Pathophysiology of nocturnal lower urinary tract symptoms in older patients with urinary incontinence

Polo-like kinase 1 inhibition modulates urinary tract smooth muscle contraction and bladder cell transcriptional programs

The serine/threonine kinase polo-like kinase 1 (PLK1) is a master regulator of cell proliferation and contraction, but its physiological role in the lower urinary tract is unknown. We utilized transcriptomic programs of human bladder smooth muscle cells (hBSMCs), 3D bladder spheroid viability assays, and human ureterovesical junction contractility measurements to elucidate the impacts of PLK1 inhibition. This work reveals PLK1 reduction with the selective inhibitor TAK-960 (500 nM) suppresses high K+-evoked contractions of human urinary smooth muscle ex vivo while decreasing urothelial cell viability. Transcriptomic analysis of hBSMCs treated with TAK-960 shows modulation of cell cycle and contraction pathways, specifically through altered expression of Cys2/His2-type zinc finger transcription factors. In bladder spheroids, PLK1 inhibition also suppresses smooth muscle contraction protein filamin. Taken together, these findings establish PLK1 is a critical governor of urinary smooth muscle contraction and urothelial proliferation with implications for lower urinary tract disorders. Targeting PLK1 pharmacologically may therefore offer therapeutic potential to ameliorate hypercontractility and aberrant growth. Further elucidation of PLK1 signaling networks promises new insights into pathogenesis and much needed treatment advances for debilitating urinary symptoms.

The role of renal circadian biorhythms in lifelong LUTS

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Determinants of Bladder Care at Night in a Subacute Ward for Aged Patients: An Observational Study

PURPOSE

The purpose of this study was to evaluate how bladder care at night correlates to patients' mobility status.

DESIGN

This was an observational study.

SUBJECTS AND SETTING

The sample comprises 63 aged care subacute patients who were observed over 3 consecutive nights in an inpatient subacute aged care ward located in Melbourne, Australia. Half of the participants were female; their mean age was 82.0 (standard deviation 8.2) years. Data were collected from December 2020 to March 2021.

METHODS

Outcome variables included demographic and pertinent clinical characteristics, type and timing of toileting and/or bladder care provided, and mobility classification. Descriptive statistics were used to summarize the frequency of nocturnal bladder care provided each night and as a mean over the 3 nights. The relationship between the type of care units provided and other variables was explored using a 1-way analysis of variance; values ≤.05 were deemed statistically significant.

RESULTS

Findings indicate that 27% (n = 17), 41% (n = 26), and 48% (n = 30) of participants required assistance to move in bed, sit up in bed, and stand from sitting, respectively. Care episodes for both incontinence and assistance with voiding were significantly associated with functional mobility in bed ( F = 5.52, P < .001; F = 2.14, P = .02) and with ambulation independence ( F = 3.52, P = .001; F = 2.04, P = .03) but not with age or ambulation distance.

CONCLUSIONS

Care provided for urinary incontinence during the night was related to the need for physical support of ambulation and poor mobility in bed. Targeted input from a multidisciplinary team is warranted to facilitate change of practice at night.

Nocturnal polyuria in women: results from the EpiNP study

INTRODUCTION AND HYPOTHESIS

Data from a large US population-based, cross-sectional, epidemiological study (the EpiNP Study) were used to assess the symptoms and bother experienced by women with nocturnal polyuria (NP).

METHODS

Consenting participants recruited from an online panel completed the baseline EpiNP survey online (Lower Urinary Tract Symptoms Tool and urological comorbidities). All reporting ≥2 voids/night and a random sample of 100 respondents, each reporting 0 or 1 void/night were asked to complete a 3-day web-based bladder diary recording time, volume, and urgency rating of each void. NP was calculated by the proportion of urine production that occurred during nocturnal hours using a Nocturnal Polyuria Index (NPI33) threshold of >0.33 or nocturnal urine production of >90 ml/h (NUP90). The frequency of participants reporting LUTS and bother was determined by age and NP: idiopathic NP, NP associated with overactive bladder (NPOAB), NP associated with comorbidities (NPCom), and no NP (did not meet NP criteria).

RESULTS

A total of 5,290 women completed the baseline survey. Mean age (range) was 54.9 (30-95) years; 1,841 (34.8%) reported ≥2 nocturnal voids. The prevalence of LUTS increased across the lifespan; however, bother associated with each LUTS decreased with increasing age. The percentage of women rating bother by nocturia episodes ≥2 "> somewhat" ranged from 40.3% to 68.3%, with bother ratings highest in the NPOAB and No NP groups.

CONCLUSIONS

NP is prevalent in women with considerable bother and is often associated with other urinary symptoms. Multifactorial causes and potential treatments of NP should be considered, particularly at a later age.

The impact of movement, physical activity and position on urine production: A pilot study

BACKGROUND

Many different internal factors have been proven to influence urine production such as age, weight, and quality of sleep. External factors such as consumption of caffeine and fluid consumption have been shown to have an impact on urine production.

AIM

To investigate the impact of movement, physical activity and position on urine production.

METHODS

This prospective observational study was executed at Ghent University Hospital, Belgium. Study participation was open for anyone visiting the hospital. Participants collected one basic and two extended 24-hour urine collections and filled in questionnaires concerning their general health and physical activity. Urinary levels of osmolality, sodium and creatinine were determined. Data on movement, physical activity and position was described.

RESULTS

An increase in body movement leads to a significant increase in diuresis during daytime, night-time, and 24 hours (P = .002, P < .001, and P < .001, respectively). An increase in body movement leads to a significant decrease in osmolality during night-time and 24 hours (P = .009, and P = .004, respectively). However, no significant influence of movement on osmolality was found during daytime (P = .12). An increase in body movement leads to a significant decrease in creatinine during daytime, night-time and 24 hours (P = .001, <0.001, and P < .001, respectively). An increase in body movement leads to a significant increase in sodium during daytime (P = .046) but this was statistically significant during night-time and 24 hours (P = .32, and P = .84 respectively).

CONCLUSION

Our study demonstrates a statistically significant association of movement, physical activity, and position with urine production. It would therefore be interesting to explore this association further with the use of new technology to have more accurate data. Here, lays a potential role for conservative measurements and lifestyle adaptations in the management of patients with bothersome LUTS and more precisely nocturia.

Urgency urinary incontinence, loss of independence, and increased mortality in older adults: A cohort study

Objectives

To investigate the longitudinal association of urgency urinary incontinence (UUI) with loss of independence (LOI) or death among independent community-dwelling older adults.

Design

Population-based cohort study.

Setting

The Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS), Minami-Aizu Town and Tadami Town, Fukushima, Japan.

Participants

A total of 1,580 participants aged ≥65 years who underwent a health check-up conducted by LOHAS in 2010.

Measurements

Exposure was defined as the presence of UUI, which was measured by a questionnaire based on the definition of UUI from the International Continence Society. The primary outcome was defined as incidence of LOI or death. After the check-up in 2010, the outcome was monitored until March 2014. A multivariable Cox proportional hazard analysis was performed to estimate the hazard ratio for the outcome. Ten potential confounders were adjusted in the analysis. Furthermore, we defined the secondary outcomes as two separate outcomes, LOI and death, and performed the same analysis.

Results

Among all participants, 328 reported UUI. The incidence rates of the outcome were 20.4 and 11.4 (per 1,000 person–years) among participants with and without UUI, respectively. After multivariable adjustment, those who experienced UUI showed a substantial association with LOI or death (HR, 1.65; 95% CI, 1.01–2.68). However, they did not show such an association with LOI alone (HR, 1.07; 95% CI, 0.49–2.33). On the other hand, those with UUI exhibited a substantial association with death (HR, 2.23; 95% CI, 1.22–4.31).

Conclusions

In this study, UUI was associated with the occurrence of LOI or death; however, UUI is not associated with the occurrence of LOI alone among independent community-dwelling older adults. Our results suggest that there may be a difference between UUI-associated diseases that cause LOI and those that cause death.

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

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

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.

Nocturnal Urine Production in Women With Global Polyuria

PURPOSE

Low nocturnal urine production (NUP) may be sufficient to rule out global polyuria (GP) in men. This study determines the sensitivity of indices for nocturnal polyuria (NP), defined as nocturnal polyuria index (NPi; nocturnal urine volume/24-hour urine volume) ≥0.33 or NUP ≥90 mL/hr, for detecting GP in women.

METHODS

Data were analyzed from 2 prospective protocols involving subjects recruited from a urology ambulatory care unit and a continence clinic. Women ≥18 years with nocturia were included if they met either of 2 common criteria for GP: (1) ≥40 mL/kg/24 hr or (2) ≥3,000 mL/24 hr.

RESULTS

Thirty-one women were included (NPi, 28.6 [21.3-40.7]; NUP, 100.8 [68.3-135.8] mL/hr). At the ≥40 mL/kg/24-hr cutoff, 40% and 63% of women reporting ≥1 nocturnal void(s) (n=30) had NPi ≥0.33 and NUP ≥90 mL/hr, respectively. Additionally, 53% and 71% of subjects reporting ≥2 nocturnal voids (n=17) had NPi ≥0.33 and NUP ≥90 mL/hr, respectively. At the ≥3,000 mL/24-hr cutoff, 38% and 69% of women reporting ≥1 nocturnal void(s) (n=13) had NPi ≥0.33 and NUP ≥90 mL/hr, respectively, and 63% and 88% of subjects reporting ≥2 nocturnal voids (n=8) had NPi ≥0.33 and NUP ≥90 mL/hr, respectively. By extension, 37%-62% of women with nocturia and GP did not have NP by NPi ≥0.33 criteria, and 12%-37% did not have NP by NUP ≥90 mL/hr criteria.

CONCLUSION

Indices of excess nighttime urination do not reliably predict GP in women. A full-length voiding diary may be particularly important in the evaluation of women with nocturia. Nocturia in women merits further consideration as a distinct entity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diagnosing Nocturnal Polyuria from a Single Nocturnal Urine Sample

BACKGROUND

Patients with nocturnal polyuria (NP) experience a unique surge in nocturnal diuresis rate during the early hours of sleep.

OBJECTIVE

To determine the diagnostic utility of the volume and osmolality of a single early nocturnal urine sample in detecting NP.

DESIGN, SETTING, AND PARTICIPANTS

Analysis of 1 am urine samples obtained from two prospective observational studies at Ghent University Hospital involving participants recruited from a urology ambulatory care unit and those who consulted a continence clinic. Nocturic participants (one or more nocturnal void[s]; n=176) were stratified based on the presence (n=87) or absence (n=89) of NP (>90ml/h).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Receiver operating characteristic curves with Youden's Index were used to determine cutoff values for urine volume and urine osmolality (Uosm).

RESULTS AND LIMITATIONS

Individuals with NP demonstrated higher 1 am volume (400 [interquartile range 300-515] vs 210 [160-300] ml, area under the curve [AUC]=0.843, p< 0.001, cutoff = 350 ml) and lower Uosm (274 [201-348] vs 430 [320-664] mOsm/kg H₂O, AUC=0.774, p<0.001, cutoff=314 mOsm/kg H₂O) than those without NP. In combining cutoffs, the criteria of either 1 am volume ≥350ml or Uosm ≤314 mOsm/kg H₂O were 85% sensitive and 75% specific for NP, while criteria of both 1 am volume ≥350ml and Uosm ≤314 mOsm/kg H₂O were 60% sensitive and 92% specific for NP. Comparable AUC values, sensitivities, and specificities were observed in both men and women. Limitations include post hoc design and a relatively small study sample.

CONCLUSIONS

Individuals with NP are more likely than those without NP to produce a higher volume of more dilute urine (ie, "aquaresis") in the early hours of sleep. Analysis of easily measurable parameters of the first nocturnal void (for which 1 am values serve as a surrogate) in men and women with nocturia can predict a diagnosis of NP with a reasonably high degree of sensitivity and specificity.

PATIENT SUMMARY

Urologists often try to understand the specific reason why people wake up to urinate at night by asking them to record the amount of urine they make every time they go to the bathroom (also known as a "voiding diary") during the nighttime as well as the daytime-typically for a total of 1-3 days. In this study, we showed that an analysis of the composition of the urine that people produce when they first wake up to urinate at night might be sufficient to determine whether their symptoms are caused by excessive urine production or something else, and some people might find this urine study easier than keeping a voiding diary.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

International Continence Society consensus on the diagnosis and treatment of nocturia

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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