How do you treat the patient

For mild cases, no specific therapy is needed. Advice to avoid sudden changes of body position and gradual erection from supine position are usually sufficient measures for avoiding symptoms. For symptomatic postural hypotension, application of elastic stockings on the lower extremities during the day, mild regular physical activity and raising of the head of the bed by 25-30 degrees are advised. The last measure is necessary to restrict the increase of blood pressure seen in these persons when lying down. When fainting spells are present, manoeuvres that transiently increase blood pressure are recommended, such as bending forward or squatting. Increased intake of NaCl to 4-6g/day is also recommended, unless contraindications exist. If these measures are not enough, fludrocortisone is administered at a dose of 0.1-0.3 mg/day. Patients with orthostatic hypotension and a decreased erythrocyte mass benefit from small doses of erythropoietin administration (50IU/kg of body weight) three times a week. Dihydroergotamine, metoclopramide and octreotide have also been used for the treatment of orthostatic hypotension with fairly good results.

CASE STUDY 5

A 45 year old patient with Type 1 DM since the age of 13 reports urinary incontinence and a feeling of incomplete bladder emptying after urination. He also reports that he no longer has the same urge to urinate as in the past. These symptoms first occurred two years ago, and although mild in the beginning, they gradually deteriorated thereafter. What is the diagnosis?

The patient is suffering from neurogenic bladder due to damage of autonomous system nerves from DM. Bladder involvement is not rare in DM and is associated with duration of the disease. In practice, there is no bladder dysfunction in DM of less than 10 years' duration. Its main feature is the asymptomatic gradual onset and progression. In advanced stages, damage of the centripetal sensory fibres of the bladder wall causes a decrease in urination urge. Thus, bladder capacity gradually increases and the detrussor muscle atrophies (neurogenic bladder). The patient may manifest overflow incontinence and urinate once or twice a day. Other clinical symptoms include decrease of the urinary flow rate, a feeling of incomplete emptying of the bladder and need to press the hypogastric area for initiation and continuance of urination.

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