Unrecognized Voiding Difficulty in Female Type 2 Diabetic Patients in the Diabetes Clinic: A prospective case-control study
HONG-JENG YU
1
WEI-CHIA LEE
1
SHIH-PING LIU
1
TONG-YUAG TAI
0
HUEY-PEIR WU
0
JUN CHEN
1
0
Department of Internal Medicine, College of Medicine, National Taiwan University
, Taipei,
Taiwan
. Taiwan University Hospital
, 7 Chungshan South Rd., Taipei,
Taiwan
, 100
1
Department of Urology, College of Medicine, National Taiwan University
, Taipei,
Taiwan
; and the
P diabetic cystopathy, which is charatients with diabetes may develop acterized mainly by impaired detrusor sensation and contractility (1,2). Impaired detrusor contractility may lead to incomplete bladder emptying and subsequently result in voiding difficulty, urinary retention, chronic urinary tract infection (UTI), and upper urinary tract damage (1,3,4). Although diabetic cystopathy is common, with a reported prevalence ranging from 25 to 87% (1), it is frequently not recognized by patients and physicians due to its insidious development and inconspicuous symptoms. Usually, genitourinary dysfunction in diabetic patients has reached an advanced stage by the time urologists are consulted. The present study was designed to investigate the prevalence of voiding difficulty in female patients regularly treated in the diabetes outpatient clinic.
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RESEARCH DESIGN AND
METHODS From July 2001 to June
2003, we conducted a prospective study
to compare voiding function between 176
female type 2 diabetic patients and 162
age-matched nondiabetic women.
Diabetic patients were regularly treated in the
diabetes outpatient clinic for 1 year,
and nondiabetic women were mostly
hospital employees or family members of
admitted patients in the urological ward,
none of whom had ever sought treatment
for voiding dysfunction. Those with
coexisting medical factors that could affect
voiding function were excluded. Clinical
parameters used to evaluate diabetic
patients were collected in detail for data
analysis. The study protocol was
approved by the institutional review board
of the National Taiwan University
Hospital.
Each patient received a questionnaire
interview regarding urinary symptoms,
uroflow analysis, and postvoid residual
urine (PVR) estimate. We used the
American Urological Association Symptom
Index questionnaire (5) to evaluate the
prevalence of urinary symptoms (Table
1). Uroflow analysis was performed using
a rotating disc flow meter (Dantec,
Skovlunde, Denmark), and the PVR was
measured by urethral catheterization
immediately after voiding. Essential
requirements included a minimum voided
volume of 150 ml and the patients
confirmation of voiding taking place with the
usual force. Voiding difficulty was
defined as a maximal flow rate (Qmax) of
12 ml/s or a PVR of 100 ml on two or
more determinations (3,4,6). The same
protocol was used in the control subjects
with one exceptionthe PVR was
estimated by abdominal ultrasound
(JustVision 200 System; Toshiba, Tochigi,
Japan) with a 3.75-MHz PVG-366M
transducer. The bladder height (H),
width (W), and depth (D) were measured,
and PVR was calculated using the
following formula: PVR 0.625 (H W
D) (7). Due to ethical concerns, urethral
catheterization was only performed in
those with a PVR of 50 ml (n 8) on
ultrasound estimation.
For statistical analysis, mean values of
continuous variables were compared
using an independent sample t test.
Univariate 2 analyses were performed to
compare the differences between
categorized clinical factors. Multivariate logistic
regression analysis was then performed to
determine whether the significant factors
found in the univariate analysis were
independently associated with voiding
difficulty.
RESULTS The average patient age
was 62 years (range 40 85), the mean
duration of diabetes was 11 years (range
136), and the mean HbA1c value was
7.8% (range 5.312.4). Retinopathy was
the most frequent complication (46.0%).
Diabetes was mainly controlled by oral
hypoglycemic agents (84.1%).
Comparison of urinary symptoms and uroflow
results between the control and diabetic
groups is shown in Table 1. Diabetic
women reported a significantly higher
prevalence of nocturia. Voiding difficulty
was detected in 22.2% of the diabetic
patients versus 5.6% of the control subjects
(odds ratio [OR] 4.8, 95% CI 2.310.4).
In the diabetic group, patients with
voiding difficulty reported a higher
prevalence of weak urinary stream,
intermittency, and hesitancy than those without
voiding difficulty (data not shown). Of
the clinical parameters examined, 2
analysis showed that age, duration of diabetes
of 20 years, the presence of peripheral
neuropathy, and two or more episodes of
UTI in the preceding year were
significantly associated with higher odds for
voiding difficulty. After controlling for
age, only duration of diabetes 20 years
(OR 3.2 versus duration 10 years, 95%
CI 1.37.8) and two or more episodes of
Data are n (%) or means SD, unless noted otherwise. *Comparison of variables between control and
patient groups was made by an independent sample t t (...truncated)