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August 18, 2004

Aches and Pains, Diagnosis and Symptoms

Question from Oswego, New York, USA:

We were told my four year old son has type 1 last month. He had been complaining about his penis hurting, so, after three days, my wife took him to the pediatrician for "possibly" a yeast infection. That is when they informed us of the elevated sugar. We were sent to the Joslin Center in Syracuse and it was determined he had type 1. He was positive 1CA512 and GAD antibody; negative islet cell antibody and Transglutaminase antibody. The urine culture was negative. His A1C was 9.7%. With all this, we have been able to keep my son off insulin through diet. He generally starts the day out in the 80s mg/dl [4.4 to 4.9 mmol/L] and sometimes jumps into the 200s mg/dl [11.1 to 16.3 mmol/L] during the day, 300s mg/dl [16.7 to 22.1 mmol/L], if he sneaks something. But, whenever he starts out higher at bedtime, he will come back down overnight. We even had a couple of readings in the 60's mg/dl [3.3 to 3.8 mmol/L], all with no insulin. The thirty day average is 140 mg/dl [7.8 mmol/L]. Though we are fortunate to keep him off shots for now, he still complains that his penis hurts. He shows no ketones and the Diastix are negative. Do you have any idea what might be causing his discomfort and is there anything I can do before going to a urologist?

Answer:

It sounds like he has diabetes and needs insulin, to me. Why is he not receiving insulin with such abnormal blood glucose levels for most of the day? Penile discomfort could be related to irritation from hyperglycemia or from infections with either yeast or other bacteria, so, I would suggest more detailed urinalysis. IF he has large amounts of urine, then any organisms present could be “diluted” and “fool” the laboratory. Under such circumstances, there is more reason to treat the hyperglycemia and to also treat what is likely cystitis or urethritis as well.

SB
Additional comments from Dr. Jim Lane:

It sounds like your son is in the honeymoon phase of his diabetes. That means there has been some recovery of the surviving insulin-producing cells. However, the elevated hemoglobin A1c, his age, and his antibody status are all consistent with type 1 diabetes. The reason he probably had symptoms of a sore penis in the first place is the frequent urination. It is good he had a negative urine culture. However, with sugars going into the 300s mg/dl [16.7 to 22.1 mmol/L], on occasion, he is still probably having increased urination. I would recommend he go back to his physician and have the area reexamined. Sometimes a yeast infection can involve the opening of the urethra at the end of the penis. It may not be seen from the outside and it may not show up on a culture.

JTL
Additional comments from Dr. David Schwartz:

First of all, I do hope that his being off insulin is with the blessing and support of your pediatric diabetes healthcare team. It is rare, in my experience, to be able to get a child off any insulin during the honeymoon phase. In theory, by not giving ANY insulin, his own pancreas is “using up” it’s insulin production reserves, thus contributing to a shorter honeymoon.

As for the discomfort urinating (“dysuria”), I would have your pediatrician perform a simple urine analysis to exclude other issues, such as blood or infection, but also to measure the relative concentrations of calcium and creatinine (a waste product) in the urine. This might also be done in conjunction with measurement of calcium and other basic chemistries in the blood. Excess urinary calcium can lead to microscopic “crystals” in the urine that can irritate the urinary tract. This is the precursor to kidney stones. Is there a history of kidney stones in the family? Diabetes, with the efflux of glucose in the urine, especially if sub-optimally controlled, is a higher risk category for excess urinary calcium excretion. Remember that the kidney “threshold” for glucose generally corresponds to a blood glucose of about 180 mg/dl [10.0 mmol/L]. Blood glucose much above 180 mg/dl will typically lead to increased urine production.

DS