic diaphragm
Treat the whole body- look at the feet( flat footed which causes poor posture)
Notes:
When treating the bladder area, the anterior Chapman points are going to be the
periumbilical region.