The urological complications arising due to diabetes include bladder dysfunction, sexual and erectile dysfunction, as well as urinary tract infections (UTIs). The diagnosis, symptoms and treatment of diabetic urological complications are explained in this article. 

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Urological complications

The urological complications that are caused due to diabetes involve endothelial and neural damage all along the genitourinary tract which degrades the patient’s quality of life. The incidence of urological complications associated with diabetes is increasing because of the higher incidence of obesity.

Due to a long period of exposure to hyperglycemia the cells are accumulated with oxidative stress products which result in axonal degeneration and nerve damage ultimately decreasing nerve conduction.

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Diabetic cytopathic or diabetic bladder dysfunction

It is characterised by reduced bladder sensation and increased post-voiding residual volume due to incomplete bladder emptying which results in increased bladder capacity. This ultimately results in recurrent infections, and bladder stones eventually leading to kidney damage. In males age-associated increase in prostate volume worsens bladder disorders, females on the other hand have disorders related to the pelvic floor like stress incontinence. Numerous clinical studies have reported around 39% to 61% of diabetic patients have bladder hypersensitivity. Patients with diabetic bladder dysfunction usually present with somatic and autonomic neuropathy.

Diabetic patients complain of LUTS symptoms like urgency, increased frequency, and difficulty to begin, maintain and finish micturition. Inadequate emptying sensation, nocturia and diminished urine flow. Patient bladder symptoms can be broadly classified under irritative and obstructive symptoms. Irritative symptoms are caused by overexcited detrusor muscle causing urgency, nocturia, incontinence and pollakiuria. Obstructive symptoms include decreased voiding flow, terminal dribbling, and decreased sensation of full bladder along with increased post-void residual volume.

Diagnosis

Diabetic cystopathy can be suspected after detailed clinical history along with a physical examination which includes neurologic reflex and rectal examination. Uroflowmetry, kidney function test and urine routine microscopy are some investigations to confirm the diagnosis.

Treatment 

Blood glucose control remains the first and foremost line of treatment. For hyperactive bladder oral muscarinic drugs and uroselective anticholinergics like oxybutynin, darifenacin or solifenacin are available. For urgent incontinence infiltration of the detrusor muscle with botulinum toxin has proven to be effective. Patients not responding to conservative treatment can be offered surgical approaches like bladder denervation, myomectomy and bladder augmentation with ileal cystoplasty. In male patients with bladder outlet obstruction associated with prostrate hyperplasia can be started on alpha-blockers such as tamsulosin and terazosin.

Transurethral resection of the prostate is to be considered in advanced stages. Newer drugs like mirabegron which is a β3 adrenergic agonist can be used to increase urine storage capacity. In cases of failure of bladder emptying, frequent clean intermittent catheterisation can be used as permanent catheterisation is associated with increased infection risk and epidermoid bladder carcinoma. In cases of urge incontinence anticholinergics, schedule voiding and kegel exercises strengthen pelvic floor muscle which may improve quality of life. Diabetes prevention programs showed that lifestyle modification in female diabetic patients resulted in an improvement of symptoms associated with bladder dysfunction.

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Genitourinary infections

Genitourinary infections are the most common infections in diabetic patients. The variety of UTIs seen in diabetic patients ranges from asymptomatic bacteriuria to cystitis, pyelonephritis, renal abscess, and xanthogranulomatous pyelonephritis, to severe urosepsis.

Hospitalisation due to pyelonephritis occurs more frequently in diabetic patients who could progress to a renal abscess or bacteriemia or emphysematous cystitis. Patients present with complaints of urinary urgency, frequency, bad urine odour, painful micturition, burning micturition, dysuria, tenesmus, incomplete emptying, and incontinence for lower UTI. Patient with upper UTI presents with high-grade fever with chills, costovertebral angle pain or tenderness.

Diagnosis

In cases of suspicion of UTI a urine routine microscopy should be done, morning urine sample usually midstream is examined for the presence of leukocytes (more than 10 leukocytes/mm3) or a positive dipstick leukocyte esterase test to detect pyuria. It is advised to order a urine culture before initiating antibiotics. Type 2 DM is a risk factor for fungal UTIs such as candida. USG KUB and a complete haemogram can help in ruling out complicated UTIs.

Treatment

The patient should be counselled about the importance of good glycemic control as it prevents recurrent UTIs. Treatment of asymptomatic bacteriuria is not indicated until the patient is pregnant. As first-line therapy, a 3 days course with cotrimoxazole or nitrofurantoin is recommended for the treatment of uncomplicated cystitis. The antimicrobials should be prescribed as per the culture sensitivity report. Recurrent UTIs can be prevented by postcoital antibiotics and prophylactic antibiotics taken regularly. The complicated UTI should be managed with IV antibiotics.

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Benign Prostatic Hyperplasia (BPH) and urethral obstruction

It has largely been associated with diabetes, obesity, hypertension and metabolic syndrome. Increased plasma insulin levels are positive independent predictors of BPH. Initially, patients with BPH complain of symptoms of lower urinary tract symptoms. Progressive complications include bleeding, recurrent infections, lithiasis, and renal insufficiency. With time patients presents with painful manifestation due to acute urinary retention.

Diagnosis

Evaluation includes detailed history including LUTS questions, severity and influence on patient quality of life. Digital rectal examination should be incorporated into the physical examination. Renal ultrasonography, prostate-specific antigen (PSA), urinalysis, and uroflowmetry can help in diagnosis.

Treatment

The first line of therapy is treatment with alpha-1 blocker monotherapy which includes tamsulosin, alfuzosin, and silodosin. Patients should be counselled about the side effects of these drugs postural hypotension, dizziness, rhinitis, asthenia, sexual dysfunction, and abnormal ejaculation. Patients with enlarged prostate over 30-40 grams should be given a combination of alpha-5 reductase inhibitors (finasteride or dutasteride) and alpha-1 blockers. Transurethral resection of the prostate is the gold standard for patients not responding to conservative therapy. Newer techniques with less invasive approaches like bipolar resection and the use of laser vaporisation cryotherapy, and high-intensity focused ultrasound, botox infiltration is gaining popularity.

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Sexual dysfunction

It is not uncommon for both males and females to suffer from diabetes. It is defined as the inability to achieve or maintain an adequate sexual response to complete a sexual encounter or intercourse resulting in a satisfactory orgasmic sensation.

Sexual dysfunction includes painful coitus, loss of libido, ejaculatory problems like premature ejaculation, erectile dysfunction, and orgasmic abnormalities. It’s harder to diagnose sexual dysfunction in females because of various social stigmas, but it has been proposed that its prevalence in type 1 diabetes is around 71% and 42% in females with type 2 diabetes. The reported prevalence of sexual dysfunction in men with type 2 diabetes is up to 46%.

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Erectile Dysfunction (ED) 

It is defined as a long-term, persistent inability to achieve or maintain an adequate rigid erection to have a satisfactory sexual encounter. It is the third most frequent complication of diabetes usually manifesting after 10–12 years after the onset of diabetes. ED is directly associated with poor glycemic control. As per studies, ED is an early sign of cardiovascular events. Therefore prevention through screening and managing cardiovascular risk factors in men diagnosed with ED is important for treating physicians.

Diagnosis

The international index for erectile function questionnaire helps to determine the degree of erectile dysfunction and to evaluate the progression or response to medical treatment.

The first line of therapy is oral phosphodiesterase-5 inhibitors (PD5i) like Sildenafil citrate, tadalafil, vardenafil hydrochloride and udenafil. It not only helps in the improvement of sexual function but also diminishes urinary tract symptoms arising due to enlarged prostate. Meta-analysis has confirmed that PD5i are an effective treatment of ED in patients with diabetes. Side effects like headache, dyspepsia, bluish eyesight and facial flushing are common with PD5i.

Vacuum erection devices are another option available for ED patients. Injections of prostaglandin E-1 like alprostadil are directly injected into the corpus cavernosum which has a direct effect on vessels and causes an immediate penile erection, with a response rate above 83%. Side effects common with intracavernosal injections are penile pain, hematomas, fibrosis, infection, priapism, and prolonged painful erections. Patients not responding to the above-mentioned therapy can opt for a penile prosthesis implant (PPI), which improves rigidity and flaccidity resulting in improved satisfaction for the patient and their partner.

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Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Hitesh Saraogi is a diabetologist and physician at Dhanvantari Hospital, Raj Nagar Extension, Ghaziabad.