Thinking beyond the bladder: antidiuretic treatment of nocturia P. van Kerrebroeck, 1 H. Hashim, 2 T.Holm-Larsen, 3 D. Robinson, 4 N. Stanley 5 Introduction Is nocturia worth worrying about? Isn’t it just a normal part of ageing? And something which affects elderly men and can routinely be treated with prostate therapy? These are just some of the common beliefs and mis- conceptions which surround the area of nocturia. The aim of this article is to address these issues and provide an overview of the latest data on the aetiology of noct- uria in men and women, assess its real impact on patients, and review best practice approaches to the use of antidiuretic therapy in nocturia. What is nocturia? Nocturia is defined by the International Continence Society as ‘the complaint that the individual has to wake at night one or more times to void… each void is preceded and followed by sleep’ (1). While indi- viduals who experience one void per night are there- fore considered to have nocturia, it is generally accepted that most patients find the condition both- ersome when they experience two or more voids per night (2,3). Nocturia was traditionally believed to be a symp- tom of some other primary disorder, or just one of many lower urinary tract symptoms (LUTS) (1). The therapy and research area lacked clear delineation of the problem, standardisation of terminology and of definitions, and understanding of the significance of the condition for patients’ day-to-day lives. How- ever, in recent years, nocturia has begun to be recog- nised as a clinical entity in its own right, deserving of more than cursory evaluation and treatment. Stan- dardisation within the field has emerged, helping to establish greater clarity in diagnosis and allow com- parison across studies. Nocturia is now recognised as a condition that affects a large proportion of the adult population, and which may have several causes (see Table 1). Broadly speaking, these may be related to hormonal imbalances, uncompensated heart ABSTRACT Nocturia is a bothersome and highly prevalent urological condition characterised by the need to wake to void at night. Contrary to popular misconception, nocturia is equally common in men and women, and although its prevalence increases with age, a significant proportion of younger people are also affected. Nocturia leads to repeated fragmentation of sleep and consequently to a serious decline in daytime functioning and in overall quality of life and health. As such, its impact should not be underestimated by clinicians. Traditionally, nocturia has been regarded as a symptom of benign prostatic enlargement and / or overactive bladder syndrome, with treatment therefore directed towards increasing the capacity of the bladder to hold urine. Such treatments have proven largely ineffective in many patients, likely because nocturnal polyuria (NP), a condition that results in overproduction of urine at night, has been found to be present in the majority of nocturia patients. As such, the traditional belief that nocturia is attributable to some other underlying pathological factors, is now being replaced by the acknowledgment that it can be a distinct clinical entity with specific pathogenesis. Frequency-volume charts are an invaluable tool, recommended for routine use in clinical practice, to determine whether nocturia is a result of excessive urine production at night, or of small voided volumes (indicating bladder storage problems), or indeed a combination of these factors. Given the specific antidiuretic action of desmopressin, a synthetic analogue of the body’s own antidiuretic hormone, it should be considered as first- line therapy for patients with nocturia where NP is present. Review Criteria The information gathered is based on the scientific literature in peer-reviewed journals and also on consensus documents, especially the 4th International Consultation on Incontinence. Message for the Clinic Nocturia is a prevalent condition in men and women, with a major impact upon the quality of life of patients (and partners) because of chronic sleep fragmentation. Its multifactorial nature renders determination of individual aetiology complex, but voiding charts have proven invaluable in identifying major contributory factors in each patient and making rational treatment choices. Nocturnal polyuria is present in most patients and antidiuretic therapy is therefore an important tool. 1 University of Maastricht, Maastricht, The Netherlands 2 Bristol Urological Institute, Bristol, UK 3 Ferring Pharmaceuticals A / S, Copenhagen, Denmark 4 King’s College Hospital, London, UK 5 Clinical Research and Trials Unit, University of East Anglia, Norwich, UK Correspondence to: Philip E. V. van Kerrebroeck, MD, PhD, MMSc, Fellow EBU Department of Urology, Maastricht University Medical Center, PO Box 5800, NL-6202 AZ Maastricht, The Netherlands Tel.: + 31 43 3877258 Fax: + 31 43 3875259 Email: p.vankerrebroeck@mumc.nl Disclosures Philip van Kerrebroeck has acted as a speaker and member of an Advisory Safety Board for Ferring Pharmaceuticals. Hashim Hashim has been a speaker for Ferring Pharmaceuticals. Neil Stanley has received honoraria for speaking and / or advisory board work from Ferring Pharmaceuticals, Pfizer and GlaxoSmithKline. Tove Holm- Larsen is an employee of Ferring Pharmaceuticals. Dudley Robinson has acted as a speaker and consultant to Ferring, Astellas, Recordati, Novo Nordisk, Uroplasty and Gynaecare. He has been an investigator with Ferring, Astellas, Allergan and Pfizer. Linked Comment: Chapple and Mangera. Int J Clin Pract 2010; 64: 666–7. REVIEW ARTICLE ª 2010 Blackwell Publishing Ltd Int J Clin Pract, May 2010, 64, 6, 807–816 doi: 10.1111/j.1742-1241.2010.02336.x 807