Introduction

Nocturia is defined as needing to urinate more than once during the night. In fact, voiding one time at night is more common, while 2 times or more during night is considered more clinically significant. The prevalence of experiencing two or more voids per night is around 34.9% in women and 30.5% in men.¹

It was discovered that as people age, nocturia becomes much more common. 56.8% of males and 68.9% of women in their 20s to 39s report experiencing at least one nighttime emptiness. The percentage increases to 74.3% for women and 70.2% for males between the ages of 40 and 59. Remarkably, 82.7% of men and 84.7% of women over 60 report having at least one nocturia.¹

Since nocturia is associated with a number of medical disorders, it is important to address it. This article aims to provide a detailed understanding of nocturia, including its causes, symptoms, diagnosis, and available treatments. 

Causes of nocturia

Nocturia can be a sign of an underlying condition, and its causes include the following:²

Nocturnal Polyuria (NP)

It is excessive urine production at night. It is caused by decreased nighttime production of the hormone vasopressin, leading to increased urine output.

The conditions include:

• Heart failure: Fluid accumulation in the body can lead to increased urine production at night
• Neuropathy: Nerve damage can affect bladder function, resulting in excessive nighttime urination
• Vein/Lymph issues: Problems with blood or lymph circulation can cause fluid retention and increased nighttime urine output
• Liver/Kidney problems: Impairment in liver or kidney function can disturb the body's fluid balance
• Excessive fluid intake in the evening
• Deficient daily vasopressin: Conditions such as brain or pituitary damage, Parkinson's disease, and multiple sclerosis (MS) can result in low vasopressin levels
• Medications: Diuretics, steroids can increase urine production
• Alcohol: Alcohol consumption can inhibit vasopressin, leading to increased urination
• Kidney tubule damage: Conditions like diabetes and albuminuria can damage the kidney tubules, increasing urine output
• Sleep apnea syndrome: Sleep apnea can increase renal sodium and water excretion due to elevated plasma atrial natriuretic peptide levels

Reduced bladder capacity

The following factors reduce the bladder's capacity:

• Bladder outlet obstruction: It can be decreased by obstructions caused by pelvic organ prolapse and benign prostatic hyperplasia (BPH)
• Overactive bladder: It is characterised by abrupt, strong desires to pee, which frequently lead to overnight voiding
• Painful bladder syndrome: Frequent urination and bladder discomfort can be due to inflammation and infection
• Neurogenic bladder: Neural injury can impair bladder function, resulting in recurrent urination
• Lower urinary tract cancer: Tumours can obstruct the bladder and reduce its capacity
• Urolithiasis: Kidney stones can cause frequent urination and discomfort
• Postoperative issues: Surgery affecting the urinary tract can lead to reduced bladder capacity
• Increased post-void residual: Incomplete bladder emptying can result in frequent urination
• Ageing bladder: Age-related changes can reduce bladder capacity

Sleep disorders

Some people struggle with sleeping disorders that can be a factor for nocturia, as following:

• Primary sleep disorders: Such as insomnia, narcolepsy, and sleepwalking, can lead to frequent nighttime awakenings and urination
• Secondary sleep disorders: Like heart failure, chronic obstructive pulmonary disease (COPD), and hormonal disorders, can disrupt sleep and increase urination
• Neurological diseases: Disorders like parkinson's disease, dementia, and epilepsy can affect sleep and bladder function
• Psychiatric illnesses: Depression and anxiety can cause insomnia and increased nighttime urination
• Chronic pain syndromes: chronic pain can interfere with sleep and lead to frequent urination
• Drug abuse: It might interfere with sleep and urination
• Medications: Medications that cause nighttime urination include diuretics, beta-blockers, thyroid hormones, corticosteroids, psychotropics, and anti-seizure drugs

Symptoms of nocturia

The symptoms vary from person to person, depending on the root cause. The symptoms could be as follows:^3,4

Nighttime urinary frequency

Being awoken two or more times overnight to urinate is difficult. Waking up at night may or may not be accompanied by the sudden urge to pee. 

Large urine volumes

Excessive nighttime urination is the act of urinating very large amounts of urine at intervals each time you wake up during the night.

Disrupted sleep

Waking up to urinate several times a night, which disrupts sleep. It was difficult to go back to sleep after waking up to urinate. It causes sleep deprivation and disturbance in sleeping patterns.

Symptoms at daytime

For most, it is not unusual for daytime exhaustion caused by disrupted sleep at night. You can adjust your routine and lifestyle around these frequent urination needs. After emptying your bladder, you may feel like peeing again right after you're done. Experiencing a daily cesspool and keeping up is the challenge of coping with this leakage/accidental urination.

Impact on quality of life⁵

Sleep plays a vital role in physical/mental functioning, and repeated nighttime voiding can reduce sleep quantity and quality. Some studies have connected nocturia to big health-related quality-of-life disorders. Nocturia is considered concerning because it can be a symptom of several underlying medical conditions, such as diabetes and heart failure, but also sleep apnea.⁶

Poor quality of sleep is independently associated with bad health indicators like disturbed sugar levels, diabetes, and hypertension; therefore, nocturia will raise the red flag for an early alarm to these problems.

Maybe most alarming, some studies have even found a possible link between nocturia and increased mortality risk. The general negative impacts of impaired sleep throughout the night could be the cause, alongside the growing risk of falls and consequent fractures happening at night because of frequent urination, mostly in older individuals.

Diagnosis of nocturia

Even while nocturia occurs more often, it is frequently underreported, improperly managed, and gets little treatment. Many people are reluctant to talk about this issue with their doctors, feel too embarrassed about it, or they think it's just a natural part of ageing.⁶

The following elements may be included in an assessment:⁴

Medical history

A complete medical history is necessary to make a nocturia diagnosis. Asking about symptoms of the lower urinary tract (LUTS), such as incontinence, urgency, and frequency, falls under this category. Finding any underlying medical conditions and urogenital disorders, such as diabetes, heart failure, or renal disease, is also vital. Additionally, reviewing the record of previous surgeries and current medications as they can contribute to nocturia.

Bladder diary 

Maintaining a bladder journal is a crucial step in the diagnosis procedure. For many days, patients are asked to note their urine patterns, including how often and how much they urinate throughout the day and at night. This record-keeping facilitates the monitoring of symptoms and the detection of associations that may lead to a diagnosis.

Physical examination

An examination that is specific to the patient's gender must be performed.

• Especially those assigned female at birth patients: Gynaecological examination with pelvic organ prolapse assessment
• Especially those assigned male at birth patients: Prostate evaluation

Laboratory tests

• Urinalysis: are conducted to detect any infections, kidney issues, or other abnormalities
• In specific cases, cytological analysis of urine sediment may be performed to check for cancer cells or other signs of disease

Imaging and procedures

Imaging approaches, such as ultrasound, may be used to visualise the bladder, kidneys, and other parts of the urinary tract. Cystoscopy, a procedure that involves inserting a camera into the bladder through the urethra, may also be performed to identify any abnormalities within the bladder or urethra.

By comprehensively evaluating these elements, healthcare providers can identify the underlying causes of nocturia and develop an effective treatment plan tailored to the patient's specific needs.

Treatment of nocturia

There are plenty of choices available in treating nocturia, however the treatment plan should be tailored to the causative factor and the patient's needs.

Lifestyle and behaviour adjustment⁷

One of the main steps is management, and it contains the following instructions:

• Reduce fluid intake at least 2 hours before bed, particularly avoiding caffeine and alcohol
• Limit overall daily fluid consumption to less than 2 litres
• Empty the bladder before sleeping
• Make sure that there is easy access to a toilet or a toilet chair
• Increase physical activity and fitness, including pelvic floor exercises if needed
• Lower dietary salt intake
• Losing weight for those who are overweight.
• For patients with peripheral oedema due to CHF or chronic venous insufficiency, elevate legs above heart level for a few hours before bed.
• Adjust the timing of diuretics to midafternoon rather than before bed

Medical interventions⁷

If lifestyle changes are insufficient, medical treatments are considered.

Treatment objectives include:

• Enhancing bladder emptying
• Increasing nocturnal bladder storage capacity
• Raising the threshold for bladder activity
• Reducing nighttime urine production

Pharmacotherapy

Antimuscarinic Agents and α-Blockers: Commonly used for overactive bladder and benign prostatic hyperplasia.

β3-Adrenoceptor Agonists (Mirabegron) and Phosphodiesterase Type 5 Inhibitors: Provide minimal reduction in nocturnal voiding frequency.

Desmopressin Acetate: Effective for nocturia associated with nocturnal polyuria (NP). In addition, it decreases urine production and increases urine concentration.

FAQs

What is the most common cause of nocturia?

It is nocturnal polyuria, which produces large amounts of urine at night.

What happens if nocturia is left untreated?

Nocturia has an impact on quality of life that can affect mental and physical health.

When should I see a doctor for nocturia?

It is advisable to see the doctor when you start to affect your daily life activities and feel that you need help, especially if you do not know the cause.

Summary

Nocturia is a common condition. It is provoked by a lot of causes, including nocturnal polyuria, reduced the capacity of the bladder and sleeping disorders. One of the core symptoms is waking up once or more during the night to urinate which leads to disruption of the sleep cycle. It is important to seek medical attention for your condition to have the right support.