Conservative
management of
nocturia
Claire ErvinClinical Nurse Consultant Continence
MN (Urology)
Overview
Nocturia key points
Definitions
Prevalence
Causality
Subtypes of nocturia
Assessment
Conservative treatment
Michael Murray Award
Nocturia:
key points
Increased mortality risk
Often under reported, delayed medical intervention1
A mismatch between nocturnal urine production and bladder storage capacity results in nocturia
1.Oelke et al. 2016
ICS 2018
Definitions:
Nocturia
The symptom of nocturia is number of times urine passed during the main sleep period. Each void is followed by sleep or the intention to sleep.
The sign is the number of overnight voids, quantifiable by the health professional using bladder diary/questionnaire
Changes to
nocturia
definition
No longer defined as a complaint
New definition includes pts who:
• void multiple times, often in a row and may not return to sleep
• incomplete bladder emptying, who void frequently
• Pts unable to return to sleep due to painful/sensitive bladder
• Pts with insomnia/difficulty returning to sleep unrelated to bladder
Hashim Hashim et al.,2019
Time Scenario
1 2 3
2200 Bed & sleep Bed bed2300 X X2400 Sleep Sleep0100
0200 Wake to void
XSleep after void
Wake to void
X
Wake to void
XSleep after void
0300
0400 Wake to void
XSleep after void
XSleep after void
Wake to voidX
0500 XIntention to sleep /unable
0600
0700 Wake & Risefor day
Wake & Risefor day
Rise for the day
N2002: 2N2018: 2
N2002: 0N2018 :2
N2002: 1N2018: 3
Adapted from Hashim et al.2019N2002= previous definition N2018=new definition, X=void
Definition:
nighttime
Night-time for nocturia terminology
Defined by the individuals sleep cycle1
• Commences at time of falling asleep
• Concludes when sleep no longer attempted1
1.Hashim et al., 2018
Definitions:
Polyuria
Global
- Symptom: excessive excretion of urine
- Sign: Over 40ml/kg per body weight over 24 hrs
Nocturnal
- Symptom: report of passing large volume of urine
overnight
- Sign: Excessive urine production during main
sleep period
- Determined by bladder diary (Npi)
• >33% of 24-hr urine volume in >65 yrs.
• 20-30% of 24-hr urine volume in middle age
• >20 % of 24-hr urine volume in younger individuals
Prevalence of Nocturia
9Cornu et al. European Urology 2012; 62:877-890
MEN WOMEN
age age
Pathophysiology
underlying
nocturia
Nocturnal Polyuria
Global polyuria
Reduction of capacity of bladder
Sleep disorders
Underlying
causes
of nocturia
Bower et al,.2018
Diabetes mellitus
Sleep
Impact of
nocturia
Most bothersome symptom of LUTS1
Significant factor in sleep disturbance
↑ bother and ↓QoL directly related to severity of nocturia
1:Andersson et al.,2016
Outcome measures:
What Matters vs What is the Matter
Or is it
Improvement in QoL
↑FUST ↑ Sleep quality↑Daytime function
Should the focus be the number of nocturia episodes?
Nocturia:
Evaluation
Patient history
Current medications
Physical examination
Bladder Diary
Investigations
Questionnaires
Bladder
Diary
Essential part of a continence assessment
Gold standard: 3-day bladder
Tool to support diagnosis
May repeat to evaluate treatment efficacy
Addition relevant clinical data is collected
• fluid intake
• sleep/wake times
• FUST
• other symptoms
Bladder diary
• 2018 study showed 45% of 3-day diaries were incomplete 1
• To completion, provide clear instructions, individualize.
Compliance may be problematic
• Timing- may vary from day to day
• incomplete data as not fully completedDiary limitations
• time consuming, pt./ carer burden
• physical difficulties
• mobility
• vision, dexterity, language
Barriers
1. Cameron et al., 2018
Nocturia
treatments
Individualized
Target identified underlying pathophysiology
Combination therapies recommended
1st line treatments are conservative
2nd line pharmacotherapies
A multidisciplinary team may be required
Nocturnal
Polyuria
Treatment can be subtyped to guide treatment pathway
Water diuresis
Osmolite diuresis
Reduced
functional
bladder
capacity
Treatment dependent on underlying cause
If associated with OAB
- Bladder training
- 2nd line- pharmacotherapy
-Treatment for prostatic obstruction
If associated with BOO
Everaert et al.,2016
Nocturia
associated
with sleep
Address underlying sleep dysfunction
Sleep hygiene
Identify and address other factors impeding sleep
• Pain
• Depression/anxiety
1ST Line
treatments
Minimize fluid intake at least 2 hrs before bed
↓intake of caffeine and alcohol
Restrict 24-hr intake to < 2.0L, dependent on comorbidities
Empty bladder prior to sleep
↓dietary salt intake
↑ exercise levels
For patients on diuretics - consider timing
Compression if dependent peripheral oedema-
Adapted from Oelke et a.,2017
Fluid restriction Individual needs determined by:
Health status
Age
Activity levels
↓ daily fluid intake by 25%1
Restrict evening fluid intake
Baseline consumption 30mL/kg bodyweight
(1.5L minimum)2
Consider if sodium or fluid restriction
previously advised
1.Hashim and Abrams. 2008
2. Skokan and Newman 2016
Caffeine reduction
Produces diuretic effect on kidneys1
May increase smooth muscle contractility, ↑ existing
detrusor instability2
No guideline on recommended daily intake in
relation to bladder
Slight ↑ risk of nocturia if 3 or more cups of tea/
day3
Caffeine dose of 400mg/day- not associated with
adverse effect4
1. Fenton et al. 2015 2.Weiss et al. 2012
3. Bradley et al. 2017 4.Cornelis. 2019
Reduce Alcohol
Alcohol contributes to nocturnal
polyuria
↓ Production of ADH
related to ↑ in water diuresis1
No guidelines available related to
bladder
1.Shiri et al., 2008
Limit salt intake
Reduced salt intake reduces
nocturnal polyuria by ↓ sodium
excretion
No guidelines on salt intake
In nocturic pts with ↑salt intake.
A salt reduction of 2g/day may ↓
nocturia by one episode1
1.Matsuo et al.,2018
Physical exercise
No guidelines for aged/frail to ↓nocturia
150 minutes per week recommended
Limited evidence 30 minutes per day
↓ nocturia by one episode as sleep improved1
Increased levels of exercise may promote
weight loss
1. Sugaya et al., 2007
Medication timing: diuretics
Short-acting loop diuretics
5-6 hours before bed
Stimulates diuresis prior to sleep
to reduce nocturnal urine
volume
Lower leg oedema
Compression stockings during the day
to ↓ fluid accumulation.
Leg elevation in evening to reduce 3rd
space fluid volume
No guidelines on timing, duration or
degree
Bladder training
Pelvic floor training– urge strategies to promote voiding when bladder is at capacity
Consider combination with Antimuscarinics or B3 antagonist medication1 ± Botox
Where NP has been excluded
Pharmacotherapy
Bladder storage
- Antimuscarinics
- Beta-3 adrenoceptors
Bladder outlet obstruction
- Alpha blockers
Pharmacotherapy:
Hormonal
Vaginal oestrogen therapy
Anti-diuretic hormone
- Sodium level screening required
- Caution in > 65 yr old1
- Nocturnal polyuria
1:Chung 2018
Practice Points
Need to look beyond the bladder
Multidisciplinary team required to optimize
management of comorbidities
Nocturnal polyuria is the most common
cause
Multi modal therapy
↑ health literacy on nocturia
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