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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Nocturia in Overactive Bladder


GOAL
To provide urologists, urogynecologists, and primary care physicians with up-to-date information on the treatment and management of patients with nocturia.

TARGET AUDIENCE
This activity is designed for urologists, urogynecologists, and primary care physicians.
No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, the participant should be able to:

  • Define, diagnose, and assess the impact of nocturnal urinary frequency (nocturia).
  • Evaluate causes and treatment options that support 24-hour urinary control and may reduce nocturia and its associated consequences.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for
a maximum of 2 category 1 credits toward the AMA Physician's Recognition Award.
Each physician should claim only those credits that he/she actually spent in the activity.

The estimated time to complete this educational activity: 2 hours.
Release date: January 15, 2006. Expiration date: January 15, 2008.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Pfizer Inc.

Full Disclosure Policy Affecting CME Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

Geoffrey W. Cundiff, MD
Professor and Chair
Department of Obstetrics and Gynecology
Johns Hopkins Bayview Medical Center
Baltimore, Maryland
Dr Cundiff reports receiving grants/research support from COOK OB/GYN; serving as a consultant for CR Bard, Inc and Lilly; and serving on the SpeakerÕs Bureau of GlaxoSmithKline.

PARTICIPATING FACULTY

Raymond R. Rackley, MD
Section Head
Section of Voiding Dysfunction and Female Urology
Director, Urothelial Biology Laboratory
Lerner Research Institute
Cleveland Clinic Foundation
Glickman Urological Institute
Cleveland, Ohio
Dr Rackley reports receiving grants/research support from Watson Pharmaceuticals; and receiving honoraria from Novartis, Pfizer Inc, and Yamanouchi.

Eric S. Rovner, MD
Associate Professor of Urology
Medical University of South Carolina
Charleston, South Carolina
Dr Rovner reports receiving grants/research support from Allergan, Pfizer Inc, and Q-Med; serving as a consultant for GlaxoSmithKline, Indevus Pharmaceuticals, Inc, Novartis, and Pfizer Inc; and receiving honoraria from Allergan, Novartis, and Pfizer Inc.

David H. Thom, MD, PhD
Associate Professor
Department of Family and Community Medicine
University of California
San Francisco, California
Dr Thom reports having no significant financial or advisory relationships with corporate organizations related to this activity.

Phyllis C. Zee, MD, PhD
Professor
Department of Neurology
Northwestern University
Feinberg School of Medicine
Chicago, Illinois
Dr Zee reports serving as a consultant for Neurocrine and Pfizer Inc.

Notice: Faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Nocturia In Overactive Bladder
Geoffrey W. Cundiff, MD

Nocturia is a disease state that has a significant impact on general health and quality of life. The prevalence of nocturia increases with age. Nocturia is among the most bothersome symptoms that patients with lower urinary tract disorders experience. It has been associated with an increased risk of falls and sleep disruption that can lead to a host of other problems, including excessive somnolence, decreased cognitive and work performance, dizziness, and depression. Treatment of nocturia can have a profound effect on a patient's quality of life. Behavioral and pharmacologic interventions are the most commonly used modalities.1,2

Nocturia has been defined as "the complaint that the individual has to wake at night one or more times to void." It can be a symptom of many different systemic diseases, including overactive bladder (OAB), although it is not part of the diagnostic criteria of OAB.3 The causes of nocturia can be categorized according to the following conditions: diminished nocturnal bladder capacity, nocturnal polyuria, and polyuria. Diminished nocturnal bladder capacity results from disorders, such as OAB, bladder obstruction, urogenital aging, malignancy, and infection. Nocturnal polyuria results from abnormalities in secretion or utilization of arginine desmopressin, obstructive sleep apnea, congestive heart failure, and renal insufficiency. Polyuria results from diabetes mellitus or insipidus. Other causes of nocturia include sleep disorders, peripheral edema, and consumption of excessive fluids shortly before bedtime.4,5

Treatment of nocturia is driven by the underlying cause of the patient's symptoms. A proper diagnostic assessment before starting treatment is crucial to achieving success. A complete medical history, physical examination, and laboratory assessments are needed to exclude polyuria and nocturia resulting from systemic diseases, such as those associated with edema (eg, chronic heart failure or renal disease), decreased renal concentrating capacity (eg, diabetes insipidus or renal insufficiency), and irritative bladder symptoms caused by bacterial cystitis, chronic interstitial cystitis, bladder calculi, or bladder cancer. Details of bladder filling and outflow symptoms should be obtained from the patient to rule out an underlying bladder outlet obstruction. Other factors that should be evaluated include fluid intake, medications, neurologic disorders, and nocturnal apnea. Conservative measures, such as behavior modification therapy (eg, bladder retraining and pelvic floor muscle training) and lifestyle modifications (eg, changes in medication/medication schedule or elevation of legs or use of compression stockings to reduce fluid accumulation), usually are tried before initiation of pharmacologic therapy. Symptoms that are refractory to behavioral and pharmacologic therapy may respond to surgery (eg, sacral nerve neuromodulation).2,5-8

Desmopressin acetate and imipramine have been shown to be effective for the treatment of nocturnal polyuria. Nocturia associated with OAB can be successfully treated with an antimuscarinic agent. Nonselective muscarinic receptor antagonists, including oxybutynin, tolterodine, and trospium, in addition to selective muscarinic receptor antagonists, including darifenacin and solifenacin, have been shown to be effective for the treatment of OAB symptoms. Specifically, in clinical studies, tolterodine, trospium, and solifenacin have been associated with significant decreases in the number of nocturnal voids per day.9-14

Many patients with OAB symptoms, such as nocturia, fail to seek medical assistance because of embarrassment or the misconception that OAB is a natural part of aging. These patients often adopt coping strategies, such as limiting travel to locations near a bathroom or avoiding sexual intimacy, to make the condition bearable; patients may continue using these coping strategies for extended periods of time before consulting a healthcare professional. The treating healthcare professional should be aware of which symptoms are most bothersome to the patient and focus on treatment of those symptoms to ensure patient satisfaction with treatment.15

In this issue of Advanced Studies in Medicine, the review article, authored by Raymond R. Rackley, MD, reviews in detail important issues to consider when diagnosing and treating the patient with nocturia. This review is practical and geared toward the practicing clinician.

An interview with David H. Thom, MD, PhD, details the considerations of the primary care physician (PCP) when diagnosing and treating a patient with nocturia. In an interview with Eric S. Rovner, MD, the steps to be taken to assess, diagnose, and manage nocturia are described while providing Òclinical pearlsÓ regarding the important interactions between the PCP and the specialist.

Drs Thom and Rovner also present a case that illustrates the importance of the interaction process between the PCP and specialist in obtaining a successful result for the patient. Phyllis C. Zee, MD, PhD, presents a case that describes the importance of evaluation and treatment to identify the underlying cause of nocturia and associated or comorbid conditions, such as sleep disorders.


The content in this monograph was developed with the assistance of a medical writer. Each author had final approval of his/her article and all its contents.

REFERENCES

1. Asplund R. Nocturia in relation to sleep, health, and medical treatment in the elderly. BJU Int. 2005;96:15-21.
2. Wagg A, Andersson KE, Cardozo L, et al. Nocturia: morbidity and management in adults. Int J Clin Pract. 2005;59:938-945.
3. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Urology. 2003;61:37-49.
4. Weiss JP, Blaivas JG. Nocturnal polyuria versus overactive bladder in nocturia. Urology. 2002;60:28-32.
5. Marinkovic SP, Gillen LM, Stanton SL. Managing nocturia. BMJ. 2004;328:1063-1066.
6. Nitti V, Taneja S. Overactive bladder: achieving a differential diagnosis from other lower urinary tract conditions. Int J Clin Pract. 2005;59:825-830.
7. Park SH, Davila GW. Overactive bladder: treatment options for the aging woman. Int J Fertil Womens Med. 2005;50:37-44.
8. Lundgren R. Nocturia: a new perspective on an old symptom. Scand J Urol Nephrol 2004;38:112-116.
9. Ouslander JG. Management of overactive bladder. N Engl J Med. 2004;350:786-799.
10. Singh-Franco D, Machado C, Tuteja S, Zapantis A. Trospium chloride for the treatment of overactive bladder with urge incontinence. Clin Ther. 2005;27:511-530.
11. Brunton S, Kuritzky L. Recent developments in the management of overactive bladder: focus on the efficacy and tolerability of once daily solifenacin succinate 5 mg. Curr Med Res Opin. 2005;21:71-80.
12. Andersson KE. Antimuscarinics for treatment of overactive bladder. Lancet Neurol. 2004;3:46-53.
13. Salvatore S, Soligo M, Proietti F, et al. Overactive bladder syndrome: considerations in pharmacotherapy and new perspectives. Eur J Obstet Gynecol Reprod Biol. 2005;120:129-133.
14. Rackley RR, et al. A double-blind, placebo-controlled, randomized US/Latin America study to evaluate the effect of tolterodine prolonged release on nocturia in patients with symptoms of overactive bladder (OAB). In press.
15. Epstein LB, Goldberg RP. The overactive bladder and quality of life. Int J Fertil Womens Med. 2005;50:30-36.


*Professor and Chair, Department of Obstetrics and Gynecology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland.
Address correspondence to: Geoffrey W. Cundiff, MD, Professor and Chair, Department of Obstetrics and Gynecology, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Room A1C, Baltimore, MD 21224.
E-mail:
gcundiff@jhmi.edu.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.