Nicturia

The term "nicturia" is used when a person has a predominance of nighttime urine volume over daytime urine volume, and the number of trips to the toilet in the middle of a night's rest is two or more.

In a healthy person, the nocturnal volume of urine usually does not exceed 35-40% of the total daily diuresis. If this volume increases, then there are forced awakenings, sleep is interrupted, sleep deprivation occurs, performance suffers, irritability appears, and general indicators of health and well-being decrease.

Important: Nicturia should not be confused with nocturia, a condition in which a person does not empty the bladder before going to bed, which naturally leads to forced awakening and nighttime trips to the toilet. [1]

Epidemiology

In most cases, nicturia is detected simultaneously with polyuria - excretion of more urine not only at night, but also during the day. This phenomenon is often found in elderly men suffering from prostate hypertrophy, age-related anatomical and physiological displacements of the lower urinary tract.

According to the available statistics, nicturia is detected:

• in 4% of children in the age range of 7-15 years;
• in more than 65% of men over the age of 50;
• in more than 90% of people over the age of 80.

The diagnosis of elderly patients often reveals a significant decrease in the level of antidiuretic hormone - vasopressin. The focus of this hormone is to reduce the frequency of nocturnal urination. Thus, age-related changes include a decrease in vasopressin production.

Most often, nicturia is found against the background of such diseases as heart failure, prostate adenoma, chronic pyelonephritis, liver cirrhosis, _{B12-deficiency} anemia. [2]

Causes of the nocturia

Urinary fluid is produced by the kidney system around the clock. However, it is considered normal when the daytime amount of urine significantly prevails over the nighttime amount (approximately 70% and 30%). Thus, a person rests comfortably at night, not getting up to go to the toilet at all, or getting up once. If the urge to urinate more often, and this happens regularly, then they say about nicturia, which should be a reason to contact doctors.

Nocturnal urination may be normal only in children under 2-3 years of age and in women during pregnancy. In other cases, the cause of the disorder should be sought primarily among kidney diseases, such as nephrotic syndrome, decreased reabsorption of fluid in the renal tubules, and impaired blood supply to the pelvis.

In general, among the most frequent causes are the following:

• Heart failure, resulting in venous stasis and fluid retention in the tissues;
• Renal pathologies (glomerulonephritis, pyelonephritis, nephrosclerosis);
• overactive bladder syndrome, cystitis;
• thyroid disease;
• Non-sugar diabetes, in which there is a decreased level of antidiuretic hormone;
• pernicious anemia, accompanied by low blood pressure and, as a consequence, slow kidney function;
• cirrhosis of the liver;
• vein diseases of the lower extremities, which is accompanied by fluid retention in the tissues;
• orthostatic swelling;
• hypercalcemia.

In addition, nicturia is often provoked by taking medications, particularly diuretics, especially in the afternoon. In women, the cause is often hidden in hypotrophy of the pelvic musculature, and in men - in prostate disease, associated with impaired natural urinary outflow. According to some reports, in older men, nicturia is most often caused by the development of prostate adenoma. [3]

Nicturia in glomerulonephritis

Glomerulonephritis is an autoimmune pathology affecting mainly glomeruli - the tubular mechanism of the kidneys. The disease is accompanied by the development of bilateral inflammation - primary or secondary, which results from some other inflammatory process. Glomerulonephritis begins acutely, vividly, and with chronicization of the disease continues for years, interspersed with cyclic exacerbations and remissions.

Most patients with glomerulonephritis have swelling in the face and urinary syndrome, blood pressure rises. Sometimes the swelling spreads to other parts of the body, which often causes the appearance of nicturia: during the day, fluid is intensely accumulated in the tissues, and during the night rest there are "unscheduled" urges to urinate. Although experts note that in the early stages of acute glomerulonephritis patients are more often faced not with nicturia, but with oliguria and even anuria - a condition in which the urinary fluid is excreted in extremely small volumes (up to 50 ml per day), or is not excreted at all. Nicturia is more characteristic of the chronic form of the disease. The problem is detected in the course of diagnostics - Zimnitsky's test, and indicates the oppression of renal function.

Cardiac nicturia

One of the signs of heart disease is edema due to stagnation of fluid in the body. The peculiarity of edema syndrome is that fluid accumulation can occur in almost any part of the body, which depends on the type of heart disorder. For example, if the left side of the heart is affected, the fluid accumulates mainly in the lungs, and if the right side is affected, edema is noted throughout the body, which is especially noticeable in the lower extremities.

With the progression of the heart disease, the symptomatology worsens. At the initial stage, urination is practically not disturbed, but over time this sign becomes more obvious. A sick person initially believes that swelling and "extra" going to the toilet at night is a temporary phenomenon. Often this condition is associated with excessive activity and fatigue, because the morning discomfort almost completely disappears. However, further the disease progresses, the fluid accumulates more intensively, which is reflected in the frequency of night urges to urinate. Along with this, the patient detects a gradual deterioration of general well-being, other characteristic signs of cardiac pathology appear, including nicturia.

Nicturia in pyelonephritis

Pyelonephritis is an infectious nonspecific renal pathology involving the kidney tissue and the urinary system, which includes the tubules, pelvis, and calyx. The disease is quite common, regardless of age.

Acute pyelonephritis is characterized by a sharp rise in temperature to high figures. Patients complain of marked weakness, increased sweating, deterioration of appetite, the appearance of dull pain in the lower back (mainly unilateral). When urinating, there is also pain, cutting. Urine becomes cloudy-reddish.

Chronic pyelonephritis is a consequence of an under-treated acute inflammatory process. Symptoms of the chronic form are relatively sluggish, erased. Patients complain of periodic mild pain in the lower back, increased fatigue, frequent urges to urinate. Swelling, increased blood pressure and nicturia are not noted in all patients, so these signs can not be called specific.

Diagnosis is made based on laboratory instrumental diagnostics including excretory urography, ultrasound and CT of the kidneys.

Nicturia in renal failure

Renal failure is a severe pathology that develops as a consequence of other disorders and is manifested by a serious disorder of kidney function. A distinction is made between acute and chronic renal failure. The main signs (depending on the stage) are considered as follows:

• Oliguria stage (daily urine volume drops, lethargy and lethargy occur, arrhythmia appears; nicturia is not characteristic of oliguria stage);
• Polyuria stage (daily volume of urine increases, normalizes, the ligament "polyuria nicturia" may appear).

In the chronic course of renal failure, the clinical picture is often hidden, but periodically still draw attention to unusual weakness, dry mouth, drowsiness, lethargy, increased fatigue, as well as nicturia. Any of these symptoms is a reason to contact doctors. Ignore renal dysfunction can not be ignored, as it threatens the development of serious complications - up to death.

Nicturia in heart failure

In patients with chronic heart failure, there is a decrease in the daily amount of urine against the background of the appearance of nicturia. Among additional symptoms there is shortness of breath, coughing, blueing of the nasolabial triangle. On examination, swelling can be detected, many patients gradually develop ascites - an accumulation of fluid in the abdominal cavity.

Heart failure develops as a result of ischemic heart disease, myocardiopathy, myocarditis and other cardiac pathologies, and can also be a complication of chronic intoxication.

The cause of nicturia in heart failure is venous stasis and accumulation of fluid in the tissues throughout the day, when the person consumes the main amount of drinking, and the cardiovascular apparatus works with the most intensive load.

As congestive heart failure develops, the kidneys find it increasingly difficult to cope with changing fluid volumes, which can lead to the development of renal failure. Salt normally excreted by the kidneys in the urine is retained in the body, which causes and aggravates the swelling that already exists.

Speaking about nicturia, most often refers to right-sided cardiac dysfunction, in which the outflow of blood from the right atrium and right ventricle is impeded (e.g., this is observed in patients with heart valve disease). As a result of these processes, pressure increases, the venous system that supplies blood to the right heart chambers - these are the veins of the lower extremities and the liver - becomes overloaded. As a result, the liver increases in volume, becomes painful, and the lower extremities swell. In such patients, nicturia is found in almost one hundred percent of cases.

Risk factors

Several risk factors have been found to increase the likelihood of developing nicturia. Although it is important to keep in mind that not all people associated with these risks will necessarily have problems with nocturnal urination.

It is about the following factors:

• congenital defects of the urinary tract;
• bad habits - in particular smoking and alcohol consumption;
• bladder catheterization;
• diabetes;
• excessive fluid intake (especially in the afternoon);
• genital piercings;
• Individual or family history of urinary disorders;
• pregnancy (especially multiple pregnancies or large fetuses), recent childbirth;
• abdominal trauma;
• sexually transmitted infectious diseases;
• potentially damaging, unsafe sexual practices;
• Wearing poor quality or dirty underwear, using irritating spermicides or lubricants;
• lack of personal hygiene.

Pathogenesis

In the elderly, daily diuresis often remains within normal limits or increases slightly. At the same time, the circadian rhythm of urinary excretion is altered: urine output increases at night and nocturnal polyuria or nicturia occurs. Compared to young and middle-aged people, in whom daytime urine output is about ¾ of the total diuresis, in older people this ratio is estimated to be 50/50. This phenomenon can be explained by various factors: cardiac dysfunction, sleep apnea, renal pathologies, hormonal changes, multiple sclerosis and so on.

Factors such as drinking alcohol, coffee or large amounts of fluids in the evening can also contribute to nicturia. Another factor can be called a small bladder capacity, which may be associated with fibrotic, oncologic processes, or previous radiation treatment. The so-called lower urinary tract symptomatology in prostate adenoma often leads to a decrease in the functional volume of the bladder due to obstructive changes in the neck, caused by excessive detrusor activity, or an increased amount of residual urinary fluid after urination. Such phenomena may be accompanied by periodic episodes of nicturia (with relatively small urinary portions). [4]

Symptoms of the nocturia

Increased number of trips to the toilet at night is the main bothersome symptom of nicturia. More than half of patients come to urologists with complaints of increased night urge to urinate, associated sleep disturbance and, as a consequence, a decrease in further daytime activity.

Specialists point out a number of severe conditions associated with the appearance of nicturia, significantly and negatively affecting the quality of life:

• sleep disorders, from insomnia to interrupted, restless sleep;
• daytime sleepiness and severe fatigue throughout the day;
• mental disorders, cognitive impairment, increased risk of depression;
• memory impairment;
• pronounced reduction in the ability to work and quality of life.

It is known that prolonged and regular sleep deprivation can lead to a condition similar to dementia, although it is reversible and passes when a person returns to an adequate sleep and rest regimen. However, we should not forget that sleep disorders are the number one factor for the development of depressive states.

The urinary symptomatology noted in patients with nicturia may be due to both features of bladder emptying (obstructive, micturition signs) and phase accumulation (irritative signs).

• Emptying symptomatology: prolonged delay before the act of urination, thin urine stream, "drip" discharge of urine, involuntary "drip" discharge after completion of urination, feeling of incomplete emptying of the bladder.
• Cumulative symptomatology: frequent urges to urinate, imperative urges, urge urinary incontinence.

The intensity of these symptoms may vary, but it is the negative impact of nicturia on sleep quality that is of primary concern to patients.

In general, the first signs of nicturia are defined as a person having to wake up in the middle of the night two or more times due to urge to urinate. A single night urge and the associated trip to the toilet cannot be called true nycturia.

Although before and after nocturnal urination a person in most cases sleeps, such sleep can no longer be called a full-fledged sleep: each subsequent episode of falling asleep is painful, long, there are difficulties in returning to sleep. As a consequence, sleep disorders become a factor in the emergence of anxiety and depressive disorders.

Nicturia in women

Frequent night urination in women can be physiological, or indicate endocrine diseases, pathology of the kidneys and urinary system, gynecological problems.

It is considered a natural phenomenon to increase the frequency of night trips to the toilet after drinking coffee, tea or alcoholic beverages, as well as after significant cooling of the body, swimming in cool water bodies. A similar effect is caused by eating juicy and watery fruits and berries, or herbal teas with diuretic effect (lime, lingonberry, mint infusions).

Nicturia is especially common in pregnancy, when in general the frequency of urination increases significantly. In the first trimester, the problem is caused by hormonal changes and the production of hCG - chorionic gonadotropin, which repeatedly increases the production of female sex hormones: estrogen and progesterone. Progesterone contributes to the accumulation of fluid in the tissues and relaxation of the urovesical muscles. This results in more frequent urinary urges.

In the last trimester, frequent trips to the toilet are associated with increased pressure of the growing uterus on the bladder, increasing the volume of amniotic fluid.

In menopausal women, there are also marked hormonal changes that weaken the urethral tone. After about 55 years of age, the urge to urinate becomes more frequent and there may be uncontrolled dripping of urine due to physiologic incontinence.

Another factor is the work of higher nervous activity. Thus, women are more emotional and are more prone to fears, strong excitement, stress. This also affects the amount of urine production and the frequency of urination.

Possible gynecologic pathologies that can lead to the appearance of nicturia:

• tumor processes - for example, fibroids;
• Uterine prolapse (usually occurs in women over 40 who have given birth);
• Cystocele (bladder prolapse due to weakened pelvic floor muscles, perineal birth ruptures).

Nicturia in men

Nicturia at any age interferes with good sleep and well-being even in healthy, active men, leading to decreased productivity and domestic problems. Frequent night awakenings are one of the most common complaints voiced by patients with lower urinary tract syndrome due to prostate adenoma. Nicturia has a negative impact on the quality of rest of the body and can directly affect the well-being of the person in the following day: first of all, the level of energy, concentration and mood suffer, and ultimately - and the quality of life.

Obstructive changes in the urinary tract increase the volume of residual urine and further activate the detrusor, resulting in increased frequency of both daytime and nocturnal urination. It has been reported that prolonged urinary tract obstruction leads to increased pressure in the upper urinary tract, which impairs the function of the renal medullary system and the distal tubule mechanism, causing nocturnal polyuria. In addition, decreased sodium excretion during the daytime due to obstructive changes disrupts the cycle of sodium metabolism and leads to sodium hypersecretion at night.

Urinary obstruction and increased detrusor activity contribute to a decrease in the functional capacity of the urethra at night. Therefore, increased urine production at night against the background of reduced functional capacity of the bladder aggravates the situation with nicturia in men.

Nicturia in children

Nicturia is not considered a pathological condition in children under seven years of age. After the age of two, the vast majority of children begin to ask to go to the toilet at night on their own, and the frequency of such trips may depend on various reasons:

• ambient temperature (cold weather may increase the frequency of urges);
• quality and strength of sleep;
• of childhood fears;
• the quality of the urethral sphincter, etc.

All of these factors are mostly transient and are overcome over time, particularly as the child grows older. During this period, it is important to ensure that the air temperature in the sleep room is at a comfortable level (at least +18°C), to put warm pajamas on the child if necessary, to limit the baby's intake of liquids 2-3 hours before night rest, and to teach him/her to go to the toilet immediately before going to bed.

If all the conditions are met, but after reaching the age of seven years, the problem with nicturia remains, it is absolutely necessary to consult a doctor. Do not start the development of neuroses, fears, negative behavioral reactions in the baby. It is obligatory to urgently seek medical help at the appearance of other pathological symptoms, such as pain, urinary retention, fever, lethargy and so on.

Nicturia in the elderly

Nicturia is a special unfavorable factor for elderly people, which is associated, among other things, with walking around the apartment in conditions of incomplete awakening and insufficient light. Doctors note a multiple increase in the number of falls of elderly patients who have to get up several times during the night for another trip to the toilet. In addition, falls with fractures due to lack of sleep and the associated inattention or distraction are not uncommon. Drowsiness and increased fatigue during the day can lead to the threat of orthostatic pressure drop during abrupt standing up, balance problems, especially in people with cardiovascular problems.

The age of 65-70 years is particularly dangerous for traumatic injuries. It is important to take into account that in many elderly patients the healing of the injury is prolonged and even accompanied by long-term or lifelong disability. In the elderly 85 years and older, severe injuries are often fatal.

Complications and consequences

Many patients suffer from sleep disturbance due to nicturia. And most of them note that discomfort is experienced not only by them, but also by their family members and partners. Night awakenings and forced trips to the toilet demonstrate their impact on the next day: a person begins to feel a drop in energy, weakness and drowsiness, decreased concentration. As a result, the general well-being, ability to work and quality of life suffer greatly. According to experts, nicturia and related disorders of night rest can cause trouble at work and in family life, lead to traffic accidents, and also increase the risk of developing various pathologies in the future.

Lack of sleep provokes a feeling of fatigue throughout the day. Patients universally complain of general malaise, decreased mental capacity, loss of energy, low mood up to depression. Some people suffering from nicturia try to avoid long-distance travel, in many cases have to stay at home because they are not sure that there is constant access to a toilet in unfamiliar places, or deliberately limit the volume of fluid intake.

Regardless of the etiologic cause of nicturia, frequent urges to urinate are associated with a lack of rest at night, the main consequence of which is insomnia. The more nocturnal trips to the toilet, the more obvious the problem becomes. It is known that therapeutic interventions that eliminate nicturia also improve sleep - this fact confirms the causal relationship between nocturnal urge to urinate and insomnia.

In addition to the appearance of fatigue during the day, impaired performance and health in general, most couples, where one of the partners suffers from nicturia, experience general discomfort. That is, sleep is disturbed not only in the patient, but also in his "other half". According to statistics, more than 50% of women surveyed indicated that they are very tired during the day as a result of nighttime sleep deprivation caused by waking up their husbands for another trip to the toilet. This information suggests that nicturia is a problem for both the patient and his partner.

According to the same statistics, about 20% of road accidents occur as a result of lack of concentration caused by lack of sleep, or as a result of falling asleep at the wheel. Inattention and inability to concentrate can have very dangerous and even fatal consequences.

There is some evidence that nicturia significantly increases the risks of developing depressive states, diabetes mellitus, cardiovascular pathologies. [5]

Diagnostics of the nocturia

Diagnostic measures are performed by a urologist. If indicated, it may additionally require consultation with a neurologist, endocrinologist, cardiologist and others. In the process of collecting information, the specialist determines when exactly the nicturia appeared, with what other manifestations it was combined, how the symptomatology changed in dynamics. In order to clarify the degree of nicturia, male patients may be asked to fill out a diary of urinary acts for 3 days, and female patients - for 4 days.

To rule out gynecologic diseases, women are additionally examined by a gynecologist. For men, a finger examination of the prostate gland through the rectum is indicated.

Ancillary instrumental diagnostics include the following procedures:

• Ultrasound examination of the urinary system - to detect inflammatory changes, exclude stone formation, tumors, residual urinary fluid. In the process of ultrasound of the kidneys can detect changes in the structure, and to determine the state of the vascular network additionally prescribe duplex scanning or ultrasound Doppler ultrasonography.
• Sonography is prescribed, depending on the indications: if the suspected violation of the prostate - perform ultrasound of the prostate gland, if there is hyperthyroidism - conduct ultrasound of the thyroid gland, if the suspected problem with the cardiovascular system - echocardiography is shown, and women are recommended to undergo ultrasound of the pelvic organs.
• Radiographic examination is recommended in patients with diseases and developmental defects of the renal system, with neurologically determined nicturia. It is appropriate to perform review and excretory urography. In some cases it is necessary to perform ascending pyelography, conventional and micturition urocystography.
• Endoscopic examinations include cystoscopy - to determine the morphological type of chronic bladder inflammation, nephroscopy - to detect kidney malformations or nephrosclerosis. During endoscopy it is possible to take biomaterial for further histological analysis.
• Urodynamic diagnosis is appropriate for patients with prostatic adenoma, cystitis, or neurogenic disorders. Patients are referred for uroflowmetry, intraurethral pressure profilometry, cystometry. If indicated, a complex urodynamic study is performed.

Laboratory tests are ordered to detect inflammatory signs. The 3 cup test identifies the location of the inflammatory focus. The Zimnitsky test is necessary to assess renal concentration function, and culture on nutrient media is important to establish the type of microflora.

Histology and cytologic examination are used to determine structural changes in tissue and neoplasia.

If there is an inflammatory process in the body, the general blood test will demonstrate leukocytosis, accelerated COE. Patients with diabetes mellitus are mandatorily assigned to determine the level of sugar in the blood, and in thyroid pathologies hormonal studies are shown. Men with prostate adenoma are evaluated for prostate specific antigen (PSA) to rule out prostate cancer. [6]

Differential diagnosis

The phenomenon of nicturia is differentiated in terms of the causes of its occurrence. It is necessary to exclude the presence of the following pathologies and conditions:

• Heart failure causing fluid retention in tissues and venous stasis;
• thyroid disorders;
• overactive bladder;
• calcium channel blocking, renal diseases (glomerulonephritis, interstitial nephritis, pyelonephritis, cystitis, nephrosclerosis, cystopielitis);
• pernicious anemia (accompanied by low blood pressure and postanemic kidney damage);
• prostate adenoma in men;
• venous pathologies;
• cirrhosis of the liver;
• hypercalcemia;
• atrophy of the pelvic floor muscles in women;
• Diabetes mellitus, non-sugar diabetes (caused by vasopressin deficiency or hypertensive dehydration).

Nicturia is often combined with polyuria - excretion of more than 2 liters of urine per day. In this situation, frequent urges to urinate are present not only at night, but also during the day. In some patients, nocturnal nicturia is combined with daytime oliguria, with a total excretion of less than 0.4 liters of urine per day. This is common in edema.

The combination of "anuria nicturia" is relatively rare. It is said if during the daytime urine completely stops excreting, and the daily volume is 200-300 ml. The causes of this phenomenon: secretory and excretory disorders, disorders of glomerular filtration (including shock, acute blood loss, uremia), functional disorders of the bladder.

Cystitis and cystourethritis are characterized by the dysuria-nicturia linkage of discomfort, pain during urination, tearing and burning. Dysuria is caused by irritation of the mucosal tissue in the urovesical triangle or urethra. Often this phenomenon is the result of an infection in the lower urinary tract, but sometimes occurs when the upper urinary tract is affected by infection.

When the term pollakiuria is used, nicturia is just a variation of this condition. Pollyakiuria is defined as the need to urinate repeatedly throughout the day or night - it is in the latter case that we speak of nicturia. The main condition for pollakiuria: a person excretes a normal or reduced daily amount of urinary fluid. Imperative urges may be present.

"Nicturia-hypostenuria" is accompanied by an increase in the frequency of nocturnal urges to urinate against the background of a decrease in urine density: during diagnosis, none of the portions of the density does not demonstrate values higher than 1.012-1.013 g/mL. This condition indicates a failure of the concentration properties of the kidneys, which can be associated with both chronic renal or cardiac insufficiency and non-sugar diabetes.

The combination of "nicturia-isosthenuria" is characterized by nocturnal trips to the toilet against the background of constant urine density not exceeding 1.009 g/ml (hypoisosthenuria) or constantly high specific gravity of urine (hyperisosthenuria). This disorder occurs in patients with severe renal failure or glomerulonephritis, diabetes mellitus, nephrotic syndrome, as well as in pregnant women with the development of toxicosis.

Daytime ichuria, nicturia is a problem mainly in elderly men suffering from hyperplasia and tumors of the prostate gland, as a result of which the urinary function is impaired. The term ichuria is understood as a pathological delay in urinary excretion, the inability to empty the filled bladder. This symptom is very dangerous and requires immediate medical intervention.

Treatment of the nocturia

Many patients with nicturia provoked by kidney disease or cardiovascular disease require special dietary correction. Reduce the consumption of salt, spices, hot spices. Alcoholic beverages are necessarily excluded.

To treat the diseases that caused the development of nicturia, the doctor may prescribe such drugs:

• Antibiotics - appropriate for inflammatory pathologies such as cystitis, glomerulonephritis, pyelonephritis, and can also be used if infectious complications develop - for example, in patients with prostate adenoma or neurological disorders. As a rule, antibacterial drugs with a broad spectrum of activity are initially used, and after identification of the causative agent, it is possible to adjust the prescription taking into account the sensitivity of microorganisms.
• Nonsteroidal anti-inflammatory drugs - used to reduce the intensity of inflammation and eliminate pain syndrome.
• Additional drugs (as indicated): in cystitis - uroseptic, in glomerulonephritis - hormonal drugs, in adenoma - α-adrenoblockers and α-reductase inhibitors, in detrusor overactivity - anticholinergic agents and selective β-3-adrenoreceptor agonists, in cardiac pathologies - cardiac glycosides, vasodilators, anticoagulants, β-adrenoblockers, nitrates.

Local therapy often includes physiotherapy, such as ultra-high frequency therapy, inductothermia, ultrasound and laser therapy. If it is a question of neurogenic disorders or weakening of the pelvic floor muscles, then prescribe electrical stimulation, LFK. It is possible to use intravesical instillations.

Some patients may benefit from behavioral intervention, which involves controlling the volume and timing of fluid intake.

The root cause of the nicturia	Treatment recommendations
Physiologic nicturia caused by large fluid intake	Correction of drinking regimen, introduction of a rational scheme of fluid and food intake.
Hypotension resulting in nocturnal renal hypoperfusion	Introduction of regimen measures, control and stabilization of blood pressure.
Age-related nicturia due to decreased production of antidiuretic hormone	Administration of vasopressin replacement therapy (in most cases, such therapy is prescribed for life).
Pediatric borderline nicturia (enuresis)	Administration of vasopressin replacement therapy until problematic symptoms are eliminated.
Psychogenic nicturia	Psychotherapeutic treatment
Medication-induced nicturia	Correction of medication prescriptions, use of potentially diuretic medications in the morning.
Heart failure leading to edema due to abnormal pumping function of the heart	Treatment of the underlying pathology.
Diabetes mellitus leading to edema due to hyperglycemia	Treatment of the underlying pathology.
Non-sugar diabetes of central genesis associated with deficiency of antidiuretic hormone production	Carrying out vasopressin replacement therapy until its concentration in the body is normalized.

In decreased renal concentrating ability due to interstitial nephritis, the causes of the disorder are established, exclude the factor that supports this mechanism. Treatment with angiotensin II receptor blockers, angiotensin-converting enzyme inhibitors is prescribed.

Patients with increased urine in nonsugar diabetes and tubulopathy are treated for the underlying disease.

In arterial hypertension prescribe medication correction of blood pressure indices. Preference is given to angiotensin-converting enzyme inhibitor drugs, angiotensin II receptor blockers. Treatment is combined.

Men with benign hyperplasia are recommended drug treatment of pathology with the reception of tamsulosin, and with inflammation of the lower urinary system, therapy of infectious disease is carried out.

Women suffering from atrophy of the pelvic floor muscles should perform special training of the relevant muscles. In addition, hormone replacement therapy is also used. [7]

In some cases, surgical treatment is necessary:

• In renal diseases, surgery is performed to restore urinary outflow by nephropexy, removal of stones, excision of neoplasms, ureteral stenting. Reconstructive interventions are indicated for defects and anomalies.
• Transurethral resection, laser enucleation or vaporization, adenectomy are performed for prostate adenoma. If radical surgery is not possible, a urethral stent is placed or a cystostomy is performed.
• In neurogenic nicturia, botulinum toxin injection, augmentation cystoplasty, sacral neuromodulation, pudendal and sacral neurotomy, pyelostomy, epicystostomy, and funnel-shaped resection of the bladder neck are practiced.
• In hyperthyroidism it is possible to perform thyroid lobe resection, hemithyroidectomy, subtotal thyroid resection, other operations. In some cases, radioiodotherapy is indicated.

Treatment with folk remedies

Many medicinal plants have a pronounced therapeutic effect due to their content of biologically active substances. Some of them are successfully used in urology - for the treatment of cystitis, renal failure, as well as such an undesirable manifestation as nicturia.

It is recommended to use such medicinal herbs and collections with them:

• Goldenseal herb - helps reduce the risk of crystal formation, improves urine outflow, removes uric acid. It has antispasmodic, anti-inflammatory, antibacterial, antiproteinuric activity, inhibits the adhesion of bacteria to the urothelium, prevents the negative effects of free radicals.
• Lubistka rhizome - relaxes the bladder, relieves spasms, eliminates urodynamic disorders, increases the threshold of pain sensitivity in patients with cystitis or prostatitis, has anti-adhesive, nephroprotective, antimicrobial action.
• Rosemary leaves - has diuretic action, normalizes urodynamics, reduces the intensity of the inflammatory process, relieves pain and burning, prevents the multiplication of pathogenic flora, slows the progression of renal pathology, demonstrates anti-adhesive, antioxidant effect.

Prevention

Increased nocturnal diuresis negatively affects the quality of sleep, which adversely affects the state of health and violates the quality of life. To prevent the appearance of the problem, it is necessary to consult doctors in a timely manner, treat the underlying diseases already present, and undergo regular preventive examinations.

The following simple rules should be followed to avoid physiologic nicturia:

• drink less fluids in the afternoon and even less at night;
• The last meal should be taken no later than 1-2 hours before going to bed;
• avoid soups, compotes, juicy fruits in the evening;
• After a large evening meal, it is better to go to bed a little later - 2-3 hours after the meal;
• it's not advisable to get up at night to drink water.

If the doctor prescribes drugs that should be taken in the evening, it is advisable to ask whether they do not have a diuretic effect. If the patient is prone to nicturia, it is necessary, if possible, to adjust the time of taking such drugs.

Forecast

Successful elimination of nicturia is possible if the appropriate disease or condition is competently managed in patients with such disorders:

• Physiologic nicturia in people who are known to consume large amounts of fluid;
• Hypotensive physiologic nicturia;
• age-related changes;
• pediatric inadequate vasopressin production;
• psychogenic disorders;
• medication-induced nicturia;
• heart failure;
• Diabetes mellitus and non-diabetes mellitus.

Treatment of patients with situational increase in nocturnal urine volume is usually quite effective. These are individuals with arterial hypertension, benign prostatic hyperplasia, lower urinary tract inflammation, age-related decreased bladder capacity, and postmenopausal women with pelvic muscle atrophy.

If the nocturnal increase in urge to urinate is associated with chronic renal pathology, then in this case polydipsia is compensatory. This should be taken into account when correcting the drinking regimen: such patients should not limit the use of liquids and salt. In such situations, the prognosis for complete cure is not quite favorable: unfortunately, nicturia continues to bother patients up to complete renal dysfunction.