Nocturia

Nocturia is often described as the most bothersome of all urinary symptoms and is also one of the most common. It affects 50 million people in the United States, with 10 million actually diagnosed with nocturia but only 1.5 million receiving specific therapy for it. One in three adults older than age 30 make at least two trips to the bathroom every night, and about 70% of these individuals are bothered by this. Nocturia can be associated with long-term sleep deprivation in addition to the inconvenience that it causes. Nocturia is defined as the need for a patient to get up at night on a regular basis to urinate. A period of sleep must precede and follow the urinary episode to count as a nocturnal void. This means the first-morning void is not considered when determining nocturia episodes. Nocturnal enuresis is a completely different disorder as patients are generally not aware of a full bladder and typically experience an involuntary void while in bed. Nocturnal frequency is very similar to nocturia except that in nocturia the voiding episodes are each preceded and followed by sleep periods. Nocturia frequently accompanies an overactive bladder not explainable by urinary tract infections or other identifiable disorders. About half of the patients with daytime urinary urgency will also have nocturia. Those with nocturia of three or more nocturnal voids per night have a significantly higher overall mortality rate than the general population. Nocturia affects overall health and daytime functioning from loss of sleep, risks falls and injuries at night, reduces the quality of life, lowers productivity, and may even affect the health of the partner whose sleep is often disrupted as well. In particular, older adults with nocturia who make multiple nocturnal trips to the bathroom are at substantially increased risk of potentially serious falls. A quarter of all the falls that occur in older individuals happen overnight. Of these, 25% are directly related to nocturia. Patients who make at least 2 or more nocturnal bathroom visits a night, have more than double the risk of fractures and fall-related traumas. Nocturia leads to sleep deprivation, which can cause exhaustion, mood changes, somnolence, impaired productivity, increased risk of falls and accidents, fatigue, lethargy, inattentiveness, and cognitive dysfunction. It has been shown that over 40% of people who have a nighttime awakening will have trouble going back to sleep. It is also associated with decreased physical health, obesity, diabetes, depression, and heart disease. There is a significant financial aspect associated with nocturia. The disorder costs an estimated $62.5 billion dollars to Americans each year due to lost productivity and sick leave associated with nocturia; primarily as a result of preventable falls, fractures, and associated injuries. Despite its relative frequency, nocturia is often under-reported, poorly managed, and inadequately treated. Many patients are reluctant or too embarrassed to mention this problem to their physicians, or they mistakenly believe it is a normal part of aging. Compounding the problem, initial treatment of nocturia by physicians is often superficial and somewhat routine regardless of the actual underlying etiology; with men typically receiving alpha blockers and women prescribed overactive bladder medications without any substantial diagnostic investigation. Further evaluation and management of nocturia are often lacking even when these initial measures fail. For these reasons, it may take one or even two years between the onset of significant symptoms and the beginning of physician-directed, effective nocturia treatment. This creates an obligation of physicians to ask patients about their nocturia, explain that it is an abnormal but treatable condition and offer appropriate help. Treatment should be based on the underlying cause, which requires further evaluation. The purpose of this review is to facilitate improved diagnosis and treatment of this common and bothersome urinary disorder that often requires additional diagnostic and therapeutic measures beyond simple drug treatment of benign prostatic hyperplasia (BPH) in men or bladder overactivity (OAB) in women. A simple evaluation, based on thorough medical history, diabetes screening, a voiding diary, urinalysis, and post-void residual determination, can identify the underlying etiology (such as diabetes or nocturnal polyuria) leading to better treatment outcomes, improved quality of life scores, and substantial symptom resolution.