Boris van Doorn

Prevalence, Incidence, and Resolution of Nocturnal Polyuria in a Longitudinal Community-based Study in Older Men: The Krimpen Study

BACKGROUND Nocturnal polyuria (NP) is common in older men and can lead to nocturia. However, no longitudinal data are available on the natural history of NP. OBJECTIVE To determine prevalence, incidence, and resolution rates of NP. DESIGN, SETTING, AND PARTICIPANTS A longitudinal, community-based study was conducted among 1688 men aged 50-78 yr in Krimpen aan den IJssel, The Netherlands (reference date: 1995), with planned follow-up rounds at 2, 4, and 6 yr. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS NP was determined with frequency-volume charts. Two definitions of NP were used: (1) a nocturnal urine production (NUP) of >90 ml/h (NUP90) and (2) the nocturnal voided volume plus first morning void being >33% of the 24-h voided volume (NUV33). Nocturia was defined as two or more voids per night. We determined the prevalence of NP at each study round. At first follow-up, we determined the incidence in men without baseline NP and the resolution in men with baseline NP. Prevalence of NP in men with or without nocturia was also determined. RESULTS AND LIMITATIONS At baseline, the prevalence of NUP90 was 15.0% and increased to 21.7% after 6.5 yr, whereas the prevalence of NUV33 was 77.8% at baseline and 80.5% after 6.5 yr. At 2.1 yr of follow-up, the incidences of NUP90 and NUV33 were 13.6% and 60.3%, respectively, and the resolution rates were 57.0% and 17.8%, respectively. Because of this fluctuation in NP, no reliable long-term incidences could be calculated. At baseline, NUP90 was prevalent in 27.7% of men with nocturia and in 8.0% of those without nocturia. At baseline, NUV33 was prevalent in 91.9% of men with nocturia and in 70.1% of men without nocturia. CONCLUSIONS Due to the fluctuation of NP, it is advisable to first determine its chronicity and cause before starting treatment. Because of the high prevalence of NP in men without nocturia, NUV33 should be reconsidered as a discriminative definition of NP.

Once Nocturia, Always Nocturia? Natural History of Nocturia in Older Men Based on Frequency-Volume Charts: The Krimpen Study

PURPOSE Nocturia is a highly prevalent and bothersome symptom that might (spontaneously) resolve. However, longitudinal data are not available on the incidence and resolution of nocturia assessed with frequency-volume charts. In this study we determined the prevalence, incidence and resolution rates of nocturia assessed by frequency-volume charts, and compared nocturnal voiding frequency over time as assessed by frequency-volume charts and questionnaires. MATERIALS AND METHODS A longitudinal, population based study was conducted among 1,688 men 50 to 78 years old with followup rounds at 2.1, 4.2 and 6.5 years. Nocturnal voiding frequency was determined with frequency-volume charts and, for comparison purposes, with a question from the International Prostate Symptom Score. Nocturia was defined as nocturnal voiding frequency 2 or greater. Prevalence, incidence and resolution rates were also determined. RESULTS At the 2.1-year followup the incidence rate was 23.9% and the resolution rate was 36.7%. The incidence rate was highest in the oldest group (70 to 78 years) and lowest in the youngest (50 to 54 years), whereas the resolution rate was highest in the group 55 to 59 years old and lowest in the oldest group. Because of the high resolution rate, no reliable incidence rates can be calculated. Despite fluctuation, the prevalence of nocturia increased with age and over time (from 34.4% to 44.7% for the total group, p <0.05). Men who had a frequency-volume chart-nocturnal voiding frequency less than International Prostate Symptom Score-nocturnal voiding frequency (6% of the population) more often had this later on. CONCLUSIONS In this population frequency-volume chart assessed nocturia shows considerable fluctuation. Nevertheless, prevalence increases over time and with increasing age. Men who once had frequency-volume chart-nocturnal voiding frequency less than International Prostate Symptom Score-nocturnal voiding frequency are more likely to have this again. Therefore, frequency-volume charts as well as the International Prostate Symptom Score should be used when evaluating nocturia.

Determinants of nocturia: the Krimpen study.

PURPOSE Many conditions and characteristics are cross-sectionally associated with nocturia. However, to our knowledge longitudinal associations of frequency-volume chart based nocturia have not yet been studied. We identify (modifiable) determinants of nocturia in older men in a longitudinal setting. MATERIALS AND METHODS A longitudinal, community based study was conducted among 1,688 men age 50 to 78 years in Krimpen aan den IJssel, The Netherlands with planned followup rounds at 2, 4 and 6 years. Men without a history of radical prostatectomy, transurethral surgery, or bladder or prostate cancer were included in the study. Data were obtained using frequency-volume charts, from which the nocturnal voiding frequency, maximum voided volume and (nocturnal) urine production were determined. Nocturia was defined as a nocturnal voiding frequency of 2 or more episodes. Polyuria was defined as greater than 2,800 ml voided per 24 hours. For nocturnal polyuria we used the 2 definitions of 1) greater than 33% of 24-hour voided volume and 2) nocturnal urine production of greater than 90 ml per hour. Conditions and characteristics were determined via medical examinations and questionnaires. A generalized linear mixed effect model was used to determine factors longitudinally associated with nocturia. RESULTS Age (50 to 55 years vs greater than 60 years), maximum voided volume (greater than 300 ml vs less than 300 ml), 24-hour polyuria, nocturnal polyuria (both definitions) and lower urinary tract symptoms were all longitudinally associated with an increased prevalence of nocturia in older men. CONCLUSIONS A smaller maximum voided volume, lower urinary tract symptoms, 24-hour polyuria and nocturnal polyuria are significant and potentially modifiable determinants of nocturia. The finding that both definitions for nocturnal polyuria are independent significant determinants may indicate a 2-step etiologic process for nocturnal polyuria.

Nocturia in older men

Nocturia is a common and bothersome symptom that impacts on sleep-quality and quality of life. Nocturia often has a multi-factorial etiology which makes thorough assessment of the complaint indispensable. This review summarizes the definition of nocturia, its epidemiology, clinical presentation, pathophysiology, diagnostics, and treatment options with special reference to older men. Nocturia is defined as a nocturnal voiding frequency of two or more, based on impact on quality of life. It is very prevalent in older men. Apart from the negative effects of sleep-disruption, it may be a risk-factor for hip fractures and increased mortality. Most common causes are: nocturnal polyuria, 24-h polyuria, overactive bladder (sometimes due to BPH) and sleep disturbance. A clear understanding of the etiology in the individual patient is indispensable when addressing the various possible causes and co-morbidities. Most important tool for this is the frequency-volume chart, but also patient history, physical examination and serum analysis. For treatment, lifestyle adjustments are often helpful. Medical therapy with 5-alpha reductase inhibitors, alpha-blockers, a combination of the two, or anti-muscarinics, has a limited effect. Most important medical option is desmopressin (arginine vasopressin analogue); however, treatment with this drug is limited to men under 65 years mainly due to the risk of hyponatraemia.

Determinants of nocturia severity in men, derived from frequency-volume charts

Abstract Objective. Nocturia may be characterized by indices derived from the frequency–volume chart (FVC). The objective of this study was to determine how these parameters relate to the severity of nocturia in men with and without lower urinary tract symptoms (LUTS). Materials and methods. A retrospective analysis of FVCs was performed in two cohorts of men: those presenting with LUTS in a New York ambulatory urology clinic and those from the longitudinal population-based Krimpen study. Nocturnal urine volume (NUV), nocturia index (Ni), nocturnal polyuria index (NPi), nocturnal maximal voided volume (nMVV) and sleep duration were derived from FVCs. Comparisons were made using Spearman’s rank correlation coefficient between actual number of nightly voids (ANV) and the other diary parameters. Results. Eighty-eight consecutive men who presented with LUTS completed a 24 h FVC [median age 70 years, interquartile range (IQR) 64.5–74.5, median ANV 2, IQR 1.5–4]. Nocturnal voiding frequency and volume were analyzed in 1082 community-dwelling men (median age 61 years, IQR 56.1–66.4, range 49.4–78.2; median ANV 1.5, IQR 1.0–2.0, range 0–4.5). Both cohorts demonstrated strong correlations between nocturia severity (represented as ANV) and Ni (0.797, 0.658 for cohorts 1 and 2, respectively). There were moderate correlations between nocturia severity and NPi (0.545, 0.394), NUV (0.463, 0.432) and sleep duration (0.306, 0.272). The nMVV correlated poorly with nocturia severity (0.159, 0.146). Conclusions. Treatment of nocturia should aim to match nocturnal urine production with bladder capacity. Given the lack of known effective pharmacotherapy for low bladder volume, the first attempt nocturia treatment could focus on volume reduction.

The Natural History and Predictive Factors of Voided Volume in Older Men: The Krimpen Study

PURPOSE Although functional bladder capacity, as expressed by maximum voided volume and other frequency-volume chart parameters, are important determinants of lower urinary tract symptoms, to our knowledge no population based data are available on changes in voided volume. We determined changes in and determinants of voided volume and voiding frequency with advancing age and with time, as measured by frequency-volume charts. MATERIALS AND METHODS We performed a longitudinal, population based study in 1,688 men 50 to 78 years old with followup at 2.1, 4.2 and 6.5 years. Data were obtained using frequency-volume charts for maximum, 24-hour and average voided volume, and 24-hour voiding frequency as well as physical and urological measurements, and self-administered questionnaires. We used a linear mixed effect model to determine factors predicting volume changes. RESULTS Median maximum and average voided volume decreased with time from 400 to 380 and 245 to 240 ml, respectively, and were smaller in older age groups while 24-hour voided volume showed no change. The 24-hour voiding frequency increased with time and with advancing age. Maximum, 24-hour and average voided volumes were positively related to alcohol intake. Maximum and average voided volumes were negatively related to higher age at baseline and the passage of time. Hypertension, diuretics and post-void residual volume were related to higher 24-hour voided volume. CONCLUSIONS In older men maximum and average voided volume show a small but statistically significant decrease with time and with advancing age while 24-hour voided volume does not. Factors predicting the change in maximum or average voided volume are alcohol intake and higher age.

1743 WHAT PREDICTS INCIDENT NOCTURIA? A POPULATION-BASED STUDY IN OLDER MEN: THE KRIMPEN STUDY

INTRODUCTION AND OBJECTIVES: Many conditions and characteristics are associated with nocturia, however, there is a paucity of data on the factors that predict the development of nocturia. We therefore determined factors predictive of incident nocturia. METHODS: We analyzed the database of a population-based cohort study among 1,688 men aged 50-78 years old, without radical prostatectomy, transurethral surgery, or bladder or prostate cancer, living in Krimpen aan den IJssel, The Netherlands. Data were obtained using frequency-volume charts (FVC), from which the nocturnal voiding frequency (NVF) was determined. Nocturia was defined as NVF ≥ 2. Conditions and characteristics were determined via medical examination and a 113-item questionnaire. Men without nocturia at baseline (BL) and no exclusion criteria met were selected. At the first follow-up round (FU-1; after 2.1 years) we determined how many men developed nocturia. Univariable analyses were done to determine the association between the BL characteristics and nocturia-status at FU-1. Variables with an association p <0.25 were selected to create a multivariable logistic regression model. After a manual backward selection procedure a final model was created with only significant associations (piu0.05). RESULTS: At BL 1597 men completed an FVC, 133 men met the exclusion criteria. 342 men were excluded because of missing sleeping-hours, and 386 men had nocturia (34.4%), resulting in a target population of 736 men. At FU-1, 341 men were excluded because they did not void during the night or within the first hour of rising, did not complete a FVC, or due to loss to follow up. Therefore, analysis could was possible in 395 men. These men did not significantly differ from the total population regarding conditions and characteristics. Median age was 59.8, the incidence-rate after 2.1 years for nocturia was 24.8%. Table 1 shows the univariable and multivariable logistic regression models. Univariably as well as in the final model only age and alcohol intake were significantly related to incident nocturia. CONCLUSIONS: Although many characteristics are associated with nocturia, only age could significantly predict incident nocturia. Alcohol intake had a protective effect. (Table presented).

Diary-Based Population Analysis of Nocturia in Older Men: Findings of the Krimpen Study

Increased diurnal and nocturnal voiding frequency are common and bothersome symptoms in older men and interfere with daily activities, whereas nocturia may result in sleep disturbance, daytime fatigue, a lower level of general well-being, and is a risk factor for nightly falls [1]. In the FInnish National Nocturia and Overactive bladder (FINNO) study, health-related quality of life was not impaired when subjects voided once a night, but slightly or moderately impaired with two or three or more voids per night, respectively [2]. In addition to the association with urological conditions, such as prostate enlargement, diurnal and nocturnal urinary frequencies are reported as symptoms of various diseases [3]. Many physicians consider increased nocturnal voiding frequency a sign of increased nocturnal urine production, which may represent a pathologic condition reflective of congestive heart failure, venous stasis or hormonal changes with ageing. Besides the relation to nocturnal urine production, nocturnal voiding frequency has been described as a result of diuretic use and awakenings for other reasons such as sleep disorders or anxiety [3].

1725 ONCE NOCTURIA, ALWAYS NOCTURIA? NATURAL HISTORY OF NOCTURIA IN A COMMUNITY-BASED POPULATION OF OLDER MEN

INTRODUCTION AND OBJECTIVES: Nocturia is a highly prevalent symptom. However, no data are available on the longitudinal fluctuation of nocturia (i.e. switching from nocturia to a non-nocturia state). We determined the prevalence of nocturia and its fluctuation over time, measured with frequency-volume charts (FVCs). METHODS: We conducted a longitudinal, population-based study among 1,688 men aged 50 to 78 years old. Men who had undergone radical prostatectomy, a history of transurethral surgery, or had bladder or prostate cancer were excluded. At baseline (reference date: June 1995), data were obtained using FVCs, from which the nocturnal voiding frequency was determined. Nocturia was defined as 2 or more (N 2) and 3 or more (N 3) voids per night. Measurements were repeated during 2 follow up rounds after 2.1 and 4.2 years. We estimated the prevalence of nocturia for both definitions and analyzed the fluctuation between consecutive follow up rounds. RESULTS: At baseline 1597 men (95% of the responders) completed a 3-day FVC. However, due to missing data regarding bedtime/time of rising (n 375) and due to meeting the exclusion criteria (n 108), the nocturnal voiding frequency (N) could be analyzed for 1117 men at baseline (70% of the completed charts). A total of 948 and 458 FVCs were available for the follow-up rounds at 2.1 (FU1) and 4.2 years (FU2), respectively. The prevalence of N 2 had increased 34.6% to 43.7%; the prevalence of N 3 had increased from 2.3% to 4.7%. The chance of having N2was significantly higher after 4.2 years. However, the chance of having N 3 was higher after 2.1 years, but not after 4.2 years (McNemar s test, p 0.05). The fluctuation for N 2 showed the following pattern: Of the men who did not have N 2 at baseline (BL), 23.9% got N 2 at FU1. However, of these latter men, 46.0% no longer had N 2 at FU2: Also, 36.7% of the men who did have N 2 at BL did not have N 2 at FU1. Of this latter group, 48.8% had N 2 again at FU2. Of the 26.6% of men who had N 2 at both BL and FU1, 21.6% did not have N 2 at FU2. The percentages for N 3 show a different pattern: of the men who did not have N 3 at BL, 4.3% had N 3 at FU1. However, of these latter men, 71.4% did not have N 3 at FU-2. Also, 77.8% of the men who did have N 3 at BL no longer had N 3 at FU1. Of this latter group, 37.5% had N 3 again at FU2. CONCLUSIONS: Nocturia is highly prevalent but also highly fluctuant in older men in the open population when measured with FVCs. Nocturia seems to be a inconstant phenomenon which implies that once nocturia does not mean always nocturia. This fluctuation might be due to the multi-factorial aetiology and many possible causes of nocturia.