Nocturia in Menopausal Women: The Link Between Two Common Problems of the Middle Age.

INTRODUCTION AND HYPOTHESIS: The aim of this review is to discuss the link between menopause and nocturia and to give an overview of the increasing prevalence, risk factors, causative factors, treatment needs and options for nocturia in peri-menopausal women. METHODS: This opinion article is a narrative review based on the expertise and consensus of a variety of key opinion leaders, in combination with an extensive literature review. This literature search included a thorough analysis of potential publications on both the PubMed Database and the Web of Science and was conducted between November 2022 and December 2022. The following key words were used "nocturia" and "menopause" or "nocturnal frequency and menopause." Moreover, key words including "incidence," "prevalence," "insomnia," "estrogen therapy," "metabolic syndrome," and "hot flushes" were used in combination with the aforementioned key words. Last, the reference lists of articles obtained were screened for other relevant literature. RESULTS: The perimenopause can be a trigger for inducing nocturia. Typically, obesity, body mass index (BMI), and waist circumference are risk factors for developing peri-menopausal nocturia. Presumably the development of peri-menopausal nocturia is multifactorial, with interplay among bladder, sleep, and kidney problems due to estrogen depletion after the menopause. First, impaired stimulation of estrogen receptors in the urogenital region leads to vaginal atrophy and reduced bladder capacity. Moreover, menopause is associated with an increased incidence of overactive bladder syndrome. Second, estrogen deficiency can induce salt and water diuresis through blunted circadian rhythms for the secretion of antidiuretic hormone and the activation of the renin-angiotensin-aldosterone system. Additionally, an increased incidence of sleep disorders, including vasomotor symptoms and obstructive sleep apnea signs, is observed. Oral dryness and a consequent higher fluid intake are common peri-menopausal symptoms. Higher insulin resistance and a higher risk of cardiovascular diseases may provoke nocturia. Given the impact of nocturia on general health and quality of life, bothersome nocturia should be treated. Initially, behavioral therapy should be advised. If these modifications are inadequate, specific treatment should be proposed. Systemic hormone replacement is found to have a beneficial effect on nocturia, without influencing sodium and water clearance in patients with nocturnal polyuria. It is presumed that the improvement in nocturia from hormonal treatment is due to an improvement in sleep disorders.

Pediatric incontinence questionnaire (PINQ): translation and transcultural adaptation to Brazilian Portuguese

Abstract Objective Lower urinary tract symptoms (LUTS) affect approximately 10% of children worldwide and are related to psychosocial manifestations and compromised quality of life, both for children and their families. The assessment of emotional conditions of LUTS in children is recommended by International Children's Continence Society; however, there is no specific instrument in the Brazilian Portuguese language. Therefore, the aim of this study was to translate, culturally adapt and assess the internal consistency of the Brazilian Portuguese version of the Pediatric Incontinence Questionnaire (PINQ). Material and methods This cross-sectional study was performed at two referral centers for childhood voiding dysfunction. The 20-item PINQ was translated into Brazilian Portuguese and culturally adapted according to Beaton, 2000. His-standard methodology consists of 6 phases: translation, synthesis, back-translation, expert committee, and pre-test. The internal consistency was assessed using Cronbach's alpha. Results The PINQ-br version was developed, validated by a committee of experts, and pre-tested on 44 children diagnosed with lower urinary tract symptoms, 23 boys and 21 girls (mean age: 9.7 and 9.6 years old respectively), as well as on their parents. The internal consistency was considered satisfactory, reaching Cronbach's alpha coefficient of 0.74 when applied to children and 0.82 when applied to parents. Conclusions The PINQ was translated and culturally adapted to Brazilian Portuguese to assess the impact of LUTS on the health-related quality of life in Brazilian children and adolescents.

Hormone therapy as a possible solution for postmenopausal women with nocturia: results of a pilot trial.

OBJECTIVE: To observe the impact of different hormonal treatment options on nocturia, its causative factors and bother in postmenopausal women. METHODS: This prospective study recruited 245 postmenopausal women and divided them into four treatment groups based on patient's choice: Estrogen + Progesterone (E+P), Estrogen-only in patients with a prior hysterectomy, tissue-selective estrogen complex (TSEC) and no treatment. Nocturia and its causative factors were observed using two standardized questionnaires before and after treatment: the International Consultation on Incontinence Questionnaire Nocturia Module and the Targeting the individual's Aetiology of Nocturia to Guide Outcomes (TANGO). The results of the Targeting the individual's Aetiology of Nocturia to Guide Outcomes were divided in four influencing topics of which the sum score was calculated. RESULTS: A significant reduction in prevalence of nocturia ≥ twice per night was seen after treatment, as the prevalence decreased from 27.7% (59/213) to 16.4% (35/213). Specified per therapy, a significant reduction in nocturnal voiding frequency was observed in patients treated with E+P and TSEC (P = 0.018 and P = 0.018, respectively). This improvement could be explained by a significant reduction in SLEEP sum score in patients treated with E+P and TSEC (P < 0.001, P = 0.013, respectively). Estrogen-only led to a significant change in URINARY TRACT sum score, which is the result of a reduction in urgency prevalence (P = 0.039). CONCLUSIONS: E+P and TSEC treatment led to a significant reduction in nocturia prevalence and bother in women with ≥ 2 nocturnal voids. This effect is mainly the result of improvement in sleep disorders, however an improvement in bladder disorders can be suggested as well. More research is necessary to confirm these findings.

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"TANGO" nocturia scanning tool: Turkish validity and reliability study.

BACKGROUND: The aim of this study is to evaluate the validity and reliability of the Targeting the Individual's Aetiology of Nocturia to Guide Outcomes (TANGO) screening tool, which is used to determine nocturia etiology. METHODS: Patients hospitalized in urology, orthopedics, and general surgery clinics between September 2019 and January 2020 were included in the study. Demographic characteristics of the participants such as age, gender, drug use, and nocturia severity were assessed by the researchers. The Turkish version of the TANGO questionnaire consisting of 22 questions was filled in by the patients. The patients were asked to repeat the same test 4 weeks later. RESULTS: A total of 124 patients were included in the study. The mean age of the patients participating in the study was 51.20 ± 18.50 (38-82). The result of the reliability assessment showed that the total score intraclass correlation coefficient was 0.715 (individual item score weighted kappa coefficients, 0.696-0.731) and the Cronbach's alpha coefficient was 0.727. A total of 112 patients filled in the TANGO screening tool again after 4 weeks. The test-retest reliability analysis kappa value was 0.75 (0.68-0.83). In the validity analysis, a moderately positive correlation was observed between the TANGO-Urinary Incontinence Score and the number of nocturia (r = 0.452, P = .003). CONCLUSION: According to the validation study, the TANGO screening tool is valid and reliable to determine the nocturia etiology for the Turkish population.

Dutch version of the TANGO nocturia screening tool: cross-culturally translation and reliability study in community-dwelling people and nursing home residents.

Objectives: The purpose of this study was to translate and culturally adapt the self-administered screening instrument 'Targeting the individual's Aetiology of Nocturia to Guide Outcomes' (TANGO) into Dutch for Belgium and to assess its test-retest reliability. Methods: This study has a cross-sectional, descriptive study design. Cross-cultural adaption of TANGO into Dutch for Belgium was performed according to a standardized method. Convenience samples of community-dwelling people and NH residents with nocturia (≥1void/night) completed TANGO-D at baseline and 1-2 weeks later. Community-dwelling people filled in the questionnaire at home and the NH residents were interviewed by a study nurse. Results: TANGO-D was completed by 33 community-dwelling middle-aged people and 45 NH residents. Completeness of responses was adequate in both populations and almost all items had positive and negative answers. In the NH residents, 12 out of 22 items required clarification, wherein five items adjustments are essential. Test-retest reliability analysis revealed an overall median Kappa of .75 [IQR: .78-1] in community-dwelling people and .54 [IQR: .31-.65] in NH residents, confirming substantial and moderate agreement, respectively. Conclusion: TANGO-D is a cross-cultural adapted Dutch translation of the original TANGO and showed good test-retest reliability in community-dwelling middle-aged people. However, validation of TANGO is required before use in clinical practice and the addition of a module of environment-related items to extend the utility of the instrumentwhen used in NH is desirable.

Effect of diuresis on bother related to lower urinary tract symptoms.

AIMS: To explore and objectify the impact of diuresis on the presence of daytime and nighttime LUTS, and associated bother. METHODS: Participants (healthy volunteers and patients referred to our hospital for a urologic consultation) were asked to complete a 72-hour bladder diary and also had to fill in a Likert scale (0: no bother; 10: maximal bother) to evaluate the LUTS-associated bother during daytime and nighttime. Three groups were defined: no/mild bother (Bother ≤2), moderate bother (3 ≤ Bother ≤ 6), and strong bother (Bother ≥7). Questionnaires in order to assess LUTS (ICIQ MLUTS and ICIQ FLUTS), quality of life (SF-36, NqOL), and quality of sleep (PSQI) were completed. RESULTS: During daytime and nighttime, the study of participants with a strong bother associated with LUTS revealed a statistically significant higher fluid intake than those without bother (1640 mL vs 1800 mL during daytime, P = 0.007). Also, those with higher diuresis rate had more bother related to LUTS than the others (71.3 mL/h in group 1 vs 87.3 mL/h in group 3 (P < 0.001) during daytime). As might be expected, lower urinary tract such as bladder, for example, studied through maximal voided volume does play a role. The lower the maximal voided volume is, the more bother the participants described. CONCLUSIONS: This study pointed out the implication of diuresis in bother related to LUTS. Our findings showed that there was an increase in bother by 1 when diuresis increased by 100 mL/h.

Nocturia as a marker of poor health: Causal associations to inform care.

AIMS: Nocturia is a common symptom of many conditions and is encountered in patients presenting to services across different medical specialities and health disciplines. The causal pathway of nocturia is multi-factorial and differs between patients. There is currently no symptom-specific clinical algorithm for all-cause diagnosis of nocturia. The aim of this study was to investigate the interrelationships between causes of nocturia in order to inform the development of a comprehensive multidisciplinary assessment metric. METHODS: A PubMed search that identified studies reporting relationships between nocturia and a priori aetiological factors was conducted by cross referencing the term "nocturia" with "polyuria, postural hypotension, hypertension, cardiac function, heart failure, depression, anxiety, polypharmacy, sleep disturbance, sleep disorder, apnoea, and lower urinary tract symptoms." Directed acyclic graphs (DAGS) were constructed to visually represent causal assumptions and to identify underlying relationships. RESULTS: This study confirmed that causality of nocturia can be expressed in a directed acyclic graph, with the key variables being cardiovascular dysfunction, polyuria, sleep disturbance, mental health, metabolic and inflammatory changes, health status and lower urinary tract symptoms. None of the variables were independently a sufficient or necessary direct cause of nocturia and multiple backdoor pathways exist to nocturnal voiding. Polypharmacy, increasing age and BMI all have confounding effects. CONCLUSIONS: There are significant interactions between voiding at night and metabolic, cardiovascular, hormonal, mental health, sleep and inflammatory changes that flag nocturia as a likely marker of co-morbid poor health. Patients should be comprehensively evaluated for all-causes of nocturia since multiple aetiologies commonly co-exist. Neurourol. Urodynam. 36:697-705, 2017. © 2016 Wiley Periodicals, Inc.

Timeliness of lung cancer care in Victoria: a retrospective cohort study.

OBJECTIVE: To assess factors associated with second-line delays in the management of patients diagnosed with lung cancer. DESIGN, SETTING AND PARTICIPANTS: A retrospective cohort study, conducted in six public and two private Victorian hospitals, of 1417 patients aged 18 years or more who were diagnosed between July 2011 and October 2014 with an incident case of lung cancer identified by International Classification of Diseases, 10th revision codes (C34.0-C34.9, Z85.1, Z85.2) on the basis of either a clinical or pathological diagnosis. OUTCOME MEASURES: Time intervals between referral, diagnosis and initial definitive management. RESULTS: The median time from referral to diagnosis was 15 days (interquartile range [IQR], 5-36); from diagnosis to initial definitive management, 30 days (IQR, 6-84); and from referral to initial definitive management, 53 days (IQR, 25-106). Factors that were significantly associated with delay between referral and initial definitive management include declining or not being referred to palliative care (hazard ratio [HR], v patients referred for palliation, 0.73; 95% CI, 0.62-0.86; P < 0.001), and being treated in a public hospital (HR, v patients managed in a private hospital, 0.55; 95% CI, 0.48-0.64; P < 0.001). The median time from referral to initial definitive management in public and private hospitals was 61 days (IQR, 35-118) and 30 days (IQR, 13-76) respectively; 48% of patients in public hospitals waited longer than the British National Health Service target of a maximum 62 days between referral and first definitive treatment. CONCLUSION: There are significant delays at various stages of the patient journey after referral for initial definitive management. Having a greater understanding of these delays will enable strategies to be developed that improve the timeliness of care for patients with lung cancer.

Mode of treatment affects quality of life in head and neck cancer survivors: Implications for holistic care.

CONCLUSION: As adverse effects of live-saving treatment are unavoidable surgeons have a duty to address physical changes and quality of life issues that matter to head and neck (H&N) cancer patients. We propose a tailored holistic care package. OBJECTIVES: This study compared the quality of life of H&N cancer survivors managed with different approaches in the follow-up phase after initial treatment and identified factors adversely impacting quality of life parameters. METHODS: H&N cancer patients studied: 1) surgery only, 2) radiotherapy only, 3) surgery and radiotherapy, and 4) any combination of surgery, chemotherapy or radiotherapy. Patients unable to communicate in Cantonese, with thyroid cancer or end-of-life disease were excluded. EORTC QLQ-H&N35 Cantonese version was administered at least 1 year after initial H&N cancer treatment. RESULTS: Quality of life impairment was worse in all of the domains for combination therapy versus monotherapy patients. Scores between surgery or radiotherapy-only patients were not significantly different. Radiotherapy preceding surgery impacted significantly more on speech than surgery before the radiotherapy. Patients with advanced disease had more impairment of quality of life in each domain than patients with early disease. Coughing, eating problems, sticky saliva, and difficulties with social contact were all significant predictors of problems associated with a dry mouth.

Endoscopic assessment of the nasopharynx: an objective score of abnormality to predict the likelihood of malignancy.

OBJECTIVES: We developed an objective endoscopic score of abnormality of the nasopharynx to predict the likelihood of malignancy. METHODS: A score sheet with 44 variables was developed to objectively quantify the bilateral endoscopic assessment of the nasopharynx. Patients scheduled to undergo nasopharyngeal biopsies were recruited. The nasopharynx was assessed endoscopically, photographed, and scored on 44 variables. The scores were compared to the biopsy results, and predictors of malignancy were modeled with regression analysis. The sensitivity and specificity of the novel scoring system were examined. RESULTS: Seventeen patients had carcinoma, and 60 had a benign lesion or no disease. Patients with a nasopharyngeal malignancy scored significantly higher than did patients with a benign lesion or no disease. No patient with a malignant lesion had a score of less than 12. With a receiver operating characteristic curve area of 0.917, the score demonstrated an excellent ability to discriminate between nasopharynges that were likely or unlikely to contain malignant disease. Independent predictors for both malignant disease and a score greater than 12 were modeled. CONCLUSIONS: A cutoff score above 12 on the novel objective endoscopic assessment of the nasopharynx measure was highly predictive of possible malignancy.

Peri-operative hyperglycemia: a consideration for general surgery?

BACKGROUND: Intraoperative hyperglycemia in cardiac and neurosurgical patients is significantly associated with morbidity. Little is known about the perioperative glycemic profile or its impact in other surgical populations or in nondiabetic patients. METHODS: A systematic review of blood glucose values during major general surgical procedures reported since 1980 was conducted. Data extracted included blood glucose measures, study sample size, gender distribution, age grouping, study purpose, surgical procedure, anesthetic details, and infusion regime. Excluded studies were those with subjects with diabetes insipidus, insulin-treated diabetes, renal or hepatic failure, adrenal gland tumors or dysfunction, pregnancy, and emergency or trauma surgery. RESULTS: Blood glucose levels rose significantly with the induction of anesthesia (P < .001) in nondiabetic patients. At incision, 2 hours, 4 hours, and 6 hours, 30%, 40%, 38%, and 40% of studies, respectively, reported hyperglycemia. CONCLUSIONS: Factors that confound or protect against significant rises in perioperative glycemic levels in nondiabetic patients were identified. The findings facilitate investigating the impact of hyperglycemia on general surgical outcomes.

Overt diabetes mellitus adversely affects surgical outcomes of noncardiovascular patients.

BACKGROUND: It is known that cardiac surgical patients with diabetes have greater peri-operative mortality and morbidity when compared with nondiabetic patients; the rate of adverse events in other surgery subspecialties has been only investigated minimally. The aim of this study was to test the magnitude of association between overt diabetes mellitus and postoperative complications across a spectrum of noncardiac surgical patients. METHODS: Prospective outcome data registries describing 1,343 data sets from a spectrum of surgical subspecialties were examined to establish the prevalence of diagnosed diabetes, the incidence of intra- and postoperative complications, and the difference in proportion of morbidity between diabetic versus nondiabetic patients. RESULTS: There was a significant difference in overall morbidity between diabetic and nondiabetic patients with a 2.0 and 1.6 times increased morbidity risk in known diabetic patients with and without malignancy, respectively. Known diabetes was related to the number of postoperative complications in noncardiovascular patients. CONCLUSION: This study quantified the association between known diabetes and the occurrence of complications during recovery after a spectrum of noncardiac surgery. Because of a high prevalence of prediabetic and undiagnosed conditions, the strength of associations between glucose dysregulation and operative outcomes may be even greater than we report.

An audit of risk factors for wound infection in patients undergoing coronary artery bypass grafting or valve replacement.

OBJECTIVES: To investigate the epidemiology of surgical site infection in cardiac surgery patients operated on in 2006. DESIGN: Retrospective study of a case-control sample. SETTING: Cardiac surgery unit of a university teaching hospital in Hong Kong. PATIENTS: Cardiac surgery patients with surgical site infection were matched by procedure type, sex, and year of surgery with non-infected patients. MAIN OUTCOME MEASURES: Identification of risk factors for surgical site infection. RESULTS: The infected and non-infected cardiac surgery patients did not differ in age, sex, or smoking history; however, patients with surgical site infection were significantly heavier (mean body mass index, 26.6 vs 23.9 kg/m2, P < 0.046). Almost 41% of the subjects had a history of diabetes mellitus, there being a significantly greater proportion among infected than non-infected patients (53.1% vs 28.1%, P < 0.042). All 37 of the patients without a diagnosis of diabetes had normal (ie < 8 mmol/L) preoperative glucose levels, but 99% of them yielded evidence of subsequent glycaemic dysfunction during or after surgery. Overall, 50% of the patients had a blood transfusion during the operation, with infected patients significantly more likely to have been transfused than the non-infected ones (65.6% vs 34.4%, P < 0.008). CONCLUSIONS: There appears to be a relationship between surgical site infection in cardiac surgery patients and pre-existing (diagnosed and covert) diabetes mellitus and blood transfusion. Future studies should consider these factors in relation to surgical site infections, both in the wider surgical population and from a risk-minimisation perspective.

Fetoscopy under gas amniodistension: pressure-dependent influence of helium vs nitrous oxide on fetal goats.

PURPOSE: Recently, gas amniodistension has been advocated for fetoscopic surgery to employ ergonomics similar to laparoscopy. However, neither the optimal type of gas nor its physiological influence on the fetus have been clearly outlined yet. This study investigates the impact of helium (HE) vs nitrous oxide (N2O) on fetal goats during fetoscopy. METHODS: We insufflated either HE or N2O in 12 pregnant goats (15 fetuses; HE = 7, N2O = 8), then increased the pressures from 0, 4, 7, to 10 mm Hg in 30-minute intervals and recorded the fetal and maternal vital parameters. Finally, whole-body computed tomography to asses for intracorporeal gas was performed. RESULTS: All fetuses survived. Mean fetal vital signs showed no significant differences between HE or N2O at specific pressure levels. In detail, HE/N2O at 0 vs 10 mm Hg caused a fetal temperature decrease (32.9 degrees C/33.2 degrees C vs 32 degrees C/32.5 degrees C), heart rate increase in the N2O group (100/102 vs 102/121 beats per minute), and no significant change in arterial pressure (45.8/48.3 vs 53.7/46.7 mm Hg). The PO2 was adequate (3.7/3.3 vs 3.7/2.9 kPa), whereas the pH remained unchanged (7.4/7.3 vs 7.3/7.3). However, fetal pCO2 was elevated in the N2O group before insufflation (5.5/7.2 vs 6.8/8.0 kPa) owing to maternal hypoventilation (maternal PCO2: 4.9/5.8 vs 5.0/5.4 kPa), correction of which was slower in the fetus than in the maternal animal. Computed tomography ruled out intracorporeal gas accumulation. CONCLUSION: Neither HE nor N2O impose significant physiological harm for the fetus. Heating of the gas and maternal anesthesia seem essential. Considering the potential teratogenicity of N2O, however, HE could be the favorable environment for fetoscopic procedures under gas amniodistension.