Nocturia

Waking up multiple times each night to urinate can disrupt your sleep and leave you exhausted during the day. This common condition, called nocturia, affects more than half of adults over 50 and can significantly impact your quality of life.

Table of contents

• What Is Nocturia?
• How Common Is Nocturia?
• Symptoms of Nocturia
• What Causes Nocturia?
• How Is Nocturia Diagnosed?
• Treatment Options
• Lifestyle Changes and Prevention

What Is Nocturia?

nocturnal urinary frequency

Nocturia is a condition that causes you to wake up during the night to urinate. This condition is also called nocturnal urinary frequency, meaning you need to pee more often at night than normal^[1]. For a bathroom visit to count as nocturia, a sleep period must come before and after the urinary episode. This means your first-morning urination does not count when determining nocturia episodes^[2].

Most adults should be able to sleep six to eight hours during the night without needing to get up to use the bathroom^[1]. While it can be common for people to wake up once during the night to pee, waking up more frequently may signal an underlying condition or problem. Nocturia is different from frequent urination during the daytime. When a person pees too much during the daytime but can limit bathroom trips at night, it’s referred to as frequent urination^[1].

Nocturia is also different from nocturnal enuresis, which is bedwetting. With nocturnal enuresis, patients are generally not aware of a full bladder and typically experience an involuntary void while in bed^[2].

How Common Is Nocturia?

Nocturia is a very common condition. It affects more than 50% of adults after age 50 and becomes more common as people age^[1]. The condition affects up to 1 in 3 people over the age of 30^[1]. In fact, about 50 million people in the United States experience this condition, with one in three adults older than age 30 making at least two trips to the bathroom nightly^[2].

Before age 50, nocturia is more common in females. After age 50, it becomes more common in males^[1]. Men over the age of 60 have a high incidence of nocturia, and about 80% of elderly people over age 75 are affected^[3]. Despite how common it is, many patients are reluctant to mention nocturia to their doctors or mistakenly believe it is a normal part of aging^[2].

Symptoms of Nocturia

The main symptom of nocturia is waking up more than once during the night to urinate. People who have nocturia wake up more than once a night to pee, which causes disruptions in their normal sleep cycle and leaves them tired with less energy during the day^[1].

Symptoms of nocturia can include^[1]:

• Waking up twice or more to pee at night
• Peeing more in volume if polyuria is present (polyuria means peeing too much in total volume, but not necessarily peeing too many times)
• Fatigue and sleepiness during the day, which occurs because peeing so frequently can interrupt your typical sleep cycle

Without quality, uninterrupted sleep, you may have difficulty concentrating and performing daily activities^[3]. Poor sleep quality caused by nocturia can raise the risks of certain health conditions like stroke, heart disease, and dementia^[16]. For older adults, nocturia can also increase the risk of falling at night, with about 25% of all falls in older adults happening in the middle of the night, some due to nocturia^[16].

What Causes Nocturia?

Nocturia has many possible causes. It is often described as one of the most bothersome of all urinary symptoms^[2]. The condition is generally caused by one of four main problems: nocturnal polyuria (overproduction of urine at night), global polyuria (overproduction of urine during both day and night), bladder functional storage issues, and sleep disorders. A combination of these can also lead to nocturia^[2].

There are differences between the sexes that can contribute to waking up to pee at night. For example, males have a prostate, but females may have pelvic organ prolapse due to childbirth^[1].

Common causes of waking up to pee at night in all people include^[1]:

• Drinking too much fluid before bedtime, especially beverages containing alcohol and caffeine, which may make it worse
• Medications that contain a diuretic (water pills that cause your body to remove excess fluid and salt and make you pee more often)
• Reduced bladder capacity due to bladder obstruction, swelling, infection, or pain in your bladder
• Habit or routine, where you may have unintentionally trained yourself to wake up and go to pee, even if you don’t have to

Certain health conditions can cause you to need to wake up to pee at night. These include^[1]:

• Polyuria (your body produces too much pee for your bladder to hold)
• Diabetes
• High blood pressure
• Benign prostatic hyperplasia or prostate obstruction
• Heart disease or congestive heart failure
• Obstructive sleep apnea or other sleep disorders
• Pelvic organ prolapse
• Childbirth, pregnancy, or menopause
• Restless legs syndrome
• Edema (fluid retention)

The two major causes of nocturia identified by researchers are nocturnal polyuria and global polyuria^[7]. Nocturnal polyuria occurs when there is an overproduction of urine at night. According to the International Continence Society, this type of nocturia is defined by nighttime urine volume that is greater than 20-30% of the total 24-hour urine volume. Global polyuria consists of both day and nighttime urine overproduction^[7].

How Is Nocturia Diagnosed?

The cornerstone of nocturia diagnosis and evaluation is the 24-hour voiding diary^[2]. To help your doctor make an accurate diagnosis, keeping a fluid and voiding diary would be helpful. A fluid and voiding diary is a record showing^[14]:

• How much you drink
• How often you must use the bathroom
• How much urine you release
• Any medications you are taking

This diary helps your healthcare provider identify any patterns in your urination and can be kept for at least a week^[10]. Your doctor will also assess whether you have any underlying medical conditions that could be causing your nocturia.

Treatment Options

The treatment for nocturia depends on its cause^[11]. In order to treat nocturia, the underlying disorder needs to be identified and treated. For example, if nocturia is caused by an infection, antibiotics may clear up the symptoms. If it is caused by a medication, doctors may consider changing the medication or recommend taking it earlier in the day^[11].

Management strategies consist of lifestyle modification, behavioral therapy, and medications, and should be offered to all patients with significant nocturia, at least on a trial basis^[2].

Medications that may be prescribed include^[11]:

• Antidiuretics such as desmopressin, which can be taken to reduce the amount of urine produced
• Anti-cholinergics or anti-muscarinics, which help prevent spasms of the bladder muscle and reduce urgency and frequency
• Loop diuretics such as furosemide, which may be prescribed to help treat nocturia by increasing urine output during the day so that your body doesn’t produce so much urine at night^[10]

Anticholinergic medications that may be prescribed include^[11]:

• Darifenacin
• Fesoterodine
• Oxybutynin
• Solifenacin
• Tolterodine
• Trospium

Women may also be prescribed estrogen creams to treat stress incontinence^[11].

Bladder training may be offered if you’ve been diagnosed with urge incontinence. Bladder training involves learning techniques to increase the length of time between feeling the need to urinate and passing urine^[13].

Pelvic floor muscle training may also be recommended. Weak or damaged pelvic floor muscles can cause urinary incontinence, so exercising these muscles is often recommended. Your program should include a minimum of eight muscle contractions at least three times a day and last for at least three months^[13].

In some cases, for example if an individual with nocturia also has an enlarged prostate, surgery may be necessary^[1].

Lifestyle Changes and Prevention

Many doctors and healthcare providers will recommend lifestyle changes as a first step in treating nocturia. People who have nocturia caused by lifestyle choices may find that their symptoms go away as they change their habits^[11].

Simple lifestyle changes may improve bladder control^[18]. Here are some strategies^[1][6][16]:

• Regulate how much liquid you drink before bedtime. The more you drink, the more you will tend to urinate. Avoid drinking two glasses of water right before you go to bed. If you do get up in the middle of the night to urinate, don’t drink another glass of water while up.
• Stop drinking a few hours before bedtime. For those who get up several times at night to urinate, drink more fluids in the morning and afternoon, not at night.
• Watch what you drink. Avoid caffeine and alcohol, especially at night, because they act as diuretics and promote dehydration. Beverages to avoid include coffee, tea, cola, chocolate, and drinks with bubbles. These can irritate the bladder and increase the need to go.
• Avoid bladder irritants. Certain foods and beverages might irritate the bladder, including alcohol, artificial sweeteners, acidic items such as fruit juice and soda, spicy foods, and sugar-sweetened beverages.
• Elevate your legs during the day. If your nocturia is caused by fluid distribution, keeping your legs elevated during the day can help improve your circulation and avoid fluid collecting in your ankles and legs, which should help decrease urine output at night.
• Get plenty of fresh air and exercise during the day so you’re tired when you go to bed.
• Develop good sleep habits. Avoid napping in front of the TV before bedtime. Avoid computers and phones before bed, as the blue light that screens emit can keep you awake.

These lifestyle modifications work and are safe, easy, and cost little or nothing. Try them before trying other types of treatment, such as medicines or surgery, or use them with other treatments^[18].

If symptoms persist after trying lifestyle changes, it may be time to see a doctor to make sure nocturia is not caused by an underlying medical condition^[11]. Many conditions that affect your bladder or prostate can lead to having to wake up to pee, and not treating these underlying conditions can lead to complications^[1].