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