Hip fractures, nocturia, and nocturnal polyuria in the elderly

Analysis on fluid intake and urination behaviors among the elderly in five cities in China: a cross-sectional study

Background

Fluid intake in the elderly may influence urination behaviors and further influence their health status. This study investigated the behaviors of fluid intake, urination and their relationships among the elderly in China.

Methods

Stratified random sampling was used to recruit the elderly participants who met the inclusion criteria from five cities in China. Participants' total fluid intake (TFI) level was investigated using a validated 7-day 24 h fluid intake questionnaire. Their urination behaviors in real time were also recorded using a validated 7-day 24 h urination behavior record.

Results

A total of 524 participants completed the study, including 233 males and 291 females. The average age was 69.7 years. The median daily TFI was 1,241 mL, with a frequency of 8.1 times per day. Approximately 73.3% of the participants did not reach the amount of adequate fluid intake (1.7 L for males and 1.5 L for females) recommended in China. Fluid intake in the morning, afternoon, and evening among participants was 594 mL, 305 mL and 342 mL, with a frequency of 3.0 times, 1.7 times, and 2.0 times, respectively. The median urination frequency was 7.4 times per day. The percentage of participants who urinated >7 times during the day was 44.3%. The percentage of participants who urinated ≥1 time at night was 77.5%. Age and BMI were not the main influence factors for fluid intake and urination behaviors. The preliminary analysis showed that higher TFI, plain water intake, dairy products intake, and fluid intake frequency were significantly associated with higher urination frequency (t = 6.553, p < 0.05; t = 5.291, p < 0.05; t = 4.667, p < 0.05; t = 13.413, p < 0.05). Higher fluid intake per time was significantly associated with lower urination frequency (t = -3.562, p < 0.05). Correlations between TFI, fluid intake frequency, fluid intake in night, fluid intake frequency in night and urination at night were also found (r = 0.114, p < 0.05; r = 0.091, p < 0.05; r = 0.146, p < 0.05; r = 0.331, p < 0.05).

Conclusion

Fluid intake was inadequate in terms of the elderly participants. Participants with higher fluid intake and frequency in night had a greater incidence of nocturia. Thus, correcting fluid intake behaviors can improve urination behavior and promote health.

Clinical trial registration

https://www.chictr.org.cn/searchprojEN.html, identifier CTR1900023355.

[Nocturia in Parkinson's disease]

OBJECTIVE

Evaluation of nocturia and its relationship with clinical characteristics of Parkinson's disease (PD) and dopaminergic therapy.

MATERIAL AND METHODS

One hundred and thirteen patients with PD of I-III Hoehn and Yahr stage (H&Y) were examined using the following scales: IPSS, including nocturia domain, UPDRS, Sch&En, PDQ-39, MMSE, FAB, BDI, STAI-S and STAI-T, PFS-16, NMSQuest, GDSS, GSRS, and orthotest.

RESULTS

Nocturia was detected in 93 patients. It depended on the age of the patients (rS=0.345; p<0.001) and was more spread among women (p=0.002). We obtained positive correlations of nocturia (p<0.05) with: PDQ-39 (rS=0.296), H&Y (rS=0.223), UPDRS (rS=0.265) and its items (speech, walking disorders, standing up from chair, posture and postural stability), NMSQ (rS=0.318), FAB (rS= -0.359), BDI, STAI-S and STAI-T, PFS-16, gastrointestinal parameters and blood pressure in the supine position. No significant effect of dopaminergic therapy on the severity of nocturia was found. According to regression analysis (stepwise method), predictors of nocturia are depression, higher lying blood pressure, constipation and postural instability (R2=0.474).

CONCLUSIONS

Nocturia is the most common urological symptom in patients with PD and it significantly reduces the quality of life starting from the early stages of the disease. Nocturia increases as PD progresses, it is independent of dopaminergic medications, and it is directly associated with a number of parkinsonian symptoms (postural, frontal cognitive, affective and autonomic), which are partly dopamine-resistant. This indicates the common pathogenesis of nocturia and other symptoms of PD and the significant influence of polytransmitter imbalance.

Effectiveness of melatonin for the treatment of nocturia: a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

Nocturia affects health and quality of life (QoL). Current medical treatments can cause severe adverse effects, especially when treating elderly patients. Endogenous melatonin has a physiologic role in urinary bladder function, and the exogenous one may be beneficial for this condition. This article aims to evaluate the effectiveness and safety of melatonin for ameliorating nocturia in older women.

METHODS

This randomized, double-blind, placebo-controlled trial was conducted at a university hospital in Thailand. Sixty women with nocturia, aged > 55 years, were prospectively recruited and were later randomly allocated to treatment (melatonin 2 mg/day, n = 30) and control (placebo, n = 30) arms for 2 weeks. Outcome measures included nocturia episodes, nocturia-related parameters, Nocturia Quality of Life Questionnaire (N-QoL) scores, and adverse events.

RESULTS

The treatment and control groups were comparable in mean age (65.9 + 7.5 vs. 68.5 + 6.3 years). Both groups had comparable causes of nocturia with a baseline median voiding frequency of 2.3 (1.3, 6.3) and 2.3 (1.7, 5.3) episodes/night, respectively. The treatment group had significantly better outcomes than the placebo group in terms of median reduction in nocturia [-1.0 (-3.0, 0.0) vs. 0.0 (-2.3, 1.3) episodes/night; p < 0.001], increased median duration of the first uninterrupted sleep [1.0 (-0.3, 4.5) vs. 0.0 (-3.0, 2.3) h; p < 0.001], and improvement in N-QoL scoring, especially in the sleep/energy subscale (p = 0.019) and the total score (p = 0.016). Adverse events were comparable between groups.

CONCLUSIONS

Melatonin can be considered a safe and effective treatment for nocturia in elderly women.

Association of lower urinary tract symptoms and hip fracture in adults aged ≥ 50 years

Aim

Lower urinary tract symptoms (LUTS) result in morbidities; however, their association with the occurrence of hip fracture is relatively unknown in the context of Asian studies. The purpose of the study was to investigate this link with the hip fracture risk in Taiwanese men and women aged 50 years and above.

Materials and methods

From 2000 through 2012, a population-based retrospective cohort study was conducted; claims data of 18,976 patients diagnosed with LUTS (dysuria, urinary retention, incontinence, and increased urinary frequency and urgency) were retrieved from Taiwan’s National Health Insurance Research Database. The patients were compared with 1:2 age, sex, and index year-matched controls (comparison group, n = 37,952). The incidence and hazard ratios of the hip fracture risk were calculated by the Cox proportional hazard regression models.

Results

The mean age was 66.2 ± 9.7 years, and the proportion of men was 58.1% in both study groups. Fractures occurred in 772 patients and 1,156 control subjects. The corresponding incidences were 7.0 and 5.0/1000 person-years. Compared to the control subjects, the patients with LUTS had an increased hip fracture risk [adjusted hazard ratio (aHR) = 1.29; 95% confidence interval (CI): 1.17–1.42]. LUTS was independently associated with an increased hip fracture risk in both men (aHR = 1.24; 95% CI: 1.08–1.42) and women (aHR = 1.34; 95% CI: 1.18–1.53) (p for interaction = 0.557). Similarly, the subgroup effect of age on hip fracture risks was not found (p for interaction = 0.665).

Conclusion

The study found LUTS was associated with an increased risk of hip fracture. Large-scale prospective studies in diverse populations are required to investigate causalities.

Mastering nocturnal jigsaws in Parkinson's disease: a dusk-to-dawn review of night-time symptoms

Finding out about night-time symptoms from Parkinson's disease (PD) patients can be a challenge as many patients and their carers cannot recall many symptoms that occur during the night, resulting in an under-recognition or a large variability of responses from clinical interviews and scales. Moreover, technology-based assessments for most night-time symptoms are still not universally available for use in a patient's home environment. Therefore, most physicians rely on their clinical acumen to capture these night-time symptoms based on pieces of patients' history, bedpartner's reports, clinical features, associated symptoms or conditions. To capture more night-time symptoms, the authors identified common nocturnal symptoms based on how they manifest from dusk to dawn with selected features relevant to PD. While some symptoms occur in healthy individuals, in PD patients, they may impact differently. The authors intend this narrative review to provide a practical guide on how these common night-time symptoms manifest and highlight pertinent issues by focusing on prevalence, clinical symptomatology, and specific relationships to PD. It is also important to recognise that PD-specific sleep disturbances increase with advancing disease with additional contributions from ageing, comorbidities, and medication side effects. However, the relative contribution of each factor to individual symptom may be different in individual patient, necessitating clinical expertise for individual interpretation. While there are debatable issues in certain areas, they underlie the complexity of night-time symptoms. Understanding night-time symptoms in PD is like re-arranging jigsaw pieces of clinical information to create, but never complete, a picture for physicians to instigate appropriate management.

Stimulation of the tibial nerve: a protocol for a multicentred randomised controlled trial for urinary problems associated with Parkinson's disease-STARTUP

INTRODUCTION

Parkinson's disease is the second most common chronic neurodegenerative condition with bladder dysfunction affecting up to 71%. Symptoms affect quality of life and include urgency, frequency, hesitancy, nocturia and incontinence. Addressing urinary dysfunction is one of the top 10 priority research areas identified by the James Lind Alliance and Parkinson's UK.

OBJECTIVES

Conduct a randomised controlled trial (RCT) targeting people with Parkinson's disease (PwP) who have self-reported problematic lower urinary tract symptoms, investigating the effectiveness of transcutaneous tibial nerve stimulation (TTNS) compared with sham TTNS. Implement a standardised training approach and package for the correct application of TTNS. Conduct a cost-effectiveness analysis of TTNS compared with sham TTNS.

METHODS AND ANALYSIS

An RCT of 6 weeks with twice weekly TTNS or sham TTNS. Participants will be recruited in 12 National Health Service neurology/movement disorder services, using a web-based randomisation system, and will be shown how to apply TTNS or sham TTNS. Participants will receive a weekly telephone call from the researchers during the intervention period. The trial has two coprimary outcome measures: International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and the International Prostate Symptom Score. Secondary outcomes include a 3-day bladder diary, quality of life, acceptability and fidelity and health economic evaluation. Outcomes will be measured at 0, 6 and 12 weeks.A sample size of 208 randomised in equal numbers to the two arms will provide 90% power to detect a clinically important difference of 2.52 points on the Internatioanl Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) and of 3 points in the International Prostate Symptom Score total score at 12 weeks at 5% significance level, based on an SD of 4.7 in each arm and 20% attrition at 6 weeks. Analysis will be by intention to treat and pre defined in a statistical analysis plan ETHICS AND DISSEMINATION: East of Scotland Research Ethics Service (EoSRES), 18/ES00042, obtained on 10 May 2018. The trial will allow us to determine effectiveness, safety, cost and acceptability of TTNS for bladder dysfunction in PWP. Results will be published in open access journals; lay reports will be posted to all participants and presented at conferences.

TRIAL REGISTRATION NUMBER

ISRCTN12437878; Pre-results.

Nocturia and its clinical implications in older women

The aim of this study is to demonstrate the relationship between nocturia and geriatric syndromes, and comprehensive geriatric assessment parameters (CGA) in older women. 858 older outpatient women were included in this cross-sectional study. For the nocturia variable, the question, "Generally, during the past 30 days, how many times did you usually urinate after you have gone to sleep at night until the time you got up in the morning?'' was used. The relationships between nocturia status and common geriatric syndromes, and CGA parameters were determined. The mean age of patients was 74.1 ± 8.0 years. The prevalence of patients who reported average of 0, ≥1, ≥2, ≥3, and ≥4 nocturnal episodes was 14.7%, 85.3%, 66.3%, 42.13%, and 24.1%, respectively. When all the covariates including age, education, Charlson Comorbidities Index score, glomerular filtration rate, antimuscarinic drugs and alpha-blockers use, diabetes mellitus, chronic obstructive pulmonary disease, and incontinence were adjusted, there were higher rates of insomnia, recurrent falls and higher scores of Timed Up-Go test in older women with ≥2 nocturia episodes (p < 0.05). There was a significant correlation between ≥3 nocturia episodes and lower Instrumental Activities of Daily Living scores and a significant correlation between ≥4 nocturnal episodes and frailty and polypharmacy (p < 0.05). Nocturia is quite common and associated with insomnia, frailty, polypharmacy, incontinence, falls, lower gait speed, and functionality in older women.Therefore, nocturia is very important for geriatric practice and ≥2 nocturia episodes can be a marker of poor health status in older women.

Nocturia: A Highly Prevalent Disorder With Multifaceted Consequences

Nocturia is a bothersome, multifactorial condition with many underlying causes and contributing factors. Nocturnal polyuria (NP; overproduction of urine at night) is a frequent component. The prevalence of nocturia increases with age; specific estimates of prevalence are influenced by frequency thresholds used to define it. There is a tendency toward higher prevalence in young women than young men, which is reversed in later life. The association between frequency of nocturnal voiding and sleep disruption is well-documented. Nocturia correlates strongly with shorter sleep during the first part (2-4 hours) of the night, during which the first nocturnal void often occurs. A short time to first void after sleep onset (often referred to as "first uninterrupted sleep period") is associated with increased daytime dysfunction and decreased sleep quality and/or sleep efficiency. Adverse health consequences related to nocturia include poor sleep, depression, reduced quality of life, and increased risk of morbidity, mortality, falls, and fractures; studies have been able to establish a causal role for nocturia in only some of these. The potential impact of nocturia on health increases with age. By age 80, 80% of people will rise at least once per night to void. Despite its associated bother, nocturia is often accepted as a natural consequence of aging and many people do not seek help. Women, in particular, may be reluctant to report nocturia. This article reviews the prevalence of nocturia, possible impact on sleep, mortality and morbidity, and falls, and its importance in the elderly/frail population and women.

Are night-time voiding and lower urinary tract symptoms significant risk factors for hip fractures caused by falling during the night in male subjects?

OBJECTIVES

The aim of our study was to assess the incidence of night-time voiding in a population of male patients with hip fracture, and to analyze the correlations between the severity of the lower urinary symptoms and the other most significant comorbidities of the patients.

PATIENTS AND METHODS

We have initially selected a group of patients containing all males admitted into a Department of Orthopedic Surgery with the diagnosis of hip fracture, with indication for replacement surgery, over a four-year period. Applying well-defined inclusion and exclusion criteria, we have selected all the patients who have reported that falling during the night, on the way to the toilet (for micturition), was the event leading to the hip fracture. A comprehensive medical history and the International Prostate Symptom Score (IPSS) Questionnaire were gathered from all the patients and the obtained data were analyzed.

RESULTS

From a total of 363 patients with hip fractures, 68 cases were attributable to night-time voiding. The detailed analysis of the 68 patients has shown that all of them had significant nocturia (2.72 episodes of voiding per night, in average), but only 11 of them were already diagnosed with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). Moreover, only four of the eleven patients diagnosed with BPH were taking specific therapy at the moment of their falling leading to hip fracture. Subsequent analysis has shown that a group of 45 patients with no previously known co-morbidities, had similar IPSS score results with the total group of 68 patients.

CONCLUSIONS

Night-time voiding and LUTS are underdiagnosed in the general male population, as they represent significant risk factors for hip fractures due to falling during the night. The low level of BPH/LUTS therapy adherence adds a supplementary risk for falling during the night.

The Association Between Overactive Bladder and Falls and Fractures: A Systematic Review

INTRODUCTION

Urinary symptoms are associated with an increased risk of falls, but few studies have focused on patients with overactive bladder (OAB). This study aimed to synthesize estimates of the risk of falls and fractures in patients with OAB.

METHODS

Medline, EMBASE, the Cumulative Index to Nursing and Allied Health Literature, and Scopus were systematically searched for observational studies that focused on patients with OAB. When available, data from a non-OAB comparison sample were included. Double independent review and data extraction were performed. Falls and fractures data were summarized by unadjusted and adjusted risks, and percent attributable risk (PAR) of falls and fractures associated with OAB.

RESULTS

Fifteen studies were included in the analyses. The proportion of patients with OAB experiencing at least one fall over a year ranged from 18.9% to 50.0%, and the proportion of patients with OAB experiencing recurrent or serious falls ranged from 10.2% to 56.0%. In studies that included a non-OAB comparison sample, a higher risk of falls was observed in patients with OAB compared to those without. A significantly increased (1.3- to 2.3-fold) adjusted OAB-associated risk of falls was reported, while unadjusted PARs for OAB associated falls ranged from 3.7% to 15.5%. Risk was higher among women and those 65 years of age or older. While analysis of fractures showed elevated point estimates, most studies were underpowered to detect a statistically significant difference between groups.

CONCLUSIONS

Evidence from the published literature clearly demonstrates the importance of OAB and its symptoms as risk factors for falls and fractures.

FUNDING

Astellas.

Female Voiding Dysfunction and Urinary Incontinence

Female voiding dysfunction and incontinence are common in the general population and symptoms have been shown to have a significant negative impact on health-related quality of life. This article highlights the epidemiology, evaluation, diagnosis, pharmacologic therapies, and surgical treatment for overactive bladder, stress urinary incontinence, and urogenital fistulas.

A Behavioral Weight Loss Program and Nonurinary Incontinence Lower Urinary Tract Symptoms in Overweight and Obese Women with Urinary Incontinence: A Secondary Data Analysis of PRIDE

PURPOSE

We sought to determine whether a behavioral weight reduction intervention would improve nonurinary incontinence lower urinary tract storage symptoms at 6 months, including urinary frequency, nocturia and urgency, compared to a structured education program serving as the control group among overweight and obese women with urinary incontinence.

MATERIALS AND METHODS

PRIDE (Program to Reduce Incontinence by Diet and Exercise) was a randomized clinical trial performed in 338 overweight or obese women with urinary incontinence. Participants were randomized, including 226 to 6-month behavioral weight loss intervention and 112 to the control group. All participants received a self-help behavioral treatment booklet to improve bladder control. On this secondary data analysis we examined changes in nonurinary incontinence lower urinary tract storage symptoms from baseline to 6 months and the impact of treatment allocation (intervention vs control), weight loss and physical activity.

RESULTS

Nonurinary incontinence lower urinary tract storage symptoms were common at baseline, varying from 48% to 62%. In the 2 groups combined women experienced significant improvement in nocturia, urgency and International Prostate Symptom Score at 6 months (all p <0.001). However, lower urinary tract storage symptom outcomes at 6 months did not differ between the intervention and control groups. Similarly no difference was observed in the amount of weight lost (5% or greater vs less than 5%) or physical activity (1,500 kcal or greater expenditure per week compared to less than 1,500 kcal).

CONCLUSIONS

Lower urinary tract storage symptoms were common among overweight and obese women with urinary incontinence. The prevalence decreased significantly after 6 months independent of treatment group assignment, amount of weight lost or physical activity. These improvements may have been due to self-help behavioral educational materials, trial participation or repeat assessment of symptoms.

The association of lower urinary tract symptoms with incidental falls and fear of falling in later life: The Community Health Survey

AIM

To evaluate the association between lower urinary tract symptoms (LUTS) and incidental falls and fear of falling.

METHODS

We used data obtained from the 2011 Korean Community Health Survey (KCHS) conducted between August and October 2011 in South Korea. The survey was carried out to estimate patterns of disease prevalence and morbidity in men >40 years old. The trained interviewers performed face-to-face sociodemographic questionnaires using computer-assisted personal interviewing (CAPI) software, the International Prostate Symptom Score (IPSS), the Quality of Life score (EQ-5D), and a questionnaire about past falls and fear of falling.

RESULTS

Data from 67 457 men were collected and analyzed. The subjects who had previously experienced a fall had slightly higher scores for IPSS, severity of LUTS, voiding LUTS, and storage LUTS than subjects with no prior fall history. A multivariate model of the relationship between falls and LUTS severity indicated that the relationship between the IPSS components and fall history was significant (mild, moderate, severe: OR = 1.00, 2.53, 3.91, respectively, P < 0.0001). A multivariate model of fear of falling and LUTS also showed a significant relationship between severity, voiding, and storage symptoms (severe IPSS: OR = 2.411, 95%CI: 2.2-2.642, P < 0.001; voiding symptoms: OR = 1.766, 95%CI: 1.681-1.856, P < 0.001; storage symptoms: OR = 1.705, 95%CI: 1.625-1.789, P < 0.001).

CONCLUSION

This study emphasizes the relationship between LUTS and falling. Furthermore, increased LUTS severity led to a higher risk of incidental falls. A high correlation between fear of falling and LUTS was also observed in this study.

Obesity and the prevalence of nocturia in Japanese elderly patients with type 2 diabetes mellitus: The Dogo study

AIM

Nocturia is common among patients with type 2 diabetes mellitus, but limited evidence regarding the association between body mass index (BMI) and nocturia exists among such patients. The aim of the present study, therefore, was to evaluate the association between BMI and nocturia among Japanese patients with type 2 diabetes mellitus.

METHODS

Study participants were 809 Japanese patients with type 2 diabetes mellitus. Study participants were considered to have nocturia if they answered "two or more" to the question: "How many times do you typically wake up to urinate from sleeping at night until waking in the morning?" We used the following two outcomes: (i) moderate nocturia was defined as ≥2 voids per night; and (ii) severe nocturia was defined as ≥3 voids per night. Participants were categorized into four groups according to their BMI: (i) BMI <18.5; (ii) 18.5 ≤ BMI < 25; (iii) 25 ≤ BMI < 30; and (iv) BMI ≥30. Multiple logistical regression analysis for nocturia in relation to BMI was used, with the category of 18.5 ≤ BMI < 25 as the reference.

RESULTS

Obesity (BMI ≥30) was independently positively associated with severe nocturia among elderly patients (age ≥65 years) with type 2 diabetes mellitus, but not among young and middle-aged patients: the adjusted OR was 2.96 (95% CI 1.10-7.83). BMI was not associated with moderate nocturia in all patients.

CONCLUSIONS

In Japanese elderly patients with type 2 diabetes mellitus, obesity was independently positively associated with severe nocturia. Geriatr Gerontol Int 2017; 17: 2460-2465.

Incontinence and Nocturia in Older Adults After Hip Fracture: Analysis of a Secondary Outcome for a Parallel Group, Randomized Controlled Trial

Objective: To test the effect of a follow-up clinic on urinary incontinence (UI) and nocturia among older adults with hip fracture. Method: Fifty-three older adults (≥65 years) 3 to 12 months following hip fracture were enrolled and randomized to receive usual care plus the intervention (B4), or usual care (UC) only. The B4 group received management by health professionals, with need-based referrals. UI, nocturia, and quality of life were measured with questionnaires at baseline, 6 months, and 12 months. Results: There were 48 participants included in this analysis, and at baseline, 44% of study participants self-reported UI. At final assessment, six out of 24 B4 participants and 12 out of 24 UC participants reported UI. Four out of five study participants reported nocturia at baseline; this did not decrease during the study. Discussion: Following hip fracture, many older adults report UI and most report nocturia. Health professionals should be aware of the high occurrence of urinary symptoms among older adults post hip fracture.

Clock Genes Regulate the Circadian Expression of Piezo1, TRPV4, Connexin26, and VNUT in an Ex Vivo Mouse Bladder Mucosa

Objectives

Clock^Δ19/Δ19 mice is an experimental model mouse for nocturia (NOC). Using the bladder mucosa obtained from Clock^Δ19/Δ19 mice, we investigated the gene expression rhythms of mechanosensory cation channels such as transient receptor potential cation channel subfamily V member 4 (TRPV4) and Piezo1, and main ATP release pathways including vesicular nucleotide transporter (VNUT) and Connexin26(Cx26), in addition to clock genes.

Materials and methods

Eight- to twelve-week-old male C57BL/6 mice (WT) and age- and sex-matched C57BL/6 Clock^Δ19/Δ19 mice, which were bred under 12-h light/dark conditions for 2 weeks, were used. Gene expression rhythms and transcriptional regulation mechanisms in clock genes, mechanosensor, Cx26 and VNUT were measured in the mouse bladder mucosa, collected every 4 hours from WT and Clock^Δ19/Δ19 mice using quantitative RT-PCR, a Western blot analysis, and ChIP assays.

Results

WT mice showed circadian rhythms in clock genes as well as mechanosensor, Cx26 and VNUT. Their expression was low during the sleep phase. The results of ChIP assays showed Clock protein binding to the promotor regions and the transcriptional regulation of mechanosensor, Cx26 and VNUT. In contrast, all of these circadian expressions were disrupted in Clock^Δ19/Δ19 mice. The gene expression of mechanosensor, Cx26 and VNUT was maintained at a higher level in spite of the sleep phase.

Conclusions

Mechanosensor, Cx26 and VNUT expressed with circadian rhythm in the mouse bladder mucosa. The disruption of circadian rhythms in these genes, induced by the abnormalities in clock genes, may be factors contributing to NOC because of hypersensitivity to bladder wall extension.

A systematic review of the association between lower urinary tract symptoms and falls, injuries, and fractures in community-dwelling older men

BACKGROUND

Lower urinary tract symptoms (LUTS) have been associated with falls in studies either exclusively or predominantly of women. It is, therefore, less clear if LUTS are risk factors for falls in men.

METHODS

We conducted a systematic review of the literature on the association between LUTS and falls, injuries, and fractures in community-dwelling older men. Medline, Embase, and Cinahl were searched for any type of observational study that has been published in a peer-reviewed journal in English language. Studies were excluded if they did not report male-specific data or targeted specific patient populations. Results were summarized qualitatively.

RESULTS

Three prospective cohort studies and six cross-sectional studies were identified. Incontinence, urgency, nocturia, and frequency were consistently shown to have weak to moderate association with falls (the point estimates of odds ratio and relative risk ranged from 1.31 to 1.67) in studies with low risk of bias for confounding. Only frequency was shown to be associated with fractures.

CONCLUSIONS

Urinary incontinence and lower urinary tract storage symptoms are associated with falls in community-dwelling older men. The circumstances of falls in men with LUTS need to be investigated to generate hypotheses about what types of interventions may be effective in reducing falls.

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.

Prevalence of Sleep Disordered Breathing among Patients with Nocturia at a Urology Clinic

OBJECTIVE

We assessed the prevalence of sleep disordered breathing (SDB) and characteristics among patients who visited a urology clinic complaining of nocturia (URO group) and those who visited a sleep apnea (SA) clinic complaining of excessive daytime sleepiness (EDS) (SA group). Additionally, we evaluated the effects of continuous positive airway pressure (CPAP) therapy in the URO group patients with nocturia and SDB resistant to conventional therapy for nocturia.

METHODS

Questionnaires were used to assess EDS, nocturia and lower urinary tract symptoms in 34 URO group patients and 49 age-matched SA group patients. We also compared these factors in the male patients in both groups and the male and female patients in the SA group. Significant SDB was diagnosed as a 3% oxygen desaturation index (3%ODI) on pulse oximeter of >5/h. The treatment response was analyzed in six URO group patients treated with CPAP after not responding to the conventional medical treatment.

RESULTS

SDB was found in 91.8% of the SA group patients and 70.6% of the URO group patients. The level of EDS and lower urinary tract symptoms were similar in both groups. The SA group showed higher 3%ODI values, while the frequency of urination during bedtime was higher in the URO group. The frequency of nocturnal urination was reduced after CPAP in the subjects resistant to conventional therapy.

CONCLUSION

SDB is as prevalent in patients who visit a urology clinic complaining of nocturia as in those who visit a sleep apnea clinic. Patients who complains of nocturia must be assessed for SDB before starting therapy for nocturia.

Nocturia: state of the art and critical analysis of current assessment and treatment strategies

This editorial of the topic issue of the World Journal of Urology provides a state of the art on nocturia which includes descriptions of the terminology, epidemiology, health-related quality of life, medical and financial consequences, pathophysiology, assessment tools and treatment strategies of nocturia. This summary also includes a flowchart on the pathophysiology of nocturia with illustration of the various causes of reduced bladder capacity, increased fluid intake or increased diuresis; a flowchart with the key findings of frequency-volume charts to determine the underlying pathophysiology; and a flowchart on the treatment of the various causes of nocturia. The editorial critically discusses current assessment and treatment strategies in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) and nocturia. The outcome of nocturia remains hidden in drug trials of patients with LUTS/BPH because nocturia-specific measures were not included. The authors recommend using frequency-volume charts, measurement of the hours of undisturbed sleep, and nocturia-specific quality of life questionnaires (e.g., ICIQ-N or N-Qol) in all future studies in patients with LUTS/BPH and nocturia.

Risk of Fractures and Falls during and after 5-α Reductase Inhibitor Use: A Nationwide Cohort Study

Background

Lower urinary tract symptoms are common among older men and 5-α reductase inhibitors (5-ARI) are a group of drugs recommended in treating these symptoms. The effect on prostate volume is mediated by a reduction in dihydrotestosterone; however, this reduction is counterbalanced by a 25% rise in serum testosterone levels. Therefore, 5-ARI use might have systemic effects and differentially affect bone mineral density, muscular mass and strength, as well as falls, all of which are major determinants of fractures in older men.

Methods

We conducted a nationwide cohort study of all Swedish men who used 5-ARI by comparing their risk of hip fracture, any type of fracture and of falls with matched control men randomly selected from the population and unexposed to 5-ARI.

Results

During 1 417 673 person-years of follow-up, 10 418 men had a hip fracture, 19 570 any type of fracture and 46 755 a fall requiring hospital care. Compared with unexposed men, current users of 5-ARI had an adjusted hazard ratio (HR) of 0.96 (95% CI 0.91–1.02) for hip fracture, an HR of 0.94 (95% CI 0.90–0.98) for all fracture and an HR of 0.99 (95% CI 0.96–1.02) for falls. Former users had an increased risk of hip fractures (HR 1.10, 95% CI 1.01–1.19).

Conclusion

5-ARI is safe from a bone health perspective with an unaltered risk of fractures and falls during periods of use. After discontinuation of 5-ARI, there is a modest increase in the rate of fractures and falls.

Underweight body mass index is a risk factor of mortality in outpatients with nocturia in Japan

Background

Although nocturia has been reported to increase mortality in elderly individuals, the particular risk factors that are associated with this event are unclear. Therefore, we evaluated risk factors for death in outpatients with nocturia.

Methods

Between October 2002 and December 2009, 250 consecutive patients with nocturia were enrolled in two general hospitals in Japan. Among them, 193 patients were able to be followed for at least 1 year and up to 9 years (median 4.8 years) if the patients did not die. Mortality rates and risk factors were evaluated in the nocturic outpatients.

Results

Two- and 5-year survival of the nocturic outpatients was 94.6 % [95 % confidence interval (CI) = 92.2–97.1] and 82.6 % (95 % CI = 75.4–87.8), respectively. Higher Charlson Comorbidity Score, lower body mass index (BMI) and lower Physical Component Summary of Short Form-36 item scores were significantly correlated with mortality (p < 0.0001, p < 0.005 and p < 0.05, respectively) in multivariate analysis. The International Prostate Symptom Score, Pittsburgh Sleep Quality Index, Mental or Role/Social Component Summary of Short Form-36 item scores and Nocturnal Polyuria index were not significantly correlated with mortality. The mortality rate was significantly higher in subjects with an underweight BMI (<18.50) compared with a normal range (18.50–24.99) or overweight (≥25.00) BMI [p < 0.00005, hazard ratio (HR) = 5.84, 95 % CI = 2.03–16.8; p < 0.0005, HR = 5.92, 95 % CI = 1.94–18.0].

Conclusions

Additional attention is required for nocturic outpatients with not only a high Charlson Comorbidity Score but also an underweight BMI because of their high mortality. Large prospective studies are warranted to validate this finding and extend more.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1456-6) contains supplementary material, which is available to authorized users.

Indoor cold exposure and nocturia: a cross-sectional analysis of the HEIJO-KYO study

OBJECTIVES

To investigate the association between indoor cold exposure and the prevalence of nocturia in an elderly population.

SUBJECTS AND METHODS

The temperature in the living rooms and bedrooms of 1 065 home-dwelling elderly volunteers (aged ≥60 years) was measured for 48 h. Nocturia (≥2 voids per night) and nocturnal urine production were determined using a urination diary and nocturnal urine collection, respectively.

RESULTS

The mean ± sd age of participants was 71.9 ± 7.1 years, and the prevalence of nocturia was 30.8%. A 1 °C decrease in daytime indoor temperature was associated with a higher odds ratio (OR) for nocturia (1.075, 95% confidence interval [CI] 1.026-1.126; P = 0.002), independently of outdoor temperature and other potential confounders such as basic characteristics (age, gender, body mass index, alcohol intake, smoking), comorbidities (diabetes, renal dysfunction), medications (calcium channel blocker, diuretics, sleeping pills), socio-economic status (education, household income), night-time dipping of ambulatory blood pressure, daytime physical activity, objectively measured sleep efficiency, and urinary 6-sulphatoxymelatonin excretion. The association remained significant after adjustment for nocturnal urine production rate (OR 1.095 [95% CI 1.042-1.150]; P < 0.001).

CONCLUSIONS

Indoor cold exposure during the daytime was independently associated with nocturia among elderly participants. The explanation for this association may be cold-induced detrusor overactivity. The prevalence of nocturia could be reduced by modification of the indoor thermal environment.

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.

Nocturia is an independent predictive factor of prevalent hypertension in obstructive sleep apnea patients

OBJECTIVE

The aim of this study was to determine whether nocturia is an independent predictor for prevalent hypertension in obstructive sleep apnea (OSA).

METHODS

We analyzed data from a national prospective clinical cohort of OSA patients participating in the French national prospective registry. Anthropometric data, comorbidities, OSA severity, and number of voids/night were included in multivariate analyses to determine the independent variables associated with prevalent hypertension.

RESULTS

A total of 22,674 OSA patients were included, of which 11,332 were hypertensive. The prevalence of hypertension among OSA patients was about 1.3 times higher in patients suffering from nocturia at 61.45% versus 46.52% in hypertensive and non-hypertensive OSA patients (p <0.001). There was a significant positive relationship between hypertension and the severity of nocturia beyond two voids/night: two voids/night versus none: odds ratio (OR) = 1.270 (95% confidence interval (CI) = 1.175; 1.372), three voids/night versus none: OR = 1.422 (95% CI = 1.293; 1.565), and four voids/night versus none: OR = 1.575 (95% CI = 1.394; 1.781). The strength of the association was enhanced in patients over 64 years of age.

CONCLUSIONS

Nocturia is a strong independent predictor of prevalent hypertension in OSA. This association exhibited a "dose-response" relationship beyond two voids/night. The resolution of nocturia after continuous positive airway pressure (CPAP) treatment might be an important outcome to consider for the response of hypertension to CPAP.

The economic impact of nocturia

Sleep disturbances associated with nocturia cause direct, indirect, and intangible costs. Direct costs are primarily associated with injuries from falling. Indirect costs are associated with loss of work productivity. Intangible costs include emotional distress, behavioral modifications, feelings of loss of control, poor mood, and cancellation of planned activities. A study that compared the number of falls for patients with varying numbers of voids per night demonstrated that the incremental risk (population attributable risk [PAR]) of falling as a result of nocturia (≥ 2 voids compared with ≤ 1 void) was 16.2%. Using the 16.2% PAR, the annual direct cost of nocturia in the USA was estimated at $1.5 billion. An analysis in the EU-15 countries estimated the total annual cost of hospitalizations for hip fracture due to severe nocturia to be approximately € 1 billion. Studies have shown that periods of sick leave are significantly greater in both men and women who have more nocturnal voids, with an estimated annual indirect cost of nocturia of $61 billion in the USA. A similar European analysis showed an estimated annual cost of lost work productivity due to nocturia of € 29 billion in the EU-15. The intangible personal costs of nocturia are related to diminished quality of life and overall health status. High-quality articles on the cost of illness associated with nocturia, as well as cost-benefit analyses of nocturia treatment, are generally lacking.

Effects of testosterone replacement therapy on nocturia and quality of life in men with hypogonadism: a subanalysis of a previous prospective randomized controlled study in Japan

OBJECTIVE

We investigated the effects of testosterone replacement therapy (TRT) on nocturia and general health among men with hypogonadism and nocturia.

METHODS

From our previous EARTH study population, 64 patients with a clinical diagnosis of nocturia (two or more times per one night) and hypogonadism, comprising the TRT group (n = 31) and controls (n = 33), were included in this analysis. The TRT group was administered 250 mg of testosterone enanthate as an intramuscular injection every 4 weeks for 6 months. All patients responded to the following questionnaires: International Prostatic Symptoms Score (IPSS), Aging Male Symptoms (AMS) score and Short Form-36 health survey at baseline and 6-month visit. These categories were compared based on changes from baseline to the 6-month visit between TRT and control groups.

RESULTS

At the 6-month visit, the TRT group had a significant decrease in IPSS question no. 7 and AMS question no. 4, whereas no significant changes were observed in the control group. Additionally, role limitation because of health program, vitality and mental health domains were significantly improved in the TRT group.

CONCLUSIONS

Six-month TRT may improve nocturia, sleep conditions and quality of life among men with hypogonadism and nocturia.

Nocturia in older adults: implications for nursing practice and aging in place

Nocturia is a bothersome symptom that increases with age, resulting in sleep disruption, an increased risk of falls, and a greater likelihood of rating one's health as poor. It is often a symptom of conditions that cause low volume voiding, overproduction of urine across the day or only at night and a symptom of a sleep disorder. Nocturia affects quality of life and has an impact on aging in place, thus assessment and treatment are essential. Behavioral treatments should be explored first, keeping in mind what the affected older adult defines as the desired outcomes of treatment.

Can treatment of nocturia increase testosterone level in men with late onset hypogonadism?

OBJECTIVE

To assess the effect of desmopressin on serum testosterone level in men with nocturia and late onset hypogonadism.

METHODS

We prospectively enrolled men with nocturia and symptoms of late onset hypogonadism. Desmopressin (0.1 mg) was administered once daily to patients for 12 weeks, and we then compared serum testosterone levels, electrolytes, frequency volume chart indices, and changes in the International Prostate Symptom Score (IPSS), International Index of Erectile Function, and Aging Male's Symptom scales before and after treatment. Patients with a history of cardiovascular disease or hyponatremia, those using hypnotics, and those who had primary hypogonadism or hypogonadotrophic hypogonadism were excluded from the study.

RESULTS

Sixty-two men (mean age, 68.4 years) completed pre- and post-treatment questionnaires and underwent laboratory testing. At the end of the study, the testosterone levels in men with low testosterone levels (<3.5 ng/mL) increased after the 12-week desmopressin treatment (2.85 ± 0.58 to 3.97 ± 1.44 ng/mL; P = .001). Mean scores had decreased from 17.7 to 13.9 (IPSS), 3.8 to 3.2 (IPSS-Quality of Life), and 33.7 to 31.1 (Aging Male's Symptom). On the frequency volume chart, nocturnal urine volume, nocturnal polyuria index, actual number of nocturia events, nocturia index, and nocturnal bladder capacity index were significantly decreased.

CONCLUSION

Desmopressin improved nocturia and other urinary symptoms. Moreover, serum testosterone levels increased significantly in men with low testosterone levels after 12-week desmopressin treatment.

Safety and efficacy of desmopressin for the treatment of nocturia in elderly patients: a cohort study

PURPOSE

Desmopressin is used widely to treat nocturnal polyuria (NP), but there is concern of hyponatremia especially in elderly patients. This study aimed to evaluate the safety and efficacy of long-term desmopressin treatment in elderly patients with NP.

METHODS

Patients who were ≥65 years old with NP were analyzed. All patients were started on 0.1 mg desmopressin, and the dose was escalated to 0.2 mg depending on patient symptoms. All patients were educated the mechanism of desmopressin. The voiding diary and serum sodium levels were evaluated at baseline, 3-7 days after starting treatment and every 3-6 months. Safety was evaluated by hyponatremia, hyponatremic symptoms and other adverse drug events. The mean changes in number of nocturia and nocturnal urine volume (NUV) were evaluated for efficacy.

RESULTS

A total of 68 patients were included. The mean age was 72.6 (66-85) years. The mean night-time frequency was 3.0 ± 1.8 day, and the mean serum sodium level was 141.2 ± 2.1 mEq/L at baseline. The mean follow-up period was 27.9 months. The mean decrease in serum sodium level was 1.3 ± 3.4 mEq/L at the last follow-up (p = 0.003). Hyponatremia incidence was 4.4 %, and all patients recovered by stopping medication. Severe adverse events were not observed. The mean night-time frequency had decreased by 2.1, and the NUV had decreased by 374.2 ± 261.3 mL at the last follow-up (p < 0.001).

CONCLUSIONS

Desmopressin at doses below 0.2 mg is safe and effective in elderly patients with NP if patients are well informed and are closely followed up.

Nocturia in arterial hypertension: a prevalent, underreported, and sometimes underestimated association

Nocturia is a risk factor for morbidity and mortality but is frequently overlooked and underreported by patients and unrecognized by physicians. Epidemiologic studies reported that nocturnal voiding is associated not only with aging and benign prostatic hyperplasia, but also with many other clinical conditions. The majority of epidemiologic studies reported a significant relationship between nocturia and hypertension. However, the cause-and-effect relationship between them has not been established. Some physiopathological changes in hypertension are conducive to result in nocturia. These include the effects of hypertension on glomerular filtration and tubular transport, resetting of the kidney pressure-natriuresis relationship, atrial stretch and release of atrial natriuretic peptide when congestive heart failure complicates hypertension, and peripheral edema. Another link between hypertension and nocturia is obstructive sleep apnea. Furthermore, some evidence supports the relationship between nondipping behavior of blood pressure and an increased prevalence of nocturia. The use of some classes of antihypertensive agents may result in nocturia. The present review aims to provide a comprehensive evaluation of the epidemiologic evidence and physiopathological links that correlate hypertension and nocturia. Emphasis is placed on the need to take a pro-active attitude to detect and treat this hazardous condition.

Urogenital consequences in ageing women

Various anatomical, physiological, genetic, lifestyle and reproductive factors interact throughout a woman's life span and contribute to pelvic floor disorders. Ageing affects pelvic floor anatomy and function, which can result in a variety of disorders, such as pelvic organ prolapse, lower urinary tract symptoms, dysfunctional bowel and bladder evacuation, and sexual dysfunction. The exact mechanisms and pathophysiological processes by which ageing affects pelvic floor and lower urinary and gastrointestinal tract anatomy and function are not always clear. In most cases, it is difficult to ascertain the exact role of ageing per se as an aetiological, predisposing or contributing factor. Other conditions associated with ageing that may co-exist, such as changes in mental status, can result in different types of pelvic floor dysfunction (e.g. functional incontinence). Pelvic organ dysfunction may be associated with significant morbidity and affect quality of life. These groups of patients often pose difficult diagnostic and therapeutic dilemmas owing to complex medical conditions and concurrent morbidities. In this chapter, we summarise the current evidence on the management of pelvic floor disorders, with emphasis on elderly women and the associations between the ageing process and these disorders. Clinicians with an understanding of the affect of ageing on the pelvic floor and lower urinary and gastrointestinal tract anatomy and function, and the complex interplay of other comorbidities, will be able to investigate, diagnose and treat appropriately there women. A holistic approach may result in substantial improvements in their quality of life.

Geriatric gynecology: promoting health and avoiding harm

Age increases vulnerability, commonly accompanied by greater reliance on others and susceptibility to maltreatment. Physiologic processes become less resilient; the potential for harm from medical care increases. Awareness of frailty, functional, social, and potential maltreatment issues enables early referrals to help the patient maintain her independence. Health issues that may impede both gynecologic care and self-sufficiency include sensory deficits, physical disability, and cognitive impairment. Speaking slowly and providing contextual information enhance patient comprehension. Cancer screening depends on life expectancy. Osteoporosis treatment requires managing fall risk. Gynecologic symptoms more likely have multiple contributing factors than one etiology. Incontinence is a particularly complex issue, but invariably includes bladder diary assessment and pelvic floor muscle training. Function and frailty measures best predict perioperative morbidity. Communication with the patient, her family, other providers, and health care organizations is an important frontier in avoiding errors and adverse outcomes.

Associations between improvements in lower urinary tract symptoms and sleep disturbance over time in the CAMUS trial

PURPOSE

We recently reported an association between the bother and severity of lower urinary tract symptoms secondary to benign prostatic hyperplasia and the severity of sleep disturbance. However, few studies have examined whether alterations in the severity of urinary symptoms influence the degree of sleep problems over time.

MATERIALS AND METHODS

The severity of lower urinary tract symptoms in men enrolled in CAMUS (Complementary and Alternative Medicine for Urological Symptoms), a clinical trial of saw palmetto (Serenoa repens), was evaluated using AUASI (American Urological Association symptom index) and quality of life scores. Sleep disturbance was evaluated by the Jenkins sleep scale at 0, 24, 48 and 72 weeks. Statistical analyses were used to assess the relationship(s) between changes in lower urinary tract symptoms and sleep disturbance.

RESULTS

The baseline characteristics of the 339 men (172 placebo arm and 167 saw palmetto arm) enrolled in the CAMUS trial with assessment of sleep disturbance and urinary symptoms were similar. There were no differences between improvements in the severity of sleep disturbance or urinary symptoms between the 2 experimental arms. Combined analyses of the entire cohort revealed significant associations (p <0.001) between the AUASI score and sleep disturbance severity with time. Multivariate analyses demonstrated that improvements in lower urinary tract symptoms other than nocturia were the most significant predictors of improvements in sleep disturbance. Specific analyses adjusting for other baseline characteristics demonstrated that a 3-point improvement in AUASI score was associated with a 0.73-point improvement in the Jenkins sleep scale with time.

CONCLUSIONS

Improvements in lower urinary tract symptoms correlate with changes in sleeping abilities with time in men with benign prostatic hyperplasia. While nocturia is significantly associated with sleep disturbance, other changes in overall lower urinary tract symptoms are better predictors of changes in sleep dysfunction.

Efficacy of Ramelteon in Patients with Insomnia and Nocturia

OBJECTIVES

To study the efficacy of ramelteon for patients with insomnia and nocturia.

METHODS

Forty-nine patients experiencing insomnia and two or more nocturnal voids were included. The degree of lower urinary tract symptoms and sleep disorders was evaluated using the International Prostate Symptom Score (IPSS), Pittsburg Sleep Quality Index (PSQI)(1) score, and frequency/volume chart (FVC). The patients were treated with ramelteon (8 mg) for four weeks and then reexamined by questionnaire and FVC to evaluate the therapeutic efficacies.

RESULTS

The mean IPSS score was 16.1 ± 6.9 at baseline and 12.4 ± 7.1 at four weeks. The subject scores for the number of nocturnal voids also decreased significantly from 3.3 ± 0.9 to 2.9 ± 1.0. In addition, PSQI scores improved significantly from 7.4 ± 2.9 to 5.4 ± 2.8. According to the FVC, the number of nocturnal voids decreased significantly from 3.1 ± 1.2 at baseline to 2.2 ± 1.1 at four weeks, and nighttime bladder capacity improved significantly from 181.4 ± 79.9 to 201.1 ± 93.7 mL.

CONCLUSION

Ramelteon alleviated nocturia and disturbed sleep in patients with insomnia and nocturia and led to increased nighttime bladder capacity.

Risk factors for fracture in elderly men: a population-based prospective study

SUMMARY

Risk factors for fractures were assessed in a random sample of 4,696 elderly men followed for 5.4 years. Results highlighted the importance of assessment of falls and dizziness as well as novel risk factors including frequent urination and erectile dysfunction.

INTRODUCTION

Knowledge about risk factors for fracture in men is limited. The aim of this study was to evaluate factors potentially associated with fracture risk in men.

METHODS

A questionnaire enquiring about potential risk factors for fractures in men was posted to a random sample of 9,314 men aged 60-74 years. A completed questionnaire was returned by 4,696 (50.4%). Follow-up on incident fractures over 5.4 years was performed using public registries.

RESULTS

During the study, 203 individuals experienced a first clinical fracture, of which 85 patients were considered osteoporotic (9 in humerus, 10 vertebral, 32 in the hip and 34 in the forearm). Cox proportional hazard regression models were used to evaluate risk factors for any and osteoporotic fractures. The following variables were found to be associated with increased risk of any fracture in adjusted models family history of a hip fracture (HR; 95%CI: 1.56; 1.05-2.33), falls (2-4/year: 2.10; 1.35-3.27, >4/year: 2.46; 1.12-5.41, both compared to no falls), dizziness (2.36; 1.51-3.71), erectile dysfunction (1.41; 1.06-1.87) and frequent urination (2.06; 1.26-3.39). Similarly, falls (2.36; 1.45-3.86), dizziness (2.83; 1.52-5.25), erectile dysfunction (2.01; 1.30-3.09) and pulmonary illness (1.90; 1.03-3.53) were associated with increased risk of osteoporotic fractures in adjusted models.

CONCLUSION

These results underline the importance of assessment of dizziness, falls and those with a family history of hip fracture. Frequent urination and erectile dysfunction were independently associated with increased fracture risk. Although the mechanism of association is unknown, these variables are likely to be indicators of frailty or hypogonadism.

Nocturia is associated with an increased risk of coronary heart disease and death

What's known on the subject? and What does the study add? Nocturia has been associated with multiple chronic conditions, however, previous studies have been conducted only at a single time. We found that nocturia preceded the development CHD in young men. Moderate nocturia may be an early marker of CHD in young men.

OBJECTIVE

To determine whether nocturia is associated with the development of diabetes mellitus, hypertension, coronary heart disease (CHD) and occurrence of death.

MATERIALS AND METHODS

We studied data obtained from a retrospective cohort of randomly selected men, aged 40-79 years in 1990, from Olmsted County, MN, USA. Moderate nocturia was defined as waking to urinate ≥2 times per night. Men were followed every 2 years through repeated questionnaires and community medical records to assess development of diabetes mellitus and hypertension, and occurrence of death. CHD was ascertained through ongoing surveillance of heart disease in Olmsted County. Cox proportional hazard models were used to estimate associations between baseline nocturia and each of the outcomes.

RESULTS

A total of 2447 men were followed for a median of 17.1 years (25th and 75th percentiles: 15.0, 17.4 years). Moderate nocturia was not significantly associated with the later development of diabetes mellitus or hypertension in this study. Younger men (<60 years of age) with moderate nocturia were more likely to develop CHD later in life than younger men without nocturia (hazard ratio [HR]: 1.68; 95% confidence interval [CI]: 1.13, 2.49). This association was no longer significant when adjusted for age, body mass index (BMI) and urological medications (HR: 1.36; 95% CI: 0.87, 2.12). Older men (≥60 years of age) with moderate nocturia were more likely to die than older men without moderate nocturia, even after adjusting for age, BMI, urological medications and CHD (HR: 1.48; 95% CI: 1.15, 1.91).

CONCLUSION

Nocturia may be a marker for increased risk of CHD in younger men, and death in older men.

Nocturia: current status and future perspectives

PURPOSE OF REVIEW

Nocturia is a bothersome and highly prevalent condition characterized by the need to wake to void at night. Nocturia is equally common in men and women, and although its prevalence increases with age, a significant proportion of younger people are also affected. Nocturia leads to fragmentation of sleep and consequently to a serious decline in daytime functioning and in quality of life and health. Its impact should not be underestimated by clinicians and therefore a review on nocturia is timely and relevant.

RECENT FINDINGS

Traditionally, nocturia is regarded as a symptom of benign prostatic enlargement and/or overactive bladder syndrome, with treatment therefore directed toward increasing the capacity of the bladder to hold urine. Such treatments have proven ineffective in many patients because nocturnal polyuria, an overproduction of urine at night, has been found to be present in the majority of patients. Nocturia can be attributed to some underlying pathological factors but it can also be a distinct clinical entity with specific pathogenesis. Frequency-volume charts are recommended for routine use in clinical practice, to determine whether nocturia is a result of excessive urine production at night, or of small voided volumes due to bladder problems, or a combination of these factors. Desmopressin, a synthetic analogue of the antidiuretic hormone, should be considered in patients with nocturia where nocturnal polyuria is present.

SUMMARY

Contrary to popular and medical misconception nocturia is an important condition leading to general morbidity and with serious impact on overall quality of life and health. We advise clinicians to pay attention to nocturia and diagnostics should be offered. Treatment modalities are available and have to be discussed with the patient.