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Nocturia: Current Levels of Evidence and Recommendations From the International Consultation on Male Lower Urinary Tract Symptoms.

By S.D. Marshall, D. Raskolnikov, M.H. Blanker, H. Hashim, V. Kupelian, K.A. Tikkinen, K. Yoshimura, M.J. Drake, and J.P. Weiss

Urology, 14 April 2015, Article in Press

Editorial comment
The International Consultation on Urologic Diseases (ICUD) partnered with the Societé International d’Urologie to convene a consultation on male lower urinary tract symptoms (LUTS), with the aim of using established criteria to assign objective levels of evidence (LOEs, 1 through 4) and grades of recommendation (GORs) based on the actual knowledge regarding several aspects of nocturia (epidemiology, pathophysiology, clinical presentations, diagnosis and treatment).

Particularly important are the levels of evidence and grades of recommendation provided by the ICUD on the treatment of nocturia. These are summarized below for the reader’s practical use.

Conservative management of nocturia: The ICUD committee considers that lifestyle changes, such as reducing intake of caffeine and alcohol, limiting night-time fluid intake, and improving sleep hygiene, are effective methods that help reduce nocturnal urine volume and episodes of nocturia (GOR C).

Conservative pharmacological treatment of nocturia: The ICUD committee considers that alpha-adrenergic antagonists may be offered to men with nocturia in association with LUTS and Benign Prostatic Enlargement (BPE) (GOR A). In this pathologic condition, alpha-adrenergic antagonists can also be offered in conjunction with 5-ARIs (GOR A), antimuscarinic drugs (GOR A) and, finally, PDE5 inhibitors (GOR C). What appears very important is the consideration whether nocturia is due to OAB: the ICUD committee states that antimuscarinics can be offered to men with OAB-related and severe OAB-related nocturnal micturitions if appropriate counseling with regard to potential adverse effects is ensured (GOR A). Conversely, these drugs should not be offered to men with nocturnal polyuria and no urinary urgency symptoms (GOR B).

With regard to desmopressin, the ICUD considers that this agent can be prescribed to decrease nocturnal diuresis and night-time frequency in men (GOR A). Considering the risk of hyponatremia, serum sodium measurement to exclude low sodium levels is essential before starting desmopressin, particularly in patients aged more than 65 years (GOR A). In addition, men with NP may benefit from diuretic therapy with furosemide, given 6 hours before sleep (LOE 2; GOR B).

Other pharmacological agents: Botulinum A toxin. The ICUD committee considers that botulinum toxin can reduce the number of nocturnal micturitions in patients who fail oral medical therapy and who are not surgical candidates (LOE 3). Loxoprofen sodium. It may reduce nocturia for up to 3 months but should not be continued long term because of potential adverse effects (LOE 3). Celecoxib. It may reduce nocturia in men with BPE (LOE 3) but should not be taken long term because of potential adverse effects.

Phytotherapy: The ICUD committee considers that Serenoa repens (saw palmetto) does not reduce the number of nocturnal micturitions compared with placebo (LOE 1). P. africanum (African plum tree) and Cernilton (rye pollen) reduce the number of nocturnal voids when compared to placebo. Thus, this combination treatment can be offered to patients affected by nocturia (GOR A).

Surgical treatment of nocturia: Bladder outlet obstruction (BOO)-reducing procedures may improve nocturia in some cases with voiding LUTS and BOO refractory to medical therapy and who are good surgical candidates (GOR C). Surgical intervention for BPE-BOO is not indicated for management of patients whose primary complaint is nocturia (GOR C).

ABSTRACT

Objective
To evaluate published evidence on nocturia in men and derive expert recommendations.

Methods
The International Consultations on Urological Diseases–Société Internationale d'Urologie convened a Consultation of experts on male lower urinary tract symptoms. The Consultation assigned standardized levels of evidence and grades of recommendation to various studies of nocturia epidemiology, pathophysiology, assessment, and treatment.

Results
Evidence review and consensus recommendations were made in the areas of epidemiology, pathophysiology, assessment, and treatment.

Conclusion
The review presents a condensed summary of the International Consultations on Urological Diseases–Société Internationale d'Urologie evaluation of nocturia, which offers contemporaneous expert consensus on this topic, with an assessment algorithm emphasizing the potential contribution of systemic conditions to the symptom.