The hidden health problem of nocturia

nocturia, health problem
© Tero Vesalainen

Dr Deborah Lee, Dr Fox Online Pharmacy, explains the problem of nocturia and takes a look at what it actually means for your health

Getting up at night to have a pee is so common, many of us probably think it’s normal. But in fact, this is far from the case. There are serious health implications from nocturia, and much can be done to improve it.

Many people remain embarrassed and unaware of the implications or the management options, yet nocturia is known to severely restrict quality of life.

  • What is nocturia?
  • What causes it?
  • Why does it matter?

Read on and find out more.

What is nocturia?

The Incontinence Society define nocturia as “the complaint that the individual has to wake one or more times a night for voiding,”  and that each void is preceded or followed by sleep. Most people can put up with getting up once at night to pee, but twice or more gets very bothersome.

Technically, nocturia is said to be present if the volume of urine passed at night is more than 20% of the 24-hour urine volume in younger people, and more than 33% in older people aged 65 or older. This does not include the last pee before bedtime but does include the first pee in the morning.

The only way to know this for sure is to measure the urine output and keep a bladder diary, but this is usually only done for research purposes.

How common is it?

Getting up at night to pee is very common and is not just a problem of older age. In a 2015 study, 18.2% of women aged 18 -30 got up at least once a night to pee. In another study  of people aged over 40, 34% of men and 28% of women, were needing to pee at least once a night. In the 70-80-year age group, approximately 60% of men and women got up twice a night to pass urine.

Does it matter?

We know that getting 7-hours a night of good quality sleep is vital for health.

One of the main reasons nocturia has a negative impact on health, is that is disturbs sleep. When sleep is interrupted, and the sleep pattern is altered, the end result is daytime sleepiness, tiredness, and mood changes. There is also an increased susceptibility to infections. Poor sleep can also affect thought processes and slow reaction times, leading to reduced work performance, and an increased risk of accidents, including road traffic accidents. Sleep deprivation is known to be linked to increased mortality.

Reasons for this include the fact that frequent waking at night leads to loss of REM sleep – deep, restorative sleep – during which your body is busy undertaking numerous, extensive, cellular repair and regeneration processes. Cognitive functioning and memories are processed during this time. When you lack REM sleep, you wake unrefreshed in the mornings, and feel less alert, meaning accidents are more likely, and can result in falls and fractures.

Sleep deprivation also leads to an increased risk of high blood pressure, type-2 diabetes, heart disease, depression, and cancer.

What are the causes of nocturia?

There are many possible causes of nocturia.

Note that the following conditions cause polyuria, which means an increased need to pass urine during both day and night:

  • Drinking a lot of fluids
  • Diabetes – Type 1, and type 2 diabetes mellitus, diabetes insipidus, and diabetes in pregnancy (gestational diabetes)

Night-time nocturia may be due to:

  • Cardiac failure
  • Oedema (swelling) affecting the lower limbs of any cause
  • Sleep disorders – including obstructive sleep apnoea (OSA)
  • Drugs – such as diuretics, digoxin, lithium, phenytoin, and high dose vitamin D
  • Excess caffeine or alcohol, especially close to bedtime
  • A high salt diet

Bladder causes include:

  • Bladder obstruction, such as an enlarged prostate
  • An irritable bladder
  • A bladder, or urinary tract infection
  • Interstitial cystitis
  • Bladder cancer

Women may develop nocturia due to:

  • Menopausal estrogen deficiency
  • Prolapse
  • After gynaecological surgery

Less commonly nocturia may be due to:

  • Pressure on the spinal cord, due to spinal stenosis or neurological conditions affecting bladder control

Should you be drinking water overnight?

Many people believe they should be drinking water overnight, but in fact, this is not true. Your body is cleverly designed to regulate your fluid intake from food and drink, and your fluid loss as in what you lose every day in the form of urine, faeces, and sweat. This is the job of a clever hormone called antidiuretic hormone (ADH).

What happens if you haven’t had a drink?

If you haven’t had a drink for a while, the brain (hypothalamus) detects this and sends a message to the kidney to secrete ADH. As a result, the kidney absorbs more water from the blood. Hence, more water remains in the blood circulation, and a smaller amount of urine collects in the bladder.

What happens if you have had a drink?

If you have recently had a drink of water, this is absorbed through the stomach and intestines into the bloodstream. The hypothalamus detects there is more water in the circulation and tells the kidney to stop producing ADH. As a consequence, when blood passes through the kidney, less water is reabsorbed into the bloodstream, so there is an increased volume of water passing out into the urine. As the bladder fills up with a greater volume of urine, the more you feel the need to pee.

Your body controls the volume of fluid like this, so that your blood plasma concentration always stays within normal limits. If you go all day without drinking any water, or if you have had a night out and drunk a large amount, your fluid balance system can cope with these peaks and troughs of water intake. This means your body is robust and can cope overnight with no problem if you do not drink any water.

When to see the doctor?

If you are frequently waking up at night to pee, it’s probably best to see your GP. This is especially true if this is a new symptom. You need to have a check-up, to exclude common conditions such as diabetes, a urinary tract infection, or kidney disease. Your GP will advise you on how best to improve your symptoms.

How to reduce nocturia

Here are some steps to help improve nocturia:

  • Keep a fluid diary – Keep a written record of how much you have had to drink, and when, over a 7-day period. Also record how often you had to get up to pee at night. You may notice a pattern which will give you a baseline for making improvements.
  • Restrict fluids – Avoid any drinks in the 2 hours before bedtime, especially caffeine or alcohol. Caffeine is not recommended after 6 pm.
  • Regular exercise – Getting enough physical exercise is very important. Research has shows men who participate in at least one hour of physical exercise per week are 13% less likely to experience nocturia, and 34% less likely to experience severe nocturia. This may be because exercise helps lower your BMI, improves  sleep and reduces levels of chronic inflammation.
  • Benefits of weight loss – Being overweight or obese has a close association with nocturia. There are several reasons for this. Increasing amounts of intrabdominal fat exert increased physical pressure onto the bladder. In addition, some people who are obese are prone to night-time snacking. In men, obesity is associated with enlargement of the prostate. However, losing weight improves nocturia.
  • Eat less salt – The vast majority of people consume more than twice the daily recommended amount of salt. This is dangerous for health as it is a major cause of high blood pressure and heart disease. But eating too much salt is also a cause of nocturia because excess salt makes you thirsty, so you drink more. You can improve nocturia by lowering the salt content of your diet. Don’t add salt to food, use a low-sodium salt, and avoid salty snacks like salted peanuts and crisps.
  • Pelvic floor exercises – In women, Kegel exercises have been shown to reduce the symptoms of an overactive bladder.
  • Medication – Take diuretics (water pills), first thing in the morning, not at night, so the need to pass a larger amount of urine will long since have disappeared when it’s time for bed later in the evening.
  • Put your feet up – When you get into bed and lie flat, any fluid which has collected in your lower legs and around your ankles during the day, when you were in the upright position, will be forced back into the bloodstream. This excess fluid will then need to be passed out in the urine. To avoid having to get out of bed soon after you get in, make sure you get your legs up in the afternoon and early part of the evening, so this fluid return has taken place, and you have peed out this extra urine before you get into bed. You do need to get your legs right up above the level of your heart.
  • Stop smoking – Several studies have shown that smoking is linked to nocturia. Giving up smoking is the single best thing you can do for your health. Smoking results in bladder inflammation and irritability.

Don’t be embarrassed about nocturia. You are by no means alone. You don’t need to suffer in silence. As you can see here, there are serious conditions such as diabetes that need to be excluded. Once you have seen your GP and had some basic tests, there is much that can be done to improve your symptoms, your sleep, and your quality of life.

Is it time you made that appointment?

For more information

Contributor Profile

Freelance Health Writer, BM MRCGP FFSRH DRCOG Dip GUM
Dr Fox Online Pharmacy
Phone: +44 (0)117 2050198
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