Nocturia

Nocturia is often described as the most bothersome of all urinary symptoms and is also one of the most common. The disorder affects 50 million people in the US, with 10 mtually diagnosed with nocturia but only 1.5 million receiving specific therapy. One in 3 adults older than the age of 30 years makes at least 2 trips to the bathroom nightly, and about 70% of these individuals are bothered by this. However, approximately 50% of all adults older than the age of 65 years get up at least once a night to void, and about 24% will have ≥2 nocturia episodes nightly. 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 regularly to urinate. A sleep period 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 an entirely 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. Getting up at night for any reason other than the need to urinate is technically not nocturia, although it will appear as such on voiding diaries. However, this type of voiding is technically defined as a convenience void. 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 who have 3 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 sleep loss, risks of falls and injury at night, quality of life reduction, and lowered productivity. Nocturia may even affect the partner's health, whose sleep is often disrupted. In particular, older adults with nocturia who make multiple nocturnal trips to the bathroom are at a 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. Additionally, nocturia leads to sleep deprivation, which can cause exhaustion, mood changes, drowsiness, impaired productivity, increased risk of falls and accidents, fatigue, lethargy, inattentiveness, and cognitive dysfunction. Studies have shown that more than 40% of people with a nighttime awakening will have trouble returning to sleep. Nocturia 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 patients in the US an estimated 62.5 billion dollars annually 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, effective nocturia treatment may take 1 to 2 years between the onset of significant symptoms and the beginning of physician-directed management. This creates an obligation for physicians to ask patients about their nocturia, explain that nocturia 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 postvoid residual determination, can identify the underlying etiology (eg, diabetes or nocturnal polyuria), leading to better treatment outcomes, improved quality of life scores, and substantial symptom resolution.