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Nocturia: More Than Just a Nuisance
Read Time: 8 Minutes
Nocturia (frequent nighttime urination) is a common condition that interrupts sleep throughout the course of the night and is often described as the most bothersome of all urinary symptoms. While exact prevalence rates vary across studies depending on the definition used, nocturia has been reported in a substantial proportion of all populations studied and across nationalities as well as sex and age groups.1
Globally, nocturia tends to be overlooked in clinical practice, and patients may delay reporting their symptoms, attributing the excessive nighttime bathroom trips to an inevitable part of aging.2 According to a 2018 national online survey conducted by The Harris Poll, 72% of US adults do not know that nocturia 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 Yet personalized interventions that include lifestyle modifications may help to improve this condition and a patient’s quality of life.4,5
Studies have shown that anyone may be affected by nocturia. However, several episodes of nighttime urination are more likely to occur in certain groups without any underlying renal challenges, including:
- Men with enlarged prostates6
- Individuals over the age of 601,6
- People with sleep apnea7
As a multifactorial condition with many potential antecedents, triggers, and mediators, nocturia may present a challenge for treatment. In the following video, men’s health expert Geo Espinosa, ND, IFMCP, shares his thoughts and considerations on diagnosing and treating nocturia.
Undertreatment & Risks
Patients identify nocturia as a major source of sleep disturbance and significantly reduced quality of life.8 The condition is correlated with increased risks of a range of conditions, including:
- Depression9,10
- Cardiovascular disease11
- All-cause mortality12
Many of these correlations are likely due to the sleep disturbance associated with nocturia, particularly for early-night awakenings during slow-wave restorative sleep.13 Even in patients who report not being bothered by their nocturia, successfully reducing the number of nighttime awakenings improves overall health.14
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;15 however, 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.4,16,17 Some studies suggest that excessive sodium consumption may be associated with nocturia, and early experimental evidence in a small group of patients has shown dietary sodium reduction to improve nocturia.18 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
Nocturia is one of the most frequent urinary tract symptoms in men with benign prostatic hyperplasia (BPH), also called prostate gland enlargement.19 BPH is very common, affecting 50% of middle-aged men and 90% of men over 80 years.20 Yet only a quarter of men with BPH go on to develop benign prostatic obstruction, and many men with BPH are symptomless. For these reasons, other common causes of urinary tract problems need to be considered, even if BPH is present.20 Over the years, treatment guidelines for benign prostatic hyperplasia have evolved, and surgery is rarely a frontline intervention anymore.20
The European Association of Urology’s guidelines for treatment of BPH recommend that clinicians suggest lifestyle-based treatment options prior to or with other treatments for men with lower urinary tract symptoms.21 These 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.22 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 lessen the conversion of testosterone into dihydrotestosterone by the enzyme 5-alpha reductase.23 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.24 The most common side effect of 5-alpha reductase inhibitors is impaired sexual function.25 Their potentially debilitating impact has prompted some researchers to recommend providing counseling before their use.25 Alpha blockers, which are often also prescribed to improve urine flow, also have sexual and other adverse effects.25
If liquid intake and smoking have already been considered, next steps to address lifestyle factors can include:
- Nutrition interventions: decreasing starch and red meat and increasing polyunsaturated fats and vegetables.26
- Testing for and treating metabolic syndrome, which increases the likelihood of needing treatment for BPH.27
- Inquiring about erectile dysfunction, which is common in patients with lower urinary tract symptoms and BPH.28,29
Key Consideration: Sleep Apnea
Sleep apnea alters the production of anti-diuretic hormone, causing more frequent urination.30,31 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.”7 A 2020 meta-analysis suggests that men with obstructive sleep apnea (OSA) have a high incidence of nocturia; however, there was no significant relationship between OSA and nocturia in the women included in the studies.32
In women, menopause increases the likelihood of sleep apnea and sleep disorders in general.33,34 However, sleep apnea tends to be more common in men, with some older male populations having as high as 90% prevalence.35 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.36
In other contexts, correction of the sleep apnea also reduces nocturia.37-39 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,40-42 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.43,44 An increase in the number of nighttime voids is correlated with circadian blood pressure abnormalities.43
Furthermore, BPH and hypertension may both be related to diet-induced hyperinsulinemia.45 A diet high in processed and high glycemic foods can cause insulin resistance and hyperinsulinemia. The renin-angiotensin-aldosterone system may be altered, and insulin also alters sympathetic nervous system activity. All of these elements that can underpin development of BPH are also linked to hypertension.47 Shifting to a healthier diet may thus reduce BPH as well as hypertension.
Patients with hypertension are more likely to also have nocturia.46,47 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.48
Importantly, cardiac risks are elevated for women with nocturia.49 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, and studies have indicated a positive correlation between metabolic syndrome and nocturia severity.50,51 In a 2018 study on men with BPH, metabolic syndrome doubled the risk of troublesome nocturia.52 In addition, nocturia may not only be a diagnostic marker of existing metabolic syndrome but also of precursors to cardiometabolic dysfunctions.53
Nocturia or other lower urinary tract symptoms are also seen more frequently in patients with type 2 diabetes. In one study of 1,301 patients with type 2 diabetes, almost 60% reported nocturia.54 In women with type 2 diabetes, nocturia is common, and women with both conditions report impaired sleep.55 Importantly, when the time to first awakening is longer (allowing for deeper sleep), blood glucose measures can improve significantly.56 And screening for nocturia in older women with type 2 diabetes may prove beneficial. A 2020 cross-sectional correlation study found that women aged ≥65 years with type 2 diabetes had a significantly higher nighttime voiding frequency than younger women (>40 to <65 years) with type 2 diabetes.57
Takeaways
- 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.
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