Kevin T. McVary, MD, presented “Management of Nocturia: An Unmet Need in LUTS” on June 21, 2018, accompanied by E. David Crawford, MD.

How to cite: McVaryKevin. “Management of Nocturia: An Unmet Need in LUTS” February 7, 2018. Accessed Jun 2018. https://grandroundsinurology.com/management-of-nocturia-an-unmet-need-in-luts/

Management of Nocturia: An Unmet Need in LUTS

Summary:

Kevin T. McVary, MD, illustrates that while nocturia is the leading lower urinary tract symptom (LUTS) complaint that prompts men to seek out urological care, the condition persists without improvement in 50% of patients, even after treatment. Therefore, there is a significant unmet need in nocturia management practices. He discusses the condition’s financial and quality of life (QOL) burdens, its multifactorial etiology, and his perspective on treatment approaches.

Following his discussion, Dr. McVary and E. David Crawford, MD, engage in a question and answer session about the subject.

Unmet Needs in Nocturia Management

Nocturia presents a challenge to urologists, firstly, because it does not have a clear definition. While The International Continence Society (ICS) defines it as waking one or more times per night to void, urologists consider clinically relevant nocturia to be voiding twice or more per night. However, neither of these definitions account for the patient’s personal degree of bother.

Secondly, nocturia causes patients substantial QOL and financial burdens. The condition leads to injuries from nighttime falls and lost work. Data shows a $61 billion estimated annual indirect cost in the USA due to nocturia-related loss of productivity and sick leave. Furthermore, nocturia is the leading LUTS complaint that prompts men to seek out urological care.

Despite this, in 50% of patients who receive treatment, nocturia persists without improvement in 50% of patients. This shows the significant unmet need in this setting.

A Systematic Approach to a Multifactorial Condition

Male nocturia is not simply a prostate or bladder problem. It could be a manifestation of a separate sleep disorder or another systemic problem.

When faced with a complaint of nocturia, Dr. McVary urges urologists to first consider sleep disorders, like sleep apnea, insomnia, parasomnias, and restless leg syndrome (RLS), as the cause of the condition. Then, clinicians should perform a complete history and physical, looking for hypertension, diabetes, coronary artery disease (CAD), or kidney disease in a patient to determine whether the condition stems from a prostate, bladder, pelvis, or a more global issue.

Furthermore, many common medications can increase diuresis or induce insomnia, causing iatrogenic nocturia.

Due to this multitude of common etiologies, it is important clinicians investigate beyond their own specialties to discern the true source of the condition.

Clinicians should also assess patient bother and desired treatment, proteinuria and glucosuria through urinalysis, post-void residual, and a patient-reported voiding diary.  

A Conservative Treatment Approach

Dr. McVary recommends approaching cases of nocturia conservatively. First, advise the patient on behavioral techniques to reduce his symptoms before moving to complicated treatments or workups. Next, consider taking the patient off any medication exacerbating the nocturia. For some patients, it is prudent to prescribe low-dose intranasal desmopressin acetate (Noctiva) or antidiuretics in the evening. Most importantly, identify the mechanism of action behind the patient’s nocturia to individualize treatment.

Other non-surgical treatment options include botulinum toxin A injections and sacral neuromodulation. Surgery should always be a last-resort.

If, through pressure flow studies and void diaries, bladder neck obstruction from benign prostatic hyperplasia (BPH) proves to be the cause of the patient’s nocturia, then clinicians should pursue surgical options.