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Nocturia

When deep slumber at night is regularly disrupted by an urgent feeling of urination, it is a condition called nocturia. It is common in older adults, both men and women, usually in the age group of 55 and 84 years. Nocturia is different from enuresis or bed-wetting wherein the person does not wake up from sleep but involuntarily empties the bladder. Nocturia affected person experiences sleep loss due to an urgent need to urinate. Mild nocturia is characterized by a need to urinate two to three times and in severe cases it can be anywhere between five to six times on a particular night, occasionally or daily.

Nocturia types and causes

Besides the normal aging process, nocturia is also linked to other causes. In women, besides age, childbirth or pelvic organ prolapse and menopause are often contributing factors to nocturia.

Nocturnal Polyuria

There is an overproduction of urine at night. In a 24-hour cycle the urine volume may be greater than 40 ml/kg or if the volume of urine passed at night exceeds one-third of the total daily urine output. The main feature of nocturnal polyuria is that more urine is produced during sleep which in turn induces more nighttime urination.

All fluids or even certain foods like salads, vegetables, fruits, rice and pasta with high water content can cause nocturnal polyuria. Diuretics, cardiac glycosides, demeclocycline, lithium, methoxyflurane, phenytoin, propoxyphene and excessive Vitamin D medication can lead to frequent urination. Ankle swelling is another common cause of nocturnal polyuria. Congestive heart failure, venous stasis, hypoalbuminemia or excessive salt intake are other causes for fluid retention.


Polyuria

In adults, the normal urine production is 1 to 2 liters. Polyuria is characterized by urine output that exceeds 2500 ml/24 hours during the day as well as at night. Polyuria is common in people with diabetes mellitus and diabetes insipidus. Other conditions causing polyuria are Polycystic kidney disease, Sickle cell disease, Pyelonephritis, Amyloidosis, Sjogren syndrome and Myeloma. Vascular disease, restless leg syndrome, thyroid disorder and congestive heart failure are some causes for increased urinary output at night by the kidneys. Polydispisia or excessive thirst that compels drinking lots of water can cause polyuria. The thirst center or hypothalamus is affected due to anxiety, stress or psychiatric illness and leads to excessive thirst. Intravenous saline drip excessively administered can lead to polyuria. Hypercalcemia and hypokalemia lead to abnormal levels of electrolytes that can result in excessive urination.


Inadequate bladder storage

The urinary bladder has the capacity to hold as much as 600 ml of urine. But the desire to urinate is experienced when the level reaches about 150 ml. There are various reasons and conditions that lead to inadequate bladder storage. Bladder obstruction, bladder infection or recurrent urinary tract infection, bladder inflammation, pain in the bladder, bladder cancer can reduce bladder storage capacity. Stroke and Parkinson's disease can also lead to reduction in its storage capacity thus inducing an urgent need to empty the bladder.


Mixed Nocturia

A combination of nocturnal polyuria with reduced bladder capacity is termed as mixed nocturia.

Diagnosis of Nocturia

Basic diagnostic procedure is to record the frequency, volume and timing both daytime and nighttime for a minimum of 1-3 days. Certain diagnostic tests like urine analysis, urine culture or an ultrasound are done. Accordingly, the treatment procedure is determined. Treatment options include making dietary changes, behavioral changes with a combination of medications.

Benign Prostatic Hyperplasia

Benign Prostatic Hyperplasia or BPH, also referred to as prostate gland enlargement is one of the most significant medical conditions among elderly men. It is a serious condition which proactively leads to other complications such as urinary tract infections and prostate gland functional abnormalities. The prostate gland is a two-lobed walnut shaped gland often associated with sperm mobilization. The growth of the prostate gland is directly related to age. The exact mechanism or the cause of this condition is not well determined. However, many studies indicate that the hormonal imbalance as the age increases in a man is responsible for the enlargement of the prostate gland. This refers to the excessive production of estrogen and decrease in the male sex hormone testosterone.


Clinical manifestations of BPH

The symptoms of Benign Prostatic Hyperplasia (BPH) worsen with age. The most common clinical symptom is repeated urination episodes. Often patients either complain of frequent urination, urinary urge or even difficulty in passing urine if there is an associated infection. These symptoms occur because of the inability of the tissues to make space for the enlarged or hypertrophic prostate gland. This lays pressure on the urethra to stimulate the process of urination frequently. Many patients complain of Nocturia. In addition to these symptoms, patients also suffer renal stones and reduced kidney function.


Diagnosis and Management of Benign Prostatic Hyperplasia

BPH is diagnosed based on various urological criteria. The American Urological Association recommends a score system. In most cases patients are examined to identify the presence of malignancy in the prostate region and hence test such as prostate specific antigen (PSA) is recommended along with cytological study of the prostate gland. Important parameters such as post-void residual volume, uroflowmetry, urinary pressure studies are conducted. Along with these diagnostic parameters, kidney function test is done to rule out other associated complications.

BPH can also transmit as a genetic disorder in some cases. The high risk groups are generally obese or suffer diabetes and hypertension. Along with these, other factors such as alcoholism, drug abuse and erectile dysfunction can lead to BPH.


Treatment of Benign Prostatic Hyperplasia

BPH patients are often kept under surveillance to avoid medical emergencies. The drugs administered for this condition reduce blood pressure and facilitate smooth muscle relaxation of the prostate gland thereby regulating urine flow. The drugs used are predominantly alpha blockers such as alfuzosin, terazosin and anticholinergics.


Uroflowmetry

Urinary disorders can often indicate a lot of underlying complications. Urination and the excreted product is very significant in evaluating a person's health in associated with kidney function and prostrate health in case of men. Urination is a complex procedure, which involves the contraction of the muscles associated with the detrusor and the external bladder tissues. The cerebral cortex facilitates the initiation and emptying of the bladder during the urination process.


Urination can be affected for various reasons such as weather, emotions, and hormonal imbalance, incontinence due to anatomical disorders and also underlying inflammations or infections. The regulation of blood pressure and adrenal surge is also involved in proper generation of urine. Physicians analyze the uroflowmetry parameters in order to diagnose urinary tract infections and also to evaluate the normal flow rate of urine to determine the normal function of the urinary tract and associated muscles.


Uroflowmetry is widely recommended in many countries, as it has become the foundation for diagnosing prostrate enlargement, urethritis and obstruction. Males over 30 years are advised to undergo this test as it is necessary to detect the early signs of an underlying condition such as prostate cancer, bladder tumor or neurogenic bladder dysfunction where the cause is spinal cord injury or lesion. Typical conditions where uroflowmetry might be advised are difficulty in urinating, frequency of urination, nocturia, enuresis, Benign Prostatic Hyperplasia, urethral stenosis or incomplete bladder emptying.


Preparation and procedure

Patients undergoing uroflowmetry procedure are advised to drink plenty of water in order to fill up the bladder as it provides a comprehensive analysis of the bladder functionality. They are also asked to hold the urine for a few hours before the test. Unlike other urinary examinations, here the specimen is not collected in a cup but the patient is asked to urinate into a funnel that connects to a container underneath. Special toilets are provided in some diagnostic centers for this procedure. The funnel shaped device measures the urine flow rate and quantity and the results obtained are recorded.


The normal flow rate of the urine varies from 10 ml to 20 ml per second. The results associated may vary both in males and females. The flow rate in women is often less as it may take 15 ml to 18 ml per second. In men, urine flow declines with age. Women have lesser change with age.

14 - 45 years

The average flow rate for males is 21 ml/sec.
The average flow rate for females is 18 ml/sec.

46 - 65 years

The average flow rate for males is 12 ml/sec.
The average flow rate for females is 18 ml/sec.

66 - 80 years

The average flow rate for males is 9 ml/sec.
The average flow rate for females is 18 ml/sec.


The diagnostic evaluations based on this can indicate the strength of the bladder muscles and also other disorders. Delayed urine flow indicates obstruction and also infections that are causing tissue inflammation. Increased flow of urine also indicates weak bladder muscles and also lack of cerebral cortex control. Incontinence is widely reported in elderly groups. Neurological conditions and trauma can also affect urine flow rate.


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Collection of Pages - Last revised Date: October 18, 2017