Lifelong LUTS: Understanding the bladder's role and implications across transition phases, a comprehensive review.

INTRODUCTION: Lower urinary tract symptoms (LUTSs) are a diverse array of urinary and pelvic dysfunctions that can emerge from childhood, extend through adulthood, and persist into older age. This narrative review aims to provide a comprehensive perspective on the continuum of LUTS and shed light on the underlying mechanisms and clinical implications that span across the lower urinary tract. METHODS: A panel of five experts from Belgium, the Netherlands, India, Denmark, and the United States participated in an intensive research to explore and pinpoint existing insights into the lifelong concept of LUTS, particularly at the pelvic level. The experts reviewed the existing literature and held a webinar to discuss their findings. RESULTS: Childhood LUTS can persist, resolve, or progress into bladder underactivity, dysfunctional voiding, or pain syndromes. The Lifelong character can be explained by pelvic organ cross-talk facilitated through complex neurological and nonneurological interactions. At the molecular level, the role of vasopressin receptors in the bladder's modulation and their potential relevance to therapeutic strategies for LUTS are explored. Frailty emerges as a parallel concept to lifelong LUTS, with a complex and synergistic relationship. Frailty, not solely an age-related condition, accentuates LUTS severity with insufficient evidence regarding the effectiveness and safety profile of the available therapeutic modalities. CONCLUSION: Understanding lifelong LUTSs offers insights into genetic, anatomical, neurological, and molecular mechanisms. Further research could identify predictive biomarkers, elucidate the role of clinically translatable elements in pelvic cross-talk, and uncover molecular signatures for personalized management.

Association between frailty and detrusor overactivity with detrusor underactivity in older women.

PURPOSE: While detrusor overactivity (DO) with detrusor underactivity (DU) (DO-DU) has been described as typical of aging, the pathogenesis of DO-DU is highly multifactorial, and often thought to involve medical conditions beyond the urinary tract. We aimed to explore potential associations between idiopathic DO-DU and frailty in older women after accounting for age. METHODS: The design of the study is a cross-sectional single-center study, in an outpatient urodynamic unit specializing in geriatrics. Participants are consecutive female patients aged ≥65 years without contributory neurological conditions or bladder outlet obstruction who completed a comprehensive geriatric assessment followed by urodynamic evaluation from 2015 to 2019. Participants were categorized as having DO, DU, combined DO-DU, or a negative study. Multinomial logistic regression analysis was used to assess the relationship between urodynamic outcomes and frailty, as quantified using the Frailty index (FI). RESULTS: Ninety-five patients were included (median age 78 [interquartile range: 70-83] years), among whom 29% had combined DO-DU. The median FI score was 0.27 (0.2-0.32) (5-12). A higher FI was associated with significantly greater age-adjusted odds of DO-DU when either DU or subjects with a negative urodynamic assessment were used as the reference group. Age was not significantly associated with DO-DU across all multivariable analyses. CONCLUSION: A higher FI was associated with an increased likelihood of DO-DU, which could not be attributed to the effect of age alone. The pathogenesis of DO-DU is likely more complex than chronological aging in and of itself and merits further study.

Is the insomnia phenotype the common denominator in LUTS during transition periods? An expert NOPIA research group review.

AIMS: As people age, sleep stages and characteristics transition over time, but sleep deficits can profoundly impact health and cognitive functioning. Chronic sleep deprivation is linked to impaired attention and productivity, weakened immunity, increased risk of cardiovascular disease, obesity, and mental health disorders. Insomnia, obstructive sleep apnea syndrome, hormonal changes, nocturia, neurological disorders, and life events interfere with sleep patterns and some are linked to lower urinary tract symptoms (LUTS). This NOPIA symposium on Lifelong LUTS aimed to analyze the literature on associations between sleep and LUTS, generate ideas for future research, and explore whether there is support for the concept of lifelong LUTS in relation to changes in sleep throughout the lifespan. METHODS: An international panel of experts took part in an online meeting addressing the role of lifelong LUTS in relationship to sleep and the brain organized by the NOPIA research group. The manuscript summarizes existing literature, hypotheses, future research ideas, and clinical recommendations. RESULTS: Insomnia, sleep fragmentation, hyperarousal, and sensory processing disorders emerged as potential factors in the relationship between sleep and LUTS. Insomnia is often a persistent factor and may have been the initial symptom; however, it is often unrecognized and/or unaddressed in healthcare settings. By recognizing insomnia as a primary driver of various health issues, including nocturia, transitional care aims to address root causes and underlying problems earlier to initiate appropriate treatment. CONCLUSIONS: A multidisciplinary approach with collaboration between healthcare professionals from various disciplines, such as urology, sleep medicine, gynecology, pediatrics, and geriatrics, is needed and should include validated measurements such as the insomnia severity index and sleep and voiding diaries. Ensuring ongoing follow-up and monitoring through transitional care is crucial for individuals with persistent sleep problems and LUTS, allowing issues that arise or fluctuate over the lifespan to be addressed.

Prevalence of Sleep CALM nocturia factors in a male veteran population.

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.

Nocturia and Blood Pressure Elevation in Adolescents.

Nocturia has been increasingly recognized as a manifestation of various non-urological conditions including hypertension. In adults, blood pressure (BP) elevation has been identified as a robust correlate of nocturia, but such a relationship has not been studied in pediatric populations where nocturia is often attributed to hormonal, sleep, physiological or psychological disorders. Accordingly, this study aimed to determine the relationship between nocturia and BP elevation in adolescents. We prospectively studied 100 patients, aged 10-18 years, recruited from pediatric clinics at our institution. Nocturia (defined as ≥ 1 voids on voiding diary analysis) was present in 45% of the study sample (range: 1-4 voids/night). 37% of subjects self-reported awakening to urinate, and 34% of subjects had BP elevation according to age-dependent thresholds from current Pediatrics guidelines. On multivariate analyses, BP elevation was strongly associated with nocturia determined by both voiding diary (OR 26.2, 95% CI: 6.5, 106.0) and self-report. Conversely, nocturia was associated with increased odds of elevated BP by diary (26.3, 95% CI: 6.5, 106.4) and self-report (OR 8.1, 95% CI: 3.2, 20.5). In conclusion, nocturia appears to be common and is strongly associated with BP elevation in adolescents. These findings suggest that eliciting a history of nocturia holds promise as a simple method of identifying adolescents at risk for hypertension.

Mechanical indications for inflatable penile prosthesis revision: analysis and implications for revision surgery.

BACKGROUND: Despite technical advancements, inflatable penile prostheses (IPPs) are inherently at risk of mechanical failure given their nature as hydraulic devices. AIM: To characterize IPP component failure location at the time of device revision and stratify by manufacturer: American Medical Systems (Boston Scientific [BSCI]) and Coloplast (CP). METHODS: A retrospective review of penile prosthesis cases from July 2007 to May 2022 was conducted, identifying men who underwent revision surgery. Cases were excluded if documentation did not denote the cause of failure or the manufacturer. Mechanical indications for surgery were categorized by location (eg, tubing, cylinder, or reservoir leak; pump malfunction). Nonmechanical revisions were excluded (component herniation, erosion, or crossover). Categorical variables were assessed with Fisher exact or chi-square analysis; Student t-test and Mann-Whitney U test were used for continuous variables. OUTCOMES: Primary outcomes included specific location of IPP mechanical failure among BSCI and CP devices and time to mechanical failure. RESULTS: We identified 276 revision procedures, 68 of which met inclusion criteria (46 BSCI and 22 CP). Revised CP devices were longer than BSCI devices (median cylinder length, 20 vs 18 cm; P < .001). Log-rank analysis revealed a similar time to mechanical failure between brands (P = .096). CP devices failed most often due to tubing fracture (19/22, 83%). BSCI devices had no predominant site of failure. Between manufacturers, tubing failure was more common in CP devices (19/22 vs 15/46 for BSCI, P < .001), while cylinder failure was more common among BSCI devices (10/46 vs 0/22 for CP, P = .026). CLINICAL IMPLICATIONS: The distribution of mechanical failure is significantly different between BSCI and CP devices; this has implications regarding the approach to revision surgery. STRENGTHS AND LIMITATIONS: This is the first study to directly compare when and where mechanical failure occurs in IPPs and to compare the 2 main manufacturers head-to-head. This study would be strengthened by being repeated in a multi-institutional fashion to provide more robust and objective evaluation. CONCLUSION: CP devices commonly failed at the tubing and rarely elsewhere, while BSCI devices showed no predominant failure site; these findings may inform decision making regarding revision surgery.

Polyuria in patients with lower urinary tract symptoms: Prevalence and etiology.

INTRODUCTION: Patients with lower urinary tract symptoms (LUTS) can be subcategorized into polyuria, normal or oliguria groups. Polyuria may be caused by pathologies including diabetes mellitus (DM), chronic kidney disease (CKD), diabetes insipidus (DI), or primary polydipsia (PPD). While fluid restriction is appropriate for some, doing so in all may result in serious complications. This study investigates the prevalence of these pathologies in LUTS patients with polyuria. MATERIALS AND METHODS: Two databases were retrospectively queried for men and women who filled out a lower urinary tract symptom score (LUTSS) questionnaire, 24-h bladder diary (24HBD) and were polyuric (>2.5 L/day). Patients were divided into four groups: poorly controlled DM, DI, an CKD grade 3 and PPD. One-way analysis of variance compared 24HBD and LUTSS questionnaires. Pearson correlation examined LUTSS and bother with 24-h voided volume (24 HVV), maximum voided volume (MVV) and total voids. RESULTS: Among 814 patients who completed a 24HBD, 176 had polyuria (22%). Of the patients with complete data, 7.8% had poorly-controlled DM, 3.1% had DI, 4.7% had CKD grade 3% and 84.4% had PPD. Amongst the four different sub-groups, significant differences were seen in 24 HVV (p < 0.001), nocturnal urine volume (NUV) (p < 0.001), MVV (p = 0.003), daytime voids (p = 0.05), nocturnal polyuria index (NPi) (p < 0.001) and nocturia index (Ni) (p = 0.002). Significance was also seen between LUTSS and bother subscore (r = 0.68, p < 0.001), LUTSS and total voids (r = 0.29, p = 0.001) and bother sub-score and total voids (r = 0.21, p = 0.019). CONCLUSIONS: 22% of patients with LUTS were found to have polyuria based on a 24HBD. Within this cohort, four sub-populations were identified as being demonstrating statistically significant differences in 24 HVV, NUV, MVV, daytime voids, NPi and Ni. Identifying the underlying etiology of polyuria should be carried out to safely treat patients with LUTS.

The role of renal circadian biorhythms in lifelong LUTS.

INTRODUCTION: This article delves into the intricate relationship between kidney function, diuresis, and lower urinary tract symptoms (LUTS) throughout the transitions of the human lifespan. It explores circadian regulation of urine production, maturation of renal function from birth to adulthood, and effects of aging on kidney function and LUTS. The complex connections between these factors are highlighted, offering insights into potential interventions and personalized management strategies. METHODS: An international panel of seven experts engaged in online discussions, focusing on kidney function, diuresis, and LUTS throughout life. This manuscript summarizes expert insights, literature reviews, and findings presented during a webinar and subsequent discussions. RESULTS: Renal function undergoes significant maturation from birth to adulthood, with changes in glomerular filtration rate, diuresis, and tubular function. A circadian rhythm in urine production is established during childhood. Adolescents and young adults can experience persistent enuresis due to lifestyle factors, comorbidities, and complex physiological changes. In older adults, age-related alterations in kidney function disrupt the circadian rhythm of diuresis, contributing to nocturnal polyuria and LUTS. CONCLUSION: The interplay between kidney function, diuresis, and LUTS is crucial in understanding lifelong urinary health. Bridging the gap between pediatric and adult care is essential to address enuresis in adolescents and young adults effectively. For older adults, recognizing the impact of aging on renal function and fluid balance is vital in managing nocturia. This holistic approach provides a foundation for developing innovative interventions and personalized treatments to enhance quality of life for individuals with LUTS across all stages of life.

Sleep Disorders, Comorbidities, Actions, Lower Urinary Tract Dysfunction, and Medications ("Sleep C.A.L.M.") in the evaluation and management of nocturia: A simple approach to a complex diagnosis.

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.

Home Blood Pressure Monitoring And Nocturia In Adults.

Although widely viewed as a urological condition, nocturia has been increasingly recognized to accompany various non-urological conditions such as hypertension and blood pressure (BP) elevation on office determination. Home BP monitoring (HBPM) has been shown superior to office-based readings and provides an opportunity to assess potential relationships between nocturia and novel indices derived from multiple BP recordings including BP load, BP variability, and arterial stiffness, which have prognostic significance. We retrospectively studied 103 home BP logs and nocturia frequencies provided by 61 stable cardiology patients ≥ 21 years without medication change. Nocturnal voids ranged from 0 to 5 voids per night, median: 1.5. Nocturia frequency was significantly correlated with home and office systolic BPs and with BP load, but not with diastolic BPs, BP variability or arterial stiffness. On Poisson regression analysis, the estimated prevalence ratio (PR) for home and office systolic BPs were 1.025 (CI: 1.01, 1.04; p < .001) and 1.01 (CI:1.00, 1.02; p = .019), indicating 2.5% and 1% increases in the risk of nocturia per mmHg increases in BP respectively. In conclusion, higher mean home and office systolic BPs are associated with self-reported nocturia frequency with stronger associations seen for home BP measurement. Nocturia frequency appears unrelated to mean home and office diastolic BPs. Nocturia may be related to BP load, (percentage of elevated BP values), but not to BP variability or arterial stiffness. Future prospective studies using HBPM are needed to confirm these findings and to contribute to the understanding of the elevated BP-nocturia link.

Association between pregnancy and nocturia: A National Health and Nutrition Examination Survey analysis.

AIMS: This study aimed to determine the impact of pregnancy and pregnancy-associated characteristics on nocturia. METHODS: Using the National Health and Nutrition Examination Survey (NHANES) database from 2005/06 to 2017/18, we analyzed women who completed the "Reproductive Health" and "Kidney Conditions-Urology" questionnaires by sorting them into three groups: nulligravida, previously pregnant (nonpregnant with prior pregnancies), and currently pregnant. After excluding patients with pre-existing conditions impacting nocturia or with incomplete data, we weighed and matched the groups for age, race, BMI, and number of pregnancies. The relationships of nocturia to pregnancy in all groups and pregnancy-associated characteristics (gestational diabetes mellitus [GDM], history of multiple pregnancies, and trimesters of pregnancy) in currently pregnant women were assessed. RESULTS: Of 8330 women that indicated pregnancy status, 1544 women (age range: 20-44 years; 523 nulligravida, 498 previously pregnant, 523 currently pregnant women) were included in analysis. Currently, pregnant women had a higher prevalence of nocturia than previously pregnant and nulligravida women (56.4% vs. 22.5% vs. 16.1%, p < 0.001) and had the highest odds of nocturia (OR: 6.82, p < 0.001). GDM or history of multiple pregnancies showed no associations in currently pregnant women. Increasing trimesters were associated with nocturia, with the third trimester showing the highest odds (OR: 10.35, p < 0.001) and a greater average of nighttime voids than the first and second trimesters (2.40 ± 1.42 vs. 1.56 ± 1.31 and 1.88 ± 1.32, p < 0.001). CONCLUSIONS: The association noted between pregnancy and nocturia, which strengthened with increasing trimesters, demonstrates that nocturia can significantly impact quality of life and therefore must be addressed during pregnancy.

Nocturia severely impairs the sleep quality of nursing home residents: results from a multi-center study.

OBJECTIVES: To assess the association between self-reported sleep quality and nocturia in nursing home residents. METHODS: The association between self-reported poor sleep quality and nocturia was examined in eighty nursing home residents from two nursing facilities using logistic regression analysis. RESULTS: Poor sleep quality was reported by 29% of the eighty participants (median age 89±7 years, 77% of women). Nocturia was more frequent in patients with versus without self-reported poor sleep quality (78% vs 47%, p=0.01). Nocturia was independently associated with self-reported poor sleep quality after controlling for age, gender, self-rated health status, cognitive frailty score, antidepressant and hypnosedative use (OR[95%CI] of 6.1[1.8-25.4]). CONCLUSION: Nocturia severely impaired sleep quality in nursing home residents. Nocturia should be investigated in nursing home residents to optimize sleep quality.

Phenotyping the Association between Nocturia and Hypertension: A Systematic Review and Meta-Analysis.

PURPOSE: The association between nocturia and hypertension has been widely reported yet remains poorly characterized, precluding a more refined understanding of blood pressure as it relates to the clinical urology setting. We synthesized current evidence on the relationship between nocturia and hypertension as a function of nocturia severity, age, gender, race, body mass index and diuretic use. MATERIALS AND METHODS: We searched PubMed®, EMBASE® and Cochrane databases for studies published up to May 2020. Random effects meta-analyses were performed to identify pooled odds ratios for nocturia given the presence of hypertension. Meta-regression and subgroup analyses were performed to identify differences across study samples. RESULTS: Of 1,193 identified studies, 25 met the criteria for inclusion. The overall pooled OR for the association of nocturia with hypertension was 1.25 (95% CI 1.21-1.28, p <0.001). Pooled estimates were 1.20 (1.16-1.25, p <0.001) and 1.30 (1.25-1.36, p <0.001) using a 1-void and 2-void cutoff for nocturia, respectively (p <0.001 between cutoffs). The association was more robust in patient-based (1.74 [1.54-1.98], p <0.001) vs community-based (1.24 [1.24-1.29], p <0.001) study samples (p <0.001). The association was stronger in females compared to males (1.45 [1.32-1.58] vs 1.28 [1.22-1.35], p <0.001), and Black (1.56 [1.25-1.94]) and Asian (1.28 [1.23-1.33]) vs White subgroups (1.16 [1.08-1.24]; p <0.05 for both). No effect was observed for age or body mass index. Evidence on diuretics was limited. CONCLUSIONS: Hypertension is associated with a 1.2-fold to 1.3-fold higher risk of nocturia. This association is more robust at a higher nocturia cutoff, in patient-based study samples, among females and in Black and Asian patients, but unrelated to age or body mass index.

Does traditional pharmacotherapy augment behavioral modification in the treatment of nocturia?

AIMS: To assess the efficacy of traditional first-line non-antidiuretic pharmacotherapy for nocturia in the real-world outpatient urology setting. METHODS: We retrospectively analyzed voiding diaries from adult men treated for lower urinary tract symptoms (LUTS) at an outpatient urology clinic to identify pairs of voiding diaries with ≥1 nocturnal void at baseline and a corresponding follow-up diary completed within 1 year. We compared the odds of nocturia improvement (decrease of ≥1 nocturnal void) in patients started on LUTS pharmacotherapy versus behavioral modification alone. RESULTS: Two hundred and thirteen diary pairs from 93 patients were included. Fifty-seven diary pairs were identified from patients prescribed at least one LUTS drug on the initial visit and 156 diary pairs were identified from patients receiving behavioral modification alone. All standard voiding diary parameters were assessed, and only maximum voided volume differed at baseline (240 ml [interquartile range: 200-330 ml] vs. 280 ml [200-400 ml] with and without pharmacotherapy, respectively, p = 0.04). The odds of nocturia improvement did not significantly differ between pharmacotherapy and behavioral modification treatment groups (crude odds ratio [OR]: 1.16 [95% confidence interval: 0.63-2.16], p = 0.63; maximum voided volume [MVV]-adjusted OR: 1.19 [0.63-2.22], p = 0.59). In contrast, improvement in 24-h urinary frequency was more likely with pharmacotherapy versus behavioral modification alone (crude OR: 2.36 [1.22-4.56], p = 0.01; MVV-adjusted OR: 2.05 [1.05-4.01], p = 0.04). Results were consistent on subgroup analyses restricted to first diary pairs from each patient. CONCLUSION: Despite improvement in 24-h voiding frequency, there was no evidence that adjunctive pharmacotherapy provided a benefit in the treatment of nocturia in men receiving behavioral counseling.

First voided volume: A novel approach to characterize nocturia.

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.

Nocturia and electrocardiographic abnormalities among patients at an inner-city cardiology clinic.

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.

Nocturia through the menopausal transition and beyond: a narrative review.

INTRODUCTION AND HYPOTHESIS: Nocturia, defined as the act of waking to pass urine during sleeping, is a common problem in older women and is associated with significant morbidity and impairments in health-related quality of life. The aim of this review was to synthesize the current evidence regarding the incidence, impact, pathophysiology, and specific diagnostic approach of nocturia in the postmenopausal population. METHODS: We searched PubMed and Web of Science databases to identify relevant studies published through June 2020. Reference lists of the reviews obtained were screened for other articles deemed pertinent by the authors. RESULTS: Genitourinary symptoms attributed to the menopause have been reported to occur in nearly 90% of postmenopausal women, and nocturia is one of the most common. The relative deficiency in endogenous estrogen production after the menopause is thought to exacerbate all major pathophysiological mechanisms that may underlie nocturia, including reduced bladder capacity, nocturnal polyuria, global polyuria, and sleep disorders. Diminished estrogen may induce anatomical and physiological bladder changes, contributing to a reduction in functional bladder capacity. Excess nocturnal urine production can also be provoked by estrogen depletion, either via free water-predominant diuresis by an impaired secretion of antidiuretic hormone, or a salt-predominant diuresis owing to diminished activation of the renin-angiotensin-aldosterone axis. Additionally, a relationship between the transition to menopause and impaired sleep has been described, mediated by increased incidence in vasomotor symptoms and obstructive sleep apnea signs during the menopause. CONCLUSION: Further research is necessary to better characterize and manage nocturia in postmenopausal women.

Determinants of neoadjuvant chemotherapy for urothelial muscle-invasive bladder cancer: Does location matter?

INTRODUCTION: Bladder cancer care has been increasingly concentrated in high-volume metropolitan medical centres (ie, "regionalisation" of care). We aimed to assess the potential role of geographic factors, including facility region and distance to treatment centre, as determinants of neoadjuvant chemotherapy (NAC) delivery in patients with non-metastatic urothelial muscle-invasive bladder cancer (MIBC) using nationally representative data from the United States. METHODS: We queried the National Cancer Database to identify patients with cT2-cT4a, N0M0 urothelial MIBC who underwent radical cystectomy (RC) from 2006 to 2015. Patients who received radiation therapy, single-agent chemotherapy, adjuvant chemotherapy or systemic therapies other than multi-agent chemotherapy were excluded. Multivariate logistic regression analysis was performed to identify independent predictors of receiving NAC. RESULTS: A total of 5986 patients met the criteria for inclusion, of whom 1788 (29.9%) received NAC and 4108 received RC alone. Younger age, increased Charlson-Deyo score, increased cT stage, increased annual income, increased distance from cancer treatment centre, treatment at an Academic Research Program or Integrated Network Cancer Program and a later year of diagnosis were independently predictive of NAC receipt. Older age, Medicare insurance and treatment in the East South Central or West South Central regions were independently associated with decreased odds of NAC receipt. CONCLUSIONS: Distance to treatment centre and United States geographic region were found to affect the likelihood of NAC receipt independently of other established predictors of success in this quality-of-care metric. Access to transportation and related resources merits consideration as additional pertinent social determinants of health in bladder cancer care.

Assessing the role of race in pathological upstaging of renal cell carcinoma: Results from the National Cancer Database.

PURPOSE: Pathologic upstaging in renal cell carcinoma (RCC) is common and confers a significant risk of poor surgical and survival outcomes. Preoperative predictors of upstaging are of great clinical relevance but empirical evidence specific to racial minorities remains scarce. METHODS: National Cancer Database (NCDB) analysis of T3a-specific upstaging among White, African-American, Hispanic and Asian Pacific Islander (API) patients with AJCC cT1N0M0 RCC who underwent partial or radical nephrectomy between 2010 and 2015. Independent preoperative predictors of tumour upstaging were identified using multivariate logistic regression analyses. RESULTS: A total of 81 002 patients met the criteria for inclusion (5.6% T3a-specific upstaging). Increased age, increased Charlson-Deyo comorbidity index, clinical stages cT1b and unspecified cT1, and increased Fuhrman nuclear grade were identified as independent risk factors for upstaging. Independent protective factors for upstaging were younger age, female sex, African-American race and papillary, chromophobe, and unspecified RCC histologic subtypes. Significant risk factors and protective factors within individual racial subgroups were highly consistent with those observed in the overall study sample. All independent factors identified on race-specific subgroup analyses were significant in the same direction relative to the overall study sample. Variables found to be non-significant in the overall study sample remained non-significant across all racial subgroup analyses. CONCLUSION: The present study of nationally representative data found no clinically significant differences in upstaging risk across individual racial subgroups relative to the overall study sample. Preoperative factors that can be used to predict pT3a-specific tumour upstaging in CT1N0M0 RCC likely persist across different racial groups.

Nocturia is Associated with High Atherosclerotic Cardiovascular Disease Risk in Women: Results from the National Health and Nutrition Examination Survey.

Growing evidence has identified nocturia as a potential manifestation of several cardiovascular disease states. We aimed to determine whether a relationship exists between nocturia and global atherosclerotic cardiovascular disease (ASCVD) risk, defined by the American College of Cardiology/American Heart Association (ACC/AHA) ASCVD risk calculator, using a large nationally-representative study sample from the United States. We explored potential associations between nocturia and ASCVD risk in adults aged 40-79 years with no prior history of overt/known atherosclerotic disease from 7 consecutive cycles of the National Health and Nutrition Examination Survey. Subjects were classified by whether they met the ASCVD high-risk threshold following current ACC/AHA consensus guidelines (10-year major adverse cardiovascular event risk ≥ 20%). Logistic regression analyses were used to explore associations between nocturia (defined as ≥ 2 nocturnal voids) and ASCVD risk. The prevalence of nocturia and high ASCVD risk were 27.0% and 10.9%, respectively. Nocturia, older age, increased body mass index, and diuretic use were associated with high ASCVD risk on univariate logistic regression. After adjusting for age, body mass index, and diuretic use, nocturia remained associated with significantly greater odds of high ASCVD risk in females but not in males. Elicitation of nocturia on clinical history taking may serve to identify high cardiovascular risk in females. Future studies are needed to elucidate mechanisms underlying this association.