Nocturia in Older Persons
Pages 22 - 24
Dr. Baum is Clinical Associate Professor of Urology, Tulane Medical School, New Orleans, LA; and Mr. Boyd is a pre-med student at Dartmouth College, Hanover, NH.
Nocturia, the interruption of sleep by the need to urinate, is a common condition affecting many older men and women. It is certainly a quality-of-life issue, but it is also associated with significant morbidity to those who are affected. The evaluation can be easily accomplished in the office setting, and effective medical treatment is available that will significantly improve the well-being of patients.
A 67-year-old male presents to his physician with a decrease in the force and caliber of his urinary stream. He also complains of frequency, urgency, and nocturia six times per night. The physical examination reveals a moderately enlarged, benign prostate gland, approximately 40 grams. The urinalysis is negative for glycosuria and hematuria. The prostate-specific antigen is 1.2 ng/mL. A flow rate is obtained, which is less than 5 cc/second, and he has a 55-cc post-void residual measured with an ultrasound machine. The patient is started on a urospecific alpha blocker, alfuzosin 10 mg/day, with moderate improvement in his symptoms, but he continues to have nocturia four times per night.
Discussion Prevalence of Nocturia
Nocturia becomes more prevalent and severe with age. According to the National Sleep Foundation’s 2003 Sleep in America poll, 65% of adults between ages 55 and 84 years reported nocturia at least three nights per week.1 Another study found that for patients ages 60-70 years, the prevalence of nocturia was between 11% and 50%; and for patients age 80 years, the prevalence rose to between 80% and 90%.2 However, other studies have found the prevalence to be lower, though still relatively common. One study that reviewed 10,000 men and women between ages 65 and 80 years found that 2.1%, 12.7%, and 21.9% of men experienced nocturia very often, rather often, and occasionally, respectively. Also, the study found that women experienced nocturia 3.9%, 12.7%, and 17.2% in the same corresponding categories. Therefore, while slightly more older men have nocturia, women experience more severe or incapacitating nocturia than men.3
Impact on Quality of Life
Nocturia affects the quality of life of the people who have it in various ways. Since nocturia results in sleep deprivation, it decreases productivity the following day through lack of alertness and sluggishness. Nocturia can have serious health effects as well, for sleep deprivation negatively affects mental and somatic health, leading to depression. Waking up at night can lead to increased sleep inertia and performance impairment immediately after awakening, leading to falls and fractures, especially in the elderly population where nocturia is the most prevalent.4
Nocturia can be disruptive to the normal sleep cycle and result in lethargy, loss of energy, and even loss of productivity as a result of poor sleeping habits. Symptoms of nocturia in both men and women are associated with an increased risk of depression, sexual dysfunction, sleep disruption, and loss of productivity in the workplace.5 Many patients adopt coping strategies rather than seeking treatment; therefore, available treatments are underused in this older population. The overall costs to society of nocturia in older persons are in the billions of dollars. Yet, the condition often goes unrecognized, largely because of the reluctance of those with nocturia to seek medical attention.6
Causes of Nocturia
While nocturia increases with age, its other causes include diuretic substances (ie, caffeine and alcohol) and prescription drugs (diuretics), heart conditions such as hypertension and congestive heart failure, hypercholesterolemia, insomnia, pain, depression, sleep disorders such as sleep apnea, prostate disorders such as benign prostatic hyperplasia (BPH), and bladder disorders (ie, overactive bladder).7 Other causes include nocturnal polyuria, diabetes mellitus, diabetes insipidus, chronic renal failure, and an unstable bladder, one in which urgency combines with small voiding volumes.2
Evaluation of Nocturia
The evaluation of nocturia begins with a thorough history and physical examination. It is helpful to have the patient keep a voiding diary for at least three days, noting voiding volume and time of each voiding episode. In men, the size and consistence of the prostate gland is probably the most important aspect of the physical examination. In women, a pelvic exam should be performed, which evaluates the presence or absence of prolapse of the bladder, uterus, or rectum and the status of the vaginal mucosa. The essential laboratory tests include a urinalysis with a test for blood, glucose, and nitrites. A microscopic examination of the urine looks for white blood cells, red blood cells, crystals, and bacteria. If there is evidence of infection, a urine culture is ordered. Additional laboratory tests of renal function, serum glucose, electrolytes, and calcium levels should be obtained. If there are symptoms of lower urinary tract obstruction in addition to nocturia (ie, hesitancy, intermittency, and post-micturition dribbling), a bladder ultrasound should be performed before and after voiding to determine the presence or absence of a post-voiding residual. If symptoms indicate obstructive sleep apnea, a polysomnogram may be performed.2
Treatment of Nocturia in Older Persons
Nonpharmacologic management of nocturia. Usually, nonpharmacologic therapies are an adjunct to medical management. But certainly there are steps that older patients can take that may help ameliorate the symptoms of nocturia. First, physicians can advise these patients to avoid such exacerbating factors as consuming large quantities of fluid before going to sleep, avoiding bladder irritants such as caffeine (especially in the afternoon or evening), and timing of medications such as diuretics, which should be taken in the morning instead of later in the day.
Medical management of nocturia. First-line medical management for overactive bladder accompanied by nocturia consists of anticholinergic medications. These agents suppress or diminish the intensity of detrusor contractions and increase bladder capacity. There are several anti-muscarinic agents which have greater affinity for the muscarinic receptors in the bladder than for the receptors in the salivary glands. These bladder selective agents with an extended-release formulation (tolterodine, darifenacin, transdermal oxybutynin, trospium, and solifenacin) are much better tolerated than the immediate-release medications with adverse events such as dry mouth occurring to a lesser extent. (See Table for dosages.)
In men with BPH, the combination of alpha blockers and anticholinergics has been shown to be effective. A study that evaluated the alpha blockers in men with BPH who failed to have a reduction in lower urinary tract symptoms (LUTS) that included nocturia demonstrated improvement when anticholinergic medication was added to the therapeutic regimen. This study demonstrated a decrease in LUTS that included nocturia in men treated with both alpha blockers and anticholinergic medication.8
Another study demonstrated that alpha blockers alone may not resolve the nocturnal polyuria associated with BPH. Alpha-blockade given for LUTS secondary to BPH on nocturnal polyuria is not an effective medication for relieving the nocturia.9
The complications of anticholinergic medications include decreased salivation, decreased bronchial secretions, increased pupil size, and inhibition of accommodation with accompanying blurred vision and precipitation of narrow-angle glaucoma, increased heart rate, and constipation. Anticholinergic medications are contraindicated in patients with narrow-angle glaucoma, severe constipation, a history of urinary retention, and who are at risk for QT interval prolongation.
One consideration in using the anticholinergic medications in older persons is the risk of central nervous system symptoms. The blood-brain barrier appears to be more susceptible to drugs impacting the central nervous system, especially in the elderly. Therefore, the ideal drug is a large molecule, hydrophilic, and positively charged.10 Drugs that meet those criteria include tolterodine, darifenacin, solifenacin, and trospium.
Another concern for using anticholinergic medications in the elderly is urinary retention. This is of special concern in older men with BPH. However, the incidence of retention in both men and women in clinical trials is low.11
Other medications. Transvaginal estrogen may also have a role in treating nocturia associated with vaginal atrophy. However, data are lacking to support any particular dosing regimen, route of administration, or treatment duration.12 One of the authors of this article (N.B.) recommends topical estrogen cream applied two to three times per week with favorable results in reducing irritative symptoms that include nocturia in women with vaginal atrophy. Estrogens are contraindicated in women with a history of breast cancer.
Outcome of the Case Patient
The patient continued to have nocturia that was impacting his quality of life after 1 month of taking the alpha blocker. He had a good force and caliber of his urinary stream after starting the alpha blocker. A bladder ultrasound revealed less than 60 cc of post-voiding residual. An anticholinergic medication, tolterodine LA 4 mg taken in the evening, was added to his medication regimen. After 2 weeks, the patient’s nocturia was reduced to once per night, and he was very satisfied with the treatment result.
Nocturia is a common condition in older persons that significantly impacts quality of life. An evaluation is easily accomplished in the primary care setting, and effective treatment is available.
The authors report no relevant financial relationships.