Bladder training compared to bladder training associated with pelvic floor muscle training for overactive bladder symptoms in women: A randomized clinical trial

AIMS

To compare the effects of bladder training (BT) versus BT with pelvic floor muscle training (PFMT) in women with overactive bladder (OAB) symptoms.

METHODS

Randomized controlled clinical trial including women with OAB symptoms, randomized into two groups: BT versus BT + PFMT. For 12 consecutive weeks, the women received home BT. The BT + PFMT performed supervised PFMT, once/week, associated at home PFMT protocol. Primary outcomes were urinary urgency, daytime voiding frequency, nocturia and urgency urinary incontinence assisted by both 3-day bladder diary and International Consultation on Incontinence OAB (ICIQ-OAB) questionnaire. Secondary outcomes were 24-h pad test and Patient Global Impression of Improvement. T-test, analysis of variance, Mann-Whitney (SPSS 20.0) and power/effect size (G-power) were applied in data analyses.

RESULTS

Sixty-three women were included (B = 31; BT + PFMT = 32). There was no significant statistical difference between groups in terms of urinary symptoms: daytime frequency (BT: pre: 11.59 [±5.80], post: 9.10 [±4.05]; BT + PFMT: pre: 10.67 [±3.73], post: 8.08 [±3.38]) p = 0.75; nocturia: (BT: pre: 1.46 [±0.91], post: 0.82 [±0.82]; BT + PFMT: pre: 1.80 [±2.26], post: 0.82 [±1.15]) p = 0.70; urinary urgency (BT: pre: 3.22 [±4.70], post: 4.49 [±4.32]; BT + PFMT: pre: 6.87 [±5.60], post: 6.15 [±4.52]) p = 0.10; ICIQ-OAB total score: (BT: pre: 9.16 [±2.55], post: 6.32 [±3.77]; (BT + PFMT: pre: 9.75 [±2.06], post: 5.06 [±3.44] p = 0.30.

CONCLUSIONS

Supervised PFMT added to BT did not provide further improvements than isolated BT in women with OAB symptoms.

Efficacy of cognitive behavioral therapy using self-check sheet for patients with nocturia in real-world clinical practice

OBJECTIVES

We previously demonstrated the efficacy of cognitive behavioral therapy (CBT) using a self-check sheet for patients with nocturia in a randomized controlled study. Additionally, we investigated the efficacy of the intervention in real-world clinical practice.

METHODS

Two hundred forty-three outpatients with complaint of nocturia who practiced CBT for 4 weeks using a self-check sheet were included in this trial, which took place from April 2021 to March 2022 in 20 institutions.

RESULTS

Of the 243 patients, 215 who achieved 50% or more of the behavioral therapy tasks were included in the analysis. Their mean age ± SD was 77.1 ± 7.7. A significant decrease was observed in nighttime frequency at 4 weeks after CBT using self-check sheets (pre 3.3 and post 2.8, p < .001). Nighttime frequency was decreased one or more times and was defined as treatment success in 102 patients (47.4%). Pretreatment nighttime frequency in the treatment-success group was significantly higher than that of the failure group (3.5 ± 1.0 vs. 3.2 ± 1.0, p = .013). In multivariate logistic regression analysis, predictive factors of treatment success were pretreatment nocturnal frequency of four or more (odds ratio [OR] 1.82, 95% confidence interval [CI] 1.01-3.30; p = .046) and the absence of diabetes mellitus (OR 3.08, 95% CI 1.34-7.06; p = .008).

CONCLUSIONS

CBT using a self-check sheet requiring less time, less labor, less cost, and less medication is very beneficial for both patients and medical staff in real-world clinical practice.

The Bladder at Night during Hospitalisation: Towards optimal care for elderly patients with nocturia

OBJECTIVE

This study aimed to describe the characteristics of nocturia in older hospitalised patients and to explore knowledge, beliefs and experiences associated with night toileting while in hospital in order to identify unmet care needs.

METHODS

A multisite mixed methods cross-sectional study of older hospitalised adults who were admitted for ≥2 days was conducted using a standardised researcher-administered questionnaire. An additional cohort 16 older hospitalised adults with nocturia >twice per night were interviewed to understand the experience and impact of nocturia during hospitalisation.

RESULTS

Nocturia was experienced by 260 out of 308 participants. In-hospital nocturia was significantly correlated with nocturia in the month preceding admission, high diurnal voiding frequency and nocturnal urinary urgency. Bother was attributed to multiple nocturia episodes. Participants had poor knowledge and understanding of nocturia and believed the symptom to be a normal occurrence; only 20% had discussed management with staff. Disrupted sleep and fear of falling were common in older immobile participants with nocturia.

CONCLUSION

Nocturia is highly prevalent in hospitalised older people. Toileting multiple times at night bothers patients, disrupts sleep, heightens a fear of falling yet is rarely addressed in ward management plans. A screening process to identify, assess, provide education and intervene for nocturia has the potential to improve wellbeing, safety at night and to address risk factors.

Effectiveness of acupuncture for nocturia: A protocol for systematic review and meta-analysis

BACKGROUND

Nocturia is a common and highly troubled lower urinary tract symptom, which has a wide range of effects. About 33% of patients with lower urinary tract symptoms have been affected by nocturia. Nocturia is mainly manifested as the increase of urination frequency and urine volume at night. It has been proved that acupuncture can reduce the symptoms of nocturia and regulate bladder function in Western countries. Acupuncture may be a promising choice for the treatment of nocturia.

METHODS

RCTs of acupuncture for nocturia will be searched in the relevant database, including PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure Wanfang Database, Chinese Biomedical Literature Database, and Chinese Scientific Journal Database. The studies of electronic searches will be exported to EndNote V.9.1 software. We will run meta-analyses using the Review Manager (RevMan) V.5.3 software. Any disagreement will be solved in consultation with a third reviewer.

RESULTS

Our study aims to explore the efficacy of acupuncture for nocturia and to provide up-to-date evidence for clinical of nocturia.

CONCLUSION

The conclusion of this study will provide evidence for the efficacy of acupuncture treatment of nocturia.

INPLASY REGISTRATION NUMBER

INPLASY202130100.

Treatment for overactive bladder: A meta-analysis of transcutaneous tibial nerve stimulation versus percutaneous tibial nerve stimulation

BACKGROUND

We aim to compare the safety and effectiveness of transcutaneous tibial nerve stimulation (TTNS) versus percutaneous tibial nerve stimulation (PTNS) in treating overactive bladder.

METHODS

A systematical search on PubMed, Embase, clinicalTrial.gov, and Cochrane Library Central Register of Controlled Trials from January 1, 1999 to November 1, 2020 was performed. The primary outcomes were the changes in a 3-day voiding diary. Quality of life scores were also evaluated. Review Manager 5.3 (Cochrane Collaboration, Oxford, UK) was applied to conduct all statistical analyses.

RESULTS

A total of 4 trials (2 randomized controlled trials, 1 retrospective study, and 1 before-after study) with 142 patients were eventually enrolled. Compared with PTNS, TTNS had a similar performance in the voiding frequency in 24 hours (mean difference [MD] = -0.65, 95% confidence interval [CI]: -1.35 to 0.05, P = .07), the number of urgency episodes in 24 hours (MD = 0.13, 95% CI: -0.36 to 0.62, P = .60), the number of incontinence episodes in 24 hours (MD = 0.01, 95% CI: -0.13 to 0.14, P = .93), as well as in the nocturia frequency (MD = -0.14, 95% CI: -0.52 to 0.24, P = .47). Moreover, comparable results were observed regarding HRQL scores (P = .23) and incontinence quality of life scores (P = .10) in both groups. The total complication rate in the current study was 2.1% (3/142). No adverse events were identified in the TTNS group.

CONCLUSION

Current data supported that TTNS is as effective as PTNS for the treatment of overactive bladder, moreover, with no reported adverse events. However, the evidence is low-grade and well-designed prospective studies with a large sample size are warranted to verify our findings.

Interventions for treating people with symptoms of bladder pain syndrome: a network meta-analysis

BACKGROUND

Bladder pain syndrome (BPS), which includes the condition of interstitial cystitis, is a poorly understood clinical condition for which patients present with varying symptoms. Management of BPS is challenging for both patients and practitioners. At present, there is no universally accepted diagnosis and diverse causes have been proposed. This is reflected in wide-ranging treatment options, used alone or in combination, with limited evidence. A network meta-analysis (NMA) simultaneously comparing multiple treatments may help to determine the best treatment options for patients with BPS.

OBJECTIVES

To conduct a network meta-analysis to assess the effects of interventions for treating people with symptoms of bladder pain syndrome (BPS).

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL, in the Cochrane Library), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and handsearched journals and conference proceedings (searched 11 May 2018) and the reference lists of relevant articles. We conducted a further search on 5 June 2019, which yielded four small studies that were screened for eligibility but were not incorporated into the review.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs of interventions for treating adults with BPS. All types of interventions (including conservative, pharmacological and surgical) were eligible.

DATA COLLECTION AND ANALYSIS

We assessed the risk of bias of included studies using Cochrane's 'Risk of bias' tool. Primary outcomes were the number of people cured or improved, pain, frequency and nocturia. For each outcome, random-effects NMA models were fitted using WinBUGS 1.4. We monitored median odds ratios (ORs) for binary outcomes and mean differences (MDs) for continuous outcomes with 95% credible intervals (Crls). We compared results of the NMA with direct evidence from pairwise meta-analysis of head-to-head trials. We used the CINeMA tool to assess the certainty of evidence for selected treatment categories.

MAIN RESULTS

We included 81 RCTs involving 4674 people with a median of 38 participants (range 10 to 369) per RCT. Most trials compared treatment against control; few trials compared two active treatments. There were 65 different active treatments, and some comparisons were informed by direct evidence from only one trial. To simplify, treatments were grouped into 31 treatment categories by mode of action. Most studies were judged to have unclear or high risk of bias for most domains, particularly for selection and detection bias. Overall, the NMA suggested that six (proportion cured/improved), one (pain), one (frequency) and zero (nocturia) treatment categories were effective compared with control, but there was great uncertainty around estimates of effect. Due to the large number of intervention comparisons in this review, we focus on three interventions: antidepressants, pentosan polysulfate (PPS) and neuromuscular blockade. We selected these interventions on the basis that they are given 'strong recommendations' in the EAU Guidelines for management of BPS (EAU Guidelines 2019). We found very low-certainty evidence suggesting that antidepressants were associated with greater likelihood of cure or improvement compared with control (OR 5.91, 95% CrI 1.12 to 37.56), but it was uncertain whether they reduced pain (MD -1.27, 95% CrI -3.25 to 0.71; low-certainty evidence), daytime frequency (MD -2.41, 95% CrI -6.85 to 2.05; very low-certainty evidence) or nocturia (MD 0.01, 95% CrI -2.53 to 2.50; very low-certainty evidence). There was no evidence that PPS had improved cure/improvement rates (OR 0.14, 95% CrI 0.40 to 3.35; very low-certainty evidence) or reduced pain (MD 0.42, 95% CrI -1.04 to 1.91; low-certainty evidence), frequency (MD -0.37, 95% CrI -5.00 to 3.44; very low-certainty evidence) or nocturia (MD -1.20, 95% CrI -3.62 to 1.28; very low-certainty evidence). There was evidence that neuromuscular blockade resulted in greater cure or improvement (OR 5.80, 95% CrI 2.08 to 18.30) but no evidence that it improved pain (MD -0.33, 95% CrI -1.71 to 1.03), frequency (MD -0.91, 95% CrI -3.24, 1.29) or nocturia (MD -0.04, 95% CrI -1.35 to 1.27). The certainty of this evidence was always very low.

AUTHORS' CONCLUSIONS

We are uncertain whether some treatments may be effective in treating patients with BPS because the certainty of evidence was generally low or very low. Data were available for a relatively large number of trials, but most had small sample sizes and effects of treatments often could not be estimated with precision. An NMA was successfully conducted, but limited numbers of small trials for each treatment category hampered our ability to fully exploit the advantages of this analysis. Larger, more focused trials are needed to improve the current evidence base.

A directional preference approach for chronic pelvic pain, bladder dysfunction and concurrent musculoskeletal symptoms: a case series

BACKGROUND

Chronic pelvic pain (CPP) with concurrent musculoskeletal and bladder symptoms is a complex and challenging problem. However, clinically the co-existence of these symptoms is not routinely questioned, and their musculoskeletal source is not investigated thoroughly. The purpose of this case series is to present the use of Mechanical Diagnosis and Therapy (MDT) principles in seven patients with concurrent chronic pelvic pain, bladder dysfunction and musculoskeletal symptoms.

CASE DESCRIPTIONS

Seven patients with coexisting pelvic health and musculoskeletal signs and symptoms were retrospectively reviewed. Most common symptoms were urinary frequency, incontinence, pelvic pain, nocturia, dyspareunia, bladder dyssynergia, and lumbar, pelvic or hip pain. All patients failed to recognize the possible interconnectedness of the two sets of symptoms. Each exhibited a directional preference (DP) and subsequent MDT provisional classification of derangement was established; the use of DP forces abolished or dramatically improved both symptoms and mobility impairments. In all cases DP was for sustained sagittal forces initially, but ultimately lateral forces and mobilization were indicated.

OUTCOMES

Changes in Pelvic Floor Impact Questionnaire, Care Connections Pelvic Floor and Lumbar spine were all clinically significant and exceeded minimally Clinical Important Differences several times. Average of 5.8 sessions per patient was noted. Follow-up at an average of 3.3 years revealed ongoing satisfaction and confidence in independent self-management.

DISCUSSION

These case studies highlight the importance of ensuring expansion of intake questions for possible co-existence of symptoms in both pelvic and musculoskeletal patients, possibly suggesting a mechanical intervention is indicated. Provisional subclassification into 'Mechanical Pelvic Syndrome' is proposed. Level of Evidence: 4.

Sodium restriction improves nocturia in patients at a cardiology clinic

This study aims to determine whether dietary sodium restriction counseling decreases nocturnal voiding frequency in cardiology patients with concomitant nocturia. Patients who had established care at a cardiology clinic from 2015 to 2018 reporting ≥1 average nocturnal void(s) underwent a comprehensive sodium intake interview by their cardiologist, who provided them with individualized strategies for dietary sodium reduction and assessed adherence at follow-up. Average nocturnal voiding frequency and dietary adherence were documented in the medical record. A nocturia database was compiled for retrospective analysis. A total of 74 patients were included. Patients considered to be adherent with dietary sodium restriction at follow-up (n = 56) demonstrated a decrease in median nocturia frequency (2.5 [2.3-3.0] vs 1.0 [1.0-2.0] voids, P < .001). Among nonadherent patients (n = 18), median nocturia frequency did not significantly change from baseline to follow-up (2.0 [1.5-3.8] vs 2.0 [1.5-4.8] voids, P = .423). Median changes were significantly different between the adherent and nonadherent groups (P < .001). Examination of second follow-up available from 37 patients showed a continued effect. In conclusion, adherence with dietary sodium counseling appears to improve nocturia. Accordingly, dietary modification may represent an important adjunct therapy to lifestyle and pharmacologic interventions for decreasing nocturia frequency. Reduction in nocturnal voiding frequency may also reflect an additional benefit of dietary sodium restriction in accordance with best practice standards for cardiovascular disease.

Healthcare-seeking with bothersome lower urinary tract symptoms among men in the Danish population: the impact of lifestyle and socioeconomic status

Objective: (1) To identify possible factors of importance for reporting lower urinary tract symptoms (LUTS) among men and (2) to examine possible associations between socioeconomic status (SES), lifestyle factors, and likelihood of men contacting a general pracitioner (GP) regarding LUTS reported to be of concern or influencing daily activities (bothersome LUTS). Design: Nationwide population-based, cross-sectional survey. Data was collected in 2012. Setting: The general Danish population. Subjects: A total of 48,910 randomly selected men aged 20+. Main Outcome Measures: (1) Odds ratios for reporting LUTS by lifestyle and SES, and (2) Odds ratios for GP contact with bothersome LUTS by lifestyle and SES. Results: 23,240 men participated (49.8%). Nocturia was the most commonly experienced LUTS (49.8%). Incontinence was most often reported as bothersome (64.1%) and nocturia less often reported as bothersome (34.2%). Only about one third of the men reporting a bothersome LUTS contacted their GP. Odds for reporting LUTS significantly increased with increasing age, obesity, and lack of labor market affiliation. Increasing age and symptom burden significantly increased the odds for GP contact regarding bothersome LUTS. No overall associations were found between lifestyle, SES, and GP contact. Conclusion: Bothersome LUTS are common among Danish men. Concern and influence of LUTS on daily activities are important determinants of GP contact, yet only one in three bothersome LUTS are discussed with a GP. Advanced age and symptom burden were significantly associated with GP contact. Implications: Information on treatment options for LUTS might be desirable among Danish men regardless of SES and lifestyle. Key points Urological symptoms are common among men in the Danish population and are often managed without contacting healthcare professionals. Increasing age and symptom burden significantly increase the likelihood of consulting a general practitioner regarding bothersome urological symptoms Healthcare-seeking behavior with bothersome urological symptoms is not influenced by lifestyle or socioeconomic status among Danish men; Information about available, effective treatment options for urological symptoms might be desirable among men regardless of socioeconomic status and lifestyle.

Patients' Lived Experiences of Nocturia: A Qualitative Study of the Evening, the Night, and the Next Day

BACKGROUND

Nocturia, waking to urinate two or more times during the night, is a chronic condition associated with significant patient burden due to sleep disruption. This study aimed to explore the lived experiences of patients with nocturia in terms of the disruption to their lives during the night and day.

METHODS

Adult patients in the US diagnosed with nocturia were recruited for face-to-face qualitative interviews. Thematic analysis of patients' narratives, taking a phenomenological interpretative approach, summarised their experiences throughout the night and day, including any apparent contrasts between patients.

RESULTS

Twenty patients (10 male, 10 female) aged between 39 and 80 years, averaging three night-time voids, were interviewed. Analysis revealed that nocturia has a substantial impact on sleep quality and quantity, with the frequency of night-time voids a key driver of this. In addition to night-time phenomena, patients faced various difficulties the next day, including day-time tiredness, lack of energy and concerns related to emotional wellbeing, social functioning and cognitive functioning. All of these limited patients' capacity to work, perform daily activities or fulfil role responsibilities. Patients' lifestyles influenced experience, where younger patients in employment more readily emphasised the day-time physical and psychosocial burdens. Patients employed coping behaviours in an attempt to lessen the severity of nocturia and its impact, which were both physician-led and self-taught.

CONCLUSIONS

While the symptom of nocturia only occurs during the night, the impact is longer lasting, affecting functioning and wellbeing throughout the following day. Patients' circumstances can affect the extent of their burden; recognising this can improve effective delivery of patient-centred care.

[Nocturia in aged patient: in practice]

Nocturia is defined as the complaint that the individual has to wake at night to urinate. In older persons, this urinary functional disorder is most often of multifactorial origin and/or the symptom (sometimes the unique one) of a chronic disease. Nocturia is very annoying and its impact on health and quality of life is related to the disturbance of sleep cycles. In aged patients, who are often polymorbide and polymedicated, the interaction between nocturia and geriatric syndromes as well as comorbidities has to be more particularly underlined. The impact on informal caregiver's health and the decision for institutional admission are also to be considered. An adapted management of nocturia improves quality of life and reduces morbidity in aged patients.

A practical approach to the management of nocturia

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.

Nocturia - Symptom or a Disease?

Waking at night to void is known as nocturia and it is a common condition experienced by both men and women with profound impact on patient's health, quality of life, and economic condition. It is often perceived as a symptom of an organic disease, but the pathophysiology of nocturia is now well-understood, and it is considered as a disease itself. It is classified based on four different pathophysiologic mechanisms (24-hour polyuria, nocturnal polyuria, reduced bladder capacity, and sleep disorders). The association of nocturia with impaired quality of life, cardiovascular morbidity and all-cause mortality is well established. Various pharmacological agents are available, of which desmopressin is considered safe and effective in both short- and long-term studies for the treatment of nocturia in men and women, including the elderly. Combining desmopressin with other agents provides an effective treatment option for nocturia in patients with lower urinary tract symptoms, benign prostatic hypertrophy or overactive bladder syndrome. This review covers the various aspects of pathophysiology and impact of nocturia, as well as the treatment of nocturia. We present the novel concept of a "nocturia clinic", which is a comprehensive diagnostic and management center for patients with nocturia. This set-up may help bring about a positive change in the underreported and undertreated status of nocturia, and bring relief to sufferers of nocturia. Therefore nocturia though perceived as a symptom of many disorders; it itself has a defined pathophysiology and needs treatment.

Effects of a Gentle, Self-Administered Stimulation of Perineal Skin for Nocturia in Elderly Women: A Randomized, Placebo-Controlled, Double-Blind Crossover Trial

Background

Somatic afferent nerve stimuli are used for treating an overactive bladder (OAB), a major cause of nocturia in the elderly. Clinical evidence for this treatment is insufficient because of the lack of appropriate control stimuli. Recent studies on anesthetized animals show that gentle stimuli applied to perineal skin with a roller could inhibit micturition contractions depending on the roller’s surface material. We examined the efficacy of gentle skin stimuli for treating nocturia.

Methods

The study was a cross-over, placebo-controlled, double-blind randomized clinical study using two rollers with different effects on micturition contractions. Participants were elderly women (79–89 years) with nocturia. Active (soft elastomer roller) or placebo (hard polystyrene roller) stimuli were applied to perineal skin by participants for 1 min at bedtime. A 3-day baseline assessment period was followed by 3-day stimulation and 4-day resting periods, after which the participants were subjected to other stimuli for another 3 days. The primary outcome was change in the frequency of nighttime urination, for which charts were maintained during each 3-day period.

Results

Twenty-four participants were randomized, of which 22 completed all study protocols. One participant discontinued treatment because of an adverse event (abdominal discomfort). In participants with OAB (n = 9), change from baseline in the mean frequency of urination per night during the active stimuli period (mean ± standard deviation, −0.74 ± 0.7 times) was significantly greater than that during placebo stimuli periods (−0.15 ± 0.8 times [p < 0.05]). In contrast, this difference was not observed in participants without OAB (n = 13).

Conclusions

These results suggest that gentle perineal stimulation with an elastomer roller is effective for treating OAB-associated nocturia in elderly women. Here the limitation was a study period too short to assess changes in the quality of sleep and life.

Trial Registration

UMIN Clinical Trial Registry (CTR) UMIN000015809

Nocturia: diagnosis and management for the primary care physicians

Primary care physicians commonly see men or women with nocturia (or nocturnal polyuria). Nocturia can have a dramatic impact on a patient's physical and emotional quality of life, including work performance or ability to function, because of the interrupted sleep patterns. It has also been determined that the most important sleep interval is the time from first falling asleep until first awakening. Nocturia is one of the most common and most bothersome symptoms of lower urinary tract symptoms (LUTS). In a man, LUTS is most commonly caused by benign prostatic obstruction (BPO) related to the enlargement of the prostate. In a woman, the most common cause of LUTS is overactive bladder (OAB). This article first explores the different causes and types of nocturia, then describes how to diagnose different types of nocturia (including use of frequency-volume charts), and last, discusses different approaches for managing nocturia (including the use of desmopressin), depending on the type and cause.

Nocturia: state of the art and critical analysis of current assessment and treatment strategies

This editorial of the topic issue of the World Journal of Urology provides a state of the art on nocturia which includes descriptions of the terminology, epidemiology, health-related quality of life, medical and financial consequences, pathophysiology, assessment tools and treatment strategies of nocturia. This summary also includes a flowchart on the pathophysiology of nocturia with illustration of the various causes of reduced bladder capacity, increased fluid intake or increased diuresis; a flowchart with the key findings of frequency-volume charts to determine the underlying pathophysiology; and a flowchart on the treatment of the various causes of nocturia. The editorial critically discusses current assessment and treatment strategies in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) and nocturia. The outcome of nocturia remains hidden in drug trials of patients with LUTS/BPH because nocturia-specific measures were not included. The authors recommend using frequency-volume charts, measurement of the hours of undisturbed sleep, and nocturia-specific quality of life questionnaires (e.g., ICIQ-N or N-Qol) in all future studies in patients with LUTS/BPH and nocturia.

Behavioral treatment of insomnia: also effective for nocturia

OBJECTIVES

To evaluate changes in self-reported nocturia in community-dwelling adults aged 60 and older who received behavioral treatment for chronic insomnia.

DESIGN

Secondary analysis of a randomized controlled trial of a behavioral intervention for sleep.

SETTING

Academic medical center.

PARTICIPANTS

Of the 79 enrollees, this analysis focused on 30 who, in addition to insomnia, also reported at least one nightly episode of waking up to void.

INTERVENTION

The brief behavioral treatment of insomnia (BBTI) group (n = 14) received instructions on reducing time in bed and setting a regular sleep schedule. The information control (IC) group (n = 16) received printed materials. A nurse clinician delivered both interventions.

MEASUREMENTS

Self-reported nocturnal awakenings to void assessed daily for 14 days at baseline and 4 weeks after the intervention. Participants who reported at least one episode of nocturia per night at baseline were included in this analysis.

RESULTS

In individuals with nocturia at baseline, the total number of nocturnal voids over the 14-day assessment period decreased by 6.5 ± 4.8 in the BBTI group and increased by 1.3 ± 7.3 in the IC group (P = .04, effect size 0.82). After adjusting for baseline nocturia episodes, the difference remained significant (P = .05).

CONCLUSION

In older adults with concurrent insomnia and nocturia, behavioral treatment directed solely at insomnia may also improve self-reported nocturia. Behavioral treatment of insomnia should be further investigated for its effect on nocturia in individuals with concurrent insomnia and nocturia.

The effects of age, metabolic syndrome, nocturnal polyuria and sleep disorders on nocturia

BACKGROUND

Nocturia, which is especially frequent among older men, adversely affects the individual's quality of life. It is regarded as one of the most bothersome lower urinary tract symptoms (LUTS).

OBJECTIVES

The aim of the study was to investigate factors contributing to the frequency of nocturia.

MATERIAL AND METHODS

Men ≥ 40 years with LUTS were enrolled in this study. After medical histories were taken and physical examinations conducted, biochemical tests and measures for LUTS were carried out. Anthropometric measurements were performed and Epworth scores (ES) were examined. Patients were divided into two groups with respect to nocturia: the first group having no nocturia or one incident of nocturia per night, and the second group with two or more nightly incidents of nocturia. The data were analyzed statistically; p < 0.05 was considered significant.

RESULTS

A total of 118 consecutive patients (56 ± 10 years) were enrolled in the study. The first group consisted of 31 participants, while the second group contained 87 patients. The groups differed significantly with respect to age, body height, body weight, waist circumference and body mass index (BMI). ES, prostatic volumes, maximum flow rates (Qmax) and international prostate symptom scores (IPSS) were significantly different. Fasting blood glucose levels were similar for both groups. Homeostasis model assessment (HOMA) scores showed borderline significance. Insulin levels were different, while insulin resistance (IR) was similar between the groups. Nocturnal polyuria was associated with nocturia, systolic blood pressure and IPSS.

CONCLUSIONS

Age, nocturnal polyuria, metabolic syndrome and sleep disturbances have been shown to be contributing factors in the frequency of nocturia and LUTS. Therefore, steps taken to alleviate factors that can be altered - such as hypertension, weight gain, sleep disturbances and IPSS - may improve the individual's quality of life.

Nocturia--a guide to assessment and management

BACKGROUND

Nocturia is a common cause of sleep disturbance affecting up to 40% of the adult population.

OBJECTIVE

This article provides a framework for the management of nocturia. Based on the frequency volume chart, nocturia can be divided into three categories: global polyuria, nocturnal polyuria and bladder storage disorders. Differentiating between these categories enables effective targeting of treatment.

DISCUSSION

Although nocturia is one of the most bothersome urinary symptoms, it has generally been poorly understood and managed. Aetiology is often multifactorial and includes systemic medical disease, lower urinary tract pathology, sleep disorders and behavioural and environmental factors.

[Advances in clinical study of nocturia]

Nocturia is one of the most common reasons for interrupted sleep in general adult population. The condition affects both men and women, with an incidence that increases dramatically with age. Nocturia has a negative impact on quality of life, affecting both morbidity and mortality. International Continence Society (ICS) issued a report of terminology standardization in 2002, in which nocturia is defined as waking during the night at least once to urinate. Nocturia is a common complaint in elderly population. Although most cases of nocturia are assumed to be caused by urologic problems, the interacting effects of aging and sleep on renal and urinary function, in fact, cause nocturia in the elderly. Effective diagnosis of the condition is dependent on a clear understanding of its underlying etiology. Multiple factors may cause nocturia, such as behavioral or environmental factors and pathologic conditions. In general, the causes of nocturia fall into three categories: diurnal polyuria, nocturnal polyuria, and low bladder capacity. Careful evaluation of medications and underlying medical conditions is essential for the proper management of nocturia. A voiding diary is necessary to diagnose the syndrome of nocturnal polyuria, which is a common cause of nocturia. Addressing any underlying conditions that contribute to nocturia is the first step in treating the condition. Lifestyle and behavioral changes may provide benefit in some individuals, but for many cases, pharmacotherapy is the best option. Antimuscarinic agents are first-line therapies for overactive bladder and are often used in the management of nocturia. Current treatment options also include desmopressin, a synthetic analog of arginine vasopressin, which can increase urinary osmolality and decrease total urinary volume. The desmopressin therefore increases the length of time until the first nocturnal void and decreases the number of nocturnal voids, the NUV voided, and the percentage of urine voided at night.

[Present view on the diagnostics and treatment of nocturia]

Nocturia is one of the most bothersome symptoms of lower urinary tract and may be the leading symptom in medical examination. Nocturia has a special aspect of being of multifactorial etiology so an interdisciplinary approach for the diagnosis and treatment is obligatory. At present, nocturia is considered to be a new entity excluded from the symptoms of lower urinary tract and may be a consequence of serious disease. Diagnosis consists of non-invasive methods and the mainstay is the micturition diary. Treatment is based on desmopressin therapy and drugs influencing lower urinary tract in some cases.

Nocturia, nocturnal incontinence prevalence, and response to anticholinergic and behavioral therapy

To determine whether participants in the behavior enhances drug reduction of incontinence (BE-DRI) trial experienced reduction in the frequency of nocturia and/or nocturnal leakage during treatment with antimuscarinic phamacotherapy with or without additional behavioral therapy. We analyzed urinary diary data relating to nocturia and nocturnal incontinence before and after 8 weeks of study treatment in the BE-DRI trial, in which patients were randomly assigned to receive drug therapy with tolterodine tartrate extended-release capsules 4 mg alone or in combination with behavioral training. Chi-square tests assessed whether nocturia and nocturnal incontinence prevalence varied by treatment arm and paired t tests assessed the change in mean frequency of nocturia and nocturnal leakage. Among 305 women, 210 (69%) had an average of at least one nocturia episode at baseline. There were small but statistically significant differences (p < 0.001) in mean nocturia frequency and nocturnal incontinence frequency with both treatments after 8 weeks, but no significant difference between study treatment groups. Among these urge incontinent women, tolterodine with or without supervised behavioral therapy had little impact on either nocturic frequency or nocturnal incontinence.

Pediatric voiding dysfunction: a case study

A 14-year-old male was evaluated and treated for frequent urination associated with straining to void, a sensation of incomplete emptying, and nocturia. Treatment and outcomes are presented in this article.

Beyond the Bladder: Management of Urinary Incontinence in Older Women

Unlike urinary incontinence (UI) in younger women, UI in older women is usually multifactoral in etiology and involves factors beyond the more common types of lower urinary tract (LUT) pathophysiology associated with UI in younger women. The evaluation and management of UI in older women, therefore, must itself be multifactoral and sometimes multidisciplinary, and encompass an understanding of age-related LUT changes, age-specific LUT pathophysiology, and a broadened, multidimensional concept of continence.

Nocturia in women

Nocturia, the complaint of waking at night to void, is a bothersome condition known to affect Quality of Life. In addition sleep deprivation is also known to affect daytime functioning and productivity. Whilst recently recognised as a discrete clinical entity nocturia is also a symptom of those women complaining of Overactive Bladder (OAB) syndrome. The causes of nocturia are multifactorial although in clinical practice nocturia is generally associated with either increased nocturnal urine production, problems related to bladder storage or sleep pattern abnormalities. When evaluating women complaining of nocturia a urinary diary and clinical examination is integral to making the diagnosis prior to commencing treatment. Having excluded and treated any underlying cause behavioural modification, such as moderation of fluid intake or timing of taking anti-diuretic medication, should be considered first line therapy. Should this conservative approach fail then treatment with antimuscarinic agents or desmopressin, a nona-peptide analogue of anti-diuretic hormone (ADH) is often helpful.

Sleep and aging: 2. Management of sleep disorders in older people

The treatment of sleep-related illness in older patients must be undertaken with an appreciation of the physiologic changes associated with aging. Insomnia is common among older people. When it occurs secondary to another medical condition, treatment of the underlying disorder is imperative. Benzodiazepines, although potentially effective, must be used with care and in conservative doses. Daytime sedation, a common side effect, may limit use of benzodiazepines. Newer non-benzodiazepine drugs appear to be promising. Rapid eye movement (REM) sleep behaviour disorder can be treated with clonazepam, levodopa-carbidopa or newer dopaminergic agents such as pramipexole. Sleep hygiene is important to patients with narcolepsy. Excessive daytime sleepiness can be treated with central stimulants; cataplexy may be improved with an antidepressant. Restless legs syndrome and periodic leg-movement disorder are treated with benzodiazepines or dopaminergic agents such as levodopa-carbidopa and, more recently, newer dopamine agonists. Treatment of obstructive sleep apnea includes weight reduction and proper sleep positioning (on one's side), but may frequently necessitate the use of a continuous positive air-pressure (CPAP) device. When used regularly, CPAP machines are very effective in reducing daytime fatigue and the sequelae of untreated obstructive sleep apnea.

Effects of walking exercise on nocturia in the elderly

We investigated whether nocturia in the elderly was improved by walking exercise, which involved walking rapidly for 30 min or more in the evening or night for 8 weeks. A questionnaire related to micturition and exercise, blood pressure, body composition analysis, blood biochemistry tests, and urinalysis were performed before and after 8 weeks of exercise to investigate the effects of walking. Thirty men (71 years old on average) continued the walking exercise for long enough to undergo evaluation. The number of episodes of nocturia decreased significantly (p < 0.001) from 3.3 +/- 0.7 to 1.9 +/- 0.8 after 8 weeks of walking exercise. The daytime urinary frequency, blood pressure, body weight, body fat ratio, edema ratio, serum catecholamines, triglycerides, and total cholesterol were also decreased. After 8 weeks of exercise, 20 of the subjects (67%) stated that sleep was deeper than before exercise. Assessment of the overall improvement showed that excellent or good results were obtained in 18 patients (60%). The main factor related to the influence of walking exercise on nocturia was that sleep became deeper, which increased the arousal threshold bladder volume. Walking exercise may also have a preventive effect on lifestyle-related diseases.

Perception of nocturia and medical consulting behavior among community-dwelling women

We investigated the perception of nocturia and possible explanatory factors for medical consultation among community-dwelling women. Between October 2004 and February 2005, women aged > or =40 years living in Matsu, Taiwan, who were identified as having nocturia in a previous epidemiological survey, were interviewed with a questionnaire eliciting information about nocturia-specific quality of life impact (N-QOL), perceptions of nocturia, and medical-consultation behavior. A total of 328 women completed this study. Of these, 187 (57%), 99 (30.2%), 30 (9.1%), and 12 (3.7%) reported one, two, three, and four or more nocturia episodes, respectively, per night during the past 4 weeks. Most women attributed nocturia to aging or excessive fluid intake and had a lack of medical information. Overall, only 13.1% had visited a doctor for this condition. Nocturia episodes [> or = three vs <three, odds ratio (OR) 3.8], N-QOL score (OR 2.0, per 10-point decrement), linking nocturia to a disease (OR 2.9), and medical information (OR 2.2) were independent factors associated with medical-consultation, whereas the lack of knowledge that nocturia was treatable appeared to be an important barrier to medical-consultation. Only 62.8% of the women were offered treatment upon consultation, even though nearly half of those treated reported significant improvement. A few women with nocturia have sought medical help, which appears to be affected by a compendium of factors. This study suggests that more information about nocturia should be provided to health providers and patients to identify and meet their most essential needs.