Nocturia: Current Evaluation and Treatment for Urology

Nocturia in Women With Type 2 Diabetes Mellitus: A Cross-sectional, Correlation Study

PURPOSE

The first aim of this study was to compare nighttime voiding frequency (nocturia), serum hemoglobin A1c level, peripheral neuropathy score, and global sleep quality score in younger (>40 to <65 years) versus older (≥65 years) women with type 2 diabetes mellitus (DM). Additional aims were to identify factors associated with clinically relevant nocturia (≥2 episodes/night) and to analyze relationships between nocturia frequency, glycemic control, peripheral neuropathy, and sleep quality in these women.

DESIGN

Cross-sectional study.

SETTING AND SUBJECTS

Participants were 118 women older than 40 years and with type 2 DM. Their mean age was 65.25 (SD = 9.66) years; the mean duration since diagnosis of type 2 DM was 10.96 (SD = 7.66) years. The study setting was 2 metabolism and endocrinology outpatient departments located in Taipei City and Taoyuan, Taiwan.

METHODS

Data were collected using a questionnaire that queried sociodemographic information, lower urinary tract symptoms, and sleep quality. We also assessed peripheral neuropathy and lower extremity edema and obtained pertinent information from participants' medical records. Independent t tests, multivariate logistic regression analyses, Spearman's rank correlation coefficients, and one-way analysis of variance were used to address the 3 study aims.

RESULTS

Analyses found that older women (aged ≥65 years) had a significantly higher nighttime voiding frequency, a higher peripheral neuropathy score, and a higher sleep quality score than younger (>40 to <65 years) women. Multivariate logistic regression analyses identified 4 factors associated with clinically relevant nocturia advanced age, elevated hemoglobin A1c level, suspected peripheral neuropathy, and lower extremity edema. Significant correlation coefficients were found between nighttime voiding frequency and serum hemoglobin A1c levels, peripheral neuropathy scores, and sleep quality scores. Analyses also found that women with a greater nocturia frequency had higher hemoglobin A1c levels, peripheral neuropathy scores, and sleep quality scores.

CONCLUSIONS

Healthcare professionals should screen for nocturia in women with type 2 DM and provide appropriate management for those experiencing nocturia.

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.

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.

TANGO - a screening tool to identify comorbidities on the causal pathway of nocturia

OBJECTIVES

To develop a robust screening metric for use in identifying non-lower urinary tract comorbidities pertinent to the multidisciplinary assessment of patients with nocturia.

METHODS

Variables having a significant risk association with nocturia of greater than once per night were identified. Discriminating items from validated and reliable tools measuring these comorbidities were identified. A self-completed 57-item questionnaire was developed and a medical checklist and pertinent clinical measures added. Pre-determined criteria were applied to retain or remove items in the development of the Short-Form (SF) screening tool. The tool was administered to 252 individuals with nocturia who were attending either a tertiary level Sleep, Continence, Falls or Rehabilitation service for routine care. Data collected were subjected to descriptive analysis; criteria were applied to reduce the number of items. Using pre-determined domains, a nocturia screening metric, entitled TANGO, was generated. The acronym TANGO stands for Targeting the individual's Aetiology of Nocturia to Guide Outcomes.

RESULTS

The demographic characteristics of the sample are described, along with item endorsement levels. The statistical and structural framework to justify deleting or retaining of items from the TANGO Long-Form to the SF is presented. The resultant TANGO-SF patient-completed nocturia screening tool is reported.

CONCLUSIONS

A novel all-cause diagnostic metric for identifying co-existing morbidities of clinical relevance to nocturia in patients who present across disciplines and medical specialties has been developed. TANGO has the potential to improve practice and smooth inequalities associated with a siloed approach to assessment and subsequent care of patients with nocturia.

Correlates of Nocturia and Relationships of Nocturia With Sleep Quality and Glycemic Control in Women With Type 2 Diabetes

PURPOSES

To explore correlates of nocturia, compare sleep quality and glycemic control for women with and without nocturia, and examine relationships of nocturia with sleep quality and glycemic control in women with diabetes.

DESIGN

This study was a cross-sectional, correlational study with data collected from 275 women with type 2 diabetes.

METHODS

Data were collected using a structured questionnaire. Multivariate logistic regression analyses were used to identify correlates. Chi-squared tests were used to identify candidate variables for the first logistic regression model. A one-way analysis of variance was used to compare sleep quality and glycemic control for women with and those without nocturia. Pearson correlations were used to examine the relationships of nocturia with sleep quality and glycemic control.

FINDINGS

Of the 275 participants, 124 (45.1%) had experienced nocturia (at least two voids per night). Waist circumference, parity, time since diagnosis of diabetes, sleep quality, and increased daytime urinary frequency were correlated with nocturia after adjusting for age. Compared to women without nocturia, women who had nocturia reported poorer sleep quality. A significant correlation was found between the number of nocturnal episodes and sleep quality.

CONCLUSIONS

Nocturia and poor sleep are common among women with diabetes. The multifactorial nature of nocturia supports the delivered management and treatments being targeted to underlying etiologies in order to optimize women's symptom management. Interventions aimed at modifiable correlates may include maintaining a normal body weight and regular physical exercise for maintaining a normal waist circumference, and decreasing caffeine consumption, implementing feasible modifications in sleeping environments and maintaining sleep hygiene to improve sleep quality.

CLINICAL RELEVANCE

Healthcare professionals should screen for nocturia and poor sleep and offer appropriate nonpharmacological lifestyle management, behavioral interventions, or pharmacotherapy for women with diabetes.

Basic or extended urine sampling to analyse urine production?

BACKGROUND

Frequency volume charts are valuable tools to objectify urine production in patients with nocturia, enuresis or nocturnal incontinence. Analyses of daytime and nighttime urine (=basic collection) or analyses of urine samples collected every 3 h (=extended collection) extend this evaluation by describing circadian patterns of water and solute diuresis (=renal function profiles).

AIM

To assess intra-individual correlation and agreement between renal function profiles provided using basic and extended urine collections, and using two extended urine collections. To create a short-form of the extended collection.

METHODS

This prospective observational study was executed at Ghent University Hospital, Belgium. Study participation was open for anyone visiting the hospital. Participants collected one basic and two extended 24-h urine collections. Urinary levels of osmolality, sodium and creatinine were determined.

RESULTS

There was a moderate to strong correlation between results of basic and extended urinalyses. Comparing both extended urinalyses showed a moderate correlation between the eight individual samples and a weak to strong correlation between the mean daytime and nighttime values of renal functions. Different samples could be considered as most representative for mean daytime values, while all samples collected between 03 and 05am showed the highest agreement with mean nighttime values of renal function.

CONCLUSION

Since there is a good correlation and agreement between basic and extended urine collections to study the mechanisms underlying urine production, the choice of urine sampling method to evaluate urine production depends on the purpose. A nighttime-only urine sample collected between 03 and 05am may be the most practical approach.