Page 100 - The lraternational Journal of the Royal Society of Thailand.indd

The International Journal of the Royal Society of Thailand
Volume XV-2023

Cardiac autonomic neuropathy is the more serious one which is associated with
increased overall mortality and sudden death. Most patients initially present with
parasympathetic denervation and increase of sympathetic tone leading to resting
tachycardia and decreased heart rate variability and impaired exercise tolerance and
finally orthostatic hypotension. Orthostatic hypotension is from sympathetic vasomotor

denervation causing reduced vasoconstriction of splanchnic and peripheral vascular
beds. Heart rate are often increased from vagal neuropathy and later became slow and
fixed. Orthostatic blood pressure measurement, heart rate variability test by deep

breathing and Valsalva maneuver and tilt table test are recommended as screening
tools (Spallone et al, 2019; Benichou et al, 2018).

Genitourinary dysfunction may present as impaired bladder sensation,
incomplete bladder emptying and erectile dysfunction. Gastroparesis, post prandial
bloating, constipation or profuse watery diarrhea are sometimes seen. Skin

manifestation include hypo or hyperhidrosis and gustatory sweating. Early diagnosis
and proactive management are the key management strategies. Comprehensive and
symptomatic treatment in each symptom will help alleviating the disability and reduce
mortality in these patients. Recognition and treatment of autonomic neuropathy may
improve symptoms, reduce sequelae, and improve quality of life.

Symptoms of gastrointestinal autonomic dysfunction (also known as gastroparesis)
include nausea, bloating, early satiety with poor appetite, postprandial vomiting, and
brittle diabetes (that is, hard-to-control diabetes). Esophageal dysfunction can also
occur with dysphagia (difficulty swallowing) for solid foods and heartburn secondary
to acid reflux .

Urogenital autonomic neuropathy presents as bladder dysfunction (also known
as diabetic cystopathy) that can range from urinary retention with hesitancy to urinary
incontinence with urgency. Sexual dysfunction is another common manifestation of
urogenital autonomic neuropathy. In men, sexual dysfunction manifests as impotence,
decreased libido, and abnormal ejaculation, whereas in women, sexual dysfunction

presents as pain during intercourse, poor lubrication and reduced libido. Sudomotor
autonomic dysfunction presents as dry skin (anhidrosis) with gustatory sweating.

Diagnosis and screening

ADA also recommended routine screening for symptoms and signs of
autonomic neuropathy in patients with microvascular complications. It should be
assessed in people with diabetes starting at diagnosis of type 2 diabetes and 5 years
after the diagnosis of type 1 diabetes and at least annually thereafter and with evidence

92 Revisiting Diabetic Polyneuropathy and Autonomic Neuropathy