A novel therapy for nocturnal polyuria: a double-blind randomized trial of frusemide against placebo

Reducing nocturia in the elderly: a randomized placebo-controlled trial of staggered furosemide and desmopressin

AIMS

The purpose of this study was to investigate efficacy, safety, and impact on quality of sleep of staggered furosemide and desmopressin in the treatment of nocturia in the elderly.

METHODS

Patients aged >60 years with nocturia at least two voids per night were screened for enrollment into the study. A 3-week dose-titration phase established the optimum desmopressin dose (0.1, 0.2, or 0.4 mg). After a 1-week "washout" period, patients who showed sufficient response during the dose-titration period were randomized to receive staggered furosemide and the optimal dose of desmopressin or placebo in a double-blind design for 3 weeks. Voiding diaries were assessed before and after the treatment.

RESULTS

In all, 82 patients were randomized to either staggered furosemide and desmopressin (n=41) or placebo (n=41). In the study group, most patients reported a good response with both reduced nocturnal voids (3.5 vs. 2.0, P<0.01) and urine volume (919.6 ml vs. 584.2 ml, P<0.01). The mean duration of the first sleep period was improved by 70 min (133.6 vs. 203.2, P<0.01). Compared to placebo, staggered furosemide and desmopressin resulted in a significant reduction in the mean number of nocturnal voids (43% vs. 9%; P<0.01), nocturnal urine volume (37% vs. 5%; P<0.01), and increase in the mean duration of the first sleep period (52% vs. 19%, P<0.01). Adverse events were mild.

CONCLUSIONS

Staggered furosemide and desmopressin provide an effective and well-tolerated treatment for nocturia in the elderly.

Self-management for men with lower urinary tract symptoms

Treatment for men with lower urinary tract symptoms (LUTS) has developed into a "cascade" that escalates from watchful waiting through medical treatment to surgery. Self-management can help men to adopt lifestyle and behavioral modifications that will avoid or delay an escalation in treatment and reduce symptoms. Although many of these interventions are advised to men with LUTS, it is usually in a nonstandardized and unsystematic way. Recent work in this area has defined a self-management program for men with uncomplicated LUTS using formal methods and assessed its effectiveness in a randomized controlled trial. Self-management significantly reduced the frequency of escalation through the treatment cascade and reduced urinary symptoms (as effective as medication), suggesting that self-management could be considered as first-line treatment for men with LUTS.

A systematic evaluation of factors associated with nocturia--the population-based FINNO study

In a case-control study with prevalence sampling, the authors explored the correlates for nocturia and their population-level impact. In 2003–2004, questionnaires were mailed to 6,000 subjects (aged 18–79 years) randomly identified from the Finnish Population Register (62.4% participated; 53.7% were female). Questionnaires contained items on medical conditions, medications, lifestyle, sociodemographic and reproductive factors, urinary symptoms, and snoring. Nocturia was defined as ≥2 voids/night. In age-adjusted analyses, factors associated with nocturia were entered into a multivariate model. Backward elimination was used to select variables for the final model, with adjustment for confounding. Although numerous correlates were identified, none affected ≥50% of nocturia cases of both sexes. The factors with the greatest impact at the population level were (urinary) urgency (attributable number/1,000 subjects (AN) = 24), benign prostatic hyperplasia (AN = 19), and snoring (AN = 16) for men and overweight and obesity (AN = 40), urgency (AN = 24), and snoring (AN = 17) for women. Moreover, correlates included prostate cancer and antidepressant use for men, coronary artery disease and diabetes for women, and restless legs syndrome and obesity for both sexes. Although several correlates were identified, none accounted for a substantial proportion of the population burden, highlighting the multifactorial etiology of nocturia.

Diuretic treatment of nocturnal enuresis

OBJECTIVE

Nocturnal polyuria is considered a major pathogenetic factor in nocturnal enuresis, and the antidiuretic drug desmopressin, given at bed-time, is consequently recognized as a first-line treatment alternative. The aim of this open, non-randomized study was to see whether diuretic medication, given in the afternoon, could give similar therapeutic benefit.

MATERIAL AND METHODS

Sixty-three children suffering from primary, monosymptomatic, nocturnal enuresis were included in the study by their primary care paediatrician. After 14 days without any treatment and 14 days for which 0.4 mg of desmopressin was given orally at bed-time, the children were given furosemide 1 mg/kg in the afternoon for 14 consecutive days. The numbers of wet and dry nights were recorded.

RESULTS

The numbers of wet nights at baseline, during desmopressin treatment and during furosemide treatment were 10.2+/-3.5, 6.4+/-4.6 and 8.2+/-4.5, respectively. Both drugs were significantly better than no treatment, but only a small proportion of patients became completely dry: 24% on desmopressin and 12% on furosemide. Desmopressin was significantly better than furosemide. Three children who showed no therapeutic effect on desmopressin treatment had a favourable response to furosemide.

CONCLUSION

Furosemide, given in the afternoon, has minor therapeutic potential in nocturnal enuresis.

A UK consensus on the management of the bladder in multiple sclerosis

Bladder symptoms in multiple sclerosis (MS) are common and distressing but also highly amenable to treatment. A meeting of stakeholders involved in patients' continence care, including neurologists, urologists, primary care, MS nurses and nursing groups was recently convened to formulate a UK consensus for management. National Institute for Health and Clinical Excellence (NICE) criteria were used for producing recommendations based on a review of the literature and expert opinion. It was agreed that in the majority of cases, successful management could be based on a simple algorithm which includes using reagent sticks to test for urine infection and measurement of the post micturition residual urine volume. This is in contrast with published guidelines from other countries which recommend cystometry. Throughout the course of their disease, patients should be offered appropriate management options for treatment of incontinence, the mainstay of which is antimuscarinic medications, in combination, if necessary, with clean intermittent self-catheterisation. The evidence for other measures, including physiotherapy, alternative strategies aimed at improving bladder emptying, other medications and detrusor injections of botulinum toxin A was reviewed. The management of urinary tract infections as well as the bladder problems as part of severe disability were discussed and recommendations agreed.

Alpha-blocker plus diuretic combination therapy as second-line treatment for nocturia in men with LUTS: a pilot study

OBJECTIVES

To determine the efficacy of a diuretic agent, hydrochlorothiazide, as second-line therapy after failed alpha-blocker therapy for men with nocturia.

METHODS

The study inclusion criteria were a < 25% reduction in nocturia using the International Prostate Symptom Score question 7, a < 25% reduction in nocturia using the frequency-volume chart, and/or nocturia > or = 2/night (according to the frequency-volume chart) after 4 weeks of terazosin therapy. A total of 72 patients were entered into the study and treated with 25 mg of hydrochlorothiazide and 4 mg of terazosin once daily for 4 weeks. Of the 72 eligible men, 53 completed the study.

RESULTS

No serious side effects occurred among the treated patients. Using the International Prostate Symptom Score, a reduction of > or = 50%, 25%-49%, 0%-24% and an increase in nocturia was observed in 7, 7, 31, and 8 patients, respectively. Using the frequency-volume chart, 17 patients reported reduced nocturia by more than one half, 5 reported a reduction of 25%-49%, and 31 reported no response to treatment or an increase in nocturia. At baseline, all except for 1 patient had nocturnal polyuria (nocturnal polyuria index > 33%), and, after the combination therapy, the nocturnal polyuria had resolved in 6 (11.5%) of the 52 patients with nocturnal polyuria at baseline.

CONCLUSIONS

Hydrochlorothiazide combined with terazosin was safe and effective in reducing nocturnal frequency for some men after failed terazosin therapy. Our findings suggest that the use of a diuretic agent, such as hydrochlorothiazide, might be a reasonable second-line treatment option for these patients, especially for those with nocturnal polyuria.

Correlates of self-reported nocturia among community-dwelling older adults

BACKGROUND

Nocturia is a common and bothersome problem with multifactorial etiology. This study examines clinical factors that are associated with nocturia among community-dwelling older adults.

METHODS

A questionnaire-based survey was conducted among a convenience sample of community-dwelling older adults. Nocturia was defined as waking up to urinate two or more times per night for 3 or more days per week. Associations between nocturia status and sleep disturbance, daytime sleepiness, disease burden, and history of falls were determined.

RESULTS

Questionnaires were mailed out to 433 participants, and returned questionnaires from 247 individuals (58%) individuals were adequate for analysis. There were 144 women (57%) and 103 men (42%), with mean +/- standard deviation age of 75.1 +/- 6.9 and 76.6 +/- 5.6 years for women and men, respectively. A total of 137 participants (55%) endorsed nocturia, and 57 participants (23%) endorsed nocturia and difficulty going back to sleep. Participants who endorsed nocturia and difficulty going back to sleep were more likely to report poor sleep quality, daytime sleepiness, increased disease burden, one or more falls, and symptoms related to primary sleep disorders.

CONCLUSIONS

The clinical characteristics of study participants with nocturia and difficulty going back to sleep were different from those with nocturia and no difficulty going back to sleep, suggesting that these two conditions may have different etiological factors and clinical consequences. These findings would have important implications in both clinical and research-related activities aimed at the management of nocturia in older adults.

Nocturia in women

Nocturia, the complaint of waking at night to void, is a bothersome condition known to affect Quality of Life. In addition sleep deprivation is also known to affect daytime functioning and productivity. Whilst recently recognised as a discrete clinical entity nocturia is also a symptom of those women complaining of Overactive Bladder (OAB) syndrome. The causes of nocturia are multifactorial although in clinical practice nocturia is generally associated with either increased nocturnal urine production, problems related to bladder storage or sleep pattern abnormalities. When evaluating women complaining of nocturia a urinary diary and clinical examination is integral to making the diagnosis prior to commencing treatment. Having excluded and treated any underlying cause behavioural modification, such as moderation of fluid intake or timing of taking anti-diuretic medication, should be considered first line therapy. Should this conservative approach fail then treatment with antimuscarinic agents or desmopressin, a nona-peptide analogue of anti-diuretic hormone (ADH) is often helpful.

Zolpidem pharmacotherapy combined with alpha-blocker therapy for nocturia unresponsive to alpha-blocker monotherapy in men with lower urinary tract symptoms: a preliminary study

AIM

The aim of the present study was to determine whether administration of zolpidem, a nonbenzodiazepine sedative-hypnotic agent, at night would improve the frequency of nocturia unresponsive to alpha-blocker monotherapy in men with lower urinary tract symptoms (LUTS).

MATERIALS AND METHODS

The study inclusion criteria were: age >/=50 years, nocturia twice or more per night (International Prostate Symptom Score [IPSS] question 7) after taking alpha-blockers for more than eight weeks, and incomplete frequency-flow chart (FVC). A total of 18 patients met the criteria and constituted the study cohort. Three patients were given 0.2 mg tamsulosin once daily and others were given 4 mg terazosin once daily. All patients were additionally administered 10 mg zolpidem once at night for the eight weeks.

RESULTS

There were no serious side-effects in any patient. Nocturia decreased from a baseline median (25-75th percentiles) of 3 (3-5) to 3 (3-4.5) episodes after taking alpha-blockers (p = 0.129) and to 2 (1-3) episodes after taking zolpidem and alpha-blockers (p = 0.001) on the IPSS. After treatment, the scores of uroflowmetry values did not significantly changed. However, at eight weeks, voiding symptoms (p = 0.041) and total IPSS scores (p = 0.028) significantly decreased compared with those at baseline. Median (25-75th percentiles) quality-of-life (QoL) index changed from 5 (4-5) at baseline to 3 (3-3) after eight weeks of treatment (p = 0.005).

CONCLUSION

Our results indicate that zolpidem resulted in a subjective reduction in nocturia episodes when given to some men with LUTS.

Frequency volume charts should be used in men with lower urinary tract symptoms

A frequency volume chart is a simple, easy-to-use, non-invasive tool that is useful in the assessment of patients with lower urinary tract symptoms. Though more sophisticated techniques are now available for diagnosis, the frequency volume chart should still be considered the first line investigation. In this review we summarize the indications and value of this age old investigation. Urologists and primary care physicians should use the frequency volume chart more frequently in their practice.

Pharmacotherapy for Nocturia in the Elderly Patient

Nocturia may be attributable to nocturnal polyuria (nocturnal urine overproduction), a diminished nocturnal bladder capacity or a combination of the two conditions.A disorder of the vasopressin (antidiuretic hormone) system with very low or undetectable levels of vasopressin at night, affecting some elderly people, may cause an increase in the nocturnal urine output, which in the most extreme cases accounts for 85% of the 24-hour diuresis. The increased urine output can be treated with desmopressin orally at bedtime, generally using low doses. Self-imposed fluid restrictions before bedtime are not effective in reducing the nocturnal urine output in this condition. Nocturia is also more prevalent in association with a reduced bladder capacity. Antimuscarinic drugs are used in attempts to depress involuntary bladder contractions. Decreased nocturnal voided volumes in men and consequent increased nocturia may suggest difficulty in emptying the bladder or detrusor overactivity. alpha(1)-Adrenoceptor antagonists and 5alpha-reductase inhibitors are often used in men with symptoms indicative of benign prostatic hyperplasia, and one of their effects is reduction of nocturia. In women, estrogen deficiency, a common consequence of the menopausal transition, causes atrophic changes within the urogenital tract. Consequently, such women are more disposed to having urogenital symptoms, among them nocturia. This review emphasises the importance of correctly diagnosing and treating nocturia in elderly patients. This will improve patients' sleep and, in turn, reduce their risk of fall injuries and the associated detrimental consequences, thereby improving patients' health and quality of life.

Nocturia in women

Nocturia, one of the most bothersome of all urological symptoms, has previously been both poorly classified and understood. Multiple factors may result in nocturia, among which are pathological conditions such as cardiovascular disease, diabetes mellitus, lower urinary tract obstruction, anxiety or primary sleep disorders, and behavioral and environmental factors. Nocturia may be attributed to nocturnal polyuria (nocturnal urine overproduction), diminished nocturnal bladder capacity, polyuria or a combination of the three. These conditions can be distinguished by a simple arithmetic analysis of the patients 24-h voiding diary. After reviewing the current state of knowledge, a scheme for rational diagnosis and care of patients suffering from loss of sleep due to nocturnal micturition is presented in this article.

alpha-blocker monotherapy in the treatment of nocturia in men with lower urinary tract symptoms: a prospective study of response prediction

OBJECTIVE

To determine the efficacy of an alpha-adrenoceptor antagonist, terazosin, in reducing nocturia in men with lower urinary tract symptoms (LUTS), and to identify the factors predicting treatment outcome.

PATIENTS AND METHODS

In all, 100 patients were treated with 2 mg of terazosin once daily for the first 7 days, and continued to receive 4 mg of terazosin once daily for the following 3 weeks. The men were assessed at baseline and at the end of treatment using uroflowmetry, the International Prostate Symptom Score (IPSS), and the degree of nocturia estimated from a frequency-volume chart (FVC) and objectively.

RESULTS

On the FVC, 27 patients reported that the terazosin treatment reduced their nocturia by more than half, and 14 reported a reduction of 25-49%. On the IPSS, 31 patients reported that the treatment reduced their nocturia by more than half and 27 reported a reduction of 25-49%. On multivariate regression analysis, only the actual number of nightly voids on the FVC was associated with a 2.1-fold chance of an improvement of >25% in objective nocturia (P = 0.016). Using a comparable model, a greater nocturia score on the IPSS was associated with a higher likelihood of improvement in subjective nocturia (odds ratio, 1.653; 95% confidence interval, 1.079-2.533; P = 0.021).

CONCLUSION

Treatment with terazosin can reduce patients' episodes of nocturia both subjectively and objectively in some men with LUTS. Our results suggest that both subjective and objective numbers of nocturia episodes are associated with improvements in subjective and objective nocturnal frequencies, respectively.

Diclofenac for treatment of nocturia caused by nocturnal polyuria: a prospective, randomised, double-blind, placebo-controlled crossover study

OBJECTIVES

To investigate the efficacy of diclofenac 50 mg enteric-coated tablet (Non-Steroidal Anti-Inflammatory Drug) in the treatment of nocturnal polyuria.

MATERIALS AND METHODS

26 patients (20 male and 6 female) with a mean age of 72 years (range 52-90) diagnosed with nocturnal polyuria were recruited. The study period comprised 2 weeks of either placebo or active medication taken at 2100 h. Following one-week rest period, patients were crossed over to the other medication for a further 2 weeks. Frequency volume charts were completed during the second week of each of the two study periods along with feedback forms to assess any subjective improvement in symptoms during each of the study periods.

RESULTS

A significant improvement in the symptoms was noted for diclofenac when compared with the placebo. The mean nocturnal frequency decreased from 2.7 to 2.3 (p<0.004) and the mean ratio of night-time to 24 h urine volume decreased from 44% to 39% (p<0.001). No significant side effects were reported.

CONCLUSIONS

NSAIDs are effective in the treatment of nocturnal polyuria causing a decrease in nocturnal frequency with subjective symptom improvement. Our study suggests a novel treatment option for this common condition.

Nocturia in relation to sleep, health, and medical treatment in the elderly

Nocturia is a common condition in the elderly that profoundly influences general health and quality of life. It appears to predict a higher risk of death. One consequence of nocturia is sleep deterioration, with increased daytime sleepiness and loss of energy and activity. Accidents, e.g. falls, are increased both at night and during the day in elderly persons with nocturia. Nocturia is caused by nocturnal polyuria, reduced voided volumes, or a combination of the two. Nocturnal polyuria can be caused by numerous diseases, e.g. diabetes insipidus, diabetes mellitus, congestive heart failure, and sleep apnoea. A disorder of the vasopressin system, with very low or undetectable vasopressin levels at night, is manifested as an increased nocturnal urine output, which in the most extreme cases reaches 85% of the 24-h diuresis: the prevalence of low or undetectable vasopressin levels at night has been estimated to be 3-4% in those aged >or= 65 years. Treatment of nocturia may include avoiding excessive fluid intake and use of diuretic medication in the afternoon rather than the morning, oral desmopressin at bedtime in cases of nocturnal polyuria, and antimuscarinic agents in the case of overactive bladder or impaired storage capacity of the bladder.

Nocturia: morbidity and management in adults

Nocturia is an increasingly prevalent and bothersome urinary symptom associated with considerable impact and morbidity in later life. Nocturnal frequency is associated with a number of underlying pathologies, both related and unrelated to the lower urinary tract. Following careful assessment, diagnosis and management, the condition is amenable to amelioration, if not complete cure in the majority of cases. This paper outlines the epidemiology, underlying pathophysiology and diseases associated with nocturia and reviews current treatment strategies.

Nocturnal polyuria in community-dwelling women

OBJECTIVE

To determine the age prevalence of nocturnal polyuria among older women in the community, and to investigate the relationship between nocturnal polyuria and nocturia.

PATIENTS AND METHODS

In all, 1183 women aged > or = 50 years, who were registered with a family doctor practice and who had taken part in a prevalence study, were sent brief questionnaires and a frequency/volume chart (FVC) to complete.

RESULTS

There were 227 FVCs with adequate data and 264 completed questionnaires available for analysis. The prevalence of nocturnal polyuria increased disproportionately with age. There was no clear relationship between nocturia or nocturnal polyuria and daytime frequency, nor was there a clear relationship between diuretic use and nocturnal polyuria.

CONCLUSION

Nocturnal polyuria is common among women in the community and not obviously related to daytime frequency. Night-time symptoms are common in women as well as men, and are troublesome to them.

Nocturia, nocturnal polyuria, and sleep quality in the elderly

Nocturia is a common symptom in the elderly, which profoundly influences general health and quality of life. One consequence of nocturia is sleep deterioration, with increased daytime sleepiness and loss of energy and activity. Accidents, e.g., fall injuries, are increased both at night and in the daytime in elderly persons with nocturia. Nocturia is caused by nocturnal polyuria, a reduced bladder capacity, or a combination of the two. Nocturnal polyuria can be caused by numerous diseases, such as diabetes insipidus, diabetes mellitus, congestive heart failure, and sleep apnoea. In the nocturnal polyuria syndrome (NPS), the 24-h diuresis is normal or only slightly increased, while there is a shift in diuresis from daytime to night. NPS is caused by a disturbance of the vasopressin system, with a lack of nocturnal increase in plasma vasopressin or, in some cases, no detectable levels of the hormone at any time of the 24-h period. The calculated prevalence of NPS is about 3% in an elderly population, with no gender difference. In NPS, there are serious sleep disturbances, partly due to the need to get up for micturition, but there is also increased difficulty in falling asleep after nocturnal awakenings and increased sleepiness in the morning. The treatment of NPS may include avoidance of excessive fluid intake, use of diuretics medication in the afternoon rather than the morning, and desmopressin orally at bedtime.

Nocturia in older people: a review of causes, consequences, assessment and management

Nocturia is common in older people and it may be bothersome for both patients and carers. It is most commonly related to bladder storage difficulties and nocturnal polyuria. The former results most frequently from an uninhibited overactive bladder. The latter occurs as a consequence of age-associated changes in the circadian rhythm of urine excretion. The management of an overactive bladder includes both behavioural and drug treatment. The management options for nocturnal polyuria include an afternoon diuretic and desmopressin, but caution is required, particularly with the latter, as it can cause significant hyponatraemia.

Melatonin Pharmacotherapy for Nocturia in Men With Benign Prostatic Enlargement

PURPOSE

Nocturia is a common condition often attributed in aging men to benign prostatic enlargement. Older adults are prone to nocturnal sleep disturbance, of which disturbed circadian rhythm may be a component since it improves with nighttime administration of melatonin. This study was designed to investigate melatonin as a potential treatment for nocturia associated with bladder outflow obstruction in older men.

MATERIALS AND METHODS

A total of 20 men with urodynamically confirmed bladder outflow obstruction and nocturia were entered into a randomized, double blind, placebo controlled crossover study assessing the effect of 2 mg controlled release melatonin at night on nocturia. Symptoms were assessed at baseline and after each 4-week treatment period using a frequency volume chart, the International Prostate Symptom Score and symptom problem index. Maximum urinary flow rate and post-void residual urine volume were also assessed.

RESULTS

Baseline frequency of nocturia was 3.1 episodes per night. There were 7 men (35%) with detrusor overactivity and 10 (50%) had nocturnal polyuria. Melatonin and placebo caused a decrease in nocturia of 0.32 and 0.05 episodes per night (p = 0.07) and a decrease in the nocturia bother score of 0.51 and 0.05, respectively (p = 0.008). Nocturia responder rates (a reduction from baseline of at least -0.5 episodes per night) differed between the active medication and placebo groups (p = 0.04). Daytime urinary frequency, International Prostate Symptom Score, relative nocturnal urine volume, maximum urinary flow rate and post-void residual were unaffected by melatonin treatment.

CONCLUSIONS

Melatonin treatment is associated with a significant nocturia response rate, improvement in nocturia related bother and a good adverse effect profile. However, it is uncertain whether the observed changes in this study are clinically significant.

Nocturia

This article reviews the state of knowledge and the algorithms for the diagnosis, classification, and treatment of nocturia. The state of the art in diagnosis, classification, and treatment of nocturia is presented. Nocturia has been poorly classified and poorly understood. Multiple factors may result in nocturia, among which are pathologic conditions such as cardiovascular disease, diabetes mellitus, lower urinary tract obstruction, anxiety or primary sleep disorders, and behavioral and environmental factors. Nocturia may be attributed to nocturnal polyuria (nocturnal urine overproduction), diminished nocturnal bladder capacity, or a combination of the two. Distinction between these conditions is made by a simple arithmetic analysis of the 24-hour voiding diary. Nocturia has been poorly studied and, only recently, has been classified according to its etiology and pathogenesis. Based on a review of the current state of knowledge, this article presents a scheme for the classification and treatment of patients suffering from loss of sleep resulting from nocturnal micturition.

Clinical pharmacology of old age syndromes

Several syndromes occur in old age. They are often associated with increased mortality and in all there is a paucity of basic and clinical research. The recent developments in the clinical pharmacology of three common syndromes of old age (delirium, urinary incontinence, and falls) are discussed along with directions for future research.

Neurological disorders cerebrovascular disease and parkinsonism

To store and expel urine at appropriate intervals, the lower urinary tract requires extensive input and control from the peripheral autonomic, somatic, and central nervous systems. Neurological disorders, such as cerebrovascular disease and Parkinson's disease, often cause functional disturbances of the lower urinary tract.

Incontinência urinária no idoso

A prevalência da incontinência urinária no idoso varia de 8 a 34% segundo o critério ou método de avaliação. A principais causas são: alterações teciduais da senilidade que comprometem o trato urinário inferior e o assoalho pélvico, do sistema nervoso central e periférico, alterações hormonais como a menopausa, poliúria noturna, alterações psicológicas, hiperplasia prostática benigna, doenças concomitantes e efeitos colaterais de medicamentos. A incontinência pode ser transitória ou permanente. Além da anamnese cuidadosa para caracterização das perdas urinárias, a busca de causas associadas ou concomitantes e o diário miccional, recorre-se com freqüência a exames especializados como a urodinâmica. O diagnóstico preciso é importante para o manejo adequado que pode requerer apenas medidas conservadoras baseadas em orientações e mudanças de hábitos, como o uso de medicamentos, ou então métodos invasivos que incluem procedimentos cirúrgicos específicos.

Prognostic significance of the nocturnal decline in blood pressure in individuals with and without high 24-h blood pressure: the Ohasama study

OBJECTIVE

To examine the relationship between the normal nocturnal decline in blood pressure and the risk of cardiovascular mortality in individuals with and without high 24-h blood pressure values.

METHODS

We obtained 24-h ambulatory blood pressure readings from 1542 residents of Ohasama, Japan, who were aged 40 years or more and were representative of the Japanese general population. We then followed up their survival for a mean of 9.2 years. The relationship was analysed using a Cox proportional hazards model adjusted for possible confounding factors.

RESULTS

There was a linear relationship between the nocturnal decline in blood pressure and cardiovascular mortality. On average, each 5% decrease in the decline in nocturnal systolic/diastolic blood pressure was associated with an approximately 20% greater risk of cardiovascular mortality. There were no significant interactions for the risk between 24-h systolic/diastolic blood pressure values and continuous values for the nocturnal decline in blood pressure ( for interaction 0.6). Even when 24-h blood pressure values were within the normal range ( 135/80 mmHg, average 118/69 mmHg), diminished nocturnal decreases in systolic/diastolic blood pressure were associated with an increased risk of cardiovascular mortality.

CONCLUSIONS

This is the first study to demonstrate that a diminished nocturnal decline in blood pressure is a risk factor for cardiovascular mortality, independent of the overall blood pressure load during a 24-h period, in the general population.

Relation between nocturnal voiding frequency and nocturnal urine production in older men:a population-based study

OBJECTIVES

To describe the normal values for nocturnal urine production and its determinants, as well as the relation between nocturnal urine production and voiding frequency.

METHODS

Data were collected from 1688 men aged 50 to 78 years without bladder or prostate cancer, radical prostatectomy, neurogenic bladder dysfunction, or negative advice from their general practitioner. Measurements included self-administered questionnaires, a 3-day frequency-volume chart, transrectal ultrasonography of the prostate, uroflowmetry, and postvoid residual urine volume measurement. The mean nocturnal urine production was computed from the frequency-volume charts. Linear regression analyses were performed to determine associated factors for nocturnal urine production. Areas under the receiver operating characteristic curves were used to describe the discriminative value of nocturnal urine production on nocturnal voiding frequency. A cutoff value for "increased" nocturnal urine production was defined using logistic regression analysis.

RESULTS

The nocturnal urine production was 60.6 mL/hr for the total study population; it increased with age and was significantly higher in men with 24-hour polyuria. Nocturnal urine production was on average higher in men with increased nocturnal voiding frequency, but had only a reasonable discriminative value on nocturnal voiding frequency (areas under receiver operating characteristic curve of 0.71 and 0.76). Nocturnal urine production exceeding 90 mL/hr is suggested as abnormal.

CONCLUSIONS

On average, nocturnal voiding frequency is indicative of nocturnal urine production. However, nocturnal urine production is only a modest discriminator for increased nocturnal voiding frequency. Therefore, the use of nocturnal urine production as an explanatory variable for nocturnal voiding frequency in daily practice is of little value.

Nocturia in relation to sleep, somatic diseases and medical treatment in the elderly

OBJECTIVE

To assess the influence of somatic diseases, symptoms and medication on nocturnal micturition in an elderly population.

SUBJECTS AND METHODS

All 10 216 members of the pensioners' association in two Swedish counties were asked to participate in a questionnaire survey. The questions concerned their general state of health, occurrence of somatic diseases and symptoms, number of voiding episodes per night, and the use of drugs.

RESULTS

There were 6143 evaluable questionnaires, of which 39.5% were from men. The mean (sd) age of the men and women participating were 73.0 (6.0) and 72.6 (6.7) years, respectively. In a multivariate logistic model, significant independent correlates of having > or = 3 nocturnal voids (vs < or = 2 voids) were: being 70-79 years vs < 70 years (odds ratio, OR, 1.7, 95% confidence interval, CI, 1.3-2.2), being > or = 80 years old vs < 70 years (OR, 1.9, CI, 1.3-2.5) and poor sleep vs good sleep (OR, 2.6, CI, 2.1-3.2), sequelae after stroke (OR, 2.0, CI, 1.1-3.6), irregular heart beats (OR, 1.6, CI, 1.2-2.1) and diabetes (OR, 1.5, CI, 1.1-2.3). Sex, spasmodic chest pain and snoring were all deleted by the logistic model.

CONCLUSION

Increasing age, poor sleep, irregular heart beats, diabetes and stroke are associated with an increase in nocturnal micturition in the elderly.

Human atrial natriuretic peptide is a useful criterion in treatment of nocturia

BACKGROUND

Nocturia is one of the major problems of elderly people. The possible causes of nocturia include irritation of lower urinary tract obstruction, disturbance of the fluid balance, and sleep disturbance. In a significant proportion of patients, the mechanism of nocturia is still unclear and a definitive method of treatment has yet to be determined. This study investigated how to treat nocturia.

MATERIALS AND METHODS

We analyzed 51 patients who visited Kobe City General Hospital between January 1998 and June 1999 with nocturia (three or more nocturnal voidings) and no daytime urological problems. Twenty-two of these patients were given daytime diuretic therapy (azosemide 60 mg), while 29 other patients received a minor tranquilizer. The method of treatment was selected randomly. Correlations between the plasma level of atrial natriuretic peptide (hANP) and the effect of treatment were analyzed.

RESULTS

Daytime diuretics decreased the nocturnal frequency of voiding in 10 out of 22 patients. The plasma hANP level at the first visit was significantly higher in the patients with improvement (p = 0.0026). Furthermore, the plasma hANP level was significantly decreased after daytime diuretic therapy in patients who showed improvement of nocturia with diuretic therapy (p = 0.0180). Minor tranquilizer administration decreased nocturia in 22 out of 29 patients. The plasma hANP level at the first visit was significantly lower in the patients who improved (p = 0.0021).

CONCLUSIONS

These findings suggest that patients with higher plasma hANP levels should be treated as having subclinical heart failure, while nocturia in patients with a normal plasma hANP level might be caused by sleep disturbance.

Nocturia in women

Frequent episodes of nocturnal voiding disturb the sleep and well-being of women. The prevalence of nocturia is more common in parous women and shows a linear increase with age, occurring in more than 50% of women > or =80 years old. Nocturia has a multifactorial origin that develops through a pathophysiologic mechanism of nocturnal polyuria or low functional bladder capacity or through a combination of both. Nocturia is also one of the most bothersome lower urinary tract symptoms and has a significant impact on quality of life. However, most women accept symptoms of nocturia as part of the aging process and few seek medical help. Treatments for nocturia (behavior modification and pharmacologic treatment) are effective in many cases, although it is important to tailor treatment to the underlying pathophysiology. This review discusses the impact of nocturia on women and reviews the current situation regarding the definition, prevalence, diagnosis, and treatment of this condition in this patient population.

Voiding and sexual dysfunction after cerebrovascular accidents

PURPOSE

We provide an up-to-date review of the urological manifestations of cerebrovascular accidents and their management, including sexual manifestations.

MATERIALS AND METHODS

We performed a comprehensive MEDLINE search for peer reviewed articles using key words and incorporated these data with our experience with the treatment of patients in an acute stroke unit, rehabilitation unit and ambulatory care center.

RESULTS

The knowledge of urological dysfunction after stroke is based largely on the evaluation of symptomatic patients. The predominant symptoms are urinary frequency, urgency and urge incontinence. Time after stroke has a significant influence on urological findings. Detrusor hyperreflexia is the most common urodynamic finding. Whereas the site and size of the stroke clearly have an influence on urological findings, to our knowledge the effect of the involved hemisphere is unclear. Urinary incontinence as an initial presentation in acute stroke is associated with a high mortality rate. Sexual dysfunction is common in men and women. Co-morbid conditions, such as diabetes mellitus, benign prostatic hyperplasia and urethral incontinence, may complicate evaluation and management.

CONCLUSIONS

A stroke has a profound effect on lower urinary tract function, sometimes resulting in significant morbidity. In well rehabilitated patients sexual dysfunction should be assessed and treatment may be considered to improve quality of life with safety. An overall conservative approach to management is recommended in the initial 3 to 6 months since improvement is common with time.

Nocturnal polyuria in older people: pathophysiology and clinical implications

OBJECTIVES

To review the physiological changes of aging which affect the systems involved in urine formation and to consider how these changes interact with changes in bladder function, thereby leading to the onset of nocturnal polyuria with associated urinary frequency, nocturia, and incontinence. Based on this information, data are presented on the effectiveness of pharmacological interventions which reduce the rate of urine formation and, thus, can be of benefit in reducing symptoms, especially during the nighttime.

METHODS

Peer-reviewed journal articles were identified by MEDLINE Search and by review of the literature.

CONCLUSIONS

As a consequence of age-associated diminished renal concentrating capacity, diminished sodium conserving ability, loss of the circadian rhythm of antidiuretic hormone secretion, decreased secretion of renin-angiotensin-aldosterone, and increased secretion of atrial natriuretic hormone, there is an age-related alteration in the circadian rhythm of water excretion leading to increased nighttime urine production in older people. The interaction of nocturnal polyuria with age-related diminution in functional bladder volume and detrusor instability results in the symptoms of urinary frequency, nocturia and, in some persons, incontinence. The additional impact of Alzheimer's disease on these physiological and aging changes, as well as on a diminished perception of bladder fullness, leads to an even greater risk of urinary incontinence in these patients. Treatment of nocturnal polyuria with the antidiuretic hormone analog, DDAVP (desmopressin), can result in decreased nocturnal urine production with improvement in symptoms of frequency, nocturia, and incontinence.

Relation of nocturnal polyuria of the elderly to essential hypertension

Nocturnal polyuria is common in the elderly. In this condition the normal circadian rhythm of urine production is reversed so that urine flow is higher at night than during the day. Elderly men with nocturnal polyuria are commonly referred for prostate surgery, which, not surprisingly, fails to relieve their symptoms. Compared with controls, patients with nocturnal polyuria have higher nocturnal sodium excretion but not higher nocturnal free-water clearance. Similar results have been obtained in children with nocturnal enuresis. Use of vasopressin analogues to induce water retention in elderly patients with nocturnal polyuria is illogical and potentially hazardous; nocturia can be more safely alleviated by diuretic therapy. Nocturnal polyuria in the elderly is associated with hypertension: this is consistent with studies in younger age groups that show that essential hypertension is associated with nocturia and with increased night/day ratios for sodium excretion. We propose that nocturnal polyuria and essential hypertension share some of the same pathophysiological determinants. Specifically, we suggest that a defect in the nitric-oxide pathway may lead to resetting of the pressure-natriuresis relation in the kidney, sodium retention, and compensatory nocturnal natriuresis. This suggestion is consistent with evidence that ageing and essential hypertension are both associated with defects in the nitric-oxide pathway. Our hypothesis has obvious therapeutic implications. More generally, studying the pathogenesis of nocturnal polyuria in the elderly may advance our understanding of the pathogenesis of essential hypertension.

Evaluation of the etiology of nocturia in men: the nocturia and nocturnal bladder capacity indices

To determine and quantify the cause of nocturia in men, we describe and evaluate the relative contribution of two complementary indices of nocturia: the nocturia index (Ni), a measure of nocturnal urine overproduction, and the nocturnal bladder capacity index (NBCi), reflective of nocturnal bladder capacity. The records of 100 consecutive men with lower urinary tract symptoms (LUTS), having undergone video-urodynamic studies (VUDS), were prospectively studied. Evaluation included American Urological Association symptom score (AUASS), micturition diary (day, night, and 24-hr voided volume), and VUDS. Voiding diary analysis was carried out as previously described by us, determining the Ni, NBCi, and nocturnal polyuria index (NPi) (nocturnal urine volume/24-hr urine volume). In the case of AUASS question #7 (degree of nocturia), the odds of having a severe AUA question #7 response was found to be 4.09 times higher for patients with NBCi > 2.0 compared with patients whose NBCi was </= 2.0 using logistic regression analysis. In comparing patients with severe nocturia and low NBCi with those having mild nocturia and low NBCi, Ni performed in a fashion superior to NPi in identifying relative nocturnal urine overproduction as the suspected explanation for their nocturia (Ni = 3.42 vs. 1.42, P = 0.0002 cf. Npi = 0.44 vs. 0.27, P = 0.018, Mann-Whitney test, respectively). We suggest a discriminating threshold of NBCi > 2 as highly significant in defining diminished NBC as a factor in the etiology of nocturia. In addition, we propose Ni of 1.5 as a threshold greater than which nocturia may be attributed to nocturnal urine overproduction in excess of maximum bladder capacity. Together, these indices describe in quantitative fashion the relative contributions of nocturnal urine overproduction and diminished NBC in identifying the etiology of nocturia in male patients. Neurourol. Urodynam. 18:559-565, 1999.