Introduction

Definition of Nocturia

The Standardization Subcommittee of the International Continence Society defined nocturia as a condition in which an individual is required to wake up one or more times during the night to relieve themselves.¹ Nocturia, which is also known as frequent nighttime urination, is referred to as urination at night associated with a degree of impairment that includes a urinary frequency that is regarded as disruptive and excessive. This could involve either an increased volume of urine passed at a time or an increased number of times an individual wakes to urinate.²

Nocturia is a prevalent cause of interrupted or disturbed sleep in the general adult population.³ Disturbed or interrupted sleep is clinically defined as a difficulty in staying asleep or a non-restorative sleep that significantly impairs social or professional functioning during the day. For many years, it has been understood that it is important for adults to have 7 to 8 hours of sleep per night. More evidence supports the higher dangers linked to sleep deprivation such as decreased cognitive function, reduced quality of life, increased risk of poor physical function, falls and mortality. It is very important to focus on the treatment of nocturia because it disrupts sleep, affecting not just the individual but also their family and society as a whole. By addressing this, people's quality of life can be improved.⁴

Prevalence of Nocturia 

Obtaining a precise figure for the prevalence of nocturia has proved difficult due to variations in the definition of nocturia in epidemiological studies. A survey conducted by telephone included 5,204 adults from a community, with an average participant age of 45.8 years. The results showed that 14.2% of respondents reported waking at least twice at night to urinate, whereas 31% reported waking at least once at night. Comparative studies in Austria and Japan, where nocturia was defined as fewer than two nightly voids, found rates of 11.3% and 28.5%, respectively. In different studies, It was discovered that the prevalence of nocturia increases rapidly with age.⁵

It is commonly believed that nocturia is more frequent in men due to its association with lower urinary tract symptoms (LUTS) linked to benign prostatic hyperplasia (BPH), however, both men and women develop nocturia at similar rates.⁶ 

Physical impact

Sleep disruption

Sleep is vital for an individual’s mental and physical health and well-being. One of the main reasons for disrupted sleep is nocturia which involves waking at night more than once to urinate. Disrupted sleep, often caused by nocturia, has been commonly associated with mental and physical disorders such as mood alterations and depression.³ Nocturia disrupts sleep patterns by causing frequent awakenings during the night to urinate, leading to fragmented sleep and reduced sleep efficiency. This interruption can result in difficulty falling back asleep, further decreasing total sleep time.⁴

Fatigue and daytime sleepiness

Nocturia can cause fatigue and daytime sleepiness in individuals. A study done in patients who were 50 to 65 years of age observed that daytime sleepiness was an early indicator of nocturia and reduced physical activity. Fatigue caused by nocturia affects productivity by reducing concentration, cognitive function, and physical energy. This can lead to decreased efficiency in work and daily activities, increased errors, and increased rates of absence.³

Increased risk of falls and injuries 

There is an increased risk of falls and injuries during nighttime bathroom trips because a high number of patients suffering from nocturia are elderly. A study done on nighttime falls of the elderly with nocturia discovered that there was a higher risk of falling from 10% to 21% whenever they woke up two or more times to urinate each night. Falls can cause serious health conditions like fractures, especially hip fractures in elderly patients.³

Psychological impact

Anxiety and stress

Anxiety about the need to urinate during the night can significantly impact an individual's mental well-being, leading to stress and a fixation with the possibility of waking up frequently.^​7 This increased anxiety can worsen the problem by making it more difficult to fall asleep initially or return to sleep after waking. Over time, this creates a vicious cycle where the anxiety about nocturia continues, worsening overall sleep quality and reducing the individual’s quality of life. ⁸

Depression 

Nocturia can lead to depression by disrupting the balance of neurotransmitters and stress hormones, which regulate mood and emotional stability. This can make individuals more vulnerable to negative thoughts and feelings, further worsening depressive symptoms like loss of interest, fatigue, persistent sadness, insomnia, difficulty concentrating, weight loss and lack of appetite. Over time, the total effect of inadequate sleep can greatly affect mental health, increasing the risk of developing clinical depression​.⁹ 

The impact of nocturia on overall mental well-being includes increased irritability, reduced cognitive function, and impaired decision-making. These effects can decrease the quality of life and contribute to a continuous state of mental and emotional distress​.⁹

Reduced quality of life

Health-related quality of life (HRQoL) can be defined as an individual’s or patient’s assessment of how their health, including their disease and its treatment, affects their ability to perform physically, psychologically, and socially.¹⁰ For a significant percentage of the general population, nocturia is a bothersome symptom that has been linked to a reduced quality of life.¹¹

According to a population-based study carried out in Finland, two nightly voids or urination leads to a slightly impaired quality of life and a single one does not.¹¹ Another study, carried out in a community sample in the United States of America (USA), discovered that even one void per night is not just bothersome and affects sleep and HRQoL. However, it can be stated that as the number of voids per night increases, the individual’s quality of life reduces significantly. Nocturia reduces the quality of life by causing sleep disruptions and deficits, general feelings of frustration and helplessness, and anxiety and depression. These affect an individual’s daytime physical activity, physical and mental health, personal relationships and social activities, thereby, reducing the quality of life.¹⁰ 

Managing Nocturia

Lifestyle changes

Monitoring the amount of fluid intake in an individual with nocturia is crucial in managing nocturia. A high amount of consumption of fluid, especially before bedtime, can lead to nocturia. In the late afternoon and evening, intake of caffeine and alcohol should be reduced because caffeine intake can lead to increased bladder activity and frequent urination.¹²

Healthcare practitioners encourage elderly patients and people with nocturia to take extra fluids during the day and to restrict fluid intake before bedtime to prevent the worsening of nocturia symptoms and improve patient’s quality of life. It is also encouraged that patients create a regular sleep schedule to avoid waking up frequently at night to urinate.¹²

Medical treatments 

Certain medications help in managing nocturia. These include bladder-relaxing drugs like anticholinergics, alpha-blockers, antidiuretic hormone therapy such as desmopressin and Botox bladder injections. These medications have proven to reduce nocturia incidents in patients and improve their quality of life. Although there are no surgical options, particularly for nocturia, there are other surgical remedies, for example, prostate surgery has been seen to relieve nocturia symptoms in men.¹²

Behavioral therapies 

Behavioural therapies that can be used in managing nocturia include kegel exercises, practising good sleep hygiene, efficiently managing fluid intake and delayed urination, employing techniques that help suppress the urge to urinate, pelvic floor exercises and managing peripheral oedema. These therapies help decrease nocturia in some patients by 50% and are highly recommended to improve patients’ quality of life.¹²

FAQs

What is nocturia?

Nocturia is simply referred to as frequent urination or voiding at nighttime. It is usually related to interrupted sleep and can significantly affect an individual’s quality of life.

What are the common causes of nocturia?

The common causes of nocturia include increased bladder activity, high fluid intake before bedtime, sleep apnea, some medications like diuretics, and health conditions such as benign prostatic hyperplasia (BPH), diabetes and heart disease.

How is nocturia diagnosed?

Nocturia is diagnosed through the collection of a detailed patient medical history and physical examination. Healthcare professionals observe the patient’s fluid intake, sleep schedule, medication use and any health conditions they might have to determine the cause of nocturia.

What treatments are available for nocturia?

Available treatments for nocturia include lifestyle changes such as managing fluid intake before bedtime, creating and sticking to a sleep schedule, medical treatments with drugs like alpha-blockers, and bladder-relaxing drugs, and undergoing behavioural therapies like kegel exercises and pelvic floor exercises. 

Can nocturia be prevented?

In some cases, but not all, nocturia can be prevented by managing fluid intake before bedtime and maintaining a healthy lifestyle. Regular check-ups with a healthcare practitioner are also crucial for early detection and management of nocturia.

Summary

Nocturia, which is frequent nighttime urination, disrupts sleep, causes fatigue and depression, and increases fall risk in the elderly. This results in a decreased quality of life. To prevent this, it is recommended to seek medical advice for treatment plans and maintain a healthy lifestyle. Effective management of nocturia can significantly improve an individual’s quality of life.