Nocturia is the medical term for the need to awaken from sleep to urinate. Getting up once to relieve your bladder during sleep hours is usually not particularly troublesome. However, when it happens two or more times it can negatively impact one’s quality of life because of sleep disruption, leading to an increased risk of fall-related nighttime injuries, daytime fatigue and an increased risk of fatigue-related accidents.
How many times is normal to urinate at night?
Not everyone is the same, and there are factors that determine what is “normal” for most people. For example, nighttime urination is more common if you have something to drink right before bed, and is also more common in older adults. Most people without nocturia can sleep for 6 to 8 hours without having to urinate, but getting up to go to the bathroom once during the night is still within the realm of normal. If you have to use the restroom two or more times per night, it is a good idea to talk to your urologist about nocturia.
What causes nocturia?
Nocturia correlates with aging and the associated decline in kidney function and decreased ability to concentrate urine. Although having an enlarged prostate may contribute to nocturia, it’s much more complicated than that since women do not have prostates and nocturia is equally prevalent in men and women.
Nocturia is based on multiple factors that require careful evaluation in order to sort out and treat appropriately. As a urologist, my goal is to distinguish between urological and non-urological causes for nighttime urinating. It often comes down to one of three factors:
- Nighttime urine production by the kidneys
- Urinary bladder capacity
- Sleep status.
In the elderly population, excessive nighttime urine production is a factor almost 90% of the time.
Nocturia can be classified into 5 categories:
- Global polyuria (making too much urine, day and night)
- Nocturnal polyuria (making too much urine at night)
- Sleep disorders
- Reduced bladder capacity
- Overactive bladder
Global polyuria can result from excessive fluid intake or from dehydration from poorly controlled diabetes mellitus. The pituitary gland produces an important hormone responsible for water regulation — ADH (anti-diuretic hormone) — and it works by giving the message to the kidneys to concentrate urine. Diabetes insipidus is a disease of either kidney origin in which the kidneys do not respond to ADH, or pituitary origin in which there is deficient secretion of ADH. In either case, lots of urine will be made, resulting in frequent urination, both daytime and nighttime. Medications including diuretics, SSRIs (selective serotonin reuptake inhibitors), calcium blockers, tetracycline and lithium may induce global polyuria.
Nocturnal polyuria may be on the basis of excessive fluid intake, especially diuretic beverages including caffeine and alcohol. It may also occur because of a nocturnal defect in the secretion of ADH or an unresponsiveness of the kidneys to the action of ADH. Congestive heart failure, sleep apnea and kidney insufficiency also may play a contributory role. Certain conditions result in accumulation of fluids in the tissues of the body, particularly the legs (peripheral edema); when lying down to sleep, the fluid is no longer under the same pressures as determined by gravity, and returns to the intravascular (within the blood vessels) compartment. It is then subject to being released from the kidneys as urine. Such conditions include heart, kidney and liver impairment, nephrotic syndrome, malnutrition and venous stasis.
Primary sleep disorders may also cause nocturia, including insomnia, restless leg syndrome, narcolepsy, and arousal disorders (sleepwalking, nightmares, etc.).
Reduced bladder capacity may be caused by numerous urological issues. Many processes can occur within the bladder that can irritate its delicate lining, causing a reduced “functional” capacity: bladder infections, bladder stones, bladder cancer, bacterial cystitis, radiation cystitis, and interstitial cystitis.
An overactive bladder—a bladder that “squeezes without its owner’s permission”—can give rise to nocturia. Some people have small “anatomical” bladder capacities on the basis of scarring, radiation, or other forms of damage. Prostate enlargement commonly gives rise to nocturia, as can many neurological diseases that often have profound effects on bladder function. Incomplete bladder emptying can give rise to frequent urination since the bladder is already starting out with the bias of being partially filled. Incomplete emptying is often seen with prostate enlargement, scar tissue in the urethra, neurologic issues, and bladder prolapse.
How is nocturia diagnosed?
The key diagnostic tool for nocturia is the frequency-volume chart (FVC), a simple test that can effectively guide diagnosis and treatment. This is a 24-hour record of the time of urination and volume of urination, requiring a clock, pencil, paper and measuring cup. Typical bladder capacity is 10–12 ounces with 4–6 urinations per day.
How is nocturia treated?
Nocturia is treated on a case-by-case basis under the direction of a physician. This treatment may contain lifestyle modifications, medication, or both.
Lifestyle modifications to improve nocturia include:
- Preemptive voiding before bedtime – Ensuring that there is as little urine in your bladder as possible right before bed can help eliminate the need to get up to urinate at night.
- Intentional nocturnal and late afternoon dehydration – Ensure that you are consuming enough fluids during the day, but limit them in the 2-4 hours before you go to bed.
- Salt restriction – In patients with a high salt intake, a reduction in salt has been clinically shown to reduce instances of nighttime urination (source)
- Dietary restriction of caffeine and alcohol – Caffeine increases bladder activity and therefore can cause nighttime urination, especially if consumed later in the day (note that even decaf coffee and tea do contain some caffeine). Alcohol can function as a bladder irritant and should be avoided as well.
- Adjustment of medication timing – Different medications, especially diuretic medications, can impact nighttime urine production. Note that it is extremely important to consult with your doctor before making any changes to your medication.
- Use of compression stockings with afternoon and evening leg elevation – Elevating the legs and use of compression stockings helps to prevent fluid build-up in the legs. This ensures the fluids are properly distributed throughout the bloodstream and helps reduce the need to urinate.
- Sleep medications – Sleep medications may be a part of lifestyle modification plan developed by your physician in order to maintain healthy sleep patterns when it is determined that there are no other potential harmful underlying conditions and sleeping through signals to urinate would not cause any additional issues.
Urological issues may need to be managed with medications that vary based on the underlying causes of the condition. Medications that relax or shrink the prostate are typically used when the issue is prostate obstruction. In the instance of an overactive bladder, bladder relaxants may be of help. For nocturnal polyuria, synthetic ADH can be highly effective.
Questions Your Doctor Will Ask
If you decide to make an appointment to consult your urologist regarding nocturia, the doctor will likely have multiple questions for you in order to properly diagnose. Having the answers to the following questions ready will help you and your doctor quickly develop the right treatment plan:
- How many times do you wake up at night to urinate?
- When did your symptoms first start?
- What medications are you currently taking?
- How much is your bladder actually storing during the day and at night (is there a large or small amount of urine)?
- Are you typically a good sleeper?
- How much caffeine or alcohol do you drink each day? When?
- Has your diet changed recently?
The more detail you have, the more helpful it is for the physician in making a diagnosis and finding the root cause of the issue.
Bottom Line: Nocturia should be investigated to determine its cause, which may often be related to conditions other than urinary tract issues. Nighttime urination is not only bothersome, but may also pose real health risks. Chronically disturbed sleep can lead to a host of collateral wellness issues.
If you are routinely waking up at night to urinate, especially if it is happening more than once per night, we recommend setting up an appointment with your urologist. To set up an appointment with one of our physicians or to see a list of our locations, please contact us.