Evaluation and Treatment in Urology for Nocturia Caused by Nonurological Mechanisms: Guidance from the PLANET Study

Nocturnal polyuria is common in Parkinson's and is associated with orthostatic hypotension

Background

Nocturia is the most common lower urinary tract symptom (LUTS) in Parkinson's disease (PD) and impacts sleep and subsequent daytime function. Often nocturia in PD is attributed to overactive bladder, however we explored the contribution of the over-production of urine at night, nocturnal polyuria (NP), as another factor.

Objectives

To assess the prevalence and severity of NP in a PD cohort with LUTS and explore associations with autonomic and other patient characteristics.

Methods

Sub-study nested within a trial for LUTS in PD. All participants performed 72-hour bladder diaries. Nocturnal polyuria index (NPi) was calculated from diaries and key associations were explored.

Results

62.6 % of participants had NP based on the NPi33 threshold (producing > 33 % urine at night). Increasing NPi was strongly significantly associated with greater nocturia (OR 1.7 per 5 % NPi unit; 1.5-2.0; P < 0.001). A significant association was observed between NPi and orthostatic hypotension (OR 1.2 per 5 % NPi unit increase; 1.0-1.4; P = 0.03) and reported cardiovascular symptoms (coefficient 0.07; 0.03-0.11; P = 0.002). A marked association was seen with severe NP and orthostatic hypotension (OR 4.9; 1.56-15.57; P = 0.006).

Conclusion

NP is very common in this PD cohort symptomatic for LUTS, and is closely associated with increasing rate of nocturia. NP is linked to cardiovascular symptoms and autonomic dysfunction, particularly blood pressure lability which may be causal or simply reflect advanced disease state.

Five-year Follow-up of the Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods-A Noninferiority Randomised Controlled Trial of Urodynamics

BACKGROUND AND OBJECTIVE

Lower urinary tract symptoms (LUTS) are a key indication for surgery in older men. The Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM) study evaluated the diagnostic pathway for men considering surgery to treat LUTS and reported the outcomes at 18 mo. This long-term follow-up study reports the symptoms and rates of prostate surgery at 5 yr.

METHODS

UPSTREAM participants who had consented to long-term follow-up received postal questionnaires at 5 yr after randomisation (October 2019-December 2021). The primary outcome was the patient-reported International Prostate Symptom Score (IPSS, scale 0-35). Rates of surgery, derived from the National Health Service (NHS) England routine data, were a key secondary outcome. An intention-to-treat analytic approach was utilised.

KEY FINDINGS AND LIMITATIONS

At 5 yr, 211/427 (49.4%) participants in the intervention group and 204/393 (51.9%) in the routine care group completed the questionnaires, with routine data obtained for 801/820 (97.7%). The mean IPSS at 5 yr did not differ between randomised groups (adjusted difference 0.41, 95% confidence interval -1.10, 1.93), nor did the rates of surgery (0.96 [0.71, 1.28]). Urinary and sexual symptoms also showed no differences between the randomised groups. The main limitation is the reduced numbers of men in follow-up. In UPSTREAM, men were randomised to routine care diagnostic tests plus invasive urodynamics (intervention) or routine care only for LUTS. Treatment choice was made by the participants, advised by their clinicians.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Five-year follow-up does not support the routine use of invasive urodynamics in reducing LUTS or rates of prostate surgery. Urodynamics should be used selectively in the evaluation of uncomplicated LUTS.

Water Intake in Drinks and Food: How Should We Advise Patients With Lower Urinary Tract Dysfunction on Their Water Intake and/or Urine Output, as a Cornerstone of Lifestyle Interventions? ICI-RS 2024

CONTEXT

Water intake in drinks and food is essential for life. Multiple guidelines exist to help give recommendations for healthy water intake and urine output, but few of these are specific to patients with lower urinary tract symptoms.

METHODS

A debate held at the International Consultation on Incontinence-Research Society meeting, held in Bristol in June 2024, considered ways to improve this situation.

RESULTS AND CONCLUSION

There are challenges in measuring both total water intake and also urine output, but we suggest that urine output may be the most helpful measure to focus on for future guidelines for patients.

A multisite feasibility study of integrated cognitive-behavioral treatment for co-existing nocturia and chronic insomnia

BACKGROUND

Nocturia (waking from sleep at night to void) and chronic insomnia frequently co-exist in older adults, contributing synergistically to sleep disturbance. Treatments typically target either nocturia or insomnia rather than simultaneously addressing shared mechanisms for these disorders.

METHODS

We conducted a multisite feasibility study to: (1) test and refine a protocol for recruitment, randomization, and assessment of older adults with co-existing nocturia and insomnia; and (2) examine preliminary changes in outcome measures to inform a future larger, multisite clinical trial. Participants were men and women aged 60 years and older recruited from outpatient clinics, reporting an average of two or more nocturia episodes per night over the past 4 weeks and meeting diagnostic criteria for chronic insomnia disorder. Participants were randomized to receive either integrated cognitive-behavioral therapy for insomnia and nocturia or a health education control program involving five weekly visits with a trained nurse practitioner interventionist. Outcomes (e.g., nocturia episodes) were measured 1-week post-treatment and 4-month post-randomization. Descriptive statistics examined the feasibility of outcomes to guide preparations for a future efficacy trial.

RESULTS

Of 245 adults screened, 55% were ineligible and 25% declined to participate. Sixty-one percent of 49 participants who provided informed consent were randomized. Of the 30 participants randomized (mean age = 70.6 years, 60% White), 14 were assigned to integrated cognitive-behavioral treatment and 16 to the control group. All randomized participants provided 4-month follow-up data. At 4 months, mean nightly nocturia episodes decreased by 0.9 (SD 1.0) in the integrated treatment group and by 0.2 (SD 1.2) in the control group compared with baseline.

DISCUSSION

Findings demonstrate the feasibility of recruiting, randomizing, and collecting outcome data from older adults (predominantly male) assigned to an integrated cognitive-behavioral therapy for coexisting insomnia and nocturia or a health education control program.

Bidirectional relationships between depression, anxiety and urinary symptoms in women: A prospective cohort study

OBJECTIVES

To examine (i) if depression and anxiety are prospectively associated with subsequent lower urinary tract symptoms (LUTS) and (ii) if LUTS are prospectively associated with subsequent depression.

PARTICIPANTS AND METHODS

The study is based on data from parous middle-aged women from the Avon Longitudinal Study of Parents and Children. LUTS were assessed using the Bristol Female LUTS Questionnaire and the International Consultation on Incontinence Questionnaire on Female LUTS. Depression was assessed using the Edinburgh Postnatal Depression Scale and anxiety was assessed using the Crown Crisp Experiential Index. We used multivariable logistic regression to examine (i) associations between depression and anxiety at baseline in 2002-04 and subsequent LUTS at follow-up in 2011-2012 (n = 5291) and (ii) associations between LUTS at baseline in 2002-04 and subsequent depression at follow-up in 2010-11 (n = 6147). Analyses were adjusted for age, socioeconomic factors, stressful life events, social support, smoking, weekly alcohol consumption, BMI, physical activity, obstetric/reproductive factors, and menopausal status.

RESULTS

We found evidence of prospective associations between depression and subsequent mixed urinary incontinence [odds ratio = 1.97, 95 % confidence interval = 1.16, 3.33], any urinary incontinence [1.68 (1.21, 2.31)], and urgency [1.90 (1.28, 2.83)]. Anxiety was only associated with subsequent nocturia [1.84 (1.04, 3.26)]. Only stress urinary incontinence was associated with subsequent depression [1.37 (1.03, 1.83)].

CONCLUSIONS

We find evidence that mental health problems could be contributing factors, as well as consequences, of LUTS. Research is needed to determine if these observed associations are causal and to identify underlying mechanisms.

Nocturia and obstructive sleep apnoea

Nocturia, the need to urinate at night, is a common symptom in patients with obstructive sleep apnoea (OSA). Continuous positive airway pressure treatment can reduce nocturia in some patients, but the underlying mechanisms are complex and not fully understood. OSA affects the autonomic nervous system, oxidative stress and endothelial damage. Furthermore, the commonly held theory attributing polyuria to a false signal of cardiac overload and response natriuresis has limitations. A comprehensive approach to the management of nocturia in OSA, considering factors such as comorbidities, medication use, alcohol consumption and lifestyle, is needed. Effective management of nocturia in OSA requires a multidisciplinary approach, and urologists should be aware of the potential effect of OSA on physiology and refer patients for further testing at a sleep centre. In addition to continuous positive airway pressure, other interventions such as oral appliances and surgical obstruction treatment could be beneficial for some patients. Overall, understanding the complex interplay between OSA and nocturia is crucial for optimizing patient outcomes.

Characteristics of Geriatric Rehabilitation Inpatients with Nocturia: RESORT

INTRODUCTION

Nocturnal lower urinary tract symptoms are common in geriatric rehabilitation inpatients but have not been well described. The aim of this study was to compare patient characteristics stratified by self-reported nocturia severity in geriatric rehabilitation inpatients.

METHODS

The REStORing health of acutely unwell adulTs (RESORT) is an observational, longitudinal, prospective inception cohort of geriatric rehabilitation inpatients who underwent a Comprehensive Geriatric Assessment (CGA) at admission and discharge. Nocturia was captured by item 7 of the American Urology Association Symptom Score (AUASS) and dichotomised as ≤1 void and >1 void at night as per the International Continence Society definition. Differences in demographic, functional, and medical characteristics of the inpatients with and without nocturia >1 were compared.

RESULTS

Overall, 641 inpatients completed the nocturia item (mean age 82.6 [SD 7.7] years, 59.9% female). Nocturia occurred >once per night in 57.4%; mean number of episodes was 1.96 (SD 1.38), ranging from 0 to 5. There was no change in nocturia severity between admission and discharge. Daily urinary incontinence, urinary urgency, and comorbid illness were independently associated with multiple nocturia episodes. A history of falls within the last year, difficulty climbing stairs pre-admission, higher faecal incontinence score, impaired quality of life domains, higher levels of anxiety and depression were significantly more common in inpatients with multiple episodes of nocturia compared to no or only one episode of nocturia.

CONCLUSION

Lower urinary tract symptoms, poor functional status and frailty markers were associated with repeated episodes of nocturia. Targeted intervention may reduce the severity of nocturia, with potential to improve sleep quality, impact therapeutic gains and influence discharge destination.

How should we assess the cardiovascular system in patients presenting with bothersome nocturia? ICI-RS 2023

AIMS

The link between nocturia and cardiovascular disease (CVD) is frequently discussed in literature, yet the precise nature of this relationship remains poorly characterized. The existing literature was reviewed in order to address issues concerning the origin, diagnosis, management, and implications of the co-occurrence of CVD and nocturia.

METHODS

This review summarizes literature and recommendations regarding the link between CVD and nocturia discussed during a think-tank meeting held at the 2023 International Consultation on Incontinence-Research Society.

RESULTS

Cardiovascular disorders are often underestimated contributors to nocturia, with various potential mechanisms influencing nighttime urination, such as impact on fluid retention, atrial natriuretic peptide, and glomerular filtration rate. The redistribution of fluid from leg edema in supine position can lead nocturnal polyuria (NP). Additionally, sleep disturbances due to nocturia in itself may lead to CVD through an increase in blood pressure, insulin resistance, and inflammation. Disrupted circadian rhythms (e.g., in sleep pattern and urine production) were identified as critical factors in most etiologies of nocturia, and their contribution is deemed imperative in future research and treatment approaches, particularly in the aging population. NP can be detected through a simple bladder diary and can even be used to distinguish cardiac from noncardiac causes of nocturia. For the treatment of NP, desmopressin can be effective in select patients, however, caution and close monitoring is warranted for those with CVD due to increased risk of side effects.

CONCLUSIONS

Gaps were identified in the available evidence and clear cut recommendations were put forth for future research. It is essential to gain a deeper understanding of the mechanisms linking nocturia and CVD to develop optimal management strategies.

The role of renal circadian biorhythms in lifelong LUTS

INTRODUCTION

This article delves into the intricate relationship between kidney function, diuresis, and lower urinary tract symptoms (LUTS) throughout the transitions of the human lifespan. It explores circadian regulation of urine production, maturation of renal function from birth to adulthood, and effects of aging on kidney function and LUTS. The complex connections between these factors are highlighted, offering insights into potential interventions and personalized management strategies.

METHODS

An international panel of seven experts engaged in online discussions, focusing on kidney function, diuresis, and LUTS throughout life. This manuscript summarizes expert insights, literature reviews, and findings presented during a webinar and subsequent discussions.

RESULTS

Renal function undergoes significant maturation from birth to adulthood, with changes in glomerular filtration rate, diuresis, and tubular function. A circadian rhythm in urine production is established during childhood. Adolescents and young adults can experience persistent enuresis due to lifestyle factors, comorbidities, and complex physiological changes. In older adults, age-related alterations in kidney function disrupt the circadian rhythm of diuresis, contributing to nocturnal polyuria and LUTS.

CONCLUSION

The interplay between kidney function, diuresis, and LUTS is crucial in understanding lifelong urinary health. Bridging the gap between pediatric and adult care is essential to address enuresis in adolescents and young adults effectively. For older adults, recognizing the impact of aging on renal function and fluid balance is vital in managing nocturia. This holistic approach provides a foundation for developing innovative interventions and personalized treatments to enhance quality of life for individuals with LUTS across all stages of life.

Prevalence of Sleep CALM nocturia factors in a male veteran population

INTRODUCTION

Nocturia is a complex and multifactorial condition, associated with several genitourinary abnormalities as well as a host of conditions beyond the urinary tract, and thus often poses a significant diagnostic challenge in real-world practice. Sleep Disorders, Comorbidities, Actions, Lower Urinary Tract Dysfunction, and Medications, the so-called "Sleep C.A.L.M." factors, are five common causes of nocturia requiring judicious evaluation according to current consensus guidelines. This study aims to assess the prevalence of the Sleep C.A.L.M. factors in a nocturia clinical population.

METHODS

Retrospective analysis of frequency-volume charts from men with ≥2 nocturnal voids as well as concurrent demographic, clinical, and medical history data to identify patients with each of the Sleep C.A.L.M.

FACTORS

Comorbidities and medications were classified as a single group.

RESULTS

A total of 213 subjects met the criteria for inclusion (median age 68.0 [63.5-75.5] years). The prevalence of 1) sleep disorders, 2) comorbidities and/or medication use, 3) actions (i.e., modifiable behaviors/lifestyle factors), and 4) lower urinary tract dysfunction was 31%, 31%, 19%, and 41%, respectively. Among included participants, 73% were found to have at least 1 Sleep C.A.L.M. factor, and 33% had multiple Sleep C.A.L.M.

FACTORS

Results were similar upon stratification by age and nocturnal polyuria status.

CONCLUSIONS

The Sleep C.A.L.M. factors are highly common among nocturia patients in the clinical urology setting. Although many of these factors are strongly associated with advanced age in community-based nocturia study samples, they appear common even among younger men in a nocturia patient population; the differential effect of age and individual Sleep C.A.L.M. factors on nocturia pathophysiology requires further investigation.

Predicting Prostate Surgery Outcomes from Standard Clinical Assessments of Lower Urinary Tract Symptoms To Derive Prognostic Symptom and Flowmetry Criteria

BACKGROUND

Assessment of male lower urinary tract symptoms (LUTS) needs to identify predictors of symptom outcomes when interventional treatment is planned.

OBJECTIVE

To develop a novel prediction model for prostate surgery outcomes and validate it using a separate patient cohort and derive thresholds for key clinical parameters.

DESIGN, SETTING, AND PARTICIPANTS

From the UPSTREAM trial of 820 men seeking treatment for LUTS, analysis of bladder diary (BD), International Prostate Symptom Score (IPSS), IPSS-quality of life, and uroflowmetry data was performed for 176 participants who underwent prostate surgery and provided complete data. For external validation, data from a retrospective database of surgery outcomes in a Japanese urology department (n = 227) were used.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Symptom improvement was defined as a reduction in total IPSS of ≥3 points. Multiple logistic regression, classification tree analysis, and random forest models were generated, including versions with and without BD data.

RESULTS AND LIMITATIONS

Multiple logistic regression without BD data identified age (p = 0.029), total IPSS (p = 0.0016), and maximum flow rate (Qmax; p = 0.066) as predictors of outcomes, with area under the receiver operating characteristic curve (AUC) of 77.1%. Classification tree analysis without BD data gave thresholds of IPSS <16 and Qmax ≥13 ml/s (AUC 75.0%). The random forest model, which included all clinical parameters except BD data, had an AUC of 94.7%. Internal validation using the bootstrap method showed reasonable AUCs (69.6-85.8%). Analyses using BD data marginally improved the model fits. External validation gave comparable AUCs for logistic regression, classification tree analysis, and random forest models (all without BD; 70.9%, 67.3%, and 68.5%, respectively). Limitations include the significant number of men with incomplete baseline data and limited assessments in the external validation cohort.

CONCLUSIONS

Outcomes of prostate surgery can be predicted preoperatively using age, total IPSS, and uroflowmetry data, with prognostic thresholds of 16 for IPSS and 13 ml/s for Qmax.

PATIENT SUMMARY

This study identified key preoperative factors that can predict outcomes of prostate surgery for bothersome urinary symptoms, including which patients are at risk of a poor outcome.

Treatment of lower urinary tract symptoms in men in primary care using a conservative intervention: cluster randomised controlled trial

OBJECTIVE

To determine whether a standardised and manualised care intervention in men in primary care could achieve superior improvement of lower urinary tract symptoms (LUTS) compared with usual care.

DESIGN

Cluster randomised controlled trial.

SETTING

30 National Health Service general practice sites in England.

PARTICIPANTS

Sites were randomised 1:1 to the intervention and control arms. 1077 men (≥18 years) with bothersome LUTS recruited between June 2018 and August 2019: 524 were assigned to the intervention arm (n=17 sites) and 553 were assigned to the usual care arm (n=13 sites).

INTERVENTION

Standardised information booklet developed with patient and expert input, providing guidance on conservative and lifestyle interventions for LUTS in men. After assessment of urinary symptoms (manualised element), general practice nurses and healthcare assistants or research nurses directed participants to relevant sections of the manual and provided contact over 12 weeks to assist with adherence.

MAIN OUTCOME MEASURES

The primary outcome was patient reported International Prostate Symptom Score (IPSS) measured 12 months after participants had consented to take part in the study. The target reduction of 2.0 points on which the study was powered reflects the minimal clinically important difference where baseline IPSS is <20. Secondary outcomes were patient reported quality of life, urinary symptoms and perception of LUTS, hospital referrals, and adverse events. The primary intention-to-treat analysis included 887 participants (82% of those recruited) and used a mixed effects multilevel linear regression model adjusted for site level variables used in the randomisation and baseline scores.

RESULTS

Participants in the intervention arm had a lower mean IPSS at 12 months (adjusted mean difference -1.81 points, 95% confidence interval -2.66 to -0.95) indicating less severe urinary symptoms than those in the usual care arm. LUTS specific quality of life, incontinence, and perception of LUTS also improved more in the intervention arm than usual care arm at 12 months. The proportion of urology referrals (intervention 7.3%, usual care 7.9%) and adverse events (intervention seven events, usual care eight events) were comparable between the arms.

CONCLUSIONS

A standardised and manualised intervention in primary care showed a sustained reduction in LUTS in men at 12 months. The mean difference of -1.81 points (95% confidence interval -0.95 to -2.66) on the IPSS was less than the predefined target reduction of 2.0 points.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN11669964.

Sleep Disorders, Comorbidities, Actions, Lower Urinary Tract Dysfunction, and Medications ("Sleep C.A.L.M.") in the evaluation and management of nocturia: A simple approach to a complex diagnosis

INTRODUCTION

Nocturia arises from a fundamental mismatch between nocturnal urine production, storage capacity, and sleep architecture, which may be driven by abnormalities of the genitourinary tract, but also by sleep disorders, medical diseases, patient actions/lifestyle factors, or medications. This article introduces a novel system for organizing the complex differential diagnosis for nocturia, as proposed by an international collective of practicing urologists, physician specialists, and sleep experts: "Sleep CALM"-Sleep Disorders, Comorbidities, Actions, Lower Urinary Tract Dysfunction, and Medications.

METHODS

Narrative review of current evidence regarding the relevance of each "Sleep CALM" factor to nocturia pathogenesis, evaluation, and management.

RESULTS

Nocturia and sleep disorders are highly intertwined and often bidirectional, such that nocturnal awakenings for reasons other than a sensation of bladder fullness should not be used as grounds for exclusion from nocturia treatment, but rather leveraged to broaden therapeutic options for nocturia. Nocturia is an important potential harbinger of several serious medical conditions beyond the genitourinary tract. Urologists should have a low threshold for primary care and medical specialty referral for medical optimization, which carries the potential to significantly improve nocturnal voiding frequency in addition to overall health status. Adverse patient actions/lifestyle factors, lower urinary tract dysfunction, and medication use commonly coexist with disordered sleep and comorbid medical conditions, and may be the primary mediators of nocturia severity and treatment response, or further exacerbate nocturia severity and complicate treatment.

CONCLUSION

"Sleep CALM" provides a memorable and clinically relevant means by which to structure the initial patient history, physical exam, and clinical testing in accordance with current best-practice guidelines for nocturia. Although not intended as an all-encompassing diagnostic tool, the "Sleep CALM" schema may also be useful in guiding individualized ancillary testing, identifying the need for specialty referral and multidisciplinary care, and uncovering first-line treatment targets.