Diabetic neuropathy- symptoms, causes, risk factors, complications

There are four main types of diabetic neuropathy. You may have just one type or symptoms of several types. Most develop gradually, and you may not notice problems until considerable damage has occurred.

The signs and symptoms of diabetic neuropathy vary, depending on the type of neuropathy and which nerves are affected.

Peripheral neuropathy
Peripheral neuropathy is the most common form of diabetic neuropathy. Your feet and legs are often affected first, followed by your hands and arms. Possible signs and symptoms of peripheral neuropathy include:

• Numbness or reduced ability to feel pain or changes in temperature, especially in your feet and toes
• A tingling or burning feeling
• Sharp, jabbing pain that may be worse at night
• Pain when walking
• Extreme sensitivity to the lightest touch — for some people, even the weight of a sheet can be agonizing
• Muscle weakness and difficulty walking
• Serious foot problems, such as ulcers, infections, deformities, and bone and joint pain

Autonomic neuropathy
The autonomic nervous system controls your heart, bladder, lungs, stomach, intestines, sex organs and eyes. Diabetes can affect the nerves in any of these areas, possibly causing:

• A lack of awareness that blood sugar levels are low (hypoglycemia unawareness)
• Bladder problems, including frequent urinary tract infections or urinary incontinence
• Constipation, uncontrolled diarrhea or a combination of the two
• Slow stomach emptying (gastroparesis), leading to nausea, vomiting and loss of appetite
• Difficulty swallowing
• Erectile dysfunction in men
• Vaginal dryness and other sexual difficulties in women
• Increased or decreased sweating
• Inability of your body to adjust blood pressure and heart rate, leading to sharp drops in blood pressure when you rise from sitting or lying down (orthostatic hypotension) that may cause you to feel lightheaded or even faint
• Problems regulating your body temperature
• Changes in the way your eyes adjust from light to dark
• Increased heart rate when you're at rest

Radiculoplexus neuropathy (diabetic amyotrophy)
Instead of affecting the ends of nerves, like peripheral neuropathy, radiculoplexus neuropathy affects nerves in the thighs, hips, buttocks or legs. Also called diabetic amyotrophy, femoral neuropathy, or proximal neuropathy, this condition is more common in people with type 2 diabetes and older adults. Symptoms are usually on one side of the body, though in some cases symptoms may spread to the other side too. Most people improve at least partially over time, though symptoms may worsen before they get better. This condition is often marked by:

• Sudden, severe pain in your hip and thigh or buttock
• Eventual weak and atrophied thigh muscles
• Difficulty rising from a sitting position
• Abdominal swelling, if the abdomen is affected
• Weight loss

Mononeuropathy
Mononeuropathy involves damage to a specific nerve. The nerve may be in the face, torso or leg. Mononeuropathy, which may also be called focal neuropathy, often comes on suddenly. It's most common in older adults. Although mononeuropathy can cause severe pain, it usually doesn't cause any long-term problems. Symptoms usually diminish and disappear on their own over a few weeks or months. Signs and symptoms depend on which nerve is involved and may include:

• Difficulty focusing your eyes, double vision or aching behind one eye
• Paralysis on one side of your face (Bell's palsy)
• Pain in your shin or foot
• Pain in the front of your thigh
• Chest or abdominal pain

Sometimes mononeuropathy occurs when a nerve is compressed. Carpal tunnel syndrome is a common type of compression neuropathy in people with diabetes.

Signs and symptoms of carpal tunnel syndrome include:

• Numbness or tingling in your fingers or hand, especially in your thumb, index finger, middle finger and ring finger
• A sense of weakness in your hand and a tendency to drop things.

When to see a doctor
Seek medical care if you notice:

• A cut or sore on your foot that doesn't seem to be healing, is infected or is getting worse
• Burning, tingling, weakness or pain in your hands or feet that interferes with your daily routine or your sleep
• Dizziness
• Changes in your digestion, urination or sexual function

These symptoms don't always indicate nerve damage, but they may signal other problems that require medical care. In either case, early diagnosis and treatment offer the best chance for controlling symptoms and preventing more-severe problems.

Even minor sores on the feet that don't heal can turn into ulcers. In the most severe cases, untreated foot ulcers may become gangrenous — a condition in which the tissue dies — and require surgery or even amputation of your foot. Early treatment can help prevent this from happening.

Causes of Diabetic Neuropathy

Damage to nerves and blood vessels
Prolonged exposure to high blood sugar (glucose) can damage delicate nerve fibers, causing diabetic neuropathy. Why this happens isn't completely clear, but a combination of factors likely plays a role, including the complex interaction between nerves and blood vessels. High blood glucose interferes with the ability of the nerves to transmit signals. It also weakens the walls of the small blood vessels (capillaries) that supply the nerves with oxygen and nutrients.

Other factors
Other factors that may contribute to diabetic neuropathy include:

• Inflammation in the nerves caused by an autoimmune response. This occurs when your immune system mistakenly attacks part of your body as if it were a foreign organism.
• Genetic factors unrelated to diabetes that make some people more susceptible to nerve damage.
• Smoking and alcohol abuse, which damage both nerves and blood vessels and significantly increase the risk of infections.

Risk factors

Anyone who has diabetes can develop neuropathy, but these factors make you more susceptible to nerve damage:

• Poor blood sugar control. This is the greatest risk factor for every complication of diabetes, including nerve damage. Keeping blood sugar consistently within your target range is the best way to protect the health of your nerves and blood vessels.
• Length of time you have diabetes. Your risk of diabetic neuropathy increases the longer you have diabetes, especially if your blood sugar isn't well controlled. Peripheral neuropathy is most common in people who have had diabetes for at least 25 years.
• Kidney disease. Diabetes can cause damage to the kidneys, which may increase the toxins in the blood and contribute to nerve damage.
• Smoking. Smoking narrows and hardens your arteries, reducing blood flow to your legs and feet. This makes it more difficult for wounds to heal and damages the integrity of the peripheral nerves.

Complications

Diabetic neuropathy can cause a number of serious complications, including:

• Loss of a limb. Because nerve damage can cause a lack of feeling in your feet, cuts and sores may go unnoticed and eventually become severely infected or ulcerated — a condition in which the skin and soft tissues break down. The risk of infection is high because diabetes reduces blood flow to your feet.
  Infections that spread to the bone and cause tissue death (gangrene) may be impossible to treat and require amputation of a toe, foot or even the lower leg. More than half the non-traumatic lower limb amputations performed every year in the United States are due to diabetes.
• Charcot joint. This occurs when a joint, usually in the foot, deteriorates because of nerve damage. Charcot joint is marked by loss of sensation, as well as swelling, instability and sometimes deformity in the joint itself.
• Urinary tract infections and urinary incontinence. Damage to the nerves that control your bladder can prevent it from emptying completely. This allows bacteria to multiply in your bladder and kidneys, leading to urinary tract infections. Nerve damage can also affect your ability to feel when you need to urinate or to control the muscles that release urine.
• Hypoglycemia unawareness. Normally, when your blood sugar drops too low — below 70 milligrams per deciliter (mg/dL), or below 3.9 millimoles per liter (mmol/L) — you develop symptoms such as shakiness, sweating and a fast heartbeat. These symptoms alert you to the problem so that you can take steps to raise your blood sugar quickly. Autonomic neuropathy can interfere with your ability to notice these symptoms. This is extremely serious — untreated hypoglycemia can be fatal.
• Low blood pressure. Damage to the nerves that control circulation can affect your body's ability to adjust blood pressure. This can cause a sharp drop in pressure when you stand after sitting (orthostatic hypotension), which may lead to dizziness and fainting.
• Digestive problems. Damage to the nerves in the digestive system can cause a range of problems, including severe constipation or diarrhoea — or alternating bouts of constipation and diarrhoea — as well as nausea, vomiting, bloating and loss of appetite. One particularly serious digestive problem is gastroparesis, a condition in which the stomach empties too slowly or not at all. This can interfere with digestion, cause nausea and vomiting, and severely affect blood sugar levels and nutrition.
• Sexual dysfunction. Autonomic neuropathy often damages the nerves that affect the sex organs, leading to erectile dysfunction in men and problems with lubrication and arousal in women.
• Increased or decreased sweating. When the sweat glands don't function normally, your body isn't able to regulate its temperature properly. A reduced or complete lack of perspiration (anhidrosis) can be life-threatening. Autonomic neuropathy also causes excessive sweating, particularly at night.
• Social isolation. The pain, disability and embarrassment caused by nerve damage can rob people — particularly older adults — of their independence, leaving them increasingly isolated and depressed.

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