What is the initial line of questioning for a patient presenting with nocturia (peeing at night)?

Initial Line of Questioning for Nocturia

Begin by establishing the severity and impact of nocturia using a 72-hour bladder diary to quantify nocturnal voids and overnight urine volume, then systematically screen for underlying systemic causes using the SCREeN framework (Sleep, Cardiovascular, Renal, Endocrine, Neurology), as nocturia is commonly multifactorial and often caused by non-urological conditions. 1

1. Establish Impact and Severity

• Quantify nocturia: Ask how many times the patient wakes to urinate during their main sleep period (each void must be followed by sleep or intention to sleep). 1
• Assess overnight urine volume: Determine if nocturnal polyuria is present (>33% of 24-hour urine output occurring at night). 2
• Evaluate quality of life impact: Ask about daytime fatigue, impaired function the following day, fall risk, and sleep fragmentation. 1, 2

2. Review Past Medical History (SCREeN Conditions)

Systematically review for previously diagnosed conditions that commonly cause nocturia: 1

Sleep Medicine:

• Obstructive sleep apnea (OSA), insomnia, restless legs syndrome (RLS), periodic limb movements of sleep (PLMS), parasomnias 1

Cardiovascular:

• Hypertension, congestive heart failure (CHF) 1

Renal:

• Chronic kidney disease (CKD) 1

Endocrine:

• Diabetes mellitus, thyroid disorders (hyper/hypothyroidism), pregnancy/menopause, diabetes insipidus, testosterone deficiency 1

Neurological:

• Most neurological diseases are potentially relevant (Parkinson's, multiple sclerosis, stroke, etc.) 1

Other:

• Autoimmune diseases affecting salivary glands (causing xerostomia/dry mouth leading to increased fluid intake) 1

3. Comprehensive Medication Review

Review all medications that may contribute to nocturia: 1

• Diuretics (timing is critical—late afternoon/evening dosing worsens nocturia) 1
• Calcium channel blockers 1
• Lithium 1
• NSAIDs (prolonged use) 1
• Medications causing xerostomia: Anxiolytics, antidepressants (especially tricyclics), antimuscarinics, antihistamines, decongestants, antiparkinsonians, pain medications, antipsychotics 1
• Alcohol and caffeine (diuretic effects) 1

4. Screening Questions for Undiagnosed SCREeN Conditions

Ask these specific questions to identify previously undiagnosed systemic causes: 1

Sleep Disorders:

• "Do you have problems sleeping aside from needing to get up to urinate?" 1
• "Have you been told that you gasp or stop breathing at night?" 1
• "Do you wake up without feeling refreshed? Do you fall asleep during the day?" 1

Cardiovascular/Renal:

• "Do you experience ankle swelling?" 1
• "Do you get short of breath when walking for a certain distance?" 1
• "Do you get lightheaded on standing?" 1

Endocrine:

• "Have you been feeling excessively thirsty?" 1
• "(For females of relevant age) Have you noticed changes in your periods?" 1

Neurological:

• "Do you have any problems controlling your legs? Do you experience slowness of movement? Have you noticed a tremor in your hands?" 1

5. Additional Sleep-Specific Questions (If Initial Screening Suggests Sleep Disorder)

For Suspected OSA: 1

• "Do you snore and sometimes wake up choking?"
• "Does your partner say that you stop breathing?"
• "Do you often wake with a headache?"

For Suspected Insomnia: 1

• "Do you have difficulty falling or staying asleep?"
• "How well do you function during the day?"

For Suspected RLS/PLMS: 1

• "What does it feel like?"
• "Does it vary over the day and is it worse later in the day/evening?"
• "Is it relieved by movement?"
• "Does your bed partner complain that you have twitchy legs or make kicking movements in your sleep?"

6. Physical Examination Findings to Assess

• Reduced salivation/xerostomia (suggests medication effect or autoimmune disease) 1
• Peripheral edema (suggests cardiac or renal disease) 1
• Lower limb weakness, abnormal gait, speech abnormalities, or tremor (suggests neurological disease) 1
• Blood pressure measurement (both sitting and standing if orthostatic hypotension suspected) 1, 3

7. Baseline Investigations

Order these tests for all patients with nocturia: 1

• 72-hour bladder diary (essential for diagnosis) 1, 3
• Blood tests: Electrolytes/renal function, thyroid function, calcium, HbA1c 1
• Urine dipstick: Albumin:creatinine ratio, blood, protein 1
• Blood pressure assessment 1
• Pregnancy test (where applicable) 1

Common Pitfalls to Avoid

• Don't assume nocturia is solely due to benign prostatic hyperplasia or overactive bladder—most cases have systemic causes, particularly nocturnal polyuria from cardiovascular, endocrine, or sleep disorders. 3, 4
• Don't overlook sleep apnea—up to 79% of awakenings attributed to "needing to urinate" are actually caused by sleep disorders (especially OSA), not bladder pressure. 5
• Don't forget to review ALL medications, including over-the-counter drugs, supplements, and timing of diuretics. 3
• Don't skip the bladder diary—clinical assessment alone is insufficient to distinguish nocturnal polyuria from reduced bladder capacity. 3, 6