Austin, TX (UroToday.com) A panel discussion on the management of nocturia, A Nocturia Clinical Pathway was held and Dr. Tamsin J. Greenwell began by addressing medical risk factors for nocturia. He states the most important thing is to try and address the etiology of the nocturia. The clinician should make note of the patient’s fluid intake, especially alcohol and caffeine. Assess the patients sleep using the Epworth Sleepiness Scale (ESS). Assess cardiovascular function, as well as BMI and hip to waist ratio, as these may be risk factors for obstructive sleep apnea. Obtain a frequency volume chart. Finally, obtain baseline labs: a urinalysis to exclude DM, UTI, or hematuria. Obtain renal function, hemoglobin A1c, liver function tests, lipid profile, and PSA, if indicated.
Nocturia CausesDr. Greenwell discussed global polyuria; one of most common causes for this is DM. Other etiologies include habitual polydipsia, renal insufficiency, diabetes insipidus, hypercalciuria, and estrogen insufficiency. Nocturnal polyuria is caused by a decrease in AVP, an increase in ANP, hepatic failure, hypoalbuminemia, diuretic use in the late evening, lower limb venous insufficiency, or the intake of too many fluids at night. Sleep disturbances can also be an underlying cause of nocturia. These include poor sleep environment, anxiety, depression, and stimulant use. A decrease in nocturnal bladder capacity is also a cause of nocturia, seen in cases of OAB and nocturnal DO. She recommends referral to appropriate consultants to help manage comorbid conditions, including endocrinology, sleep studies, cardiology, nephrology, and psychology/psychiatry.
Behavioral Management of Nocturia
Dr. Una Lee discussed lifestyle changes and behavioral changes for nocturia. To begin, start with fluid management; reduce fluid intake and bladder irritants (caffeine, alcohol). It is important to promote mobilization of fluids with leg elevation in the afternoon, and timing of diuretic use to earlier in the afternoon. There have been studies done which correlate between a higher quality diet, money spent on groceries, and family income with less nocturia. Also, patients with higher levels of exercise tend to have less nocturia. Therapies such as pelvic floor physical therapy, urge suppression techniques, delayed voiding are used to decrease nocturia. Finally, an important component to improve nocturia is to improve sleep hygiene and insomnia. Dr. Lee recommends the book to patients entitled, “Sleep Revolution.”
Clinical Pathway of Nocturia
Dr. Jerry G. Blaivas discussed the clinical pathway of nocturia. His evaluation begins with history and exam, bladder diary, UA and culture, and uroflow and PVR. The keystone to the evaluation is the bladder diary. He uses a mobile app to obtain data from the LUTSS questionnaire and 24 hour bladder diary. He is also able to track why the patient voided at night and correlates the severity of the urge to void at night. Has describes the 5 phenotypes associated with nocturia. These are polyuria (>2500 ml/24hr), nocturnal polyuria (>90 cc/hr), low bladder capacity (<150 cc), mismatch (Ni>1, BIadder capacity WNL, no nocturnal polyuria), and sleep disorder. The etiology of nocturia can be complex and multifactorial and treatment may require a multispecialty approach. He advocates for the utilization of treatment algorithms to manage, but states the medical problem needs more research.
Jerry G. Blaivas, MD - A Nocturia Clinical Pathway
Tamsin J. Greenwell, MBChB, MD FRCS(Urol) - Addressing Medical Risk Factors
Una J. Lee, MD, FPMRS - Behavioral Therapies
Moderated by: Jeffrey P. Weiss, MD
Written by: Cristina Palmer, DO. Female Urology, Pelvic Reconstruction, Voiding Dysfunction Fellow, Department of Urology, UC Irvine Medical Center, Orange, California at the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction Winter Meeting (SUFU 2018), February 27-March 3, 2018, Austin, Texas