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Published in Primary Care

Journal Scan / Review · September 02, 2015

Nocturia: Current Evaluation and Treatment Options

Current Urology Reports

 

Take-Home Message

  • An increased focus on nocturia has recently developed due to its association with adverse conditions including heart disease, diabetes, and mortality. This review summarizes the work done to date to diagnose, investigate, and treat nocturia. Initial assessment should involve frequency volume charts to understand the cause, since there are many possibilities (eg, reduced bladder capacity, sleep disturbances, and elevated urine production).
  • Optimal management of the nocturia depends on accurate diagnosis. Many behavioral and pharmacologic treatment options are available.

Nocturia represents a real diagnostic challenge because it can be caused by different system disturbances; however, once the problem is identified, the path to treatment is often very rewarding because of the significant improvements in patients' quality of life. This brief review of nocturia aims to highlight a few clinically relevant points that can help healthcare providers contextualize and manage an extremely common and important yet nonspecific symptom increasingly seen in our aging patient population.

Clinicians need to specifically ask their patients about nocturia.

 

When patients start experiencing nocturia, they may simply adapt to the bother associated with it and may not complain about it for years. Moreover, they may feel that it is part of “growing old” and may not bring it to the attention of their physicians. It is important for primary care physicians to specifically ask their patients if they get up at night to urinate and how many times. Furthermore, although common, nocturia is associated with significant health consequences such as diabetes, elevated BMI, heart disease, and overall mortality. This is another reason why clinicians can better serve their patients by emphasizing the importance of nocturia as a symptom warranting further investigation and not just a behavior pattern to be expected with age.

Nocturia is a nonspecific symptom that needs to be fully worked up.

 

Nocturia is a nonspecific symptom that may be caused by one or a combination of several potential diseases. The first step in managing nocturia is identifying the system responsible for its occurrence.

Sleep issues: A patient may wake up for another reason and incidentally empty his/her bladder.

Bladder problem: Multiple bladder disturbances can result in nocturia with or without daytime frequency, such as overactive bladder (caused by tumors, infections, stones, etc), underactive bladder with overflow voiding (where the bladder is never completely empty), and decreased bladder capacity resulting in frequent small voids.

Fluid problem: High nighttime urine production may result in frequent high-volume urinations at night with or without an accompanying daytime high urine production. Examples of underlying causes are diabetes mellitus, diabetes insipidus, obstructive sleep apnea, and day–night body fluid shifts.

The history is necessary but insufficient: we always need FVCs.

 

A thorough history is important in the beginning to rule out potential causes and further focus on suspicious systems for a specific patient; however, it isn’t enough. Frequency volume charts (also known as a voiding diary) kept for a period of 3 days are a requirement for the accurate diagnosis of the underlying problem. Patients must record their fluid intakes (time and volume) as well as their urinations (time and volume) for a period of 3 days and report back to the clinician for analysis and diagnostic assessment. In our clinics, we provide patients with a pre-labeled empty grid to fill out at home as well as a urinal to measure their voided volumes. These are basic homework tools without which patients cannot realistically accomplish this tedious and unpleasant task. Other tools (such as the Berlin Sleep Questionnaire, urinalysis and urine culture, cytology, etc) are also important to rule out other common causes such as obstructive sleep apnea, urinary tract infections, and bladder tumors.

Primary care physicians have a particularly important role to play.

 

Primary care physicians are particularly well positioned to complete the first-line investigations geared at attributing this nonspecific symptom to the appropriate system that may be at cause. A thorough and organized approach can be very rewarding; the root cause may not always be obvious, but most underlying pathologies can be reliably managed, resulting in a significant improvement in quality of life.

 
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