Symptom Assessment of Candidates for Sacral Neuromodulation Therapy With Urologic and Colorectal Conditions: Time for a Holistic Approach? Results and Findings From a Prospective Single-Center Study.

OBJECTIVES: Sacral neuromodulation (SNM) has evolved as a therapeutic intervention for various pelvic floor dysfunctions. However, the traditional approach primarily assesses discipline-specific symptoms, potentially overlooking holistic symptom improvement. We aimed to investigate whether a more comprehensive evaluation of pelvic floor symptoms enhances the assessment of SNM's test phase. MATERIAL AND METHODS: A prospective single-center trial (Optimization of Lower Urinary Tract Symptoms study) assessed SNM efficacy from March 2018 to December 2021 in patients from the urology department (UD) and colorectal surgery department (CRD) with a follow-up of 12 months. Objective and subjective outcomes were examined using diaries and patient-reported outcome measures. Statistical analyses were conducted to determine predictive factors for treatment success, expressed by the patient global impression of change. SPSS 29.0 was used. RESULTS: A total of 85 participants were included, displaying concomitant pelvic floor symptoms. After the first phase, significant improvements on all pelvic floor domains questionnaires were seen for both patients from UD and those from CRD. Although improvements were observed in bladder and bowel diaries, the traditional criteria for success (≥50% improvement in diary variables) did not consistently correlate with the patients' global impression of change. The absolute reductions in bother sum scores from multiple domains were significant predictors for the patients' global impression of change, outperforming discipline-specific assessments. Patients from UD benefit from both a urologic and pelvic pain symptom evaluation, and those from CRD, from both a urologic and bowel symptom evaluation. CONCLUSIONS: SNM shows positive effects across various pelvic floor domains, even beyond the primary intended indication of implantation. The rather rigid approach of patient selection of discipline-specific symptoms alone can be questioned. A more comprehensive evaluation encompassing various pelvic floor symptoms with the emphasis on subjective outcome measures could enhance SNM's efficacy assessment during the test phase. CLINICAL TRIAL REGISTRATION: The Clinicaltrials.gov registration number for the study is NCT05313984.

Nocturia in Menopausal Women: The Link Between Two Common Problems of the Middle Age.

INTRODUCTION AND HYPOTHESIS: The aim of this review is to discuss the link between menopause and nocturia and to give an overview of the increasing prevalence, risk factors, causative factors, treatment needs and options for nocturia in peri-menopausal women. METHODS: This opinion article is a narrative review based on the expertise and consensus of a variety of key opinion leaders, in combination with an extensive literature review. This literature search included a thorough analysis of potential publications on both the PubMed Database and the Web of Science and was conducted between November 2022 and December 2022. The following key words were used "nocturia" and "menopause" or "nocturnal frequency and menopause." Moreover, key words including "incidence," "prevalence," "insomnia," "estrogen therapy," "metabolic syndrome," and "hot flushes" were used in combination with the aforementioned key words. Last, the reference lists of articles obtained were screened for other relevant literature. RESULTS: The perimenopause can be a trigger for inducing nocturia. Typically, obesity, body mass index (BMI), and waist circumference are risk factors for developing peri-menopausal nocturia. Presumably the development of peri-menopausal nocturia is multifactorial, with interplay among bladder, sleep, and kidney problems due to estrogen depletion after the menopause. First, impaired stimulation of estrogen receptors in the urogenital region leads to vaginal atrophy and reduced bladder capacity. Moreover, menopause is associated with an increased incidence of overactive bladder syndrome. Second, estrogen deficiency can induce salt and water diuresis through blunted circadian rhythms for the secretion of antidiuretic hormone and the activation of the renin-angiotensin-aldosterone system. Additionally, an increased incidence of sleep disorders, including vasomotor symptoms and obstructive sleep apnea signs, is observed. Oral dryness and a consequent higher fluid intake are common peri-menopausal symptoms. Higher insulin resistance and a higher risk of cardiovascular diseases may provoke nocturia. Given the impact of nocturia on general health and quality of life, bothersome nocturia should be treated. Initially, behavioral therapy should be advised. If these modifications are inadequate, specific treatment should be proposed. Systemic hormone replacement is found to have a beneficial effect on nocturia, without influencing sodium and water clearance in patients with nocturnal polyuria. It is presumed that the improvement in nocturia from hormonal treatment is due to an improvement in sleep disorders.

Association between frailty and detrusor overactivity with detrusor underactivity in older women.

PURPOSE: While detrusor overactivity (DO) with detrusor underactivity (DU) (DO-DU) has been described as typical of aging, the pathogenesis of DO-DU is highly multifactorial, and often thought to involve medical conditions beyond the urinary tract. We aimed to explore potential associations between idiopathic DO-DU and frailty in older women after accounting for age. METHODS: The design of the study is a cross-sectional single-center study, in an outpatient urodynamic unit specializing in geriatrics. Participants are consecutive female patients aged ≥65 years without contributory neurological conditions or bladder outlet obstruction who completed a comprehensive geriatric assessment followed by urodynamic evaluation from 2015 to 2019. Participants were categorized as having DO, DU, combined DO-DU, or a negative study. Multinomial logistic regression analysis was used to assess the relationship between urodynamic outcomes and frailty, as quantified using the Frailty index (FI). RESULTS: Ninety-five patients were included (median age 78 [interquartile range: 70-83] years), among whom 29% had combined DO-DU. The median FI score was 0.27 (0.2-0.32) (5-12). A higher FI was associated with significantly greater age-adjusted odds of DO-DU when either DU or subjects with a negative urodynamic assessment were used as the reference group. Age was not significantly associated with DO-DU across all multivariable analyses. CONCLUSION: A higher FI was associated with an increased likelihood of DO-DU, which could not be attributed to the effect of age alone. The pathogenesis of DO-DU is likely more complex than chronological aging in and of itself and merits further study.

Nocturia severely impairs the sleep quality of nursing home residents: results from a multi-center study.

OBJECTIVES: To assess the association between self-reported sleep quality and nocturia in nursing home residents. METHODS: The association between self-reported poor sleep quality and nocturia was examined in eighty nursing home residents from two nursing facilities using logistic regression analysis. RESULTS: Poor sleep quality was reported by 29% of the eighty participants (median age 89±7 years, 77% of women). Nocturia was more frequent in patients with versus without self-reported poor sleep quality (78% vs 47%, p=0.01). Nocturia was independently associated with self-reported poor sleep quality after controlling for age, gender, self-rated health status, cognitive frailty score, antidepressant and hypnosedative use (OR[95%CI] of 6.1[1.8-25.4]). CONCLUSION: Nocturia severely impaired sleep quality in nursing home residents. Nocturia should be investigated in nursing home residents to optimize sleep quality.

Does hormonal therapy affect the bladder or the kidney in postmenopausal women with and without nocturnal polyuria: Results of a pilot trial?

AIM: To observe the impact of hormonal treatment (HT) on voiding patterns and renal circadian rhythms in postmenopausal women with and without nocturnal polyuria (NP). MATERIAL AND METHODS: A prospective, observational study was executed at the menopause clinic of a tertiary hospital. HT was based on patients' choice and was in the form of either oral and transdermal oestrogen. Participants completed a 72-hour bladder diary, completed the ICIQ-FLUTS questionnaire, recorded a renal function profile and gave a blood sample. This set of tests was done before and after 3 months of HT. RESULTS: 32 postmenopausal women with a median age of 52.5 (49.3-56.0) years were enroled in this study. Three months of HT resulted in a significant decrease in fluid intake (p < 0.001) and daytime voiding frequency (p = 0.019). No impact on nocturnal parameters was observed. Observations drawn from the questionnaires did not differ between the baseline and three-month assessments. HT led to a disappearance of the circadian rhythm of the diuresis rate and sodium clearance in patients without NP, as no significant difference between daytime and night-time values was observed (diuresis rate p = 0.3; sodium clearance p = 0.08). In patients with NP at baseline, HT did not induce a circadian rhythm of the diuresis rate and sodium clearance (p = 0.2; p = 0.7). In contrast, free water clearance did change to a clear circadian rhythm (p = 0.02). CONCLUSION: HT led to a significant reduction in both fluid intake and daytime frequency. In women without NP, HT led to a disruption of the circadian rhythms of water and salt diuresis. In patients with NP, a limited normalisation of the circadian rhythm of free water clearance was observed after three months of HT. CLINICAL TRIAL REGISTRATION NUMBER FROM CLINICALTRIALS.GOV: NCT04891926.

Hormone therapy as a possible solution for postmenopausal women with nocturia: results of a pilot trial.

OBJECTIVE: To observe the impact of different hormonal treatment options on nocturia, its causative factors and bother in postmenopausal women. METHODS: This prospective study recruited 245 postmenopausal women and divided them into four treatment groups based on patient's choice: Estrogen + Progesterone (E+P), Estrogen-only in patients with a prior hysterectomy, tissue-selective estrogen complex (TSEC) and no treatment. Nocturia and its causative factors were observed using two standardized questionnaires before and after treatment: the International Consultation on Incontinence Questionnaire Nocturia Module and the Targeting the individual's Aetiology of Nocturia to Guide Outcomes (TANGO). The results of the Targeting the individual's Aetiology of Nocturia to Guide Outcomes were divided in four influencing topics of which the sum score was calculated. RESULTS: A significant reduction in prevalence of nocturia ≥ twice per night was seen after treatment, as the prevalence decreased from 27.7% (59/213) to 16.4% (35/213). Specified per therapy, a significant reduction in nocturnal voiding frequency was observed in patients treated with E+P and TSEC (P = 0.018 and P = 0.018, respectively). This improvement could be explained by a significant reduction in SLEEP sum score in patients treated with E+P and TSEC (P < 0.001, P = 0.013, respectively). Estrogen-only led to a significant change in URINARY TRACT sum score, which is the result of a reduction in urgency prevalence (P = 0.039). CONCLUSIONS: E+P and TSEC treatment led to a significant reduction in nocturia prevalence and bother in women with ≥ 2 nocturnal voids. This effect is mainly the result of improvement in sleep disorders, however an improvement in bladder disorders can be suggested as well. More research is necessary to confirm these findings.

Video Summary:http://links.lww.com/MENO/A710 .

Nocturia through the menopausal transition and beyond: a narrative review.

INTRODUCTION AND HYPOTHESIS: Nocturia, defined as the act of waking to pass urine during sleeping, is a common problem in older women and is associated with significant morbidity and impairments in health-related quality of life. The aim of this review was to synthesize the current evidence regarding the incidence, impact, pathophysiology, and specific diagnostic approach of nocturia in the postmenopausal population. METHODS: We searched PubMed and Web of Science databases to identify relevant studies published through June 2020. Reference lists of the reviews obtained were screened for other articles deemed pertinent by the authors. RESULTS: Genitourinary symptoms attributed to the menopause have been reported to occur in nearly 90% of postmenopausal women, and nocturia is one of the most common. The relative deficiency in endogenous estrogen production after the menopause is thought to exacerbate all major pathophysiological mechanisms that may underlie nocturia, including reduced bladder capacity, nocturnal polyuria, global polyuria, and sleep disorders. Diminished estrogen may induce anatomical and physiological bladder changes, contributing to a reduction in functional bladder capacity. Excess nocturnal urine production can also be provoked by estrogen depletion, either via free water-predominant diuresis by an impaired secretion of antidiuretic hormone, or a salt-predominant diuresis owing to diminished activation of the renin-angiotensin-aldosterone axis. Additionally, a relationship between the transition to menopause and impaired sleep has been described, mediated by increased incidence in vasomotor symptoms and obstructive sleep apnea signs during the menopause. CONCLUSION: Further research is necessary to better characterize and manage nocturia in postmenopausal women.

Characterizing nocturia among Belgian healthy postmenopausal women: Prevalence, degree of bother, etiology and risk factors for nocturia.

INTRODUCTION: Limited literature concerning nocturia in early postmenopausal women is available. However, due to the lack of endogenous estrogen in these women, an increased prevalence of nocturia is expected. MATERIAL AND METHODS: This prospective observational trial recruited 210 'early' postmenopausal women consulting the Ghent University menopause clinic. Postmenopausal status was biochemically confirmed. Women completed 3 questionnaires: the ICI questionnaire on nocturia (ICIQ-N); 'Targeting the individual's Aetiology of Nocturia to Guide Outcomes' (TANGO) and the Perceived Stress Scale (PSS). Moreover, information concerning women's age, anthropometrics and lifestyle was collected. Nocturia was defined as two or more nocturnal voids. RESULTS: Nocturia was reported in 24.8% (52/210) of the postmenopausal women. Bother increased with every nocturnal void. Women with two or more nighttime voids were found to have significantly increased prevalence of urgency compared with women with only one (p < 0.001; 38.5% versus 22.7%). Trouble initiating sleep at the start of the night and insomnia during the night were significantly different in women with a different nocturnal frequency (initiating sleep p = 0.09, no voids 34.4 %, 1 void 39.2 %, ≥ 2 voids 53.8 %; insomnia p < 0.001; no voids 1.6%, 1 void 22.7 %, ≥ 2 voids 53.8 %). In addition to bladder and sleep dysfunctions, waist circumference was a risk factor for nocturia (OR 1.04; 95 % CI: 1.01-1.08). CONCLUSION: Nocturia is an important problem in early postmenopausal women, affecting a quarter of the questioned women. Etiology of nocturia in this population is multifactorial as estrogen withdrawal is accompanied by bladder and sleep dysfunctions.

Phenotyping nocturnal polyuria: circadian and age-related variations in diuresis rate, free water clearance and sodium clearance.

BACKGROUND: this study compares diuresis rate, sodium clearance and free water clearance (FWC) by age and time of day (nighttime vs. daytime) in subjects with and without nocturnal polyuria (NP) to determine whether these variables affect the phenotype of NP. METHODS: post hoc analysis of two prospective observational studies. Eight urine samples collected at 3-h intervals and a single blood sample were used to calculate daytime (10a/1p/4p/7p/10p) and nighttime (1a/4a/7a) diuresis rates, sodium clearance and FWC. Three mixed linear models were constructed for diuresis rate, sodium clearance and FWC using four predictor variables: NP status (present [nocturnal urine production >90 ml/h] vs. absent [≤90 ml/h]), time of day, age and study identification. RESULTS: subjects with NP experienced higher nighttime versus daytime diuresis rates, sodium clearance and FWC. Regardless of NP status, increased age was accompanied by an increase in the ratio of nighttime/daytime diuresis rate, nighttime sodium clearance and daytime sodium clearance. FWC showed a complex age effect, which was independent of time of day or NP status. CONCLUSIONS: age-related increases in nighttime/daytime diuresis rate, 24-h sodium clearance and 24-h FWC are not specific to subjects with NP. The age-related surge in either nocturnal sodium clearance or nocturnal FWC may represent the relevant substrate for behavioural or pharmacologic interventions targeting sodium diuresis or free water diuresis, respectively. Increases in FWC in older age groups may reflect impaired circadian rhythmicity of endogenous AVP or changes in responsiveness of the aged nephron to water clearance.

Diagnosing Nocturnal Polyuria from a Single Nocturnal Urine Sample.

BACKGROUND: Patients with nocturnal polyuria (NP) experience a unique surge in nocturnal diuresis rate during the early hours of sleep. OBJECTIVE: To determine the diagnostic utility of the volume and osmolality of a single early nocturnal urine sample in detecting NP. DESIGN, SETTING, AND PARTICIPANTS: Analysis of 1 am urine samples obtained from two prospective observational studies at Ghent University Hospital involving participants recruited from a urology ambulatory care unit and those who consulted a continence clinic. Nocturic participants (one or more nocturnal void[s]; n=176) were stratified based on the presence (n=87) or absence (n=89) of NP (>90ml/h). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Receiver operating characteristic curves with Youden's Index were used to determine cutoff values for urine volume and urine osmolality (Uosm). RESULTS AND LIMITATIONS: Individuals with NP demonstrated higher 1 am volume (400 [interquartile range 300-515] vs 210 [160-300] ml, area under the curve [AUC]=0.843, p< 0.001, cutoff = 350 ml) and lower Uosm (274 [201-348] vs 430 [320-664] mOsm/kg H2O, AUC=0.774, p<0.001, cutoff=314 mOsm/kg H2O) than those without NP. In combining cutoffs, the criteria of either 1 am volume ≥350ml or Uosm ≤314 mOsm/kg H2O were 85% sensitive and 75% specific for NP, while criteria of both 1 am volume ≥350ml and Uosm ≤314 mOsm/kg H2O were 60% sensitive and 92% specific for NP. Comparable AUC values, sensitivities, and specificities were observed in both men and women. Limitations include post hoc design and a relatively small study sample. CONCLUSIONS: Individuals with NP are more likely than those without NP to produce a higher volume of more dilute urine (ie, "aquaresis") in the early hours of sleep. Analysis of easily measurable parameters of the first nocturnal void (for which 1 am values serve as a surrogate) in men and women with nocturia can predict a diagnosis of NP with a reasonably high degree of sensitivity and specificity. PATIENT SUMMARY: Urologists often try to understand the specific reason why people wake up to urinate at night by asking them to record the amount of urine they make every time they go to the bathroom (also known as a "voiding diary") during the nighttime as well as the daytime-typically for a total of 1-3 days. In this study, we showed that an analysis of the composition of the urine that people produce when they first wake up to urinate at night might be sufficient to determine whether their symptoms are caused by excessive urine production or something else, and some people might find this urine study easier than keeping a voiding diary.

The OptiLUTS trial: improving care for therapy-resistant symptoms of the pelvis in Belgium.

INTRODUCTION/BACKGROUND: The management of therapy-resistant lower urinary tract symptoms (LUTS) and symptoms resulting from pelvic organ dysfunctions are subject to a high variability in the Belgian health-care centres. Practical guidelines and standardized patient clinical care pathways are often lacking and unadapted to the Belgian healthcare system. OBJECTIVES: The OptiLUTS trial aims to improve the multidisciplinary care of therapy-resistant symptoms of the pelvis in the Belgian healthcare setting. Project A aims for the improvement of knowledge of 2nd line treatments for LUTS among general practitioners. In project B a treatment algorithm for the overactive bladder syndrome and non-obstructive urinary retention will be developed specifically for Belgium. In Project C a patient customized sacral neuromodulation (SNM) care pathway will be set up. METHODS: Part A: Explorative study among general practitioners by distribution of a  questionnaire. Part B: Review of existing guidelines and use of the Delphi method to obtain expert consensus. Part C: A single center comparative study to compare outcomes before and after implementation of the SNM care pathway. Patients scheduled for the first stage of Interstim therapy™ will be included (N=100). Primary endpoints are the sensitivity and specificity of a new pelvic symptom assessment tool, the conversion to implant and explantation rates. CONCLUSION: There is a margin for improvement in the care process of patients with therapy-resistant symptoms of the pelvis in the Belgium healthcare system. In the OptiLUTs trial adapted guidelines and a clinical care pathway will be developed to standardize and increase the efficiency of care. TRIAL REGISTRATION: Approval for the trial by the Ethics Committee of the Ghent University hospital: EC/2018/0244.

Conservative treatment for leg oedema and the effect on nocturnal polyuria in patients with spinal cord injury.

OBJECTIVES: To evaluate the possible influence of non-pharmacological interventions, such as compressive bandages and intermittent pneumatic compression (IPC), on leg oedema and nocturnal polyuria (NP), and the possible interrelation between both pathologies in patients with spinal cord injury (SCI), as patients with SCI often have leg oedema and during the night the oedema decreases as a result of natural drainage mechanisms that can cause NP. PATIENTS AND METHODS: Patients with SCI who followed their first rehabilitation after their SCI with bilateral leg oedema and/or with as much or a larger urine volume at night as during the day. The patients were all wheelchair users and followed the rehabilitation programme daily for 3 weeks. In all, 24 patients, aged between 21 and 63 years, were selected for participation in the 3-week rehabilitation programme. During the first week, baseline data were collected. During the second week, IPC was executed from the moment the patient went to lie down. During the third week, the patients wore multilayer compressive bandages. Leg circumference was measured in the morning before sitting up and at the moment they went to lie down in bed. During each study week, a daily frequency-volume chart (24 h) was completed. RESULTS: The leg volume of both legs was significantly different between the morning and evening (right leg F = 103.90, P < 0.001; left leg F = 100.77, P < 0.001) and between the three treatments (right F = 9.70, P < 0.001; left F = 9.66, P < 0.001). There was a significant difference between the compressive bandages and the baseline period (right and left leg, both P < 0.001) and between the compressive bandages and IPC (right leg P = 0.009 and left leg P = 0.015). There was no significant difference between IPC and the baseline. When no treatment or IPC was used, urine production was significantly higher during the bed-rest period. The urine production was significantly lower comparing the use of compressive bandages to baseline and IPC, during bed rest (P = 0.009) and during sleep (P < 0.001). There was a significant decrease in absolute voided volume at night with the compressive bandages as treatment (P < 0.001). There was a significant positive association between the leg volume change during the day and the urine-production ratio, 100 mL increase in leg volume was associated with 8% increase in the log-transformed urine-production ratio. CONCLUSION: There are alternative treatment options for patients with SCI who have oedema or NP. Oedema formation and urine production appear to be related to each other. Therefore, the use of compressive bandages was shown to be a valuable treatment option to improve both leg oedema and NP.

Evaluation of the occurrence and diagnose definitions for nocturnal polyuria in spinal cord injured patients during rehabilitation.

BACKGROUND: Little is known about the occurrence of nocturnal polyuria (NP) in spinal cord injured (SCI) patients and the definitions which are preferable in this population. AIM: To determine the occurrence of NP in SCI patients during in-patient rehabilitation in the Ghent University Hospital. To study the influence of different time periods (daytime, bed rest and sleep) on the accuracy of the existing diagnose definitions for NP specifically for this type of patients. DESIGN: Retrospective study using patient records. SETTING: SCI patients during hospital-based rehabilitation between 2011 and 2014. POPULATION: Seventy-four SCI patients were selected and their records of frequency-volume charts (FVC) were examined, after exclusion of unreliable data, forty-seven patients were retained for the current study. METHODS: Retrospective study using data from FVC of either two or three days from patients with SCI. Nocturnal urine production (NUP) and nocturnal polyuria index (NPi) were calculated. RESULTS: There was a significant increase in diuresis, calculated as urine production, between day time and bed rest (P=0.008) and between day time and sleep (P=0.001). All patients showed NP during a 12-hour night time period (including both bed rest and sleep) and 39 patients showed NP during the 8-hour period of sleep. There was no significant difference in mean urine production between bed rest and sleep. Prevalence of NP did not significantly differ between the complete or incomplete SCI patients or between patients with higher and lower SCI levels. CONCLUSIONS: This study showed that the occurrence of NP in patients with SCI is high and that it is important to consider which definitions of NP are used for diagnosis. Increase in diuresis is observed during bed rest and sleep and the diagnose is correctly estimated when nocturnal urine production definitions are used in both time periods. In accordance with what was expected, diagnose of NP was overestimated when NP index type definitions were used. CLINICAL REHABILITATION IMPACT: It is important to be aware of the frequent-occurrence of NP in SCI patients and the impact of their daily routine to the accuracy of the diagnosis of NP. More knowledge about this topic can help to avoid incontinence caused by nocturnal polyuria.

An exploratory pilot study with copeptin as a biomarker for individualizing treatment for nocturnal polyuria.

OBJECTIVE: The aim of the present study was to investigate the use of random copeptin concentrations as possible biomarkers for the differential diagnosis of nocturnal polyuria (NP). METHODS: In all, 111 patients with and without nocturia were enrolled in the study. Patients with a neurogenic bladder and/or those who had undergone bladder or urethral surgery were excluded from the study. All patients completed a 72-hour frequency-volume chart and a renal function profile. A random blood sample was obtained during the day for measurement of plasma copeptin concentrations, osmolality, and serum sodium and creatinine concentrations. The effect of the use of different definitions for NP was evaluated. RESULTS: The median age of the study participants was 61 years, and 48% were female. Copeptin was significantly correlated with urinary and plasma osmolality, as well as free water clearance (r=0.43, 0.56 and -0.38 respectively; P < .001 for all). Study participants were divided into 3 groups: controls (n = 51), those with NP (n = 41), and those with global polyuria (n = 19). Copeptin concentrations were significantly lower in subjects with global polyuria than in those with NP and the control group (2.96 vs 3.97 and 3.94 pM, respectively; P = .008 and .005). There was no significant difference in random daytime copeptin concentrations between the NP and control groups (P = .972). The results differed when other definitions for NP were used (e.g. NPi33 or NUP10). CONCLUSIONS: We could not confirm our hypothesis that patients with NP have lower copeptin concentrations, although random blood sampling is not ideal. Further research is required to determine the use of copeptin in NP, perhaps in the identification of the desmopressin response.

A different way to study frequency volume charts in patients with nocturia.

BACKGROUND: Nocturia results from a mismatch between bladder capacity and nocturnal urine production (NUP), which is determined with a frequency volume charts (FVC). AIM: This is the first study that aimed to describe variations in nocturia severity and its associated factors by evaluating FVCs per single 24 h-period. METHODS: This was a post-hoc analysis of patients who completed a 72 h-FVC in prospective, observational studies. The nocturnal polyuria index (NPi ) was defined as the ratio of nocturnal and 24 h urine output. Subgroups were defined according to variations in nocturia frequency during the three 24 h-periods of the FVC (fluctuating/consistent) and to the number of nocturia episodes during a single night (0/1/≥2). RESULTS: We analyzed 504 24 h-FVC, collected by 168 subjects (58% female) with a median age of 60 (50-68) years. Nocturia frequency fluctuated in 69 (41%) subjects. For the same number of nocturnal voids, we found no differences in NPi and maximum voided volume (MVV) between consistent and fluctuating nocturia frequency. Increasing numbers of nocturnal voids were associated with an increasing NPi in subjects with fluctuating nocturia, while for consistent nocturia, it was linked to an increase in NPi and a decrease in MVV. For both subjects with fluctuating and consistent nocturia, increasing nocturia severity was associated with increasing daytime fluid intake. CONCLUSION: For the same number of nocturnal voids, bladder capacity, and NUP were similar between patients with consistent and fluctuating nocturia. An increasing number of nocturnal voids in subjects with fluctuating nocturia was linked to more NUP and more daytime fluid intake.

Pathophysiology of nocturnal lower urinary tract symptoms in older patients with urinary incontinence.

OBJECTIVES: To explore the mismatch between functional bladder capacity and nocturnal urine production, and to study the pathophysiology of an increased nocturnal urine production in older patients with urinary incontinence. METHODS: The present prospective observational study included adults aged ≥65 years with urinary incontinence. Participants completed questionnaires, frequency volume charts and renal function profiles. The nocturnal lower urinary tract symptom index was defined as nocturnal urine output/maximum voided volume; the nocturnal polyuria index as nocturnal/24 h urine output. RESULTS: The median age (n = 95) was 74 years (69-79), 87% were women and 73% had nocturnal lower urinary tract symptoms (nocturnal urinary incontinence or nocturia ≥2). Participants with nocturnal lower urinary tract symptoms had a significantly higher nocturnal urine output (809 mL vs 650 mL; P = 0.001) and no significant difference in maximum voided volume (350 mL vs 437 mL; P = 0.079) compared with participants without nocturnal lower urinary tract symptoms. Participants (nocturnal polyuria index >33% [n = 56], nocturnal polyuria index >40% [n = 42], nocturnal lower urinary tract symptom index >1.87 [n = 51]) showed higher night-time diuresis rates, free water and sodium clearance compared with during the daytime. Controls (nocturnal polyuria index ≤33% [n = 26], nocturnal polyuria index ≤40% [n = 40], nocturnal lower urinary tract symptom index ≤1.87 [n = 44]) had no circadian rhythm in their diuresis rate or sodium clearance, but more nocturnal free water clearance compared with during the daytime. CONCLUSIONS: The majority of older adults with urinary incontinence present nocturnal lower urinary tract symptoms. An increased nocturnal sodium diuresis seems to be the only mechanism differentiating patients with nocturnal lower urinary tract symptoms from controls.

Basic or extended urine sampling to analyse urine production?

BACKGROUND: Frequency volume charts are valuable tools to objectify urine production in patients with nocturia, enuresis or nocturnal incontinence. Analyses of daytime and nighttime urine (=basic collection) or analyses of urine samples collected every 3 h (=extended collection) extend this evaluation by describing circadian patterns of water and solute diuresis (=renal function profiles). AIM: To assess intra-individual correlation and agreement between renal function profiles provided using basic and extended urine collections, and using two extended urine collections. To create a short-form of the extended collection. METHODS: This prospective observational study was executed at Ghent University Hospital, Belgium. Study participation was open for anyone visiting the hospital. Participants collected one basic and two extended 24-h urine collections. Urinary levels of osmolality, sodium and creatinine were determined. RESULTS: There was a moderate to strong correlation between results of basic and extended urinalyses. Comparing both extended urinalyses showed a moderate correlation between the eight individual samples and a weak to strong correlation between the mean daytime and nighttime values of renal functions. Different samples could be considered as most representative for mean daytime values, while all samples collected between 03 and 05am showed the highest agreement with mean nighttime values of renal function. CONCLUSION: Since there is a good correlation and agreement between basic and extended urine collections to study the mechanisms underlying urine production, the choice of urine sampling method to evaluate urine production depends on the purpose. A nighttime-only urine sample collected between 03 and 05am may be the most practical approach.

Circadian Rhythms in Water and Solute Handling in Adults with a Spinal Cord Injury.

PURPOSE: We evaluated nocturnal urine production and circadian rhythms of renal function (glomerular filtration, and water and solute diuresis) in adults with spinal cord injury compared to controls. MATERIALS AND METHODS: This prospective observational study was done at Ghent University Hospital, Belgium. Participants were asked to perform a 24-hour urine collection. A blood sample was taken to calculate the diuresis rate and the renal clearance of creatinine, free water, solutes, sodium and urea. RESULTS: A total of 119 patients were divided into 32 with spinal cord injury, and 68 controls with and 19 without nocturnal polyuria. Spinal cord injured patients showed no circadian rhythms in the diuresis rate or in the renal clearance of creatinine, free water, solutes, sodium or urea. Controls without nocturnal polyuria reported a lower nighttime diuresis rate and lower nighttime clearance of creatinine, solutes, sodium and urea compared to daytime levels. Controls with nocturnal polyuria had no circadian rhythms in the diuresis rate or creatinine clearance and a significant increase in nocturnal free water clearance compared to daytime levels. CONCLUSIONS: Comparing the mechanisms underlying nocturnal urine production between patients with spinal cord injury and controls revealed important differences. Spinal cord injured patients showed absent circadian rhythms in the renal clearance of creatinine (glomerular filtration), free water (water diuresis) and solutes such as sodium and urea (solute diuresis). Future research must be done to evaluate the role of patient stratification to find the most effective and safe treatment or combination of treatments for spinal cord injured patients with complaints or complications related to nocturnal polyuria.

Persistent urinary incontinence after a robot-assisted artificial urinary sphincter procedure: lessons learnt from two cases.

This case report describes 2 cases of persistent urinary incontinence in the beginning of the learning curve of robot-assisted bladder neck implantation of an artificial urinary sphincter (RA-AUS) in men at risk for erosion due to neurological lesions. Among a series of 4 RA-AUS, 2 patients still experienced urinary incontinence after surgery. A complete urological workup was strictly normal and did not show any device malfunction. However, during an AUS revision in these two patients, exploration revealed that the cuff was not tight enough. This issue was resolved by placing smaller cuffs. After re-do surgery, one of the two patients no longer had urinary incontinence, while the second patient was lost to follow-up. Insufficient tightness of the cuff could be explained by an inability of the surgeon to feel the force while pulling the cuff around the urethra due to the absence of haptic sensation in robotic surgery.