Etiology, evaluation, and management of nocturia in elderly men and women

Age and metabolic syndrome are associated with unsatisfactory improvement in nocturia after holmium laser enucleation of the prostate

Objective

To investigate the association between age, metabolic syndrome (MetS) and improvement in nocturia in patients with benign prostate hyperplasia (BPH) receiving holmium laser enucleation of the prostate (HoLEP).

Methods

The retrospective study was conducted on patients treated for BPH using HoLEP between January 2021 and May 2022. Lower urinary tract symptoms (LUTS) were measured before surgery and at 3 months postoperatively using the International Prostate Symptom Score (IPSS). The criteria of the Adult Treatment Panel III (ATP III) were adopted to diagnose the MetS. Unsatisfactory improvement in nocturia was defined as <50% reduction in nocturia from baseline on the IPSS.

Results

One hundred and seventy-five patients were eventually enrolled, with a median age of 69 years (IQR: 63/73). Unsatisfactory improvement in nocturia was reported in 95 patients (54%) after HoLEP. These patients were older (73; IQR: 67/79 vs. 66; IQR: 60/71, P < 0.001) and more likely to present with higher postoperative total (6; IQR: 4/9 vs. 3; IQR:2/5, P < 0.001), voiding (1; IQR: 0/3 vs. 1; IQR: 0/2, P = 0.017), and storage (4; IQR: 3/6 vs. 2; IQR: 1/4, P < 0.001) IPSS when compared to patients with satisfactory improvement in nocturia. Overall, 63 of 175 (36%) patients were diagnosed with MetS and of these, 44 (70%) reported unsatisfactory improvement in nocturia (P = 0.002) after HoLEP. Multivariate analysis revealed that age (OR = 1.117, 95% CI: 1.068-1.169, P < 0.001) and MetS (OR = 3.613, 95% CI: 1.727-7.562, P = 0.001) were independent risk factors for unsatisfactory improvement in nocturia after HoLEP.

Conclusion

Our findings suggest that increased age and MetS were associated with unsatisfactory improvement in nocturia in patients with BPH after HoLEP. Lifestyle management, including weight loss, may be of great importance in the improvement of nocturia.

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.

Female Urgency, Trial of Urodynamics as Routine Evaluation (FUTURE study): a superiority randomised clinical trial to evaluate the effectiveness and cost-effectiveness of invasive urodynamic investigations in management of women with refractory overactive bladder symptoms

BACKGROUND

Overactive bladder (OAB) syndrome is a symptom complex affecting 12-14% of the UK adult female population. Symptoms include urinary urgency, with or without urgency incontinence, increased daytime urinary frequency and nocturia. OAB has a negative impact on women's social, physical, and psychological wellbeing. Initial treatment includes lifestyle modifications, bladder retraining, pelvic floor exercises and pharmacological therapy. However, these measures are unsuccessful in 25-40% of women (refractory OAB). Before considering invasive treatments, such as Botulinum toxin injection or sacral neuromodulation, most guidelines recommend urodynamics to confirm diagnosis of detrusor overactivity (DO). However, urodynamics may fail to show evidence of DO in up to 45% of cases, hence the need to evaluate its effectiveness and cost-effectiveness. FUTURE (Female Urgency, Trial of Urodynamics as Routine Evaluation) aims to test the hypothesis that, in women with refractory OAB, urodynamics and comprehensive clinical assessment is associated with superior patient-reported outcomes following treatment and is more cost-effective, compared to comprehensive clinical assessment only.

METHODS

FUTURE is a pragmatic, multi-centre, superiority randomised controlled trial. Women aged ≥ 18 years with refractory OAB or urgency predominant mixed urinary incontinence, and who have failed/not tolerated conservative and medical treatment, are considered for trial entry. We aim to recruit 1096 women from approximately 60 secondary/tertiary care hospitals across the UK. All consenting women will complete questionnaires at baseline, 3 months, 6 months and 15 months post-randomisation. The primary outcome is participant-reported success at 15 months post-randomisation measured using the Patient Global Impression of Improvement. The primary economic outcome is incremental cost per quality-adjusted life year gained at 15 months. The secondary outcomes include adverse events, impact on other urinary symptoms and health-related quality of life. Qualitative interviews with participants and clinicians and a health economic evaluation will also be conducted. The statistical analysis of the primary outcome will be by intention-to-treat. Results will be presented as estimates and 95% CIs.

DISCUSSION

The FUTURE study will inform patients, clinicians and policy makers whether routine urodynamics improves treatment outcomes in women with refractory OAB and whether it is cost-effective.

TRIAL REGISTRATION

ISRCTN63268739 . Registered on 14 September 2017.

Nocturia: Prevalence and associated factors in community-dwelling subjects - a population- based study

OBJECTIVES To assess the prevalence of nocturia and identify factors associated with it in a community-dwelling population. METHODS A cross-sectional study was conducted in subjects aged 45 years or more and registered with a Family Doctor Program. Information was collected about nocturia, other urinary symptoms, physical examination, co-morbidities, demographics, socio-economic, and lifestyle factors. Multiple logistics regression models were developed to analyze associated factors for nocturia according to gender and the number of nocturnal micturitions(≥1 and ≥2). RESULTS Out of the 661 individuals included in the study, 62.3% were women. Among the women, the prevalence rates for nocturia ≥1 time and ≥2 times were, respectively, 68.4% and 49%, whereas, among the men, they were 64.3% and 43.8%. Among the women, nocturia ≥1 time was associated with brown skin, a higher BMI, lower schooling, and calcium channel blockers(CCB) use, while nocturia ≥2 times showed association with higher BMI, lower schooling, obstructive sleep apnea (OSA), and the use of CCB. Among the men, nocturia ≥1 time was associated positively with age, alcohol intake, and OSA, and negatively with angiotensin receptor blockers and beta-blockers use. Besides, nocturia ≥2 times was associated with age, not having health insurance, and OSA. CONCLUSIONS Nocturia is a condition highly prevalent in the studied population. For the female subjects, a higher BMI, lower schooling, and the use of CCB were associated with nocturia regardless of the definition used, whereas, among the men, that same association was found with age, not having health insurance, and OSA.

Effect of Cognitive Behavioral Therapy for Insomnia on Insomnia Symptoms for Individuals With Type 2 Diabetes: Protocol for a Pilot Randomized Controlled Trial

Background

Insomnia symptoms are a common form of sleep difficulty among people with type 2 diabetes (T2D) affecting sleep quality and health outcomes. Several interventional approaches have been used to improve sleep outcomes in people with T2D. Nonpharmacological approaches, such as cognitive behavioral therapy for insomnia (CBT-I), show promising results regarding safety and sustainability of improvements, although CBT-I has not been examined in people with T2D. Promoting sleep for people with insomnia and T2D could improve insomnia severity and diabetes outcomes.

Objective

The objective of this study is to establish a protocol for a pilot randomized controlled trial (RCT) to examine the effect of 6 sessions of CBT-I on insomnia severity (primary outcome), sleep variability, and other health-related outcomes in individuals with T2D and insomnia symptoms.

Methods

This RCT will use random mixed block size randomization with stratification to assign 28 participants with T2D and insomnia symptoms to either a CBT-I group or a health education group. Outcomes including insomnia severity; sleep variability; diabetes self-care behavior (DSCB); glycemic control (A_1c); glucose level; sleep quality; daytime sleepiness; and symptoms of depression, anxiety, and pain will be gathered before and after the 6-week intervention. Chi-square and independent t tests will be used to test for between-group differences at baseline. Independent t tests will be used to examine the effect of the CBT-I intervention on change score means for insomnia severity, sleep variability, DSCB, A_1c, fatigue, sleep quality, daytime sleepiness, and severity of depression, anxiety, and pain. For all analyses, alpha level will be set at .05.

Results

This study recruitment began in February 2019 and was completed in September 2019.

Conclusions

The intervention, including 6 sessions of CBT-I, will provide insight about its effect in improving insomnia symptoms, sleep variability, fatigue, and diabetes-related health outcomes in people with T2D and those with insomnia symptoms when compared with control.

Trial Registration

ClinicalTrials.gov NCT03713996; https://clinicaltrials.gov/ct2/show/NCT03713996

International Registered Report Identifier (IRRID)

DERR1-10.2196/14647

Does pre-operative urodynamics lead to better outcomes in management of urinary incontinence in women? A linked systematic review and meta-analysis

The use of preoperative urodynamics as a standard investigation for urinary incontinence (UI) has long been a subject of debate, with a lack of robust evidence to demonstrate improved patients' outcomes. We aim to compare the clinical and cost effectiveness of urodynamics versus office clinical evaluation only, prior to the treatment of UI. We conducted three linked systematic reviews and meta-analyses of randomised controlled trials (RCTs) comparing urodynamics assessment versus clinical evaluation only in women prior to 1) non-surgical treatment of UI, 2a) surgical treatment of stress urinary incontinence (SUI) and 2b) invasive treatment for overactive bladder (OAB). Women with severe pelvic organ prolapse, previous continence surgery and neuropathic bladder were excluded. Primary outcomes were patient-reported and objective success post-treatment. Secondary outcomes were adverse events, quality of life, sexual function and health economic measures. We searched MEDLINE, Embase and Cochrane Central Register of Controlled Trials databases for each category, which was last updated on January 2019. Study selection, risk of bias assessment and data extraction were performed independently by two reviewers. The random effects model was used to assess risk ratio and mean difference with 95% confidence interval. Statistical heterogeneity was assessed by I² statistics and the quality of evidence by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Four RCTs compared urodynamics versus clinical evaluation only prior to non-surgical management of UI. Treatment consisted of pelvic floor muscle training, with or without pharmacological therapy. Meta-analysis of 150 women showed no evidence of significant difference in the patient-reported and objective success rates between groups (P = 0.520, RR: 0.91, 95% Cl 0.69-1.21, I² = 0% and P = 0.470, RR:0.87, 95% Cl 0.59-1.28, I² = n/a, respectively). Seven RCTs were identified for surgical management of SUI. The majority of women underwent mid-urethral tape procedures (retropubic or transobturator approach). Meta-analysis of 1149 women showed no evidence of significant difference in patient-reported (P = 0.850, RR:1.01, 95% CI 0.88-1.16, I² = 53%) and objective success between groups (P = 0.630, RR:1.02, 95% CI 0.95-1.08, I² = 28%). There was no significant difference in incidence of voiding dysfunction, de novo urgency, and urinary tract infection between groups. No RCTs were identified for invasive management of OAB. In conclusion, limited evidence shows that routine urodynamics prior to non-surgical management of UI or surgical management of SUI is not associated with improved treatment outcomes, when compared to clinical evaluation only. Well-designed clinical trials are needed to evaluate the clinical and cost-effectiveness of routine urodynamics prior to surgical management of SUI and OAB.

Nocturia and its clinical implications in older women

The aim of this study is to demonstrate the relationship between nocturia and geriatric syndromes, and comprehensive geriatric assessment parameters (CGA) in older women. 858 older outpatient women were included in this cross-sectional study. For the nocturia variable, the question, "Generally, during the past 30 days, how many times did you usually urinate after you have gone to sleep at night until the time you got up in the morning?'' was used. The relationships between nocturia status and common geriatric syndromes, and CGA parameters were determined. The mean age of patients was 74.1 ± 8.0 years. The prevalence of patients who reported average of 0, ≥1, ≥2, ≥3, and ≥4 nocturnal episodes was 14.7%, 85.3%, 66.3%, 42.13%, and 24.1%, respectively. When all the covariates including age, education, Charlson Comorbidities Index score, glomerular filtration rate, antimuscarinic drugs and alpha-blockers use, diabetes mellitus, chronic obstructive pulmonary disease, and incontinence were adjusted, there were higher rates of insomnia, recurrent falls and higher scores of Timed Up-Go test in older women with ≥2 nocturia episodes (p < 0.05). There was a significant correlation between ≥3 nocturia episodes and lower Instrumental Activities of Daily Living scores and a significant correlation between ≥4 nocturnal episodes and frailty and polypharmacy (p < 0.05). Nocturia is quite common and associated with insomnia, frailty, polypharmacy, incontinence, falls, lower gait speed, and functionality in older women.Therefore, nocturia is very important for geriatric practice and ≥2 nocturia episodes can be a marker of poor health status in older women.

Bladder ultrasonography for diagnosing detrusor overactivity: test accuracy study and economic evaluation

BACKGROUND

Urodynamics (UDS) has been considered the gold standard test for detrusor overactivity (DO) in women with an overactive bladder (OAB). Bladder ultrasonography to measure bladder wall thickness (BWT) is less invasive and has been proposed as an alternative test.

OBJECTIVES

To estimate the reliability, reproducibility, accuracy and acceptability of BWT in women with OAB, measured by ultrasonography, in the diagnosis of DO; to explore the role of UDS and its impact on treatment outcomes; and to conduct an economic evaluation of alternative care pathways.

DESIGN

A cross-sectional test accuracy study.

SETTING

22 UK hospitals.

PARTICIPANTS

687 women with OAB.

METHODS

BWT was measured using transvaginal ultrasonography, and DO was assessed using UDS, which was performed blind to ultrasonographic findings. Intraobserver and interobserver reproducibility were assessed by repeated measurements from scans in 37 and 57 women, respectively, and by repeated scans in 27 women. Sensitivity and specificity were computed at pre-specified thresholds. The smallest real differences detectable of BWT were estimated using one-way analysis of variance. The pain and acceptability of both tests were evaluated by a questionnaire. Patient symptoms were measured before testing and after 6 and 12 months using the International Consultation on Incontinence modular Questionnaire Overactive Bladder (short form) (ICIQ-OAB) questionnaire and a global impression of improvement elicited at 12 months. Interventions and patient outcomes were analysed according to urodynamic diagnoses and BWT measurements. A decision-analytic model compared the cost-effectiveness of care strategies using UDS, ultrasonography or clinical history, estimating the cost per woman successfully treated and the cost per quality-adjusted life-year (QALY).

RESULTS

BWT showed very low sensitivity and specificity at all pre-specified cut-off points, and there was no evidence of discrimination at any threshold (p = 0.25). Extensive sensitivity and subgroup analyses did not alter the interpretation of these findings. The smallest detectable difference in BWT was estimated to be 2 mm. Pain levels following both tests appeared relatively low. The proportion of women who found the test 'totally acceptable' was significantly higher with ultrasonography than UDS (81% vs. 56%; p < 0.001). Overall, subsequent treatment was highly associated with urodynamic diagnosis (p < 0.0001). There was no evidence that BWT had any relationship with the global impression of improvement responses at 20 months (p = 0.4). Bladder ultrasonography was more costly and less effective than the other strategies. The incremental cost-effectiveness ratio (ICER) of basing treatment on the primary clinical presentation compared with UDS was £491,500 per woman successfully treated and £60,200 per QALY. Performing a UDS in those women with a clinical history of mixed urinary incontinence had an ICER of £19,500 per woman successfully treated and £12,700 per QALY compared with the provision of urodynamic to all women. For DO cases detected, UDS was the most cost-effective strategy.

CONCLUSION

There was no evidence that BWT had any relationship with DO, regardless of the cut-off point, nor any relationship to symptoms as measured by the ICIQ-OAB. Bladder ultrasonography has no diagnostic or prognostic value as a test in this condition. Furthermore, despite its greater acceptability, BWT measurement was not sufficiently reliable or reproducible.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN46820623.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 7. See the NIHR Journals Library website for further project information.

Medication adherence in the management of nocturia: challenges and solutions

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.