Nocturia and quality of life: results from the Boston area community health survey

Reduction of lower urinary tract symptoms in prostate cancer patients treated with robot assisted laparoscopic prostatectomy

PROBLEM

The aim of this study was to evaluate the change in LUTS in patients treated with RALP and to assess factors that may predict an improvement of LUTS.

MATERIALS AND METHOD

In our institutional prospective research registry, 1935 patients operated in the period between 2009 and 2021 with complete baseline- and 12-month EPIC-26 questionnaire were eligible for the study. Also SF-12 data estimating general quality of life (QoL) were analyzed. A LUTS summary score was constructed from the two questions concerning voiding stream/residual and frequency, and transformed linearly to a 0-100 scale with higher scores representing less symptoms  A change of 6 points or more were considered Meaningful Clinical Differences (MCD). Two summary scores were calculated from the SF-12 - a mental component score (MCS-12) and a physical component score (PCS-12). Multivariate regression was used to estimate covariates associated with postoperative MCD, MCS-12 and PCS-12.

RESULTS

Mean change of LUTS-score showed an increase of 10 points 12-months post-RALP.  52% of patients achieved MCD. In multivariate logistic regression, preoperative LUTS was statistically significant associated with MCD. Reduction of LUTS was associated improved mean score of MCS-12 and PCS-12.

DISCUSSION AND CONCLUSION

Along with information about risk for urinary incontinence after RALP, patients with LUTS at baseline must be informed that these symptoms may be reduced after RALP. In our study, this LUTS reduction was associated with better general QoL.

Association of nocturia with cardiovascular and all-cause mortality: a prospective cohort study with up to 31 years of follow-up

Background

Nocturia is a highly prevalent and under-considered condition and impacts the quality of life for many individuals. The long-term impact of nocturnal voiding on mortality, especially mortality from cardiovascular disease, remains unknown. The current study aimed to evaluate the relationship of nocturnal voiding episodes with cardiovascular and all-cause mortality among adults in the United States.

Methods

This is a prospective cohort study of a nationally representative sample of 13,862 U.S. adults aged 20 years or older who participated in the National Health and Nutrition Examination Survey III (1988-1994). Nighttime urination frequency was reported during an in-house interview. All-cause and cause-specific mortality were ascertained by linking to National Death Index mortality data through December 31, 2019. The associations of nocturia with cardiovascular and all-cause mortality were estimated using weighted Cox proportional hazards regression models.

Results

Throughout a median follow-up of 26.7 years, 5,029 deaths were reported, comprising 1,720 deaths from cardiovascular disease. In the fully adjusted model, participants who reported once, twice, and three or more times nocturnal voiding episodes have a higher risk of cardiovascular mortality (HR1, 1.22 [95% CI, 0.997-1.49], HR2, 1.47 [95% CI, 1.13-1.91], and HR ≥ 3, 1.96 [95% CI, 1.52-2.53]) as well as all-cause mortality (HR1, 1.12 [95% CI, 0.90-1.39], HR2, 1.54 [95% CI, 1.23-1.93], and HR ≥ 3, 2.48 [95% CI, 1.81-3.40]), compared to those without nocturia, and heart disease-specific mortality (HR1, 1.33 [95% CI, 1.08-1.64], HR2, 1.62 [95% CI, 1.25-2.10], and HR≥3, 2.07 [95% CI, 1.61-2.67]). Nevertheless, there was no significant relationship between the number of nocturia episode changes and stroke-specific mortality.

Conclusion

Nocturia was associated with a significantly augmented risk of overall and heart disease-specific mortality in a dosage-dependent manner. Early recognition and taking precautions may benefit individuals with nocturia by promoting quality of life and cardiac health.

Epidemiological trends and risk factors related to lower urinary tract symptoms around childbirth: a one-year prospective study

BACKGROUND

Lower urinary tract symptoms (LUTS) are prevalent and distressing concerns for women worldwide. The prevalence of LUTS reaches the first peak during pregnancy and postnatal period. However, less attention has been paid to LUTS around childbirth and little progress has been made in the prevention of LUTS. Understanding the epidemiological characteristics of LUTS around childbirth would inform decision making for health care providers and perinatal women in the prevention of LUTS. The study aims to investigate the epidemiological trends and associated risk factors related to LUTS around childbirth.

METHODS

Pregnant women were consecutively enrolled during pregnancy in the obstetrical wards of a tertiary hospital and followed up at 6-8 weeks and one year postpartum through a prospective design. Urinary incontinence was assessed with the International Consultation on Incontinence Modular Questionnaire-Urinary Incontinence Short Form. Other symptoms were measured with questions based on definitions of the International Incontinence Society. Multiple logistic regression was used to examine the risk factors for LUTS including urinary incontinence, increased daytime frequency, nocturia and urgency. The report followed the STROBE statement.

RESULTS

A total of 1243 pregnant women participated in this study. The prevalence of at least one type of storage symptoms was 94%, 55% and 35% in late pregnancy, at 6-8 weeks and one year postpartum, respectively. The prevalence of urinary incontinence remained at 21% within one year postpartum. The majority of the participants suffered from mild to moderate urinary incontinence. Age, job, BMI before pregnancy, gestational diabetes mellitus, urinary tract infection history, previous history of LUTS, age at first birth and birth mode were predictors of LUTS one year postpartum.

CONCLUSION

LUTS were highly prevalent during pregnancy and postnatal period. The prevalence of urinary incontinence was more stable than that of other LUTS within one year postpartum. Women aged more than 35 years, engaging in manual work, with gestational diabetes mellitus, with a history of urinary tract infection and LUTS, with advanced age at first birth and vaginal delivery were more likely to suffer from LUTS postpartum. The findings provided a novel and deep insight into the epidemiological trends and related risk factors of LUTS around childbirth.

Association of nocturia of self-report with estimated glomerular filtration rate: a cross-sectional study from the NHANES 2005-2018

Nocturia is a manifestation of systemic diseases, in which chronic kidney disease (CKD) is an independent predictor of nocturia due to its osmotic diuretic mechanism. However, to our knowledge, previous studies have not examined the association between nocturia and estimated glomerular filtration rate (eGFR). The purpose of this study was to assess the association between nocturia exposure and eGFR in the general US population. This study presents a cross-sectional analysis of the general US population enrolled in the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2018. To account for potential confounding factors, linear regression analysis was conducted to investigate the association between nocturia and eGFR. Stratified analyses and interaction tests were employed to examine the variables of interest. Additionally, sensitivity analyses were conducted across diverse populations. A total of 12,265 individuals were included in the study. After controlling for confounding factors, the results of the linear regression analysis indicated that a single increase in nocturnal voiding frequency was associated with a decrease in eGFR by 2.0 mL/min/1.73 m2. In comparison to individuals with a nocturnal urinary frequency of 0, those who voided 1, 2, 3, 4, and ≥ 5 times at night experienced a decrease in eGFR by 3.1, 5.4, 6.4, 8.6 and 4.0 mL/min/1.73 m2, respectively. Nocturia was found to be associated with a decreased eGFR of 4 mL/min/1.73 m2 when compared to individuals without nocturia. The sensitivity analysis yielded consistent findings regarding the association between nocturia and eGFR in both CKD and non-CKD populations, as well as in hypertensive and non-hypertensive populations. Nevertheless, inconsistent conclusions were observed across various prognostic risk populations within the CKD context. The presence of nocturia and heightened frequency of nocturnal urination have been found to be associated with a decline in eGFR.

Role of circadian rhythms and melatonin in bladder function in heath and diseases

The circadian system modulates all visceral organ physiological processes including urine storage and voiding. The "master clock" of the circadian system lies within suprachiasmatic nucleus of the hypothalamus while "peripheral clocks" are found in most peripheral tissue and organs, including the urinary bladder. Disruptions of circadian rhythms can cause organ malfunction and disorder or exacerbate pre-existing ones. It has been suggested that nocturia, which develops mostly in the elderly, could be a circadian-related disorder of the bladder. In the bladder, many types of gap junctions and ion channels in the detrusor, urothelium and sensory nerves are likely under strict local peripheral circadian control. The pineal hormone, melatonin, is a circadian rhythm synchroniser capable of controlling a variety of physiological processes in the body. Melatonin predominantly acts via the melatonin 1 and melatonin 2 G-protein coupled receptors expressed in the central nervous system, and many peripheral organs and tissues. Melatonin could be beneficial in the treatment of nocturia and other common bladder disorders. The ameliorating action of melatonin on bladder function is likely due to multiple mechanisms which include central effects on voiding and peripheral effects on the detrusor and bladder afferents. More studies are warranted to determine the precise mechanisms of circadian rhythm coordination of the bladder function and melatonin influences on the bladder in health and diseases.

Partially different? The importance of general equilibrium in health economic evaluations: An application to nocturia

Both the human capital approach and the friction cost approach are frequently used to quantify the productivity costs associated with illness, disability or death in health economic evaluations. In this paper we argue that these approaches have one major, but common shortcoming: they only capture partial equilibrium (PE) effects and therefore underestimate the true potential productivity costs associated with health conditions. They neglect the sizable, indirect, ripple effects in the economy captured by general equilibrium (GE) models. To demonstrate our point, we compare a traditional PE with a GE approach for the application to nocturia, a condition characterized by the need to frequently wake up at night to urinate. Nocturia is associated with substantial impairment of daytime functioning and work productivity. We employ large-scale United Kingdom (UK) employer-employee survey data to estimate the prevalence and productivity loss. These estimates are then used as shared inputs to drive both approaches. We find that the traditional PE approach underestimates the annual productivity cost of clinically relevant nocturia by around 16%. We propose a generalized GE/PE multiplier to approximate the GE effect for other health conditions. Our findings stress the importance of accounting for sizable GE effects when conducting health economic evaluations.

Urodynamic findings in female patients with nocturia: An age-matched case-control study

INTRODUCTION

Nocturia negatively impacts the quality of life and is associated with poor general health, but our understanding of its etiologies is incomplete. Urodynamic studies (UDS) findings in patients with nocturia are not well described and may help guide management. Our objective was to compare UDS findings with age-matched patients with and without nocturia.

MATERIALS AND METHODS

We retrospectively reviewed UDS findings of 1124 patients (2010-2017). A total of 484 (43%) presented with nocturia and 821 (73%) were female. Female patients were separated into age-matched groups with and without nocturia. Urinary symptoms, past medical diagnoses, demographic information, and UDS findings were compared.

RESULTS

A total of 596 female patients were included, 298 (50%) with nocturia and 298 without. Past medical history, including diabetes mellitus and cardiovascular disease, did not differ between groups. Patients with nocturia were more likely to have pelvic pain (p = 0.0014) and other daytime symptoms (frequency, urgency, and urgency incontinence). On UDS, patients with nocturia were more likely to have bladder outlet obstruction (BOO) (p = 0.025) and dysfunctional voiding (DV) (p < 0.0001). There was no difference in the frequency of detrusor overactivity (DO). Bladder capacity and postvoid residual volumes were lower, though not significantly, in the nocturia group.

CONCLUSIONS

When comparing UDS findings in contemporary, age-matched groups of female patients with and without nocturia, we found only BOO and DV to be associated with nocturia. While the treatment of nocturia is often aimed at managing DO, our data suggest that this may not be the primary urodynamic correlation with nocturia. Further studies are needed to assess whether successful treatment of BOO and DV can improve nocturia.

Laying the foundation for enhancing safety of desmopressin in older people: Validation of capillary blood sodium levels

PURPOSE

We aim to make desmopressin a safe treatment option for (older) patients at risk for hyponatremia, by introducing a new way of sodium monitoring. The goal is to reduce the risk of hyponatremia, enhance patient safety and ultimately introduce self-monitoring of sodium levels. The first step in the aforementioned is to validate capillary sodium.

MATERIALS AND METHODS

100 randomly selected patients admitted to the urology department received a single finger prick to collect capillary blood (250 µl) in a lithium-heparin tube. Each patient acted as its own control for the capillary and venous blood sample. Venous and capillary plasma sodium were analyzed by indirect ion-selective electrode measurement. The primary outcome was the agreement between capillary and venous sodium measurements, measured by the intra-class correlation coefficient (ICC).

RESULTS

One hundred paired blood samples were obtained of which four were excluded. There was no significant statistical difference observed between venous and capillary sodium (-0.23 mmol/L, p = 0.374). The ICC for single measures between capillary and venous sodium was 0.82 (95% confidence interval 0.75-0.88). Inter-method differences analyzed by a Bland-Altman plot and a Passing-Bablock regression did not reveal a statistically significant difference between both groups.

CONCLUSIONS

We demonstrated that venous and capillary sodium levels are interchangeable, taken into account the inter- and intravariability between analyses. We provided the first step towards a simple and safe solution for frequent sodium monitoring through a minimal invasive capillary blood collection. The results are of direct clinical relevance to safely use desmopressin in (older) patients at risk.

What Are Realistic Expectations to Become Free of Overactive Bladder Symptoms? Experience from Non-interventional Studies with Propiverine

INTRODUCTION

Unmet expectations are a major cause of perceived treatment failure and discontinuation of treatment. To enable evidence-based counselling of patients on realistic expectations, we determined the chance of patients with overactive bladder becoming free of a given symptom upon treatment with a muscarinic antagonist in a non-interventional setting.

METHODS

Two non-interventional studies included 1335 and 745 patients, respectively, who received 30 or 45 mg q.d. propiverine ER for 12 weeks. They were monitored for becoming free of urgency, urinary incontinence, frequency, or nocturia. Analyses were also performed in subgroups defined by basal symptom severity, age, and gender. Categorical data are shown as a percentage of the respective population. Continuous data are expressed as means or as median depending on whether the variability was considered to exhibit a normal distribution.

RESULTS

The probability of becoming symptom-free was largest for incontinence and frequency (about 50%), but lesser for urgency (about 20%) and nocturia (about 10%). Greater basal severity of a symptom reduced the chance to become free of that symptom upon treatment, but the chance to become free of incontinence and frequency was still considerable. Age and gender had only minor if any effects on the chance of becoming symptom-free. These findings are in line with those of a limited number of randomized controlled trials.

CONCLUSION

These data provide an evidence base for the counselling of patients with overactive bladder on realistic expectations of treatment outcomes. We propose that realistic expectations can lead to greater long-term adherence.

Lower urinary tract symptoms and functional ability in older adults: a community-based cross-sectional study

OBJECTIVES

Functional ability, or the ability to live actively in older age, is essential for healthy ageing. This study assessed the association between the five types of lower urinary tract symptoms (LUTS) and functional ability among community-dwelling older adults (≥65 years old).

DESIGN

A cross-sectional study.

SETTING

Community-dwelling older adults (≥65 years old) randomly selected from the basic resident register of Kashiwa city as part of the Kashiwa study.

PARTICIPANTS

The study included 916 community-dwelling older adults (481 male participants) in Japan.

OUTCOME MEASURES

A self-administered questionnaire was used to collect data regarding LUTS, which included frequency, nocturia, urgency, urinary incontinence and overactive bladder (OAB). Functional ability was measured using the Japan Science and Technology Agency Index of Competence. Sex-stratified logistic regression analyses were conducted, adjusting age, obesity, alcohol consumption, polypharmacy and comorbidities.

RESULTS

Male participants experienced symptoms of frequency, nocturia, urgency, urinary incontinence and OAB at rates of 68.0%, 89.0%, 16.0%, 3.7% and 4.3%, respectively. Female participants experienced these symptoms at rates of 68.3%, 80.0%, 11.0%, 7.4% and 8.5%, respectively. Among male participants, lower functional ability was only associated with nocturia (≥3 times/night) (adjusted OR (AOR): 1.71, 95% CI 1.05 to 2.79). Contrarily, lower functional ability among female participants was significantly associated with frequency (AOR: 1.61, 95% CI 1.04 to 2.49), urgency (AOR: 2.06, 95% CI 1.08 to 3.95) and OAB (AOR: 2.43, 95% CI 1.15 to 5.11).

CONCLUSION

The different associations between LUTS and functional ability by sex might be related to differences in the effect of comorbidities and physical fatigue. Our results help clarify the multifaceted effects of LUTS in old age, the need for early detection and treatment of LUTS, and the importance of maintaining functional ability.

Desmopressin therapy in children and adults: pharmacological considerations and clinical implications

PURPOSE

This review aims to provide prescribing clinicians a deeper appreciation of desmopressin's clinical indications and formulation types, to better balance efficacy and safety through proper formulation selection.

BACKGROUND

Since its discovery 50 years ago, desmopressin's antidiuretic properties have been used for central diabetes insipidus, primary monosymptomatic nocturnal enuresis and adult nocturnal polyuria, while its coagulant effects are useful for mild hemophilia A and von Willebrand Disease. During this time, newer formulations of desmopressin have also been introduced to the market raising questions on interchangeability, dose conversion and safety. The wide array of clinical indications and variable pharmacokinetic properties of different desmopressin preparations raises the possibility of medication error, especially the risk of hyponatraemia.

METHODOLOGY

A narrative review to explore clinically relevant aspects of desmopressin therapy, synthesising information obtained from searches of published literature.

RESULTS

We identified that the risk factors for developing hyponatremia include extremes of age, existing comorbidity, drug interaction, intranasal formulations and intercurrent illness. We describe the dose equivalence between all formulations to facilitate conversion. We highlight that in view of inter-subject variability, close monitoring is recommended when switching preparations. We found that paediatric data remains limited, leading to recent proposals for age- and weight-based dosing regimens.

CONCLUSION

The risk of hyponatremia, albeit small, can be reduced by adhering to the indication-specific doses and taking steps to govern the safe prescription of the drug. Further paediatric clinical trials are awaited to expand the evidence base of childhood desmopressin therapy.

Effects of consultation for voiding behavior on nocturnal urination status of older adults living alone: A preliminary study

Nocturia and its related arousal may impair the quality of life and increase the risk of falls in older adults. This study aimed to clarify the change in urination status during the main sleeping period within 1 year. We also aimed to examine the effects of a consultation for voiding behavior in addition to the traditional behavioral therapy on urination status during sleep in a group of independent community-dwelling older adults. A single-arm intervention study was conducted in 10 older adults, with a mean age of 80.1 years and nocturia frequency of 1-4 times/day. Natural changes in urination status were observed between 2016 and 2017. Participants received traditional behavioral therapy and a consultation related to voiding behavior four times from summer 2017 to spring 2018. Urination status was monitored using sensing devices placed in the participant's home. The average time staying in the toilet significantly increased after 1 year. Although this parameter significantly decreased after the first consultation in 2017, this change was not observed with the subsequent consultation. A combination of traditional behavioral therapy and consultation for voiding behavior may be effective in improving urination status during the main sleeping period.

Depressive symptoms in individuals diagnosed with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) in middle-aged and older Chinese individuals: Results from the China Health and Retirement Longitudinal Study

OBJECTIVES

Male lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) is common and may increase the risk of depressive symptoms. This study aimed to investigate the associated factors of LUTS/BPH and its association with depressive symptoms in middle-aged and older Chinese men.

METHODS

This study used data from the 2015 China Health and Retirement Longitudinal Study (CHARLS). A total number of 8,586 men aged ≥45 years were included in this study. Participants answered positively to whether they have ever been diagnosed with a prostate illness (excluding prostatic cancer) were defined as LUTS/BPH individuals. Depressive symptoms were assessed using the 10-item Center for Epidemiological Studies Depression Scale (CESD-10). Multivariate logistic analyses were applied to explore the associated factors of LUTS/BPH, association between LUTS/BPH and depressive symptoms, and risk factors of depressive symptoms according to LUTS/BPH status.

RESULTS

The weighted overall prevalence of LUTS/BPH was 13.1% in Chinese men aged ≥45 years. The prevalence of depressive symptoms was 29.1% in LUTS/BPH individuals and 22.9% in non-LUTS/BPH individuals. Depressive symptoms and LUTS/BPH shared some same risk factors, which were education, living regions, annual household consumption, sleep duration and multimorbidity. The results from logistic models showed that education, sleep duration and multimorbidity were significantly and independently associated with depression of LUTS/BPH individuals (P<0.001).

CONCLUSIONS

Prevalence of depressive symptoms in LUTS/BPH population was higher than in non-LUTS/BPH population. Education, sleep duration and multimorbidity were associated with the onset of depressive symptoms in LUTS/BPH individuals (P<0.001).

Psychometric validation and interpretation of the Nocturia Impact Diary in a clinical trial setting

Purpose

Psychometric evaluation of the Nocturia Impact (NI) Diary was conducted to support its use as a trial endpoint.

Methods

As part of a randomized, controlled Phase 2 clinical trial investigating a novel drug candidate for nocturnal polyuria, adult nocturia patients completed the NI Diary and a voiding diary for three nights preceding their clinic visit at Baseline and Weeks 1, 4, 8, and 12 (end of treatment). Exit interviews were conducted to obtain patient impressions of the NI Diary.

Results

A total of N = 302 participants were included. Confirmatory factor analysis (CFA) indicated that the 11-item measure is unidimensional with values of CFI, TLI, and RMSEA meeting relevant thresholds. Good internal consistency (Cronbach’s α 0.941) and test–retest reliability (intra-class correlation coefficients 0.730–0.880). Convergent validity with two reference measures was demonstrated with strong correlations of 0.573–0.730 were shown. Significant differences (P = 0.0018, standardized effect size = 0.372) between groups defined by number of night-time voids supported known-groups validity. Exit interviews in 66 patients indicated all participants experienced improvement in at least 1 NI Diary item and that a 1-point improvement on the item response scale and 1-void reduction per night (associated with an average best cut point on ROC analysis of − 11.6) constituted meaningful improvement. Anchor and distribution-based analyses identified a meaningful change threshold of − 15 to − 18 points on the NI Diary.

Conclusion

The NI Diary is a reliable and valid patient-reported psychometric instrument which is fit-for-purpose to evaluate the impact of nocturia on patient quality of life in the clinical trial setting.

Trial registration number and registration date NCT03201419; June 28, 2017.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-021-03060-4.

Psychometric evaluation of the Overactive Bladder Questionnaire (OAB-q) for measuring quality of life and clinical implications in Greek patients with overactive bladder

INTRODUCTION AND HYPOTHESIS

The Overactive Bladder Questionnaire (OAB-q) measures overactive bladder patients' severity of symptoms and their impact on health-related quality of life (HRQoL). The aim of this study was to validate the OAB-q in Greek patients with overactive bladder and report clinical implications of the disease.

METHODS

In total, 107 patients were recruited consecutively in our clinic. They completed the OAB-q and Short Form-36 Health Survey (SF-36) twice, 3 months apart. Simultaneously, they initiated lifestyle changes and drug therapy. The reliability of OAB-q was estimated by its internal consistency (Cronbach's α). Validity was estimated by criterion validity and concurrent validity by comparison with SF-36.

RESULTS

The sample's mean age was 62.1 years, and 74.8% were women. Cronbach's α exceeded the 0.7 threshold in all OAB-q subscales, implying good reliability of internal consistency for the OAB-q. In addition, moderate (Pearson's r > 0.3) or strong (r > 0.5) correlations were observed between OAB-q subscales and the relevant SF-36 subscales, implying concurrent validity. Clinically, urgency incontinence affected symptom bother (p = 0.001), concern/worry (p = 0.031) and social interaction (p = 0.027). Nocturia had the largest impact on HRQoL in patients with overactive bladder, as it affected all the OAB-q subscales (p < 0.001).

CONCLUSIONS

The Greek version of the OAB-q has shown strong psychometric properties of reliability and validity in our study. Urgency incontinence and especially nocturia seem to affect the HRQoL of patients with overactive bladder. OAB-q is valid for Greek patients with overactive bladder and can be used for clinical and academic purposes.

A Comprehensive Community-Based Prevalence Study on Nocturia in Hong Kong Male Adults

Background: Most prevalence surveys on nocturia have focused on older populations. This study aimed to measure the nocturia prevalence across the full spectrum of male adults living in Hong Kong, where severity and associated quality-of-life (QoL) were also explored. Methods: A cross-sectional population-based survey was conducted in men aged 18 or above using the ICIQ-NQoL Questionnaire. Results: With 1239 respondents at age ranged 18–99, the overall nocturia prevalences were found to be 63.0% (ranged 41.6–84.6% at different age groups) and 31.2% (ranged 13.0–56.3% at different age groups), for ≥1 and ≥2 bedtime voiding episodes, respectively. The chance of nocturia was dramatically increased at age 60 or above while both prevalence and voiding frequency were increased with advancing age. About 83% of the nocturia men experienced one to two voiding episodes per night, but many of them had self-rated their QoL poor or very poor and indicated moderate-to-high bothersome. Younger men at age 18–39 were found to have high prevalence as 41.6% and almost 30% of them rated poor or very poor QoL. Conclusions: Nocturia was not only affecting the older populations but also caused significant bothersome and negative impacts on QoL in younger males.

Improvement of quality of life and symptom burden after robot-assisted radical prostatectomy in patients with moderate to severe LUTS

The aim of this study was to assess clinically meaningful differences of preoperative lower urinary tract symptoms (LUTS) and quality of life (QoL) before and after robot-assisted radical prostatectomy (RARP). Therefore we identified 5506 RARP patients from 2007 to 2018 with completed International Prostate Symptom Score (IPSS) and -QoL questionnaires before and 12 months after RARP in our institution. Marked clinically important difference (MCID) was defined by using the strictest IPSS-difference of − 8 points. Multivariable logistic regression analyses (LRM) aimed to predict ∆IPSS ≤ − 8 and were restricted to RARP patients with preoperatively moderate (IPSS 8–19) vs. severe (IPSS 20–35) LUTS burden (n = 2305). Preoperative LUTS was categorized as moderate and severe in 37% (n = 2014) and 5.3% of the complete cohort (n = 291), respectively. Here, a postoperative ∆IPSS ≤ − 8, was reported in 38% vs. 90%. In LRM, younger age (OR 0.98, 95%CI 0.97–0.99; p = 0.007), lower BMI (OR 0.94, 95%CI 0.92–0.97; p < 0.001), higher preoperative LUTS burden (severe vs. moderate [REF.] OR 15.6, 95%CI 10.4–23.4; p < 0.001), greater prostate specimen weight (per 10 g, OR 1.12, 95%CI 1.07–1.16; p < 0.001) and the event of urinary continence recovery (OR 1.66 95%CI 1.25–2.21; p < 0.001) were independent predictors of a marked LUTS improvement after RARP. Less rigorous IPSS-difference of − 5 points yielded identical predictors. To sum up, in substantial proportions of patients with preoperative moderate or severe LUTS a marked improvement of LUTS and QoL can be expected at 12 months after RARP. LRM revealed greatest benefit in those patients with preoperatively greatest LUTS burden, prostate enlargement, lower BMI, younger age and the event of urinary continence recovery.

New insights in treatment of monosymptomatic enuresis

Objective

Nocturnal enuresis (NE) is defined as uncontrollable bed-wetting for at least three consecutive months in children over 5 years. Sleep could be dramatically altered in children with primary nocturnal enuresis (PNE); consequently, this helps to confirm the assumption that PNE appears to modify sleep structure, or it might be the result of an irregular sleep structure itself.

Method

This study conducted on 180 patients with monosymptomatic nocturnal enuresis. Their age was ranged from 6 to 18 years, and they were still having nocturnal enuresis episodes. We record two main points: first, if the child is a regular sleeper or not. The second point if the child is a regular bed wetter or not. This work fully compliant with the STROCCS criteria (Agha et al., 2019).

Result

A total of 180 children were included (Male 122, 67.8%, Female 58, 32.2%). The mean age was 8.9 (±2.4). This study showed that children aged 7–10 years are significantly more inclined to be reported as specific time bed-wetter's, whereas those aged between 11 and 13 are significantly less likely to wet their bed at a specific time (p = 0.001). Children who tend to sleep more often near a specific time each night are 6.74 times more prone to bed-wet around a particular time during their sleep (p < 0.001).

Conclusion

This study can be considered as hypothesis-generating that shed light on the possible correlation between the adherence to sleep at a specific time and its effect on the time of enuresis and the number of bedwetting.

•

Nocturnal enuresis is a common compliant among the pediatric age group.

•

The incidence of Nocturnal enuresis varies with age.

•

There is possible correlation between the adherence to sleep at a specific time and its effect on the time of enuresis and number of bedwetting.

•

The majority of children who sleep at a particular time suffer from Nocturnal enuresis at a specific time and are younger than the rest of the children, while children who sleep at an unspecified time suffer from multiple bed wettings at an undetermined time.

•

The chronobiology of micturition plays a vital role in the regulation of bedwetting in Monosymptomatic Nocturnal Enuresis (MNE) children.

Self-Assessed Benefits of a Prostate Health Formulation on Nocturia in Healthy Males With Mild Lower Urinary Tract Symptoms: An Open Label Study

Background

Nocturia is the most bothersome lower urinary tract symptoms (LUTS) and can significantly reduce men's quality of life. It is often poorly managed with conventional treatments.

Objective

The purpose of this study was to evaluate the self-assessed benefits of a prostate health dietary combination formulation on mild LUTS, especially nocturia in healthy males.

Methods

In an open label clinical study, thirty healthy male subjects with mild LUTS took one daily capsule of the product for 60 days. The primary outcome was self-assessed severity of LUTS using the International Prostate Symptoms Score (IPSS) questionnaire at Day 1 (baseline), Day 30 and Day 60. Safety and compliance were also evaluated.

Results

At Day 60, IPSS significantly decreased from baseline by 16.3% (3.6 ± 2.1 vs. 4.3 ± 1.5, p < 0.05). Although the reduction in IPSS did not reach statistical significance at Day 30, it was mostly driven by a 30.7% decrease (p < 0.05) in the nocturia sub-score compared with baseline. While 37% of subjects reported at baseline waking up 2‒3 times/night to void, none did so after taking the study product for 60 days. Compliance was very high throughout the study. No adverse events related to the study product were reported.

Conclusions

The study product might be a safe alternative for individuals willing to explore a non-conventional approach to manage their nocturia. A larger randomized placebo-controlled clinical trial is warranted to confirm these results. Clinical trial registry: Clinical Trials.gov. Registration number (September 1st, 2016): NCT02886832.

Dutch version of the TANGO nocturia screening tool: cross-culturally translation and reliability study in community-dwelling people and nursing home residents

Objectives: The purpose of this study was to translate and culturally adapt the self-administered screening instrument 'Targeting the individual's Aetiology of Nocturia to Guide Outcomes' (TANGO) into Dutch for Belgium and to assess its test-retest reliability. Methods: This study has a cross-sectional, descriptive study design. Cross-cultural adaption of TANGO into Dutch for Belgium was performed according to a standardized method. Convenience samples of community-dwelling people and NH residents with nocturia (≥1void/night) completed TANGO-D at baseline and 1-2 weeks later. Community-dwelling people filled in the questionnaire at home and the NH residents were interviewed by a study nurse. Results: TANGO-D was completed by 33 community-dwelling middle-aged people and 45 NH residents. Completeness of responses was adequate in both populations and almost all items had positive and negative answers. In the NH residents, 12 out of 22 items required clarification, wherein five items adjustments are essential. Test-retest reliability analysis revealed an overall median Kappa of .75 [IQR: .78-1] in community-dwelling people and .54 [IQR: .31-.65] in NH residents, confirming substantial and moderate agreement, respectively. Conclusion: TANGO-D is a cross-cultural adapted Dutch translation of the original TANGO and showed good test-retest reliability in community-dwelling middle-aged people. However, validation of TANGO is required before use in clinical practice and the addition of a module of environment-related items to extend the utility of the instrumentwhen used in NH is desirable.

Managing Nocturia in Frail Older Adults

This review discusses the available evidence in the current evaluation and treatment of nocturia in frail older adults. No evidence specifically evaluates the use of behavioral interventions in the treatment of the frail older adult with nocturia, but their use is supported in other cohorts. Behavioral modifications and optimal management of comorbidities remain the first-line treatment for all age groups and should be emphasized in the frail due to their favorable safety profile. No studies specific to the frail older adult support the use of pharmacotherapy. Some evidence exists for the efficacy of several agents in the older adult; however, this is difficult to extrapolate to the frail, and safety concerns abound. Desmopressin may be effective in the older adult, but a high risk of hyponatremia raises concerns for its safety, and therefore it is not recommended in the frail. α-Antagonists may have limited efficacy in men with known benign prostatic hyperplasia (BPH); they are relatively well tolerated, although the risk of orthostatic hypotension in the frail should be considered. β3-agonist trials suggest limited clinical utility. Antimuscarinics are not found to be useful in this cohort and are contraindicated in the frail older adult given the ability of antimuscarinics to cause cognitive impairment, delirium, and falls. No data examine the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the frail older adult. Additionally, the American Geriatrics Society Beers Criteria recommends against the use of muscarinics in those over the age of 75 years and therefore their use is not supported.

The Association between Insomnia and Orgasmic Difficulty for Prostate Cancer Patients - Implication to Sex Therapy

Sexual dysfunction and insomnia are common side effects of prostate cancer (PCa) treatment, but the link between these symptoms has not been explored. We explore here the association between various sexual parameters and insomnia symptoms in PCa patients. Data were collected via an online survey with recruitment through various PCa organizations. One hundred and forty two patients (age = 67.3 ± 8.9 years) completed the survey. The majority were in a relationship (84.6%), of Caucasian ethnicity (83.1%), and 33% had previously received androgen deprivation therapy (ADT). Control variables-age, number of comorbidities, past ADT use, body mass index, depression, anxiety, fatigue and daytime sleepiness-explained 58.2% of the variance for insomnia symptoms. Including orgasm difficulty in the models accounted for an additional 2.1% in the variance in insomnia symptoms. Conversely, the control variables listed above together with insomnia symptoms predicted 37.7% of the overall variance in orgasm difficulty in PCa patients. These data suggest that sexual rehabilitation programs for PCa patients should assess insomnia symptoms, and therapies to improve sexual function or sleep quality may be beneficial in both functions given the relationship between sleep and orgasm functions in this population.

Defining nocturnal polyuria in women

AIMS

Nocturnal polyuria (NP) is defined by the International Continence Society (ICS) as "excessive production of urine during the main sleep period" and is one of the main causes of nocturia. The ICS recognized that "excessive" is not clearly defined and that this needs to be highlighted in both clinical and research settings. The aim of this study was to identify different definitions of NP and apply them to a population of women attending the Urogynaecology clinic.

METHODS

This was a retrospective study of complete bladder diaries collected from women attending a tertiary Urogynaecology Unit. Six different definitions were identified and were divided into "absolute," "relative," and "functional definitions." Prevalence data were calculated and values generated for sensitivity, specificity, positive and negative predictive values when related to women voiding ≥ 2 times per night.

RESULTS

Complete bladder diaries were obtained from 1398 women, over 6 years, with a mean age of 57 years. Prevalence varied across the definitions from 21.5% (absolute definition) to 77% (relative definition). Sensitivity ranged from 43% (absolute) to 87% (relative). The definitions that showed the highest combined sensitivity and specificity were the functional definitions.

CONCLUSION

From this study it is clear that more work needs to be done to arrive at a consensus for defining NP to enable accurate diagnosis and development of treatment pathways. We propose that a relative definition may provide a more clinically relevant method of defining NP.

Assessing the burden of nocturia in the workplace: the associations between nocturnal voiding, subjective well-being, work engagement and productivity

Aims: Nocturia (getting up at night to urinate, where each urination being followed by sleep or intention to sleep) is a bothersome symptom with potentially negative consequences for individual health and daytime functioning. This study assessed the burden of nocturia in the workplace by investigating associations between nocturia and subjective well-being (SWB), work engagement and productivity.Methods: Using large-scale international workplace survey data, the associations between nocturia, SWB, work engagement (Utrecht Work Engagement Scale, UWES-9) and productivity (Work Productivity and Activity Impairment, WPAI) were assessed. Bivariate and multivariate regression analysis was used with adjustment for a large set of confounding factors, including sleep duration and sleep quality.Results: Across a study sample of 92,129 observations, aged 18-70, an average of 10% of the survey population reported ≥2 nocturnal voids (generally considered clinically significant nocturia), with prevalence of nocturia increasing with age. Individuals with nocturia reported a 35.7% (p < .001) higher relative sleep disturbance score and were 10.5 percentage points (pp) (p < .001) more likely to report short sleep. Adjusted for covariates, nocturia was associated with a 3.5% (p < .001) lower relative SWB score and a 2% (p < .001) lower relative UWES-9 work engagement score. Nocturia was associated with a 3.9 pp (p < .001) higher work impairment due to absenteeism and presenteeism (WPAI). Adjusting additionally for sleep disturbance and sleep duration reduced the magnitude of the estimated effects, suggesting a key role for poor sleep in explaining the relationship between nocturia and the outcomes (SWB, UWES-9, WPAI) assessed.Conclusions: A key contribution of this study is the assessment of the association between nocturia and a range of work performance outcomes in a sizeable study using validated instruments to measure work engagement and productivity. The study highlights the importance of taking sleep into account when assessing the relationship between nocturia and associated outcomes.

PERSONAL: Feasibility Study Protocol for Placebo-Controlled, Randomized n-of-1 Trials of Tamsulosin for Lower Urinary Tract Symptoms

Background: Lower urinary tract symptoms (LUTS) affect more than half of men over age 70 and contribute to both poor health-related quality of life and polypharmacy. Tamsulosin hydrochloride, a selective α₁-blocker, is the most common medication used to treat LUTS due to presumed benign prostatic hyperplasia and is often prescribed indefinitely, although not all men benefit from long-term therapy. N-of-1 trials allow for individualized estimates of benefit and harm and could facilitate decisions regarding chronic tamsulosin therapy for LUTS, particularly among older men. Our team developed the PERSONAL (PlacEbo-controlled, Randomized, patient-Selected Outcomes, N-of-1 triALs) app to track daily urinary symptoms and medication side effects for n-of-1 trials among older men with LUTS.

Materials and Methods: We will conduct a feasibility study of 20 individual randomized n-of-1 trials using the PERSONAL app to compare tamsulosin (0.4 or 0.8 mg) vs. placebo among older men taking tamsulosin for LUTS. We will include men over age 65 with a smartphone for whom temporary discontinuation of tamsulosin is safe, (e.g., no history of acute retention). Participants will work with research staff to prospectively identify the most important urinary symptoms and medication side effects that they would like to digitally track. Men will then be randomized to 2-week treatment periods of tamsulosin or placebo followed by a 1-week wash-out with placebo, for 4 distinct treatment periods and 3 wash-out periods, totaling 11 weeks. Study medications will be blinded using over-encapsulation of tamsulosin pills and matching placebo. Our primary outcomes for this study will be recruitment and retention of eligible men, completion rates of n-of-1 trials and daily questionnaires using the PERSONAL app, and participants' perceived usefulness of their n-of-1 trial for determining whether tamsulosin is effective for them. Linear mixed effects models with individual-specific intercepts and intervention effects will also be used to estimate within-individual effects of tamsulosin.

Discussion: The goal of this innovative study is to establish feasibility and acceptability of using a mobile health app and n-of-1 trials to provide older men with individualized estimates of benefits and harms of chronic tamsulosin therapy for LUTS.

Factors Associated With Nocturia-Related Quality of Life in Men With Lower Urinary Tract Symptoms and Treated With Tamsulosin Oral Controlled Absorption System in a Non-Interventional Study

Nocturia impairs quality of life (QoL). We have performed a non-interventional study in which men with lower urinary tract symptoms (LUTS) were treated for at least 3 months with tamsulosin oral controlled absorption system (0.4 mg q.d.). Other than observing efficacy and tolerability of this drug formulation, the study was designed to explore the relative roles of number of nocturia episodes and of non-urological causes of nocturia on nocturia-related QoL at baseline and treatment-associated changes thereof. The study enrolled 5775 men seeking treatment of their LUTS. Tamsulosin improved LUTS, e.g. International Prostate Symptom Score from 19.5 ± 5.9 to 10.1 ± 4.9 (means ± SD). This was associated by clinically meaningful improvements in the Nocturia QoL score (from 45 ± 19 to 73 ± 17 points) and other QoL scores. Number of nocturnal voids was the key driver of all QoL scores at baseline; change of number of nocturia episodes that of improvement of all QoL scores upon treatment. In contrast, non-urological causes of nocturia such as heart failure, diabetes, sleep apnea, fluid or alcohol intake or use of diuretics or hypnotics had only small if any effects on baseline QoL or treatment-associated improvements thereof. The observed effects of non-urological causes on QoL apparently were largely driven by their effect on number of nocturnal voids. These data further support the idea that improvement of nocturia may be an important treatment goal in male LUTS.

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.

Bladder sensations in women with nocturia due to overactive bladder syndrome

OBJECTIVES

Nocturia is the number of times urine is passed during main sleep. This definition tells us that it is a need to void; it does not tell us what triggers it. The aim of this study is to report bladder sensations that wake up women with nocturia (N). Descriptions of sensations in relation to various overactive bladder (OAB) symptoms, most bothersome symptoms, urinary incontinence (UI) and urodynamic findings are examined.

MATERIALS AND METHODS

A prospective study of women > 18 years old presenting with OAB and nocturia. Data collected included presenting and most bothersome symptoms, descriptions of bladder sensations associated with nocturia, number of frequency and nocturia episodes, nighttime UI and urodynamic findings.

RESULTS

One hundred fifty women were recruited with mean age 52 years, mean duration of symptoms 10.5 months and mean number of nocturia episodes 4.5. All women reported multiple presenting and bothersome symptoms. Fifty-five per cent had detrusor overactivity (DO). "Multiple" and "more intense" bladder sensation descriptions of nocturia were associated with advanced age, more frequent nighttime UI, when nocturia was considered most bothersome and in the presence of DO. The most frequent single description was "strong desire to void". The most frequently used combination was "strong desire to void, sudden compelling desire to void, bladder pain and full bladder".

CONCLUSION

Descriptions of bladder sensations associated with nocturia in women with OAB were diverse and overlapping. It is important to report clinically and in research why patients have nocturia as this will have bearing on its treatment.

A systematic approach to the investigation and treatment of nocturia

Level of evidence: 4.

Treatment Preferences of Patients With Benign Prostatic Hyperplasia Before and After Using a Web-based Decision Aid

OBJECTIVE

To evaluate treatment preferences of patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) before and after using a web-based decision aid (DA).

PATIENTS AND METHODS

Between July 2016 and January 2017 patients were invited to use a web-based LUTS/BPH DA. Treatment preferences (for lifestyle advices, medication or surgery) before and after DA use and responses on values clarification exercises were extracted from the DA.

RESULTS

In total, 126 patients were included in the analysis. Thirty-four percent (43/126) had not received any previous treatment and were eligible for (continuation of) lifestyle advices or to start medication, as initial treatment. The other 66% (83/126) did use medication and were eligible, either for continuing medication or to undergo surgery. Before being exposed to the DA, 67 patients (53%) were undecided and 59 patients (47%) indicated an initial treatment preference. Half of the patients who were initially undecided were able to indicate a preference after DA use (34/67, 51%). Of those with an initial preference, 80% (47/59) confirmed their initial preference after DA use. Five out of 7 values clarification exercises used in the DA were discriminative between final treatment preferences. In 79%, the treatment preferred after DA use matched the received treatment. Overall, healthcare providers were positive about DA feasibility.

CONCLUSION

Our findings suggest that a LUTS/BPH DA may help patients to confirm their initial treatment preference and support them in forming a treatment preference if they did not have an initial preference.

Trends and prevalence of nocturia among US adults, 2005-2016

PURPOSE

Increased nocturia episodes can be a clinical marker of poor health status. The present study aimed to evaluate patterns and temporal trends in nocturia and sociodemographic and lifestyle correlates in the US population.

METHODS

Participants, aged 20 years or older, were included in this repeated cross-sectional study. The National Health and Nutrition Examination Survey from 2005 to 2016 was used. Participants were asked "During the past 30 days, how many times per night did you most typically get up to urinate, from the time you went to bed at night until the time you got up in the morning?". Individuals were categorized as either ≥ 1 nocturia episode or ≥ 2 nocturia episodes per night.

RESULTS

The estimated prevalence of ≥ 1 nocturia was high among men (20-39 years, 56.8%; 40-59 years, 70.2%; ≥ 60 years, 82.7%) and women (20-39 years, 68.9%; 40-59 years, 74.3%; ≥ 60 years, 84.7%), particularly in Non-Hispanic-blacks. From 2005-2016, the trends in prevalence of ≥ 1 nocturia increased for the age groups 20-39 and 40-59 years among men (p < 0.001 and p = 0.001, respectively) and women 20-39 and 40-59 years (p < 0.001 and p = 0.032, respectively), but a stable trend was observed among men and women who were 60 years and older (p = 0.814, and p = 0.64, respectively). A significant increasing trend of ≥ 2 nocturia episodes was observed among men only aged 40-59 years (p = 0.007).

CONCLUSIONS

From 2005 through 2016, the secular trend in the frequency of nocturia increased in both men and women in general, which was significant under the age of 60 years, particularly in Non-Hispanic-blacks.

The mediating role of sleep quality in the association between nocturia and health-related quality of life

Background

Even though the negative impacts of nocturia on sleep quality and health-related quality of life (HRQOL) have been documented in previous research, their interrelationship has been poorly studied. This study aimed to explore whether nocturia would affect sleep quality, which in turn affects HRQOL.

Methods

Participants aged 40 and above were randomly recruited from a Hong Kong public primary care clinic. Participants were asked to report the average number of nocturia (waking up at night to void) pisodes per night over a 1-month period. The Pittsburgh Sleep Quality Index (PSQI) and the 12-Item Short Form Health Survey version 2 (SF-12 v2) were administered. The mediation analysis was tested using multistage regression approach and bootstrap method.

Results

Of the 500 subjects who completed the survey, 31.2% reported symptomatic nocturia (having ≥2 nocturia episodes per night), and 60.4% experienced poor sleep quality (a PSQI global score > 5). Respondents with symptomatic nocturia had a poorer HRQOL in the domains of physical functioning (PF), role physical (RP) and social functioning (SF), general health (GH), vitality (VT) and physical component summary (PCS) of the SF-12 v2 than those without. Compared with the respondents without poor sleep quality, those with poor sleep quality had poorer HRQOL across all domains and summaries of the SF-12 v2. Mediation analysis found that sleep quality fully mediated the association between nocturia and the PF, RP and SF domains of the SF-12 v2, respectively, and partially mediated the association between nocturia and the GH, VT and PCS domains of the SF-12 v2, respectively.

Conclusions

We found that sleep quality mediated the association between nocturia and HRQOL. To enhance the HRQOL of patients with nocturia, clinicians should not only focus on nocturia symptoms, but also on their sleep quality.

The Economic Burden of Nocturia on the U.S. Health Care System and Society: A National Health and Nutrition Examination Survey Analysis

BACKGROUND

Nocturia, characterized as waking during the main sleep period to urinate, is a common condition. Persistent nocturia results in sleep fragmentation with deleterious effects on health and well-being. Yet, there are limited data on the economic burden of nocturia in the United States.

OBJECTIVE

To assess the association of nocturia with health care resource utilization (HRU), work productivity, and self-rated health while estimating the societal costs of nocturia in the United States in 2017.

METHODS

A retrospective cross-sectional study was conducted using data from the National Health and Nutrition Examination Survey (NHANES; 2005-2006 to 2013-2014). Adults aged ≥ 18 years (excluding pregnant women) were stratified into individuals with nocturia (≥ 2 voids/night) and individuals without nocturia (< 2 voids/night), based on the threshold for clinically significant nocturia. Outcomes were self-reported and included HRU (hospitalizations, outpatient visits); work productivity (weekly hours worked, employment); and current health status. Multivariable regression analyses adjusting for age, race, sex, body mass index, insurance status, education level, alcohol use, smoking status, and self-reported comorbid conditions were used to compare the 2 cohorts, overall and stratified by age group (20-44 years, 45-64 years, and 65+ years) to distinguish the effects on different age groups including the Medicare-aged population. Excess direct health care costs and indirect productivity costs associated with nocturia in the United States were then calculated using a prevalence-based approach and available literature (i.e., nocturia prevalence estimates, aggregated unit costs by HRU type, and average hourly earnings in the United States).

RESULTS

22,300 individuals were identified, and 24% had nocturia (≥ 2 voids/night). Median age was 55.2 and 43.2 years among individuals with and without nocturia, respectively, and the proportion of males was 43.3% and 51.3%, respectively. Individuals with nocturia had significantly more HRU, including hospitalizations and outpatient visits, worked significantly fewer hours weekly, and were significantly less likely to be employed when compared with those without nocturia. They were also significantly less likely to report being in very good/excellent health. These comparisons remained statistically significant across age groups. Total excess direct health care costs were $62.9 billion (hospitalization: $47.6 billion; outpatient: $15.3 billion). Total excess indirect productivity costs were $151.7 billion. Altogether, costs were estimated at $214.5 billion, equivalent to $3,491 per individual with nocturia. Individuals aged 20-44 years incurred 23.5% of total excess costs, while those aged 45-64 and 65+ years incurred 48.2% and 28.3%, respectively. Sensitivity analyses based on lower prevalence estimates resulted in costs of $94.0 billion, while those based on higher prevalence estimates reached up to $231.1 billion.

CONCLUSIONS

Nocturia is associated with a substantial economic burden in the United States even when evaluated based on lower prevalence estimates. This study underscores the importance of timely diagnosis and management of nocturia patients to alleviate health-related and economic consequences to patients and society.

DISCLOSURES

This work was supported by Ferring Pharmaceuticals, which contributed to and approved the study design and participated in the interpretation of data, review, and approval of the manuscript. Gauthier-Loiselle, Gagnon-Sanschagrin, and Wu are employees of Analysis Group, which received consultancy fees from Ferring Pharmaceuticals for work on this study. Jhaveri is a full-time employee of Ferring Pharmaceuticals. Parts of this work were presented as a poster presentation at AMCP Nexus 2018; October 22-25, 2018; Orlando, FL.

Incidence of Nocturia in Men with Lower Urinary Tract Symptoms Associated with Benign Prostatic Enlargement and Outcomes After Medical Treatment: Results from the Evolution European Association of Urology Research Foundation Prospective Multinational Registry

BACKGROUND

Nocturia is one of the most prevalent and bothersome lower urinary tract symptoms (LUTS) in men, leading to increased morbidity and mortality and a considerable economic burden on healthcare systems. Understanding its natural history, effect of pharmacotherapy, and predictors of failure of pharmacotherapy would allow optimised patient management.

OBJECTIVE

To evaluate the prevalence and effect of clinically relevant nocturia (crN) on quality of life in a contemporary cohort of European men aged ≥50 yr in a "real-life" setting, to understand its natural history, to detect any effect of pharmacotherapy, and to identify predictors of pharmacotherapy failure.

DESIGN, SETTING, AND PARTICIPANTS

This is a secondary analysis of the data from the Evolution Registry-a European, multicentre, prospective, observational registry, conducted in five European countries within a sample of general practitioners' and urologists' clinics. A consecutive sample of 2175 men aged ≥50 yr with LUTS in association with benign prostatic enlargement was enrolled between February 2010 and April 2011, and followed up for 2yr. Overall, data from 1838 men were suitable for analysis.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was evaluation of the baseline incidence of nocturia in the study population. Secondary outcomes included the impact of nocturia on quality of life, efficacy of pharmacotherapy, and predictive factors associated with persistence of nocturia. Descriptive statistics were used to examine the data. Logistic regressions were used to analyse associations between comorbid conditions and risk factors in men with nocturia.

RESULTS AND LIMITATIONS

Overall, 1198 men (65%) reported crN (two or more voids per night). This increased age dependently from 59% in the 50-59-yr age group (n=74) to 89% in the 80-99-yr age group (n=25). Overall, the incidence of crN improved in those who commenced pharmacological treatment at study entry, from 69% at baseline to 49% at 24 mo (p<0.00001). This was statistically significant only in those <80 yr old. A weak correlation was found between the severity of nocturia at baseline and quality-of-life scores on the International Prostate Symptom Score questionnaire (r=0.33, p<0.001). Of the patients treated with an alpha-blocker or a 5-alpha reductase inhibitor, 62% still had crN at 24 mo.

CONCLUSIONS

Almost two-thirds of men in the Evolution Registry reported clinically significant nocturia with increased incidence with age. Despite prostate-targeted treatment, most patients, especially older men, still had persistent or worsening nocturia at 2-yr follow-up, and in this study, it was not possible to identify specific clinical factors that predicted those who could respond well to treatment in this regard.

PATIENT SUMMARY

This large study of men from five different European countries has shown that waking up at night to pass urine (nocturia) is very common and becomes more common with older age, and treatments that target the prostate do not significantly improve symptoms over 2yr in most men.

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.

Silodosin: An Update on Efficacy, Safety and Clinical Indications in Urology

INTRODUCTION

Silodosin determines smooth muscle relaxation in bladder and prostate tissues, increases bladder blood flow in conditions of chronic bladder ischemia and regulates the activity of transcriptional factors responsible for stromal growth and prostate hyperplasia. Phase III trials have already demonstrated the efficacy and safety of silodosin in the treatment of patients bothered by lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

OBJECTIVE

We aimed to describe the rationality for the use of silodosin and to summarize the current literature on the use of Silodosin for the treatment of LUTS.

METHODS

PubMed and Web of Science were queried with the terms: 'silodosin' in combination (AND) with the terms 'lower urinary tract symptoms', 'LUTS', 'pathophysiology', 'symptoms' OR 'therapy'. Studies published in the last 10 years (2007-2017) in adults and core clinical journals in English were included.

RESULTS

Silodosin 8 mg once-daily was superior to placebo in improving IPSS total score, voiding subscore, storage subscore and QoL score, and at least as effective as tamsulosin 0.4 mg once-daily in all the efficacy analyses. In addition, studies assessing the effect on urodynamic parameters showed that silodosin determined a higher improvement in the bladder outlet obstruction index compared to other alpha1 adrenergic receptor antagonists. Concerning the safety profile, long-term data (after 9 months of treatment) confirmed the limited effect of silodosin on the cardiovascular and gastrointestinal systems. Although ejaculatory disorders represented the main complaint of patients taking silodosin, the discontinuation rate due to this condition remained low even in a long-term follow-up study (7.5%). Encouraging findings showed that silodosin may be administered as a medical expulsive therapy for promoting spontaneous stone passage of distal ureteral stones < 10 mm, to relieve LUTS in patients who underwent prostate cancer brachytherapy and to increase the likelihood of successful trials without a catheter in patients experiencing acute urinary retention.

CONCLUSION

Silodosin is one of the drugs approved for the treatment of BPH, being highly effective in improving not only LUTS but also urodynamic parameter impairments secondary to BPH. Moreover, it has shown efficacy as medical expulsive therapy for distal ureteral stones in previous prospective randomized trials.

FUNDING

Sponsorship for this study and article processing charges were funded by Recordati.

[Impact of medical and surgical treatments of LUTS on nocturia]

INTRODUCTION

Nocturia is the most frequently reported lower urinary tract symptom, but the impact of medical and surgical treatments on this symptom remains poorly evaluated. The objective of this work was to carry out a systematic review of the literature on the medical and surgical management of nocturia in men with bladder outlet obstruction due to benign prostatic hyperplasia.

MATERIAL AND METHOD

A systematic review of the literature was conducted including the effects of medical and surgical treatments on nocturia. Articles were selected by 3 independent reviewers before being analyzed and synthesized.

RESULTS

Among medical treatments, the most effective on nocturia seems to be desmopressin. Nevertheless, prescribing restrictions to men under 65 years of age hinder its use in routine practice. The effect of other medical treatments remains modest, although significant compared to placebo groups. The decrease in the number of nocturia would decrease from 0.25 to 0.7 in placebo group and from 0.29 to 1.1 in active treatment groups (alpha blocker, diuretic, anti-inflammatory, IPDE-5, 5 alpha reductase inhibitor). Surgical treatments seem to be more effective on nocturia. Although persistent in half of the patients undergoing surgery, the number of nocturia episodes decreased in 70% of them.

CONCLUSION

Nocturia is one of the most common urinary symptoms and the one that responds the least to the proposed medical and surgical treatments. The information given to patients by urologists must emphasize the modest effects to be expected in this area.

Burden of renal angiomyolipomas associated with tuberous sclerosis complex: results of a patient and caregiver survey

Background

Tuberous sclerosis complex (TSC) is a rare genetic disorder characterized by benign tumors in multiple organs, including non-cancerous kidney lesions known as renal angiomyolipomas. This study’s objective is to describe the age-stratified morbidity, treatment patterns, and health-related quality of life of TSC patients with renal angiomyolipomas in the United States. A cross-sectional, anonymous web-based survey was conducted with a convenience sample of TSC patients and caregivers identified through a patient advocacy organization.

Results

Out of the total sample of 676, 182 respondents reported having kidney complications with 33% of the pediatric group and 25% of the adult group with TSC reporting them. Of those with kidney complications, 110 (60%) reported a diagnosis of renal angiomyolipomas, of which 79 (72%) were adult patients and 31 (28%) were pediatric age patients. Eighty-four percent of the pediatric group and 76% of the adult group reported lesions on both kidneys. Of the patients experiencing involvement of only one kidney, 60% of the pediatric group and 21% of the adult group reported having multiple tumors within the affected kidney. Almost all of the sample (99%) reported seeing a physician and having a procedure or test for TSC in the past year. Less than half the respondents (44%) reported being hospitalized in the past year. Thirty-nine percent reported an emergency room visit as well. Compared to scores for patients with kidney disease, the angiomyolipoma adult patients reported significantly lower Mental Component Summary scores on the SF-12.

Conclusions

Renal angiomyolipomas burden leads to frequent healthcare resource use including hospitalization, invasive treatments, and surgical procedures, which result in an impaired mental health related quality of life.

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.

Nocturia is Associated with Poor Sleep Quality Among Older Women in the Study of Osteoporotic Fractures

OBJECTIVES

(1) To examine relationships between frequency of nocturia and self-reported sleep quality and objective sleep measures in older women, and (2) to estimate the amount of variation in sleep measures that is specifically attributable to frequency of nocturia.

DESIGN AND SETTING

Secondary, cross sectional analysis of the multicenter prospective cohort Study of Osteoporotic Fractures (SOF).

PARTICIPANTS

Community-dwelling women aged ≥80 years.

MEASUREMENTS

Frequency of nocturia in the previous 12 months, Pittsburgh Sleep Quality Index sleep quality subscale, and actigraphy-measured wake after sleep onset (WASO) and total sleep time (TST).

RESULTS

Of 1,520 participants, 25% (n = 392) reported their nocturia frequency was 3-4 times/night and an additional 60% (n = 917) reported their nocturia frequency was 1-2 times/night. More frequent nocturia was associated with poor sleep quality (3-4/night: 26.8% reported fairly bad or very bad sleep quality; 1-2/night: 14.7%; 0/night: 7.7%; P < .001) and longer WASO (3-4/night: 89.8 minutes; 1-2/night: 70.6; 0/night: 55.5; P < .001). In nested regression models, a nocturia frequency of 3-4/night quadrupled the odds of poor sleep quality (odds ratio: 4.26 [95% CI 1.65, 11.01]; P = .003) and was associated with a 37-minute worsening in WASO (95% CI 26.0, 49.0; P < .001). Frequency of nocturia explained an additional 6% variation in WASO, above and beyond demographic, medical/psychiatric conditions, and medication factors (∆R² = 0.06).

CONCLUSIONS

Nocturia is common among octogenarian and nonagenarian women and is independently associated with poor sleep quality and longer wake time at night. Interventions that improve nocturia may be useful in improving sleep quality and wake time at night.

Daily use of sildenafil 50mg at night effectively ameliorates nocturia in patients with lower urinary tract symptoms associated with benign prostatic hyperplasia: an exploratory multicenter, double-blind, randomized, placebo-controlled study

PURPOSE

To compare the efficacy and safety of sildenafil 25 mg qd, 25 mg bid or 50 mg qd - on treating lower urinary tract symptoms with benign prostatic hyperplasia (LUTS/BPH).

MATERIALS AND METHODS

Men aged > 45 years with LUTS/BPH were randomly assigned to receive sildenafil 25 mg qd (n = 42), bid (n = 41), 50 mg qd (n = 38) or placebo (n = 41) for 8 weeks. Changes from baseline in International Prostate Symptom Score (I-PSS), maximum urinary flow rate (Qmax) and postvoid residual urine volume (PVR) were assessed at week 4 and week 8.

RESULTS

Sildenafil 25 mg qd (-7.3 ± 5.8) and 25 mg bid (-7.0 ± 5.7) exhibited significant improvements of I-PSS compared to placebo (-5.2 ± 6.4) (p = 0.020, 0.025, respectively). In particular, voiding domain was more affected than storage domain. Only sildenafil 50 mg qd improved nocturia significantly (versus placebo, p = 0.027). Quality of life score was improved in all treatment groups. Q_max and PVR did not change significantly in all groups. All regimens were well tolerated.

CONCLUSIONS

Sildenafil 25 mg qd, 25 mg bid and 50 mg qd are safe and effective to improve LUTS/BPH in long term, along with coexisting ED. In particular, nocturia is most well-controlled by 50 mg qd.