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TURP Has Limited Effect on Nocturia

By Professor Philip van Kerrebroeck

TURP (transurethral resection of the prostate) is commonly performed in men with nocturia on the basis that their nocturia is presumed to be due to bladder outlet obstruction resulting from benign prostatic hyperplasia. This presumption is perhaps not 

surprising given that nocturia, along with other voiding or storage symptoms, is considered one of the global LUTS (lower urinary tract symptoms) and is indeed common in men with benign prostatic hyperplasia.1

However, TURP (or any other form of prostate surgery) is often not an effective therapy for nocturia. For example, in a study that included assessment of the degree of improvement in nocturia after treatment for benign prostatic hyperplasia, Yoshimura et al.2 found that of 138 patients who underwent TURP, 118 had nocturia (defined by a score of 2 or more on question 7 of the International Prostate Symptom Score) before treatment. Three months after treatment, 91 reported still having nocturia. The rate of improvement in nocturia was less than 20%, and nocturia was the LUTS least improved by TURP. Rates of improvement in other LUTS ranged from 37% (for urgency) to 63% (for a weak stream). These authors commented that “the association between BPH and nocturia is controversial”.

Clearly, we need to re-evaluate the idea that bladder outlet obstruction, commonly due to benign prostatic hyperplasia, is a primary cause of nocturia.

Causes of nocturia have been prospectively examined in a study of 41 men “bothered” by nocturia: that is, as defined in this study, needing to void twice or more per night.3 According to 3-day frequency-volume charts, the average frequency of voiding by these men during the study was 3.9 per night, and 34 (83%) of them had nocturnal polyuria (as defined in this study by a night-time urine volume more than 35% of the total daily volume of urine). Compared with men who did not have nocturnal polyuria, those with nocturnal polyuria had almost double the frequency of night-time voiding (4.2 versus 2.4). Men with nocturnal polyuria also differed from those without (and from controls) in having a significantly higher urinary excretion of sodium and lower urine osmolality at night than during the day. In total, causes of nocturia were identified as one or more of nocturnal polyuria, small nocturnal bladder capacity, bladder output obstruction, and sleep apnoea syndrome. But nocturnal polyuria was by far the most common cause of nocturia, and these authors called for “detailed workup … to elucidate all causes”.

No wonder, then, that TURP is so often ineffective as a treatment for nocturia. Yoong et al.4 have suggested that patients with benign prostatic hyperplasia and nocturia should undergo work-up to identify and treat underlying conditions that contribute to their nocturia. The list is long and includes diabetes, primary polydipsia, hypercalcaemia, daytime fluid retention, venous insufficiency, hypoalbuminaemia, diuretic therapy, congestive heart failure, renal disease, neurological dysfunction, and sleep apnoea. TURP should no longer be considered a primary treatment for nocturia without first identifying the true cause of the nocturia.

References

1. Tikkinen KAO, Auvinen A, Johnson TM, et al. A systematic evaluation of factors associated with nocturia--the population-based FINNO study. Am J Epidemiol. 2009;170(3):361-368.

2. Yoshimura K, Ohara H, Ichioka K, et al. Nocturia and benign prostatic hyperplasia. Urology. 2003;61(4):786-790.

3. Chang S-C, Lin ATL, Chen K-K, Chang LS. Multifactorial nature of male nocturia. Urology. 2006;67(3):541-544.

4. Yoong HF, Sundaram MB, Aida Z. Prevalence of nocturnal polyuria in patients with benign prostatic hyperplasia. Med J Malaysia. 2005;60(3):294-296.

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Lecture from the ICS

6th - 9th October 2015

ICS 2015: Nocturia Plenary Satellite Symposium, Montreal, Canada

Program Chair: Philip E. V. Kerrebroeck

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