Introduction

Nocturia is the medical term for the frequent urge to urinate during the night, which interrupts sleep and impacts overall health. It refers to the act of urinating one or more times during the sleep period. Clinically significant nocturia (defined as having two or more voids per night) affects approximately 2% to 18% of individuals aged 20 to 40, with the prevalence increasing to 28% to 62% among those aged 70 to 80.¹

Nocturia can affect the quality of life of the individual, cause falls and fractures, anxiety and depression, and reduce work productivity. Even though this is a prevalent condition, it often goes unreported, undertreated and undermanaged.

Understanding nocturia

According to the International Continence Society (ICS) definition, nocturia is “waking at night one or more times to void … with each void is preceded and followed by sleep”.¹

Nocturia can be associated with a 1.2-fold risk of falls and a 1.3-fold risk of fractures.² It affects men and women equally and is more prevalent in older people. Nocturia can be due to a variety of medical conditions, reduced bladder capacity or increased water intake. Many patients may not recognise this condition as treatable or may be reluctant to discuss the symptoms with others.

Common causes

Age-related changes

Physiological, structural, hormonal, and histological changes associated with aging may result in nocturia. As age increases, kidney sodium handling, water-conserving mechanism, and circadian rhythm of glomerular filtration rate (GFR) is affected, which results in frequent urination. The ability of the bladder to store urine overnight also gets impaired.³

Medical conditions

Nocturia can be associated with conditions like diabetes, cardiovascular disease, chronic respiratory diseases like chronic hypoxia and pulmonary vasoconstriction, obstructive sleep apnea, advanced kidney disease and malignancy.

Bladder problems

• Urge incontinence (overactive bladder) is a sudden urge to pass urine and may be associated with a leak before reaching the toilet
• Bladder infections will be symptoms of infections like dark, cloudy and foul-smelling urine, burning sensation and pain while passing urine and not being able to empty the bladder completely
• In conditions like benign prostatic hyperplasia, there is reduced bladder capacity due to urinary outlet obstruction, resulting in the retention of urine⁴

Medications

Diuretics, like furosemide or torasemide, are medications used for increased blood pressure, heart failure and fluid retention. These drugs increase the urinary output and can cause nocturia. Calcium channel blockers (used to treat high blood pressure) such as amlodipine or nifedipine also cause increased fluid output. Certain medications containing lithium cause a drug-induced nephrogenic diabetes insipidus causing nocturia.⁴

Hormonal imbalance

It has been found that the prevalence of nocturia is higher in postmenopausal women.⁵ There is also an association between testosterone deficiency and nocturia.⁶ ADH is a hormone that helps in fluid balance in the body. When there is a decreased level of ADH hormone, there is an increased sense of thirst and increased frequency of urination.

Lifestyle factors

Some of the lifestyle factors that may result in nocturia are alcohol use, increased caffeine and increased fluid intake, especially before going to bed.⁴

Management of nocturia

Behavioural modifications

Fluid management

• Limit the fluid intake at least 2 hours before bed, especially caffeine and alcohol
• Reduce fluid consumption in the evening; however, make sure you are following the recommended daily amount of water intake (about three to four pints or 1.5 - 2 litres)
• If you are taking any diuretic drugs, take them in the midafternoon
• Restrict the total fluid consumption in a day to less than 2 litres if possible¹
• Avoid caffeine, alcohol, carbonated drinks
• Food is also an important source of total fluid intake hence, dinner should be finished as early as possible

Bladder training 

• Try to empty the bladder before going to bed
• Provide barrier-free access to the toilet or toilet chair¹
• Establishing a regular urination schedule may also help
• Try delayed voiding, like trying to hold the urine for some time and gradually increasing the time between bathroom visits
• Pelvic floor exercises like kegel exercises can help strengthen the pelvic muscles

Lifestyle modifications

Dietary adjustments

• Reduce salt intake

Increased salt consumption increases thirst and fluid intake

• Include plenty of fruits and vegetables rich in vitamins, minerals, fibres and antioxidants
• Reduce caffeine, tea and chocolate drink intake

Caffeine increases lower urinary tract smooth muscle contraction and stimulates the central nervous system, which is responsible for the urge to urinate

Coffee, tea and chocolate can affect your sleep pattern also

• Limit or avoid spicy foods, acidic foods, and artificial sweeteners like aspartame and saccharin, which are bladder irritants
• There are some expert opinions that some food items like blue leek, chickpea, wild rocket, cabbage, onion, cinnamon, Celtic spikenard, celery, olive, garlic and wild iris may increase the urine output⁷

Weight management 

• Maintain a healthy weight
• Overweight or obese individuals (with a body mass index (BMI) above 30 kg/m2) have an increased chance of being affected by nocturia⁸

Physical activity

• Exercise regularly and maintain a healthy lifestyle
• Include pelvic floor exercises in your exercise routine¹

Sleep hygiene

• Try to create a calm and peaceful environment to sleep so that your sleep does not get disturbed
• Use a comfortable mattress and pillows
• Sleep in a dark, quiet and cool room
• Limit naps during the day
• Try to establish a bedtime routine with a consistent sleep schedule
• Relaxation techniques like meditation and yoga can improve your sleep quality
• Some people may get a sound sleep by reading a good book or listening to calm, soothing music before going to bed
• For patients with swollen legs due to congestive heart failure or chronic venous insufficiency try to keep the legs elevated a few hours before going to bed

Monitoring and tracking

• Keep a bladder diary

A bladder diary is a very effective diagnostic tool for nocturia. Ideally, it is recorded for 3 days, but 2 days of data will give a picture of the diagnosis. Doing this on a weekend is best when you have a few commitments.

• Keep a closer look at fluid intake and output. Each day, record how much fluid intake you have, what you drink, and at what time.
• When you go to the toilet, try to measure the urine output. If you notice a leak note that also (N-none, S-small, M-medium, L-large). If you experience an urgency to pass urine score it in the range 0-3. Discuss your findings with your healthcare provider⁹
• Here is an example of a bladder diary:

Medical consultation

If nocturia persists or if it is severe, you may be experiencing prostate problems, urinary incontinence or several other medical conditions. If you experience any painful condition that is disturbing your sleep or pain, blood, pus or loss of bladder control, consult your health care provider immediately.

Possible medical treatments

The treatment is based on the underlying cause. Any medications that may cause nocturia should be reviewed. However, do not stop the medication without consultation by a physician. If the cause is any underlying medical conditions like diabetes, heart problems, hormonal imbalance, etc that should be addressed first. Antidiuretics like desmopressin can also be used for the treatment of nocturia. If the cause is bladder outlet obstruction, surgical procedures like transurethral resection of the prostate can be considered.¹

Summary

Nocturia is a condition that may affect any individual regardless of age and sex. It is characterised by the urge to urinate frequently at night, thus disturbing sleep. It is a condition that needs attention since the quality of sleep is linked to the overall quality of life. The cause of nocturia can be multifactorial. The management involves identifying the underlying reason and if there are no medical conditions involved, it can be managed by simple behavioural and lifestyle modifications. Patience and consistency are the key factors for the effective management of nocturia. Behavioural and lifestyle modifications include fluid management and bladder training, regular exercise, diet modification, management of weight and good sleep hygiene. Nocturia can be self-identified by using a simple bladder diary, and the findings can be discussed with your healthcare practitioner. If required, medications and other medical interventions should be considered.