Management of Nocturia: An Unmet Need in LUTS
Kevin T. McVary, MD, presented “Management of Nocturia: An Unmet Need in LUTS” on June 21, 2018, accompanied by E. David Crawford, MD.
How to cite: McVary, Kevin. “Management of Nocturia: An Unmet Need in LUTS” February 7, 2018. Accessed Jun 2018. https://dev.grandroundsinurology.com/management-of-nocturia-an-unmet-need-in-luts/
Management of Nocturia: An Unmet Need in LUTS
Summary:
Kevin T. McVary, MD, illustrates that while nocturia is the leading lower urinary tract symptom (LUTS) complaint that prompts men to seek out urological care, the condition persists without improvement in 50% of patients, even after treatment. Therefore, there is a significant unmet need in nocturia management practices. He discusses the condition’s financial and quality of life (QOL) burdens, its multifactorial etiology, and his perspective on treatment approaches.
Following his discussion, Dr. McVary and E. David Crawford, MD, engage in a question and answer session about the subject.
To further expand your knowledge of the management of nocturia, visit the Nocturia Next Generation Learning Center.
Unmet Needs in Nocturia Management
Nocturia presents a challenge to urologists, firstly, because it does not have a clear definition. While The International Continence Society (ICS) defines it as waking one or more times per night to void, urologists consider clinically relevant nocturia to be voiding twice or more per night. However, neither of these definitions account for the patient’s personal degree of bother.
Secondly, nocturia causes patients substantial QOL and financial burdens. The condition leads to injuries from nighttime falls and lost work. Data shows a $61 billion estimated annual indirect cost in the USA due to nocturia-related loss of productivity and sick leave. Furthermore, nocturia is the leading LUTS complaint that prompts men to seek out urological care.
Despite this, in 50% of patients who receive treatment, nocturia persists without improvement in 50% of patients. This shows the significant unmet need in this setting.
A Systematic Approach to a Multifactorial Condition
Male nocturia is not simply a prostate or bladder problem. It could be a manifestation of a separate sleep disorder or another systemic problem.
When faced with a complaint of nocturia, Dr. McVary urges urologists to first consider sleep disorders, like sleep apnea, insomnia, parasomnias, and restless leg syndrome (RLS), as the cause of the condition. Then, clinicians should perform a complete history and physical, looking for hypertension, diabetes, coronary artery disease (CAD), or kidney disease in a patient to determine whether the condition stems from a prostate, bladder, pelvis, or a more global issue.
Furthermore, many common medications can increase diuresis or induce insomnia, causing iatrogenic nocturia.
Due to this multitude of common etiologies, it is important clinicians investigate beyond their own specialties to discern the true source of the condition.
Clinicians should also assess patient bother and desired treatment, proteinuria and glucosuria through urinalysis, post-void residual, and a patient-reported voiding diary.
A Conservative Treatment Approach
Dr. McVary recommends approaching cases of nocturia conservatively. First, advise the patient on behavioral techniques to reduce his symptoms before moving to complicated treatments or workups. Next, consider taking the patient off any medication exacerbating the nocturia. For some patients, it is prudent to prescribe low-dose intranasal desmopressin acetate (Noctiva) or antidiuretics in the evening. Most importantly, identify the mechanism of action behind the patient’s nocturia to individualize treatment.
Other non-surgical treatment options include botulinum toxin A injections and sacral neuromodulation. Surgery should always be a last-resort.
If, through pressure flow studies and void diaries, bladder neck obstruction from benign prostatic hyperplasia (BPH) proves to be the cause of the patient’s nocturia, then clinicians should pursue surgical options.
ABOUT THE AUTHOR
Dr. Kevin T. McVary received his MD from Northwestern Medical School. He joined the faculty at Northwestern Memorial Hospital and was a Professor of Urology at Northwestern University Feinberg School of Medicine for 23 years. He served as the Director of the Center for Sexual Health at Northwestern Memorial Hospital and was Director of the Andrology Fellowship Program at Northwestern Memorial Hospital. In 2013, he joined the faculty of the Southern Illinois University School of Medicine in Springfield, Illinois, his hometown. He currently serves as Chair of the Division of Urology and Professor of Urology there.
Dr. McVary’s primary clinical areas of interest include prostate cancer and BPH, as well as the evaluation and treatment of sexual dysfunction. Dr. McVary has had extensive experience conducting clinical trials for the National Institutes of Health as well as numerous private and industry foundations.
Dr. McVary is the Chairman of the AUA’s BPH Clinical Guidelines Committee, the Co-Chair of the International Consultation on Male LUTS, and the Associate Editor of the Journal of Urology. He is also Chairman of the Special Emphasis Urology Study Section for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), as well as Co-Chairman of the Clinical Section of the NIDDK Strategic Pathway for Prostate Basic and Clinical Science. He also served on the American Board of Urology Exam Committee for four years. He was named a Sommer Lecturer at the University of Oregon in 2008.
