Elsevier

European Urology

Volume 62, Issue 5, November 2012, Pages 877-890
European Urology

Review – Voiding Dysfunction
A Contemporary Assessment of Nocturia: Definition, Epidemiology, Pathophysiology, and Management—a Systematic Review and Meta-analysis

https://doi.org/10.1016/j.eururo.2012.07.004Get rights and content

Abstract

Context

Nocturia is a common urologic symptom that has been covered in a variety of reported studies in the literature but is not specifically covered in current guidelines.

Objective

To comprehensively review the literature pertaining to the definition, etiologies, and consequences of nocturia and assess the evidence supporting the use of conservative medical and interventional therapy.

Evidence acquisition

A literature search was conducted using the keyword nocturia, restricted to articles in the English language, after 2000 and before April 2012, in PubMed/Medline, Embase, Scopus, Web of Science, and Cochrane Library databases. Regarding treatment modalities, studies were included only if nocturia was a primary end point and if the studies were designed as randomized controlled trials without limit of date. When suitable, a meta-analysis was conducted. Papers covering treatment options for nocturia specifically related to nonurologic conditions were excluded.

Evidence synthesis

Nocturia is still defined as the symptom of wakening from sleep once or more often to void. The prevalence is high in both genders and increases with age. Frequency–volume charts, which are the pivotal tool of clinical assessment, detect 24-h polyuria, nocturnal polyuria (NP), or reduced nocturnal bladder capacity and help to target specific nonurologic etiologies. Nocturia is a morbid condition that significantly affects quality of life and increases mortality. Besides behavioral measures, validated treatment options include oral desmopressin, which is superior to placebo in treating NP. While the level of evidence for desmopressin is high, limited data support the use of α1-blockers and antimuscarinics; however, only rarely has nocturia been a primary end point when studying these drug classes, and studies have not consistently controlled for the effect of NP.

Conclusions

Our knowledge of nocturia, its etiology, and its management has substantially improved in recent years. The evidence available on the management of nocturia remains limited; contributory factors include (1) the complexity of associated conditions, (2) the underuse of objective evaluation tools, and (3) the lack of specific focus on nocturia in clinical trials.

Introduction

Nocturia is a well-recognized, highly prevalent symptom in both men and women [1]. The term nocturia is defined by the International Continence Society (ICS) as “the complaint that the individual has to wake at night one or more times to void” [2]. In epidemiological studies, nocturia is often associated with a range of other lower urinary tract symptoms (LUTS) and, especially in elderly patients, is often not seen as the principal symptom [3]. Nocturia is even considered by some authors as “normal” and is not considered a major reason for seeking treatment [4], [5]. Clearly, nocturia is a symptom, not a disease. Similarly, it is classified as one component of common urologic conditions harbored by community-dwelling individuals, such as LUTS, overactive bladder (OAB), and urinary incontinence. As a matter of fact, despite the high prevalence, diverse etiology, and clinical importance of nocturia, no existing guideline has specifically addressed the subject of nocturia and its management over the last decade since the first landmark ICS document [2].

The last decade has been marked by a growing interest in nocturia as a specific symptom, in particular considering its etiology and consequences. This movement has led a number of groups of experts to provide consensus statements and helpful collaborative documents to summarize the knowledge on nocturia. These publications have emphasized that nocturia is a symptom that has been underreported, understudied, and often not adequately considered [6], [7], [8]. The reports follow the introduction [9] and the further development of the concept of LUTS [10], which has heralded a new era for medical research and clinical practice improvement in the field of functional urology.

Given the growing interest in nocturia as an important cornerstone of LUTS, the aim of the present work was to provide a systematic review of the available scientific evidence regarding the definition, physiopathology, epidemiology, and management of nocturia.

Section snippets

Evidence acquisition

A systematic review was conducted based on a literature search through the PubMed/Medline, Embase, Scopus, Web of Science, and Cochrane Library databases using the keyword nocturia. The literature search was restricted to full-length articles, in the English language (for practical reasons), after 2000 and before April 2012.

A first selection was made based on the titles and abstracts of the papers. After removal of duplicates and the exclusion of conference abstracts, the articles were

Evidence synthesis

The initial search yielded 11 361 potential citations. After removal of duplicates and application of language limits, 1365 articles were considered and reviewed based on title and abstract. At the end of the process, 277 full papers were obtained and considered for inclusion in this review. The flow diagram is given in Figure 1.

Conclusions

Nocturia has been comprehensively studied; it is a highly prevalent symptom with multiple potential underlying pathophysiologic mechanisms, some of which may have life-threatening consequences. In addition to an adequate history and clinical examination, an FVC is the cornerstone of initial assessment of this symptom and is suggested as such in all modern guidelines. The treatment options are largely determined by the clinical context and the etiology of the nocturia (NP, 24-h polyuria, reduced

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