The aging process, behavioural habits and a multitude of pathological conditions are the main contributors to the development of nocturia in the elderly. Age-related physiological changes can alter the regular pattern of urine excretion and lead to increased nocturnal frequency of voiding. In addition, aging is associated with anatomical and physiological changes of the urinary tract itself that predispose to increased urinary frequency without affecting urine volume.
Several urinary and extra-urinary tract conditions may have nocturia as a prominent symptom. These conditions can be grouped as those associated with bladder overactivity, bladder outlet obstruction, bladder hypotonicity and an increased urine volume. A detailed assessment that gathers clues from the medical history, physical examination and laboratory is of utmost importance in identifying the specific causes.
Overactive bladder can be idiopathic or associated with different triggers such as UTI, bladder stones, bladder tumours and CNS diseases that disrupt the normal inhibitory signals to the bladder. It may be cured by the successful elimination of the trigger conditions. Therapeutic modalities include behavioural therapies with scheduled voiding, anticholinergic drugs and in women the use of transvaginal electrical stimulation.
Benign prostatic hyperplasia is the most common cause of bladder outlet obstruction in men. Different drug classes (e.g. peripheral α-adrenoceptor blockers and 5 α-reductase inhibitors) are now available for the treatment of mild to moderate symptoms. Surgery is reserved for patients with severe symptoms or with complications, with new and less invasive surgical techniques being preferred.
Bladder hypotonicity is usually caused by peripheral neuropathies, spinal cord lesions and the indiscriminate use of drugs with anticholinergic actions. Treatment involves discontinuation of implicated drugs, short term use of cholinergic drugs and urinary catheterisation.
Increased urine volumes and nocturia are frequently seen in hyperosmolar and oedematous states. Excessive ingestion of fluids, caffeinated or alcoholic beverages are habits that commonly produce nocturia. Although more definitive studies are awaited, low dose loop diuretics given a few hours prior to bedtime and desmopressin nasal spray or tablets may be useful alternatives for the control of nocturic symptoms in elderly patients with nocturnal polyuria syndrome.
Whenever nocturia is present, clinicians should try to identify its causes by means of a thorough history, physical examination and pertinent complimentary tests. Once the specific cause or causes are found, most cases can be satisfactorily managed with behavioural, pharmacological or surgical therapies.
Malmsten UG, Milsom I, Molander U, et al. Urinary incontinence and lower urinary tract symptoms: an epidemiological study of men aged 45 to 99 years. J Urol 1997; 158 (5): 1733–7PubMedCrossRefGoogle Scholar
Saito M, Kondo A, Kato T, et al. Frequency-volume charts: comparison frequency between elderly and adult patients. Br J Urol 1993; 72: 38–41PubMedCrossRefGoogle Scholar
Asplund R, Aberg HE. Micturition habits of older people, voiding frequency and urine volumes. Scand J Urol Nephrol 1992; 26: 345–9PubMedCrossRefGoogle Scholar
Kirkland JL, Lye M, Levy DW, et al. Patterns of urine flow and electrolyte excretion in healthy elderly people. BMJ 1983; 287: 1665–7PubMedCrossRefGoogle Scholar
Ouslander J, Schnelle J, Simmons S, et al. The dark side of incontinence: nighttime incontinence in nursing home residents. J Am Geriatr Soc 1993; 41: 371–6PubMedGoogle Scholar
Asplund R, Aberg H. Diurnal variation in the levels of antidiuretic hormone in the elderly. J Intern Med 1991; 229: 131–4PubMedCrossRefGoogle Scholar
Standaert DG, Cechetto DF, Needleman P, et al. Inhibition of the firing of vasopressin neurons by atriopeptin. Nature 1987; 329: 151–3PubMedCrossRefGoogle Scholar
Needleman P, Greenwald JE. Atriopeptin: a cardiac hormone intimately involved in fluid, electrolyte, and blood-pressure homeostasis. N Engl J Med 1986; 314: 828–34PubMedCrossRefGoogle Scholar
Tan T, Hoefnagels W, Swinkels LM, et al. The effect of volume expansion on atrial natriuretic peptide and cyclic guanosine monophosphate levels in young and aged subjects. J Am Geriatr Soc 1990; 38: 1215–9PubMedGoogle Scholar
Haller BG, Zust H, Shaw S, et al. Effects of posture and ageing on circulating atrial natriuretic peptide levels in man. J Hypertens 1987; 5: 551–6PubMedCrossRefGoogle Scholar
Ohashi M, Fujio N, Nawata H, et al. High plasma concentrations of human atrial natriuretic polypeptide in aged men. J Clin Endocrinol Metab 1987; 64: 81–5PubMedCrossRefGoogle Scholar
Quay W. Diffuse endocrine and chemical mediators. In: Timiras P, Quay W, Vernadakis A, editors. Hormones and aging. Boca Raton (FL): CRC Press, 1995: 107–20Google Scholar
Resnick NM. Voiding dysfunction in the elderly. In: Yalla SV, McGuire EJ, Elbadawi A, et al, editors. Neurourology and urodynamics: principles and practice. New York (NY): Macmillan Publishing Co. Inc., 1988: 303–30Google Scholar
Diokno AC, Brown MB, Brock BM, et al. Clinical and cystometric characteristics of continent and incontinent noninstitutionalized elderly. J Urol 1998; 140: 567–71Google Scholar
Gillenwater JY, Conn RL, Chrysant SG, et al. Doxazosin for the treatment of benign prostatic hyperplasia in patients with mild to moderate essential hypertension: a double-blind, placebocontrolled, dose-response multicenter study. J Urol 1995; 154: 110–5PubMedCrossRefGoogle Scholar
Lepor H, Auerbach S, Puras-Baez A, et al. Arandomized, placebocontrolled multicenter study of the efficacy and safety of terazosin in the treatment of benign prostatic hyperplasia. J Urol 1992; 148: 1467–74PubMedGoogle Scholar
Noble AJ, Chess-Williams R, Couldwell C, et al. The effects of tamsulosin, a high affinity antagonist at functional alpha 1A and alpha 1D-adrenoceptor subtypes. Br J Pharmacol 1997; 120: 231–8PubMedCrossRefGoogle Scholar
Chapple CR, Baert L, Thind P, et al. Tamsulosin 0.4mg once daily: tolerability in older and younger patients with lower urinary tract symptoms suggestive of BPH (symptomatic BPH), the European Tamsulosin Study Group. Eur Urol 1997; 32 (4): 462–70PubMedGoogle Scholar
Lowe FC. Coadministration of tamsulosin and three antihypertensive agents in patients with BPH: pharmacodynamic effect. Clin Ther 1997; 19 (4): 730–42PubMedCrossRefGoogle Scholar
Lowenthal DT, Maruenda J, Chintanadilok J, et al. Clinical pharmacology-physiology conference: the hypertensive elderly male with prostatism. Geriatr Nephrol Urol 1999; 9: 57–60PubMedCrossRefGoogle Scholar
Moore E, Bracken B, Bremner W, et al. Proscar: five year experience. Eur Urol 1995; 28: 304–9PubMedGoogle Scholar
Boyle P, Gould AL. Prostate volume predicts outcome of treatment of BPH with finasteride: meta-analysis of randomized clinical trials. Urology 1996; 48: 398–405PubMedCrossRefGoogle Scholar
Lepor H, Williford WO, Barry MJ, et al. The efficacy of terazosin, finasteride, or both in benign prostatic hyperplasia. N Engl J Med 1996; 335: 533–9PubMedCrossRefGoogle Scholar
Berges RR, Windeler J, Trampisch HJ, et al. Randomised, placebo-controlled, double-blind clinical trial of beta-sitosterol in patients with benign prostatic hyperplasia. Lancet 1995; 345: 1529–32PubMedCrossRefGoogle Scholar
Ziada A, Rosenblum M, Crawford ED. Benign prostatic hyperplasia: an overview. Urology 1999; 53 (3 Suppl. 3a): 1–6PubMedCrossRefGoogle Scholar
Chutka DS, Fleming KC, Evans MP, et al. Urinary incontinence in the elderly population. Mayo Clin Proc 1996; 71: 93–101PubMedCrossRefGoogle Scholar
Ulfberg J, Thuman R. A non-urologic cause of nocturia and enuresis-obstructive sleep apnea syndrome (OSAS). Scand J Urol Nephrol 1996; 30 (2): 135–7PubMedCrossRefGoogle Scholar
Krieger J. Mechanisms of daytime pulmonary hypertension and altered renal function in obstructive sleep apnea. In: Guilleminault C, Partinen M, editors. Obstructive sleep apnea syndrome: clinical research and treatment. New York (NY): Raven Press, 1990: 71–9Google Scholar
Reynard JM, Cannon A, Yang Q, et al. A novel therapy for nocturnal polyuria: a double-blind randomized trial of frusemide against placebo. Br J Urol 1998; 81: 215–8PubMedCrossRefGoogle Scholar
Pedersen PA, Johansen PB. Prophylactic treatment of adult nocturia with bumetanide. Br J Urol 1998; 62 (2): 145–7CrossRefGoogle Scholar
Physician’s desk reference. Oradell (NJ): Medical Economics, 1997: 2180–2Google Scholar
Eckford SD, Swami KS, Jackson SR, et al. Desmopressin in the treatment of nocturia and enuresis in patients with multiple sclerosis. Br J Urol 1994; 74: 738–5Google Scholar
Valiquette G, Abrams GM, Herbert J. DDAVP in the management of nocturia in multiple sclerosis [letter]. Ann Neurol 1992; 31: 577PubMedCrossRefGoogle Scholar
Hilton P, Hertogs K, Stanton SL. The use of desmopressin (DDAVP) for nocturia in women with multiple sclerosis. J Neurol Neurosurg Psychiatry 1983; 46: 854–5PubMedCrossRefGoogle Scholar
Eckford SD, Carter PG, Jackson SR, et al. An open, in-patient incremental safety and efficacy study of desmopressin in women with multiple sclerosis and nocturia. Br J Urol 1995; 76: 459–63PubMedCrossRefGoogle Scholar
Mathias CJ, Fosbraey P, Da CD, et al. The effect of desmopressin on nocturnal polyuria, overnight weight loss, and morning postural hypotension in patients with autonomic failure. BMJ 1986; 293: 353–4PubMedCrossRefGoogle Scholar
Suchowersky O, Furtado S, Rohs G. Beneficial effect of intranasal desmopressin for nocturnal polyuria in Parkinson’s disease. Mov Disord 1995; 10: 337–40PubMedCrossRefGoogle Scholar
Mansson W, Sundin T, Gullberg B. Evaluation of a synthetic vasopressin analogue for treatment of nocturia in benign prostatic hypertrophy: a double-blind study. Scand J Urol Nephrol 1980; 14: 139–41PubMedCrossRefGoogle Scholar
Hilton P, Stanton SL. The use of desmopressin (DDAVP) in nocturnal urinary frequency in the female. Br J Urol 1982; 54: 252–5PubMedCrossRefGoogle Scholar
Asplund R, Sundberg B, Bengtsson P. Desmopressin for the treatment of nocturnal polyuria in the elderly subjects: a dose titration study. Br J Urol 1998; 82: 642–6PubMedCrossRefGoogle Scholar
Asplund R, Sundberg B, Bengtsson P. Oral desmopressin for nocturnal polyuria in 60–74 year old subjects: a double-blind, placebo-controlled and randomised exploratory study. Br J Urol 1999; 83: 591–5Google Scholar
Carter PG, McConnell AA, Abrams P. The safety and efficacy of DDAVP in the elderly. Neurourol Urodyn 1992; 11: 421–2Google Scholar