Nocturia can be defined as the need to wake and pass urine at night, in contrast to enuresis, where urine is passed unintentionally during sleep - see separate Nocturnal Enuresis in Children article. One episode of nocturia per night is considered within normal limits. The term nocturia, as a symptom, is generally used to mean that the patient is waking to pass urine more frequently than normal, ie more than once per night. The rest of this article will use nocturia in this way.
- Nocturia is a common symptom in men and women.
- It can be troublesome in itself, by disturbing sleep, and can have a significant impact on quality of sleep and quality of life.
- Nocturia is a symptom, not a diagnosis.
- It is important to assess underlying causes, as some important conditions, such as diabetes, may present in this way.
Urinary symptoms defined:
- Nocturia: waking up at night to pass urine.
- Daytime urinary frequency: this is so variable that it is difficult to assess; however, establish how it affects lifestyle.
- Urinary incontinence or leakage:
- In men, a small urinary leakage at the end of the stream (also known as 'post-micturition dribble') is so common that it does not constitute an abnormality.
- Many women leak a little urine on coughing.
- The most important question to follow a complaint of urinary incontinence is: "What protection do you need to cope with the leakage?"
- Obstructive symptoms (or 'voiding symptoms'): hesitancy, poor stream, intermittent stream, terminal dribbling.
- Irritative symptoms (or 'filling symptoms'): urgency, burning on micturition, daytime frequency, nocturia, urge incontinence.
There are three ways in which nocturia can be caused:
- By problems of fluid balance.
- By neurological diseases affecting bladder control.
- By disorders of the lower urinary tract (LUT)[3, 4]. It is easy to overlook the first two categories while concentrating on the urinary tract.
Fluid balance causes of nocturia
Polyuria (day and night) - defined as urine volume >40 ml/kg/24 hours
- Excess fluid intake - including alcohol.
- Diabetes mellitus (DM).
- Diabetes insipidus.
- Renal failure (more likely in chronic kidney disease rather than acute kidney injury).
Nocturnal polyuria - defined as normal 24-hour urine volume, with nocturnal volume >35% total
- Excessive evening fluid intake, including alcohol.
- Diuretics (may depend on time of day taken).
- Disruption of normal vasopressin (antidiuretic hormone) secretion - more common in the elderly.
- Nocturnal redistribution of fluid - cardiac failure; other causes of oedema - eg, venous stasis.
- Sleep apnoea (unknown mechanism).
Neurological causes of nocturia
The bladder is controlled via the brain, spinal cord tracts, sacral segments S2-S4 and peripheral nerves. Therefore, many neurological conditions affect bladder function. Nocturia may be a symptom because:
- The neurological problem may cause urinary frequency: this can occur in multiple sclerosis (MS) and has been reported as an early feature of cervical cord compression and tethered spinal cord syndrome (TSCS).
- The neurology may cause retention of urine, which either results in frequency and true nocturia, or leads to overflow incontinence, which may be misinterpreted as nocturia.
Doctors should be aware that:
- If retention occurs in women or patients aged under 60, who are unlikely to have bladder obstruction, neurological causes need to be considered.
- Important, urgent conditions to diagnose are:
- Cord compression and cauda equina syndrome (CES); the bladder innervation is easily damaged and prompt referral/treatment can save bladder function.
- TSCS - although usually less acute, this again needs early referral.
Other common neurological disorders causing urinary symptoms are:
LUT causes of nocturia
This is a 'low nocturnal bladder capacity', which can be classified as due to:
- Bladder outflow obstruction (where chronic retention in effect lowers any additional bladder capacity):
- Bladder overactivity.
- Sensory urgency.
- Urinary tract infection.
- Inflammation - eg, interstitial cystitis/painful bladder syndrome.
Assessment of nocturia in primary care
- Nocturia in often ascribed to prostatic disease (in men), without due consideration of other causes.
- Other factors, or a combination, are just as likely to be the cause.
- The cause of nocturia can usually be determined by simple assessment using history, examination and a voiding diary, plus urodynamics if necessary.
- Clarify the patient's symptoms and ask about other LUT symptoms.
- Establish how these symptoms are affecting life and sleep.
- Consider whether this is a fluid balance problem:
- Fluid intake pattern (including alcohol).
- Excessive thirst suggests diabetes (mellitus or insipidus) or hypercalcaemia.
- Establish whether there are any systemic illnesses which could be contributing - eg, cardiac failure, obstructive sleep apnoea, oedema, chronic kidney failure.
- Explore whether there any neurological or spinal symptoms: neck or back pain, limb weakness or sensory loss. Important symptoms and signs are:
- Abnormal gait or spasticity, suggesting upper motor neurone lesions.
- Limb sensory loss or weakness: widespread or bilateral symptoms are worrying and suggestive of cord or cauda equina lesions (nerve root lesions usually cause more localised and unilateral symptoms).
- Constipation - can also occur as part of sphincter disturbance.
- Saddle area sensory loss and sexual dysfunction ('numb bum') suggest CES.
- Medication: consider any contributing medicines - eg, diuretics, excessive calcium supplementation or antacids, or lithium.
- Percuss the abdomen to examine for an enlarged bladder.
- Establish whether there is leg oedema present.
- Urine dipstick will screen for, but not exclude, DM, infection, haematuria and proteinuria.
- Other relevant examination, depending on the suspected cause:
- Neurological - especially important if there is urinary retention where obstructive causes are unlikely, ie in women and the under-60s.
- Rectal examination (men) to assess the prostate; pelvic examination (women).
Investigations in primary care.
- Voiding diary by the patient, including the time and volume of fluid intake and urine output.
- Blood tests: renal function, electrolytes, glucose and calcium.
- Midstream urine culture and microscopy.
- Urodynamics: GPs may have direct access to these clinics, which assess urinary flow rate and residual volume. Some clinics perform additional measurements, such as bladder capacity by ultrasound, bladder pressures using a urethral catheter, or fluoroscopic pressure and flow measurement.
Urgent problems which will need same-day referral are:
- Metabolic problems - eg, DM if ketotic, dehydrated or severely hyperglycaemic; hypercalcaemia; significant renal failure, electrolyte disturbance or lithium toxicity.
- Neurological problems: suspected cord compression or CES.
- Urological problems: acute retention, chronic retention with renal impairment.
Other problems, after initial assessment and investigations, can be classified according to the type of cause above and then managed accordingly. Note that several conditions may co-exist, all contributing to nocturia - eg, cardiac impairment, DM and prostatic hypertrophy.
Further reading and references
Dawson, Chris; ABC of urology: Urological evaluation. BMJ March 2012
Marinkovic SP, Gillen LM, Stanton SL; Managing nocturia. BMJ. 2004 May 1328(7447):1063-6.
Treatment of Non-neurogenic Male LUTS; European Association of Urology (2016)
Guidelines on the Management of Non-Neurogenic Male Lower Urinary Tract symptoms (LUTS), incl. Benign Prostatic Obstruction (BPO); European Association of Urology (2015)
Paton A; Alcohol in the body. BMJ. 2005 Jan 8330(7482):85-7.
Hilton R; Acute renal failure. BMJ. 2006 Oct 14333(7572):786-90.
Payne J; Tethered spinal cord syndrome. BMJ. 2007 Jul 7335(7609):42-3.
Clarke CE; Parkinson's disease. BMJ. 2007 Sep 1335(7617):441-5.
Klijer R, Bar K, Bialek W; Bladder outlet obstruction in women: difficulties in the diagnosis. Urol Int. 200473(1):6-10.
Urinary incontinence in women: management; NICE Clinical Guideline (September 2013)
Baxby K; Prostatic symptoms. Essential simple investigations were not mentioned. BMJ. 2001 Sep 29323(7315):750
Kaklamanos M, Perros P; Milk alkali syndrome without the milk. BMJ. 2007 Aug 25335(7616):397-8.
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