Nocturia

[Dantheman]

Any other night pissers around? Anyone seen a doctor about it and tried to treat it with any success?

The frequency of my night time bladder emptying has been slowly but steadily increasing over the last several years. When it was only twice per night it wasn't a big deal since I normally went right back to sleep pretty easily. But now I've hit a point where three times is a "good" night, and five times is not uncommon. It's like I'm a god damn 75 year old man. Alcohol really fucks things up. One drink with dinner and I'm guaranteed to be up 5(+) times.

With that many sleep interruptions I feel like my quality of life is starting to seriously suffer no matter how easily I fall back asleep afterwards. I had a bit of a revelation about a month back when one night I only had to go once for some reason. I felt better when I woke up than I had in a very long time. I haven't hit my deductible yet for the year, so I figured I'd ask around first before I eat $150 to see my GP.

[zion zig zag]

I've been dealing with this for a few years now. It started with getting up once or twice a night which was ok, but, like you, three is too many. I did ask my doc about it in a checkup a couple of years ago and after a prostate check and PSA screening the only suggestion he had was medication. I'm fairly medication adverse so I've just become really careful about how much I drink after about 6pm. Despite being careful there are some nights that I'll still get up a few times even after limiting fluids. If I want to drink alcohol at night I'll usually make it bourbon, neat.

What really sucks is being on crutches with this problem. I have to wake myself up well so that I don't trip on stairs then turn on lights and put forth some effort in the process. Consequently, I'm peeing in a Gatorade bottle for now.

Are you like me in that the urge to go wakes you up even if you don't have much in your bladder?

[Dantheman]

I already do my best to limit fluids in the evening. I usually don't drink anything after dinner unless I'm really thirsty. Liquor seems to exaccerbate it just as bad or worse than any other type of alcohol. I seem to empty a normal volume when I get woken up by needing to go.

[Whiteroom_Guardian]

I have this issue. Usually only once per night though. Definitely see a urologist. I'm only 31 and my prostate is totally normal. Turns out I have a narrow bladder neck and that makes complete emptying not always possible. As a result you end up peeing more times. They went in with a scope to check it out and then stretched the neck while they were in there. Luckily I was on michael jackson drugs so its not like I was really awake or felt anything. Took a while to see changes but I went down from 3+ times a night to once or zero a night. Good luck.

[Dantheman]

Long term update: 2.5 doctors (my GP, a urologist, and her PA), a voiding diary, 4 drugs, no results. Drugs tried include oxybutinin, tolterodine, desmopressin and mirabegron. They were all ineffective at best to ineffective with significant side effects. My voiding diary was "totally normal" besides the nighttime events. There was discussion of doing some test where they would catheterize me and stick electrodes up my rectum that would measure the electrical activity in my bladder while they repeatedly filled it with saline. I never got a satisfactory explanation of what that would tell them or how they could use the results to treat the problem. Haven't been back since.

[yeahman]

Sorry if this sounds silly but....Have you tried suffering through a few nights without yielding to the urge to get up and go? Kind of like a baby "crying it out" for a few nights and then the hunger pains go away.

Reason I suggest these things is because I've had sporadic periods where I had these urges to get up and go, but I've found that if I just don't do it, my body quickly gets used to not doing it. Maybe it stretches the bladder or muscles or something, if you hold it in? It's partly psychological. Also, not sure if it would help but those Kegel exercises might be something to look into. I find they help the urge go away if I wake up in the middle of the night.

Good luck man, lack of sleep sucks bad.

[Dantheman]

It's definitely not psychological. For the "voiding diary" you measure every emptying over a 72 hour period. All the nighttime events were ~300 mL's, so the tank is full.

[old goat]

What tests did the urologist do? I assume a post void residual with either an ultrasound or catheter. Also, I assume your blood chemistry shows no suggestion of diabetes or kidney abnormalities that would make you urinate more.

[mcski]

I was wondering about diabetes too. I find my frequency of nite pees varies more by food than how much water I've drank. I'm not diabetic, but I'm probably predisposed because of family history. As for "toughing it out" to try and retrain ? No dice, if don't wake up or try to sleep it off I'll get nite sweats, which is even more annoying than having to get up to pee.

[old goat]

I was wondering about diabetes too. I find my frequency of nite pees varies more by food than how much water I've drank. I'm not diabetic, but I'm probably predisposed because of family history. As for "toughing it out" to try and retrain ? No dice, if don't wake up or try to sleep it off I'll get nite sweats, which is even more annoying than having to get up to pee.

There are some foods or food ingredients that increase urine volume--the most famous being caffeine and chocolate.

Dantheman--what medications have they tried?

There are two reasons for increased urination at night. Too much urine and not enough bladder. Not enough bladder is most commonly due to a bladder that is not emptying completely due to enlargement of the prostate or other cause. The bladder remains fairly fully after urination so it fills up again rapidly. Urine amounts are usually small each time. You say your urine amounts are large so that explanation seems unlikely. A post void residual is a test to see how much urine remains in the bladder after urinating--should be close to zero.
Too much urine has multiple causes. The obvious ones are drinking a lot of fluid, using diuretic drugs, using diuretic foods. Diabetes mellitus is easily tested for. Diabetes insipidus is due to either reduced antidiuretic hormone production by the brain or disease in the kidneys--both are easily tested for with blood tests. The nocturnal polyuria syndrome is a condition where the brain does not increase it's production of ADH at night. Normally people produce most of their urine during the day. People with NPS make normal amounts of urine, so the usual blood tests don't show anything wrong. They just make too much of their daily urine at night. To detect it you have to measure the hormone levels. The treatment is desmopressin, which is inhaled through the nose.

[skideeppow]

i was having this issue a while back. I changed my diet. No soda, greens three times a day. Start with a vitamix shake in am, flax see, spinach, kale, some fruit, in coconut milk.
Havent had the problem since i changed it up.

[PB]

...but do you vomit after every meal??

[Dantheman]

What tests did the urologist do? I assume a post void residual with either an ultrasound or catheter. Also, I assume your blood chemistry shows no suggestion of diabetes or kidney abnormalities that would make you urinate more.

They didn't do many tests, honestly. Peed in a cup (not sure what they tested besides glucose and protein), the voiding diary, a prostate questionnaire (score was very low, to paraphrase the PA "Your prostate score was really low. I'll stick my finger up your ass if you really want me too, but it I don't think it's necessary"). No blood work. I had a full metabolic panel done about two years before, so maybe they looked at those results and decided there wasn't a reason to draw blood again. If that was the case they didn't mention it, though.

No post-void residual. I think they may have done that as part of the "urodynamics" test they proposed that would have involved catheterizing me and sticking electrodes up my rectum that would measure the electrical activity in my bladder while they repeatedly filled it with saline. That sounded rather invasive, and when I asked what that would tell them or how they could use the results to treat the problem I never got a coherent explanation so I politely declined.

Dantheman--what medications have they tried?

Oxybutinin, tolterodine, desmopressin and mirabegron. They were all ineffective at best to ineffective with significant side effects.

Too much urine has multiple causes. The obvious ones are drinking a lot of fluid, using diuretic drugs, using diuretic foods. Diabetes mellitus is easily tested for. Diabetes insipidus is due to either reduced antidiuretic hormone production by the brain or disease in the kidneys--both are easily tested for with blood tests. The nocturnal polyuria syndrome is a condition where the brain does not increase it's production of ADH at night. Normally people produce most of their urine during the day. People with NPS make normal amounts of urine, so the usual blood tests don't show anything wrong. They just make too much of their daily urine at night. To detect it you have to measure the hormone levels. The treatment is desmopressin, which is inhaled through the nose.

I drink reasonable amounts. I tracked both "In" and "Out" when I did the diary and both volumes were about 2.5 L. 2.5 L is technically the cutoff for global polyuria, but they told me it was pretty normal. I take no diuretic medications or lithium. I drink 1-2 cups of coffee or tea in the morning but never later in the day. No indications of diabetes mellitus, and frankly with my diet and lifestyle if I did it would probably have to be late-onset Type 1.

I didn't respond to desmopressin, so neurogenic diabetes insipidus seems unlikely. Nephrogenic diabetes insipidus sounds somewhat plausible after reading up on it, but I don't experience the excessive thirst and, based on color, my urine is not typically highly diluted.

i was having this issue a while back. I changed my diet. No soda, greens three times a day. Start with a vitamix shake in am, flax see, spinach, kale, some fruit, in coconut milk.
Havent had the problem since i changed it up.

I already eat very healthy. Besides a cup of black coffee in the morning and an occasional beer I drink nothing but water. Lots of veggies and fruit, very few processed foods.

[splat]

...but do you vomit after every meal??

heh.
Anyone tried saw palmetto w/beta sitosterol? That's the natural prostate treatment.
I tried it, didn't do anything for me. Others swear by it. I think I simply drink too much coffee and/or tea.

[old goat]

Sorry I'm late. Did they ultrasound your bladder? That's a non invasive way to test for post void residual. Urine test would have picked up diabetes mellitus, maybe kidney disease. Blood chemistry would seem like a reasonable thing to check and a lot cheaper than 4 different meds, but I agree with your analysis--probably not your kidneys. You might ask the doc about the PVR. If none of that pans out then we're left with what we always think when we don't know what's going on--the patient is crazy.

I don't particularly like having my prostate checked, especially by a doc I used to work with, and docs don't like doing it either--especially not on a colleague, but it still makes me a little less trusting in the doc's thoroughness. That said I'm sure not going to ask for it if it isn't offered.

[Dantheman]

Thanks, goat. No ultrasound, I don't even remember that being mentioned. Maybe that was discussed behind closed doors and they decided not to do it based on the diary results. The drugs weren't expensive. Besides mirabegron they're all cheap generics, and they gave me samples of the mirabegron. Maybe I'll try another urologist, but at this point it's unclear what another doc could offer me and the bills for that shit add up fast.

[old goat]

Thanks, goat. No ultrasound, I don't even remember that being mentioned. Maybe that was discussed behind closed doors and they decided not to do it based on the diary results. The drugs weren't expensive. Besides mirabegron they're all cheap generics, and they gave me samples of the mirabegron. Maybe I'll try another urologist, but at this point it's unclear what another doc could offer me and the bills for that shit add up fast.

the only thing I can think of is the pvr (either ultrasound or catheter) to see if there's some reason your bladder isn't emptying--of which there are several potential causes. I'm not a urologist and your urologist probably had a good reason not to do it, as you said. You might ask him about it, at least for your own edification. But whatever you do don't tell him I put you up to it--docs hate that. Tell him you googled it.

[Dantheman]

Tell him you googled it.

Because there's nothing docs these days love more than patients who have self-diagnosed themselves over the internet

[old goat]

Because there's nothing docs these days love more than patients who have self-diagnosed themselves over the internet

Nah, we're used to that. But tell me that some other doc in my specialty said this or that and I go ape shit (on the inside--on the outside just my usual resting bitch face.) Nothing wrong with the internet--when a patient would come in with a disease or drug I didn't know much or anything about my first move was Wikipedia. Pretty much the same stuff as in the textbooks, except up to date and you can't smash a ganglion with Wikipedia.

[Dantheman]

Been awhile since I updated my self-pity blog:

Drank ~6 oz of water with dinner last night around 6:00 pm, my last fluid intake of the night. Previous fluid intake before that was ~8 oz of water at about 2:30. Peed in the shower around 7:30, full bladder. Emptied another full bladder right before bed at 9:30. Emptied another full bladder at 10:15, then another at 11:20, another at 1:30 am, another at 4:30, and another at 6:30. How in the fuck is that possible?

That's not necessarily typical, I usually make it until at least close to midnight before I first have to void and void 3-4x total, but multiple voids before midnight happens at least once every 10-14 days. On Xmas eve I somehow made it to 3:30 am. I have no idea when the last time was that I didn't wake up to void until that late, a true Xmas miracle.

Since my sleep gets interrupted so much I need at least 9.5-10 hours in bed each night to accumulate enough sleep to feel good. I made the mistake of doing some math the other day--compared to sleeping 8 hours per night that works out to an extra 23-30 24-hour days per year I spend in bed. Sobering.

I saw my PCP for a physical in early November. All bloodwork was excellent. Talked to him about this issue specifically again. Based on my lack of response to DDAVP he thinks my kidneys are just insensitive to ADH. He offered to refer me to a nephrologist, but also said:

1. In general they're not that interested in treating polyuria.
2. There's probably not anything they can do to help me anyway.
3. If I did see one they'd probably want to MRI my kidneys ($$). Benign adrenal tumors are common, so there's a decent chance the MRI would show some kind growth on my adrenal gland(s). If the MRI shows something they'll probably want to biopsy it to be sure it's not malignant, thus necessitating a likely unnecessary surgical biopsy ($$$$+risks involved with abdominal surgery).

[detrusor]

Did they do a 24 hour urine collection to check for urine osmolality, sodium etc?

Checking urine electrolytes against serum can give meaningful info.

Is your PCP an internist? Can not recommend enough an internist as a PCP


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[Dantheman]

Did they do a 24 hour urine collection to check for urine osmolality, sodium etc?

Checking urine electrolytes against serum can give meaningful info.

No. Peed in a cup at the urologist's office but was never asked to bring in a full day's worth in a gallon jug.

Is your PCP an internist? Can not recommend enough an internist as a PCP

His bio on IHC's website doesn't say anything about it. I can PM you his name if you'd like.

[detrusor]

For sure. My wife is an internal medicine doc at imc for inpatient. She’ll know if they’re good....


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[Dantheman]

I decided to see an Internist for a second opinion. Other than being emphatic that I needed to see a nephrologist, she was useless. It took three weeks and multiple calls to her office to actually get the referral she was so insistent I needed.

Eventually I got in to see the nephrologist. Despite just having bloodwork done a few weeks ago (all normal/excellent) he insisted that I get all the same tests done again a few days before coming in. For reasons unknown (though likely related to working out the day before the blood draw, I had some pretty good DOMS going) those results came back with a serum creatinine of 2.8. He walks into the exam room and immediately starts telling me that I have acute kidney failure. When I was eventually I was able to get a word in edgewise I discovered he had no idea that that serum creatinine result post-dated my referral and my nocturnal polyuria is the reason I was actually there.

At that point we discussed the actual issue at hand some, but this guy was already so far down a mental rabbit hole that I had AKI that it was basically an afterthought. Despite the fact that a 1 L bottle isn't large enough to work as an overnight pee bottle while camping, he questioned whether I actually had nocturnal polyuria at all and the possibility that it is nephrogenic was dismissed out of hand. He wanted me to come back in a week to get my creatinine checked again, do an ultrasound of my kidneys, and get further counseling regarding my "AKI"--AKI that he has diagnosed based on a single serum creatinine result while ignoring my otherwise clearly robust health and extensive history of normal creatinine levels.

I was a bit incredulous at this point and quite skeptical that I actually had AKI. So, rather than sitting around for a week worried that my kidneys were failing, I suggested that we pull another blood sample right now. He begrudgingly agreed to this, then while he went off to order the test he had a nurse come in to go over a "Living with Kidney Disease" pamphlet with me. The nurse clearly found it a lot stranger than he did that I had AKI, and went so far as to say "Well, looking at you I don't think we to bother with the diet and exercise parts."

Shockingly, the follow-up blood sample showed normal serum creatinine at 1.18. He called me the next day and said while that was good news he was still worried about me and wanted to do a 24-hour urine collection for creatinine clearance. Collecting 24 hours worth of urine is only mildly inconvenient and the test is cheap so I was happy to do this. For various reasons it took me a while to get to it but I finally did it last week. CrCl came back at 140 mL/min which puts my GFR at 100+. In other words, my kidneys run like a top. Seven days later I have yet to get a call back abut those results. I only know what they are because I looked them up myself and found a CrCl calculator online.

FTR, my 24-hr urine volume was 3,000 mL with 1,350 mL of it at night (45% of the total, the clinical definition of nocturnal polyuria is >33%). I did see something online about nocturnal polyuria being associated with sleep apnea, so I used a snore tracking app for two weeks. My "Snore Score" every night was 1, out of 100, and the average score for a new user is 25. Yeah, it's not a true sleep study, but it seems exceedingly unlikely that I have sleep apnea or need to do a clinical sleep study.

That's a long way of saying I've wasted many more hours of my life and over $500 in medical bills with nothing to show for it. Good times.

[::: :::]

you are aging
and you drink a lot

back off the liquids by 25%
& after 4pm, only 6oz w/ dinner
see how that goes


$500 please