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Kyoda Y, Ichihara K, Muranaka I, Sakai Y, Nakamura M, Shinkai N, Kozen N, Yorozuya W, Morooka D, Maruo K, Tachikawa K, Shibamori K, Nofuji S, Fujino K, Kato S, Yoshida T, Shindo T, Maehana T, Hashimoto K, Kobayashi K, Tanaka T, Masumori N. Efficacy of cognitive behavioral therapy using self-check sheet for patients with nocturia in real-world clinical practice. Low Urin Tract Symptoms 2023; 15:225-230. [PMID: 37614063 DOI: 10.1111/luts.12498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/30/2023] [Accepted: 07/26/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVES We previously demonstrated the efficacy of cognitive behavioral therapy (CBT) using a self-check sheet for patients with nocturia in a randomized controlled study. Additionally, we investigated the efficacy of the intervention in real-world clinical practice. METHODS Two hundred forty-three outpatients with complaint of nocturia who practiced CBT for 4 weeks using a self-check sheet were included in this trial, which took place from April 2021 to March 2022 in 20 institutions. RESULTS Of the 243 patients, 215 who achieved 50% or more of the behavioral therapy tasks were included in the analysis. Their mean age ± SD was 77.1 ± 7.7. A significant decrease was observed in nighttime frequency at 4 weeks after CBT using self-check sheets (pre 3.3 and post 2.8, p < .001). Nighttime frequency was decreased one or more times and was defined as treatment success in 102 patients (47.4%). Pretreatment nighttime frequency in the treatment-success group was significantly higher than that of the failure group (3.5 ± 1.0 vs. 3.2 ± 1.0, p = .013). In multivariate logistic regression analysis, predictive factors of treatment success were pretreatment nocturnal frequency of four or more (odds ratio [OR] 1.82, 95% confidence interval [CI] 1.01-3.30; p = .046) and the absence of diabetes mellitus (OR 3.08, 95% CI 1.34-7.06; p = .008). CONCLUSIONS CBT using a self-check sheet requiring less time, less labor, less cost, and less medication is very beneficial for both patients and medical staff in real-world clinical practice.
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Affiliation(s)
- Yuki Kyoda
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
- Yakumo General Hospital, Yakumo, Japan
- Hokkaido Prefectural Haboro Hospital, Haboro, Japan
- Rumoi Municipal Hospital, Rumoi, Japan
| | | | - Ippei Muranaka
- Hokkaido Social Work Association Obihiro Hospital, Obihiro, Japan
| | | | | | | | | | | | | | | | | | - Kosuke Shibamori
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
- Kuriyama Red Cross Hospital, Kuriyama, Japan
- Hokkaido Social Work Association Toya Hospital, Toyako, Japan
- JCHO Noboribetsu Medical Center, Noboribetsu, Japan
| | - Seisuke Nofuji
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
- Kuriyama Red Cross Hospital, Kuriyama, Japan
- Hokkaido Social Work Association Toya Hospital, Toyako, Japan
- JCHO Noboribetsu Medical Center, Noboribetsu, Japan
| | - Keiko Fujino
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
- Kuriyama Red Cross Hospital, Kuriyama, Japan
- Hokkaido Social Work Association Toya Hospital, Toyako, Japan
- JCHO Noboribetsu Medical Center, Noboribetsu, Japan
| | | | | | - Tetsuya Shindo
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Takeshi Maehana
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Kohei Hashimoto
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Ko Kobayashi
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
- Nemuro City Hospital, Nemuro, Japan
| | - Toshiaki Tanaka
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Naoya Masumori
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
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Stoniute A, Madhuvrata P, Still M, Barron-Millar E, Nabi G, Omar MI. Oral anticholinergic drugs versus placebo or no treatment for managing overactive bladder syndrome in adults. Cochrane Database Syst Rev 2023; 5:CD003781. [PMID: 37160401 PMCID: PMC10167789 DOI: 10.1002/14651858.cd003781.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Around 16% of adults have symptoms of overactive bladder (OAB; urgency with frequency and/or urge incontinence), with prevalence increasing with age. Anticholinergic drugs are commonly used to treat this condition. This is an update of a Cochrane Review first published in 2002 and last updated in 2006. OBJECTIVES To assess the effects of anticholinergic drugs compared with placebo or no treatment for treating overactive bladder syndrome in adults. SEARCH METHODS We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 14 January 2020), and the reference lists of relevant articles. We updated this search on 3 May 2022, but these results have not yet been fully incorporated. SELECTION CRITERIA We included randomised or quasi-randomised trials in adults with overactive bladder syndrome that compared an anticholinergic drug alone with placebo treatment. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility and extracted data from the included studies, including an assessment of the risk of bias. We assessed the certainty of the body of evidence using the GRADE approach. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We included 104 studies, 71 of which were new or updated for this version of the review. Although 12 studies did not report the number of participants, there were 47,106 people in the remainder of the included studies. The majority of the studies had insufficient information to allow judgement of risk of bias and we judged them to be unclear for all domains. Nine anticholinergic drugs were included in these studies: darifenacin; fesoterodine; imidafenacin; oxybutynin; propantheline; propiverine; solifenacin; tolterodine and trospium. No studies were found that compared anticholinergic drugs to no treatment. At the end of the treatment period, anticholinergics may slightly increase condition-specific quality of life (mean difference (MD) 4.41 lower, 95% confidence interval (CI) 5.28 lower to 3.54 lower (scale range -100 to 0); 12 studies, 6804 participants; low-certainty evidence). Anticholinergics are probably better than placebo in terms of patient perception of cure or improvement (risk ratio (RR) 1.38, 95% CI 1.15 to 1.66; 9 studies, 8457 participants; moderate-certainty evidence), and the mean number of urgency episodes per 24-hour period (MD 0.85 lower, 95% CI 1.03 lower to 0.67 lower; 23 studies, 16,875 participants; moderate-certainty evidence). Compared to placebo, anticholinergics may result in an increase in dry mouth adverse events (RR 3.50, 95% CI 3.26 to 3.75; 66 studies, 38,368 participants; low-certainty evidence), and may result in an increased risk of urinary retention (RR 3.52, 95% CI 2.04 to 6.08; 17 studies, 7862 participants; low-certainty evidence). Taking anticholinergics may be more likely to lead to participants withdrawing from the studies due to adverse events (RR 1.37, 95% CI 1.21 to 1.56; 61 studies, 36,943 participants; low-certainty evidence). However, taking anticholinergics probably reduces the mean number of micturitions per 24-hour period compared to placebo (MD 0.85 lower, 95% CI 0.98 lower to 0.73 lower; 30 studies, 19,395 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS The use of anticholinergic drugs by people with overactive bladder syndrome results in important but modest improvements in symptoms compared with placebo treatment. In addition, recent studies suggest that this is generally associated with only modest improvement in quality of life. Adverse effects were higher with all anticholinergics compared with placebo. Withdrawals due to adverse effects were also higher for all anticholinergics except tolterodine. It is not known whether any benefits of anticholinergics are sustained during long-term treatment or after treatment stops.
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Affiliation(s)
- Akvile Stoniute
- Evidence Synthesis Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Priya Madhuvrata
- Obstetrics & Gynaecology, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - Madeleine Still
- Evidence Synthesis Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Evelyn Barron-Millar
- Evidence Synthesis Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ghulam Nabi
- Section of Academic Urology, Division of Cancer Research, University of Dundee, Dundee, UK
| | - Muhammad Imran Omar
- Guidelines Office, European Association of Urology, Arnhem, Netherlands
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
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Monaghan TF, Weiss JP, Wein AJ, Rahman SN, Lazar JM, Bliwise DL, Everaert K, Lemack GE, Cornu JN, Drake MJ, Chapple CR, Hashim H, Blaivas JG, Dmochowski RR. Sleep Disorders, Comorbidities, Actions, Lower Urinary Tract Dysfunction, and Medications ("Sleep C.A.L.M.") in the evaluation and management of nocturia: A simple approach to a complex diagnosis. Neurourol Urodyn 2023; 42:562-572. [PMID: 36655726 DOI: 10.1002/nau.25128] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Nocturia arises from a fundamental mismatch between nocturnal urine production, storage capacity, and sleep architecture, which may be driven by abnormalities of the genitourinary tract, but also by sleep disorders, medical diseases, patient actions/lifestyle factors, or medications. This article introduces a novel system for organizing the complex differential diagnosis for nocturia, as proposed by an international collective of practicing urologists, physician specialists, and sleep experts: "Sleep CALM"-Sleep Disorders, Comorbidities, Actions, Lower Urinary Tract Dysfunction, and Medications. METHODS Narrative review of current evidence regarding the relevance of each "Sleep CALM" factor to nocturia pathogenesis, evaluation, and management. RESULTS Nocturia and sleep disorders are highly intertwined and often bidirectional, such that nocturnal awakenings for reasons other than a sensation of bladder fullness should not be used as grounds for exclusion from nocturia treatment, but rather leveraged to broaden therapeutic options for nocturia. Nocturia is an important potential harbinger of several serious medical conditions beyond the genitourinary tract. Urologists should have a low threshold for primary care and medical specialty referral for medical optimization, which carries the potential to significantly improve nocturnal voiding frequency in addition to overall health status. Adverse patient actions/lifestyle factors, lower urinary tract dysfunction, and medication use commonly coexist with disordered sleep and comorbid medical conditions, and may be the primary mediators of nocturia severity and treatment response, or further exacerbate nocturia severity and complicate treatment. CONCLUSION "Sleep CALM" provides a memorable and clinically relevant means by which to structure the initial patient history, physical exam, and clinical testing in accordance with current best-practice guidelines for nocturia. Although not intended as an all-encompassing diagnostic tool, the "Sleep CALM" schema may also be useful in guiding individualized ancillary testing, identifying the need for specialty referral and multidisciplinary care, and uncovering first-line treatment targets.
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Affiliation(s)
- Thomas F Monaghan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jeffrey P Weiss
- Department of Urology, SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - Alan J Wein
- Division of Urology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Syed N Rahman
- Department of Urology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jason M Lazar
- Department of Medicine, Division of Cardiovascular Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - Donald L Bliwise
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Karel Everaert
- Department of Human Structure and Repair, Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium
| | - Gary E Lemack
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jean-Nicolas Cornu
- Department of Urology, Charles Nicolle University Hospital, Rouen, France
| | - Marcus J Drake
- Department of Urology, Imperial College London, Imperial College Healthcare NHS Trust, London, UK
| | - Christopher R Chapple
- Department of Urology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Hashim Hashim
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Jerry G Blaivas
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Roger R Dmochowski
- Department of Urological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Kyoda Y, Okada M, Kato R, Matsuki M, Ito N, Takahashi A, Tanuma Y, Tachiki H, Fukuta F, Hashimoto K, Kobayashi K, Tanaka T, Masumori N. Does cognitive behavioral therapy using a self-check sheet improve night-time frequency in patients with nocturia? Results of a multicenter randomized controlled trial. Int J Urol 2021; 28:444-449. [PMID: 33458939 DOI: 10.1111/iju.14489] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 12/14/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine whether cognitive behavioral therapy using a self-check sheet is effective in improving night-time frequency of patients with nocturia. METHODS We carried out a multicenter, open-labeled, randomized controlled trial in eight institutions. Patients having two or more episodes of nocturia were randomly assigned to either cognitive behavioral therapy with completion of frequency volume charts regularly (cognitive behavioral therapy group) or frequency volume charts regularly alone (frequency volume charts group). The cognitive behavioral therapy checklist was composed of eight items: wake up time/bedtime, mealtime, napping, alcohol/caffeine intake, water intake, salt intake, exercise and taking a bath. A physician explained cognitive behavioral therapy within 5 min using a brief manual. The patients in the cognitive behavioral therapy group filled out the self-check sheet every day. The primary end-point was the difference in night-time frequency based on the International Prostate Symptom Score Q7 at 4 weeks. RESULTS Of the 100 first-visit patients randomly allocated, 37 in the cognitive behavioral therapy group and 41 in the frequency volume charts group completed the protocol. No difference was observed in the mean ± standard deviation of night-time frequency at 4 weeks between the cognitive behavioral therapy group (2.6 ± 1.0) and the frequency volume charts group (3.1 ± 1.2; P = 0.056). However, when six patients with achievement of cognitive behavioral therapy of <50% were excluded from the analysis, night-time frequency at 4 weeks was significantly lower in the cognitive behavioral therapy group (2.5 ± 1.0) than in the frequency volume charts group (3.1 ± 1.2; P = 0.027). CONCLUSIONS The efficacy of cognitive behavioral therapy using a self-check sheet for nocturia remains to be shown. However, strictly practicing cognitive behavioral therapy might be beneficial to these patients.
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Affiliation(s)
- Yuki Kyoda
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Manabu Okada
- Department of Urology, Obihiro Kyokai Hospital, Obihiro, Hokkaido, Japan
| | - Ryuichi Kato
- Department of Urology, Muroran City General Hospital, Muroran, Hokkaido, Japan
| | - Masahiro Matsuki
- Department of Urology, Kushiro Red Cross Hospital, Kushiro, Hokkaido, Japan
| | - Naoki Ito
- Department of Urology, NTT-East Sapporo Hospital, Sapporo, Hokkaido, Japan
| | - Atsushi Takahashi
- Department of Urology, Hakodate Goryoukaku Hospital, Hakodate, Hokkaido, Japan
| | - Yasushi Tanuma
- Department of Urology, Hakodate Kyokai Hospital, Hakodate, Hokkaido, Japan
| | - Hitoshi Tachiki
- Department of Urology, Steel Memorial Muroran Hospital, Muroran, Hokkaido, Japan
| | - Fumimasa Fukuta
- Department of Urology, Steel Memorial Muroran Hospital, Muroran, Hokkaido, Japan
| | - Kohei Hashimoto
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Ko Kobayashi
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Toshiaki Tanaka
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Naoya Masumori
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
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Xu L, Fu C, Zhang Q, Xiong F, Peng L, Liang Z, Chen L, He C, Wei Q. Efficacy of biofeedback, repetitive transcranial magnetic stimulation and pelvic floor muscle training for female neurogenic bladder dysfunction after spinal cord injury: a study protocol for a randomised controlled trial. BMJ Open 2020; 10:e034582. [PMID: 32759239 PMCID: PMC7409967 DOI: 10.1136/bmjopen-2019-034582] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 05/14/2020] [Accepted: 06/23/2020] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Neurogenic bladder dysfunction is prevalent in female patients with spinal cord injury (SCI), and previous guidelines have recommended pelvic floor muscle training (PFMT) for first-line conservative treatment. However, the actual regimen of PFMT varies widely and the single treatment does not satisfy the need of some patients. Therefore, this study aims to provide a detailed rationale and methodology for comparing the effectiveness of PFMT, biofeedback and repetitive transcranial magnetic stimulation (rTMS) as adjunct treatments for neurogenic bladder dysfunction. METHODS AND ANALYSIS This trial is a single-centre randomised controlled trial for female patients with urinary incontinence (UI) in phase of chronic SCI. Eligible participants will be randomised to one of four arms: (1) PFMT, (2) PFMT with biofeedback, (3) PFMT and rTMS and (4) PFMT with biofeedback and rTMS. There will be 44 participants in each arm and all the subjects will undergo 20 treatment sessions, five times a week for 4 weeks. The outcomes will be evaluated at 4 weeks, 3 months and 6 months after randomisation. The primary outcome is the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form, and the secondary outcomes include bladder diary, pelvic floor muscle function and the International Spinal Cord Injury Quality of Life Basic Data Set. ETHICS AND DISSEMINATION The Clinical Research and Biomedical Ethics Committee of the West China Hospital, Sichuan University has approved this trial and the approval number is 2019-885. All participants will be provided written informed consent after verification of the eligibility criteria. The results of this study will be accessible in peer-reviewed publications and be presented at academic conferences. TRIAL REGISTRATION NUMBER Chinese Clinical Trial Registry (ChiCTR1900026126).
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Affiliation(s)
- Lin Xu
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Chenying Fu
- State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
| | - Qing Zhang
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Feng Xiong
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Lihong Peng
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Zejun Liang
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Li Chen
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Chengqi He
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
| | - Quan Wei
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China
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Burgio KL, Kraus SR, Johnson TM, Markland AD, Vaughan CP, Li P, Redden DT, Goode PS. Effectiveness of Combined Behavioral and Drug Therapy for Overactive Bladder Symptoms in Men: A Randomized Clinical Trial. JAMA Intern Med 2020; 180:411-419. [PMID: 31930360 PMCID: PMC6990866 DOI: 10.1001/jamainternmed.2019.6398] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IMPORTANCE First-line behavioral and drug therapies for overactive bladder (OAB) symptoms in men are effective but not usually curative. OBJECTIVE To determine whether combining behavioral and drug therapies improves outcomes compared with each therapy alone for OAB in men and to compare 3 sequences for implementing combined therapy. DESIGN, SETTING, AND PARTICIPANTS In this 3-site, 2-stage, 3-arm randomized clinical trial, participants were randomized to 6 weeks of behavioral therapy alone, drug therapy alone, or combined therapy followed by step-up to 6 weeks of combined therapy for all groups. Participants were recruited from 3 outpatient clinics and included community-dwelling men 40 years or older with urinary urgency and 9 or more voids per 24 hours. Data were collected from July 2010 to July 2015 and analyzed from April 2016 to September 2019. INTERVENTIONS Behavioral therapy consisted of pelvic floor muscle training with urge suppression strategies and delayed voiding. Drug therapy included an antimuscarinic (sustained-release tolterodine, 4 mg) plus an α-blocker (tamsulosin, 0.4 mg). MAIN OUTCOMES AND MEASURES Seven-day bladder diaries completed before and after each 6-week treatment stage were used to calculate reduction in frequency of urination (primary outcome) and other symptoms (ie, urgency, urgency incontinence, and nocturia). Other secondary outcomes included validated patient global ratings of improvement and satisfaction, Overactive Bladder Questionnaire score, and International Prostate Symptom Score. RESULTS Of the 204 included men, 133 (65.2%) were white, and the mean (SD) age was 64.1 (11.1) years. A total of 21 men discontinued treatment and 183 completed treatment. Mean (SD) voids per 24 hours decreased significantly in all 3 groups from baseline to 6-week follow-up (behavioral therapy: 11.7 [2.4] vs 8.8 [2.1]; change, 2.9 [2.4]; percentage change, 24.7%; P < .001; drug therapy: 11.8 [2.5] vs 10.3 [2.7]; change, 1.5 [2.3]; percentage change, 12.7%; P < .001; combined therapy: 11.8 [2.4] vs 8.2 [2.3]; change, 3.6 [2.1]; percentage change, 30.5%; P < .001). Intention-to-treat analyses indicated that posttreatment mean (SD) voiding frequencies were significantly lower in those receiving combined therapy compared with drug therapy alone (8.2 [2.3] vs 10.3 [2.7]; P < .001) but not significantly lower compared with those receiving behavioral therapy alone (8.2 [2.3] vs 8.8 [2.1]; P = .19) and were lower for behavioral therapy alone compared with drug therapy alone (8.8 [2.1] vs 10.3 [2.7]; P < .001). At 12-week follow-up, after all groups had received combined therapy, improvements in mean (SD) voids per 24 hours were also greatest for those receiving initial combined therapy compared with baseline (behavioral therapy: 11.7 [2.4] vs 8.0 [2.2]; change, 3.7 [2.3]; percentage change, 31.6%; P < .001; drug therapy: 11.8 [2.5] vs 8.6 [2.3]; change, 3.2 [2.5]; percentage change, 27.1%; P < .001; combined therapy: 11.8 [2.4] vs 8.0 [2.2]; change, 3.8 [2.1]; percentage change, 32.2%; P < .001), but there were no statistically significant group differences on primary or secondary measures. CONCLUSIONS AND RELEVANCE Combining behavioral and drug therapy yields greater improvements in OAB symptoms than drug therapy alone but not behavioral therapy alone. When using a stepped approach, it is reasonable to begin with behavioral therapy alone. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01175382.
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Affiliation(s)
- Kathryn L Burgio
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham.,Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama
| | - Stephen R Kraus
- Department of Urology, University of Texas Health Science Center at San Antonio, San Antonio
| | - Theodore M Johnson
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Atlanta, Georgia.,Division of General Internal Medicine and Geriatrics, Department of Medicine, Emory University, Atlanta, Georgia
| | - Alayne D Markland
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham.,Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama
| | - Camille P Vaughan
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Atlanta, Georgia.,Division of General Internal Medicine and Geriatrics, Department of Medicine, Emory University, Atlanta, Georgia
| | - Peng Li
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham.,School of Nursing, University of Alabama at Birmingham, Birmingham
| | - David T Redden
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham
| | - Patricia S Goode
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham.,Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama
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Abstract
PURPOSE OF REVIEW Nocturia is defined as awakening due to the desire to void during a period of intended sleep. The pathophysiology of nocturia is multifactorial and management remains a challenge. Herein, we provide an overview of the management strategies for nocturia and summarize the existing evidence for treatment of nocturia across the condition's broad etiologic categories: nocturnal polyuria, diminished bladder capacity, and global polyuria. RECENT FINDINGS Treatment should begin with behavioral modification. A high level of evidence supports the efficacy of desmopressin in the treatment of nocturnal polyuria. Data supporting the efficacy of α-blockers, antimuscarinics, and surgical bladder outlet procedures in the treatment of nocturia remains limited. Treatment options for nocturia are determined by underlying mechanism. Desmopressin is effective in treating nocturnal polyuria. Surgical intervention, α-blockers, and antimuscarinics may improve nocturia when associated with lower urinary tract symptoms or overactive bladder in the setting of diminished bladder capacity.
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Affiliation(s)
- Danielle J Gordon
- Department of Urology, SUNY Downstate College of Medicine, 450 Clarkson Avenue, Box 79, Brooklyn, NY, 11203, USA.
| | - Curran J Emeruwa
- Department of Urology, SUNY Downstate College of Medicine, 450 Clarkson Avenue, Box 79, Brooklyn, NY, 11203, USA
| | - Jeffrey P Weiss
- Department of Urology, SUNY Downstate College of Medicine, 450 Clarkson Avenue, Box 79, Brooklyn, NY, 11203, USA
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Silva V, Grande AJ, Peccin MS. Physical activity for lower urinary tract symptoms secondary to benign prostatic obstruction. Cochrane Database Syst Rev 2019; 4:CD012044. [PMID: 30953341 PMCID: PMC6450803 DOI: 10.1002/14651858.cd012044.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Lower urinary tract symptoms caused by benign prostatic obstruction (LUTS/BPO) represents one of the most common clinical complaints in men. Physical activity might represent a viable first-line intervention for treating LUTS/BPO. OBJECTIVES To assess the effects of physical activity for lower urinary tract symptoms caused by benign prostatic obstruction (LUTS/BPO). SEARCH METHODS We performed a comprehensive search of multiple databases (CENTRAL, MEDLINE, Embase, Web of Science, LILACS, ClinicalTrials.gov, and WHO ICTRP); checked the reference lists of retrieved articles; and handsearched abstract proceedings of conferences with no restrictions on the language of publication or publication status from database inception to 6 November 2018. SELECTION CRITERIA We included published and unpublished randomised controlled and controlled clinical trials that included men diagnosed with LUTS/BPO. We excluded studies in which medical history suggested non-BPO causes of LUTS or prior invasive therapies to physical activity or that used electrical stimulation. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility, extracted data, and assessed the risk of bias of included studies. We assessed primary outcomes (symptom score for LUTS; response rate, defined as 20% improvement in symptom score; withdrawal due to adverse events) and secondary outcomes (change of medication use; need for an invasive procedure; postvoid residual urine). We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included six studies that randomised 652 men over 40 years old with moderate or severe LUTS. The four different comparisons were as follows:Physical activity versus watchful waitingTwo RCTs randomised 119 participants. The interventions included tai chi and pelvic floor exercise. The evidence was overall of very low quality, and we are uncertain about the effects of physical activity on symptom score for LUTS (mean difference (MD) -8.1, 95% confidence interval (CI) -13.2 to -3.1); response rate (risk ratio (RR) 1.80, 95% CI 0.81 to 4.02; 286 more men per 1000, 95% CI 68 fewer to 1079 more); and withdrawal due to adverse events (RR 1.00, 95% CI 0.59 to 1.69; 0 fewer men per 1000, 95% CI 205 fewer to 345 more).Physical activity as part of self-management programme versus watchful waitingTwo RCTs randomised 362 participants. Pelvic floor exercise was one of multiple intervention components. The evidence was of very low quality, and we are uncertain about the effects of physical activity for symptom score for LUTS (MD -6.2, 95% CI -9.9 to -2.5); response rate (RR 2.36, 95% CI 1.32 to 4.21; 424 more men per 1000, 95% CI 100 more to 1000 more); and withdrawal due to adverse events (risk difference 0.00, 95% CI -0.05 to 0.06; 65 fewer men per 1000, 95% CI 65 fewer to 65 fewer).Physical activity as part of weight reduction programme versus watchful waitingOne RCT randomised 130 participants. An unclear type of intense exercise was one of multiple intervention components. The evidence was of very low quality, and we are uncertain about the effects for symptom score for LUTS (MD -1.1, 95% CI -3.5 to 1.3); response rate (RR 1.20, 95% CI 0.74 to 1.94; 67 more men per 1000, 95% CI 87 fewer to 313 more); and withdrawal due to adverse events (RR 1.63, 95% CI 1.03 to 2.57; 184 more men per 1000, 95% CI 9 more to 459 more).Physical activity versus alpha-blockersOne RCT randomised 41 participants to pelvic floor exercise or alpha-blockers. The evidence was of very low quality, and we are uncertain about the effects for symptom score for LUTS (MD 2.8, 95% CI -0.9 to 6.4) and response rate (RR 0.80, 95% CI 0.55 to 1.15; 167 fewer men per 1000, 95% CI 375 fewer to 125 more). The evidence was of low quality for withdrawal due to adverse events; the effects for this outcome may be similar between interventions (RR 0.86, 95% CI 0.06 to 12.89; 7 fewer men per 1000, 95% CI 49 fewer to 626 more). AUTHORS' CONCLUSIONS We rated the quality of the evidence for most of the effects of physical activity for LUTS/BPO as very low. We are therefore uncertain whether physical activity affects symptom scores for LUTS, response rate, and withdrawal due to adverse events. Our confidence in the estimates was lowered due to study limitations, inconsistency, indirectness, and imprecision. Additional high-quality research is necessary.
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Affiliation(s)
- Valter Silva
- Centro Universitário Tiradentes (UNIT/AL)Postgraduate Program on Society, Technology and Public Policies (SOTEPP); Department of MedicineAv. Comendador Gustavo Paiva, 5017Cruz das AlmasMaceióALBrazil57038‐000
| | - Antonio Jose Grande
- Universidade Estadual de Mato Grosso do SulLaboratory of Evidence‐Based PracticeAv. Dom Antônio Barbosa, 4155Vila Santo AmaroCampo GrandeMato Grosso do SulBrazil79115‐898
| | - Maria S Peccin
- Universidade Federal de São PauloDepartment of Human Movement SciencesR. Silva Jardim, 136 ‐ Vl. Mathias ‐SantosSão PauloBrazil11015‐020
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9
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Epstein MR, Monaghan T, Weiss JP. Etiology of nocturia response in men with diminished bladder capacity. Neurourol Urodyn 2018; 38:215-222. [DOI: 10.1002/nau.23832] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/08/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Matthew R. Epstein
- Department of Urology; SUNY Downstate College of Medicine; Brooklyn New York
| | - Thomas Monaghan
- Department of Urology; SUNY Downstate College of Medicine; Brooklyn New York
| | - Jeffrey P. Weiss
- Department of Urology; SUNY Downstate College of Medicine; Brooklyn New York
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Bliwise DL, Howard LE, Moreira DM, Andriole GL, Hopp ML, Freedland SJ. Nocturia and associated mortality: observational data from the REDUCE trial. Prostate Cancer Prostatic Dis 2018; 22:77-83. [DOI: 10.1038/s41391-018-0090-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 07/27/2018] [Accepted: 08/02/2018] [Indexed: 12/28/2022]
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Rizvi RM, Chughtai NG, Kapadia N. Effects of Bladder Training and Pelvic Floor Muscle Training in Female Patients with Overactive Bladder Syndrome: A Randomized Controlled Trial. Urol Int 2018; 100:420-427. [PMID: 29672306 DOI: 10.1159/000488769] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 03/23/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of our study was to see the efficacy of 3 different modes of treatment for overactive bladder (OAB) in symptoms reduction and quality of life improvement. METHODS We conducted a 12-week single-blinded randomized controlled trial of women aged 22-65 years with clinical diagnosis of OAB. Arm A (n = 47) received bladder training, arm B (n = 50) received pelvic floor muscle training (PFMT), and arm C (n = 50) received PFMT with biofeedback. Bladder diary was used to assess the difference in urinary frequency, urgency, and leak accidents before and after treatment. Initial and final assessment was made using -validated urogenital distress inventory short form 6 (UDI-SF6) and incontinence impact questionnaire short form 7 (IIQ-SF7). RESULTS UDI-SF6 scores showed significant improvement in all arms. There was a reduction in UDI-6 scores from 8.38 ± 4.3 to 4.77 ± 5.5 with a mean difference of 3.61 ± 7.4 in patients in arm A (p = 0.002), arm B (p = 0.01), and arm C (p = 0.016). All patients in arms A, B, and C reported significant improvement in quality of life as assessed by IIQ-SF7 scores with significant p values of 0.009, 0.051, and 0.001, respectively. Bladder diary results using paired t test showed the significant difference in day time urinary frequency in arm A after treatment, as well as the reduction in both leak accidents and urgency score in all 3 arms. CONCLUSIONS All 3 arms of study showed significant results and can be used as the first line of management.
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Affiliation(s)
- Raheela Mohsin Rizvi
- Department of Obstetrics and Gynecology, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Naheed Kapadia
- Department of Physiotherapy, Aga Khan University Hospital, Karachi, Pakistan
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12
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Bennett JB, Gillard KK, Banderas B, Abrams S, Cheng L, Fein S. Development of a new patient-reported outcome (PRO) measure on the Impact of Nighttime Urination (INTU) in patients with nocturia-Psychometric validation. Neurourol Urodyn 2018; 37:1678-1685. [PMID: 29574972 DOI: 10.1002/nau.23451] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 10/15/2017] [Indexed: 11/08/2022]
Abstract
AIMS To psychometrically evaluate the Impact of Nighttime Urination (INTU) questionnaire, a new patient-reported outcome measure developed to assess the impact of nocturia on health and functioning in a multicenter, behavioral modification (fluid restriction) study. METHODS Participants aged 50-95 years with at least two voiding episodes/night for ≥6 months completed voiding diaries and the INTU on 3 consecutive days during weeks 1 and 2 (same day recall) and completed the Pittsburgh Sleep Quality Index (PSQI) and Nocturia Quality of Life Questionnaire (N-QOL) at baseline and days 8 and 15. Psychometric evaluations of the INTU were conducted. RESULTS Rasch analysis showed the INTU to be a unidimensional construct, with most items located on the severe end of the symptom severity continuum. In addition to an Overall Impact Score (10 items), exploratory factor analysis affirmed by confirmatory factor analysis identified two domains: Daytime (six items) and Nighttime (four items) Impact Scores (comparative fit index = 0.968; root mean square error of approximation = 0.08). Concurrent validity met prespecified hypotheses, indicating similarity of concepts with the PSQI (correlation [r] = 0.627) and N-QOL (r = -0.784) total scores. The INTU differentiated among patients with different nocturic episode frequencies (P < 0.05 for all three summary scores). Statistically significant decreases were observed in mean Overall and Nighttime Impact Scores at week 2 versus week 1 in responders, indicating that the instrument can detect changes in response to symptom improvements. CONCLUSIONS The INTU questionnaire demonstrated robust measurement properties and is a suitable tool for assessing the patient-reported impact of nocturia on health and functioning.
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Affiliation(s)
| | | | | | | | - Linda Cheng
- Serenity Pharmaceuticals, LLC, Milford, Pennsylvania
| | - Seymour Fein
- Serenity Pharmaceuticals, LLC, Milford, Pennsylvania
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13
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Wu D, Rosedale R. The use of Mechanical Diagnosis and Therapy (MDT) in patients with lower urinary tract symptoms (LUTS): case series. Physiother Theory Pract 2018; 35:383-391. [PMID: 29482406 DOI: 10.1080/09593985.2018.1443359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Lower urinary tract symptoms (LUTS) are highly prevalent among men over the age of 40. Even though associations between lumbar spine conditions and LUTS have been documented in the literature, no studies have detailed a specific lumbar assessment and classification process, and the related treatment effects in patients with LUTS. In this case series, we present three male patients with LUTS as primary complaints, who were evaluated and treated with Mechanical Diagnosis and Therapy (MDT) for the lumbar spine. The duration of their symptoms was between 4 months and 7 years. Urogenital pathologies were ruled out for all patients. The Chronic Prostatitis Symptom Index was used as a functional outcome measure. All patients were classified as having lumbar derangements. Treatment of derangements with directional preference exercises resulted in the improvement of their LUTS, with clinically significant improvements (56.0%-77.4%) in functional outcome measures over an average of six sessions. Preliminary indications suggest that these LUTS cases may possibly have had a lumbar spine origin and "mechanical" nature. Therefore, they may be within the scope of MDT assessments and interventions. With careful monitoring of symptoms, MDT may serve as a screening tool and conservative treatment option.
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Affiliation(s)
- Di Wu
- a Physiothérapie Polyclinique Cabrini , Montreal , Quebec , Canada
| | - Richard Rosedale
- b Occupational Health and Safety , London Health Sciences Centre , London , Ontario , Canada
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14
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Abstract
Older adults frequently experience nocturia and sleep disturbance concurrently, and problems with sleep resulting from nocturia are a major factor accompanying the bother associated with nocturia. A multicomponent treatment strategy is usually warranted. Initial treatment includes lifestyle modification and behavioral treatment with consideration of pelvic floor muscle exercise-based therapy. Early evidence suggests that behavioral treatment results in similar nocturia reductions compared with the most frequently used drug therapies. Providers should consider formal sleep evaluation if initial treatment strategies for nocturia do not result in significant improvement, because specific sleep disorders may predispose to nocturia.
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Affiliation(s)
- Camille P Vaughan
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Atlanta VA Medical Center, Decatur, GA, USA; Division of General Medicine and Geriatrics, Department of Medicine, Emory University, Atlanta, GA, USA.
| | - Donald L Bliwise
- Program in Sleep, Aging and Chronobiology, Department of Neurology, Emory University, 12 Executive Park Drive, Atlanta, GA 30329, USA
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Homma Y, Gotoh M, Kawauchi A, Kojima Y, Masumori N, Nagai A, Saitoh T, Sakai H, Takahashi S, Ukimura O, Yamanishi T, Yokoyama O, Yoshida M, Maeda K. Clinical guidelines for male lower urinary tract symptoms and benign prostatic hyperplasia. Int J Urol 2017; 24:716-729. [DOI: 10.1111/iju.13401] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 05/23/2017] [Indexed: 12/29/2022]
Affiliation(s)
- Yukio Homma
- Department of Urology; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Momokazu Gotoh
- Department of Urology; Nagoya University Graduate School of Medicine; Nagoya Japan
| | | | - Yoshiyuki Kojima
- Department of Urology; Fukushima Prefectural University of Medicine; Fukushima Japan
| | - Naoya Masumori
- Department of Urology; Sapporo Medical University School of Medicine; Sapporo Japan
| | - Atsushi Nagai
- Department of Urology; Kawasaki Medical School; Kurashiki Japan
| | | | - Hideki Sakai
- Department of Urology; Nagasaki University; Nagasaki Japan
| | | | - Osamu Ukimura
- Department of Urology; Kyoto Prefectural University of Medicine; Kyoto Japan
| | | | | | - Masaki Yoshida
- Department of Urology; National Center of Geriatrics and Gerontology; Obu Japan
| | - Kenji Maeda
- Department of Urology; Maeda Clinic of Internal Medicine; Ageo Japan
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16
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ROVNER ES, RAYMOND K, ANDRUCZYK E, JUUL KV. Low-dose Desmopressin and Tolterodine Combination Therapy for Treating Nocturia in Women with Overactive Bladder: A Double-blind, Randomized, Controlled Study. Low Urin Tract Symptoms 2017; 10:221-230. [DOI: 10.1111/luts.12169] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 12/07/2016] [Accepted: 01/15/2017] [Indexed: 12/31/2022]
Affiliation(s)
- Eric S. ROVNER
- Department of Urology, Medical University of South Carolina; Charleston South Carolina USA
| | | | - Eugene ANDRUCZYK
- Clinical Research of Philadelphia, LLC; Philadelphia Pennsylvania USA
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18
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Johnson TM, Vaughan CP, Goode PS, Bliwise DL, Markland AD, Huisingh C, Redden DT, McGwin G, Eisenstein R, Ouslander JG, Issa M, Burgio KL. Pilot Results from a Randomized Trial in Men Comparing Alpha-Adrenergic Antagonist versus Behavior and Exercise for Nocturia and Sleep. Clin Ther 2016; 38:S0149-2918(16)30742-1. [PMID: 28029383 DOI: 10.1016/j.clinthera.2016.10.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 09/06/2016] [Accepted: 10/01/2016] [Indexed: 11/17/2022]
Abstract
PURPOSE Nocturia and sleep problems are common in older adults. We developed and tested a novel intervention, multicomponent behavioral treatment and exercise therapy (M-BET), that may reduce nocturia and improve sleep in men. We compared reductions in nocturia and improvement in sleep in men with M-BET versus an active drug comparator (α-blocker) used alone or in combination (M-BET + α-blocker) METHODS: This randomized, controlled trial was conducted in the ambulatory setting in 2 US Department of Veterans Affairs medical centers in men at least 40 years of age with nocturia (defined as ≥2 nightly episodes). Participants were randomized to receive either M-BET, including pelvic floor muscle training, urge-suppression techniques, delayed voiding, fluid management, sleep hygiene, and peripheral edema management; an active comparator of known efficacy (the α-blocker tamsulosin, one 0.4-mg tablet nightly); or both therapies combined. Participants received interventions over 12 weeks. Outcomes were assessed via voiding diaries, wrist actigraphy, and validated questionnaires. The primary outcome was change in diary-recorded nocturia, assessed using ANCOVA for the between-group changes and paired t tests for within-group changes. FINDINGS A total of 72 men with a mean age of 65.8 years participated. At 12 weeks, mean diary-recorded nocturia changed with M-BET by -1.39 episodes/night (P < 0.001), with α-blocker therapy by -0.59 episodes/night (P < 0.01), and with combination therapy by -1.03 episodes/night (P < 0.01). Reductions were not statistically different across treatment groups (P = 0.41). M-BET also showed statistically significant improvements in sleep quality, bother from nocturia, and nocturia-specific quality of life. All treatment groups indicated global satisfaction with treatment. IMPLICATIONS Behavioral therapy in men, alone or combined with α-blocker therapy, consistently showed large and statistically significant nocturia reductions and favorable effects on sleep and quality of life. Based on these findings, behavioral therapy, while not statistically superior to α-blocker therapy, may provide a meaningful treatment option for men with nocturia. Future research should include the development of behavioral treatment and exercise therapy interventions that could be more easily deployed. ClinicalTrials.gov identifier: NCT00824200.
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Affiliation(s)
- Theodore M Johnson
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Atlanta VAMC, Decatur, Georgia; Department of Medicine, Emory University, Atlanta, Georgia.
| | - Camille P Vaughan
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Atlanta VAMC, Decatur, Georgia; Department of Medicine, Emory University, Atlanta, Georgia
| | - Patricia S Goode
- Birmingham/Atlanta GRECC, Birmingham VAMC, Birmingham, Alabama; Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama-Birmingham, Birmingham, Alabama
| | - Donald L Bliwise
- Program in Sleep, Aging and Chronobiology, Department of Neurology, School of Medicine, Emory University, Atlanta, Georgia
| | - Alayne D Markland
- Birmingham/Atlanta GRECC, Birmingham VAMC, Birmingham, Alabama; Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama-Birmingham, Birmingham, Alabama
| | | | - David T Redden
- Birmingham/Atlanta GRECC, Birmingham VAMC, Birmingham, Alabama; Biostatistics, School of Public Health, University of Alabama, Birmingham, Alabama
| | - Gerald McGwin
- Birmingham/Atlanta GRECC, Birmingham VAMC, Birmingham, Alabama; Departments of Epidemiology, Birmingham, Alabama
| | - Rina Eisenstein
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Atlanta VAMC, Decatur, Georgia; Department of Medicine, Emory University, Atlanta, Georgia
| | - Joseph G Ouslander
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Atlanta VAMC, Decatur, Georgia; Department of Medicine, Emory University, Atlanta, Georgia
| | - Muta Issa
- Department of Urology, Atlanta Veterans Affairs Medical Center (VAMC), Decatur, Georgia
| | - Kathryn L Burgio
- Birmingham/Atlanta GRECC, Birmingham VAMC, Birmingham, Alabama; Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama-Birmingham, Birmingham, Alabama
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Shin YS, Zhang LT, You JH, Choi IS, Zhao C, Park JK. Efficacy and safety of tamsulosin hydrochloride 0.2 mg and combination of tamsulosin hydrochloride 0.2 mg plus solifenacin succinate 5 mg after transurethral resection of the prostate: a prospective, randomized controlled trial. Clin Interv Aging 2016; 11:1301-1307. [PMID: 27698559 PMCID: PMC5034924 DOI: 10.2147/cia.s115042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Objective The objective of this study was to evaluate the safety and efficacy of tamsulosin hydrochloride 0.2 mg (TAM) and its combination with solifenacin succinate 5 mg (SOL) after transurethral resection of the prostate (TURP). Patients and methods The patients were randomized into three groups: TURP (group 1), TURP plus TAM (group 2), and TURP plus TAM + SOL (group 3). Patients in group 2 and group 3 received medication for 4 weeks. The primary efficacy end points were the mean change in total International Prostate Symptom Score (IPSS) and IPSS subscores. The secondary end points included quality-of-life score, Overactive Bladder Symptom Score, and short-form voiding and storage score of International Continence Society. Results In total, 37 men (31.8%) in group 1, 37 men (31.8%) in group 2, and 42 men (36.2%) in group 3 completed the study. In total IPSS, no significant improvement was seen from baseline to the end of treatment in groups 2 and 3 compared with group 1. However, in group 2, the decrement in the IPSS storage score was smaller than group 1 (P=0.02), and in group 3, the decrement in the IPSS voiding score was smaller than group 1 (P=0.05). In groups 2 and 3 compared with group 1, improvements in the quality of life score, total score of Overactive Bladder Symptom Score, and short-form voiding score and storage score of International Continence Society were not statistically significant. Conclusion Treatment with TAM and combination of TAM and SOL did not have significant additional benefits for lower urinary tract symptoms during the early recovery period after TURP.
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Affiliation(s)
- Yu Seob Shin
- Department of Urology, Chonbuk National University and Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute and Medical Device Clinical Trial Center of Chonbuk National University, Jeonju, Republic of Korea
| | - Li Tao Zhang
- Department of Urology, Chonbuk National University and Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute and Medical Device Clinical Trial Center of Chonbuk National University, Jeonju, Republic of Korea
| | - Jae Hyung You
- Department of Urology, Chonbuk National University and Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute and Medical Device Clinical Trial Center of Chonbuk National University, Jeonju, Republic of Korea
| | - In Sung Choi
- Department of Urology, Chonbuk National University and Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute and Medical Device Clinical Trial Center of Chonbuk National University, Jeonju, Republic of Korea
| | - Chen Zhao
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, and Shanghai Institute of Andrology, Shanghai, People's Republic of China
| | - Jong Kwan Park
- Department of Urology, Chonbuk National University and Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute and Medical Device Clinical Trial Center of Chonbuk National University, Jeonju, Republic of Korea
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20
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Abstract
Nocturia is an extremely common condition that has major sequelae for affected patients. Through disruption of sleep, nocturia impairs quality of life and worsens health outcomes, and is associated with a variety of morbidities including diabetes, coronary artery disease, obstructive sleep apnoea, obesity, metabolic syndrome, and depression. Unsurprisingly, several studies have also linked nocturia with reduced survival. Nocturia is not simply a consequence of lower urinary tract disease; rather, it is a multifactorial disorder that is often a manifestation of an underlying renal or systemic disease. Through the use of the frequency volume chart, clinicians can accurately quantify nocturia and determine its aetiology. Evaluation of quality of life and sleep using simple measures is essential in order to assess the impact of nocturia on a patient. Numerous treatment options for nocturia exist, but most are associated with minor benefit or lack sufficient evidence supporting their use. By systematically analysing an individual's causes of nocturia, clinicians can design appropriate treatment strategies to most effectively treat this condition.
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Affiliation(s)
- Hasan Dani
- Department of Urology, SUNY Downstate College of Medicine, 450 Clarkson Avenue, Brooklyn, New York 11226, USA
| | - Ashanda Esdaille
- Department of Urology, SUNY Downstate College of Medicine, 450 Clarkson Avenue, Brooklyn, New York 11226, USA
| | - Jeffrey P Weiss
- Department of Urology, SUNY Downstate College of Medicine, 450 Clarkson Avenue, Brooklyn, New York 11226, USA
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Allen S, Aghajanyan IG. Thermobalancing conservative treatment for moderate-to-low-degree lower urinary tract symptoms (LUTS) secondary to prostate enlargement. COGENT MEDICINE 2016. [DOI: 10.1080/2331205x.2016.1195067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Simon Allen
- Department of Health, Fine Treatment, 29 Rewley Road, Oxford OX1 2RA, UK
| | - Ivan Gerasimovich Aghajanyan
- Department of Urology, Yerevan State Medical University, 9 Ezras Hasratyan St, Yerevan 0052, Republic of Armenia
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Kim JW, Moon YT, Kim KD. Nocturia: The circadian voiding disorder. Investig Clin Urol 2016; 57:165-73. [PMID: 27195315 PMCID: PMC4869573 DOI: 10.4111/icu.2016.57.3.165] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 04/22/2016] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Jin Wook Kim
- Department of Urology, Chung-Ang University, Seoul, Korea
| | - Young Tae Moon
- Department of Urology, Chung-Ang University, Seoul, Korea
| | - Kyung Do Kim
- Department of Urology, Chung-Ang University, Seoul, Korea
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Aikawa K, Kataoka M, Ogawa S, Akaihata H, Sato Y, Yabe M, Hata J, Koguchi T, Kojima Y, Shiragasawa C, Kobayashi T, Yamaguchi O. Elucidation of the Pattern of the Onset of Male Lower Urinary Tract Symptoms Using Cluster Analysis: Efficacy of Tamsulosin in Each Symptom Group. Urology 2015; 86:349-53. [PMID: 26194300 DOI: 10.1016/j.urology.2015.04.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 04/09/2015] [Accepted: 04/29/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To present a new grouping of male patients with lower urinary tract symptoms (LUTS) based on symptom patterns and clarify whether the therapeutic effect of α1-blocker differs among the groups. METHODS We performed secondary analysis of anonymous data from 4815 patients enrolled in a postmarketing surveillance study of tamsulosin in Japan. Data on 7 International Prostate Symptom Score (IPSS) items at the initial visit were used in the cluster analysis. IPSS and quality of life (QOL) scores before and after tamsulosin treatment for 12 weeks were assessed in each cluster. Partial correlation coefficients were also obtained for IPSS and QOL scores based on changes before and after treatment. RESULTS Five symptom groups were identified by cluster analysis of IPSS. On their symptom profile, each cluster was labeled as minimal type (cluster 1), multiple severe type (cluster 2), weak stream type (cluster 3), storage type (cluster 4), and voiding type (cluster 5). Prevalence and the mean symptom score were significantly improved in almost all symptoms in all clusters by tamsulosin treatment. Nocturia and weak stream had the strongest effect on QOL in clusters 1, 2, and 4 and clusters 3 and 5, respectively. CONCLUSION The study clarified that 5 characteristic symptom patterns exist by cluster analysis of IPSS in male patients with LUTS. Tamsulosin improved various symptoms and QOL in each symptom group. The study reports many male patients with LUTS being satisfied with monotherapy using tamsulosin and suggests the usefulness of α1-blockers as a drug of first choice.
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Affiliation(s)
- Ken Aikawa
- Department of Urology, Fukushima Medical University, Fukushima, Japan.
| | - Masao Kataoka
- Department of Urology, Fukushima Medical University, Fukushima, Japan
| | - Soichiro Ogawa
- Department of Urology, Fukushima Medical University, Fukushima, Japan
| | - Hidenori Akaihata
- Department of Urology, Fukushima Medical University, Fukushima, Japan
| | - Yuichi Sato
- Department of Urology, Fukushima Medical University, Fukushima, Japan
| | - Michihiro Yabe
- Department of Urology, Fukushima Medical University, Fukushima, Japan
| | - Junya Hata
- Department of Urology, Fukushima Medical University, Fukushima, Japan
| | - Tomoyuki Koguchi
- Department of Urology, Fukushima Medical University, Fukushima, Japan
| | - Yoshiyuki Kojima
- Department of Urology, Fukushima Medical University, Fukushima, Japan
| | | | | | - Osamu Yamaguchi
- Division of Bioengineering and LUTD Research, Nihon University College of Engineering, Koriyama, Japan
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Weiss JP, Juul KV, Wein AJ. Management of nocturia: the role of antidiuretic pharmacotherapy. Neurourol Urodyn 2015; 33 Suppl 1:S19-24. [PMID: 24729149 DOI: 10.1002/nau.22592] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 02/20/2014] [Indexed: 11/11/2022]
Abstract
Strategies to manage nocturia include lifestyle modifications and treatment with alpha-blockers, antimuscarinic therapies, and antidiuretics. The concept of achieving success should not be limited to reduction of nighttime voids; it should ideally include proof of improvement of conditions generally associated with nocturia, such as falls, quality of life, and overall health. Few studies have looked specifically at parameters other than nocturnal voids, such as sleep latency, first undisturbed sleep period (FUSP), and total sleep time, including their clinical relevance to patient well-being. Lifestyle modifications, such as voiding before bedtime, limiting caffeine and alcohol, and adjusting medication timing, may be initially effective in mild cases of nocturia. Statistically significant reductions in voiding have been reported with antimuscarinic agents and alpha-blockers as initial therapy, but these reductions generally are not clinically relevant. The antidiuretic therapy desmopressin acetate, a selective vasopressin receptor 2 agonist, is effective in adults with nocturia associated with nocturnal polyuria; however, hyponatremia can occur. The newest formulation-desmopressin orally disintegrating sublingual tablet (ODST)--has greater bioavailability; thus, lower doses can be used, potentially reducing hyponatremia risk. A phase 3 study demonstrated statistically significant reductions in nocturnal voids for desmopressin ODST 50 and 100 µg versus placebo (-1.18 and -1.43 vs. -0.86; P = 0.02 and P < 0.0001, respectively) in patients with nocturia. Treatment was well-tolerated, and low-dose desmopressin ODST was associated with statistically significant increases in duration of FUSP. Development of a validated composite endpoint may help clinicians identify and compare strategies for treating nocturia.
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Affiliation(s)
- Jeffrey P Weiss
- Department of Urology, SUNY Downstate Medical School, Brooklyn, New York
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Jayadevappa R, Newman DK, Chhatre S, Wein AJ. Medication adherence in the management of nocturia: challenges and solutions. Patient Prefer Adherence 2015; 9:77-85. [PMID: 25609929 PMCID: PMC4298292 DOI: 10.2147/ppa.s51482] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Nocturia affects millions of men and women. No prior reviews or meta-analyses have explored the issue of adherence in nocturia patients. The objective of our study was to examine the attributes and their interaction that might impact pharmacological adherence in nocturia care using a conceptual model of adherence. MATERIALS AND METHODS A literature search of the Medline, PubMed, Embase, PsycInfo, and CINAHL databases for studies published between January 1990 and June 2014 was conducted. We developed a conceptual model in order to facilitate our review. RESULTS Currently, multiple treatment options for nocturia exist, depending on the underlying cause. Adherence to nocturia treatment and outcomes are complex and intertwined, and nonadherence to nocturia treatment is common. In 15 studies meeting eligibility criteria, behavioral and pharmacologic interventions for nocturia were associated with reduced nocturia symptoms. Urinary symptoms that are associated with nocturia need individualized management depending on renal and hepatic function, medical comorbidities, and ongoing medication use in a patient. Another important factor related to adherence is the bother. Although nocturia is defined as nighttime-voiding frequency of one or more, not all persons may find this bothersome. The degree of bother is subjective, and may change from person to person. However, there is no information related to the association between bother and adherence to medication or behavioral treatments for nocturia. Medication dosing convenience, preference, and cost play important roles in adherence. We present a patient-centered conceptual model that brings together the various dimensions of medication adherence for nocturia. CONCLUSION Few studies have explored adherence to medication and related factors in the care of nocturia. Our conceptual model can aid development of interventions to improve adherence to nocturia medications.
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Affiliation(s)
- Ravishankar Jayadevappa
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Diane K Newman
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sumedha Chhatre
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alan J Wein
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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An evidence-based strategy for the conservative management of the male patient with incontinence. Curr Opin Urol 2014; 24:553-9. [DOI: 10.1097/mou.0000000000000115] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Abstract
PURPOSE OF REVIEW Male patients with lower urinary tract symptoms have historically been managed in a prostate centric fashion. Population studies highlighting the prevalence and significance of storage symptoms, including nocturia, have meant a shift in the way men with lower urinary tract symptoms are assessed and managed. We review the recent guidelines and publications that have addressed this change in approach. RECENT FINDINGS A new β-3 adrenoreceptor agonist has demonstrated significant improvement in storage symptoms and appears to be well tolerated. SUMMARY We support a continued move towards a patient-focused and management using the current guidelines.
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Raskolnikov D, Friedman FM, Etwaru DJ, Weiss JP. The evaluation and management of persistent nocturia. Curr Urol Rep 2014; 15:439. [PMID: 25007892 DOI: 10.1007/s11934-014-0439-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Nocturia, or waking at night to void, is a common symptom that leads to substantial morbidity. Men and women are both affected across a wide age range, such that the objective evaluation of nocturia remains a challenge, due largely to its multifactorial etiology. While for some patients, nocturia is caused by common structural conditions such as prostatic obstruction, for others it is due to a complex interplay between multiple underlying systemic diseases. For this reason, persistent nocturia merits particularly careful consideration. The purpose of this review is to describe the most recent salient research in the field of nocturia, with a particular emphasis on its evaluation and management.
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Affiliation(s)
- Dima Raskolnikov
- Department of Urology, SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY, 11203, USA,
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Burgio KL. Update on behavioral and physical therapies for incontinence and overactive bladder: the role of pelvic floor muscle training. Curr Urol Rep 2014; 14:457-64. [PMID: 23913199 DOI: 10.1007/s11934-013-0358-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Behavioral and physical therapies have been used for many years to treat incontinence and overactive bladder (OAB). This paper focuses on programs that include pelvic floor muscle training (PFMT) as a component in treatment for women or men. PFMT was long used almost exclusively for treatment of stress incontinence. When it became evident that voluntary pelvic floor muscle contraction can be used to control bladder function, PFMT was also integrated into the treatment of urge incontinence and OAB as part of a broader behavioral urge suppression strategy. PFMT has evolved over decades, both as a behavioral therapy and a physical therapy, combining principles from behavioral science, nursing, and muscle physiology into a widely recommended conservative treatment. The collective literature indicates that PFMT is effective for incontinence, as well as urgency, frequency, and nocturia. It can be combined with all other treatment modalities and holds potential for prevention of bladder symptoms.
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Affiliation(s)
- Kathryn L Burgio
- University of Alabama at Birmingham and the Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, AL 35244, USA.
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Newman DK, Wein AJ. Office-Based Behavioral Therapy for Management of Incontinence and Other Pelvic Disorders. Urol Clin North Am 2013; 40:613-35. [DOI: 10.1016/j.ucl.2013.07.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Kawahara T, Morita S, Ito H, Terao H, Sakata R, Ishiguro H, Tanaka K, Miyamoto H, Matsuzaki J, Kubota Y, Uemura H. Ramelteon combined with an α1-blocker decreases nocturia in men with benign prostatic hyperplasia. BMC Urol 2013; 13:30. [PMID: 23758651 PMCID: PMC3687682 DOI: 10.1186/1471-2490-13-30] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Accepted: 06/04/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nocturia is defined as waking one or more times during the night due to the urge to void. Recently, the effectiveness of several sedatives and analgesics for nocturia has been reported. We herein investigated the effects of ramelteon, an antioxidant and sleep inducer, on nocturia unresponsive to α1-blocker monotherapy in males with lower urinary tract symptoms (LUTS) as a pilot study. METHODS Subjects were 19 patients who had LUTS suggestive of benign prostate hyperplasia, received α1-blockers (tamsulosin, silodosin, or naftopidil), and continued to have two or more episodes of nocturia per night before starting ramelteon. Ramelteon at 8 mg once daily for one month was added to the α1-blocker. A self-administered questionnaire including the International Prostate Symptom Score (IPSS), quality of life (QoL) index, Overactive Bladder Symptom Score (OABSS), and Nocturia Quality-of-Life Questionnaire (N-QOL) were assessed before and one month after starting ramelteon. RESULTS The mean score on IPSS question 7 (nocturia) decreased significantly from 2.88 before starting ramelteon to 2.41 one month after starting the medication (P = 0.03). The mean total OABSS decreased significantly from 6.31 to 5.38 (P = 0.03), and the mean for OABSS question 2 (nighttime frequency of nocturia) also significantly decreased from 2.63 to 2.13 (P = 0.01). The mean total N-QOL score did not change significantly. Two patients had dizziness; the remaining patients had no adverse drug-related events. CONCLUSIONS Ramelteon in combination with an α1-blocker could be a treatment option for reducing nocturia in men with BPH.
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