Unrecognized Voiding Difficulty in Female Type 2 Diabetic Patients in the Diabetes Clinic: A prospective case-control study

Diabetes Care, Apr 2004

Hong-Jeng Yu, Wei-Chia Lee, Shih-Ping Liu, Tong-Yuag Tai, Huey-Peir Wu, Jun Chen

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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. - 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)


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Hong-Jeng Yu, Wei-Chia Lee, Shih-Ping Liu, Tong-Yuag Tai, Huey-Peir Wu, Jun Chen. Unrecognized Voiding Difficulty in Female Type 2 Diabetic Patients in the Diabetes Clinic: A prospective case-control study, Diabetes Care, 2004, pp. 988-989, 27/4, DOI: 10.2337/diacare.27.4.988