Nocturia Archives - Grand Rounds in Urology

Overactive Bladder vs. Interstitial Cystitis: Overlapping Conditions?

by John Thomas Stoffel, MD | May 2022

John Thomas Stoffel, MD, Associate Professor of Urology and Chief of the Division of Neurourology and Pelvic Reconstruction within the University of Michigan Department of Urology in Ann Arbor, Michigan, discusses how to differentiate overactive bladder (OAB) from interstitial cystitis (IC), as well as how to appropriately treat both conditions. He begins with some background, explaining that OAB is common and affects 30 to 50 million women worldwide. IC is also common, and may affect between 2 and 17% of US adults. Dr. Stoffel argues that despite this prevalence, clinicians do not understand the depth of these conditions nor how to differentiate them. He then defines OAB as “[urinary] urgency, with or without urgency incontinence, usually with increased daytime frequency and nocturia,” whereas IC is an unpleasant sensation (pain, pressure, discomfort) perceived to be related in the urinary bladder, associated with LUTS, of greater than 6 weeks duration in the absence of infection. Dr. Stoffel posits that IC is more associated with sensory symptoms while OAB more associated with motor symptoms. He then discusses the work-up for OAB and IC, explaining that the work-up for the former should include a physical exam, urine analysis, and a voiding diary, while the work-up for the latter should feature a physical exam, a history of symptoms, urinalysis, urine culture, and urine cytology. Dr. Stoffel moves on to treatment strategies, describing the treatment of OAB as like a ladder, moving sequentially from behavioral therapy to medications to neuromodulation/onabotulinum toxin. He recommends tracking outcomes for OAB with patient reported outcome measures (PROMS), and highlights the effectiveness of behavioral therapies such as timed voiding/fluid management, weight loss, and biofeedback. Dr. Stoffel also notes that there are no clear winners among OAB medications, and he emphasizes the need to define patients’ expectations. He describes the treatment strategy for IC as less like a ladder than a grab bag, explaining that “initial treatment type and level should depend on symptom severity, clinician judgment, and patient preferences.” Dr. Stoffel briefly considers the evidence for neuromodulation and onabotulinum toxin, concluding that they are effective for OAB, but there is little extended data in IC.

LUTS: Latest in Prevention, Clinical Trials, and Approved Treatments

by Michael E. Albo, MD | Mar 2022

Michael E. Albo, MD, Vice Chair of the Department of Urology at the University of California, San Diego, gives an overview of how to assess and treat lower urinary tract symptoms (LUTS) in men. He presents a case of a 65-year-old patient referred to a urologist due to benign prostatic hyperplasia (BPH). Dr. Albo explains that in the old treatment algorithm, the question of how to treat this patient would have been simple: urinary symptoms would be treated with a non-specific Alpha blocker, and then if symptoms persisted, the urologist would offer transurethral prostatectomy (TURP) or a simple prostatectomy. However, Dr. Albo notes, the updated treatment algorithm currently in use is far more complex and features many options. This is due in part, he observes, to the realization that LUTS is not just related to the prostate, but rather has a complicated etiology related to other parts of the body including the bladder and urinary tract. Dr. Albo returns to the example of the 65-year-old referred for BPH, and explains that based on the new algorithm, initial evaluation of this patient will likely feature taking his medical history, giving him a physical examination, getting his International Prostate Symptom Score (IPSS), performing urinalysis, having him keep a 3-day voiding diary, and counseling him on options for intervention. Dr. Albo explains that determining prostate size is important as well since volume predicts symptom progression and risk of complications, and can inform treatment selection. He also observes that when selecting a treatment, a treatment’s effect on sexual function is an important factor for most men, regardless of age. Dr. Albo then lists additional suggested evaluation techniques for patients with LUTS, including assessment of prostate size and shape, checking post-void residual (PVR) volume, and performing uroflowmetry and urodynamic testing. He notes that none of these has enough data to prove they should be used in everybody. Dr. Albo moves on to how to treat LUTS, explaining that the goals of treatment include alleviation of bothersome symptoms, prevention of complications, prevention of progression, and minimization of complications of treatment. He discusses watchful waiting for LUTS, highlighting that 85% of men with mild LUTS are stable at one year, but 36% of men with moderate LUTS cross over to surgery within 5 years. Dr. Albo concludes that the complicated new guidelines are helpful, but far from where they need to be.

Optimizing the Diagnosis and Management of Nocturia

by Neil H. Baum, MD | Oct 2019

Neil H. Baum, MD, discusses the frequency and danger of falls and fractures in older Americans, noting that nocturia is a major cause. He emphasizes the important role urologists play in screening patients for falls, and explains the multifactorial nature of nocturia and corresponding treatment options, as well as how to manage patients’ comorbidities.

Prevalence of Nocturia in US Women

by Timothy K. Byler, MD | Aug 2019

Timothy K. Byler, MD, discusses the significant quality of life impact associated with nocturia, as well as underlying diseases and causative factors. He then reviews findings on the epidemiology of nocturia and its prevalence in women in the United States.

New Treatment Options in LUTS

by Matt T. Rosenberg, MD | Dec 2018

Matt T. Rosenberg, MD, discusses treating of lower urinary tract symptoms (LUTS) through a framework of inhibiting overproduction of urine by the kidneys. In this dual-presentation, he describes behavioral modifications as well as pharmacologic agents for the management of overactive bladder (OAB) and nocturia.

Nocturia: Symptom or Disease?

by Matt T. Rosenberg, MD | Sep 2018

Matt T. Rosenberg, MD, discusses the multiple etiologies of nocturia and nocturnal polyuria and corresponding treatment options, emphasizing the need for shared care when managing nocturia. He then reviews the efficacy and safety of a novel version of desmopressin for reducing the kidney’s production of urine at night time.

Future Directions in the Treatment of Nocturia

by Matt T. Rosenberg, MD | Sep 2018

Matt T. Rosenberg, MD, reviews treatment options for nocturia, such as patient counseling, medications, and newly available molecules that can safely control urine excretion from the kidneys. He also discusses quality of life burden nocturia poses on patients, as well as differentiating between nocturia and nocturnal polyuria.

Management of Nocturia: An Unmet Need in LUTS

by Kevin T. McVary, MD, FACS | Jun 2018

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.

Topic: Nocturia