Faecal incontinence in diabetes mellitus: is it correlated to diabetic autonomic or peripheral neuropathy?

Faecal incontinence is a frequent manifestation of diabetic enteropathy. The purpose of this study was to determine whether faecal incontinence in diabetes mellitus correlates with manifestations of diabetic autonomic or peripheral neuropathy at other organ sites. In 12 incontinent and 15 continent diabetics stool frequency and stool continence, basal and squeeze anal sphincter pressures, and continence to rectally infused isotonic saline solution (1500 ml) were prospectively evaluated. These data were correlated to quantitative measures of autonomic neuropathy as assessed by heart rate variation and pupillary reflex response to light, and to quantitative measures of peripheral neuropathy as assessed by nerve conduction velocity and sensitivity to vibration. Incontinent diabetics exhibited decreased basal and squeeze anal sphincter pressures, and reduced continence for fluid compared to their continent controls. The degree of incontinence correlated well with the maximal volume of retained rectally infused saline solution, but neither with basal and squeeze anal sphincter pressures, nor with the severity of autonomic or peripheral neuropathy at other organ sites. It is concluded that a generalized dysfunction of the autonomic or peripheral nervous system does not play a major role in the pathogenesis of faecal incontinence in diabetes mellitus. The great overlap of basal and squeeze anal sphincter pressures in incontinent and continent diabetics raise evidence for disturbances of additional extrasphincteric factors as part of the pathomechanism of faecal incontinence in diabetes mellitus.     

Vertebral hyperostosis and diabetes mellitus: a case-control study.

OBJECTIVE--To compare glucose metabolism in patients with vertebral hyperostosis (VH), with that in control patients. METHODS--We studied 50 patients aged 60 years or more who had VH according to Resnick's criteria, and 50 control patients without VH, matched for sex, age, weight and height. Plasma glucose was evaluated before and 120 minutes after ingestion of 75 g glucose. World Health Organisation criteria for diabetes mellitus (DM) were used. Radiographs of the pelvis and thoracic and lumbar spine were performed and read blind by two physicians. RESULTS--Statistical analysis showed no difference between cases and control patients for prevalence of DM, and plasma glucose at 0 and 120 minutes. CONCLUSION--These data suggest that glucoregulation in patients with VH does not differ from that in matched controls.     

The prevalence of anal sphincter defects in faecal incontinence: a prospective endosonic study.

Forty six patients (median age 61 years; 42 women) with faecal incontinence and 16 age and sex matched controls undergoing a restorative proctocolectomy were assessed by clinical examination, anorectal physiology, and anal endosonography. Forty patients (87%) with faecal incontinence had a sphincter defect demonstrated on anal endosonography (31 external and 21 internal anal sphincter defects). The commonest cause of faecal incontinence was obstetric trauma. This occurred in 35 women, 30 of whom exhibited a morphological defect in the anorectal sphincter complex. In 22 of these patients with a history of a perineal tear or episiotomy, 21 (95%) had a sphincter defect. Sphincter defects were commonly located at the level of the midanal canal.     

Relation between perineal descent and pudendal nerve damage in idiopathic faecal incontinence

In 60 patients with idiopathic anorectal incontinence, without neurological disease, there was a significant relationship, shown by regression analysis, between the pudendal nerve terminal motor latency and the extent of perineal descent during straining (r0.59;p<0.001), and the plane of the perineum on straining (r–0.61;p<0.001). These data are consistent with the suggestion that perineal descent can lead to stretch-induced damage to the perineal nerves in this condition.     

The artificial bowel sphincter for faecal incontinence: a single centre study

Background and aims Faecal incontinence (FI) is a socially devastating problem. The treatment algorithm depends on the aetiology of the problem. Large anal sphincter defects can be treated by sphincter replacement procedures: the dynamic graciloplasty and the artificial bowel sphincter (ABS). Materials and methods Patients were included between 1997 and 2006. A full preoperative workup was mandatory for all patients. During the follow-up, the Williams incontinence score was used to classify the symptoms, and anal manometry was performed. Results Thirty-four patients (25 women) were included, of which, 33 patients received an ABS. The mean follow-up was 17.4 (0.8–106.3) months. The Williams score improved significantly after placement of the ABS (p < 0.0001). The postoperative anal resting pressure with an empty cuff was not altered (p = 0.89). The postoperative ABS pressure was significantly higher then the baseline squeeze pressure (p = 0.003). Seven patients had an infection necessitating explantation. One patient was successfully reimplanted. Conclusion The artificial bowel sphincter is an effective treatment for FI in patients with a large anal sphincter defect. Infectious complications are the largest threat necessitating explantation of the device.     

Cardiac autonomic neuropathy in patients with type 2 diabetes mellitus having peripheral neuropathy: A cross-sectional study

AimsThe aim was to see the frequency of CAN in type 2 diabetes mellitus patients with peripheral neuropathy, and its association with peripheral nerve conduction abnormalities.MethodsA cross-sectional study at BIRDEM was conducted in 62 patients with type 2 diabetes mellitus having electrophysiologically diagnosed peripheral neuropathy. CAN was detected by four clinical tests - heart rate response to deep breathing and valsalva maneuver, blood pressure response to standing and sustained handgrip.ResultThe study showed that all patients had CAN – 14.52% had early, 26.67% had definitive and 59.68% had severe CAN. Patients with severe CAN had significantly reduced nerve conduction velocity and amplitude of peripheral nerves (sural 4.36 ± 12.77 vs 9.65 ± 17.77 m/s, p = 0.009; 2.23 ± 1.89 vs 3.01 ± 2.76 mV, p = 0.001; peroneal 7 ± 4.23 vs 8.53 ± 5.99 mV, p = 0.047; tibial 0.008 ± 0.03 vs 0.026 ± 0.05 mV, p = 0.009) and higher serum triglyceride levels (221.17 ± 120.61 vs 197.76 ± 68.43 mg/dl, p = 0.033).ConclusionDiabetic patients with peripheral neuropathy have CAN, the severity of which increases with worsening neuropathy.     

Relationship between symptoms and disordered continence mechanisms in women with idiopathic faecal incontinence

BACKGROUND AND AIMS: Anal sphincter weakness and rectal sensory disturbances contribute to faecal incontinence (FI). Our aims were to investigate the relationship between symptoms, risk factors, and disordered anorectal and pelvic floor functions in FI. METHODS: In 52 women with "idiopathic" FI and 21 age matched asymptomatic women, we assessed symptoms by standardised questionnaire, anal pressures by manometry, anal sphincter appearance by endoanal ultrasound and magnetic resonance imaging (MRI), pelvic floor motion by dynamic MRI, and rectal compliance and sensation by a barostat. RESULTS: The prevalence of anal sphincter injury (by imaging), reduced anal resting pressure (35% of FI), and reduced squeeze pressures (73% of FI) was higher in FI compared with controls. Puborectalis atrophy (by MRI) was associated (p<0.05) with FI and with impaired anorectal motion during pelvic floor contraction. Volume and pressure thresholds for the desire to defecate were lower, indicating rectal hypersensitivity, in FI. The rectal volume at maximum tolerated pressure (that is, rectal capacity) was reduced in 25% of FI; this volume was associated with the symptom of urge FI (p<0.01) and rectal hypersensitivity (p = 0.02). A combination of predictors (age, body mass index, symptoms, obstetric history, and anal sphincter appearance) explained a substantial proportion of the interindividual variation in anal squeeze pressure (45%) and rectal capacity (35%). CONCLUSIONS: Idiopathic FI in women is a multifactorial disorder resulting from one or more of the following: a disordered pelvic barrier (anal sphincters and puborectalis), or rectal capacity or sensation.     

Autonomic neuropathy: a high risk complication for type 1 diabetes mellitus

The pathological alteration of the nervous system in diabetic patients is extensive and frequently severe. The prevalence of the diabetic neuropathy reach high levels with the evolution of the diabetes, often showing frequencies higher than 50% in several groups of patients. The neurological lesion in this pathological situation is extensive in the diabetic patient, including widely the peripheral nervous system with its components sensory, motor and autonomic: with typical symptoms and in accordance with the pathogenesis of metabolic origin and/or microvascular disease. The autonomic nervous system is a main regulator of many systems in the human body. Then its lesion can promote significant alterations in the function of the cardiovascular, respiratory, gastrointestinal, urogenital system, that can be related to increased motality. This review anlyses the abnormalities related to lesion of the autonomic nervous system, particularly in type 1 diabetic patients, trying to characterize the risk of morbidity and mortality.     

Posterior tibial nerve stimulation and faecal incontinence: a review

Purpose  

Faecal incontinence is a common and important multifactorial disorder with a range of treatment options. Over the last two decades, neuromodulation via sacral nerve stimulators has been shown to be effective for both faecal and urinary incontinence, although associated with complications. Peripheral neuromodulation, via the posterior tibial nerve, is widely used in urinary incontinence; however, its use in faecal incontinence, whilst evolving is limited to eight small heterogeneous studies.     

Ulnar entrapment neuropathy in patients with type 2 diabetes mellitus: An electrodiagnostic study

Aims

This study aimed to assess the prevalence and electrophysiological features of ulnar entrapment neuropathy in patients with type 2 diabetes mellitus (DM).

Methods

Nerve conduction studies (NCS) were performed in a sample of consecutive diabetic patients aged 25–75 years, referred by the Diabetology Unit. NCS of the median, ulnar, radial, peroneal and sural nerves were performed on the non-dominant side. Median entrapment neuropathy at the wrist (MNW) and ulnar neuropathy at the elbow (UNE) and wrist (UNW) were diagnosed according to standard electrodiagnostic criteria.

Results

Sixty-four patients were enrolled, 28 male (44%), average age 61, average DM duration 14.5 years. Polyneuropathy was diagnosed in 45 subjects (70%). UNE was detected in 22 patients (34%) (4 did not have polyneuropathy), in the abductor digiti minimi in 16, the first interosseus in 14 and in both in 8. UNW was detected in 7 (11%) subjects and MNW in 40 (63%). NCS alterations consistent with ulnar neuropathy were detected in a high proportion of patients (45%), suggesting that the ulnar nerve is very susceptible to focal entrapment in DM.

Conclusions

Upper limb sensory and motor NCS, including motor conduction velocity across the elbow, should be considered in the staging of DM patients.     

The effects of low-frequency endo-anal electrical stimulation on faecal incontinence: a prospective study

Background and aims Faecal incontinence is a distressing problem that is often not amenable to surgical correction. Chronic low-frequency electrical stimulation of damaged axons is thought to reduce synaptic resistance, increase the size of motor units by axonal sprouting and increase the rate of conduction of the pudendal nerve. The aim of this study was to prospectively evaluate the effect of chronic low-frequency endo-anal electrical stimulation on faecal incontinence using a home-based unit and hospital-supervised therapy.Materials and methods Forty-eight patients with faecal incontinence completed a prospective randomised trial. Patients were allocated randomly to one of two groups; group 1 was exposed to endo-anal pudendal nerve stimulation daily at home with a portable home unit, group 2 attended the physiotherapy department for endo-anal electrical stimulation under supervision.Results Continence scores improved significantly after treatment in both groups (p<0.001). Both groups showed improved manometric scores, although only group 1 showed significant improvement in both resting and squeeze pressures (mean total resting pressure 184–224 mmHg, p<0.001; mean total squeeze pressure 253–337 mmHg, p<0.001). This was also reflected by an improvement in quality of life in both groups.Conclusions Low-frequency endo-anal electrical stimulation significantly improves continence scores and quality of life in patients with faecal incontinence not amenable to surgical correction. It leads to improved manometric values when carried out on a daily basis with a portable home unit.     

Esophageal function in diabetes mellitus and its relation to peripheral neuropathy.

Esophageal function was determined in 50 unselected patients with diabetes mellitus (DM). Fourteen age-matched healthy subjects served as controls. The presence of peripheral neuropathy (PN) was determined by a neurological examination and by nerve conduction studies. An intraluminal transducer assembly placed in the distal esophagus measured pressure in the lower esophageal sphincter and body of the esophagus. Esophageal function was studied both before and after edrophonium chloride, 80 microgram per kg intravenously. There was no significant difference in peristaltic amplitude between the controls and diabetics. There was also no difference in amplitude when DM was divided into presence or absence of PN. However, there was a significant decrease in velocity of peristalsis in DM with PN when compared to DM without PN and to controls. Resting lower esophageal sphincter pressure in DM was similar to controls, with no difference with or without PN. Twenty-eight patients (56%) with DM had abnormal motility, characterized by frequent spontaneous contractions, and decreased prevalence of peristalsis. Abnormal motility in DM was associated with PN and was characterized by a dysfunction of esophageal innervation with intact smooth muscle function.     

Ophthalmoplegia in diabetes mellitus: a retrospective study

Ophthalmoplegia, despite being a rare entity in diabetes mellitus, is associated with great anxiety for the patients and often appears to be a serious problem from a diagnostic and therapeutic point of view. There have been few studies primarily concerned with the relative frequencies and clinical characteristics of oculomotor neuropathies in diabetic subjects. Those published have emanated largely from neurological and/or ophthalmological referral centres rather than metabolic departments. Objective of this study was to determine the incidence, the clinical characteristics and risk factors for developing ophthalmoplegia among persons with diabetes mellitus. We have performed a retrospective study of all diabetic patients with ophthalmoplegia who were seen in the Metabolic Division at “S. Biagio” Hospital, Marsala, over the 10 year period from 1998 to 2007. A detailed history and blood laboratory profile were obtained for each patient. During the period of the survey a total of 6,765 diabetic subjects were hospitalised and ophthalmoplegia was identified in 27 patients (0.40%). Isolated III nerve palsies accounted for the majority of patients (59.3%), with VI nerve palsies (29.6%) occurring more frequently than multiple palsies (11.1%). These patients had a marked comorbidity and were found to have a poorly controlled diabetes. The patients with VI nerve palsies showed a tendency toward a higher coexistence of diabetic retinopathy and cardiovascular risk factors than those with III cranial nerve palsies. Ophthalmoplegia is a serious and not common problem among patients with diabetes mellitus; the oculomotor nerve was most frequently affected in our case-report. The fact that the coexistence of diabetic complications and cardiovascular risk factors was slightly higher in patients with VI nerve palsy is compatible with the hypothesis that this ischemic event might be more closely related to diabetes and metabolic syndrome in its pathogenesis.     

Manometric evaluation of rectal prolapse and faecal incontinence.

Sixty-three patients with complete rectal prolapse and/or faecal incontinence have undergone anal manometry and the results have been compared with an equal number of age- and sex-matched controls. Maximal basal pressure (MBP) and maximum squeeze pressure (MSP) were measured before and at four months and a year after treatment. The anal pressures of normal subjects are presented. Patients with rectal prolapse alone had normal anal pressures, whereas patients with incontinence with or without prolapse had significantly lower basal and squeeze pressures than controls. Successful surgical treatment of prolapse or incontinence did not produce significant change in anal canal pressures, whereas the combination of pelvic floor exercises and a continence aid was associated with a significant rise in MSP.