diabetic uropathy dr. ursua - isdfidiabetes and uti •asymptomatic women-2 consecutive voided urine...
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Diabetic UropathyJoseph Michael A. Ursua, MD, FPUA
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Definition
• Diabetic Uropathy - range of debilitating urologic
complications secondary to diabetes
• Bladder dysfunction
• urinary tract infection
• sexual dysfunction
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• 70% - lower urinary tract complications
• 50% nephropathy
• 35% to 75% develop sexual dysfunction.
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Diabetes and UTI• asymptomatic women - 2 consecutive voided urine
specimens with isolation of the same bacterial strain in quantitative counts ≥ 100,000 cfu/mL.
• In men - single, clean-catch voided urine specimen with one bacterial species isolated in a quantitative count ≥ 100,000 cfu/mL identifies bacteriuria.
• single catheterized urine specimen with one bacterial species isolated in a quantitative count ≥ 100 cfu/mL identifies bacteriuria.
Philippine Clinical Practice Guidelines on UTI 2015 Update: Part 2
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Diabetes and UTI
DM NON DMAsymptomatic Bacteuria
26% 6%
Bacteremia 26% 13%Urinary tract source 8.7% 2.2%
Higher incidence of Asymptomatic bacteuria and Comlicated UTIassociated with symptomatic Bacteremia
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Diabetes and UTI
Why?
• Different Bacteria
• Glucosuria
• Impairment of granulocyte function
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Diabetes and UTI
Different BacteriaSame number of virulence
factors
No difference in microbial resistance
Geerling et al, International Journal of Antimicrobial Agents 19 (2002)
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Diabetes and UTI
Glucosuria In Vitro In Vivo
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Diabetes and UTI
Impairment of granulocyte function
Equal granulocyte function test:chemotaxis
OpsonisationPhagocytosis
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Diabetes and UTI
Pathogenesis
• Lower urinary concentration of IL-6 and IL-8
• E. Coli with type 1 fimbriae adheres better to
patients with high level of glycosylated HbA1C
Geerling et al, International Journal of Antimicrobial Agents 19 (2002)
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Diabetes and UTI
Treatment• Asymptomatic Bacteruria:• No progression• No reduction of Renal function
• Screening and Treatment is not warranted• Treatment depends on clinical presentation
Harding et al, N Engl J Med 2002;
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Diabetes and UTI
Antimicrobial Agent
• Same as non diabetic
• Tmp/Smx may induce hypoglycemic effect
• Treatment duration 7-14 days
Philippine Clinical Practice Guidelines on UTI 2015 Update: Part 2
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Diabetes and UTI
Philippine Clinical Practice Guidelines on UTI 2015 Update: Part 2
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Diabetes and UTI
Emphysematous Pyelonephritis• Urologic emergency• Necrotizing parenchymal infection caused by gas
forming pathogens• Usually occurs in diabetic patients• Mortality rate 19% to 47%
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Diabetes and UTI
Emphysematous Pyelonephritis• Severe acute pyelonephritis• Triad of fever, flank pain and vomiting• E. coli is most commonly identified
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Diabetes and UTI• X-ray shows mottled gas
pattern over affected kidney
• Streaky or mottled gas with or without bubbly and loculated gas - 50% to 60% motality rate• Renal scan
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Diabetes and UTI
Treatment• Surgical emergency• If the kidney is functioning, medical therapy can be
considered• Nephrectomy for patients who do not improve
after a few days of therapy
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Diabetic Bladder dysfunction
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Diabetic Bladder dysfunction
• spectrum of clinical symptoms
• bladder overactivity
• impaired bladder contractility
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Diabetic Bladder dysfunction
• 55% have detrusor hyperreflexia
• 23% have reduced detrusor contractility
• 10% detrusor areflexia
• 11% indeterminate findings
Kaplan et al, 1995
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Diabetic Bladder dysfunction
Storage VoidingUrgency Hesitancy Overflow
incontinence
Urge incontinence Weak Stream Bilateral hydronephrosis
Frequency Post void dribbling Rising serum creatinine
Nocturia
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Diabetic Bladder dysfunction
Role of Detrussor
muscle
Role of Neuronal Damage
Role of Urothelium
Golbidi et al 2010
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Diabetic Bladder dysfunction
Role of Detrusor Muscle
• The detrusor muscle shows an enhanced response
to muscarinic agonists in diabetes. It may be due to
an increased muscarinic receptor density or
increases in smooth muscle sensitivity to calcium
(Saito et al., 1997)
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Diabetic Bladder dysfunction
• Glucosuria and osmotic diuresis both lead to increased bladder stretch, elevated intravesicalpressure, leading to bladder hypertrophy, which upon decompensation can cause increased
residual volume
(Daneshgari et al., 2006).
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Diabetic Bladder dysfunction
Role of Neuronal Damage
• activation of the polyol pathway increases
• production of free radicals
• activates protein kinase C
• formation of advanced glycated end products
Fedele, 2005
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Diabetic Bladder dysfunction
Role of Neuronal Damage• Decreased synthesis of nerve growth factor• defective transport of nerve growth factor
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Diabetic Bladder dysfunction
• Gastrointestinal complications of diabetes• Pressure from an over-distended bladder can
reflexively inhibit parasympathetic activity, a stimulus for fecal retention and soiling• Straining to defecate can affect pelvic floor muscles
and lead to rectocele, cystocele (in women), and an increased risk of stress incontinence and incomplete bladder emptying
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Diabetic Bladder dysfunction
Role of Urothelium• interruption of barrier function of the urothelium• toxic substances can diffuse to the underlying
tissues to induce symptoms of urgency, frequency, and pain during bladder filling and voiding
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Diabetic Bladder dysfunction
Deneshgari et al,Diabetic Bladder Dysfunction: Current Translational Knowledge J Urol. 2009 December
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Diabetic Bladder dysfunction
Diagnosis• History• Physical
Examination• Laboratories• Urodynamic studies
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Diabetic Bladder dysfunction
Diagnosis• Good History taking
SymptomsHesitancy
Weak streamDribbling
Incomplete emptyingInfrequent voiding
Urgency and nocturia
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Diabetic Bladder dysfunction
Physical Examination• Complete physical exam• Genitourinary• Obstetric • Neurologic
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Diabetic Bladder dysfunction
Laboratories• Urinalysis/ Urine culture• Serum glucose/ HBA1c• Bun/Creatinine• KUBP Ultrasound – post void residual,
hydronephrosis
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Diabetic Bladder dysfunction
Urodynamics• Cornerstone in diagnosis of DBD• Differentiate between bladder pathology and
bladder outlet obstruction• Detrussor overactivity• Detrussor Hypoactivity
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Diabetic Bladder dysfunction
• relief of symptoms
• prevention and treatment of urinary tract infections
• adequate bladder emptying.
Goals of treatment
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Diabetic Bladder dysfunction
• Behavioral
• Pharmacologic
• Surgical
Strategies
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Diabetic Bladder dysfunction
Behavioral• weight reduction• avoiding bladder irritants e.g caffeinated drinks• Pelvic floor exersizes• Timed voiding• Crede’s or valsalva• Clean intermittent catheterization
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Diabetic Bladder dysfunctionPharmacologicAntimuscarinic• Tolterodine• Oxybutynin• SolifenacinAnticholinergic• Fesoterodine• Trospium chloride
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Diabetic Bladder dysfunction
Surgery• Vesical neck resection• Selective pudendal nerve block• Sacral neuromodulation
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Diabetic Bladder dysfunction
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Sexual Dysfunction
• Diabetes is associated with sexual dysfunction both in men and in women• threefold increased risk of erectile dysfunction (ED)
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Sexual Dysfunction
Erectile Dysfunction• persistent inability to achieve or maintain penile
erection for successful sexual intercourse• 10–15 years earlier in men with diabetes and
usually more severe• less responsive to oral drugs
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Sexual Dysfunction
• Hyperglycemia as risk factor
• diabetes is commonly associated with hypertension, hyperlipidemia, obesity, metabolic syndrome, smoking
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Sexual Dysfunction
Pathogenesis of ED• Vasculopathy• Neuropathy• visceral adiposity• insulin resistance• hypogonadism.
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Sexual Dysfunction
Treatment• Glycemic control and lifestyle modification• weight reduction• smoking cessation• physical exercise
• Pharmacological Therapy• PDE5 inhibitors• Intracavernosal or transurethral vasoactive
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Sexual Dysfunction
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Thank you
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