Simple presentation to understand effects of diabetes on our excretory system so learn urology ,discuss urology at my channel https://www.youtube.com/my_videos?o=U next presentaiton will investigation in non invasive urinary bladder carcinoma .......soon

1. Urological manifestation of
diabetes
Dr Vipin Sharma
https://www.youtube.com/my_videos?o=U
REFERENCE ; DIABETES CARE, VOLUME 28, NUMBER 1, JANUARY 2005, CAMPBELL - WALSH UROLOGY

2. For discussion
• What is diabetes ,
• How to diagnose diabetes
• Types of diabetes
• Basic difference in different types of diabetes
• What r the urological manifestation of DM and management
• What is stage of nephropathy
• What is emphysematous pyelonephritis and management
• Why erectile dysfunction in diabetes and management
• Why infection common in female
• What id diabetic food pyramid
• Sliding scale of blood sugar management

3. • India has largest number of
diabetics in the world with
prevalence of 3.8% in rural and
11.8% in urban adults
• is a group of metabolic disorders
in which there are high blood
sugar levels over a prolonged
period present
• effects the quality of life of men
and women with diabetes

4. Type 1
• is also called insulin-dependent diabetes. It used to be called juvenile-
onset diabetes, because it often begins in childhood.
• an autoimmune condition.
• genetic predisposition.
• the damaged pancreas doesn't make insulin.
• eyes (diabetic retinopathy), nerves (diabetic neuropathy), and kidneys
(diabetic nephropathy), Ketoacidosis . Even more serious is the
increased risk of heart disease and stroke.
• Treatment for type 1 diabetes involves taking insulin,

5. Type 2
• adult-onset diabetes,
• non-insulin-dependent diabetes.
• Type 2 diabetes also increases your risk of heart disease and stroke,
and kidney diseases
• insulin is not enough for the body's needs, or the body's cells are
resistant to it.
• Insulin resistance, or lack of sensitivity to insulin, happens primarily in
fat, liver, and muscle cells.
• controlled with weight management, nutrition, and exercise , OHA
And medications

7. WHO diabetes diagnostic criteria
Condition 2 hour glucose Fasting glucose HbA1c
Unit mmol/l(mg/dl) mmol/l(mg/dl) mmol/mol DCCT %
Normal <7.8 (<140) <6.1 (<110) <42 <6.0
Impaired fasting
glycaemia
<7.8 (<140)
≥6.1(≥110) &
<7.0(<126)
42-46 6.0–6.4
Impaired glucose
tolerance
≥7.8 (≥140) <7.0 (<126) 42-46 6.0–6.4
Diabetes mellitus ≥11.1 (≥200) ≥7.0 (≥126) ≥48 ≥6.5

8. Urologic complications
• Nephropathy ,nephritis , pyonephrosis ,
• Bladder dysfunction,
• Sexual and erectile dysfunction,
• Urinary tract infections (UTI),
• Prostatitis , prostatic abscess
• Cystitis,
• Fournier's gangrene
• Wound infections
• Balonopthitis
• Wound infection

9. Renal manifestations
• 25-40% of these develop End Stage Renal Disease
• Both type 1 and type 2 diabetes lead to ESRD but majority of patients
are those with NIDDM
• In Diabetic Nephropathy, Glomeruli and Kidneys are normal or
increased in size

11. RISK FACTORS
• Genetic Factors
• Inadequate Glucose Control
• High blood pressure
• Hyperlipidaemia
• Smoking
• Long Standing Diabetes
• Pregnancy

12. Nephropathy
• Stage 1 (very early diabetes )
• an above-normal glomerular filtration rate (GFR).
• Hyperglycaemia
• increased kidney filtration , due to osmotic load
• toxic effects of high sugar levels on kidney cells Increased Glomerular Filtration Rate ( GFR
>90ml/min )
• Stage 2 (developing diabetes)
• Clinically silent phase with continued hyper filtration and hypertrophy
• GFR remains elevated or has returned to normal ( GFR 60-89ml/min )
• significant micro albuminuria
• Significant micro albuminuria will progress to end-stage renal disease (ESRD).
• all diabetes patients should be screened for micro albuminuria on a routine basis.

13. • Stage 3 (overt, or dipstick-positive diabetes)
• clinical albuminuria
• containing more than 300 mg of albumin in a 24-hour period.
• GFR 30-59ml/min
• Basement membrane thickening
• Hypertension (high blood pressure) typically develops during stage 3.
• Stage 4 (late-stage diabetes)
• increasing amounts of protein albumin in the urine.
• blood urea nitrogen (BUN) and creatinine (Cr) has begun to increase.
• The glomerular filtration rate (GFR) decreases further more with ( GFR 15-29ml/min ).
• Almost all patients have hypertension at stage 4
• Stage 5 (end-stage renal disease, chronic kidney disease)
• GFR has fallen to <15 ml/min and
• renal replacement therapy (i.e., haemodialysis, peritoneal dialysis, kidney transplantation) is
needed

14. SCREENING METHODS
• It can be done by
• random spot check to ACR
• 24-hr collection for creatinine
• proteinuria in fasting urine sample using a urine dipstick:-
• it is +ve, person should check for urinary infection and a lab urine PCR
(Protein: Creatinine ratio)
• If it is –ve, urine albumin should check using a lab ACR (Albumin: Creatinine
ratio)
• If PCR or ACR are elevated check should be repeated twice in next 4
months.
• ACR <2.5mg/mmol is normal in males ACR <3.5mg/mmol is normal in
females

15. • HEMODIALYSIS
• KIDNEY TRANSPLANTATION

16. pyelonephritis
• defined as inflammation of the kidney and renal pelvis,
• the diagnosis is clinical.
• The clinical spectrum ranges from gram-negative sepsis to cystitis with mild
flank pain
• The classic presentation is an abrupt onset of chills, fever (100° F or
greater), and unilateral or bilateral flank or costovertebral angle pain
and/or tenderness.
• often accompanied by dysuria, increased urinary frequency, and urgency.
• Urinalysis usually reveals numerous WBCs, often in clumps, and bacterial
rods or chains of cocci.

17. Radiology
• Ultrasonography and CT show
• renal enlargement,
• hypo echoic or attenuated parenchyma, and
• compressed collecting system
• delineate focal bacterial nephritis and obstruction.
• destruction becomes pronounced, a more disorganized parenchyma
and abscess formation associated with complicated renal and
perirenal infections may be identified

18. Management
No sepsis, nausea, or vomiting
• Urine culture
• Optional radiologic evaluation to
rule out complicating factors (e.g.,
obstruction, stones)
• Outpatient Rx: 7-10 days
• Fluoroquinolone
• Oral Rx
• Urine culture 4 days on and 10
days off Rx
• Urologic evaluation if indicated
Sepsis
Radiologic evaluation for
complicating factors Blood and urine
cultures
Inpatient Rx: 14-21 days Parenteral
• Ampicillin plus gentamicin
• Fluoroquinolone or
• Third-generation cephalosporin
• Review cultures and sensitivities
• Drain obstruction or abscess

19. Emphysematous pyelonephritis
• urologic emergency characterized by
• acute necrotizing parenchymal and
• perirenal infection caused by gas-forming uropathogens.
• Ascending infection
• high tissue glucose levels provide the substrate for microorganisms such as E. coli,
• Produces carbon dioxide by the fermentation of sugar
• In addition to diabetes, many patients have urinary tract obstruction
associated with urinary calculi or papillary necrosis and significant renal
functional derangement
• Almost all patients display the classic triad of fever, vomiting, and flank
pain

20. Radiology
• Tissue gas that is distributed in the parenchyma may appear on abdominal
radiographs as mottled gas shadows over the involved kidney
• crescentic collection of gas over the upper pole of the kidney
• CT
• imaging procedure of choice in
• Defines the extent of the emphysematous process and guiding management
• absence of fluid in CT images or
• the presence of streaky or mottled gas with or without bubbly and loculated gas
appears to be associated with rapid destruction of renal parenchyma and a
• 50% to 60% mortality rate
• resuscitation and broad-spectrum antimicrobial therapy are essential.
• If the kidney is functioning, medical therapy can be considered

21. BLADDER DYSFUNCTION
• Over 50% of men and women with diabetes have bladder dysfunction
• symptoms including
• urinary urgency,
• frequency,
• nocturia,
• incontinence ,
• diminished bladder sensation,
• poor contractility, and
• increased post void residual urine,
• bladder cystopathy most likely represents end stage bladder failure with
symptoms of infrequent voiding, difficulty initiating voiding, and post void
fullness and is relatively uncommon.

22. • an alternation in the detrusor smooth muscle function
• enhanced muscarinic sensitivity
• Neuronal dysfunction,
• deficiency of axonal transport of nerve growth factor (NGF)
• Urothelial dysfunction
• There are progressive increases in total bladder tissue with hypertrophy of
the bladder wall and dilation of the bladder

23. SEXUAL DYSFUNCTION
• male
• Erectile dysfunction,
• reduced libido,
• orgasmic dysfunction, and
• retrograde ejaculation.
• Female
• Reduced desire,
• decreased arousal, and
• painful intercourse
• reported prevalence of 18–42%

24. Erectile dysfunction(ED)
• Prevalence estimates ranging from 20 to 71%
• Risk factors of ED include
• Hypertension,
• Lipid disorders,
• Coronary heart disease,
• LUTS,
• Older age,
• Higher BMI, and
• Cigarette smoking.
• Relative risk for ED increases with poor glycemic control, duration of
diabetes, and the number of other non urologic complications of diabetes
(i.e., Retinopathy, nephropathy, and limb loss).
• Decrease in relative risk of ED with increased physical activity

25. PATHOGENESIS
• NO from nonadrenergic noncholinergic neurons and the endothelium
is required to induce smooth muscle relaxation in the corpus
cavernosum,resulting in sinusoidal filling and penile erection
• IN DM PT have impaired neurogenic and endothelium-mediated
relaxation of smooth muscle,
• increased accumulation of advanced glycation end products (AGEs),
and altered expression farginase,acompetitor with NO synthase (NOS)
for its substrate L-arginine
• Neuropathy and arterial disease is associated

26. MANAGEMENT
• Phosphodiesterase-5 inhibition leads to significant improvements in
function in 50–70% patient
• Non responders to oral treatment benefit from intracavernosal
injections of prostaglandin-E1 and related agents,
• progressive replacement of cavernosal smooth muscle by fibrosis may
lead to complete erectile failure
• Effective surgical interventions in such cases are limited to penile
implants.
• The risk of periprosthetic infection after implantation in diabetic men
ranges from 3.2–15%

27. INFECTIONS
• asymptomatic bacteriuria (ASB) and symptomatic UTIs occur more
commonly in women with diabetes than in those without diabetes.
• In postmenopausal women, type 2 diabetes has been associated with a
two fold increased risk for UTIs,
• women on treatment with oral hypoglycemics or insulin have a three- to
four fold higher risk of UTI, possibly indicating an association with severity
of diabetes
• The development of UTI in women is preceded by colonization of the
vaginal and periurethral epithelium by the infecting organism
• E. coli
• most common cause of UTI among men or women with diabetes in community
acquired or nosocomial UTI.
• Other gram negative bacteria

30. SUMMARY

32. • Thank you