In men, DAN may cause loss of penile erection and/or retrograde ejaculation. Specialized assessment of bladder dysfunction will typically be performed by a urologist. Evaluation of bladder dysfunction should be performed for individuals with diabetes who have recurrent urinary tract infections, pyelonephritis, incontinence, or a palpable bladder. DAN is also associated with genitourinary tract disturbances including bladder and/or sexual dysfunction. Occasionally, anorectal manometry and other specialized tests typically performed by the gastroenterologist may be helpful. Diagnostic approaches should rule out autonomic dysfunction and the well-known causes such as neoplasia. Constipation is the most common lower-GI symptom but can alternate with episodes of diarrhea. Whereas a radiographic gastric emptying study can definitively establish the diagnosis of gastroparesis, a reasonable approach is to exclude autonomic dysfunction and other known causes of these upper-GI symptoms. Upper-GI symptoms should lead to consideration of all possible causes, including autonomic dysfunction. Gastroparesis should be suspected in individuals with erratic glucose control. GI disturbances (e.g., esophageal enteropathy, gastroparesis, constipation, diarrhea, and fecal incontinence) are common, and any section of the GI tract may be affected. DAN may affect many organ systems throughout the body (e.g., gastrointestinal, genitourinary, and cardiovascular). Major clinical manifestations of DAN include resting tachycardia, exercise intolerance, orthostatic hypotension, constipation, gastroparesis, erectile dysfunction, sudomotor dysfunction, impaired neurovascular function, “brittle diabetes,” and hypoglycemic autonomic failure.
DAN frequently coexists with other peripheral neuropathies and other diabetic complications, but DAN may be isolated, frequently preceding the detection of other complications.
In randomly selected cohorts of asymptomatic individuals with diabetes, ∼20% had abnormal cardiovascular autonomic function. The reported prevalence of DAN varies widely depending on the cohort studied and the methods of assessment. Despite its relationship to an increased risk of cardiovascular mortality and its association with multiple symptoms and impairments, the significance of DAN has not been fully appreciated. Diabetic autonomic neuropathy (DAN) is a serious and common complication of diabetes.
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