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Demystifying Nocturia: Identifying the Cause and Tailoring the Treatment

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SERIES Demystifying Nocturia: Identifying the Cause and Tailoring the Treatment Paula Laureanno, Pamela Ellsworth octuria is a highly Nocturia is a common problem with a significant impact on quality of life. The prevalent and bother- etiology of nocturia is multifactorial. Recent standardized terminology with some condition with respect to nocturia has been developed to promote more efficient communica- significant health- tion among providers/specialists. A careful history, physical examination, and Nre lated consequences. Patients use of a voiding diary are important steps in identifying the etiology of nocturia with nocturia may present to mul- and assist in tailoring the treatment regimen. tiple practitioners, including a © 2010 Society of Urologic Nurses and Associates urologist, gynecologist, geriatri- Urologic Nursing, pp. 276-287. cian, neurologist, sleep expert, endocrinologist, and primary care provider. Each practitioner/spe- Key Words: Nocturia, polyuria, voided volume. cialty may approach patients from a different perspective. Therefore, it is important that some of the Objectives basic terms surrounding nocturia 1. Define nocturia. have specific definitions so each 2. Explain the impact of nocturia on sleep. individual provider refers to the 3. Discuss the evaluation of nocturia. same condition in his or her clin- ical evaluation and management. 4. Explain the treatment options currently being used for patients with nocturia. Despite its impact, nocturia Prevalence of Nocturia has been poorly described and Historically, the definition of Paula Laureanno, RN, is a Staff Nurse, managed. In 2002, the Inter- nocturia has varied, making it dif- University Urological Associates, Providence, national Continence Society (ICS) ficult to arrive at a precise preva- RI. defined nocturia as the complaint lence figure. Furthermore, few epi- the individual has to wake at night Pamela Ellsworth, MD, FACS, FAAP, is an demiologic studies have been per- one or more times to void (Abrams Associate Professor of Surgery (Urology), formed in the United States. Warren Alpert School of Medicine, Brown et al., 2003). The standardization Nocturia prevalence has been University, Providence, RI. subcommittee of the ICS further reported to be between 58% and defined the terminology related to Statements of Disclosure: Pamela 66% in women and men ages 50 nocturia so that colleagues in dif- Ellsworth, MD, FACS, FAAP, disclosed that to 59 years, and 72% and 91% she is on the consultant/presenter bureau for ferent specialties could communi- in women and men over 80 Novartis and Pfizer, receives grant support cate effectively with respect to years, respectively (Middelkoop, from Novartis, and is on the advisory board nocturia. Developments in the for Pfizer and Allergan. She further disclosed Smilde- van den Doel, Neven, characterization of nocturia have that there is mention of off-label drug use in Kamphuisen, & Springer, 1996). In allowed for simplified and concise this article, stated as “not FDA-approved” in a more recent national survey con- the text. approaches to the evaluation of ducted by telephone of 5204 com- patients presenting with nocturia. munity-based adults with an aver- Paula Laureanno, RN, reported no actual or A greater understanding of the eti- potential conflict of interest in relation to this age age of 45.8 years, 31% report- ologies of nocturia has promoted continuing nursing education article. ed at least one void per night, and the development of more focused 14.2% reported at least two voids Note: Objectives and CNE Evaluation Form treatment strategies. appear on page 287. per night (Coyne et al., 2003). 276 UROLOGIC NURSING / September-October 2010 / Volume 30 Number 5 SERIES Studies in Japan and Austria, in Table 1. which nocturia was defined as Nocturia Terminology and Definitions two voids or more per night, found rates of 28.5% and 11.3%, Term Definition respectively (Schatzl et al., 2000; Night time The period of time between going to bed Yoshimura et al., 2004). with the intention of sleeping and waking with the intention of rising. Nocturia The number of voids recorded during a Impact of Nocturia night’s sleep. Each void is preceded and fol- The impact of nocturia is sig- lowed by sleep. nificant. A number of studies has Nocturnal urine volume Total volume of urine passed during the demonstrated that a high propor- night including the first morning void. tion (63% to 75%) of individuals with nocturia perceive it to be Rate of nocturnal urine production The nocturnal volume/time asleep (for troublesome (Jolleys, Donovan, example, night), measured in ml/minutes. Nanchahal, Peters, & Abrams, Nocturnal polyuria The production of an abnormally large vol- 1994; Scarpa, 2001; Swithinbank ume of urine during sleep – Should include et al., 1999). Nocturia has a signif- all urine produced after going to bed and icant impact on sleep, and accord- the first void after arising, nocturnal volume ing to Marschall-Kehrel (2004), greater than 20% to 30% of total 24-hour uninterrupted sleep is necessary urine volume (age dependent). for the maintenance of physical, mental, and emotional well-being. 24-hour voided volume Total volume of urine voided during a 24- In a Dutch cross-sectional epi- hour period (first void to be discarded; 24 hours begins at the time of the next void). demiologic study, nocturia was found to be one of the two most Polyuria 24-hour voided volume in excess of 2800 important causes of sleep distur- ml in a 70 kg person or more than 40 ml/kg. bance in adults over 50 years of age (Middelkoop et al., 1996). In Night time frequency The number of voids recorded from the time an elderly population in Sweden, the individual goes to bed with the intention of going to sleep, to the time the individual nocturia was found to be associat- wakes with the intention of rising. ed with an increased prevalence of sleep disorders, poorer quality First morning void The first void after waking with the intention sleep, and increased day time of rising. fatigue (Asplund & Aberg 1992). Maximum voided volume (MVV) The largest single voided volume measured This population experienced fre- in a 24-hour period. quent awakenings and a general feeling of insufficient and non- Nocturia index (Ni) Mean-measured nocturnal urine volume restorative sleep. In addition, nor- (NUV) divided by the functional bladder capacity (deduced from the frequency vol- mal somatic symptoms, such as ume chart). An Ni greater than 1 means that muscle cramps in the calves, leg nocturnal urine production is greater than tingling, and nocturnal sweating, the functional bladder capacity. are also increased in parallel with increasing number of voids Nocturnal polyuria index (NPi) Mean-measured nocturnal volume/24-hour (Asplund & Aberg 1992). The voided volume. NPi greater than 33% changes in sleep associated with implies nocturnal polyuria as opposed to diurnal polyuria. nocturnal voiding result in day time sleepiness and impaired per- Nocturia bladder capacity index The difference between the actual number ception and balance, which can (NBCi) of nocturnal voids (ANV) and the predicted also increase the risk of fall number of nocturnal voids (PNV). The injuries (Van Balen et al., 2001). In greater the NBCi, the more often nocturia is a study of night time falls in the occasioned by nocturnal voided volumes smaller than the MVV. elderly, it was found that the occurrence of two or more noctur- Predicted number of nocturnal voids Ni minus 1. nal voids was associated with a two-fold increase in falls com- Source: Abrams et al., 2003. pared with fewer than two voids (Stewart, Moore, May, Marks, & Hale, 1992). UROLOGIC NURSING / September-October 2010 / Volume 30 Number 5 277 SERIES Nocturia is associated with an Table 2. increased mortality. In an epi- Causes of Polyuria demiologic study of over 6000 Diabetes Mellitus Type 1 (IDDM) and Type 2 (NIDDM) men and women 65 years of age and older in northern Sweden, Diabetes insipidus 190 men and 287 women reported Pituitary having three or more nocturnal Renal voids. Fifty-four deaths were noted among the men with three Secondary nephrogenic due to: or more nocturnal voids and 34 Lithium deaths among the women. The Electrolyte disturbances – Hypercalcemia, hypokalemia death rate was twice as high for Primary polydipsia males and females, with three or more voids per night as all men Psychogenic and women in the study Dipsogenic (Asplund, 1999). Finally, there is Iatrogenic some evidence to suggest that sleep deprivation may have an effect on the function of the Nocturnal Polyuria uria can be divided into those that immune system (Benca & Urine output normally de- cause a water diuresis or a solute/ Quintas, 1997) and that sleep is creases during the night. This water diuresis (see Table 3.). important in maintaining host appears to be related to a corre- Congestive heart failure, low defenses (Irwin et al., 1996). sponding increase in secretion of blood volume, venous stasis dis- antidiuretic hormone (ADH). As ease, and high intake of salt may Terminology Related to Nocturia ADH secretion increases, there is result in third spacing of fluid in increased resorption of water from the lower extremities, which can ICS has developed several the renal tubule, resulting in lower contribute to fluid retention asso- definitions for terms that apply to volumes of concentrated urine. ciated with nocturnal polyuria, as the evaluation and identification The urine output during sleep can can renal insufficiency (Weiss & of the cause of an individual’s be expressed as a percentage of the Blaivas, 2000, 2002). With certain nocturia (van Kerrebroeck et al., total urine output over 24 hours if respiratory conditions such as 2002). Weiss and colleagues have the 24-hour urine output is nor- sleep apnea, hypoxia in the lungs also identified several parameters mal. This value can vary consider- can lead to pulmonary vasocon- pertinent to the evaluation of noc- ably from person to person and striction and increased concentra- turia (Weiss, Blaivas, & Stember, normally increases with age.
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