Holding Urine for a Prolonged Period of Time and Acute Urinary Retension

Acute urine retention is a common condition affecting most of the elder males. There are several etiological factors for acute retention of urine. Holding urine for a prolonged period of time is one such etiology. How does holding urine for a long period of time cause acute urinary retention.

This can be explained by the LaPlace Law. When you hold urine for a long time, urine accumulate slowly and the bladder volume slowly increases. Finally, the bladder gets over-distended.  When the detrusor muscles are overstretched, they cannot contract. As a result, the bladder cannot empty itself by contracting. This process finally results in acute urinary retention.

How to and where to Inject Insulin?

Many people with diabetes mellitus come to point where they have to inject insulin. In such cases they have inject insulin at least two times a day. That means you will have to prick your skin at least sixty times a month. Pricking the same site of the skin for a long time can damage the skin. Insulin itself acts on the tissues surrounding the injection site and aggravates the tissue damage. Therefore, it is important that you know the correct method and site of insulin injection to minimize tissue trauma.

When injecting insulin, the preferred site of injection is around the umbilicus. You can also inject insulin to the upper outer aspect of the arms and to the outer aspect of the middle one third of the thighs. umbilicus is regarded as the best place to inject insulin. This is because its blood supply is very low. When there is less blood supply, insulin is absorbed in to the circulation very slowly. Therefore, the risk of hypoglycemia is very low. The next preferred place of insulin injection is the arms. Legs have the highest rate of absorption. This causes rapid reduction of blood glucose. Therefore, you can develop hypoglycemia very quickly.

Always follow the following steps when injecting insulin.

1. Check the insulin vial. If you are using soluble insulin, the solution should be clear and colorless. If you are using a suspension, it should be uniformly cloudy. If there is any abnormality, discard the vial and take a new one. Clean the top of the vial with alcohol. Check the insulin pen for the same abnormalities if you are using an insulin pen.
2. Prepare  the site. The site is best prepared by cleaning with alcohol. But, if alcohol is not available, maintaining a good hygiene by cleaning yourself daily is enough.
3.  Draw air in to the syringe. The amount of air drawn is same as the dose you are going to take from the insulin valve. Then inject the air in to the insulin valve. Now you can easily draw out the amount of insulin you want.
4. If you are going to inject insulin to a site around the umbilicus, take a point two finger breadths away from the umbilicus. Likewise go inject subsequent doses around the umbilicus for a month. Then choose another side to inject insulin. For example, the arms. Inject insulin to one arm for a month and then change it to the other arm. Rotating sites like this allows the site to heal.
5. The angle of insulin injection is usually 90 degrees. Bit, if you are a very thin person and going to inject insulin to a place with minimum fat content you can inject in 90 degree angle but, insert only half of the length of the needle. If not, you can insert the needle in a 45 degree angle to avoid going in to deep structures other than the fat tissues. 

Is Insulin The Last Resort To Treat Diabetes Mellitus?

Many people think that insulin therapy is started when there is nothing else to do. They also think that there is no hope. But, this is a wrong belief. Insulin is the best method of treatment for diabetes. It is started in young people instead of drugs to prevent tissue damage. Diabetic people lack insulin. Therefore, providing insulin from outside is almost equal to the normal body functions. On the other hand, diabetic drugs are artificial preparations. They exert various side effects in the human body. Insulin should never be regarded as the last resort.

According to the available research findings, injecting insulin has shown to reserve the function of the residual beta cells. So, insulin therapy is started for those who are diagnosed with diabetes mellitus type 2 as soon as possible. 

How Long will if Take to Cure Mononuritis and Mononuritis Multiplex in diabetes?

Mononuritis and mononuritis multiplex are neurological complications of diabetes mellitus. As the names imply single nerves are affected in these conditions. Both cranial and peripheral nerves can be damaged.  Commonest nerves affected are the occulomotor nerve, radial nerve, median nerve, ulnar nerve and common peroneal nerve.

When a diabetic person gets these diseases, the commonest mistake they do is thinking that only drugs can cure them, but this is not true. If the blood sugar levels are controlled for a certain period of time, the symptoms will spontaneously disappear over 3 to 6 months. Therefore, make sure you adhere to the diabetic diet. Engage in exercises at least for 20 minutes, 5 days a week. You will feel that you are getting better in no time.

Having Diabetes? Are You Having Acute Painful Neuropathy?

Acute painful neuropathy is a microvascular complication of diabetes neuropathy. If your are experiencing burning or crawling pains in your feet, shins and anterior thighs, you may be having acute painful neuropathy. These symptoms usually get worse during the night. Even the touch of your bedsheets may cause severe pain making a good night sleep impossible. Muscle wasting is not a feature of acute painful neuropathy. 

What Should You Do If You Have Acute Painful Neuropathy?

As for every symptom and complication in diabetes, good blood sugar control is the key to relieve the symptoms. If you control your blood sugar levels well, the symptoms will disappear spontaneously within three to twelve months. 

There are pharmacological and non pharmacological methods to relieve pain. Medications given to treat acute painful neuropathy include tricyclics, gabapentin, pregabalin, duloxetine, mexilentine, valprovate and carbamazepine. Non pharmacological methods to relieve pain include acupuncture and transdermal nerve stimulation. 

Can Diabetes Cause Anemia?

Diabetes is a multi systemic disorder which affects almost every part of the body. Diabetes can also cause anemia. There are several ways that a diabetic patient can become anemic.

1. Due to nephropathy - Diabetic nephropathy is a microvascular complication of diabetes mellitus. Kidney secretes a chemical called erythropoetin which stimulates red blood cell production. Unfortunately, erythropoetin production is also reduced in diabetic nephropathy. As a result, less amount of red blood cells are produced making the person anemic. 
2. Due to autoimmune diabetes
3. Anemia in chronic disorder - Any chronic illness can cause anemia. Diabetes mellitus is also a chronic disorder.
4. As a side effect of diabetic medications - Unfortunately some of the medications given to treat diabetes cause anemia as a side effect. For example glitazone and metformmine cause anemia as a side effect.
5. As a result of autoimmune associated pernicious anemia - Some times diabetes results from an autoimmune disorder. In autoinnume disorders, antibodies are produced against the body's own cells. When these cells attack the beta cells of Islets of Lngarhan, diabetes develops. In such patients, the autoantibodies can also attack cells secreting intrinsic factor. Intrinsic factor is required to absorb Viatamin B 12 from the gut. Vitamin B 12 is required to produce red blood cells. Therefore, when there is reduced amount of intrinsic factor, the number of red blood cells produced gets reduced.

Above mentioned are the mechanism of anemia in diabetes mellitus. Anemia in diabetic patients should be identified and treated early. All preventive measured should also be taken because prevention is always better than cure.

Normal Glucose Metabolism in the Body

The body in a way is like a machine. As all machine need fuel in order to function, our body also needs fuel. So, what is the fuel to the body? There are several energy sources to the body. They are,

• Glucose
• Fat
• Proteins

Among these energy sources, glucose plays a major role, since it is the only energy source for red blood cells, and an essential energy source for the brain. In diabetes glucose metabolism is affected mainly.

We gain these fuels from our food. Once absorbed from the gut, first these molecules are transported to the liver, which is one of the major metabolic organs in our body. In the liver some are metabolized and some are converted to other storage forms.

As we are mainly considering about glucose, we’ll see what happens to glucose. Once absorbed from the gut, glucose is taken to the liver. In the liver, most of these molecules are metabolized. It means that it is burned mainly through glycolysis. This is one place where insulin comes in to action.

Some are converted to the storage form, glycogen. The rest is released again in to the circulation, by which glucose is transported though out the body. The glucose concentration in the blood should be kept with in an optimal range, unless it will lead to many problems.

 Then glucose is taken up into almost all of the cells in the body. Skeleton muscle cells and adipose tissue cells (fat cells) are two of such important cells, which play major roles in regulating the blood glucose levels. The uptake of glucose into these cells is also tightly regulated by insulin.

In this way, glucose concentration in the body is tightly regulated by insulin. Any derangement in insulin production or its action gives rise to diabetes.

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Role of Insulin

Insulin secretion or its action is affected in Diabetes Mellitus. It is the hormone that is responsible in regulating the blood glucose level. The blood glucose level rises when glucose is absorbed from the gut after a meal.

The pancreas detects the rise in glucose level. Pancreas is the organ involved in secreting insulin. There are special groups of cells in pancreas called islets of Langerhan. These islets have two kinds of cells, alpha and beta, secreting glucagon and insulin respectively. Both hormones are involved in regulating the blood glucose level.

When the pancreas detects the rise in blood glucose, beta cells start secreting insulin. Insulin goes and acts on several organs and stimulates activities that reduce blood glucose level and inhibit activities that increase blood glucose level.

It acts by binding with insulin receptors that are situated in cell surface. Then cascades of events that are involved in intracellular signal transduction take place.

Liver is one of the major organs, on which insulin acts on. Insulin stimulates rapid removal of glucose from the circulation, by stimulating intracellular breakdown of glucose and inhibits gluconeogenesis (production of glucose from other molecules). Insulin also acts on skeletal muscle and adipose tissue to increase glucose uptake from the circulation. It stimulates lipogenesis in adipose tissues.

All the above reactions lead to rapid removal of glucose from the circulation and thereby reducing the blood glucose level. Therefore, any defect in insulin secretion or its action leads to increased blood glucose levels.

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Diabetic Nephropathy

What is diabetic nephropathy?

Diabetic nephropathy also called Kimmelstiel-Wilson disease; Diabetic glomerulosclerosis; is a progressive kidney disease that occurs as result of long term uncontrolled diabetes mellitus. It is a complication of diabetes Mellitus with a significant mortality and morbidity rate.

Causes

Several factors play part in development of diabetes Nephropathy.

• Uncontrolled high blood sugar
• High blood pressure
• Afro-Americans (13%), Hispanic (9.5%) and people with an Indian origin are said to be in higher risk of developing the condition than others.  
• Genetics

Does everyone with diabetes develop this?

No. Most people with diabetes do not develop this condition. People with type one diabetes are said to be at a higher risk of developing the disease than those with Type two diabetes.

What Happens in Diabetes Nephropathy?

In this condition, abnormality is found in the kidney. That is why it is called diabetes nephropathy. Kidneys are the organs, which filters blood and remove the waste products and other substances which are present in excess amounts from the body. This process occurs in millions of small units called the nephrones. Each nephrone has a part called the glomerulus. The glomerulus is composed of a tuft of tiny capillaries, which brings in blood and another membrane called the Bowman’s capsule. Both membranes of capillaries and the Bowman’s capsule have tiny holes, so they can act as a filter.  Most of the blood constituents with small molecular weight are filtered in to the glomerular filtrate. But, the bigger molecules like plasma proteins like albumin are not filtered. 

In uncontrolled Diabetes Mellitus, there is persistently high blood sugar. These high concentrations of blood sugar damage the above mentioned filtering membrane causing them to thickened (glomerulosclerosis). The pores in those membranes become lager. As a result the bigger molecules like plasma proteins like albumin leeks in to the membrane. So, finally albumin is found in the urine. Initially as the damage is little, only small amount of albumin is found. Therefore, it is called microalbuminuria. 

How to find out whether you have Diabetes Nephropathy? What are the Symptoms and signs?

• The initial abnormality found is microalbuminuria, which will not usually be detected unless you specially looked for it. People with type 1 diabetes are said develop microalbuminuria typically after 5 years. At this stage there are no symptoms. Therefore the patient feels fine. It is very important to detect the disease at this stage, because the kidney damage might be reversible. Microalbuminuria will present in urine for 5-10 years before the major symptoms of the disease start to show. The glomerular damage is not reversible once the renal damage has progressed to a level that a lot of albumin is found in urine. Therefore, doing urine analysis in diabetes patients is very important. 

• As the damage progresses high level of protein is found in urine even by a normal urine analysis. The patient himself may be able to detect high level of protein in urine.  This is indicated by presence of froth in urine and its foamy appearance.

• As the body continues to loose protein, the blood albumin levels gradually falls. Albumin plays a major role in keeping water getting out of blood vessels in to the surrounding tissues. As the albumin concentration goes down, more water gets off from the vascular compartment. This ultimately leads to swelling off the body. The swelling will first appear around in the mornings. Later as the disease progressed the swelling will start appearing in the legs and the feet. 

• High blood pressure
• High cholesterol and triglyceride levels
• Leg cramps
• Nocturia – passing urine several times at night
• Less need for antidiabetic treatment

Rests of the symptoms are very non specific and could be due to any other illness. They are,

• Fatigue
• Frequent hiccups
• Gastrointestinal symptoms like nauseas and vomiting
• Poor appetite
• General ill feeling

How is it confirmed?

The following parameters are considered when diagnosing the disease.

• Presence of macroalbuminuria – 300 mg of albumin present in urine passed within 24 hours.
• Presence of abnormal renal function tests – serum creatinine

                                                                          Calculated creatinine clearance
                                                                          Abnormal glomerular filtration rate

•   Presence of diabetes retinopathy
• Renal biopsy can confirm the diagnosis, but it is not always necessary if the history and clinical findings points towards the disease.

              - early stages shows mesangial expansion and glomerular basement membrane thickening.

              - Later stages - nodular glomerulosclerosis, also referred to as Kimmelstiel-Wilson disease.

                                                                  

How the Condition is managed? What are the Treatments?

Treatment of this condition is pointed towards the slowing down of kidney damage and controlling the associated problems. In this case, controlling the blood pressure plays a major role. It helps both in slowing the renal damage as well as reducing the cardiovascular damage (e.g.: strokes) seen in diabetes patients. Currently it is recommended to maintain blood pressure less than 130/80 mmHg. Following drugs are used to meet this goal.

• ACE Inhibitors – Causes renal vasodilatation and thereby increases renal blood flow.
• Diuretics also play a major role.

• Angiotensin receptor blockers – but the combination therapy has shown to worsen the outcome.

Tight control of blood glucose level – This has lead to a significant reduction in the progression of the disease.

Diet control to reduce blood glucose level

Avoid renal toxins – NSAIDs, Cyclooxygenase 2 inhibitors, radio contrast media