Nocturia: new directions

Impact of sleep on chronobiology of micturition among healthy older adults

Nocturia (waking to void) is prevalent among older adults. Disruption of the well-described circadian rhythm in urine production with higher nighttime urine output is its most common cause. In young adults, their circadian rhythm is modulated by the 24-h secretory pattern of hormones that regulate salt and water excretion, including antidiuretic hormone (ADH), renin, angiotensin, aldosterone, and atrial natriuretic peptide (ANP). The pattern of hormone secretion is less clear in older adults. We investigated the effect of sleep on the 24-h secretion of these hormones in healthy older adults. Thirteen participants aged ≥65 yr old underwent two 24-h protocols at a clinical research center 6 wk apart. The first used a habitual wake-sleep protocol, and the second used a constant routine protocol that removed the influence of sleep, posture, and diet. To assess hormonal rhythms, plasma was collected at 8:00 am, 12:00 pm, 4:00 pm, and every 30 min from 7:00 pm to 7:00 am. A mixed-effects regression model was used to compare subject-specific and mean trajectories of hormone secretion under the two conditions. ADH, aldosterone, and ANP showed a diurnal rhythm that peaked during sleep in the wake-sleep protocol. These nighttime elevations were significantly attenuated within subjects during the constant routine. We conclude that sleep has a masking effect on circadian rhythm amplitude of ADH, aldosterone, and ANP: the amplitude of each is increased in the presence of sleep and reduced in the absence of sleep. Disrupted sleep could potentially alter nighttime urine output in healthy older adults via this mechanism.NEW & NOTEWORTHY Nocturia (waking to void) is the most common cause of sleep interruption among older adults, and increased nighttime urine production is its primary etiology. We showed that in healthy older adults sleep affects the 24-h secretory rhythm of hormones that regulate salt-water balance, which potentially alters nighttime urine output. Further studies are needed to elucidate the impact of chronic insomnia on the secretory rhythms of these hormones.

Exploratory pilot study of exogenous sustained-release melatonin on nocturia in Parkinson's disease

INTRODUCTION

Nocturia is one of the commonest non-motor symptoms in Parkinson's disease (PD). Nocturia has evolved from being understood as a symptom of urological disorders or neurogenic bladder dysfunction to being considered as a form of circadian dysregulation. Exogenous melatonin is known to help circadian function and can be an effective strategy for nocturia in PD.

METHODS

In this open-label, single-site, exploratory, phase 2 pilot study, adults with PD and nocturia underwent assessments using standardized questionnaires, urodynamics studies and a bladder scan. This was followed by completion of a frequency volume chart (FVC) and 2-week sleep diary. Sustained-release melatonin 2 mg was then administered once-nightly for 6 weeks. A repeat assessment using questionnaires, the FVC and sleep diary was performed whilst on treatment with melatonin. Companion or bed partners filled in sleep questionnaires to assess their sleep during the intervention.

RESULTS

Twenty patients (12 males; mean age 68.2 [SD = 7.8] years; mean PD duration 8.0 [±5.5] years) with PD reporting nocturia were included. Administration of melatonin was associated with a significant reduction in the primary outcome bother related to nocturia measured using the International Consultation on Incontinence Questionnaire Nocturia (ICIQ-N) (p = 0.01), number of episodes of nocturia per night (p = 0.013) and average urine volume voided at night (p = 0.013). No serious adverse events were reported. No significant improvement was noted in bed partner sleep scores.

CONCLUSIONS

In this preliminary open-label study, administration of sustained-release melatonin 2 mg was found to be safe for clinical use and was associated with significant improvements in night-time frequency and nocturnal voided volumes in PD patients.

Mechanisms and grading of nocturia: Results from a multicentre prospective study

OBJECTIVE

To identify the pathophysiological mechanisms of nocturia and the correlation of these mechanisms with nocturia severity.

METHODOLOGY

After approval by the local ethics committee, all patients with nocturia (≥1 nocturnal void/night) were included and filled the Overactive Bladder questionnaire, Nocturia Quality of Life, Incontinence Questionnaire - Male Lower Urinary Tract Symptoms (male), International Consultation on Incontinence Questionnaire - Female Lower Urinary Tract Symptoms (female) and 3-day frequency-volume chart. Patients were divided into three groups according to the severity of nocturia: group 1 consisted of patients with mild (1-2 voids/night), group 2 with moderate (3-4 voids/night) and group 3 with severe nocturia (>4 voids/night). Comparative analysis was performed between groups, and P < .05 was deemed as statistically significant.

RESULTS

About 68.1%, 64.1% and 8.7% of the patients had nocturnal polyuria (NP), reduced bladder capacity and global polyuria, respectively. 42.7% of the patients had mixed nocturia. 6.1% of the patients did not comply with the aforementioned subtypes and defined as isolated nocturia. Regarding the severity of nocturia, 155 (41%) patients had mild, 167 (45%) patients had moderate and 57 (15%) patients had severe nocturia. Increased nocturia severity was related with decreased quality of life; higher age, urinary tract symptom scores, nocturnal urine volume, evening fluid consumption and beta-blocker medication rates. Increased nocturia severity was also associated with higher NP, global polyuria and reduced bladder capacity rates.

CONCLUSIONS

Nocturia mechanisms may vary between mild and moderate to severe nocturia groups according to the present study. Nocturia grading with identification of subtypes may help for better standardisation of the diagnostic and treatment approaches as well as for the design of future clinical trials.

Therapeutic Effects of Prolonged Release Melatonin (Circadin®) in Patients with Overactive Bladder and Chronic Insomnia in More Than 55 Years Old

Objectives Bladder storage symptoms including nocturia is the most common cause of sleep disturbance in all age groups. Sleep disturbance is also a main cause of nocturia so that sleep recovery can clinically improve nocturia. Melatonin has main action to induce sleep and additional effects of smooth muscle relaxation, free radical scavenging, anti-inflammation, et cetera. This study was evaluated the improvement of sleep quality after administrating prolonged-release melatonin in elderly patients with overactive bladder and chronic insomnia. Methods This clinical trial was performed with a randomized single open study. Thirty-seven patients with overactive bladder and chronic insomnia were initially enrolled in this study. After 4 or 12 weeks treating with 2 mg of prolonged-release melatonin, clinical outcomes were evaluated with OABSS, IPSS, PSQI and WHO 5 well-being index. Results Of the 37 patients, 34 (91.9%) were included in the ITT group and 26 (76.5%) in the PP group. In the primary outcome of PP group, significant improvements were observed in total OABSS and nocturia frequencies at 12 weeks, respectively. Secondary outcome measurement including in voiding, storage symptoms, and total IPSS scores showed the improvement at 4 and 12 weeks and in total and sleep quality PSQI scores at 12 weeks, and in quality of life scores of the WHO 5 well-being index at 12 weeks. Only one (3.8%) adverse event was observed. Conclusions These results suggest clearly that prolonged-release melatonin in elderly patients with overactive bladder and chronic insomnia has the potential to control concomitant voiding and sleep difficulty.

Comparison of nocturia response to desmopressin treatment in elderly men with and without nocturnal polyuria in real-life practice

OBJECTIVES

To evaluate the safety and efficacy of low-dose desmopressin in elderly men with and without nocturnal polyuria (NP) in real-life practice.

METHODS

Patients with lower urinary tract symptoms (LUTS)/ benign prostate hyperplasia (BPH) who were≧ 65 years old with refractory nocturia were enrolled in this study. We retrospectively analysed elderly men treated with adding desmopressin to current medications for nocturia according to category of the baseline nocturnal urine volume. The 48-h frequency volume chart (FVC), International Prostate Symptom Score (IPSS) and quality of life (QoL) were initially assessed and re-evaluated 12 weeks later. Serum sodium level was checked 1 week, 4 weeks, and 12 weeks after initiation of desmopressin therapy or suspected hyponatremia event. The mean change in numbers of nocturnal voids was evaluated for efficacy of treatment.

RESULTS

A total of 136 patients were included with 55 in non-NP group and 81 in NP group. Hypertension was more common in NP group in regard of comorbidities. During treatment period, there were significant reductions of nocturnal voids from 4.22 ± 1.38 to 2.31 ± 0.98 (p < 0.001) in non-NP group and from 4.52 ± 1.23 to 2.07 ± 0.89 (p < 0.001) in NP group. The reduction in nocturnal voids was more significant in NP group (2.44 ± 1.15 vs. 1.91 ± 1.48, p = 0.003). The mean decrease in serum sodium levels were 3.89 ± 1.22 mmol/l (p < 0.001) in non-NP group and 4.69 ± 3.5 mmol/l (p < 0.001) in NP group at the extreme value.

CONCLUSIONS

Long-term treatment with low-dose desmopressin is safe and effective for nocturia with or without NP in elderly patients with LUTS/BPH during real-life practice. Patients should be well informed about the disease and are closely followed.

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.

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.

Hidden prevalence of lower urinary tract symptoms in healthy nulligravid young women

Introduction and hypothesis

Lower urinary tract symptoms (LUTS) and urinary incontinence (UI) may have a major impact on quality of life. However, not all individuals with urological complaints seek medical advice. The aim of this study was to investigate the prevalence of LUTS in young otherwise healthy nulligravid women and the accompanying burden.

Methods

A total of 159 young presumably healthy female medical students aged 18–30 years were recruited at their university. All completed the International Consultation on Incontinence Modular Questionnaire for Female Lower Urinary Tract Symptoms. The prevalence of LUTS and the accompanying burden were measured. Correlations between symptoms and bother were analysed using Spearman’s rho.

Results

LUTS was found in 94.3 % of the women, urgency at least sometimes in 14.5 %, and hesitancy in 14.5 %. Nocturia once a night was reported by 18.2 % of the women; none reported nocturia of more than twice a night. Involuntarily loss of urine was reported by 20.1 % of the women but none reported this occurring more than twice a week. The median value of all bother scores was 0; the highest bother score was for urgency. For all questions a positive correlation was found between symptoms and bother; a strong correlation was found for bladder pain, urgency UI, stress UI and overall UI.

Conclusions

In a presumably healthy population of young nulligravid women the prevalence of LUTS and UI was high, but with relatively low bother.

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.

A guideline for the management of bladder dysfunction in Parkinson's disease and other gait disorders

Parkinson's disease (PD) is a common neurodegenerative disorder, and lower urinary tract (LUT) dysfunction is one of the most common autonomic disorders with an estimated incidence rate of 27-80%. Studies have shown that bladder dysfunction significantly influences quality-of-life (QOL) measures, early institutionalisation, and health economics. We review the pathophysiology of bladder dysfunction in PD, lower urinary tract symptoms (LUTS), objective assessment, and treatment options. In patients with PD, disruption of the dopamine D1-GABAergic direct pathway may lead to LUTS. Overactive bladder (OAB) is the most common LUT symptom in PD patients, and an objective assessment using urodynamics commonly shows detrusor overactivity (DO) in these patients. The post-void residual (PVR) volume is minimal in PD, which differs significantly from multiple system atrophy (MSA) patients who have a more progressive disease that leads to urinary retention. However, subclinical detrusor weakness during voiding may also occur in PD. Regarding bladder management, there are no large, double-blind, prospective studies in this area. It is well recognised that dopaminergic drugs can improve or worsen LUTS in PD patients. Therefore, an add-on therapy with anticholinergics is required. Beta-3 adrenergic agonists are a potential treatment option because there are little to no central cognitive events. Newer interventions, such as deep brain stimulation (DBS), are expected to improve bladder dysfunction in PD. Botulinum toxin injections can be used to treat intractable urinary incontinence in PD. Transurethral resection of the prostate gland (TURP) for comorbid BPH in PD is now recognised to be not contraindicated if MSA is excluded. Collaboration of urologists with neurologists is highly recommended to maximise a patients' bladder-associated QOL. Neurourol. Urodynam. 35:551-563, 2016. © 2015 Wiley Periodicals, Inc.

Medication adherence in the management of nocturia: challenges and solutions

OBJECTIVE

Nocturia affects millions of men and women. No prior reviews or meta-analyses have explored the issue of adherence in nocturia patients. The objective of our study was to examine the attributes and their interaction that might impact pharmacological adherence in nocturia care using a conceptual model of adherence.

MATERIALS AND METHODS

A literature search of the Medline, PubMed, Embase, PsycInfo, and CINAHL databases for studies published between January 1990 and June 2014 was conducted. We developed a conceptual model in order to facilitate our review.

RESULTS

Currently, multiple treatment options for nocturia exist, depending on the underlying cause. Adherence to nocturia treatment and outcomes are complex and intertwined, and nonadherence to nocturia treatment is common. In 15 studies meeting eligibility criteria, behavioral and pharmacologic interventions for nocturia were associated with reduced nocturia symptoms. Urinary symptoms that are associated with nocturia need individualized management depending on renal and hepatic function, medical comorbidities, and ongoing medication use in a patient. Another important factor related to adherence is the bother. Although nocturia is defined as nighttime-voiding frequency of one or more, not all persons may find this bothersome. The degree of bother is subjective, and may change from person to person. However, there is no information related to the association between bother and adherence to medication or behavioral treatments for nocturia. Medication dosing convenience, preference, and cost play important roles in adherence. We present a patient-centered conceptual model that brings together the various dimensions of medication adherence for nocturia.

CONCLUSION

Few studies have explored adherence to medication and related factors in the care of nocturia. Our conceptual model can aid development of interventions to improve adherence to nocturia medications.

Exploring nocturia: gender, age, and causes

PURPOSE

This study aims to clarify differences in parameters based on frequency volume chart (FVC) and on daytime and nighttime urine according to the nocturia frequency, age, and gender.

MATERIALS AND METHODS

This observational study was executed between 2011 and 2013. Participants (>18 years, ≤65 years) with or without nocturia (controls) were included and completed a 72 hr FVC; osmolality and sodium excretion were analyzed on daytime and nighttime urine.

RESULTS

(1) Nocturia severity: Compared to controls (N = 38), those with ≥2 nocturia episodes (N = 29) have higher nocturnal voided volume (NVV) (P < 0.001) based on increased sodium excretion (P = 0.003) and lower functional bladder capacity (P < 0.001). Those with one nocturia episode (N = 21) present with lower bladder capacity (P = 0.005). (2) Gender: women with 1 and ≥2 episodes have lower bladder capacity than controls (P = 0.047 and P < 0.001, respectively). Men with ≥2 episodes present with increased NVV (P = 0.001) and decreased bladder capacity (P = 0.049). (3) Age: Younger participants (<44 years) with ≥2 nocturia episodes present with lower functional bladder capacity than controls (P < 0.001). Older participants (45-65 years) present with both increasing NVV and decreasing bladder capacity with increasing nocturia frequency (P < 0.001); sodium excretion is higher in those with ≥2 episodes (P = 0.029). (4) Causes: the percentage of isolated NP decreases (P = 0.005), whereas the combination of both causes increases with increase in number of nocturia episodes (P = 0.020).

CONCLUSIONS

The mismatch between functional bladder capacity and NVV with increasing nocturia frequency demands a comprehensive diagnostic approach to subtype the patient, which involves anamnesis, FVC, and analysis of daytime and nighttime urine.

The fluctuation of nocturia in men with lower urinary tract symptoms allocated to placebo during a 12-month randomized, controlled trial

PURPOSE

We determined the fluctuation of nocturia in a 12-month period in men with lower urinary tract symptoms.

MATERIALS AND METHODS

Men with lower urinary tract symptoms were allocated to the placebo arm of the United States Department of Veterans Affairs Cooperative Studies Program Benign Prostatic Hyperplasia Study. Reported nocturia frequency using the American Urological Association Symptom Index was collected at 6 time points (2, 4, 13, 26, 39 and 52 weeks). Repeat measurements of nocturia during a 1-year period were analyzed using a generalized mixed linear model.

RESULTS

Of the 305 men allocated to the placebo group 256 participants (84%) gave answers for all 6 time points. In the entire sample the mean nocturia count did not significantly vary from baseline (week 2) after adjusting for covariates (p = 0.542). However, there was considerable fluctuation in nocturia during 1 year. Of the 93 men with 3 or 4 episodes at baseline 47% had improvement and 12% had worsening at 1 year. Of the 184 men who reported 2 or greater nocturia episodes at baseline 15% reported 0 or 1 at 52 weeks. Depending on the case definition during followup the probability of nocturia progression varied between 8% and 54% while nocturia regression varied between 2% and 33%.

CONCLUSIONS

Using repeat questionnaire based assessments we observed considerable fluctuation in nocturia. However, overall there was no significant increase in prevalence in a 1-year period. These findings may be reassuring to providers and patients who elect to delay interventions for nocturia.

A cutoff value based on analysis of a reference population decreases overestimation of the prevalence of nocturnal polyuria

PURPOSE

We sought criteria for nocturnal polyuria in asymptomatic, nonurological adults of all ages by reporting reference values of the ratio of daytime and nighttime urine volumes, and finding nocturia predictors.

MATERIALS AND METHODS

Data from a database of frequency-volume charts from a reference population of 894 nonurological, asymptomatic volunteers of all age groups were analyzed. The nocturnal polyuria index and the nocturia index were calculated and factors influencing these values were determined by multivariate analysis.

RESULTS

The nocturnal polyuria index had wide variation but a normal distribution with a mean ± SD of 30% ± 12%. The 95th percentile of the values was 53%. Above this cutoff a patient had nocturnal polyuria. This value contrasts with the International Continence Society definition of 33% but agrees with several other reports. On multivariate regression analysis with the nocturnal polyuria index as the dependent variable sleeping time, maximum voided volume and age were the covariates. However, the increase in the nocturnal polyuria index by age was small. Excluding polyuria and nocturia from analysis did not alter the results in a relevant way. The nocturnal voiding frequency depended on sleeping time and maximum voided volume but most of all on the nocturia index.

CONCLUSIONS

The prevalence of nocturnal polyuria is overestimated. We suggest a new cutoff value for the nocturnal polyuria index, that is nocturnal polyuria exists when the nocturnal polyuria index exceeds 53%. The nocturia index is the best predictor of nocturia.

Self-rated sleep characteristics and bother from nocturia

PURPOSE

The aim of this study was to evaluate if men with varying degrees of bother from a similar number of nocturia episodes differ with respect to self-rated sleep characteristics and fatigue.

MATERIALS AND METHODS

As part of the baseline assessments during a nocturia treatment trial, 55 participants reported frequency and bother of nocturia using the AUA Symptom Inventory and completed 7-day sleep diaries prior to treatment. Participants who reported moderate nocturia (either two or three episodes nightly) were further grouped into categories of LOW (nocturia is no problem or a very small problem) or HIGH bother (nocturia is a big problem). Information from the participant completed sleep diaries was abstracted, including information on daytime napping, total sleep time, mean time needed to return to sleep, nighttime ratings of fatigue, and daytime ratings of fatigue.

RESULTS

Of the 55 individuals who completed the pilot study, 24 study participants reported two or three episodes of nocturia and had either HIGH (n = 11) or LOW (n = 13) bother. Participants categorised with HIGH bother were significantly more likely than those with LOW bother to report difficulty initiating sleep (47.7 ± 34.4 vs. 23.5 ± 13.6 min, p = 0.05), difficulty returning to sleep after an awakening (28.9 ± 16.1 vs. 15.4 ± 9.6 min, p = 0.03) and greater morning fatigue (3.3 ± 0.7 vs. 2.5 ± 1.0, p = 0.04 on a 7-point scale).

CONCLUSIONS

Since bother related to nocturia is linked to sleep quality, interventions targeting fatigue and sleep maintenance may provide useful targets in the management of nocturia in men.