Dean Elterman, MD, FRCSC, Assistant Professor, University of Toronto, Toronto Western Hospital, Toronto, ON.

Its causes are numerous and multisystem in nature, including congestive heart disease, kidney dysfunction, diabetes and nocturnal polyuria – an over production of urine at night. Nocturia is a lower urinary tract symptom, and may be seen with several common urologic conditions such as overactive bladder and benign prostatic hyperplasia.

Nocturia is particularly important because of its impact on quality of life. Frequently waking to pass urine can leave patients chronically fatigued and sleep deprived, leading to impairment during the day and at work. For those at risk of falls and fractures it can be a cause, especially with poor visibility at night. Patients who are unable to make it to the washroom urgently may experience episodes of incontinence during the night. As a possible symptom of many different diseases, nocturia may be the presenting complaint that prompts further investigations and eventually leads to a diagnosis and treatment. It may be associated with other urinary tract conditions including infection and inflammation. Its diagnosis is equally important because of available treatments for either the underlying disease or for nocturnal polyuria—a common cause of nocturia.

This publication focuses on nocturnal polyuria as a common and treatable cause of nocturia. Diagnosis of nocturnal polyuria is made via history, physical exam and frequency-voiding charts. Treatment is tailored to the degree that the patient is symptomatic and begins conservatively with reduction in fluid intake (alcohol and caffeine) before bed, timed voiding and sleep hygiene. Many patients are unaware of the impact that their habits have on nocturia, and simple changes may be very effective.

Medical management involves desmopressin taken as an oral disintegrating tablet before bed which acts as an antidiuretic hormone to reduce urine production overnight in a short acting manner. Newer formulations have significantly lower rates of hyponatremia which must be measured before initiating therapy.

Dean Elterman, MD, FRCSC, ¹Co-authors: Brandon Van Asseldonk B. Eng ²

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Références

1. Gilbert J. Nocturia and Diabetes. Journal of Current Clinical Care Educational Supplement. 017.
2. Shapiro C. Nocturia & Sleep. Journal of Current Clinical Care Educational Supplement. 2017.
3. Elterman D. Nocturia & Urology. Journal of Current Clinical Care Educational Supplement. 2017.
4. Von Ruesten A, Weikert C, Fietze I, Boeing H. Association of sleep duration with chronic diseases in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam study. PLoS One. 2012;7(1):e30972.
5. InterAct Consortium, Scott RA, Langenberg C, et al. The link between family history and risk of type 2 diabetes is not explained by anthropometric, lifestyle or genetic risk factors: the EPIC-InterAct study. Diabetologia. 2013;56(1):60-9.
6. Redeker NS, Adams L, Berkowitz R, et al. Nocturia, sleep and daytime function in stable heart failure. J Card Fail. 2012;18(7):569-75.
7. Morris JL, Sereika SM, Houze M, Chasens ER. Effect of nocturia on next-day sedentary activity in adults with type 2 diabetes. Appl Nurs Res. 2016; 32:44-46.
8. Destors M, Tamisier R, Sapene M, et al. Nocturia is an independent predictive factor of prevalent hypertension in obstructive sleep apnea patients. Sleep Med. 2015;16(5):652-8.
9. Ayik S, Bal K, Akhan G. The association of nocturia with sleep disorders and metabolic and chronic pulmonary conditions: data derived from the polysomnographic evaluations of 730 patients. Turk J Med Sci. 2014;44(2):249-54.
10. Bliwise DL, Foley DJ, Vitiello MV, Ansari FP, Ancoli-Israel S, Walsh JK. Nocturia and disturbed sleep in the elderly. Sleep Med. 2009;10 (5):540–8.
11. Stanley, N. The underestimated impact of nocturia on quality of life. Eur Urol. 2005;4(Suppl):17-19.
12. Denys MA, Cherian J, Rahnama'i MS, O'Connell KA, et al. ICI-RS 2015-Is a better understanding of sleep the key in managing nocturia? Neurourol Urodyn. 2016 Sep 21 (in press).
13. Hajduk IA, Strollo PJJ, Jasani RR, Atwood CWJ, Houck PR, Sanders MH. Prevalence and predictors of nocturia in obstructive sleep apnea-hypopnea syndrome--a retrospective study. Sleep. 2003;26(1):61-64.
14. Yalkut D, Lee LY, Grider J, Jorgensen M, Jackson B, Ott C. Mechanism of atrial natriuretic peptide release with increased inspiratory resistance. J Lab Clin Med. 1996;128(3):322-328.
15. McIntyre R. Nocturia and marjor Depressive Disorder. Journal of Current Clinical Care Educational Supplement. 2017.
16. Breyer BN, Shindel AW, Erickson BA, Blaschko SD, Steers WD, Rosen RC. The association of depression, anxiety and nocturia: a systematic review. J Urol. 2013;190(3):953-7.

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References

1. Gilbert J. Nocturia and Diabetes. Journal of Current Clinical Care Educational Supplement. 017.
2. Shapiro C. Nocturia & Sleep. Journal of Current Clinical Care Educational Supplement. 2017.
3. Elterman D. Nocturia & Urology. Journal of Current Clinical Care Educational Supplement. 2017.
4. Von Ruesten A, Weikert C, Fietze I, Boeing H. Association of sleep duration with chronic diseases in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam study. PLoS One. 2012;7(1):e30972.
5. InterAct Consortium, Scott RA, Langenberg C, et al. The link between family history and risk of type 2 diabetes is not explained by anthropometric, lifestyle or genetic risk factors: the EPIC-InterAct study. Diabetologia. 2013;56(1):60-9.
6. Redeker NS, Adams L, Berkowitz R, et al. Nocturia, sleep and daytime function in stable heart failure. J Card Fail. 2012;18(7):569-75.
7. Morris JL, Sereika SM, Houze M, Chasens ER. Effect of nocturia on next-day sedentary activity in adults with type 2 diabetes. Appl Nurs Res. 2016; 32:44-46.
8. Destors M, Tamisier R, Sapene M, et al. Nocturia is an independent predictive factor of prevalent hypertension in obstructive sleep apnea patients. Sleep Med. 2015;16(5):652-8.
9. Ayik S, Bal K, Akhan G. The association of nocturia with sleep disorders and metabolic and chronic pulmonary conditions: data derived from the polysomnographic evaluations of 730 patients. Turk J Med Sci. 2014;44(2):249-54.
10. Bliwise DL, Foley DJ, Vitiello MV, Ansari FP, Ancoli-Israel S, Walsh JK. Nocturia and disturbed sleep in the elderly. Sleep Med. 2009;10 (5):540–8.
11. Stanley, N. The underestimated impact of nocturia on quality of life. Eur Urol. 2005;4(Suppl):17-19.
12. Denys MA, Cherian J, Rahnama'i MS, O'Connell KA, et al. ICI-RS 2015-Is a better understanding of sleep the key in managing nocturia? Neurourol Urodyn. 2016 Sep 21 (in press).
13. Hajduk IA, Strollo PJJ, Jasani RR, Atwood CWJ, Houck PR, Sanders MH. Prevalence and predictors of nocturia in obstructive sleep apnea-hypopnea syndrome--a retrospective study. Sleep. 2003;26(1):61-64.
14. Yalkut D, Lee LY, Grider J, Jorgensen M, Jackson B, Ott C. Mechanism of atrial natriuretic peptide release with increased inspiratory resistance. J Lab Clin Med. 1996;128(3):322-328.
15. McIntyre R. Nocturia and marjor Depressive Disorder. Journal of Current Clinical Care Educational Supplement. 2017.
16. Breyer BN, Shindel AW, Erickson BA, Blaschko SD, Steers WD, Rosen RC. The association of depression, anxiety and nocturia: a systematic review. J Urol. 2013;190(3):953-7.

Roger S. McIntyre, MD, FRCPC

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Abstract: Research has shown that nocturia and major depressive disorder are often correlated. The clinician should take a complete history along with performing a physical examination when patients present with symptoms that may be associated with nocturia. Patients rarely seek medical attention solely for treatment of nocturia, so direct questions along with use of the Frequency Volume Chart (FVC) should be used to assess whether underlying disorders or conditions are present. Clinicians should also be alert to the possible presence of nocturia in patients who suffer from major depressive disorder since nocturia rates for this population is significantly higher. Behavioural modifications alone may be insufficient to improve nocturia where clinically depressive symptoms are also present. Pharmacological treatments may provide improvement when nocturia and major depressive disorder are both present.

Key Words: Nocturia, major depressive disorder, anxiety, lithium, SSRIs, Frequency Volume Chart (FVC), sleep hygiene, desmopressin.

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Research has shown that nocturia and major depressive disorder are often correlated.

It is essential that the clinician take a comprehensive history since patients often report symptoms associated with nocturia rather than nocturia itself.

The Frequency Volume Chart (FVC) is a reliable tool the clinician can use to assess whether underlying disorders or conditions are present, which will help determine treatment.

Given the poor physical and mental health that can result when nocturia and major depressive disorder are both present, the clinician should consider pharmacological treatment for nocturia if behavioural changes prove ineffective.

When a patient suffers from nocturia, the clinician should also screen for major depressive disorder.

Individuals who suffer from nocturia are more likely to report feelings of anxiety and depression than the general population.

Individuals who suffer from major depressive disorder are more likely suffer from nocturia.

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Jeremy Gilbert, MD, FRCPC

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Abstract: Reduced sleep duration and quality can affect slow wave sleep (SWS) or restorative sleep, which is associated with an increased risk of developing type 2 diabetes mellitus. In patients who have been diagnosed with type 2 diabetes mellitus, treating nocturia and the associated deterioration of sleep duration and quality is particularly important to avoid the worsening of symptoms and the potential development of serious complications. Low-dose sublingual desmopressin (25 µg for adult women or 50 µg for adult men) has proven effective in reducing nocturia with the goal of improving SWS.

Key Words: type 2 diabetes mellitus (T2DM), sleep duration, sleep quality, sleep hygiene, slow wave sleep (SWS), optimal glycemic control, desmopressin.

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Type 2 diabetes mellitus (T2DM) is an increasingly common chronic disorder.

Type 2 diabetes mellitus (T2DM) rates have risen in recent years in proportion to rising obesity rates, increasing BMIs, and ever more sedentary adult populations.

Research has demonstrated that reduced sleep duration and quality can affect slow-wave sleep (SWS), which is associated with an increase to the risk of developing type 2 diabetes mellitus.

In patients with type 2 diabetes mellitus, treating nocturia and deteriorated sleep duration and quality may be useful to reduce symptoms of hyperglycemia and potentially reduce the development of serious complications.

The initiation of SWS coincides with the hormonal changes that affect glucose regulation.

When researchers supressed SWS in young, healthy, adult participants, they found a significant decrease in insulin sensitivity.

Low-dose sublingual desmopressin (25 µg for adult women or 50 µg for adult men), in addition to optimal glycemic control, has proven effective in reducing nocturia in patients with type 2 diabetes mellitus.

When nocturia events are decreased or eliminated, SWS is improved.

To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.