Nocturia: Why You're Waking to Pee at Night (and What You Can Do About It)

In this episode, I'll break down the real reasons behind getting up at night to pee, a condition called nocturia. From overactive bladder to fluid intake and systemic conditions like sleep apnea or diabetes, and why looking at the whole picture is essential. I'll also discuss effective treatments from bladder training to Botox and why a 3-day voiding diary is a crucial first step in figuring it all out.

Timeline:

00:30 Introduction to Nighttime Urination Issues 

01:06 Understanding Nocturia

 02:58 Common Causes of Frequent Nighttime Urination 

03:23 Bladder Issues and Treatments 

05:19 Evaluating Fluid Intake 

06:26 Medical Conditions Affecting Urine Production 

07:41 Importance of Accurate Voiding Diaries 

08:21 Conclusion and Key Takeaways 

08:58 Sleep Apnea and Its Impact on Nocturia 

11:14 Recent Studies and Treatments 

11:59 Final Thoughts and Recommendations

Transcript

 Hi there. Today I wanted to talk to you about getting up at night, a lot to pee. I think everybody loves a good night's sleep. It's definitely one of my favorite things, and we don't like anything that interferes with our sleep. I see a lot of patients who come up who come in because they're waking up at night to pee.

You know, if you're getting up. Once a night, that's pretty normal. Um, two is hard to fix. But then I also see people who are getting up 3, 4, 5, maybe even more times than that. Um, in a night, some patients get up every hour, so we call this noria. Noria means getting up at night to go to the bathroom. N normal is considered to be getting up once or less at night.

It's clinically relevant if you're getting up two or more times at night, and this happens to, you know, somewhere between two to 15% of 20 to 40 year olds. And the risk, uh. Or the rate of this increases as we get older, and you can see it in, you know, somewhere between 30 to 60% of 70 to 80 year olds. So it is not an uncommon thing.

And the thing that we know about less sleep or poor sleep, decreased amounts of sleep, is that it is associated with a lower quality of life. People are less productive and they are more likely to be depressed when they're not sleeping well. And people come in and say this to me all the time. I'm, I'm not sleeping well, and I just don't feel like I am functioning well during the day.

So the thing that's important to remember with this, with this Nour getting up at night to go to the bathroom is that it may be a bladder issue. There may be something going on in your bladder or your bladder may be an innocent bystander. It's actually an issue that is happening in your whole system that is causing you to produce more urine, and it is not the bladder's fault at all.

So these are really important things to clinically figure out because the, the treatments are. So very much different. So there are three main reasons that people get up a lot at night. So one bladder can't hold as much. Two, you're drinking too much, so there's too much fluid input. And then three, you are making too much urine and that's something that, um, is impacting your whole system.

So we see that with different medical conditions and I'll get into that in just a second. So if it's a bladder issue and the, the bladder isn't holding as much, there are are different things that can cause that. I mean, patients that have radiation can have that. Um, but the most common thing is that it is a form of overactive bladder or detrusor overactivity, urgency, urinary incontinence.

Um, and so in that situation. Um, people usually have other symptoms. They usually have daytime symptoms too. They don't usually just have the nighttime system symptoms in isolation, but it may be that those nighttime symptoms are the ones that bother them the most. So that's what they're really talking about.

And in that situation, treatments for overactive bladder will definitely work. Um, so medications will work, um, after behavioral training and, um, muscle strengthening. Botox can work really well. Nerve stimulation can work really well. So in that situation, we're looking at, um, just treating the overactive bladder.

The other thing that you need to look at is, is the patient emptying well. So if you go to sleep with a full bladder because you're not emptying well through no fault of your own. You're more likely to wake up frequently, right? Because you're never kind of emptying your cup, and just that little bit of increase in urine will stimulate you to wake up.

And so then in that situation, overactive bladder medications or overactive bladder treatments would not work, and we need to get you to empty. Better. Um, we don't have particularly great treatments for people when they're not emptying well. And so then in that situation, we need to teach you to catheterize yourself, or we need to look at nerve stimulation, which can help people empty.

Or if there's something else that could be causing your poor emptying, like perhaps a bladder sling that is a little bit too tight. So those are things that we have to look at for patients that are drinking too much. One of the things that we always do when someone comes in with overactive bladder, and especially with nighttime symptoms, is we have to look at your fluid intake.

And so we have to have you do a 24 hour diary for a couple of days, usually three days where you're writing down what you're drinking, and then actually measuring and writing down how much you're emptying. So we can look at all of those things and compare. Some people are just drinking too much in general.

Sometimes they're drinking too much at the wrong points in time, and we need to have you restrict your fluids, let's say after dinner, and that can make a huge difference. I. If you are making too much urine, we figure that out with a 24 hour voiding diary as well where you are writing down how much you are emptying, that can happen globally, meaning that you're making too much urine all the time, right?

So at every point in the day and night, or it can be nocturnal where you're just making too much urine, um, at night. This nocturnal polyuria making too much urine at night is, is something that we see pretty commonly. And the medical diagnoses that are associated that with that are obstructive sleep apnea.

That's probably the most common one that I see. Congestive heart failure, um, some kidney diseases, um, some liver diseases, but usually it's um, kind of an end stage liver disease. And so you would, you would know that there would be many other symptoms or a decrease of in albumin, in protein in your system.

You can also see an increase in urine production with patients that have. Diabetes mellitus, right? So diabetes that isn't controlled. If you're someone that is diabetic and your diabetes is very well controlled, this is not you. It's usually someone who is poorly controlled or doesn't know that they have diabetes, yet diabetes insipidus can do it as well.

And this makes you make too much urine all the time. Um, it can be drug-induced, so there are different medications that can do it, and having a high level of calcium can do it as well. So when we're evaluating this, you know, we do a history, we do a physical, we're examining, looking for all kind of the normal things, and then again, doing a three day voiding diary so that we can see your, um.

Day-to-day intake, your day-to-day output. It's important when you're doing avoiding diary that that avoiding diary represents what's happening to you. Sometimes patients will do avoiding diary and they have the most perfect three days ever and it doesn't really show us the symptoms that are bothering you and in that situation you have to repeat it, 'cause it, it has to demonstrate the problem or it isn't really helpful.

So the take home points that I would make is that, um, one, getting up a lot at night to pee is actually an important problem that can impact your whole life because less sleep and less sleep of good quality. Has a dramatic impact on the way our bodies function. So it's an important thing to bring up and and talk about.

And then it is an important thing to evaluate pretty carefully to make sure that you know, if it's a bladder problem or if there's something else going on in your system that needs to be. Evaluated. Um, there was a recent article in Urogynecology that looked at whether we should universally screen for, um, sleep apnea because it is such a common cause of Nour.

And what they found is when they screened all of their patients in a urogynecology clinic about one in five screened positive for sleep apnea, and then of those patients, about 80% went on to actually be a diagnosed with sleep apnea. So you know, that is a very high percentage. You know, without screening we're missing some of those patients and so not, um, able to treat the symptom that is causing this.

I think when someone comes in with sleep apnea and I. You know, their, their symptom, the thing that's bugging them the most isn't so much gasping at night, waking yourself up, but you know, they're feeling like they're getting up at and going to the bathroom frequently at night. That's what they're coming in and saying.

When I talk to those patients about, I. How I think it is because of the sleep apnea or I think they have sleep apnea. We need to have them evaluated. That's something that people are always surprised to hear about. Um, the correlation doesn't really make sense to people. I. But what happens is your body tightly regulates the pressure around your heart.

And when you're holding your breath, you're gasping at night, the pressure around your heart goes up, um, because of, um, different hormones that you release. And then you body wants to decrease that pressure. And so. It emits different, um, hormones and regulators that make you urinate and release more urine.

And all of that is just to decrease the pressure and, you know, kind of protect your system. So that's something that people are always very surprised about. But then when they go and are treated, it's amazing, treated for the sleep apnea, they're always amazed at how much better their bladder symptoms get.

I. So it, it's an important thing to discuss. It's an important thing to, to evaluate there. Also, there was also a recent study in urogynecology that looked at treating Nour with Botox. Um, and this clearly in this situation is in patients who don't have other medical conditions that are causing the overactive bladder, right?

That it really is just overactive bladder causing you to get up a lot at night. So what they found is that patients went from getting up to 3.5 times per night to 1.5 times per night. So a dramatic, um, improvement and that there was a decrease in mild to moderate sleep disturbance. There was an increase in the longest sleep interval so that you stayed asleep longer, um, and an increase in quality of life.

So. If there are lots of things that we can do to treat this, I would encourage you, if you're someone who feels like you're getting up all the time at night, that's something that you should talk to your physician about. It's something that should be evaluated. We shouldn't just throw a medication at you.

There are bigger things that we need to think about, um, depending on the other symptoms that you're having and what might be going on with you. But I, I think this is always an important thing to treat and to evaluate.