Optimizing the Diagnosis and Management of Nocturia

I don't know how many of you have heard me speak before but I usually begin with a magic trick or a statistic that will shock you and get your immediate attention but today I want to start with a story a story not too long ago when I checked into a hotel in Dallas Texas a young man 18 to 20 years of age takes my bags brings them up to the room puts them on the edge of the bed and I reached into my pocket to give the man a tip and I only had 32 cents and change.i says wait a minute I've got a great idea let me unzip my suitcase I happen to have a copy of my new book impotence it's reversible now you did not need to draw a serum testosterone level on this man to understand that he hardly needed the services of my book he looks at the back of the book and he sees who the authors are doctors Wilson and Baum he says they're you dr. Baum or dr. Wilson I said I am dr. Baum and he says well dr. Baum if it's okay with you he says I'll just take the 32 cents now I hope to be able to give you a little more than 32 cents worth of useful information about the relationship between nocturia and Falls and fractures I also have to make a disclosure you know when you give one of these talks you're supposed to disclose what companies you work for who who you have spoken for what scratchpad you've received what you have received from the pharmaceutical industry so I have to make a disclosure I did not write this book the book was written by dr. Wilson but I did create the title and it's the title that made it the New York Times bestseller Falls and fractures are a huge problem one in four people over the age of 65 are going to fall I'm one of those I'm that I'm that person on the right end edge of that slide I have noticed my difficulties with balance as I've gotten older and I recognize that I'm at risk and guess what so are our patients who are at risk there are over 29 million people will fall each year over the age of 65 30 thousand deaths each year from Falls and fraction from Falls and fractures and less than 50% of patients are going to discuss this with their physician I have never had a patient come in to me and say I'm having nocturia I'm at risk for Falls and fractures they don't say it we have to elicit that that is our responsibility so where do we as urologists fit into this scenario of Falls and fractures there are so many comorbid conditions that we treat on a regular daily basis that are causing nocturia the lower urinary tract symptoms are very common in men over the age of 50 urge incontinence in women is a risk for fall and fractures and the studies show that the greater the frequency of Nigeria the greater the risk for Falls and fractures and nocturia not urea is the leading factor for nighttime Falls and fractures and we have an opportunity to impact that and to change that and so my purpose of this presentation is not to teach you how to treat Nigeria but to call to your attention this relationship and what we as urologist can do to change that there are so many medications medications that we prescribe that can result in orthostatic hypotension and can result in Nigeria putting them at risk for Falls and fractures so what's the urologist involvement what can we do first we've got to recognize it then we need to treat lower urinary tract symptoms we need to recognize what comorbid conditions and we have if there are comorbid conditions we have to report that to the primary care physician to the orthopedist if it's a mobility problem to the physical therapists even the pharmacist needs to be aware of this relationship also patients who have osteoporosis osteopenia are at risk for a fracture if they fall we have a responsibility because we are treating patients with kidney stones to watch what we do in terms of dietary management to give them make sure that they are if appropriate on calcium and vitamin D patients who have vision problems a very simple example and I recognize this myself I had bifocal glasses and I noticed that when I would take a step or go up a step or down with the bifocal glasses there was distortion and a change in perception and so it is recommended that patients who are at risk for Falls and fractures particularly when it's not involving reading that they use single focus distance lenses also we need to make sure that they have barrier free access to the restroom or if not they can use a urinal a lot of this can be done by your medical assistants your nurse practitioners and your physician's assistants I'm not suggesting that the urologist who is so overwhelmed now with the amount of patients we have to see in the contracture of time that we can't do this but people in our practice can do this so what can the urologist do in regarding screening for Falls and fractures well one if they've had a history of previous Falls then we need to make sure that we are taking care of their urologic problems so they aren't having so much nocturia patients who are agitated patients who are wearing bifocal lenses or are visually impaired patients who have transfer mobility Walker's canes are going to be at risk when they have urgency in the night the urologic approach to knock teary eye train 1972 to 76 in the 1970s the management of nocturia and then was we are the only diagnosis we had in the 1970s was BPH and the treatment was the TU RP we were told at that time to avoid the use of anticholinergics in patients with BPH we were told at that time you remember we were told don't give testosterone to patients with prostate cancer it's like putting a gasoline on the fire and the same thing we were told in the 1970s never give pace with BPH or obstruction an anticholinergic because you'll throw them into retention well that's change now we don't we don't have that admonition and the urologist in terms of Nigeria now today it's more whole lot more than BPH these are just the majority of the classifications of the drugs in 2009 the conditions in 2019 that are associated with Nigeria that we see on a regular basis again the list is quite extensive and if you're just a if you are a clinical urologist on any given day you are seeing men and women you can estimate that nearly half of the patients that you see on a regular basis have a problem of nocturia and we can do something about it so what are the goals of therapy I have these in the reverse ordered so first we have to relieve any outlet obstruction now we have the possibility of increasing the bladder capacity and third I'll talk for one slide on we have the capacity of the ability of decreasing urine production so for looking at lower urinary tract symptoms we need to look for the low-hanging fruit and the low-hanging fruit is looking at the medications that our patients are on that are contributing to Nigeria we can advise them to restrict their fluids we can treat these other conditions that I talked about in the previous two slides we can give them medications for overactive bladder if we have ruled out bladder outlet obstruction and then we can easily evaluate in a single visit a patient for outlet obstruction and treat them first with medications which we're all familiar and now we have the ability to use minimally invasive therapy for the management of the enlarged prostate there's two kinds of polyuria the one which is the global polyuria we don't see very we seldom see or not responsible for treating but the one that we do see most of the time is nocturnal polyuria and so what can we do simple thing you know make sure the you know patients who is on lasix or a diuretic takes it early in the day rather than late in the day if they have congestive heart failure diabetes we can refer them we can encourage them to decrease their fluid intake I haven't found that to be very successful nor have I found it to be very successful to encourage men to decrease their alcohol intake but sleep hygiene is a simple thing my wife and I are constantly arguing about the temperature in the room and that seems to be kind of pervasive but particularly in older men and older women women like it 72 I would prefer it 68 and that is a big difference to me and I am much more comfortable you know at 68 and sleep better than when it is at 70 to encourage patients who have venous stasis though where the stockings can make sure that their primary care physician is knowledgeable about that also obstructive sleep apnea I had a patient who was telling me that he was you know getting up you know six eight times at night going you know to the bathroom and I asked him how he slept and did he snore he didn't he wasn't aware of his snoring but his wife was and shared that they had to have separate bedrooms because of the snoring referred him to a sleep lab or he had a sleep study he had six to eight APNIC episodes an hour and he was hypoxic during this time he was at risk you know for stroke and heart disease he had got a CPAP mask and he said his whole life turned around less nocturia more energy in the during the day improvement in his libido and sex life and he significantly he wasn't aware of this reduced his risk for heart disease and a stroke so we need to look at but you can't ask the patient do you snore there they're not they're not aware of it you have to ask the partner let's look at overactive bladder and detrusor overactivity anti muscarinic s-- i think we are all aware that we have to be careful about the use of oxybutynin in in the elderly i have taught the patients aren't aware of it but the caregivers will tell you that there's cognitive impairment in older people who are taking oxybutynin so i think although that's you know the least expensive and the pharmaceutical the insurance companies will mandate to you you must try this before you try second and third-tier anticholinergic s-- i think you have to put your foot down and say this is contraindicated in this 75 year old lady or man b3 at nergic agonist near metric and now we have the capacity with the desmopressin to decrease urine production and mechanism of action is that it absorbs water from the collecting duct and it is at risk for hyponatremia the incidence of hyponatremia is very low too two to three percent let me ask dr. Kara do you check the serum sodium on patients that you put on routinely do okay so that that's a good caveat even though it's very low incidence you should check the serum sodium our program director said in the a you a consensus statement he said consideration of newer formulation these are the ADH drugs when contraindications to ADH is eliminated and other interventions are not optimal and so there is a role for ADH for treating of not not your nasal sprays and and tablets so in summary we see patients who are at risk for Falls and fractures because of nocturia every single day third there are 30,000 deaths annually as a result of Falls and fractures usually the problem is multifactorial there are multiple comorbid conditions in the elderly that contribute to nocturia we have to identify those and we have to ask the patients you know about their comorbid conditions and make sure that they receive proper follow-up bottom line we need to identify the risk for Falls and fractures and bring those risks attention to the referring doctors and their care and their caregivers and we need to help them find ways to prevent Falls and fractures so my final bottom line is let's as a urology take a stand on Falls let's step up to the plate let's recognize the risk of this and let's not just put this into the Bally wick of the primary care physician the orthopedic physician we have a role in this and we can't improve on this if we are aware of it you