NOCTURIA

Investigating the Link Between Free Androgen Index and Nocturia in Women: Findings From National Health and Nutrition Examination Survey

BACKGROUND

Nocturia is the most prevalent lower urinary tract symptom in women, affecting approximately 54.5% of female patients and significantly impacting the quality of life. While the androgen levels may be related to urinary function, its association with nocturia in women remains unclear. This study aims to explore the relationship between androgen levels and nocturia in women.

METHODS

This study utilized data from the 2013-2016 National Health and Nutrition Examination Survey (NHANES), including 4531 women aged 20 and above. The level of androgen is reflected by the total testosterone (TT) and free androgen index (FAI). Weighted logistic regression models were employed to analyze the association between FAI, TT, and nocturia.

RESULTS

After comprehensive adjustment for confounding factors, higher FAI levels were significantly associated with a reduced risk of nocturia (OR = 0.84, 95% CI: 0.74-0.95). Women in the highest FAI tertile had a significantly lower incidence of nocturia compared to those in the lowest tertile (OR = 0.75, 95% CI: 0.60-0.93). Trend analysis indicated a significant decrease in nocturia occurrence with increasing FAI levels (P for trend = 0.0177). No significant association was found between TT levels and nocturia.

CONCLUSIONS

Higher FAI levels are significantly inversely associated with nocturia in women, suggesting that bioavailable testosterone may have a protective effect against nocturia. This finding underscores the importance of considering FAI levels in research and clinical practice, and future studies should explore the potential benefits of modulating FAI levels in women with nocturia.

Disruption of circadian rhythm as a potential pathogenesis of nocturia

Increasing evidence suggested the multifactorial nature of nocturia, but the true pathogenesis of this condition still remains to be elucidated. Contemporary clinical medications are mostly symptom based, aimed at either reducing nocturnal urine volume or targeting autonomic receptors within the bladder to facilitate urine storage. The day-night switch of the micturition pattern is controlled by circadian clocks located both in the central nervous system and in the peripheral organs. Arousal threshold and secretion of melatonin and vasopressin increase at night-time to achieve high-quality sleep and minimize nocturnal urine production. In response to the increased vasopressin, the kidney reduces the glomerular filtration rate and facilitates the reabsorption of water. Synchronously, in the bladder, circadian oscillation of crucial molecules occurs to reduce afferent sensory input and maintain sufficient bladder capacity during the night sleep period. Thus, nocturia might occur as a result of desynchronization in one or more of these circadian regulatory mechanisms. Disrupted rhythmicity of the central nervous system, kidney and bladder (known as the brain-kidney-bladder circadian axis) contributes to the pathogenesis of nocturia. Novel insights into the chronobiological nature of nocturia will be crucial to promote a revolutionary shift towards effective therapeutics targeting the realignment of the circadian rhythm.

Sleep Assessment in Competitive Athletes: Development and Validation of French Versions of the Athens Insomnia Scale and the Athlete Sleep Behavior Questionnaire

Objective  The purpose of this study was to develop and validate French versions of two questionnaires assessing competitive athletes' sleep: the Athens Insomnia Scale (AIS-FR) and the Athlete Sleep Behavior Questionnaire (ASBQ-FR). Methods  Four complementary studies were carried out, with a total sample of 296 French competitive athletes from different sports and expertise levels. The studies aimed to develop preliminary versions of the AIS-FR and the ASBQ-FR (study 1), and then to examine their respective dimensionality and reliability (study 2), temporal stability (study 3), and concurrent validity (study 4). The dimensionality was established using confirmatory factor analysis. Similar and correlated psychological factor scales were used to examine the concurrent validity (the Insomnia Severity Index, the Pittsburgh Sleep Quality Index, the State-Trait Anxiety Inventory and the Positive and Negative Affect Schedule). Results  The AIS-FR consists of eight items with two subfactors: nocturnal symptoms and diurnal symptoms, assessed by a uniformized 4-point Likert-type scale. The ASBQ-FR is composed of 15 items with three subfactors, which differs from the original English version: behaviors affecting sleep, behaviors related to anxiety, and sleep disturbances. Due to the Covid context and curfews, three items of the original scale were excluded from the statistical analyses because non-applicable. Both scales presented satisfactory psychometric properties. Discussion  The AIS-FR and ASBQ-FR appear to be valid and reliable tools that can be used with competitive athletes for everyday training and research purposes. An ASBQ-FR version that includes the three excluded items should undergo validation testing once pandemic restrictions are eased.

Polyuria in patients with lower urinary tract symptoms: Prevalence and etiology

INTRODUCTION

Patients with lower urinary tract symptoms (LUTS) can be subcategorized into polyuria, normal or oliguria groups. Polyuria may be caused by pathologies including diabetes mellitus (DM), chronic kidney disease (CKD), diabetes insipidus (DI), or primary polydipsia (PPD). While fluid restriction is appropriate for some, doing so in all may result in serious complications. This study investigates the prevalence of these pathologies in LUTS patients with polyuria.

MATERIALS AND METHODS

Two databases were retrospectively queried for men and women who filled out a lower urinary tract symptom score (LUTSS) questionnaire, 24-h bladder diary (24HBD) and were polyuric (>2.5 L/day). Patients were divided into four groups: poorly controlled DM, DI, an CKD grade 3 and PPD. One-way analysis of variance compared 24HBD and LUTSS questionnaires. Pearson correlation examined LUTSS and bother with 24-h voided volume (24 HVV), maximum voided volume (MVV) and total voids.

RESULTS

Among 814 patients who completed a 24HBD, 176 had polyuria (22%). Of the patients with complete data, 7.8% had poorly-controlled DM, 3.1% had DI, 4.7% had CKD grade 3% and 84.4% had PPD. Amongst the four different sub-groups, significant differences were seen in 24 HVV (p < 0.001), nocturnal urine volume (NUV) (p < 0.001), MVV (p = 0.003), daytime voids (p = 0.05), nocturnal polyuria index (NPi) (p < 0.001) and nocturia index (Ni) (p = 0.002). Significance was also seen between LUTSS and bother subscore (r = 0.68, p < 0.001), LUTSS and total voids (r = 0.29, p = 0.001) and bother sub-score and total voids (r = 0.21, p = 0.019).

CONCLUSIONS

22% of patients with LUTS were found to have polyuria based on a 24HBD. Within this cohort, four sub-populations were identified as being demonstrating statistically significant differences in 24 HVV, NUV, MVV, daytime voids, NPi and Ni. Identifying the underlying etiology of polyuria should be carried out to safely treat patients with LUTS.

Transition from Childhood Nocturnal Enuresis to Adult Nocturia: A Systematic Review and Meta-Analysis

Purpose

Current literature has suggested a relationship between nocturnal enuresis (NE) in childhood and the development of nocturia later in life as both disorders have similar underlying etiologies, comorbidities, and treatments. The objective was to synthesize the available evidence on the association between childhood NE and later presentation of nocturia.

Methods

PubMed, CINAHL, Scopus, and Google Scholar were searched for peer-reviewed studies published between January 1980 and April 2021. Case–control and cohort studies that reported on childhood NE and current nocturia were included. The PRISMA protocol was followed (PROSPERO ID: CRD42021256255). A random-effects model was applied to calculate the pooled odds ratio (OR) and 95% confidence interval (CI). Risk of bias was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria and with a funnel plot.

Results

Of the 278 articles identified, 8 studies met inclusion criteria. The 6 case–control and 2 prospective cohort studies resulted in a total sample size of 26,070 participants. In a random-effect pooled analysis, childhood NE was significantly associated with the development of nocturia (OR: 1.75, 95% CI: 1.11–2.40). Significant heterogeneity (I² = 92.7%, p < 0.01) was identified among the included studies, which was reflected in an asymmetrical funnel plot. NE and nocturia have similar underlying etiologies of hormonal abnormalities, sleep disorders, physiological disorders, and psychological disorders.

Conclusion

The history of childhood NE is significantly associated with nocturia later in life. The data in this meta-analysis support this transition and identify potential similarities between the two disorders. The sparse number of articles relevant to this topic is a strong indicator of the need for more work on this transition from childhood to maturity. More studies are warranted to further explore the association between NE and nocturia.

Best Practices in the Clinical Management of Progressive Supranuclear Palsy and Corticobasal Syndrome: A Consensus Statement of the CurePSP Centers of Care

Progressive supranuclear palsy (PSP) and corticobasal syndrome (CBS; the most common phenotype of corticobasal degeneration) are tauopathies with a relentless course, usually starting in the mid-60s and leading to death after an average of 7 years. There is as yet no specific or disease-modifying treatment. Clinical deficits in PSP are numerous, involve the entire neuraxis, and present as several discrete phenotypes. They center on rigidity, bradykinesia, postural instability, gait freezing, supranuclear ocular motor impairment, dysarthria, dysphagia, incontinence, sleep disorders, frontal cognitive dysfunction, and a variety of behavioral changes. CBS presents with prominent and usually asymmetric dystonia, apraxia, myoclonus, pyramidal signs, and cortical sensory loss. The symptoms and deficits of PSP and CBS are amenable to a variety of treatment strategies but most physicians, including many neurologists, are reluctant to care for patients with these conditions because of unfamiliarity with their multiplicity of interacting symptoms and deficits. CurePSP, the organization devoted to support, research, and education for PSP and CBS, created its CurePSP Centers of Care network in North America in 2017 to improve patient access to clinical expertise and develop collaborations. The directors of the 25 centers have created this consensus document outlining best practices in the management of PSP and CBS. They formed a writing committee for each of 12 sub-topics. A 4-member Steering Committee collated and edited the contributions. The result was returned to the entire cohort of authors for further comments, which were considered for incorporation by the Steering Committee. The authors hope that this publication will serve as a convenient guide for all clinicians caring for patients with PSP and CBS and that it will improve care for patients with these devastating but manageable disorders.

A Subset of Primary Polydipsia, "Dipsogneic Diabetes Insipidus", in Apparently Healthy People Due to Excessive Water Intake: Not Enough Light to Illuminate the Dark Tunnel

Dipsogenic diabetes insipidus (DDI) is a subtype of primary polydipsia (PP), which occurs mostly in healthy people without psychiatric disease. In contrast, PP is characterized by a polyuria polydipsia syndrome (PPS) associated with psychiatric illness. However, the pathogenesis of DDI is not well established and remains unexplored. In order to diagnose DDI, the patient should exhibit excessive thirst as the main symptom, in addition to no history of psychiatric illness, polyuria with low urine osmolality, and intact urine concentrating ability. Treatment options for DDI remain scarce. On this front, there have been two published case reports with successful attempts at treating DDI patients. The noteworthy commonalities in these reports are that the patient was diagnosed with frequent excessive intake of water due to a belief that drinking excess water would have pathologic benefits. It could therefore be hypothesized that the increasing trend of excessive fluid intake in people who are health conscious could also contribute to DDI. Hence, this review provides an overview of the pathophysiology, diagnosis, and treatment, with a special emphasis on habitual polydipsia and DDI.

The role of morphometric and respiratory factors in predicting the severity and evolution of urinary symptoms in patients with obstructive sleep apnea syndrome

OBJECTIVES

To assess the severity, evolution, and behaviour of several urinary symptoms in patients with obstructive sleep apnea syndrome (OSAS) before and after the treatment with continuous positive airway pressure (CPAP).

METHODS

A prospective study was performed on patients with a recent diagnosis of sleep apnea confirmed by nocturnal sleep polygraphy and absence of medical urological past history. The symptom incidence was analysed seeking predictive factors for initial nocturia, nocturnal polyuria (NP), and unfavourable International Prostate Symptoms Score (IPSS) before and after a 1-year period of treatment using a CPAP device. Morphometric variables (body mass index, BMI; neck and abdominal diameter) and functional respiratory variables (FEV1, FVC, and FEV1/FVC) were analysed. A multivariate analysis was performed with a calculation of Pearson's correlation coefficient to establish a linear relation between the variables.

RESULTS

A total of 43 patients completed the two-step study (IPSS and bladder diary before and after the CPAP treatment). IPSS decreased by 3.58 points. Nocturia decreased to once per night. Neck diameter, FEV1, and FEV1/FVC significantly predicted the initial severity of some lower urinary tract symptoms (LUTS), (p=0.015, p=0.029, p=0.008, respectively). Neck diameter, abdominal perimeter, and FEV1/FVC significantly predicted the LUTS evolution throughout the study (p=0.023, p=0.007, p=0.05, respectively).

CONCLUSION

Some pre-treatment morphometry and spirometry parameters such as abdominal or neck diameter, FEV1, and FEV1/FVC were predictive of the severity and evolution of LUTS in patients with OSAS.

ICI-RS 2019 nocturia think tank: How can experimental science guide us in understanding the pathophysiology of nocturia?

INTRODUCTION

The following is a report on the proceedings of the 2019 International Consultation on Incontinence-Research Society nocturia think tank (NTT).

OBJECTIVES

The objectives of the 2019 NTT were as follows: (a) to evaluate the role of urothelium in the pathophysiology of nocturia; (b) to determine whether nocturia is a circadian disorder; (c) to discuss the role of melatonin in nocturia; (d) to consider ambulatory urodynamic monitoring in evaluating patients with nocturia; (e) to explore studies of water handling in human compartments utilizing heavy water; and (f) to explore whether basic science is the key to understanding the treatment options for diminished bladder capacity in patients with nocturia.

METHODS

A compendium of discussions of the role of experimental science in understanding the pathophysiology of nocturia is described herein.

RESULTS AND CONCLUSIONS

Translational science will play an increasing role in understanding the pathophysiology of nocturia, which may result in improved treatment strategies.

A Prospective, Multicenter, Open-Label Study of Dose Escalation Therapy in Male Patients With Nocturia Refractory to 0.2-mg Tamsulosin Monotherapy

Purpose

To investigate the efficacy and safety of 0.4 mg of tamsulosin in patients with nocturia not responding to 0.2 mg.

Methods

Patients with intractable nocturia after treatment with 0.2 mg of tamsulosin for>1 month were included in a multicenter, prospective, observational, single-arm study. Patients were prescribed 0.4 mg of tamsulosin and followed up for 2 months to assess nocturnal voiding and nocturia-related bother. Changes in the mean number of nocturnal voids, the proportion of 50% responders, 3-day frequency-volume chart parameters, and questionnaire scores were assessed.

Results

Sixty-two patients were prescribed 0.2 mg of tamsulosin, of whom 56 were prescribed 0.4 mg of tamsulosin. Ten patients dropped out. A single case of orthostatic hypotension was reported. The mean age was 68 years. After 1 and 2 months of taking 0.4 mg of tamsulosin, 23.9% and 22.7% of patients demonstrated a>50% reduction of nocturia, and 16.1% and 19.4% of patients rated the treatment as “very effective,” respectively. Dose escalation to 0.4 mg of tamsulosin, compared to 0.2 mg, did not show an additional effect on reducing nocturnal urine volume. Multivariate logistic regression analysis showed that lower serum sodium levels (odds ratio [OR], 0.41, P=0.037) and the presence of urge incontinence (OR, 7.08, P=0.036) were predictors of a significant improvement of nocturia in response to 0.4 mg of tamsulosin.

Conclusions

Dose escalation may yield a significant improvement of nocturia in>20% of patients, and may be especially helpful in patients with lower sodium levels and urge incontinence.

Therapeutic efficacy of mirabegron 25 mg monotherapy in patients with nocturia-predominant hypersensitive bladder

OBJECTIVE

The objective of this study was to evaluate the efficacy of mirabegron 25 mg daily in patients with nocturia-predominant hypersensitive bladder (HSB).

MATERIALS AND METHODS

This study prospectively investigated 219 consecutive patients with nocturia-predominant HSB and treated with mirabegron 25 mg daily from July 2015 to 2016. Patient with nocturia episode decreased by ≥1/night after treatment was considered successful. The subjective symptom score, such as International Prostate Symptom Score (IPSS), Quality of life index, Overactive Bladder Symptom Score (OABSS), Urgency Severity Scale, patient perception of bladder condition (PPBC), and nocturia episodes per night, was assessed before and 1 month after mirabegron treatment and between successful and failed groups.

RESULTS

A total of 219 patients, including 51 women and 168 men, were enrolled. The mean age of the population was 72.3 ± 11.0 years. Totally, 58 (26.5%) of the patients had improvement in nocturia at 1 month after treatment. Among them, 14 (27.5%) women and 44 (26.2%) men had improvement in nocturia episodes after treatment (P = 0.858). Compared the clinical data between successful and failed group, the baseline symptom scores were more severe in successful group, including IPSS-storage subscore (4.84 ± 2.09 vs. 4.11 ± 2.19, P = 0.031), OABSS (3.21 ± 0.67 vs. 2.91 ± 1.00, P = 0.037), and nocturia episodes (3.81 ± 0.95 vs. 3.095 ± 1.32, P = 0.000). Multivariate analysis revealed only a higher nocturia episodes (P = 0.046) predict a successful treatment result. Mirabegron 25 mg daily significantly improved PPBC score along the 3 months' follow-up (P < 0.05), and postvoid residual volume did not increase after mirabegron treatment in overall patients.

CONCLUSIONS

Mirabegron 25 mg daily treatment showed a limited therapeutic effect on nocturia-predominant HSB patients. The patients with higher OAB symptoms predict a successful result.

Lower urinary tract symptoms and obstructive sleep apnea syndrome: Urodynamic evolution before and after one year of treatment with continuous positive airway pressure

OBJECTIVE

To report the clinical evolution and the urodynamic behaviour of several lower tract urinary symptoms in patients with obstructive sleep apnea syndrome before and after the treatment with continuous positive airway pressure (CPAP) devices.

METHODS

A prospective study was performed; patients with recent diagnosis of sleep apnea confirmed by nocturnal sleep polygraphy and absence of medical urological past history. In order to discard important lower urinary tract conditions, urological examinations were previously performed. Urinary symptoms were evaluated using the IPSS and OAB-V8 validated questionnaires, three-day Bladder Diary and invasive urodynamic examinations with a gap of one year before and one year after using the CPAP.

RESULTS

84 urodynamic studies were carried out in 43 patients. The IPSS score decreased by 3.58 points. The OAB-V8 score decreased by 2.87 points. Nocturia episodes decreased to one per night. The percentage of patients with nocturnal polyuria went down to 26%. The bladder compliance significantly increased (97.39 vs 200.40ml/cm H2O). The presence of detrusor overactivity decreased from 11 (before CPAP) to 5 patients (after CPAP).

CONCLUSION

The proper treatment with CPAP showed a statistical and clinical improvement of several LUTS with limited urodynamic modifications.

Low and high body mass index values are associated with female nocturia

Aims

We evaluated the relationship between body mass index (BMI), including low BMI, and nocturia in Japanese women.

Methods

We collected data on 18 952 women who participated in a multiphasic health screening in Fukui, Japan, in 2006. The participants were asked to report any current or previous disease. Self‐reported current body weight and height were used to calculate the BMI. We analyzed the relationship between nocturia, as assessed by a questionnaire, and other variables including age, BMI, and comorbidities.

Results

The participants’ mean age was 60.6 years. Overall, the prevalence of nocturia (two or more voids/night) was 4.3% and increased in an age‐dependent manner. BMI did not affect nocturia in the young participants. The prevalence of nocturia was higher in the high‐BMI women (>25.0 kg/m ²) in their fifth and sixth decades, but the prevalence was higher in the low‐BMI (<18.5 kg/m ²) in the women more than 80‐years old. A multivariate analysis revealed a significant association between nocturia and the following: age, BMI, sleep disturbance, arteriosclerosis, cerebrovascular disease, chronic pulmonary disease, diabetes mellitus, and hypertension. Not only high BMI (which is already reported as a risk of nocturia) but also low BMI was a factor related to nocturia.

Conclusion

Our findings indicate that in addition to obesity, low BMI is a factor of nocturia in women.

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.

Nocturia in women

PURPOSE OF REVIEW

Nocturia in women is a notable health concern, associated with significant morbidity and decreases in health-related quality of life. It is implicated in daytime somnolence and poor sleep quality, and has been found to negatively impact household activities, work, exercise, and sexual activity. This review is intended to relay new information regarding the prevalence, cause, risk factors, ramifications, and treatment options for nocturia in women as it gains traction as a clinical entity in and of itself.

RECENT FINDINGS

New literature exposes the prevalence and burden of nocturia among young, healthy nulliparous women; reveals its presence in women without daytime symptoms; suggests its relationship with abnormal bowel function; and supports its association with obesity, cardiac burden and poor sleep. The link between nocturia and menopause has been challenged, and recent nomenclature describing the genitourinary symptoms of menopause excludes it from the list. Desmopressin and tamsulosin trials in women have demonstrated safety and efficacy in limiting nocturia frequency and severity, as well as in improving sleep parameters.

SUMMARY

Nocturia is an impactful health issue at risk of being missed, especially in younger female patients. Open dialogue, purposeful questioning, and screening surveys can help elicit this symptom in women who are embarrassed or who accredit it to normal aging and therefore do not seek medical attention. In light of a growing geriatric population, nocturia is a clinical entity of increasing importance as it can be a clue to underlying systemic disorder or it can be an isolated symptom with significant clinical implications if left unaddressed.

Increased Urine Production Due to Leg Fluid Displacement Reduces Hours of Undisturbed Sleep

OBJECTIVE

To investigate whether or not the leg fluid displacement observed when moving from the standing to recumbent position at bedtime reduces the hours of undisturbed sleep (HUS).

METHODS

Men aged 50 years or older who were hospitalized for urological diseases were investigated. Body water evaluation was performed three times with a bioelectric impedance method: (i) 17:00, (ii) 30 min after (short-term), and (iii) waking up (long-term). A frequency volume chart was used to evaluate the status of nocturnal urine production, and the factors affecting HUS were investigated.

RESULTS

A total of 50 patients (mean age: 68 years) were enrolled. Short-term changes in extracellular fluid (ECF in the legs showed a significant positive correlation with urine production per unit of time at the first nocturnal voiding (UFN/HUS) (r = 0.45, P = 0.01). In the comparison between patients who had <3 HUS vs. those who had ≥3 HUS, the <3 HUS group showed significantly greater short-term changes in leg fluid volume, night-time water intake (17:00-06:00), and UFN/HUS. Multivariate analysis to assess the risk factors for <3 HUS indicated UFN/HUS as a risk factor in the overall model, and short-term changes in leg ECF and night-time water intake as risk factors in the model that only considered factors before sleep.

CONCLUSIONS

Nocturnal leg fluid displacement may increase urine production leading up to first voiding after going to bed, and consequently, induce early awakening after falling asleep.

Treatment Options for Urogenital Dysfunction in Parkinson's Disease

Urogenital dysfunction is commonly reported in Parkinson’s disease (PD), and history taking and a bladder diary form the cornerstone of evaluation. The assessment of lower urinary tract (LUT) symptoms include urinalysis, ultrasonography, and urodynamic studies and help to evaluate concomitant urological pathologies such as benign prostate enlargement. Antimuscarinic medications are the first line treatment for overactive bladder (OAB) symptoms and solifenacin has been specifically studied in PD. Antimuscarininc drugs may exacerbate PD-related constipation and xerostomia, and caution is advised when using these medications in individuals where cognitive impairment is suspected. Desmopressin is effective for the management of nocturnal polyuria which has been reported to be common in PD. Intradetrusor injections of botulinum toxin have been shown to be effective for detrusor overactivity, however, are associated with the risk of urinary retention. Neuromodulation is a promising, minimally invasive treatment for PD-related OAB symptoms. Erectile dysfunction is commonly reported and first line treatments include phosphodiesterase-5 inhibitors. A patient-tailored approach is required for the optimal management of urogenital dysfunction in PD.

Frequent nocturia episodes, a suboptimal response to treatment, and small bladder capacity predict the need for persistent antimuscarinic therapy or re-treatment after discontinuation of antimuscarinics in female overactive bladder

OBJECTIVE

The aim of the study was to investigate predictive factors of the need for persistent antimuscarinic therapy or re-treatment (PR) after discontinuation of antimuscarinic therapy for women with overactive bladder syndrome (OAB).

METHODS

All consecutive OAB women were enrolled in a prospective cohort study, and treated with solifenacin for 12 weeks in a University Hospital. Factors affecting PR were analyzed by Cox regression analysis.

RESULTS

A total of 122 women were enrolled, and 107 women underwent 12-week solifenacin treatment. The dropout rate was 12.3%. The median follow-up period was 20.4 weeks (25-75 interquartile range: 16-102.3 wk). Twenty-seven (25%) women had PR. The median PR-free interval was 125.4 weeks (95% CI = 58.4 to - wk). Nocturia episodes (hazard ratio = 1.54), a suboptimal response (hazard ratio = 2.53), and the strong-desire volume (hazard ratio = 0.992) were independent predictors of PR by Cox backward stepwise regression analysis. The areas under the receiver-operating characteristic curves for nocturia episodes, a suboptimal response, and the strong-desire volume to predict PR were only 0.65, 0.63, and 0.59, respectively. In addition, normalized urinary nerve growth factor level was not significant (hazard ratio = 1.005, P = 0.68) for predicting PR. Furthermore, normalized urodynamic findings did not correlate with PR, a suboptimal response, or changes of Overactive Bladder Symptom Score and urinary nerve growth factor level.

CONCLUSIONS

Frequent nocturia episodes, a suboptimal response, and small bladder capacity may predict PR after solifenacin treatment. These findings may serve as an initial guide in consultation regarding the treatment of OAB.

Nocturia in Parkinson's Disease: Why Does It Occur and How to Manage?

BACKGROUND

Nocturia is one of the commonest nonmotor symptoms in Parkinson's disease (PD) and has a significant impact on quality of life both for patients and their carers. There exists a relation between nocturia and poor sleep quality, falls, and institutionalization. Nocturia may manifest as a result of reduced functional bladder capacity or nocturnal polyuria; however, most often the cause is multifactorial. Disorders of circadian rhythm regulation are known to occur with sleep disturbances in PD may also contribute to nocturia.

METHODS AND RESULTS

In this review, an overview of the assessment and management of nocturia in patients with PD is presented. History taking, medication review, and a bladder diary form the cornerstone of the evaluation. Urinalysis, ultrasonography, and urodynamic studies help to assess the cause for lower urinary tract symptoms and exclude concomitant pathologies, such as bladder outlet obstruction. Antimuscarinic medications are the first-line treatment for the overactive bladder; however, caution is needed when using these medications in individuals predisposed to cognitive impairment. Desmopressin is effective for managing nocturnal polyuria.

CONCLUSIONS

An individualized approach is recommended to optimize the management of nocturia in PD.

Effects of Melatonin and Rilmazafone on Nocturia in the Elderly

We compared the effects of melatonin, an antioxidant and sleep inducer in humans, and rilmazafone hydrochloride, a hypnotic, in elderly patients with nocturia. Patients received either melatonin (2 mg/day; n = 20) or rilmazafone (2 mg/day; n = 22) for 4 weeks. There were no significant differences in the mean age, the quality of life (QoL) score and the serum melatonin levels between the two groups at baseline. After 4 weeks' treatment, the number of nocturnal urinations was significantly decreased and the QoL score was significantly improved in both groups. There was no significant difference between the patient-reported effectiveness ratings between the two groups. The serum melatonin level was significantly increased in the melatonin-treated group, but it remained unchanged in the rilmazafone-treated group. Melatonin and rilmazafone were equally effective for nocturia in the elderly. We recommend that the problems of sleep disturbance should be considered when choosing a therapy for nocturia.

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.

Efficacy of Desmopressin to Treat Nocturnal Polyuria in Elderly Men: Effects on Sleep Quality

BACKGROUND

We investigated the efficacy of desmopressin in elderly patients with nocturnal polyuria (NP) to evaluate its effects on sleep quality.

METHODS

Patients with NP (defined as the nighttime urine production >33% of total 24-hour urine volume determined from a frequency-volume chart) were recruited. Desmopressin (0.2 mg) was treated orally at bedtime for 12 weeks. The participants completed the Medical Outcomes Study (MOS) Sleep Scale.

RESULTS

The mean patient age was 62.7 ± 13.0 (range 42-78 years). The mean symptom duration was 42.2 ± 39.7 months. The number of nocturia episodes (from 3.49 ± 1.83 to 2.03 ± 1.35, p = 0.01), nocturnal urine volume (p = 0.01), NP index (p = 0.01), and nocturia index (p = 0.01) decreased significantly after treatment with desmopressin. Among the MOS Sleep Scale categories, hours slept/night (p = 0.042), shortness of breath (p = 0.019), and adequacy of sleep (p = 0.001) changed significantly with a decrease in the number of nocturia episodes. Adverse events were mild.

CONCLUSIONS

Desmopressin is an effective treatment for NP and improved sleep quality in elderly men.

Desmopressin in adult urological disease: clinical evidences

Desmopressin is a synthetic analogue of arginine vasopressin, commercially available since 1974. Desmopressin is proven effective for the treatment primary nocturnal enuresis and polyuria. It has been considered by several investigators for the treatment of nocturia with positive results and is now an established treatment for this indication. In this review, we assessed the available clinical data on desmopressin in adult urological disease.

Determinants of nocturia severity in men, derived from frequency-volume charts

OBJECTIVE

Nocturia may be characterized by indices derived from the frequency-volume chart (FVC). The objective of this study was to determine how these parameters relate to the severity of nocturia in men with and without lower urinary tract symptoms (LUTS).

MATERIALS AND METHODS

A retrospective analysis of FVCs was performed in two cohorts of men: those presenting with LUTS in a New York ambulatory urology clinic and those from the longitudinal population-based Krimpen study. Nocturnal urine volume (NUV), nocturia index (Ni), nocturnal polyuria index (NPi), nocturnal maximal voided volume (nMVV) and sleep duration were derived from FVCs. Comparisons were made using Spearman's rank correlation coefficient between actual number of nightly voids (ANV) and the other diary parameters.

RESULTS

Eighty-eight consecutive men who presented with LUTS completed a 24 h FVC [median age 70 years, interquartile range (IQR) 64.5-74.5, median ANV 2, IQR 1.5-4]. Nocturnal voiding frequency and volume were analyzed in 1082 community-dwelling men (median age 61 years, IQR 56.1-66.4, range 49.4-78.2; median ANV 1.5, IQR 1.0-2.0, range 0-4.5). Both cohorts demonstrated strong correlations between nocturia severity (represented as ANV) and Ni (0.797, 0.658 for cohorts 1 and 2, respectively). There were moderate correlations between nocturia severity and NPi (0.545, 0.394), NUV (0.463, 0.432) and sleep duration (0.306, 0.272). The nMVV correlated poorly with nocturia severity (0.159, 0.146).

CONCLUSIONS

Treatment of nocturia should aim to match nocturnal urine production with bladder capacity. Given the lack of known effective pharmacotherapy for low bladder volume, the first attempt nocturia treatment could focus on volume reduction.

Add-on anticholinergic therapy for residual nocturia in patients with lower urinary tract symptoms receiving α1-blocker treatment: a multi-centre, prospective, randomised study

PURPOSE

To evaluate the efficacy and safety of imidafenacin (IM), a novel short half-life anticholinergic, as add-on therapy for male LUTS with nocturia and nocturnal polyuria.

MATERIALS AND METHODS

This multicenter, prospective, randomized, open-labelled study was conducted and involved men who had frequency, urgency, and nocturia despite receiving a stable dose of α1-blocker for ≥1 month. Subjects were randomised to control (α1-blocker alone), IM twice/day (α1-blocker +0.1 mg imidafenacin twice daily), or IM nightly (α1-blocker plus 0.1 mg imidafenacin nightly) group; the treatment period was 8 weeks. Primary endpoints included improvements in night-time frequency and Nocturia Quality of Life Questionnaire (N-QOL) scores. Secondary endpoints included changes from the baseline in frequency volume chart variables, and post-void residual volume.

RESULTS AND LIMITATIONS

Compared with the controls, IM twice/day and IM nightly patients had a significantly lower night-time frequency (changes from baseline: 0.1 ± 0.8 in control, -0.6 ± 0.9 in IM twice/day, and -0.4 ± 1.0 in IM nightly, p = 0.5227, 0.0006 and 0.0143, respectively). The hours of undisturbed sleep and N-QOL score were significantly improved in IM twice/day group, though not IM nightly group. Nocturnal urine volume was significantly reduced in IM nightly group, although total urine volume remained unchanged.

CONCLUSIONS

A short half-life anticholinergic is suggested to be safe and effective as an add-on therapy for residual nocturia in patients with male LUTS receiving α1-blocker treatment. Anticholinergic administration nightly could reduce the nocturnal urine volume.

Guidance on water intake effectively improves urinary frequency in patients with nocturia

OBJECTIVES

To evaluate how guidance on water-intake impacts the degree of nocturia.

METHODS

A total of 67 male patients were enrolled in the present study. Patients were asked to adjust their water and food intakes so that their 24-h urine production/bodyweight would be equal or lower than 30 mL/kg. One month after the treatment, the therapeutic gain from and adverse effects of fluid restriction were examined by comparing the pretreatment and post-treatment value of various parameters.

RESULTS

Overall, 65 eligible patients were evaluated. In 44 patients (67%), the frequency of nocturia was improved to one or more times. The change in frequency of nocturia showed a positive correlation with the change in nocturnal urine volume. The change in nocturnal urine volume showed a positive correlation with the changes in 24-h urine production/bodyweight, 24-h drinking volume and daytime drinking volume. The changes in 24-h urine production/bodyweight and daytime drinking volume were independent factors influencing therapeutic effect. None of the participants reported any adverse event.

CONCLUSIONS

In patients with a 24-h urine production/bodyweight equal or higher than 30 mL/kg, guidance on water intake might be considered effective and safe as a lifestyle therapy. Water restriction should be carried out not only in the evening, but also during daytime.

Rhazes, a genius physician in the diagnosis and treatment of nocturnal enuresis in medical history

Context

Nocturnal enuresis has undoubtedly occurred since man's earliest days and the first references are found in the Ebers papyri of 1550 BC. The purpose of this study is to review of Rhazes opinion about diagnosis and treatment of nocturnal enuresis and compare his belief and clinical methods with modern medical practice.

Evidence Acquisition

In the review study we searched all available and reliable electronic and paper sources using appropriate keywords about the views of Rhazes, and compared them with recent medical evidence about diagnosis and treatment of nocturnal in medication.

Results

Our findings proved that Rhazes described the symptoms, signs, and the treatment of nocturnal enuresis in accordance with contemporary medicine.

Conclusions

A review of opinion Rhazes and other ancient Islamic medical textbooks on nocturnal enuresis reveals that medical practice in those days was comparable to modern medicine yet avoiding the side effects that are commonly experienced with the modern medical approach.

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

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

Antidiuretic effect of antimuscarinic agents in rat model depends on C-fibre afferent nerves in the bladder

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Antichollnergic agents are anticipated to diminish storage symptoms, as well as nocturia. Nevertheless, the effect of this treatment on polyuria related to nocturia is not clear. By subgroup analysis of the data set from a phase III clinical trial of antimuscarinic agent for OAB patients in Japan, imidafenacin was found to improve nocturia with a reduction in nocturnal polyuria. This study adds the effects and underlying mechanism of antimuscarinic agents decreasing urine production through inhibition of C-fibre in the bladder of water-leaded rats.

OBJECTIVE

To evaluate the effects and underlying mechanisms of antimuscarinic agents used to decrease in urine production in water-loaded rats.

SUBJECTS AND METHODS

Urine production was measured using a cystostomy catheter in female Sprague-Dawley rats every 2 h. The effect of the antimuscarinic agents atropine, tolterodine and imidafenacin on urine production was investigated under water-loaded conditions, which were induced by i.p. injection of 15 mL saline. Blood samples were collected to determine the levels of antidiuretic hormone (ADH), aldosterone (ALD), atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) before, and 2 and 8 h after, antimuscarinic agent administration. To induce desensitization of C-fibre afferent nerves, resiniferatoxin (RTX)was injected s.c. or intravesically 2 days before experiments.

RESULTS

Urine production increased and reached its maximum 2 h after 15 mL saline injection. Imidafenacin and tolterodine decreased urine production in water-loaded rats, but ADH, ALD, ANP and BNP levels were not different between imidafenacin-treated and vehicle-treated rats. The inhibitory effect on urine production was not found in RTX-treated rats. Atropine did not reduce urine production.

CONCLUSION

These results suggest that antimuscarinic agents decrease urine volume through C-fibres in the bladder; thus, antimuscarinics with inhibitory effects on C-fibres could be beneficial for nocturia with nocturnal polyuria.

A parallel, randomized, double-blind, placebo-controlled study to investigate the effect of SagaPro on nocturia in men

Objective.

This study aimed to investigate the effect of SagaPro, a product derived from Angelica archangelica leaf, on nocturia.

Material and methods.

Sixty-nine male patients 45 years or older with at least two nocturnal voids were randomized to receive SagaPro or placebo in a double-blind design for 8 weeks. Voiding diaries were assessed before and after the treatment.

Results.

The results indicate that SagaPro is safe. The actual number of nocturnal voids (ANV), nocturnal polyuria index (NPi) and nocturnal bladder capacity index (NBC index) decreased in the test population, but there was no significant difference between the treatment groups. Subsequent subgroup analysis showed that SagaPro significantly reduced the NBC index and nocturnal voids per sleeping hour in comparison to the placebo in participants with baseline NBC index above 1.3. When participants with sleep disorders were excluded from this group, ANV was also significantly reduced for the SagaPro group in comparison to the placebo group.

Conclusion.

SagaPro, made from an extract of the medicinal herb Angelica archangelica, is safe. This study did not show that SagaPro improved nocturia overall compared to placebo. Subgroup analysis suggested a beneficial effect in individuals with decreased nocturnal bladder capacity, which warrants further study.

Fluid intake and voiding parameters in asymptomatic Turkish women

INTRODUCTION AND HYPOTHESIS

For an accurate evaluation of bladder diaries, we aim to investigate normal urinary habits and determining factors on functional bladder capacity, frequency, and 24-h volume in the bladder diaries of asymptomatic women.

METHODS

One-hundred and fifteen asymptomatic women who recorded a 24-h bladder diary were included in the study. Linear regression analyses were used to explore associations between diary values and patient characteristics.

RESULTS

Total number of voids was related to age, body mass index, total voided volume, total fluid intake, total diuresis rate, and maximum fluid intake in one go. Maximum, average, and minimum volumes per void were found to be related to body mass index, total voided volume, total fluid intake, total diuresis rate, and maximum fluid intake. When we used multiple regression analysis, only maximum fluid intake was found to be related to the total number of voids, maximum, average, and minimum volumes per void.

CONCLUSIONS

Maximum fluid intake rather than total voided volume seems to be an important determinant factor for total number of voids and functional bladder capacity.

Nocturia: new directions

The Nocturia Think Tank (TT) met during the 2010 meeting of the International Consultation on Incontinence-Research Society to discuss present knowledge and future directions in care and research of this prominent component of the spectrum of lower urinary tract symptoms. Questions raised included whether nocturia should be re-defined as a function of its bother, effects on quality of life, and economic impact upon society. At issue is the need to delineate the determinants of successful nocturia management. The multifactorial nature of nocturia requires that progress in its treatment will be dependent upon the cooperative investigation on the part of urologists, urogynecologists, geriatricians, epidemiologists, medical economists and pharma. Areas for future avenues of research were outlined at the conclusion of the meeting.

Nocturia in women

Nocturia is a common problem in adults, which adversely affects quality of sleep and quality of life. This review summarizes the definition, epidemiology, clinical presentation, pathophysiology, diagnostic evaluation, and the therapeutic options with regard to a female population. Based on the degree of bother nocturia is classified as two or more episodes per night. It is most prevalent in older woman but also affects younger individuals. Voiding during nighttime leads to a disruption of sleep, affecting both sleep onset and maintenance. A clear understanding of its underlying pathophysiology, including diurnal polyuria, nocturnal polyuria, and bladder storage problems is necessary to address symptoms and co-morbid conditions. Diagnostic evaluation includes a detailed patient's history, physical examination, laboratory tests, and a voiding bladder diary. For treatment, tailored lifestyle and behavioural changes are able to decrease bother. In addition some patients profit from pharmacological therapy with antimuscarinic agents and analogue of arginine vasopressin, however this strategy is often restricted by side effects.

Impact of nocturia on health-related quality of life and medical outcomes study sleep score in men

Purpose

To evaluate the impact of nocturia on health-related quality of life and sleep in men.

Methods

From January 2008 to December 2008, 284 patients with lower urinary tract symptoms were selected for this study. The participants completed a series of questionnaires on health-related quality of life (the overactive bladder questionnaire, or OAB-q), the Medical Outcomes Study (MOS) sleep scale, and the frequency volume chart.

Results

The patient population had a mean age of 60.0±13.4 years (range, 40 to 79 years). The mean duration of symptoms was 28.8±34.6 months. The mean number of voiding episodes per night was measured as follows: 88 patients (31.0%) reported no nocturia, 60 patients (21.1%) reported 2>voids/night ≥1, 56 patients (19.7%) reported 3>voids/night ≥2, and 80 patients (28.2%) reported ≥3 voids/night. The mean number of nocturia episodes increased with age (P=0.001), and the number of nocturia episodes was significantly associated with the OAB-q symptom score (P=0.001) and symptom bother (P=0.001). Among the categories of the MOS sleep scale, sleep index I (P=0.020), sleep disturbance (P=0.010), adequacy of sleep (P=0.005), and somnolence (P=0.041) were significantly associated with an increased number of nocturia episodes.

Conclusions

The number of nocturia episodes increased with age in men. Nocturia appeared to be associated with further negative effects on sleep quality, health-related quality of life, and symptom bother.

Urinary incontinence in the aging female: etiology, pathophysiology and treatment options

Not only does the prevalence of incontinence increase with age, but the incidence does as well, in no small part due to the greater recognition of its signs and symptoms and the significant negative impact on quality of life. Elderly women differ from their younger counterparts by the presence of several physiologic changes in the urinary tract, as well as the presence of concomitant morbidity and polypharmacy. While the elderly have the same treatment options as younger women, they may experience a greater incidence of adverse events due to urologic and nonurologic factors. The objective of this article is to elucidate the unique changes in the elderly population and summarize the treatment options.

Prevalence and risk factors of nocturia and nocturia-related quality of life in the Chinese population

OBJECTIVES

To evaluate the prevalence, risk factors of nocturia and nocturia-related quality of life.

METHODS

Age, hypertension, cardiovascular disease, diabetes mellitus, benign prostatic hyperplasia (BPH), alcohol abuse and smoking were analyzed using logistic analysis. Multiple linear-regression analysis was used to identify factors predicting the score on the Nocturia Quality of Life (N-QOL) questionnaire.

RESULTS

1,198 adults completed this study. 411 individuals (34.3%) answered that they arose for urination at least twice during the night. The incidence of nocturia increased with age from 8.6% in individuals younger than 40 to 67.7% in those older than 70. Hypertension [odds ratio (OR) 2.322; 95% confidence interval (95% CI): 1.387-3.887] and diabetes (OR 2.298; 95% CI: 1.066-4.954) were possible risk factors for nocturia. In male individuals, BPH (OR 3.900; 95% CI: 1.890-8.049) was another risk factor. Gender was not found to be associated with nocturia. Increasing episodes of nocturia (regression coefficient: -2.564; 95% CI: -3.08 to -2.049) and decreasing total sleeping hours (regression coefficient: 1.738; 95% CI: 0.948-2.527) were independent factors predicting a significantly lower N-QOL score.

CONCLUSIONS

Hypertension, diabetes and BPH are associated with nocturia, suggesting that multiple approaches are needed when treating patients with nocturia. Nocturia has a significant impact on the nocturia-related quality of life when the patient has 2 or more episodes per night.

Age related change of nocturia in women

Purpose

The precise etiology and classification of nocturia in women is not enough. We evaluated age related changes and classified the type of nocturia by age in women.

Methods

We included 118 women 20 years or older with nocturia at least one time during night time. Subjects were divided into three groups by the age: group 1, under 40 years; group 2, 40 through 59 years; group 3, 60 years and above. The causes of nocturia and its pattern changed by age in women were evaluated using 3 days frequency volume chart. Nocturia was devided into three types: nocturnal polyuria, decreased nocturnal bladder capacity and mixed type.

Results

The mean age was 57.2±11.8 and the mean nocturnal frequency was 2.7±1.8. In all age group, noctural polyuria was the major cause for noturia (40.8%), followed by low nocturnal bladder capacity (23.7%). As a major cause of nocturia, there was a significant increase of the incidence of nocturnal polyuria in aged people: group 1, 32.4%; group 2, 41.0%; group 3: 47.6% (P<0.04).

Conclusions

Nocturnal polyuria and decreased nocturnal bladder capacity are the major causes of nocturia in women. Nocturnal polyuria was the major cause of nocturia with age over 60 years old. In aged women, nocturnal polyuria should be considered as a main cuase of nocturia and treated based on these result.

Short term effect and safety of antidiuretic hormone in the patients with nocturia

PURPOSE

To investigate the short-term safety of antidiuretic hormone in elderly patients with nocturnal polyuria, focus on hyponatremia and others electrolytes disturbances and to assess short-term effects on nocturnal urine output and number of nocturnal voids.

METHODS

Between June 2005 and August 2006, a total of 34 patients with nocturnal polyuria were orally administered 0.2 mg desmopressin tablet at bedtime for two weeks. Serum sodium, others electrolytes, urine sodium and urine osmolarity were assessed in the third days, one week and two weeks after treatment with desmopressin and compared adult group (<65 years of age) with elderly group (≥65 years of age). We assessed the effect of desmopressin using a frequency-volume charts and analysed.

RESULTS

In total 34 patients (20 adult, 14 elderly) were analyzed. Desmopressin treatment did not significantly change serum and urine electrolytes include soduim concentration in elderly patients comparied with adult patients. Serum sodium concentration below normal range was recorded in 2 patients in elderly group, but no serious adverse events occurred and recovered without sequelae. The mean number of nocturnal voids decresed (54% reduction) and nocturnal urine output decreased (57% reduction) after using desmopressin.

CONCLUSIONS

Desmopressin was well tolerated and effective in elderly patients with nocturnal polyuria without clinically significant hyponatremia.