Nocturia

Aka: Nocturia, Nocturnal Frequency, Nighttime Urination

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II. Definitions

  1. Nocturia
    1. Frequent Urination at night (more than once)

III. Epidemiology

  1. Prevalence: 30% of adults age >60 years

IV. Pathophysiology

  1. Urine Volumes are typically reduced at night via diurnal rhythm
  2. Nocturia occurs when urine formed exceeds Bladder capacity
    1. Decreased Bladder capacity
    2. Decreased renal concentrating function
    3. High Sodium excretion or other solute diuresis

V. Risk Factors

  1. Diabetes Mellitus
  2. Hypertension
  3. Obstructive Sleep Apnea
  4. Congestive Heart Failure

VI. Causes

  1. All causes of Polyuria also cause Nocturia
    1. Diabetes Mellitus
    2. Diabetes Insipidus
    3. Primary Polydipsia (e.g. Water Intoxication)
  2. Decreased Bladder capacity (may be due to inflammation or irritability)
    1. Urinary Tract Infection
    2. Bladder Tumor
    3. Urinary tract stone
  3. Edematous State fluid redistributes at night into dependent positions and then intravascularly mobilized
    1. Congestive Heart Failure
    2. Nephrotic Syndrome
    3. Hepatic Cirrhosis with Ascites
    4. Venous Insufficiency
  4. Bladder outflow obstruction or Urinary Retention
    1. See Medication Causes of Urinary Retention
    2. Benign Prostatic Hyperplasia
    3. Urethral Stricture
    4. Urinary tract stone
    5. Pelvic tumor
  5. Other causes
    1. Obstructive Sleep Apnea

VII. History

  1. Urinary symptoms
    1. Number of night awakenings to urinate
    2. First Nocturia episode within 3 hours of going to sleep\
    3. Daytime urine frequency
    4. Urine urgency
    5. Urinary Tract Infection symptoms
    6. Incomplete Bladder emptying, double voiding or decreased urinary stream
  2. Nocturia degree of bothersomeness
    1. Less than 5 hours of sleep per night
    2. Daytime Somnolence
    3. Associated falls or injuries
  3. Past medical history
    1. Diabetes Mellitus (esp. with poor control)
    2. Congestive Heart Failure
    3. Hypertension
    4. Chronic Kidney Disease
    5. Obstructive Sleep Apnea
      1. See STOP-Bang Questionnaire
    6. Benign Prostatic Hyperplasia
      1. See Benign Prostatic Hyperplasia Symptom Index
  4. Medications
    1. Diuretics
    2. Timing and amount of fluid intake
    3. Caffeine
    4. Alcohol

VIII. Exam

  1. Vital Signs
    1. Blood Pressure (evaluate for Uncontrolled Hypertension)
    2. Orthostatic Blood Pressure and pulse
  2. Cardiopulmonary exam
    1. Volume overload (e.g. Lower Extremity Edema)
  3. Genitourinary exam
    1. Benign Prostatic Hyperplasia
    2. Pelvic Organ Prolapse
    3. Atrophic Vaginitis (Menopause)

IX. Labs

  1. Urinalysis
  2. Fingerstick or Blood Glucose (and consider Hemoglobin A1C)
  3. Post-void residual Urine Volume (via Ultrasound, Bladder scan or urine catheterization)

X. Management: General

  1. Identify and treat underlying causes
    1. Diabetes Insipidus
    2. Benign Prostatic Hyperplasia
      1. Consider Alpha Adrenergic Receptor Blocker (e.g. Tamsulosin)
      2. Consider urology Consultation
    3. Diabetes Mellitus
      1. See Noninsulin Therapy of Type 2 Diabetes
      2. Optimize Diabetes MellitusGlucose control
    4. Overactive Bladder
      1. Consider Bladder Antispasmodics (e.g. Oxybutynin, Tolterodine)
    5. Obstructive Sleep Apnea
      1. See STOP-Bang Questionnaire
      2. Optimize management (e.g. CPAP)
  2. Employ simple strategies
    1. Practice Sleep Hygiene
    2. Dose Loop Diuretics earlier in the day
    3. Limit Alcohol and Caffeine intake (Diuretics)
    4. Avoid excessive daytime fluid intake (esp. within 2-3 hours of bed)
    5. Pelvic Floor Exercises
    6. Redistribute edema during the daytime (esp. in the afternoon)
      1. Compression Socks
      2. Leg elevation

XI. Management: Unclear Cause and Refractory to General Measures

  1. Evaluate urine frequency and volume for those without underlying cause
    1. Diary for 2-3 days of urine frequency and volume logs (including nighttime voids)
  2. Nocturnal Polyuria
    1. Diagnosis
      1. Older patients: Nocturnal Urine Volume >33% of total Urine Output in 24 hours
      2. Younger patients: Nocturnal Urine Volume >20% of total Urine Output in 24 hours
    2. Management
      1. Exclude underlying Edematous States (e.g. CHF) and causative medications and habits
      2. Consider Low dose Desmopressin (Noctiva)
        1. Expensive, marginal efficacy, risk of Hyponatremia (requires Sodium monitoring)
        2. See Desmopressin for contraindications and Drug Interactions
  3. Men with suspected Benign Prostatic Hyperplasia (BPH)
    1. Consider Alpha Adrenergic Receptor Blocker (e.g. Tamsulosin)
    2. Consider urology Consultation
  4. Women with suspected Overactive Bladder (Urge Incontinence)
    1. Diagnosis
      1. Day and night frequency, urine urgency, and Urge Incontinence
    2. Management
      1. Consider Bladder Antispasmodics (e.g. Oxybutynin, Tolterodine)
      2. Consider Atrophic Vaginitis management (Menopause)
      3. Consider urology referral for advanced treatments (e.g. Detrussor Muscle Botulinum Toxin Injection)

XII. Complications

  1. Sleep disruption related complications
  2. Fall Risk

XIII. References

  1. (2018) Presc Lett 25(5): 27
  2. Coe in Wilson (1991) Harrison's Internal Medicine, 12th ed, McGraw Hill, p. 275
  3. Getaneh (2025) Am Fam Physician 111(6): 515-23 [PubMed]

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