Introduction

Definition of nocturia

Nocturia means waking up at night to urinate, which is common for both men and women.¹ Especially, in older adults, it is often linked with other urinary problems and is sometimes considered a normal part of ageing. It disturbs sleep, so people feel tired during the day affecting how well someone functions physically and mentally. So in the long run it may contribute to other health problems and even shorten life expectancy. Nocturia has various causes like trouble storing urine and producing too much urine at night, also it is often linked with Overactive Bladder (OAB) syndrome.

Importance of effective treatment

Nocturia treatment is essential due to its remarkable impact on quality of life. Disturbance in sleep may lead to fatigue and cognitive impairment, increased risks of injuries and potential complications of mental health issues such as anxiety and depression. Properly addressing the condition of nocturia can also help to identify important but hidden health conditions like diabetes or further complications. Improved sleep from treatment also enhances productivity and social and economic relationships. Timely evaluation of chronic sleep disruption helps healthcare professionals to reduce long-term health risks.

Causes of nocturia

Nocturia, the need to urinate frequently during the night, is generally caused by one of the four main reasons:²

Nocturnal polyuria

One of the common causes responsible for 88% of nocturia cases, is where urine production at night exceeds normal levels. It is more common in older adults. Decreased levels of a hormone called Arginine Vasopressin (AVP) is the reason behind it as it helps to conserve water. In people suffering from nocturia, AVP will be released less at night, which leads to increased urine production during sleep. Increases urine output; conditions like sleep apnea contribute to nocturnal polyuria.³

Global polyuria

This term refers to the condition when there is continuous excessive urine production throughout the day(>40 mL/kg per 24 hours), not just at night linked to conditions such as diabetes mellitus or insipidus, hypercalcemia, and renal insufficiency.⁴

Bladder storage issues

Reduced bladder capacity can lead to frequent voiding with small volumes which contributes to nocturia. Common in conditions like bladder calculi, overactive bladder, and prostate enlargement in men.

Sleep disorders

Patients with obstructive sleep apnea often experience increased nighttime urine due to elevated AVP levels.⁶ Insomnia, sleep apnea, and other sleep disturbances can cause or worsen nocturia.

Other contributing factors

Excessive nighttime fluid intake, peripheral oedema, hypertension, heart failure and certain medications such as diuretics or antidepressants can aggravate nocturnal polyuria. Conditions such as depression and Parkinson's disease can also contribute to nocturnal polyuria due to their effects on hormonal balance and the urinary system. Excessive caffeine intake, alcoholism, high dietary salt intake, and chronic venous insufficiency are other contributing factors to nocturia.

Non-pharmacological treatment and management

Natural remedies for the treatment and management of nocturia include:⁶

Avoid food and drinks that irritate the bladder

• Some drinks and foods may make your bladder more sensitive and can force you to go to the bathroom more often like alcohol, caffeine, artificial sweeteners, citrus fruits and juices, and chocolate
• Other foods and drinks you should avoid are sodas and fizzy drinks, cranberry juice, corn syrup, tomatoes, sugar, honey, vinegar, dairy, and spicy foods. Some people find these products make their bladder symptoms worse
• Keep a diary of what you eat and drink, helps you to figure out which ones make your symptoms worse and try to avoid them

Make healthy lifestyle changes

• Quit Smoking: Smoking irritates your bladder, so symptoms of an overactive bladder become visible and responsible for more leaks
• Medications: Some medicines can make your symptoms worse like water pills and antihistamines. If your medicine causes problems, talk to your doctor for a better alternative
• Lose Weight: If you're overweight, it can put extra pressure on your bladder. So losing weight can help you to reduce bladder problems

Practice bladder control techniques

• Scheduled bathroom visits: Try to go to the bathroom at a regular time interval even if you don't feel like you need to go and gradually increase the time between bathroom trips. It will track when you usually need to go to the bathroom⁷
• Wait before you go: When you feel like you need to pee, try to wait for a few minutes before you go. Relaxation techniques like deep breathing can help you hold it longer
• Empty your bladder completely: After going to the bathroom, when you pee, wait a bit and try to empty your bladder completely and make sure it is empty

Strengthen your pelvic muscles

• Do Kegel exercises: To strengthen the muscles around your bladder do these exercises, it will help you control when you need to go to the bathroom. Practice squeezing them for a few seconds and then relaxing to know where those muscles are. Do this several times a day to help strengthen your pelvic muscles and try stopping your pee midstream next time you go⁷

Manage your fluid intake and stay hydrated

• Dehydration can irritate your bladder and your symptoms can become worse, so drink plenty of water throughout the day to stay healthy
• Watch when you drink: Try to avoid drinking water just before bed, it will help to reduce how often you wake up at night to use the bathroom

You can manage your overactive bladder naturally and improve your quality of life by following these steps, if still you are not sure about any of these changes, for personalized advice talk to your doctor.

Pharmacological treatments

Nocturia caused by different conditions like prostate issues in men, overactive bladder and nocturnal urine production can get help in treatment through medications.

Diuretics

Diuretics like hydrochlorothiazide or furosemide are generally prescribed by doctors in the morning but it will work better for nocturia patients in the afternoon by increasing urine production during the day so that your body doesn't produce so much urine at night.⁸ 

Alpha-blockers

Alpha-blockers, also known as alpha adrenoreceptor antagonists are effective for men with prostate problems by improving urine flow, reducing residual urine and relaxing the prostate's smooth muscles. It will decrease resistance to urine flow and increase the space available for storing urine at night. However, alpha-blockers alone are not sufficient to treat nocturia, so studies suggested combining these drugs with other medications for better results. 

Bladder-relaxing drugs

These drugs help with nocturia or frequent urination at night by reducing the need to urinate by increasing bladder capacity and reducing urinary urgency, which leads to urinary retention in men.

Topical vaginal estrogen

Vaginal estrogen creams provide benefits in managing nocturia by reducing symptoms like urinary frequency and urgency in the genitourinary syndrome of menopause. In such conditions, it becomes difficult to control your bladder. Due to low levels of estrogen pelvic floor muscles become weak and the urinary tract loses elasticity, which is responsible for urine leakage.

Desmopressin

This drug helps in nighttime urination by acting on the kidneys to reduce the flow of urine. It is similar to a hormone produced in the body. Although it is effective in nocturia it needs careful monitoring for side effects like low sodium levels.

Other treatments

Onabotulinum toxin A injections and PTNS can help with overactive bladder symptoms, including nocturia. Behavioural therapies and managing sleep patterns also play a role.

Alternative therapies

Some alternative treatments like antidepressants or NSAIDs are uncertain in their effectiveness for treating nocturia.¹⁰

Combination therapy

To get an effective treatment using different treatments together in combination for reducing nocturia episodes.¹¹

Surgical options

There's no specific surgery for nocturia, but procedures for prostate issues can help with related symptoms.

Overall, treatment for nocturia depends on the underlying cause and may involve medications, lifestyle adjustments, or a combination of both.

Conclusion

Addressing nocturia is crucial due to its significant impact on quality of life, affecting sleep, cognitive function, and overall health. Understanding its causes, such as nocturnal and global polyuria, bladder storage issues, and sleep disorders, helps tailor effective treatments. Non-pharmacological approaches like dietary adjustments, lifestyle changes, bladder control techniques, and pelvic muscle exercises offer initial management. Pharmacological options, including diuretics, alpha-blockers, and bladder-relaxing drugs, provide additional avenues for treatment. Combined therapies and alternative treatments may also be considered, underscoring the importance of personalized care in managing this common yet disruptive condition.