07 Dic Bladder in osteopathy
Mobility
The Bladder
The bladder has two fixation points: the pubic symphysis via the pubovesical ligament and the urethra.
The inferior fixation point is stronger in the man due to the prostate enveloping the urethra.
The superior and posterior aspects of the bladder are very mobile so as to allow distension when filling.
The infero-lateral part of the bladder is lightly fixed (in a latero-lateral direction) by the lamina sacro-recto-genito-vesico-pubicalis.
Possible Lesions
Ptosis of the Bladder
A ptosis of the bladder is induced by a ptosis of the uterus.
The posterior and inferior parts of the bladder are most displaced – the strong anterior fixation from the pubovesical ligament holds the anterior surface of the bladder in place.
Bladder ptosis is usually associated with a hypotonic detrusor muscle and results in an incomplete emptying of the bladder during micturition, which increases accumulation of urine residue. This can, in turn, lead to chronic bladder infection.
- PS: a lesion is a functional loss of mobility. The term lesion has another meaning in osteopathy than in classic medicine where it refers to a structural defect in the human structure. Due to the descended position of the bladder in case of ptosis, it is referred to as a loss of mobility under the influence of diaphragmal respiration.
Associated findings:
- Hypotonic detrusor muscle
- Hypotonic pelvic floor.
- Ptosis of the uterus.
- Congestion of the abdominal organs.
- Hormonal dysfunctions leading to general hypotonic pelvic structures.
- Ptosis of the peritoneum.
Adhesion of the Bladder with the Uterus
Occurs due to adhesion of the peritoneum in the vesico-uterine recess (Figure 17). Often associated with intestinal congestion.
Adhesion of the Bladder with the Small Intestine
Often associated with congestion of the small intestine.
Adhesion Bladder or Prostate with Levator Ani / Internal Obturator Muscle
Often associated with:
- Hypertonic internal obturator muscle.
- Hip in external rotation.
- Entrapment of the obturator N/A/V in the obturator canal, which can lead to decreased vascular supply to the acetabulum and caput femoris – a predisposing factor in the development of cox arthrosis.
- Hypertonic bladder.
- Hypertonic prostate (increased sympathetic tone) and levator prostate muscles, painful palpation of the prostate, premature ejaculation, weakness of adductor muscles.
Transverse Mobility Test of Bladder or Test of the Lamina Sacro-Recto-Genito-Vesico-Pubicalis
Two fingers of each (supinated) hand are placed equally left and right of the bladder.
The fingertips are used to push the bladder medially from left and right. The resistance in both directions is compared.
Palpation for Pain in the Direction of the Obturator Membrane (Unilateral)
The knee of the patient is placed relaxed against the hip of the osteopath.
Using the thumb, the osteopath follows the cranial surface of the adductor longus muscle.
In this way a pressure is given in the direction of the obturator membrane. The patient’s leg is kept relaxed and placed in external rotation so that the palpation is easier.
The palpation tests for pain. Care must be taken not to irritate other structures in the region.
Palpation for Pain in the Direction of the Obturator Membrane (Bilateral)
Both thumbs are placed caudal to both adductor longus muscles facing in a cranial direction. A pressure to cranial is given so that the thumbs deviate lightly medially – in the direction of the obturator membrane.
The test evaluates pain and elasticity. Bilateral comparison is readily achieved.
Lift of the Bladder: Sitting Position
Using the fingers of both hands, the bladder is palpated and ‘hooked onto’. From this grip it is possible to lift the bladder. This is very difficult and in cases of ptosis, impossible.
Test for Adhesion with the Uterus
The fingers take up as much skin slack as possible and are placed on the anterior surface of the uterus, just above the pubic symphysis.
A pressure to posterior/caudal upon the uterus is used to test the mobility to posterior. If the bladder is adhered to the uterus an abnormal resistance is felt and most likely a light stretching pain.
Osteopathic Techniques
General Techniques
Visceral Drainage of the lesser Pelvis
The patient flexes both hips.
The osteopath cups both hands as deep as possible, caudal and posterior, in the lesser pelvis. The visceral mass is lifted during an exhalation.
This cranial traction is held until the patient feels the traction as a stretch. The patient is then instructed to inhale again (the lift is held).
During the following exhalation the hands are placed deeper into the lesser pelvis. This technique is repeated until the patient feels no more traction.
During the last phase the osteopath holds the visceral mass cranial and instructs the patient to slowly straighten both legs along the table. The drainage occurs mostly due to the stretch of the underlying fascia – where many of the blood vessels are embedded.
Muscular Drainage of the lesser Pelvis
The patient lifts the pelvis during a deep abdominal inhalation. The pelvis is held in this position.
During full exhalation the patient is instructed to open the knees (hip abduction) against the resistance from the osteopath.
During the following abdominal inhalation the patient continues to push the knees apart against resistance from the osteopath.
During the last exhalation the patient slowly lowers the pelvis back to the table. This procedure is repeated up to 10 times.
The Bladder
Direct Stretch of the Urachus
The urachus is palpated and stretched by spreading the fingers apart. This technique can also be done using both hands.
Stretch of the Median Umbilical Ligaments
The osteopath places the fingers on the topographical line between the umbilicus and pubic tubercle.
A light pressure to posterior is given to palpate the ligament. The stretch is in a cranio-caudal direction.
