Excessive nocturnal urine production is a major contributing factor to the etiology of nocturia

The role of renal circadian biorhythms in lifelong LUTS

INTRODUCTION

This article delves into the intricate relationship between kidney function, diuresis, and lower urinary tract symptoms (LUTS) throughout the transitions of the human lifespan. It explores circadian regulation of urine production, maturation of renal function from birth to adulthood, and effects of aging on kidney function and LUTS. The complex connections between these factors are highlighted, offering insights into potential interventions and personalized management strategies.

METHODS

An international panel of seven experts engaged in online discussions, focusing on kidney function, diuresis, and LUTS throughout life. This manuscript summarizes expert insights, literature reviews, and findings presented during a webinar and subsequent discussions.

RESULTS

Renal function undergoes significant maturation from birth to adulthood, with changes in glomerular filtration rate, diuresis, and tubular function. A circadian rhythm in urine production is established during childhood. Adolescents and young adults can experience persistent enuresis due to lifestyle factors, comorbidities, and complex physiological changes. In older adults, age-related alterations in kidney function disrupt the circadian rhythm of diuresis, contributing to nocturnal polyuria and LUTS.

CONCLUSION

The interplay between kidney function, diuresis, and LUTS is crucial in understanding lifelong urinary health. Bridging the gap between pediatric and adult care is essential to address enuresis in adolescents and young adults effectively. For older adults, recognizing the impact of aging on renal function and fluid balance is vital in managing nocturia. This holistic approach provides a foundation for developing innovative interventions and personalized treatments to enhance quality of life for individuals with LUTS across all stages of life.

The association between testosterone deficiency and nocturia: Insights from The National Health and Nutrition Examination Survey data set

AIMS

To examine the association between testosterone deficiency (TD) and nocturia in males, with specific attention to age and cardiovascular disease (CVD) comorbidity.

METHODS

This cross-sectional study utilized the National Health and Nutrition Examination Survey (NHANES) data from 2011 to 2016, assessing 6137 adult male participants. TD was defined by a serum total testosterone (TT) concentration less than 300 ng/dL. Nocturia was determined based on participants' responses to a standard NHANES question regarding the frequency of urination during the night.

RESULTS

The study observed a significant association between TD and nocturia (adjusted odds ratio [95% confidence interval] = 1.211 [1.060-1.384], p = 0.005). Moreover, a U-shape pattern was noted in the relationship between serum TT concentration and the relative odds of nocturia. Subgroup analysis revealed a robust correlation between TD and nocturia in those over 60 years old, and those with hypertension, dyslipidemia, and CVDs.

CONCLUSION

Our findings suggest a positive correlation between TD and nocturia, particularly among elderly individuals with CVD. This association underscores the potential therapeutic significance of addressing TD in the management of nocturia. Furthermore, longitudinal studies are needed to establish a causal relationship between TD and nocturia.

Assessment of nocturnal polyuria in patients with spinal cord injury at three different mobilization phases: A multicenter cross-sectional study

OBJECTIVE

To determine the prevalence of nocturnal polyuria (NP) in patients with spinal cord injury (SCI) during three different particular phases, and investigate the impact of injury level and injury type on the prevalence of NP.

DESIGN

A cross-sectional study.

SETTING

Neurogenic Bladder Study Group from six different rehabilitation centers across the country.

PARTICIPANTS

40 patients with SCI.

OUTCOME MEASURES

Patients were divided into three groups according to mobilization phase; 1st group included patients confined to bed (n = 14), 2nd group included patients sitting on a wheelchair (n = 19) and 3rd group included patients standing with an assistive ambulation device (n = 7). NP was assessed by nocturnal polyuria index (NPi) and nocturnal urine production (NUP) indexes.

RESULTS

No significant difference was found between the groups (P = 0.312 for NPi and P = 0.763 for NUP) in terms of the presence of NP according to their mobilization phase. The night and 24-hour urine volumes showed no significant difference between the groups (P = 0.907 and P = 0.395 respectively). The NPi and NUP values did not show a significant difference between male and female patients (P = 0.826, P = 0.364 respectively), patients with the injury level of ≥T6 and

CONCLUSION

In this study, NP was found to be a common problem in patients with SCI regardless of their mobilization phase, injury level and injury type. It was revealed that both NPi and NUP parameters could be used to determine the prevalence of NP in this patient group.

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Key Words

• Neurogenic bladder
• Nocturia
• Nocturnal polyuria index
• Spinal cord injury

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MESH Headings

• Humans
• Male
• Female
• Polyuria/epidemiology
• Polyuria/etiology
• Cross-Sectional Studies
• Spinal Cord Injuries/complications
• Spinal Cord Injuries/epidemiology
• Nocturia/epidemiology
• Nocturia/etiology
• Prevalence

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Affiliation(s)

Hilal Yesil Department of Physical Medicine and Rehabilitation, Afyonkarahisar Health Sciences University, Afyon, Turkey
Yesim Akkoc Department of Physical Medicine and Rehabilitation, Ege University, Izmir, Turkey
Necmettin Yıldız Department of Physical Medicine and Rehabilitation, Pamukkale University, Denizli, Turkey
Haydar Gok Department of Physical Medicine and Rehabilitation, Ankara University, Ankara, Turkey
Ayse Nur Bardak Department of Physical Medicine and Rehabilitation, Istanbul Physical Therapy and Rehabilitation Training and Research Hospital, Istanbul, Turkey
Murat Ersoz Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey Department of Physical Medicine and Rehabilitation, Ankara Yildirim Beyazıt University, Ankara, Turkey
Sehim Kutlay Department of Physical Medicine and Rehabilitation, Ankara University, Ankara, Turkey
Derya Bugdaycı Department of Physical Medicine and Rehabilitation, Istanbul Physical Therapy and Rehabilitation Training and Research Hospital, Istanbul, Turkey
Nurdan Paker Department of Physical Medicine and Rehabilitation, Istanbul Physical Therapy and Rehabilitation Training and Research Hospital, Istanbul, Turkey
Hakan Tunc Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey
Kurtulus Koklu Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey
Ebru Alemdaroglu Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey
Engin Koyuncu Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey
Zuhal Ozisler Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey
Secilay Gunes Department of Physical Medicine and Rehabilitation, Ankara University, Ankara, Turkey
Hakan Alkan Department of Physical Medicine and Rehabilitation, Pamukkale University, Denizli, Turkey
Tevfik Tezer Department of Physical Medicine and Rehabilitation, Pamukkale University, Denizli, Turkey
Aysenur Bas Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey
Meryem Burcu Turkoglu Department of Physical Medicine and Rehabilitation, Ege University, Izmir, Turkey
Zeynep Yazar Department of Physical Medicine and Rehabilitation, Ege University, Izmir, Turkey
Simin Hepguler Department of Physical Medicine and Rehabilitation, Ege University, Izmir, Turkey

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Efficacy of cognitive behavioral therapy using self-check sheet for patients with nocturia in real-world clinical practice

OBJECTIVES

We previously demonstrated the efficacy of cognitive behavioral therapy (CBT) using a self-check sheet for patients with nocturia in a randomized controlled study. Additionally, we investigated the efficacy of the intervention in real-world clinical practice.

METHODS

Two hundred forty-three outpatients with complaint of nocturia who practiced CBT for 4 weeks using a self-check sheet were included in this trial, which took place from April 2021 to March 2022 in 20 institutions.

RESULTS

Of the 243 patients, 215 who achieved 50% or more of the behavioral therapy tasks were included in the analysis. Their mean age ± SD was 77.1 ± 7.7. A significant decrease was observed in nighttime frequency at 4 weeks after CBT using self-check sheets (pre 3.3 and post 2.8, p < .001). Nighttime frequency was decreased one or more times and was defined as treatment success in 102 patients (47.4%). Pretreatment nighttime frequency in the treatment-success group was significantly higher than that of the failure group (3.5 ± 1.0 vs. 3.2 ± 1.0, p = .013). In multivariate logistic regression analysis, predictive factors of treatment success were pretreatment nocturnal frequency of four or more (odds ratio [OR] 1.82, 95% confidence interval [CI] 1.01-3.30; p = .046) and the absence of diabetes mellitus (OR 3.08, 95% CI 1.34-7.06; p = .008).

CONCLUSIONS

CBT using a self-check sheet requiring less time, less labor, less cost, and less medication is very beneficial for both patients and medical staff in real-world clinical practice.

The prevalence and predictive factors of nocturnal polyuria in Japanese patients with nocturia: a multicentral retrospective cohort study

The aims of this study were to determine the prevalence and predictors of nocturnal polyuria (NP) in Japanese patients. This multicentral, observational study enrolled patients with the chief complaint of nocturia at 17 Japanese institutions between January 2018 and December 2022. The frequency of daily voiding and volume of urination were evaluated using bladder diaries. NP was diagnosed in patients with an NP index of > 33%. The primary endpoint was NP prevalence in patients with nocturia. The secondary endpoints were the prevalence of NP according to sex and age and the identification of factors predicting NP. This study analyzed 875 eligible patients. NP was present in 590 (67.4%) patients, with prevalence rates of 66.6% and 70.0% in men and women, respectively. Age ≥ 78 years, body mass index (BMI) < 23.0 kg/m2, and patients with ischemic heart or cerebrovascular disease were significant predictors of NP (P < 0.001, P < 0.001, P = 0.014, P = 0.016, respectively). This is the first large multicenter study to investigate the prevalence of NP in Japanese patients with nocturia. NP has a prevalence of 67.4%. Significant predictors of NP include age, BMI, and cardiovascular disease.

Impact of sleep on chronobiology of micturition among healthy older adults

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

Nocturnal polyuria and nocturia

BACKGROUND

Nocturia is a common complaint that can have a significant impact on quality of life. The pathophysiology is usually multifactorial and can be due to poor sleep, nocturnal polyuria, or low bladder capacity alone or in combination.

OBJECTIVE

Nocturnal polyuria (NP) is the most common cause of nocturia in older adults. We hereby review the role of nocturnal polyuria in nocturia.

PATIENTS AND METHODS

To manage nocturia, a multipronged approach personalized to the patient's multifactorial etiology is warranted, with a focus on lifestyle modifications and behavioral approaches as first-line therapies. Pharmacologic treatment should be considered based on underlying disease processes, and healthcare providers should be mindful of potential drug interactions and polypharmacy in older adults.

RESULT

Referral to specialists in sleep or bladder-related disorders may be necessary for some patients. With comprehensive and individualized management, patients with nocturia can achieve improved quality of life and overall health outcomes.

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.

Determining the optimal initial dose for Japanese patients with nocturnal polyuria using an initial dose of desmopressin 50 μg

OBJECTIVE

There is no consistent opinion on the optimal initial dose of desmopressin for patients with nocturnal polyuria. Over a period of 12 weeks, we investigated the safety and efficacy of an initial dose of 50 μg of desmopressin for elderly men.

METHODS

Eighty patients (mean age: 78.8 years) were started on an initial dose of 50 μg of desmopressin for nocturia associated with nocturnal polyuria. Safety and efficacy were evaluated after 1, 4, and 12 weeks using a frequency-volume chart, Athens Insomnia Scale, Patient Global Impression of Improvement scale, physical examination, blood tests, and a body composition analyzer.

RESULTS

Along with reduction in the frequency and volume of night-time urination, improvements in hours of undisturbed sleep, nocturnal polyuria index, and International Prostate Symptom Score, and Overactive Bladder Symptom Scores on quality of life measures were also observed. Hyponatremia was observed in 15 patients (18.7%). However, only 5.0% of patients had hyponatremia after the dose was reduced to 25 μg, and the continuation rate at 12 weeks was high at 87.5%. Age and other physical factors, such as body mass index, body water content, body fat mass, and muscle mass were not significant predictors of adverse events.

CONCLUSIONS

Our study suggests that an initial dose of 50 μg is more effective than a uniformly minimum dose based on factors such as age and physique. Furthermore, a high continuation rate can be achieved by appropriately reducing the dose, if adverse events occur.

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.

Nocturia due to nocturnal polyuria (NP). A common disorder

To the Editor, Nocturia is a significantly underestimated medical problem that affects seriously patients' quality of life, work engagement, productivity, and overall life conditions per se. Nocturia is a common condition, proven to be the most bothersome for patients with Lower Urinary Tract Symptoms (LUTS). People with two or more events of micturition per night have a significant increase in mortality rate and an increased risk of fall-related fractures if they visit the toilet two or more times per night [...].

The Prevalence of Nocturnal Polyuria in the United States: Results from the Epidemiology of Nocturnal Polyuria Study

BACKGROUND

The prevalence of nocturnal polyuria (NP), which is passing large volumes of urine during the main sleep period, has been investigated primarily in middle-aged to older men. There is thus a gap in the NP evidence base for women and for younger individuals.

OBJECTIVE

To estimate the prevalence of nocturia due to NP in the USA.

DESIGN, SETTING, AND PARTICIPANTS

This large epidemiologic study used a US population-representative sample of men and women aged ≥30 yr to assess the prevalence of NP (NCT04125186).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Consenting participants completed an online survey (Lower Urinary Tract Symptoms Tool and comorbidities). All who reported two or more voids per night and 100 random respondents each reporting no or one void per night were asked to complete a 3-d bladder diary. Two NP definitions were used: nocturnal urine production >90 ml/h (NUP90) and Nocturnal Polyuria Index >0.33 (NPI33). Crude and population-adjusted prevalence results were calculated from completed diaries for the following subgroups by sex and age: idiopathic NP; NP with overactive bladder (NP-OAB) or bladder outlet obstruction (NP-BOO; men only); NP associated with other comorbidities; and no NP (did not meet the NPI33 or NUP90 definition).

RESULTS AND LIMITATIONS

Among the 10,190 respondents who completed the survey, the mean age was 54.4 yr (range 30-95); 3,339 reported two or more nocturnal voids and 1,763 completed the 3-d diary (response rate 49.3%). The adjusted overall NP prevalence was 31.5% among men and 38.5% among women using the NPI33 definition, and 23.8% among men and 18.1% among women using NUP90. The adjusted idiopathic NP prevalence was lower among men (NPI33: 5.2%; NUP90: 1.4%) than among women (NPI33: 9.8%; NUP90: 4.0%). The prevalence of idiopathic NP decreased with age as NP associated with other possible causes increased with age in men (most common, BOO) and women (most common, OAB).

CONCLUSIONS

This is the first population-based study of NP prevalence to include men, women, and young adults. NP is common; a multifactorial etiology should be considered, particularly as age increases.

PATIENT SUMMARY

In this population-based US study, we examined the frequency of nighttime urination among men and women aged ≥30 y and older. We found that nighttime urination is common among men and women. Many conditions can lead to increased nighttime urination as people age.

Reduced salt intake partially restores the circadian rhythm of bladder clock genes in Dahl salt-sensitive rats

AIMS

To examine the circadian expression changes in bladder clock genes in Dahl salt-sensitive rats following high salt intake.

MAIN METHODS

Eighteen rats were divided into three groups: the high-salt diet group (HS group), the normal-salt diet group (NS group), and the salt-load interruption group (from a 4 % salt diet to a normal diet; salt-load interruption group [SI group]). Each rat was placed in an individual metabolic cage for 24 h twice weekly. Water intake, urine production, voiding frequency, and voided volume per micturition were recorded. Furthermore, 108 control rats were prepared. Bladders were harvested every 4 h at six time points. Furthermore, the mRNA expression of clock genes and mechanosensors was analyzed.

KEY FINDINGS

In the HS group, the bladder clock genes showed lower mRNA levels than in the NS group. The amplitude of circadian expression changes in bladder clock genes in the HS group was lower than that in the NS group. However, after changing from a 4 % salt diet to a normal diet, the waveforms of the clock gene expression in the SI group were closer to those of the NS group. The 24-hour water intake and urinary volume of the SI group decreased to levels comparable to those of the NS group.

SIGNIFICANCE

Reduced salt intake partially restored the circadian rhythms of bladder clock genes.

Piezo channels in the urinary system

The Piezo channel family, including Piezo1 and Piezo2, includes essential mechanosensitive transduction molecules in mammals. Functioning in the conversion of mechanical signals to biological signals to regulate a plethora of physiological processes, Piezo channels, which have a unique homotrimeric three-blade propeller-shaped structure, utilize a cap-motion and plug-and-latch mechanism to gate their ion-conducting pathways. Piezo channels have a wide range of biological roles in various human systems, both in vitro and in vivo. Currently, there is a lack of comprehensive understanding of their antagonists and agonists, and therefore further investigation is needed. Remarkably, increasingly compelling evidence demonstrates that Piezo channel function in the urinary system is important. This review article systematically summarizes the existing evidence of the importance of Piezo channels, including protein structure, mechanogating mechanisms, and pharmacological characteristics, with a particular focus on their physiological and pathophysiological roles in the urinary system. Collectively, this review aims to provide a direction for future clinical applications in urinary system diseases.

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.

[INITIAL TREATMENT OF NOCTURIA CAUSED BY NOCTURNAL POLYURIA WITH LOW-DOSE DESMOPRESSIN]

(Objective) Nocturia, an important male lower urinary tract symptom (LUTS), is often difficult to treat. Herein, we report our experience of the initial treatment of nocturia with the novel drug desmopressin. (Subjects and methods) Subjects included 25 patients with LUTS treated with desmopressin who had the chief complaint of nocturia. Before treatment, the frequency of nocturnal urination (≥2) and nocturnal polyuria index (≥0.33) were confirmed based on the urination diary for ≥ 72 h. Before sleep, 25 or 50 mg desmopressin (Minirin^® Melt OD tablets) was administered once daily. The frequency of nocturnal urination, volume of nocturnal urine, time from falling asleep to first urination, first urinary volume after falling asleep, nocturnal polyuria index, International Prostate Symptom Score (IPSS), quality of life index, Overactive Bladder Symptom Score, and residual urine volume were comparatively evaluated before and 4 weeks after treatment. Treatment effect was self-evaluated by patients 4 weeks after the treatment. Safety was evaluated by interview and blood testing 1 and 4 weeks after the treatment. (Results) Decrease in the frequency of nocturnal urination and improvement in IPSS were observed. According to self-evaluation of the treatment, 72.6% of the patients considered the treatment efficacious. Regarding safety, adverse events were observed in 28% of the patients, particularly hyponatremia (12% of the patients). (Conclusion) Desmopressin is a potential key drug for the treatment of nocturia caused by nocturnal polyuria.

[EFFICACY AND SAFETY OF INITIAL DESMOPRESSIN DOSE OF 50 μg IN ELDERLY MALE PATIENTS WITH NOCTURNAL POLYURIA]

(Introduction) Low-dose desmopressin is now available for the treatment of nocturia associated with nocturnal polyuria in men, and its usefulness in a dose-dependent manner has been reported. Since side effects such as hyponatremia have reported frequently, the initial dose has been set at 25 μg in many cases considering age and other factors. In the present study, we investigated the efficacy and safety of an initial dose of 50 μg in elderly patients. (Subjects and methods) At Chikugo city hospital, 45 patients were started on desmopressin at an initial dose of 50 μg for nocturia with nocturnal polyuria. Efficacy and safety after one and four weeks were evaluated based on bladder (micturition) diary. The investigated parameters included frequency of nocturnal urination, nocturnal polyuria index, time to first nocturnal void, first nocturnal urine volume, nocturnal urine volume, International Prostate Symptom Score (IPSS), Overactive Bladder Symptom Score (OABSS), and Athens Insomnia Scale. Physical examinations were also carried out, along with blood tests. (Results) The mean age of the patients was 78.3 years, which was higher than that reported in prior studies. After one week of treatment, there was a significant decrease in the frequency of nocturnal urination and nocturnal urine volume, as well as a prolongation of the time to first nocturnal void, improvement in nocturnal polyuria index, and improvement in IPSS, IPSS-QOL, OABSS, and Athens Insomnia Scale. In terms of safety, adverse events were observed in eight patients (17.8%), and hyponatremia was observed in seven patients (15.6%), which was comparable to the findings of prior reports. (Conclusion) Good therapeutic results were obtained in elderly patients at an initial desmopressin dose of 50 μg, indicating that the drug could be safely administered to elderly patients with regular follow-ups and appropriate withdrawal and dose reductions.

Nocturnal polyuria in men performing uroflowmetry for lower urinary tract symptoms

PURPOSE

To assess the prevalence of nocturnal polyuria (NP) in males performing uroflowmetry (UF) for lower urinary tract symptoms (LUTS), the impact of NP on UF outcomes, and bladder emptying, the association between NP and LUTS.

MATERIALS AND METHODS

Men scheduled for UF were recruited in two Centres. Data collected were medical history, IPSS, UF, post-void residual urine volume (PVR), 3-day frequency-volume charts (FVC). The NP index was used to assess NP with a threshold of ≥ 33%. The relationship between NP and patient's aging was assessed.

RESULTS

162 patients were included in the analysis. Mean age was 70.95 ± 8.04 years. The prevalence of NP was 54.9% (89/162). 110 (68%) patients reported nocturia, and among these, NP was documented in 76 (69%). Nocturia was found in 85% (76/89) of the population with NP. Total IPSS score, IPSS items #1, #2 and #7 showed a significant difference in men with NP compared with those without. Maximum flow rate and PVR did not significantly change comparing men with or without NP. Mean voiding volume (VV) of the night-time micturitions was significantly higher in men with NP compared to those without NP (532.1 ± 275.6 ml vs 175 ± 168.7 ml respectively, p < 0001), while mean VV day-time micturitions and mean VV at UF did not change between groups.

CONCLUSIONS

NP had a high prevalence in men with LUTS performing UF. Aged males were more commonly affected by NP. Data demonstrated a strong relationship between NP and nocturia and increased urinary frequency while voiding symptoms were poorly related to NP.

The effects of choreito on a model of nocturnal polyuria using Dahl salt-sensitive rats

OBJECTIVES

This study aimed to determine whether Dahl salt-sensitive rats fed a high-salt diet would show features of nocturia due to nocturnal polyuria and to examine the efficacy of choreito (CRT) on nocturnal polyuria.

METHODS

Dahl salt-sensitive rats were divided into three groups. Group A was fed a 4% salt diet, group B a 2% salt diet, and group C a normal 0.3% salt diet. In groups α and β, other rats were further divided into two groups: The rats in group α were fed a 2% salt plus 3% CRT diet, and those in group β, were fed a 2% salt diet. Each rat was placed in an individual metabolic cage for 24 hours every week for 6 weeks. Water intake, urine production, voiding frequency, and voided volume per micturition were recorded.

RESULTS

The systolic blood pressure increased in the group fed a 4% salt diet compared to groups fed with a 2% and 0.3% salt diet. The urinary volume was higher in the groups fed with 4% and 2% salt than in the group fed with 0.3% salt. Further, water intake in the group fed a 2% salt plus 3% CRT diet was significantly lower than that in the group fed with a 2% salt diet.

CONCLUSIONS

Dahl salt-sensitive rats fed a 2% salt diet were candidates for a model of nocturnal polyuria. Using this model, we suggest that CRT reduces water intake in the active phase and contributes to water restriction in the treatment of nocturnal polyuria.

Assessment of bladder function for stabilizing urinary volume overnight with recording of brain waves (ABSORB study)

OBJECTIVES

The bladder urothelium is not always impermeable. During sleep, the bladder might absorb urine in healthy individuals who sleep through the night. This study aimed to determine whether the bladder absorbs urine by using a method other than ultrasonic scanning and to simultaneously evaluate sleeping conditions.

METHODS

Eleven participants (five males, six females) aged 20 to 49 years without lower urinary tract symptoms or urination while sleeping were enrolled. Bladder volume was estimated by studying the relationship between dilution and absorbance of indigo carmine dissolved in urine. A 12F Foley catheter was inserted into the bladder before sleep. Urine samples (5 mL) were extracted at 2, 3, 4, 5, and 6 am sleep stages were monitored with a single-channel portable electroencephalograph device.

RESULTS

The estimated bladder volume at 6 am and voided volume immediately after rising were significantly correlated (Spearman's ρ = 0.62, P = .046). Eight participants (three males, five females) showed an absorption pattern of the estimated bladder volume change. In a male participant, the blue dye's strength gradually decreased until 4 am (estimated 859 mL) and increased from 5 am (estimated 455 mL). In another, the blue dye's strength increased at 4 am (estimated 449 mL) vs at 3 am (estimated 757 mL). In all participants, electroencephalograph data demonstrated that sleep was maintained despite having a full bladder.

CONCLUSIONS

The bladder absorbs urine and maintains an approximate volume of functional bladder capacity during sleep to avoid incontinence and maintain sleep in adults due to an urge to void urine during the sleep cycle.

Desmopressin acetate the first sublingual tablet to treat nocturia due to nocturnal polyuria

Introduction: Desmopressin was widely used to treat nocturnal polyuria in adults under the age of 65 due to the well-established risk of hyponatremia. Since the prevalence of nocturia increases with age, and with an aging population, those most affected were excluded from treatment. Recently, a new lower dose sublingual tablet formulation that optimizes the balance between efficacy and tolerability has been licensed for symptomatic treatment of nocturia due to idiopathic nocturnal polyuria in adults of any age, with the caveat of regular serum monitoring for those over 65. This newer formulation aims to achieve the same clinical outcomes as previous formulations while reducing the risk of hyponatremia.Areas covered: This review will look at the pharmacology of the newly formulated desmopressin and examine the results of the clinical trials that would support its treatment of adult nocturia with idiopathic nocturnal polyuria.Expert opinion: When reporting on the clinical efficacy of desmopressin on nocturia, it is important for clinical trials to publish their complete data on nocturnal and 24-hour urine voided volumes. Further research examining the physiological reasoning behind this gender-specific dosing for desmopressin and the optimal recommended treatment duration of desmopressin for those over 65 is needed.

Decreased renal function increases the nighttime urine volume rate by carryover of salt excretion to the nighttime

To determine the pathophysiology of nocturnal polyuria associated with renal dysfunction, patients who underwent laparoscopic nephrectomy were prospectively studied. The diurnal variation in urine volume, osmolality, and salt excretion were measured on preoperative day 2 and postoperative day 7. The factors associated with an increase in the nighttime urine volume rate with decreased renal function were evaluated using multiple linear regression analysis. Forty-nine patients were included. The estimated glomerular filtration rate decreased from 73.3 ± 2.0 to 47.2 ± 1.6 mL/min/1.73 m² (P < 0.01) and the nighttime urine volume rate increased from 40.6% ± 2.0% to 45.3% ± 1.5% (P = 0.04) with nephrectomy. The nighttime urine osmolality decreased from 273 ± 15 to 212 ± 10 mOsm/kg and the nighttime salt excretion rate increased from 38.7% ± 2.1% to 48.8% ± 1.7% (both P < 0.01) with nephrectomy. Multiple linear regression analysis showed that the increase in the nighttime urine volume rate was strongly affected by the increase in the nighttime salt excretion rate. A decrease in renal function causes an increase in the nighttime urine volume rate, mainly because of an increase in nighttime salt excretion.

Trial registration number: UMIN000036760 (University Hospital Medical Information Network Clinical Trials Registry).

Date of registration: From 1 June 2019 to 31 October 2020.

Urinary reabsorption in the rat kidney by anticholinergics

Anticholinergics, therapeutic agents for overactive bladder, are clinically suggested to reduce urine output. We investigated whether this effect is due to bladder or kidney urine reabsorption. Various solutions were injected into the bladder of urethane-anesthetized SD rats. The absorption rate for 2 h was examined following the intravenous administration of the anticholinergics imidafenacin (IM), atropine (AT), and tolterodine (TO). The bilateral ureter was then canulated and saline was administered to obtain a diuretic state. Anticholinergics or 1-deamino-[8-D-arginine]-vasopressin (dDAVP) were intravenously administered. After the IM and dDAVP administrations, the rat kidneys were immunostained with AQP2 antibody, and intracellular cAMP was measured. The absorption rate was ~ 10% of the saline injected into the bladder and constant even when anticholinergics were administered. The renal urine among peaked 2 h after the saline administration. Each of the anticholinergics significantly suppressed the urine production in a dose-dependent manner, as did dDAVP. IM and dDAVP increased the intracellular cAMP levels and caused the AQP2 molecule to localize to the collecting duct cells' luminal side. The urinary reabsorption mechanism through the bladder epithelium was not activated by anticholinergic administration. Thus, anticholinergics suppress urine production via an increase in urine reabsorption in the kidneys' collecting duct cells via AQP2.

First voided volume: A novel approach to characterize nocturia

AIMS

Nocturnal polyuria syndrome (NPS) denotes nocturnal polyuria (NP) in the absence of identifiable contributory factors. The trajectory of nocturnal urine production (NUP; typically expressed as ml/hour) may be useful in delineating between NP patients with versus without NPS, but changes in absolute urine volume, the directly measured substrate for behavioral and pharmacologic interventions targeting nocturnal urine production, have not been well characterized. This study compares the ratio of the first nocturnal voided volume (FNVV) to the nocturnal average voided volume (NAVV) in patients with versus without NPS.

METHODS

Secondary analysis of 24-h voiding diaries from male patients greater than or equal to 18 years of age with two or more nocturnal voids and NP using two different criteria for NP: NUP greater than or equal to 90 ml/h and nocturnal polyuria index (NPi) greater than or equal to 0.33. Patients with diabetes insipidus and CPAP-adherent obstructive sleep apnea (OSA) were excluded. Patients were divided into 2 groups: secondary NP (OSA, congestive heart failure, and chronic kidney disease) and NPS (absence of edema, diuretic use, and the aforementioned comorbidities). FNVV was defined as the volume of urine accompanying the first nocturic episode. NAVV was defined as nocturnal urine volume/(number of nocturnal voids + 1). The nocturnal urine trajectory ratio (NUTR) was defined as FNVV/NAVV.

RESULTS

At NUP greater than or equal to 90 ml/h, NUTR was significantly greater in patients with (n = 73) versus without (n = 28) NPS (1.10 [0.89-1.33] vs. 0.91 [0.55-1.15], p = .012). At NPi greater than or equal to 0.33, NUTR was likewise significantly greater in patients with (n = 92) versus without (n = 32) NPS (1.09 [0.90-1.33] vs. 0.91 [0.57-1.17], p = .010).

CONCLUSIONS

The volume of urine produced in the early hours of sleep is central to identification of NPS in patients with nocturia.

Does cognitive behavioral therapy using a self-check sheet improve night-time frequency in patients with nocturia? Results of a multicenter randomized controlled trial

OBJECTIVE

To determine whether cognitive behavioral therapy using a self-check sheet is effective in improving night-time frequency of patients with nocturia.

METHODS

We carried out a multicenter, open-labeled, randomized controlled trial in eight institutions. Patients having two or more episodes of nocturia were randomly assigned to either cognitive behavioral therapy with completion of frequency volume charts regularly (cognitive behavioral therapy group) or frequency volume charts regularly alone (frequency volume charts group). The cognitive behavioral therapy checklist was composed of eight items: wake up time/bedtime, mealtime, napping, alcohol/caffeine intake, water intake, salt intake, exercise and taking a bath. A physician explained cognitive behavioral therapy within 5 min using a brief manual. The patients in the cognitive behavioral therapy group filled out the self-check sheet every day. The primary end-point was the difference in night-time frequency based on the International Prostate Symptom Score Q7 at 4 weeks.

RESULTS

Of the 100 first-visit patients randomly allocated, 37 in the cognitive behavioral therapy group and 41 in the frequency volume charts group completed the protocol. No difference was observed in the mean ± standard deviation of night-time frequency at 4 weeks between the cognitive behavioral therapy group (2.6 ± 1.0) and the frequency volume charts group (3.1 ± 1.2; P = 0.056). However, when six patients with achievement of cognitive behavioral therapy of <50% were excluded from the analysis, night-time frequency at 4 weeks was significantly lower in the cognitive behavioral therapy group (2.5 ± 1.0) than in the frequency volume charts group (3.1 ± 1.2; P = 0.027).

CONCLUSIONS

The efficacy of cognitive behavioral therapy using a self-check sheet for nocturia remains to be shown. However, strictly practicing cognitive behavioral therapy might be beneficial to these patients.

Pharmacologic management of nocturnal polyuria: a contemporary assessment of efficacy, safety, and progress toward individualized treatment

This narrative review synthesizes current evidence on the medical management of nocturnal polyuria, including antidiuretic replacement therapy as well as other emerging modalities, with particular emphasis on areas of active investigation and future research directions. Relative to earlier formulations, the pharmacological profiles of novel desmopressin acetate nasal spray and orally disintegrating tablet formulations appear favorable in optimizing the balance between efficacy and safety. Additionally, several highly selective small-molecule arginine vasopressin 2 receptor agonists are under active development, while appropriately timed short-acting diuretics, pharmacotherapy for hypertension, nonsteroidal anti-inflammatory drugs, and sex hormone replacement therapy are also a focal point of extensive ongoing nocturnal polyuria research. Emerging laboratory technologies now make feasible a sub-stratification of nocturnal polyuria patients into substrate-based phenotypes for individualized treatment. An increasingly refined understanding of the pathogenesis of nocturnal polyuria, and arginine vasopressin dysregulation in particular, has also introduced new opportunities for point-of-care testing in patients with nocturnal polyuria.

[EFFICACY AND SAFETY OF 25 AND 50 μg DESMOPRESSIN ORALLY DISINTEGRATING TABLETS IN NOCTURIA DUE TO NOCTURNAL POLYURIA IN JAPANESE MALE PATIENTS]

(Purpose) To conduct a prospective study on the efficacy and safety of desmopressin for nocturnal polyuria. (Materials and methods) We selected 51 Japanese men, aged ≥50 years, with complaints of nocturia and a nocturnal polyuria index of ≥0.33. We administered 25 or 50 μg desmopressin (Minirinmelt Orally Disintegrating Tablet^®), once daily at bedtime. We evaluated the nighttime urinary frequency and urine volume, nocturnal polyuria index, time to the first urination after falling asleep, and International Prostate Symptom Score (IPSS) at baseline and at 4, 8, and 12 weeks after administration. In addition, they underwent clinical examinations and blood tests at 1, 4, and 12 weeks to evaluate the safety of the drug. (Results) We observed a decrease in the nighttime urinary frequency and urine volume, and nocturnal polyuria index, increased prolonged time to the first urination after falling asleep, and improved IPSS at and after 4 weeks, compared to baseline data. Furthermore, the drug remained effective even at 12 weeks for all parameters. We observed adverse events in 31.3% of the patients. The incidence of hyponatraemia was particularly high in 15.7% of the patients. Those with a lower serum sodium level and lesser body weight at baseline were more likely to develop hyponatraemia. (Conclusion) Desmopressin was identified as a potential drug for the treatment of nocturnal polyuria. However, hyponatraemia, an important adverse event, resulted in treatment discontinuation in several patients. A sodium level lower than the normal level and low body weight at baseline were the risk factors for hyponatraemia.

Could Evening Dietary Protein Intake Play a Role in Nocturnal Polyuria?

Urea is the most abundant and the largest contributing factor for urine osmolality. Urinary urea excretion is highly interrelated with dietary protein intake. Accordingly, an increase of urinary urea excretion due to high protein diet may lead to urea-induced osmotic diuresis. This study aims to explore the association between nocturnal polyuria (NP) and urea. This is a post hoc analysis of a prospective observational study of subjects who completed a renal function profile between October 2011 and February 2015 (n = 170). Each subject underwent a 24 h urine collection, which included 8 urine samples collected at 3 h intervals. Urine volume, osmolality, creatinine, urea and sodium were determined. Urinary urea excretion was used to estimate dietary protein intake. Compared to the control group, subjects with NP exhibited significantly higher nighttime urea and sodium excretion. Estimated evening dietary protein intake was correspondingly significantly higher amongst the NP subgroup. Nighttime diuresis rate was positively associated with age and nighttime free water clearance, creatinine clearance, sodium excretion, and urea excretion in NP subjects. Therefore, increased nocturnal urinary urea excretion may reflect an additional important mediator of nocturia owing to excess nocturnal urine production.

Phenotyping nocturnal polyuria: circadian and age-related variations in diuresis rate, free water clearance and sodium clearance

BACKGROUND

this study compares diuresis rate, sodium clearance and free water clearance (FWC) by age and time of day (nighttime vs. daytime) in subjects with and without nocturnal polyuria (NP) to determine whether these variables affect the phenotype of NP.

METHODS

post hoc analysis of two prospective observational studies. Eight urine samples collected at 3-h intervals and a single blood sample were used to calculate daytime (10a/1p/4p/7p/10p) and nighttime (1a/4a/7a) diuresis rates, sodium clearance and FWC. Three mixed linear models were constructed for diuresis rate, sodium clearance and FWC using four predictor variables: NP status (present [nocturnal urine production >90 ml/h] vs. absent [≤90 ml/h]), time of day, age and study identification.

RESULTS

subjects with NP experienced higher nighttime versus daytime diuresis rates, sodium clearance and FWC. Regardless of NP status, increased age was accompanied by an increase in the ratio of nighttime/daytime diuresis rate, nighttime sodium clearance and daytime sodium clearance. FWC showed a complex age effect, which was independent of time of day or NP status.

CONCLUSIONS

age-related increases in nighttime/daytime diuresis rate, 24-h sodium clearance and 24-h FWC are not specific to subjects with NP. The age-related surge in either nocturnal sodium clearance or nocturnal FWC may represent the relevant substrate for behavioural or pharmacologic interventions targeting sodium diuresis or free water diuresis, respectively. Increases in FWC in older age groups may reflect impaired circadian rhythmicity of endogenous AVP or changes in responsiveness of the aged nephron to water clearance.

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.

Nocturia and Nocturnal Polyuria in Neurological Patients: From Epidemiology to Treatment. A Systematic Review of the Literature

CONTEXT

Nocturia is among the most common and bothersome lower urinary tract symptoms (LUTS), but there is no clear consensus on how to identify and manage this symptom in the neurological population.

OBJECTIVE

To systematically review the literature about nocturia in neurological patients.

EVIDENCE ACQUISITION

Studies were identified by electronic search of Cochrane and Medline databases. The studies were included if their participants had acquired neurological pathology among multiple sclerosis (MS), Parkinson's disease (PD), stroke, spinal cord injury (SCI), and reported data on the epidemiology, aetiology, diagnosis, or treatment of nocturia. An independent extraction of the articles was performed by two authors using predetermined datasets, including quality-of-study indicators.

EVIDENCE SYNTHESIS

A total of 132 studies were included; 46 evaluated the epidemiology of nocturia, 28 the possible aetiologies, 10 the diagnostic tools, and 60 the treatments. Nocturia prevalence ranged from 15% to 96% depending on the pathology and definition used. It was one of the most frequently reported LUTS in PD and stroke patients. Several validated questionnaires were found to screen for nocturia in this population. Causalities were numerous: LUT, renal, sleep, cardiovascular dysfunctions, etc. Treatments targeted these mechanisms, with an overall risk of bias assessed as high or serious. The highest level of evidence was seen in MS patients: pelvic floor muscle training, cannabinoids, and desmopressin were effective, but not melatonin. In stroke patients, transcutaneous sacral and transcutaneous tibial nerve stimulation (TTNS) improved nocturia; in PD patients, TTNS, solifenacin, and rotigotine did not.

CONCLUSIONS

Nocturia is highly prevalent in patients with neurological disorders. Causalities and treatments are not different from the general population, but are poorly studied in neurological patients.

PATIENT SUMMARY

In this report, we looked at the published studies about nocturia-the fact of waking to void during the hours of sleep-in patients with neurological diseases. We found that nocturia is very frequent in this population, that the causes are the same as in the general population but may be combined, and that treatments are also the same but have an overall weak level of evidence. We conclude that more research is needed on this topic.

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.

Nocturnal Excretion in Healthy Older Women and Rationale for a Safer Approach to Sleep Disruption

OBJECTIVES

Insomnia, especially difficulty maintaining sleep, is prevalent among older adults and increases the incidence of falls and fractures. Moreover, the drugs used to treat it exacerbate the risk. Yet current therapies fail to address one of its most common causes in older adults: nocturia and its primary contributor, nocturnal polyuria (NP), especially among the majority of individuals without lower urinary tract symptoms (LUTS). Therefore, we examined the factors associated with nocturia in two groups of such older women and the impact of nocturia on sleep.

DESIGN

Secondary analysis of two observational studies of bladder function in carefully evaluated healthy older women.

SETTING

Academic medical center.

PARTICIPANTS

A total of 39 women without LUTS who had adequate fluid intake (ie, >1200 mL urine output/24 h recorded on their diary), normal videourodynamic testing, and normal daytime frequency (≤7 voids).

MEASUREMENTS

Voided volumes and sleep duration obtained from subjects' 3-day voiding diary, and sleep quality from the Center for Epidemiologic Studies Depression Scale. Nighttime excretion of more than 33% of 24-hour urine volume was considered NP.

RESULTS

Overall, 21 of these healthy subjects (54%) awakened at least once nightly to void, and 19 (90%) of them had NP. Compared with those without nocturia, participants with nocturia had shorter duration of the first uninterrupted sleep period (182 ± 100 vs 250 ± 60 min; P = .03), and they reported worse sleep quality. Two factors contributed independently to nocturia: (1) a larger proportion of 24-hour urine output at night (43.4 ± 7.4% vs 25.4 ± 5.5%; P = <.001) and (2) smaller bladder capacity (484 ± 157 mL vs 608 ± 167 mL; P = .02).

CONCLUSIONS

Nocturia, NP, and reduced bladder capacity are very common even in healthy older women without LUTS and are associated with impaired sleep. Thus applying currently available modalities to address both NP and reduced bladder capacity may effectively treat sleep disruption without incurring the complications of sedative-hypnotics. J Am Geriatr Soc 67:2610-2614, 2019.

Development of a multivariate prediction model for nocturia, based on urinary tract etiologies

PURPOSE

The main objective of our study was to determine which combination of modifiable and non-modifiable parameters that could discriminate patients with nocturia from those without nocturia. This was a post-hoc analysis of 3 prospective, observational studies conducted in Ghent University. Participants completed frequency volume chart (FVC) to compare characteristics between patients with and without nocturia.

METHOD

This was a post hoc analysis of three prospective, observational studies conducted in Ghent University. Participants completed frequency volume chart (FVC) to compare characteristics between adults with and without nocturia. Study 1: adults with and without nocturia (n = 148); Study 2: patients ≥65 years with and without nocturnal LUTS (n = 54); Study 3: menopausal women before and after hormone replacement therapy (n = 43). All eligible patients (n = 183) completed a FVC during 24 hours (n = 13), 48 hours (n = 30) or 72 hours (n = 140). The combination of algorithms and number of determinants obtaining the best average area under the receiver operating curve (AUC-ROC) led to the final model. Differences between groups were assessed using the AUC-ROC and Mann- Whitney-Wilcoxon tests. Holm corrections were applied for multiple statistical testing. Also, the stability of the feature selection was evaluated.

RESULTS

The best discrimination was obtained when 13 determinants were included. However, a logistic regression model based on seven determinants selected with random forest had comparable discrimination including an optimal signature stability. It was able to discriminate almost perfectly between nights with and without nocturia.

CONCLUSION

Relevant information to accomplish the excellent predictability of the model is; functional bladder capacity, 24 hours urine output, nocturnal output, age, BMI. The multivariate model used in this analysis provides new insights into combination therapy as it allows simulating the effect of different available treatment modalities and its combinations.

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.

Does successful treatment of overactive bladder improve co-morbidities in patients with nocturia?

OBJECTIVE

To investigate whether treatment of overactive bladder (OAB), one comorbidity of nocturia, could reduce waking to void and improve other co-existing symptoms.

METHODS

A prospective cohort study was conducted at Royal Melbourne Hospital. Participants received 12 weeks of standard treatment, including lifestyle interventions and pharmacotherapy. Outcome measures were nocturia episodes, severity of urinary urgency/incontinence, sleep quality, daytime somnolence, anxiety and depression scores, quality of life and change in blood pressure.

RESULTS

Twenty participants completed the study. Nocturia frequency improved by one void per night. Overactive Bladder Symptom Score, sleep quality, first uninterrupted sleep time and systolic blood pressures improved. There were no significant changes in daytime somnolence, mood or quality of life.

CONCLUSIONS

In this pilot study, nocturia and other co-morbid dysfunctions appeared to improve when the severity of OAB was reduced. Treatment of OAB co-morbid with nocturia reduces urinary symptoms and may improve sleep parameters and positively impact return to health.

International Continence Society consensus on the diagnosis and treatment of nocturia

INTRODUCTION

Patients with nocturia have to face many hurdles before being diagnosed and treated properly. The aim of this paper is to: summarize the nocturia patient pathway, explore how nocturia is diagnosed and treated in the real world and use the Delphi method to develop a practical algorithm with a focus on what steps need to be taken before prescribing desmopressin.

METHODS

Evidence comes from existing guidelines (Google, PubMed), International Consultation on Incontinence-Research Society (ICI-RS) 2017, prescribing information and a Delphi panel (3 rounds). The International Continence Society initiated this study, the authors represent the ICI-RS, European Association of Urology, and Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU).

RESULTS

Diagnostic packages: consensus on, history taking for all causalities, intake diary (fluid, food) and bladder diary, not for its duration. Pelvic (women) or rectal (men) examination, prostate-specific antigen, serum sodium check (SSC), renal function, endocrine screening: when judged necessary. Timing or empty stomach when SSC is not important. Therapeutic packages: the safe candidates for desmopressin can be phenotyped as no polydipsia, heart/kidney failure, severe leg edema or obstructive sleep apnea syndrome. Lifestyle interventions may be useful. Initiating desmopressin: risk management consensus on three clinical pictures. Follow-up of desmopressin therapy: there was consensus on SSC day 3 to 7, and at 1 month. Stop therapy if SSC is <130 mmol/L regardless of symptoms. Stop if SSC is 130 to 135 mmol/L with symptoms of hyponatremia.

CONCLUSION

A summary of the nocturia patient pathway across different medical specialists is useful in the visualization and phenotyping of patients for diagnosis and therapy. By summarizing basic knowledge of desmopressin, we aim to ease its initiation and shorten the patient journey for nocturia.

Nocturnal polyuria: Literature review of definition, pathophysiology, investigations and treatment

Nocturnal polyuria (NP) is characterised by increased urine production overnight in comparison to daytime. It has significant adverse events in adults including reduced quality of life, increased risk of falls and increased mortality.

Although NP can be a manifestation of other significant conditions like heart failure and sleep apnoea, there are lots of unanswered questions about NP. What is the underlying pathophysiology? Is NP a physiological manifestation of ageing? Is the circadian change of vasopressin release the primary pathology? Or is it a secondary phenomenon to a low diurnal production of urine? Is the primary pathology at the kidney level or is there another humoral, cardiac, or endovascular element? In this article, we summarise the available English-language literature on the subject of NP, including its epidemiology, pathogenesis, diagnosis and treatment.

Level of evidence: Not applicable for this multicentre audit.

Managing nocturia: The multidisciplinary approach

Nocturia, defined as waking at night to pass urine, is a common condition which increases with age. Whilst nocturia is known to have an important effect on quality of life, more recent evidence has linked the symptom with significant morbidity and mortality due to the effects of sleep deprivation on glucose metabolism and the immune system. The causes of nocturia are multifactorial and may be related to urine overproduction, storage disorders and primary sleep disorders. The commonest underlying pathology, however, is nocturnal polyuria, which may be associated with a number of medical conditions. This review explores the underlying causes of nocturia and nocturnal polyuria and, by doing so, describes a multidisciplinary approach to managing patients effectively.

Relationship between nocturnal polyuria and non-dipping blood pressure in male patients with lower urinary tract symptoms

OBJECTIVE

The aim of the present study was to examine factors of nocturnal polyuria and blood pressure variability in male patients with lower urinary tract symptoms (LUTS) who were treated.

METHODS

Two hundred and forty-two male patients with LUTS who were treated recorded frequency volume charts. We investigated their urinary condition and characteristics, medical history, and medications. Thirty-four of these patients underwent ambulatory blood pressure monitoring (ABPM) for 24 hours to evaluate blood pressure variability.

RESULTS

In the present study, 194 patients (80.2%) had nocturia and 136 (56.2%) had nocturnal polyuria (NP). Among patients with nocturia (≥2 voids/night), 130 (67.0%) had nocturnal polyuria, and 26 of those with nocturia (13.4%) had reduced functional bladder capacity. The use of 2 or more antihypertensive medications was significantly higher in the NP than non-NP group (22.8% vs. 12.3%; P = .035). Significantly more patients in the NP group had non-dipping blood pressure (P = .037). Non-dipping blood pressure was considered a potential factor for NP.

CONCLUSION

We suggest that treatment of non-dipping blood pressure may improve NP.

The oscillation of intracellular Ca2+ influx associated with the circadian expression of Piezo1 and TRPV4 in the bladder urothelium

We previously showed that bladder functions are controlled by clock genes with circadian rhythm. The sensation of bladder fullness (SBF) is sensed by mechano-sensor such as Piezo1 and TRPV4 in the mouse bladder urothelium. However, functional circadian rhythms of such mechano-sensors remain unknown. To investigate functional circadian changes of these mechano-sensors, we measured circadian changes in stretch-evoked intracellular Ca²⁺ influx ([Ca²⁺] _i ) using mouse primary cultured urothelial cells (MPCUCs). Using Ca²⁺ imaging, stretch-evoked [Ca²⁺] _i was quantified every 4 h in MPCUCs derived from wild-type (WT) and Clock ^Δ19/Δ19 mice, which showed a nocturia phenotype. Furthermore, a Piezo1 inhibitor GsMTx4 and a TRPV4 inhibitor Ruthenium Red were applied and stretch-evoked [Ca²⁺] _i in MPCUCs was measured to investigate their contribution to SBF. Stretch-evoked [Ca²⁺] _i showed a circadian rhythm in the WT mice. In contrast, Clock ^Δ19/Δ19 mice showed disrupted circadian rhythm. The administration of both GsMTx4 and Ruthenium Red eliminated the circadian rhythm of stretch-evoked [Ca²⁺] _i in WT mice. We conclude that SBF may have a circadian rhythm, which is created by functional circadian changes of Piezo1 and TRPV4 being controlled by clock genes to be active during wakefulness and inactive during sleep. Abnormalities of clock genes disrupt SBF, and induce nocturia.