In the patient who presents with urinary incontinence (UI), it is always important to find out what co-morbidities are present in her history. When a patient who has UI is dealing with diabetes, the pelvic rehabilitation provider needs to ask several questions related to the management of diabetes. Some of the questions that I have found to be useful include: "Are your blood sugars well-managed at this time?", and, "If your blood sugars are unstable, what symptoms should I look for?" The second question allows me to be alert to changes in patient behavior that might mean a blood sugar level should be tested or a quick-acting sugar might need to be consumed by the patient. Some patients have very obvious reactions to changes in blood sugar levels and some patients have very subtle reactions. A therapist can also inquire how often the patient tests her blood sugar levels and if she brought a testing kit to the clinic. A "diabetic kit" should be available in every clinic setting so that a patient can have immediate access to readily available sugar such as candy, glucose tablets, or soda.
Urinary incontinence has been found to co-exist at higher levels in patients with diabetes (Type 1 or Type 2) than in patients who do not have diabetes. The reference that discusses this issue also states that physicians need to be aware of and ask questions about incontinence in the patients who have diabetes because patients tend to not bring it up independently. Denise Elser, MD, reports in this article on the National Association for Continence (NAFC) website that over 50% of men and women with diabetes also suffer from UI. She describes issues that occur within the scope of diabetes that can cause incontinence for patients. For example, if blood sugars are not managed well, sugars can get into the urine (glycosuria) and irritate the bladder, creating urinary urgency, frequency, and incontinence. These symptoms can be mistaken for a urinary tract infection, leaving the patient to over-treat with repeat antibiotics.
Dr. Elser also points out that patients who have diabetes are more prone to urinary tract infections, often with chronic bacteria in the bladder that irritates the tissues and creates symptoms of overactive bladder (OAB). The neurologic dysfunction that accompanies diabetes can lead to impaired ability of the bladder to empty well, creating opportunities for urinary leakage as well as urinary tract infection due to poor emptying. Lastly, fluid retention can create urinary issues for the patient who has diabetes, as heart conditions may co-exist. When a patient lies supine, the extra fluid volume in the lower extremities can now more easily be moved through the patient's system to be voided out, usually leading to night time voiding frequency. This can interrupt a patient's sleep, and more alarmingly, create unsafe situations because the tired patient (who may have vision loss due to diabetes) is now frequently walking in darkened surroundings, leading to increased fall risk.
One home program strategy that is taught in the Institute's Level 1 course is to ask the patient to elevate the lower extremities and do ankle pumping towards evening but prior to bedtime so that fluids are encouraged to move out of the legs. This might increase voiding prior to bedtime, but it may allow the patient to have less interruption to her sleep hours. Many patients with increased swelling in the limbs are also taking diuretics, and if taken in the evening, may lead to frequency of voiding at night. The pelvic rehab therapist can encourage the patient to talk to her prescribing medical provider (or the therapist can contact the provider directly) to discuss the option of having the diuretic dose or timing reviewed. Many patients have been taking the same dose for years and, once reviewed by an appropriate medical provider, may be adjusted with improved outcomes for the patient.
When all of these puzzle pieces are put together, it is clear that our patients who have urinary incontinence as well as diabetes may require a very thorough history-taking and an equally comprehensive treatment strategy. If your patient is not managing blood sugars well, it is important to explain the above issues and encourage the patient to be more adherent to her diabetic home management program, or to return to her medical provider for further counseling and required care. The National Institute of Diabetes, Digestive, and Kidney Diseases (NIDDK) can be a wonderful resource for patients as well as pelvic rehabilitation providers.