A practical approach to the management of nocturia

Abstract

Aim: To raise awareness on nocturia disease burden and to provide simplified aetiologic evaluation and related treatment pathways.

Methods: A multidisciplinary group of nocturia experts developed practical advice and recommendations based on the best available evidence supplemented by their own experiences.

Results: Nocturia is defined as the need to void ≥1 time during the sleeping period of the night. Clinically relevant nocturia (≥2 voids per night) affects 2%-18% of those aged 20-40 years, rising to 28%-62% for those aged 70-80 years. Consequences include the following: lowered quality of life; falls and fractures; reduced work productivity; depression; and increased mortality. Nocturia-related hip fractures alone cost approximately €1 billion in the EU and $1.5 billion in the USA in 2014. The pathophysiology of nocturia is multifactorial and typically related to polyuria (either global or nocturnal), reduced bladder capacity or increased fluid intake. Accurate assessment is predicated on frequency-volume charts combined with a detailed patient history, medicine review and physical examination. Optimal treatment should focus on the underlying cause(s), with lifestyle modifications (eg, reducing evening fluid intake) being the first intervention. For patients with sustained bother, medical therapies should be introduced; low-dose, gender-specific desmopressin has proven effective in nocturia due to idiopathic nocturnal polyuria. The timing of diuretics is an important consideration, and they should be taken mid-late afternoon, dependent on the specific serum half-life. Patients not responding to these basic treatments should be referred for specialist management.

Conclusions: The cause(s) of nocturia should be first evaluated in all patients. Afterwards, the underlying pathophysiology should be treated specifically, alone with lifestyle interventions or in combination with drugs or (prostate) surgery.

Keywords: assessment of healthcare needs; desmopressin; expert opinion; morbidity; mortality; nocturia; pathophysiology.

Figure 1

Pathophysiology of nocturia (adapted from Oelke et al32)

Figure 2

Nocturia evaluation algorithm based on frequency‐volume chart (adapted from Oelke et al32). *Some patients might not require referral to a cardiologist. The National Institute for Health and Care Excellence (NICE) guidelines for chronic heart failure state that referral of patients to a cardiologist is only necessary for initial diagnosis and patients with severe heart failure or where the condition is not responding to treatment62

Figure 3

Management algorithm for patients with nocturia/nocturnal polyuria (adapted from Oelke et al32)