Urologic Complications In Diabetics
Category : Diabetes And Urinary Tract Infections
Urologic complications, including bladder dysfunction, sexual and erectile dysfunction, as well as urinary tract infections (UTIs) have a profound effect on the quality of life of men and women with diabetes.
Over 50% of men and women with diabetes have bladder dysfunction
Bladder dysfunction reflects a progressive condition encompassing a broad spectrum of lower urinary tract symptoms including urinary urgency, frequency, nocturia, and incontinence.
A number of clinical studies in men and women with diabetes have reported bladder instability or hypersensitivity as the most frequent finding, ranging from 39–61% of subjects .
People with a diabetic bladder can have a variety of symptoms: Common ones include frequent urination, incontinence, difficulty starting a urinary stream, urinary tract infections, and sensations of needing to urinate urgently.
The underlying problem is that neuropathy (nerve damage) causes the bladder to lose the ability to sense when it is full, just as neuropathy in the feet can interfere with a person’s ability to sense pressure or pain.
The result is a tendency to retain large amounts of urine in the bladder.
The healthy bladder holds 300–350 cc (cubic centimeters, about 10–12 fluid ounces), but someone with a severely diabetic bladder might end up with a bladder that holds two or three times that amount.
As the bladder stretches out to accommodate increasingly larger volumes, it starts to lose its normal tone, and eventually begins to lose the ability to empty completely.
A healthy bladder will have about a fluid ounce (30 cc) of urine left in it after voiding.
Because of the stretching effects that result from losing sensation in the bladder, this volume (known as the “postvoid residual,” or PVR) eventually creeps up.
People with diabetes who are diagnosed with bladder problems can have PVRs of 100 cc, 200 cc, or even higher, depending on how severe the damage is and on how long the problem has been going on.
The other symptoms of diabetic bladder are nearly all related, in one way or another, to this incomplete emptying of the bladder.
For instance, when the bladder doesn’t empty completely, its remaining capacity fills up more quickly, causing frequent urination.
If a bladder is not emptying regularly, it can become so full that it overcomes the sphincter muscle and just “overflows,” resulting in incontinence.
Urinary tract infections can easily develop in these situations because the PVR in a bladder that doesn’t empty well becomes stagnant, allowing any bacteria that enter the bladder to grow and develop more easily into an infection.
Someone with diabetes is susceptible to this kind of infection to begin with, since diabetes can hamper the function of the immune system.
In women, urinary incontinence is estimated to affect nearly 50% of middle aged and older women, leading to significant distress, limitations in daily functioning, and poorer quality of life .
Diabetes has been identified as an important independent risk factor for incontinence in several large observational studies,
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The Diabetes Prevention Program (DPP) randomized trial demonstrated that an intensive lifestyle intervention involving weight loss and exercise reduced the incidence of diabetes among women with impaired glucose tolerance (IGT) .
Prevalence of weekly stress incontinence was also substantially decreased by the DPP intensive lifestyle intervention. Importantly, reducing incontinence may be a powerful motivator for women with IGT to choose healthy lifestyle modification to prevent diabetes.
Common treatments for urinary incontinence in women include conservative management (e.g., pelvic muscle training or bladder training), medications, and surgery.
Keeping in mind that every situation is different, a sample treatment plan for someone with a severely distended and poorly-emptying bladder might begin with the placement of a Foley catheter.
This is a tube inserted into the bladder that drains into a bag taped to the leg. This bag can be emptied as needed, and the catheter is left in for five to seven days to allow the bladder to drain and for the bladder muscles to regroup.
When the Foley catheter is removed, the next step is self-catheterizing — inserting a catheter yourself when your bladder needs to be emptied, and removing it afterward.
This may seem intimidating, but it is usually easier than feared, and also usually more comfortable than having a full-time catheter in place.
People new to self-catheterization may also worry about contracting an infection, but there is less risk of infection with self-catheterization than there is with a full-time Foley catheter.
In most people, the bladder eventually recovers, and catheterization can be eliminated entirely. (If it is eliminated too quickly, though, recovery may be slowed or even stalled completely.)
Over time, many people even regain more normal sensations reminding them to void, but they can never again depend only on sensation.
Once you’ve been diagnosed with diabetic bladder, making sure you void at least every few hours while awake must become a lifelong habit.
2.Sexual and Erectile Dysfunction
Sexual dysfunction is more common in people with diabetes because poorly controlled diabetes can damage the blood vessels and nervous system causing reduced blood flow and loss of sensation in sexual organs. This can contribute to vaginal dryness in women and erection difficulties in men.
Erectile dysfunction (ED) occurs in a substantial number of men with diabetes, with prevalence estimates ranging from 20 to 71% . ED in diabetic men significantly impacts their quality of life .
Men with diabetes tend to develop erectile dysfunction 10 to 15 years earlier than men without diabetes. As men with diabetes age,erectile dysfunction becomes even more common.
Above the age of 50, the likelihood of having difficulty with an erection occurs in approximately 50% to 60% of men with diabetes.
Above age 70, there is about a 95% likelihood of having some difficulty with erectile dysfunction.
Risk factors associated with an increased risk of ED include hypertension, lipid disorders, coronary heart disease, older age, higher Body Mass Index (BMI) and cigarette smoking.
In men with diabetes, the relative risk for ED increases with poor glycemic control, duration of diabetes, and the number of other complications of diabetes (i.e., retinopathy, nephropathy, and limb loss).
Urinary infections are more common in people with poorly controlled diabetes and can cause discomfort for women during intercourse and for men during urination and ejaculation.
These generally are temporary complications, but they can recur.
Sexual activity should be stopped during treatment of urinary tract and yeast infections, which also are relatively common in people with diabetes.
Sexually transmitted diseases (STDs) can be transmitted easily because of the dry, cracked skin found in many people who have diabetes. This makes it important to practice safe sex.
Chronic high blood sugar levels can lead to reduced testosterone and may contribute to decreased sexual interest (libido).
Thrush is a common condition, made worse by high blood glucose levels, which can make sex uncomfortable. Good control of diabetes will help to prevent this.
Chronic high blood sugars can lead to abnormal nerve function, leading to pain with only light touch.
Heightened sense of pain associated with neuropathy can make sexual relations uncomfortable.
Because intercourse is exercise, people with diabetes should watch for signs of hypoglycemia (low blood sugar) after sex.
People with diabetes (particularly men whose disease is poorly controlled) may have too little or too much of certain hormones, such as prolactin, testosterone or thyroid hormone. Generally these conditions can be treated with pills.
Certain drugs for heart problems, high blood pressure, anxiety, depression, pain, allergies and weight control sometimes cause impotence. Switching medications may solve the problem.
Stress and other mental health problems can cause or worsen sexual dysfunction, as can smoking and alcohol use.
Physical problems not caused by diabetes, such as accidents that injure nerves, prostate surgery, and spinal cord injuries, can cause impotence.
Make an appointment to see your doctor if you are experiencing sexual dysfunction. Your doctor should perform a physical exam, which includes:
1.Medical history, including questions about morning erections (a sign that the impotence probably is not due to a physical problem); how long the problem has occurred; and whether you are experiencing anxiety or stress
2.A physical exam and review of diabetes complications
3.Lab tests to check hormone levels
4.Review of medicines taken
5.Occasionally additional testing, including measurements of erections, an ultrasound, and/or neurological and other tests done at the doctor’s office or by you at home.
6.About 25 percent of ED cases are caused by drugs. Many medications, including common medicines prescribed for diabetes and its complications, can cause ED.
The most common offenders are blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine (an ulcer drug).
In addition, over-the-counter medications, including certain eye drops and nose drops, have been associated with ED.
That does not mean you should stop taking these medications! Rather, you should discuss them with your doctor to determine whether a different dosage, an alternate medicine, or additional treatments will resolve the ED.
Viagra (sildenafil citrate, made by Pfizer, Inc.), Levitra (vardenafil HCl, made by Bayer and GlaxoSmithKline), and Cialis (tadalafil, made by Eli Lilly).
The three are chemically very similar, and all have proven very effective. Because they are effective, convenient, and relatively inexpensive , these medicines have become the treatment of choice for most men experiencing ED.
The main difference among the three is in how long they last. Viagra is supposed to work for between 30 minutes and four hours; Levitra for 30 minutes to two hours, and Cialis for up to 36 hours. In addition, Viagra is slightly less effective if taken with food; Viagra can also cause temporary abnormalities of color vision.
In some cases, however, these drugs may be unsuitable for patients with heart disease. If you are considering one of these drugs and you have heart disease, as many diabetics do, be sure to tell your doctor.
In rare cases, the pills may create “priapism,” a prolonged and painful erection lasting six hours or more (although reversible with prompt medical attention).
8.Topical medicines: When the problem is insufficient blood flow, vasodilators (such as nitroglycerine ointment) can be applied to the penis to increase penile blood flow and improve erections. The main side effect of nitroglycerine ointment is that it may give the partner headaches. To prevent this, the man should use a condom.
9.Penile Injection Medication: This is just what it sounds like. Injected at home directly into the penis, the medication alprostadil produces erection by relaxing certain muscles, increasing blood flow into the penis and restricting outflow.
Although some sources report an 80 percent success rate, the therapy has disadvantages, such as risks of infection, pain, and scarring—fibrosis—in the penis, and it may also cause priapism.
10.External Mechanical Devices:
This category of treatments includes external vacuum therapies: devices that go around the penis and produce erections by increasing the flow of blood in, while constricting the flow out.
Such devices imitate a natural erection, and do not interfere with orgasm. External vacuum therapy mechanisms are approximately 95 percent successful in causing and sustaining an erection.
The vacuum constriction device consists of a vacuum cylinder, various sizes of tension rings, and a vacuum pump, either hand-operated or electric.
The penis is placed in a cylinder to which a tension ring is attached. Air is evacuated from the cylinder by means of the pump, creating a vacuum, which produces the erection. The cylinder is removed, leaving the tension ring at the base of the penis to maintain the erection.
Vacuum therapy devices have a few disadvantages. One must interrupt foreplay to use them. You must use the correct-size tension ring and remove it, to prevent penile bruising, after sustaining the erection for 30 minutes.
Initial use may produce some soreness. Such devices may be unsuitable for men with certain bleeding disorders. In general, vacuum constriction devices are successful in management of long-term ED.
“Rejoyn” is an inexpensive, nonprescription alternative to the vacuum-actuated devices. Described by its manufacturer as a “support sleeve,” it does not “cause” an erection, but rather supports the flaccid penis as if it were erect (one wears it under a condom).
The great majority of ED cases in diabetic men have a physical cause, such as neuropathy or circulatory problems. In some cases, however, the cause of ED is psychological, including depression, guilt, or anxiety.
With a thorough exam, the doctor should be able to determine whether the ED is psychological or physical in nature.
If the cause is psychological, your doctor may refer you to a psychiatrist, psychologist, sex therapist, or marital counselor. Do not view such a diagnosis as an insult. Most psychologically-based ED is easily and successfully treated.
There are two kinds of surgery for ED: one involves implantation of a penile prosthesis; the other attempts vascular reconstruction.
Expert opinion about surgical implants has changed during recent years; today, surgery is no longer so widely recommended. There are many less-invasive and less-expensive options, and surgery should be considered only as a last resort.
The obvious risks are the same that accompany any surgery: infection, pain, bleeding, and scarring. If for some reason the prosthesis or parts become damaged or dislocated, surgical removal may be necessary. With a general success rate of about 90 percent, any of the devices will restore erections, but they will not affect sexual desire, ejaculation, or orgasm.
13.People with diabetes can lower their risk of sexual and urologic problems by keeping their blood glucose, blood pressure, and cholesterol levels close to the target numbers their health care provider recommends.
Being physically active and maintaining a healthy weight can also help prevent the long-term complications of diabetes.
For those who smoke, quitting will lower the risk of developing sexual and urologic problems due to nerve damage and also lower the risk for other health problems related to diabetes, including heart attack, stroke, and kidney disease.
3.Urinary Tract Infections
When treated promptly and properly, lower urinary tract infections rarely lead to complications. But left untreated, a urinary tract infection can have serious consequences.
Complications of a UTI may include:
1.Recurrent infections, especially in women who experience three or more UTIs.
2.Permanent kidney damage from an acute or chronic kidney infection (pyelonephritis) due to an untreated UTI.
Pyelonephritis is caused by a bacterium or virus infecting the kidneys. Though many bacteria and viruses can cause pyelonephritis, the bacterium Escherichia coli is often the cause.
Bacteria and viruses can move to the kidneys from the bladder or can be carried through the bloodstream from other parts of the body.
A UTI in the bladder that does not move to the kidneys is called cystitis.
Symptoms of pyelonephritis can vary depending on a person’s age and may include the following:
3.Back, side, and groin pain
6.Frequent, painful urination
Children younger than 2 years old may only have a high fever without symptoms related to the urinary tract.
Older people may not have any symptoms related to the urinary tract either; instead, they may exhibit confusion, disordered speech, or hallucinations.
Pyelonephritis is treated with antibiotics, which may need to be taken for several weeks.
While a urine sample is sent to a lab for culture,your health care provider may begin treatment with an antibiotic that fights the most common types of bacteria.
Once culture results are known and the bacteria is clearly identified, the health care provider may switch the antibiotic to one that more effectively targets the bacteria.
Antibiotics may be given through a vein, orally, or both. Urinary tract obstructions are often treated with surgery.
Severely ill patients may be hospitalized and limited to bed rest until they can take the fluids and medications they need on their own. Fluids and medications may be given intravenously during this time.
In adults, repeat urine cultures should be performed after treatment has ended to make sure the infection does not recur.
If a repeat test shows infection, another 14-day course of antibiotics is prescribed; if infection recurs again, antibiotics are prescribed for 6 weeks.
Most people with pyelonephritis do not have complications if appropriately treated with bacteria-fighting medications called antibiotics.
In rare cases, pyelonephritis may cause permanent kidney scars, which can lead to chronic kidney disease, high blood pressure, and kidney failure.
These problems usually occur in people with a structural problem in the urinary tract, kidney disease from other causes, or repeated episodes of pyelonephritis.
3.Increased risk in pregnant women of delivering low birth weight or premature infants.
4.Urethral narrowing (stricture) in men from recurrent urethritis.
The urethra is the muscular tube that runs from the bladder to the external urethral orifice where it carries urine from the bladder to be expelled into the environment.
In men, the urethra traverses the prostate gland, passes along the penis to terminate at the glans penis (penis tip).
With women, the urethra is much shorter, runs against the anterior vagina wall to terminate in the vestibule between the clitoris and vaginal orifice.
A narrowing of the urethra can be asymptomatic and remain silent throughout life.
The most common symptoms of urethral strictures are :
A.difficulty passing urine (voiding) – hesitance, straining and sometimes pain .
B.urinary retention due to incomplete emptying of the bladder
C.repeated urinary tract infections (UTIs – urethritis and/or cystitis)
Other signs and symptoms that may be due to the stricture itself may include :
pelvic and/or lower abdominal pain
blood in the semen (hematospermia)
blood in urine (hematuria)
changes in urine stream – slow, weak and spray
post-micturition dribble – dribbling after passing urine
The presence and severity of any of the symptoms may vary depending on the degree of the narrowing.
5.Sepsis, a potentially life-threatening complication of an infection, especially if the infection works its way up your urinary tract to your kidneys.
Sepsis is a serious medical condition caused by an overwhelming immune response to infection. Chemicals released into the blood to fight infection trigger widespread inflammation.
Bacterial infections are the most common cause of sepsis. However, sepsis can also be caused by other infections.
The infection can begin anywhere bacteria or other infectious agents can enter the body.
It can result from something as seemingly harmless as a scraped knee or nicked cuticle or from a more serious medical problem such as appendicitis, pneumonia, meningitis, or a urinary tract infection.
When infection overwhelms the body, the body can respond by developing sepsis and going into septic shock.
Sometimes called blood poisoning, sepsis is the body’s often deadly response to infection or injury. Sepsis kills and disables millions and requires early suspicion and rapid treatment for survival.
Because sepsis can begin in different parts of the body, it can have many different symptoms. Rapid breathing and a change in mental status, such as reduced alertness or confusion, may be the first signs that sepsis is starting.
Other common symptoms include:
Fever and shaking chills or, alternatively, a very low body temperature
Nausea and vomiting
The first step to successful treatment for sepsis is quick diagnosis.
If sepsis is suspected, the doctor will perform an exam and run tests to look for:
Bacteria in the blood or other body fluids
Source of the infection, using imaging technology such as X-ray, CT scan, or ultrasound
A high or low white blood cell count
A low platelet count
Low blood pressure
Too much acid in the blood (acidosis)
Altered kidney or liver function
Other tests of bodily fluids and radiologic tests, such as X-ray or CT scan, can often help in diagnosing the cause of the infection.
People diagnosed with severe sepsis are usually placed in the intensive care unit (ICU), where doctors try to stop the infection, keep vital organs functioning, and regulate blood pressure.
Worldwide, one-third of people who develop sepsis die. Many who do survive are left with life-changing effects, such as post-traumatic stress disorder (PTSD), chronic pain and fatigue, and organ dysfunction (don’t work properly) and/or amputations.
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