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CLINICAL REVIEW: Serge P Marinkovic, Lisa M Gillen, and Stuart L Stanton Managing nocturia BMJ 2004; 328: 1063-1066 [Full text]

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Nocturia BMJ 2004;328:1063-1066

Roger M walker   (29 April 2004)

A scrambled message

Hubertus H von Blumenthal   (3 May 2004)

Nocturia and Sacral Neuromodulation Device!

Dr.Naseem A. Qureshi MD, IMAPA, LMIPS   (6 May 2004)

Is Nocturia a Urological Condition?

Neil W Matheson   (6 May 2004)

Nocturia and nocturnal polyuria are not strongly related

Marco H. Blanker, Siep thomas, J.L.H. Ruud Bosch   (23 May 2004)

Nocturia

Dan Wood, J.M.Barua   (26 May 2004)

Nocturia BMJ 2004;328:1063-1066 29 April 2004
Roger M walker, Consultant Urologist Christchurch Hospital, Christchurch, New Zealand Send response to journal: Re: Nocturia BMJ 2004;328:1063-1066	Dear Sirs, I would like to express a number of areas of concern relating to the article on nocturia. Firstly the suggestion that Melatonin is effective in men with nocturia is misleading. The study quoted involved only 20 patients, many of them with treatable conditions that would explain their nocturia – detrusor overactivity, and benign prostatic enlargement. The authors of that paper themselves claim that the clinical significance of melatonin is uncertain. Secondly for an article entitled a clinical review, no or very little mention is made of the common causes or treatments of nocturia for example bladder overactivity, prostatic disease and urinary tract infection Thirdly, sacral neuromodulation, whilst undoubtedly an important area for research, is not as suggested in the article a widely suitable and recognised treatment for nocturia. It is in fact a very expensive treatment. The success rate of 85% quoted does not reflect the literature. Most publications suggest 1/3 of patients don’t respond to the test stimulation, 1/3 respond but subsequently fail or have complications with the permanent implant. On an intention to treat basis the overall success rates are more likely to be in the order of 33% which is similar to a placebo response. Nocturia itself is only evaluated as a secondary endpoint in most studies on neuromodulation. In addition it has been studied and used in only a very small group of patients with intractable problems. This represents probably <5% of patients who fail to respond to simple conservative, pharmacological or surgical treatments. Of most concern is the fact that the long term effects and results are not yet known. The article seems very removed from everyday clinical practice and is surprising. It reads as a wonderful promotion tool for the sacral neuromodulation company Medtronic and their Interstim device. The company must be rubbing their hands together with glee. I’m very surprised at the BMJ editorial panel for publishing such a blatantly commercially biased and incomplete article on such an important area. Roger Walker Consultant Urologist Christchurch, New Zealand. 1. Marinkovic S, Gillen L, Stanton S.Managing Nocturia BMJ 2004;328:1063 -1066 2. Drake MJ, Mills IW, Noble JG. Melatonin pharmacotherapy for nocturia in men with benign prostatic enlargement. J Urol 2004;171: 1199-202. Competing interests: None declared
A scrambled message 3 May 2004
Hubertus H von Blumenthal, GP Greensands Medical Practice, Gamlingay, SG19 3JR Send response to journal: Re: A scrambled message	Figure 2 of Hay Schroeder and Fahey's article shows a device in the palm of one hand which looks not dissimilar to a cardiac pacemaker with a battery unit and some electronic processing parts. In the other palm is a shiny ovoid object with no other discernible features. The explanatory subtitle is 'InterStim neuromodulation device'. Whilst the purpose of the metallic object is well explained by the text and more or less self evident I am intrigued by the other object. What is it's function? What does it do? Where does it go? Could it really be an egg? Why? To size the electronic device to a scale we are all familiar with? Surely we all get a good understanding of the devices size by fitting it in a palm. And why on earth did the authors decide on a hardboiled peeled egg as the shiny surface would suggest? ANSWERS PLEASE!! Competing interests: None declared
Nocturia and Sacral Neuromodulation Device! 6 May 2004
Dr.Naseem A. Qureshi MD, IMAPA, LMIPS, Medical Director(A), Director CME&R Buraidah Mental Health Hospital, Postcode:2292, Saudi Arabia Send response to journal: Re: Nocturia and Sacral Neuromodulation Device!	Dear Sir: I have special interest in the management of nocturia as it is not only found in medical/surgical patients but also neuropsychiatric patients in particular those who are partially institutionalized in mental hospitals. Notably, a group of patients with a variety of chronic mental disorders including schizophrenia, severe mental disabilities, uncontrolled chronic epilepsies with psychiatric manifestations, and agitated depressions with chronic anxieties manifests nocturia. Adverse life styles related to diet, personal hygiene, smoking and excercise of such patients have an influential impact on nocturia. Moreover, all these patients have additional risks of developing chronic medical diseases including cardiovascular diseases, strokes, malignancies, diabetes mellitus, respiratory diseases and other diseases such as urological disorders, which further complicate the problem of nocturia. The review article by Marinkovic and colleagues (2004) addressed defining concepts, assessment issues, etiological perspectives, and most commendably the treatment perspectives of nocturia, certainly a puzzling disorder, which has remarkable, adverse psychosocial effects on the psyche of sufferers. The introduction of a new sacral neuromodulation device as the last option of treatment in resistant cases of nocturia who don't respond to all available treatments is a welcome move. Simply speaking, not only the manufacturer of this device but also the readers including patients and their family members of the BMJ should feel happy about it and take a sigh of relief when they have a device with 85% success rate. Finally, elderly patients with multiple physical and neuropsychiatric disorders have many types of burdens on the family members or carers and nocturia adds further fuel to the fire. Any suitable treatment such as Sacral Neuromodulation Device with high initial success rate is a very important therapeutic contribution to the medical sciences, which we all must appreciate. Reference: Serge P Marinkovic, Lisa M Gillen, and Stuart L Stanton Managing nocturia. BMJ 2004; 328: 1063-1066 Competing interests: Pro-Drug, medical device and herbal products industries.y
Is Nocturia a Urological Condition? 6 May 2004
Neil W Matheson, CEO AXIS Healthcare Communications LLC, 800 Township Line Road, Ste 250, Yardley, PA 19067, USA Send response to journal: Re: Is Nocturia a Urological Condition?	The review of nocturia by Stanton et al is comprehensive and very well written. While I am not a physician my knowledge of medicine gained through many years of working in medical education has taught me that a description of a symptom or a group of symptoms (syndrome) is not a diagnosis. I was taught that the term 'nocturia' was used to describe the symptom of increased nocturnal voiding. When taking a history or writing on a patient chart one would write nocturia x3 to describe the three voids at night. This symptom may be indicative of a variety of underlying conditions. Blaivas and Weiss did an excellent job of classifying those conditions as those that cause nocturnal polyuria versus nocturnal overactive bladder. As described by Stanton et al nocturnal polyuria may be the simple consequence of excessive night time fluid intake or fluid redistribution due to CHF. There are many other underlying pathologies that might give rise to increased night time urine production. It is critical that the underlying cause of the excess urine production is diagnosed and treated appropriately. On the other hand patients experiencing increased day-time frequency and urgency with or without urge incontinence may also experience these symptoms at night. These patients may have nocturnal overactive bladder and may respond to treatment with antimuscarinic therapy (although clinical trials to date are not that compelling). We should not continue to use the term nocturia as a diagnosis that can be treated when it it is a symptom of an underlying condition oor disease. After all we don't make the diagnosis of proteinuria or hematuria but we certainly look for the cause of such symptoms and treat them accordingly. Competing interests: My company develops educational programs for Pfizer is support of Detrol LA and Detrusitol.
Nocturia and nocturnal polyuria are not strongly related 23 May 2004
Marco H. Blanker, epidemiologist Erasmus Medical Center, dept. General Practice, PO box 1738, 3000DR Rotterdam. The Netherlands, Siep thomas, J.L.H. Ruud Bosch Send response to journal: Re: Nocturia and nocturnal polyuria are not strongly related	Dear Sirs, In their clinical review, Marinkovic et al. present an algorithm for the definition and treatment of nocturia. Although nocturnal polyuria plays a key role in this article, the authors do not clarify how they selected the 22 reference sources from a total of 117. In their algorithm, definitions for “nocturnal polyuria” are given that are not properly validated, nor based on normal distributions. For example the definition of nocturnal polyuria defined by Asplund et al (nocturnal volume > 6.4 ml/kg) was based on a sample of young men from another study.(4) In our opinion, these younger subjects cannot serve as reference for older men. Moreover, using this definition in the general population of older men, would lead to a True positive Rate of 0.67 and 0.77 and a False Positive Rate of 0.38 and 0.44 for, respectively, men with two or more and three or more nocturnal voidings.(1) From our own analyses in 1688 older Dutch men, recruited from the general population we concluded that the use of nocturnal urine production as an explanatory variable for nocturnal voiding frequency is of little value for daily practice. (1) This study also yielded normal values for nocturnal voiding frequency, as well as nocturnal urine production and circadian urine production.(2, 3) Using a definition of nocturnal polyuria based on a day night ratio as Marinkovic et al did also has limitations: men with a significantly increased nocturnal urine production can easily have a normal day/night ratio, whereas men with a normal nocturnal urine production can have a disturbed day/night ratio. (2, 3) The clinical effect of most treatment options for nocturia (both in the algorithm and main text) is small even when statistical significance is present. We believe that algorithms should be validated and be based on proper definitions. This is sadly not the case in Marinkovic et al’s article. Furthermore, the suggestion that nocturia can be treated succesfully by sacral nerve stimulation is misleading and certainly not supported by the references given by the authors. Sacral neuromodulation is being used in the treatment of patients with an overactive bladder mainly suffering from urge compliants and urinary frequency (daytime or combined day- and nighttime frequency) and / or urge urinary incontinence. Many patients (but not all) with an overactive bladder according to International Continence Society definition, have an increased nighttime frequency. There is some evidence (based on abstracts presented during scientific meetings) that nighttime frequency responds to this treatment in concert with daytime frequency. There is no evidence that isolated nocturia would respond in the same fashion. 1. Blanker MH, Bernsen RM, Bosch JL, Thomas S, Groeneveld FP, Prins A, et al. Relation between nocturnal voiding frequency and nocturnal urine production in older men: a population-based study. Urology 2002;60(4):612- 6. 2. Blanker MH, Bohnen AM, Groeneveld FP, Bernsen RM, Prins A, Ruud Bosch JL. Normal voiding patterns and determinants of increased diurnal and nocturnal voiding frequency in elderly men. J Urol 2000;164(4):1201-5. 3. Blanker MH, Bernsen RM, Ruud Bosch JL, Thomas S, Groeneveld FP, Prins A, et al. Normal values and determinants of circadian urine production in older men: a population based study. J Urol 2002;168(4 Pt 1):1453-7. 4. Kirkland JL, Lye M, Levy DW, Banerjee AK. Patterns of urine flow and electrolyte excretion in healthy elderly people. Br Med J (Clin Res Ed) 1983;287(6406):1665-7. Marco H. Blanker, MD PhD, epidemiologist, General practitioner trainee Siep Thomas, MD PhD, professor of General Practice J.L.H. Ruud Bosch, MD PhD, professor of Urology Competing interests: None declared
Nocturia 26 May 2004
Dan Wood, SpR Urology Thames Deanery Harold Wood Hospital, Essex, RM3 OBE, J.M.Barua Send response to journal: Re: Nocturia	Sir, Whilst we welcome the authors’ intention to provide a review and guide for assessment of the difficult and common clinical problem of nocturia. We have some concerns about the management pathways suggested. We believe that this review may be open to misinterpretation by practitioners not expert in the field. Nocturia is a symptom and should not be presented as a diagnosis. It is therefore important to emphasise the need to establish the underlying diagnosis before prescribing treatment. In this respect the algorithm is somewhat oversimplified and does not make proper distinction between diagnoses and how these may be treated appropriately. The concern is that a publication classed as a review from authors of such regard will lead to practitioners outside the specialist field making assumptions that may impact adversely on patient care. The review does not cite any reference to the consultation on nocturia published in the British Journal of Urology International, December 2002. The views expressed therein may not agree with the authors’ view of nocturia but should surely be mentioned in the interests of balance. Our greatest concern is the fact that the last 300 words or so of the article may lead the reader to believe that sacral nerve neuromodulation is an established treatment for nocturia. None of the peer reviewed literature cited in this article mentions this as a treatment for nocturia. A single abstract presented at the American Urogynaecologic Society in 2000[1] mentions that of eight patients who had nocturia most were improved. This is clearly a very small study. Sacral neuromodulation can undoubtedly have significant treatment benefits when applied appropriately. It may well be that with time it will show itself to have a significant effect in nocturia of all or perhaps certain aetiologies. However, we contend that this is not a conclusion we can draw from the current literature. The role of sacral neuromodulation in nocturia requires further research before it can be considered as a safe and effective treatment for nocturia. Reference 1. Spurlock JW & Mangel JM. Initial experience with sacral nerve stimulation as a treatment for intractable urge incontinence. Proceedings American Urogynaecologic Society 2000. D.N.Wood PhD FRCS – SpR Urology, Thames Deanery J.M.Barua MD FRCS Ed(Urol) FEBU – Consultant Urological Surgeon, Harold Wood Hospital, Essex, RM3 OBE Competing interests: None declared