Nocturia

Nocturia — excessive urination at night — may result from disruption of the normal diurnal pattern of urine concentration or from overstimulation of the nerves and muscles that control urination. Normally, more urine is concentrated during the night than during the day. As a result, most people excrete three to four times more urine during the day and can sleep for 6 to 8 hours during the night without being awakened. The patient with nocturia may awaken one or more times during the night to empty his bladder and excrete 700 ml or more of urine.

Although nocturia usually results from renal and lower urinary tract disorders, it may result from certain cardiovascular, endocrine, and metabolic disorders. This common sign may also result from drugs that induce diuresis, particularly when they’re taken at night, and from drinking large quantities of fluids, especially caffeinated beverages or alcohol, at bedtime.

History and physical examination

Begin by exploring the history of the patient’s nocturia. When did it begin? How often does it occur? Can the patient identify a specific pattern? Precipitating factors? Also, note the volume of urine voided. Ask the patient about changes in the color, odor, or consistency of his urine. Has the patient changed his usual pattern or volume of fluid intake? Next, explore associated symptoms. Ask about pain or burning on urination, difficulty initiating a urine stream, costovertebral angle (CVA) tenderness, and flank, upper abdominal, or suprapubic pain.

Determine if the patient or his family has a history of renal or urinary tract disorders or endocrine and metabolic diseases, particularly diabetes. Is the patient taking a drug that increases urine output, such as a diuretic, a cardiac glycoside, or an antihypertensive?

Focus your physical examination on palpating and percussing the kidneys, CVA, and bladder. Carefully inspect the urinary meatus. Inspect a urine specimen for color, odor, and the presence of sediment.

Medical causes

Benign prostatic hyperplasia (BPH)

Common in men older than age 50, BPH produces nocturia when significant urethral obstruction develops. Typically, it causes frequency, hesitancy, incontinence, reduced force and caliber of the urine stream and, possibly, hematuria. Oliguria may also occur. Palpation reveals a distended bladder and an enlarged prostate. The patient may also complain of lower abdominal fullness, perineal pain, and constipation. Obstruction may lead to renal failure.

Cystitis

All three forms of cystitis may cause nocturia marked by frequent, small voidings and accompanied by dysuria and tenesmus.

Bacterial cystitis may also cause urinary urgency; hematuria; fatigue; suprapubic, perineal, flank, and lower back pain; and, occasionally, a low-grade fever. Most common in women between ages 25 and 60, chronic interstitial cystitis is characterized by Hunner’s ulcers — small, punctate, bleeding lesions in the bladder; it also causes gross hematuria. Because symptoms resemble bladder cancer, this must be ruled out.

Viral cystitis also causes urinary urgency, hematuria, and a fever.

Diabetes insipidus

The result of antidiuretic hormone deficiency, diabetes insipidus usually produces nocturia early in its course. It’s characterized by periodic voiding of moderate to large amounts of urine. Diabetes insipidus can also produce polydipsia and dehydration.

Diabetes mellitus

An early sign of diabetes mellitus, nocturia involves frequent, large voidings. Associated features include daytime polyuria, polydipsia, polyphagia, frequent urinary tract infections, recurrent yeast infections, vaginitis, weakness, fatigue, weight loss and, possibly, signs of dehydration, such as dry mucous membranes and poor skin turgor.

Hypercalcemic nephropathy

With hypercalcemic nephropathy, nocturia involves the periodic voiding of moderate to large amounts of urine. Related findings include daytime polyuria, polydipsia and, occasionally, hematuria and pyuria.

Prostate cancer

The second leading cause of cancer deaths in men, prostate cancer usually produces no symptoms in the early stages. Later, it produces nocturia characterized by infrequent voiding of moderate amounts of urine. Other characteristic effects include dysuria (most common symptom), difficulty initiating a urine stream, an interrupted urine stream, bladder distention, urinary frequency, weight loss, pallor, weakness, perineal pain, and constipation. Palpation reveals a hard, irregularly shaped, nodular prostate.

Pyelonephritis (acute)

Nocturia is common with acute pyelonephritis and is usually characterized by infrequent voiding of moderate amounts of urine, which may appear cloudy. Associated signs and symptoms include a high, sustained fever with chills, fatigue, unilateral or bilateral flank pain, CVA tenderness, weakness, dysuria, hematuria, urinary frequency and urgency, and tenesmus. Occasionally, anorexia, nausea, vomiting, diarrhea, and hypoactive bowel sounds may also occur.

Renal failure (chronic)

Nocturia occurs relatively early in chronic renal failure and is usually characterized by infrequent voiding of moderate amounts of urine. As the disorder progresses, oliguria or even anuria develops. Other widespread effects of chronic renal failure include fatigue, an ammonia breath odor, Kussmaul’s respirations, peripheral edema, elevated blood pressure, a decreased level of consciousness, confusion, emotional lability, muscle twitching, anorexia, a metallic taste in the mouth, constipation or diarrhea, petechiae, ecchymoses, pruritus, yellow- or bronze-tinged skin, nausea, and vomiting.

Other causes

Drugs

Any drug that mobilizes edematous fluid or produces diuresis (for example, a diuretic or cardiac glycoside) may cause nocturia; obviously, this effect depends on when the drug is administered.

Special considerations

Patient care includes maintaining fluid balance, ensuring adequate rest, and providing education. Monitor the patient’s vital signs, intake and output, and daily weight; continue to document the frequency of nocturia, the amount, and specific gravity. Plan administration of a diuretic for daytime hours, if possible. Also plan rest periods to compensate for sleep lost because of nocturia.

Prepare the patient for diagnostic tests, which may include routine urinalysis; urine concentration and dilution studies; serum blood urea nitrogen, creatinine, and electrolyte levels; and cystoscopy.

Pediatric pointers

In children, nocturia may be voluntary or involuntary. The latter is commonly known as enuresis, or bedwetting. With the exception of prostate disorders, causes of nocturia are generally the same for children and adults.

However, children with pyelonephritis are more susceptible to sepsis, which may display as a fever, irritability, and poor skin perfusion. In addition, girls may experience vaginal discharge and vulvar soreness or pruritus.

Geriatric pointers

Postmenopausal women have decreased bladder elasticity, but urine output remains constant, resulting in nocturia.

Book Source Details

• Book Title: Handbook of Signs & Symptoms (Third Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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