1. Nocturia: Causes, Consequences and Clinical Approaches
Jeffrey P. Weiss, MD, FACS
Professor and Chair
Department of Urology
SUNY Downstate College of Medicine
Brooklyn, NY

2. Nocturia Definition: voiding during (nocturnal) sleep time
Preceded and followed by sleep (ICS guidelines)
Normal: nocturia < 1x*
Scientific problems:
How to define sleep time
Is patient awakened by the need to void, or,
Do patients void because they’re awake
*van Kerrebroeck et al Neurourol and Urodyn 21: , 2002

3. What triggers nocturia*?
50 men and women
mean # nocturia=2.6
Nocturia awakenings attrib’d to urge vs not
78% nocturic voids prec’d by urge to void
In the remainder the pt awakened for some other reason, then voids out of habit or convenience before going back to sleep
The etiology and treatment of these two groups is likely different
*Blaivas JG, Amirian M, Weiss JP et al: Why do people void at night?. SUFU abstract 2010

4. Nocturia Medical/Renal? Urological/Lower tract dysfunction?
Nocturnal polyuria
Polyuria
Urological/Lower tract dysfunction?
Diminished global/nocturnal bladder capacity

5. Nocturia – at least 1 void/night

6. Nocturia: Consequences
Mediated by Sleep Deprivation

7. Nocturia is associated with increased mortality%
100 95 ≤1 2
Percent survival 90 3 85 ≥4 80
Copyright for abstract book if key slide
Days
Hazard Ratio of all-cause mortality: Night time frequency ≤1
(n=425) 2
(n=219) 3
(n=99) ≥4
(n=41)
p for trend
1.00
1.59 (0.80, 3.17)
2.34 (1.09, 5.00)
3.60 (1.38, 9.35)
<0.01
Adjusted for age, sex, BMI, diabetes, smoking status, history of coronary heart disease renal diseases and stroke, use of tranquilizers, hypnotics, and diuretics.
Nakagawa et al. J Urol 2010;183(Suppl):4 7 7

8. Nocturia is associated with increased mortality
Summary of 3 major new studies
Nakagawa et al.1 (788 men and women, yrs): significantly increased mortality risk in elderly patients with 2, 3, and 4 vs. 1 voids/night
Kupelian et al.2 (15,988 men and women, ≥20yrs): significantly increased mortality risk with 2+ vs. <2 voids/night
Magnitude of the nocturia and mortality association was greater in those younger than 65 years and in those without baseline comorbidities
Lightner et al.3 (2,447 men, yrs): significantly increased mortality risk and CHD risk in younger patients (40 to 59 yrs) with ≥3 voids/night
The impact is greater in younger patients
The impact increases with number of voids
Details from references 3
MORTALITY IN THE ELDERLY CORRELATES WITH THE FREQUENCY OF NIGHTTIME VOIDING: RESULTS OF A 5-YEAR PROSPECTIVE COHORT STUDY IN JAPAN
Haruo Nakagawa*, Sendai, Japan; Kaijun Niu, Aendai, Japan;
Yasuhiro Kaiho, Yoshihiro Ikeda, Yoichi Arai, Sendai, Japan
INTRODUCTION AND OBJECTIVES: Nocturia is a common problem that increases with age. It is often the result of an overproduction of urine at night (nocturnal polyuria), but may also be associated with several pathophysiological conditions, such as cardiovascular disease, diabetes mellitus, sleep apnea syndrome, renal dysfunction, lower urinary tract dysfunction and sleep disorders. An increased mortality rate has been reported with nocturia, and may be related to
these associated conditions, or independently to nocturia. This study aimed to evaluate the association between night time frequency and
mortality in a community-based elderly population.
METHODS: We conducted a Comprehensive Geriatric Assessment of all residents aged 70 years in 2003 in an urban district of north Japan. The population-based cross-sectional survey was conducted using an extensive health interview for each participant. Mortality was investigated using data from the national health insurance system over 5 years. Differences in survival stratified by the night time frequency of urination were assessed with Kaplan-Meier curves. Hazard
ratios (HRs) were estimated from multivariate Cox proportional hazard models.
RESULTS: Seven hundred and eighty-eight subjects were included in the study (28.9% participation rate; 429 females, 359 males; mean age 76.0 years: range: years). Kaplan-Meier curves representing mortality are shown in Figure 1. After multivariable adjustment, the HRs (95% confidence intervals) for mortality were 1.59
( ), 2.34 ( ) and 3.60 ( ) for people who voided 2, 3 and 4 times/night compared with 1 per night (p-value for trend 0.01: Table 1). The number of nighttime voiding episodes was associated with a significantly increased mortality.
CONCLUSIONS: We conclude that there is a significantly increased mortality associated with the nighttime frequency of urination, even after adjustment for several factors that could contribute to mortality. 56
NOCTURIA IS A MARKER OF INCREASED MORTALITY RISK:
RESULTS FROM THE THIRD NATIONAL HEALTH AND
NUTRITION EXAMINATION SURVEY
Varant Kupelian*, Watertown, MA; Mary Fitzgerald, Maywood, IL;
Steven Kaplan, New York, NY; Jens Peter Norgaard, Copenhagen,
Denmark; Gretchen Chiu, Raymond Rosen, Watertown, MA
INTRODUCTION AND OBJECTIVES: Nocturia, a common
symptom in both men and women, has been shown to be associated
with chronic illnesses such as heart disease and hypertension. Using
data from the Third National Health and Nutrition Examination Survey
(NHANES III), the objective of this study is to investigate the association
of nocturia with subsequent mortality risk.
METHODS: NHANES III is a national probability survey of the
U.S. conducted between 1988 and Nocturia was assessed by the
question “how many times a night do you usually get up to urinate (pass
water)?”. Mortality data was obtained by linkage of the NHANES III to
death certificate data found in the National Death Index with follow-up
through December 31, Cox proportional hazards regression
models were used to assess the association between nocturia and
mortality and to control for the effect of potential confounders and effect
modifiers. Analyses were conducted on a sample of 15,988 men and
women age 20 and older.
RESULTS: Overall prevalence of nocturia, defined as two or
more episodes of urination per night, was 15.5% among men and
20.9% among women, and increased rapidly with age. Multivariate
analyses show a statistically significant trend towards increased mortality
risk with increased number of voiding episodes among both men
and women. Analyses stratified by age groups (50, 50-64, and 65 and
older), show associations of larger magnitudes in the younger age
groups with attenuated but statistically significant associations in the
oldest age group. Adjustment for heart disease, diabetes, and obesity
suggests that the association between nocturia and mortality is only
partially explained by those chronic conditions.
CONCLUSIONS: Nocturia is a predictor of mortality, more so in
relatively younger men and women, rather than in the elderly. Comorbid
conditions that are already recognized as being related to nocturia,
only partially explain the increased risk of mortality. This suggests that
other, unmeasured factors are contributory. Possible candidates include
effects of sleep disruption and of other unrecognized comorbid
medical conditions.
Association of nocturia and mortality by gender and age. Unadjusted
and adjusted hazard ratios (HR) and 95% confidence intervals
(95%CI) comparing respondents with nocturia >2
to those with nocturia <2 per night.
Age
Men Women
Unadjusted HR
(95% CI)
Adjusted HR*
(95%CI)
(2.20, 7.63) 2.56 (1.32, 4.94) 2.70 (1.53, 4.76) 1.10 (0.66, 1.86)
(1.40, 3.02) 1.60 (1.06, 2.41) 2.25 (1.56, 3.25) 1.94 (1.27, 2.96)
(1.36, 2.00) 1.35 (1.11, 1.63) 1.54 (1.31, 1.82) 1.19 (1.04, 1.37)
Overall 4.75 (3.95, 5.72) 1.49 (1.25, 1.78) 3.58 (3.05, 4.20) 1.32 (1.14, 1.51)
*Adjusted for age, BMI, marital status, education, smoking, CVD, diabetes, hypertension,
medications use (diuretics, antihypertensive, lipid lowering, antidepressants)
1527
SIGNIFICANT NOCTURIA IS ASSOCIATED WITH AN INCREASED
RISK OF CORONARY HEART DISEASE AND DEATH
Deborah Lightner*, Amy Krambeck, Debra Jacobson, Michaela
McGree, Rochester, MN; Steven Jacobsen, Pasadena, CA; Michael
Lieber, Veronique Roger, Rochester, MN; Cynthia Girman, Chapel
Hill, NC; Jennifer St. Sauver, Rochester, MN
INTRODUCTION AND OBJECTIVES: Nocturia is increasingly
seen as a marker of overall health, and specifically of cardiac
risk. We examined the associations between nocturia and development
of diabetes, hypertension, coronary heart disease (CHD) and
death in a population-based cohort of men.
METHODS: A randomly selected cohort of 2,447 Caucasian
men, aged years in 1990, from Olmsted County, MN was
enrolled in the study (55% baseline participation). Participants completed
a questionnaire that assessed lower urinary tract symptoms
(LUTS) with questions similar to the AUA Symptom Index (AUASI).
Nocturia was defined as awakening to urinate 0, 1, 2, or 3 or more
times a night. Diabetes was determined by self-report or use of
anti-hyperglycemic medication. Hypertension was determined by
self-report or use of anti-hypertensive medication. CHD was ascertained
through ongoing surveillance of heart disease in Olmsted
County (RO1 HL 59205; Principal Investigator: VL Roger). Proportional
hazard models were used to determine associations between
baseline nocturia and time to development of diabetes, hypertension,
CHD or death.
RESULTS: At baseline, 934 (39%), 1055 (43%), 247 (10%)
and 193 (8%) men reported awakening to urinate 0, 1, 2 and 3 or
more times per night, respectively. Baseline nocturia was not associated
with the development of diabetes or hypertension. However,
baseline nocturia of 3 or more times per night was associated with
development of CHD among younger men (40 to 59 years old at
baseline; hazard ratio (HR): 2.06, 95% confidence interval (CI): 1.11,
3.82). This association was not observed in men greater than 60
years old (HR: 0.90, 95% CI: 0.54, 1.48). Baseline nocturia of 3 or
more times per night was also associated with an increased risk of
death (age-adjusted HR: 1.59, 95% CI: 1.20, 2.11). This association
remained after further adjustment for CHD (age and CHD-adjusted
HR: 1.49, 95% CI: 1.12, 1.99).
CONCLUSIONS: Significant nocturia in young men appears
to be associated with CHD and mortality, but not with other markers
of vascular status, such as diabetes and hypertension. As the
etiology of nocturia was not determined, attribution is not possible,
but men under 60 years of age with significant nocturia may be
candidates for further evaluation.
Nakagawa et al. J Urol 2010;184:
Kupelian et al. J Urol Vol. 185, , February 2011
Lightner et al. AUA 2010

9. Nocturia: Evaluation
Simple arithmetic analysis of 24 hour voiding diary
First AM voided volume included in NUV
First AM void diurnal, not nocturnal

10. Diary Assessment NPi (Nocturnal polyuria index = NUV/240 volume):
Ni (Nocturia index = NUV/MVV):
Ni >1: Nocturia occurs because functional bladder capacity (maximum voided volume) is exceeded

11. Diary Assessment: NBCi
NBCi (Nocturnal Bladder Capacity index) > 0: Diminished nocturnal bladder capacity
Higher NBCi >> Nocturia occurs at voided volumes < MVV

12. Diary Assessment: NBCi
NBCi = Actual minus Predicted # nightly voids (ANV-PNV)
PNV = Ni - 1
Example: Patient with Nocturia (ANV) x7
NUV = 750 ml
MVV = 250 ml
Ni = NUV / MVV = 3
PNV = 3-1 = 2
NBCi = ANV-PNV = 7-2 = 5

13. Formulas for evaluation of nocturia
Analysis
Nocturia index
Ni = NUV  MVV
Ni >1  nocturia is due to NUV exceeding MVV
Nocturnal Polyuria index
NPi = NUV  24hV
NPi >33%  Dx is nocturnal polyuria
Nocturnal bladder capacity index
Ni – 1 = PNV
NBCi = ANV – PNV
NBCi >0  nocturia occurring at volumes < MVV

14. Nocturia Category Causes Congestive heart failure Diabetes mellitus
Nocturnal polyuria
Congestive heart failure
Diabetes mellitus
Obstructive sleep apnea
Peripheral edema
Excessive nighttime fluid intake

15. Diminished global/NBC
Nocturia Category
Causes
Diminished global/NBC
Prostatic obstruction
Nocturnal detrusor overactivity
Neurogenic bladder
Cancer of bladder, prostate, or urethra
Learned voiding dysfunction
Anxiety disorders
Pharmacologic agents
Bladder calculi
Ureteral calculi

16. Nocturia Category Causes Polyuria (global) Diabetes mellitus
Diabetes insipidus
Primary polydipsia

17. Summary
Classification of nocturia through use of the voiding diary “unlocks” up to 17 significant underlying medical conditions which potentially contribute to its genesis
Efficacy of nocturia treatment based upon this analysis is unproven
summary

18. Nocturia: Classification
Nocturnal polyuria (NP)
Diminished global/nocturnal bladder capacity (NBC)
Mixed (NP +  NBC)
Polyuria

19. Nocturnal polyuria: “medical” cause for nocturia
NUV > 6.4 ml / kg*
Nocturnal diuresis  0.9 ml/min (54 ml/hr)
Krimpen study (Bosch): Men 50-78: mean NUV=60 ml/hr
Suggest NP cutpoint >90 ml/hr**
NUV/24h urine ≥ 0.33 (ICS)
<25 years: mean NPi=0.14
>65 years: mean NPi=0.34***
*Matthiesen, T.B., et al: J. Urol., 156: 1292, 1996
**Blanker, M. H. et al: J. Urol., 164: 1201, 2000
***Kirkland J.L. et al: Br Med J., 287: 1665, 1983

20. Sleep Disordered Breathing / Nocturia
Sleep apnea: Sudden cessation of respiration due to airway obstruction during sleep
Older adults with severe SDB have a greater number of nocturia episodes
Yalkut, D., et al.: J. Lab. Clin. Med., 128: 322, 1996
Endeshaw, YW et al: J Am Geriatrics Soc. 52(6):957-60, 2004

21. Sleep Apnea: Rx with nasal CPAP (continuous positive airway pressure)
*Nocturia in 88 men studied with OSA: avg. x3.8 ± 0.4
Diminished to x 0.7 ± 0.27 after Rx with nasal CPAP*
**Nocturia in 196 women: median 3 episodes > 0 episodes per night (p<.001) with CPAP
“Nocebo” effect of CPAP machine obviates lack of placebo
Greater contribution to nocturia etiology in younger pts***
*Guilleminault C, Lin CM, Goncalves MA and Ramos E: J Psychosomatic Res 56: , 2004
**Fitzgerald MPet al: Am J Obstet Gynecol. 2006;194:
***Moriyama Y, Miwa K, Tanaka H et al. Urology 2008; 71:1096-8

22. Remember: Patients are on many agents which may cause nocturia
Increased urine output
Insomnia and CNS effects
Direct LUT effects
Diuretics
CNS stimulants (dextroamphetamine, methylphenidate)
Ketamine: Direct toxin
SSRIs
Antihypertensives (alpha-blockers, beta-blockers, methyldopa)
Tiaprofenic acid (Surgam): Toxic cystitis
Calcium channel blockers
Respiratory (albuterol, theophylline)
Cyclophosphamide
Tetracycline
Decongestants (phenylephrine, pseudoephedrine)
Lithium
Hormones (corticosteroids, thyroid)
Psychotropics (MAOIs, SSRIs, atypical antidepressants)
Dopaminergic agonists (carbidopa)
Antiepileptics (phenytoin)

23. Pharmacological treatment of nocturnal polyuria
(Timed) Diuretics
Prevent water accumulation by forcing water out of the system
May be helpful in patients with lower limb venous insufficiency or congestive cardiac failure
Level 2 evidence, Grade C recommendation (ICI 2005)
Bumetanide 1mg po in afternoon (Pederson PA et al BJU 1988)
Furosemide 40mg po in afternoon (Reynard JM et al BJU 1998)
(Timed) Antidiuretics
Helps retain water until a more appropriate time
Reduce nocturnal voids and voided volume
Level 1 evidence, Grade A recommendation
Desmopressin 0.1mg po titrated to 0.4mg (van Kerrebroeck PE et al: Desmopressin in the treatment of nocturia: a double-blind, placebo-controlled study. Eur Urol 2007; 52: 221.)
No direct bladder effect
No direct cardiovascular actions
Hyponatremia main potentially adverse effect

24. Nocturia: Classification
Nocturnal polyuria (NP)
Diminished global/nocturnal bladder capacity (NBC)
Mixed (NP +  NBC)
Polyuria

25. Causes of Low global/NBC: Urologic
Infravesical obstruction
Idiopathic nocturnal detrusor overactivity
Neurogenic bladder
Cystitis: bacterial, interstitial, tuberculous, radiation
Cancer of bladder, prostate, urethra

26. Other causes of low global/NBC
Learned voiding dysfunction
Anxiety disorders
Pharmacologic
xanthines (theophylline, caffeine)
beta-blockers
Other (see next slide)
Bladder calculi
Ureteral calculi

27. Drug effects Increased urine output Insomnia and CNS effects
Direct LUT effects
Diuretics
CNS stimulants (dextroamphetamine, methylphenidate)
Ketamine: Direct toxin
SSRIs
Antihypertensives (alpha-blockers, beta-blockers, methyldopa)
Tiaprofenic acid (Surgam): Toxic cystitis
Calcium channel blockers
Respiratory (albuterol, theophylline)
Cyclophosphamide
Tetracycline
Decongestants (phenylephrine, pseudoephedrine)
Lithium
Hormones (corticosteroids, thyroid)
Psychotropics (MAOIs, SSRIs, atypical antidepressants)
Dopaminergic agonists (carbidopa)
Antiepileptics (phenytoin)

28. Low global/NBC: Treatment
Dx & Rx of remediable conditions
Empiric Rx

29. Nocturia persists despite prostate surgery
Third National Health and Nutrition Examination Survey (NHANES III) in the USA showed
Amongst those who undergo TURP, Nocturia (≥2 voids per night) persists for
41% of 60–69 year olds
50% of ≥70 year olds
P=0.099 and in paper
Platz et al. Urology 2002;59;877–883

30. Patients scoring ≥2 before TURP
TURP and nocturia
118/138 (85.5%) BPO patients had nocturia before TURP
After treatment, 91 of these (77.1%) still reported nocturia
Mean improvement in nocturia score (1.0) significantly inferior to improvements for all other IPSS symptoms
Patients scoring ≥2 before TURP
Patients scoring ≥2
after TURP
Rate of response (%)
Emptying
102 27
54.3
Voiding frequency
116 63
38.4
Intermittency
101 33
49.3
Urgency
103 70
37.0
Weak stream
122 35
63.0
Hesitancy 84 18
47.8
Nocturia
118 91
19.6
Yoshimura et al. Urology 2003;61:786–790

31. Summary* 5 ARI : Little success
α (-) : Occ statistical, not clinically
5 ARI + α (-) : Same as α - blocker
Antimuscarinics : Some statistical, minimal clinical
AntiM + α (-) : Some statistical, minimal clinical
Optimal group: Large # N episodes, most due to severe urgency, no NP
Likely that other types of therapy will be necessary to achieve a clinically significant reduction in nocturia
* AJ Wein MD

32. Nocturia: Classification
Nocturnal polyuria (NP)
Diminished global/nocturnal capacity (NBC)
Mixed (NP +  NBC)
Polyuria

33. “Mixed” Nocturia etiology
Review of 194 consecutive patients with nocturia
13 (7%) had NP, 111 (57%)  NBC, 70 (36%) had “mixed” etiology
Forty-five (23%) also had polyuria
NP = a significant component of nocturia in 43% of the patients
Conclude: Etiology of nocturia multifactorial and often unrelated to underlying urologic condition
Weiss JP, Stember DS and Blaivas JG: Nocturia in adults: Classification and etiology. Neurourol Urodyn 16:401, 1997

34. Nocturia: Classification
Nocturnal polyuria (NP)
Diminished global/nocturnal bladder capacity (NBC)
Mixed (NP +  NBC)
Polyuria

35. Polyuria Polyuria (24 hr urine output > 40 ml/kg)
Once steady state is reached polyuria is associated with excessive oral intake (polydipsia)
Results in both day and night urinary frequency due to global urine overproduction in excess of bladder capacity

36. Common Causes of Polyuria
Diabetes mellitus
Diabetes insipidus
Polydipsia: Primary thirst disorder (dipsogenic, psychogenic)

37. Diabetes Insipidus (DI)
Disorder of water balance
Inappropriate excretion of water leads to polydipsia to prevent circulatory collapse
Central vs Nephrogenic

38. Central DI Deficient ADH synthesis or secretion
Causes: Loss of neurosecretory neurons in hypothalamus or posterior pituitary gland

39. Nephrogenic DI ADH secretion normal
Kidneys are non-responsive (eg chronic renal failure)

40. Polyuria: Diagnostic algorithm
Overnight water deprivation (OWD)
If normal, DDx is polydipsia, either dipsogenic or psychogenic
If OWD is abnormal, do renal concentrating capacity test (DDAVP)
If RCCT normal, Dx = central DI: Tx with DDAVP
If RCCT abnormal, Dx = nephrogenic DI: No specific treatment

41. Water deprivation test
No drinking overnight
Normal: first AM urine osmolality > mOsm/kg H2O
Normal means that there is normal AVP secretion and normal renal response

42. Renal Concentrating Capacity Test
40 mcg desmopressin intranasally (0.4 mg po)
Bladder emptied; urine sample for osmolality obtained 3-5 hours later
Water intake restricted for the first 12 hours after drug administration
Normal > 800 mOsm/kg H2O

43. Normal water deprivation studies Dipsogenic vs. psychogenic
Primary polydipsia
Normal water deprivation studies
Dipsogenic vs. psychogenic
Dipsogenic polydipsia associated with Hx central neurologic abnormality such as Hx of brain trauma, radiation
Psychogenic polydipsia is long-term behavioral or psychiatric disorder

44. Polyuria: Treatment of Remediable Conditions
Reduce water intake in patients without DI
Treat diabetes mellitus
Vasopressin analogues in patients with central DI
Psychotherapy for compulsive water drinkers

45. Antidiuretics: Indications
Antidiuretic hormone vasopressin is important for urinary concentration
Antidiuretic therapy (desmopressin*) affects urine production. Proven benefit in treatment of polyuric conditions:
Pituitary diabetes insipidus
Primary nocturnal enuresis (PNE)
Nocturia
* vasopressin analogue

46. Desmopressin: mechanism of action
Desmopressin is a selective V2-receptor agonist:
Retains antidiuretic properties of vasopressin1
Lacks unwanted pressor activity of vasopressin
Desmopressin, when bound to V2-receptors in kidney:
Increases tubular water permeability
Enhances water reabsorption
Extracellular fluid = more dilute
Urine = more concentrated2
ICI and EAU recommendations added.
Recommendation references:
In Abrams et al. (eds) Incontinence; 4th International Consultation on Incontinence. Paris: Health Publication Ltd, 2009
2010 EAU nocturia guideline (part of "Guidelines on Conservative Treatment of Non-neurogenic Male LUTS", desmopressin is featured in section 3.5).
Recommendations for desmopressin in nocturia: ICI: Grade A (Level 1 evidence); EAU: Grade A (Level 1b evidence)
References
1. Vilhardt H. Drug Investigation 1990; 2(Suppl. 5):2–8.
2. Hammer M and Vilhardt H. J Pharmacol Exp Ther 1985; 234(3):754–760.

47. Desmopressin formulations
Intranasal: 10 mcg/spray; Max 40 mcg/day (CDI indication only)
Oral: 0.1 mg tablets; Max 0.6 mg/day for PNE
Melt: 60, 120, 240 mcg melt tabs
Melt in development: 25 mcg (women) and mcg (men)
New doses added

48. Ferring US Nocdurna Study Results – All Subjects
Pbo
N=156
10 μg
N=155
25 μg
N=152
50 μg
N=148
100 μg
N=146
Change from baseline
-0.86
-0.83
-1.00
-1.18
-1.43
33% Responders
47%
50%
53%
71%
HN < 130 mmol/L 1 2 5 9 17
HN < 125 mmol/L 4
First sleep (min) 39 51 83 85
107
ΔNoct diurese (ml)
-109
-164
-224
-272
-312 48

49. Summary of recommendations for potential desmopressin patients
All patients – use voiding diary
Global polyuria – exclude for further evaluation
Low volume per void and no nocturnal polyuria – other Rx?
? Dosing differential between genders
Baseline sodium a good idea
Where does pediatric ”no need” to check Na+ end and adult ”need” begin?
Elderly (>65 years) with nocturnal polyuria
All need baseline serum sodium
Closely monitor serum sodium at 4 and 28 days after starting therapy or increasing dose
Monitor fluid intake
Use judgment: It’s always OK to check serum Na if you think it’s necessary

51. Nocturia: Future Considerations
Outcome studies
Behavioral modification
Stockings
Targeted therapy
? Desmopressin for nocturnal polyuria
? Antimuscarinics for nocturnal urgency
Treatment of Nocturia irrespective of bother?
Is nocturia itself morbid or just a symptom of a morbid underlying condition?
Analagous to
HTN
Hypercholesterolemia

52. Nocturia: Discussion/Questions