When I was a little girl we occasionally visited relatives in a small rural hamlet in the countryside where New York, Vermont and Massachusetts are all neighbors. Outside of Brunswick New York, which is itself outside of Troy New York, this little hamlet was multiple times removed from the ‘big city’ (meaning Troy). Even at that time their farmhouse was remote and very rustic. No surprise, they had an outhouse. [Understand it did not look like this picture.] Never planning these structures too close to a home, it was probably about 50 steps away, constructed of unpainted wood and held up by the bugs and spider webs. Okay, maybe that was my youthful vision.
Luckily, the supplies were better than a Montgomery Ward or Sears & Roebuck catalogue (a half-joke reference that only those of a certain age can appreciate). Anyway, I hated the outhouse and always waited as long as I could before admitting that one discomfort must outweigh the other. Although, being fearful of missing out on an adult conversation was probably part of my delay as well. When inside I actually remember thinking “you’d never catch me in here after dark.” That brings me to the dilemma of those who have little choice, even if they have the luxury of inside plumbing.
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I had a lovely woman friend, actually a nurse, who became worried because she would wake up several times a night to frequent the bathroom. I had a male friend, actually several, who was (were) in the same situation. Did they have something in common? Maybe. The full answer may surprise you. Either way, there are some points for us all to consider, young or old, male or female, sick or healthy.
Nocturia is frequent nighttime urination. And just like bed-wetting in childhood, it is more complicated than it seems, although for different reasons. Another similarity is the reluctance to speak about it. Luckily it doesn’t carry the ‘shame’ that embarrassed kids feel with their problem.
What’s Normal?
An important point is the answer to the question – what is considered ‘normal’ (at least normal for this situation). You may be surprised but getting up twice (2x) in the night IS normal, or at least common, and not generally considered true ‘nocturia.’ You may have some habits (like me) that encourage it as well, which I’ll address below.
Furthermore, nightly urination is not necessarily an ‘overactive bladder’ (OAB) either. Despite that the little cartoon blob on the TV commercial would make you think that people are dragged out of bed in the middle of the night and led by the hand to the bathroom, all suffering with OAB – that’s not the whole story. And in regard to nocturia, its causes, prevention or treatment may be relevant to you even if you would not be officially diagnosed with it. Knowing some of the details can be of benefit.
I recently attended a lecture by a local urologist and surgeon from Asante Health Services, Kadi Ann Bryan, MD. My interest level going in was minimal at best, as admittedly I may have simply been seeking inspiration for another article. Pleasantly, her whole presentation was quite interesting. While the issue of nocturia was only a small part, I realized it was important if for no other reason than its prevalence. And since I try not to lose sight of one goal for my blog, namely capturing the ‘low hanging fruit,’ I figured this was a natural.
Aside from the fact of what is normal and not nocturia, it is surprising in another way. The condition is rarely related to the bladder at all.
Why does it Happen?
What might strike us as unlikely is that most of the time the underlying cause of nocturia is quite unrelated to any urinary tract diagnosis at all – whether you are a man or woman. Some of the more serious causes include diabetes, or neurodegenerative conditions (such as Parkinson’s or Alzheimer’s). More common origins are not the serious ones. These more frequent causes are insomnia, depression (interfering with sleep), sleep apnea and too much fluid before bedtime. Many things that disturb our sleep and wake us up may encourage a toilet visit. That is partially because now that someone is awake they figure ‘might as well’ use the bathroom.
I mentioned sleep apnea as a cause of nighttime urination, because it has such a disruptive effect on our nightly slumber. Non-invasive treatments for obstructive sleep apena are common and can do double duty.
Hormonal changes can increase nighttime urination as well, especially as we age (again not directly related to the bladder, but nevertheless common). Night flashes and flushes which are notorious for disrupting sleep for women are also hormone-related. Some Docs will prescribe estrogen or hormone replacement treatment; those with a more holistic approach may have you try Black Cohosh first (which does work for some women). Fluctuations in the hormone melatonin (naturally occurring in the body) can disrupt sleep and many people self-prescribe or are prescribed it as a supplemental remedy for insomnia. Side effects aren’t common, but possible. Yet it remains widely used for jet lag and other sleep disorders and is effective with correct doses.
Few of us have missed out on the opportunity to learn in detail that an aging male friend is up several times a night, and has been told it is his enlarged prostate causing that. Can’t say that I remember a lion’s share of my medical courses. Hardly so. Still, one phrase I do remember is that ‘of men over 70 years old, 70% of them will have BPH (Benign Prostate Hypertrophy), commonly just called enlarged prostate. Most of these men would out-live any associated medical side-effects (and do so). And many would not need medicine or surgery if it were not for either a zealous doctor or their overwhelming annoyance from the effects of urinary problems. [The prostate as it gets bigger can ‘lean’ on the bladder and feels kind of like a cat sitting on your lap when your bladder is full. It can get very uncomfortable, especially when the relief is not complete.] If a man can’t totally empty his bladder at one time (as the enlargement can obstruct flow), he may be up again shortly (sometimes called ‘double urination’). So this certainly IS a physical condition that affects the bladder directly, despite not being a bladder disease. For less severe cases there are some preventative measures without medication or surgeries.
Medications are another likely culprit, especially diuretics. Diuretics are common, especially as so many people in older age groups are prescribed them due to conditions such as cardiac and vascular problems, high blood pressure or kidney diseases. These drugs which folks sometimes call ‘water pills’ do just that – extract water (and salt) from the body and turn it out into urine. This is the most common category directly related to the effect on the bladder. Other medications can disturb sleep as well, such as calcium channel blockers, cardiac glycosides or psychotropic drugs called SSRI (which when you hear the whole name of Selected Serotonin Reuptake Inhibitors you are glad for the abbreviation). Even excessive vitamin D is accused of having this effect, despite its many advantages.
Not to be forgotten is the major factor of diabetes. Why this link? Diabetes has a bad effect on many parts of the body’s circulatory system. With the disease the body has too much sugar (the reason decades ago it was called ‘sugar’). The body wants to get rid of it and your kidneys work overtime to do it. The body makes more urine to flush the sugar out, which seems like a good plan. But it is not that simple. The attempt to flush happens when the excess sugar (or glucose) soaks up water all over your body and uses it as urine to remove the sugar. Thus people with diabetes can go to the bathroom even once an hour and have a full bladder each time. When this is the cause of nocturia more help is needed. Clearly, it easily causes dehydration in the body (the reason thirst is a sign of diabetes). This is another reminder why if you are told you are in a ‘pre-diabetic’ category (usually meaning a bit overweight and a glucose score over 99 mg/dl) you should act. It’s worth it to do everything you can to reverse it while you are able, such as dropping some weight, moving more to compensate for the weight and watching glycemic levels in food. In fact even if you aren’t “told” but recognize the rising score and body-mass, you might address it proactively on your own.
Sadly, I must report that chocolate is also on the list of culprits that disturb sleep. But I may actually pretend I don’t know that disheartening connection.
Fluids
Obviously, the more we drink, the more we go. Personally I have conflict over encouraging anyone to hydrate less. I confess I drink before bed and keep ice water available throughout the night. You have to consider the question for yourself. Do you wake up, trot off and then go easily back to sleep? In that case, the extra fluid may be doing you more good than harm. Although if you can avoid that fluid in the form of caffeine you then avoid a double whammy, since caffeine also stimulates urination. On the other hand, if that late night herbal tea wakes you at 3:00 am and you stay awake, obviously, the sleep deprivation is an issue and most likely outweighs the benefits of a bit more hydration. It is often recommended to restrict caffeine about 6 hours before retiring. This is a rather common suggestion, but is one that people can easily experiment with themselves. Can you do 3 hours? Do you need 9? Or 10? If you use caffeine (especially coffee) it is valuable to evaluate your reactions. Keep in mind that these reactions to caffeine can change with age.
A second fluid-related double whammy is alcohol. Most of us have either read, heard or experienced the fact that alcohol may make you feel sleepy and send you to dreamland quickly, but after the initial sleepy-bye, shortly thereafter interrupts our sleep. So now you have drunk more fluid and are awake a few hours later due to the nature of the drink. If you drink alcohol, and have problems with nighttime bathroom visits, you may wish to stop consuming alcoholic beverages 3-4 hours before bedtime if possible.
Edema. Carrying extra fluid in the lower extremities can call our name at night. Compression stockings are an interesting solution and one that doesn’t pop immediately to mind. However, since nighttime polyuria can be caused from edema (swelling) in the legs, these stockings can help relieve that. Granted, it is treating the symptom more than the cause, but certainly has fewer side effects than diuretics do. Watching foods, fluids and moving more can be the longer term solution. Elevating the legs during rest or a nice daytime nap will help. And if you are considering the stockings more than likely you need that nap as well to recharge a bit.
A Funny Thing happened on the Way to the Throne
Despite our reasons for nightly trips to the loo, according to Dr. Bryan this nighttime activity is the reason for most falls occurring as we age. It’s common knowledge that ‘most falls happen in the bathroom.’ But this time issue is another element. It makes sense. At night we are groggy, unware, perhaps less stable and often circumnavigate our typical route without turning on the lights. This amplifies the risk that nighttime bathroom trips present. Safety precautions at night are vital.
GREAT TIP. One interesting tip this urologist gave (related more to an over-active balder than directly to nighttime urination) would still be helpful to experiment with yourself. She proclaimed that the advice our mothers gave us about ‘holding it’ by crossing our legs or tightening our muscles is probably the opposite of what we should do when we feel the urge. Often this urge is brought on by re-positioning the body (thus bladder) when we suddenly move. Her advice compared to that of our mothers’ was ‘instead relax, close your eyes and breath, the untimely urge may pass.’
Important Note: this tip is not to contradict Kegel exercises which strengthen the ‘pelvic floor’ – meaning muscles and structures within our pelvic region. Women have long known this exercise, but it can help men as well. As it is easily hidden, this exercise is a great distraction in a boring meeting; or as medical students remember, in a boring class which introduced the movement. Done correctly, it should be unnoticed and simply feel like it does when you try to stop a urine stream and then release it again (tightening pelvic floor muscles but not tightening stomach or legs). Since weakness of these muscles can cause incontinence, or just ‘leaking’, this is an effective and inexpensive preventative exercise. As men have so long relied on the muscles at the prostate, strengthening muscles in this region is a unique but helpful tool for them.
Consider this.
By 80 years old, approximately 80% of people
will have signs and symptoms related to nocturia.
Lack of sleep itself has a negative effect on MOST bodily functions (including renal).
Some prevention may lighten the load.
Self-Help
One of the significant take-ways here should be not to fret about nighttime bathroom trips of two or less (especially if you are getting good sleep and walking safety). It’s common. Still if we can evaluate the underlying cause it may be that we not only sleep more soundly, but address psychological or physical conditions as well. If nocturia or simple nighttime urination is disturbing your sleep, consider any of these ideas:
* step up your exercise routine;
* change fluid consumption or types of fluid (as mentioned above);
* use relaxation techniques, including regular biofeedback exercise;
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* try therapy or other behavior modifications that increase sleep, especially if
….disruptions are caused by depression, psychological, emotional or situational
….stresses. This may sometimes include hormone replacement.
* evaluate the effect of OTC, non-steroidal anti-inflammatories
….(such as aspirin or ibuprofen)
* careful use of Melatonin (never more than 10 mg and not on-going indefinitely)
* consider weight loss (especially if overweight or pre-diabetic);
* wear compression socks at night
Sometimes just knowing how common or normal a situation is for others helps us relax a bit. Further, when you have several points of control, you can benefit from both the prevention and decreased concern. Obviously there are caveats here as you may truly need to address possible causes of nocturia since it can result from changes in renal function, cardiac problems, urinary tract, medications or other diseases happening at the same time (such as diabetes or Parkinson’s). And it can lead to other disease (especially due to lack of sleep) and affect motality (as in falls). Still, the positive news is that so many of the causes are ones we can learn to control by simply changing habits or patterns.
Before you visit the Doc
Nocturia or nightime urination can be the interplay of so many different elements in your life that if you have a concern, you may wish help through an evaluation process. Understand that if you are concerned, it is reasonable to consider a urology or nephrology consultation. To repeat however, the most common causes might be controlled and do not necessarily have to lead you down a path of more intervention or medications. So ask about the preventative options.
Tip for your visit. One procedure to consider ahead of the appointment with the urologist is a ‘voiding diary.’ Keep a voiding diary for a couple/several weeks if you suspect a problem that you would like to discuss with your physician. This will save a step (and perhaps extra visits or costs) when they recommend you keep a voiding diary as the next stage. The ‘yuck factor’ here is that along with time-tracking, you need to incorporate volume measurements for it to be of best value, meaning measuring your urine. So find a large mouth container with ml markings (milliliters) and after collecting the specimen, track and record the amounts before discarding. [In general, more than 2 liters a day and physicians become suspicious. Although this could be normal for those who hydrate often.] The voiding diary may be your most valuable tool for the consultation, but also be prepared to answer the questions about health history and habits that we have discussed above, especially if you have explored changing these habits. Proactivity on both counts will accelerate the diagnostic process which consequently will decrease your time of worry.
FINAL THOUGHT
It’s just my opinion, but I say nix to avoiding the chocolate! It wouldn’t be on my list.
By the Way, considering my recent post on Maximizing your Potty Potential (Squatty Potty) and now this, I promise to stay out of the bathroom for a while. Let’s see if I can hold that.
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Other References:
Cleveland Clinic Foundation. Diseases and Conditions: Nocturia. http://my.clevelandclinic.org/health/diseases_conditions/hic_Bladder_Irritating_Foods/hic_nocturia Accessed 5/10/2016
Boongird S1, Shah N, Nolin TD, Unruh ML.(Authors) Fried, Linda and Unruh, Mark (Editors).(Department of Medicine, University of Pittsburg Medical Center). ‘Nocturia and Aging: Diagnosis and Treatment’ Advanced Chronic Kidney Disease Volume 17, Issue 4, July 2010, Pages e27–e40. doi:10.1053/j.ackd.2010.04.004 Full text available for purchase; abstract accessed 5/13/2016.
Kujubu, Dean A, clinical assistant professor (UCLA School of Medicine), American Society of Nephrology. Geriatric Nephrology Curriculum. ‘Nocturia in Elderly Persons and Nocturnal Polyuria (Chapter 19). 2009
Marinkovic SP, Gillen LM, Stanton SL. BMJ 2004;328:1063. Managing nocturia. Abstract Accessed 5/12/2016. Full text available.
National Association for Continence. Nocturia. Accessed 5/10/2016.
National Sleep Foundation. Frequent urination at night. Accessed 5/7/2016.
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