Nocturia arises from a fundamental mismatch between nocturnal urine production, storage capacity, and sleep architecture, which may be driven by abnormalities of the genitourinary tract, but also by sleep disorders, medical diseases, patient actions/lifestyle factors, or medications. This article introduces a novel system for organizing the complex differential diagnosis for nocturia, as proposed by an international collective of practicing urologists, physician specialists, and sleep experts: "Sleep CALM"-Sleep Disorders, Comorbidities, Actions, Lower Urinary Tract Dysfunction, and Medications.
Narrative review of current evidence regarding the relevance of each "Sleep CALM" factor to nocturia pathogenesis, evaluation, and management.
Nocturia and sleep disorders are highly intertwined and often bidirectional, such that nocturnal awakenings for reasons other than a sensation of bladder fullness should not be used as grounds for exclusion from nocturia treatment, but rather leveraged to broaden therapeutic options for nocturia. Nocturia is an important potential harbinger of several serious medical conditions beyond the genitourinary tract. Urologists should have a low threshold for primary care and medical specialty referral for medical optimization, which carries the potential to significantly improve nocturnal voiding frequency in addition to overall health status. Adverse patient actions/lifestyle factors, lower urinary tract dysfunction, and medication use commonly coexist with disordered sleep and comorbid medical conditions, and may be the primary mediators of nocturia severity and treatment response, or further exacerbate nocturia severity and complicate treatment.
"Sleep CALM" provides a memorable and clinically relevant means by which to structure the initial patient history, physical exam, and clinical testing in accordance with current best-practice guidelines for nocturia. Although not intended as an all-encompassing diagnostic tool, the "Sleep CALM" schema may also be useful in guiding individualized ancillary testing, identifying the need for specialty referral and multidisciplinary care, and uncovering first-line treatment targets.
Neurourology and urodynamics. 2023 Jan 19 [Epub ahead of print]
Thomas F Monaghan, Jeffrey P Weiss, Alan J Wein, Syed N Rahman, Jason M Lazar, Donald L Bliwise, Karel Everaert, Gary E Lemack, Jean-Nicolas Cornu, Marcus J Drake, Christopher R Chapple, Hashim Hashim, Jerry G Blaivas, Roger R Dmochowski
Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA., Department of Urology, SUNY Downstate Health Sciences University, Brooklyn, New York, USA., Division of Urology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA., Department of Urology, Yale University School of Medicine, New Haven, Connecticut, USA., Department of Medicine, Division of Cardiovascular Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, USA., Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA., Department of Human Structure and Repair, Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium., Department of Urology, Charles Nicolle University Hospital, Rouen, France., Department of Urology, Imperial College London, Imperial College Healthcare NHS Trust, London, UK., Department of Urology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK., Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK., Icahn School of Medicine at Mount Sinai, New York, New York, USA., Department of Urological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.