Nocturia resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahmoud Sakr, M.D. [2]

Overview

Waking up multiple times during night to urinate is termed as Nocturia. It can be caused by simple increased fluid intake, as consequence of other medical illness or intrinsically overactive bladder. If a patients presents with night time increase urine frequency ask him about his intake of fluids, cardiovascular factors (like hypertension, diabetes, obesity, heart failure) , sleep ( restless leg, OSA ), and patient is an old women menopause can be a contributing factor. It isn't a medical emergency but by simple life style changes and treatment of comorbidities patient can feel better. But if not treated properly it can result in fatigue, memory deficits, depression, increased risk of heart disease, gastrointestinal disorders, and, at times, traumatic injury through falls. Waking up multiple times disturb sleep and healthy sleep is important for a healthy body and active life.

Causes

Common Causes

• Hormonal imbalance which may leads to:
  • Global polyuria
  • Nocturnal polyuria
• Vesical problems which includes bladder storage disorders:
  • Benign prostatic hyperplasia (BPH)
  • Neurogenic bladder dysfunction
  • Learned voiding dysfunction
  • Anxiety disorders

Common Factors	Diseases Associated with Nocturia
Old Age	Men: BPH Women: Interstitial cystitis, menopause, bladder prolapse, pelvic organ prolapse
Endocrine	Diabetes Mellitus, diabetes insipidus, High blood pressure.
Cardiovascular	Congestive heart failure, Heart disease, vascular disease, Edema in the lower limbs, or leg swelling
Genito-urinary	Bladder obstruction (stones), inflammation, or other problems that affect bladder capacity (like bladder surgery or fibrosis from radiation), Overactive bladder symptoms, Prostate obstruction, Vaginal prolapse, Menopause, Childbirth, Reduced bladder capacity, Interstitial cystitis
Sleep disorders	insomnia, sleep apnea, Restless leg syndrome
Timing or dose of medicines	Diuretic medicine (water pills), cardiac glycosides, demeclocycline, lithium, methoxyflurane, phenytoin, propoxyphene, and excessive vitamin D
uricosuric agents	Increase and night time caffeine or alcohol Intake
Renal	CKD, Infections, hypercalcemia, kidney stones
Hepatic	hepatic failure
CNS	Parkinson Disease, stroke, neurogenic bladder, Multiple sclerosis
psychiatirc	anxiety disorders, learned voiding dysfunction, psychogenic polydipsia
Gastrointestinal	certain pancreatic cancer

Diagnosis

Urinary frequency volume chart

Reduced urinary frequency

{{{24hr Polydipsia}}}

{{{ 24HR Urine volume }}}

{{{ Nocturnal urine volume }}}

May have reduced bladder capacity

{{{ Increased fluid intake }}}

{{{ Global polyuria }}}

{{{Nocturnal polyuria }}}

Check for primary or secondary bladder disorders which include: Post void residual volume Urinalysis Uroflowmetry Urodynamic studies Bladder biopsies

{{{ Check for: Diabetes Insipidus Diabetes Mellitus Amount of fluid intake Type of fluid intake }}}

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Treatment

Shown below is an algorithm summarizing the treatment of Nocturia according the the [...] guidelines.

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Start with Conservative Treatment: - First, educate the patient about the nature of his disease by drawing flowcharts or simple diagrams. - Restrict fluid intake at night. - avoid sugary food and coffee before bedtime -Manage use of diuretics -If previous illness leads to nocturia, then treating that illness will surely help. It's important to treat diabetes, an enlarged prostate (BPH), congestive heart failure, obstructive sleep apnea (OSA), and/or high blood pressure. Changing the timing and dose of prescribed medication may also help sometimes. Always look into the patient's previous records. -Scheduled voiding at timed intervals, varying from 15 min to 1 h, based on the patient’s own frequency or incontinence intervals - Make a record of their voiding during day and night. -Do pelvic muscle strengthening exercises (contracting pelvic floor muscles) to suppress urgency. -Elastic compression stockings prevent fluid build-up. So the use of compression stockings can be helpful. -Increase compliance determines the success of treatment,

Successful

Failed

-Follow-up visits are scheduled every 1 to 2 weeks if the patient's condition is stable and he is responding to conservative therapy

At some point Patients stops responding to behavioral modifications

-Continue conservative treatments till it works

If lifestyle changes alone don't help with your nocturia, some medicines may help.

-Start Medical Intervention. -If patient experience bed-wetting, he can keep himself and his bed dry by using different products For example, waterproof mattress covers, absorbent briefs and skincare products.

Medicines to help the kidneys produce less urine. For example, Desmopressin, Anticholinergic medicines to treat bladder muscle problems. for example: Darifenacin, Oxybutynin, Tolterodine. a-Adrenergic agonists: Increases urethral closure pressure. it includes Ephedrine and Pseudoephedrine. Antispasmodic like Baclofen Botulinum toxin Tricyclic antidepressant: Imipramine, Amitriptyline Diuretic medicines to regulate urine production and high blood pressure. For example, Bumetanide, Furosemide Women experiencing stress incontinence can use estrogen creams.

Some patients who are refractory to behavioral and pharmacologic therapies respond to FES. Functional electrical stimulation (FES) increasing pelvic floor muscle and urethral striated muscle contractility.

Do's

• Taking afternoon naps
• Maintaining a healthy weight, as excess weight can put pressure on your bladder
• Avoiding beverages with caffeine and alcohol after evening.
• Always perform voiding diary in patient complaining of Nocturia. The frequency volume chart (FVC) is helpful in diagnosing underlying etiology for disease.
• Doctors may also suggest that people with Nocturia drink fewer liquids during the evening and before bed.
• Keeping a food diary is a helpful tool for many people

Don'ts

• Don't confuse Nocturia with overactive bladder. While people with Overactive Bladder may experience frequent urination at night, people with Nocturia tend to only experience frequent urination at night.

References

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