Conservative treatment for leg oedema and the effect on nocturnal polyuria in patients with spinal cord injury

Nocturia in Menopausal Women: The Link Between Two Common Problems of the Middle Age

INTRODUCTION AND HYPOTHESIS

The aim of this review is to discuss the link between menopause and nocturia and to give an overview of the increasing prevalence, risk factors, causative factors, treatment needs and options for nocturia in peri-menopausal women.

METHODS

This opinion article is a narrative review based on the expertise and consensus of a variety of key opinion leaders, in combination with an extensive literature review. This literature search included a thorough analysis of potential publications on both the PubMed Database and the Web of Science and was conducted between November 2022 and December 2022. The following key words were used "nocturia" and "menopause" or "nocturnal frequency and menopause." Moreover, key words including "incidence," "prevalence," "insomnia," "estrogen therapy," "metabolic syndrome," and "hot flushes" were used in combination with the aforementioned key words. Last, the reference lists of articles obtained were screened for other relevant literature.

RESULTS

The perimenopause can be a trigger for inducing nocturia. Typically, obesity, body mass index (BMI), and waist circumference are risk factors for developing peri-menopausal nocturia. Presumably the development of peri-menopausal nocturia is multifactorial, with interplay among bladder, sleep, and kidney problems due to estrogen depletion after the menopause. First, impaired stimulation of estrogen receptors in the urogenital region leads to vaginal atrophy and reduced bladder capacity. Moreover, menopause is associated with an increased incidence of overactive bladder syndrome. Second, estrogen deficiency can induce salt and water diuresis through blunted circadian rhythms for the secretion of antidiuretic hormone and the activation of the renin-angiotensin-aldosterone system. Additionally, an increased incidence of sleep disorders, including vasomotor symptoms and obstructive sleep apnea signs, is observed. Oral dryness and a consequent higher fluid intake are common peri-menopausal symptoms. Higher insulin resistance and a higher risk of cardiovascular diseases may provoke nocturia. Given the impact of nocturia on general health and quality of life, bothersome nocturia should be treated. Initially, behavioral therapy should be advised. If these modifications are inadequate, specific treatment should be proposed. Systemic hormone replacement is found to have a beneficial effect on nocturia, without influencing sodium and water clearance in patients with nocturnal polyuria. It is presumed that the improvement in nocturia from hormonal treatment is due to an improvement in sleep disorders.

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

OBJECTIVE

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

DESIGN

A cross-sectional study.

SETTING

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

PARTICIPANTS

40 patients with SCI.

OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

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Key Words

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

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MESH Headings

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

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Affiliation(s)

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

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Nocturnal bladder emptying and Quality of Life in patients with spinal cord injury

BACKGROUND

Little is known about the relationship between sleep disruption due to nocturnal bladder emptying and Quality of Life in patients with spinal cord injury.

AIM

The aim of this study was to evaluate the possible influence of number of nocturnal bladder emptying, bladder emptying method and nocturnal incontinence on the Quality of Life of patients with spinal cord injury.

DESIGN

The design of this paper is a cross-sectional descriptive study.

SETTING

The setting is in- and outpatient.

POPULATION

Seventy-nine patients aged between 18 and 77 years with SCI in a first rehabilitation period or follow-up.

METHODS

Patients were asked to complete Short Form-36 and Incontinence Quality of Life questionnaires and a medical information form. Independent samples t-tests and ANOVA were used to compare scores between groups.

RESULTS

The response rate was 71 out of 79 (89%; 51 males and 20 females). 16 paraplegic and 4 tetraplegic patients were chronic, 29 paraplegic and 22 tetraplegic patients were in rehabilitation therapy or had finished this treatment recently. The paraplegic group had a significantly better Short Form-36 total score and emotional function score, while the tetraplegic group had a significantly better Incontinence Quality of Life total score and avoidance and limiting behavior score. The paraplegic patients with 0-1 nocturnal bladder emptying had better Short Form-36-derived Quality of Life than those with ≥2 emptying. Quality of Life score was not associated with gender, leg oedema, incontinence, or acute/chronic group. Incontinence Quality of Life score was significantly better for patients with incomplete spinal cord injury. Fully completed questionnaires were returned by 36 patients; at least 1 item was missing for 35 participants.

CONCLUSIONS

General Short Form-36-derived Quality of Life was better for the paraplegic population. Incontinence-related Quality of Life was better in tetraplegic patients, most of whom used suprapubic catheterization. Paraplegic patients had compromised sleep and Quality of Life when the patient had to wake up two or more times at night to empty the bladder by voiding or intermittent catheterization. The high number of incomplete responders indicates the shortcomings of Quality-of-Life questionnaires for wheelchair-bound patients with spinal cord injury.

CLINICAL REHABILITATION IMPACT

The use of suprapubic catheterization should be considered to improve Quality of Life for tetraplegic patients. For paraplegic patients, we must focus urological policy on aiming to reduce the number of nighttime bladder emptying to one or none.

Observing the water handling in humans to resolve the role of the interstitium: preliminary results of the usability of deuterium oxide and bio-impedance analysis - a pilot analysis

The aim of this research was to evaluate the relevance of using deuterium oxide (²H₂O) and bio-impedance analysis (BIA) to assess size and function of the interstitium for urological research. Nineteen volunteers were recruited to this prospective trial combining ingestion of ²H₂O and BIA. Blood samples were obtained every 10 min after ingestion of ²H₂O. Urine was collected before and after the experiment. BIA was performed every 5 min. Body position was alternated to study the effect on fluid distribution. First order kinetics were assumed for the uptake of ²H₂O from the gastrointestinal tract to the blood. Sex seemed to have an influence with a significantly slower exchange for women (p = 0.041, men: 0.052 min^-1, women: 0.038 min^-1). Impedance measured in legs (men: p = 0.012, women: p = 0.008) and trunk (both p < 0.001) decreased significantly with posture change. These changes probably reflect the orthostatic redistribution of fluid with an increase of fluid in both trunk and legs. Both methods were tested and found to be useful for further urological research. Significant gender differences in ²H₂O uptake dynamics from the gastrointestinal pool were observed. An impact of posture changes on the electrical impedance measured was observed.

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.

Managing Nocturia in Frail Older Adults

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

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

CONTEXT

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

OBJECTIVE

To systematically review the literature about nocturia in neurological patients.

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

PATIENT SUMMARY

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

Activity-Based Training Reverses Spinal Cord Injury-Induced Changes in Kidney Receptor Densities and Membrane Proteins

Complications in upper and lower urinary function arise after spinal cord injury (SCI), which creates a significant impact on quality of life for those affected. One upper urinary complication is SCI-induced polyuria, or the overproduction of urine, of which the underlying mechanisms have yet to be elucidated. Activity-based training (ABT) has been utilized in both animal and clinical settings as a rehabilitative therapy to improve many issues that arise after SCI, including more recently urogenital function. The goal of the current study was to identify potential mechanisms contributing to previously identified improvements in polyuria with ABT, using a male rat moderate-severe spinal contusion model. Although ABT had no significant effect on reversing injury-induced alterations of serum arginine vasopressin and urinary atrial natriuretic peptide levels, there was a dramatic effect upon the receptors of these fluid balance hormones (vasopressin receptor 2 and natriuretic peptide A receptor), as well as kidney aquaporin 2 and sodium channels. ABT changes in densities of key receptors and kidney membrane proteins involved in fluid balance after chronic SCI support the likelihood of multiple mechanisms through which exercise can positively influence urinary tract function after SCI. By understanding the mechanisms, amount, and timing regarding how ABT improves different aspects of urinary function, more targeted training strategies can be developed to optimize the functional gains within the SCI population.