NOCTURIA

Agus Sudarso
Syakib Bakri

Introduction
The International Continence Society (ICS): the
complaint that an individual wakes on one or more
times to void urine during night

A common reason for interrupted

sleep in general adult population
NOCTURIA

Multifactorial and complex

pathogenesis
Not include the first void in the
morning
Prevalence: Male>Female, increased with
ageing

Prevalence

Baverstock, R. Can J Diag. 2004;75

Physiology of Void
Bladder filling
Neural
stimulation
Bladder
relaxation

Subcortical

Cortical
Cortex
stimulation

Delay voiding

Cholinergic
action
Pelvic nerves

Full bladder
Detrusor
contraction

Voiding

Etiophatogenesis
GLOBAL
POLYURIA
Diab mellitus
Diab insipidus
Primary
polydipsia

DIMINISHED
NOCTURNAL
BLADDER CAPACITY
Prostatic obstruction
Nocturnal detrusor
overactivity
Neurogenic bladder
Cancer of bladder, prostate,
urethra
Learned voiding
dysfunction
Anxiety disorders
Pharmacologic agents
Bladder calculi
Ureteral calculi

NOCTURNAL
POLYURIA
Congestive heart
failure
Diabetes mellitus
Obstructive sleep
apnea
Peripheral edema
Venous stasis
Nephrotic syndrome
Hepatic failure
Hypoalbuminemia
Excessive nighttime
fluid intake

Weiss J, Curr Urol. 2008;364

M
E
C
H
A
N
I
S
M
S

NOCTURNAL
POLYURIA
LOW NOCTURNAL
BLADDER CAPACITY
MIXED NOCTURIA

Urine production followed normal

circadian rhythm
Began at 2-5 y.o
At 7 y.o daytime urine production
2-3> night
Adult nighttime urine production
<25%
Normal person circadian rhythm
maintained until 60 y.o
Elderly large proportion of 24 h
urine production at nighttime

POLYURIA
A 24 h urine production > 40 mL/Kg
Common causes :
Diabetes mellitus
Insulin dependent diabetes (Type I)
Non insulin dependent diabetes (Type II)
Diabetes insipidus
Pituitary (central) deficiency in AVP at the pituitary level
Nephrogenic renal insensitivity to AVP
Gestational related to pregnancy
Primary polydipsia
Psycogenic related to psychological and cognitive
impairment
Dipsogenic caused by a primary abnormality in the thirst
Mechanism
Iatrogenic
Robinson, D. Int J Clin Pract.2007;61:24

Nocturnal Polyuria

An increase in nighttime urine production

resulted from low production in daytime to
meet a normal 24-h urine production
NPI (nocturnal polyuria index)= NUV/24-h urine
In individual <25 y.o, average NPI 14%
NPI increased over age
In elderly, NPI <34%
NPI >35% indicated for nocturnal polyuria
Nocturnal polyuria: NUV > 6.4 ml/Kg or NUV
>0,9 mL/min

Etiology of nocturnal polyuria

WATER DIERESIS
Circadian defect in secretion or action of antidiuretic
hormone
Primary (Idiopathic)
Secondary (Excessive evening intake of fluid, caffeine,
alcohol)
SOLUTE/WATER DIERESIS

Congestive heart failure

Diabetes mellitus
Obstructive sleep apnea
Peripheral edema
Nephrotic syndrome
Hypoalbuminemia

Low nocturnal bladder capacity

Prostatic obstruction
Neurogenic bladder
Nocturnal detrusor overactivity
Drugs
Bladder or ureteral calculi

NBCi calculation
NBCi (Nocturnal Bladder Capacity Index), a complex
formula to calculate NBC

NBCi = ANV PNV

Expanded: NBC = ANV (Ni* - 1)
Ni = NUV MVV
Ni = 750 250 = 3
NBCi = 7 (3 - 1)
NBCi = 7 2 = 5
ANV: actual number of nightly voids
PNV: predicted number of nightly voids
NUV: nocturnal urine volume
MVV: maximum voided volume
Ni: Nocturnal index

Weiss, J. J Urology.2006;175:17

Mixed nocturia

Combination between nocturnal

polyuria and low nocturnal bladder
capacity
Commonly in elderly
A study with 194 subjects : nocturnal
polyuria (7%), polyuria (23%), low
nocturnal bladder capacity (57%) and
mixed nocturia (36%)

Evaluation

Marinkovic, S. et al. BMJ.2004;328:1064

FORMULAS FOR NOCTURIA EVALUATION

FORMULA

ANALYSIS

Nocturia index
Ni = NUV : MVV
Nocturnal polyuria index
NPi = NUV : 24hV
Nocturnal
bladder
capacity
index
Ni 1 = PNV*
NBCi = ANV PNV

Ni > 1 nocturia is due to NUV

exceeding MVV
NPi > 35% dx is nocturnal
polyuria
NBCi > 0 nocturia occurring at
volumes <MVV

*Round up to next higher number if Ni 1 is not an integer

Weiss, J. J Urology.2006;175:18

Management

Comprehensive management, depends

on the underlying disease
Lifestyle modification, pharmacology
treatment and surgery

Lifestyle modification

Water restriction
Reduced alcohol and caffeine
consumption
Wearing compression sock to reduced
edema
Right timing for diuretics

Pharmacotherapy : depends on the

underlying cause

Diabetes melitus
Glycemia control

Diabetes insipidus
(central)
Diuretic : Desmopressin (1-deamino8-D-arginine vasopressin, DDAVP)

Pharmacotherapy (contd)

Desmopressin
Analog synthetic of AVP, for treatment of DI and
PNE
NOCTOPUS (2002) : Effectivity and safety in short
and long time period of therapy
Adverse effect : dilutional hyponatremia
Orally : initial dose of 0.1 mg, could be increased
up to 0.2 mg, maximum dose of 0.4 mg

Pharmacotherapy (contd)

Nocturnal polyuria
Mid day diuretic
Diuretic 6 hours before
bedtime
Elderly : low to undetected
level of vasopressin
R/ Desmopresin (Kuo,
2002)

Pharmacotherapy (contd)

Low nocturnal bladder capacity

Anticholinergic agents : oxybutynin,
tolterodine
Adverse effects : dry mouth,
constipation, vision disturbances,
sedative, insomnia, tachycardia,
confusion (elderly)
New agents : solifenacin, darifenacin
better effect and tolerability
Tricyclic antidepressant : imipramin
anticholinergic effect

Pharmacotherapy (contd)

Prostate hypertrophy
Alfa blocker :
tamsulosin selective,
less postural
hypotension effect,
adverse effect: erectile
dysfunction

Surgery

Overactive bladder :
Transurethral prostatectomy
Prolapse uteri surgery
Sacral nerve neuromodulation
Detrusor myomectomy
Clamp cystoplasty

Asplund
et al

40-60 y.o female tend to loose

30-days of work in a year
compared to those without
nocturia who only loose 15 days

Study in
Sweden

200 subjects with nocturia had 2

times decreased in energy,
productivity and quality of life

Great impact but tend to underestimate

Increased fatigue and decreased productivity &
quality of life
Increase falls and mortality in elderly

Clinical Implications

Summary
Nocturia is a complaint of individual wakes
one or more during night to void
Male>female, increased over age
Multifactorial etiology, not always associated
to urology abnormality
4 main etiologies : polyuria, sleep disorder,
bladder disorder, nocturnal polyuria
Voiding diary established diagnosis and
treatment
Management includes life style modification,
pharmacotherapy and surgery

Thank You

DI neurogenik

DI nefrogenik

P.Psikogenik

Osmolalitas plasma

meningkat

meningkat

menurun

Osmolalitas urine

menurun

menurun

menurun

Osmol. Urine selama

tes puasa minum

tetap

tetap

meningkat

Osmol. Urine selama

NaCl hipertonik

tetap

tetap

meningkat

Osmol. Urine setelah

vasopressin iv

meningkat

tetap

tinggi

Vasopressin plasma

rendah

Normal/tinggi

rendah

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