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Diabetic autonomic neuropathy (DAN) is a serious and common complication of diabetes. Despite its relationship to an increased risk of cardiovascular mortality and its association with multiple symptoms and impairments, the significance of DAN has not been fully appreciated. The reported prevalence of DAN varies widely depending on the cohort studied and the methods of assessment. In randomly selected cohorts of asymptomatic individuals with diabetes, approximately 20% had abnormal cardiovascular autonomic function. DAN frequently coexists with other peripheral neuropathies and other diabetic complications, but DAN may be isolated, frequently preceding the detection of other complications. Major clinical manifestations of DAN include resting tachycardia, exercise intolerance, orthostatic hypotension, constipation, gastroparesis, erectile dysfunction, sudomotor dysfunction, impaired neurovascular function, "brittle diabetes," and hypoglycemic autonomic failure. DAN may affect many organ systems throughout the body (e.g., gastrointestinal [GI], genitourinary, and cardiovascular). GI disturbances (e.g., esophageal enteropathy, gastroparesis, constipation, diarrhea, and fecal incontinence) are common, and any section of the GI tract may be affected. Gastroparesis should be suspected in individuals with erratic glucose control. Upper-GI symptoms should lead to consideration of all possible causes, including autonomic dysfunction. Whereas a radiographic gastric emptying study can definitively establish the diagnosis of gastroparesis, a reasonable approach is to exclude autonomic dysfunction and other known causes of these upper-GI symptoms. Constipation is the most common lower-GI symptom but can alternate with episodes of diarrhea. Diagnostic approaches should rule out autonomic dysfunction and the well-known causes such as neoplasia. Occasionally, anorectal manometry and other specialized tests typically performed by the gastroenterologist may be helpful. DAN is also associated with genitourinary tract disturbances including bladder and/or sexual dysfunction. Evaluation of bladder dysfunction should be performed for individuals with diabetes who have recurrent urinary tract infections, pyelonephritis, incontinence, or a palpable bladder. Specialized assessment of bladder dysfunction will typically be performed by a urologist. In men, DAN may cause loss of penile erection and/or retrograde ejaculation. A complete workup for erectile dysfunction in men should include history (medical and sexual); psychological evaluation; hormone levels; measurement of nocturnal penile tumescence; tests to assess penile, pelvic, and spinal nerve function; cardiovascular autonomic function tests; and measurement of penile and brachial blood pressure. Neurovascular dysfunction resulting from DAN contributes to a wide spectrum of clinical disorders including erectile dysfunction, loss of skin integrity, and abnormal vascular reflexes. Disruption of microvascular skin blood flow and sudomotor function may be among the earliest manifestations of DAN and lead to dry skin, loss of sweating, and the development of fissures and cracks that allow microorganisms to enter. These changes ultimately contribute to the development of ulcers, gangrene, and limb loss. Various aspects of neurovascular function can be evaluated with specialized tests, but generally these have not been well standardized and have limited clinical utility. Cardiovascular autonomic neuropathy (CAN) is the most studied and clinically important form of DAN. Meta-analyses of published data demonstrate that reduced cardiovascular autonomic function as measured by heart rate variability (HRV) is strongly (i.e., relative risk is doubled) associated with an increased risk of silent myocardial ischemia and mortality. The determination of the presence of CAN is usually based on a battery of autonomic function tests rather than just on one test. Proceedings from a consensus conference in 1992 recommended that three tests (R-R variation, Valsalva maneuver, and postural blood pressure testing)or longitudinal testing of the cardiovascular autonomic system. Other forms of autonomic neuropathy can be evaluated with specialized tests, but these are less standardized and less available than commonly used tests of cardiovascular autonomic function, which quantify loss of HRV. Interpretability of serial HRV testing requires accurate, precise, and reproducible procedures that use established physiological maneuvers. The battery of three recommended tests for assessing CAN is readily performed in the average clinic, hospital, or diagnostic center with the use of available technology. Measurement of HRV at the time of diagnosis of type 2 diabetes and within 5 years after diagnosis of type 1 diabetes (unless an individual has symptoms suggestive of autonomic dysfunction earlier) serves to establish a baseline, with which 1-year interval tests can be compared. Regular HRV testing provides early detection and thereby promotes timely diagnostic and therapeutic interventions. HRV testing may also facilitate differential diagnosis and the attribution of symptoms (e.g., erectile dysfunction, dyspepsia, and dizziness) to autonomic dysfunction. Finally, knowledge of early autonomic dysfunction can encourage patient and physician to improve metabolic control and to use therapies such as ACE inhibitors and beta-blockers, proven to be effective for patients with CAN.
Diabetes Care 2003 May
PMID:Diabetic autonomic neuropathy. 1271 21

It is important for primary care physicians to take fecal incontinence seriously and not dismiss it as a normal part of aging. Elderly patients may be reluctant to admit fecal incontinence, so clinicians need to ask about it. Two of the most common causes are fecal impaction (especially in nursing home patients) and rectosphincter dysfunction in people with diabetes.
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PMID:Fecal incontinence in elderly patients: common, treatable, yet often undiagnosed. 1277 33

Nursing home residence is by far the most prominent association with fecal incontinence, with a prevalence approaching 50%. In one major survey, urinary incontinence was the greatest risk factor for developing fecal incontinence, and fecal incontinence was the greatest risk factor for developing urinary incontinence. Immobility, dementia, and the use of physical restraints were also important risk factors. Specific diseases associated with fecal incontinence include diabetes, multiple sclerosis, Parkinson's disease, stroke, and spinal cord injury. The surgical procedures lateral internal sphincterotomy for anal fissure, fistulotomy, and ileal pouch reconstruction can result in fecal incontinence. Children who are born with congenital abnormalities, such as imperforate anus, often experience soiling for many years. Future studies to determine the prevalence and etiology of fecal and urinary incontinence will need to first define these conditions and eliminate referral bias. Epidemiologic investigations of both disorders should be performed jointly because the conditions are so often comorbid.
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PMID:Epidemiology of fecal incontinence. 1497 32

Urinary incontinence is common in the elderly. The epidemiology of fecal and double (urinary and fecal) incontinence is less known. The Canadian Study of Health and Aging (CSHA) is a national study of elderly living in the community at baseline (n = 8,949) and interviewed in 1991-1992, 1996, and 2001. Using data from the CSHA, we report the prevalence of urinary, fecal, and double incontinence in each wave and the cumulative incidence between waves and investigate the predictors of urinary and fecal incontinence. Urinary incontinence increased rapidly in old age, being almost twice as high in women as in men. Fecal and double incontinence were less common, but also increased rapidly with age. In women, parity showed a positive relationship with (prevalent) urinary incontinence. In men, diabetes was a risk factor for urinary and fecal incontinence. We conclude that urinary, fecal, and double incontinence increase rapidly with age and that inquiry about incontinence should be part of routine medical and nursing assessment of all elderly.
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PMID:A 10-year follow-up of urinary and fecal incontinence among the oldest old in the community: the Canadian Study of Health and Aging. 1583 15

Plantago ovata is a high fibre bulk forming laxative. It absorbs water and expands to provide increased bulk and moisture content to the stool. The increased bulk encourages normal peristalsis and bowel motility. Clinical Indications: Constipation, Fecal Incontinence, Hemorrhoids, Ulcerative Colitis, Appetite, Hyperlipidemia, Diabetes mellitus.
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PMID:[Plantago ovata]. 1698 39

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) may occur in association with diabetes mellitus (DM). We report a case of a poorly controlled diabetic patient who presented with rapid onset of bilateral lower extremity weakness and sensory loss associated with sacral and posterior thigh paresthesias and urinary and bowel incontinence, indicative of cauda equina syndrome (CES). Subsequent evaluation was consistent with CIDP. Monthly infusions with intravenous immunoglobulins (IVIg) with strict glycemic control using insulin resulted in remarkable clinical and electrophysiological recovery. This case report describes a rare presentation of CIDP and emphasizes the importance of early utility of electrodiagnostic (EDX) studies in the clinical evaluation of diabetic patients presenting with rapidly progressive lower extremity weakness and sensory loss associated with diminished reflexes.
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PMID:Chronic inflammatory demyelinating polyradiculoneuropathy presenting as cauda equina syndrome in a diabetic. 1752 74

Normal pressure hydrocephalus (NPH) is one of the few reversible causes of dementia in older adults and accounts for approximately 6% of all dementias. The cardinal sign of NPH is a hypokinetic gait disorder in which the older adult's feet look as though they are glued to the floor. The gait also has been described as magnetic. People with NPH also may have mild dementia and bladder and bowel incontinence. A 78-year-old man exhibited symptoms of NPH for at least 4 years before being diagnosed. A neurological assessment of the patient revealed gait, posture, and balance abnormalities; mild dementia; and urinary urgency, frequency, nocturia, and incontinence at least once a day. His risk factors for NPH included diabetes and hypertension. A computed tomography (CT) scan revealed dilated lateral ventricles in the brain. A lumbar puncture was used to remove 50 ml of cerebrospinal fluid, which resulted in a transient improvement in his gait for approximately 18 hours. A ventriculoperitoneal shunt was then inserted in the patient, and during a 1-year period his symptoms gradually improved. He recovered without any complications and was eventually able to resume his usual activities. When the gait associated with NPH is observed in an older adult, he or she should be referred to a neurologist or multidisciplinary team for a comprehensive evaluation. If an individual receives treatment for NPH, he or she may have an improved quality of life and the opportunity to reduce functional limitations and disability. Families may also experience positive outcomes, such as having a loved one who is cognitively improved and requires less care.
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PMID:Gait disorder is the cardinal sign of normal pressure hydrocephalus: a case study. 1759 8

Fecal incontinence (FI), the involuntary loss of formed stool, can a social and as well as hygiene problem and is often devastating for patients and their caretakers. Current data, which are probably underestimated, indicate that the occurrence is remarkably high. The etiology of FI is multifactorial; risk factors including advancing age, previous obstetric trauma, diabetes, fecal impaction, stroke, and dementia. The management of FI in the elderly depends on etiologic factors. However, there are many treatment options for sufferers of FI including bulking agents, antidiarrheals, anticholinergics, biofeedback, surgery for sphincter defects, and sphincter bulking devices. The appropriate treatment can be guided by a thorough workup of these patients and result in a significant improvement in quality of life.
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PMID:Fecal incontinence in the elderly. 1831 19

The aim was to measure prevalence and correlates of urinary incontinence in community-dwelling Mexican American (MA) and European American (EA) women from a cross-sectional analysis of baseline data from a longitudinal cohort. Participants were MA and EA women, aged 65 years and older, in the San Antonio Longitudinal Study of Aging (SALSA), of whom 421 (97.4%) responded to the question "How often do you have difficulty holding your urine until you can get to a toilet." Measurements included sociodemographic, functional, cognitive, psychosocial, and clinical status variables derived from bilingual interviews and performance-based tests. Urinary incontinence prevalence was 36.6% (n=154). MA women reported less incontinence than did EAs (29% versus 45%, p=0.001). In multivariable analyses in MA women, urinary incontinence correlated with the presence of fecal incontinence (OR 4.0, 95% CI 1.1-14.0) and more dependency in activities of daily living (1.4, 1.1-1.8) after controlling for significant sociodemographic factors. In EA women, only age >75 (4.2, 1.4-12.4) was associated with urinary incontinence. MA women were less likely to report incontinence compared to EAs, despite MAs having increased number of children, less education, higher BMI, and more diabetes. Further research is needed to evaluate risk factors for urinary incontinence among MA women.
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PMID:Urinary incontinence in community-dwelling older Mexican American and European American women. 1831 55

Microscopic colitis, comprising collagenous colitis and lymphocytic colitis, is characterised clinically by chronic watery diarrhoea, a macroscopically normal colonic mucosa where diagnostic histopathological features are seen on microscopic examination. The annual incidence of each disorder is 4-6/100,000 inhabitants, with a peak incidence in 60-70 year old individuals and a noticeable female predominance in collagenous colitis. The aetiology is unknown. Abdominal pain, weight loss, fatigue, and faecal incontinence are common symptoms in addition to chronic diarrhoea that impair the health-related quality of life of the patient. There is an association to other autoimmune disorders such as celiac disease, diabetes mellitus, thyroid disorders and arthritis. Budesonide is the best-documented short-term treatment, but the optimal long-term strategy needs further study. The long-term prognosis is good and the risk of complications including colonic cancer is low.
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PMID:Microscopic colitis: a common and an easily overlooked cause of chronic diarrhoea. 1839 61


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