Chief Complaint: “I Am Up All Night” – How Should You Respond
“I am up all night” is a complaint voiced by many of my patients, both male and female patients. But when I hear this, I know that they are not saying they are continuously awake all night but that they are up enough times to make it feel like they never got to sleep at all. When asked why, this complaint usually translates to a prevalent symptom, nocturia, when you get up more than two times per night to urinate. What I have found to be the most important next question is: “How many times do you awaken at night to urinate?” followed by “How much does this bother you?” But is also very important that you take a complete history in these patients, as there are many causes for nocturia, such as the kinds of medications being taken (e.g. a diuretic). A diuretic, for example, taken in the evening hours may increase urine output while asleep, triggering urinary urgency. So all the causes of nocturia run through my mind. An article by Bower and colleagues emphasizes the need to investigate comorbidities in these patients and suggest follow-up questions1:
What is the patient’s bladder capacity if he or she has daytime frequency;
Is the patient diuresing because of some type of congestive heart failure;
Is the patient going through menopause and have insomnia;
Do they have a sleep disorder such as obstructive sleep apnea or restless leg syndrome;
Or possibly, do they have hypertension with heart failure and obesity;
Do they have polydipsia with uncontrolled hyperglycemia?
Since we now have medication specifically approved for nocturia (e.g. Noctiva), I have become more confident that I can address this complaint and suggest drug therapy with more confidence. To aid in the screening process, Bower suggests a screening questionnaire called “TANGO” which identifies comorbidities associated with nocturia2.