## Basic introduction:
## Epidemiology and Statistics:
## Classification of DN:
_It affects the autonomic nerves controlling internal organs in the genitourinary, gastrointestinal and cardiovascular systems as well as the peripheral autonomic nerves.
_Peripheral autonomic neuropathy presents with the following symptoms/signs: Neuropathic arthropathy (Charcot’s foot), aching, pulsation, tightness, cramping, dry skin, pruritus, edema, sweating abnormalities, weakening of the bones in the foot leading to fractures
_Peripheral autonomic neuropathy is tested by direct microelectrode recording of postganglionic C fibers, Galvanic skin responses, and measurement of vascular responses
_Genitourinary autonomic neuropathy manifests as bladder dysfunction, retrograde ejaculation, erectile dysfunction, and dyspareunia
_Gastrointestinal autonomic neuropathy manifests as gastroparesis (delayed gastric emptying) that can lead to anorexia, nausea, vomiting, and early satiety. Gastrointestinal autonomic neuropathy can also manifest as diabetic enteropathy that can lead to diarrhea and constipation
_Cardiovascular autonomic neuropathy manifests as exercise intolerance and postural hypotension
_Gustatory sweating (sweating on the forehead, face, scalp, and neck occurring soon after ingesting food)
_Polyradiculopathy is the damage of the multiple nerve roots that is sufficient to produce neurologic symptoms and signs such as pain, weakness, and sensory loss
_The common types of polyradiculopathy include: Lumbar polyradiculopathy (diabetic amyotrophy), thoracic polyradiculopathy and Diabetic neuropathic cachexia
_Lumbar polyradiculopathy (diabetic amyotrophy) is characterized by thigh pain followed by muscle weakness and atrophy
_Thoracic polyradiculopathy is characterized by severe pain on one or both sides of the abdomen, mostly in a band-like pattern
_Diabetic neuropathic cachexia is a combination of polyradiculopathy and peripheral neuropathy that is characterized by weight loss and depression.
_Diagnosis of polyradiculopathy is by Electromyographic (EMG) examination.
_This is one of the members of focal and multifocal neuropathies:
_The two main classes of mononeuropathy are: peripheral mononeuropathy and cranial mononeuropathy
_Peripheral mononeuropathy occurs due to a single nerve damage, as a result of compression or ischemia, and it is characterized by numbness, edema, pain and prickling (or tickling) in the wrist (carpal tunnel syndrome), elbow, and/or foot (unilateral foot drop).
_Cranial mononeuropathy is known to affect the 12 pairs of nerves that are connected with the brain and control sight, eye movement, hearing, and taste. It manifests as unilateral pain adjacent to the affected eye, double vision, and paralysis of the eye muscle
_It is further classified into acute sensory DN, autonomic DN and distal symmetrical polyneuropathy (of which diabetic peripheral neuropathy is the most common presentation).
_It is the most common form of DN
_It affects distal lower extremities and hands (“stocking-glove” sensory loss)
_Its symptoms and signs include pain, loss of vibratory sensation, paresthesia, and dysesthesia (which is unpleasant sensation, such as pain, burning, or tingling when a part of the body is touched)
_Complications of symmetric polyneuropathy include ulcers, Charcot arthropathy (which is a progressive degeneration of a weight bearing joint that is marked by bony destruction, bone resorption, and eventual deformity), dislocation and stress fractures, and amputation.
## Pathology DN:
## Risk factors for DN:
_Peripheral neuropathy with loss of protective sensation
_Altered biomechanics (with neuropathy)
_Evidence of increased pressure
_Peripheral vascular disease
_History of ulcers or amputation
_Severe nail pathology
_Peripheral autonomic neuropathy is managed by appropriate Foot care (like elevation of feet when sitting), avoiding aggravating drugs, diuretics to reduce edema and wearing of support stockings as well as regular screening for cardiovascular diseases
_Genitourinary autonomic neuropathy symptoms are managed as follows: bladder dysfunction by voluntary urination or catheterization, retrograde ejaculation by antihistamines such chlorpheniramine, erectile dysfunction by use of PDE5 inhibitors such as sildenafil, tadalafil, and vardenafil, and dyspareunia by use of lubrication creams and estrogen cream
_Gastrointestinal autonomic neuropathy symptoms are managed as follows: gastroparesis by ruling out other causes first, small and frequent meals and metoclopramide or erythromycin. Diarrhea is managed by loperamide, and constipation by stool softeners or dietary fiber
_Cardiovascular autonomic neuropathy symptoms are managed as follows: discontinuing aggravating medicines, changing the posture slowly and using elevated bed, and increasing plasma volume.
_ Polyradiculopathy symptoms are managed by observing appropriate foot care, control of glucose and analgesics