Pseudo-nocturia & Nocturia

Nocturia and pseudo nocturia

(Nocturia = Frequent Awakenings via Nocturnal or Night-time Compulsory Urination - FANCU)

A note against nocturnal dehydration. The oversimplistic home made cure which qualifies to be referred to as “old-wives’ tale” that restriction of fluid intake in the evening and prior to hitting the bed for sleep would remedy the nocturia. Firstly 2-3 awakenings at night must be tolerated as normal by all seniors especially women. I firmly advise against the popular simple-minded advice over fluid restriction in the evening. The risk of coronary occlusion at night (the commonest time for heart attacks tends to be in the early morning from dehydration) with evening fluid restriction is a bigger concern of mine than waking up couple of times at night. For those who are chronically dehydrated which most seniors are to begin with and have coronary disease the water restriction to avoid the hassle of urination at night time is a risky advice and I take a very firm stand in favor of drinking a glass of water before going to bed. I follow my advice to drink a glass of water before going to bed and I also preach and practice ample hydration during the day. While polydipsia or overloading of fluids in the evening is not advised, a liberal consumption of fluids is clearly not admonished or medical proscribed.

Waking up to pee once every night is normal for the young adults and twice for seniors. More than these accepted nocturnal awakenings for micturition qualify for the term nocturia. For it to be real nocturia the individual must be unable to suppress the urge to void for later. Among younger adults it is self-limiting but, in the elderly, it is pervasive and that is a sinister phenomenon.

Sinister nature of persistent senile nocturia.

Nocturia among younger adults tends to be short limited or self-limiting and ends when the trigger is removed. Among seniors a persistent nocturia is indicator of fairly advanced state of neurodegeneration that would progress to urinary incontinence and is associated with lifespan abbreviation. The impoverishing of sleep quality from nocturia sets a difficult to break vicious cycle among elderly which combined with daytime fatigue, sleep deprivation induced irritability and lowered alertness level and lousy affect accelerates the neurodegeneration. This vicious cycle makes persistent senile nocturia a harbinger or early demise.

Late evening stimulant beverages imbibing is not a major villain.

The term bladder irritants are a misnomer unless you are talking of carcinogen aniline dyes etc. which don’t picture into nocturia. The CNS and cardio-stimulants like caffeine, strongly brewed teas and alcoholic beverages (alcohol especially beer is a short term soporific but causes rebound awakening causing mid-night or early morning awakening) are diuretics and increase urinary output but if your endocrines and bladder sensitivity are working properly and your bladder is not overly shrunken (there proceeds some bladder shrinkage or reduction of bladder capacity with age) most people can manage ample amounts of diuretic beverages because the anti-diuretic hormone (ADH) and the sleep induced dilation of the bladder and reduced bladder sense in sleep tend to successfully negate the diuretic effect of beverages and even diuretics during sleep as ADH output gets upregulated. If you have too much caffeine you won’t be sleeping much anyway then you are into pseudonocturia cycle by paying more attention to bladder due to being awake. The hallmark of pseudo-nocturia is the person is awake, he or she has nothing better to do so takes a trip to washroom just to keep busy are used to fill up the night time with nothing else to do. There are anecdotes of many individuals who have had several cups of caffeine in the evening and fall asleep and stay asleep through. After 59 the level of ADH begin to decline as bladder loses elasticity therefore its volume at the full capacity signal, causing a majority of seniors awaken couple of times which must be tolerated as a part of normal aging. Being bitter about it is multiplies the problem by adding chronic anxiety state – to the mix and inferring with sleep such that unwittingly the person falls into the cycle of pseudonocturia, such that acceptance of some nocturia is strongly advisable. The adoption of the practice of mindful meditation in the morning and prior to bedtime would go a long way to allay anxiety and escape pseudo nocturia. Meditation probably does nothing to the bladder capacity or ADH levels directly but by elimination of anxiety and improving the sleep quality it goes a long way to manage the crisis of nocturia blended with pseudonocturia. It works most potently through building a tolerance to minor annoyances at night. Meditators begin to not get bothered with minor annoyances of life that drive non-meditators completely nuts.

If necessary, the deficiency of ADH of the elderly can be remedied with desmopressin, a synthetic version of the ADH, is possible.

Oral desmopressin is an effective and well-tolerated treatment for nocturia in women. And desmopressin is an effective treatment for NP and improved sleep quality in elderly men. (Source: Lose et al published Efficacy of desmopressin (Minirin) in the treatment of nocturia: a double-blind placebo-controlled study in women in American Journal of Obstetrics & Gynecology Oct 2003;189(4):1106-13. doi: 10.1067/s0002-9378(03)00593-3; Kim et al published Efficacy of Desmopressin to Treat Nocturnal Polyuria in Elderly Men: Effects on Sleep Quality in Urologia Internationalis . 2016;96(4):438-42. doi: 10.1159/000443968.)

Additional to desmopressin, to escape becoming subjected to polypharmacy with some drugs being prescribed to counteract the side effects of others, it is desirable to master the art of tolerating if not prevented successfully all minor annoyances of senior years such that for adults over 69 meditations must become a routinely prescribed ritual as it builds tolerance and helps adapt to boredom of life. It might be possible to evade a sizable fraction of neurodegeneration by resorting to Vrish breathing in middle age or sooner which is a variation on the yoga-breathing exercise meditation practice and potent antidote against sleep paucity- stress duo, which plays a prominent part in overactive bladder and nocturia and obstructive sleep apnea.

The blended or hybrid of overactive bladder and the ADH depletion.

The age-linked decline in bladder elasticity and capacity is very difficult to distinguish from what is termed “overactive bladder” which must be viewed entirely a problem with the CNS or white matter disease of the seniors which proceeds pretty much ubiquitously if not universally. White matter densities on MRI are noted in over 80% of seniors. Overactive bladder and ADH depletion would tend to progress in tandem because both are manifestations of age-linked neurodegeneration. Unlike the anterior pituitary hormones like growth hormone, ACTH and gonadotrophins, ADH is a hormone secreted from neural tissues. And there would invariably be an accompanying mild to moderate prostate enlargement as well.

In relation to double voiding for men I would recommend doing the second voiding in a cup while standing. The point about diuretic in the evening is also flaky. They become ineffective after a few weeks anyway. There is a time lag between ingestion of diuretic and their effect and there are individual differences so I would not fret over diuretic use. What is said of beverage diuretics also holds for pharmaceutical kind. They are not a big issue in real life. It is the anxiety that keeps people up that mask as pseudonocturia. Respecting cutting sugar intake in the evening for diabetics or non-diabetics my position is SUGAR IS A TOXIN. Stop using it, it kills. The maximum daily dose of his poison is 8 teaspoonfuls. Drink black coffee only, always. Why get into diabetic crisis to begin with? Same is the case with salt, this too is a toxin if sprinkled. There is enough salt in food to contradict adding salt to any food EVER! The elimination of saturated fats, sugar and salt is for protection of heart and brain and less so for bladder. I will write a comprehensive essay on problematic nocturia tonight. Those so inclined may wish to read it there.

But the best way to help with nocturia is to escape hypertension and the white matter densities from it. Besides ADH decline white matter disease of the brain is a lot more common driver of nocturia. It goes with Mild Cognitive Deficit (MCI) or “dumbing”. Fight this age-linked dumbing or it would keep you awake with the bladder thing. The best way for women to elevate legs in the evening that I advise is having sex for a long long time. My take on Kegel is to just forget Dr. Kegel, have three or four orgasms daily. That is lot more fun. Women can do the pubococcygeus contraction with a penis inside vagina with far superior results. That is like using dumb bell or bar bell in the gym for that muscle. If you have hit 49 and have nocturia it is too late to begin doing the Kegel workouts. The time to start them is in the teen years. After 69 with stress incontinence in the picture you might as well forget about the Kegel. It won’t work for you; you missed the boat. There is no muscle left to work with.

Most of the nocturia and even overactive bladder syndrome in the head not bladder. Pseudo nocturia whereby the multiple night time trips to the toilet to empty the bladder are the result of sleep paucity and not the cause are clearly a problem with the brain or CNS, there are a vast majority of nocturia that are also the result of disturbances of the CNS especially when a narrow and pure use of overactive bladder excludes bacterial cystitis, interstitial cystitis etc., and circumscribed to pre-depression (chronic anxiety state ) and depression related poverty over the voluntary bladder control in terms of loss of ability to withhold bladder from spontaneously emptying for several minutes and possibly up to half or full hour. The shrinkage of aged bladder with loss of collagen or elastic tissue content, interstitial cystitis, radiation cystitis etc., should not be strictly deemed as overactive bladder nor should the prostatic enlargement with protrusion of prostate into bladder such that the voiding reflex tends to become overly sensitive.

Overactive Bladder Overactive bladder (OAB) or mixed central peripheral detrusor overactivity syndrome. OAB is a syndrome that consists of urinary urgency, with or without urgency urinary incontinence, usually with urinary frequency and nocturia, in the absence of causative infection or pathologic conditions and suggestive of underlying detrusor overactivity. OAB is common, affecting millions of individuals worldwide. In the United States, around 1 out of 7 people have OAB.

Strictly speaking overactive bladder does nor or should not be causing nocturia. When asleep the sensory processing is powerfully inhibited so the overactivity part of the bladder calms down or “sleeps” as well. Overactive bladder patients would experience symptoms only that upon awakening in the morning and not be able to wait a few minutes to fully awaken if there is a strong bladder sensation to void, then they would have to rush to the bathroom as they have hard time delaying the visit once the urge appears. Overactive bladder cases sleep through the bladder sensation just fine. It is a day time frequency not a real nocturia. It is necessary to distinguish whether there is an urgency to void and precipitancy or the urine would leak without you waiting to be in the proper location and posture to void. That is the classic symptom of overactive bladder which is not a real source of nocturia but can look like that due to the urgency to void upon awakening.

Poorly controlled or uncontrolled diabetes mellitus usually type 2 diabetes associated nocturia.

Obstructive sleep apnea associated nocturia, is strictly a pseudonocturia because the real culprit is fragmented or saw tooth sleep with multiple awakenings, urination is the result not cause of awakening.

Definition of nocturia and pseudo nocturia?

In synch with the biorhythms, urinary output at night drops significantly with elevation of density or specific gravity of urine that is visible as deep yellow or orange colored urine, and that is the result of upregulation of ADH secretion during sleep. Loss of ADH in younger adults due to pituitary diseases or brain injury causes a loss of this natural ability of reduced urinary output at night and causes nocturia.

Use of diuretic medications not a major driver of nocturia.

Use of diuretics or “water pills” such as chlorothiazide (Diuril) and spironolactone (Aldactone), for high blood pressure which work through reducing the blood volume to control the blood pressure by shedding excess fluid and salt, or to protect the heart by lowering the load on the overburdened heart tend only to be problematic for short time and the link is easy to see as is the cure. After a while the diuretics begin to work more like vasodilators and not diuretic so this side effect disappears.

Enlarged prostate

Voiding bladder to often especially at night, is deemed to be a hallmark symptom of BPH. An enlarged prostate, known as benign prostatic hyperplasia or BPH, is one of the most common affection of older men. The prostate is a gland located next to and around the bladder and urethra; it produces the fluid found in semen.

Heart failure and hypertension associated nocturia.

Nocturia is a common symptom of heart failure, a chronic condition in which the heart enlarges and has difficulty pumping enough blood. Because the heart doesn’t beat as strongly, salt and fluid buildup in your body during the day. When you lie down at night, it retreats into the blood. The bladder then works overtime to get rid of the excess fluid. Several studies have also linked nighttime trips to the toilet with hypertension. In fact, studies have shown that the worse the nocturia, the higher the blood pressure.

Remember that diuretics are one of the most common treatments for hypertension and heart failure. These drugs may also be causing you to pee more at night. (Check out more heart health tips from real cardiologists.)

Diabetes

Undiagnosed or poorly controlled diabetes (type 1 and type 2), is linked with higher urination rates overall, including at night.

“High blood sugar content leads to a diuretic effect,” explains Dr. Ohmann. In other words, all that excess glucose gets flushed out in the urine. Obesity, a major risk factor for type 2 diabetes, links to both daytime and nighttime peeing. (Learn to spot the subtle signs you might have diabetes.)

Sleep apnea

Sleep apnea is when you briefly but repeatedly stop breathing at night. Nocturia is so common in people with sleep apnea that it’s one of the symptoms doctors look for when diagnosing the condition. “When someone is not breathing well at night, their body senses that the volume of fluid is overloaded so it sends hormones to tell the kidneys to make more urine,” explains Elena Campbell, MD, a urologist with Ochsner Health System in Baton Rouge. If your doctor suspects sleep apnea, they will likely send you off for a sleep study to confirm. Treating the sleep apnea (often with a CPAP machine which is a face mask worn at night that delivers a stream of air in the nose) will also resolve the urination issue.

Snoring, a common symptom of sleep apnea, has also been linked with nocturia. (Find out more medical reasons you can’t sleep.)

Swelling in your legs and feet

Nocturia can be a sign of daytime fluid retention in your legs and feet, which is known as edema. “If someone has a lot of fluid on their legs during the day, when they put their legs up at nighttime, the fluid goes back into [blood] circulation, so your body produces more urine in the nighttime,” explains Dr. Campbell. “We recommend elevating your feet above the level of the heart in the [day] to allow some of that urine to pass in the early evening rather than during the night.” Compression stockings may also help.

The swelling itself could be due to something as simple as standing on your feet all day or a more serious medical condition like heart failure. (Here are the heart attack symptoms that are frequently misdiagnosed.)

Chronic kidney disease

Your kidneys normally concentrate urine at night in response to antidiuretic hormone. If you have kidney problems, however, the kidneys lose some of that ability, leading to increased urine production, says Dr. Borawski.

Overactive bladder

“It’s characterized to be a combination of frequent urination, the urge to get to a bathroom right away and incontinence, meaning you can’t make it to the bathroom in time,” explains Dr. Campbell. One cause may be involuntary muscle contractions, but the reasons aren’t always clear. (Learn to spot the signs you could suffer from overactive bladder syndrome.)

Treating nocturia

The best treatment for nocturia is to do identify and treat any underlying causes, says Dr. Ohmann. Many of the factors contributing to nocturia are interrelated (for example, sleep apnea, diabetes, and hypertension). And about half of patient’s report having at least three conditions contributing to their nighttime excursions. The first option for treatment is behavioral changes like drinking less caffeine and alcohol before bed, elevating your feet, and making sure you’re taking diuretics at the appropriate time. Behavioral therapy, including pelvic floor muscle exercises, is also an option.

Simple sleep “hygiene” measures can also help. This includes keeping a regular sleep schedule and keeping your bedroom dark at a comfortable temperature. (Find out more things you can do all day long for a better night’s sleep.)

When to see a doctor about nocturia

If you suspect nocturia is due to anything other than your daily behaviors (drinking too much before bed, for instance), especially if it’s robbing you of sleep, you should see a doctor. It’s also time to get medical help if you see blood in your urine, if you have any abrupt changes in your symptoms or if you think you might have an infection (you’d probably also be experiencing burning when you urinate), says Dr. Borawski. “There are many, many causes of nocturia,” adds Dr. Ohmann. “Seeing a provider can help with quality of life and prevent complications.”

Dr. Rena Malik TIPS to stop FREQUENT URINATION AT NIGHT | Nocturia management

Waking up at night to urinate can be incredibly annoying and disruptive! Not only will you have difficulty trying to sleep again, but you'll also feel tired and horrible the morning after because of your low-quality sleep! So be sure to stick around until the end to learn these 8 tips to help lessen your nighttime urination episodes!

Chapters:

0:00 Intro Card

0:53 Tip #1 Avoid fluids before Bedtime

1:22 Tip #2 Avoid bladder irritants

1:53 Tip #3 Try double voiding

2:26 Tip #4 Change the timing of your Diuretic "Water Pill"

2:55 Tip #5 Control your sugars if you're diabetic

3:05 Tip #6 Limit your salt intake

3:21 Tip #7 Wear Compression Stockings or Elevate your legs

3:36 Tip #8 Kegel Exercises