Reasons and treatment for Nocturnal Urination in women

by admin-blog-kh | January 25, 2022 8:58 am

Nocturia is a condition in which people experience the urge to urinate one or more times in the night, when typically, they should be asleep. The condition is prevalent in both men and women but for the purpose of this article we will focus on Nocturia Urination in women. Nocturia leads to disturbed or incomplete sleep, which in turn causes fatigue and reduced productivity in the day-time.

A vicious cycle of fatigue and Nocturia can compromise one’s health leading to more complications over time. Most women, especially in their middle-ages, dismiss it as a natural outcome of aging, which it is not. It’s important to take the condition seriously, and receive treatment for the same, for overall, long-term health.

Types and Causes of Nocturia

There are 4 major ways in which the condition manifests itself, each with its own set of reasons.

1. Polyuria
2. Nocturnal Polyuria
3. Nocturnal Urinary Frequency
4. Mixed Nocturia – when more than one of the above 3 types are present.

A. Polyuria

As the name implies, Polyuria is a condition in which the volume of urine is excessive. Too much water is filtered from the body, by the kidneys[2] of the women with Nocturia. While normal women form 800 ml to 2 liters of urine in 24-hours’ time, women with Nocturia can form as much as 3 liters in 24-hours’ time. As is obvious, there is something in the urine or body of such women which is pulling or draining excess water from the body. The reasons could be:

• High fluid intake in the evening or night. The intake can come from soups, alcoholic beverages, caffeinated drinks, fruit juices and even too much of plain water.
• Diabetes[3] of either type (Type 1 and Type 2) that has not been detected and hence untreated
• Diabetes insipidus: There is a thin layer of fluid that surrounds all the cells in our body. The quantity of water in it must be properly balanced for good cell function. This is turn is achieved by maintaining osmolality or the perfect balance of dissolved particles, glucose and salts in the blood serum. This function is regulated by a hormone secreted by the pituitary gland, called vasopressin. Diabetes insipidus is a condition in which the body does not respond properly to vasopressin secretions leading to large quantity of urine formed through the day and night, leading to frequent urination, dehydration and excessive thirst.
• Gestational diabetes: Some pregnant women show elevated levels of glucose in their blood, for most of the term. This can trigger Nocturia temporarily.

B. Nocturnal Polyuria

While Polyuria causes frequent urination through day and night, in women with Nocturnal Polyuria, a normal quantity of urine is formed in the day, while excessive quantity is formed in the night, leading to nocturnal urination. This happens because their bodies are retaining fluid throughout the day. This fluid accumulates in the legs, especially feet, during the day time. When the woman is lying down for a long time (night sleep vs day-time nap), gravity is no longer pulling the fluid into the legs. The fluid enters the veins again, and from there, the kidneys filter them and form urine. There are various causes for this:

• Congestive heart failure[4] and hence Edema: In this heart condition, the blood is not circulated efficiently by the heart, so some of the blood starts backing up in the legs due to gravity, causing edema or swelling, especially in the lower leg, ankles and feet.
• Sleeping disorders[5]: Obstructive sleep apnea (OSA) is a condition in which breathing is interrupted many times during sleep.
• Certain medication: Diuretics, excessive vitamin D, lithium, propoxyphene, cardiac glycosides, phenytoin, demeclocycline, methoxyflurane, etc. can cause fluid retention.
• Excessive fluid intake before bedtime – as explained before.
• Consuming a diet that’s high in sodium (from salt, soda and MSG)

C. Nocturnal Urinary Frequency

When adequate quantity of urine fills up in the bladder, a signal is sent to the brain that the person must urinate soon, during which, the bladder empties the urine fully (called voiding of urine). This is the normal urination process. In some people, this voiding does not happen properly, or enough urine is not filled up but the brain still sends a signal for urination. The person wakes up to urinate small quantities of urine every time. This leads to disturbed sleep, and associative urination. That is, the person is woken up and decides to urinate even if the urge is not strong and then forms a habit around it. The causes for these conditions ae varied:

Causes for bladder not voiding properly are generally

• An obstruction in the bladder

Causes for bladder not filling up fully before brain signals are sent:

• An overactive bladder which causes bladder spasms
• Urinary tract infection[6] or a bladder infection that keeps recurring
• Swelling or inflammation of the bladder
• Interstitial cystitis: A chronic condition in which there is excessive pressure or pain in the bladder and pelvic area
• A malignant tumor in the bladder
• Obstructive sleep apnea

D. Mixed Nocturia and other causes

Some women may suffer from more than one of the above types of Nocturia, in which case more than one of the underlying causes across those types are present in the body. In addition to those causes, obesity, menopause, kidney stones[7], kidney failure, kidney disease, some pancreatic cancers and hypercalcemia (excess calcium in the blood) can also cause Nocturia.

Diagnosis

A urologist or nephrologist will conduct a series of tests on the patient to assess the extent of the problem and detect the underlying cause:

• Face-to-face discussion: The doctor will ask several questions around the patient’s personal and family medical history, lifestyle, habits and urinary activity. He/she may also ask the patient to maintain a diary of urination, covering various details, for a couple of days before the next session.
• Blood test: This will measure cholesterol [8]levels and check for conditions such as diabetes, anemia, thyroid disorders among others
• Bladder scan: This will measure how much urine is retained in the bladder after the patient urinates
• Urine culture and Urinalysis: This will look for unwanted elements such as blood in the urine and detect any infections
• Cystoscopy: A narrow tube with camera lens fitted at one end, is inserted into the bladder. This will look for tumor and other physical conditions in the bladder
• Urodynamic testing: This will study how efficiently the bladder stores and releases urine

Treatment options

Treatment options are either Lifestyle changes or Medication. Surgery is rarely an option, unless a large kidney stone or a tumor must be removed.

Lifestyle changes

1. Restricted fluid intake: Two to four hours before going to bed, patient must restrict or reduce all kinds of fluid intake, listed earlier
2. Manage diuretics better: If a doctor has prescribed diuretics to the patient, he/she must consult the doctor[9] and reduce their intake. Or take them all during the day and early evening, avoiding the same in the late evening or night hours.
3. Elevating the leg while lying down and using compression socks: These measures prevent fluid build-up in the body
4. Taking brief afternoon naps: These help reduce the sleep deficit and also ensure the body is able to absorb fluids into the bloodstream during day-time.

Medication

1. Diuretics: These regulate blood-pressure and urine production
2. Anticholinergics and antimuscarinics: These alleviate bladder muscle problems, thereby helping the bladder fill adequately and void completely
3. Medicines that prevent excess urine production: These help the body respond better to the hormone vasopressin.
4. Estrogen creams: Among various functions, Estrogen helps regulate stress in women. Since estrogen production reduces post-menopause, stress incontinence or leaking of urine due to stress is one of the consequences. Estrogen creams supplement estrogen and prevent this condition.

Outlook

If you, or any of the women near and dear to you, are waking every night to urinate, it could be a sign of Nocturia. Do not dismiss this lightly, or do not panic. Nocturia is perfectly treatable. Consult a urologist[10] at a reputed hospital. He/she will conduct the tests mentioned above and put you on the right course of treatment for quick and long-term relief from Nocturia.

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Reviewed by Dr Suresh S Venkita, Group Medical Director, Kauvery Hospitals

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Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai, Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.

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