Nocturia

Overview

Nocturia is defined by the American Urological Association (AUA) as "the need to urinate at least twice during the night." This can occur at any age, although it is less frequent in the age range below 60 years, and becomes more common as the person becomes older. A common pattern seen among people with this condition is an increased number of times to wake to pass urine per decade of life (i.e. once in your sixties, twice in your seventies, etc.). Though this is not a consistent pattern among all individuals with nocturia, it is seen among most.

Nocturnal Polyuria is an important cause of nocturia in which there is an overproduction of urine at night. According to the International Continence Society, it is defined to be nighttime urine volume that is greater than 20-30% of the total 24 hour urine volume and is an age dependent observation.

Global Polyuria is another major cause of nocturia that consists of both day and nighttime urine overproduction.

Prevalence

Studies and research have been few causing nocturia to be misunderstood. Yet, it has recently been recognized as a “clinical entity in its own right;” in other words, it is not just seen by doctors as a symptom, but rather a condition.2

Background

How Urination Occurs:

Urine is produced by the kidneys and travels through the ureters to the bladder to be stored. The bladder is a muscular sac that holds urine until it is ready to be released into the urethra, the tube that connects the bladder to the outside of the body. The bladder is emptied when the detrusor muscle, the muscle within the bladder wall, contracts thereby squeezing urine out of the body. At the same time the bladder contracts, the urinary sphincter relaxes. The relaxed sphincter acts like an open door, which allows the urine to pass and exit the body.

Causes

Nocturia occurs more commonly among older people than younger people. It also occurs in women and men differently since the anatomy between the two is different. Women generally experience nocturia as a result of the consequences from childbirth, menopause, and pelvic organ prolapse. Yet, unlike women, nocturia in men can be directly attributed to benign prostatic hyperplasia (BPH), also known as enlarged prostate.

For both men and women there are multiple factors that could cause nocturia including:

  • Behavioral patterns
  • Diuretic medications
  • Caffeine
  • Alcohol
  • Overactive bladder treatment
  • Excessive fluids before bedtime
  • Diminished nocturnal bladder capacity- This can be due to decreased functional or nocturnal bladder capacity. Urine production will then exceed the bladder capacity causing the individual to be awakened in order to void.
  • Fluid redistribution- When a person lies down to sleep, fluid is reabsorbed into the blood stream. During the day, gravity causes fluid to accumulate in the body’s lower extremities. When this happens, the kidneys clean the increased fluid in the blood by producing more urine. This leads to excess fluid in legs, ankles, and fingers causing them to swell.

Possible Underlying Conditions of Nocturia:

Nocturia, as described above, can be a result of excess fluids before bedtime, medications, alcohol, caffeine, reduced bladder capacity, or diuretic medications. Yet, while nocturia can occur because of these factors, sometimes nocturia is a symptom of a greater problem. Certain conditions can alter the way in which your body functions causing urine to be passed in the evening and during sleep. Such conditions include:

  • Diabetes mellitus
  • Diabetes insipidus
  • High blood pressure
  • Heart disease
  • Congestive heart failure
  • Vascular disease
  • Restless leg syndrome
  • Sleep disorders
  • Insomnia

Treatment

What to do if you have Nocturia:

Consumers need as much information as possible about symptoms and general habits to discuss circumstances with their healthcare providers so they can diagnosis the condition. As mentioned above, a two-day diary must be maintained. When organizing a diary be sure to note some of these points:

  • Take care to mention when you void during the day and night
  • The number of times you wake in order to void
  • Amount of urine voided
  • Drinking patterns (do you drink a lot of fluids in the later afternoon/evening?)
  • What you drink (sugary, caffeinated, artificially sweetened, carbonated, alcoholic drinks, etc.)
  • Medications (do you take diuretics? do you take them in the evening?)
  • Any recurrent urinary tract infections
  • In addition, note any other symptoms that accompany nocturia

This information can help a healthcare provider determine the cause of the problem and the appropriate treatment. At the time of the appointment, you should be prepared to supply such information and details related to personal and family medical history as well as medication usage. In addition to helping you find options to help cure nocturia, it is also important to see a healthcare provider to rule out any other serious problems that may cause nocturia as a side effect. At the appointment you can expect:

  • A physical examination
  • Urinalysis and urine culture:the urinalysis and urine culture are different tests that determine the contents of the urine.

Further tests include:

  • Post-void residual urine measurements: require an ultrasound and are non-invasive procedures that determine the volume of urine left in the bladder after voiding.

If other problems are suspected, you can expect further tests for diagnosis.

What type of professional should you see?

While you may be uncomfortable addressing the issue with others, a medical professional is able to provide you with options to help alleviate and in some cases treat nocturia.

If you believe that you are experiencing nocturia and/or nocturnal polyuria, you should first see a primary care professional such as a family care physician, nurse practitioner, physician’s assistant, or general practitioner. This could also be an internist or geriatrician serving as your primary care provider. Once your provider has determined if, in fact, you have this condition, you should be referred to a specialist:

  • Urologist
  • Urogynecologist
  • Gynecologist
  • Neurologist
  • Sleep Expert
  • Endocrinologist

Treatment Options:

Considering that nocturia has only recently been researched in more depth, treatment options are currently limited. They are also dependent upon the diagnosis and the underlying cause(s) determined by a healthcare professional.5 This is why it is so important to consult a healthcare physician prior to treatment.

Behavioral Therapy:

  • Restriction of Fluid Intake: Limiting the intake of fluids in the evening results in a decreased amount of urine produced in the late evening into the night.
  • Afternoon Naps
  • Elevation of Legs
  • Compression Stockings

The combination of these three behavioral treatments (afternoon naps, elevation of legs, and compression stockings) may reduce fluid build up and help alleviate nocturia, but in some individuals one of these three options is sufficient in reduction and alleviation.

Pharmacological Therapy:

Different medicinal options exist to alleviate and even treat nocturia. These may be used alone or combined with some of the behavioral treatments listed above, which generally have been proven to be more effective. Many studies have shown, however, that while pharmacological treatment may be initially effective in lowering the number of times awakened to void, the medicine is generally effective only as long as it is taken. In other words, relapse rates are high once treatment has stopped, as only symptoms are addressed by the medication rather than the underlying condition or causal factors. The professional medical advice of a healthcare provider should be sought before starting any of these treatments.

Anticholinergic Medications: These prescription medications are effective for treating nocturia due to detrusor overactivity. The main side effects with anticholinergic medications are dry mouth, dizziness, and blurred vision.

  1. Darifenacin: This medication relieves bladder spasms and treats overactive bladder. It basically decreases bladder contractions and increases bladder capacity.
  2. Oxybutynin: This anticholinergic medicine relaxes the detrusor muscle of the bladder. It reduces wet nights in those with nocturnal enuresis and can be combined with bladder volume training. It is available in immediate and time-release tablets as well as transdermal patches.
  3. Tolterodine: This medication is an antimuscarinic [an-tee-mus-kuh-rin-ik] antagonist that is available in both short-and long-acting doses and functions much like oxybutynin.
  4. Trospium Chloride: This anticholinergic medication treats an unstable bladder by blocking cholinergic receptors that are found on muscle cells in the wall of the bladder. Once the receptors are blocked the bladder then can relax so overactivity does not occur.
  5. Solifenacin: This is a recently introduced anticholinergic that is a more selective antimuscarinic agent with fewer anticholinergic side-effects.

If this first line drug therapy is considered ineffective, one or more of the following may be prescribed.

  • Desmopressin: One of the more popular pharmacological options is desmopressin, also known as DDAVP. This medication is an analog of the hormone ADH or vasopressin. By mimicking this hormone, the kidney produces less urine. Taken at night before bedtime, many respond well and do not wake during sleep in order to void when taking the medicine, which comes in the form of a nasal spray or pill. This is also a good option while using other treatments especially when spending the night away from home. Studies have also shown that this treatment is more successful when the drug is slowly discontinued over a period of weeks by weaning the individual from the treatment and then restarting the medication again after some time has been spent without it. In fact, its effects are not long lasting and thus it is most often recommended for short term usage. The most common side effects included mood changes, dry mouth, and sleep disturbances. As a general rule it has been contraindicated for use in the elderly for reasons such as electrolyte imbalance. DDAVP is not generally recommended at high doses for older people because the possible risk of elevation of blood pressure. This has been proven to reduce and/or eliminate nocturia in patients experiencing diabetes insipidus, autonomic dysfunction, and Parkinson’s disease.
  • Imipramine: Although the mechanism of this tricyclic-antidepressant is not known, it has been shown to decrease the production of urine in order to eliminate being awakened to void. This option must be used with extreme caution and would be most appropriate as an alternative option in cases where individuals have not responded to other treatments such as desmopressin. The reason extreme caution needs to be used is because of the more serious side effects, which are heart related problems including the lowering of blood pressure and an increased risk of suicide. The more commonly noted side effects include sleep disturbance, loss of appetite, gastrointestinal symptoms, and in some cases personality changes have been exhibited.
  • Furosemide: This loop diuretic is used in order to regulate urine production in the daytime hours in order to decrease urine production during sleep. Furosemide functions to block ion flow in the kidneys allowing urine production to be more controlled. It is important to consult a healthcare professional to find out if this medication is the right one for you.
  • Bumetanide: This loop diuretic is often used when high doses of furosemide are ineffective. It assists an individual in regulation of urine production prior to sleep so waking during the nighttime does not occur. Bumetanide must be taken with caution and consultation with a healthcare professional prior to taking this medication is highly recommended.

Research

Research by NAFC about nocturia in middle-aged American women was published in the March/April 2011 issue of Urologic Nursing, the official journal of the Society of Urologic Nurses and Associates (SUNA). The purpose of this research was to assess the severity of overactive bladder (OAB) and nocturia in middle-aged American women, their attitudes about seeking treatment and the impact of symptoms of OAB, including nocturia, on quality-of-life.
Click here to download a PDF version of this research.

Conclusion

Nocturia can be a debilitating problem for many people who experience it because of the negative effects of chronic sleep impairment. However, with proper management, motivation, and dedication this condition can be overcome to better the quality of life. Please contact NAFC by e-mail at memberservices@nafc.org or call 1-800-BLADDER. In addition to contacting NAFC, you should visit a healthcare provider to discuss symptoms and receive proper treatment.

This content has been reviewed by Diane Smith RN, MSN, CRNP. Contributing author: Megan Drake