The Relationship of Diabetes to Bladder and Bowel Dysfunction

For the past several years, one of the top reasons people have come to the website of The Simon Foundation for Continence is for information on diabetes and urinary/bowel dysfunction. As we know, common risk factors are associated with and link these conditions. A growing number of people with type 2 diabetes mellitus and prediabetes are trying to understand the links between diabetes and the different kinds of bladder and bowel dysfunction they encounter; they need information and education. Wound care nurses are in a perfect position to provide this information and to teach prevention in outpatient clinics and home care settings.

The United States diabetes forecast is not good, nor does it appear it will improve any time soon. The newest statistics from the Centers for Disease Control and Prevention (CDC), published in October 2018, show the prevalence of people, 20 years of age and older, with diagnosed type 2 diabetes continues to rise, from 6.2% in 1999–2000 to 10.0% in 2015–2016. The total prevalence of diabetes (diagnosed and undiagnosed) increased from 9.0% in 1999–2000 to 12.9% in 2015–2016.¹ In 2017, the CDC reported 84 million Americans (1 in 3) are living with prediabetes.²

Because we currently have a large portion of the US population presenting with diabetes and prediabetes, patients need to understand the normal progression of these diseases. This understanding needs to include the risk for incontinence and other bladder and bowel complications and how these symptoms can be prevented by taking steps to manage diabetes. What patients do to improve their health — allaying and/or reversing the damage of diabetes and its precursors — may well depend on the amount and quality of information and education provided by health care professionals.

Nerve damage. Our patients need to understand diabetes can lead to nerve damage that effects peripheral, autonomic, and cranial nerves and, as such, both bladder and bowel. Nerve damage can lead to multiple and ongoing changes in bladder function known as diabetic cystopathy; this includes decreased/diminished bladder sensation of filling, increased bladder capacity, and impaired detrusor contractility (a flaccid or atonic bladder). An underactive bladder often is the chief cause of diabetic cystopathy. Ongoing nerve damage can lead to changes that may include a weak stream, dribbling, incomplete emptying, urinary retention with elevated post void residuals, and frequency.³ The residual urine in the bladder can lead to chronic urinary tract infections (UTIs), which may lead to frequency and urgency. Persistent and repeated UTIs may lead to infection of the kidneys. A person with diabetes also may experience an overactive bladder with or without urge incontinence (affecting both men and women and increasing with age³). 

Likewise, the bowel is impacted (no pun intended) by a diabetic condition known as diabetic enteropathy. Constipation alternating with diarrhea is a common symptom, along with large bowel dysfunction. Diarrhea may be associated with bowel incontinence and often occurs at night. Constipation can make it difficult for persons to empty their bladder. Nearly 60% of patients with diabetes are affected by constipation without diarrhea. Severe constipation leading to megacolon or colonic intestinal pseudo-obstruction are rare occurrences. The risk for bowel incontinence increases with acute hyperglycemia, which inhibits external anal sphincter function and decreases rectal compliance.⁴ Teaching patients with diabetes about good bowel habits and a healthy bowel diet will help prevent these complications.

Gestational diabetes. Women with diabetes or who have developed gestational diabetes may deliver large-sized infants. These women are susceptible to injuries of the perineum and bladder, particularly the urinary sphincter. This, in turn, can result in urinary retention or urinary incontinence, as well as fecal incontinence. 

The role of medicines. There are also pharmacologic implications in addition to the neural effects of diabetes on bladder/bowel function. Congestive heart failure from diabetes-related coronary artery disease can cause legs and feet to retain water. This may lead to patients getting up many times at night to urinate (nocturia) and may lead to nocturnal incontinence. Patients on angiotensin-converting-enzyme (ACE) inhibitors, which are frequently used to treat high blood pressure in persons with diabetes, may experience a cough. Coughing can trigger stress urinary incontinence or make it worse. Calcium channel blockers (CCBs), also used to treat high blood pressure, can make it difficult for the bladder to contract and empty completely, potentially leading to overflow incontinence or retention. Additionally, some CCBs can cause swelling in the feet and constipation, further worsening function. Instructing patients to elevate their legs during the afternoon along with other simple remedies may help relieve some of these symptoms. Also, working with the prescribing practitioner on medication schedules may provide relief.

Stroke. A stroke from diabetes may effect bladder sensation and the ability to retain urine. Additionally, any secondary cognitive impairment can make it difficult for an individual to toilet independently (and if severe, even toileting with assistance may be difficult). Teaching patients and their caregivers how to create a safe environment for toileting and about toileting aids for the home will help improve this process for everyone involved. Patients and caregivers often do not know where to find information on the different kinds of toileting aids available and where to purchase them. Clinicians can direct them to websites such as Continence Central (continencecentral.org) and provide multiple vendors of toileting aids. 

Ambulatory ability. Patients with diabetes may have mobility challenges due to diabetic neuropathy, peripheral vascular disease, and/or amputation. These challenges can prevent them from reaching a toilet and/or removing clothing “in time,” leading to episodes of functional incontinence. Counseling the patient and caregivers on alternate clothing (such as the use of Velcro instead of buttons and pull-on pants in lieu of those with zippers) and clearing pathways to the bathroom may reduce these episodes and may prevent slips and falls. You also might suggest the use of products that will keep patients dry if leakage occurs.

Metabolic disorders. Metabolic syndrome is the cluster of biological factors characterized by abdominal obesity, dyslipidemia, hypertension, and type 2 diabetes. The number of people with this syndrome continues to rise in the US. In 2017, the CDC reported that among US adults aged 18 years or older, the prevalence rose by more than 35% from 1988–1994 to 2007–2012, increasing from 25.3% to 34.2%. Additionally, during the time period from 2007 to 2012 low education level (odds ratio [OR] 1.56; 95% confidence interval [CI]: 1.32–1.84) and advanced age (OR 1.73; 95% CI: 1.67–1.80) were independently associated with increased likelihood of metabolic syndrome.⁵ Because type 2 diabetes is part of this syndrome, these individuals also may become part of our wound care patient population and further increase the numbers of people with bladder and bowel dysfunction.

Urinary and bowel dysfunction are risks our patients should understand and know. We can help our patients lower their risks of these complications through education. Counseling on diet, exercise, smoking cessation, blood sugar control, and follow-through on treating any associated hypertension, high cholesterol, and obesity will go a long way in helping reach the goal of Health People 2020(healthypeople.gov/2020/topics-objectives/topic/diabetes). The huge return on our investment in educational efforts on the risks for bladder and bowel dysfunction in patients with diabetes, along with solutions for prevention and/or treatment, is worthy of our time and effort.

Dr. Faller is an ET Nurse Clinical Specialist in Private Practice. Ms. LaGro is Vice President of Communications and Education Services at the Simon Foundation for Continence. Please address correspondence to: Elizabeth A. LaGro, MLIS; email: bethlagro@simonfoundation.org.

This article was not subject to the Ostomy Wound Management peer-review process.