Clinical reviewThe effect of nocturia on sleep
Introduction
The importance of good sleep has only begun to be understood. It has been known for many years that a good night's sleep is important, with 7–8 h endorsed for adults. New data reinforce the increased risks associated with insufficient sleep. In a series of studies by Stone and associates in older men and women,1, 2, 3, 4, 5 less sleep at night and lower sleep efficiency (defined as the amount of sleep given the amount of time in bed) were both associated with increased risk of poor physical function, decreased cognitive function, falls and mortality. There are many reasons why sleep can be disrupted or shortened at night, including primary sleep disorders, changes in circadian rhythms, or just not spending enough time in bed. In addition, both exogenous and endogenous factors can disrupt sleep, such as too much light or noise in the bedroom. The sensation of a full bladder may also cause awakening and ultimately lead to the conscious decision to get out of bed to go to the bathroom; when this happens multiple times during the night, it is defined as nocturia.
Section snippets
What is ‘disturbed sleep’?
Disturbed sleep can mean many things but it is often equated with insomnia, which is clinically defined as persistent difficulty in initiating or maintaining sleep, or non-restorative sleep, that causes significant daytime distress and impaired social or occupational functioning.6 Insomnia affects around 15% of adults and is among the most prevalent chronic disorder in the general population.7 Three types of insomnia have been characterized: sleep onset insomnia (difficulty falling asleep),
Insomnia co-morbid with nocturia
Disturbed sleep, or insomnia, is often co-morbid with nocturia, i.e., the sensation of a full bladder leading to the need to get up to urinate at night.*10, *11 Three-quarters of participants in a survey of US residents aged 18 years or over cited the need to go to the bathroom as the most frequent reason for nocturnal awakenings.8 Indeed, going to the toilet was the primary reason for night-time awakening across all age groups, and the proportion affected increased with age: 39.9% in those
Quality of life
Chronic lack of sleep can have a great impact on ability to function. Sleep disturbances which result in sleep deprivation can also exact an immense personal toll, as evidenced by the adverse impact of disturbed sleep on physical and emotional health as well as overall quality of life (QoL). Sleep disruption among insomnia sufferers has been associated with impairments in daytime functioning and cognition, and with increased medical illnesses, hospitalizations and work absences due to sickness.7
Clinical evaluation of nocturia
Nocturia is multifactorial and can be associated with serious medical conditions such as diabetes mellitus, diabetes insipidus and congestive heart failure. Once such underlying illnesses have been excluded through thorough history-taking and patient evaluation, other possible contributory factors need to be explored. A fundamental issue in most patients is that the amount of urine produced overnight exceeds the capacity of the bladder. This may be due to an overproduction of urine (nocturnal
Treatment of nocturia
Before entering into discussion of available therapies for nocturia and their effect on subsequent sleep, it should first be highlighted that the question of which sleep endpoints are most relevant is as yet unresolved. Efficacy in nocturia trials is generally reported as the reduction in number of voids per night, or percentage reduction in voids per night, and QoL studies indicate that those people with fewer than two voids/night experience minimal impact on their daytime functioning.*15, 21
Conclusions
Sleep plays a vital role in physical and mental functioning. It is increasingly recognized that poor sleep quality is a highly prevalent and chronic condition that merits greater awareness due to the wide-ranging and serious repercussions associated with it. Nocturia is one of the primary causes of sleep disturbance and has been shown to impair functioning, QoL, health and productivity, with those experiencing two or more voids per night reporting significant ‘bother’. Many urologists have
Conflict of interest
Sonia Ancoli-Israel, Ph.D: Consultant/Scientific Advisory Board: Ferring Pharmaceuticals Inc., GlaxoSmithKline, Merck, Orphagen Pharmaceuticals, Pfizer, Philips-Respironics, sanofi-aventis, Schering-Plough. Grants/Contracts: Litebook, Inc.
Donald L. Bliwise, PhD: Consultant, New England Research Institute.
Jens Peter Nørgaard MD DMSC: Full time employee at Ferring Pharmaceuticals in Copenhagen, Denmark. Ferring is the manufacturer of several desmopressin formulations (rhinyle, spray, tablets and
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