Nocturia
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Nocturia is defined by the
International Continence Society The International Continence Society (ICS) is a registered Charitable Incorporated Organization, UK charity with a global health focus on the development in the field of incontinence. It strives to improve the quality of life for people affected ...
(ICS) as "the complaint that the individual has to wake at night one or more times for
voiding Urination is the release of urine from the bladder through the urethra in placental mammals, or through the cloaca in other vertebrates. It is the urinary system's form of excretion. It is also known medically as micturition, voiding, ures ...
(''i.e., to urinate'')". The term is derived from
Latin Latin ( or ) is a classical language belonging to the Italic languages, Italic branch of the Indo-European languages. Latin was originally spoken by the Latins (Italic tribe), Latins in Latium (now known as Lazio), the lower Tiber area aroun ...
''nox'' – "night", and
Greek Greek may refer to: Anything of, from, or related to Greece, a country in Southern Europe: *Greeks, an ethnic group *Greek language, a branch of the Indo-European language family **Proto-Greek language, the assumed last common ancestor of all kno ...
'' αούρα'' – "urine". Causes are varied and can be difficult to discern. Although not every patient needs treatment, most people seek treatment for severe nocturia, waking up to void more than 2 or 3 times per night.


Prevalence

Studies have shown that 5–15% of people who are 20–50 years old, 20–30% of people who are 50–70 years old, and 10–50% of people 70+ years old urinate at least twice a night. Nocturia becomes more common with age. More than 50 percent of men and women over the age of 60 have been measured to have nocturia in many communities. Even more over the age of 80 are shown to experience symptoms nightly. Nocturia symptoms also often worsen with age. Contrary to popular belief, nocturia prevalence is about the same for both sexes.


Impact

Research suggests that more than 60% of people are negatively affected by nocturia. The resulting
insomnia Insomnia, also known as sleeplessness, is a sleep disorder where people have difficulty sleeping. They may have difficulty falling asleep, or staying asleep for as long as desired. Insomnia is typically followed by daytime sleepiness, low ene ...
and
sleep deprivation Sleep deprivation, also known as sleep insufficiency or sleeplessness, is the condition of not having adequate duration and/or quality of sleep to support decent alertness, performance, and health. It can be either Chronic (medicine), chronic ...
can cause exhaustion, changes in mood, sleepiness, impaired productivity, fatigue, increased risk of accidents, and cognitive dysfunction. 25% of falls that older individuals experience happen during the night, of which 25% occur while waking up to void. A quality-of-life test for people who experience nocturia was published in 2004. The pilot study was conducted only on men.


Diagnosis

Nocturia diagnosis requires knowing the patient's nocturnal urine volume (NUV). The ICS defines NUV as "the total volume of urine passed between the time the individual goes to bed with the intention of sleeping and the time of waking with the intention of rising". Thus, NUV excludes the last void before going to bed but includes the first morning void, if the urge to urinate woke the patient. The amount of sleep a patient gets and the amount they intend to get are also considered in a diagnosis. As with any patient, a detailed history of the problem is required to establish what is normal for that patient. The principal diagnostic tool for nocturia is the voiding bladder diary. Based on information recorded in the diary, a physician can classify the patient as having global polyuria, nocturnal polyuria, or bladder storage problems. A voiding bladder diary should record: * number of voids * timing of voids * volume voided * volume and time of fluid intake Patients should include the first morning void in the NUV. However, the first morning void is not included with the number of nightly voids.


Causes


Polyuria

Polyuria Polyuria () is excessive or an abnormally large production or Frequent urination, passage of urine (greater than 2.5 L or 3 L over 24 hours in adults). Increased production and passage of urine may also be termed as diuresis. Polyuria often appe ...
is excessive, or abnormally large, production or passage of urine. Increased production and passage of urine may also be termed
diuresis Diuresis () is the excretion of urine, especially when excessive (polyuria). The term collectively denotes the physiologic processes underpinning increased urine production by the kidneys during maintenance of fluid balance. In healthy people, ...
. Polyuria is usually viewed as a
symptom Signs and symptoms are diagnostic indications of an illness, injury, or condition. Signs are objective and externally observable; symptoms are a person's reported subjective experiences. A sign for example may be a higher or lower temperature ...
or
sign A sign is an object, quality, event, or entity whose presence or occurrence indicates the probable presence or occurrence of something else. A natural sign bears a causal relation to its object—for instance, thunder is a sign of storm, or me ...
of another disorder (not a disease by itself), but it can be classed as a disorder, at least when its underlying causes are not clear.


Global polyuria

Global polyuria is the continuous overproduction of urine that is not only limited to sleep hours. This occurs in response to increased fluid intake and is defined as urine outputs of greater than 40 mL/kg/24 hours. Common causes of global polyuria are primary thirst disorders, such as
diabetes mellitus Diabetes mellitus, commonly known as diabetes, is a group of common endocrine diseases characterized by sustained hyperglycemia, high blood sugar levels. Diabetes is due to either the pancreas not producing enough of the hormone insulin, or th ...
and
diabetes insipidus Diabetes insipidus (DI) is a condition characterized by large amounts of dilute urine and increased thirst. The amount of urine produced can be nearly 20 liters per day. Reduction of fluid has little effect on the concentration of the urine. ...
(DI). Urination imbalance may lead to polydipsia or excessive thirst to prevent circulatory collapse.
Central diabetes insipidus Central diabetes insipidus, recently renamed arginine vasopressin deficiency (AVP-D), is a form of diabetes insipidus that is due to a lack of vasopressin (ADH) production in the brain. Vasopressin acts to increase the blood volume, volume of bl ...
is caused by low levels of
vasopressin Mammalian vasopressin, also called antidiuretic hormone (ADH), arginine vasopressin (AVP) or argipressin, is a hormone synthesized from the ''AVP'' gene as a peptide prohormone in neurons in the hypothalamus, and is converted to AVP. It ...
(also called
antidiuretic An antidiuretic is a chemical substance, substance that helps to control fluid balance in an animal's body by reducing urination, opposing diuresis. Its effects are opposite that of a diuretic. The major endogeny (biology), endogenous antidiuretics ...
hormone (ADH),
arginine vasopressin Mammalian vasopressin, also called antidiuretic hormone (ADH), arginine vasopressin (AVP) or argipressin, is a hormone synthesized from the ''AVP'' gene as a peptide prohormone in neurons in the hypothalamus, and is converted to AVP. It ...
, or argipressin). ADH is produced in the
hypothalamus The hypothalamus (: hypothalami; ) is a small part of the vertebrate brain that contains a number of nucleus (neuroanatomy), nuclei with a variety of functions. One of the most important functions is to link the nervous system to the endocrin ...
and stored in and released from the posterior
pituitary gland The pituitary gland or hypophysis is an endocrine gland in vertebrates. In humans, the pituitary gland is located at the base of the human brain, brain, protruding off the bottom of the hypothalamus. The pituitary gland and the hypothalamus contr ...
. ADH increases water absorption in the
collecting duct system The collecting duct system of the kidney consists of a series of tubules and ducts that physically connect nephrons to a minor calyx or directly to the renal pelvis. The collecting duct participates in electrolyte and fluid balance through rea ...
s of kidney
nephron The nephron is the minute or microscopic structural and functional unit of the kidney. It is composed of a renal corpuscle and a renal tubule. The renal corpuscle consists of a tuft of capillaries called a glomerulus and a cup-shaped structu ...
s, subsequently decreasing urine production. ADH regulates hydration levels in the body, which helps regulates water levels. In nephrogenic DI, the kidneys do not respond properly to the normal amount of ADH. Diagnosis of DI can be made by an overnight water deprivation test. This requires the patient to eliminate fluid intake for a fixed period of time, usually around 8–12 hours. If the first morning void is not highly concentrated, the patient is diagnosed with DI. Central DI usually can be treated with a synthetic replacement of ADH, called
desmopressin Desmopressin, sold under the trade name DDAVP among others, is a medication used to treat diabetes insipidus, bedwetting, hemophilia A, von Willebrand disease, and high blood urea levels. In hemophilia A and von Willebrand disease, it should ...
. This is taken to control thirst and frequent urination. Although there is no substitute for nephrogenic DI, it may be treated with careful regulation of fluid intake.


Nocturnal polyuria

Nocturnal polyuria is defined as an increase in urine production during the night but with a proportional decrease in daytime urine production that results in a normal 24-hour urine volume. With the 24-hour urine production within normal limits, nocturnal polyuria can be translated to having a nocturnal polyuria index (NPi) greater than 35% of the normal 24-hour urine volume. NPi is calculated simply by dividing NUV by the 24-hour urine volume. Similar to the inability to control urination, a disruption of arginine vasopressin (AVP) levels has been proposed for nocturia. Compared with normal patients, nocturia patients have a nocturnal decrease in AVP level. Other causes of nocturnal polyuria include diseases such as *
congestive heart failure Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome caused by an impairment in the heart's ability to fill with and pump blood. Although symptoms vary based on which side of the heart is affected, HF typically pr ...
*
nephritic syndrome Nephritic syndrome is a syndrome comprising medical sign, signs of nephritis, which is kidney disease involving inflammation. It often occurs in the Glomerulus (kidney), glomerulus, where it is called glomerulonephritis. Glomerulonephritis is ch ...
*
liver failure Liver failure is the inability of the liver to perform its normal synthetic and metabolic functions as part of normal physiology. Two forms are recognised, acute and chronic (cirrhosis). Recently, a third form of liver failure known as acute- ...
* lifestyle patterns such as excessive nighttime drinking *
sleep apnea Sleep apnea (sleep apnoea or sleep apnœa in British English) is a sleep-related breathing disorder in which repetitive Apnea, pauses in breathing, periods of shallow breathing, or collapse of the upper airway during sleep results in poor vent ...
increasing obstructive airway resistance. Obstructive sleep apnea sufferers have been shown to have increases in renal sodium and water excretion that are mediated by elevated plasma atrial natriuretic hormone (ANH) levels. ANH is released by cardiac muscle cells in response to high blood volume. When activated, ANH releases water, subsequently increasing urine production.


Bladder storage

Normal human bladder storage capacity varies from person to person and is considered 400–600 mL."Picture of the Bladder" Matthew Hoffman MD, webmd.com
/ref> A bladder storage disorder is any factor that increases the frequency of small volume voids. These factors are usually related to
lower urinary tract symptoms Lower urinary tract symptoms (LUTS) refer to a group of clinical symptoms involving the bladder, urinary sphincter, urethra and, in men, the prostate. The term is more commonly applied to menover 40% of older men are affectedbut lower urinary t ...
that affect the capacity of the bladder. Some patients with nocturia have neither global nor nocturnal polyuria, according to the above criteria. Such patients most likely have a bladder storage disorder that impacts their nighttime voiding, or a
sleep disorder A sleep disorder, or somnipathy, is a medical disorder affecting an individual's sleep patterns, sometimes impacting physical, mental, social, and emotional functioning. Polysomnography and actigraphy are tests commonly ordered for diagnosing sle ...
. Nocturnal bladder capacity (NBC) is defined as the largest voided volume during the sleep period. Decreased NBC can be traced to a decreased maximum voided volume or decreased bladder storage. Decreased NBC can be related to other disorders, such as: *
benign prostatic hyperplasia Benign prostatic hyperplasia (BPH), also called prostate enlargement, is a noncancerous increase in size of the prostate gland. Symptoms may include frequent urination, trouble starting to urinate, weak stream, urinary retention, inability t ...
, also known as prostate enlargement *
neurogenic bladder dysfunction Neurogenic bladder dysfunction, often called by the shortened term neurogenic bladder, was technically termed neurogenic lower urinary tract dysfunction by the International Continence Society. It refers to urinary bladder problems due to disease ...
* learned voiding dysfunction *
anxiety disorders Anxiety disorders are a group of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired. Anxiety may cause phys ...
*
urinary tract infection A urinary tract infection (UTI) is an infection that affects a part of the urinary tract. Lower urinary tract infections may involve the bladder (cystitis) or urethra (urethritis) while upper urinary tract infections affect the kidney (pyel ...
* certain pharmacological agents.


Mixed causes

A significant number of nocturia cases occur from a combination of causes. Mixed nocturia is more common than many realise and is a combination of nocturnal polyuria and decreased nocturnal bladder capacity. In a study of 194 nocturia patients: * 7% were determined to solely have nocturnal polyuria * 57% solely had decreased NBC * 36% had a mixed cause of the two Multifactorial nocturia is often unrelated to an underlying urological condition. Mixed nocturia is diagnosed through the maintenance and analysis of bladder diaries of the patient. Assessment of cause contributions is done through formulas.


Management


Lifestyle changes

Although there is no cure for nocturia, many actions can manage the symptoms. * Limiting
caffeine Caffeine is a central nervous system (CNS) stimulant of the methylxanthine chemical classification, class and is the most commonly consumed Psychoactive drug, psychoactive substance globally. It is mainly used for its eugeroic (wakefulness pr ...
and
alcohol Alcohol may refer to: Common uses * Alcohol (chemistry), a class of compounds * Ethanol, one of several alcohols, commonly known as alcohol in everyday life ** Alcohol (drug), intoxicant found in alcoholic beverages ** Alcoholic beverage, an alco ...
intake. Both are diuretic. * Beverage consumption regulation. In regard to nocturia, this specifically means avoiding consuming fluids for three or more hours before bedtime and thus giving the bladder less fluid to store overnight. This especially helps people with urgency incontinence. However, one study regarding geriatric patients showed that this measure reduced voiding at night by only a small amount and is thus suboptimal for managing nocturia in older people. Fluid restriction does not help people who have nocturia due to gravity-induced third spacing of fluid, because fluid is mobilized when they lie in a reclining position. *
Compression stockings Compression stockings (Flight Socks, Support Bandage) are a specialized hosiery designed to help prevent the occurrence of, and guard against further progression of, venous disorders such as edema, phlebitis and thrombosis. Compression stockings ...
may be worn through the day to prevent fluid from accumulating in the legs, unless heart failure or another contraindication is present. * Drugs that increase the passing of urine can help decrease the third spacing of fluid, but they could also increase nocturia.


Medications

* ADH replacements, such as
desmopressin Desmopressin, sold under the trade name DDAVP among others, is a medication used to treat diabetes insipidus, bedwetting, hemophilia A, von Willebrand disease, and high blood urea levels. In hemophilia A and von Willebrand disease, it should ...
and
vasopressin Mammalian vasopressin, also called antidiuretic hormone (ADH), arginine vasopressin (AVP) or argipressin, is a hormone synthesized from the ''AVP'' gene as a peptide prohormone in neurons in the hypothalamus, and is converted to AVP. It ...
* Selective
alpha-1 blocker Alpha-1 blockers (also called alpha-adrenergic blocking agents or alpha-1 antagonists) constitute a variety of drugs that block the effect of catecholamines on alpha-1 adrenergic receptors, alpha-1-adrenergic receptors. They are mainly used to tr ...
s are the most commonly used medicine to treat BPH. Alpha-1 blockers are first-line treatment for the symptoms of BPH in men.
Doxazosin Doxazosin, sold under the brand name Cardura among others, is a medication used to treat symptoms of benign prostatic hyperplasia (enlarged prostate), hypertension (high blood pressure), and post-traumatic stress disorder (PTSD). For high bloo ...
,
terazosin Terazosin, sold under the brand name Hytrin among others, is a medication used to treat symptoms of an enlarged prostate and high blood pressure. For high blood pressure, it is a less preferred option. It is taken by mouth. Common side effec ...
,
alfuzosin Alfuzosin, sold under the brand name Uroxatral among others, is a medication of the α1 blocker class. It is used to treat benign prostatic hyperplasia (BPH). As an antagonist of the α1-adrenergic receptor, it works by relaxing the muscles ...
, and tamsulosin have all been well established in treatment to reduce lower urine tract symptoms caused by benign prostatic hyperplasia. They are all believed to be similarly effective for this purpose. First-generation alpha-1 blockers, like prazosin, are not recommended to treat lower urinary tract symptoms because of their blood-pressure-lowering effect. Later-generation drugs in this class are used for this purpose. In some cases, alpha-1 blockers have been used in combined therapy with 5-alpha reductase blockers.
Dutasteride Dutasteride, sold under the brand name Avodart among others, is a medication primarily used to treat the symptoms of a benign prostatic hyperplasia (BPH), an enlarged prostate not associated with cancer. A few months may be required before bene ...
and tamsulosin are on the market as combined therapy, and results have shown that they improve symptoms significantly versus monotherapy. * If urinary tract infection is causative, it can be treated with urinary
antimicrobial An antimicrobial is an agent that kills microorganisms (microbicide) or stops their growth (bacteriostatic agent). Antimicrobial medicines can be grouped according to the microorganisms they are used to treat. For example, antibiotics are used aga ...
s. *
Antimuscarinic A muscarinic acetylcholine receptor antagonist, also simply known as a muscarinic antagonist or as an antimuscarinic agent, is a type of anticholinergic drug that blocks the activity of the muscarinic acetylcholine receptors (mAChRs). The muscarin ...
agents such as oxybutynin, tolterodine, and solifenacin are especially used in patients who suffer from nocturia due to an overactive bladder and urgency incontinence, because they help bladder contractility.


Surgery

If the cause of nocturia is related to
benign prostatic hyperplasia Benign prostatic hyperplasia (BPH), also called prostate enlargement, is a noncancerous increase in size of the prostate gland. Symptoms may include frequent urination, trouble starting to urinate, weak stream, urinary retention, inability t ...
or an
overactive bladder Overactive bladder (OAB) is a common condition where there is a frequent feeling of needing to urinate to a degree that it negatively affects a person's life. The frequent need to urinate may occur during the day, at night, or both. Loss of bl ...
, surgical actions may be sought out. * Surgery for benign prostatic hyperplasia includes increasingly popular and minimally invasive
laser surgery Laser surgery is a type of surgery that cuts tissue using a laser in contrast to using a scalpel. Soft-tissue laser surgery is used in a variety of applications in humans ( general surgery, neurosurgery, ENT, dentistry, orthodontics, and ...
. * Surgical correction of the
pelvic organ prolapse Pelvic organ prolapse (POP) is characterized by descent of pelvic organs from their normal positions into the vagina. In women, the condition usually occurs when the pelvic floor collapses after gynecological cancer treatment, childbirth or hea ...
* sacral nerve stimulation * Bladder augmentation *
Detrusor muscle The detrusor muscle, also detrusor urinae muscle, muscularis propria of the urinary bladder and (less precise) muscularis propria, is smooth muscle found in the wall of the bladder. The detrusor muscle remains relaxed to allow the bladder to s ...
myectomy


See also

*
Polyuria Polyuria () is excessive or an abnormally large production or Frequent urination, passage of urine (greater than 2.5 L or 3 L over 24 hours in adults). Increased production and passage of urine may also be termed as diuresis. Polyuria often appe ...
*
Enuresis Enuresis is a repeated inability to control urination. Use of the term is usually limited to describing people age-appropriateness, old enough to be expected to exercise such control. Involuntary urination is also known as urinary incontinence. Th ...


References


External links


European Board of Urology
{{SleepSeries2 Symptoms and signs: Urinary system