Editing Functional: Nocturia (section)

== Nocturnal polyuria ==

=== Definitions ===
* '''<span style="color:#ff0000">If nocturnal urine volume (3):'''
** '''<span style="color:#ff0000">>20%-33% of total 24-hr volume (age dependent)'''
*** Normal circadian urine production is age dependent and '''the proportion of total urine output at night increases with age.'''
**** Age < 25: nocturnal urine volume/total = 14%
**** Age > 65: nocturnal urine volume/total = 34%
** '''>6.4 mL/kg'''
** '''>54 mL/hr'''

=== Causes ===
'''<span style="color:#0000ff">Diuretics Can Over Do Evening Pee (6):</span>'''
# '''<span style="color:#0000ff">D</span><span style="color:#ff0000">iuretics</span> (depending on time of administration)'''
# '''<span style="color:#0000ff">C</span><span style="color:#ff0000">ongestive heart failure</span>'''
# '''<span style="color:#0000ff">O</span><span style="color:#ff0000">bstructive sleep apnea</span>'''
#* Defined as the sudden cessation of respiration during sleep because of airway obstruction
#** Increased airway pressures lead to '''hypoxia''', which in turn causes pulmonary vasoconstriction, the latter leading to increased right atrial transmural pressure with '''resulting increase in ANP''' production and ultimately increased renal sodium and water excretion
#* '''<span style="color:#ff0000">Common cause of nocturnal polyuria</span>'''
# '''<span style="color:#0000ff">D</span><span style="color:#ff0000">iabetes mellitus</span>'''
# '''<span style="color:#0000ff">E</span><span style="color:#ff0000">xcessive nighttime fluid intake</span>'''
# '''<span style="color:#0000ff">P</span><span style="color:#ff0000">eripheral edema</span>'''

=== Management ===
* '''<span style="color:#ff0000">Treat underlying contributing medical comorbidities'''
** Treating sleep disturbances, hypertension, and obesity may decrease the number of nightly voids and improve quality of life
** '''<span style="color:#ff0000">Treating sleep apnea with continuous positive airway pressure (CPAP) can improve nocturia</span>'''
* '''<span style="color:#ff0000">Conservative management (3)</span>''' 
*#'''<span style="color:#ff0000">Cessation of fluid intake 4 hours before bedtime</span>'''
*#'''<span style="color:#ff0000">Compressive lower extremity stockings</span>''' 
*#'''<span style="color:#ff0000">Administration of diuretics in the mid-afternoon for edema states</span>'''
* '''<span style="color:#ff0000">Medical management (2):</span>'''
*# '''<span style="color:#ff0000">Demopressin (</span><span style="color:#ff0000">antidiuretic therapy at bedtime</span><span style="color:#ff0000">)</span>'''
*#* '''<span style="color:#ff0000">Mechanism of action: binds to V2 receptors in the renal collecting tubules, resulting in increased water permeability, enhanced water reabsorption,''' diluted extracellular fluid, and concentrated urine.
*#* '''<span style="color:#ff0000">Adverse events:</span>'''
*#** '''<span style="color:#ff0000">Hyponatremia</span>'''
*#*** '''Risk is <1% in those age < 65 and 8% in those age > 65'''
*#* '''Contraindications:'''
*#** '''Campbell’s: Elderly patients (>65 years) with baseline hyponatremia'''
*#** '''Product monograph:'''
*#*** '''Patients with type IIB or platelet-type (pseudo) Willerbrand disease, because of the risk of platelet aggregation and thrombocytopenia'''
*#*** '''Any condition associated with impaired water excretion, such as:'''
*#**** '''Hyponatremia'''
*#**** '''Severe liver disease'''
*#**** '''Nephrosis'''
*#**** '''Cardiac insufficiency'''
*#**** '''Chronic renal insufficiency'''
*#**** '''Congestive heart failure'''
*#**** '''Habitual or psychogenic polydypsia'''
*#*** '''Any medical conditions which lead to sodium losing states such as:'''
*#**** '''Vomiting'''
*#**** '''Diarrhoea'''
*#**** '''Bulimia'''
*#**** '''Anorexia nervosa'''
*#**** '''Adrenocortical insufficiency'''
*#**** '''Salt losing nephropathies'''
*#* '''There appears to be a lower risk of hyponatremia in patients with the nasal spray as opposed to oral preparations.''' 
*#* '''<span style="color:#ff0000">Dosing of desmopressin melt</span>'''
*#** '''<span style="color:#ff0000">Females are more sensitive to demopressin</span>''' in terms of effects on nocturnal urine production and duration of action; 
*#***'''50 μg of desmopressin melt may be the lowest therapeutically beneficial dose for males while females do well with a lower dose of 25 μg'''
*#* '''<span style="color:#ff0000">Monitoring</span>'''
*#** '''<span style="color:#ff0000">Obtain a baseline serum sodium before initiating therapy</span>'''
*#** '''<span style="color:#ff0000">Monitor the serum sodium within 7 days and then 28 days after initial or incremental dosing, then continue to check sodium levels every 6 months</span> (or more often as indicated).'''
*# '''<span style="color:#ff0000">Imipramine</span>'''
*#* '''<span style="color:#ff0000">MOA: a tricyclic antidepressant</span>''' with a complex pharmacologic profile including:
*#** Nonsubtype-selective '''antimuscarinic effect'''
*#** Effects in '''modulating vasopressin release'''
*#** Potentiating renal proximal tubular sodium and water reabsorption
*#* '''Adverse events:'''
*#** '''Arrythmia, should be used with caution'''
*#*** Has been shown to prolong the PR, QRS, and QTc intervals, increase heart rate, and lower T-wave amplitude during a 4-week treatment course. There have been rare reports of '''torsades de pointes and sudden death resulting from imipramine administration'''