Nocturia
Steven C. Campbell, M.D., Ph.D.; Associate Editor(s)-in-Chief:  Venkata Sivakrishna Kumar Pulivarthi M.B.B.S  Nasrin Nikravangolsefid, MD-MPH 

# Overview
Nocturia (derived from Latin nox, night, and Greek  , urine), also called nycturia (Greek ), is the need to get up during the night in order to urinate, thus interrupting sleep.  Its occurrence is more frequent in the elderly.  Nocturia could result simply from too much liquid intake before going to bed, or it could be a symptom of a larger problem, such as chronic renal failure, urinary incontinence, Interstitial Cystitis, diabetes, benign prostatic hyperplasia, Ureteropelvic junction obstruction or prostate cancer.

# Historical Perspective
- Nocturia was defined by International Continence Society (ICS) in 2002, as the need to wake up one or more times at nights to void. 
- Clinical definition of nocturia is awaking from sleep to urinate two or more that two times per night.  
The association between  and  was made in/during .
In ,  was the first to discover the association between  and the development of .
In ,  mutations were first implicated in the pathogenesis of .
There have been several outbreaks of , including -----.
In ,  was developed by  to treat/diagnose .

# Pathophysiology
- It is thought that nocturia is caused by a number of factors, including 
urological disorders
abnormalities of bladder capacity
prostate enlargement
urine overproduction due to
depletion of third-space fluid in overload states following a recumbent position during sleep
-verproduction of atrial natriuretic peptide (ANP) caused by
sleep apnea
congestive heart failure
deficiency or dysfunction of antidiuretic hormone (ADH) or arginine vasopressin (AVP)
medications such as diuretics
behavioral factors such as high water intake at night
- urological disorders
abnormalities of bladder capacity
prostate enlargement
- abnormalities of bladder capacity
- prostate enlargement
- urine overproduction due to
depletion of third-space fluid in overload states following a recumbent position during sleep
-verproduction of atrial natriuretic peptide (ANP) caused by
sleep apnea
congestive heart failure
deficiency or dysfunction of antidiuretic hormone (ADH) or arginine vasopressin (AVP)
medications such as diuretics
behavioral factors such as high water intake at night
- depletion of third-space fluid in overload states following a recumbent position during sleep
- overproduction of atrial natriuretic peptide (ANP) caused by
sleep apnea
congestive heart failure
- sleep apnea
- congestive heart failure
- deficiency or dysfunction of antidiuretic hormone (ADH) or arginine vasopressin (AVP)
- medications such as diuretics
- behavioral factors such as high water intake at night
- AVP regulates urine production by antidiuretic effects in the collecting system in the kidneys, resulted in
increasing water reabsorption
decreasing urine volume
- increasing water reabsorption
- decreasing urine volume
- AVP deficiency or AVP dysfunction leads to decreasing urine concentration, increasing urine volume and nocturia. 

# Causes

## Causes by Pathogenesis

### Causes Due to Hormonal Imbalance

### Causes Due to Vesical Problems

## Causes by Organ System

## Causes in Alphabetical Order
- Anxiety disorders
- Benign prostatic hyperplasia
- Bicalutamide
- Bladder outlet obstruction
- Cardiac glycosides
- Chronic renal failure
- Demeclocycline
- Depression
- Detrusor hyperactivity
- Diabetes
- Diabetes insipidus
- Diuretics
- Excessive vitamin D intake
- Granulomatous prostatitis
- Heart failure
- Interstitial cystitis
- Learned voiding dysfunction
- Lithium
- Liver failure
- Methoxyflurane
- Nephrotic syndrome
- Neurogenic bladder
- Obesity
- Obstructive sleep apnea
- Parkinson disease
- Phenytoin
- Primary hyperaldosteronism
- Propoxyphene
- Primary polydipsia
- Prostate cancer
- Recurrent UTI
- Restless leg syndrome
- Tiagabine
- Ureteropelvic junction obstruction
- Urge incontinence
- Venous insufficiency

# Differentiating ((Page name)) from other Diseases
 must be differentiated from other diseases that cause , , and , such as , , and .
OR
 must be differentiated from , , and .

# Epidemiology and Demographics
- The prevalence of nocturia  1 voids is approximately 69000 per 100,000 men aged  40 years and 76000 per 100,000 women aged  40 years in the United States, United Kingdom, and Sweden.  
- The prevalence of nocturia  2 voids in population aged 20-30 years is approximately 4000 to 18000 per 100,000 women and 2000 to 17000 per 100,000 men. 
- The prevalence of nocturia  2 voids in population aged 70-80 years is 28000 to 62000 per 100,000 women and 29000 to 59000 per 100,000 men. 
- The prevalence of nocturia  2 voids in in Canada, Germany, Italy, Sweden, and the United Kingdom is 13000 to 17000 per 100,000 individuals aged < 40 years and 20000 to 21000 per 100,000 middle-aged populations and 35000 to 36000 per 100,000 individuals aged  60 years. 
- The incidence of nocturia increases with age. 
- Nocturia can affect younger people as 1 from 5 or 6 younger population wake up at least two times per night to void.  
- non-Hispanic black men are more likely to develop nocturia.  
- nocturia affects men and women equally. However, nocturia incidence are more in young women than young men, and also old men are more likely to develop nocturia than old women. 

# Risk Factors
- Common risk factors in the development of nocturia include 
aging
Hispanic and Black race
history of nocturia during childhood
history of pre-existing conditions
Diabetes mellitus
Diabetes insipidus
Hypertension
Arthritis
Airway disease such as Asthma
history of psychological disease
Depression
Anxiety disorders
history of diuretic intake
- aging
- Hispanic and Black race
- history of nocturia during childhood
- history of pre-existing conditions
Diabetes mellitus
Diabetes insipidus
Hypertension
Arthritis
Airway disease such as Asthma
- Diabetes mellitus
- Diabetes insipidus
- Hypertension
- Arthritis
- Airway disease such as Asthma
- history of psychological disease
Depression
Anxiety disorders
- Depression
- Anxiety disorders
- history of diuretic intake
- Potent risk factors in the development of nocturia in men include
prostatitis
benign prostatic hyperplasia
prostate cancer
- prostatitis
- benign prostatic hyperplasia
- prostate cancer
- Potent risk factors in the development of nocturia in women include
high BMI
Heart disease
Inflammatory bowel disease
Uterine prolapse
Hysterectomy
Menopause
recurrent UTI
- high BMI
- Heart disease
- Inflammatory bowel disease
- Uterine prolapse
- Hysterectomy
- Menopause
- recurrent UTI

# Screening
There is insufficient evidence to recommend routine screening for nocturia.

# Natural History, Complications, and Prognosis
- Common complications of nocturia include
Sleep disorders
Depression
anxiety disorders
lower quality of life
increased risk of falling and bone fracture
increased mortality
- Sleep disorders
- Depression
- anxiety disorders
- lower quality of life
- increased risk of falling and bone fracture
- increased mortality

# Diagnosis

## Diagnostic Study of Choice
- The diagnosis of nocturia is based on the clinical history defined by International Continence Society (ICS) in 2002, which includes wake up at night 1 times to void. 
- According to new revised definition in 2017 , nocturia is to wake up to void during the sleep period. 
- Bladder diary should be asked from the patients, including 
the amount of water intake
the time of water intake
time and volume of urination
the number of urinations during the day
the number of nocturia (urination during the sleep),
the number of urinations and the amount of urine production during the day
- the amount of water intake
- the time of water intake
- time and volume of urination
the number of urinations during the day
the number of nocturia (urination during the sleep),
the number of urinations and the amount of urine production during the day
- the number of urinations during the day
- the number of nocturia (urination during the sleep),
- the number of urinations and the amount of urine production during the day
- Frequency- volume charts can be diagnostic for nocturia. 

## History and Symptoms
- The most common symptoms of nocturia include passing urine, urgency and frequency at nights. 
- History of fluid, alcohol and caffeine intake, urinary symptoms, medications , sleep disorders should be asked from the patients. 
Some medications that cause nocturia include diuretics, amlodipine and nifedipine should be discontinued.
- Some medications that cause nocturia include diuretics, amlodipine and nifedipine should be discontinued.

## Physical Examination
- physical examination should include 
Checking Blood pressure
digital rectal examination of the prostate in men and pelvic examination in women
checking edema of the lower limbs
checking genitalia diseases (phimosis, meatal stenosis or cancer)
abdominal examination especially bladder to assess urinary retention
calculating BMI and/or waist circumference
filling the chart of Frequency-volume for at least 3 days
- Checking Blood pressure
- digital rectal examination of the prostate in men and pelvic examination in women
- checking edema of the lower limbs
- checking genitalia diseases (phimosis, meatal stenosis or cancer)
- abdominal examination especially bladder to assess urinary retention
- calculating BMI and/or waist circumference
- filling the chart of Frequency-volume for at least 3 days

## Laboratory Findings
- Laboratory tests that should be helpful for the diagnosis of nocturia include 
urine analysis with urine culture to rule out urinary tract infection
serum electrolytes
renal function tests such as BUN, creatinine, GFR
serum glucose level and HbA1c to rule out diabetes mellitus
lipid profile
PSA level to rule out prostate cancer and BPH
- urine analysis with urine culture to rule out urinary tract infection
- serum electrolytes
- renal function tests such as BUN, creatinine, GFR
- serum glucose level and HbA1c to rule out diabetes mellitus
- lipid profile
- PSA level to rule out prostate cancer and BPH

## Electrocardiogram
There are no ECG findings associated with nocturia.

## X-ray
There are no x-ray findings associated with nocturia.

## Ultrasound
- ultrasound may be helpful in the diagnosis of nocturia associated conditions. Ultrasound can measure postvoid residual volume and bladder wall thickness. 

## CT scan
- There are no CT scan findings associated with nocturia. However, a CT scan may be helpful in the diagnosis of bladder, prostate and urinary tracts abnormalities.

## MRI
There are no MRI findings associated with nocturia.

## Other Imaging Findings
There are no other imaging findings associated with .
OR
 may be helpful in the diagnosis of . Findings on an  suggestive of/diagnostic of  include , , and .

## Other Diagnostic Studies
- Cystoscopy may be helpful in the diagnosis of bladder abnormalities that cause nocturia. 

# Treatment

## Medical Therapy

## Treatment
- Treatment options for nocturia depend on the underlying causes.
- Behavioral modification includes  
limiting fluid intake in the evening
avoiding alcohol, coffee and tea
treating underlying conditions such as chronic constipation, diabetes mellitus, diabetes insipidus
elevation of the lower limbs in the evening
avoiding diuretics intake in the evening and night
physical exercise
- limiting fluid intake in the evening
- avoiding alcohol, coffee and tea
- treating underlying conditions such as chronic constipation, diabetes mellitus, diabetes insipidus
- elevation of the lower limbs in the evening
- avoiding diuretics intake in the evening and night
- physical exercise
- Pharmacologic medical therapies for nocturia include
desmopressin (arginine vasopressin) 
It decreases urine volume through vasopressin V2 receptors, which leads to increase water reabsorption in renal tubules.
It is the preferred drug for the treatment of nocturia due to nocturnal polyuria according to the European Association of Urology (EAU) recommendation. 
-blockers
antimuscarinics
phosphodiesterase type 5 inhibitors
Botulinum toxin
- desmopressin (arginine vasopressin) 
It decreases urine volume through vasopressin V2 receptors, which leads to increase water reabsorption in renal tubules.
It is the preferred drug for the treatment of nocturia due to nocturnal polyuria according to the European Association of Urology (EAU) recommendation. 
- It decreases urine volume through vasopressin V2 receptors, which leads to increase water reabsorption in renal tubules.
- It is the preferred drug for the treatment of nocturia due to nocturnal polyuria according to the European Association of Urology (EAU) recommendation. 
- -blockers
- antimuscarinics
- phosphodiesterase type 5 inhibitors
- Botulinum toxin

## Surgery
Surgical intervention is not recommended for the management of .
OR
Surgery is not the first-line treatment option for patients with . Surgery is usually reserved for patients with either , , and 
OR
The mainstay of treatment for  is medical therapy. Surgery is usually reserved for patients with either , , and/or .
OR
The feasibility of surgery depends on the stage of  at diagnosis.
OR
Surgery is the mainstay of treatment for .

## Primary Prevention
- Effective measures for the primary prevention of nocturia include lifestyle modifications such as 
reducing intake of fluid, caffeine, alcohol, diuretics in the evening and night
less salt intake
take naps in the afternoon
weight loss in obese and overweight individuals
urination before going to bed
using compression stocks or elevating legs to reduce edema
- reducing intake of fluid, caffeine, alcohol, diuretics in the evening and night
- less salt intake
- take naps in the afternoon
- weight loss in obese and overweight individuals
- urination before going to bed
- using compression stocks or elevating legs to reduce edema

## Secondary Prevention
There are no established measures for the secondary prevention of nocturia.