Nocturia

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What is nocturia?

Nocturia is waking up one or more times during the night because of the need to urinate.

You do not have nocturia if you experience the following, waking up during the night — for instance, because you are thirsty, hear noises, worry, or feel unwell — and, in the meantime, you decide to visit the toilet. You also do not suffer from nocturia if you go to the toilet first thing in the morning.

Waking up once in a while to urinate is common and is generally not very bothersome. However, if you regularly wake up two or more times a night, this can negatively impact your daily activity and quality of life. The lack of sleep can affect your balance and concentration.

Nocturia can disrupt your sleep and make you more tired than usual during the day. As a result, it can be more difficult to concentrate at work and carry out your daily activities. Your lowered energy levels could also affect your social life.

How common is nocturia?

Nocturia affects both men and women, and becomes more common as you grow older. In adults under 30 years of age, more women than men suffer from nocturia. Men over the age of 50, are more often affected than women of the same age. Over the age of 60, there is often an increased chance of suffering from nocturia.

Diagnosis of nocturia

Your doctor may order a series of tests to understand what causes your symptoms. This is called an investigation in order to make a diagnosis. This is because nocturia may be a symptom of other medical conditions.

First, the doctor or nurse will take your medical history and do a physical examination. If needed, other tests will be performed, depending on:

  • your age
  • the impact the symptoms have on your daily life
  • other medical conditions you may suffer from (in particular heart, kidney neurological or psychiatric conditions)
  • your current medications

Based on the results of your examination and tests, your doctor will identify the cause of your nocturia and recommend the treatment.

Physical examination

Your doctor or nurse will do a physical examination. They will be looking for:

Your doctor or nurse may also do a pelvic examination in women, test your blood pressure, and look for signs of heart, lung, or neurological conditions. Also, more tests may be needed such as: urine analysis measuring the flow of your urine, or ultrasound examination of the kidneys, bladder and/or prostate.

Bladder diary

Your doctor may ask you to keep a bladder diary.

Interesting Fact

While nocturia literally means “urination at night”, it may also occur during the day, for those who work night shifts and sleep in the daytime.

Questionnaires

Your doctor may ask you to fill out a questionnaire to better understand your symptoms and their impact on your daily life. The most common questionnaire is Nocturia-Quality of Life (N-QoL).

Treatment of nocturia

Your doctor may suggest treatment options to improve your nocturia. This section describes different treatments. Together with your doctor you can decide which approach is best for you.

Factors which influence this decision include:

  • Your medical and surgical history
  • Your drug history
  • Medication available in your country
  • Your personal preferences and values

This section offers general information about treatment for nocturia in men older than 40 years of age. Situations can vary in different countries.

Watchful waiting

If your symptoms are only bothering you a little, Watchful Waiting can be an option. Watchful Waiting means that you see your doctor regularly (usually every year) or when the symptoms become worse.

Over-the-counter supplements

You may want to try supplements which have not been prescribed by your doctor because you consider them more natural and safer. However, it is not entirely clear how these supplements work to relieve nocturia. It is also not clear how effective they are because their quality can vary greatly. Doctors do not recommend taking them to improve nocturia. If you take any supplements to relieve your symptoms, inform your doctor during consultation.

Bladder relaxing medication

Bladder relaxing medication are drugs used to reduce the abnormal contractions of the bladder (contractions that are stronger than usually and more frequent than usually). They may lessen the sudden and frequent need to pass urine which is difficult to hold back.

First group of bladder relaxing medications are called, Muscarinic receptor antagonist (muscarinic blockers). Muscarinic receptors are normal part of the bladder muscle. They are part of the muscle movement  in bladder contraction when you pass urine.

Side effects of most drugs are usually mild, but some drugs may give you more intense side effects. They may include dry mouth and eyes (blurred vision), gastric reflux and constipation. In  rare cases they may cause symptoms of the common cold, dizziness as well as difficulty urinating.

The second type of medication is receptor beta-3 agonist (beta-3 mimetic). Beta-3 receptors are a normal part of bladder muscle and help the bladder to relax and store your urine. Side effects of beta-3 mimetic may include high blood pressure, urine tract infections, headache or symptoms of having a cold.

In the elderly, long-time use of bladder relaxing drugs may worsen the side effects. You should always follow your doctor’s advice about how long you should take your medication(s).

Drugs that lessen the production of urine

If you have nocturia because your kidneys make too much urine, you may benefit from a drug that helps to reduce urine production.

These drugs can cause a drop in blood sodium levels. That is why it is common to have your blood tested before and during your treatment occasionally.

Prostate medication

Because of the relationship between the prostate and the bladder, some men are prescribed medication to relax the muscle within the prostate gland or reduce the size of the prostate. This may improve their lower urinary tract symptoms (LUTS) but is less effective in improving nocturia alone.

Other medications

Medications that increase the urine production (sometimes called water pills, or diuretics). These products may help to produce more urine during the day, in that way your body gets rid of excess water, and your body produces less urine during the night. They are sometimes used to treat hypertension (high blood pressure). Some side effects include dizziness and low blood pressure.

Prostate surgery

In some cases, transurethral resection of the prostate (TURP) is recommended to improve the symptoms of benign prostatic enlargement (BPE) when it affects bladder function (Fig. 1 and 2). The surgery unblocks the bladder outlet by cutting away parts of the prostate.

Fig. 1: A healthy prostate in the lower urinary tract.
Fig. 1: A healthy prostate in the lower urinary tract.
Fig. 2: An enlarged prostate compressing the urethra and bladder.
Fig. 2: An enlarged prostate compressing the urethra and bladder.

General information about nocturia

What causes nocturia?

Nocturia is a symptom caused by many different conditions.

  • In some people the kidneys produce too much urine. If the kidneys overproduce urine at night, this is called nocturnal polyuria.
  • There are several conditions which can cause overproduction of urine, such as diabetes type I or II or primary polydipsia, the sensation that your mouth is dry which leads you to drink more than usual.
  • Some people have a smaller bladder which is filled more quickly and cannot store the urine all night.
  • If you have a bladder or prostate condition, such as benign prostatic enlargement (BPE), you may not be able to empty your bladder completely before going to bed. As a result, the bladder fills more quickly and may not store the urine all night

Other possible causes of nocturia are:

  • Overactive Bladder Symptoms (OAB, see EAU Patient Information on Overactive Bladder)
  • A decrease in the production of the hormone vasopressin (antidiuretic hormone)
  • Obstructive sleep apnoea, or heavy snoring that affects breathing
  • Swelling of the ankles and legs, a condition known as peripheral oedema, which is a symptom of retention of water in your body
  • Heart failure
  • Narrowing of the urethra (which is a pipe that transports urine from the bladder to the outside)

Your doctor needs to investigate your symptoms to correctly identify the underlying cause of the nocturia and will then be able to offer the best possible treatment option for your individual situation.

Lifestyle advice for nocturia

General lifestyle changes can help manage your symptoms and improve your quality of life:

  • Maintain a good sleep routine:
    • Go to bed and wake up around the same time 7 days a week
    • Stay in bed as long as you need to be alert and active the next day. Staying in bed too long or too short, may have a negative impact on the quality of your sleep
    • Avoid taking naps during the day
    • Sleep in an environment free from light and noise, which wakes you up or keeps you from sleeping, and has a comfortable temperature
  • Drink less in the late afternoon and evening to avoid getting up at night to urinate
  • Drink at least 1-1.5 litre every day and discuss with your doctor if you should drink more
  • Reduce alcohol and caffeine, because they may increase urine production and irritate the bladder. Remember that even drinks marked as decaffeinated, such as tea, coffee or soft drinks, may have some caffeine
  • Avoid eating large meals shortly before you go to sleep. Also, certain foods can worsen nocturia. It may be helpful to reduce chocolate and spicy foods, especially in the evenings
  • Avoid smoking because nicotine is a stimulant and can affect your sleep
  • If recommended by your doctor, encourage yourself to “hold it” longer when you feel the urgency to urinate. This will train your bladder to keep more urine so that you will urinate less often
  • Reduce swelling in your ankles and legs by lying down or elevating your legs in the afternoon. During the day, water in your body may flow down to your legs, causing swelling. This condition is called peripheral oedema. When you lie down or elevate your legs for several hours, the fluid returns to the kidneys. Your body will then get rid of it when you urinate. If this happens at night, it causes nocturia. By actively trying to reduce the swelling in your ankles and legs in the afternoon, you may have more hours of uninterrupted sleep.
  • Self-management sessions as part of watchful waiting can also help improve your symptoms and quality of life.

Living with nocturia

There are many ways to keep the symptoms under control. They should not stop you from being happy in your relationships and participating in the social and cultural life of your community. Read about changes in your habits which may improve your nocturia in the section Lifestyle advice for nocturia.

Nocturia can have a negative effect on your personal relationships. It can be difficult to feel attractive and confident when you do not always feel in control of your body. Do not be embarrassed to seek help if your symptoms bother you: consult your family doctor, general practitioner, or a urologist.

This information was produced by the European Association of Urology (EAU), January 2014.

  • Prof. Christopher Chapple, Sheffield (UK)
  • Dr. Jean-Nicolas Cornu, Paris (FR)
  • Prof. Stavros Gravas, Larissa (GR)
  • Dr. Diane Newman, Philadelphia (USA)
  • Prof. Andreas Skolarikos, Athens (GR)
  • Mr. Nikesh Thiruchelvam, Cambridge (UK)

This information was updated by the EAU Patient Information Working Group, July 2021.