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Nocturia: Getting up at Night


“Nocturia.” We may not know the term, but we know the condition―waking up during the night because we have to urinate. It is a condition that people commonly attribute to older age.


“In men, nocturia is a very common and very disruptive symptom of an enlarged prostate. Because the prostate is enlarged, additional pressure is put on the urethra – the tube through which urine flows from the bladder and out of the body – and as a result, urine is retained in the bladder and difficult to pass.


“A common second-hand effect of nocturia is that the sufferer’s significant other will often be disturbed as well. As the patient wakes to go to the bathroom, most often so will their significant other. The result can lead to difficult nights, drowsy days, and many of the most common consequences of lack of sleep – irritability, weight gain, lack of focus and much more.”

https://www.urologix.com/2013/04/what-is-nocturia/


“The prostate gland continues to grow throughout a man's life. This rarely causes problems until later in life. The layer of tissue around the prostate keeps it from growing outward. As a result, the prostate gland begins to press inward on the urethra like a clamp. It is a noncancerous condition.

“Benign prostate hyperplasia (BPE) or enlarged prostate causes the prostate gland to squeeze the urethra that it surrounds. In time, this blocks the flow of urine and causes a number of symptoms, including:


· Not being able to empty the bladder completely

· Needing to go to the bathroom more often.

https://www.cedars-sinai.org/health-library/diseases-and-conditions/e/enlarged-prostate-gland.html



Image from https://my.clevelandclinic.org/health/diseases/9100-benign-prostatic-enlargement-bph


“Waking at night to pass urine, or nocturia, is a symptom that can be caused by a wide variety of conditions (besides an enlarged prostate), such as congestive heart failure (CHF), poorly controlled diabetes mellitus (DM), medications, or diseases of the bladder or prostate. Nocturia is the most frequent cause of disturbed sleep in older adults.


Nocturia is defined as clinically significant if it involves the disturbance of sleep two or more times at night. One recent study noted that the prevalence of nocturia was estimated at 28.4%, 17.6%, and 8.9% for one, two or three voiding episodes each night, respectively.” It appears I’m in a category all by myself. I typically get up three to four times a night. While I get more Fitbit ‘steps’ than I would without nocturia, I’d rather sleep.


Nocturnal polyuria (NP) is a condition in which high volumes of urine are produced during sleep. The definition of NP adopted by the International Continence Society is a nighttime volume of >33% of the daily total in the elderly (aged >65 years). The prevalence of nocturnal polyuria increases with age, with as many as 77% of older women and 93% of older men affected. Based on estimates, it is suggested that NP affects approximately 90% of individuals >80 years of age.” https://www.uspharmacist.com/article/nocturia-in-older-adults-highlighting-nocturnal-polyuria. Jackpot! I also qualify for NP.


“Chronic nocturia can significantly affect a person's well-being and quality of life, causing sleep deprivation, daytime fatigue, impaired concentration, depression, and a loss of productivity.

What can we do about it?


If nocturia is not caused by one or more of the conditions noted above such as congestive heart failure, there are several things we can do to get up less frequently:


· “Alcohol and caffeine have diuretic properties that stimulate urine production.

· Excessive salt can trigger nocturia in people with obesity or poor cardiac output. Sodium increases fluid retention, the fluid of which may only be released at night when the bladder is full.

· Hyperhydration: Simply drinking too much water before bedtime is enough to trigger a middle-of-the-night bathroom visit.

· Low-fiber diet: Chronic constipation is a common consequence of a diet low in dietary fiber. At night, the buildup of stool can cause the bowel to distend, placing direct pressure on the bladder.”

https://www.verywellhealth.com/frequent-urination-at-night-nocturia-3300107


“While it is a relatively uncommon complaint among younger adults, the prevalence of nocturia increases with …age in both men and women. For those age 60 to 70 years, the prevalence of nocturia is between 11% and 50%. For those who are age 80 years, the prevalence rises to between 80% and 90%―OMG!


“Older adults already experience more frequent arousals from sleep and less deep sleep compared with younger adults. The presence of nocturia further disrupts sleep, leading to daytime somnolence, symptoms of depression, cognitive dysfunction, and a reduced sense of well-being and quality of life.


“Moreover, nocturia is associated with a 1.8-fold increased risk of hip fracture. Men who arise more than three times a night to urinate also have a twofold (twice as many or twice as much) increase in mortality compared with those with fewer episodes of nocturia. Nocturia is a frequent patient complaint leading to urologic and nephrologic (diseases of the kidneys) consultations.


“The causes of nocturia can be divided into conditions affecting the storage of urine in the bladder and those involving the excessive production of urine by the kidneys. Although it is commonly assumed that the reason for nocturia is bladder dysfunction, particularly among elderly men, this assumption is not accurate. (Bladder dysfunction is a general term to describe abnormalities in either the filling and/or emptying of the bladder.)


“Nocturia persisted in 25% of men who underwent prostate surgery for presumed bladder outlet obstruction (BOO is most common in older men and often is linked to prostate problems) and were monitored for three years, suggesting that the etiology (the cause of a disease or condition) of nocturia had not been addressed (corrected) by surgery in these patients.” (Bladder outlet obstruction is usually caused by physical pressure at the bladder outlet leading to the urethra as shown in the above picture.)


“A careful history and physical examination provide clues to the etiology. Symptoms such as decreased urinary stream, hesitancy, and a sense of incomplete voiding suggest bladder outlet obstruction (enlarged prostate). Frequency, urgency, and bladder spasms suggest bladder irritation, perhaps due to infection. Gross hematuria (blood in urine) may be an indication of a bladder tumor or stones.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3061378/


“Many men worry that having an enlarged prostate means they have an increased risk of developing prostate cancer. This is not the case. The risk of prostate cancer is no greater for men with an enlarged prostate than it is for men without an enlarged prostate.”

https://www.nhs.uk/conditions/prostate-enlargement/


In an attempt to cut down on the number of times I have to get up at night, I restricted the amount of water I drank from about 3:00 pm onward. I then kept a record of the number of times I got up at night, the amount of urine I passed, the total amount of urine passed for a 24-hour time period, and the percent passed during the night. By not drinking so much, there was a slight decrease in the number of nighttime wake ups, but it wasn’t significant, and I was damaging my kidneys with dehydration. Shown below is the form I use to keep track:


Date/ Times up/ ML passed at Night / ML passed During Day/Total in 24hrs

and lastly, Percent of total passed at night


“Can dehydration affect your kidneys? The answer is yes. Dehydration happens when you lose an excess amount of water because of diarrhea, vomiting, sweating, or extra losses in your urine, such as poorly controlled diabetes.” I would add that dehydration can also happen when you restrict the amount of fluid you drink.


“Mild dehydration can make you feel tired, and it can also impair normal body functions. Severe dehydration can lead to kidney damage…Some studies have shown that frequent dehydration, even if it’s mild, may lead to permanent kidney damage.”https://www.kidney.org/newsletter/can-dehydration-affect-your-kidneys


Fluid Input and Fluid Output


Most studies recommend drinking between 1,000 to 2,000 ml per day while “the normal range for 24-hour urine volume is 800 to 2,000 milliliters per day.” https://www.ucsfhealth.org/medical-tests/urine-24-hour-volume (800 ml equals 3.4 eight-ounce glasses of fluid. 2000 ml equals 8.4 glasses.)


The image below depicts how we intake and expel water.

https://www.austincc.edu/apreview/EmphasisItems/Electrolytefluidbalance.html


Notice that it assumes we drink 1,500 ml or 6.3 glasses of fluid and pee the same amount. The statement that we get 10% of our fluid intake from our own metabolism was new to me. “Metabolic water refers to water created inside a living organism through their metabolism, by oxidizing energy-containing substances in their food.” https://en.wikipedia.org/wiki/Metabolic_water


This may be TMI, but will assist you in determining a “normal” upon which to evaluate your own circumstances. For a 14-day period, I eliminated an average of 1,385 ml in a 24-hour period or 5.9 eight ounces glasses of water and eliminated an average of 548 ml or 2.4 eight ounces glasses of water during the night. I got up an average of 4.4 times.


Pills and Surgery


My doctor prescribed pills to help reduce the number times I get up, but they gave me a terrible sore throat akin to strep, a bit of nausea, and general feeling of malaise. I took them for four days and stopped. I plan to ask for a different brand of pills and give it another shot.


I’ve had mixed results with my three prostate surgeries that removed prostate tissue to open a pathway for the urethra. The first one failed from the start. The second one worked for a glorious ten years then succumbed to my ever-growing prostate. The third was like the first―a failure from the get go. Since my second prostate surgery was successful, the possibility for a fourth surgery is still on the table.

The picture at the top of this post lists “bladder prolapse and pelvic prolapse” and is a problem specific to women. Use an internet search engine to learn more.


Intentional dehydration to get up less often at night is not healthy, so I now try to drink water, tea, and soup to my heart’s content before 3 pm, but if 8 glasses of fluid is the goal, I’m failing. Yesterday, I drank 5 cups before 3. It seems that there is no silver bullet to resolve this medical condition. If you are one of the few men without this condition, give thanks. If not, there are choices. I’d be interested to hear what may be working for you.

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