Disorders of automatic (or autonomic) nerves often go unrecognized even though they may have a profound effect on the patient's quality of life and even survival.
As you're reading this page, many movements are going on in your body, but you're unaware of them. Your heart muscle is squeezing down and relaxing. Your diaphragm is rising up to empty the lungs of air and then relaxing to draw air in. Your esophagus is carrying saliva (or food, if you're a multitasker who's eating and reading) from your mouth to your stomach, and in turn, your stomach pushes it into the small intestine, which pushes it into the large intestine.
All these muscle functions are under the control of nerves from the brain, and diabetic neuropathy can affect them all. The nerves that perform these functions are called autonomic nerves. As many as 40 percent of people with T1DM have some form of autonomic neuropathy.
The clinical presentation of this type of neuropathy depends upon the involved nerve. Some possibilities include:
^ Bladder abnormalities starting with a loss of the sensation of bladder fullness. The urine isn't eliminated, and urinary tract infections result. After a while, loss of bladder contraction occurs, and the patient has to strain to urinate and loses urine by dribbling. The diagnosis is made by determining how much urine is left in the bladder after urination has taken place. It's treated by remembering to urinate every four hours or by taking a drug to increase the force of bladder contraction.
^ Sexual dysfunction, which occurs in as many as 60 percent of males and 30 percent of females with diabetes. Males can't sustain an erection, and females have trouble lubricating the vagina for intercourse. The drugs Viagra, Cialis, or Levitra are helpful for males with sexual dysfunction. For females, use of lubricating fluids may be helpful.
^ Intestinal abnormalities of various kinds. The most common abnormality is constipation. In 25 percent of patients with autonomic neuropathy, nerves to the stomach are involved, so the stomach doesn't empty on time in a condition called gastroparesis. The precise timing of injected insulin and food intake (see Chapter 10 for the basics of using insulin) is thrown off; hypoglycemia occurs as the insulin finds no food, and hyper-glycemia occurs later as the food finds no insulin (see Chapter 4 for more about these conditions). Several drugs are helpful in treating intestinal abnormalities from autonomic nerve disorders, including metocloprim-ide and erythromycin. Some changes in eating habits are also helpful, including lowering fat intake and eating up to six small meals daily.
^ Gallbladder involvement leading to gallstones. Normally the gallbladder empties each time you eat, especially if you eat a fatty meal, because the substances in the bile (which is in the gallbladder) help to break down fat. If disease to the nerve to the gallbladder prevents emptying, gallstones form, often requiring surgical removal of the gallbladder.
^ Large intestinal involvement resulting in diabetic diarrhea and up to ten or more bowel movements per day. Accidental loss of bowel contents can also occur. Autonomic neuropathy may cause bacteria to grow abnormally in the intestine. The problem may respond to antibiotics, and diarrhea is treated with one of several drugs that quiet the large intestine.
^ Heart abnormalities. If loss of nerves to the heart occurs, the heart may not respond to exercise by speeding up as it should. The pressure from the heart may not increase as the patient stands and he may become lightheaded. A very fast fixed heart rate also may occur, and patients experiencing this are at risk for sudden death. Autonomic neuropathy can also cause decreased perception of heart pain. Several drugs are available that may help.
^ Sweating problems, especially in the feet. The body may try to compensate for the lack of sweating in the feet by sweating excessively on the face or trunk. Heavy sweating can occur when certain foods like cheese are eaten. There's no particular treatment other than avoidance of foods that set it off.
^ Abnormalities of the pupil of the eye. Neuropathy may prevent the pupil from opening to let more light in when necessary. Reduced vision in low light means that the patient has to be much more careful about driving at night. There's no treatment other than better glucose control.
This long list can be a bit scary, but none of it need ever happen if you control your blood glucose.
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