Use of dried fruits to decrease nocturnal polyuria

[Guest guest]

Dear Colleagues,

Has anyone heard of, or have experience with, use of dried fruit to

prevent/treat nocturnal polyuria? I have a reference, but no abstract to:

J Urol. 2003 Nov;170(5):1956-7. Links

Dried fruits decrease nocturnal polyuria.

* DV.

PMID: 14532830 [PubMed - indexed for MEDLINE]

Also, the following article mentions it, but does not elaborate:

Evaluation of Nocturia in the Elderly | to pdf >>

By Dean A Kujubu, MD; Sherif R Aboseif, MD

Report of a Case

A colleague asks for your suggestions on the evaluation and treatment of

a 78-year-old woman whose chief complaint is that she awakens four to

five times each night to urinate. Your colleague adds that the patient

does not have diabetes mellitus, is not taking diuretics, and had a

physical examination that produced normal findings.

Discussion

Nocturia is defined as the interruption of sleep by the need to urinate.

While it is a relatively uncommon complaint among younger adults, the

prevalence of nocturia increases with increasing age in both men and

women. For patients who are age 60 to 70 years, the prevalence of

nocturia is between 11% and 50%. For those who are age 80 years, the

prevalence rises to between 80% and 90%, with nearly 30% experiencing

two or more episodes nightly.1 The older adult already experiences more

frequent arousals from sleep and less deep sleep compared with younger

adults. The presence of nocturia further disrupts sleep, leading to

daytime somnolence, symptoms of depression, cognitive dysfunction, and a

reduced sense of well-being and quality of life. Moreover, nocturia is

associated with a 1.8-fold increased risk of hip fracture.2 Men who

arise more than three times a night to urinate also have a twofold

increase in mortality compared with those with fewer episodes of

nocturia.3 Nocturia is a frequent patient complaint leading to urologic

and nephrologic consultations.

The causes of nocturia are many (Table 1). They can be divided into

conditions affecting the storage of urine in the bladder and those

involving the excessive production of urine by the kidneys. Although it

is commonly assumed that the reason for nocturia is bladder dysfunction,

particularly among elderly men, this assumption is not accurate.

Bruskewitz et al noted that nocturia persisted in 25% of men who

underwent prostate surgery for presumed bladder outlet obstruction and

were monitored for three years, suggesting that the etiology of nocturia

had not been addressed by surgery in these patients.4 A careful history

and physical examination provide clues to the etiology. Symptoms such as

decreased urinary stream, hesitancy, and a sense of incomplete voiding

suggest bladder outlet obstruction. Frequency, urgency, and bladder

spasms suggest bladder irritation, perhaps due to infection. Gross

hematuria may be an indication of a bladder tumor or stones. The absence

of such symptoms, however, does not rule out bladder pathology, because

bladder outlet obstruction can be clinically subtle, with symptoms

attributed to " old age. "

Many other medical conditions have been associated with nocturia.

Important conditions to inquire about include diabetes mellitus,

diabetes insipidus, congestive heart failure, nephrotic syndrome,

obstructive sleep apnea, chronic kidney disease, and neurologic

conditions such as autonomic neuropathy, Parkinsonism, and Alzheimer's

disease. In congestive heart failure, nephrotic syndrome, and autonomic

neuropathy, nocturia is due to the mobilization of pooled interstitial

fluid on recumbency. With obstructive sleep apnea, high negative

intrathoracic pressures during episodes of airway obstruction and

systemic hypoxemia lead to solute and water excretion mediated in part

through atrial natriuretic peptide. Chronic kidney disease is associated

with tubular concentrating defects and large solute delivery through the

remaining functional nephrons. Neurologic disease may affect central

control over the circadian release of hormones, such as antidiuretic

hormone. Use of medications, such as diuretics and calcium channel

blockers, and habits, such as excessive fluid intake and alcohol and

caffeine use, are important to note. Why calcium channel blockers have a

diuretic effect in some but not all patients is not known.

During a physical examination, orthostatic vital signs should be

obtained to evaluate for evidence of autonomic neuropathy. Evidence of

heart failure or other edema-forming states, including venous

insufficiency, should be sought. An abdominal examination may reveal a

large distended bladder or evidence of fecal impaction. A careful

genitourinary examination should include a search for prostatic

enlargement in men, pelvic relaxation in women, detrusor dysfunction as

manifested by a large postvoid residual, and evidence of neurologic

deficits related to the sacral nerve roots, including sensory deficits,

poor sphincter tone, or absent anal wink reflex.

Initial laboratory tests should include an assessment of renal function,

glucose, electrolytes, and calcium and urinalysis with a microscopic

examination of the urine. If symptoms suggest infection, a urine culture

should be obtained. An ultrasound bladder evaluation before and after

voiding should also be performed. If the patient manifests symptoms

suggestive of obstructive sleep apnea, a polysomnogram is indicated. If,

after initial assessment, no clear etiology is discovered, the patient

should be asked to keep a careful voiding diary for at least three days.

The volume and time of each void should be noted, as well as whether the

voiding episode disrupted sleep. These data will allow the physician to

determine the patient's functional bladder capacity and whether the

patient passes a significant fraction of the daily urine output at

night. The typical functional bladder capacity is approximately 350 to

400 mL. Urine production at night is usually less than one-third of the

total daily urine output. If the nocturnal urine volume exceeds this

amount, the patient is deemed to have nocturnal polyuria.

Saito et al reviewed voiding diaries of 85 study subjects older than age

65 years and compared them to the diaries of 130 study subjects younger

than age 65 years, all of whom had been referred for a complaint of

nocturia.5 After exclusion of benign prostatic hypertrophy, neurogenic

bladder, cystitis, diabetes mellitus, diabetes insipidus, and chronic

kidney disease, the most common condition accounting for nocturia among

the elderly study subjects was nocturnal polyuria, seen in 37%. The

second most common cause was an unstable bladder (small voiding volumes

associated with urgency), seen in 34%.

Nocturnal polyuria is a syndrome seen in older patients where the usual

ratio of day to night urine production is altered.6 Normally, after an

individual reaches the age of seven years, urine volume produced during

the day is twice as much as nightly urine volume. In patients with

nocturnal polyuria, this ratio is altered such that >35% of the total

daily urine output occurs at night despite a normal daily total urine

output of 1000 to 1500 mL/day. In some individuals, nocturnal urine

production exceeds that produced during the day. The reason for the

excessive nocturnal urine production is not clear. Some suggest that

antidiuretic hormone levels, typically elevated during sleep, are

abnormally low in these individuals, resulting in diuresis. This finding

is not universally seen, however, particularly among women with

nocturnal polyuria. A relative nocturnal deficiency of antidiuretic

hormone also does not explain the altered pattern of sodium and

nonelectrolyte solute excretion that also occurs among these

individuals. A full explanation of nocturnal polyuria syndrome has yet

to be provided.

Several pharmacologic agents have been used to treat nocturnal polyuria

with various degrees of success. Simple maneuvers such as reducing fluid

intake for six hours before recumbency are usually not successful.

Compression stockings may prevent dependent edema that can start when a

patient lies down and results in nocturia. Loop diuretics taken

approximately six to eight hours before the patient lies down induce

transient volume depletion, thereby reducing nocturnal urine production

once the diuretic effect has diminished. Other agents, such as

nonsteroidal anti-inflammatory drugs, melatonin, imipramine, and dried

fruits, have been tried. The use of continuous positive airway pressure

ventilation in patients with documented obstructive sleep apnea reduces

symptoms of nocturia. Most studies have focused on the use of

desmopressin, an antidiuretic hormone analogue, to reduce nocturnal

polyuria. Multicenter, double blinded, placebo-controlled studies using

oral desmopressin have demonstrated reduced nocturnal voiding among

patients with nocturnal polyuria during a follow-up period of 10 to 12

months.7 Desmopressin was generally well tolerated; the most frequent

adverse effects were headache, nausea, dizziness, and peripheral edema,

seen in fewer than 5% to 10% of patients. Hyponatremia was seen in 14%

of patients but was asymptomatic and mild (>130 mEq/L) in nearly all

cases. In small case series, intranasal desmopressin has also been used

successfully.

If the patient has symptoms suggestive of bladder outlet obstruction, a

urologic referral is indicated. Detailed urodynamic evaluation and/or

cystoscopy may be necessary. Anticholinergic agents may benefit those

with an overactive bladder. In contrast, cholinergic agents or

intermittent catheterization may be required in those with poor detrusor

function and large postvoid residual. Alpha-adrenergic blocking agents

and 5·-reductase inhibitors may help men with bladder outlet obstruction

and prostatic hypertrophy. Surgery may be indicated if there is evidence

of mechanical obstruction refractory to drug therapy.

Conclusion

This particular patient should be questioned about any symptoms of heart

failure and obstructive sleep apnea. Her fluid intake habits, her

medications, and her caffeine and alcohol use should be noted. A careful

abdominal and genitourinary examination should be performed,

specifically looking for cystocele, uterine prolapse, sensory neurologic

findings, and fecal impaction. A postvoid residual measurement and

screening laboratory tests, including those for electrolytes,

creatinine, calcium, and glucose and a urinalysis, should be obtained.

If the initial evaluation is unrevealing, she should be asked to

maintain a voiding diary and minimize her fluid intake for six to eight

hours before going to bed. Should her voiding diary demonstrate

nocturnal polyuria syndrome, she can try eating some dried fruits before

bedtime and consider a trial of a low-dose loop diuretic to be taken six

hours before going to bed. Should she continue to have symptoms, a trial

of 100 mg of oral desmopressin at night can be considered, with careful

and frequent monitoring of her serum electrolytes.

References

1. 1Weiss JP, Blaivas JG. Nocturia. J Urol 2000 Jan;163(1):5-12.

2. RB, MT, May FE, Marks RG, Hale WE. Nocturia: a risk

factor for falls in the elderly. J Am Geriatr Soc 1992 Dec;40(12):1217-20.

3. Asplund R. Mortality in the elderly in relation to nocturnal

micturition. BJU Int 1999 Aug;84(3):297-301.

4. Bruskewitz RC, Larsen EH, Madsen PO, Dorflinger T. Three-year

follow-up of urinary symptoms after transurethral resection of the

prostate. J Urol 1986 Sep;136(3):613-5.

5. Saito M, Kondo A, Kato T, Yamada Y. Frequency-volume charts:

comparison of frequency between elderly and adult patients. Br J Urol

1993 Jul;72(1):38-41.

6. Asplund R. The nocturnal polyuria syndrome (NPS) Gen Pharmacol

1995 Oct;26(6):1203-9.

7. Lose G, Mattiasson A, Walter S, et al. Clinical experiences with

desmopressin for long-term treatment of nocturia. J Urol 2004

Sep;172(3):1021-5.

--

ne Holden, MS, RD < fivestar@... >

" Ask the Parkinson Dietitian " http://www.parkinson.org/

" Eat well, stay well with Parkinson's disease "

" Parkinson's disease: Guidelines for Medical Nutrition Therapy "

http://www.nutritionucanlivewith.com/