Autonomic Neuropathy

Diabetic autonomic neuropathy is a type of diabetic neuropathy characterized by damage to small fiber autonomic nerves; multiple organ systems are susceptible.

• Sexual dysfunction (e.g., erectile dysfunction)

• Neurogenic bladder, e.g.:

  • Urinary retention

  • Incomplete bladder emptying

  • Bladder distention

  • Overflow incontinence

  • Poor urinary stream

• Early: decreased heart variability [6]

• Late:

  • Orthostatic hypotension

  • Tachycardia at rest

Patients with cardiovascular autonomic neuropathy are at increased risk for silent myocardial infarction, arrhythmias, and death. [5][6]

• Diabetic gastroparesis

• Stool changes (e.g., diarrhea, fecal incontinence, constipation)

• Esophageal dysmotility

• Impaired pupillary tone [10]

• Sudomotor dysfuncton

  • Dry skin

  • Heat intolerance

  • Abnormal sweating (e.g., anhidrosis, gustatory sweating)

• Hypoglycemia unawareness

• Perform a focused history based on the suspected affected organ.

• Obtain diagnostic studies as needed to rule out alternative etiologies and confirm the diagnosis.

• Optimize diabetes management to achieve glycemic targets in DM.

• Treat dyslipidemia and hypertension, if present.

• If possible, discontinue medications that may contribute to symptoms.

• Consider specialist referral.

• Treatment varies depending on the organ system(s) affected:

  • Genitourinary symptoms: See “Treatment of urinary incontinence” and “Sexual dysfunction.”

  • Symptoms of diabetic gastroparesis, see “Management of diabetic gastroparesis.”

  • Manage orthostatic hypotension.

    • Nonpharmacological management of orthostatic hypotension and syncope, including regular exercise

    • Pharmacological management (e.g., fludrocortisone, midodrine)

• Educate patients on symptoms of diabetic neuropathies.

• Optimize diabetes management to achieve glycemic targets in DM.

• Encourage smoking cessation.

• Initiate ASCVD prevention.

Screening for diabetic neuropathy

Perform annually, starting at the time of diagnosis for patients with T2DM and 5 years after diagnosis for patients with T1DM (earlier if symptoms develop).

Screening for diabetic peripheral neuropathy

• Inquire about subjective symptoms of diabetic peripheral neuropathy.

• Assess ankle reflexes and perform a focused examination of sensation.

Screening for diabetic autonomic neuropathy

• Inquire if patient is experiencing:

  • Symptoms of diabetic gastroparesis

  • Symptoms of erectile dysfunction or female sexual dysfunction

  • Recurrent urinary tract infections and/or symptoms of urinary incontinence

  • Peripheral dry and/or cracked skin

  • Symptoms of hypotension or syncope

• Record resting heart rate: A resting heart rate > 100 bpm suggests cardiovascular autonomic neuropathy.

• Check orthostatic vital signs.

• Assess for decreased heart rate variability by recording an ECG either:

  • When the patient rises from seated to standing

  • Continuously while the patient takes deep breaths for 1–2 minutes