Nocturia as an Unrecognized Symptom of Uncontrolled Hypertension in Black Men Aged 35 to 49 Years

How should we assess the cardiovascular system in patients presenting with bothersome nocturia? ICI-RS 2023

AIMS

The link between nocturia and cardiovascular disease (CVD) is frequently discussed in literature, yet the precise nature of this relationship remains poorly characterized. The existing literature was reviewed in order to address issues concerning the origin, diagnosis, management, and implications of the co-occurrence of CVD and nocturia.

METHODS

This review summarizes literature and recommendations regarding the link between CVD and nocturia discussed during a think-tank meeting held at the 2023 International Consultation on Incontinence-Research Society.

RESULTS

Cardiovascular disorders are often underestimated contributors to nocturia, with various potential mechanisms influencing nighttime urination, such as impact on fluid retention, atrial natriuretic peptide, and glomerular filtration rate. The redistribution of fluid from leg edema in supine position can lead nocturnal polyuria (NP). Additionally, sleep disturbances due to nocturia in itself may lead to CVD through an increase in blood pressure, insulin resistance, and inflammation. Disrupted circadian rhythms (e.g., in sleep pattern and urine production) were identified as critical factors in most etiologies of nocturia, and their contribution is deemed imperative in future research and treatment approaches, particularly in the aging population. NP can be detected through a simple bladder diary and can even be used to distinguish cardiac from noncardiac causes of nocturia. For the treatment of NP, desmopressin can be effective in select patients, however, caution and close monitoring is warranted for those with CVD due to increased risk of side effects.

CONCLUSIONS

Gaps were identified in the available evidence and clear cut recommendations were put forth for future research. It is essential to gain a deeper understanding of the mechanisms linking nocturia and CVD to develop optimal management strategies.

Nocturia and Blood Pressure Elevation in Adolescents

Nocturia has been increasingly recognized as a manifestation of various non-urological conditions including hypertension. In adults, blood pressure (BP) elevation has been identified as a robust correlate of nocturia, but such a relationship has not been studied in pediatric populations where nocturia is often attributed to hormonal, sleep, physiological or psychological disorders. Accordingly, this study aimed to determine the relationship between nocturia and BP elevation in adolescents. We prospectively studied 100 patients, aged 10-18 years, recruited from pediatric clinics at our institution. Nocturia (defined as ≥ 1 voids on voiding diary analysis) was present in 45% of the study sample (range: 1-4 voids/night). 37% of subjects self-reported awakening to urinate, and 34% of subjects had BP elevation according to age-dependent thresholds from current Pediatrics guidelines. On multivariate analyses, BP elevation was strongly associated with nocturia determined by both voiding diary (OR 26.2, 95% CI: 6.5, 106.0) and self-report. Conversely, nocturia was associated with increased odds of elevated BP by diary (26.3, 95% CI: 6.5, 106.4) and self-report (OR 8.1, 95% CI: 3.2, 20.5). In conclusion, nocturia appears to be common and is strongly associated with BP elevation in adolescents. These findings suggest that eliciting a history of nocturia holds promise as a simple method of identifying adolescents at risk for hypertension.

Application of the Sleep C.A.L.M. Tool for Assessing Nocturia in a Large Nationally Representative Cohort

PURPOSE

Nocturia significantly impacts patients' quality of life but remains insufficiently evaluated and treated. The "Sleep C.A.L.M." system categorizes the factors thought to collectively reflect most underlying causes of nocturia (Sleep disorders, Comorbidities, Actions [i.e., modifiable patient behaviors such as excess fluid intake], Lower urinary tract dysfunction, and Medications). The purpose of this study was to assess the association of nocturia with the Sleep C.A.L.M. categories using a nationally representative dataset.

METHODS

Retrospective analysis of the National Health and Nutrition Examination Survey from 2013/14-2017/18 cycles was conducted. Pertinent questionnaire, laboratory, dietary, and physical examination data were used to ascertain the presence of Sleep C.A.L.M. categories in adults ≥20 years of age. Nocturia was defined as ≥2 nighttime voids.

RESULTS

A total of 12,274 included subjects were included (51.6% female; median age, 49.0 years [interquartile range, 34.0-62.0 years]; 27.6% nocturia). Among subjects with nocturia, the prevalence of 0, ≥1, and ≥2 Sleep C.A.L.M. categories was 3.5% (95% confidence interval [CI], 2.8%-4.4%), 96.5% (95% CI, 95.6%-97.2%), and 81.2% (95% CI, 78.9%-83.3%), respectively. Compared to those with 0-1 Sleep C.A.L.M. categories, the adjusted odds of nocturia in subjects with 2, 3, and 4-5 Sleep C. A.L.M. categories were 1.77 (95% CI, 1.43-2.21), 2.33 (1.89-2.87), and 3.49 (2.81-4.35), respectively (P<0.001). Similar trends were observed for most age and sex subgroups. When assessed individually, each of the 5 Sleep C.A.L.M. categories were independently associated with greater odds of nocturia, which likewise persisted across multiple age and sex subgroups.

CONCLUSION

Sleep C.A.L.M. burden is associated with increased odds of nocturia in a dose-dependent fashion, and potentially a relevant means by which to organize the underlying etiologies for nocturia among community-dwelling adults.

Association of nocturia with cardiovascular and all-cause mortality: a prospective cohort study with up to 31 years of follow-up

Background

Nocturia is a highly prevalent and under-considered condition and impacts the quality of life for many individuals. The long-term impact of nocturnal voiding on mortality, especially mortality from cardiovascular disease, remains unknown. The current study aimed to evaluate the relationship of nocturnal voiding episodes with cardiovascular and all-cause mortality among adults in the United States.

Methods

This is a prospective cohort study of a nationally representative sample of 13,862 U.S. adults aged 20 years or older who participated in the National Health and Nutrition Examination Survey III (1988-1994). Nighttime urination frequency was reported during an in-house interview. All-cause and cause-specific mortality were ascertained by linking to National Death Index mortality data through December 31, 2019. The associations of nocturia with cardiovascular and all-cause mortality were estimated using weighted Cox proportional hazards regression models.

Results

Throughout a median follow-up of 26.7 years, 5,029 deaths were reported, comprising 1,720 deaths from cardiovascular disease. In the fully adjusted model, participants who reported once, twice, and three or more times nocturnal voiding episodes have a higher risk of cardiovascular mortality (HR1, 1.22 [95% CI, 0.997-1.49], HR2, 1.47 [95% CI, 1.13-1.91], and HR ≥ 3, 1.96 [95% CI, 1.52-2.53]) as well as all-cause mortality (HR1, 1.12 [95% CI, 0.90-1.39], HR2, 1.54 [95% CI, 1.23-1.93], and HR ≥ 3, 2.48 [95% CI, 1.81-3.40]), compared to those without nocturia, and heart disease-specific mortality (HR1, 1.33 [95% CI, 1.08-1.64], HR2, 1.62 [95% CI, 1.25-2.10], and HR≥3, 2.07 [95% CI, 1.61-2.67]). Nevertheless, there was no significant relationship between the number of nocturia episode changes and stroke-specific mortality.

Conclusion

Nocturia was associated with a significantly augmented risk of overall and heart disease-specific mortality in a dosage-dependent manner. Early recognition and taking precautions may benefit individuals with nocturia by promoting quality of life and cardiac health.

Addressing urinary incontinence by gender: a nationwide population-based study in Turkiye

BACKGROUND

Urinary incontinence (UI), which usually occurs in women but affects both sexes, is a significant public health challenge. This study aims to comprehensively investigate the prevalence and determinants of UI in men and women, considering gender-specific factors.

METHODS

The study performed a secondary analysis on data obtained from 13,383 individuals surveyed in the 2019 Turkish Health Survey, providing a representation of the Turkish population. The dataset included sociodemographic and health-related variables like UI, body mass index (BMI), physical activity, smoking, and chronic diseases-statistical analysis employed chi-square tests and gender-stratified logistic regression models to identify UI-associated factors.

RESULTS

Our results showed that UI affected 8.8% of the population, with a striking gender disparity. Women had a notably higher prevalence at 11.2%, while men had a lower rate of 5.5%. Importantly, this gender gap narrowed with age. For example, in the 34-44 age group, the female/male ratio was 6.9, but it decreased to 1.4 in the 65-74 age group. Marital status and employment status played significant roles. Separated, divorced, or widowed individuals, particularly women, had the highest prevalence at 19.3%. Employment status influenced UI prevalence, with employed men having the lowest rate (2.1%), while retired women faced the highest rate (15.0%). Higher BMI, especially in obese individuals, significantly raised UI prevalence, reaching 7.9% for men and 15.8% for women. Physical inactivity, notably in women (17.0%), and prolonged sedentary hours (13.9%) were associated with higher UI rates. Former smokers, especially women (15.9%), had a notable impact on UI. Poor perceived health and chronic conditions like Chronic Obstructive Pulmonary Disease (COPD), hypertension, and diabetes were significantly associated with higher UI prevalence. Logistic regression analysis revealed that age, education, perceived health status, COPD, and diabetes were significant factors associated with UI in both sexes, while in women, BMI, physical activity, and smoking also played notable roles.

CONCLUSIONS

This extensive UI study has unveiled notable gender disparities and determinants. Notably, these disparities decrease with age, underlining UI's changing nature over time. Modifiable factors impact women more, while non-modifiable factors are linked to men. The study underscores the importance of tailoring healthcare strategies to address UI based on gender.

The Relationships between Various Factors and Sleep Status: A Cross-Sectional Study among Healthy Saudi Adults

Impaired sleep can adversely affect daily life. This study assesses the association between different factors and sleep status among apparently healthy Saudi adults. In total, 478 adults were included in this study. Data on anthropometrics, body composition, stress scales, physical activity, and dietary habits were collected. Fasting blood glucose and lipid profile were measured. Sleep quality and duration were assessed using the Pittsburgh Sleep Quality Index. Larger neck circumference (NC) was associated with short sleep duration (odds ratio (OR) 1.23; 95% confidence interval (CI) [1.08, 1.41]; p = 0.002). Higher triglyceride levels were associated with poor sleep quality (OR 1.01; 95% CI [1.002, 1.02]; p = 0.019) and short sleep duration (OR 1.01; 95% CI [1.004, 1.02]; p = 0.005). Stress was a risk factor for poor sleep quality (OR 1.15; 95% CI [1.09, 1.22]; p < 0.001). Being married was significantly associated with good sleep quality (OR 2.97; 95% CI [1.32, 6.71]; p = 0.009), while being single was correlated with longer sleep duration (OR 0.46; 95% CI [0.22, 0.96]; p = 0.039). Other factors such as having a larger waist circumference and more muscle mass were protective factors against poor sleep quality and/or short sleep duration. In conclusion, a larger NC is suggested as a risk factor for short sleep duration and a higher triglyceride level for both short and poor sleep among healthy Saudis. Investigating the factors associated with sleep status may help alleviate sleep disturbances and improve overall health. Further studies are needed to confirm causality using objective sleep measures.

Association of nocturia of self-report with estimated glomerular filtration rate: a cross-sectional study from the NHANES 2005-2018

Nocturia is a manifestation of systemic diseases, in which chronic kidney disease (CKD) is an independent predictor of nocturia due to its osmotic diuretic mechanism. However, to our knowledge, previous studies have not examined the association between nocturia and estimated glomerular filtration rate (eGFR). The purpose of this study was to assess the association between nocturia exposure and eGFR in the general US population. This study presents a cross-sectional analysis of the general US population enrolled in the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2018. To account for potential confounding factors, linear regression analysis was conducted to investigate the association between nocturia and eGFR. Stratified analyses and interaction tests were employed to examine the variables of interest. Additionally, sensitivity analyses were conducted across diverse populations. A total of 12,265 individuals were included in the study. After controlling for confounding factors, the results of the linear regression analysis indicated that a single increase in nocturnal voiding frequency was associated with a decrease in eGFR by 2.0 mL/min/1.73 m2. In comparison to individuals with a nocturnal urinary frequency of 0, those who voided 1, 2, 3, 4, and ≥ 5 times at night experienced a decrease in eGFR by 3.1, 5.4, 6.4, 8.6 and 4.0 mL/min/1.73 m2, respectively. Nocturia was found to be associated with a decreased eGFR of 4 mL/min/1.73 m2 when compared to individuals without nocturia. The sensitivity analysis yielded consistent findings regarding the association between nocturia and eGFR in both CKD and non-CKD populations, as well as in hypertensive and non-hypertensive populations. Nevertheless, inconsistent conclusions were observed across various prognostic risk populations within the CKD context. The presence of nocturia and heightened frequency of nocturnal urination have been found to be associated with a decline in eGFR.

Relationship between nocturia and hypertension: findings from the NHANES 2005-2016

Objectives

The objective of this study was to explore the association between nocturia and hypertension in a large, nationally representative adult sample.

Methods

We used data from 2005 to 2016 National Health and Nutritional Examination Surveys (NHANES). A total of 29,505 participants aged 20 years old or older were included. A participant was considered to have nocturia if he or she had two or more voiding episodes at night. Multivariable logistic regression models were used to explore the association between nocturia and hypertension.

Results

Participants with nocturia were associated with a higher risk of hypertension (OR, 1.36; 95% CI, 1.28-1.45). Interaction tests revealed no significant effect of sex, age, race, or body mass index on the association of nocturia with hypertension. As the severity of nocturia increases, the risk of hypertension increases (P for trend <0.0001). In addition, nocturia was also related to different grades of hypertension (II vs. I: OR, 1.34, 95% CI, 1.16-1.55; III vs. I: OR, 1.67, 95% CI, 1.32-2.13).

Conclusion

In this cross-sectional study, our results suggest that nocturia is associated with an increased risk for hypertension.

'Nocturomics': transition to omics-driven biomarkers of nocturia, a systematic review and future prospects

OBJECTIVE

To systematically review studies that investigated different biomarkers of nocturia, including omics-driven biomarkers or 'Nocturomics'.

MATERIALS AND METHODS

PubMed® , Scopus® , and Embase® were searched systematically in May 2022 for research papers on biomarkers in physiological fluids and tissues from patients with nocturia. A distinction was made between biomarkers or candidates discovered by omics techniques, referred to as omics-driven biomarkers, and classical biomarkers, measured by standard laboratory techniques and mostly thought from pathophysiological hypothesis.

RESULTS

A total of 13 studies with 18 881 patients in total were included, eight of which focused on classical biomarkers including: atrial natriuretic peptide (ANP), B-type natriuretic peptide (BNP), C-reactive protein (CRP), aldosterone, and melatonin. Five were 'Nocturomics', including one that assessed the microbiome and identified 27 faecal and eight urinary bacteria correlated with nocturia; and four studies that identified candidate metabolomic biomarkers, including fatty acid metabolites, serotonin, glycerol, lauric acid, thiaproline, and imidazolelactic acid among others. To date, no biomarker is recommended in clinical practice. Nocturomics are in an embryonic phase of conception but are developing quickly. Although candidate biomarkers are being identified, none of them are yet validated on a large sample, although some preclinical studies have shown a probable role of fatty acid metabolites as a possible biomarker of circadian rhythm and chronotherapy.

CONCLUSION

Further research is needed to validate biomarkers for nocturia within the framework of a diagnostic and therapeutic precision medicine perspective. We hope this study provides a summary of the current biomarker discoveries associated with nocturia and details future prospects for omics-driven biomarkers.

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

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.

Home Blood Pressure Monitoring And Nocturia In Adults

Although widely viewed as a urological condition, nocturia has been increasingly recognized to accompany various non-urological conditions such as hypertension and blood pressure (BP) elevation on office determination. Home BP monitoring (HBPM) has been shown superior to office-based readings and provides an opportunity to assess potential relationships between nocturia and novel indices derived from multiple BP recordings including BP load, BP variability, and arterial stiffness, which have prognostic significance. We retrospectively studied 103 home BP logs and nocturia frequencies provided by 61 stable cardiology patients ≥ 21 years without medication change. Nocturnal voids ranged from 0 to 5 voids per night, median: 1.5. Nocturia frequency was significantly correlated with home and office systolic BPs and with BP load, but not with diastolic BPs, BP variability or arterial stiffness. On Poisson regression analysis, the estimated prevalence ratio (PR) for home and office systolic BPs were 1.025 (CI: 1.01, 1.04; p < .001) and 1.01 (CI:1.00, 1.02; p = .019), indicating 2.5% and 1% increases in the risk of nocturia per mmHg increases in BP respectively. In conclusion, higher mean home and office systolic BPs are associated with self-reported nocturia frequency with stronger associations seen for home BP measurement. Nocturia frequency appears unrelated to mean home and office diastolic BPs. Nocturia may be related to BP load, (percentage of elevated BP values), but not to BP variability or arterial stiffness. Future prospective studies using HBPM are needed to confirm these findings and to contribute to the understanding of the elevated BP-nocturia link.

The association between diabetes and nocturia: A systematic review and meta-analysis

Background

Many studies have explored the association between diabetes and nocturia, but it remains unclear. This article systematically analyses existing evidence of the relationship between diabetes and nocturia, including subgroup analysis based on the number of voids, gender, and continent, in the hope of reaching more reliable clinical conclusions relating to diabetes and nocturia.

Methods

PubMed, Web of Science, and Cochrane Library were searched for identifying studies relating to diabetes and nocturia prior to July 2021. Literature quality evaluation was performed using the Newcastle Ottawa Scale. A random effect meta-analysis was used for pooled odds ratios (ORs) and confidence intervals (CIs) as a means of evaluating the relationship between diabetes and nocturia.

Results

In total, 29 of 781 potentially relevant studies were proven to be eligible. The overall pooled OR demonstrated that diabetes increases the risk of nocturia (OR: 1.49; 95% CI: 1.38, 1.61; P < 0.00001). The association was found to be more robust among subjects ≥ 1 void than ≥ 2 void (OR: 1.74; 95% CI: 1.41, 2.14; P < 0.00001 vs. OR: 1.45; 95% CI: 1.33, 1.59; P < 0.00001), in males than females (OR: 1.59; 95% CI: 1.41, 1.79; P < 0.00001 vs. OR: 1.41; 95% CI: 1.20, 1.66; P < 0.0001) and in Asia than Europe or North America (OR: 1.54; 95% CI: 1.36, 1.75; P < 0.00001 vs. OR: 1.43; 95% CI: 1.19, 1.72; P = 0.0001 vs. OR: 1.45; 95% CI: 1.22, 1.73; P < 0.0001).

Conclusions

Diabetes has an association with a 1.49-fold higher risk of nocturia. This association is more robust for Asian and male subjects or those at a lower nocturia cut-off.

Nocturia independently predicts left ventricular hypertrophy and left atrial enlargement among patients with cardiac symptoms

Nocturia can be caused by urological disorders and systemic diseases, including heart diseases. We aimed to investigate the relationship between nocturia and structural abnormalities on echocardiography. Adult patients who underwent echocardiography for cardiac symptoms or heart murmur or had a history of structural heart disease were included. The voiding times during sleep hours were collected prospectively. Univariate and multivariate analyses were performed to evaluate the predictive value of bothersome nocturia (nocturia ≥ 2) on echocardiographic abnormalities. Of 299 patients, 182 (60.9%) reported bothersome nocturia. In patients aged ≥ 65 years, hypertension and left atrial enlargement (LAE) were associated with higher occurrences of bothersome nocturia. On multivariate analysis, bothersome nocturia was a predictive factor of LAE (odds ratio [OR] 2.453, 95% confidence interval [CI] 1.363–4.416, p = 0.003). Moreover, bothersome nocturia could predict both LAE and left ventricular hypertrophy (LVH) (OR 2.285, 95% CI 1.151–4.536, p = 0.018; OR 2.056, 95% CI 1.025–4.124, p = 0.043) in the elderly. Older age, hypertension, and LAE were risk factors for bothersome nocturia. Moreover, bothersome nocturia was predictive of LAE and LVH in the elderly. Patients with bothersome nocturia without other significant lower urinary tract symptoms should be referred to cardiologists.

Noncancerous Genitourinary Conditions as a Public Health Priority: Conceptualizing the Hidden Burden

OBJECTIVE

To provide a conceptual framework to guide investigations into burdens of noncancerous genitourinary conditions (NCGUCs), which are extensive and poorly understood.

METHODS

The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop of diverse, interdisciplinary researchers and health professionals to identify known and hidden burdens of NCGUCs that must be measured to estimate the comprehensive burden. Following the meeting, a subgroup of attendees (authors of this article) continued to meet to conceptualize burden.

RESULTS

The Hidden Burden of Noncancerous Genitourinary Conditions Framework includes impacts across multiple levels of well-being and social ecology, including individual (ie, biologic factors, lived experience, behaviors), interpersonal (eg, romantic partners, family members), organizational/institutional (eg, schools, workplaces), community (eg, public restroom infrastructure), societal (eg, health care and insurance systems, national workforce/economic output), and ecosystem (eg, landfill waste) effects. The framework acknowledges that NCGUCs can be a manifestation of underlying biological dysfunction, while also leading to biological impacts (generation and exacerbation of health conditions, treatment side effects).

CONCLUSION

NCGUCs confer a large, poorly understood burden to individuals and society. An evidence-base to describe the comprehensive burden is needed. Measurement of NCGUC burdens should incorporate multiple levels of well-being and social ecology, a life course perspective, and potential interactions between NCGUCs and genetics, sex, race, and gender. This approach would elucidate accumulated impacts and potential health inequities in experienced burdens. Uncovering the hidden burden of NCGUCs may draw attention and resources (eg, new research and improved treatments) to this important domain of health.

De novo nocturia: A red flag for coronary heart disease patients

OBJECTIVES

Nocturia is frequent among older patients and has been linked to cardiovascular diseases. The aim of this study was to assess the time relationship between the onset of nocturia and coronary heart disease (CHD). Specifically, this study investigated whether nocturia can be identified as a red flag de novo symptom in patients with CHD.

METHODS

This cross-sectional study consisted of patients with CHD-related cardiac complaints who were prospectively recruited from November 2019 till March 2020 at the cardiac catheterization laboratory of the Ghent University Hospital. An analysis was performed to determine the time relationship between nocturia and CHD and to describe the nocturia characteristics.

RESULTS

Forty-five patients with nocturia and established CHD were included. Of these patients, 74% (31/42) developed nocturia before their cardiac symptoms occurred, with a median time gap of 57 months (IQR 19-101). Furthermore, 64% (29/45) of them had clinically significant nocturia (≥2 nocturnal voids) and there was a significant correlation between age at which nocturia and cardiac symptoms occurred (r=0.89, p<0.001).

CONCLUSION

This is the first study that analysed the time relationship between onset of nocturia and onset of cardiac complaints in patients with CHD. In most of the patients, nocturia had started before they were diagnosed with CHD, meaning that nocturia might precede the development of cardiac symptoms, such as angina and shortness of breath. Keeping this in mind, de novo nocturia may or even should be considered as a red flag for CHD.

LEVEL OF EVIDENCE: 4

(cross sectional study with prospectively recruitement) Source: https://www.ciap.health.nsw.gov.au/training/ebp-learning-modules/module1/grading-levels-of-evidence.html.

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

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

PATIENT SUMMARY

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

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Calcium Channel Blockers Are Associated with Nocturia in Men Aged 40 Years or Older

BACKGROUND

The associations of nocturia with hypertension and anti-hypertensive agents (AHTs) remain to be validated.

METHODS

This cross-sectional study examined whether blood pressure and/or frequently used classes of AHTs had consistent associations with nocturia.

METHODS

A total of 418 male patients aged ≥ 40 years were retrospectively assessed in terms of the International Prostate Symptom Score (IPSS), prescription medications, and blood pressure. Nocturia was evaluated using item 7 of the IPSS, and two or more episodes of nocturia per night was considered to indicate clinically important nocturia.

RESULTS

Patients taking calcium channel blockers (CCBs), but not other AHTs, experienced more episodes of nocturia than patients not taking AHTs (1.77 ± 1.07, 1.90 ± 1.19, and 1.48 ± 0.98 in CCBs alone, CCBs + other AHTs, and other AHTs alone, vs. 1.35 ± 1.08 in not taking AHTs; p = 0.014, p < 0.0001, and p = 0.91, respectively), whereas there was no significant difference in the number of nocturia episodes between patients with elevated and normal blood pressure. In multivariate analysis, CCB (odds ratio (OR) = 2.68, p < 0.0001) and age (OR = 1.06, p < 0.0001) were independently associated with clinically important nocturia.

CONCLUSION

CCB was associated with nocturia, while AHTs other than CCBs and elevated blood pressure were not.

Nocturia and electrocardiographic abnormalities among patients at an inner-city cardiology clinic

AIMS

Nocturia has been increasingly recognized as a potential manifestation of cardiovascular disease. However, the relationship between nocturia and electrocardiographic (ECG) abnormalities has not been studied. This study aims to characterize the diagnostic utility of nocturia in identifying left ventricular hypertrophy (LVH), left atrial enlargement (LAE), and prolonged QTc on ECG.

METHODS

Retrospective analysis of nocturnal voiding frequency and contemporaneous ECG data from consecutive patients evaluated at a university-based outpatient cardiology clinic. Three sets of three incremental binary multiple logistic regression models controlling for (1) age, (2) sex and race, and (3) body mass index, hypertension, diabetes mellitus, and diuretic utilization were performed to determine whether nocturia was predictive of LVH, LAE, and prolonged QTc.

RESULTS

Included patients (n = 143, 77.6% nocturia) were predominantly African-American (89.5%), female (74.1%), and obese (61.5%), of whom 44.1%, 41.3%, and 27.3% had LVH, LAE, and prolonged QTc, respectively. Older age, African-American race, obesity, hypertension, diuretic use, LVH, and LAE were significantly associated with nocturia on univariate analysis. No significant differences were observed in the strength of associations between nocturia and LVH, LAE, or QTc prolongation based on age. Nocturia independently predicted LVH in Models I-III (odds ratios [ORs], 2.99-3.20; relative risks [RRs], 1.18 for all, p ≤ .046) and LAE in Models I-III (ORs, 4.24-4.72; RRs, 1.21 for all, p ≤ .015). No significant associations were observed between nocturia and prolonged QTc.

CONCLUSIONS

Nocturia may be a risk marker for underlying structural cardiac abnormalities.

Nocturia is an Independent Predictor of Abdominal Aortic Calcification in Women: Results from the National Health and Nutrition Examination Survey

Nocturia is generally considered a urological condition, but may be an indicator of cardiovascular disease, as prior studies have found associations with cardiovascular risk factors as well as clinical and subclinical markers of coronary artery disease. This study aimed to explore potential associations between nocturia and abdominal aortic calcification (AAC). We analyzed 2013-2014 National Health and Nutrition Examination Survey dual energy x-ray absorptiometry-derived AAC data and concurrent interview data on kidney conditions from respondents aged 40-80 years. AAC was defined as a score ≥ 1 on the 24-point semi-quantitative AAC scale. Nocturia was defined as an average of ≥ 2 voids per night. Three incremental multivariate logistic regression models controlling for (1) age, (2) sex, race, and BMI, and (3) hypertension, diabetes mellitus, and smoking history were used to determine whether nocturia predicted AAC. These models were and modified to exclude age and/or sex to perform age- and/or sex-specific sub-analyses, respectively. Complete data were available from 2,945 participants (29.1% AAC, 31.4% nocturia). On univariate analysis, the association between nocturia and AAC was significant in women (OR 1.77 [95% CI 1.37-2.29], p < 0.001), but not in men (1.14 [0.74-1.76], p = 0.531). Multivariate analysis showed nocturia was an independent predictor of AAC in women in Models I-II (ORs 1.49-1.58, p ≤ 0.032) but not Model III (1.37 [0.90-2.09], p = 0.133). Stratification by age revealed a strong univariate association among women aged 50-59 (3.88 [1.97-7.61], p < 0.001), which persisted across all multivariate models (ORs 4.05-4.41, p ≤ 0.001). The presence of nocturia is an important clue of AAC in women, especially those middle-aged.

Nocturia as an Unrecognized Symptom of Uncontrolled Hypertension in Black Men Aged 35 to 49 Years

Background

Hypertension is assumed to be asymptomatic. Yet, clinically significant nocturia (≥2 nightly voids) constitutes a putative symptom of uncontrolled hypertension. Black men with hypertension may be prone to nocturia because of blunted nocturnal blood pressure (BP) dipping, diuretic drug use for hypertension, and comorbidity that predisposes to nocturia. Here, we test the hypothesis that nocturia is a common and potentially reversible symptom of uncontrolled hypertension in black men.

Methods and Results

We determined the strength of association between nocturia (≥2 nightly voids) and high BP (≥135/85 mm Hg) by conducting in‐person health interviews and measuring BP with an automated monitor in a large community‐based sample of black men in their barbershops. Because nocturia is prevalent and steeply age‐dependent after age 50 years, we studied men aged 35 to 49 years. Among 1673 black men (mean age, 43±4 years [SD]), those with hypertension were 56% more likely than men with normotension to have nocturia after adjustment for diabetes mellitus and sleep apnea (adjusted odds ratio, 1.56; 95% CI, 1.25–1.94 [P<0.0001]). Nocturia prevalence varied by hypertension status, ranging from 24% in men with normotension to 49% in men whose hypertension was medically treated but uncontrolled. Men with untreated hypertension were 39% more likely than men with normotension to report nocturia (P=0.02), whereas men whose hypertension was treated and controlled were no more likely than men with normotension to report nocturia (P=0.69).

Conclusions

Uncontrolled hypertension was an independent determinant of clinically important nocturia in a large cross‐sectional community‐based study of non‐Hispanic black men aged 35 to 49 years.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unqiue identifier: NCT 02321618.

Sodium restriction improves nocturia in patients at a cardiology clinic

This study aims to determine whether dietary sodium restriction counseling decreases nocturnal voiding frequency in cardiology patients with concomitant nocturia. Patients who had established care at a cardiology clinic from 2015 to 2018 reporting ≥1 average nocturnal void(s) underwent a comprehensive sodium intake interview by their cardiologist, who provided them with individualized strategies for dietary sodium reduction and assessed adherence at follow-up. Average nocturnal voiding frequency and dietary adherence were documented in the medical record. A nocturia database was compiled for retrospective analysis. A total of 74 patients were included. Patients considered to be adherent with dietary sodium restriction at follow-up (n = 56) demonstrated a decrease in median nocturia frequency (2.5 [2.3-3.0] vs 1.0 [1.0-2.0] voids, P < .001). Among nonadherent patients (n = 18), median nocturia frequency did not significantly change from baseline to follow-up (2.0 [1.5-3.8] vs 2.0 [1.5-4.8] voids, P = .423). Median changes were significantly different between the adherent and nonadherent groups (P < .001). Examination of second follow-up available from 37 patients showed a continued effect. In conclusion, adherence with dietary sodium counseling appears to improve nocturia. Accordingly, dietary modification may represent an important adjunct therapy to lifestyle and pharmacologic interventions for decreasing nocturia frequency. Reduction in nocturnal voiding frequency may also reflect an additional benefit of dietary sodium restriction in accordance with best practice standards for cardiovascular disease.

Management Strategies for Nocturia

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.