Sleep disruption has many negative health effects, and frequent nighttime urination (nocturia) that interrupts sleep is common, under-recognized, and benefits from personalized treatment. Nocturia is prevalent and worrisome,1 and treatment can greatly improve health-related quality of life.2 Yet according to one poll, 62% of Americans do not know that this is a medical condition with potential treatment, and, perhaps more concerning, 66% of sufferers polled had not talked to a doctor about their symptoms.3
Many patients view nocturia as a natural part of aging, which may account for the sometimes very low reports of visits to clinicians—for instance, in one study focused on female Taiwanese patients, only 13% saw a clinician to discuss their nocturia.4 This creates an opportunity for primary care providers to step in with personalized, preventative medicine for long-term health.
Several episodes of nighttime urination are more likely to occur in certain groups without any underlying renal challenges:
- Men with enlarged prostates (and it is one of the most bothersome symptoms)5,6
- Individuals over the age of 60 (estimates vary from up to 60%7 to 77%8 in men and women)
- People with sleep apnea9
However, anyone may be affected by nocturia. Although definitions vary, most of the health effects are seen in patients who are waking up two or more times a night to urinate.10 As a multifactorial condition with many potential antecedents, triggers, and mediators, nocturia presents a challenge for personalized treatment.
Men’s health expert Geo Espinosa, ND, shares his thoughts and considerations on diagnosing and treating nocturia:
Undertreated & Risky
Patients identify nocturia as a major source of sleep disturbance,11 and the condition is correlated with increased risks of a range of conditions, including:
- Lower self-related health16,17
- All-cause mortality18
In all likelihood, many of these correlations are due to the sleep disturbance associated with nocturia, particularly for early-night awakenings during slow-wave restorative sleep.19,20
Even in patients who report not being bothered by their nocturia, successfully reducing the number of nighttime awakenings improves overall health.21
Most sleep diaries do not include nocturia, but a commonly utilized tool in urology is a bladder diary. Studies show that prescription treatment for nocturia has low efficacy.22 Personalized lifestyle interventions may help to improve quality of life for these patients. Many patients will see symptom relief with simple modifications to liquid, caffeine, and alcohol intake, reductions in smoking, or exercise interventions.23,24,25 However, for others, underlying causes may not be as easily controlled.
What considerations may improve these patients’ quality of life?
Key Consideration: Benign Prostatic Hyperplasia
Over the years, treatment guidelines for benign prostatic hyperplasia (BPH) have evolved, and surgery is rarely a frontline intervention anymore.26 BPH is very common, affecting 50% of middle-aged men and 90% of men over 80 years.26 Yet only a quarter of men with BPH go on to develop benign prostatic obstruction, and many men with BPH are symptomless.26 For these reasons, other common causes of urinary tract problems need to be considered even if BPH is present.26
The European Association of Urology’s guidelines for treatment of BPH recommends that clinicians, “offer men with [lower urinary tract symptoms] lifestyle advice prior to or concurrent with treatment.”27 Since “watchful waiting” is recommended for many men,27 lifestyle recommendations may be highly important for health-related quality of life. This is particularly true because the evidence for pharmacologic treatments is limited, as a large 2019 systematic review and meta-analysis concluded.28 The review also found the evidence for lifestyle interventions limited, but many lifestyle interventions have extremely low risk and can improve many aspects of health.
Furthermore, prescription treatments for BPH have their own side effects. 5-alpha reductase inhibitors act by reducing the enzyme 5-alpha reductase, reducing the conversion of testosterone into dihydrotestosterone.29 However, as Dr. Espinosa alluded to in the video above, 5-alpha reductase inhibitors decrease the effects of testosterone throughout the body, which can have systemic effects.
In one systematic review, the authors estimated that 10% of BPH patients treated with 5-alpha reductase inhibitors had adverse sexual effects, and although for most men the prostate became smaller, the effect was “modest.”30 The most common side effect of 5-alpha reductase inhibitors is impaired sexual function, and it can be “debilitating,” so much so that some researchers recommend providing counseling before their use.31 Alpha blockers, which are often also prescribed to improve urine flow, also have sexual and other adverse effects.31
If liquid intake and smoking have already been considered, next steps can include:
- Nutrition interventions: decreasing starch and red meat and increasing polyunsaturated fats and vegetables.32
- Testing for and treating metabolic syndrome, which increases the likelihood of needing treatment for BPH.33
- Inquiring about erectile dysfunction, which is common in patients with lower urinary tract symptoms and BPH.34, 35
Key Consideration: Sleep Apnea
Sleep apnea alters the production of anti-diuretic hormone, causing more frequent urination.36,37 With aging, nocturia becomes more likely. However, age also increases the risk of sleep apnea. The connection between sleep apnea and nocturia is so strong that one article in the World Journal of Urology was titled, “Obstructive sleep apnea syndrome should always be screened in patients complaining of nocturia.”9 In an Indian population, one study found that in patients with obstructive sleep apnea, 86% had hypertension, 59% were diabetics, and 80% experienced sleep disturbances, including nocturia.38
In women, menopause without hormone replacement therapy dramatically increases the likelihood of sleep apnea39 and sleep disorders in general.40,41 However, sleep apnea tends to be more common in men, with some older male populations having as high as 90% prevalence.42 In one urology clinic, assessment revealed that 90% of the patients with nocturia had sleep apnea; CPAP treatment reduced nocturia significantly in patients who had been resistant to other therapies.43
In other contexts, correction of the sleep apnea also reduces nocturia.44,45,46,47 To adequately address patients with either sleep apnea or nocturia, assessment for the other condition should be high on the list of priorities.
Key Consideration: Blood Pressure
Treatment of sleep apnea also reduces high blood pressure,64,66,67 which has been tied to nocturia as well. Whether nocturia alters blood pressure or hypertension increases nocturia is not entirely clear in the literature, but a connection has been established.51,52 In particular, it’s been suggested that when blood pressure does not dip at night in patients who perceive themselves to have poorer quality sleep, this may be related to nocturia.53 The variability of nighttime BP dipping metrics make that sign a challenge to use diagnostically,53 unlike tracking nocturia itself. An increase in the number of nighttime voids is correlated with circadian blood pressure abnormalities.51
Furthermore, BPH and hypertension may both be related to diet-induced hyperinsulinemia.54,55 A diet high in processed and high glycemic foods can cause insulin resistance and hyperinsulinemia. The renin-angiotensin-aldosterone system is altered. Insulin alters the sympathetic nervous system at the same time. All of these elements that can underpin development of BPH are also linked to hypertension.54 Shifting to a healthier diet may thus reduce BPH as well as hypertension.
Patients with hypertension are more likely to also have nocturia.56,57 In men with benign prostatic hyperplasia and hypertension, nocturia is much more common.58 This suggests that treatment of hypertension could beneficially affect not only cardiovascular health risks, but potentially nocturia symptoms. In at least one community study, focused on black men aged 35-49, nocturia was significantly correlated with undiagnosed, uncontrolled hypertension.59
Importantly, cardiac risks are elevated for women with nocturia.60 Like in men, nocturia in women can occur at any age, and can be a hallmark of an underlying condition or a standalone symptom.
Key Consideration: Metabolic Syndrome & Type 2 Diabetes
Both sleep apnea and hypertension are correlated with metabolic syndrome. In a 2018 study on men with BPH, metabolic syndrome also doubled the risk of troublesome nocturia.61 In younger men, the presence of nocturia may also indicate an increased likelihood of metabolic syndrome.62
Patients with type 2 diabetes are also more likely to have nocturia or other lower urinary tract symptoms.63 In one study of 1,301 patients with type 2 diabetes, almost 60% reported nocturia.64 However, hypertension was more predictive.64 In women with type 2 diabetes, nocturia is common, and women with both conditions report impaired sleep.65 Importantly, when the time to first awakening is longer (allowing for deeper sleep), blood glucose measures can improve significantly.66 Nocturia may also be an early precursor to metabolic syndrome.67
Researchers have proposed that lower urinary tract symptoms in men with BPH, erectile dysfunction, and metabolic syndrome may have common underlying pathophysiology.68
To support patients’ cardiovascular health, a nighttime bladder diary may be a useful tool.
- Nocturia affects a wide range of patients and causes many negative health effects.
- Most patients do not know nocturia can be treated; screening is essential.
- In patients with either sleep apnea or nocturia, screening for the other condition is beneficial.
- Reducing frequency of nighttime urination can dramatically improve quality of life, as well as other health symptoms.
- Lifestyle interventions and treatment of underlying problems are cornerstones to successful nocturia reduction.
- Assess for sleep apnea.
- Consider untreated hypertension.
- Assess for metabolic syndrome.
- Miranda Ede P, Gomes CM, Torricelli FC, et al. Nocturia is the lower urinary tract symptom with greatest impact on quality of life of men from a community setting. Int Neurourol J. 2014;18(2):86-90. doi:10.5213/inj.2014.18.2.86
- Van Dijk MM, Wijkstra H, Debruyne FM, De La Rosette JJ, Michel MC. The role of nocturia in the quality of life of men with lower urinary tract symptoms. BJU Int. 2010;105(8):1141-1146.
- The medical condition 72 percent of Americans don’t know about is stealing sleep and disrupting lives, survey shows. P&T Community. Published September 12, 2018. Accessed April 25, 2019. http://www.ptcommunity.com/wire/medical-condition-72-percent-americans-don-t-know-about-stealing-sleep-and-disrupting-lives
- Chen FY, Dai YT, Liu CK, Yu HJ, Liu CY, Chen TH. Perception of nocturia and medical consulting behavior among community-dwelling women. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(4):431-436. doi:10.1007/s00192-006-0167-x
- DuBeau CE, Yalla SV, Resnick NM. Implications of the most bothersome prostatism symptom for clinical care and outcomes research. J Am Geriatr Soc. 1995;43(9):985-992. doi:10.1111/j.1532-5415.1995.tb05562.x
- A comparison of quality of life with patient reported symptoms and objective findings in men with benign prostatic hyperplasia. The Department of Veterans Affairs Cooperative Study of transurethral resection for benign prostatic hyperplasia. J Urol. 1993;150(5 Pt 2):1696-1700. doi:10.1016/S0022-5347(17)35870-6
- Bosch JL, Weiss JP. The prevalence and causes of nocturia. J Urol. 2013;189(1 Suppl):S86-92. doi:10.1016/j.juro.2012.11.033
- Bing MH, Moller LA, Jennum P, Mortensen S, Skovgaard LT, Lose G. Prevalence and bother of nocturia, and causes of sleep interruption in a Danish population of men and women aged 60-80 years. BJU Int. 2006;98(3):599-604. doi:10.1111/j.1464-410X.2006.06390.x
- Misraï V, Charbonneau H, Attias D, Pathak A. Obstructive sleep apnea syndrome should always be screened in patients complaining of nocturia. World J Urol. Published online October 22, 2018. doi:10.1007/s00345-018-2534-x
- Dmochowski R, Brucker BM, Cole E, et al. Economic burden of illness in adult patients with nocturia. J Manag Care Spec Pharm. 2019:25(5):593-604. doi:10.18553/jmcp.2019.18067
- Middelkoop HA, Smilde-van den Doel DA, Neven AK, Kamphuisen HA, Springer CP. Subjective sleep characteristics of 1,485 males and females aged 50-93: effects of sex and age, and factors related to self-evaluated quality of sleep. J Gerontol A Biol Sci Med Sci. 1996;51(3):M108-115. doi:10.1093/gerona/51a.3.m108
- van der Vaart CH, Roovers JP, de Leeuw JR, Heintz AP. Association between urogenital symptoms and depression in community-dwelling women aged 20 to 70 years. Urology. 2007;69(4):691-696. doi:10.1016/j.urology.2007.01.017
- Drake M. Nocturia and depressive symptoms in older men. BJU Int. 2017;120(2):159. doi:10.1111/bju.13849
- Pietrzyk B, Olszanecka-Glinianowicz M, Owczarek A, et al. Depressive symptoms in patients diagnosed with benign prostatic hyperplasia. Int Urol Nephrol. 2015;47(3):431-440. doi:10.1007/s11255-015-0920-5
- 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):953-957. doi:10.1016/j.juro.2013.03.126
- Kobelt G, Borgström F, Mattiasson A. Productivity, vitality and utility in a group of healthy professionally active individuals with nocturia. BJU Int. 2003;91(3):190-195.
- Robertson C, Link CL, Onel E, et al. The impact of lower urinary tract symptoms and comorbidities on quality of life: the BACH and UREPIK studies. BJU Int. 2007;99(2):347-354. doi:10.1111/j.1464-410X.2007.06609.x
- Bliwise DL, Howard LE, Moreira DM, Andriole GL, Hopp ML, Freedland SJ. Nocturia and associated mortality: observational data from the REDUCE trial. Prostate Cancer Prostatic Dis. 2019;22(1):77-83. doi:10.1038/s41391-018-0090-5
- Bliwise DL, Holm-Larsen T, Goble S. Increases in duration of first uninterrupted sleep period are associated with improvements in PSQI-measured sleep quality. Sleep Med. 2014;15(10):1276-1278. doi:10.1016/j.sleep.2014.05.013
- Stanley N. The underestimated impact of nocturia on quality of life. Eur Urol Suppl. 2005;4(7):17-19. doi:10.1016/j.eursup.2005.07.002
- Park K, Park HK, Kim SW, et al. Is it worth treating non-bothering nocturia? Results of a multicenter prospective observational study. World J Mens Health. 2018;36(3):248-254. doi:10.5534/wjmh.170003
- Drangsholt S, Ruiz MJA, Peyronnet B, Rosenblum N, Nitti V, Brucker B. Diagnosis and management of nocturia in current clinical practice: who are nocturia patients, and how do we treat them? World J Urol. Published online October 4, 2018. doi:10.1007/s00345-018-2511-4
- Van Kerrebroeck P, Andersson KE. Terminology, epidemiology, etiology, and pathophysiology of nocturia. Neurourol Urodyn. 2014;33(Suppl 1):S2-5. doi:10.1002/nau.22595
- Weiss JP, Bosch JL, Drake M, et al. Nocturia Think Tank: focus on nocturnal polyuria: ICI-RS 2011. Neurourol Urodyn. 2012;31(3):330-339. doi:10.1002/nau.22219
- Miotla P, Dobruch J, Lipinski M, et al. Diagnostic and therapeutic recommendations for patients with nocturia. Cent European J Urol. 2017;70(4):388-393. doi:10.5173/ceju.2017.1563
- Song Q, Abrams P, Sun Y. Beyond prostate, beyond surgery and beyond urology: the “3Bs” of managing non-neurogenic male lower urinary tract symptoms. Asian J Urol. 2019;6(2):169-173. doi:10.1016/j.ajur.2017.11.002
- Gravas S, Cornu JN, Drake MJ, et al. EAU Guidelines on Management of Non-neurogenic Male Lower Urinary Tract Symptoms (LUTS), incl. Benign Prostatic Obstruction (BPO). European Association of Urology; 2018. Accessed May 14, 2019. https://uroweb.org/wp-content/uploads/EAU-Guidelines-on-the-Management-of-Non-neurogenic-Male-LUTS-2018-large-text.pdf
- Karavitakis M, Kyriazis I, Omar MI, et al. Management of urinary retention in patients with benign prostatic obstruction: a systematic review and meta-analysis. Eur Urol. 2019;75(5):788-798. doi:10.1016/j.eururo.2019.01.046
- Kim EH, Brockman JA, Andriole GL. The use of 5-alpha reductase inhibitors in the treatment of benign prostatic hyperplasia. Asian J Urol. 2018;5(1):28-32. doi:10.1016/j.ajur.2017.11.005
- Vaughan ED. Long-term experience with 5-alpha-reductase inhibitors. Rev Urol. 2003;5(Suppl 5):S22-27.
- Jiwrajka M, Yaxley W, Ranasinghe S, Perera M, Roberts MJ, Yaxley J. Drugs for benign prostatic hypertrophy. Aust Prescr. 2018;41(5):150-153. doi:10.18773/austprescr.2018.045
- Espinosa G. Nutrition and benign prostatic hyperplasia. Curr Opin Urol. 2013;23(1):38-41. doi:10.1097/MOU.0b013e32835abd05
- Yoo S, Oh S, Park J, et al. The impacts of metabolic syndrome and lifestyle on the prevalence of benign prostatic hyperplasia requiring treatment: historical cohort study of 130 454 men. BJU Int. 2019;123(1):140-148. doi:10.1111/bju.14528
- Calogero AE, Burgio G, Condorelli RA, Cannarella R, La Vignera S. Epidemiology and risk factors of lower urinary tract symptoms/benign prostatic hyperplasia and erectile dysfunction. Aging Male. 2019;22(1):12-19. doi:10.1080/13685538.2018.1434772
- De Nunzio C, Roehrborn CG, Andersson KE, McVary KT. Erectile dysfunction and lower urinary tract symptoms. Eur Urol Focus. 2017;3(4-5):352-363. doi:10.1016/j.euf.2017.11.004
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