ADULT UROLOGY

NOCTURIA AND BENIGN PROSTATIC HYPERPLASIA

KOJI YOSHIMURA, HIROKI OHARA, KENTARO ICHIOKA, NAOKI TERADA, YOSHIYUKI MATSUI,
AKITO TERAI, AND YOICHI ARAI

ABSTRACT
Objectives. To examine the frequency of and risk factors for nocturia in patients with symptomatic benign
prostatic hyperplasia (BPH), and the degree of improvement of nocturia after treatment for BPH.
Methods. A total of 505 consecutively selected, newly diagnosed patients with symptomatic BPH were
evaluated in studies examining frequency of and risk factors for nocturia. We analyzed the relationships
between nocturia assessed by International Prostate Symptom Score (IPSS) and other parameters, including
age, prostate volume, serum prostate-specific antigen level, and uroflow variables. Other studies examining
the impact of conservative and invasive treatments on nocturia were also conducted using 165 patients
receiving tamsulosin and 138 undergoing transurethral resection of the prostate (TURP).
Results. Overall, 359 of the 505 patients (71.1%) answered that they arose at least twice for urination at
night. Patient age, score of urgency, and functional bladder capacity were each significantly associated with
nocturia. Tamsulosin therapy and TURP significantly reduced the number of episodes of nocturia in 17.9%
and 32.2% of patients, respectively. These rates of improvement were lowest for nocturia among the seven
individual symptom scores.
Conclusions. In this study using selected cohorts, the frequency of nocturia in patients with BPH was higher
than that in community-based studies. Although we cannot estimate patients’ satisfaction by the observed
changes in scores, the rates of improvement were lowest for nocturia among the seven symptoms of IPSS
after conservative and invasive treatments for BPH. UROLOGY 61: 786–790, 2003. © 2003, Elsevier
Science Inc.

B enign prostatic hyperplasia (BPH) can cause

bladder outlet obstruction and induce second-
ary bladder overactivity and reduction of func-
tional bladder capacity, which may result in filling
symptoms including nocturia. Therefore, urolo-
gists often treat patients whose chief symptom is
nocturia with modalities for BPH, including con-
servative medical treatment and surgical interven-
tion. However, it appears that there are many other
factors associated with nocturia, including patho-
logic conditions such as cardiovascular disease and
diabetes mellitus, anxiety and primary sleep disor-
ders, and behavioral and environmental factors.1
Nocturnal polyuria has become a major concern in
the diagnosis and treatment of nocturia.1 Blanker et
al.2 reported that nocturia is strongly associated
From the Department of Urology, Kurashiki Central Hospital,
Kurashiki, Okayama, Japan; and Tohoku University School of
Medicine, Tohoku, Japan
Reprint requests: Koji Yoshimura, M.D., Kurashiki Central
Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710, Japan
Submitted: July 22, 2002, accepted (with revisions): November
8, 2002
with BPH and noctural polyuria, but Homma et al.3
concluded that nocturia is the least specific symp-
tom associated with BPH and is least sensitive to
treatment for BPH.
In this study we elucidate the frequency of and
risk factors for nocturia in patients with BPH and
also examine the degree of improvement of noctu-
ria by conservative and interventional treatment
for BPH.
PATIENTS AND METHODS
STUDY OF FREQUENCY AND ASSOCIATED FACTORS
Our study included 505 consecutive patients
who consulted our clinic for lower urinary tract
symptoms (LUTS) potentially due to BPH, be-
tween January 1997 and December 2001. Patients
eligible for inclusion in this study (newly diag-
nosed group) were free of urothelial malignancy,
lower urinary tract lithiasis, evident urinary tract
infection, and evident neurogenic bladder; had
complete baseline data regarding LUTS, symptom-
specific quality of life (QOL), and uroflow vari-

© 2003, ELSEVIER SCIENCE INC. 0090-4295/03/$30.00

786 ALL RIGHTS RESERVED doi:10.1016/S0090-4295(02)02444-5
ables; and had a prostate with a volume larger than
20 cm3 as estimated by transabdominal ultra-
sonography. Patients ranged in age from 42 to 93
years. LUTS and symptom-specific QOL were as-
sessed using the International Prostate Symptom
Score (IPSS) and IPSS QOL score,4 and uroflow
variables included peak urinary flow rate (Qmax),
voiding volume (VV), and postvoid residual
(PVR). Data obtained on the day of the first visit to
our clinic were used in this study.
Patients were screened before the operation with
digital rectal examination and measurement of
prostate-specific antigen (PSA). Patients with sus-
picion of prostate cancer underwent systematic
needle biopsies of the prostate before inclusion in
the study. Prostate volume was estimated by trans-
abdominal ultrasound using the formula: ␲/6 ⫻
(transverse dimension)2 ⫻ (anteroposterior di-
mension). Although this formula was presented by
Terris and Stamey5 as one for volume estimation
using transrectal ultrasound, we applied it in a
comparable manner. PVR was measured by cathe-
terization.
Nocturia was assessed using the score for the
seventh question of the IPSS. A score of 2 or more
on this question was considered indicative of “noc-
turia.” We examined the frequency of nocturia in
this patient population, and the association be-
tween nocturia and other variables, including age,
other individual scores on the IPSS, IPSS QOL
score, and uroflow data.
STUDY OF IMPACT OF TREATMENT ON NOCTURIA
Of the 505 patients in group 1, 353 initially un-
derwent administration of tamsulosin (0.2 mg/
day), which is a selective alpha1a-adrenoreceptor
blocker. The remaining 152 patients were treated
with naftopidil (n ⫽ 28), other medicines includ-
ing Oriental medicine (n ⫽ 33), or watchful wait-
ing (n ⫽ 91). Of the 353 patients undergoing tam-
sulosin therapy, 165 were assessed with IPSS at 2
weeks to 6 months after initiation of treatment
(median 41 days). Most of the remaining patients
without IPSS assessment after treatment received
short-term administration of tamsulosin due to
lack of desire for longer tamsulosin therapy or de-
sire to receive tamsulosin from their local physi-
cians. In a comparison of the 165 patients assessed
after treatment and the remaining 188 patients
without assessment after treatment, there were no
significant differences in baseline data, including
age, PSA level, prostate volume, uroflow variables,
total IPSS score, nocturia score, and QOL score
(data not shown). Although these 165 patients
were a subset of the newly diagnosed group and
subject to selection bias, their data were used for
analysis of the impact of conservative treatment on
nocturia (tamsulosin group).
UROLOGY 61 (4), 2003
From January 1996 to December 2001, 188 pa-
tients underwent transurethral resection of the
prostate (TURP) at our clinic. Of these, 138 were
free of other factors causing LUTS and were as-
sessed entirely by preoperative IPSS, uroflow-
metry, transrectal ultrasonography, and PSA level,
as well as postoperative IPSS and uroflowmetry.
Postoperative data were obtained 3 months after
TURP. The data for these 138 patients were used
for analysis of the impact of invasive treatment on
nocturia (TURP group).
For comparison between nocturia and six other
symptoms, the frequency rates of patients who had
scores of 2 or more for each of the other six symp-
toms were calculated.
STATISTICS
For the study of frequency and associated fac-
tors, we used a logistic regression model and the
unpaired t test. For the study of impact of treat-
ment on nocturia, we used paired and unpaired t
tests. P ⬍ 0.05 was considered statistically signifi-
cant.
RESULTS
Patient characteristics and baseline data in the
three groups are summarized in Table I. Not sur-
prisingly, the distributions of age, uroflow vari-
ables, PSA level, IPSS total score, and scores for
individual symptoms differed among the three
groups. Although the tamsulosin group was a sub-
set of the newly diagnosed group, patients in the
former tended to have higher symptom scores than
those in the latter on the basis of selection bias.
Furthermore, those in the TURP group were older
and had higher symptom scores than those in the
tamuslosin group.
FREQUENCY OF NOCTURIA IN PATIENTS WITH BPH
Of the 505 patients in group 1, 359 (71.1%) com-
plained of two or more episodes of nocturnal uri-
nation.
ASSOCIATION OF NOCTURIA WITH OTHER FACTORS
Of the variables analyzed, age, Qmax, VV, PVR,
PSA, prostate volume, and scores for urgency and
voiding frequency were each significantly associ-
ated with nocturia as determined by univariate
analysis (Table II). On multivariate analysis, pa-
tient age, score for urgency, and VV continued to
exhibit statistically significant associations with
nocturia. Thus, a patient with BPH who is 69 years
or older, has a score of 3 or more for urgency, and
has less than 150 mL of functional bladder capac-
ity, is 15.2 times more likely to experience nocturia
than a patient who is 68 years or younger, has a
787
 TABLE I. Patient characteristics
P Values
Newly Newly
Newly Diagnosed Tamsulosin Diagnosed
Diagnosed Tamsulosin TURP versus versus versus
(n ⴝ 505) (n ⴝ 165) (n ⴝ 138) Tamsulosin TURP TURP
Age (yr) 67.6 ⫾ 9.3 68.3 ⫾ 7.9 71.1 ⫾ 7.5 0.3444 0.0018 ⬍0.0001
Qmax (mL/s) 9.7 ⫾ 5.7 8.8 ⫾ 4.9 7.1 ⫾ 4.6 0.0664 0.0027 ⬍0.0001
VV (cm3) 178.0 ⫾ 124.4 159.0 ⫾ 104.7 123.1 ⫾ 99.3 0.0781 0.0026 ⬍0.0001
PVR (cm3) 48.8 ⫾ 93.6 59.4 ⫾ 96.2 151.8 ⫾ 198.4 0.2120 ⬍0.0001 ⬍0.0001
PSA (ng/mL) 2.7 ⫾ 2.7 2.9 ⫾ 2.8 6.9 ⫾ 19.2 0.3591 0.0079 0.0009
Prostate volume (cm3) 42.7 ⫾ 19.3 44.5 ⫾ 18.3 53.9 ⫾ 24.4 0.3021 ⬍0.0001 0.0002
IPSS 15.2 ⫾ 6.8 17.1 ⫾ 6.7 20.1 ⫾ 7.9 0.0022 0.0004 ⬍0.0001
Emptying 2.0 ⫾ 1.6 2.1 ⫾ 1.7 2.8 ⫾ 1.7 0.3004 0.0013 ⬍0.0001
Voiding frequency 2.5 ⫾ 1.5 2.7 ⫾ 1.5 2.9 ⫾ 1.5 0.0814 0.2252 0.0021
Intermittency 1.8 ⫾ 1.6 2.2 ⫾ 1.7 2.7 ⫾ 1.7 0.0028 0.0094 ⬍0.0001
Urgency 2.1 ⫾ 1.6 2.4 ⫾ 1.7 2.8 ⫾ 1.7 0.0129 0.0509 ⬍0.0001
Weak stream 3.0 ⫾ 1.6 3.3 ⫾ 1.5 3.5 ⫾ 1.5 0.0451 0.2119 0.0011
Hesitancy 1.5 ⫾ 1.6 1.7 ⫾ 1.6 2.4 ⫾ 1.8 0.1468 0.0013 ⬍0.0001
Nocturia 2.3 ⫾ 1.3 2.5 ⫾ 1.3 3.0 ⫾ 1.4 0.1119 0.0048 ⬍0.0001
QOL 4.2 ⫾ 1.2 4.5 ⫾ 1.1 4.8 ⫾ 1.3 0.0838 0.0194 ⬍0.0001
KEY: TURP ⫽ transurethral resection of the prostate; VV ⫽ voiding volume; PVR ⫽ postvoid residual; PSA ⫽ prostate-specific antigen; IPSS ⫽ International Prostate Symptom
Score; QOL ⫽ quality of life.
Tamsulosin group was a subset of the newly diagnosed group, which received tamsulosin and had follow-up data.

TABLE II. Associations between nocturia and variables

Multivariate
Without With
Nocturia Nocturia Univariate (Hazard
Categories (n ⴝ 146) (n ⴝ 359) (P Value) Ratio) (P Value)
Age (yr) 68ⱖ vs. 69ⱕ 61.8 ⫾ 9.3 69.9 ⫾ 8.1 ⬍0.0001 3.292 ⬍0.0001
Qmax (mL/s) 8.8ⱖ vs. 8.9ⱕ 11.9 ⫾ 6.2 8.7 ⫾ 5.1 ⬍0.0001 1.667 0.0547
VV (cm3) 149ⱖ vs. 150ⱕ 240.3 ⫾ 142.7 152.5 ⫾ 106.2 ⬍0.0001 1.681 0.0491
PVR (cm3) 18ⱖ vs. 19ⱕ 33.1 ⫾ 77.2 55.1 ⫾ 99.0 0.0020 1.161 0.5257
PSA (ng/mL) 1.700ⱖ vs. 1.701ⱕ 2.3 ⫾ 2.6 2.8 ⫾ 2.8 0.0157 1.110 0.7074
Prostate volume (cm3) 38.4ⱖ vs. 38.5ⱕ 40.4 ⫾ 20.6 43.6 ⫾ 18.7 0.0339 1.165 0.5505
Emptying 2ⱖ vs. 3ⱕ 1.9 ⫾ 1.5 2.0 ⫾ 1.7 0.0981 1.079 0.7834
Voiding frequency 2ⱖ vs. 3ⱕ 2.0 ⫾ 1.5 2.7 ⫾ 1.5 0.0004 1.461 0.1306
Intermittency 2ⱖ vs. 3ⱕ 1.6 ⫾ 1.6 1.8 ⫾ 1.6 0.0774 1.084 0.7942
Urgency 2ⱖ vs. 3ⱕ 1.4 ⫾ 1.3 2.4 ⫾ 1.6 ⬍0.0001 2.737 0.0010
Weak stream 2ⱖ vs. 3ⱕ 3.0 ⫾ 1.5 3.1 ⫾ 1.6 0.6624 1.266 0.3742
Hesitancy 2ⱖ vs. 3ⱕ 1.5 ⫾ 1.5 1.6 ⫾ 1.6 0.4174 1.062 0.8511
KEY: VV ⫽ voiding volume; PVR ⫽ postvoid residual; PSA ⫽ prostate-specific antigen.

score of 0 to 2 for urgency, and has at least 150 mL
of functional bladder capacity.
IMPACT OF TAMSULOSIN THERAPY ON NOCTURIA
Of the 165 patients in the tamsulosin group, 130
had nocturia before tamsulosin therapy (Table III).
After treatment, 107 patients reported nocturia, in-
dicating a 13.9% reduction rate. This rate was,
however, lowest among those of the seven individ-
ual symptom scores. The average point reduction
was 0.5 for nocturia, and this was lowest as well.
The paired t test revealed that improvement in
score for nocturia was significantly inferior to
those in scores for weak stream, voiding frequency,
and emptying.
Of this cohort of 165 patients, 73 (44.2%) re-
ported at least a 1-point reduction in score for noc-
turia after tamsulosin therapy. Between these 73
patients and the remaining 92, baseline data dif-
fered significantly in score for nocturia (P
⬍ 0.0001, 3.3 versus 1.9), PVR (P ⫽ 0.0198, 39.6
mL versus 74.7 mL), and score for voiding fre-
quency (P ⫽ 0.03354, 3.0 versus 2.5).
IMPACT OF TURP THERAPY ON NOCTURIA
Of the 138 patients in the TURP group, 118 had
nocturia before tamsulosin therapy (Table IV). Af-

788 UROLOGY 61 (4), 2003

 TABLE III. Impact of tamsulosin therapy on nocturia
Average Score of
No. of Patients No. of Patients Rate of Reduction Versus
with >2 Scores with >2 Scores Improvement (ⴞ Standard Nocturia
Before Therapy After Therapy (%) Deviation) (P Values)
Emptying 105 67 23.0 0.8 ⫾ 1.4 0.0037
Voiding frequency 133 98 21.2 0.9 ⫾ 1.5 0.0015
Intermittency 107 77 18.2 0.6 ⫾ 1.5 0.2471
Urgency 115 85 18.2 0.7 ⫾ 1.6 0.1162
Weak stream 152 105 28.5 1.1 ⫾ 1.5 ⬍0.0001
Hesitancy 81 50 18.8 0.7 ⫾ 1.4 0.1210
Nocturia 130 107 13.9 0.5 ⫾ 0.9

TABLE IV. Impact of TURP on nocturia

Average Score of
No. of Patients No. of Patients Rate of Reduction Versus
with >2 Scores with >2 Scores Improvement (ⴞ Standard Nocturia
Before Therapy After Therapy (%) Deviation) (P Values)
Emptying 102 27 54.3 2.0 ⫾ 1.9 ⬍0.0001
Voiding frequency 116 63 38.4 1.5 ⫾ 1.9 0.0011
Intermittency 101 33 49.3 1.9 ⫾ 1.8 ⬍0.0001
Urgency 103 70 37.0 1.5 ⫾ 2.0 0.0035
Weak stream 122 35 63.0 2.6 ⫾ 1.7 ⬍0.0001
Hesitancy 84 18 47.8 1.8 ⫾ 1.7 ⬍0.0001
Nocturia 118 91 19.6 1.0 ⫾ 1.3 ⬍0.0001
KEY: TURP ⫽ transurethral resection of the prostate.

ter treatment, 91 patients reported nocturia, indi-
cating a 19.6% reduction rate. The average point
reduction was 1.0 for nocturia, and this was lowest
as well. The paired t test revealed that improve-
ment in score for nocturia was significantly inferior
to those of scores for all others.
Of this cohort of 138 patients, 83 (60.1%) re-
ported at least a 1-point reduction in score for noc-
turia after TURP therapy. Between these 83 pa-
tients and the remaining 55, baseline data differed
significantly in score for nocturia (P ⬍ 0.0001, 3.6
versus 2.1), total score of IPSS (P ⫽ 0.0028, 21.7
versus 17.7), score for voiding frequency (P ⫽
0.0066, 3.2 versus 2.5), score for urgency (P ⫽
0.0110, 3.1 versus 2.4), PVR (P ⫽ 0.0110, 187.9
versus 97.4 mL), and Qmax (P ⫽ 0.0474, 6.5 ver-
sus 8.1 mL/s).
COMMENT
Nocturia is considered a main cause of distur-
bance of sleep maintenance for men and women
aged 50 years and older,6 and Asplund and Aberg7
reported that nocturia may result in daytime fa-
tigue, a lower level of general well-being, and a risk
of nightly falls. In another study they reported that
the death rate in men with three or more nocturnal
voiding episodes was 1.9-fold greater than that for
all men studied.8 Thus, nocturnal voiding fre-
quency is a common and bothersome symptom in
elderly men. Although IPSS and most other ques-
tionnaires estimating lower urinary tract symp-
toms, especially those due to BPH, include one or
more questions on nocturia, the association be-
tween BPH and nocturia is controversial. Our pre-
vious study demonstrated that nocturia had a sig-
nificant but weak impact on the symptom-specific
QOL of Japanese patients with BPH.9
Previous community-based studies using ques-
tionnaires reported two or more episodes of noc-
turia in 24% to 45% of elderly men.2,10 –17 This rate
was almost the same as that in elderly women.18 –21
On the other hand, two or more episodes of noc-
turnal voiding were observed for more than 60% of
patients with BPH in other studies.3,22 The present
study found that 71.1% of patients newly diag-
nosed with BPH arose to void two or more times at
night, and this rate was clearly higher than those
reported in community-based studies of
men.2,10 –17 Thus, BPH may be one of potential risk
factors for nocturia, as suggested by Blanker et al.2
Several other risk factors for nocturia have been
reported, including patient age,2,12,15,23–25 noctur-
nal bladder capacity,25 and nocturnal urine vol-
ume.25,26 Our study also demonstrated that older
age, voiding episodes estimated by score of severity
of urgency, and smaller functional bladder capac-

UROLOGY 61 (4), 2003 789

ity as represented by VV were predictors of fre-
quent nocturnal voiding even in patients with
BPH.
Our studies of the impact of treatment on noctu-
ria showed that conservative and invasive treat-
ments decreased both the percentage of patients
with nocturia and the average score for nocturia.
However, the degrees of improvement were lowest
among the seven individual symptoms included in
the IPSS. These findings are consistent with those
reported by Homma et al.3 and imply that, unlike
the other six symptoms, nocturia is influenced
markedly by various factors other than BPH. Other
approaches might be required for the treatment of
noctuia. Between the patients who had reduced
frequency of nocturnal voiding after treatment and
those who did not, several factors differed signifi-
cantly at baseline. However, most factors (especial-
ly the objective ones) other than the score for noc-
turia exhibited only marginal differences between
the groups. Thus, none of these variables can reli-
ably detect the impact of treatment for BPH on the
status of nocturia.
In this study, we did not investigate nocturnal
polyuria and natriuresis, which have been reported
to induce nocturia in some elderly men.25,26 The
relationships between nocturia, BPH, and noctur-
nal polyuria will be examined in future studies.
CONCLUSIONS
The high prevalence of nocturia in patients with
BPH suggests the possibility of a relationship of
BPH to nocturia. However, because symptom im-
provement by treatment was lowest for nocturia
among the seven symptoms included in the IPSS,
the indications for treatment of BPH for patients
whose chief symptom is nocturia should be care-
fully considered.
ACKNOWLEDGMENT. To Masahiro Namba, Takashi Ito,
Masako Fujii, and Etsuko Shibusawa for technical assistance.
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