Nocturia: Mind vs medication

Urology Times Journal, Vol 49 No 08, Volume 49, Issue 08

"By all means, educate patients about causes of nocturia, suggest behavior modifications...but don’t throw a drug at them unless there are daytime symptoms of urgency, high postvoid residual, or large volume output at night," writes Gopal H. Badlani, MD.

Badlani, professor and vice chair of urology at Wake Forest Baptist Health High Point Medical Center, Winston-Salem, North Carolina, is a coeditor-in-chief for Urology Times®.

Nocturia, or waking up to urinate at night, continues to be a vexing problem for clinicians and patients. In an earlier review1 and in-depth interview of subject matter expert Jeffrey P. Weiss, MD, PhD, a variety of causes of nocturia were discussed.2

Writing a prescription for a malady makes the clinician and patient feel better about doing something for the condition. In a study3 reported on in an article in this month’s issue of Urology Times®, the authors suggest that adding medication (non-antidiuretic) to behavioral therapy does not make a difference in veterans studied over a year. In the detailed analysis of their voiding diaries and metabolic characterization, it was shown that all patients did not have significant high nocturnal volume (< 650 for all) and peripheral edema was present in larger proportion of the behavioral therapy-alone group. Obstructive sleep apnea, another common cause of nocturia, was present in a higher percentage of the same group (not statistically significant)

What is difficult to characterize in this retrospective study, or any study for that matter, is how many patients are following the simple instructions of not drinking the last 2 hours before sleep and leg elevation in the evening hours to alleviate some of the volume-induced first instance of waking up at night. Other unexplored reasons of nocturia are restless leg syndrome, painful conditions, anxiety, etc. In this paired analysis, hopefully they do not affect the data analysis.

So what is the take-home message? By all means, educate patients about causes of nocturia, suggest behavior modifications mentioned above, but don’t throw a drug at them unless there are daytime symptoms of urgency (anticholinergics or β-3 agonists), high postvoid residual (α-blockers), or large volume output at night (desmopressin). Complex interactions between the heart, the kidneys, and the bladder warrant a multidisciplinary approach in patients with nocturia. A personalized treatment should be designed, taking into account gender, comorbidities, and identified etiological factors. This is time-consuming and in the future, bladder mobile apps may help obtain logs and be reminders of the bladder training.

As the Dalai Lama said, “Sleep is the best meditation.”

References

1. Daugherty M, Ginzburg N, Byler T. Prevalence of nocturia in US women: results from NHANES. Paper presented at: American Urological Association annual meeting. May 18-21, 2018. Abstract PD32-03

2. Nocturia: How to define it, and how treat it. Urology Times®. August 25, 2020. Accessed July 27, 2021. https://www.urologytimes.com/view/nocturia-how-to-define-it-and-how-to-treat-it

3. Miller CD, Monaghan TF, Robins DJ, Weiss JP. Does traditional pharmacotherapy augment behavioral modification in the treatment of nocturia? Neurourol Urodyn. Published online May 11, 2021. doi:10.1002/nau.24692