Nocturia: Current Levels of Evidence and Recommendations From the International Consultation on Male Lower Urinary Tract Symptoms

Efficacy and safety of desmopressin in nocturia and nocturnal polyuria control of neurological patients: A systematic review and meta-analysis

PURPOSE

Evidence on the efficacy of desmopressin in nocturia in patients with neurological diseases is still very limited except for multiple sclerosis (MS). Our aim was to evaluate the efficacy and safety of desmopressin treatment on nocturia in patients with underlying neurological diseases.

METHODS

Studies were identified by electronic search of PubMed, Embase, Cochrane, CINAHL, and Google Scholar databases. Studies were considered if they provided information on the effectiveness and safety of desmopressin (1-desamino-8-d-arginine vasopressin, or DDAVP) in the treatment of nocturia and their participants had acquired neurological pathology. Two researchers independently extracted the articles using specified datasets, such as quality-of-study indicators. Statistical meta-analysis was carried out using Review Manager (RevMan) 5.4 statistical software (Cochrane Collaboration).

RESULTS

Of a total of 1042 articles in the initial search, 14 studies were included. Most of the published papers were related to MS (n = 7), two were on spinal cord injury, and other conditions were neural tube defect, myelodysplasia, Parkinson's disease, stroke, and multiple system atrophy. Overall, a total of 200 patients (mostly females) were enrolled. Thirteen studies evaluated the intranasal formulation of desmopressin and one study evaluated oral desmopressin. A significant decrease in nocturia episodes was reported in seven studies evaluating this topic. An increase in the maximum hours of uninterrupted sleep was reported in the three studies in which this outcome was assessed. A significant reduction in the volume of nocturnal incontinence was found in one study. Three studies were eligible to include in the meta-analysis. The results showed that desmopressin compared to placebo, significantly reduced nighttime urination (mean difference: -0.75, 95% CI: -1.10 to -0.41; p < 0.00001). The rate of adverse events ranged from 0% to 68.42%. The critical appraisal results for all trials showed that most of the studies had low or moderate quality.

CONCLUSIONS

Our results emphasized desmopressin's safety and efficacy in reducing nocturia episodes, with transient adverse effects on neurological patients. However, the data were achieved from low or medium-quality trials, and further well-designed randomized controlled trials are needed.

Treatment of lower urinary tract symptoms in men in primary care using a conservative intervention: cluster randomised controlled trial

OBJECTIVE

To determine whether a standardised and manualised care intervention in men in primary care could achieve superior improvement of lower urinary tract symptoms (LUTS) compared with usual care.

DESIGN

Cluster randomised controlled trial.

SETTING

30 National Health Service general practice sites in England.

PARTICIPANTS

Sites were randomised 1:1 to the intervention and control arms. 1077 men (≥18 years) with bothersome LUTS recruited between June 2018 and August 2019: 524 were assigned to the intervention arm (n=17 sites) and 553 were assigned to the usual care arm (n=13 sites).

INTERVENTION

Standardised information booklet developed with patient and expert input, providing guidance on conservative and lifestyle interventions for LUTS in men. After assessment of urinary symptoms (manualised element), general practice nurses and healthcare assistants or research nurses directed participants to relevant sections of the manual and provided contact over 12 weeks to assist with adherence.

MAIN OUTCOME MEASURES

The primary outcome was patient reported International Prostate Symptom Score (IPSS) measured 12 months after participants had consented to take part in the study. The target reduction of 2.0 points on which the study was powered reflects the minimal clinically important difference where baseline IPSS is <20. Secondary outcomes were patient reported quality of life, urinary symptoms and perception of LUTS, hospital referrals, and adverse events. The primary intention-to-treat analysis included 887 participants (82% of those recruited) and used a mixed effects multilevel linear regression model adjusted for site level variables used in the randomisation and baseline scores.

RESULTS

Participants in the intervention arm had a lower mean IPSS at 12 months (adjusted mean difference -1.81 points, 95% confidence interval -2.66 to -0.95) indicating less severe urinary symptoms than those in the usual care arm. LUTS specific quality of life, incontinence, and perception of LUTS also improved more in the intervention arm than usual care arm at 12 months. The proportion of urology referrals (intervention 7.3%, usual care 7.9%) and adverse events (intervention seven events, usual care eight events) were comparable between the arms.

CONCLUSIONS

A standardised and manualised intervention in primary care showed a sustained reduction in LUTS in men at 12 months. The mean difference of -1.81 points (95% confidence interval -0.95 to -2.66) on the IPSS was less than the predefined target reduction of 2.0 points.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN11669964.

The effect of electromagnetic field on sleep of patients with nocturia

INTRODUCTION

Accumulated studies revealed that electromagnetic field can affect human brain and sleep. We explored the effectiveness of electromagnetic field [Schumann resonance (SR)] on nocturia symptoms, quality of life, and sleep in patients with nocturia.

METHODS

This is a randomized, open-label, and active-controlled study, in which 35 participants were randomized into 2 groups. Group A received oxybutynin and the SR device for 12 weeks, while the active-control group received only the medication. We followed these patients every 4 weeks with a number of questionnaires, including the Pittsburgh sleep quality index (PSQI) and Epworth sleepiness scale (ESS) for sleep, the American Urological Association Symptom Score (AUASS) for nocturia symptoms, and the Nocturia-Quality-of-Life-questionnaire (N-QOL) for quality of life. Descriptive statistics, pair t-tests, Chi-squared tests, and repeated measures were applied for data analysis.

RESULTS

No significant difference was found in the demographic data between the 2 groups. The AUASS, N-QOL, PSQI, and ESS total scores were significantly improved in the SR-sleep-device group (P < .001, P = .005, P < .001, P = .001) after treatment, but no significant change was found in the active-control group. Several variables of AUASS in the SR-sleep-device group were significantly improved, especially streaming and sleeping (both P = .001), and subjective sleep quality and sleep efficiency also demonstrated significant improvement (both P < .001).

CONCLUSIONS

Our study revealed that electromagnetic field (SR) as an add-on can improve not only sleep and quality of life but also nocturia symptoms in patients with nocturia. These findings suggest that SR can be effective for sleep disturbance secondary to physical disease, which can be a new application of the electromagnetic field.

Evaluation and Treatment in Urology for Nocturia Caused by Nonurological Mechanisms: Guidance from the PLANET Study

Patients with nocturia are commonly referred to urology clinics, including many for whom a nonurological medical condition is responsible for their symptoms. The PLanning Appropriate Nocturia Evaluation and Treatment (PLANET) study was established to develop practical approaches to equip healthcare practitioners to deal with the diverse causes of nocturia, based on systematic reviews and expert consensus. Initial assessment and therapy need to consider the possibility of one or more medical conditions falling into the "SCREeN" areas of Sleep medicine (insomnia, periodic limb movements of sleep, parasomnias, and obstructive sleep apnoea), Cardiovascular (hypertension and congestive heart failure), Renal (chronic kidney disease), Endocrine (diabetes mellitus, thyroid disease, pregnancy/menopause, and diabetes insipidus), and Neurology. Medical and medication causes of xerostomia should also be considered. Some key indicators for these conditions can be identified in urology clinics, working in partnership with the primary care provider. Therapy of the medical condition in some circumstances lessens the severity of nocturia. However, in many cases there is a conflict between the two, in which case the medical condition generally takes priority on safety grounds. It is important to provide patients with a realistic expectation of therapy and awareness of limitations of current therapeutic options for nocturia. PATIENT SUMMARY: Nocturia is the symptom of waking at night to pass urine. Commonly, this problem is referred to urology clinics. However, in some cases, the patient does not have a urological condition but actually a condition from a different speciality of medicine. This article describes how best the urologist and the primary care doctor can work together to assess the situation and make sensible and safe treatment suggestions. Unfortunately, there is sometimes no safe or effective treatment choice for nocturia, and treatment needs to focus instead on supportive management of symptoms.

Qualitative Assessment of the Conservative Management of Nocturia with Standardised Written Materials for Lower Urinary Tract Symptoms in Men Treated in Primary Care

BACKGROUND

Many men prefer conservative treatment of lower urinary tract symptoms (LUTS) but education and self-help guidance are limited in primary care.

OBJECTIVE

To report qualitative interview findings for men reporting nocturia in a primary care setting for LUTS.

DESIGN, SETTING, AND PARTICIPANTS

TRIUMPH (Treating Urinary Symptoms in Men in Primary Healthcare) is a multicentre cluster randomised trial of standardised manualised care (a booklet delivered by a health care professional) versus usual care for LUTS. The participants (524 in the intervention arm and 553 in the usual care arm) were men presenting for primary care for LUTS at 30 general practice (GP) sites in the UK.

INTERVENTION

Delivery of a LUTS self-management booklet by health care staff in comparison to usual care for men with LUTS.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The qualitative component included 58 early-stage (0-3 mo after study enrolment) and 33 late-stage (3-9 mo later) interviews with participants to assess their experience of LUTS and conservative treatment in primary care. Purposive sampling was used to select participants for interview.

RESULTS AND LIMITATIONS

Nocturia is a common driver for seeking health care and is perceived by men as relatively acceptable to discuss. Information and self-help guidance were largely absent from descriptions of GP consultations, other than reducing evening caffeine and fluid intake. The TRIUMPH LUTS intervention booklet offers explanations and self-management guidance. Men with long-term disruptive symptoms, a perception that the booklet content was novel or worthwhile, and a belief that self-management might help, were more receptive to the intervention. In follow-up, improvements in nocturia were related to successful implementation of several aspects of the guidance. Most men were willing to complete a bladder diary, but some found it inconvenient, especially men in employment. The characteristics of the trial population mean that the findings may not apply to all men.

CONCLUSIONS

Reassuring men that nocturia is part of ageing without offering them information and support risks reinforcing the tendency to discount problematic LUTS. The trial booklet and the training of health care professionals support guidance on nocturia self-management, which is most effective for men receptive to this approach. However, the nature of the trial population means that the findings may not apply to all men.

PATIENT SUMMARY

Men are more comfortable in discussing waking at night to urinate than talking about other urinary symptoms with their GP. This problem should lead to a detailed discussion of all urinary symptoms rather than being thought of as a sign of ageing. An information booklet and nurse consultation helped many men to improve this symptom.

Assessment and Treatment of Nocturia in Neurological Disease in a Primary Care Setting: Systematic Review and Nominal Group Technique Consensus

CONTEXT

Neurological disease can affect the rate of urine production and bladder storage function, increasing nocturia severity, with additional risks if mobility or cognition is impaired.

OBJECTIVE

To conduct a systematic review (SR) of nocturia in neurological diseases and achieve expert consensus for management in clinics without neurologist input.

EVIDENCE ACQUISITION

Four databases were searched from January 2000 to April 2020. A total of 6262 titles and abstracts were screened and 43 studies were included for full-text screening. Eleven of these met the inclusion criteria and two studies were identified through other sources. The nominal group technique (NGT) was used to develop consensus in panel comprising experts and public representation.

EVIDENCE SYNTHESIS

Thirteen studies (seven in Parkinson's disease, five in multiple sclerosis) were included, all undertaken in secondary care. Neurological disease severity was incompletely described, and nocturia severity was generally measured subjectively. NGT consensus supported basic neurological assessment, and the use of bladder diaries where neurological impairment permits. Treatments include pelvic-floor muscle training, review of medications, risk mitigation, improving bowel function, therapy for overactive bladder syndrome (if urgency is reported in association with nocturia episodes), treatment of postvoid residual and desmopressin according to licence. Measures to improve mobility and mitigate risk when using the toilet overnight should be considered. Multifactorial issues such as obstructive sleep apnoea and hypoventilation must be considered.

CONCLUSIONS

Nocturia in neurological disease is complex and lacks a robust evidence base, with very little research done in the primary care context. Guidance should be pragmatic, with reduction of risk a key requirement, until a multidisciplinary evidence base can be developed.

PATIENT SUMMARY

People with a neurological disease can suffer severe sleep disturbance because of the need to pass urine several times overnight (called nocturia). We looked at published research and found very little information to help general practitioners in managing this condition. We assembled a group of experts to develop practical approaches for assessing and treating nocturia in neurological disease.

Nocturia and Chronic Kidney Disease: Systematic Review and Nominal Group Technique Consensus on Primary Care Assessment and Treatment

CONTEXT

Reduced renal function impairs salt and water homeostasis, which can drive nocturnal or 24-h polyuria. Nocturia can arise early in chronic kidney disease (CKD). Evidence-based recommendations can facilitate management outside nephrology clinics.

OBJECTIVE

To conduct a systematic review (SR) of nocturia in CKD and achieve expert consensus for management in primary care and in specialist clinics outside nephrology.

EVIDENCE ACQUISITION

Four databases were searched from January 2000 to April 2020. A total of 4011 titles and abstracts were screened, and 108 studies underwent full-text screening. Seven studies met the inclusion criteria and two were identified through other sources. Consensus was achieved among an expert panel with public involvement using the nominal group technique (NGT).

EVIDENCE SYNTHESIS

Several plausible mechanisms contribute to nocturnal or 24-h polyuria in CKD, but there is little evidence on interventions to improve nocturia. NGT assessment recommendations for nocturia (at least two voids per night) in patients with CKD or at risk of CKD being assessed in a non-nephrology setting are: history (thirst, fluid intake), medication review (diuretics, lithium, calcium channel antagonists, nonsteroidal anti-inflammatory medications), examination (oedematous state, blood pressure), urinalysis (haematuria and albumin/creatinine ratio), blood tests (blood urea, serum creatinine and electrolytes, estimated glomerular filtration rate), and a bladder diary. Renal ultrasound should follow local CKD guidelines. Treatment options include optimising blood pressure control, dietary adjustment to reduce salt intake, fluid advice, and a medication review. Referral to specialist nephrology services should follow local guidelines.

CONCLUSIONS

CKD should be considered when evaluating patients with nocturia. The aim of assessment is to identify mechanisms and instigate therapy, but the latter may be more applicable to reducing wider morbidity associated with CKD than nocturia itself.

PATIENT SUMMARY

People with kidney disease can suffer severe sleep disturbance because of a need to pass urine overnight. We looked at published research and found some useful information about the underlying mechanisms. A group of experts was able to develop practical approaches for assessing and treating this condition.

Implications of Cardiovascular Disease for Assessment and Treatment of Nocturia in Primary Care: Systematic Review and Nominal Group Technique Consensus

CONTEXT

Heart conditions affect salt and water homeostasis as a consequence of the underlying condition, compensatory processes, and therapy, and can result in nocturnal polyuria. These processes need to be identified as part of a full evaluation of nocturia.

OBJECTIVE

To conduct a systematic review of nocturia in cardiovascular disease and achieve expert consensus for primary care management. Primary care was defined as a health care setting in which the expertise did not include specialist cardiology.

EVIDENCE ACQUISITION

Four databases were searched from January 2000 to April 2020. A total of 3524 titles and abstracts were screened and 27 studies underwent full-text screening. Of these, eight studies were included in the analysis. The nominal group technique (NGT) was used to achieve consensus among an expert panel incorporating public involvement.

EVIDENCE SYNTHESIS

Most studies focused on nocturia related to blood pressure (BP), while one investigated leg oedema. Hypertension, particularly overnight blood pressure above normal, corresponds with higher risk of nocturia. NGT identified fluid and salt overload, nondipping hypertension, and some therapeutic interventions as key nocturia contributors. History taking and examination should identify raised jugular venous pressure/ankle swelling, with relevant investigations including measurement of BP, resting electrocardiogram, and B-type natriuretic peptide. Treatment recommends reducing salt (including substitutes), alcohol and caffeine. Heart failure is managed according to local guidance and controlling fluid intake to 1-2 l daily. If there is no fluid retention, reduce or discontinue diuretics or calcium channel blockers and follow up to reassess the condition. The target clinic blood pressure is 140/90 mm Hg.

CONCLUSIONS

Cardiovascular disease and its treatment are influential for understanding nocturia. Management aims to identify and treat heart failure and/or hypertension.

PATIENT SUMMARY

People with cardiovascular disease can suffer severe sleep disturbance because of a need to pass urine at night due to increased overnight blood pressure or heart failure. Following a detailed evaluation of the published research, a group of experts recommended practical approaches for assessing and treating these issues.

Use of the International Consultation on Incontinence Questionnaires Bladder Diary in Men Seeking therapy for Lower Urinary Tract Symptoms

BACKGROUND

Completion rates and correspondence to other measures need to be established for the International Consultation on Incontinence Questionnaire (ICIQ) bladder diary (ICIQ-BD) in the assessment of male lower urinary tract symptoms (LUTS).

OBJECTIVE

To evaluate ICIQ-BD completion rates, frequency, volume, and sensation reporting for men.

DESIGN, SETTING, AND PARTICIPANTS

Baseline data from the Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM) randomised controlled trial evaluating 820 men at 26 UK hospitals, looking at the ICIQ-BD, uroflowmetry, International Prostate Symptom Score, and ICIQ symptom score for male LUTS (ICIQ-MLUTS), were assessed.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The ICIQ-BD, IPSS, ICIQ-MLUTS, and uroflowmetry data at baseline obtained from UPSTREAM were assessed. Correlations were analysed by Pearson's correlation coefficient, and comparison between groups were performed using paired or unpaired t tests or Tukey's test. All statistical tests were two sided and the strength of evidence was presented using p values.

RESULTS AND LIMITATIONS

Of the participants, 25.0% (205/820) provided complete voiding and bedtime information for 3 d, 41.2% (338/820) omitted bedtime information, and the remainder omitted some or all voiding information. Median values (minimum - maximum) of 24-h, daytime, and night-time frequencies were 9.7 (3.3-24.0), 7.7 (3.3-22.7), and 1.7 (0.0-5.7), respectively. The mean voided volume per micturition for day and night times were 175.8 ± 74.2 and 264.4 ± 150.7 ml (p < 0.001), respectively. For fully completed diaries, day- and night-time frequency showed a weak-to-moderate correlation with symptom score questionnaires. More severe nocturia was generally reported in symptom scores than in the ICIQ-BD. In patients with high bother for increased daytime frequency (symptom), the mean daytime frequency (ICIQ-BD) was 9.6 ± 3.2 versus 7.6 ± 2.2 for low bother (p < 0.001). High bother for nocturia showed night-time frequency of 2.3 ± 1.2 versus 1.5 ± 1.1 for low bother (p < 0.001). For fully and partially completed diaries, ICIQ-BD sensation scores correlated weakly with symptom scores. Voided volumes from the bladder diary and uroflowmetry correlated weakly.

CONCLUSIONS

Two-thirds of men (543/820) fully completed voiding information in the ICIQ-BD, but many omitted bedtime information, limiting the ability to quantify nocturia and diagnose nocturnal polyuria.

PATIENT SUMMARY

Most men with urinary symptoms complete a bladder diary fully but may fail to indicate bedtimes. Extra information from a diary helps support symptom questionnaires to explain a patient's urinary habits.

Assessment and Treatment of Nocturia in Endocrine Disease in a Primary Care Setting: Systematic Review and Nominal Group Technique Consensus

CONTEXT

Salt and water homeostasis is regulated hormonally, so polyuria can result from endocrine disease directly or via secondary effects. These mechanisms are not consistently considered in primary care management of nocturia.

OBJECTIVE

To conduct a systematic review (SR) of nocturia in endocrine disease and reach expert consensus for primary care management.

EVIDENCE ACQUISITION

Four databases were searched from January 2000 to April 2020. A total of 4382 titles and abstracts were screened, 36 studies underwent full-text screening, and 14 studies were included in the analysis. Expert and public consensus was achieved using the nominal group technique (NGT).

EVIDENCE SYNTHESIS

Twelve studies focused on mechanisms of nocturia, while two evaluated treatment options; none of the studies took place in a primary care setting. NGT consensus identified key clinical evaluation themes, including the presence of thirst, a medical background of diabetes mellitus or insipidus, thyroid disease, oestrogen status, medications (fluid loss or xerostomia), and general examination including body mass index. Proposed investigations include a bladder diary, renal and thyroid function, calcium, and glycated haemoglobin. Morning urine osmolarity should be examined in the context of polyuria of >2.5 l/24 h persisting despite fluid advice, with urine concentration >600 mOsm/l after fluid restriction excluding diabetes insipidus. Treatment should involve education, including adjustment of lifestyle and medication where possible. Any underlying endocrine disorder should be managed according to local guidance. Referral to endocrinology is needed if there is hyperthyroidism, hyperparathyroidism, or morning urine osmolarity <600 mOsm/l after overnight fluid avoidance.

CONCLUSIONS

Endocrine disease can result in nocturia via varied salt and water regulation pathways. The aim of management is to identify and treat causative factors, but secondary effects can restrict improvements in nocturia.

PATIENT SUMMARY

People with altered hormone function can suffer from severe sleep disturbance because of a need to pass urine caused by problems in controlling water and salt levels. An expert panel recommended the best ways to assess and treat these problems on the basis of the rather small amount of up-to-date published research available.

The Challenges of Real-life Bladder Diary Use and Interpretation

The International Consultation on Incontinence Questionnaire bladder diary records the amount and type of drinks, urine output, bladder sensation, and pad use for assessing nocturia and storage urinary symptoms. Instructions before completion, checks after completion, and training of staff in diary analysis are essential.

Population-Based Study of Prevalence, Bother and Behavior Related to Treatment for Lower Urinary Tract Symptoms and Overactive Bladder among Polish Neurogenic Patients

Background: The aim of this study was to perform a cross-sectional study of Polish neurogenic patients to measure, at the population level, the prevalence, bother and behavior associated with treatment for lower urinary tract symptoms (LUTS) and overactive bladder (OAB). Methods: This epidemiological study was based on data from LUTS POLAND, a computer-assisted and population-representative telephone survey. Participants were classified by age, sex and place of residence. Results: LUTS POLAND includes 6005 completed interviews, of which 1166 (19.4%) were for individuals who had ever received any treatment by neurologists and/or neurosurgeons. Among these neurogenic participants, LUTS prevalence was 72.3%, statistically higher than for non-neurogenic respondents. At the population level, neurogenic patients had about a 20% higher risk for LUTS presence than non-neurogenic participants (relative risk: 1.17–1.21). LUTS prevalence did not differ between men and women. Frequency was the most common of the LUTS. Forty percent of neurogenic respondents described having more than one LUTS subtype (i.e., storage, voiding, and/or post-micturition symptom subtype), and more than 50% of respondents reported OAB symptoms. Both storage and voiding symptoms were bothersome, and many neurogenic individuals (42.3–51.0%) expressed anxiety about bladder function affecting quality of life. Only one-third (34.9–36.6%) of neurogenic participants had sought treatment for their LUTS, and the majority of such individuals received and maintained treatment. Conclusions: LUTS and OAB symptoms were highly prevalent and bothersome among Polish neurogenic patients at the population level. Because the scale of seeking treatment for LUTS was low, Polish neurogenic patients may not be adequately informed about multiple effects of LUTS and OAB.

Association of nocturia and cardiovascular disease: Data from the National Health and Nutrition Examination Survey

AIMS

To investigate the association of nocturia with the prevalence of cardiovascular disease (CVD) using the National Health and Nutrition Examination Survey (NHANES) data.

METHODS

Among the 40 790 individuals who participated in NHANES from 2005 to 2012, 14 114 adults were analyzed in this study. A participant was considered to have nocturia if they have two or more voiding episodes nightly. In addition, participants with nocturia more than four times in a day were considered to have severe nocturia. A multivariate logistic regression analysis with adjustment for confounding variables, including age, sex, race, body mass index (BMI), smoking status, alcohol consumption, sleeping time, dyslipidemia, hypertension, and diabetes mellitus was performed with 1:1 propensity score matching (PSM).

RESULTS

Nocturia occurred in 4610 individuals (32.7%). The prevalence of CVD was significantly higher in men, older individuals, those with higher BMI, smokers, and those with diabetes, hypertension, and hyperlipidemia. There was also a significantly higher prevalence of nocturia in the participants with CVD. Multivariate analysis showed that odds ratios (ORs) of mild and severe nocturia for CVD were 1.23 (95% confidence interval [CI]: 1.08-1.39) and 1.74 (95% CI: 1.39-2.17), respectively. After 1:1 PSM, the ORs of mild and severe nocturia were 1.27 (95% CI: 1.10-1.48) and 1.73 (95% CI: 1.33-2.26), respectively, showing statistical significance.

CONCLUSION

Data from the NHANES indicate that CVD was significantly associated with the prevalence of nocturia, after taking major confounding factors into account. Furthermore, the risk for CVD increases with increasing nocturia severity.

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.

Nocturia at the Population Level in Poland: Prevalence, Bother, Quality of Life, and Treatment-Related Behavior

Background and Objectives: The purpose of this study was to measure at the population level the prevalence, bother, effect on quality of life, and behavior associated with treatment for nocturia in a large representative cohort of Polish adults aged ≥40 years. Materials and Methods: Data were derived from LUTS POLAND, a computer-assisted telephone survey of urological health that mirrored the entire Polish population in urban and rural areas. Results: Six thousand persons completed the survey. The respondents were representative for age, sex, and place of residence. Nocturia was highly prevalent because 73.7% of all participants reported ≥1 nocturia episode, and 36.1% reported ≥2 nocturia episodes. We did not identify differences between urban and rural areas. Women were more often affected than men, and the prevalence of nocturia increased with age. More than one-third (29.7–45.3%) of respondents who reported nocturia were bothered by the symptom and, thereby, concerned about their urinary-specific quality of life. Notably, we found a statistically significant correlation between the frequency of nocturia and intensification of its bother (p < 0.001 for men and women). However, only about one-fourth (22.2–29.2%) of respondents with nocturia sought treatment, most of whom received treatment. Conclusions: Nocturia was highly prevalent and often bothersome with negative effects on quality of life of Polish adults aged ≥40 years. However, the percentage of treatment seeking was low. Combined with the fact that nocturia has multiple causes and consequences, including high morbidity and mortality, our findings revealed that nocturia was a significant public health issue. We need to develop strategies to specifically increase awareness about nocturia and provide greater healthcare and financial resources for persons with nocturia in Poland.

Association between Lower Urinary Tract Symptoms and Sleep Quality of Patients with Depression

Background and Objectives: In the general population, sleep disorders are associated with lower urinary tract symptoms (LUTS) including urinary incontinence (UI). This connection has not been explored fully in specific patient groups. Thus, we investigated the association between sleep quality and LUTS for patients with depression. Materials and Methods: This study was prospective and cross-sectional. We analyzed questionnaire data on depression, sleep quality, LUTS, and UI from depressed patients treated in our department of adult psychiatry. We used the Hamilton Rating Scale for Depression, the Holland Sleep Disorders Questionnaire, the International Prostate Symptom Score, and the International Consultation on Incontinence Questionnaire-Short Form. Results: In total, 102 patients treated for depression were enrolled. We found a statistically significant correlation between depression severity and sleep quality. A significant correlation was also investigated for sleep quality and LUTS severity. The group of depressed patients with moderate or severe LUTS had greater sleep problems compared with patients who had mild urinary tract symptoms or no symptoms. With regression analysis, we further demonstrated that the relationships between LUTS and sleep quality as well as UI and sleep quality in depressed patients are independent from age and sex. Conclusions: In the cohort of patients treated for depression, sleep quality correlated with LUTS including UI. We suggest that the negative effect of LUTS and UI on sleep quality that we observed should lead to the re-evaluation of current recommendations for diagnosis and treatment of sleep problems among patients with depression.

Overactive Bladder Symptoms Negatively Affect Sleep Quality of Patients With Depression

Purpose

An established link exists between overactive bladder (OAB) syndrome and impaired sleep. However, earlier research on this subject only focused on the general population, and certain patient subgroups have not been examined adequately. Depressed patients constitute a unique population because of a possible bidirectional relationship between OAB and depression. Thus, we investigated the association between OAB symptoms and sleep quality in patients with depression.

Methods

In this prospective, cross-sectional study, we analyzed data on depression, sleep quality, and OAB symptoms from depressed patients treated at our department of adult psychiatry. Data were collected with the Hamilton Rating Scale for Depression, the Holland Sleep Disorders Questionnaire, the Athens Insomnia Scale, and the OAB Module of the International Consultation on Incontinence Questionnaire.

Results

In total, 102 patients treated for depression were enrolled. Thirteen patients (12.7%) met the diagnostic threshold of OAB with the International Consultation on Incontinence Questionnaire OAB Module. Patients with depression and concomitant OAB had significantly higher scores on the Holland Sleep Disorders Questionnaire than patients classified as nonOAB (P<0.01). OAB patients also had a higher risk of insomnia relative to non-OAB individuals (P<0.05). In addition, the relationship between OAB symptoms and sleep quality in patients with depression was independent from age and sex.

Conclusions

In our cohort composed exclusively of individuals treated for depression, OAB symptoms were present in a significant proportion of patients, and OAB negatively affected sleep quality. Therefore, we recommend that OAB symptoms should be assessed collectively in patients with depression.

Polysomnography and Nocturia Evaluations after Uvulopalatopharyngoplasty for Obstructive Sleep Apnea Syndrome

A higher incidence rate of nocturia in patients with obstructive sleep apnea (OSA) has been observed. We investigated the differences in clinical examinations between OSA patients with and without nocturia, and further compared those with successful and unsuccessful uvulopalatopharyngoplasty (UPPP). This retrospective study enrolled 103 patients with OSA undergoing UPPP. Patients were diagnosed with OSA by following the 2018 American Academy of Sleep Medicine (AASM) Scoring Manual Version 2.5. Patients were divided into two groups depending on if they urinated more than twice per night. The medical data of body mass index (BMI), nocturia frequency per night, apnea–hypopnea index (AHI), Epworth Sleepiness Scale (ESS), International Prostatic Symptom Score (IPSS), and Overactive Bladder Symptom Score (OABSS) were analyzed before and after uvulopalatopharyngoplasty (UPPP) surgery. All of the measurements were compared between successful and unsuccessful surgery in the non-nocturia or nocturia groups, respectively. Fifty patients (41 males and nine females) without nocturia were assigned to group 1, and 53 patients (43 males and 10 females) with nocturia were assigned to group 2. Nocturia frequency and post-surgery AHI in group 2 were significantly higher than those in group 1 (p < 0.05). Significant decreases in IPSS and OABSS were observed in the successful surgery subgroup of group 2 (p < 0.05). A significant decrease in post-surgery AHI was observed between unsuccessful and successful surgery in patients with nocturia (p < 0.05), but not in the non-nocturia group (p > 0.05). Although AHI had a significant correlation to nocturia frequency in all OSA patients before UPPP, no significant correlation between AHI reduction and nocturia frequency was found. UPPP appeared to be an effective treatment for nocturia associated with OSA. OSA should be taken into consideration for patients who complain of nocturia syndrome. The relationship of AHI reduction and nocturia improvement after OSA treatment with UPPP is still unclear. In addition, it is necessary to establish the existence of nocturia in patients with OSA, as a result of its high prevalence in OSA patients. UPPP could reduce the symptoms of OSA and could also contribute to a reduction of nocturia even in the unsuccessful surgery group.

[Diagnostic and therapeutic approach to nocturia in Primary Care]

Nocturia is the interruption of the main sleep, one or more times, due to the need for urination. It is associated with a decrease in the quality of life and an increase in mortality. It is a complex and multifactorial symptom in which two pathophysiological mechanisms are mainly involved. These occur alone or in combination as nocturnal polyuria or decreased bladder capacity. Nocturnal polyuria is the most frequent. The preparation of a bladder diary is the key to diagnosis. Treatment usually combines lifestyle changes and drug therapy. Desmopressin has proven to be an effective and well-tolerated treatment in patients with nocturnal polyuria. The risk of hyponatraemia should be controlled in patients treated with desmopressin.

What Is the Most Effective Treatment for Nocturia or Nocturnal Incontinence in Adult Women?

CONTEXT

Nocturia is a prevalent symptom with varied aetiology and no consensus on treatment options.

OBJECTIVE

We systematically reviewed evidence comparing the benefits and harms of various treatment options for nocturia or nocturnal incontinence in women.

EVIDENCE ACQUISITION

Literature search was performed using Embase, Medline, and Cochrane databases (from 1 January 1946 to 26 September 2017), following the methods detailed in the Cochrane Handbook. The protocol was registered with PROSPERO. Certainty of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

EVIDENCE SYNTHESIS

The literature search identified 3573 citations, of which 11 full-text articles were included. Three studies on desmopressin and four on antimuscarinics provided evidence of improving nocturia symptoms. Four studies on behavioural treatment provided limited evidence and controversial results. One study on oestrogen did not prove the benefit of any mode of administration, and one small study on functional magnetic stimulation provided some evidence of effectiveness in nocturia. One randomised controlled trial (RCT; 141 participants) reported a statistically significant difference between the desmopressin and placebo groups (desmopressin patients experienced 0.75 [95% confidence interval {CI} 0.47-1.03] nocturia episodes less than those experience by the placebo group; certainty of evidence = low). The only RCT on antimuscarinics in women with nocturia reported that oxybutynin reduced the number of nocturia episodes by 0.3 (95% CI -0.02 to 0.62) versus placebo. In one RCT comparing tolterodine with the combination of tolterodine with behavioural therapy, there was significant change from baseline nocturnal incontinence episodes in both groups.

CONCLUSIONS

There is some evidence that desmopressin and antimuscarinics are effective treatment options for nocturia; however, there is very limited evidence for other treatment options. The findings should be interpreted with caution as there were some methodological flaws in the included studies, particularly outcome heterogeneity.

PATIENT SUMMARY

This review identified several medical treatments for nocturia in women, such as desmopressin and antimuscarinics, which appear to improve the severity of the condition.

The role of intravesical prostatic protrusion in the evaluation of overactive bladder in male patients with LUTS

PURPOSE

To evaluate the association of intravesical prostatic protrusion (IPP) and overactive bladder (OAB) in male patients with lower urinary tract symptoms (LUTS). IPP has been suggested to correlate with storage symptoms in addition to bladder outlet obstruction.

METHODS

This was an open-labeled, single-center, prospective study involving 128 men older than 40 years presenting with LUTS. We analyzed the relationship of IPP with age, prostate volume, uroflowmetry, post-void residual urine volume (PVR), International Prostate Symptom Score (IPSS), urgency severity scale (USS), and OAB symptom score (OABSS). The patients with an urgency score of ≥ 2 (OABSS question 2) and sum score of ≥ 3 were considered to have OAB. IPP was measured in the mid-sagittal section using transrectal ultrasound. The degree of IPP was classified as grade 1 (≤ 5 mm), grade 2 (> 5-10 mm), and grade 3 (> 10 mm).

RESULTS

The mean age of the patients was 64.9 ± 9.2 years, and 101 patients were diagnosed with OAB (79%). Mean IPPs were 2.4 ± 1.4 mm (grade 1, n = 77), 7.6 ± 1.4 mm (grade 2, n = 27), and 14.8 ± 4.4 mm (grade 3, n = 24). IPP was positively correlated with age, prostate size, PSA, PVR, and OABSS nocturia subscore, but not correlated with the presence or severity of OAB. Areas under the receiver-operating characteristic (ROC) curves for the diagnosis of OAB were 0.807 and 0.604 for IPSS-storage subscore and IPP, respectively.

CONCLUSION

IPP is not a good predictor of OAB in men presenting with LUTS. However, grade 3 IPP indicates higher frequency of nocturia.

Current guidelines and treatment paradigms for nocturnal polyuria: A "NEW" disease state for US physicians, patients and payers

Nocturia is one of the most bothersome symptoms encountered in urology, and its prevalence rises with age. Causes include both urological and non-urological aetiologies, often in combination. The effects of nocturia on a patient's quality of life can be detrimental. The initial approach to managing this condition includes appropriately classifying nocturia based on the results of a 24-hour bladder diary. Broadly, the categories under which nocturia can be classified include: low nocturnal or global bladder capacity, nocturnal polyuria, global polyuria and mixed.Based on the type of nocturia and possible underlying causes, clinicians can appropriately discuss with patients the treatment plans that may include a combination of behavioural, pharmacologic, and invasive therapy. The available literature on the management of nocturia was reviewed. Findings were incorporated into a practice-based approach for its workup and treatment.

International Continence Society (ICS) report on the terminology for nocturia and nocturnal lower urinary tract function

INTRODUCTION

The terminology for nocturia and nocturnal lower urinary tract function is reviewed and updated in a clinically and practically-based consensus report.

METHODS

This report has been created by a Working Group under the auspices and guidelines of the International Continence Society (ICS) Standardisation Steering Committee (SSC). All relevant definitions were updated on the basis of research over the last 16 years since the publication of the first nocturia standardization document in 2002. An extensive process of 16 rounds of internal and external reviews was involved to examine each definition exhaustively, with decision-making by collective opinion (consensus).

RESULTS

A clinically-based terminology report for nocturia and nocturnal lower urinary tract function, encompassing five key definitions divided into signs and symptoms has been developed. Clarity and user-friendliness have been key aims to make it interpretable by healthcare professionals and allied healthcare practitioners involved in the care of individuals with nocturnal lower urinary tract function.

CONCLUSION

A consensus-based terminology report for nocturia and nocturnal lower urinary tract function has been produced to aid clinical practice and research.

[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.

Results of a randomized, double blind, placebo controlled, crossover trial of melatonin for treatment of Nocturia in adults with multiple sclerosis (MeNiMS)

Background

Nocturia is a common urinary symptom of multiple sclerosis (MS) which can affect quality of life (QoL) adversely. Melatonin is a hormone known to regulate circadian rhythm and reduce smooth muscle activity such as in the bladder. There is limited evidence supporting use of melatonin to alleviate urinary frequency at night in the treatment of nocturia. The aim of this study was to evaluate the effect of melatonin on the mean number of nocturia episodes per night in patients with MS.

Methods

A randomized, double blind, placebo controlled crossover trial was conducted. 34 patients with nocturia secondary to multiple sclerosis underwent a 4-day pre-treatment monitoring phase. The patients were randomized to receive either 2 mg per night (taken at bedtime) of capsulated sustained-release melatonin (Circadin®) or 1 placebo capsule for 6 weeks followed by a crossover to the other regimen for an additional 6 weeks after a 1-month washout period.

Results

From the 26 patients who completed the study, there was no significant difference observed in the signs or symptoms of nocturia when taking 2 mg melatonin compared to placebo. The primary outcome measure, mean number of nocturia episodes on bladder diaries, was 1.8/night at baseline, and 1.4/night on melatonin, compared with 1.6 for placebo (Medians 1.70, 1.50, and 1.30 respectively, p = 0.85). There was also no significant difference seen in LUTS, QoL and sleep quality when taking melatonin. No significant safety concerns arose.

Conclusions

This small study suggests that a low dose of melatonin taken at bedtime may be ineffective therapy for nocturia in MS.

Trial registration

(EudraCT reference) 2012–00418321 registered: 25/01/13. ISRCTN Registry: ISRCTN38687869.

Pharmacotherapy for Nocturia

Purpose of Review

To assess current pharmacological principles used for treatment of nocturia/nocturnal polyuria.

Recent Findings

The pathophysiology of nocturia is often multifactorial, but two main mechanisms have been identified, occurring alone or in combination: low functional bladder capacity and nocturnal polyuria. The multifactorial pathophysiology not only implies several possible targets for therapeutic intervention but also means that it is unlikely that one treatment modality including drugs will be successful in all patients. Drugs approved for the treatment of male LUTS and male and female OAB are known to be far more effective for treatment of the daytime symptoms than for nocturia.

Summary

Several pharmacological principles have been tested with varying success. The treatment of choice should depend upon the main underlying cause, thus aiming primarily to increase bladder capacity by counteracting detrusor overactivity and/or reducing nocturnal polyuria. Using current available agents, effective, personalized treatment should be designed taking into account gender, co-morbidities, and identified etiological factors. However, there is a medical need for new, approved drugs for treatments for patients with nocturia.

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: consequences, classification, and management

Nocturia is a widespread condition that can negatively impact quality of sleep and overall health. This condition is multifactorial in nature and is best approached through the analysis of frequency volume charts. Through these charts, clinicians may classify each individual case of nocturia into one of four distinct categories: global polyuria, nocturnal polyuria, reduced bladder capacity, and mixed. Treatments should then be tailored to each individual based upon the category of their nocturia. In some cases, appropriate therapy will consist of behavioral modification techniques or addressing underlying systemic diseases. In other cases, medical therapy may be necessary, but, to date, medications have shown limited efficacy at treating nocturia.

Protocol for a randomized, double blind, placebo controlled, crossover trial of Melatonin for treatment of Nocturia in adults with Multiple Sclerosis (MeNiMS)

BACKGROUND

Nocturia (the symptom of needing to wake up to pass urine) is common in progressive Multiple Sclerosis (MS) patients. Moderate-to-severe nocturia affects quality of life, can exacerbate fatigue and may affect capacity to carry out daily activities. Melatonin is a natural hormone regulating circadian cycles, released by the pineal gland at night-time, and secretion is impaired in MS. Melatonin levels can be supplemented by administration in tablet form at bedtime. The aim of this study is to evaluate the effect of melatonin on mean number of nocturia episodes per night in MS patients. Secondary outcome measures will assess impact upon quality of life, urinated volumes, lower urinary tract symptoms (LUTS), cognition, sleep quality and sleep disturbance of partners.

METHODS

A randomized, double blind, placebo controlled, crossover trial consisting of two, six week treatment phases (active drug melatonin 2 mg or placebo), with a 1 month wash-out period in between. The primary outcome (change in nocturia episodes per night) in this two arm, two treatment, two period crossover design, will be objectively measured using frequency volume charts (FVC) at baseline and following both treatment phases. Questionnaires will be used to assess quality of life, sleep quality, safety and urinary tract symptoms. Qualitative interviews of participants and partners will explore issues including quality of life, mechanisms of sleep disturbance and impact of nocturia on partners.

DISCUSSION

This study will evaluate whether melatonin reduces the frequency of nocturia episodes in MS patients, and therefore whether 'Circadin' has the potential to reduce LUTS and fatigue, and improve cognition and overall quality of life.

TRIAL REGISTRATION

(EudraCT reference) 2012-00418321 registered: 25/01/13. ISRCTN Registry: ISRCTN38687869.

Differences in the Association of Nocturia and Functional Outcomes of Sleep by Age and Gender: A Cross-sectional, Population-based Study

PURPOSE

Nocturia is associated with poor sleep quality; however, little is known about the relationship between nocturia and sleep quality across different workforce-relevant age groups of adults. This has implications for developing new treatment strategies that are well tolerated across populations.

METHODS

We conducted a cross-sectional study involving merged data from the 2005-2006 and 2007-2008 waves of the National Health and Nutrition Examination Survey. Participants responded to validated questions on nocturia frequency and sleep from the Functional Outcomes of Sleep Questionnaire General Productivity subscale (FOSQ-gp, range 1-4). Analyses included multivariable linear regression with stratification by gender to examine associations between nocturia frequency (higher worse) and the FOSQ-gp scores (lower scores indicating worse daytime function related to sleep disturbance).

FINDINGS

Of 10,512 adults aged ≥20 years who completed the survey, 9148 (87%) had complete nocturia and FOSQ-gp data. The population age-adjusted prevalence of nocturia at least twice nightly was 21.1% among men and 26.6% among women (P < 0.001), and nocturia increased with age (P < 0.001). Compared with those with no or 1 episode of nocturia, those with nocturia at least twice nightly reported lower mean FOSQ-gp scores (3.65; 95% CI, 3.61-3.69 vs 3.19; 95% CI, 3.09-3.31 for men and 3.52; 95% CI, 3.48-3.56 vs 3.09; 95% CI, 3.02-3.16 for women). Older adults (aged >65 years) with greater nocturia frequency reported worse FOSQ-gp scores compared with younger adults with similar nocturia frequency (P < 0.001 among men and women).

IMPLICATIONS

In a population-based sample of community-dwelling men and women, the association between nocturia and worsened functional outcomes of sleep was greater among adults older than 65 years-a group more vulnerable to drug side effects, and in whom nocturia is typically multifactorial. Additionally, these analyses found that the association between nocturia and functional outcomes of sleep is stronger with increasing age among men. Effective treatment strategies that are well tolerated by older adults, such as multicomponent treatments that simultaneously address the combined effects of lower urinary tract and sleep dysfunction, are needed.

Nocturia: aetiology and treatment in adults

Nocturia is an extremely common condition that has major sequelae for affected patients. Through disruption of sleep, nocturia impairs quality of life and worsens health outcomes, and is associated with a variety of morbidities including diabetes, coronary artery disease, obstructive sleep apnoea, obesity, metabolic syndrome, and depression. Unsurprisingly, several studies have also linked nocturia with reduced survival. Nocturia is not simply a consequence of lower urinary tract disease; rather, it is a multifactorial disorder that is often a manifestation of an underlying renal or systemic disease. Through the use of the frequency volume chart, clinicians can accurately quantify nocturia and determine its aetiology. Evaluation of quality of life and sleep using simple measures is essential in order to assess the impact of nocturia on a patient. Numerous treatment options for nocturia exist, but most are associated with minor benefit or lack sufficient evidence supporting their use. By systematically analysing an individual's causes of nocturia, clinicians can design appropriate treatment strategies to most effectively treat this condition.

Nocturia: The circadian voiding disorder

Nocturia is a prevalent condition of waking to void during the night. The concept of nocturia has evolved from being a symptomatic aspect of disease associated with the prostate or bladder to a form of lower urinary tract disorder. However, recent advances in circadian biology and sleep science suggest that it might be important to consider nocturia as a form of circadian dysfunction. In the current review, nocturia is reexamined with an introduction to sleep disorders and recent findings in circadian biology in an attempt to highlight the importance of rediscovering nocturia as a problem of chronobiology.

Incidence and Remission of Nocturia: A Systematic Review and Meta-analysis

CONTEXT

Although vital for decision-making about management, the natural history of nocturia remains uncertain. A systematic review would clarify the issue, but because natural history reviews are uncommon it would require methodological innovations.

OBJECTIVE

To estimate the incidence and remission of nocturia, and refine methods for meta-analyses assessing natural history.

EVIDENCE ACQUISITION

We conducted a comprehensive search of PubMed, Scopus, and Cumulative Index of Nursing and Allied Health Literature databases and abstracts of major urologic meetings as far as August 31, 2015. Random effects meta-analyses addressed incidence/remission rates of nocturia; meta-regression explored potential determinants of heterogeneity. Studies were categorized as either low or high risk of bias using a novel instrument specifically designed for longitudinal symptom studies aimed at the general population.

EVIDENCE SYNTHESIS

Of 4165 potentially relevant reports, 16 proved eligible. Pooled estimates from 13 studies (114 964 person-years of follow-up) demonstrated that annual incidence was strongly associated with age: 0.4% (0-0.8%) for adults aged < 40 yr; 2.8% (1.9-3.7%) for adults aged 40-59 yr; and 11.5% (9.1-14.0%) for adults aged ≥ 60 yr. Of those with nocturia, each year 12.1% (9.5-14.7%) experienced remission.

CONCLUSIONS

The available evidence suggests that nocturia onset is strongly associated with age, with much higher rates in those over 60 yr; remission occurs in approximately 12% each year. These estimates can aid with management decisions and counseling related to nocturia.

PATIENT SUMMARY

We reviewed all previous studies of progression of night-time urination (nocturia). We found that in any given year 0.4% of adults aged < 40 yr, 3% of adults aged 40-59 yr, and 12% of adults aged ≥ 60 yr will develop nocturia, while overall 12% of those with nocturia will improve. These findings may be helpful in making decisions about coping with or treating nocturia.

Changes in Nocturia and Lower Urinary Tract Symptoms after Radical Prostatectomy

Purpose

The goal of this study was to evaluate changes in nocturia and other lower urinary tract symptoms (LUTS) after laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALP).

Materials and Methods

We reviewed the medical records of 96 patients who underwent LRP or RALP for clinically localized prostate cancer and completed the International Prostate Symptom Score (IPSS) questionnaire, which provided a basis for assessing their symptoms. We also evaluated maximal flow rate and post-void residual urine volume over a follow-up period of at least 24 months. We divided the patients into three groups according to postoperative changes in the frequency of nocturia.

Results

Voiding symptoms significantly improved over the course of 24 months in patients who underwent LRP or RALP. However, most patients showed persistent or increased nocturia after LRP or RALP. Moreover, more than one third of the patients (33/96) presented with exacerbated nocturia (1.0±0.9 episodes of preoperative nocturia vs. 3.0±1.3 episodes of postoperative nocturia). Multiple regression analysis showed that preoperative IPSS storage sub-score had negative association with the nocturia after radical prostatectomy (p=0.005). However, patients' age, body mass index, preoperative prostate specific antigen, Gleason score, T-stage, and prostate volume had no association.

Conclusions

The present study showed that nocturia was influenced by a range of factors, including other storage LUTS and the relief of bladder outlet obstruction after radical prostatectomy. Moreover, the preoperative storage symptoms are regarded as an important factor which influences the changes of nocturia after radical prostatectomy.