Demystifying Nocturia: Identifying the Cause and Tailoring the Treatment

Paula Laureanno, RN; Pamela Ellsworth, MD, FACS, FAAP

Urol Nurs. 2010;30(5):276-287.

Treatment of Nocturia

Once a patient has undergone an evaluation of nocturia and the etiology has been defined, treatment will then be tailored to the specific etiology. A formalized diagnostic and treatment algorithm may be useful in directing clinical care. An algorithm developed and used in the authors' clinical practice is presented in Figure 1.

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Figure 1.

Clinical Algorithm for the Diagnosis and Treatment of Nocturia

In most individuals, the first steps in treatment are lifestyle and behavioral changes. Fluid intake in the evening should be discontinued, if possible, and alcohol and caffeine consumption reduced. For individuals with lower extremity edema and venous stasis, the use of compression stockings and afternoon leg elevation may combat fluid retention before retiring at night. The use of nasal continuous positive airway pressure can be used to treat sleep apnea, therefore reducing associated nocturia (Appell & Sand, 2008).

Diuretic use is associated with a two-fold increase in nocturia (Asplund, 2003). Diuretics are generally taken in the morning, which can lead to increased thirst and increased fluid intake later in the day, thereby increasing nocturnal urine output (Asplund, 2007). If furosemide (Lasix®) is taken six hours before going to bed, nocturnal diuresis may be reduced (Reynard, Cannon, Yang, & Abrams, 1998). In a randomized, placebo-controlled trial comparing night time doses of placebo and bumetamide (Bumex®) 1 mg, bumetamide treatment decreased nocturia episodes by 25% compared with placebo (Pedersen & Johansen, 1988).

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Table 1. Nocturia Terminology and Definitions
Term	Definition
Night time	The period of time between going to bed with the intention of sleeping and waking with the intention of rising.
Nocturia	The number of voids recorded during a night's sleep. Each void is preceded and followed by sleep.
Nocturnal urine volume	Total volume of urine passed during the night including the first morning void.
Rate of nocturnal urine production	The nocturnal volume/time asleep (for example, night), measured in ml/minutes.
Nocturnal polyuria	The production of an abnormally large volume of urine during sleep – Should include all urine produced after going to bed and the first void after arising, nocturnal volume greater than 20% to 30% of total 24-hour urine volume (age dependent).
24-hour voided volume	Total volume of urine voided during a 24-hour period (first void to be discarded; 24 hours begins at the time of the next void).
Polyuria	24-hour voided volume in excess of 2800 ml in a 70 kg person or more than 40 ml/kg.
Night time frequency	The number of voids recorded from the time the individual goes to bed with the intention of going to sleep, to the time the individual wakes with the intention of rising.
First morning void	The first void after waking with the intention of rising.
Maximum voided volume (MVV)	The largest single voided volume measured in a 24-hour period.
Nocturia index (Ni)	Mean-measured nocturnal urine volume (NUV) divided by the functional bladder capacity (deduced from the frequency volume chart). An Ni greater than 1 means that nocturnal urine production is greater than the functional bladder capacity.
Nocturnal polyuria index (NPi)	Mean-measured nocturnal volume/24-hour voided volume. NPi greater than 33% implies nocturnal polyuria as opposed to diurnal polyuria.
Nocturia bladder capacity index (NBCi)	The difference between the actual number of nocturnal voids (ANV) and the predicted number of nocturnal voids (PNV). The greater the NBCi, the more often nocturia is occasioned by nocturnal voided volumes smaller than the MVV.
Predicted number of nocturnal voids	Ni minus 1.

Source: Abrams et al., 2003.

Table 2. Causes of Polyuria
Diabetes Mellitus Type 1 (IDDM) and Type 2 (NIDDM)
Diabetes insipidus
Pituitary
Renal
Secondary nephrogenic due to:
Lithium
Electrolyte disturbances – Hypercalcemia, hypokalemia
Primary polydipsia
Psychogenic
Dipsogenic
Iatrogenic

Table 3. Causes of Nocturnal Polyuria
Secondary to Water Diuresis
Circadian defect in secretion or action of antidiuretic hormone
• Primary (idiopathic)
• Secondary
→ Excessive intake of fluid, caffeine, alcohol
→ CNS lesion from CVA which affects hypothalamic-pituitary axis
Solute/Water Diuresis
Congestive heart failure
Autonomic dysfunction
Sleep apnea syndrome
Renal insufficiency
Estrogen deficiency

Table 4. Bladder Storage Problems
Decreased functional bladder capacity
Bladder outlet obstruction with increased post-void residual
Cancer of the bladder, prostate, or urethra
Decreased bladder contractility with increased post-void residual
Decreased nocturnal bladder capacity
Detrusor over-activity
Idiopathic (overactive bladder)
Secondary to neurogenic causes (multiple sclerosis)
Bladder irritation
Urinary tract infection
Interstitial cystitis/painful bladder syndrome
Bladder calculi

Source: Weiss & Blaivas, 2002.

Table 5. Risk Factors for Obstructive Sleep Apnea
Excessive weight	Family history of sleep apnea
Neck circumference greater than 17.5 inches	Use of alcohol, sedatives, or tranquilizers
Hypertension	Smoking
Narrowed airway – Naturally or secondary to enlarged tonsils or adenoids	Ethnicity – African Americans have highest risk than any other ethnic group
Male sex	Diabetes mellitus
Postmenopausal	GERD
Older age – 3 times more likely in adults older than 65 years of age	Polycystic ovary syndrome – 3 times more likely

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Demystifying Nocturia: Identifying the Cause and Tailoring the Treatment

Treatment of Nocturia

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Figure 1.

Figure 1.

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