What is the cause of urinary frequency and nocturia in a 70-year-old woman?

From the Guidelines

For a 70-year-old woman experiencing urinary frequency and nocturia, I recommend starting with a thorough evaluation to determine the underlying cause, considering nonurological mechanisms such as sleep disorders, cardiovascular conditions, renal disease, endocrine issues, and neurological problems, as suggested by the PLANNING Appropriate Nocturia Evaluation and Treatment (PLANET) study 1. The evaluation should include a careful history, physical exam, and urinalysis, as well as screening for conditions such as obstructive sleep apnea, hypertension, congestive heart failure, chronic kidney disease, diabetes mellitus, and thyroid disease, which can contribute to nocturia 1. Initial management should include lifestyle modifications such as:

• Fluid restriction in the evening (stopping fluids 2-3 hours before bedtime)
• Avoiding bladder irritants like caffeine and alcohol
• Scheduled voiding every 2-3 hours during the day If overactive bladder is diagnosed, first-line pharmacotherapy includes antimuscarinic medications such as oxybutynin (5mg twice daily), solifenacin (5mg daily), or tolterodine (2mg twice daily), or the beta-3 agonist mirabegron (25-50mg daily) 1. For nocturia specifically, low-dose desmopressin (0.1mg at bedtime) may be considered if nocturnal polyuria is confirmed, though with caution due to hyponatremia risk in older adults 1. Urinary tract infections should be ruled out with urinalysis and treated with appropriate antibiotics if present. In cases where urinary retention is suspected, post-void residual should be measured. These symptoms in older women often result from age-related detrusor overactivity, reduced bladder capacity, or nocturnal polyuria due to altered circadian rhythm of antidiuretic hormone secretion. Pelvic floor physical therapy may also provide benefit for urge symptoms and should be considered as part of a comprehensive treatment approach.

From the Research

Causes of Urinary Frequency and Nocturia

• Urinary frequency and nocturia can be symptoms of overactive bladder (OAB), a common condition characterized by unstable bladder contractions 2, 3, 4
• OAB can be caused by a variety of factors, including psychosocial, medical, sexual, urological, gynecologic, endocrine, and pharmacological factors 5
• The prevalence of OAB increases with age, and it can have a significant impact on quality of life 2, 3

Diagnosis and Evaluation

• The diagnosis of OAB is made by history, physical examination, and urinalysis to rule out underlying infection or other concerning potential etiologies 2
• Additional testing, such as frequency-volume charts, cystourethroscopy, urodynamics, and genitourinary imaging, may be necessary to evaluate urinary frequency and nocturia 5
• A targeted history and examination of the urogenital system can help assess the burden of disease on the patient 4

Treatment Options

• Behavioral modification, including weight reduction, decrease in exposure to bladder stimulants, fluid optimization, and pelvic floor exercises, is a first-line treatment for OAB 2, 4, 6
• Antimuscarinic agents, such as oxybutynin, tolterodine, and trospium chloride, can be used to treat OAB, but may have adverse effects, particularly in elderly patients 3
• More advanced treatments, such as sacral neuromodulation, percutaneous tibial nerve stimulation, and intradetrusor injection of onabotulinumtoxinA, may be considered for patients refractory to behavioral therapy and oral medications 2
• Bladder training and Kegel exercises can be an effective treatment for urinary incontinence in elderly women living in a rest home 6