What is nocturia?

The International Continence Society defines nocturia quite simply as, “the complaint that the individual has to wake at night one or more times to void,” their bladder. Each void is proceeded and followed by sleep.¹ While patients who experience one or more trips to the bathroom per night are therefore considered to have nocturia, it is widely accepted that most patients find the condition bothersome when they encounter two or more nightly bathroom visits. In Thinking beyond the bladder: antidiuretic treatment of nocturia (published in The International Journal of Clinical Practice, May 2010) Van Kerrebroeck P et al. reported that: Nocturia was traditionally believed to be a symptom of some other primary disorder, or just one of many lower urinary tract symptoms (LUTS). In recent years, however, nocturia has begun to be understood as a clinical entity, that deserves more than cursory evaluation and treatment. Standardisation within the field has emerged, helping to establish greater clarity in diagnosis and allow comparison across studies. Nocturia is now recognised as a condition that affects a large proportion of the adult population, and which may have several causes.²

Causes

Due to obvious anatomical differences, the National Association for Continence (NAC) explains that men and women experience nocturia for different reasons. “Women generally experience nocturia as a consequence of childbirth, menopause, and/or pelvic organ prolapse. In men, nocturia can be directly attributed to benign prostatic hyperplasia (BPH), also known as enlarged prostate.”³

Additional factors that can contribute to nocturia in both sexes according to the NAC, include:

• Behavioural patterns: something a patient has conditioned their body to do as a routine
• Diuretic medications
• Caffeine
• Alcohol
• Overactive bladder treatment
• Excessive fluids before bedtime
• Diminished nocturnal bladder capacity: urine production exceeds the bladder capacity causing the individual to be awakened in order to void
• Fluid redistribution³

“The pathophysiology of nocturia is complex and multifactorial, which may partly explain why the condition has not received appropriate attention as a disorder in its own right,” said Dr Jeffrey Weiss in Nocturia: Focus on aetiology and consequences (published in Reviews in Urology). Dr Weiss lists the following as nonurologic conditions as possible causes of nocturia:

• Chronic heart failure
• Diabetes mellitus (uncontrolled)
• Diabetes insipidus
• Hypoalbuminemia
• Sleep apnoea
• Multiple sclerosis
• Depression
• Chronic pain
• Inadequate fluid intake⁴

IMPACT ON A PATIENT’S LIFE

“Nocturia affects overall health and daytime functioning from loss of sleep, risks falls and injuries at night, reduces the quality of life, lowers productivity, and may even affect the health of the partner whose sleep is often disrupted as well,” explained Leslie SW et al. in Nocturia (published online in StatPearls). “Older adults with nocturia who make multiple nocturnal trips to the bathroom are at substantially increased risk of potentially serious falls. It is also associated with decreased physical health, obesity, diabetes, depression, and heart disease.”⁵

TREATMENT

Despite its relative frequency, Leslie SW et al. warned that nocturia is often under-reported, poorly managed, and inadequately treated. “Many patients are reluctant or too embarrassed to mention this problem to their physicians, or they mistakenly believe it is a normal part of aging.”⁵

Lifestyle adjustments

Once a patient has been diagnosed with nocturia, Dr Jack Barkin advised that initial treatment should be aimed at lowering the amount of urine that is produced/excreted at night (Nocturia: Diagnosis and Management for the Primary Care Physicians, published in The Canadian Journal of Urology). According to Dr Barkin, the first approach is to manage symptoms through adopting certain lifestyle changes such as:

• Empty the bladder immediately before going to bed.
• Modify diet and restrict fluids (e.g., avoid caffeinated beverages and alcohol).
• Take diuretics in the mid-afternoon.
• Elevate the legs in the evenings to mobilise fluids.
• Use of sleep medications/aids.⁶

Pharmacologic Options

According to Oelke M et al. (A practical approach to the management of nocturia (published in International Journal of Clinical Practice), “pharmacological therapies are indicated after failure of lifestyle modifications and behavioural treatments which, however, should be continued together with the drugs. Several pharmacological therapies have been used for the treatment of nocturia, depending on the underlying cause(s) including antidiuretic agents (vasopressin receptor agonists; desmopressin), diuretics, muscarinic receptor antagonists (antimuscarinics), β3‐adrenoceptor agonists (mirabegron), alpha‐adrenoceptor antagonists (α1‐blockers), 5α‐reductase inhibitors, phosphodiesterase type 5 inhibitors (PDE5i) and plant extracts.”⁷

REFERENCES

1. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, Van Kerrebroeck P, Victor A, Wein A; Standardisation Sub-Committee of the International Continence Society. The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Urology. 2003 Jan;61(1):37-49. doi: 10.1016/s0090-4295(02)02243-4. PMID: 12559262. https://www.goldjournal.net/article/S0090-4295(02)02243-4/fulltext
2. Van Kerrebroeck P et al. (2010). ‘Thinking Beyond the Bladder: Antidiuretic Treatment of Nocturia.’ Available from: https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1742-1241.2010.02336.x
3. https://www.nafc.org/nocturia/
4. Weiss JP. Nocturia: focus on etiology and consequences. Rev Urol. 2012;14(3-4):48-55.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3602727/
5. Leslie SW, Sajjad H, Singh S. Nocturia. [Updated 2022 Feb 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK518987/
6. Barkin J. Nocturia: diagnosis and management for the primary care physicians. Can J Urol. 2016 Feb;23(Suppl 1):16-9. PMID: 26924591. http://www.sleepclinic.be/wp-content/uploads/Nocturia-diagnosis-and-management-for-the-primary-care-physicians.pdf
7. Oelke M, De Wachter S, Drake MJ, et al. A practical approach to the management of nocturia. Int J Clin Pract. 2017;71(11):e13027. doi:10.1111/ijcp.13027. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5698733/