Chiropractic Management of a 7-year-old Female with Recurrent Urinary Tract Infections

Chiropractic Management of a 7-year-old Female with Recurrent Urinary Tract Infections

ABSTRACT. Urinary tract infections may be caused by a variety of organisms commonly found in the intestinal tract or by obstructive lesions (congenital or functional). The occurrence of common urinary tract infections are traditionally treated by antibiotics. The possibility of a structural cause increasing susceptibility to bladder infection or mimicking its symptoms is explored in this unique case presentation. A 7-year-old female who sustained trauma to the thoracic and lumbar spine responded unfavorably to traditional antibiotic therapy and homeopathic protocol in the treatment of recurrent urinary tract infections over a period of 2 years. This patient received 8 chiropractic adjustments over a period of 2 months with complete resolution of the complaint.

KEY WORDS: Chiropractic -- Pediatric -- Urinary tract infection -- Cystitis -- Bladder infection -- Secondary enuresis -- Incontinence.

INTRODUCTION

A urinary tract infection is a bacterial infection of the urethra, ureters, kidneys or bladder. An infection of the bladder, called cystitis, is the most common type of urinary tract infection.

Classic symptoms of urinary tract infections may be mild or absent in the case of many children. Common symptoms include fever and chills, urinary urgency and frequency, incontinence, dysuria, or a burning pain upon urination. There may be foul smelling, dark or bloody urine and abdominal or back pain. Occasionally, there may be complaints of anorexia and nausea or vomiting, diarrhea, lethargy and irritability. More pronounced symptoms may be indicative of acute pyelonephritis (Table 1).

In females, the urethra is close to the rectum. Bacteria can easily migrate from the lower intestine or vagina to the bladder. The bacteriostatic nature of urine usually prevents infection but sometimes this protective mechanism breaks down. It is noted in the Handbook of Pediatrics, 17th edition, that asymptomatic bacteriuria occurs in 1% of schoolgirls [ 1].

Signs an examining physician may find include dull or sharp pain and tenderness in the kidney area or abdomen. Lab findings may include characteristic slight or moderate pyuria, slight proteinuria, pathogenic organisms and casts of all types may be present in the urine, anemia in cases of long standing infection, and leukocytosis, usually in the range of 15,000-35,000 ul. Culture should be performed on a mid-stream, clean catch urine specimen (see Table 2). Advanced diagnostics including intravenous urography and voiding cystourethrography are reserved for high risk cases.

The traditional allopathic approach to urinary tract infections is to eradicate infection with appropriate chemotherapeutic or antibiotic therapy. A child with recurrent infections may be exposed to a prolonged course of treatment of 2-6 months.

Conservative measures might include increased fluid intake and reducing sugar in the diet. Increasing water intake as well as unsweetened citrus or cranberry juice may be beneficial. Caffeinated and alcoholic beverages should be avoided. Uva ursi, garlic, ecchinacea and golden seal are popular herbs frequently used to treat bladder infections as well as supplementing with acidophilus to help restore the normal, beneficial flora to the digestive and urinary tracts after antibiotic treatment [ 2]. Another nonpathologic etiology for a change in bladder function has been explored by John Gerrard, MD, professor of pediatrics at the University of Saskatchewan, linking allergies with detrusor muscle spasm [ 3, 4]. An elimination diet to remove potential allergens might identify a cause of recurrent urinary tract infections.

Showers should be substituted for bathing (especially "bubble baths"). Constipation is to be avoided by increasing fluid and fiber intake. The child should be screened for "pinworms", which are often associated with cystitis. Exploring the child's hygiene habits is important, including assessing their ability to clean themselves after voiding or moving their bowels so as not to carry bacteria from the fecal material to the urethra on toilet tissue (wiping back to front) or from contaminated hands. And last but not least, the occurrence of sexual activity must be explored to include an active consensual or nonconsensual sexual history with a partner or by masturbation.

CASE REPORT

This case study involves a 7-year-old female who presented to a private chiropractic office suffering from recurrent urinary tract infections, documented by clean catch urine culture by her pediatric nurse practitioner over the course of the last 24 months. The most recent culture was positive for bacterial overgrowth 1 wk prior to examination. These episodes were characterized by urgency and "leaking" or intermittent incontinence. She infrequently complained of pain on urination and her mother related no incidence of fevers or abdominal pain. It is important to differentiate "leaking" or intermittent incontinence from diurnal enuresis or wetting that occurs during the day. The patient has normal bladder control and responds to a full bladder by voluntarily voiding, yet she experiences leakage when she has an active urinary tract infection. This situation might be considered secondary enuresis which is defined as "urinary incontinence recurring after 3-6 months of dryness" [ 5].

The patient's history relates the onset of urinary tract infections at 5-years-old when she slipped and fell twice onto her back, and most significantly, attempted a gymnastic maneuver called a "Swedish roll" on the bed and experienced a trauma to the thoracolumbar junction. The child heard a "snapping" sensation and experienced pain at the thoracolumbar junction at the time of injury. This pain resolved within hours of the injury. The urinary tract infections began shortly thereafter and have not stopped. Twenty-one incidents of urinary tract infections (noted by urgency and wet underpants) have been recorded by the mother over the last 2 years.

The patient is currently under the care of a nurse practitioner and medical physician who practices homeopathy. She had been treated previously with antibiotics, bactrim and nitrofurantoin, and a homeopathic remedy, cali carb, without resolution of the problem.

The patient's medical history (including prenatal) and systems survey were unremarkable except for the chief complaint and chicken pox at age five. She was fully toilet trained at the age of three. There was no history of diurnal or nocturnal enuresis preceding the onset of urinary tract infections. She has a known allergy to sulfa. She has had no hospitalizations, surgeries or traumas other than the trauma related previously.

The child is characterized by her mother as a normal, active 7-year-old. Her family unit is intact, she is the youngest of three children (older brother 14-years-old, sister 18-years-old). She attends a progressive day school and excels academically. Her social development appears normal to mother and teachers evaluated through observation of relations with siblings and classmates. She sleeps 10-11 hr at night. Her diet consists of high vegetable and fruit intake, low dairy and animal fat intake, and very little junk food. She has not been on an elimination diet to see if food allergies have played a role in her complaint. She is right hand dominant. The child is shy but willing to answer questions and interacts openly. Mother and child are loving and comfortable with each other

Physical Exam

Physical exam revealed a 50", 59 lb., Caucasian female, BPl10/70, respirations 14 cpm, afebrile, pulse 80 bpm. Postural analysis (weight bearing): forward head carriage, rounded shoulders, exaggerated thoracic kyphosis. She stands with the right knee flexed, unleveling the pelvis by dropping the right iliac crest below the left. The patient relates that she "does not like to stand up straight. It doesn't feel normal." A mild scoliosis is present with a dextrorotary curve (right concavity) of the thoracic spine and levorotary curve (left concavity) of the lumbar spine. Both curves decreased on full forward flexion. Cervical, thoracic and lumbar ranges of motion appeared to all be within normal limits of a flexible child and the patient indicated no discomfort in any ranges of motion except for extension of the spine to 55ø and her discomfort "standing straight" (head erect, shoulders back) at rest. Reflexes, muscle strength and dermatomal discrimination to pin, brush, and cold were tested for the upper and lower extremities and were all symmetrical and within normal limits. Abdominal lumbar dermatomes were tested and were symmetrical and within normal limits for discrimination of pin, brush and cold. Motion palpation revealed subluxation of T7 in left rotation (-theta Y rotation), L2 in extension (-theta X rotation) and S2 in left rotation (-theta Y rotation).

No radiologic study was performed at this time. A routine lumbar series was recommended to the mother if there was no response after 3 treatments (response measured by decrease in urgency or incontinence). The mother and child were also instructed to begin a food diary to assess potential allergens that might be implicated in the chief complaint.

Management

The following therapeutic treatment plan was proposed: adjustment of appropriate segments twice weekly for 3 weeks, then re-evaluation. Deferred X-ray would be performed after 3 visits if no change in urgency or incontinence noted. Dietary modifications would not be instituted at this time but a food diary would be recorded for future analysis and recommendation.

Chiropractic analysis using motion palpation was performed at each visit and chiropractic adjustments of vertebral segments were given twice weekly for 3 weeks utilizing diversified technic, including T7 (adjusted prone, PA with lamina contact), L2 (adjusted prone, PA with bimamillary x contact (Carver technic), S2 (sidelying, PA thrust with contact on tubercle of S2). Myofascial technic was utilized to release the pelvic diaphragm.

Re-evaluation after 6 treatments was performed 16 days later. The patient's ranges of motion were full and pain free with a complete reduction of the lateral curves of the thoracic and lumbar spine. Her resting, upright stance was more erect (with a visible reduction in the thoracic kyphosis) and she measured an inch taller than the measurement at initial exam. The original subluxations at T2, L2 and S2 had been reduced. There appeared to be complete reduction of thoracolumbar scoliosis. There had been a complete remission in urgency and incontinence over the last 1 and 1/2 weeks as noted by the mother and child. The child was rescheduled for a one month follow up.

The patient presented 2 weeks before the scheduled follow up because she had been struck in the back while playing with her older brother and had developed an upper respiratory infection. There was no indication of a recurrence in the urinary tract infections. Exam findings were all normal except for the detection of subluxation through motion palpation of T7 in extension (-theta x rotation), L5 in right rotation (+ theta y rotation) and C1 in right rotation (+ theta y rotation). She was adjusted utilizing diversified technic as outlined previously for the same listings.

One week later, the patient stated that she experienced no symptoms (i.e. urgency) of recurrent problems but the mother noted the smell of urine in the underwear on several occasions since the injury wrestling with her brother. Exam revealed L5 subluxation in left rotation (- theta y rotation) and T7 in left rotation (- theta y rotation). Myofascial release of the pelvic diaphragm was performed again.

The patient returned in 2 weeks for follow up. The patient had begun skating lessons several weeks earlier and appeared to be redeveloping a dextrorotary curve (right concavity) in the thoracic spine secondary to right dominant activity learning speed skating. Suggested left-sided exercises included (brushing dog with left hand, skipping) to compensate and establish symmetrical development. L5 was subluxation in left rotation (- theta y rotation) and T7 in left rotation (- theta y rotation). There were no symptoms of urinary tract infection since the last adjustment.

Patient returned in 6 weeks for routine maintenance visit. Patient and mother reported no incidence of recurrent urinary tract infections and chiropractic examination revealed an absence of subluxation. The patient was not treated at this visit.

Patient and mother reported no incidence of recurrent urinary tract infections 9 weeks later. The patient's mother had noted a posterior scapular rotation and elevated hip and brought her in for an evaluation.

Ergonomics of sitting at school desk was discussed to prevent forward head carriage and rotational strain on the spine. C1 was subluxated in left rotation (- theta y rotation), T1 in left rotation (-theta y rotation), T7 in right lateral flexion (+ theta z rotation), and L5 in right rotation (+ theta y rotation).

DISCUSSION

Although a literature search reveals a vast array of publications addressing enuresis and implications of chiropractic adjustments or osteopathic manipulation in management, no studies were recovered pertinent to the topic of urinary tract infections and chiropractic or osteopathic management. One hypothesis draws an interrelationship between structural inadequacies and urologic manifestation [ 6] and another paper studies the somato-visceral reflex response of the urinary bladder to spinal somatic nerve stimulation [ 7]. Several chiropractic authors elucidate mechanically induced pelvic pain and pelvic organ dysfunction [ 8-10] and bowel and bladder dysfunction secondary to lumbar dysfunctional syndrome [ 11].

In 1993, Fysh hypothesized that micturition is controlled by detrusor and trigone muscles. The nerve supply to these muscles is via the sacral parasympathetic nerves from S2 to S4. Appropriate bladder function is also controlled by the urogenital diaphragm. Nerve supply is from the L2 spinal nerve.

The sacrum develops as five separate segments. These segments remain separated until puberty and are fused by mid 20's [ 12]. The developing sacrum is highly mobile in early childhood as separate spinal segments and is subject to trauma and subluxation from falls commonly associated with early walking, climbing, swing sets, bike riding, etc.

In this patient's case, the child sustained traumatic subluxation to the lumbar and thoracic spine during a gymnastic maneuver. Correction of the subluxation resulted in symptomatic relief. I hypothesize that subluxation of the lumbar and sacral spine result in deafferentation of the mechanoreceptors located in the zygapophyseal joints, resulting in a decrease in the central integrated state causing bladder dysfunction (i.e. decreased tonus). Conversely, it is also a possible hypothesis that subluxation results in facilitation of inappropriate neural impulses to the bladder resulting in altered bladder function and a flaccid type of neurogenic bladder which is associated with disorders of the posterior roots. This lesion results in an accumulation of large amounts of urine before sensing the need to void. Over time, residual urine volume increases predisposing the patient to cystitis [ 13]. Alteration in function could be the basis of enuresis or urinary tract infections if function of the sphincter becomes faulty allowing leakage or entry of organisms from the digestive tract into the sterile bladder environment.

CONCLUSION

In the preceding case, recurrent bladder infections might have been caused by dysfunction of posterior nerve roots associated with subluxation at the level of L2 and S2 because of a decrease in the central integrated state secondary to joint deafferentation. When adjustments of the spine restored functional motion and reafferentation occurred through normal childhood activities, symptoms ceased and infection did not recur.

There is a mixed review when reading the anecdotal history of chiropractic treatment for enuresis [ 14, 15]. To the best of the author's knowledge, there is no recorded anecdotal history of chiropractic treatment in children with urinary tract infection. Additional study is encouraged to understand the possible correlation of lumbosacral subluxation and the occurrence and effective management of some urinary tract infections (Table 3).

References
1. Merenstein G, Kaplin D. Rosenberg A. Handbook of Pediatrics. 17th Edition. Norwalk, CT: A. Appleton & Lange; 1994:621-3

2. Weil A. Self healing. 42 Pleasant St. Watertown, MA; 1997:2

3. Gerrard JW. Understanding allergies. Thomas Springfield; 1973

4. Gerrard JW. Allergies and urinary tract infections: is there an association. Pediatr 1971;48:994-5

5. Berkoxitz CD. A primary care approach. Chapter 32, Enuresis. Philadelphia: WB Saunders Co; 1996:120-3

6. Nelson C. Urologic manifestations of man's constitutional inadequacies: structural diagnosis and treatment. JAOA 1954;53:255-7

7. Sato A. The reflex effects of spinal somatic nerve stimulation on visceral function. J Manipulative Physiol Ther 1992;15:57-61

8. Browning J. Chiropractic distractive decompression in treating pelvic pain and multiple system pelvic organic dysfunction. J Manipulative Physiol Ther 1989;12:265-74

9. Browning J. Uncomplicated mechanically induced pelvic pain and organic dysfunction in low back patients. Can Chiro Assoc 1991;35:149-55

10. Browning J. Distractive manipulative protocols in treating the mechanically induced pelvic pain and organic dysfunction patient. J Manipulative Physiol Ther 1995;7:1-11

11. Falk J. Bowel and bladder dysfunction secondary to lumbar dysfunctional syndrome. Chiropr Technique 1990;2:45-8

12. Fysh P. Kids need chiropractic too: chiropractic management of enuresis. Dynamic Chiropractic 1993

13. Borregard P. Neurogenic bladder and spina bifida occulta: a case report. J Manipulative Physiol Ther 1987;10:122-3

14. LeBoeufe C, Brown P, Herman A, Leembruggen K, Walton D, Crisp T. Chiropractic care of children with nocturnal enuresis. J Manipulative Physiol Ther 1991;14:111-5

15. Gemmell H, Jacobson B. Chiropractic management of enuresis. J Manipulative Physiol Ther 1989;12:386-9

The National College of Chiropractic.

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By Sharon A. Vallone

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