Nocturia

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For patient information click here Template:Search infobox Steven C. Campbell, M.D., Ph.D.; Associate Editor(s)-in-Chief: Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [1] Nasrin Nikravangolsefid, MD-MPH [2]

Overview

Nocturia (derived from Latin nox, night, and Greek [τα] ούρα, urine), also called nycturia (Greek νυκτουρία), is the need to get up during the night in order to urinate, thus interrupting sleep. Its occurrence is more frequent in the elderly. Nocturia could result simply from too much liquid intake before going to bed, or it could be a symptom of a larger problem, such as chronic renal failure, urinary incontinence, Interstitial Cystitis, diabetes, benign prostatic hyperplasia, Ureteropelvic junction obstruction or prostate cancer.

Historical Perspective

• Nocturia was defined by International Continence Society (ICS) in 2002, as the need to wake up one or more times at nights to void.
• Clinical definition of nocturia is awaking from sleep to urinate two or more that two times per night.

The association between [important risk factor/cause] and [disease name] was made in/during [year/event].

In [year], [scientist] was the first to discover the association between [risk factor] and the development of [disease name].

In [year], [gene] mutations were first implicated in the pathogenesis of [disease name].

There have been several outbreaks of [disease name], including -----.

In [year], [diagnostic test/therapy] was developed by [scientist] to treat/diagnose [disease name].

Pathophysiology

• It is thought that nocturia is caused by a number of factors, including
  • urological disorders
    • abnormalities of bladder capacity
    • prostate enlargement
  • urine overproduction due to
    • depletion of third-space fluid in overload states following a recumbent position during sleep
    • overproduction of atrial natriuretic peptide (ANP) caused by
      • sleep apnea
      • congestive heart failure
    • deficiency or dysfunction of antidiuretic hormone (ADH) or arginine vasopressin (AVP)
    • medications such as diuretics
    • behavioral factors such as high water intake at night
• AVP regulates urine production by antidiuretic effects in the collecting system in the kidneys, resulted in
  • increasing water reabsorption
  • decreasing urine volume
• AVP deficiency or AVP dysfunction leads to decreasing urine concentration, increasing urine volume and nocturia.

Causes

Causes by Pathogenesis

Causes of Nocturia

Due to Hormonal imbalance

Due to Vesical problems

Global Polyuria

Nocturanl Polyuria

Sleep disorders

Bladder storage disorders

Causes Due to Hormonal Imbalance

Global Polyuria	Nocturnal Polyuria	Sleep disorders
Defined as a 24-hour urine volume that exceeds 3 liters per day (or 40 mL per kg). The common causes of global polyuria are Diabetes mellitus- caused by low levels of Insulin Diabetes insipidus- caused by low levels of AVP	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. Nocturnal polyuria may be due to age-related changes in the secretion and action of arginine vasopressin (AVP). There is a diurnal periodicity in AVP release in young, healthy subjects, with higher AVP plasma levels in the evening contributing to decreased nighttime urine output. The diurnal variation in AVP release is absent in many older people. Compared with the normal patients, nocturia patients have a nocturnal decrease in AVP level. Other causes of nocturnal polyuria include diseases such as congestive heart failure, nephrotic syndrome and Hepatic failure or lifestyle patterns such as excessive nighttime drinking.	Sleep disorders have been demonstrated to be a frequent cause of nocturia in men younger than 50 years and in women with symptoms of daytime overactive bladder syndrome. Primary sleep disorders may result in nocturia either because of hormonal changes related to sleep-disordered breathing or due to patient misperception of the reason for awakening due to the sleep disturbance but recall this as an awakening to void. e.g. Obstructive sleep apnea(OSA) Restless leg syndrome OSA may also cause nocturnal polyuria by release of atrial natriuretic peptide (ANP).

Causes Due to Vesical Problems

Bladder storage disorder
Reduced bladder capacity or impaired bladder function results in low-volume voids. Most common causes of low-volume bladder voids are Overactive bladder (e.g. Urge incontinence) Bladder outlet obstruction (e.g. BPH)

Causes by Organ System

Cardiovascular	Heart failure
Chemical/Poisoning	No underlying causes
Dental	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	Bicalutamide, Cardiac glycosides, Demeclocycline, Diuretics, Excessive vitamin D intake, Lithium, Methoxyflurane, Phenytoin, Propoxyphene, Tiagabine
Ear Nose Throat	No underlying causes
Endocrine	Liver failure
Environmental	No underlying causes
Gastroenterologic	No underlying causes
Genetic	No underlying causes
Hematologic	No underlying causes
Iatrogenic	No underlying causes
Infectious Disease	Interstitial cystitis, Recurrent UTI
Musculoskeletal/Orthopedic	No underlying causes
Neurologic	Detrusor hyperactivity, Diabetes insipidus, Neurogenic bladder , Parkinson disease, Restless leg syndrome, Urge incontinence
Nutritional/Metabolic	Diabetes, Obesity
Obstetric/Gynecologic	No underlying causes
Oncologic	Prostate cancer
Ophthalmologic	No underlying causes
Overdose/Toxicity	No underlying causes
Psychiatric	Anxiety disorders, Depression, Obstructive sleep apnea, Primary polydipsia
Pulmonary	No underlying causes
Renal/Electrolyte	Chronic renal failure, Diabetes insipidus, Nephrotic syndrome
Rheumatology/Immunology/Allergy	No underlying causes
Sexual	No underlying causes
Trauma	No underlying causes
Urologic	Benign prostatic hyperplasia, Bladder outlet obstruction, Detrusor hyperactivity, Granulomatous prostatitis, Interstitial cystitis, Neurogenic bladder, Prostate cancer, Ureteropelvic junction obstruction
Miscellaneous	Learned voiding dysfunction, Venous insufficiency

Causes in Alphabetical Order

• Anxiety disorders
• Benign prostatic hyperplasia
• Bicalutamide
• Bladder outlet obstruction
• Cardiac glycosides
• Chronic renal failure
• Demeclocycline
• Depression
• Detrusor hyperactivity
• Diabetes
• Diabetes insipidus
• Diuretics
• Excessive vitamin D intake
• Granulomatous prostatitis
• Heart failure
• Interstitial cystitis
• Learned voiding dysfunction
• Lithium
• Liver failure
• Methoxyflurane
• Nephrotic syndrome
• Neurogenic bladder
• Obesity
• Obstructive sleep apnea 
• Parkinson disease
• Phenytoin
• Primary hyperaldosteronism
• Propoxyphene
• Primary polydipsia
• Prostate cancer
• Recurrent UTI
• Restless leg syndrome
• Tiagabine
• Ureteropelvic junction obstruction
• Urge incontinence
• Venous insufficiency

Differentiating ((Page name)) from other Diseases

[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].

OR

[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].

Epidemiology and Demographics

• The prevalence of nocturia ≥ 1 voids is approximately 69000 per 100,000 men aged ≥ 40 years and 76000 per 100,000 women aged ≥ 40 years in the United States, United Kingdom, and Sweden.
• The prevalence of nocturia ≥ 2 voids in population aged 20-30 years is approximately 4000 to 18000 per 100,000 women and 2000 to 17000 per 100,000 men.
• The prevalence of nocturia ≥ 2 voids in population aged 70-80 years is 28000 to 62000 per 100,000 women and 29000 to 59000 per 100,000 men.
• The prevalence of nocturia ≥ 2 voids in in Canada, Germany, Italy, Sweden, and the United Kingdom is 13000 to 17000 per 100,000 individuals aged < 40 years and 20000 to 21000 per 100,000 middle-aged populations and 35000 to 36000 per 100,000 individuals aged ≥ 60 years.

• The incidence of nocturia increases with age.
• Nocturia can affect younger people as 1 from 5 or 6 younger population wake up at least two times per night to void.
• non-Hispanic black men are more likely to develop nocturia.
• nocturia affects men and women equally. However, nocturia incidence are more in young women than young men, and also old men are more likely to develop nocturia than old women.

Risk Factors

• Common risk factors in the development of nocturia include
  • aging
  • Hispanic and Black race
  • history of nocturia during childhood
  • history of pre-existing conditions
    • Diabetes mellitus
    • Diabetes insipidus
    • Hypertension
    • Arthritis
    • Airway disease such as Asthma
  • history of psychological disease
    • Depression
    • Anxiety disorders
  • history of diuretic intake
• Potent risk factors in the development of nocturia in men include
  • prostatitis
  • benign prostatic hyperplasia
  • prostate cancer
• Potent risk factors in the development of nocturia in women include
  • high BMI
  • Heart disease
  • Inflammatory bowel disease
  • Uterine prolapse
  • Hysterectomy
  • Menopause
  • recurrent UTI

Screening

There is insufficient evidence to recommend routine screening for nocturia.

Natural History, Complications, and Prognosis

• Common complications of nocturia include
  • Sleep disorders
  • Depression
  • anxiety disorders
  • lower quality of life
  • increased risk of falling and bone fracture
  • increased mortality

Diagnosis

Diagnostic Study of Choice

• The diagnosis of nocturia is based on the clinical history defined by International Continence Society (ICS) in 2002, which includes wake up at night ≥1 times to void.

• According to new revised definition in 2017 , nocturia is to wake up to void during the sleep period.
• Bladder diary should be asked from the patients, including
  • the amount of water intake
  • the time of water intake
  • time and volume of urination
    • the number of urinations during the day
    • the number of nocturia (urination during the sleep),
    • the number of urinations and the amount of urine production during the day
• Frequency- volume charts can be diagnostic for nocturia.

History and Symptoms

• The most common symptoms of nocturia include passing urine, urgency and frequency at nights.
• History of fluid, alcohol and caffeine intake, urinary symptoms, medications , sleep disorders should be asked from the patients.
  • Some medications that cause nocturia include diuretics, amlodipine and nifedipine should be discontinued.

Physical Examination

• physical examination should include
  • Checking Blood pressure
  • digital rectal examination of the prostate in men and pelvic examination in women
  • checking edema of the lower limbs
  • checking genitalia diseases (phimosis, meatal stenosis or cancer)
  • abdominal examination especially bladder to assess urinary retention
  • calculating BMI and/or waist circumference
  • filling the chart of Frequency-volume for at least 3 days

Laboratory Findings

• Laboratory tests that should be helpful for the diagnosis of nocturia include
  • urine analysis with urine culture to rule out urinary tract infection
  • serum electrolytes
  • renal function tests such as BUN, creatinine, GFR
  • serum glucose level and HbA1c to rule out diabetes mellitus
  • lipid profile
  • PSA level to rule out prostate cancer and BPH

Electrocardiogram

There are no ECG findings associated with nocturia.

X-ray

There are no x-ray findings associated with nocturia.

Ultrasound

• ultrasound may be helpful in the diagnosis of nocturia associated conditions. Ultrasound can measure postvoid residual volume and bladder wall thickness.

CT scan

• There are no CT scan findings associated with nocturia. However, a CT scan may be helpful in the diagnosis of bladder, prostate and urinary tracts abnormalities.

MRI

There are no MRI findings associated with nocturia.

Other Imaging Findings

There are no other imaging findings associated with [disease name].

OR

[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

• Cystoscopy may be helpful in the diagnosis of bladder abnormalities that cause nocturia.

Treatment

Treatment

• Treatment options for nocturia depend on the underlying causes.
• Behavioral modification includes
  • limiting fluid intake in the evening
  • avoiding alcohol, coffee and tea
  • treating underlying conditions such as chronic constipation, diabetes mellitus, diabetes insipidus
  • elevation of the lower limbs in the evening
  • avoiding diuretics intake in the evening and night
  • physical exercise
• Pharmacologic medical therapies for nocturia include
  • desmopressin (arginine vasopressin)
    • It decreases urine volume through vasopressin V2 receptors, which leads to increase water reabsorption in renal tubules.
    • It is the preferred drug for the treatment of nocturia due to nocturnal polyuria according to the European Association of Urology (EAU) recommendation.
  • α-blockers
  • antimuscarinics
  • phosphodiesterase type 5 inhibitors
  • Botulinum toxin

Surgery

Surgical intervention is not recommended for the management of [disease name].

OR

Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]

OR

The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].

OR

The feasibility of surgery depends on the stage of [malignancy] at diagnosis.

OR

Surgery is the mainstay of treatment for [disease or malignancy].

Primary Prevention

• Effective measures for the primary prevention of nocturia include lifestyle modifications such as
  • reducing intake of fluid, caffeine, alcohol, diuretics in the evening and night
  • less salt intake
  • take naps in the afternoon
  • weight loss in obese and overweight individuals
  • urination before going to bed
  • using compression stocks or elevating legs to reduce edema

Secondary Prevention

There are no established measures for the secondary prevention of nocturia.

See also

• Polyuria
• Enuresis