Jeannette Potts: Thank you very much. So, I will begin with an overview. The International Continent Society defines nocturia as waking up at night to void. It's a very simple definition, but as you will see, clinically, it is kind of confusing. It's the most common lower urinary tract symptom that patients complain about. And it's also the most bothersome because it's disrupting sleep. It increases with age, and it's estimated that up to 69% of men and 76% of women suffer from nocturia. And it's more than a nuisance. It actually is associated with poor mental health and decreased quality of life. It's associated with serious medical conditions and even higher mortality. So, we need to look at it, first, in terms of a symptom. Is it just a symptom, nocturia? Or is it a risk factor or a marker of disease? And I would submit to you that it is both a risk factor to cause serious illness and a marker of serious underlying medical conditions.
And it's an opportunity. So, first, when we look at it as a symptom, we have to determine whether it's just a sleep disturbance. Sometimes, patients will say, "Oh yeah, I do get up. I get three times at night to pee." But in fact what happens is that they're waking up for other reasons or they're just poor sleepers to begin with. And then, along the way, "Well, I might as well get up and go to the bathroom." That's not really nocturia, and sometimes, I think we over diagnose it in those settings. Or is it just that the patient has a condition that's causing a reduced bladder capacity and therefore, whether it's day or night, they're going to go to the bathroom frequently, and it's going to be disruptive? Or is it actually that the person is producing more urine at night? As we all know, our circadian rhythms mature and evolve to provide us with decreased urine production overnight so that we can sleep effectively.
So, first, as a sleep disturbance, things that can cause this are neurological disorders of any kind can actually impair sleep. Depression can impair sleep and maybe cause nocturia, but truly the primary driver here is the depression. Hormonal changes, which, again, are just causing the changes in the sleep cycle. Alcohol, which greatly impairs effective and sound sleep. And finally, medications. Medications of any type, including psychotropics, can impair sleep. But what if there is a decreased bladder capacity? Does this patient have an overactive bladder? Does the patient have bladder outlet obstruction due to BPH, and therefore, they're actually experiencing more urgency, frequency throughout the day and night? Or do they have a combination?
In men, some men have BPH and an overactive bladder. What can sometimes seem like a decreased bladder capacity are other settings where, in BPH, there's an elevated post void residual. So, the patient's going frequently because they're never effectively emptying the bladder. And underactive bladder, which is only more recently becoming less sedated. It also has many features or symptomatic presentations that look like overactive bladder like frequency in nocturia, but in fact it's because the bladder is underactive. And finally, in that same category, there could be urinary retention and just constantly urinating throughout the night, or leaking throughout the night.
What if it's just too much urine, polyuria? So, this is defined, generally speaking, as greater than 40 mLs per kilogram produced in a 24 hour period. But nocturnal polyuria is defined as a nocturnal polyuria index of greater than 0.33, which actually just means that the patient is excreting more than one third of their total 24 hour urine output overnight. It's important to bear in mind, like I said before, around 70% of all adults experience nocturia. Well, among those adults, some of them do have urological conditions, like the ones I outlined and still others. But they have urological conditions. But the overwhelming majority, 88% actually have nocturnal polyuria. Another way to look at this is that even though your patient may have a urological condition, that patient, in most instances, is dealing with nocturnal polyuria. So, we just can't treat the urological condition or invent a neurological condition to erase the fact that they're really suffering from nocturnal polyuria.
And to that point, there was this large study reviewing the incidents in nocturia with men who had BPH. There were over 2100 men tested, they were over 50, they had lower urinary tract symptoms that were attributed to BPH, and there was a two year follow up. So, they had about 1800 of evaluable patients at the end of two years. 65% of these men had greater than two episodes of nocturia per night. They were treated with alpha blockers or 5 alpha reductase inhibitors, and still 62% had nocturia. And over the two year period, the nocturia had worsened. So, the take home message for me from this article was that, well, that cohort of men were suffering from nocturnal polyuria as well as BPH. This study, the title's a little bit laughable because they're using an alpha blocker to treat nocturnal polyuria. And as one could expect, nothing really happened. It's a really tiny study, too. But it may have decreased urinary frequency, but it made no change in the NPI whatsoever. So, the nocturnal polyuria index is an important tool for us to use in this setting.
Diane Newman: Thank you so much, Dr. Potts. That was an excellent review of nocturia, and discussing also nocturnal polyuria. I always say that this is just the symptom I don't want to hear about in my exam room because, especially with overactive bladder, I feel that I've got some really great solutions for urgency, frequency, and even incontinence with a lot of the behavioral. And then, we, of course, have drug therapy. But I don't really see that this is a symptom that is, I think, sometimes I try to avoid in practice because I don't feel a lot of my basic tools in my treatment algorithm really work with this population. So, I'm not surprised that it's missed. And when we talk about this, who do you think is treating the most? Is it going to urologists? Or is it going to primary care? Or where really do we see the treatment for nocturia?
Jeannette Potts: Well, that's hard for me to say, actually. And I know that sometimes the assumption is that, because my background is in family medicine, that I am only dealing with family medicine patients. And it's really not the case. Most of the nocturia patients, if not all, are patients seeking multiple opinion, like second, third opinion from urology. But not because the urologists are referring them. It's because the patients are self-referred seeking another opinion. So, I'm skewed. I'm seeing just urology patients who are wanting another opinion, and I'm not seeing it from the family practitioners.
Diane Newman: And that's a shame because you see how many other medical problems that are associated with it, and how it increases morbidity. But I agree with you that it's still looked on as "a urology condition," when really it's got to be expanded because it impacts so many other systems.
Jeannette Potts: Yes. And that's probably my number one recommendation in my treatment plan for every patient, regardless of diagnosis. It's like, "You need a primary care doctor. You need a good primary care doctor." Even my patients with pelvic pain, when I retired, I'm like, "I need to refer you to a good family doctor because that's who's going to take the best care of you." So, anyway. But it is hard because I don't know which part of medicine is being more squeezed. And that's a whole other topic, squeezed for time. And there are so many people who are good doctors who were trained very well, but the practice, the actual day to day clinical setting, doesn't allow us sometimes to be the good practitioners that we were trained and intended to be.
Diane Newman: But there's much more research now in this area telling us about that impact. I mean, this has really changed, I think, in the last five years that we now understand nocturia is a symptom of many conditions.
Jeannette Potts: Yes.
Diane Newman: It's not just the bladder, the heart, the issue about diabetes, and that. So, I think that this is really evolving in this area, understanding it, which is what you really showed in this talk.
Jeannette Potts: Yeah. And hopefully, the days of people getting one alpha blocker, two alpha blockers, add an alpha reductase, and then a terp, and it's like, "Oh, you still have nocturia." Hopefully those days are gone.
Diane Newman: We at least hope so. Well, thanks so much for this presentation.
Jeannette Potts: You're welcome. Thank you.