Nocturia and Sleep

“When you gotta go, you gotta go.”

This classic line, originally from Jurassic Park, has entered the lexicon and been harnessed for jokes and memes. But it also reflects a fundamental reality: sometimes the urge or need to pee comes at inconvenient times.

For some people, this problem becomes particularly significant at night. Nocturia is the medical term for having to get up out of bed multiple times to urinate. This condition is believed to affect 50 million Americans, with nearly one in three people over age 30 having to get up to pee at least twice per night.

Heightened urinary frequency at night can be a major barrier to quality sleep. Nighttime awakenings can cause fragmented sleep, and for people who already have sleep problems like insomnia, getting back to bed can be a real challenge. Surveys have found that nocturia in older adults is a leading cause of poor sleep, increasing the risk of insomnia by 75%.

The connection between nocturia and sleep may stretch even deeper. Sleeping disturbances, especially sleep apnea, may spur or exacerbate problems of nighttime urinary frequency. As a greater percentage of the U.S. population enters older age, steps to understand and address both sleep and nocturia become increasingly important.

This guide goes into detail about nocturia, including its prevalence, health impacts, causes, and treatments. It reviews the existing research about nocturia’s connection to sleep and sleep disorders and provides practical tips for how people who have experienced nocturia can improve their sleep.

What is Nocturia?

Technically, nocturia is simply waking up at night to urinate. According to the definition from the International Continence Society, waking up one or more times during the night to pee is nocturia.

In the clinical medical context, though, researchers have argued that this definition is far too broad. When patients complain about nighttime urinary frequency, it usually involves waking up two or more times. As a result, much of the literature about nocturia focuses on “bothersome nocturia” that is more likely to affect a person’s quality of life. In this guide, we will refer to nocturia using this more specific characterization.

What Are the Health Consequences of Nocturia?

Poor sleep is the most obvious negative health impact of bothersome nocturia. A preponderance of evidence has demonstrated that nocturia has a detrimental effect on sleep. Studies have found that it can cause sleep disruptions, reduce total sleep time, harm sleep efficiency, and alter time spent in different sleep stages. Adverse effects on sleep are often not limited just to the person going to the bathroom; they may extend to a partner who shares the bed.

These nightly disruptions have been shown to harm not just sleep but also overall quality of life. In both men and women, nocturia has been found to significantly increase a person’s risk of depression. A common symptom of depression is disturbed sleep, which may mean that nightly trips to the bathroom sow the seeds for even worse sleeping problems.

Having to get up and go to the bathroom creates a heightened risk of falls, which are especially dangerous for older adults. Studies have found that the majority of nighttime falls happen as part of a trip to the bathroom, and each additional time a person has to go, the greater their risk. Having to urinate two or more times at night more than doubles a person’s overall risk of injuries from a fall, including bone fractures.

Though the exact cause-and-effect is not entirely clear, some studies have looked broadly at nocturia and health outcomes and have found that nocturia is associated with a higher all-cause mortality rate, specifically in elderly people. These studies are observational and not predictive, but they highlight the fact that nocturia can be a significant problem with profound implications for a person’s well-being.

Who is Affected by Nocturia?

Make up for a bad night's sleepThe exact prevalence of nocturia is hard to estimate because many people do not report it to their doctor. Some people may think of even bothersome nocturia as normal or something to just cope with. For this reason, statistics about nocturia are often believed to underestimate its true prevalence.

Surveys of individuals in various countries have found that nocturia is a condition that can affect both young and old, but it becomes increasingly more common with age. Age is considered to be the most significant risk factor nocturia.

To provide a statistical explanation, a review of various studies found that bothersome nocturia affects up to one in five younger adults and one-third of older adults. In younger people, it has been found to be more common in women while in older people, it is more common in men.

Prevalence rates of nocturia are higher in black men and in people who are obese. Pregnant women are also more likely to experience nocturia, but this usually goes away within a few months after they give birth.

How is Nocturia Different From Incontinence or Bedwetting?

While nocturia affects the urinary system, it is distinct from urinary incontinence or nocturnal enuresis (also known as bedwetting). In nocturia, patients have the sensation of needing to urinate, but in nocturnal enuresis, urination is usually involuntary as people do not realize that they have a full bladder.

What Are the Causes of Nocturia?

Nocturia has multiple causes, and in any individual patient, it is common for nocturia to be related to more than one cause. Some of these causal factors are specifically urologic while others are related to other conditions or circumstances.

Many people who have nocturia, especially older adults, think of it as simply a standard part of aging. But the truth is that bothersome nocturia is often indicative of an underlying issue, and patients should not just accept it as inevitable.

Overproduction of Urine

When people produce more urine than is normal, it can lead to a need to go to the bathroom more often at night. When overproduction of urine happens generally, it is called polyuria. If it happens just at night, it is called nocturnal polyuria.

Polyuria

Polyuria is when a person has an increased volume of urine over a normal 24-hour period.

The two most common causes of polyuria are increased fluid intake and diabetes. Increased fluid intake is straightforward: if a person drinks much more water or other liquids than normal, they will usually have an elevated amount of urine production.

Different types of diabetes can cause polyuria. Diabetes mellitus, commonly just referred to as diabetes, is a condition in which a person’s blood sugar levels are elevated. That blood sugar is called glucose, and it can become concentrated in the urine as well as the blood. When that happens, the kidneys generate excess fluid to try to dilute the glucose, leading to greater urine production.

In another, more rare type of diabetes, called diabetes insipidus, a person lacks a hormone called vasopressin. Vasopressin is an antidiuretic hormone that helps regulate fluid levels in the body. People with diabetes insipidus tend to produce significant amounts of urine that is very diluted, creating polyuria and the frequent need to urinate.

Nocturnal Polyuria

Nocturnal polyuria is the overproduction of urine that specifically occurs at night. It is often a factor in nocturia with some studies estimating that it is involved in 88% of cases either as a primary or contributing cause.

Nocturnal polyuria may be caused by heavy fluid intake that happens late in the day or evening. This is especially likely if a person consumes caffeinated beverages (like coffee, tea, or energy drinks) or alcoholic beverages close to bedtime.

Some medications can cause nocturnal polyuria. These medications are often called diuretics or water pills, which are generally prescribed specifically to help the body generate more urine. With some other drugs, increased urine production is a side effect rather than the intended goal.

Swelling in the legs, known as peripheral edema, is also associated with nocturnal polyuria. Studies have indicated that the extra fluid in the legs may manifest as increased urine production at night.

Nocturnal polyuria can be related to cardiovascular problems including high blood pressure and congestive heart failure. It is also more likely among people with sleep-disordered breathing such as obstructive sleep apnea (OSA).

Lower Urinary Tract Problems

While many cases of nocturia are related to the body making too much urine, the condition can also be caused by problems affecting the lower urinary tract. In some situations, polyuria and lower urinary tract problems may occur at the same time. This is known as mixed nocturia.

Bladder Problems

In normal bladder function, urine produced by the kidneys is stored in the bladder until the brain sends a signal that it is time to empty the bladder. When it’s time to urinate, signals from the brain cause the muscles of the bladder to contract, effectively squeezing out urine.

Many conditions that disrupt this normal bladder operation can contribute to nocturia. If bladder storage is reduced, for example, then a person will typically need to urinate more often, including at night. These storage problems become more noticeable if someone is also producing more urine.

Overactive bladder is when a person has involuntary contractions of the bladder muscles, leading to a frequent need to urinate. People with overactive bladder may find that it affects them at night, causing nocturia.

Reduced bladder storage and overactive bladder can be caused by many underlying problems. For example, a bladder obstruction, including by kidney stones, can interfere with proper bladder function. So can interstitial cystitis, a condition marked by unexplained pain in the bladder. Inflammation, infections, cancer, and damage or scar tissue from surgery or radiation therapy can all contribute to nocturia because of their effect on how well the bladder works.

Prostate Problems

Prostate issues can also affect the proper functioning of the lower urinary tract in men.

The prostate is a small gland, about the size of a walnut, that is part of the male reproductive system. The prostate makes fluid that helps compose semen. This gland is located just below the bladder and around the urethra, the tube that carries urine out of the body. As a result, problems with the prostate can affect urination.

The most common prostate issue that can contribute to nocturia is benign prostatic hyperplasia (BPH). BPH is an enlarging of the prostate that typically happens in older men. Its cause is not fully understood, but the growth of the prostate can pinch the urethra and put pressure on the bladder. BPH is not cancer and does not raise the risk of cancer.

Another prostate problem that can cause nocturia is inflammation of the prostate, which is called prostatitis. Prostatitis can be chronic or acute. Acute prostatitis is more often associated with nocturia, and it usually caused by an infection.

Prostate cancer, which is when cancerous cells develop in the tissue of the prostate, can also have urinary symptoms that include a greater need to go to the bathroom during the night.

Other Causes

Other types of urinary tract infections (UTIs) besides those that affect the bladder and prostate can contribute to nocturia. For example, an infection in the urethra may disrupt normal urination.

Pelvic floor disorders, such as a vaginal or pelvic prolapse, may also play a part in nocturia in women. In these conditions, the muscles supporting pelvic organs become weakened, and as a result, those organs can shift downward. For example, the uterus, cervix, and/or bladder may move down, disrupting the normal flow of urine or pinching the urethra.

How is Nocturia Diagnosed and Treated?

If a person is experiencing nocturia, it is important for them to talk with their doctor. This section explains how nocturia is typically diagnosed and treated.

How is Nocturia Diagnosed?

Patient reports of needing to frequently wake up to use the bathroom are a central part of the diagnosis of nocturia. It is important for patients to raise this concern with their doctor and not be ashamed about it or assume it is a normal part of aging. Hesitance to discuss nocturia with the doctor can lead to delays of a year or more in diagnosis and initiation of treatment.

Many doctors request that their patients creating a daily journal, sometimes using the technical term for urinating and calling it a “voiding journal,” so that they have a detailed record of how often they are going to the bathroom. This journal may be kept for a few days and tracks fluid intake, trips to the restroom, and any other urinary issues. A template for a voiding journal is available from the Urology Care Foundation and may be useful for patients to complete and take with them when planning to discuss nocturia with their doctor.

Once the pattern of nocturia has been established, the next step in the diagnostic process is to look for an underlying cause. In addition to discussing a patient’s urinary habits and fluid intake, the doctor will likely ask questions about medical history and any other symptoms or ongoing health issues. Taking all of these factors into account, different tests may be ordered to provide additional information.

  • Urinalysis and urine culture: these tests examine the urine to look for the presence of infections or other abnormalities.
  • Blood tests: a general blood test may offer insight into any cardiovascular or metabolic issues that can be affecting nocturia, including diabetes.

More involved testing may be considered depending on the results of blood and urine testing.

  • Bladder scan (radionuclide cystogram): this test puts a special liquid material into the bladder to analyze its shape, and it may be used to look at how well the bladder fills and empties.
  • Cystoscopy: this test inserts a tiny tube with a camera on the end through the urethra and into the bladder to provide a direct picture of the interior of the bladder.
  • Urodynamic testing: urodynamic testing encompasses numerous types of exams that evaluate the function of the lower urinary tract.

Because of the diverse range of conditions that can be related to nocturia, additional testing or referrals to specialists, including urologists, may be necessary depending on the findings of these tests.

How is Nocturia Treated?

Because nocturia is often caused by multiple overlapping factors, treatment can involve several different elements.

If nocturia is caused by an identifiable underlying condition, one aspect of treatment will focus on that cause. A straightforward example is treating a urinary tract infection with antibiotics. More complicated underlying conditions, like diabetes, may require more involved management.

A common first line of therapy for nocturia is to try to eliminate nocturnal polyuria with behavior changes. Reducing nighttime urine production is often an essential step in decreasing trips to the bathroom. Decreasing fluid intake, altering the timing and dosage of diuretics, and trying to control leg swelling with elevation or compression stockings are examples of ways that behavioral interventions may be directed at nocturnal polyuria. Other behavioral steps can focus on increasing control over urination, including exercises designed to strengthen the muscles in the pelvic floor.

If behavior changes do not work, some medications can be prescribed to try to address nocturia. These medications are usually designed to regulate or reduce the body’s overall production of urine or to decrease the contractions of the bladder. Medications tend to have the most efficacy when patients have nocturnal polyuria, overactive bladder, or prostate obstructions.

How Does Sleep Affect the Urinary System?

It’s natural to think of nocturia as a urinary problem that disrupts sleep, but there are reasons to believe that the relationship is more complex.

There’s no doubt that having to urinate can cause someone to wake up during the night. But it’s also possible that a person first is awoken by a sleeping problem, and upon waking up, realizes that they need to go to the bathroom. In most cases, a person will attribute their awakening to the need to urinate, but this may be because they are not aware of an underlying sleep problem.

Research has indicated that this situation may, in fact, be quite common. In people with insomnia, nocturia is usually more of an effect than a cause of sleep problems. This explanation is more likely if a person otherwise has problems with sleep or normally finds that it is difficult to fall back asleep after having woken up to go to the bathroom.

Nocturia may also have a link to age-related changes to sleep patterns and circadian rhythms. In younger, healthy people who get quality sleep, the body tends to produce less urine at night, making it easier to sleep for a solid six to eight hours without having to get up to go to the bathroom. But aging affects when a person sleeps and how they move through sleep cycles, and those changes may influence the production or hormones that regulate urine volume. As a result, it appears that in older adults, many of whom suffer from sleeping problems, these circadian rhythm changes can promote nocturia, which can then further complicate sleeping issues.

Another way that sleeping problems and nocturia are connected is through the sleep disorder obstructive sleep apnea. Patients with OSA experience frequent lapses in breathing during the night when the airway in the throat gets blocked. OSA, a type of sleep-disordered breathing, has negative effects on sleep quality and on the cardiovascular system because the pauses in breathing reduce the consistency of oxygen input.

Studies have found that OSA increases the risk of nocturia. This happens because OSA induces changes in the hormones that are involved in urine production. In addition, because of their regular brief awakenings, people with OSA are more likely to become aware of a need to urinate and to get out of bed to go to the bathroom. Estimates of the prevalence of nocturia in people with OSA are as high as 50%, and treatment of OSA with positive airway pressure (PAP) devices may help reduce nocturia.

How Can People With Nocturia Get Better Sleep?

Nocturia can be a major barrier to sleep, but there are ways to try to manage the condition and get better rest.

Work With a Doctor

As we’ve mentioned, people who are experiencing bothersome nocturia should not treat it as a normal or inevitable condition. It is important to discuss it with a doctor who can follow the necessary steps for diagnosis and treatment.

The doctor is likely to recommend specific behavior modifications to help reduce nighttime urine production, and if needed, can prescribe medication to help with this goal. If an underlying condition, including a sleep disorder like OSA, is involved in nocturia, the doctor is in the best position to properly identify and prescribe therapy to resolve that contributing cause.

People with nocturia and other sleeping problems can also talk with their doctor about taking a small nightly dose of melatonin, a hormone that is normally produced by the body to help promote sleep. When melatonin production is delayed or suppressed, supplementation may help, including in people with nocturia. Melatonin supplements do not require a prescription, but they should only be taken after consulting with a doctor.

Improve Sleep Hygiene

For most patients, changes to behavior and daily practices can decrease both nocturnal polyuria and the number of nightly trips to the bathroom. Many of these behavior changes fit under the umbrella of sleep hygiene.

Sleep hygiene is made up of two elements: sleep-related habits and sleep environment. Small changes can make it easier to fall asleep, stay asleep, and get back to sleep if disturbed during the night. Simple steps can improve sleep for anyone, including people with nocturia, some of whom find that their problems are reduced by up to 50% by making positive changes to their sleep hygiene.

Sleep Habits and Routines

Central to sleep hygiene is making daily habits work in your favor. For people with nocturia, there are several ways to optimize routines to get better sleep:

  • Drink less at night: this simple behavior change can help reduce nocturnal polyuria. For the two to four hours before bed, decrease the amount of fluid that you drink.
  • Avoid caffeine and alcohol: both caffeine and alcohol, especially before bed, can increase your fluid intake and make it more likely that you’ll need to urinate. In addition, they can both reduce sleep quantity and quality.
  • Have the same routine every night before bed: put yourself in the right mindset for bed by following the same set of steps before getting tucked in. For people with nocturia, make sure going to the bathroom is part of that routine. Other elements could include putting on pajamas, brushing your teeth, stretching, reading, or whatever helps you get comfortable and relaxed.
  • Keep a fixed schedule: as much as possible, try to go to bed and wake up at the same time each day, even on the weekends. This schedule provides predictability that makes it more likely that you can get solid and consistent sleep.
  • Get daily exercise: exercise has a proven positive effect on sleep and confers numerous other health benefits as well.
  • Avoid electronics before bed: electronic devices like cell phones, laptops, and tablets emit blue light that can interrupt our body’s circadian rhythm such as by decreasing production of melatonin that gets us ready for sleep. These devices can also stimulate the mind in ways that make it harder to fall asleep. As a matter of routine, try to stop using these devices in the hour before bedtime, and if you can, don’t use them in your bedroom at all.
  • Minimize activities in bed: when your bed is associated with sleep, it helps put you in the right frame of mind to doze off easily. For this reason, try to keep activities in bed limited to just sleep and sex.
  • Keep calm and carry on: if you have a hard time falling asleep or getting back to sleep when you wake up at night, it can be helpful to learn and practice relaxation techniques. These help calm the mind and reduce anxiety about sleep. Examples include deep breathing, progressive muscle relaxation, meditation, and others.

Sleep Environment

Cultivating the right conditions for sleep is another vital part of sleep hygiene. Some ways that people with nocturia can enhance their sleep environment include:

  • Create a safe path to the bathroom: people with nocturia are often waking up groggy and with an urgent need to go to the bathroom. These bathroom trips heighten the risk of falls and related injuries like broken bones. To help prevent this, create a path to the bathroom that is free of obstacles or hazards (including rugs and cords) that could cause someone to trip and fall. Low-wattage nightlights, including those that have a motion sensor, can be useful for avoiding falls as well.
  • Make the bedroom like a cave: the most sleep-conducive environments are dark, quiet, and slightly on the cool side. Blackout curtains or a sleep mask can reduce intrusive light, earplugs, a fan, or white noise machine can filter out external sounds, and a cool thermostat setting can create a sleep-friendly climate.
  • Choose a mattress for comfort and motion isolation: a quality mattress can make sure that your body is comfortable and that your spine is well-supported to avoid back pain. A mattress with good motion isolation is important for couples because it can help reduce disruptions to one person when the other gets up to go to the bathroom.
  • Make the bed inviting and cozy: in addition to your mattress, a good pillow can keep your head and neck aligned with the rest of your body to protect against waking up with a stiff neck. High-performance sheets and a cozy comforter help round out your setup, helping make sure that your bed offers the deep, restorative sleep that you deserve.
  • If necessary, add a mattress protector: while nocturia is distinct from incontinence, some people with urinary problems at night, including nocturnal polyuria, do have occasional bedwetting incidents. If you’re worried about this and want to prevent stains or damage to your mattress, consider a robust mattress protector that adds a waterproof barrier to your bed.
  • If necessary, consider a bedside commode or urinal: some people who have nocturia may have limited mobility that makes it hard to get out of bed safely and with enough time to get to the bathroom. In this situation, it can be useful to have a bedside urinal or commode as a precaution.

Learn More About Nocturia and Sleep

The following resources provide additional information about nocturia, urological issues, sleep, and related conditions.

Information and Support

  • The Urology Care Foundation. The Urology Care Foundation is associated with the American Urological Association (AUA) and provides extensive resources for patient education relating to a broad range of topics related to urology.
  • National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). NIDDK is the agency of the U.S. National Institutes of Health (NIH) that is responsible for research into conditions that affect urology.
  • MedlinePlus: Bladder Diseases. This page from MedlinePlus, a program of the National Library of Medicine (NLM), provides links to learn more about numerous health problems that can affect the bladder and urination.
  • American Sleep Apnea Association (ASAA): This organization works to improve the health of people with sleep apnea. ASAA promotes research, distributes information, and provides resources to assist people who cannot afford medical equipment to treat sleep apnea.
  • American Diabetes Association. The American Diabetes Association works to reduce the burden of diabetes on society by promoting research, advocating for patients, and disseminating information about different types of diabetes.

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