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Nocturia: Clinical presentation, diagnosis, and treatment

INTRODUCTION

Nocturia, a common symptom, is defined as waking at night from sleep to void [1]. Although by definition even a single episode of awakening to urinate is nocturia, most clinicians consider nocturia to have significance when a patient voids two or more times nightly. Patients themselves are more likely to consult a provider about nocturia if they have three or more episodes [2]. Nocturnal urinary incontinence or nighttime bed wetting (enuresis) is distinct from nocturia.

Nocturia is a source of significant distress for some patients [3]. Nocturia is cited as one of the most distressing symptoms in older men with benign prostatic hyperplasia (BPH) [4]. Patients report nocturia as a leading cause of sleep disturbance, affecting both sleep onset and maintenance [5]. Nocturia is associated with increased rates of depression [6], work absenteeism [7], and lower self-rated physical and mental health [8]. In the very old, nocturia is associated with higher rates of accidental falls [9].

Because nocturia is associated with a variety of clinical syndromes and disorders, the diagnostic approach is often challenging, and treatment may result in only small improvement [10].

This topic will discuss the clinical presentation, diagnosis, and treatment of nocturia in adults. Detailed discussions of some conditions that cause or are associated with nocturia are presented separately. (See "Diagnosis of polyuria and diabetes insipidus" and "Clinical manifestations and diagnosis of benign prostatic hyperplasia" and "Clinical presentation and diagnosis of urinary incontinence".)

EPIDEMIOLOGY

The prevalence of nocturia, and the number of episodes occurring nightly, increase with age [11]. Occasional nocturia is present in 50 percent of men and women aged 50 to 59 years. Among 18 to 49 year olds, more women than men have nocturia; the sex ratio reverses after 60 years of age, with prevalence greater in men than women [11]. The prevalence of twice nightly or greater nocturia among men between 70 and 79 is nearly 50 percent [11].
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References Top
  1. van Kerrebroeck, P, Abrams, P, Chaikin, D, et al. The standardisation of terminology in nocturia: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002; 21:179.
  2. Chen, FY, Dai, YT, Liu, CK, et al. Perception of nocturia and medical consulting behavior among community-dwelling women. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:431.
  3. A comparison of quality of life with patient reported symptoms and objective findings in men with benign prostatic hyperplasia. The Department of Veterans Affairs Cooperative Study of transurethral resection for benign prostatic hyperplasia. J Urol 1993; 150:1696.
  4. DuBeau, CE, Yalla, SV, Resnick, NM. Implications of the most bothersome prostatism symptom for clinical care and outcomes research. J Am Geriatr Soc 1995; 43:985.
  5. Middelkoop, HA, Smilde-van den, Doel DA, Neven, AK, et al. Subjective sleep characteristics of 1,485 males and females aged 50-93: effects of sex and age, and factors related to self-evaluated quality of sleep. J Gerontol A Biol Sci Med Sci 1996; 51:M108.
  6. van der, Vaart CH, Roovers, JP, de, Leeuw JR, Heintz, AP. Association between urogenital symptoms and depression in community-dwelling women aged 20 to 70 years. Urology 2007; 69:691.
  7. Asplund, R, Henriksson, S, Johansson, S, Isacsson, G. Nocturia and depression. BJU Int 2004; 93:1253.
  8. Fitzgerald, MP, Litman, HJ, Link, CL, McKinlay, JB. The association of nocturia with cardiac disease, diabetes, body mass index, age and diuretic use: results from the BACH survey. J Urol 2007; 177:1385.
  9. Stewart, RB, Moore, MT, May, FE, et al. Nocturia: a risk factor for falls in the elderly. J Am Geriatr Soc 1992; 40:1217.
  10. Weiss, JP, Blaivas, JG. Nocturia. Curr Urol Rep 2003; 4:362.
  11. Tikkinen, KA, Tammela, TL, Huhtala, H, Auvinen, A. Is nocturia equally common among men and women? A population based study in Finland. J Urol 2006; 175:596.
  12. Johnson TM, 2nd, Sattin, RW, Parmelee, P, et al. Evaluating potentially modifiable risk factors for prevalent and incident nocturia in older adults. J Am Geriatr Soc 2005; 53:1011.
  13. Digesu, GA, Khullar, V, Panayi, D, et al. Should we explain lower urinary tract symptoms to patients?. Neurourol Urodyn 2008; 27:368.
  14. Hillier, P, Knapp, MS, Cove-Smith, R. Circadian variations in urine excretion in chronic renal failure. Q J Med 1980; 49:461.
  15. Michel, MC, Oelke, M, Goepel, M, et al. Relationships among symptoms, bother, and treatment satisfaction in overactive bladder patients. Neurourol Urodyn 2007; 26:190.
  16. Gibbs, C, Nagamia, Z, Johnson, T. Self-rated sleep characteristics and bother from nocturia. J Am Geriatr Soc 2006; 54:S139.
  17. Weiss, JP, Blaivas, JG. Nocturia. J Urol 2000; 163:5.
  18. Chang, SC, Lin, AT, Chen, KK, Chang, LS. Multifactorial nature of male nocturia. Urology 2006; 67:541.
  19. Weiss, JP, Blaivas, JG, Jones, M, et al. Age related pathogenesis of nocturia in patients with overactive bladder. J Urol 2007; 178:548.
  20. van Haarst, EP, Heldeweg, EA, Newling, DW, Schlatmann, TJ. The 24-h frequency-volume chart in adults reporting no voiding complaints: defining reference values and analysing variables. BJU Int 2004; 93:1257.
  21. Weiss, JP, Blaivas, JG, Stember, DS, Chaikin, DC. Evaluation of the etiology of nocturia in men: the nocturia and nocturnal bladder capacity indices. Neurourol Urodyn 1999; 18:559.
  22. Miller, M. Nocturnal polyuria in older people: pathophysiology and clinical implications. J Am Geriatr Soc 2000; 48:1321.
  23. Kirkland, JL, Lye, M, Levy, DW, Banerjee, AK. Patterns of urine flow and electrolyte excretion in healthy elderly people. Br Med J (Clin Res Ed) 1983; 287:1665.
  24. George, CP, Messerli, FH, Genest, J, et al. Diurnal variation of plasma vasopressin in man. J Clin Endocrinol Metab 1975; 41:332.
  25. Asplund, R, Aberg, H. Diurnal variation in the levels of antidiuretic hormone in the elderly. J Intern Med 1991; 229:131.
  26. Matthiesen, TB, Rittig, S, Norgaard, JP, et al. Nocturnal polyuria and natriuresis in male patients with nocturia and lower urinary tract symptoms. J Urol 1996; 156:1292.
  27. Suchowersky, O, Furtado, S, Rohs, G. Beneficial effect of intranasal desmopressin for nocturnal polyuria in Parkinson's disease. Mov Disord 1995; 10:337.
  28. Hajduk, IA, Strollo, PJ Jr, Jasani, RR, et al. Prevalence and predictors of nocturia in obstructive sleep apnea-hypopnea syndrome--a retrospective study. Sleep 2003; 26:61.
  29. Moriyama, Y, Miwa, K, Tanaka, H, et al. Nocturia in men less than 50 years of age may be associated with obstructive sleep apnea syndrome. Urology 2008; 71:1096.
  30. Lowenstein, L, Kenton, K, Brubaker, L, et al. The relationship between obstructive sleep apnea, nocturia, and daytime overactive bladder syndrome in women. Am J Obstet Gynecol 2008; 198:598.
  31. Endeshaw, YW, Johnson, TM, Kutner, MH, et al. Sleep-disordered breathing and nocturia in older adults. J Am Geriatr Soc 2004; 52:957.
  32. Pressman, MR, Figueroa, WG, Kendrick-Mohamed, J, et al. Nocturia. A rarely recognized symptom of sleep apnea and other occult sleep disorders. Arch Intern Med 1996; 156:545.
  33. Fitzgerald, MP, Mulligan, M, Parthasarathy, S. Nocturic frequency is related to severity of obstructive sleep apnea, improves with continuous positive airways treatment. Am J Obstet Gynecol 2006; 194:1399.
  34. Umlauf, MG, Chasens, ER, Greevy, RA, et al. Obstructive sleep apnea, nocturia and polyuria in older adults. Sleep 2004; 27:139.
  35. Krieger, J, Laks, L, Wilcox, I, et al. Atrial natriuretic peptide release during sleep in patients with obstructive sleep apnoea before and during treatment with nasal continuous positive airway pressure. Clin Sci (Lond) 1989; 77:407.
  36. Hakkinen, JT, Shiri, R, Koskimaki, J, et al. Depressive symptoms increase the incidence of nocturia: Tampere Aging Male Urologic Study (TAMUS). J Urol 2008; 179:1897.
  37. Laven, BA, Orsini, N, Andersson, SO, et al. Birth weight, abdominal obesity and the risk of lower urinary tract symptoms in a population based study of Swedish men. J Urol 2008; 179:1891.
  38. Barry, MJ, Fowler, FJ Jr, O'Leary, MP, et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol 1992; 148:1549.
  39. Abrams, P, Klevmark, B. Frequency volume charts: an indispensable part of lower urinary tract assessment. Scand J Urol Nephrol Suppl 1996; 179:47.
  40. Matzkin, H, Greenstein, A, Prager-Geller, T, et al. Do reported micturition symptoms on the American Urological Association Questionnaire correlate with 24-hour home uroflowmetry recordings?. J Urol 1996; 155:197.
  41. Blanker, MH, Bohnen, AM, Groeneveld, FP, et al. Normal voiding patterns and determinants of increased diurnal and nocturnal voiding frequency in elderly men. J Urol 2000; 164:1201.
  42. Pedersen, PA, Johansen, PB. Prophylactic treatment of adult nocturia with bumetanide. Br J Urol 1988; 62:145.
  43. Reynard, JM, Cannon, A, Yang, Q, Abrams, P. A novel therapy for nocturnal polyuria: a double-blind randomized trial of frusemide against placebo. Br J Urol 1998; 81:215.
  44. Ouslander, JG. Management of overactive bladder. N Engl J Med 2004; 350:786.
  45. Edwards, KR, O'Connor, JT. Risk of delirium with concomitant use of tolterodine and acetylcholinesterase inhibitors. J Am Geriatr Soc 2002; 50:1165.
  46. Katz, IR, Sands, LP, Bilker, W, et al. Identification of medications that cause cognitive impairment in older people: the case of oxybutynin chloride. J Am Geriatr Soc 1998; 46:8.
  47. Weiss, JP. Nocturia: "do the math". J Urol 2006; 175:S16.
  48. Rembratt, A, Norgaard, JP, Andersson, KE. Differences between nocturics and non-nocturics in voiding patterns: an analysis of frequency-volume charts from community-dwelling elderly. BJU Int 2003; 91:45.
  49. Fantl, JA, et al. Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Practice Guideline No. 2, 1996 Update. 1996, US Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 96-0682: Rockville, MD.
  50. Diokno, AC, Brown, MB, Goldstein, NG, Herzog, AR. Urinary flow rates and voiding pressures in elderly men living in a community. J Urol 1994; 151:1550.
  51. McConnell, JD, Roehrborn, CG, Bautista, OM, et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med 2003; 349:2387.
  52. Swithinbank, L, Hashim, H, Abrams, P. The effect of fluid intake on urinary symptoms in women. J Urol 2005; 174:187.
  53. Hashim, H, Abrams, P. How should patients with an overactive bladder manipulate their fluid intake?. BJU Int 2008; 102:62.
  54. Johnson, T, Endeshaw, Y, Nagamia, Z, et al. A multicomponent intervention for nocturia in men. J Am Geriatr Soc 2005; 53:S94.
  55. Burgio, KL. Current perspectives on management of urgency using bladder and behavioral training. J Am Acad Nurse Pract 2004; 16:4.
  56. Teunissen, TA, de Jonge, A, van Weel, C, Lagro-Janssen, AL. Treating urinary incontinence in the elderly--conservative therapies that work: a systematic review. J Fam Pract 2004; 53:25.
  57. Burgio, KL, Goode, PS, Locher, JL, et al. Behavioral training with and without biofeedback in the treatment of urge incontinence in older women: a randomized controlled trial. JAMA 2002; 288:2293.
  58. Burgio, KL, Goode, PS. Behavioral interventions for incontinence in ambulatory geriatric patients. Am J Med Sci 1997; 314:257.
  59. Johnson TM, 2nd, Burgio, KL, Redden, DT, et al. Effects of behavioral and drug therapy on nocturia in older incontinent women. J Am Geriatr Soc 2005; 53:846.
  60. Johnson TM, 2nd, Jones, K, Williford, WO, et al. Changes in nocturia from medical treatment of benign prostatic hyperplasia: secondary analysis of the Department of Veterans Affairs Cooperative Study Trial. J Urol 2003; 170:145.
  61. Lepor, H, et al. The efficacy of terazosin, finasteride, or both in benign prostatic hyperplasia. Veterans Affairs Cooperative Studies Benign Prostatic Hyperplasia Study Group. N Engl J Med 1996; 335:533.
  62. de Mey, C, Michel, MC, McEwen, J, Moreland, T. A double-blind comparison of terazosin and tamsulosin on their differential effects on ambulatory blood pressure and nocturnal orthostatic stress testing. Eur Urol 1998; 33:481.
  63. Roehrborn, CG, Van Kerrebroeck, P, Nordling, J. Safety and efficacy of alfuzosin 10 mg once-daily in the treatment of lower urinary tract symptoms and clinical benign prostatic hyperplasia: a pooled analysis of three double-blind, placebo-controlled studies. BJU Int 2003; 92:257.
  64. Andersson, KE. Storage and voiding symptoms: pathophysiologic aspects. Urology 2003; 62:3.
  65. Lepor, H, Theune, C. Randomized double-blind study comparing the efficacy of terazosin versus placebo in women with prostatism-like symptoms. J Urol 1995; 154:116.
  66. Johnson TM, 2nd, Burrows, PK, Kusek, JW, et al. The effect of doxazosin, finasteride and combination therapy on nocturia in men with benign prostatic hyperplasia. J Urol 2007; 178:2045.
  67. Cardozo, L, Lisec, M, Millard, R, et al. Randomized, double-blind placebo controlled trial of the once daily antimuscarinic agent solifenacin succinate in patients with overactive bladder. J Urol 2004; 172:1919.
  68. Ruggieri MR, Sr, Braverman, AS, Pontari, MA. Combined use of alpha-adrenergic and muscarinic antagonists for the treatment of voiding dysfunction. J Urol 2005; 174:1743.
  69. Abrams, P, Kaplan, S, De Koning, Gans HJ, Millard, R. Safety and tolerability of tolterodine for the treatment of overactive bladder in men with bladder outlet obstruction. J Urol 2006; 175:999.
  70. Kaplan, SA, Walmsley, K, Te, AE. Tolterodine extended release attenuates lower urinary tract symptoms in men with benign prostatic hyperplasia. J Urol 2005; 174:2273.
  71. Malone-Lee, JG, Walsh, JB, Maugourd, MF. Tolterodine: a safe and effective treatment for older patients with overactive bladder. J Am Geriatr Soc 2001; 49:700.
  72. Rackley, R, Weiss, JP, Rovner, ES, et al. Nighttime dosing with tolterodine reduces overactive bladder-related nocturnal micturitions in patients with overactive bladder and nocturia. Urology 2006; 67:731.
  73. Kaplan, SA, Roehrborn, CG, Rovner, ES, et al. Tolterodine and tamsulosin for treatment of men with lower urinary tract symptoms and overactive bladder: a randomized controlled trial. JAMA 2006; 296:2319.
  74. Chapple, CR, Cardozo, L, Steers, WD, Govier, FE. Solifenacin significantly improves all symptoms of overactive bladder syndrome. Int J Clin Pract 2006; 60:959.
  75. Garely, AD, Lucente, V, Vapnek, J, Smith, N. Solifenacin for overactive bladder with incontinence: symptom bother and health-related quality of life outcomes. Ann Pharmacother 2007; 41:391.
  76. Wagg, A, Wyndaele, JJ, Sieber, P. Efficacy and tolerability of solifenacin in elderly subjects with overactive bladder syndrome: a pooled analysis. Am J Geriatr Pharmacother 2006; 4:14.
  77. Cvetkovic, RS, Plosker, GL. Desmopressin: in adults with nocturia. Drugs 2005; 65:99.
  78. Asplund, R, Aberg, H. Diurnal rhythm of antidiuretic hormone in elderly subjects with nocturia. Med Sci Res 1991; 19:765.
  79. Moon du, G, Jin, MH, Lee, JG, et al. Antidiuretic hormone in elderly male patients with severe nocturia: a circadian study. BJU Int 2004; 94:571.
  80. Rembratt, A, Graugaard-Jensen, C, Senderovitz, T, et al. Pharmacokinetics and pharmacodynamics of desmopressin administered orally versus intravenously at daytime versus night-time in healthy men aged 55-70 years. Eur J Clin Pharmacol 2004; 60:397.
  81. Rembratt, A, Norgaard, JP, Andersson, KE. Desmopressin in elderly patients with nocturia: short-term safety and effects on urine output, sleep and voiding patterns. BJU Int 2003; 91:642.
  82. Hvistendahl, GM, Riis, A, Norgaard, JP, Djurhuus, JC. The pharmacokinetics of 400 microg of oral desmopressin in elderly patients with nocturia, and the correlation between the absorption of desmopressin and clinical effect. BJU Int 2005; 95:804.
  83. Weatherall, M. The risk of hyponatremia in older adults using desmopressin for nocturia: a systematic review and meta-analysis. Neurourol Urodyn 2004; 23:302.
  84. Ljung, R. Use of desmopressin and concomitant use of potentially interacting drugs in elderly patients in Sweden. Eur J Clin Pharmacol 2008; 64:439.
  85. Rembratt, A, Riis, A, Norgaard, JP. Desmopressin treatment in nocturia; an analysis of risk factors for hyponatremia. Neurourol Urodyn 2006; 25:105.
  86. Chang, YL, Lin, AT, Chen, KK. Short-term effects of desmopressin on water and electrolyte excretion in adults with nocturnal polyuria. J Urol 2007; 177:2227.
  87. Lose, G, Mattiasson, A, Walter, S, et al. Clinical experiences with desmopressin for long-term treatment of nocturia. J Urol 2004; 172:1021.
  88. Mattiasson, A, Abrams, P, Van Kerrebroeck, P, et al. Efficacy of desmopressin in the treatment of nocturia: a double-blind placebo-controlled study in men. BJU Int 2002; 89:855.
  89. Lose, G, Lalos, O, Freeman, RM, van Kerrebroeck, P. Efficacy of desmopressin (Minirin) in the treatment of nocturia: a double-blind placebo-controlled study in women. Am J Obstet Gynecol 2003; 189:1106.
  90. Bae, JH, Oh, MM, Shim, KS, et al. The effects of long-term administration of oral desmopressin on the baseline secretion of antidiuretic hormone and serum sodium concentration for the treatment of nocturia: a circadian study. J Urol 2007; 178:200.
  91. Meyhoff, HH, Nordling, J. Long term results of transurethral and transvesical prostatectomy. A randomized study. Scand J Urol Nephrol 1986; 20:27.
  92. Homma, Y. Classification of nocturia in the adult and elderly patient: a review of clinical criteria and selected literature. BJU Int 2005; 96 Suppl 1:8.
  93. Drake, MJ, Mills, IW, Noble, JG. Melatonin pharmacotherapy for nocturia in men with benign prostatic enlargement. J Urol 2004; 171:1199.
  94. Fonda, D, DuBeau, CE, Hatari, MD, et al. Incontinence in the frail elderly. In: Incontinence. Abrams, P, Cardozo, L, Khoury, S, et al (Eds), Health Publications Ltd, Paris, France 2005.
  95. Tinetti, ME, et al. Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes. JAMA 1995; 273:1348.
  96. Burgio, KL, Locher, JL, Goode, PS. Combined behavioral and drug therapy for urge incontinence in older women. J Am Geriatr Soc 2000; 48:370.
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