NOCTURIA

  • Nocturia is waking up more than once in night for urinating after going to sleep.
  • Waking up more than once at night for urinating leads to sleeplessness, fatigue, poor concentration daytime, anxiety etc.
  • Nocturia can be due to increased urinary frequency at night-time or increased urine production at night (Global or Nocturnal polyuria).
Nocturia

Global Polyuria – Patient passes more urine during day time as well. Causes include uncontrolled blood sugars, diabetes insipidus (lack of vasopressin hormone).

Nocturnal polyuria – patient passes more urine only during night-time. Various reasons for increased urine output at night include congestive cardiac failure, varicose veins, sleep apnea, swelling lower limbs, drinking lot of fluid before sleep, taking certain medications that increase urine production etc.

Nocturnal frequency – Some patients may not be producing more urine at night but may wake up more often from sleep for urination due to urinary tract infection, OAB (overactive bladder), Prostate enlargement (Read BPH (Enlarged prostate) Symptoms) , small bladder capacity, stroke, interstitial cystitis etc.

Diagnosis is made by doctor after recording detailed history from patient. Patients are usually given a chart to record his drinking and urination habits over whole 24 hour, called bladder diary. Increased urine production need thorough workup to rule out heart condition, diabetes, snoring habits, lower limb edema etc. Certain conditions such as prostate enlargement need ultrasonography tests to look for prostate size. Urine infection is ruled out by taking urine sample for testing.

Treatment of nocturia is as per the underlying cause identified. Restricting fluid intake after evening and Passing urine immediately before sleep is advised. Changing the schedule of diuretic drug, wearing compression stockings during daytime, control of diabetes etc are helpful. Nocturia secondary due to cardiac dysfunction, snoring needs respective consult from cardiologist and ENT specialist. Symptoms due to prostate enlargement may need medicine or surgery for prostate. Patients experiencing increased frequency due to infection are treated with antibiotics. Certain medications such as anticholinergics and beta agonist are helpful in controlling increased frequency. Increased urine output at night is treated with desmopressin medication.

Prostate enlargement diagnosis

Prostate enlargement diagnosis starts with the history and examination of the patient. Symptoms are scored to assess the severity of disease. (Read symptoms of prostate enlargement at BPH (Enlarged prostate) Symptoms). Per rectal examination in office room gives the initial clue to the enlargement of prostate. Since the urinary symptoms are not exclusive for prostate enlargement in men, few basic investigations are often required to reach final diagnosis before initiating treatment.

  1. Urine examination – patient provides a sample of freshly passed urine in a sterile container. This test tells about presence of any infection in urine.
  2. Uroflowmetry – In this test, patient need to hold urine till he gets urge to pass urine. Patient is asked to pass urine in a machine, which then generates a report about the flow of urine. After patient finished passing urine, the presence of any residual urine in bladder is checked by ultrasound.
  3. Ultrasound abdomen – ultrasound is done to see the kidneys, bladder and size of prostate. Kidneys are part of urinary system and prostate enlargement can affect kidney function.
  4. Serum creatinine – creatinine is marker of kidney function. Long term disease can lead to kidney damage and hence need for checking creatinine.
  5.  Blood PSA – PSA is test done to screen patients aged 55-70 years to rule out presence of prostate cancer. Patient with prostate cancer have raised blood PSA levels. However PSA can be raised in other conditions also such as urine infection, prostate infection, urine retention, large prostate etc. Read more about serum PSA at Prostate cancer and PSA testing
  6. TRUS – Trans rectal ultrasound (ultrasound probe passed through rectum) is conducted in office setting under local anaesthesia as it provides the more accurate size of prostate enlargement compared to abdominal ultrasound.
  7. Endoscopy – Flexible endoscopy through urethra may be ordered by physician as per the symptoms of patients and ultrasound findings.  Patients having severe symptoms with normal prostate size on ultrasound may need this test. Flexible endoscopy is done under local anesthesia in office setting which gives visualised information about intraurethral prostate protrusion, and whether it is causing any mechanical obstruction. Sometimes physician advices about prostate operation based on endoscopy report even if size of prostate is normal on ultrasound.
  8. Urodynamics – This test is selectively performed for patients who are suspected of having poor bladder contractility as the cause of his symptoms. These patients include those having symptoms of bed wetting, spontaneous urine leakage, neurological disorders, having previous prostate surgery etc.

After these tests the decision is taken by the doctor for treating the patient with either medicines or with surgery. Read treatment of enlarged prostate at Treatment of Benign Prostatic Enlargement

Nocturnal Enuresis (Bedwetting)

  • Nocturnal enuresis or bedwetting is intermittent night-time urinary incontinence.  
  • Relatively common in children.  
  • 5-10% of children at seven year of age may continue to have bedwetting.  
  • Primary – when child has never been dry for at least six months.  
  • Secondary – when child initially achieved dry period of more than six months and started wetting again.
  • Bed wetting has significant secondary stressful, emotional and social consequences for the child and their caregivers.
  • Boys are known to have more chances of bedwetting than girls at any age.  
  • Hereditary factors are known to influence this condition.  History of bedwetting in either or both parents significantly increase the chance of having bedwetting in child.

Causes of bedwetting

  • High arousal threshold – child does not wake up when bladder is full.  
  • Imbalance between night time urine output and bladder capacity.  
  • Alteration in chronobiology of micturition in which circadian clock in kidney, brain and bladder is disturbed.
  • Symptoms such as habitual snoring, apneas, excessive sweating at night and mouth breathing leads to secondary bedwetting.  

Diagnostic tests

  • The diagnosis is mainly made by history-taking.  
  • Complete two to three days fluid intake diary and voiding diary is recorded to rule out any urinary tract pathology and excessive water drinking habit.  
  • Night time urine output can be recorded by measuring wet diaper weight.  Excessive night time urine production is calculated measuring diaper weight used night time.  
  • Urine examination for infection.  
  • Physical check up by doctor.  
  • Ultrasound and urine flow test (uroflowmetry) if prior surgery was done or suspecting urinary tract pathology.  
  • Checkup by ENT doctor if sleep disorder breathing present.      

Treatment

  • Many children stop bedwetting with age; so wait and watch can be observed for age upto five –six year age.  
  • Normal and regular drinking habits with bowel and bladder habits are encouraged.  
  • Wetting alarm system – use of a device that is activated by getting wet. The goal is that the child wakes up by the alarm, action is to repeat the awakening and therefore change the high arousal to a low arousal threshold. High success rates are noted with this therapy.  
  • Medical therapy – Used in children with high urine output at night. Desmopressin tablet or sublingual tablet is used. Imipramine is another commonly used drug.  

Ten tips to improve urological health

  1. Consume fluid intake of 2.5-3.0 litre/day in regular interval to maintain constant hydration.
  2. Drink cranberry juice to help prevent UTIs.
  3. Maintain weight in healthy range.
  4. Avoid smoking.
  5. Limit the intake of salt and caffeinated products.
  6. Empty your bladder before going to bed.
  7. Limit fluid intake 2-3 hours prior to sleep at night.
  8. Avoid prolonged holding of urine.
  9. Regular Kegal exercises to strengthen the pelvic floor muscles.
  10. Front -to- back direction cleaning of genitals in women to prevent UTIs.

Absent testes in scrotum or empty scrotum (Undescended Testes/ Cryptorchidism)

  • Absence of either testis from its normal position in scrotum is called undescended testis.
  • It is most common congenital abnormality found in male genitalia.
Undescended testis (Cryptorchidism)

Classification

  • Congenital – Undescended testis present since birth
  • Acquired – testis which has migrated up that has been previously noted to be present in scrotum
  • Location wise – Inguinal (groin), Intra-abdominal, Ectopic (not in path of normal descent)

Causes of undescended testis

  • Developmental disorder of the gonads by either environment or genetic factors.
  • Maternal smoking
  • Premature birth

Effects of undescended testes

  • Undescended testis of one side can affect the function of normally descended other testis also.
  • Impaired semen parameters
  • Impaired fertility
  • Hypogonadism (testosterone deficiency)
  • Tumors in the undescended testis

Treatment

  • Surgical treatment is mainstay of management.
  • In infants and early age, surgical correction with bringing testis down into scrotum is done.
  • In adults with intra-abdominal testis, and having normal opposite testis, orchiectomy is usually considered. However if both testes are intra-abdominal, surgical correction to bring testes down into scrotum is considered.