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CME / CE

Type 1 Diabetes and Urologic Disease: Coexisting Complications?

  • Authors: News Author: Miriam E. Tucker; CME Author: Laurie Barclay, MD
  • CME / CE Released: 10/12/2018
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 10/12/2019
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Target Audience and Goal Statement

This article is intended for diabetologists/endocrinologists, family medicine/primary care practitioners, internists, nurses, pharmacists, nephrologists, family medicine practitioners, obstetricians/gynecologists/women's health practitioners, urologists, and other members of the healthcare team who treat and manage patients with type 1 diabetes.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • Determine the prevalence of urological complications in persons with type 1 diabetes, associations with clinical and diabetes-related factors, and rates of emergence, persistence, and remission, based on Urologic EDIC, an ancillary longitudinal study among participants in the Diabetes Control and Complications Trial
  • Assess clinical implications of findings from Urologic EDIC regarding urological complications in persons with type 1 diabetes


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Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


News Author

  • Miriam E. Tucker

    Freelance writer, Medscape

    Disclosures

    Disclosure: Miriam E. Tucker has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed the following relevant financial relationships:
    Owns stock, stock options, or bonds from: Pfizer

Editor / CME Reviewer

  • Esther Nyarko, PharmD

    Associate CME Clinical Director, Medscape, LLC

    Disclosures

    Disclosure: Esther Nyarko, PharmD, has disclosed no relevant financial relationships.

Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC, CHCP

    Lead Nurse Planner, Medscape, LLC

    Disclosures

    Disclosure: Amy Bernard, MS, BSN, RN-BC, CHCP, has disclosed no relevant financial relationships.


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CME / CE

Type 1 Diabetes and Urologic Disease: Coexisting Complications?

Authors: News Author: Miriam E. Tucker; CME Author: Laurie Barclay, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME / CE Released: 10/12/2018

Valid for credit through: 10/12/2019

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Clinical Context

Persons with type 1 diabetes are known to have high rates of associated urinary and sexual conditions, such as sexual dysfunction, urinary tract infection (UTI), poor bladder emptying, urinary incontinence (UI), and other lower urinary tract symptoms (LUTS) that often result in care seeking and reduce quality of life. However, the cumulative burden and overlap of these complications have not previously been determined.

Urologic EDIC (UroEDIC) was an ancillary longitudinal study among participants in the Diabetes Control and Complications Trial (DCCT) and observational follow-up study Epidemiology of Diabetes Interventions and Complications (EDIC). The goals of UroEDIC were to examine prevalence of urological complications in persons with type 1 diabetes, associations with clinical and diabetes-related factors, and rates of emergence, persistence, and remission. These data could inform healthcare providers, patients, and families about traditionally embarrassing urological health problems and could facilitate development of risk factor models for specific urologic complications among persons with type 1 diabetes.

Study Synopsis and Perspective

Urologic complications are present in about two thirds of adults with long-duration type 1 diabetes, new research suggests.

The findings, from an ancillary study to the EDIC study, the observational follow-up to the landmark DCCT, were published online August 13 in Diabetes Care.

"Urological complications are prevalent and frequently coexist in men and women with type 1 diabetes," write Hunter B. Wessells, MD, from the Department of Urology and Diabetes Research Center, University of Washington, Seattle, and colleagues. "[A]s improvements in diabetes management reduce the severity of retinopathy, nephropathy, and neuropathy, urological complications may become important drivers of quality of life."

The DCCT, which proved the benefits of tight glycemic control in reducing microvascular complications in type 1 diabetes, ended early in 1993 after a mean follow-up of 6.5 years. In 1994, 96% of the original 1441 participants transitioned into EDIC, at which point they had a mean age of 33.6 years and mean diabetes duration of 12.2 years.

All were invited to participate in the ancillary UroEDIC study, which involved a series of well-validated self-administered urologic symptom questionnaires. A total of 508 women and 551 men completed the surveys at 2 points: UroEDIC I in 2003 and UroEDIC II in 2010 to 2011.

Overall, 65% of women and 68% of men reported at least 1 urologic complication at UroEDIC II. Among the women, 22% reported lower urinary tract symptoms, 42% sexual dysfunction, 31% urinary incontinence, and 17% urinary tract infection.

Among the men, 24% reported lower urinary tract symptoms, 45% erectile dysfunction, 40% low sexual desire, and 14% orgasmic dysfunction.

Among sexually active women, 35% reported no urologic complications, 39% had 1, and 26% had 2 or more other complications. Lower urinary tract symptoms commonly co-occurred with other urologic complications, whereas female sexual dysfunction occurred more often in isolation.

In the men, 31% reported no urologic complications, 36% had 1, and 33% had 2 or more. Here, lower urinary tract symptoms occurred more commonly in isolation, whereas erectile dysfunction, low sexual desire, and orgasmic dysfunction tended to co-occur.

Higher hemoglobin A1c levels were associated with increased risk for urologic complications in both women and men. For women, the risk for lower urinary tract symptoms among those in the highest hemoglobin A1c quartile (>8.54%) was more than twice as high as among those in the lowest quartile (≤7.38%). For the men, those in higher HbA1c quartiles had higher odds for both erectile dysfunction and orgasmic dysfunction.

A body mass index of 30 kg/m2 or higher was associated with a greater risk for urinary incontinence in women, but not with urologic complications among the men. Diabetic neuropathic and microvascular complications were also associated with urologic complications in both men and women.

The EDIC studies are funded by the National Institutes of Health. The authors have disclosed no relevant financial relationships.

Diabetes Care. Published online August 13, 2018.[1]

Study Highlights

  • The DCCT ended early in 1993 after mean follow-up of 6.5 years, and in 1994, 96% of the original 1441 participants (mean age, 33.6 years; mean diabetes duration, 12.2 years) continued into EDIC.
  • In UroEDIC I, 652 women and 713 men completed validated, self-administered urologic symptom questionnaires in 2003.
  • Of these, 508 women and 551 men completed UroEDIC II in 2010 to 2011.
  • Reported symptoms included UI, LUTS, UTI, female sexual dysfunction, erectile dysfunction, low male sexual desire, and orgasmic dysfunction.
  • The association of complications with demographics and clinical factors was examined with logistic regression.
  • Among sexually active women completing the 2010/2011 survey, the number of complications was none in 35%, 1 in 39%, 2 in 19%, 3 in 5%, and 4 in 2%.
  • Female sexual dysfunction was strongly associated with age, but not with glycemic control or diabetes complications, and it occurred as a single complication more often than did the other urological complications.
  • Among men, the number of complications was none in 31%, 1 in 36%, 2 in 22%, 3 in 9%, and 4 in 3%.
  • Among men, erectile dysfunction was the most common complication and was associated with age, poorer diabetes control, and other diabetes complications including autonomic neuropathy.
  • The most prevalent complications were sexual dysfunction, reported by 42% of women and 45% of men, followed by UI occurring weekly or more often in women (31%) and low sexual desire in men (40%).
  • Factors associated with urological complications were age, body mass index, and HbA1c.
  • During the 7-year interval between surveys, remission rates ranged from 4% to 12%.
  • On the basis of their findings, the investigators concluded that urological complications are prevalent and often coexist in men and women with type 1 diabetes.
  • Although most participants had persistence of urological complications during a 7-year period, remission in a small percentage of patients suggests the need for future studies to investigate mechanisms of symptom improvement.
  • Understanding these mechanisms could potentially help delay the onset or reduce the effect of urological complications of diabetes.
  • Metabolic effects of diabetes on genitourinary tissues and the neural, vascular, and hormonal input to these organs results in diabetes-associated urological morbidity, affecting more than 65% of middle-aged participants with type 1 diabetes enrolled in UroEDIC.
  • Prevalence of urological conditions is considerably lower in population-based surveys.
  • The urological complications observed in UroEDIC co-occurred significantly more than would be expected if these were independent complications
  • This overlap of symptom complexes may reflect common underlying mechanisms, conditioning of responses across complications, and/or other factors.
  • Sexual and urinary dysfunctions, whether occurring alone or in combination, markedly affect quality of life, health perception, and depression, similar in magnitude to the effect of hypertension or diabetes itself.
  • As advances in diabetes management lower the severity of retinopathy, nephropathy, and neuropathy, urological complications may become important drivers of quality of life.
  • The independence of female sexual dysfunction and of low sexual desire in men from glycemic control, diabetes complications, or other urological complications supports a separate etiological mechanism from UI, LUTS, and UTI, such as depression, that is independent of metabolic, neural, and vascular mechanisms.
  • Low desire also had the highest rate of remission, again suggesting a distinct mechanism from other urological complications.
  • Women with autonomic neuropathy were more likely to have UTI, which could reflect poor bladder emptying caused by diabetic cystopathy.
  • As 40% of women reporting UTI also reported either UI or LUTS, there may be overlap in mechanisms underlying these complications.
  • Retrograde ejaculation and anejaculation overlapped closely with erectile dysfunction and may reflect impaired autonomic innervation of the bladder neck or ejaculatory system.
  • LUTS in men with diabetes may partly result from benign prostatic hyperplasia and other related comorbidities.
  • An important future goal for UroEDIC is to identify factors that predict improvement in urological complications in men and women with type 1 diabetes.
  • Future studies should also examine whether the magnitudes of change are associated with increased symptom effect on quality of life.
  • Study limitations include inability to capture partial remission of urological conditions, reliance on questionnaires to define subjective complications, missing data because of nonparticipation, use of nonvalidated UTI questions, lack of generalizability to other populations, and inability to determine the effect of treatment for these complications on persistence and emergence.

Clinical Implications

  • Urological complications are prevalent and often coexist in men and women with type 1 diabetes, based on the UroEDIC ancillary longitudinal study.
  • Remission in a small percentage of patients suggests the need for future studies to investigate mechanisms of symptom improvement.
  • Implications for the Healthcare Team: As management advances enable persons with diabetes to live longer and to avoid other diabetes-related complications, urological complications may represent a more significant burden and have a greater effect on quality of life, mandating increased efforts to reduce these symptoms.

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