A Contemporary Assessment of Nocturia: Definition, Epidemiology, Pathophysiology, and Management—a Systematic Review and Meta-analysis

Desmopressin for treating nocturia in men

OBJECTIVES

To assess the effects of desmopressin as compared to other interventions in the treatment of nocturia in men.

MATERIALS AND METHODS

We performed a comprehensive search using multiple databases and abstract proceedings with no restrictions on the language of publication or publication status, up until August 2017. We included randomised or quasi-randomised trials. Inclusion criteria were men with nocturia defined as one or more voids per night. Two review authors independently examined full-text reports, identified relevant studies, assessed the eligibility of studies for inclusion, extracted data, and assessed risk of bias. We performed statistical analyses using a random-effects model and assessed the quality of the evidence (QoE) according to Grades of Recommendation, Assessment, Development and Evaluation (GRADE).

RESULTS

We included 14 studies with 2 966 randomised men across five comparisons (we did not include one comparison [desmopressin vs behaviour modification] in the abstract due to a lack of data with regard to primary outcomes). Desmopressin vs placebo: based on short-term follow-up (≤3 months), desmopressin may have a similar effect on the number of nocturnal voids (mean difference [MD] -0.46, 95% confidence interval [CI] -0.94 to 0.01; low QoE). We are uncertain about the effect of desmopressin on major adverse events (risk ratio [RR] 0.97, 95% CI: 0.10-9.03; very low QoE). For intermediate-term follow-up (3-12 months), desmopressin may reduce the number of nocturnal voids in an appreciable number of men (MD -0.85, 95% CI: -1.17 to -0.53; low QoE). Desmopressin may result in little or no difference in major adverse events (RR 3.05, 95% CI: 0.13-73.39; low QoE). We found no evidence on quality of life. Desmopressin vs α-blocker (AB): based on short-term follow-up, desmopressin likely has a similar effect on the number of nocturnal voids (MD 0.30, 95% CI: -0.20 to 0.80; moderate QoE) and quality of life (MD 0.00, 95% CI: -0.35 to 0.35; moderate QoE). There were no major adverse events in either study group. Desmopressin plus AB vs AB alone: based on short-term follow-up, combined therapy likely results in a small, unimportant reduction in the number of nocturnal voids (MD -0.47, 95% CI: -0.73 to -0.21; moderate QoE) and quality of life (MD -0.29, 95% CI: -0.51 to -0.07; moderate QoE). The risk of major adverse events may be similar (RR 0.30, 95% CI: 0.01-7.32; low QoE). Desmopressin plus AB vs AB plus an anticholinergic: based on short-term follow-up, combined therapy likely results in little or no difference in the number of nocturnal voids (MD -0.43, 95% CI: -0.97 to 0.11; moderate QoE). We found no evidence on quality of life. There were no major adverse events in either study group.

CONCLUSIONS

Desmopressin may reduce the number of nocturnal voids compared to placebo up to 12 months of follow-up without increase in major adverse events. The effect on the number of nocturnal voids is likely similar to that of ABs with very infrequent major adverse events. There appears to be no added benefit in the combined use of an AB or an anticholinergic with desmopressin.

Diagnostic and therapeutic recommendations for patients with nocturia

Introduction

Nocturia is defined as the urge to urinate at night when the micturition was directly preceded and followed by sleep. Due to its negative impact on the quality of life of patients, an effective treatment for this disease has become a significant therapeutic challenge. The aim of this article was to explain the main risk factors for the occurrence of nocturia and to present diagnostic and therapeutic schemes in the case of nocturnal polyuria (idiopathic night time polyuria).

Material and methods

A review of the literature was carried out and the available guidelines of international science societies, which provided the basis for the above recommendations, were analyzed.

Results

Detailed medical history should include information concerning: lower urinary tract symptoms (including nocturia), underlying illnesses, urogenital disorders, previous surgeries and medications administered. Keeping a bladder diary is recommended. The physical examination, depending on the patient's gender, should include gynecological examination with pelvic organ prolapse assessment or prostate evaluation. In laboratory tests, a urinalysis may be used, in particular cases a cytological analysis of urine sediment may be carried out. In addition, a possible ultrasound and/or cystoscopy may be conducted. Nocturia therapy should begin with modifying dietary habits, including compliance with the fluid regimen, avoiding alcohol, coffee and tea. Moderate physical exercise is also recommended. The pharmacological treatment of nocturia caused by nocturnal polyuria is based on the use of desmopressin at a daily single dose of 25 µg for women and 50 µg for men. The use of desmopressin allows for the reduction in the number of nocturia episodes, as well as improves the overall quality of life and sleep. Treatment with desmopressin can also be considered as a form of therapy added in people with an overactive bladder or benign prostatic hyperplasia, in which nocturia is a significant clinical problem.

Conclusions

Desmopressin is an effective and safe first-line treatment option in pharmacological therapy of nocturia caused by nocturnal polyuria.

Is It Worth Treating Non-Bothering Nocturia? Results of a Multicenter Prospective Observational Study

Purpose

The purpose of this study was to evaluate the efficacy of treatment in patients with non-bothering nocturia.

Materials and Methods

In this prospective multicenter study, patients who visited hospitals for treatment of voiding symptoms were enrolled. Inclusion criteria were: 1) men >45 years, and 2) nocturia ≥2 confirmed by a three-day voiding diary. Subjects were divided into non-bothering and bothering groups based on International Consultation on Incontinence Questionnaire Nocturia (ICIQ-N) question 2b. Changes in voiding symptoms, frequency of nocturia, and bothersomeness were evaluated with international prostate symptom score (IPSS), ICIQ-N, and three-day voiding diary at 4 and 12 weeks after treatment.

Results

A total of 48 patients in the non-bothering nocturia group and 50 patients in the bothering nocturia group who completed the 12-week treatment were analyzed. The total IPSS was decreased by 5.8 in the non-bothering group and 5.2 in the bothering group. There was no significant difference in decrease of IPSS between the two groups. Both groups showed significant reduction in discomfort of nocturia. The ICIQ-N 2b score decreased from 3.9 to 2.7 (p=0.01) in the non-bothering group and from 6.9 to 4.6 (p=0.02) in the bothering group. The number of nocturia episodes was significantly decreased in both groups.

Conclusions

Regardless of discomfort associated with nocturia, both groups showed significant improvement in nocturia-related discomfort and voiding symptoms. These results suggest that patients with nocturia who were unaware of its discomfort benefited from treatment.

Metabolic syndrome and smoking are associated with an increased risk of nocturia in male patients with benign prostatic enlargement

BACKGROUND

To evaluate the relationship between cigarette smoking, metabolic syndrome (MetS) and nocturia in patients with lower urinary tract symptoms (LUTS) and benign prostatic enlargement (BPE).

METHODS

From 2009 onward, a consecutive series of patients with LUTS/BPE were enrolled. Symptoms were assessed using the International Prostate Symptom Score (IPSS). Age, body mass index (BMI), smoker status, prostate volume (PV), prostate-specific antigen (PSA) levels, fasting glucose levels, triglyceride levels, and high-density lipoprotein levels were recorded. MetS was defined according to Adult Treatment Panel III criteria. Moderate/severe nocturia was defined as nocturnal micturition episodes ≥2.

RESULTS

Overall 492 patients were enrolled with median age and BMI of 68 years (IQR 61/74) and 26.5 kg/m² (IQR: 24/29), respectively. Moderate/severe nocturia was reported in 212 (43.1%) patients. MetS was diagnosed in 147 (29.9%) patients and out of them 89 (60.5%) complained moderate/severe nocturia (p = 0.001). Overall 187 (38%) patients were current smokers and out of them 99 (52%) presented moderate/severe nocturia(p = 0.034). Patients with moderate/severe nocturia were older (p = 0.001) and with larger prostate volume (p = 0.003). On multivariate analysis, age (OR: 1.067 per year, 95% CI: 1.036-1.098; p = 0.001), PV (OR: 1.011 per ml, 95% CI: 1.003-1.019; p = 0.006), MetS (OR: 2.509, 95% CI: 1.571-4.007; p = 0.001) and smoking (OR: 1.690, 95% CI: 1.061-2.693; p = 0.027) were associated with nocturia severity.

CONCLUSIONS

MetS and smoking doubled the risk of moderate/severe nocturia in patients with LUTS and BPE. Assessing smoking and metabolic status in LUTS/ BPE patients is suggested.

A practical approach to the management of nocturia

AIM

To raise awareness on nocturia disease burden and to provide simplified aetiologic evaluation and related treatment pathways.

METHODS

A multidisciplinary group of nocturia experts developed practical advice and recommendations based on the best available evidence supplemented by their own experiences.

RESULTS

Nocturia is defined as the need to void ≥1 time during the sleeping period of the night. Clinically relevant nocturia (≥2 voids per night) affects 2%-18% of those aged 20-40 years, rising to 28%-62% for those aged 70-80 years. Consequences include the following: lowered quality of life; falls and fractures; reduced work productivity; depression; and increased mortality. Nocturia-related hip fractures alone cost approximately €1 billion in the EU and $1.5 billion in the USA in 2014. The pathophysiology of nocturia is multifactorial and typically related to polyuria (either global or nocturnal), reduced bladder capacity or increased fluid intake. Accurate assessment is predicated on frequency-volume charts combined with a detailed patient history, medicine review and physical examination. Optimal treatment should focus on the underlying cause(s), with lifestyle modifications (eg, reducing evening fluid intake) being the first intervention. For patients with sustained bother, medical therapies should be introduced; low-dose, gender-specific desmopressin has proven effective in nocturia due to idiopathic nocturnal polyuria. The timing of diuretics is an important consideration, and they should be taken mid-late afternoon, dependent on the specific serum half-life. Patients not responding to these basic treatments should be referred for specialist management.

CONCLUSIONS

The cause(s) of nocturia should be first evaluated in all patients. Afterwards, the underlying pathophysiology should be treated specifically, alone with lifestyle interventions or in combination with drugs or (prostate) surgery.

An exploratory pilot study with copeptin as a biomarker for individualizing treatment for nocturnal polyuria

OBJECTIVE

The aim of the present study was to investigate the use of random copeptin concentrations as possible biomarkers for the differential diagnosis of nocturnal polyuria (NP).

METHODS

In all, 111 patients with and without nocturia were enrolled in the study. Patients with a neurogenic bladder and/or those who had undergone bladder or urethral surgery were excluded from the study. All patients completed a 72-hour frequency-volume chart and a renal function profile. A random blood sample was obtained during the day for measurement of plasma copeptin concentrations, osmolality, and serum sodium and creatinine concentrations. The effect of the use of different definitions for NP was evaluated.

RESULTS

The median age of the study participants was 61 years, and 48% were female. Copeptin was significantly correlated with urinary and plasma osmolality, as well as free water clearance (r=0.43, 0.56 and -0.38 respectively; P < .001 for all). Study participants were divided into 3 groups: controls (n = 51), those with NP (n = 41), and those with global polyuria (n = 19). Copeptin concentrations were significantly lower in subjects with global polyuria than in those with NP and the control group (2.96 vs 3.97 and 3.94 pM, respectively; P = .008 and .005). There was no significant difference in random daytime copeptin concentrations between the NP and control groups (P = .972). The results differed when other definitions for NP were used (e.g. NPi33 or NUP10).

CONCLUSIONS

We could not confirm our hypothesis that patients with NP have lower copeptin concentrations, although random blood sampling is not ideal. Further research is required to determine the use of copeptin in NP, perhaps in the identification of the desmopressin response.

Desmopressin for treating nocturia in men

BACKGROUND

Nocturia is the bothersome symptom of awakening one or more times per night to void. Desmopressin is a commonly used medication for treating nocturia.

OBJECTIVES

To assess the effects of desmopressin as compared to other interventions in the treatment of nocturia in men.

SEARCH METHODS

We performed a comprehensive search of medical literature with no restrictions on the language of publication or publication status. The date of the latest search of all databases was August 2017.

SELECTION CRITERIA

We included randomized or quasi-randomized trials. Inclusion criteria were men with nocturia defined as one or more voids per night. Trials of children, adults with primary or secondary enuresis or underlying distinct disorders were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently classified studies and abstracted data from the included studies. We performed statistical analyses using a random-effects model and interpreted data according to the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We included 14 studies with 2966 randomized men across five comparisons. Desmopressin versus placebo: based on short-term follow-up (up to three months), desmopressin may have a similar effect on the number of nocturnal voids (mean difference (MD) -0.46, 95% confidence interval (CI) -0.94 to 0.01; low-quality evidence). We are uncertain about the effect of desmopressin on major adverse events at short-term follow-up (risk ratio (RR) 0.97, 95% CI 0.10 to 9.03; very low-quality evidence). For intermediate-term follow-up (three to 12 months), desmopressin may reduce the number of nocturnal voids in an appreciable number of participants (MD -0.85, 95% CI -1.17 to -0.53; low-quality evidence). Desmopressin may result in little or no difference in major adverse events at intermediate-term follow-up (RR 3.05, 95% CI 0.13 to 73.39; low-quality evidence). We found no evidence on quality of life. Subgroup analyses suggest a larger effect with oral, higher-dose formulations of desmopressin and in men with documented nocturnal polyuria. Desmopressin versus behavior modification: there were no data regarding the effect on the number of nocturnal voids, quality of life, or major adverse events. Desmopressin versus alpha-blocker: based on short-term follow-up, desmopressin likely has a similar effect on the number of nocturnal voids (MD 0.30, 95% CI -0.20 to 0.80; moderate-quality evidence) and quality of life (MD 0.00, 95% CI -0.35 to 0.35; moderate-quality evidence). There were no major adverse events in either study group. Desmopressin plus alpha-blocker versus alpha-blocker alone: based on short-term follow-up, combination therapy likely results in a small, unimportant reduction in the number of nocturnal voids (MD -0.47, 95% CI -0.73 to -0.21; moderate-quality evidence) and quality of life (MD -0.29, 95% CI -0.51 to -0.07; moderate-quality evidence). The risk of major adverse events may be similar (RR 0.30, 95% CI 0.01 to 7.32; low-quality evidence). Desmopressin plus alpha-blocker versus alpha-blocker plus an anticholinergic: based on short-term follow-up, combination therapy likely results in little or no difference in the number of nocturnal voids (MD -0.43, 95% CI -0.97 to 0.11; moderate-quality evidence). We found no evidence on quality of life. There were no major adverse events in either study group.

AUTHORS' CONCLUSIONS

Desmopressin may reduce the number of nocturnal voids in an appreciable number of participants compared to placebo in intermediate-term (three to 12 months) follow-up without increase in major adverse events. We found no evidence to compare its effects to behavior modification. The effect on the number of nocturnal voids is likely similar to that of alpha-blockers short-term with very infrequent major adverse events. There appears to be no added benefit in the combined use of desmopressin with an alpha-blocker or an anticholinergic. The findings of this review were limited by short-term follow-up, study limitations, and imprecision.

Can we define and characterize the aging lower urinary tract?-ICI-RS 2015

The prevalence of lower urinary tract (LUT) symptoms increases with age but the etiology is unknown. This article aims to identify research directions that clarify the basis of this association. The initial question is whether biological age is the variable of interest or a time-dependent accumulation of factors that impact on LUT function at rates that differ between individuals. In particular, the accumulation of conditions or agents due to inflammatory states or tissue ischemia is important. Much of the above has been concerned with changes to bladder function and morphology. However, the outflow tract function is also affected, in particular changes to the function of external sphincter skeletal muscle and associated sacral motor nerve control. Nocturia is a cardinal symptom of LUT dysfunction and is more prevalent with aging. Urine production is determined by diurnal changes to the production of certain hormones as well as arterial blood pressure and such diurnal rhythms are blunted in subjects with nocturia, but the causal links remain to be elucidated. Changes to the central nervous control of LUT function with age are also increasingly recognized, whether in mid-brain/brainstem regions that directly affect LUT function or in higher centers that determine psycho-social and emotional factors impinging on the LUT. In particular, the linkage between increasing white matter hyperintensities and LUT dysfunction during aging is recognized but not understood. Overall, a more rational approach is being developed to link LUT dysfunction with factors that accumulate with age, however, the precise causal pathways remain to be characterized. Neurourol. Urodynam. 36:854-858, 2017. © 2017 Wiley Periodicals, Inc.

Desmopressin for nocturia in adults

Desmopressin has been used for many years in the treatment of diabetes insipidus, nocturnal enuresis (involuntary urination while asleep) and nocturia associated with multiple sclerosis (in adults aged up to 65 years); it has also been recommended in certain circumstances for the treatment of nocturia in men and women (previously, an unlicensed use).^1,2 Recently, a new brand of desmopressin sublingual tablet (lyophilisate-an orally disintegrating tablet; Noqdirna-Ferring) has been licensed for use in adults of any age for the treatment of nocturia due to idiopathic nocturnal polyuria.^3,4 The tablets contain a lower dose of desmopressin than was previously available. Unusually, there are different recommended doses for men and women. In this article, we consider the evidence on desmopressin in the treatment of idiopathic nocturnal polyuria in adults, and how this new formulation fits with current management strategies.

[Algorithms and urinary incontinence in the elderly. Assessment, treatment, recommendations and levels of evidence. Review]

OBJECTIVES

Search processing algorithms in a primary care setting, analyzing the specifics of care management for seniors suffering from urinary incontinence (UI), described the recommendations and levels of evidence of treatment.

METHODS

A literature review carried out via PubMed^® and websites of scientific societies with search keywords classified according to an algorithm.

RESULTS

One hundred algorithms have been discovered in the field of evaluation and treatment of UI. Screening for UI risk factors began early on in the treatment of reversible or chronic comorbidities, avoiding iatrogenic. Specific clinical features (red flags) required specialized advice. Non-pharmacological conservative treatment should be offered first in line for seniors: behavioral therapy, changes in lifestyle, walk, treatment of constipation. For women, pelvic floor muscle training combined biofeedback and functional electrical stimulation. After failure and persistence of UI with urgency, the information of the risk of a possible urinary retention or cognitive impairments preceded the prescription of an anticholinergic and the measurement of post-voiding residue done by ultrasounds. Older age is not a cons-indication for surgery UI least invasive. The cough test and Bonney maneuver can confirm a masked stress urinary incontinence and/or an associated prolapse. Cases of failure of UI, doubtful diagnosis or programmed surgery required urodynamic assessment.

CONCLUSION

Algorithms and recommendations of UI should remain a valuable aid to the clinical assessment, diagnosis and treatment of UI in the elderly.

Analysis of the Prevalence and Factors Associated with Nocturia in Adult Korean Men

This study investigated the prevalence of and factors associated with nocturia in Korean men. A total of 92,626 participants aged between 19 and 103 years from the 2011 Korean Community Health Survey (KCHS) were enrolled. Simple and multiple logistic regression analyses with complex sampling investigated participants’ personal health and socioeconomic and disease factors. The prevalence of nocturia ≥1 time and ≥2 times/night was 41.8% and 17.6%, respectively, and nocturia increased with age (1.44 [1.39–1.50] for each 10-year increase, P < 0.001). Lower income levels (lowest, 1.27 [1.19–1.36]; low-middle, 1.13 [1.07–1.19]; upper-middle, 1.00 [0.95–1.06], P = 0.022) and higher levels of stress (severe, 1.38 [1.23–1.55]; moderate, 1.23 [1.16–1.31]; some, 1.11 [1.05–1.16]) exhibited dose-dependent relationships with nocturia (≥1 time; P < 0.001). Low education level (1.27 [1.20–1.36]), long sleep duration (1.33 [1.18–1.50]), and type of occupation showed significant associations with nocturia (≥1 time; P < 0.001). Underweight (1.19 [1.05–1.34]), hypertension (1.09 [1.03–1.15]), diabetes mellitus (1.32 [1.23–1.41]), hyperlipidaemia (1.28 [1.20–1.35]), and cerebral stroke (1.63 [1.40–1.89]) were significantly related to nocturia (≥1 time; P < 0.001). Married men were less likely to experience nocturia ≥2 times per night (0.72 [0.64–0.82], P < 0.001).

Does the Age of Donor Kidneys Affect Nocturnal Polyuria in Patients With Successful Real Transplantation?

BACKGROUND

We investigated whether the age of donor kidneys influences the incidence of nocturnal polyuria in patients with successful renal transplantation (RTX).

METHODS

Eighty-five patients (45 men and 40 women) undergoing RTX (median age, 47 years) were included in this study. Twenty-four-hour bladder diaries were kept for 3 days, and nocturnal polyuria was defined as a nocturnal polyuria index (nocturnal urine volume/24-hour urine volume) of >0.33. Risk factors for nocturnal polyuria were analyzed in patients with RTX by means of the Mann-Whitney U test, χ² test, and a logistic regression analysis.

RESULTS

End-stage renal disease (ESRD) developed from diabetes mellitus in 16 patients (19%). Sixty-five patients (76%) received pre-transplant dialysis, with a median duration of 5 years. The median serum creatinine level and body mass index at the most recent visit were 1.2 mg/dL and 21.2 kg/m², respectively. On the basis of the 24-hour bladder diaries, nocturnal polyuria was identified in 48 patients (56%). A logistic regression analysis revealed that diabetes mellitus as the original disease for ESRD was the only risk factor for nocturnal polyuria (odds ratio, 8.95; 95% confidence interval, 2.01-65.3; P = .0028). The age of donor kidneys at examination did not affect the incidence of nocturnal polyuria (P = .9402).

CONCLUSIONS

Nocturnal polyuria was not uncommon in patients with successful RTX. Diabetes mellitus as the original disease for ESRD was the only risk factor for nocturnal polyuria, whereas the age of donor kidneys at examination did not affect the incidence of nocturnal polyuria. Thus, nocturnal polyuria is caused by recipient factors but not donor factors.

The Prevalence of Nocturia and Nocturnal Polyuria: Can New Cutoff Values Be Suggested According to Age and Sex?

PURPOSE

The aims of this study were to assess the prevalence of nocturia and nocturnal polyuria (NP) and to define new cutoff values according to age and sex for both conditions.

METHODS

Data from a population-based prevalence survey conducted among a random sample of 2,128 adults were analyzed in this study. Participants were requested to fill out a questionnaire including the International Continence Society (ICS) definitions of lower urinary tract symptoms and the International Consultation on Incontinence Questionnaire - Short Form. Additionally, a 1-day bladder diary was given to each individual. The participants were divided into 5 age groups. The prevalence of nocturia was calculated based on definitions of nocturia as ≥1 voiding episodes, ≥2 episodes, and ≥3 episodes. NP was evaluated according to the ICS definition. The mean±standard errors and 95th percentile values were calculated in each group as new cutoff values for NP.

RESULTS

The prevalence of nocturia was estimated as 28.4%, 17.6%, and 8.9% for ≥1, ≥2, and ≥3 voiding episodes each night, respectively. When nocturia was defined as 2 or more voiding episodes at night, the prevalence decreased significantly. The mean NP index was 29.4%±15.0% in men and 23.1%±11.8% in women. For the age groups of <50 years, 50-59 years, and ≥60 years, the new cutoff values for the diagnosis of NP were calculated as 48%, 69%, and 59% for men and 41%, 50%, and 42% for women, respectively.

CONCLUSIONS

We found that the definition of nocturia was still controversial and that waking up once for voiding might be within the normal spectrum of behavior. The definition of NP should be modified, and new cutoff values should be defined using the data presented in our study and in other forthcoming studies.

Nocturnal Polyuria in Older Women with Urge Urinary Incontinence: Role of Sleep Quality, Time in Bed and Medications Used

PURPOSE

Nocturia is common and bothersome in older adults, especially those who are also incontinent. Since nocturnal polyuria is a major contributor, we examined factors associated with nocturnal polyuria in this population to identify those possibly amenable to intervention.

MATERIALS AND METHODS

We analyzed baseline data from 2 previously completed studies of urge urinary incontinence. The studies involved 284 women (mean age ± SD 72.9 ± 7.9 years) who also completed 3-day voiding diaries. Participants with a nocturnal polyuria index greater than 33% were categorized as having nocturnal polyuria (nocturnal polyuria index = nocturnal urinary volume per 24-hour urine volume). Associations between nocturnal polyuria and various demographic, clinical and sleep related parameters were determined.

RESULTS

Overall 55% of the participants had nocturnal polyuria. Multivariable regression analysis revealed that age, body mass index, use of angiotensin converting enzyme inhibitor/angiotensin receptor blocker, time spent in bed and duration of first uninterrupted sleep were independent correlates of nocturnal polyuria. Participants with a larger nocturnal excretion reported a shorter duration of uninterrupted sleep before first awakening to void and worse sleep quality despite spending similar time in bed.

CONCLUSIONS

Body mass index, use of angiotensin converting enzyme inhibitor/angiotensin receptor blockers, time in bed and duration of uninterrupted sleep before first awakening to void are independently associated with nocturnal polyuria in older women with urge urinary incontinence, and are potentially modifiable. These findings also confirm the association between sleep and nocturnal polyuria. Further studies should explore whether interventions to reduce nocturnal polyuria and/or increase the duration of uninterrupted sleep before first awakening to void would help to improve sleep quality in this population and thereby reduce or eliminate the need for sedative hypnotics.

Treatment Options for Urogenital Dysfunction in Parkinson's Disease

Urogenital dysfunction is commonly reported in Parkinson’s disease (PD), and history taking and a bladder diary form the cornerstone of evaluation. The assessment of lower urinary tract (LUT) symptoms include urinalysis, ultrasonography, and urodynamic studies and help to evaluate concomitant urological pathologies such as benign prostate enlargement. Antimuscarinic medications are the first line treatment for overactive bladder (OAB) symptoms and solifenacin has been specifically studied in PD. Antimuscarininc drugs may exacerbate PD-related constipation and xerostomia, and caution is advised when using these medications in individuals where cognitive impairment is suspected. Desmopressin is effective for the management of nocturnal polyuria which has been reported to be common in PD. Intradetrusor injections of botulinum toxin have been shown to be effective for detrusor overactivity, however, are associated with the risk of urinary retention. Neuromodulation is a promising, minimally invasive treatment for PD-related OAB symptoms. Erectile dysfunction is commonly reported and first line treatments include phosphodiesterase-5 inhibitors. A patient-tailored approach is required for the optimal management of urogenital dysfunction in PD.

Nocturia in Parkinson's Disease: Why Does It Occur and How to Manage?

BACKGROUND

Nocturia is one of the commonest nonmotor symptoms in Parkinson's disease (PD) and has a significant impact on quality of life both for patients and their carers. There exists a relation between nocturia and poor sleep quality, falls, and institutionalization. Nocturia may manifest as a result of reduced functional bladder capacity or nocturnal polyuria; however, most often the cause is multifactorial. Disorders of circadian rhythm regulation are known to occur with sleep disturbances in PD may also contribute to nocturia.

METHODS AND RESULTS

In this review, an overview of the assessment and management of nocturia in patients with PD is presented. History taking, medication review, and a bladder diary form the cornerstone of the evaluation. Urinalysis, ultrasonography, and urodynamic studies help to assess the cause for lower urinary tract symptoms and exclude concomitant pathologies, such as bladder outlet obstruction. Antimuscarinic medications are the first-line treatment for the overactive bladder; however, caution is needed when using these medications in individuals predisposed to cognitive impairment. Desmopressin is effective for managing nocturnal polyuria.

CONCLUSIONS

An individualized approach is recommended to optimize the management of nocturia in PD.

Nocturia: aetiology and treatment in adults

Nocturia is an extremely common condition that has major sequelae for affected patients. Through disruption of sleep, nocturia impairs quality of life and worsens health outcomes, and is associated with a variety of morbidities including diabetes, coronary artery disease, obstructive sleep apnoea, obesity, metabolic syndrome, and depression. Unsurprisingly, several studies have also linked nocturia with reduced survival. Nocturia is not simply a consequence of lower urinary tract disease; rather, it is a multifactorial disorder that is often a manifestation of an underlying renal or systemic disease. Through the use of the frequency volume chart, clinicians can accurately quantify nocturia and determine its aetiology. Evaluation of quality of life and sleep using simple measures is essential in order to assess the impact of nocturia on a patient. Numerous treatment options for nocturia exist, but most are associated with minor benefit or lack sufficient evidence supporting their use. By systematically analysing an individual's causes of nocturia, clinicians can design appropriate treatment strategies to most effectively treat this condition.

Nocturia: The circadian voiding disorder

Nocturia is a prevalent condition of waking to void during the night. The concept of nocturia has evolved from being a symptomatic aspect of disease associated with the prostate or bladder to a form of lower urinary tract disorder. However, recent advances in circadian biology and sleep science suggest that it might be important to consider nocturia as a form of circadian dysfunction. In the current review, nocturia is reexamined with an introduction to sleep disorders and recent findings in circadian biology in an attempt to highlight the importance of rediscovering nocturia as a problem of chronobiology.

Benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH), which causes lower urinary tract symptoms (LUTS), is a common diagnosis among the ageing male population with increasing prevalence. Many risks factors, both modifiable and non-modifiable, can increase the risk of development and progression of BPH and LUTS. The symptoms can be obstructive (resulting in urinary hesitancy, weak stream, straining or prolonged voiding) or irritative (resulting in increased urinary frequency and urgency, nocturia, urge incontinence and reduced voiding volumes), or can affect the patient after micturition (for example, postvoid dribble or incomplete emptying). BPH occurs when both stromal and epithelial cells of the prostate in the transitional zone proliferate by processes that are thought to be influenced by inflammation and sex hormones, causing prostate enlargement. Patients with LUTS undergo several key diagnostic investigations before being diagnosed with BPH. Treatment options for men with BPH start at watchful waiting and progress through medical to surgical interventions. For the majority of patients, the starting point on the treatment pathway will be dictated by their symptoms and degree of bother.

Effect of nocturia on next-day sedentary activity in adults with type 2 diabetes

PURPOSE

Nocturia, a common cause of disturbed sleep quality and next-day fatigue, may contribute to difficulty with diabetes self-management. The purpose of this study was to examine the effect nocturia has on next-day subjectively measured mental and physical energy and objectively measured physical activity.

METHODS

This secondary analysis utilized sleep diaries over one week which measured nocturia frequency and other sleep quality indicators (wake after sleep onset, sleep quality and sleep duration) along with next-day reports of mental and physical energy. Next-day physical activity was measured with the BodyMedia Sensewear armband.

RESULTS

Sleep quality and sleep duration were associated with next-day physical and mental energy. Nocturia frequency (≥2 times per night) was associated with increased next-day sedentary activity.

CONCLUSION

These results suggest that nocturia could negatively affect next-day physical activity in people with diabetes.

Advances in the management of primary monosymptomatic nocturnal enuresis in children

Intermittent incontinence of urine in a sleeping child who has previously been dry for less than 6 months without any other lower urinary tract symptoms is considered to be primary monosymptomatic nocturnal enuresis (PMNE). Although, most children outgrow PMNE with age, the psychological impact on the child warrants parental education and patient motivation and treatment. Motivational therapy, alarm therapy and drug therapy are the mainstay of treatment. Motivational and alarm therapy have better success rates than drug therapy alone. Desmopressin is the commonly used first-line drug and is best for short-term relief. Other drugs such as anti-cholinergics, imipramine and sertraline are used in resistant cases. This review focuses on the assessment and treatment of PMNE.

Practical points in the medical treatment of overactive bladder and nocturia in the elderly

The prevalence of overactive bladder (OAB) increases with age. Degeneration of the central nervous system in the elderly has been proposed as one of the pathogenic factors of OAB. Antimuscarinic therapy is effective in the treatment of OAB; however, intolerable systemic adverse events and cognitive dysfunction during treatment with nonselective antimuscarinic agents is of growing concern in elderly patients. The newly developed beta-3 adrenoceptor agonist mirabegron does not adversely affect flow rate and detrusor pressure, and its therapeutic efficacy and tolerability are similar in patients aged > 65 years and > 75 years, suggesting it might be the therapeutic choice in older patients with OAB. Nocturia can cause sleep deprivation at night and increase daytime sleepiness and loss of energy in the elderly. Desmopressin add-on therapy is effective in improving nocturia and storage symptoms. However, elderly patients with a baseline serum sodium level below the normal range are at high risk of developing significant hyponatremia.

Nocturia in Patients With Parkinson's Disease

Background

Waking up from sleep more than once to pass urine, known as nocturia, is an important nonmotor symptom in Parkinson's disease (PD). Very little is known about the cause for nocturia. The aim of this work was to evaluate lower urinary tract (LUT) symptoms in patients with PD reporting nocturia using standardized validated questionnaires and bladder diaries and to assess the impact of nocturia on quality of life and sleep.

Methods

Twenty-three consecutive patients with PD (17 males, 6 females; mean age: 68.5 years; range, 50-85) referred to a specialist uro-neurology clinic reporting nocturia according to the International Continence Society definition were included. Patients measured their daily fluid intake, urinary output per void, and recorded these with the timing of voids on a 3-day bladder diary. Standardized questionnaires were used to assess LUT symptoms (Urinary Symptom Profile, International Prostate Symptom Score, and Qualiveen Short Form) and sleep quality (Parkinson's Disease Sleep Scale).

Results

Mean duration of PD was 10.1 years, and mean severity on H & Y scale was 3.0 (range, 1.0-5.0). Median duration of LUT symptoms was 6.0 years. Mean night-time urinary frequency was 3.5 (range, 1.0-7.3), and mean nocturnal maximum voided volume was 242 mL. Mean Nocturnal Polyuria Index (NPi) was 0.4 (range, 0.13-0.75), and 13 patients (56.5%) had nocturnal polyuria (NPi > 0.33). Patients with nocturnal polyuria reported more-severe LUT symptoms that impacted quality of life and sleep.

Conclusions

In this preliminary study, nocturnal polyuria seems to be common in patients with PD reporting nocturia and appears to affect quality of life and sleep, though this was not statistically significant. The bladder diary is an essential tool in the assessment of nocturia in patients with PD.

Overactive bladder

Overactive bladder syndrome is highly prevalent, and increasingly so with aging. It is characterized by the presence of urinary urgency, and can be associated with incontinence, increased voiding frequency, and nocturia. Assessment needs to exclude serious medical disorders that might present with similar symptoms, and a bladder diary is an invaluable part of understanding the presentation. Initial management is conservative, comprising education, bladder training, and advice on fluid intake. Drug therapy options include antimuscarinic medications and beta-3 adrenergic receptor agonists. Persistent overactive bladder syndrome, despite initial therapy, requires a review of the patient’s understanding of conservative management and compliance, and adjustment of medications. For refractory cases, specialist review and urodynamic testing should be considered; this may identify detrusor overactivity or increased filling sensation, and needs to exclude additional factors, such as stress incontinence and voiding dysfunction. Botulinum neurotoxin-A bladder injections can be used in severe overactivity, provided the patient is able and willing to do intermittent self-catheterisation, which is necessary in about 5% of treated patients. Sacral nerve stimulation and tibial nerve stimulation are other approaches. Major reconstructive surgery, such as augmentation cystoplasty, is rarely undertaken in modern practice but remains a possibility in extreme cases.

The Effectiveness of Silodosin for Nocturnal Polyuria in Elderly Men With Benign Prostatic Hyperplasia: A Multicenter Study

Purpose:

To investigate improvement in nocturia and nocturnal polyuria in nocturnal polyuria patients after silodosin administration by using a 3-day frequency volume chart.

Methods:

This was a prospective multicenter study. We enrolled nocturnal polyuria patients (nocturnal polyuria index [NPi]>0.33), aged ≥60 years, diagnosed with the 3-day frequency volume charts of patients with benign prostatic hyperplasia taking α-blockers. Of the 54 patients, 30 (55.6%) completed the study according to the study protocol (per-protocol group), and 24 dropped out (dropout group).

Results:

Of the 24 patients in the dropout group, 5 withdrew consent due to side effects or lack of efficacy, 7 were lost to follow-up at 4 weeks, 8 were lost to follow-up at 12 weeks, and 4 dropped out due to failure to complete 3-day frequency volume charts at 12 weeks. In the per-protocol group, there was significant improvement in the International Prostate Symptom Score (IPSS), especially question numbers 1, 3, 4, 5, 6, 7, and the quality of life question (P=0.001, P=0.007, P<0.001, P=0.003, P=0.049, P<0.001, and P<0.001, respectively). The Leeds sleep evaluation questionnaire (LSEQ) score for the sleep question improved from 64.36 to 70.43 (P=0.039). The NPi reduced from 0.4005 to 0.3573 (P=0.027); however, in many cases, there was no improvement in nocturnal polyuria itself. In intention-to-treat analysis, there were significant improvements in IPSS and LSEQ in 45 patients.

Conclusions:

In elderly nocturnal polyuria patients, silodosin monotherapy exhibits good efficacy in improving nocturia and nocturnal polyuria; however, the mean NPi was still >0.33. Considering the high dropout rate of our study due to no implementation of 3-day frequency volume charts, prospective and large-scale studies are needed to confirm our results.

Analyzing Why Men Seek Treatment for Lower Urinary Tract Symptoms and Factors Associated With Nonimprovement

OBJECTIVE

To determine the motivating factor for why men seek urologic care and determine persistence of these symptoms and any factors that influence resolution.

METHODS

Men presenting to an outpatient urology clinic with lower urinary tract symptoms (LUTSs) were prospectively evaluated. At each of 2 visits, surveys were administered including the American Urological Association Symptom Index and a chief LUTS complaint (CLC) identification form. On the CLC identification form, symptoms were considered "transient" if only seen at V1 and "persistent" if they were selected at both visits.

RESULTS

Sixty-five percent of the 1240 participants were able to specify a CLC. Among these, nocturia was by far the most common and was found to be persistent in 49% of cases. When comparing the groups of patients who presented with transient verses persistent nocturia, older age (P <.001), diabetes (P = .006), hypertension (P = .033), alpha-blocker use (P = .018), 5-alpha-reductase inhibitor use (P = .008), higher nocturia severity (P <.001), and more severe American Urological Association Symptom Index scores at initial visit (P = .047) were found to be predictors of persistent nocturia.

CONCLUSION

Most men with LUTS can identify a predominant CLC. Of these, nocturia is the primary CLC of most men and does not improve in almost 50% of those studied. By improving our identification of a predominant CLC and the patient factors that influence both the development and persistence of urinary symptoms, we may start to better evaluate and hopefully focus treatment on the most bothersome urinary symptom.

Combination therapies for the management of nocturia and its comorbidities

Nocturia is the most bothersome lower urinary tract symptom. It has a multifactorial etiology. It had been thought nocturia was a nonspecific symptom of lower urinary system dysfunction, but it has been determined that many diseases, related to different organ systems, might be reasons for this nonspecific symptom. Along with the importance of systemic diseases that cause nocturia, the symptom itself has adverse effects on patients’ health and quality of life. There are several studies reporting a direct relationship between nocturia and depression, cognitive dysfunction, mood disturbances, falls, and fractures. For this reason, it is important to treat nocturia both to increase quality of life and to decrease related complications. Treatment opportunities have been under investigation for 20 years. Most of the studies in the literature have reported the results of single-drug medication on nocturia, which may be insufficient for a situation that has such a multifactorial etiology. In this review, we evaluated the success of different treatment combinations on nocturia.

Nocturnal enuresis and nocturia, differences and similarities - lessons to learn?

This review highlights the current views on and differences and similarities between nocturnal enuresis (NE) in children and nocturia in adults, which might be a guidance to elucidate the missing links in our knowledge. In both conditions, a genetic factor is suspected. Reduced bladder capacity and nocturnal polyuria are the main underlying lower urinary tract-related conditions. There is a link with sleep disorders, although it is not clear whether this is a cause or consequence. Physical and mental health are comprised in both conditions, however, in different ways. In NE, constipation and attention deficit disorder are the most important comorbidities and the effect on mental health and quality of life is mainly through the negative impact on self-esteem. In nocturia, cardiovascular disease and fall injuries are important comorbidities, mainly affecting the older nocturia population; personal distress and depression are consequences of the related poor sleep quality. For both conditions, treatment is often inadequate and a more individualized approach seems to be necessary. The main difference between NE and nocturia seems to be the difference in arousal to bladder stimuli, suggesting that sleep characteristics might be a key factor in these conditions.

Management of nocturia in the female

Nocturia is a common but overlooked lower urinary tract symptom that substantially reduces patient health and quality of life. Though traditionally viewed as occurring predominantly in males, nocturia has been found to be equally as prevalent in females. The recent emphasis on the importance of nocturia has resulted in a surge of research studies, providing a foundation for current and future management decisions. In this review, we describe the current recommendations for the female patient in light of the most recently published studies, including a unique interest in predicting treatment response.