A good night sleep is the basic requirement of all human beings. It not only rejuvenates the body but helps to have a crystal clear mind to face the world the next day. A sound sleep is deprived of many due to the stress and complexities of daily life.

To rub salt to the wound many of us suffer from lack of sleep due to frequent urination in the night. Going to pee once in the night is normal. But more than once it is a health condition called Nocturia.

Nocturia increases with age and becomes more complicated with falls and injuries in the night. But it also affects people of all age group. This affects the daily routine and could be a disaster to both professional and personal life over a period of time.

In normal conditions, during sleep time your body produces less urine which is more concentrated. This is to help people not to wake up during the night to urinate and get a sound sleep for 6 to 8 hours.

Due to various causes which could also be an underlying ailment your body makes too much urine. In some cases your urinary bladder cannot hold enough urine and sometimes both could be the reason. Or it could just be the excess fluid intake before bedtime including alcohol and caffeine.

This urinary issue of nocturia can be managed on your own or would need medical treatment. Anyway, it is important to have a good night sleep without rushing now and then to the restroom to pee. So to stop walking like ghosts in the middle of the night to pee, continue reading.

Nocturia is common among both the genders and as per a study of National Sleep Foundation, it is reported that two thirds or 65 % of people above 50 years of age are affected by nocturia.

SYMPTOMS OF NOCTURIA:

Until recently nocturia was perceived to be a symptom of some organic disease or an underlying ailment. But recent studies and researches have confirmed that nocturia is a disease in itself.

Common symptoms of nocturia:

Excessive production of urine than the normal quantity of 2 liters per day
Frequent urination which is not only uncomfortable but irritating most of the times
The urinary urgency with a feeling of the bladder being full even though the urine excretion is less
Normal daytime “body clock” urination pattern to occur at night

Serious symptoms of nocturia which needs immediate medical attention:

Bloody or pink-colored urine which could be a cause of hematuria
Difficult or painful urination
Severe burning sensation with urination with fever
Urinary retention with severe abdominal pain.

CAUSES OF NOCTURIA:

Nocturia is a major concern for those affected by it because it affects the quality of life. They become the root cause of the mindset and body condition throughout the next day because of lack of sleep. This not only distorts the professional and personal life but also becomes a burden to economic responsibilities. Hence first all the normal plausible causes have to be first checked.

Common causes of nocturia:

Excess fluid intake before bedtime:

If you are drinking too much of water or other fluids like water, juices, hydrated drinks, alcohol, caffeine close to bedtime it is more possible to wake up several times to go to the bathroom during your sleep.

Urinary infection:

If you are affected by any kind of urinary tract infection or UTI you may pee a lot than normal not only in the night but also during daytime. It may hurt while you pee and it will be accompanied by stomach ache and fever which is the time you should see your doctor immediately.

Age makes the difference:

Yes if you are above 50 years of age you are prone to frequent urination at night. This is because of several medical conditions which happen with the wear and tear of age. Added to that any serious medical ailments and their medications would prompt you to wake up more times at night to void.

Reasons for nocturia among old people:

Less concentration of anti-diuretic hormones makes it impossible to retain the urine.
The urine bladder loses its capacity to hold urine for a long time with age.
For older men, an enlarged prostate is another common issue to make you pee often. This prostrated gland could be serious if it is affected by cancer.
For older women, after the menopause, they tend to produce less estrogen and that causes the change in the urinary tract and have to go often to the bathroom. For some s after having children the pelvic muscles become weaker and this also could be cause for nocturia.

Medications:

In this modern world, it is rare for many to go to sleep without any medications. This is not confined to any gender or age. But it is common for people around the world.

Most of the medicines pull fluid of your system and make you pee more. It is time to consult your doctor to check what medications could be the cause of your nocturia.

Sleep problems:

Latest studies have confirmed that nocturia is symptom of sleep apnea. Many times it is not the urge to pee that wakes you, but once you are up you need to go to the bathroom which has become a routine or practice. This can happen if you have the following issues:

Restless legs syndrome
Hot flashes
Ongoing or chronic pain
Depression
Sleep apnea

Circadian clock:

This is a biological process which controls the urine during the night by the circadian clock rhythm. It is an endogenous, entrainable oscillation about 24 hours driven by a circadian clock. Many urinary functions exhibit clear daily or circadian variation in humans. Urine production and voiding must predominate during the active phase of the circadian rhythm with the storage and reduced frequency in urination in the slower phase of it. When this is affected, it could be a cause of nocturia which happens mostly with the elderly people.

Primary causes of nocturia:

There are two primary causes of nocturia. They are the hormonal imbalances and vesical problems.

Hormonal imbalances:

The two major hormones that regulate the body’s water level are

AVP or Arginine Vasopressin
ANH or Arterial Natriuretic Hormone

AVP:

AVP or Arginine Vasopressin is an anti-diuretic hormone produced in the hypothalamus and stored in the posterior pituitary gland. The released AVP hormones from the pituitary gland increase the water absorption in the collecting duct systems of the kidney nephrons. This decreases the urine production and regulates the hydration levels in the body.

These AVP hormones production decreases with age and due to some ailment or other causes. Hence the water absorption in the collecting duct systems of the kidney nephrons decreases. This increases the urine content and causes nocturia.

ANH:

ANH or the Arterial Natriuretic hormone is released by the cardiac muscle cells in response to the high blood volume. When these ANH hormones are activated they release water and subsequently increase urine production. The main function of ANH is to lower blood pressure and to control electrolytic homeostasis.

Arterial natriuretic hormones main target is the kidney and also interacts with other hormones to regulate the secretion. When this ANH is over-activated by blood pressure it secretes more urine.

Vesical problems:

The urinary bladder problems are called vesical problems. The urinary bladder receives and stores the urine from the kidneys before disposing of them as urine. They are muscular hollow organs that are situated on the pelvic floor to retain the urine till urination.

The urine from the kidney enter the bladder by ureters and goes out my urethra. The normal urinary bladder will hold half a liter of urine and any excess to it there will be an urge to empty them. In certain cases, they can hold more than this quantity by the stretching of the bladder by forming ridges and flattening of its walls.

With aging and due to some causes the bladder weakens causing vesical problems. This result in frequent urination since the bladders does not enlarge to hold more quantity of urine. This also causes nocturia.

Major underlying causes of nocturia:

There are four major underlying causes of nocturia.

Global polyuria or 24- hour polyuria:

This is the most common cause for nocturia globally. It is because of the continuous overproduction of urine and not limited to even the sleeping hours. This excess production is a lot more than the normal level of 40 ml of urine secretion per kilogram weight of the person in 24 hours.

The main cause of this global polyuria is primary thirst disorders like diabetes mellitus and diabetes insipidus. Urination imbalance causes polydipsia which is the condition to prevent circulatory collapse by creating excessive thirst.

Central diabetes insipidus is caused by low levels of AVP hormones which help in regulating the water levels. In the case of nephrogenic diabetic insipidus the low levels of AVP hormones do not activate the kidneys properly. This causes the urination imbalance and thus nocturia. Apart from the AVP hormones the following are the Causes of global or 24-hour polyuria.

Diabetes both the types I & II
Diabetes insipidus
Gestational diabetes characterized by pregnancy
Neurological disorders like Alzheimer’s, Multiple sclerosis, Spinal cord compression, and Parkinson’s diseases

Nocturnal polyuria:

Nocturnal polyuria is a typical cause of nocturia. It is the just the reverse of normal urination. The daytime urination is less when compared to the night time urination. This balances the 24-hour urine production or NUV. Nocturnal polyuria has an NPI or nocturnal polyuria index greater than 35 % of the normal 24-hour urine volume.

Disruption of AVP levels leads to the inability to control urination causing nocturia. r Causes of nocturnal polyuria:

Congestive heart failure
Liver failure
Nephritic syndrome
Alcoholism and other lifestyle patterns
Sleep apnea

Bladder storage:

Nocturia patients who are not affected by global polyuria or nocturnal polyuria are most likely to be affected by bladder storage issues. This in contrast to extreme urination issues is more concerned with the frequent voids with small volumes of urine.

NBC or nocturnal bladder capacity is decreased during the sleep period. This could be because of decreased maximum voided volume or decreased bladder storage.

Causes of decreased NBC:

Lower urinary tract symptoms
Sleep disorders
Prostatic obstruction
Neurogenic bladder dysfunction
Anxiety disorders
Pharmacological agents
Bladder tumor
Prostate Tumor
Bladder obstruction
Overactive bladder
Bladder malignancy
Bladder inflammation
Bladder prolapse
Bladder infection
Interstitial cystitis
Pregnancy
Obesity
Benign prostatic hyperplasia in men which is a non-cancerous overgrowth of the prostate that obstructs the flow of urine

Mixed cause:

The combination of decreased NBC and nocturnal polyuria is the mixed cause. In a study of 196 patients, 7 % were diagnosed with nocturnal polyuria and 57 % with decreased NBC and the remaining 36% had a combination of both. The cause of nocturia are not often related to an underlying urological condition but that of a multifactorial one.

DIAGNOSIS OF NOCTURIA:

Diagnosis of nocturia starts with first knowing the NUV or the patient’s nocturnal urine volume. The international continence society defines the NUV as the total volume of urine passed between the time of the individual going to bed till he ends the sleep. This excludes the last void and includes the first void after waking up.

Void diary:

As with other patients of various diseases the patients of nocturia are also required to establish the history of the disease. But in the case of nocturia, it is not only the medical history but also the voiding diary of the patient is required. This is the main diagnostic tool for the doctor to classify what is the cause of nocturia.

Timing, number and volume of void recorded in the diary along with a diary of fluid intake with time help the doctor. The first void should be included in the NUV, if there are no night voids. All this could clearly establish the kind of cause whether it is global polyuria, or nocturnal polyuria or due to bladder issues could be ascertained.

This is further confirmed by the doctor by the questionnaire he puts to you. It may consist of the following questions:

Questionnaire:

When did this condition of nocturia start?
How many times do you need to urinate each night?
What is the quantity either large or small of urine when you void at night?
Has there been a change in urination output recently?
How much caffeine do you drink each day and especially during bedtime?
Do you drink alcohol? If yes, how much each day?
Does your voiding in the night affecting your quality of sleep?
Have you changed your diet lately?
How you are sleeping?
Do you sleep during the daytime?
Whether you feel tired or fatigue during the daytime?
What are the symptoms you have?
Did you have any accidents recently?
Do you wet your bed?
Any occurrence which made your nocturia worse?
What are the medications you take?
Do you have any family history of bladder problems or diabetes?

This is followed by a physical examination. Then the doctor as per his analysis will ask you to conduct certain tests to confirm his observation before treatment.

Tests for nocturia:

Blood test to check diabetes
Blood tests for blood counts and blood chemistry
Urinalysis
Urine culture
Fluid deprivation test
Urological tests like cystoscopy
Cystometry to check the pressure within the bladder
Neurological tests urgency issues
Refer you to a sleep center for testing
Imaging tests like Ultrasound and/or CT scans

TREATMENT FOR NOCTURIA:

Nocturia has been only researched recently in depth and the treatment options are hence limited. They are more dependent on the diagnosis and the underlying cause determined by the doctor. In the case of sleep apnea, you will be sent to a sleep specialist or pulmonologist.

Medications for nocturia:

Most of the medicines alleviate nocturia to a great extent and some are better for treatment. Nocturia could relapse once the medications are stopped. Also, the medications should be taken with care for elder patients to maintain the serum sodium concentration. If the concentration falls beyond a certain extent it could cause severe consequences.

The following are the first line of medications for nocturia:

Anticholinergic medicines:

Anticholinergic medications which are effective in treating enuresis or involuntary urination can be used. The detrusor over-activity is reduced by these medicines which help in softening of the bladder muscles to retain urine. These medicines demonstrate 5-40 % success. Some side effects like dry mouth, dizziness, and blurred vision are possible with this medication.

Solifenacin:

This is a recently introduced anticholinergic medicine which is a more selective antimuscarinic agent but with less anticholinergic side effects.

Trospium chloride:

This medication is useful in blocking the cholinergic receptors found on the muscles cells in the wall of the unstable bladder. Since the receptors are blocked the bladder can relax so overactivity does not occur.

Oxybutynin:

This medication relaxes the detrusor muscle of the bladder

Tolterodine:

This medication is an antimuscarinic and functions much like oxybutynin

Darifenacin:

This medication relieves the bladder spasms and treats the overactive bladder

When all this first line medications are not effective the following medications can be prescribed.

The second line of medications for nocturia:

Desmopressin:

This medicine mimics the ADH or Vasopressin hormones to make the kidney produce less urine.

Imipramine:

This medicine has a 40 % rate of treating nocturia but is considered as a toxic dose

Furosemide:

This medication is a loop diuretic helps urine production in the daytime so that it decreases the urine production during night time. Also, furosemide blocks ion flow in the kidneys allowing the urine production to be controlled.

Bumetanide:

This is another loop diuretic which helps in regulating the urine production prior to sleep to prevent waking in the night time to pee. But this medication should be only taken with proper medical advice.

Surgery:

Surgery is done if the cause of nocturia is related due to the obstruction of the prostate or an overactive bladder. Following are the surgical options for nocturia:

Transurethral prostatectomy
Incision of the prostate
Surgical correction of the pelvic organ prolapse
Sacral nerve stimulation
Clam cystoplasty
Detrusor myectomy

MANAGEMENT OF NOCTURIA:

Since there is so far not a proper cure to nocturia the following steps could be taken to alleviate it.

Restrict fluid intake:

To reduce frequent peeing in the night naturally, the best way is to restrict with awareness of fluid intake from the evening till bedtime. Avoiding caffeine beverages and alcohol..

Afternoon naps:

This could help in reducing the accumulation of the fluid by allowing liquid to be absorbed in the bloodstream. The excess urine after the nap could be peed off in the bathroom.

Keep the legs elevated while sleeping:

This can help in redistributing the fluids so that it can be absorbed into the bloodstream.

Use compression stockings:

Like elevating the legs this compression stockings will exert pressure against the leg while decreasing pressure on the veins. This again redistributes the fluids to the bloodstream. But this should not be worn by people with high blood pressure.

Avoid bladder irritant foods at night:

Some foods like chocolates, acidic foods, artificial sweeteners, spicy foods among others should be totally avoided.

Even though significant scientific developments are done on nocturia there is still no definite treatment to cure it. Hence being aware of what increases nocturia and avoiding it could be the right way to have a sound sleep and a healthy life.

https://www.ncbi.nlm.nih.gov/pubmed/27805334

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3602727/