Beruflich Dokumente
Kultur Dokumente
Agus Sudarso
Syakib Bakri
Introduction
The International Continence Society (ICS): the
complaint that an individual wakes on one or more
times to void urine during night
Prevalence
Physiology of Void
Bladder filling
Neural
stimulation
Bladder
relaxation
Subcortical
Cortical
Cortex
stimulation
Delay voiding
Cholinergic
action
Pelvic nerves
Full bladder
Detrusor
contraction
Voiding
Etiophatogenesis
GLOBAL
POLYURIA
Diab mellitus
Diab insipidus
Primary
polydipsia
DIMINISHED
NOCTURNAL
BLADDER CAPACITY
Prostatic obstruction
Nocturnal detrusor
overactivity
Neurogenic bladder
Cancer of bladder, prostate,
urethra
Learned voiding
dysfunction
Anxiety disorders
Pharmacologic agents
Bladder calculi
Ureteral calculi
NOCTURNAL
POLYURIA
Congestive heart
failure
Diabetes mellitus
Obstructive sleep
apnea
Peripheral edema
Venous stasis
Nephrotic syndrome
Hepatic failure
Hypoalbuminemia
Excessive nighttime
fluid intake
M
E
C
H
A
N
I
S
M
S
NOCTURNAL
POLYURIA
LOW NOCTURNAL
BLADDER CAPACITY
MIXED NOCTURIA
POLYURIA
A 24 h urine production > 40 mL/Kg
Common causes :
Diabetes mellitus
Insulin dependent diabetes (Type I)
Non insulin dependent diabetes (Type II)
Diabetes insipidus
Pituitary (central) deficiency in AVP at the pituitary level
Nephrogenic renal insensitivity to AVP
Gestational related to pregnancy
Primary polydipsia
Psycogenic related to psychological and cognitive
impairment
Dipsogenic caused by a primary abnormality in the thirst
Mechanism
Iatrogenic
Robinson, D. Int J Clin Pract.2007;61:24
Nocturnal Polyuria
Prostatic obstruction
Neurogenic bladder
Nocturnal detrusor overactivity
Drugs
Bladder or ureteral calculi
NBCi calculation
NBCi (Nocturnal Bladder Capacity Index), a complex
formula to calculate NBC
Weiss, J. J Urology.2006;175:17
Mixed nocturia
Evaluation
ANALYSIS
Nocturia index
Ni = NUV : MVV
Nocturnal polyuria index
NPi = NUV : 24hV
Nocturnal
bladder
capacity
index
Ni 1 = PNV*
NBCi = ANV PNV
Management
Lifestyle modification
Water restriction
Reduced alcohol and caffeine
consumption
Wearing compression sock to reduced
edema
Right timing for diuretics
Diabetes melitus
Glycemia control
Diabetes insipidus
(central)
Diuretic : Desmopressin (1-deamino8-D-arginine vasopressin, DDAVP)
Pharmacotherapy (contd)
Desmopressin
Analog synthetic of AVP, for treatment of DI and
PNE
NOCTOPUS (2002) : Effectivity and safety in short
and long time period of therapy
Adverse effect : dilutional hyponatremia
Orally : initial dose of 0.1 mg, could be increased
up to 0.2 mg, maximum dose of 0.4 mg
Pharmacotherapy (contd)
Nocturnal polyuria
Mid day diuretic
Diuretic 6 hours before
bedtime
Elderly : low to undetected
level of vasopressin
R/ Desmopresin (Kuo,
2002)
Pharmacotherapy (contd)
Pharmacotherapy (contd)
Prostate hypertrophy
Alfa blocker :
tamsulosin selective,
less postural
hypotension effect,
adverse effect: erectile
dysfunction
Surgery
Overactive bladder :
Transurethral prostatectomy
Prolapse uteri surgery
Sacral nerve neuromodulation
Detrusor myomectomy
Clamp cystoplasty
Asplund
et al
Study in
Sweden
Clinical Implications
Summary
Nocturia is a complaint of individual wakes
one or more during night to void
Male>female, increased over age
Multifactorial etiology, not always associated
to urology abnormality
4 main etiologies : polyuria, sleep disorder,
bladder disorder, nocturnal polyuria
Voiding diary established diagnosis and
treatment
Management includes life style modification,
pharmacotherapy and surgery
Thank You
DI neurogenik
DI nefrogenik
P.Psikogenik
Osmolalitas plasma
meningkat
meningkat
menurun
Osmolalitas urine
menurun
menurun
menurun
tetap
tetap
meningkat
tetap
tetap
meningkat
meningkat
tetap
tinggi
Vasopressin plasma
rendah
Normal/tinggi
rendah
28