SUFU 2019: An Update on Nocturia - What's Keeping You Up at Night?

Miami, FL ( Dr. Jeffrey Weiss provided an update of the management of nocturia. Patients are oftentimes asked to fill out a 24-hour voiding diary but compliance in completing them is sometimes very difficult to obtain. First and foremost each patient should be assessed for other comorbidities. It is also important to differentiate nocturnal polyuria defined as 33% of total urine over 24 hours or urine production>90ml/hour. There are many causes of nocturia and lower urinary tract symptoms.
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Three types of nocturia exist:
  1. Nocturnal polyuria usually is from comorbidities such as congestive heart failure, diabetes mellitus, obstructive sleep apnea, peripheral edema, excessive nighttime fluid intake, nocturnal polyuria syndrome and non-dipping nocturnal blood pressure.
  2. Diminished Global/nocturnal bladder capacity from prostate obstruction, nocturnal detrusor activity, bladder/prostate/urethral cancer, neurogenic bladder, voiding dysfunction, anxiety, medications, bladder or ureteral stones
  3. Global polyuria from diabetes mellitus, diabetes insipidus or primary polydipsia
Dr. Weiss then asks “Is it necessary to do a 24-hour diary?” Will a nocturnal diary improve patient compliance and still provide the same information?

He presents his data for the frequency volume chart (FVC) for Diary analysis in 285 subjects who completed 24-hour diary vs nocturnal FVC. The outcomes were comparable for all components except for global polyuria concluding that once global polyuria is ruled out for a patient and nocturnal FVC can be acceptable.
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Dr. Weiss then proceeds to ask about nocturnal detrusor overactivity (NDO). Nocturnal DO doesn’t usually occur during sleep.  NDS is not due to sleep disturbance or linked to nocturnal polyuria. Nocturnal DO occurs with nocturia in patients with DO with overactive bladder (OAB).  Polysomnography showed that nocturnal DO at night will wake a person up.  This was correlated with UDS.

He discussed the relationship with voided volume and urge to void and found there was no relationship with diuresis rate and urgency.

The treatment algorithm is shown in a pyramid fashion and addresses that there are several options that patients are counseled on that have low levels of evidence such as a low salt diet alone has an effect despite the level of evidence being low.

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Antidiuretics are popular and do have a proven benefit. He shares the different desmopressin formulations and follows up.

UroToday SUFU2019 Desmopressin Formulations 1

He highlighted that there are new EAU Guidelines in 2019 for nocturia.

The next topic addressed is whether nocturia a symptom of HTN??

Normally, blood pressure should drop at night but many patients did not demonstrate this. Will changing blood pressure medications and the type of antihypertensive affect the nocturnal blood pressure and nocturia. He discusses studies that showed ace inhibitors and calcium channel blockers were effective with nighttime dosing. He also discussed that chlorthalidone vs hydrochlorothiazide was more effective at night. More correlative studies are needed.

He then concluded with his algorithm for nocturia. 
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Presented by: Jeffrey P. Weiss, MD, Professor and Chair, Department of Urology, SUNY Downstate Medical Center in Brooklyn, New York and Chief of Urology at the VA New York Harbor Healthcare System, St. Albans, New York. 

Written by: M Lira Chowdhury, DO, Fellow, Female Urology, Pelvic Reconstructive Surgery & Voiding Dysfunction, The University of California Irvine, Department of Urology, @lirachowdhury at the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction Winter Meeting, SUFU 2019, February 26 - March 2, 2019, Miami, Florida
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