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Nocturia: More Than Just a Nuisance

A man sleeping soundly in bed because lifestyle-based interventions have helped decrease his symptoms of nocturia.
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.

(Video Time: 3 minutes) Dr. Espinosa is a naturopathic doctor, licensed acupuncturist, and a certified functional medicine practitioner recognized as an authority in urology and men’s health. He is co-founder, chief medical officer, and formulator of advanced nutraceutical formulas at XY Wellness, LLC, and he lectures internationally on the application of science-based holistic treatments for urological conditions.

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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References

  1. Weiss JP, Everaert K. Management of nocturia and nocturnal polyuria. Urology. 2019;133S:24-33. doi:10.1016/j.urology.2019.09.022
  2. Oelke M, Anderson P, Wood R, Holm-Larsen T. Nocturia is often inadequately assessed, diagnosed and treated by physicians: results of an observational, real-life practice database containing 8659 European and US-American patients. Int J Clin Pract. 2016;70(11):940-949. doi:10.1111/ijcp.12882
  3. Brucker BM. The medical condition 72 percent of Americans don’t know about is stealing sleep and disrupting lives, survey shows. UroToday. Published September 13, 2018. Accessed April 20, 2023. https://www.urotoday.com/recent-abstracts/pelvic-health-reconstruction/nocturia/106836-the-medical-condition-72-percent-of-americans-don-t-know-about-is-stealing-sleep-and-disrupting-lives-survey-shows.html?utm_source=newsletter_5865&utm_medium=email&utm_campaign=noctiva-harris-poll-sussman&acm=_5865
  4. 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
  5. Alwis US, Monaghan TF, Haddad R, et al. Dietary considerations in the evaluation and management of nocturia. F1000Res. 2020;9:F1000. doi:10.12688/f1000research.21466.1
  6. Leslie SW, Sajjad H, Singh S. Nocturia. StatPearls. Updated March 11, 2023. Accessed May 1, 2023. https://www.ncbi.nlm.nih.gov/books/NBK518987/
  7. Misraï V, Charbonneau H, Attias D, Pathak A. Obstructive sleep apnea syndrome should always be screened in patients complaining of nocturia. World J Urol. 2019;37(12):2801-2802. doi:10.1007/s00345-018-2534-x
  8. Everaert K, Anderson P, Wood R, Andersson FL, Holm-Larsen T. Nocturia is more bothersome than daytime LUTS: results from an observational, real-life practice database including 8659 European and American LUTS patients. Int J Clin Pract. 2018;72(6):e13091. doi:10.1111/ijcp.13091
  9. Drake M. Nocturia and depressive symptoms in older men. BJU Int. 2017;120(2):159. doi:10.1111/bju.13849
  10.  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
  11.  Lazar JM, Chobufo MD, Weiss JP, et al. Nocturia is associated with high atherosclerotic cardiovascular disease risk in women: results from the National Health and Nutrition Examination Survey. J Community Health. 2021;46(4):854-860. doi:10.1007/s10900-021-00962-9
  12.  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
  13.  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
  14.  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
  15.  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. 2019;37(7):1389-1394. doi:10.1007/s00345-018-2511-4
  16.  Van Kerrebroeck P, Andersson KE. Terminology, epidemiology, etiology, and pathophysiology of nocturia. Neurourol Urodyn. 2014;33(Suppl 1):S2-S5. doi:10.1002/nau.22595
  17.  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
  18.  Monaghan TF, Michelson KP, Wu ZD, et al. Sodium restriction improves nocturia in patients at a cardiology clinic. J Clin Hypertens. 2020;22(4):633-638. doi:10.1111/jch.13829
  19.  Oelke M, Fangmeyer B, Zinke J, Witt JH. Nocturia in men with benign prostatic hyperplasia. Aktuelle Urol. 2018;49(4):319-327. doi:10.1055/a-0650-3700
  20.  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
  21.  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 2, 2023. https://uroweb.org/wp-content/uploads/EAU-Guidelines-on-the-Management-of-Non-neurogenic-Male-LUTS-2018-large-text.pdf
  22.  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
  23.  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
  24.  Vaughan ED. Long-term experience with 5-alpha-reductase inhibitors. Rev Urol. 2003;5(Suppl 5):S22-S27.
  25.  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
  26.  Espinosa G. Nutrition and benign prostatic hyperplasia. Curr Opin Urol. 2013;23(1):38-41. doi:10.1097/MOU.0b013e32835abd05
  27.  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
  28.  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
  29.  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
  30.  Yue Z, Wang M, Xu W, Li H, Wang H. Secretion of antidiuretic hormone in children with obstructive sleep apnea-hypopnea syndrome. Acta Otolaryngol. 2009;129(8):867-871. doi:10.1080/00016480802441762
  31.  Hamada S, Tabara Y, Murase K, et al. Night-time frequency of urination as a manifestation of sleep-disordered breathing: the Nagahama study. Sleep Med. 2021;77:288-294. doi:10.1016/j.sleep.2020.09.007
  32.  Zhou J, Xia S, Li T, Liu R. Association between obstructive sleep apnea syndrome and nocturia: a meta-analysis. Sleep Breath. 2020;24(4):1293-1298. doi:10.1007/s11325-019-01981-6
  33.  Baker FC, Lampio L, Saaresranta T, Polo-Kantola P. Sleep and sleep disorders in the menopausal transition. Sleep Med Clin. 2018;13(3):443-456. doi:10.1016/j.jsmc.2018.04.011
  34.  Lee J, Han Y, Cho HH, Kim MR. Sleep disorders and menopause [published correction appears in J Menopausal Med. 2019;25(3):172]. J Menopausal Med. 2019;25(2):83-87. doi:10.6118/jmm.19192
  35.  Senaratna CV, Perret JL, Lodge CJ, et al. Prevalence of obstructive sleep apnea in the general population: a systematic review. Sleep Med Rev. 2017;34:70-81. doi:10.1016/j.smrv.2016.07.002
  36.  Yamamoto U, Nishizaka M, Yoshimura C, et al. Prevalence of sleep disordered breathing among patients with nocturia at a urology clinic. Intern Med. 2016;55(8):901-905. doi:10.2169/internalmedicine.55.5769
  37.  Park HK, Paick SH, Kim HG, et al. Nocturia improvement with surgical correction of sleep apnea. Int Neurourol J. 2016;20(4):329-334. doi:10.5213/inj.1632624.312
  38.  Miyauchi Y, Okazoe H, Okujyo M, et al. Effect of the continuous positive airway pressure on the nocturnal urine volume or night-time frequency in patients with obstructive sleep apnea syndrome. Urology. 2015;85(2):333-336. doi:10.1016/j.urology.2014.11.002
  39.  Miyazato M, Tohyama K, Touyama M, et al. Effect of continuous positive airway pressure on nocturnal urine production in patients with obstructive sleep apnea syndrome. Neurourol Urodyn. 2017;36(2):376-379. doi:10.1002/nau.22936
  40.  Miyazaki T, Kojima S, Yamamuro M, et al. Nocturia in patients with sleep-disordered breathing and cardiovascular disease. Circ J. 2015;79(12):2632-2640. doi:10.1253/circj.CJ-15-0654
  41.  Wang AY. Sleep-disordered breathing and resistant hypertension. Semin Nephrol. 2014;34(5):520-531. doi:10.1016/j.semne phrol.2014.08.006
  42.  Marcus JA, Pothineni A, Marcus CZ, Bisognano JD. The role of obesity and obstructive sleep apnea in the pathogenesis and treatment of resistant hypertension. Curr Hypertens Rep. 2014;16(1):411. doi:10.1007/s11906-013-0411-y
  43.  Matsumoto T, Tabara Y, Murase K, et al. Nocturia and increase in nocturnal blood pressure: the Nagahama study. J Hypertens. 2018;36(11):2185-2192. doi:10.1097/HJH.0000000000001802
  44.  Muiesan ML, Paini A. Nocturia and night-time blood pressure: an association too frequently overlooked. J Hypertens. 2018;36(11):2135-2137. doi:10.1097/HJH.0000000000001864
  45.  Kopp W. Diet-induced hyperinsulinemia as a key factor in the etiology of both benign prostatic hyperplasia and essential hypertension? Nutr Metab Insights. 2018;11:1178638818773072. doi:10.1177/1178638818773072
  46.  Yoshimura K, Terada N, Matsui Y, Terai A, Kinukawa N, Arai Y. Prevalence of and risk factors for nocturia: analysis of a health screening program. Int J Urol. 2004;11(5):282-287. doi:10.1111/j.1442-2042.2004.00791.x
  47.  Yokoyama O, Nishizawa O, Homma Y, et al. Nocturnal polyuria and hypertension in patients with lifestyle related diseases and overactive bladder. J Urol. 2017;197(2):423-431. doi:10.1016/j.juro.2016.08.087
  48.  Victor RG, Li N, Blyler CA, et al. Nocturia as an unrecognized symptom of uncontrolled hypertension in Black men aged 35 to 49 years. J Am Heart Assoc. 2019;8(5):e010794. doi:10.1161/JAHA.118.010794
  49.  Kurtzman JT, Bergman AM, Weiss JP. Nocturia in women. Curr Opin Urol. 2016;26(4):315-320. doi:10.1097/MOU.0000000000000287
  50.  Omran A, Leca BM, Oštarijaš E, et al. Metabolic syndrome is associated with prostate enlargement: a systematic review, meta-analysis, and meta-regression on patients with lower urinary tract symptom factors. Ther Adv Endocrinol Metab. 2021;12:20420188211066210. doi:10.1177/20420188211066210
  51.  Ineichen GB, Burkhard FC. Metabolic syndrome and male lower urinary tract symptoms. Panminerva Med. 2022;64(3):329-336. doi 10.23736/s0031-0808.21.04496-7
  52.  De Nunzio C, Brassetti A, Proietti F, Deroma M, Esperto F, Tubaro A. Metabolic syndrome and smoking are associated with an increased risk of nocturia in male patients with benign prostatic enlargement. Prostate Cancer Prostatic Dis. 2018;21(2):287-292. doi:10.1038/s41391-017-0003-z
  53.  Aoki Y, Yokoyama O. Metabolic syndrome and nocturia. Low Urin Tract Symptoms. 2012;4(Suppl 1):11-15. doi:10.1111/j.1757-5672.2011.00118.x
  54.  Chung MS, Chuang YC, Lee JJ, Lee WC, Chancellor MB, Liu RT. Prevalence and associated risk factors of nocturia and subsequent mortality in 1,301 patients with type 2 diabetes. Int Urol Nephrol. 2014;46(7):1269-1275. doi:10.1007/s11255-014-0669-2
  55.  Chang CJ, Pei D, Wu CC, et al. Correlates of nocturia and relationships of nocturia with sleep quality and glycemic control in women with type 2 diabetes. J Nurs Scholarsh. 2017;49(4):400-410. doi:10.1111/jnu.12302
  56.  Juul KV, Jessen N, Bliwise DL, van der Meulen E, Nørgaard JP. Delaying time to first nocturnal void may have beneficial effects on reducing blood glucose levels. Endocrine. 2016;53(3):722-729. doi:10.1007/s12020-016-0920-y
  57.  Wang TT, Chung MH, Chien HY, Palmer MH, Liao CH, Liao YM. Nocturia in women with type 2 diabetes mellitus: a cross-sectional, correlation study. J Wound Ostomy Continence Nurs. 2020;47(3):265-272. doi:10.1097/WON.0000000000000635

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