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Questions to Ask a Patient with Nocturia CLINICAL Questions to ask a patient with nocturia Wendy F Bower, Karel Everaert, NOCTURIA, defined as waking up from Question 1: How many times do Tee J Ong, Claire F Ervin, sleep to pass urine, is rarely benign. you wake up at night to pass urine? Jens P Norgaard, Michael Whishaw Individuals who void at least twice per The onset and duration of nocturia, night have over four times the risk of number of awakenings at night and relative developing cardiovascular disease and bother should be clarified. In particular, Background double the risk of early death, even when waking from sleep with an urge to void Patients may not raise nocturia as a controlled for known risk factors for should be differentiated from voids made concern as they mistakenly consider the 1 symptom to be a normal part of ageing. mortality. Health issues, such as diabetes, ‘just in case’, which are common in those Nocturia is associated with significant hypertension, cardiovascular disorders, who wake because of sleep disturbance. morbidity and is likely to be a marker mental health problems and obesity, are of poor health. more common in people with nocturia, Question 2: How much does nocturia generating up to a threefold increase in bother you? Objectives 2–5 This paper provides questions to guide the use of healthcare services. Persistent nocturia signals impair sleep diagnosis, evaluation and individualised Figure 1 summarises the possible quality for most patients, usually reducing treatment of nocturia. underlying causes of nocturia, many of the time per cycle spent in slow-wave sleep. which co-exist, interact and lie outside Many older patients do not automatically Discussion the urinary tract system.6–8 There is associate nocturia with their poor sleep, Nocturia results from the interplay an age-related increase in nocturnal although the symptoms drive each other. between nocturnal polyuria, reduced bladder storage and sleep disruption. urine production in older people that Recently, the first undisturbed sleep time Changes in the function of the can interact with reduced bladder (FUST) before awakening to void has urinary bladder, kidneys, brain and sensation and poor bladder emptying. been described as significant to patients. cardiovascular system, and hormone Patients with nocturia will usually Interruption early in the night causes status underlie the development and have a mismatch between nocturnal fatigue the next day and over time affects progression of nocturia. Medications urine production and bladder storage.9 functioning and quality of life.11,12 A FUST commonly prescribed to older people Alternatively, they may have insomnia of three hours or less is associated with can affect development or resolution of nocturia. The bother caused to a or sleep disturbance. high bother for most patients with nocturia. patient by waking to void relates to The aim of this paper is to provide disturbance of slow-wave sleep, the primary care practitioners with eight Question 3: What medications are physical act of getting out of bed questions to ask to guide diagnosis, you taking? and resulting chronic fatigue. An comprehensive evaluation and A review of the patient’s medications assessment process that identifies individualised treatment of nocturia. is important, especially when onset relevant and co-existing causes of an individual’s nocturia will facilitate a of nocturia coincides with recently targeted approach to treatment. History taking commenced pharmacotherapy. Medications may contribute to nocturia The patient-completed nocturia by inducing diuresis or disturbing sleep. screening tool, Targeting the individual’s A clinical overview of diuresis and Aetiology of Nocturia to Guide medication is summarised in Table 1. Outcomes (TANGO;10 Appendix 1), Concurrent medication is also important allows the general practitioner (GP) to when introducing antidiuretic therapy. consider possible causes of increased overnight urine production, sleep Question 4: How much is your bladder dysfunction and sleep disturbance; actually storing day and night? identify the presence of an overactive A bladder diary (or frequency volume bladder (OAB) and possible voiding chart [FVC]) documenting intake and dysfunction; and clarify the impact voiding over 48–72 hours is essential of nocturia. The GP can then gain to understand whether the patient has additional relevant information by normal or restricted bladder storage. It is asking the following leading questions. often a tedious task for patients and may © The Royal Australian College of General Practitioners 2018 REPRINTED FROM AJGP VOL. 47, NO. 7, JULY 2018 | 465 CLINICAL QUESTIONS TO ASK A PATIENT WITH NOCTURIA be poorly completed; however, findings do form the backbone of diagnosis. Polydipsia, Reduced bladder Collection containers with marked salt, protein capacity (overactive volumes, which fit under a toilet seat and bladder, residual urine) decrease patient burden, are available. The FVC may be web-based or a paper Intake Bladder diary and should, ideally, be in the patient’s preferred language. OAB can be associated with reduced day and night voided volumes, urinary urgency Hypertension, heart Water or salt failure, obesity, Cardiovascular Kidney and frequent micturition. In OAB, voiding diuresis frequency occurs up to eight times per day oedema and voided volumes are usually <300 mL during the day. Frequent urination and low voided volumes may also be due to Brain Hormones incomplete emptying, with increased post- void residual (PVR) volumes. Elevation of Sleep disorders (eg PVR urine volumes is particularly likely obstructive sleep apnoea, Menopause, with longstanding diabetes mellitus, restless legs syndrome), andropause, poor previous urinary retention, urinary sleep disruption and thermoregulation convenience voiding tract infections, chronic constipation, known detrusor underactivity or bladder outlet obstruction. Ultrasonography is Figure 1. Underlying causes of nocturia recommended to exclude an elevated PVR. Table 2 shows a sample FVC and diagnostic measures derived from the data. The data indicate nocturnal polyuria Table 1. Impact of medications on nocturia mechanisms and suggest the patient is likely to have OAB. There is no evidence of global Mechanism Drugs polyuria, polydipsia or overnight drinking. Increase free water clearance (diuresis) Diuretics, progesterone, melatonin Question 5: How much urine do Increase osmotic clearance (diuresis) All diuretics, ACE inhibitors, lithium, you make over night? progesterone, SGLT-2 inhibitors A bladder diary identifies whether the Decrease free water clearance dDAVP, oestrogens, testosterone, patient has either global or nocturnal (antidiuresis) antipsychotics, chemotherapeutics, polyuria. The primary measure is the antidepressants, antiepileptics, older amount of urine produced between glucose-lowering medications, opiates falling asleep and emptying the bladder Decrease osmotic clearance (antidiuresis) Calcium channel blockers, beta when waking the next day. Urine output adrenoceptor antagonists, NSAIDs, occurring overnight that exceeds 33% lithium, oestrogen, testosterone, melatonin, of 24-hour urine production indicates corticosteroids, thiazolidinediones nocturnal polyuria; this is a likely finding Induce postural hypotension Hypotensive drugs, anti-Parkinson's in up to 80% of patients with nocturia.13 medication, older psychotropic agents, Global polyuria is diagnosed when 24-hour thiazides urine production exceeds 40 mL/kg body weight (commonly seen with diabetes Induce oedema Calcium channel blockers, steroids, mellitus, diabetes insipidus and polydipsia). NSAIDs Nocturia occurs when nocturnal urine Sleep disruption Antiepileptics, decongestants, SSRIs, production exceeds the bladder capacity. SNRIs, caffeine Question 6: Do you have hypertension Bladder stimulation Caffeine, alcohol, anticholinesterase or cardiac failure, with or without leg inhibitors, cyclophosphamide, ketamine oedema? ACE, angiotensin converting enzyme; dDAVP, desmopressin acetate; NSAIDs, nonsteroidal anti- Blood pressure rises when supine, with inflammatory drugs; SGLT-2, sodium–glucose co-transporter 2; SNRIs, serotonin and noradrenaline reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors increasing renal perfusion, potentially 466 | REPRINTED FROM AJGP VOL. 47, NO. 7, JULY 2018 © The Royal Australian College of General Practitioners 2018 QUESTIONS TO ASK A PATIENT WITH NOCTURIA CLINICAL resulting in nocturnal polyuria.14 sleep quality. Testosterone production may • high body mass index (BMI) ± Antihypertensive medication taken earlier be impaired by interrupted deep sleep or metabolic syndrome in the day may not facilitate dipping of sleep apnoea.19 The mechanism is likely to • leg oedema blood pressure during the night. Swapping be related to reduced vasopressin levels, • cardiac disease treatment for high blood pressure to the preventing reduction in night diuresis. • hypertension evening may reduce the volume of urine It is not known whether testosterone • postural hypotension produced overnight. supplementation reduces nocturia.20 • evidence of neurogenic disease. Patients with accumulation of Potential causes of nocturia, such as dependent oedema will reabsorb this Examination and testing diabetes, heart, liver or kidney disease third-space fluid when supine. For most or sex hormone depletion, should be people, this occurs at night and increases A general physical examination will identified from routine blood tests. renal perfusion, resulting
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