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ORIGINAL CONTRIBUTIONS

Received: September 3^rd 2014

Accepted: April 28^th 2015

Prevalence of urinary tract symptoms in women with diabetes mellitus

Javier Jiménez-Rodríguez,^a Angélica Carbajal-Ramírez,^b Héctor Meza-Vázquez,^c Jorge Moreno-Palacios,^a Eduardo Serrano-Brambila^a

^aServicio de Urología

^bServicio de Neurología

^cServicio de Andrología

^aServicio de Urología

Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Distrito Federal, México

Communication with: Javier Jiménez-Rodríguez

Thelephone: (55) 5627 6900, extensión 21516

Email: j_arean@hotmail.com

Background: The objective was to evaluate the prevalence of urinary tract symptoms and the impact in the quality of life in women with diabetes, the association with DM and neuropathy evolution time and glycemic control.

Methods: A cohort of women from the DiabetIMSS program was evaluated from January 2011 to 2013. The personal history, time of DM diagnosis, neuropathy, urinary symptoms, glycemic control and quality of life impact were noted.

Results: A total of 169 women were evaluated. The median age was 58 years (29-85) and DM main evolution time was 9 years (0.5-31). Urinary tract symptoms were present in 128 (75.7 %) patients. Stress and urge incontinence were predominantly present (45.3 and 40.6 % respectively), followed by obstructive and irritative symptoms (25 and 10.1 % respectively). The impact in the quality of life was mild-moderate in 91.1 % of the patients. At least one criteria for neuropathy was noted in 154 (91.1 %) patients. Neuropathy evolution time was longer in the symptomatic group (12 vs 4.8 months). Symptoms were mainly present in patients with more than one year of neuropathy; p < 0.05.

Conclusion: There is a high prevalence of urinary tract symptoms in diabetic women. The only associated risk factor was neuropathy. No significative association was found between the rest of the factors.

Keywords: Diabetes mellitus; Lower urinary tract symptoms; Diabetic neuropathies.

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Diabetes mellitus (DM) is a disease of extremely high prevalence in Mexico. It is the leading cause of death and demand for outpatient medical care, and one of the leading causes of hospitalization; it is also the disease that consumes the largest percentage of expenditure from public institutions, and it has a prevalence above 20% in people older than 50.¹ DM is associated with increased fluid intake and urine output due to the hyperosmolar state induced, requiring an increase of bladder emptying due to increased urinary excretion.²

Vesicourethral dysfunction in diabetic patients (VUDDP) is found in more than 80% of individuals with DM, a higher percentage of complications than neuropathy and nephropathy, which affect less than 60 and 50% of patients, respectively.³ VUDDP includes bladder neuropathy, sphincter dysfunction, and increased susceptibility to urinary tract infections (UTI),⁴ which substantially affects quality of life and can impair kidney function.

VUDDP is characterized by changes in sensation and contractility in the detrusor, and increased bladder capacity and urine volume postvoid,⁵ which has been associated with detrusor underactivity due to alterations in the afferent pathways of A-delta and C fibers, and hyperactivity of muscle fibers with ineffective contractions due to autonomic neuropathy and detrusor myopathy.⁶ It has been reported that 28 to 38% of DM patients have voiding dysfunction due to lack of coordination between the detrusor and the external sphincter, causing obstructive and irritative symptoms, increased residual voiding volume, and UTI.^6-8 VUDDP initially manifests with storage symptoms such as urgency and urge incontinence (UI), urodynamically diagnosed detrusor hypocontractility, later adding symptoms of voiding due to high postvoid residual volume, decreased force of the urinary stream, urgency, urinary hesitancy, and urodynamically diagnosed detrusor hypocontractility due to neural changes,9 so it can be separated into an early stage (compensated) and an advanced stage (decompensated), whose main distinction is urinary retention due to vesical overstretching.⁶

High incidence and prevalence (between 61 and 90%) of various urinary symptoms have been found in diabetic women, with three main types of voiding dysfunctions: detrusor underactivity, detrusor overactivity, and bladder sphincter dyssynergia,^6-10 with 0.5 to 2 times greater prevalence of urinary incontinence in diabetic women than in non-diabetic women.¹⁰ Even after adjusting for other known risk factors for urinary incontinence such as age, body mass index (BMI), and parity, DM remains an independent risk factor for urinary incontinence. Despite the high prevalence of this type of incontinence as a complication of DM in women, there is little care sought for several reasons such as lack of information, discomfort, or lack of desire to externalize the problem,¹¹ so there is a 22% prevalence of unidentified VUDDP in women.¹² Because of this, the proper knowledge of the causes, symptoms, and treatment could result in a substantial benefit in quality of life for these patients.

VUDDP is often unrecognized by doctors and patients (22%) because of its insidious development and vague symptoms.⁵ In the Instituto Mexicano del Seguro Social, the prevalence of urinary symptoms in diabetic patients is unknown, leading to help being sought in advanced stages of underactive bladder, with lower treatment response and a significant deterioration in the quality of life.

Recognizing the problem of the lack of detection of urinary abnormalities in diabetic patients can allow us to diagnose, treat promptly, and reduce their consequences and impact on quality of life.

The aim of this study was to evaluate the prevalence of urinary symptoms in a cohort of Mexican women diagnosed with DM and the impact of these symptoms on their quality of life, and to describe the prevalence and severity according to their metabolic profile, glycemic control, and renal function.

Methods

A cross-sectional, descriptive, and observational study was conducted to evaluate women in the program DiabetIMSS in family medicine units (FMU) 52, 77, 78, and 195. Patients were interviewed at the Hospital de Especialidades del Centro Médico Nacional Siglo XXI in from January 2011 to January 2013.

The study included female patients with a diagnosis of DM registered in the DiabetIMSS program. It excluded patients with voiding dysfunction, urinary incontinence, and low obstructive urinary symptoms, before DM diagnosis, or who had other pathologies causing them.

Patients were questioned about their obstetric and gynecological and personal disease histories, the time of development of DM, presence or absence of neuropathy according to the American Diabetes Association (ADA) criteria, and urinary symptoms. They were subsequently given questionnaires for the evaluation of urinary incontinence (ICIQ-SF), the International Prostate Symptom Score (IPSS), and the impact of urinary incontinence on quality of life (Potenziani-14-CI-IO-QOL-2000). All patients had their weight measured, as well as creatinine (Cr) levels, Cr clearance by Cockcroft-Gault, cholesterol, triglycerides, glucose, hemoglobin (Hb), and glycated hemoglobin (HbA1c).

Quantitative variables with normal distribution were analyzed using Student’s t-test and for non-normal distribution the Wilcoxon test was used. Friedman’s analysis of variance was done for quantitative variables, and Cochrane’s Q for qualitative variables. A p-value of < 0.05 was considered statistically significant. SPSS, version 17 (Chicago, Illinois, USA) was used.

Results

169 women diagnosed with DM were interviewed; the median age was 58 years (29-85), and the average time of development of DM was 9 years (0.5 to 31). One hundred twenty-eight (75.7%) patients had urinary symptoms, mainly stress urinary incontinence and urge urinary incontinence (45.3 and 40.6%), obstructive symptoms (25%), and irritative symptoms (10.1%). One hundred fifty-four patients (91.1%) met one or more of the ADA’s neuropathy criteria. These changes had an impact on the patients’ quality of life that was predominantly mild to moderate (91.1%). The results of the cholesterol, triglycerides, glucose, Cr clearance, and HbA1c measurements, and the ICIQ-SF, IPSS, and QoL questionnaires are specified in Table I.

No significant differences were found between age, obstetric and gynecological history, time of DM diagnosis, and HbA1c level between symptomatic and asymptomatic patients.

The time of development of neuropathy was higher in symptomatic patients (12 versus 4.8 months); urinary symptoms also prevailed in those with neuropathy of more than a year of development, p < 0.05 (Table II).

Discussion

Neuropathy is one of the four major complications of DM,¹³ especially urinary disorders.¹⁴ The prevalence of diabetic neuropathy at the time of DM diagnosis has been reported in 8% of patients,¹⁵ and diabetic cystopathy can be extremely high (75 to 100%), especially with prior presence of neuropathy.^14,16 In this study, the prevalence of neuropathy and urinary symptoms were high (91.1 and 75.7%, respectively) with an average time of development of DM of nine years, which corresponds to that found by other authors, such as Bansal et al., evaluating men with an average time of development of DM of 11 years and an average Hb1Ac of 6.96 g / dL, finding 78% with detrusor disorders, 80.7% with electrophysiological signs of autonomic nervous system dysfunction, and 57.7% with evidence of peripheral neuropathy.⁸ Changxiao et al. also found clinical and urodynamic signs of urinary disorders in 1640 women in 93 and 88%, respectively.¹⁴

Although the etiology and pathophysiology of these disorders remain controversial, there is evidence of their origin in vascular damage and metabolic imbalance secondary to hyperglycemia with increased oxidative stress, neuronal hypoxia-ischemia due to endothelial injury, and perineural inflammation with axonal degeneration and demyelination, which seems to compromise the barrier function of the epithelial cells and create disorders in the membrane of mechanosensitive cells, causing instability, hyperactivity, and impaired vesical sensitivity.¹⁵

The studies currently available on the association of diabetic neuropathy with urinary disorders are inconclusive because urinary symptoms are found in up to 71.7% of patients; of those symptoms, bladder hypotonia is the disorder most often urodynamically diagnosed, with abnormal neuronal conduction in 100% of patients with peripheral neuropathy and voiding disorders, which seems to result from autonomous and peripheral nerve damage secondary to chronic hyperglycemia.¹⁶ These findings correlate with the findings in this study, in which longer history of diabetic neuropathy is associated with higher prevalence of urinary symptoms, and the study from Karoli et al., in which the presence of chronic disorders secondary to diabetes was significantly associated with finding urinary symptoms.¹⁹ We found no significant differences between time of development of DM and HbA1c level measured once, since none of these parameters reflects the chronic glycemic control of these patients. The association found between the time of development of diabetic neuropathy and urinary symptoms may be due to neuronal damage secondary to chronic hyperglycemia and neuronal membrane damage by free radicals.^2,6,8,15

Improving the early recognition of urinary disorders in diabetic patients can result in a benefit to their quality of life.

This study represents a transversal description of the patients at the time of evaluation and the application of questionnaires, which despite having validation, does not exemplify the long-term results.

Conclusion

The prevalence of urinary symptoms in diabetic patients is high. The impact of symptoms on the quality of life is predominantly mild to moderate. The time of development of neuropathy was the only factor associated with urinary symptoms. The time of development of DM and one determination of HbA1c to represent metabolic control showed no association with urinary symptoms.

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