Complications and Comorbidities> Renal and Urinary>

DEFINITION

• Bladder dysfunction in diabetes (DM) spans a spectrum from lower urinary tract symptoms (LUTS) to bladder cystopathy.
• Bladder cystopathy: Failure of the bladder characterized by decreased bladder sensation and contractility resulting in urinary retention, the most severe bladder disorder in DM.
• Detrusor muscle, neurologic, and urothelial dysfunction underlie bladder dysfunction in DM.

EPIDEMIOLOGY

• More than 50% of patients with DM have some bladder dysfunction (e.g., incontinence) while bladder cystopathy is rare (Brown 2005).
• Benign prostatic hyperplasia is a common cause of symptoms that can be indistinguishable from LUTS associated with DM bladder dysfunction in men.
• Of women with DM in the U.S., 35% report at least weekly incontinence, 26% at least weekly urge incontinence, and 30% at least weekly stress incontinence; corresponding prevalences in those with normal glucose (NHANES) are 17%, 8%, and 14%. (Brown, Vittinghoff, 2006)

DIAGNOSIS

• History
• Urodynamic testing (performed by urologist): Cystometry, sphincter electromyography, uroflowmetry, urethral pressure

SIGNS AND SYMPTOMS

• Symptoms of LUTS: Urinary frequency, urinary urgency, nocturia, and incontinence.
• Diabetic cystopathy: Decreased urge to urinate, incomplete bladder emptying, decreased frequency of urination.
• Urodynamic findings vary based on stage of bladder dysfunction but can show increased bladder capacity, decreased detrusor contactility, and increased post-void residual urine.
• Bladder cystopathy can lead to an atonic bladder manifested by decreased micturition reflex, poor contractility, and an increased post-void residual urine.
• Bladder dysfunction may result in urinary tract infections

CLINICAL TREATMENT

• Bladder and pelvic muscle training in women
• Voiding at regular, scheduled intervals
• Glycemic control may be important since bladder dysfunction may result from neuropathy. However intensive glucose control did not decrease prevalence of LUTS in men participating in the UroEDIC at year 10 of DCCT/EDIC (Van den Eeden)
• Cholinergic receptor agonists such as bethanechol 
• Intermittent catheterization in unusually severe cases
• Urologic consultation

EXPERT COMMENTS

• Patients with change in bladder symptoms should be evaluated for urinary tract infection with urinalysis and/or culture.
• In the Diabetes Prevention Program, intensive lifestyle modification with weight loss and increased physical activity led to a decreased prevalence of weekly urinary incontinence in women at high risk for DM relative to the metformin and placebo arms. (Brown, Wing 2006).

REFERENCES