Our Greatest Wealth Is Health

Andrew Siegel MD    6/23/18

There is compelling medical evidence that a good night’s sleep is of vital importance for one’s health. We recognize this intuitively when we compare how we feel after a night of sleeping well as opposed to a night of sleep deprivation, but it goes way beyond mere fatigue.  Sleeping well is a key component to cognitive and physical fitness as well as overall health, equally important to diet and exercise. Aside from daytime fatigue, weight gain because of altered eating patterns, and increased risk of traffic accidents and fall-related nighttime injuries, sleep deprivation has been associated with an assortment of medical problems that negatively affect quality and quantity of life.  

Although there are many reasons for failing to obtain sufficient sleep, one such cause is interrupted sleep from the need to frequently empty one’s bladder. This can be disruptive to achieving a good night’s sleep, with many nighttime voiders unable to get back to sleep after urinating. Today’s entry reviews a new medication that can help sleep-disruptive nighttime urinating when it is caused by overproduction of urine, a causal factor in over 80% of cases of nighttime urination.

Nighttime urination—nocturia in medical speak—is a complex condition that aside from affecting quality of sleep and quality of life can be a symptom of underlying medical issues, e.g., diabetes, obstructive sleep apnea and cardiovascular issues. It is common in both women and men, tends to increase with aging, and its underlying basis is often multifactorial.  If it occurs once or twice a night and is not too bothersome and one can readily get back to sleep, it is no big deal.  However, if it occurs more than twice a night and is sleep-disruptive, it may be time to consider a means of improving the situation. Importantly, although nocturia is typically a complaint that drives patients to urologists, most of the time the nocturia is NOT urological in origin.

A simple test to help assess nocturia is a 24-hour voiding diary, which requires a pen and paper, a watch or clock and a measuring cup. The time at which urination occurs and the volume of each urination are recorded. Typical bladder capacity is 10–12 ounces with 4–6 urinations per 24 hours. Such a diary will help differentiate between those with a reduced bladder capacity, those who produce lots of urine only while sleeping, and those who produce lots of urine both day and night.

Reduced bladder capacity is often a sign of urological issues including overactive bladder, benign prostate enlargement, neurological diseases affecting the bladder, and loss of elasticity of the bladder as may occur with pelvic radiation.

Those who produce lots of urine only while sleeping are commonly found to have the following causes: increased fluid intake in the evening, obstructive sleep apnea, edematous states such as congestive heart failure, and failure to produce sufficient quantity of a hormone that regulates urine production.

Drinking a few cups of coffee or tea after dinner or a few beers before bedtime will cause nighttime urination and has an obvious solution. Obstructive sleep apnea is a under-appreciated and common cause of full-volume nighttime urination that when treated with CPAP (continuous positive airway pressure) or other means will significantly reduce the nocturia. Edema is fluid within the tissues–-typically the ankles and legs–that tends to accumulate aided by gravity over the course of the day. Upon assuming the lying-down position when sleeping, the legs are relatively elevated as opposed to standing and this tissue fluid returns into circulation, causing the kidneys to increase urine production. In general, those with peripheral edema go to sleep with ankles and legs engorged with edema fluid and wake up with thinner legs, as the return of some of the fluid to the circulation and the subsequent increased urination rids them of this. Another possibility is an abnormality in the nocturnal secretion of anti-diuretic hormone.  This pituitary hormone causes the kidneys to concentrate urine and pull water back into the circulation; nocturia may occur because of an age associated decline in its secretion while sleeping.

Those who produce lots of urine both day and night often have overzealous fluid intake, diabetes mellitus or diabetes insipidus, or are on certain medications (e.g., lithium) that can cause the problem.

Noctiva (Desmopressin) to treat nocturnal excessive urine production

One of the most common reasons for nocturia is excessive nighttime urine production, defined as nighttime urine volume exceeding 1/3 of the 24-hour urine production.  If this is demonstrated on the voiding diary, you may be a candidate for this anti-diuretic medication that works by decreasing nocturnal urinary production.

Desmopressin is a synthetic version of anti-diuretic hormone. The function of this hormone is to put the “brakes” on the kidneys so that the kidneys do not allow excessive loss of body water, which could be detrimental to one’s health and lead to severe dehydration. For years, desmopressin has been used for children who are bed wetters.

Noctiva (Desmopressin) nasal spray is a new formulation of intranasal desmopressin for those who have full-bladder volume nocturia two or more times.  It is a modification of desmopressin that is designed to enhance absorption from the nasal lining, available in doses of 0.83 and 1.66 microgram.  One spray in either nostril is used about 30 minutes prior to sleep.

The absorption of this product is enhanced as compared to that of the oral version (8% vs. 0.3%), which means more consistent dosing and rapid absorption and elimination allowing more rapid onset and less prolonged drug activity.  It is well tolerated with the most common side effect low levels of sodium and other side effects including nasal irritation, nasal congestion, nosebleeds, sneezing, and high blood pressure.  The drug cannot be used in the face of excessive fluid intake, low serum sodium, steroids or loop diuretic use, heart failure, uncontrolled high blood pressure, poor kidney function, and with illnesses causing fluid and electrolyte imbalances. Sodium levels need to be monitored periodically.

Bottom Line: Nocturnal urinary frequency should be investigated to determine its cause, which may in fact be related to conditions other than urinary tract issues.  Nighttime urination is not only bothersome but may also pose real health risks as chronically disturbed sleep can lead to a host of collateral wellness issues. Noctiva is a new addition to the armamentarium to combat nighttime urination when it is due to excessive nocturnal urinary production.

Wishing you the best of health,

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

New video on female pelvic floor exercises:  Learn about your pelvic floor