Study design, materials and methods
A retrospective chart review was performed of new patient encounters seen in a functional urology practice from 5/1/2010 to 9/5/16 with the primary diagnosis of nocturia (ICD-9 788.43 and ICD-10 R35.1). Up to 3 visits within a 12-month period from the time of presenting were reviewed. Patients were excluded if they had undergone treatment for prostate cancer or bladder cancer, had a history of recurrent UTIs or had OAB predominant daytime symptoms. Patient characteristics including prior treatment, demographics, recommended treatments, and baseline nocturia number. Outcome was determined by patient reported improvement and change in nocturia events. If a patient completed a bladder diary, the following parameters were obtained: daytime voids, nighttime voids, 24-hour fluid intake and output, maximal voided volume, and 24 hour nocturnal polyuria index score (NPI). Nocturnal polyuria (NP) was defined as NPI ≥0.33 for all ages. Univariate analysis was performed using nonparametric independent tests, chi-squared analysis, and pearsons correlation using IBM® SPSS® software. A two-sided p <0.05 indicated statistical significance.
595 patients were identified, 182 were excluded and 403 were included for analysis. Of these, 239 (59%) were female, average age was 71 years (21-97) old and mean BMI was 25.6 (14-54). The median nocturia episodes were 4 (1−20) (Table 1). For patients that completed 3 visits, the mean nocturia events from the first visit improved from 4.1 to 2.96 episodes per night by the third visit (p=0.007). 192 patients (48%) reported previous treatment for nocturia. After the index visit, a bladder diary (BD) was utilized in 50% of patients, with a 63% (n=124) completion rate at follow up visit. On BD analysis, the most common etiologies of nocturia were nocturnal polyuria 76% (n=94) and bladder storage problems in 25% (n=31). Patient reported improvement with therapy after BD completion was 47% (n=34), similar to patients without voiding diaries (43% improvement, n=153). Behavioral treatment followed by anticholinergics and alpha blockers were the most commonly recommended, but no specific medication was associated with nocturia improvement (Figure 1). Oral desmopressin was used in 5% of patients.
Interpretation of results
Nocturia is a common condition and one where half of the patients seen had sought prior treatment. Patient follow up overall was poor, with over 50% of patients not returning for a third visit. With a myriad treatment options available, no particular therapy was associated with improvement suggesting these may be used in a “trial and error” fashion, which may lead to frustration and thus failure to follow up. In order to determine etiology, BD was recommended to half of the patients. Patient reported improvement with and without completion of a bladder diary was relatively low. We believe BD is the gold standard for treatment and suspect our follow up was relatively short to capture significant improvement. Use of Desmopressin was low, despite this being the most effective treatment for nocturnal polyuria. The study demonstrates that our prescribed use of treatments directed towards nocturia is modest at best or behavioral therapies that are directed toward nocturia are not complied with and follow-up is poor.