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1. Diabetic
Neuropathy
Jeetendra Bhandari

2. Introduction
– Diabetes can damage peripheral nervous tissue in number of ways
– Vascular Hypothesis
– Occlusion of Vasa Nervorum is prime cause(explain only to isolated
mononeuropathy)
– Diffuse symmetrical nature of neuropathy implies a metabolic cause
– Hyperglycemia--> increased formation of sorbitol and fructose in Schwann Cells
-->Disruption of function and structure

3. – Earliest functional change: delayed nerve conduction velocity
– Earliest histological change: segmental demyelination(due to damage of
Schwann Cell)
– In early stage axons are preserver --> possibility of recovery
– At later stage irreversible axonal degeneration

4. Variants of neuropathy
– Symmetrical mainly sensory polyneuropathy (distal)
– Acute painful neuropathy
– Mononeuropathy and mononeuritis multiplex– cranial nerve lesions–
isolated peripheral nerve lesions
– Diabetic amyotrophy (asymmetrical motor diabetic neuropathy)
– Autonomic neuropathy.

5. Symmetrical sensory
Polyneuropathy
– Often unrecognized by patient in early stage
– Early clinical sign(seen on feet)
– Loss of vibration sense
– Loss of pain sensation(deep before superficial)
– Loss of temperature sensation
– Late clinical feature
– Complain of feeling of walking on cotton wool
– Loss of balance (washing face, walking) suggesting impaired proprioception

6. – Involvement of hand is uncommon(should rule out other causes)
– Can lead to unrecognized trauma
– Sequele of poly neuropathy
– Involvement of motor nerve of smooth muscle leading to interosseous wasting
– Unbalanced traction by long flexor muscle--> characteristic structure of foot (high
arch and clawing to toes)--> abnormal distribution of pressure on walking--> callous
formation under 1st metatarsal head or on tip of toe--> perforation neuropathic
ulceration
– Neuropathic arthopathy develop in ankle
– Hand show small muscle wasting( should differenciate from carpel tunnel syndrome)

7. Acute Painful Neuropathy
– Diffuse, painful neuropathy less common
– Patient present with burning or crowling pain in feet, shins and anterior thigh
– Pain worse at night; pressure from bed cloths are unberable
– May present at diagnosis or develop after sudden improvement in glycemic
control
– Usually remits spontaneously after 3-12 months(on good glycemic control)
– Chronic form may develop later in course of disease which may be resistant to
all form of therapy
– Eurological assessment is difficult because hyperaesthesia is feature of disease

8. Management
– Explore for non diabetic causes
– Explannation and reassurance of self remission
– Duloxetine(SNRI); Tricyclics , gabapentine or pregabaline, mexiletine, valporate
and carbamazepine --> reduce perception of neurological pain
– Transepidermal nerve stimulation (TENS) can help
– Few reports have shown that acupuncture can also help

9. Mononeuritis and Mononeuitis
Multiples(Multiple Mononeuropathy)
– Any nerve can be involved
– Onset abrupt and sometime painful
– Lesions occur at common site for external pressure palsies or nerve
entrapment(eg. Median nervein carple tunnel )
– Radioculopathy(involvement of Spinal Cord)
– 3rd and 6th nerve palsy are common
– Feature of 3rd nerve palsy In diabetes
– Pupillary reflex is intactowing to sparing of pupillomotor fibers)
– Full recovery over 3-6 months period

10. Diabetic Amyotrophy
– Usually seen in older men with diabetes
– Presentation
– Painful wasting (symmetrical ) of quadriceps muscle or occassionally in shoulders
– Marked wasting
– Diminished or absent knee reflex
– Affected area extremely tendor
– Extensor plantor responses develop
– CSF protein may be elevated
– Usually associated with period of poor glycemic control; recover with glycemic
control

11. Autonomic Neuropathy
– Asymptomatic autonomic disturbance can be found on examination
– Symptomatic neuropathy is rare
– Affect both symptomatic and parasymptomatic nervous system
– Common feature seen on
– Cardiovascular system
– Gastrointestinal tract
– Bladder involvement
– Male erection dysfunction

12. Cardiovascular system
– Vagal neuropathy
– Tachycardia at rest and loss of sinus arrhythmia
– At later stage heart become denervated(like transplanted heart)
– Cardiovascular reflexes like Valsalva maneuver are impaired
– Postural hypotension due to loss of sympathetic tone to perepherial arterioles
– Warm foot with bounding pulse in neuropathy due to peripheral neuropathy

13. Gastrointestinal tract
– Vagal damage can lead to
– Gastroparesis(often asymptomatic)
– Vomiting
– Implantable devices which stimulate gastric emptying and injectable botulium
toxin into pylorus(to partly paralyse the sphincter), have shown benefit
– Autonomic diarrhoea characteristiccally occurs at night accompanied by
urgency and incontinence
– Diarrhoea and steatorrhoea can occur(small bowel bacteria vergrowth)-->
treated with antibiotic(Tetracycline)

14. Bladder Involvement
– Loss of tone, incomplete emptying and stasis(predispose to infection)
– Ultimately result in an atonic, painless, distended bladder
– Treatment
– Intermittent self-catheterization
– Permanent cauterization (if above fails)
– Prophylactic antibiotics for those prone to recurrent infection

15. Male erection dysfunction
– Common
– First manifests as incomplete erection--> total failure of erection --> retrograde
ejaculation
– May cause anxiety, depression, alcohol excess, drugs, primary or secondary
gonadal failure, hypothyroidism
– Inadequate vascular supply can lead to pudendal arteries atheroma
– Investigation
– Blood for LH, FSH, testerone, prolactin and thyroid function

16. Treatment of erectile dysfunction
– Ideally include sympathetic councelling of both partner
– Phosphodiesterase type 5 inhibitors(sildenafil) which enhance effects of nitric oxide on
smooth muscle and increase penile blood flow
– Contraindicated in patient who take nitrates for angina
– Benefit in 60% of people
– In contraindicated patient and those who dislike its side effect(headache, green tinge to
vision the next day)
– Apomorphine 2-3mg sublingually 20 min before sexual activity
– Alprostadil(prostaglandin E1 preparation) given as a small pellet inserted with device into
urethera 125microgram (should not be used if partner is pregnant)

17. Reference
– Diabetic Neuropathy, Kumar and Clark's Clinical Medicine. 8th ed. Page: 1026-8.
– Up to date. Word search:"Diabetes Mellitus"
– Medscape. Word Search:"Diabetes Neuropathy"

18. Thank you!!
Have a good day….