Why do you keep waking up to pee at night, even when you drink less water?
The phenomenon, known as nocturia, becomes more common with age. But cutting back on water before bed may not solve the problem. Urologists explain what nocturia is, why your body may produce more urine at night and why wearing compression socks may help.
Nocturia affects men and women at similar rates. (Photo: iStock/Pony Wang)
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Sleep can be so easily interrupted the older you get. Too hot, too cold, a loud thump from the upstairs neighbour… that’s all it takes to rouse you from an already-light doze. Then, as you get even older, your bladder joins the brigade to really make sure you roll out of bed a few times a night – all for a lousy trickle, not the torrential stream you’d expected from what feels like a bursting bladder.
So, you make sure your last stop before bed is the bathroom – even going as far as not drinking water past 8pm. You pass on the kimchi at dinner and night cap before bed to cut down on salt and alcohol – diuretics that cause your body to increase urine production. But you’re still getting up at least once a night to visit the loo. What is going on?
DO YOU HAVE A CONDITION IF YOU WAKE UP AT LEAST ONCE A NIGHT TO PEE?
Yes, and it is known as nocturia. “Nocturia is defined as waking from sleep one or more times during the night to pass urine, with each void preceded and followed by sleep,” said Dr Yong Jin, a consultant from Singapore General Hospital’s Department of Urology.
By strict definition, said urologist Dr Lee Yee Mun from Nexus Surgical, “any number of voiding episodes (yes, even just once) would qualify as nocturia if it occurs during the main sleep period”.
Nocturia affects men and women at similar rates, according to a Finnish study involving 6,000 subjects aged 18 to 79 years old. But as you age, some disparity can be seen between the genders; nocturia strikes more women under age 50 when it is often linked with urinary tract infections and pregnancy. Over the age of 50, nocturia incidence shifts more towards men, owing to benign prostatic hyperplasia or age-related prostate enlargement.
Nocturia is different from daytime urinary frequency, according to Cleveland Clinic. “While they can happen together, nocturia is uniquely tied to disrupted sleep and can be driven by nighttime-specific fluid shifts or overproduction rather than just bladder control issues.”
Having daytime urinary frequency does not mean you will definitely have nocturia. However, both conditions can share similar causes, said the urologists. “Some individuals could have both daytime frequency and nocturia due to underlying bladder conditions such as an overactive bladder,” said Dr Yong. Or high urine production that leads to frequent loo visits day and night.
WHY DOES DRINKING LESS WATER AT NIGHT NOT SEEM TO HELP?
“Nocturia is rarely caused by too much drinking in the evening alone, and thus, generic tips like drinking less water at night often disappoint,” said Dr Lee.
The more specific reason is “up to 80 per cent of nocturia patients have excessive night-time urine production known as nocturnal polyuria”, he continued. Nocturnal polyuria is when your body produces more than a third of its total 24-hour urine output during the night.
Your pituitary gland, located at the base of your brain, produces an antidiuretic hormone (ADH) that instructs your kidneys to go easy on the urine production while you are asleep, according to The British Association of Urological Surgeons.
When you are young, your ADH levels limit your nightly urine production to just a fifth of your total 24-hour urine output. But as you age, your ADH levels naturally fall and that, in turn, ups your nightly urine production from a fifth to about a third of your total daily urine output.
You are better off, according to Dr Lee, by spacing out the “timing, amount, and content of fluid intake throughout the whole day”.
DOES IT MEAN YOU HAVE A LAX OR LOOSE BLADDER?
“The idea of a ‘loose bladder’ is a common misconception,” said Dr Yong. “It is more accurate to say that patients with an ‘overactive bladder’ would experience symptoms of frequent toilet visits.”
Would strengthening exercises such as pelvic floor exercises help? They may somewhat help in urgency control, said Dr Yong. But exercises’ role in an “overactive bladder” is otherwise very limited. “Pelvic floor exercises are also unlikely to help if the main problem is excessive night-time urine production,” he said.
WHAT OTHER CAUSES ARE THERE?
Other than nocturnal polyuria and an overactive bladder, nocturia in individuals in their 40s and 50s, said Dr Lee, is usually caused by one or more of the following:
- Lifestyle-related metabolic conditions such as obesity, hypertension and diabetes.
- Obstructive sleep apnoea (OSA) is strongly associated with nocturia; half of OSA patients experience it.
- Behavioural factors such as smoking and alcohol as well as mental factors, including insomnia and anxiety.
In older people in their 60s and 70s, said Dr Yong, “the picture is often more complex”. Causes in aged patients can include any of the above conditions that affect younger adults, plus any of the following:
- A reduced bladder capacity and age-related bladder changes.
- In men, the enlargement of the prostate gland.
- Producing larger volumes of urine at night due to a disrupted circadian rhythm, which normally suppresses urine production during sleep.
- Medical conditions such as heart failure, diabetes and chronic kidney disease.
DO YOU HAVE TO PUT UP WITH NIGHTLY LOO VISITS FOR THE REST OF YOUR LIFE?
“Nocturia is a complex problem that usually cannot be solved just by a single lifestyle intervention,” said Dr Yong. “The key takeaway is that nocturia is often not simply a bladder problem. It can result from changes in urine production, sleep patterns, circulation or underlying medical conditions.”
To get to the cause, Dr Lee said that patients are often asked to track their drinking and voiding patterns over a three-day period known as the three-day bladder diary. “If done diligently, the information gathered may help the doctor elucidate the underlying mechanism(s), which then guides intervention.”
Here’s a look at what can be done to curb those disruptive nightly toilet visits:
- Cut down on caffeine and alcohol – and wear compression socks
For one, don’t pour yourself coffee, tea, wine or beer, particularly in the evening, advised Dr Yong, as these are diuretics that stimulate your kidneys to make more urine.
It’s also a good idea to wear compression socks or keep your legs elevated in the late afternoon. Fluid tends to pool in the legs from a whole day of sitting or standing, explained Dr Lee. Then, when you lay down at night to sleep, this pooled fluid re-enters the blood circulation, which then stimulates the kidneys to excrete the excess as urine.
- Get your snoring treated
Not all who snore have OSA but it is a good idea to see a doctor to rule that out. “During episodes of OSA, changes in pressure within the chest and heart can trigger the body to produce more urine at night,” explained Dr Yong.
“Identifying and treating OSA, for example with weight loss, positional therapy or continuous positive airway pressure (CPAP), is often necessary to achieve a sustained improvement in nocturia symptoms,” he said.
- Time your diuretics or “water pills”
Patients who have had heart failure are often medicated with diuretics. These medicines make the kidneys push extra fluid into the urine, which helps the heart to work easier since a weak heart cannot pump blood well.
“Patients who require diuretics may benefit from timing the dose,” said Dr Lee. For example, take the diuretic in the late afternoon instead of night, so that “peak urine production occurs before bedtime rather than during sleep hours”.
- Manage stress and anxiety
While Dr Yong noted that psychological factors such as stress, anxiety and insomnia can contribute, “they are rarely the sole cause” of nocturia. “Anxiety, stress and insomnia may make people more aware of bladder sensations. In some cases, individuals wake up because of poor sleep and then decide to urinate because they are already awake.”
ARE THERE MEDICATIONS FOR NOCTURIA?
“There are several classes of medications which can improve nocturia,” said Dr Lee. “But they should be prescribed only for the appropriate causes, and after careful assessment by a qualified healthcare professional.” Here’s a look:
For nocturnal polyuria: Desmopressin increases the kidneys’ ability to reabsorb water to reduce nocturnal urine volume, explained Dr Lee. “It has significant side effects, including the potentially dangerous side effect of hyponatraemia or low sodium levels in the blood.”
For reduced bladder capacity or overactive bladder: Antimuscarinics and beta-3 agonists are useful, said Dr Lee. “As antimuscarinics risk affecting cognitive function as a side effect in the elderly, beta-3 agonists are preferred for this group.”
For benign prostate enlargement in men: Alpha-blockers and 5-alpha reductase inhibitors are commonly used, said Dr Lee. Alpha-blockers relax the muscles in the prostate and the neck of the bladder to let urine flow freely without shrinking the enlarged prostate itself.
Meanwhile, 5-alpha reductase inhibitors block the enzyme that turns testosterone into dihydrotestosterone (DHT). Lower DHT shrinks the enlarged prostate, which eases physical pressure on the urethra and improves urine flow.
CAN NOCTURIA MEAN KIDNEY FAILURE OR CANCER?
Occasional nocturia is common and often benign, said Dr Yong. “However, get yourself checked if it occurs frequently and disrupts sleep.” Similarly, see a doctor if it develops suddenly and without an obvious explanation, he said. Here are other signs to make an appointment with your doctor, advised Dr Yong:
- You have other lower urinary tract symptoms such as urinary urgency, frequency, incontinence, poor urinary flow or recurrent urinary tract infections.
- You experience leg swelling and/or breathlessness.
- You have excessive thirst, weight loss or poorly controlled diabetes.
- You have difficulty passing urine or experience incomplete emptying.
Dr Lee highlighted that urological cancers may have to be considered if nocturia is accompanied by visible blood in the urine, even if it resolves after one episode.
“Nocturia can also be an early sign of kidney failure as it may be a manifestation of the kidney’s inability to concentrate urine at night,” said Dr Lee. “Foamy urine, unexplained leg swelling, marked fatigue, or unintentional weight loss are other signs that suggest kidney failure, particularly in someone with diabetes, hypertension, or known kidney disease.”
Source: CNA/bk
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