Posted by dan on July 14, 1999 at 13:12:15
I am a 34 year-old male who has had insulin-dependent diabetes for 12 years. My diabetes is under excellent control, and I have absolutely no apparent complications from the diabetes, nor other health problems, other than the following condition.
Two years after being diagnosed with the diabetes (i.e. ten years ago), I began to experience difficulty voiding - difficulty to start the stream, inability to completely empty my bladder, and reduced flow pressure. My doctors assumed that it was prostititis (i.e. not diabetes related), and treated me first with antibiotics, and then later with medication to relax the bladder opening and increase bladder strength. These treatments did not noticably improve my symptoms. Cystoscopy showed no obstructions, and after about 5 years of these symptoms, and with cystometrics showing that my bladder muscle contraction was very weak, I was put on intermittent cathertization - which I have continued (without problem) for 5 years. As I have absolutely no other symptoms or neurological complications, my doctors are not sure whether this has anything to do with my diabetes, or is some isolated problem. Two questions:
1) In almost every case of neurogenic bladder that I have seen, there are additional neurologic symptoms. Is there any information on the possible causes (or treatment) for such isolated bladder dysfunction?
2) My doctor feels that a complete neurologic work-up would be pointless, since after ten years with this condition, and no other symptoms or problems, whatever the cause of the problem is he feels it to be localized. Although the condition causes me relatively little difficulty, I am still uneasy though about what may be the source of it. Would any other tests be advisable at this time?
Posted by HFHS M.D.-AT on August 10, 1999 at 16:33:02
Thanks for your question. In summary, you have had insulin dependent diabetes mellitus (IDDM) for 10 years, poorly contractile bladder for last 10 years and your question is about possible course of action for your bladder problem.
Diabetic autonomic cystopathy is a known sequel of long standing IDDM. Diabetic cystopathy refers to the spectrum of voiding dysfunction in patients with diabetes mellitus. It is marked by insidious onset and progression with minimal symptomology. The most common urodynamic findings are impairment of bladder sensation, increased post-void residual volume, decreased detrusor (bladder muscle) contractility that may progress to detrusor areflexia (non contractility) and diminished urinary flow. Asymptomatic patients with manifestations of diabetic cystopathy may be treated with timed voiding. In contrast, the sine qua non for therapy in symptomatic patients is clean intermittent catheterization. Other associated features of this condition are the result of diabetic autonomic neuropathy such as impotence and postural hypotension (dizziness on standing). Isolated bladder involvement is possible. (See below)
Kaplan and associates (J Urol 1995 Feb;153(2):342-4) recently studied the relationship between voiding dysfunction associated with diabetes and bladder and sphincter behavior. They analyzed the video urodynamic studies of 182 patients retrospectively. Patients were classified based on urodynamic diagnosis and the presence or absence of signs of sacral cord involvement. Urodynamic findings were classified as either detrusor (bladder) hyperreflexia, impaired detrusor contractility, detrusor areflexia, indeterminate and normal. Of the 182 patients 100 (55%) had detrusor hyperreflexia, 42 (23%) had impaired detrusor contractility, 20 (11%) had indeterminate findings, 19 (10%) had detrusor areflexia and 1 (1%) was normal. Bladder outlet obstruction occurred in 66 patients (36%), all men (57%). The diagnosis was isolated in 24 patients (36%) or in combination with another diagnosis in 42 (74%). These data suggest that classical diabetic cystopathy is not the most common urodynamic findings in patients with diabetes mellitus and voiding dysfunction, and in fact these patients present with variable pathophysiological findings.
The specific response to your questions would be that if other neurological features are absent, we can omit formal and complete neurological assessment. You however may benefit from a repeat pressure-flow study (urodynamics) to assess the extent of remaining bladder function. If any new neurological symptom appears, you will need the entire battery of neurological and imaging testing.
Hope this information will be of some help to you.
This information is provided for general medical information purposes only. Please consult your physician for diagnostic and treatment options pertaining to your specific medical condition. David Burks, MD at the Henry Ford Hospital Department of Urology has experience in the evaluation and treatments of problems such as you describe. He would be most interested in helping you. You can reach him through our toll-free number (1-800-653-6568).We can also arrange local accommodations through this number if this is your need. Please bring any x-rays [and pathology slides] (not just the reports) as well as any physicians' notes and lab test results that you may be able to obtain. These will help us greatly.
*keyword: Urodynamics, Neurogenic bladder, autonomic cystopathy
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