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DIFFERENTIATING THE CAUSES OF NOCTURIA

Nocturnal polyuria (NP) is a common underlying condition of nocturia1

 

 

 

Nocturia has been traditionally regarded by urologists as a urine storage symptom associated with benign prostatic hyperplasia (BPH) and/or overactive bladder (OAB).1 BPH can result in bladder outlet obstruction (BOO) causing nocturia symptoms.1 Studies show that NP presents in 76-88% of reported nocturia cases -the majority of patients suffering from nocturia.1 More importantly, patients who suffer from OAB or BOO with persistent nocturia despite treatment may have underlying nocturnal polyuria as well.1 These findings are consistent regardless of gender, age, ethnicity and/or country;1 this discovery suggests NP can have its own pathology.1 A fuller understanding of the underlying causes of nocturia and correct diagnosis of patients suffering from nocturnal polyuria will help clinicians provide better patient care.

 

Common nocturia causes

 

Causes of nocturia can be simplified to its pathology:6

1. Increased nocturnal urine production

2. Reduced urine volume

3. Increased 24-hour urine volume

These three pathways can lead to nocturia symptoms via different mechanisms6

 

 

Adapted from: Van Karrebroeck of al. Neurourol Urodyn 2002;21:179-183.6 Copyright © 2002.

 

For more information, download our differentiation guide for further guidance in correctly diagnosis the aetiology of nocturia symptoms in your patients.

 

Nocturnal polyuria is an important contributing factor to nocturia

 

 

Common conditions causing nocturia7,8
Overactive bladder (OAB)9–12 Bladder outlet obstruction (BOO)1,12–16 Nocturnal polyuria (NP)1,6,12,17,18
Description Muscles of bladder start to contract involuntarily even when volume of urine in bladder is low Blockage to the base of the bladder, reducing or stopping the flow of urine into the urethra Passing of large volumes of urine at night due to absence of diurnal rhythm of antidiuretic hormone (ADH) system

24-hour urine output is normal or only moderately increased
Gender Female & male Male > female Female = male
Symptoms Nocturia, urinary incontinence, urinary urgency, increased frequency of urination, sleep disturbance, fatigue Abdominal pain, frequent urination, dysuria, hesitancy, poor stream, intermittent stream, terminal dribbling, nocturia, urinary tract infection, sleep disturbance Nocturia, sleep disturbance
Causes Multifactorial

Specific cause of OAB is still unknown

 Multifactorial
Large prevalence due to benign prostatic hyperplasia among men		 Multifactorial

Can be idiopathic
Risk factors for development Elderly patients with cognitive decline Largely dependent on cause Largely dependent on cause
Diagnosis Medical history

Physical exam

Urine sample

Neurological exam

Fluid and bladder diary

 Physical exam

Digital rectal exam

Blood chemistries

Prostate-specific antigen testing

Cystoscopy and retrograde urethrogram

Uroflowmetry

Urodynamic testing

Ultrasound

Urinalysis / urine culture

 Medical history

3-day bladder diary

ADH levels
Treatment Behavioural strategies such as pelvic floor exercises or scheduled toilet trips

Lifestyle modifications such as fluid restriction

Anticholinergics

Antimuscarinics

Bladder injections (e.g. botox)

Invasive/non-invasive nerve stimulation

Surgery (last resort)

 Largely dependent on cause

Urinary catheterisation

Prostate-specific:

  • 5-alpha reductase inhibitors
  • Alpha-1-adrenoreceptor antagonists
  • Trans-urethral resection of prostate (TURP)
  • Laser prostatectomy
 Largely dependent on cause

Fluid restriction

Lifestyle modification

ADH analogues (desmopressin)
  1. Weiss JP et al. J Urol 2011;186:1358–1363.
  2. Chang SC et al. Urology 2006;67:541–544.
  3. Young H et al. Med J Malaysia 2005;60(3):294–296.
  4. Kurtzman J et al. Curr Opin Urol 2016;26:315–320.
  5. Irwin DE et al. BJU Int 2008;101:1381–1387.
  6. van Kerrebroeck P et al. Neurourol Urodyn 2002;21:179–183.
  7. Henderson R. Patient. September 2016. Nocturia – Clinical Reference. Available at: https://patient.info/doctor/nocturia. Date accessed: September 2017.
  8. Guy’s and St Thomas NHS Foundation Trust. Nocturia (getting up at night to pass urine). January 2017. Available at: http://www.guysandstthomas.nhs.uk/resources/patient-information/elderly-care/nocturia.pdf. Date accessed: September 2017.
  9. Mayo Clinic. Aug 2017. Overactive Bladder. Available at: http://www.mayoclinic.org/diseases-conditions/overactive-bladder/home/ovc-20311819. Date accessed: September 2017.
  10. Ge TJ. et al. Urology. 2017 Nov;109:67-73.
  11. National Institute for Health and Care Excellence (NICE). June 2015. Incontinence – urinary, in women. Available at: https://cks.nice.org.uk/incontinence-urinary-in-women. Date accessed: September 2017.
  12. Ellis ME. Healthline. December 2016. How to Treat an Overactive Bladder at Night. Available at: http://www.healthline.com/health/overactive-bladder/overactive-bladder-night#overview1. Date accessed: September 2017.
  13. Dawson C and Whitfield H. BMJ 1996;312:767.
  14. Sobol J. MedlinePlus. April 2016. Bladder outlet obstruction. Available at: https://medlineplus.gov/ency/article/002238.htm. Date accessed: September 2017.
  15. Policastro MA et al. February 2016. Urinary Obstruction Medication. Available at: http://emedicine.medscape.com/article/778456-medication#2. Date accessed: September 2017.
  16. Dmochowski RR. Rev Urol 2005;7(Suppl 6):S3–13.
  17. Asplund R. Gen Pharmacol. 1995;26(6):1203–1209.
  18. Everaert K et al. in Practical Functional Urology, Springer 2016. Edited by Heesakkers, et al. pp 377–392.
  19. Sand PK et al. J Urol 2013;190:958–964.
  20. Weiss JP et al. J Urol 2013;190:965–972
  21. Noqdirna Summary of Product Characteristics. May 2016. Available at: http://www.medicines.org.uk/emc/medicine/32493. Date accessed: September 2017.

Job Code: UK-NOQD-2000015 - Date of preparation: January 2023

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