Getting up at night to pee is a problem that keeps many people awake. Frequent urination at night, called nocturia or nycturia in medical terms, is a phenomenon that increases with age, but it also occurs at a younger age. Both men and women can suffer from it. At a young age, women suffer more from it, in old age, men are more affected.

Between the age of 35 and 50, about 10 percent of men and 16 percent of women would suffer from the condition. Over the age of 60-70, more than half of both men and women would suffer from nycturia to a greater or lesser extent.

When is peeing at night a problem?

Getting up once a night is usually not a problem. However, from two or more toilet visits per night, the quality of sleep can be affected.

Studies on sleep problems show that nocturia is one of the main causes of disturbed sleep.

It could also potentially increase the risk of cardiovascular disease.

Nycturia also increases the increased risk of falls or other accidents, especially in the elderly.

Sometimes you might pee because you woke up. Then we do not speak of nocturnal urination or nycturia. Nycturia is when you wake up because you have to pee.

Causes of frequent urination at night

Many people associate nocturia with old age. It is true that the chance of nocturnal urination increases sharply with age. Due to several structural and functional changes in the lower urinary tract as we age, functional bladder capacity (the maximum urinated volume per urination) decreases, and older people have to urinate more often, but less per urination.

However, old age is not the only or main cause of nycturia. There are many other factors that are alone or together at the basis of repeated nocturnal urination, and which are not always or exclusively a result of the aging process, and often do not even directly affect the urinary tract.

Some of these underlying problems can also be dealt with. Thus that nightly urination is not an inevitable age phenomenon with which one has to learn to live.

Overproduction of urine during the night (nocturnal polyuria)

In about 7 to 8 in 10 people with nocturia, frequent night urination is mainly due to increased urine production during the night. Normally, our kidneys produce 1 to 2 liters of urine per day, of which about 25 percent during the night. But some people produce too much urine during the night (more than 25 percent of daily urine production).

The amount of urine produced at night can be measured using a so-called ‘urine calendar’. In it, you keep track of how often you have to urinate and what volume is urinated at a time. If this volume exceeds 20-35 percent of the 24-hour production, we talk of nocturnal overproduction of urine or nocturnal polyuria.

Sometimes not only is there nocturnal polyuria but also too much urine is produced during the day, where you also have to urinate too much during the day (more than 3 liters per day or more than 40 ml of urine per kg of body weight per day). This is called global or 24-hour polyuria.

Polyuria can have several causes. They can also occur together.

• Drinking and eating too much before bedtime.
• Excessive drinking (polydipsia) due to an underlying condition, such as diseases of the pineal gland (pituitary gland), kidneys, or compulsive drinking in some psychiatric patients.
• Reduced production of the antidiuretic hormone vasopressin (ADH) causes less urine to be produced at night.

In healthy individuals, vasopressin levels increase during the night, resulting in less urine production and less need to urinate. In many older people, vasopressin levels do not increase sufficiently at night due to a disturbance of the normal day-night rhythm (circadian rhythm). The result is excessive urine production and the need to get up at night to urinate.

Even with increased blood pressure (hypertension), the production of ADH may be disturbed and increase night urine production.

Impaired renal function

With age, the kidney reacts less efficiently to the antidiuretic hormone ADH, causing too much urine to be produced. Usually, there are other hormonal disorders that can play a role, such as the renin-angiotensin-aldosterone system (RAAS), which retains less water, and the atrial natriuretic peptide (ANP). Some kidney diseases can also lead to too much urine being produced at night.

Conditions associated with fluid accumulation (edema formation)

In various conditions associated with fluid accumulation in the lower limbs, more fluid can enter the bloodstream when lying down. This indirectly causes the kidneys to extract more fluid from the blood and produce more urine. This can occur in conditions such as congestive heart failure, nephrotic syndrome (a kidney abnormality that causes too much protein to enter the urine), liver failure, and venous insufficiency (e.g. varicose veins).

Also in wheelchair patients, fluid accumulation in the legs can lead to nocturnal polyuria.

Obstructive sleep apnea

Obstructive sleep apnea can sometimes also be the basis of nocturnal polyuria. With each period of apnea, the pressure in the breast increases, causing (as with fluid accumulation) increased urine production.

Diabetes insipidus

Diabetes insipidus is a rare condition caused by the partial or total absence of the antidiuretic hormone (ADH). Despite the name, this has nothing to do with diabetes or diabetes mellitus.

Diabetes (diabetes mellitus)

With poorly controlled diabetes mellitus, too much sugar may enter the urine (glucosuria), which can cause excessive thirst and excessive production of urine. Usually, there is overproduction of urine during the day and you also have to urinate often during the day.

Neurological disorders

Some neurological disorders such as Parkinson’s disease, Multiple Sclerosis, stroke (CVA), can be accompanied by nocturnal polyuria.

Medicines

Some medicines, such as urinary pills (diuretics) and calcium boosters used in high blood pressure, and selective serotonin reuptake inhibitors (SSRIs) used in depression can cause excessive urine production and give rise to polyuria. Especially if they are taken before bedtime in the evening.

Hormonal treatment with estrogens after menopause could also potentially provoke or worsen nycturia.

Reduced bladder capacity

Normally, an adult’s bladder can store between 200 and 500 ml of urine. During the night, a bladder can normally store up to 30 percent more urine than during the day. If the functional bladder capacity (the largest volume of urine that can be urinated at one urination) drops below 300 ml, nighttime urination complaints can occur, among other things.

Limited nocturnal functional bladder capacity can have various causes.

Overactive bladder

With an overactive bladder, the bladder becomes irritable. The bladder tightens even when it is not full at all. So, the bladder feels fuller than it really is. Your brain also gets a signal that you need to pee even though that is not really the case. The result is that you have to urinate more often. Often there is no obvious cause.

An overactive bladder is sometimes a result of damage to a part of the nervous system, because of, for example, a stroke, Multiple Sclerosis, Parkinson’s disease, a hernia, tumors, spina bifida, etc…

Benign prostate enlargement (Benign Prostate Hyperplasia)

With a benign prostate enlargement, the urethra can become narrower. Because the bladder muscle has to work harder to squeeze the urine out through the narrowed urethra, the bladder wall becomes weaker and sometimes becomes stretched. This can lead to you having to urinate more often, even at night.

A prolapse of the bladder or uterus

In women, nocturnal urination can be caused by a weakening of the pelvic floor muscles, which is often accompanied by a prolapse of the bladder and/or uterus.

Urinary tract infection

A urinary tract infection can be accompanied by frequent urination of small amounts and a strong urge to urinate, even at night.

Bladder pain syndrome (interstitial cystitis)

Bladder pain syndrome is a chronic form of bladder inflammation that is accompanied by a feeling of a full bladder and frequent urination.

Urinary stones (Lithiasis)

Urinary stones can be accompanied by frequent urination, especially with stones in the urethra.

Overweight and obesity

There is a clear relationship between nycturia and obesity (BMI = 30). However, the underlying mechanism is not entirely known. It may have to do with increased pressure on the urinary tract. But it could also be that obesity increases the risk of apnea and sleep problems, and therefore indirectly increases the risk of nightly urination.

Psychological problems

Nocturnal urination can be related to psychological problems, such as sleep problems or stress. Sometimes it can also be a result of depression.

When to consult a doctor?

Many people still think that nycturia is a normal age phenomenon with which they have to learn to live. Younger people who suffer from nycturia, especially women, often put themselves down too easily because they think there is little to be done about it.

In many cases, nycturia is caused or encouraged by an underlying problem that can often be treated, which can also solve or reduce the urination problem. Therefore, it is advisable to always consult your DOCTOR if you often have to get up at night to urinate.

Diagnosis of nocturia?

1. The doctor will ask you extensively about your complaints, whether and what medicines you are taking possible other health problems.
2. You will probably have to keep a pee diary for a few days, in which you record how much you drink and how often and how much you pee per 24 hours. The nocturnal produced urine is determined by adding the volume of the urinations after bedtime to the volume of the first puddle after getting up. If this volume exceeds 20-35 percent of the 24-hour production, doctors talk of nocturnal overproduction of urine or nocturnal polyuria.
3. The physical examination serves, among other things, to check how strong your pelvic floor muscles are and whether they work properly, in men a rectal toucher can be done to estimate the size of the prostate…
4. A urine test, among other things to detect a possible bladder infection or urinary tract infection.
5. A blood test serves, among other things, to determine kidney function, to check whether you may have diabetes or hormonal disorders.
6. Sometimes more specialized examinations are needed when your GP suspects some underlying condition (e.g., bladder examination, prostate problem, nerve disorder, sleep apnea, diabetes, etc.). You will probably be referred to a specialist, for example, a urinary tract specialist (urologist), gynecologist, a specialist in glandular diseases (endocrinologist), a nerve specialist (neurologist), cardiac specialist (cardiologist), kidney specialist (nephrologist).

What can you do yourself?

• Drink enough during the day (1.5 to 2 l). Limit drinking in the hours before bedtime, and certainly alcohol and caffeine-rich beverages.
• Digestion stimulates urine production. So, it’s best not to eat (too much) before bed. It can also help not to eat too spicy dishes in the evening.
• If you suffer from swollen legs, it can help to wear support stockings and rest during the day with your legs a little up on a pillow. Also, put your legs up in the evening.
• Before bedtime, take a pee and make sure your bladder is emptied as well as possible.
• If you are obese, it can help to lose a few pounds.
• If you are less able to walk and need to get up at night to urinate, it may be useful to have a toilet bowl by the bed to prevent falls.

How can nocturnal urination be treated?

The treatment depends on the cause.

• If there is an underlying condition, it must first be treated. For example, a urinary tract infection can be treated with medication. If you suffer from diabetes adjustments to your treatment may be needed. In the case of sleep apnea, this should be treated in the first place. The same applies to heart or kidney problems.
• If you need to take medicines that may provoke or worsen urination at night, they will be examined to determine whether they can be replaced. Or that you can take them at a different time (for example, in the afternoon instead of in the evening).
• Bladder training and pelvic floor muscle exercises: when it is clear that the nycturia is largely caused by a bladder problem, for example, an overactive bladder or urinary incontinence, then bladder training and pelvic floor muscle exercises can help. The aim of bladder training is to correct incorrect urination behavior, to counteract the urge more strongly, and to increase the bladder capacity. The bladder can be trained by delaying urination, urinating at fixed times (and therefore not waiting for you to feel pressure), and increasing the intervals each time. The aim of the exercises is to strengthen and better control the pelvic floor muscles and sphincter of the bladder. It is best to be accompanied by a physiotherapist specialized in pelvic floor reconstruction.
• Medicines: If a bladder problem is at the root of night urination, and bladder training and/or pelvic floor exercises do not help sufficiently, the doctor can also prescribe medication. Drug treatments for nycturia focus on increasing (nocturnal) bladder capacity and/or reducing night urine production. Because the cause of nycturia is usually multifactorial, the effects of drug treatment are often quite limited.
• Anticholinergics or antimuscarinics (such as darifenacin, fesoterodine, oxybutynin, propiverine, solifenacin, and tolterodine) make it less easy for the bladder to contract on its own, allowing you to keep your pee longer. Side effects often occur, such as the dry mouth and, in the elderly, impaired cognitive functioning and confusion. Therefore, it is not recommended in the elderly. Should confusion occur, the anticholinergic should be discontinued in any case. If no improvement occurs after six weeks, treatment is best discontinued.
• Alpha-blockers (Alfuzosin, silodosin, tamsulosin terazosin) are used in a (benign) prostate enlargement. International guidelines also recommend alpha-blocker treatment in case of complaints of an overactive bladder. Studies show that treatment of nycturia with alpha-blockers has only a very limited effect.
• Desmopressin: this drug – a synthetic analog of the antidiuretic hormone vasopressin (ADH) – supplements deficiencies of the antidiuretic hormone and reduces night urine production. It is used in case of nocturnal overproduction of urine (nocturnal polyuria). A dangerous side effect of desmopressin is hyponatremia (a deficiency of sodium in the blood) due to water retention. Symptoms of this can include headache, nausea, abdominal pain, swelling of arms and legs, dizziness to coma. For this reason, it is important that desmopressin is taken just before bedtime and that the patient does not drink again here and after. In addition, the sodium content in the blood must be checked regularly.
• Local (vaginal) use of estrogen may help against urinary incontinence in women.
• Surgery: in case of serious complaints and if other treatments have an insufficient effect, surgical intervention may be considered in case of prostate enlargement in men or if the symptoms are mainly due to an overactive bladder or urge incontinence. However, all of these options lack studies that have examined the specific effect on nycturia. Prostate enlargement involves, on the one hand, the TURP (transurethral resection of the prostate) and, on the other hand, open prostatectomy.
• In case of complaints of an overactive bladder, neuromodulation (sacral nerve stimulation and percutaneous tibial neurostimulation) and botulinum injection are possible.