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Introduction: Nocturia is a complex and multifactorial condition, associated with several genitourinary abnormalities as well as a host of conditions beyond the urinary tract, and thus often poses a significant diagnostic challenge in real‐world practice. Sleep Disorders, Comorbidities, Actions, Lower Urinary Tract Dysfunction, and Medications, the so‐called "Sleep C.A.L.M." factors, are five common causes of nocturia requiring judicious evaluation according to current consensus guidelines. This study aims to assess the prevalence of the Sleep C.A.L.M. factors in a nocturia clinical population. Methods: Retrospective analysis of frequency‐volume charts from men with ≥2 nocturnal voids as well as concurrent demographic, clinical, and medical history data to identify patients with each of the Sleep C.A.L.M. factors. Comorbidities and medications were classified as a single group. Results: A total of 213 subjects met the criteria for inclusion (median age 68.0 [63.5‐75.5] years). The prevalence of 1) sleep disorders, 2) comorbidities and/or medication use, 3) actions (i.e., modifiable behaviors/lifestyle factors), and 4) lower urinary tract dysfunction was 31%, 31%, 19%, and 41%, respectively. Among included participants, 73% were found to have at least 1 Sleep C.A.L.M. factor, and 33% had multiple Sleep C.A.L.M. factors. Results were similar upon stratification by age and nocturnal polyuria status. Conclusions: The Sleep C.A.L.M. factors are highly common among nocturia patients in the clinical urology setting. Although many of these factors are strongly associated with advanced age in community‐based nocturia study samples, they appear common even among younger men in a nocturia patient population; the differential effect of age and individual Sleep C.A.L.M. factors on nocturia pathophysiology requires further investigation. [ABSTRACT FROM AUTHOR]

The article discusses the use of melatonin as a potential treatment for nocturia, a condition characterized by frequent urination at night. The authors acknowledge that while some studies suggest a benefit of melatonin for both nocturia and sleep quality, the current evidence is limited and derived from small and heterogeneous study samples. They argue that larger placebo-controlled trials are needed to provide more conclusive recommendations. The article also highlights the bidirectional relationship between nocturia and sleep, and the potential for melatonin to improve sleep quality. However, the authors caution that the efficacy of melatonin may vary depending on the study population and individual patient characteristics. They emphasize the need for further research to better understand the pharmacologic effects and mechanisms of action of melatonin for nocturia. The article also mentions the importance of using high-quality melatonin supplements, as there have been reports of inconsistent adherence to label claims and contamination with other substances. Overall, the article provides a foundation for future research on melatonin for nocturia. [Extracted from the article]

Introduction: Nocturia arises from a fundamental mismatch between nocturnal urine production, storage capacity, and sleep architecture, which may be driven by abnormalities of the genitourinary tract, but also by sleep disorders, medical diseases, patient actions/lifestyle factors, or medications. This article introduces a novel system for organizing the complex differential diagnosis for nocturia, as proposed by an international collective of practicing urologists, physician specialists, and sleep experts: "Sleep CALM"—Sleep Disorders, Comorbidities, Actions, Lower Urinary Tract Dysfunction, and Medications. Methods: Narrative review of current evidence regarding the relevance of each "Sleep CALM" factor to nocturia pathogenesis, evaluation, and management. Results: Nocturia and sleep disorders are highly intertwined and often bidirectional, such that nocturnal awakenings for reasons other than a sensation of bladder fullness should not be used as grounds for exclusion from nocturia treatment, but rather leveraged to broaden therapeutic options for nocturia. Nocturia is an important potential harbinger of several serious medical conditions beyond the genitourinary tract. Urologists should have a low threshold for primary care and medical specialty referral for medical optimization, which carries the potential to significantly improve nocturnal voiding frequency in addition to overall health status. Adverse patient actions/lifestyle factors, lower urinary tract dysfunction, and medication use commonly coexist with disordered sleep and comorbid medical conditions, and may be the primary mediators of nocturia severity and treatment response, or further exacerbate nocturia severity and complicate treatment. Conclusion: "Sleep CALM" provides a memorable and clinically relevant means by which to structure the initial patient history, physical exam, and clinical testing in accordance with current best‐practice guidelines for nocturia. Although not intended as an all‐encompassing diagnostic tool, the "Sleep CALM" schema may also be useful in guiding individualized ancillary testing, identifying the need for specialty referral and multidisciplinary care, and uncovering first‐line treatment targets. [ABSTRACT FROM AUTHOR]

Aims: Nocturnal polyuria syndrome (NPS) denotes nocturnal polyuria (NP) in the absence of identifiable contributory factors. The trajectory of nocturnal urine production (NUP; typically expressed as ml/hour) may be useful in delineating between NP patients with versus without NPS, but changes in absolute urine volume, the directly measured substrate for behavioral and pharmacologic interventions targeting nocturnal urine production, have not been well characterized. This study compares the ratio of the first nocturnal voided volume (FNVV) to the nocturnal average voided volume (NAVV) in patients with versus without NPS. Methods: Secondary analysis of 24‐h voiding diaries from male patients greater than or equal to 18 years of age with two or more nocturnal voids and NP using two different criteria for NP: NUP greater than or equal to 90 ml/h and nocturnal polyuria index (NPi) greater than or equal to 0.33. Patients with diabetes insipidus and CPAP‐adherent obstructive sleep apnea (OSA) were excluded. Patients were divided into 2 groups: secondary NP (OSA, congestive heart failure, and chronic kidney disease) and NPS (absence of edema, diuretic use, and the aforementioned comorbidities). FNVV was defined as the volume of urine accompanying the first nocturic episode. NAVV was defined as nocturnal urine volume/(number of nocturnal voids + 1). The nocturnal urine trajectory ratio (NUTR) was defined as FNVV/NAVV. Results: At NUP greater than or equal to 90 ml/h, NUTR was significantly greater in patients with (n = 73) versus without (n = 28) NPS (1.10 [0.89–1.33] vs. 0.91 [0.55–1.15], p =.012). At NPi greater than or equal to 0.33, NUTR was likewise significantly greater in patients with (n = 92) versus without (n = 32) NPS (1.09 [0.90–1.33] vs. 0.91 [0.57–1.17], p =.010). Conclusions: The volume of urine produced in the early hours of sleep is central to identification of NPS in patients with nocturia. [ABSTRACT FROM AUTHOR]

Aims: Nocturia has been increasingly recognized as a potential manifestation of cardiovascular disease. However, the relationship between nocturia and electrocardiographic (ECG) abnormalities has not been studied. This study aims to characterize the diagnostic utility of nocturia in identifying left ventricular hypertrophy (LVH), left atrial enlargement (LAE), and prolonged QTc on ECG. Methods: Retrospective analysis of nocturnal voiding frequency and contemporaneous ECG data from consecutive patients evaluated at a university‐based outpatient cardiology clinic. Three sets of three incremental binary multiple logistic regression models controlling for (1) age, (2) sex and race, and (3) body mass index, hypertension, diabetes mellitus, and diuretic utilization were performed to determine whether nocturia was predictive of LVH, LAE, and prolonged QTc. Results: Included patients (n = 143, 77.6% nocturia) were predominantly African‐American (89.5%), female (74.1%), and obese (61.5%), of whom 44.1%, 41.3%, and 27.3% had LVH, LAE, and prolonged QTc, respectively. Older age, African‐American race, obesity, hypertension, diuretic use, LVH, and LAE were significantly associated with nocturia on univariate analysis. No significant differences were observed in the strength of associations between nocturia and LVH, LAE, or QTc prolongation based on age. Nocturia independently predicted LVH in Models I–III (odds ratios [ORs], 2.99–3.20; relative risks [RRs], 1.18 for all, p ≤.046) and LAE in Models I–III (ORs, 4.24–4.72; RRs, 1.21 for all, p ≤.015). No significant associations were observed between nocturia and prolonged QTc. Conclusions: Nocturia may be a risk marker for underlying structural cardiac abnormalities. [ABSTRACT FROM AUTHOR]

Aim: The relationship between maximum voided volumes (MVV) during the night and day is poorly understood. Such measurements are important because they are often used to indicate functional bladder capacity (FBC), a relevant parameter for nocturia. This study examined the association of such nighttime and daytime measurements in men with nocturia. Methods: We retrospectively analyzed 356 24‐hour voiding diaries showing ≥2 nocturnal voids from 220 men at an outpatient urology clinic. We defined small FBC as MVV ≤ 200 mL. Results: A total of 131 entries demonstrated a nocturnal MVV ≤ 200 mL, of which a majority (98 [74.8%]) also showed a 24‐hour MVV ≤ 200 mL (ie, global small FBC), and 33 (25.2%) exceeded the 200 mL threshold during the day (ie, nocturnal‐specific small FBC). Correspondingly, among voiding diaries without global small FBC (n = 258), most (225/258 [87.2%]) showed a nocturnal MVV > 200 mL. Data were similar when analyzing only the first complete voiding diary per case, when limiting analyses to those without benign prostatic obstruction, and when limiting analyses to cases with nocturnal polyuria. Conclusion: Nocturia may be attributable to nocturnal‐specific small FBC or global small FBC. Although the etiology of nocturnal‐specific small FBC remains unclear, it was present in a significant minority of patients with small FBC, thus necessitating more directed research. Conversely, diminished nocturnal MVV was nevertheless relatively uncommon in the absence of global small FBC, such that nocturnal‐only voiding diaries may provide a rational alternative for follow‐up evaluation in patients with nocturia due to global small bladder capacity. [ABSTRACT FROM AUTHOR]

This study aims to determine whether dietary sodium restriction counseling decreases nocturnal voiding frequency in cardiology patients with concomitant nocturia. Patients who had established care at a cardiology clinic from 2015 to 2018 reporting ≥1 average nocturnal void(s) underwent a comprehensive sodium intake interview by their cardiologist, who provided them with individualized strategies for dietary sodium reduction and assessed adherence at follow-up. Average nocturnal voiding frequency and dietary adherence were documented in the medical record. A nocturia database was compiled for retrospective analysis. A total of 74 patients were included. Patients considered to be adherent with dietary sodium restriction at follow-up (n = 56) demonstrated a decrease in median nocturia frequency (2.5 [2.3-3.0] vs 1.0 [1.0-2.0] voids, P < .001). Among nonadherent patients (n = 18), median nocturia frequency did not significantly change from baseline to follow-up (2.0 [1.5-3.8] vs 2.0 [1.5-4.8] voids, P = .423). Median changes were significantly different between the adherent and nonadherent groups (P < .001). Examination of second follow-up available from 37 patients showed a continued effect. In conclusion, adherence with dietary sodium counseling appears to improve nocturia. Accordingly, dietary modification may represent an important adjunct therapy to lifestyle and pharmacologic interventions for decreasing nocturia frequency. Reduction in nocturnal voiding frequency may also reflect an additional benefit of dietary sodium restriction in accordance with best practice standards for cardiovascular disease. [ABSTRACT FROM AUTHOR]

Aim: Compare the circadian trajectory of diuresis between nocturnal polyuria (NP) patients with versus without identifiable contributory comorbidities. Methods: Retrospective analysis of frequency‐volume charts from male patients with clinically‐significant nocturia (≥2 nocturnal voids) and NP (defined by nocturnal urine production [NUP] ≥90 mL/hour or nocturnal polyuria index [NPi] ≥0.33). Patients with NP and chronic kidney disease, congestive heart failure, and/or undertreated obstructive sleep apnea (OSA) were deemed to have secondary NP. Nocturnal polyuria syndrome (NPS) was defined as NP without edema, loop diuretic use, or the aforementioned conditions. Patients with diabetes insipidus or OSA with appropriate continuous positive airway pressure utilization were excluded. The timing and volumes of nocturnal voids were used to derive "early" and "late" nocturnal diuresis rates (mL/hour of urine produced before and after the first nocturnal awakening, respectively). The likelihood of an early peak nocturnal diuresis rate (ie, early >late nocturnal diuresis rate) was compared between patients with NPS versus secondary NP using both a crude and adjusted odds ratio. Results: The likelihood of an early peak nocturnal diuresis rate in patients with NPS compared with secondary NP was 2.58 (1.05‐6.31) at NUP ≥ 90 mL/hour and 1.96 (0.87‐4.42) at NPi ≥ 0.33 on crude analysis, and 2.44 (0.96‐6.24) and 1.93 (0.83‐4.48) after adjustment, respectively. Conclusions: A peak early nocturnal diuresis rate was significantly more likely in patients with NPS at NUP ≥ 90 mL/hour, with similar odds ratios at NPi ≥ 0.33 and following adjustment. Delineating nocturic patients by NP subgroup may facilitate more individualized management. Patient Summary: Many people have to wake up to urinate because they produce too much urine at night—a condition known as "nocturnal polyuria." Nocturnal polyuria might be caused by drinking too much fluid, other behavioral factors, or conditions that make your body hold on to too much fluid, like heart disease, kidney disease, and sleep apnea. In cases of nocturnal polyuria where no clear cause can be identified, it is thought that patients may suffer from a deficiency in nighttime vasopressin, a hormone that plays a key role in how much urine you produce. In this study, we compared the pattern of nighttime urine production in patients with different causes of nocturnal polyuria, which may lead to more personalized treatment options for patients with this condition. [ABSTRACT FROM AUTHOR]

Aims: Nocturnal polyuria (NP) and global polyuria (GP) are not mutually exclusive. However, by rate, the common criteria for GP (40 mL/kg/24 hours [117 mL/kg/hour in a 70‐kg individual] or 3000 mL/24 hours [125 mL/h]) are more stringent than those for NP (90 mL/hour during the sleep period or NP index [NPi; nocturnal volume/24‐hour volume] > 0.33 [no minimum rate]). It remains unclear whether total nocturnal urine volume (NUV) may reliably delineate between NP patients with and without comorbid GP. Methods: A clinical database of men with lower urinary tract symptoms was searched for voiding diaries completed by patients reporting greater than or equal to 1 nocturnal void(s). Four separate analyses were performed using all combinations of the two NP and two GP criteria listed above. For each analysis, patients were included if they met the criteria for NP, and then stratified by presence or absence of GP (ie, NP + GP vs isolated NP). Results: Median NUV was greater among patients with NP + GP for all criteria combinations. Sensitivities greater than or equal to 80%/90%/100% for NP + GP were observed at 1275/1230/1085 mL for {NPi > 0.33 + 24‐hour volume > 3000 mL}; 1075/1035/1035 mL for {NPi > 0.33 + 24‐hour volume > 40 mL/kg}; 900/745/630 mL for {NUP > 90 mL/hour + 24‐hour volume > 3000 mL}; and 1074/1035/990 mL for {NUP > 90 mL/hour + 24‐hour volume > 40 mL/kg}. Conclusions: An inordinate NUV among men with NP is fairly sensitive for comorbid GP. In the appropriate clinical setting, nocturnal‐only diaries may suffice in the evaluation and follow‐up of patients with NP, so long as outlying nocturnal volumes prompt a 24‐hour diary/urine collection. [ABSTRACT FROM AUTHOR]

Keywords: nocturnal-only; NOVD; voiding diary EN nocturnal-only NOVD voiding diary 555 557 3 01/15/21 20210101 NES 210101 Voiding diaries are a standard of care in the evaluation of nocturia.1-4 One parameter routinely derived from voiding diary analysis is the nocturia index (Ni), defined as nocturnal urine volume (NUV) divided by 24-h maximum voided volume (MVV; with the latter being a proxy for functional bladder capacity),5 such that Ni quantifies the degree of mismatch between nocturnal urine production and bladder storage capacity.6 The Ni is of central importance to the management of nocturia because it is the voiding diary parameter which most strongly correlates with nocturia severity (i.e., the actual number of nocturnal voids [ANV]), and improvement in this measure is characteristic of improvement in ANV, such that the Ni reflects an important target for nocturia treatment.7,8 However, in view of continued suboptimal utilization of voiding diaries in clinical practice,9,10 increasing investigative attention has been afforded to data which may be directly gleaned from nocturnal voiding diary data and a nocturnal-only workup for nocturia.11 Namely, restricting the voiding diary to only the hours of intended sleep stands to mitigate the potentially restrictive time commitment of the assessment period, as well as professional, familial, and social barriers that have been implicated as significant determinants of voiding diary nonadherence.12-15 Accordingly, we propose a modified Ni (mNi), analogous to the original Ni, but incorporating only values directly attainable from nocturnal urinary data: NUV divided by nocturnal maximum voided volume (NMVV). Fifth, the correlation between changes in mNi and ANV is significantly stronger than the correlation between changes in Ni and ANV, such that the mNi may thus be relatively favorable for monitoring treatment response. [Extracted from the article]

Background Takotsubo cardiomyopathy (TTC) is a condition of reversible left ventricular (LV) systolic dysfunction. However, the diastolic function (DF) manifestations of TTC have not been widely investigated. We performed a bicentric study with retrospective analysis of DF in patients with TTC, during onset and at follow-up. Methods Twenty-eight patients with TTC (64 ± 10 years, F 24) were included. All underwent echocardiograms acutely and at the recovery phase (average three months later). Diastolic and systolic function parameters were recorded, including E-wave velocity (E), A-wave velocity, E/A ratio, relaxation (e') and contractility (S') based on tissue Doppler velocities of the mitral annuli, ejection fraction (EF), left atrial (LA) size and DF stages. Results Recovery, including the mean difference with 95% confidence interval, was associated with tending improvement (i.e. uncorrected significance) in E [13 cm s-1 (-24, -2⋅3), P = 0⋅02] and in E/A ratio [0⋅2 (-0⋅41, -0⋅02), P = 0⋅04], as well as significant improvement (after multiple comparison correction) in mean e' [2⋅0 cm s-1 (-3⋅3, -1⋅2), P<0⋅001] and in A-wave duration [29 ms (_46_7, _12_7), P = 0_002]. LA area tended to decrease during recovery [-2 cm² (0⋅33, 2⋅4), P = 0⋅01]. Improvement in DF stages was significant between the phases (21% versus 58% defined as normal DF, P = 0⋅016). Improvement in LVEF correlated with improvement in mean e' (r = 0⋅52, P = 0⋅02). Conclusions TTC is associated with an acute impairment of conventional DF variables, which improves during recovery. DF recovery seems to occur in parallel with systolic recovery in patients with TTC. [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2011; 18:1223-1226 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: The authors determined if E-point septal separation (EPSS) as measured by junior emergency physicians (EPs) correlated with visual estimation of left ventricle ejection fraction (LVEF) by senior EPs and cardiologists in acutely dyspneic patients presenting to an adult emergency department (ED). Methods: Acutely dyspneic patients were enrolled in a prospective, observational study. EPSS was measured using bedside ultrasonography by junior EPs (PGY 3 and PGY 4 residents) with variable ultrasound experience. M-mode measurements of EPSS were recorded in the parasternal long-axis orientation and were calculated during diastole by measuring distance from the tip of the anterior mitral valve leaflet to the septal wall. LVEF was visually estimated at the bedside by emergency medicine (EM) ultrasound fellows and an EM ultrasound fellowship-trained attending physician and was subsequently visually estimated by two cardiologists reviewing video clips obtained by the junior EPs. The correlation between EPSS and visually estimated LVEF was calculated. Results: Of the 58 patients, the median age was 63 years (range = 28 to 90 years) and 66% were women. Interobserver reliability between EPs and cardiologists for the visual estimation of LVEF was excellent (κ = 0.75). The correlation between measurements of EPSS by junior EPs and visual estimations of LVEF by the senior EPs was ρ = −0.844 (p < 0.001). Conclusions: In this study, junior EPs were able to obtain measurements of EPSS that correlated closely with visual estimates of LVEF by clinicians with extensive point-of-care and comprehensive echocardiography experience. [ABSTRACT FROM AUTHOR]

We aimed to describe changes in nocturnal voiding frequency, as well as changes in oedema, weight and blood pressure, in cardiovascular patients with overt volume overload following treatment with furosemide. All patients experienced a diuretic effect, as evidenced by self-reported greater urine output within the first few hours after diuretic administration. Taken together, our exploratory results suggest that nocturia may represent an early marker of response to diuretic therapy in the treatment of heart failure. [Extracted from the article]