Group Therapy: Treating Diabetes and Urologic Complications

Patients with diabetes often present with urologic issues as well, which emphasizes the need for a team approach to treatment. Endocrine News spoke with urologists and an endocrinologist who all stressed the importance of working together to increase a patient’s health as well as quality of life.

Diabetes rates continue to climb as the endocrinology workforce continues to shrink. As it stands, 9.3% of the U.S. population has diabetes, and according to a study published in The Journal of Clinical Endocrinology and Metabolism, there were 4,841 practicing adult endocrinologists in the U.S. in 2011, meaning each endocrinologist would have to see about 6,000 patients. Endocrinologists have less and less quality time to spend with their patients, frustrating everyone involved.

Ask any endocrinologist, and they’ll tell you: To properly care for a patient with diabetes, it takes a team. Diabetes can set off a number of vicious cycles, even in just one patient. Here, we’ll narrow it down and look at a few of those cycles as they pertain to how diabetes affects urologic function, and how it ultimately takes the combined efforts of the primary care physicians, endocrinologists, urologists, and therapists to improve the overall health of patients with diabetes who suffer from urologic complications.

“There are some major urologic manifestations or urologic complications that are the result of diabetes, that we as urologists typically see,” says Charles Modlin, MD, MBA, a urologist with Cleveland Clinic. “Bladder dysfunction is a big one, both in men and women.”

Quality of Life Impact

Bladder dysfunction itself is a huge detriment to quality of life, which can rob patients of enjoying even the simplest everyday activities. But for patients with diabetes who suffer from bladder dysfunction, the frequency and incontinence can also be a huge detriment to their treatment. These patients may feel depressed and isolated, so they’ll be less likely to exercise, which worsens their diabetes, which worsens their urinary problems. “Urinary issues can meaningfully affect quality of life – leading to changed behavior, withdrawal from social situations, reduced flexibility in travel, increased isolation, shame, stress, and depression,” says Graham McMahon, MD, MMSc, an endocrinologist in Chicago and professor of medicine at Northwestern University.

“I have seen patients dealing with the effects of [diabetes] and the issues of frequent urination / leakage of urine,” says Kevin Ostrowski, MD, a urologist in Seattle and assistant professor of medicine at the University of Washington. “This can lead to issues with self-esteem, feelings of depression, and issues associated with recurrent urinary tract infections. This has significant personal and psychological impact on patients and their family.”

Diabetes already increases the incidence of infection in general, and it doesn’t spare the urinary tract. People with diabetes have higher rates of urinary tract infections, related to several factors including the predisposition to urinary retention associated with autonomic neuropathy. “Issues such as candidiasis are more commonly associated with diabetes than urinary tract infections,” McMahon says, “but urinary tract infections are also more common in patients with diabetes than those without.”

A Vicious Cycle

Modlin here points to another vicious cycle. Physicians treat urinary tract infections with antibiotics, which can often lead to yeast infections and even more difficult to treat antibiotic resistant urinary tract infections. Modlin also says that these urinary tract infections can escalate into pyelonephritis, which can then potentiate chronic kidney disease and lead to a need for kidney transplantation. In addition, people with diabetes are at a greater risk of developing urinary retention, which can put a lot of pressure and stress on the kidneys also contributing to kidney failure and the need for a kidney transplant.

“Urinary issues can meaningfully affect quality of life – leading to changed behavior, withdrawal from social situations, reduced flexibility in travel, increased isolation, shame, stress, and depression.” – Graham McMahon, MD, MMSc, professor of medicine, Northwestern University, Chicago, Ill.

People with diabetes are already at a higher risk for fractures. And urinary frequency or incontinence can lead to an increased risk of falls and fractures, since patients have to get out of bed at night to urinate. McMahon says, “movement in the dark increases the risk for stumbles, falls, and even fractures.”

Ostrowski adds that patients with diabetic neuropathy and urinary issues are at an increased risk of falling, since the loss of sensation or pain in their feet combined with having to get up to use the bathroom leads to higher incidence of falling.

“All of these urological complications of diabetes can negatively impact a person’s quality of life,” Modlin says. “Recurrent urinary tract infections and bladder dysfunction with the associated pain, discomfort, urinary frequency, incontinence, getting up at night a lot to urinate can understandably negatively and dramatically impact your normal everyday functioning, to where you may not want to go out and be in a public place or even be able to go to work.”

And again, a very diminished quality of life can lead to depression and other mood disorders. But sometimes the medications prescribed to treat these psychological problems can lead to bladder dysfunction.

Taking a Toll

Of course, none of this is exactly news to experts who deal with these patients. But these examples, these vicious cycles, do speak to the incredible toll diabetes takes on a person and the ever-increasing need of multidisciplinary approaches in order to optimize these patients’ health.

“And if someone does have a very negatively impacted quality of life, we need to refer them to behavioral therapist to assist in their care, which can be very valuable for the overall health of the patient.” – Charles Modlin, MD, MBA, urologist, Cleveland Clinic, Cleveland, Ohio

The adage is correct, especially here: It takes a village. Primary care physicians and urologists should consider whether a patient with urinary dysfunction might have these problems because they have undiagnosed diabetes. After all, there are some 8 million people in the U.S. who have diabetes and don’t know it. A man who suffers from frequent or urgent urination might have an enlarged prostate or the urination problems could be a result of diabetes. Sometimes it’s a combination of both. “Sometimes it may behoove the urologist to order a hemoglobin A1C test or just a serum glucose level,” Modlin says. “We can also do a urine dip and check for presence of glucose in the urine. There are certain things that we can do. I think it’s important for all healthcare providers to be on the lookout.”

Patients are often hesitant to open up about these problems. Diabetes not only affects urinary function, but sexual function as well, for men and women. Men may suffer from erectile dysfunction and women may suffer from painful intercourse. Difficult topics to broach, to be sure, so it’s on the clinician to ask about these things. “Ask about urinary issues and sexual health, normalize the conversation, and encourage ongoing dialog,” McMahon says. “Ask about how any genitourinary issues might be affecting behavior, including asking about nocturia, socializing, and support from others. Ask the patient if they have talked about their issues with their partner, family, or friends.”

“I think as healthcare providers a lot of the time we forget also that physical manifestations of diseases such as diabetes can often contribute to the onset of mental health disorders, such as stress, anxiety and depression.” Modlin says. “And if someone does have a very negatively impacted quality of life, we need to refer them to behavioral therapist to assist in their care, which can be very valuable for the overall health of the patient. We all, patients, physicians and health providers, need to be aware of the fact that in cases especially related to taking care of patients with diabetes, it does take a team approach, including having endocrinologists, primary care providers, urologists, and mental health professionals and other specialists and family members  all working in concert together.”

— Bagley is the senior editor of Endocrine News. He wrote about fatty acids in the October issue.