Nocturia

What is Nocturia?

Nocturia, usually known as nighttime urination, is a common urinary symptom that many people find annoying. It affects 50 million people in the U.S., with 10 million of these people having been diagnosed, but only 1.5 million actually getting specific treatment. One out of every three adults over the age of 30 gets up at least twice a night to go to the bathroom, and about 70% of these people find this bothersome. But, about 50% of all adults over the age of 65 get up at least once a night to urinate, and around 24% wake up more than twice a night to do so.

Nocturia is a condition that makes a person wake up regularly due to the urge to urinate. In order for urination to count as nocturia, you should have been asleep before and after the bathroom break. So, the first time you urinate in the morning is not considered a nocturia event. Conditions like nocturnal enuresis (bed-wetting) and nocturnal frequency (frequent need to urinate at night) are different from nocturia. Also, if you wake up at night for reasons other than the need to urinate, that’s not considered nocturia.

Nocturia often accompanies an overactive bladder, which is not caused by urinary tract infections or other known conditions. Half the people who have an urgent need to urinate during the day also experience nocturia. People who wake up three or more times at night to urinate have a higher rate of death than the general population. Problems linked with nocturia include tiredness due to lack of sleep, risks of falling and getting injured at night, lower productivity, and a reduced quality of life. If you have a partner, their sleep might also get disturbed which can affect their health as well. Older adults who frequently get up at night due to nocturia are at a higher risk of falls.

People who wake up at least twice a night to go to the bathroom have double the risk of fractures and injuries due to falls. Also, the lack of sleep resulting from nocturia can lead to exhaustion, mood changes, drowsiness, lower productivity, greater risk of falls and accidents, fatigue, inattention, and difficulty thinking. Studies have found that more than 40% of people who wake up at night have trouble going back to sleep. Nocturia is also associated with worsened physical health, obesity, diabetes, depression, and heart disease. This condition costs patients in the US around 62.5 billion dollars each year due to lost productivity and sick leave primarily because of preventable falls, fractures, and related injuries.

Despite being so common, nocturia is often not reported and remains misunderstood and untreated. This is because many people are too shy to discuss it with their doctors, or they wrongly think it’s a normal part of aging. As a result, effective treatment for nocturia can take 1 to 2 years from when severe symptoms start to when treatment begins. Doctors need to ask patients about their nocturia, tell them that nocturia is not normal but can be treated, and provide appropriate help based on the cause, which requires further evaluation.

The aim of this simplified summary of the medical literature is to help better diagnose and treat this common and bothersome urinary issue. Simple evaluations based on a thorough medical history, diabetes testing, a diary of urination times, urine tests, and the volume of urine left in the bladder after urination can identify the root cause of nocturia. This can lead to better treatment, improved quality of life, and significant relief from symptoms.

What Causes Nocturia?

Nocturia, or waking up during the night to urinate, can be caused by many factors, including producing too much urine at night, producing too much urine throughout the day and night, problems with bladder storage, and sleep disorders.

Nocturnal polyuria is the most common cause of nocturia. It’s when your body produces more urine at night than it should. For younger adults, this means producing more than 20% of your total urine volume at night, and for older adults, it’s more than 33%. Factors like caffeine and excessive drinking in the evenings, alcoholism, heart failure, sleep apnea, daytime use of water pills, high salt intake, and venous insufficiency (when the veins in your legs are unable to adequately pump blood back to the heart) can significantly contribute to this disorder.

Two hormones involved in determining hourly urine production are Arginine vasopressin (AVP) and atrial natriuretic peptide (ANP – heart hormone which increases urination and reduces blood volume). Imbalances in these hormones can lead to increased urination at night.

Global polyuria is another cause of nocturia and it means you’re producing too much urine throughout the day and night -not just during the night. It often happens due to increased water intake, caused by things like certain medical conditions, medication side effects or even behavioral habits.

If you don’t produce too much urine, but still have nocturia, you could have a bladder storage problem or a sleep disorder. These problems are often related to frequent urination with small volumes.

Sleep disorders, like insomnia and sleep apnea, can contribute to nocturia too. If you can’t get back to sleep quickly after urinating during the night, or wake up still feeling tired, you might have a sleep disorder.

Lastly, there are other factors that could cause nocturia. Fluid build-up in your lower body could go back into your system and be filtered out by your kidneys when you lie down, making you urinate more. You could reduce this by elevating your legs, wearing compression stockings, and adjusting when you take water pills. Drinking a lot of fluids or having caffeine or alcohol before bed can cause nocturia as well.

Depression, lack of physical activity, and certain diseases like Parkinson’s disease can also cause nocturia. While nocturia is normal during pregnancy and goes away after giving birth.

Risk Factors and Frequency for Nocturia

Nocturia, or the need to wake up at night to urinate, becomes more prevalent and serious as we age. Over half of men and women over 60 years old have been diagnosed with nocturia. While the overall rate is similar for both genders, younger women experience nocturia more frequently than younger men. However, this trend changes as we age, with older men more likely to have symptomatic nocturia than older women. With the population aging rapidly, we can expect the number of clinically significant nocturia cases to increase.

• About 50% of men aged between 70 to 79 years old have to urinate two or more times per night.
• Different factors can contribute to nocturia depending on gender.
• For example, 40% of women aged 40 years or older experience at least a minimal amount of nocturia.
• It’s common for pregnant women to have nocturia, but it usually goes away about three months after giving birth.
• Nocturia rates are highest among the black population and are not linked to socioeconomic factors.
• Hispanics generally have a slightly higher rate of nocturia than whites, but lower than the black population.
• Obesity is a separate risk factor that can increase the incidence of nocturia 2 to 3 times.

People who have nocturia and other lower urinary tract symptoms often wait before seeking help for these conditions. Keeping a ‘voiding diary’, or a record of your urination, is a great tool for doctors to diagnose nocturia and another condition called nocturnal polyuria. However, not all doctors ask for such diaries from their patients, even though they are strongly recommended. Initial treatment options for nocturia can vary, with men usually receiving alpha-blockers and women getting anticholinergics. These treatments have moderate benefits, but for most patients, nocturia, mainly caused by nocturnal polyuria, may be best treated differently, such as with desmopressin medication.

Signs and Symptoms of Nocturia

Nocturia, or frequently waking up at night to urinate, can be caused by a variety of factors. It’s important for doctors to investigate the overall habits and health of the patient to pinpoint what exactly could be causing this issue. What you eat and drink, how you sleep, if you have any existing medical conditions, and what medication you’re currently taking could all influence it. Doctors will also look out for signs of swelling or fluid buildup in the body.

One of the major methods doctors use to understand nocturia is a 24-hour voiding diary. This diary will help track urination patterns throughout the day and help identify if the issue is polyuria (frequent urination) or bladder overactivity. It’s important to discuss the severity of the nocturia symptoms with your doctor, as well as any discomfort or sleep disruption it causes.

Let’s look at some key factors that doctors will consider when evaluating nocturia:

• Fluid intake: High consumption of fluids can cause nocturia. The types of fluids matter too. For example, overconsumption of caffeine and alcohol can result in bladder overactivity and increase fluid output. To manage nocturia, it’s beneficial to reduce fluid intake before bedtime, especially in the case of elderly patients who maybe mildly dehydrated.
• Medications: Some drugs affect the bladder’s storage capacity or increase urination. Timing of medication intake should be adjusted to avoid nocturia. For instance, loop diuretics which increase urine output should be taken early in the afternoon so the effect wears off before bedtime.
• Existing health conditions: Existing health conditions like diabetes, hypertension, and sleep disorders can contribute to nocturia. Doctors will also look for situations that might increase the risk of injury when waking up at night – such as visual impairment or history of falls.
• Urinary tract issues: Urine flow issues such as hesitancy, straining, or incomplete emptying could be signs of lower urinary tract symptoms (LUTS), which need further investigation. Issues like an overactive or neurogenic bladder, benign prostatic hyperplasia (BPH) in men, or obstruction can be managed with appropriate medication or therapy.

In terms of physical examination, doctors will look for various signs that could help diagnose contributing factors to nocturia.

• Orthostasis and dizziness could indicate an adverse effect of alpha-blockers or blood pressure issues.
• Fluid overload or congestive heart failure might be observed through symptoms like rapid breathing, rapid heart rate, difficulty breathing, or auscultation of crackles (a crackling noise) in the lungs.
• Additionally, a bloated or tender lower abdomen could indicate bladder over-distension or high post-void residual volumes.
• For men, a digital rectal examination might reveal decreased rectal muscle tone, rectal masses, or fecal impaction that can contribute to nocturia.

Estimating the size of the prostate in men and checking for abnormal neurological signs such as an absent anal wink (quick contraction of the anus when the skin next to the rectum is lightly scratched) and decreased sensation in the lower region can provide valuable insights. Lower leg swelling is another indicator of fluid overload or congestive heart failure to be noted.

Testing for Nocturia

Nocturia refers to the condition where you need to wake up multiple times during the night to urinate. This condition can be complex, caused by different factors, and may not respond to initial treatment for related conditions like an ‘overactive bladder’ or ‘BPH (benign prostatic hyperplasia)’ – a non-cancerous enlarged prostate. To treat nocturia effectively, it’s important to identify its root cause, and this can’t be done reliably without a voiding diary.

A voiding diary is the main tool for evaluating nocturia. It involves you recording the time and volume of your urine over 24 hours for three consecutive days. The last urination before bedtime is not included when diagnosing nocturia but if you wake up to urinate, that is counted. Most individuals find waking up two or more times, and especially more than three times a night, annoying enough to seek treatment. However, you determine whether you need treatment based on how severe your symptoms are.

It’s also useful to note down when, what, and how much you drink. Alcoholic beverages can act as diuretics while caffeinated drinks can stimulate bladder activity. Some patients might find documenting all these details too overwhelming. But, the most vital info is the time you urinate and the volume of urine. This information, together with the urine that remains in your bladder after urinating, can be very helpful for diagnosing the type of nocturia you have. For example, if you have a large amount of urine remaining in your bladder after you urinate, you could have bladder storage issues or an enlarged prostate. If you’re having severe nocturia but only a small amount of urine is peed out and there’s minimal left thereafter, it’s likely a case of an overactive bladder. On the other hand, if you urinate a lot, you might have a condition called polyuria, where you produce abnormally large volumes of urine.

Despite its usefulness, research shows that only about 37% of nocturia patients maintain a voiding diary. If you have nocturia and want to address it seriously, it’s critical to keep a 24-hour voiding diary accurately. Even keeping the diary for a single day can be beneficial. The diary will not only help diagnose your type of nocturia and identify the root cause, but also help manage the condition. It can also show you the impact of drinking fluids at appropriate times on your nocturia problem.

It’s also important to pay attention to when you take your medications, especially diuretics. These are medicines, like furosemide, that help your body get rid of excess water and salt through urine. These medicines usually work for 6 to 8 hours after taking them, and if you take them in the morning, they can cause you to urinate more often overnight. To minimize their impact on nocturia, the best time to take these medicines would be 6 to 8 hours before bed.

In addition to the diary and understanding your fluid intake, several medical tests can be helpful. Nocturia can be associated with conditions like poorly controlled diabetes, kidney disease, or a particular type of diabetes that affects your kidneys. To assess for such underlying conditions, tests on your blood glucose levels, blood hemoglobin A1C, kidney function, osmolality (concentration) of your urine, and electrolytes in your blood may be done. Urine analysis could be useful too. In addition, a post-urination residual volume test can be performed, which measures the urine that remains in your bladder after urinating; more than 200mL of leftover urine is considered abnormal and may require deeper investigation. Generally, however, procedures like cystoscopy (a procedure to see inside your bladder) and urodynamics (testing to measure your urine’s flow-rate) are not recommended for most patients with nocturia.

Treatment Options for Nocturia

Traditionally, nocturia, which is frequent nighttime urination, has not always been regarded as a condition that needs treatment unless it bothers the person suffering from it. Because this condition is often seen as a part of aging, people and doctors sometimes overlook it as a treatable issue. However, recent research has shown that treating the condition can significantly improve a person’s quality of life, even when they initially reported little discomfort. Thus, it is now recommended that treatment should be considered for those with significant nocturia.

The first step in managing frequent nighttime urination is to set achievable goals. While it would be great if all nighttime urination could be eliminated, a reduction by about 50% or no more than 1 to 2 voids per night is a more realistic goal for most patients.

The initial management strategies for nocturia involve several lifestyle modifications. These include setting a bedtime routine which involves relaxing activities, limiting fluid intake in the afternoon and evening, reducing salt and protein intake, using compression stockings, and performing pelvic floor exercises. Other recommendations include being physically active in the afternoon but not too close to bedtime, going to bed only for sleeping, setting up a regular sleep routine, eliminating long periods of standing which can lead to swelling in the legs, and avoiding smoking, heavy meals, and exercise late in the day.

There are also some recommended exercises to aid in managing this condition. Pelvic floor muscle exercises, also known as Kegel exercises, can help. The standard exercise includes three repetitions of eight to twelve slow pelvic contractions, held for six to eight seconds, about three to four times a week. Improving sleep hygiene, such as reducing time spent in bed, making the bedroom comfortable for sleeping, and going to bed at the same time each day can also contribute to managing this condition.

There are also several kinds of medication treatments available to help manage nocturia. Medications can be helpful for nocturia caused by an overactive bladder, increased nighttime urine production, and enlarged prostate in men. The timing of taking diuretics, which are medications that increase urine production, can be adjusted to reduce symptoms. Antidiuretic hormone therapy, which reduces urine production at night, is another option. On the other hand, in some cases, medications that work by relaxing the bladder or reducing the size of the prostate can be used. Using a combination of these treatments, together with lifestyle changes, can offer the best results.

In addition to these approaches, alternative techniques such as adjustments in the timing of diuretics use, alpha-blockers for male prostatic obstruction, use of bladder-relaxing drugs, topical vaginal estrogen for postmenopausal women, and use of onabotulinum toxin A in bladder injections have also been found to be beneficial. Some studies have even shown that the combination of treatments can offer the best results in reducing the episodes of nocturia.

It is important to note that while nocturia cannot be cured by surgery, steps can be taken to minimize the risk of tripping or falling when going to the bathroom at night, such as clearing the path from the bed to the bathroom, using nightlights, and keeping a bedpan or urinal by the bed.

Thus, if you are suffering from frequent nighttime urination, several methods, including lifestyle changes, exercises, and medications, can be used to manage this condition and improve your quality of sleep and overall quality of life.

What else can Nocturia be?

When investigating the cause of frequent urination at night, also known as nocturia, doctors think about a variety of potential causes. These include:

• Benign prostatic hyperplasia (BPH)
• Bladder cancer
• Chronic bacterial prostatitis
• Prostate cancer
• Prostatitis
• Having recently had a simple prostatectomy (a surgical procedure used to treat BPH)
• Urinary tract infection in males
• Urinary tract infection in pregnant women
• A blockage in the urinary tract
• Uterine prolapse, a condition in which the uterus drops down into the vagina
• Vesicovaginal fistula, an abnormal connection between the bladder and vagina

What to expect with Nocturia

Nocturia, or frequently waking up at night to urinate, generally has a good prognosis. It’s an inconvenience and can negatively affect your quality of life by disrupting your sleep, but it’s usually not harmful. Nevertheless, it’s important to be careful to avoid accidents like falls when you get up to use the bathroom at night.

With the right evaluation and treatment, people with nocturia can greatly improve their quality of life and overall health. However, it’s important to choose the right treatments considering individual circumstances to minimize side effects, especially for older people and those with memory problems.

Possible Complications When Diagnosed with Nocturia

Nocturia, or frequent night-time urination, doesn’t cause complications on its own. However, the underlying conditions causing nocturia or the treatments for these conditions can lead to complications. Some of these complications might include an electrolyte imbalance in the blood (hyponatremia) or a state of low body water level (dehydration).

• Hyponatremia (low sodium)
• Dehydration

Preventing Nocturia

Nocturia is a condition where you have to wake up one or more times during the night to go to the bathroom. It is quite common in people aged over 60, with more than half affected. The frequency increases with age, but it’s worth remembering that it’s not just a normal part of getting older. Nocturia can be improved by a mix of lifestyle changes, exercises, dietary tweaks, medication, treatments, and other techniques.

Nocturia can impact your overall health, energy levels and quality of life. Interrupted sleep can lead to daytime sleepiness, mood changes, memory problems, and poor concentration. Nocturia is often described as the most bothersome amongst all urinary issues. Interestingly, more than a quarter of all falls at home during the night are because of bathroom visits.

There are four main conditions which can cause nocturia:

• Producing a high volume of urine within 24 hours (for instance, if you have diabetes)
• Overproducing urine during the night (for instance, if you have heart problems or hormone disorders)
• Issues with bladder storage (for instance, with an overactive bladder or prostate disorders)
• Sleep disorders (for example, sleep apnea)

If you have nocturia, you don’t always need to seek treatment. Doctors usually recommend evaluation and treatment only if the condition is really bothersome, for example, requiring bathroom visits three or more times a night, or significantly affecting your sleep. One thing doctors look closely at is whether the need to use the bathroom is waking you up, or if there’s another reason why you’re waking. The amount of time you sleep is also important in understanding thisproblem.

To analyze your condition, doctors may measure the amount of urine you pass every time over a day. This is known as a voiding diary, useful in identifying the underlying issue causing the nocturia.

Some people naturally produce more urine when asleep than when awake due to hormonal imbalance. Meanwhile, others tend to produce more urine throughout the day, which can be a symptom of diabetes. The 24-hour voiding diary can help doctors diagnose these problems without any expensive or uncomfortable tests. Doctors usually recommend consuming enough fluids everyday to produce an output of around 1,500 to 2,000 mL of urine per day, a little higher than average.

Here are some tips on managing nocturia:

• Try to limit how much liquid you drink, especially after dinner unless your doctor tells you otherwise.
• Try to avoid alcohol and caffeine, especially after lunch.
• Aim to reduce the amount of time you spend in bed. Extra time in bed can make your sleep lighter, which can worsen nocturia. The longer you stay in bed, the more likely you are to have to use the bathroom.
• Try doing daily moderate exercise, like walking at least 20 minutes a day. This is especially effective when done in the evening.

After dinner, try to keep your legs and feet lifted as it can help move any excess fluid in the legs back to your heart and kidneys, where it is turned into urine before your bedtime. A small pillow under the knees can make it more comfortable. Compression stockings can also help prevent excess fluid from accumulating in the legs.

If you are on diuretic medications, or ‘water pills’, consider changing when you take them. If you usually take them in the morning, you might want to switch to the afternoon. This is because they usually work for about 6 to 8 hours. The fluid returns to the body and tissues after about 6 to 8 hours. By switching when you take your medication, you can reduce nocturia.

Men with enlarged prostates should seek treatment as it can often help reduce episodes of nocturia. Women, particularly those postmenopausal, may benefit from bladder-relaxing medications, exercises, and vaginal estrogen cream if they have an overactive bladder.

Consider using a bedside commode or urinal to make going to the bathroom at night easier. Create a favourable sleep environment by eliminating as much light and noise as possible. Try to maintain a regular bed time and a comfortable room temperature.

Avoid watching TV, or using smartphones or computers before bed. These devices give off light that can signal your brain to wake up, making sleep difficult. Some studies suggest that taking 1 to 2 mg of melatonin, a natural sleep aid, can reduce nocturia.

This said, spending more time in bed than you need can increase your chances of nocturia. If no effective treatment is found for your nocturia, you might be recommended a sleep study to check for disorders like sleep apnea. If a sleep disorder is contributing to your nocturia, appropriate treatment is recommended.

If simpler methods do not work, considering medications may be necessary. if a hormone issue is identified, medication to correct the condition may be helpful. If these methods are not sufficient to control nocturia, a trial of bladder-relaxing drugs, prostate drugs, sleeping pills or an anti-diuretic hormone supplement may be beneficial.

However, care must be taken with anti-diuretic medications in older patients. While it can be effective for nocturia, excessive use can dangerously impact blood sodium levels, so regular checks are necessary. Anti-diuretics are inadvisable for patients with congestive heart failure, those taking diuretics like furosemide or hydrochlorothiazide, or anyone with chronic fluid overload conditions. Always consult your clinician when making changes to your medications.

If nocturia still persists after trying all of these methods, other treatment options are available, including botox injections into the bladder, nerve stimulation therapy, or installation of a bladder pacemaker. Nocturia is not a disease by itself but a condition caused by various disorders. It can be eliminated or at least significantly improved in most people by using the evaluation and treatment methods described.