OMM: Urinary Tract Infections

00:00 Let's take a look at the application of OMM in urinary tract infections. So, urinary tract infections could include cystitis or infection of the bladder and the lower urinary tract or it could ascend higher up and affect the kidneys and in that case it's called pyelonephritis. Symptoms might include dysuria, increased frequency, urgency and some suprapubic pain and cystitis, fevers and chills, flank pain, costovertebral angle tenderness, nausea and vomiting. Those symptoms tend to show up more with pyelonephritis or infection of the kidney. Urinary incontinence is also another problem that could affect the ureters and the bladder. Urinary incontinence is the involuntary leakage of urine and is common and undertreated. Nearly 50% of adult women experience it. The main types of urinary incontinence include stress, urgency and overflow incontinence. So, how could we utilize OMM to treat patients that present with issues with their bladder? So, first let's take a look at the sympathetic innervation. The distal ureters receive sympathetic innervation from T12 to L1 and the bladder receives innervation from T12 to L2. Normal effects of sympathetic tone causes contraction of the trigone muscles. It relaxes the detrusor muscle and this is necessary to allow for expansion of the bladder while it is filling. So, hypersympathetic tone to the bladder would cause decreased ureteral peristaltic waves and this might cause ureteral spasm which also will cause decrease in urine flow. Hypersympathetic tone will also cause bladder wall relaxation and incomplete emptying. This may lead to vesicoureteral reflux. Hypersympathetic tone may also increase tone to the internal urinary sphincter. So, let's look at parasympathetic innervation to the bladder and uterus. So, parasympathetic supply to the proximal ureters comes from the vagus nerve whereas the distal ureters, the bladder. Parasympathetic supply comes from the pelvic splanchnic nerves or S2, S3, S4. Normal parasympathetic tone will cause an increase in ureter peristaltic waves. It increases bladder wall tone. It relaxes internal urinary sphincter. It is excitatory to the detrusor muscle while it's inhibitory to the trigone muscle and this will allow for voiding to take place. If you have decreased parasympathetic tone, that decreases bladder wall tone and it also tightens the internal urinary sphincter. So, the bladder needs to have a coordinated activity to allow for emptying or pausing. So, the bladder wall is activated by the parasympathetics. The sphincter, trigone and ureter orifice are activated by the sympathetic innervation from T12 to L2. The sphincter, trigone and ureter orifices are inhibited then by S2 to S4. So, let's take a look at the lymphatic drainage of the ureters and bladder. The upper ureter drains into the lateral aortic nodes.

03:14 The lower part of the ureter drains into the common internal or external iliac nodes. The bladder usually drains into the external iliac nodes. The ureter drains primarily into the internal iliac nodes. The bladder is located in the anterior pelvic cavity when empty. It projects several centimeters above the pubic symphysis when it's full. It has a superior attachment to the median umbilical ligament. It has an anterior attachment to the pubovesical ligament. The peritoneum covers the superior aspect of the bladder. So, the Chapman reflex centers for the urethra lie anteriorly at the inner edge of the pubic rami near the upper edge of the superior pubic symphysis.

04:00 Posteriorly, you will find it at the upper edge of the L3 transverse process. For the bladder, the Chapman point will lie anteriorly surrounding the umbilicus and then posteriorly along the upper edge of L2 transverse process. So, let's talk a little bit about how we could use OMM to treat patients that present with issues with their kidneys. So sympathetic and parasympathetic innervation for the kidneys. Sympathetic innervation of the kidneys, the proximal ureters, the testes and ovaries arise from T10 to T11. The distal ureters are from T12 to L1 and the bladder is from T12 to L2. Parasympathetic innervation from the kidneys comes from the vagus nerve and the distal ureters, the bladder receive parasympathetic innervation from the pelvic splanchnic nerves.

04:55 So, Dr. William Sutherland was quoted "Did you realize that the kidney floats physiologically on the fascia of the psoas muscle? It may be held down instead of floating and consequently these conditions may lead to kinks in the ureter." So, let's take a closer look at that relationship. Any kidney infection or stone or inflammation could result in psoas spasm and contribute to flank pain which accompanies these presentations. So as spasms may also impede passageway of a stone in the ureter, we have to take a look at these anatomical considerations because both the psoas and the renal fascia insert into the diaphragm and so any diaphragm restrictions may also lead to problems with the psoas and the kidneys. To help address parasympathetic innervation, we have to take a look at the sacrum, the pelvis and the pelvic diaphragm. The pelvic plexus of nerves sits in direct relationship to the pelvic diaphragm and if the pelvic diaphragm is restricted it's going to affect its action and ability to supply parasympathetic innervation to the contents in the pelvis. The pelvic veins and lymphatics are also oriented around the pelvic diaphragm so that it takes advantage of its pump action. So whenever we breathe, the pelvic diaphragm will descend on inhalation and rebound and ascend on exhalation and the pelvic veins and lymphatics are taking advantage of that motion to allow it for more motion and movement of the venous and lymphatic flow.

06:35 So, if there are restrictions of the pelvic diaphragm, that's going to decrease circulatory and lymphatic flow in the pelvis. So, overall osteopathic treatment will revolve around treating any viscerosomatics, looking at the levels between T10 to L2 and the sacrum for parasympathetics.

06:56 We want to treat any biomechanical restrictions of the thoracolumbar spine and the sacrum and pelvis and this will help to treat any restrictions that may prevent proper functioning of the GU system.

07:10 You definitely want to take a look at the psoas and the quadratus lumborum and the paraspinal musculature. And finally make sure you treat the different diaphragms, the abdominal diaphragm and the pelvic diaphragm, to help move restrictions to allow for proper circulatory and lymphatic flow. By applying these concepts and treatments, we could help our patients that present with GU symptoms.