Nocturia, reducing

The initial symptoms of hypervitaminosis D include weakness, fatigue, lassitude, headache, nausea, vomiting, and diarrhea. Renal function can be impaired at an early stage, with polyuria, polydipsia, nocturia, reduced urinary concentrating ability, and proteinuria. 

Hypoperfusion of skeletal muscles leads to fatigue, weakness, and exercise intolerance. Decreased perfusion of the central nervous system (CNS) is related to confusion, hallucinations, insomnia, and lethargy. Peripheral vasoconstriction due to SNS activity causes pallor, cool extremities, and cyanosis of the digits. Tachycardia is also common in these patients and may reflect increased SNS activity. Patients will often exhibit polyuria and nocturia. Polyuria is a result of increased release of natriuretic peptides caused by volume overload. Nocturia occurs due to increased renal perfusion as a consequence of reduced SNS renal vasoconstrictive effects at night. In chronic severe HF, unintentional weight loss can occur which leads to a syndrome of cardiac cachexia. This results from several factors, including loss of appetite, malabsorption due to gastrointestinal edema, elevated metabolic rate, and elevated levels of proinflammatory cytokines. 

To reduce nocturia, patients should be instructed to stop drinking fluids several hours before going to bed, and then voiding before going to sleep. During the day, patients should avoid excessive caffeine intake, as this may cause urinary frequency. In addition, toilet mapping (knowing the location of toilets on the way to and from various destinations) may help reassure the patient that he can still continue with many of his routine daily activities. 

P. africanum improved specific urinary symptoms and flow measures. In six double-blind trials involving 430 participants, men receiving P. africanum were more than twice as likely to be rated by their physician as having overall improvement in symptoms compared with men taking placebo. P. africanum reduced nocturia compared with placebo. P. africanum also increased peak urine flow compared with placebo. Additionally, P. africanum reduced residual urine volume. 

Wilt, T. et al. A recent meta-analysis of randomized controlled studies of using Serenoa to treat BPH was recently published in the Journal of the American Medical Association. The article concluded that patients and physicians rated saw palmetto as superior to the placebo and comparable to Proscar. Serenoa reduced nocturia by 25 percent compared to the placebo and ranked equally with Proscar at improving peak and mean urine flow rates and reducing residual urine. Side effects were comparable to the placebo and did not show the high erectile dysfunction rates associated with the use of Proscar. 

Pharmacological studies have shown that bark extracts inhibit prostaglandin synthesis in prostatic tissue, reduce cholesterol and reduce oedema due to inflammation in addition to effects on growth factors involved in the pathogenesis of BPH. Numerous clinical trials have demonstrated benefits in patients with BPH. Prostate size was reduced, as were residual urine volume and the number of episodes of nocturia. A review of clinical data from over 2,000 patients published over a 25-year period showed that P. africana bark was an effective drug for the treatment of the symptoms of mild to moderate BPH. Reported side-effects were low. 

The 5-alpha-reductase inhibitors work by reducing the size of the prostate gland, resulting in a relief of the obstructive symptoms of urgency, frequency, difficulty initiating a urine stream, and nocturia. 

Renal effects of hypercalcemia include reduced glomerular filtration rate (GFR), polyuria, nephrocalcinosis, and renal stone disease. Hypercalcemia causes renal vasoconstriction which may contribute to decreased GFR. The hypercalcemia-induced polyuria results from 1) an impairment of active transport of NaCl in the loop of Henle, distal tubule and collecting duct and 2) an inhibition of vasopressin-facilitated absorption of water in the distal nephron. As a direct result of the polyuria, many side effects including polydipsia, thirst, nocturia and dehydration are common. Precipitation of calcium salts within the kidney leads to chronic inflammatory reactions (nephrocalcinosis), fibrosis, renal impairment, nephrolithiasis and urolithiasis. Further renal damage may occur indirectly from hypertension. 

In an editorial review, it was stated that addition of furosemide to desmopressin in elderly patients to reduce nocturia led to incidence of hyponatraemia in 4% out of 82 study patients [16]. Similarly, in a retrospective study, use of low-dose continuous furosemide infusion in 150 patients with acute HF developed hyponatraemia in 38%, hypokalemia in 25% and hypomagensemia in 15% of patients [12]. The EIDOS and DoTS descriptions of electrolyte disturbances due to loop diuretics, thiazide and thiazide-like diuretics have been described in previously [SEDA-35, 389]. 

Wein AJ. Re reducing nocturia in the elderly a randomized placebo-controUed trial of staggered furosemide and desmopressin. J Urol 2012 188(4) 1232-3. 

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