Diabetes and Incontinence
Diabetes-related complications can directly affect the gastrointestinal and urinary tract, however, are often under recognised and diagnosed. Understanding how urinary and faecal incontinence can occur in people with diabetes, can assist diabetes educators to be more cognisant of these issues and assist their clients in their everyday lives. Incontinence is associated with social isolation, stigmatisation, reduced quality of life and for some people an end to living independently.
Altered bowel actions and Faecal Incontinence
Constipation is common for those with diabetes, affecting nearly 60% of people with diabetes.1 Sub-optimal glycaemia can contribute to dehydration, thus increasing the risk for constipation. Constipation can also affect urinary incontinence. Nerve damage, also known as diabetic enteropathy affects bowel actions. Constipation can alternate with diarrhoea.
The risk of bowel incontinence can increase with hyperglycaemia by inhibiting external anal sphincter function and reduce rectal compliance. One study identified that a duration of diabetes for 10 years increased the risk of developing faecal incontinence.2
Metformin is the tenth most commonly prescribed medicine in Australia,3 and in a study of over 4000 people with type 2 diabetes 23.7% taking metformin reported diarrhoea,4 which can be explosive and can lead to faecal incontinence and have a direct influence on quality of life5
Loose bowel actions can occur when metformin is commenced, or when the dose is increased and can last for a few days. However, for some people it does not resolve, especially at the maximum 3g dosing, for the shorter duration formulation. In response to diarrhoea, switching to the extended release or reduced dosing can minimise GIT intolerance.3
The ability to offer another medication option if diarrhoea is ongoing or severe will depend on what a client is taking and what aligns with the PBS. If they are taking two or three other oral agents, it may mean adding an injectable glucose lowering medicine such as a GLP-1 agonist or insulin. 6
Always ask clients that are on metformin if they experience diarrhoea regularly as they may be reluctant to bring the topic up. Some clients with type 2 diabetes may feel that having diarrhoea is helpful in losing weight rather than seeing it as an adverse drug reaction that has no impact on weight status.
Acarbose slows down the action of certain chemicals, that break down food to release glucose into the blood. Slowing food digestion can assist in lowering post prandial blood glucose levels. However, it is now prescribed rarely due to its minimal glycaemic benefits, 7 additionally it can cause diarrhoea, which can lead to faecal incontinence.
Assessment of diabetes- related diarrhoea
- Assess /client for watery stools or evidence of faecal urgency
- Assess if excessive artificial sweeteners are being consumed as this can contribute to diarrhoea this diarrhoea usually occurs at night (but can also occur during the day)8
- Document changes in bowel actions as bowels can be opened up to 20 times each day and can last for days or weeks, then resolve for a period of time. Between events of diarrhoea, bowel habits may return to normal or swing towards constipation.3
Management of Diabetes- related diarrhoea
- Ensure adequate fluid and electrolyte intake, antidiarrheal agents and fibre supplements. 8
- Perineal hygiene needs to be encouraged and monitored to avoid the risk of skin breakdown8
- Check for any history of food intolerances such as fructose (FODMAP related foods) or Coeliac Disease which can cause stomach upsets (the gene for coeliac disease and diabetes is linked – up to 10% of people with type 1 diabetes developing the condition.9) Refer to a dietitian for follow-up.
- Use of a pad can assist with confidence and quality of life. TENA duo is designed specifically to absorb faeces, where there is double incontinence. Find out more here https://www.tenaprofessional.com.au/professional/products/faecal-pads/
Some effects of diabetes are well known such polyuria from hyperglycaemia and recurrent urinary tract infections leading to urgency and frequency. Microvascular and nerve damage to the bladder and urethral sphincter is attributed to bladder instability and urinary retention causing an elevated postvoid residual volumes contributing to overflow incontinence.1 Obesity can also place pressure on the bladder leading to frequency and urge incontinence. Excessive weight also places additional strain on pelvic floor muscles. According to Incontinence UK, up to 70% of people with diabetes have a greater risk of developing urinary incontinence. In a study of approximately 1000 post-menopausal women with type 2 diabetes, 60% had experienced urinary incontinence and 8% reported severe incontinence over a one month period. This is independent of parity and postvoid residual bladder volume.2
Sodium-glucose co-transporter-2 inhibitors
Sodium-glucose co-transporter-2 inhibitors (SGLT2) promote glucose excretion in the urine.
The three agents currently available are empagliflozin, dapagliflozin and ertugliflozin.
They are fast becoming one of the most prescribed diabetes medications after metformin due to their additional benefits such as:
- lowering of blood glucose levels
- assistance with weight loss
- reducing the risk of cardiac events and heart failure risk
Their therapeutic effects when blood glucose levels will cause an increase urination and urgency. An impact on urinary frequency can exacerbate urinary incontinence.
Continence aids can help clients manage bladder weakness providing dryness and comfort improving confidence. This may only be short term whilst improvement strategies are being worked out.
|Active women||Liners, pads and pants for light loss to moderate loss|
|Active men||Shields and Pull up pants for light to moderate loss|
|Larger sizes||Slip Bariatric|
|Delicate skin and perineal cleansing||Skin care|
For assistance with the TENA product range, please use our TENA product selector on tenaprofessional.com.au or tenaprofessional.co.nz
Having the conversation
In a study of more than 2000 women with diabetes, those who did not seek help reported that they3:
- Thought it was part of normal ageing
- Did not know what types of help was available
- Believed they could manage bladder leakage on their own
- Did not know where to seek help
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Vinik AI, Erbas T: Recognizing and treating diabetic autonomic neuropathy. 2001 Cleve Clin J Med 68:928â944.2.
Epanomeritakis E et al Impairment of anorectal function in diabetes mellitus parallels duration of diabetes Dis Colon Rectum 42(11)L1394-1400 1999.3.
Jabbour S & Ziring B Advantages of extended-release metformin in patients with type 2 diabetes mellitus 1011 Postgrad Med 123(1):15-23.4.
Kahn SE, et al.; ADOPT Study Group. Glycemic durability of rosiglitazone, metformin, or glyburide monotherapy. 2006 N Engl J Med 355:2427â43.5.
Florez H, Luo J, Castillo-Florez S, Mitsi G, Hanna J, Tamariz L, Palacio A, Nagendran S, Hagan M Impact of metformin-induced gastrointestinal symptoms on quality of life and adherence in patients with type 2 diabetes 2010 Postgrad Med 122(2):112-20.6.
Hillson R Diarrhoea and diabetes Rowan Hillson. Practical Diabetes 35(6):196-196.9.