Osteopathic Family Physician (2012) 4, 101-109 An osteopathic approach to the renal and urinary system Brian E. Kaufman, DO From the University of New England College of Osteopathic Medicine, Biddeford, ME and H. Goodall Hospital, Sanford ME. KEYWORDS: This article reviews the anatomy, physiology, and pathophysiology of the renal and urinary systems. Bladder; The clinically relevant interactions and contributions with the musculoskeletal system of interest and Kidneys; use to the osteopathic family physician will be discussed, and an osteopathic manipulative approach to Osteopathic medicine; the renal and urinary systems will be explored. Renal; © 2012 Elsevier Inc. All rights reserved. Urinary Introduction This article will use a model of musculoskeletal medi- cine to simplify the discussion. The somatic system can be Very little has been written about the osteopathic approach broken into five pathophysiological elements: (1) Structural, to renal and urinary issues. Many osteopathic physicians (2) neurologic, (3) respiratory-circulatory, (4) metabolic- feel that the renal system is the realm of the specialist and energetic, and (5) behavioral (See Figure 1). Although there our eyes glaze over at the mention of countercurrent mul- is considerable overlap between the different elements, re- tipliers, juxtaglomerular apparatus, and renal tubular acido- ducing the somatic system this way facilitates easier dis- sis. cussion, and the different elements can be treated with In fact, many of the clinical dilemmas we face daily in differing approaches.1 our clinical practices involve the kidneys or related struc- The kidneys are responsible for many physiological tures. In addition, there are many ways to use osteopathic functions throughout the body. Acid-base balance in con- thinking and practice that do not require advanced technical junction with the lungs, electrolyte balance, volume regu- expertise or knowledge (ie, you do not have to be the osteopathic guru we all remember from medical school) to lation, osmolality of the blood, erythropoietin secretion, and benefit our patients. vitamin D metabolism are the main functions of the kidneys. This article will address the overall approach and thought Many common clinical conditions that the OFP encounters process by which the osteopathic family physician (OFP) daily such as acute kidney injury, acute tubular necrosis, may better understand the contribution of musculoskeletal pyelonephritis, nephrolithiasis, chronic kidney disease, hy- physiology to the renal/urinary system, and practical ways pertension, acute infectious cystitis, and urinary inconti- to construct a rationally based treatment plan that could nence involve the renal or urinary system. Other clinical include the use of osteopathic manipulation as a viable disorders such as heart failure, myocardial infarction, sepsis, treatment modality. The final section will review the osteo- and malnutrition can affect renal function by altering vol- pathic approach to several common diagnoses. ume and blood flow.2 In addition, problems such as chronic interstitial cystitis and some urinary incontinence can be extremely challenging to treat using the best available conven- Corresponding author: Brian E. Kaufman, DO, University of New tional methods. Both patients and physicians can become frus- England College of Osteopathic Medicine, Stella Maris Hall, 11 Hills Beach Road, Biddeford, ME 04005. trated by the lack of effective treatment options and this can E-mail address: [email protected] lead to both patient and physician dissatisfaction.3 1877-573X/$ -see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.osfp.2012.03.001 102 Osteopathic Family Physician, Vol 4, No 4, July/August 2012 Figure 1 Model of aspects of musculoskeletal medicine. Many drugs and medical interventions can have delete- Both the lateral and medial lumbocostal arches cross rious effects on the renal system. Nonsteroidal anti-inflam- posterior to, and are in contact with, the kidneys. The arches matory drug (NSAID) use is extremely common but can are in turn connected to rib 12. Lateral traction on the cause acute nephropathy, acute interstitial nephritis, and twelfth ribs can provide tension on the arches and thereby chronic kidney disease, and it can worsen hypertension. affect the kidneys, ureter, and fascial structures.5 The kid- Computed tomography scan and cardiac catheterization neys are associated with the diaphragm and the pleura contrasts can both cause acute kidney injury. Despite the superiorly, psoas and quadratus lumborum muscles inferi- many excellent standard medical treatments available, there orly, and peritoneum anteriorly, and they lie deep to ribs 11 are a myriad of clinical cases that can benefit from non- and 12. Therefore, we can take advantage of the psoas and pharmacologic treatment. These are the situations in which quadratus lumborum muscles to affect changes directly or the OFP can use osteopathic medicine to treat their patients. we can use the relationship with the diaphragm to affect Biological, physiological, pathophysiological, and clini- changes more indirectly (See Figure 3). cal data will be cited to support an osteopathic approach The subcostal nerve, iliohypogastric nerve, and the ilioin- whenever possible. However, it should be noted that there guinal nerves cross the kidneys posteriorly, and irritation of are few randomized clinical trials that have examined this surrounding structures can lead to irritation of these nerves, subject. Therefore, biological and pathophysiological mod- which can cause some of the typical renal pain syndromes.6 els, in the context of accepted osteopathic experience, will The ureters travel along the course of the psoas muscle and be used to support this approach. are attached via the psoas fascia. The psoas in turn attaches to the lesser tubercle of the femur. Using the femur as a handle onto the psoas muscle, the practitioner can alter the tone in the Structural elements ureter, decrease smooth muscle spasm, and assist the passage Musculoskeletal changes can affect renal function either of stones. For example, if the femur is flexed and externally directly or through changes in cardiopulmonary function. rotated, psoas muscle tone and ureter tone are decreased. This The kidneys are located in the retroperitoneal space be- may aid in decreasing pain and allow a stone to pass easier tween T12 and L3 and are about 10 cm in size.4 over the pelvic brim and into the bladder (See Figure 4). The kidneys are supported only by fascial connections The bladder sits in the pelvic cavity, which is an osseous through the renal fat. The primary attachment is through the container with a muscular floor. The muscular floor is made diaphragmatic fascia as well as the psoas major fascia. The up of the pelvic diaphragm, which not only supports pelvic lower aspect of the renal fascia is in contact with the quadratus structures but aids in structural integrity of the external lumborum muscle (Figure 2).4 urethral sphincter. The bladder is attached via the pubove- Kaufman Osteopathic approach to renal and urinary system 103 Figure 2 Transverse section illustrating kidney attachments and relationships. sicular and puboprostatic ligaments; otherwise it is free in During thoracic inhalation, the diaphragms contract and the the pelvis (See Figure 5).4 spinal curves flatten. The base of the sacrum moves posterior Urinary continence is maintained by contraction of the and the overall shape of the thoracoabdominal-pelvic cylinder sphincter musculature. This is assisted by the urogenital dia- changes. These changes in shape create pressure changes in the phragm. Pubic shear, pubic/pelvic counterstrain tender points, thorax and abdomen throughout respiration. pelvic diaphragm trigger points, and innominate and sacral During inhalation, the kidneys move inferiorly along the psoas somatic dysfunction can lead to pelvic shape and tone changes, muscle. The superior aspect moves anteriorly and the entire kid- which can torque the urogenital diaphragm and lead to incon- ney rotates externally. The bladder follows the motion of the tinence. By treating these findings with manipulation and af- sacrum and moves both superiorly and posteriorly. The ureters fecting the structural mechanics, as well as normalizing mus- will follow the motion between the kidneys and bladder. cular tone, we can help restore optimal function.7 Like all structures in the body, the kidneys are designed to move and travel 3 to 4 cm on average with each breath. Multiply this by the conservative estimate of 17,000 breaths per day and the kidneys have traveled more than 600 m! This illustrates the prin- ciple that healthy function is dependent on motion. The pelvic diaphragm contracts and expands during the respiratory cycle. The pumping action of the pelvic diaphragm aids in the movement of venous and lymphatic fluids. Somatic dysfunction can alter the excursion of pelvic diaphragm con- traction and lead to stasis of lymph and venous blood in the pelvis. This leads to pelvic congestion, pain syndromes, and an inability to clear infections adequately.8 Visceral manipulation practitioners use techniques that ad- dress the kidneys and bladder directly through indirect myo- fascial unwinding. It is reported that these techniques can help restore proper motion and function. Neurological elements The majority of regulation of kidney function occurs Figure 3 Posterior aspect of kidney anatomical relationships. through endocrine and autonomic mechanisms.