Nocturia: Prevalence - Evaluation - Treatment

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Background and defintion:

• Urinary frequency and nocturia are common lower urinary tract symptoms (LUTS). 
• Nocturia is the number of voids recorded during a night's sleep: where each void is preceded and followed by sleep.
• Nocturnal polyuria means overnight urine production where it exceeds 20% to 33% of total 24-hour volume and is age dependent.
• Polyuria in a 70-kg adult is diagnosed by a 24-hour voided volume in excess of 2.8 L (>40 mL/kg).
• First morning void after night’s sleep, Volume: counted in nocturnal voided volume
• Episode: counted in diurnal and daytime, frequency, not nocturnal.

Prevalence - Nocturia

• Overall prevalence of nocturia for 5500 people in the Boston Area Community Health (BACH) study was 28.4%, affecting 25.2% of men and 31.3% of women
• Prevalence of nocturia was 48.6% of men and 54.5% in the EPIC study in Europe and Canada, evaluating 19,000 adults with or without overactive bladder (OAB).
• Aging has an impact on nocturia.
• In BACH Nocturia prevalence is 19.9% in 30 - 39 year olds and 41.2% in 60 - 79 years of age.
• Above the age of 60 prevalence is similar in both men and women.
• The prevalence of twice nightly or greater nocturia among men between 70 and 79 is nearly 50 percent.

Clinical Evaluation - Nocturia

• Evaluation includes a patient history to assess sleep, fluid intake and medications used.
• Physical examination - Lower Urinary Tract conditions that impair bladder capacity, including overactive bladder (OAB).
• Evaluate other health conditions that may impact excessive nocturnal urine output, including cardiovascular, endocrine, neurological, and renal impairment
• Symptom assessment tools are used to capture subjective elements of nocturia.
• A frequency volume chart is a patient’s recorded account of times and volumes of urine voided over several days and nights.
• The purpose is to obtain an objective record of one aspect of lower urinary tract symptoms to augment the history and other patient-recorded information, such as the international prostate symptom score (IPSS).
• Men who once had frequency-volume chart-nocturnal voiding frequency less than International Prostate Symptom Score-nocturnal voiding frequency are more likely to have this again.
• The International Prostate Symptom Score (IPSS) tool has one question reporting on nocturia.
• The patient has to indicate how many times over the past month he typically has had to get up to urinate from the time he went to bed at night until the time he got up in the morning. This can range from none (score 0) to five or more times (score 5) per night.
• A weak association has been found between the IPSS for nocturia, urgency, and counterparts on a frequency–volume (FV) chart.
• Therefore, frequency-volume charts as well as the International Prostate Symptom Score should be used when evaluating nocturia.
• Fluid intake is more difficult to measure accurately. The patient and the continence adviser can clarify details of type and quantity of fluid intake as well as other factors as they study the frequency volume chart together.
• A urinary frequency–volume chart (FVC) is used to help distinguish and diagnose:
• Frequency: high frequency with normal 24-hour volume suggests that the bladder capacity is diminished (the male bladder normally holds 300–600 mL urine comfortably).
• Polyuria: passing more urine than usual (up to 3 L of urine in 24 hours is normal).
• Nocturia: waking at night to urinate.
• Nocturnal polyuria: passing, at night, more than 35% of the 24-hour urine production.
• The frequency volume chart alone can give immediate insight into several problems underlying lower urinary tract symptoms, but is always used in combination with measures of urinary voiding flow rates and ultrasound-estimated post-void residual bladder volume, sometimes progressing to functional urodynamic measures if necessary.
• Frequency volume charts have been developed in different ways over the past 30 years so that there is no standard validated format.
• The design should accommodate ease of use for the patient and adviser.
• Although high fluid intake may be the result of choice or habit, it may indicate significant underlying causes, such as diabetes mellitus or insipidus.
• Reduced fixed volumes during the day and night may indicate a small fixed bladder capacity due to a serious underlying condition, such as interstitial cystitis or bladder carcinoma in situ.
• Reduced variable volumes during the day and night often indicate detrusor instability, while normal early morning volumes with reduced and variable day volumes may indicate psychosomatic causes or be associated with genuine stress incontinence, when the patient voids urine more frequently to avoid stress leaks with a larger bladder volume.
• Recording over one week takes into account the effect of variations in peoples’ daily life and activities through the week and weekend.

Treatment:

• Improved sleep environment, self-help, depression management, cognitive behavior therapy, relaxation techniques, and gentle exercise are used to manage co-morbid insomnia.
• Major neurologic diseases that can contribute to nocturia are prioritized in management.
• Volume, nature, and timing of fluid and solute intake can be adjusted.
• For nocturia-predominant LUTS in men, comprehensive evaluation is necessary before considering surgery to reduce the risk of a poor symptomatic outcome.
• The benefits of sedative agents may be in improving return to sleep, rather than nocturia frequency. 
• Treatment with melatonin can counteract sleep impairment and reduces nocturia in some patients.
• Desmopressin can achieve significant improvement in nocturia symptoms for the isolated symptom and when nocturia is a component of OAB.
• Dilutional hyponatremia occurs in 7.6% of patients taking desmopressin. 

References:

• Abrams P, Cardozo L, Fall M, et al: The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002; 21(2):167-178.
• Aslan D, Aslan G, Yamazhan M, et al: Voiding symptoms in pregnancy: an assessment with international prostate symptom score. Gynecol Obstet Invest 2003; 55(1):46-49.
• Coyne KS, Sexton CC, Thompson CL, et al: The prevalence of lower urinary tract symptoms (LUTS) in the USA, the UK and Sweden: results from the Epidemiology of LUTS (EpiLUTS) study. BJU Int 2009; 104(3):352-360.
• Fitzgerald MP, Litman HJ, Link CL, McKinlay JB: The association of nocturia with cardiac disease, diabetes, body mass index, age and diuretic use: results from the BACH survey. J Urol 2007; 177(4):1385-1389.
• Garfinkel D, Laudon M, Nof D, Zisapel N: Improvement of sleep quality in elderly people by controlled-release melatonin. Lancet 1995 Aug 26; 346(8974):541-544.
• Irwin DE, Milsom I, Hunskaar S, et al: Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol 2006; 50(6):1306-1314.
• Irwin DE, Milsom I, Kopp Z, et al: Prevalence, severity, and symptom bother of lower urinary tract symptoms among men in the EPIC study: impact of overactive bladder. Eur Urol 2009 Mar 3.
• Lose G, Mattiasson A, Walter S, et al: Clinical experiences with desmopressin for long-term treatment of nocturia. J Urol 2004; 172(3):1021-1025.
• Matthiesen TB, Rittig S, Mortensen JT, Djurhuus JC: Nocturia and polyuria in men referred with lower urinary tract symptoms, assessed using a 7-day frequency-volume chart. BJU Int 1999; 83(9):1017-1022.
• Rembratt A, Norgaard JP, Andersson KE: What is nocturnal polyuria?. BJU Int 2002; 90(Suppl. 3):18-20.
• Swithinbank LV, Vestey S, Abrams P: Nocturnal polyuria in community-dwelling women. BJU Int 2004; 93(4):523-527.
• Van Kerrebroeck P, Abrams P, Chaikin D, et al: The standardization of terminology in nocturia: report from the standardization subcommittee of the International Continence Society. BJU Int 2002; 90(Suppl. 3).
• van Kerrebroeck P, Rezapour M, Cortesse A, et al: Desmopressin in the treatment of nocturia: a double-blind, placebo-controlled study. Eur Urol 2007; 52(1):221-229.
• Wein A, Lose GR, Fonda D: Nocturia in men, women and the elderly: a practical approach. BJU Int 2002; 90(Suppl. 3):28-31.