Efficacy of Desmopressin in Treatment of Refractory Nocturia in Patients Aged over 65 Years

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Voiding Diary Analysis and Clinical Application

• Hann-Chorng Kuo
• Department of Urology
• Buddhist Tzu Chi General Hospital

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Lower urinary tract symptoms in geriatric
population

• LUTS are common in elderly
• Nocturia is the third most bothersome LUTS
• Prevalence of nocturia increases to 80 in
  patients aged over 80 years
• Nocturia is one of the most common causes of
  disturbed sleep pattern

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Voiding Diary

• Assessment of frequency, urgency, and nocturia in
  patients with LUTS
• Record voided urine volume and total daily urine
  volume
• Calculate nocturnal urine volume
• Investigate causes for frequency and polyuria

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Assessment of Voiding Diary

• Water intake medication
• Total urine production
• Voided volume (functional bladder capacity
  usual voided volume)
• Frequency and nocturia pattern

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Water Intake and Medication

• Normal water intake
• 100ml per hour
• 2400ml per day
• Excessive water intake - polydipsia
• Medication diuretics, antimuscarinics

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Total urine production

• Normal urine production
• lt 2800ml per day
• Daytime polyuria
• Nocturnal polyuria
• Diurnal polyuria

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Voided urine volume (Functional bladder capacity)

• Normal FBC voided volume
• Reduced bladder capacity (FBC voided volume
  lt350ml)
• Increased bladder sensation in day or night (FBCgt
  350ml, usual voided volume lt 350ml)

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Frequency urgency symptoms

• Daytime frequency/ urgency
• Nighttime frequency/ urgency
• Diurnal frequency/ urgency
• Urge incontinence

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Nocturia

• A result of excessive amount of urine production
  at night
• Noctural polyuria gt35 daily urine
• Abnormal lower urinary tract function
• A combination of two etiologies

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Etiologies of Nocturia

• Detrusor overactivity
• Increased bladder sensation
• Bladder outlet obstruction
• Nocturnal polyuria
• Small bladder capacity

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Impact of Nocturia on the Elderly

• Elderly patients are likely to be exposed to
  serious health risks
• Nocturia causes fatigue due to sleep deprivation
• Increase chance of traumatic injury through
  falling from 10 to 21 with gt2 voids per night

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Nocturnal urine volume (NUV)

• Total urine production at bed-time
• -- including the first voided urine volume
• in the early morning

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Functional bladder capacity (FBC)

• The largest voided volume during 24 hours
• -- Day or night

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Nocturia index (NI)

• Nocturnal urine volume divided by functional
  bladder capacity NI
• e.g. NUV 450ml
• FBC 300
• NI 450/300 1.5
• Increased alertness when ANV gt NI
• (Actual number of nightly voids gtNI)

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Nocturia assessment

• Predicted number of nightly voids
• PNV NI-1, if NUV 700, FBC400
• NI 700/400 1.75, PNV0.75 1
• Nocturnal bladder capacity index
• NBCI ANV-PNV, if ANV3, PNV1
• NBCI 3-1 2, indicating alertness
• anxiety or insomnia

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Nocturnal polyuria index (NPI)

• Nocturnal urine volume divided by 24-hour urine
  production
• Normal lt0.35
• Nocturnal polyuria gt0.35

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Causes of Nocturnal Polyuria
Cause Underlying cause
Poor sleep pattern Mental or physical ill health
LUT dysfunction Incomplete voiding
BOO
Detrusor under-activity
Bladder overactivity
Bladder hypersensitivity
Excessive fluid output Primary polydipsia
Drugs diuretics, alcohol, caffeine
Circadian changes to arginine vasopressin secretion
Diabetes insipidus, mellitus
Hypercalcaemia
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Analysis of Voiding Diary

• Frequent urination
• Increased bladder sensation
• Reduced bladder capacity
• Polydipsia induced polyuria and frequency
• Insomnia induced nocturia

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Analysis of Voiding Diary

• Polyuria (urine volume gt2800ml)
• Diuretics induced polyuria
• Polydipsia
• Metabolic disease induced polyuria
• Nocturnal polyuria (NPIgt0.35)

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Analysis of Voiding Diary

• Urgency and urge incontinence
• Sensory urgency
• Detrusor overactivity
• Painful bladder syndrome
• Contracted bladder reduced capacity
• Reduced bladder sensation or arousal

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Analysis of 100 cases with LUTS

• Normal FBC or Reduced capacity
• combined reduced capacity polyuria
• combined reduced capacity N.P.
• Normal FBC Nocturnal polyuria
• Increased bladder sensation
• Detrusor overactivity

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Materials and Methods

• 65 men and 35 women
• Age 6 84 years old (mean 56)
• Presented with storage symptoms of frequency
  urgency and/or urge incontinence, nocturia
• Some patient had empty symptoms
• 3- day voiding diary was recorded

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Analysis of Voiding Diary
Normal Bladder Capacity

• Normal frequency 3
• Increase daytime bladder sensation 17
• Increased daytime bladder sensation
• and nocturnal polyuria 4
• Detrusor overactivity 7
• Nocturnal polyuria 2
• Detrusor overactivity
• and nocturnal polyuria 5
  

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Analysis of Voiding Diary
Reduced Bladder Capacity

• Increased bladder sensation
  15
• Detrusor overactivity
  34
• Nocturnal polyuria
  3
• Detrusor overactivity nocturnal polyuria 10

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Normal FBC, Increased bladder sensation

Nocturnal polyuria
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Normal FBC and Nocturnal polyuria
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Normal FBC, Polydipsia polyuria,
Increased bladder
sensation
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Normal FBC, Increased daytime bladder sensation

Nocturnal polyuria
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Reduced bladder capacity
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Reduced functional bladder capacity
Increased nocturnal
bladder sensation
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Reduced bladder capacity, detrusor overactivity,
r/o I.C.
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Reduced FBC, Polydipsia Nocturnal polyuria
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Analysis of Voiding Diary

• Nocturnal polyuria (n 24)
• Monosymptomatic
  5
• Detrusor overactivity N.P. 15
• Increased bladder sensation N.P. 4

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Analysis of Voiding Diary
Detrusor overactivity ( n 56) Increased bladder sensation (n 36) Detrusor overactivity N.P. (n 15)
Normal bladder capacity 12 21 5
Reduced bladder capacity 44 15 10
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Correlation of Voiding Diary
with Urodynamic results

• Correlation of functional bladder capacity in
  voiding diary with CMG bladder capacity
• Regression analysis p 0.013

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Correlation of Voiding Diary
with Urodynamic results

• Correlation of urgency frequency symptoms with
  urodynamic DI
• Voiding diary DI non- DI
• Urodynamic DI 7 7
• non-DI 12 10
• p
  gt0.05

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Correlation of Voiding Diary
with Urodynamic results

• Correlation of reduced bladder capacity
  urodynamic DI
• FBC gt 350ml DI 30, non-DI 70
• FBC lt 350ml DI 42, non-DI 58
• Fishers exact test p 0.389

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Therapeutic strategies by Voiding
Diary Polyuria

• Polydipsia polyuria
• restricted fluid intake
• avoid specific medications
  
• - corrected metabolic disease
• Nocturnal polyuria
• desmopressin
• afternoon diuretics

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Therapeutic strategies by Voiding Diary
Reduced voided volume

• Normal FBC increased daytime sensation
• -- Bladder retraining, tranquilizer
• Normal FBC increased nighttime sensation
• -- Hypnotics or tranquilizer
• Reduced bladder capacity
• -- Urodynamic study, cystoscopy
• Detrusor overactivity
• -- Anticholinergics

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Medication induced polydipsia

• Reassurrance of adverse effect
• Discontinue antimuscarinic agent
• Change drugs for psychotic disorders
• Change time for diuretics avoid diuretics taken
  after dinner
• Encourage to take diuretic in the morning

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Thank you for your attention