Nocturia

Nocturia

What is Nocturia?

Nocturia is a condition in Singapore whereby a person wakes up one or more times during the night to urinate. It should not be confused with nocturnal enuresis, or bedwetting, which occurs involuntarily and without feeling the urge to urinate. Nocturnal enuresis occurs more commonly in children and young adults. Nocturia can be isolated or be accompanied by urinary frequency during the day as well. Over time, nocturia can negatively affect your overall health and quality of life due to disruptions in, and the resultant lack of, sleep.

Nocturia is a common condition that affects both men and women, especially those above the age of 40. It is also known to be prevalent in women during pregnancy, although the condition will generally resolve itself after giving birth.

What are the types of nocturia?

There are several types of nocturia, including:
  • Polyuria

    This is when the body produces an excessive amount of urine (>3000ml) within 24 hours.
  • Nocturnal Polyuria

    As the name suggests, nocturnal polyuria describes an overproduction of urine, but only during the night.
  • Nocturnal Urinary Frequency (commonly known as nocturia)

    This refers to frequent night-time urination consisting of small amounts of urine.

What are the common causes of Nocturia in Singapore?

The causes of nocturia vary according to the cause.

Polyuria is typically caused by the overproduction of urine by the kidneys. This may be brought about by a high fluid intake or conditions such as untreated diabetes, diabetes insipidus, and gestational diabetes.

Nocturnal polyuria can be caused by congestive heart failure, swelling or oedema of the legs, and various sleep disorders. It has also been associated with the use of certain medications, a high-sodium diet, and the excessive consumption of fluids – particularly those high in caffeine or alcohol – before sleeping.

Nocturnal urinary frequency (nocturia) is generally caused by various urological problems, including benign prostatic hyperplasia, recurrent urinary tract infection, overactive bladder, and interstitial cystitis (rare).

It may also be caused by excessive fluid intake before bedtime.

A bladder or prostate condition may also cause difficulty in emptying the bladder before going to bed, which results in the need to wake up to urinate. When the volume of urine overwhelms the normal bladder capacity, one may leak urine or have the urge to wake up multiple times to go to the washroom. For older males, the prostate is usually the issue, whereas, for females, an overactive bladder may be more common. For both females and males, as one ages, an underactive bladder may also contribute to their voiding problems.

What is the most common reversible cause of Nocturia in Singapore?

Sudden nocturia is most commonly caused by a Urinary Tract Infection (UTI), which can cause urgent urination at night. This occurs more commonly in females. Thankfully, the nocturia symptoms subside when the UTI is treated.

Does Nocturia only happen with old age?

The prevalence of nocturia increases with age. However, it is a condition not limited only to the elderly. It can be caused by a variety of factors, such as underlying medical conditions or issues with renal or cardiac function. Obstructive sleep apnoea (OSA) is a common but underdiagnosed condition that leads to nocturia. 

What are the reversible risk factors for Nocturia?

A high fluid intake and excessive consumption of caffeine and alcohol may also contribute to your likelihood of developing nocturia.

Other risk factors for nocturia include the presence of various conditions, such as:

  • Diabetes mellitus type I or II 
  • High blood pressure medications
  • Heart disease
  • Sleep disorders (eg obstructive sleep apnoea)
  • Restless leg syndrome
  • Oedema of the lower limbs
  • Bladder inflammation
  • Interstitial cystitis
  • Bladder obstruction
  • Prostate obstruction
  • Pelvic organ prolapse
  • Menopause
  • Pregnancy

 

Understanding what causes your nocturia will help your urologist tailor a treatment plan that best suits your condition. 

When should I visit a doctor?

You should visit your doctor if you often find yourself waking up to urinate in the night. This is especially so if your nocturia is disrupting other areas of your life. Your doctor might be able to find and treat any underlying causes of your nocturia or simply treat the nocturia itself.

What can I expect during my first consultation?

During your first consultation, your doctor will likely ask you about your medical history, lifestyle and your symptoms. Some common questions to expect are:

  • How often do you wake up to urinate at night?
  • Do you urinate in small or large volumes when you urinate at night?
  • When did your symptoms start?
  • How much caffeine and alcohol do you consume in a day?
  • Have you made any changes to your diet recently?
  • Are you currently taking any medications?
  • Do you smoke?
  • What do you usually eat?
  • Have you undergone any surgical procedures?

 

If necessary, your doctor may perform a physical examination as well as order various diagnostic tests to check for any underlying causes of your nocturia. They will examine you for:

  • A distended or stretched bladder as a result of not emptying completely
  • Peripheral oedema, indicated by swelling in your ankles or legs
  • Skin damage on your genitals caused by urinary incontinence
  • Urethral discharge caused by infection
  • Abnormalities in the genitals
  • A prostate exam (men)

 

Your urologist may also do a pelvic examination and carry out tests to rule out any heart, lung or neurological conditions if necessary

How is Nocturia diagnosed in Singapore?

While diagnosing nocturia may be a simple affair, it can be much more complicated to uncover the underlying cause of the nocturia. Some of the most common diagnostic tests used are:
  • Bladder Diary

    Your doctor will most likely ask that you keep a bladder diary, which is a record of how much fluid you drink, how often you urinate, and the volume of urine produced throughout a three-day period.
  • Urinalysis and Urine Culture

    Your urine sample will be sent to a laboratory to check for the presence of any infections and blood.
  • Various Blood Tests

    The most common of these will check your renal function, to determine whether your nocturia is caused by any potential kidney issues.
  • Uroflowmetry

    This is a test that will measure your voiding function by analysing the speed and volume of your urination.
  • Ultrasound Bladder

    An ultrasound bladder can show any potential issues with the structure of the bladder and reveal any obstructions or growths. In addition, this test is commonly used in conjunction with a uroflowmetry test to check for residual urine after urination.
  • Ultrasound Prostate

    This is generally used to check for benign prostate hyperplasia in men.
  • Cystoscopy

    A cystoscopy is a minimally invasive procedure whereby the urologist inserts an endoscopic tube with a lens into the bladder via the urethra in order to examine the urethra and bladder lining.

How is Nocturia treated in Singapore?

Nocturia treatment varies greatly and depends on what is causing the nocturia in the first place. It is generally treated with lifestyle modifications and the use of medications. Some examples are:

  • Anticholinergic medications

    These are drugs that minimise any abnormal bladder contractions to reduce the urge to urinate. Muscarinic Receptor Antagonists (MRAs) reduce abnormal contractions in the bladder, in turn, reducing the sudden need to urinate. These are:

    • Darifenacin
    • Fesoterodine
    • Mirabegron
    • Oxybutynin
    • Propiverine
    • Solifenacin
    • Tolterodine
    • Trospium chloride
  • Loop diuretics

    These are taken during the day to increase urination in the morning and afternoon rather than at night. Commonly prescribed loop diuretics are:

    • Furosemide
    • Bumetanide
    • Torsemide
  • Desmopressin

    Desmopressin is prescribed to patients who suffer from nocturia caused by a decrease in the production of a hormone called vasopressin. This medication helps concentrate the urine, hence reducing urine production at night.

    If your doctor has discovered an underlying cause for your nocturia, he or she may also proceed to treat that condition in addition to your nocturia. For example, men with benign prostate hyperplasia may be prescribed medications that will reduce the size of the prostate, or in more serious cases, may have to undergo a Transurethral Resection of the Prostate (TURP) to surgically remove part of the prostate gland.

How much water should I drink every day?

How much water is recommended depends on your size and the activities performed in the day. On average, an adult should drink 1.5 – 2 litres of liquid a day. 

Elderly patients with medical conditions such as kidney diseases or heart conditions may be advised by the urologist to drink less.

What lifestyle changes can I expect?

In addition to the use of medication or surgery, your doctor may also prescribe various lifestyle changes to alleviate your nocturia. This may include:

 

  • Adopting a proper sleep routine, where you wake up and sleep at the same times
  • Restricting fluid intake at night
  • Reducing consumption of caffeine and alcohol
  • Avoiding certain foods
  • Avoiding large amounts of food before bed
  • Avoiding smoking
  • Managing diuretic use
  • Using compression socks
  • Avoid taking naps in the afternoon
  • Managing other conditions that may cause nocturia symptoms

Summary

While waking up in the night to urinate may seem like a small issue, nocturia can be a sign of a more serious underlying problem and may reduce your quality of life over time by disrupting your sleep. Treating nocturia can sometimes take an extended period of time, so you should seek treatment as early as possible. If you are experiencing nocturia or any other urological conditions, please do not hesitate to visit a urologist, who will be able to diagnose and treat any issues and provide information on living with such conditions.

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Dr. Fiona Wu 2

Dr Fiona Wu
Consultant Urologist

MBBS (S'pore), MRCS (Edin), MMED (Surg),
MMED (Clinical Investigation),
FRCS (Urol) (RCPSG), FAMS (Urology)

Dr Fiona Wu is an experienced Consultant Urologist and is the Medical Director of Aare Urocare.

Prior to her private practice, she spent 15 years in public service. She was a Consultant in the Department of Urology at National University Hospital (NUH), Alexandra Hospital and Ng Teng Fong General Hospital.

She believes in treating urinary incontinence in a holistic way using minimally invasive methods – this ranges from laser treatment, neurotoxin injections, electromagnetic nerve stimulation to minimally invasive surgeries, etc. She worked closely with the gynaecology and colorectal departments to treat complex pelvic floor conditions and continues to do so in her own practice.

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