Abstract

Objective

To identify the prevalence and factors related to nocturia in women presenting lower urinary tract symptoms.

Methods

Observational cross-sectional survey, individualized, hospital-based, involving women attended by the Unified Health System in urogynecology outpatient clinics in Niterói and Petrópolis, RJ, Brazil. Sociodemographic, clinical, and lifestyle data were collected. Two outcomes of nocturia were considered: one or more nocturnal voids and two or more nocturnal voids, the latter due to its greater impact on quality of life. Associations between the investigated variables and the outcomes were assessed by logistic regression models, and crude and adjusted odds ratios were obtained.

Results

A total of 132 participants were included. The prevalence of nocturia was 71.2%, and of two or more voids, 56.8%. Lower education level OR 0,260 (0,106; 0,637), mixed urinary incontinence OR 2,533 (1,103; 5,817), and three or more comorbidities OR 3,105 (1,340; 7,196) were associated with a higher chance of nocturia. Lower education level OR 0,324 (0,148; 0,709), lower caffeine consumption OR 0,995 (0,990; 1,000), and overactive bladder syndrome OR 2,761 (1,189; 6,409) were associated with a higher chance of two or more voids.

Conclusions

In the population attending specialized services, the prevalence of nocturia was similar to that of the general population and to that of similar services, but the prevalence of two or more voids was higher. Active screening for nocturia in women with comorbidities, especially three or more, and their adequate management, proved to be important in addressing the symptom.

Keywords
Nocturia; Lower Urinary Tract Symptoms; Women's Health

Resumo

Objetivo

Identificar a prevalência e fatores relacionados à noctúria em mulheres que apresentam sintomas do trato urinário inferior.

Métodos

Inquérito observacional transversal, individuado, de base hospitalar, envolvendo mulheres atendidas pelo Sistema Único de Saúde em ambulatórios de uroginecologia em Niterói e Petrópolis, RJ, Brasil. Foram coletados dados sociodemográficos, clínicos e hábitos de vida. Foram considerados dois desfechos de noctúria: uma ou mais micções e duas ou mais micções, o segundo devido ao maior impacto na qualidade de vida. As associações entre as variáveis investigadas e os desfechos foram avaliadas por modelo de regressão logística, e obtidas razões de chances brutas e ajustadas.

Resultados

Foram incluídas 132 participantes. A prevalência de noctúria foi 71,2% e, de duas ou mais micções, 56,8%. Houve associação de menor escolaridade (OR: 0,260 [0,106;0,637], p=0,003), incontinência urinária mista (OR: 2,533 [1,103;5,817], p=0,028) e três ou mais comorbidades (OR: 3,105 [1,340;7,196], p=0,008) com maior chance de noctúria. Menor escolaridade (OR: 0,324 [0,148;0,709], p=0,005), menor consumo de cafeína (OR: 0,995 [0,990;1,000], p=0,041) e síndrome da bexiga hiperativa (OR: 2,761 [1,189;6,409], p=0,018) mostraram-se associadas a uma maior chance de duas ou mais micções.

Conclusões

Na população atendida em serviços especializados, a prevalência de noctúria foi semelhante à da população em geral e à de serviços semelhantes, mas a prevalência de duas ou mais micções foi superior. Mostrou-se importante a busca ativa de noctúria em mulheres com comorbidades, em especial três ou mais, e a adequada compensação das mesmas no manejo do sintoma.

Palavras-Chave:
Noctúria; Sintomas do Trato Urinário Inferior; Saúde da Mulher

INTRODUCTION

Nocturia is defined by the International Continence Society (ICS) as the number of voids during the main sleep period. Each void should be followed by a period of sleep or the intention to sleep¹1 Hashim H, Blanker MH, Drake MJ, Djurhuus JC, Meijlink J, Morris V, et al. International Continence Society (ICS) report on the terminology for nocturia and nocturnal lower urinary tract function. Neurourol Urodyn. 2019;38(2):499-508. Disponível em: https://doi.org/10.1002/nau.23917
https://doi.org/10.1002/nau.23917... . Studies on the impact of nocturia on quality of life (QoL), however, suggest that the symptom becomes significant from two voids onward²2 Kupelian V, Wei JT, O’Leary MP, Norgaard JP, Rosen RC, McKinlay JB. Nocturia and Quality of Life: Results from the Boston Area Community Health Survey. Eur Urol. 2012;61(1):78-84. Disponível em: https://doi.org/10.1016/j.eururo.2011.05.065
https://doi.org/10.1016/j.eururo.2011.05... .

According to a population-based study conducted in the United States of America, the prevalence of two or more episodes of nocturia in women reaches 46.6% in those aged 80 years or older, and the prevalence increases with age³3 Daugherty M, Ginzburg N, Byler T. Prevalence of Nocturia in United States Women: Results From National Health and Nutrition Examination Survey. Female Pelvic Med Reconstr Surg. 2021;27(1):e52-8. Disponível em: https://doi.org/10.1097/SPV.0000000000000792
https://doi.org/10.1097/SPV.000000000000... . In a study conducted in the same country involving patients from urology services with a mean age of 57.3 years, the prevalence of nocturia in women was 41.5%, and of two or more episodes, 14.3% ⁴4 Clemens JQ, Wiseman JB, Smith AR, Amundsen CL, Yang CC, Bradley MS, et al. Prevalence, subtypes, and correlates of nocturia in the symptoms of Lower Urinary Tract Dysfunction Research Network cohort. Neurourol Urodyn. 2020;39(4):1098-107. Disponível em: https://doi.org/10.1002/nau.24338
https://doi.org/10.1002/nau.24338... .

In a population-based study conducted among Colombian women, the prevalence of nocturia was 60.4%, and of two or more voids, 19.9% ⁵5 Azuero J, Santander J, Trujillo CG, Caicedo JI, Zuluaga L, Becerra AM, et al. Potential associations of adult nocturia. Results from a national prevalence study. Neurourol Urodyn. 2021;40(3):819-28. Disponível em: https://doi.org/10.1002/nau.24624
https://doi.org/10.1002/nau.24624... . In the LUTS Brazil study, the prevalence of two or more voids in women aged 40 and older was 32.4%. This, the largest study on the prevalence of lower urinary tract symptoms (LUTS) ever conducted in the country, was a population-based study that did not include the population of the state of Rio de Janeiro⁶6 Soler R, Gomes CM, Averbeck MA, Koyama M. The prevalence of lower urinary tract symptoms (LUTS) in Brazil: Results from the epidemiology of LUTS (Brazil LUTS) study. Neurourol Urodyn. 2018;37(4):1356-64. Disponível em: https://doi.org/10.1002/nau.23446
https://doi.org/10.1002/nau.23446... . The study by Cruz et al.⁷7 Cruz R, Garcia-Rosa M, Faria C. Prevalence and associated factors in community-dwelling subjects - a population-based study. Rev Assoc Med Bras. 2020;66(6):830-7. Disponível em: https://doi.org/10.1590/1806-9282.66.6.830
https://doi.org/10.1590/1806-9282.66.6.8... was a population-based study conducted in Niterói (RJ) and found, in women, a prevalence of nocturia of 68.4% and of two or more voids, 49%.

Regarding the morbidity and mortality associated with nocturia, the literature suggests an increased risk of nocturia in women with anxiety and depression and a higher risk of falls and fractures among those with nocturia⁸8 Madhu C, Coyne K, Hashim H, Chapple C, Milsom I, Kopp Z. Nocturia: risk factors and associated comorbidities; findings from the EpiLUTS study. Int J Clin Pract. 2015;69(12):1508-16. Disponível em: https://doi.org/10.1111/ijcp.12727
https://doi.org/10.1111/ijcp.12727... ,⁹9 Everaert K, Hervé F, Bower W, Djurhuus JC, Dmochowski R, Fine N, et al. How can we develop a more clinically useful and robust algorithm for diagnosing and treating nocturia? ICI-RS 2017. Neurourol Urodyn. 2018;37(S4):S46-59. Disponível em: https://doi.org/10.1002/nau.23569
https://doi.org/10.1002/nau.23569... . The risk of death within the next five years in individuals over 60 years old with nocturia is higher compared to non-nocturia sufferers¹⁰10 Pesonen JS, Cartwright R, Vernooij RWM, Aoki Y, Agarwal A, Mangera A, et al. The Impact of Nocturia on Mortality: A Systematic Review and Meta-Analysis. J Urol. 2020;203(3):486-95. Disponível em: https://doi.org/10.1097/JU.0000000000000463
https://doi.org/10.1097/JU.0000000000000... . Additionally, there is an association between the number of episodes of nocturia and absenteeism from work, leading to impaired work capacity¹¹11 Bliwise DL, Wagg A, Sand PK. Nocturia: A Highly Prevalent Disorder With Multifaceted Consequences. Urology. 2019;133:3-13. Disponível em: https://doi.org/10.1016/j.urology.2019.07.005
https://doi.org/10.1016/j.urology.2019.0... .

Historically, nocturia has been attributed, more specifically in women, to overactive bladder (OAB) syndrome. In recent years, there has been growing recognition that nocturia can be caused by a wide spectrum of factors. Additionally, concerning lower urinary tract dysfunctions, an increase in post-void residual volume can be mentioned, whether caused by infravesical obstruction or detrusor underactivity. Regarding other causes, they involve the mechanism of global polyuria or nocturnal polyuria and are associated with alterations in water and sodium homeostasis, such as diabetes mellitus (DM), chronic kidney disease (CKD), heart failure, chronic venous insufficiency (CVI), and obstructive sleep apnea (OSA)¹²12 Everaert K, Hervé F, Bosch R, Dmochowski R, Drake M, Hashim H, et al. International Continence Society consensus on the diagnosis and treatment of nocturia. Neurourol Urodyn. 2019;38(2):478-98. Disponível em: https://doi.org/10.1002/nau.23939
https://doi.org/10.1002/nau.23939... .

Daugherty et al.³3 Daugherty M, Ginzburg N, Byler T. Prevalence of Nocturia in United States Women: Results From National Health and Nutrition Examination Survey. Female Pelvic Med Reconstr Surg. 2021;27(1):e52-8. Disponível em: https://doi.org/10.1097/SPV.0000000000000792
https://doi.org/10.1097/SPV.000000000000... , in a population-based study, identified an association of body mass index (BMI) of 30 kg/m²2 Kupelian V, Wei JT, O’Leary MP, Norgaard JP, Rosen RC, McKinlay JB. Nocturia and Quality of Life: Results from the Boston Area Community Health Survey. Eur Urol. 2012;61(1):78-84. Disponível em: https://doi.org/10.1016/j.eururo.2011.05.065
https://doi.org/10.1016/j.eururo.2011.05... or higher, urgency urinary incontinence (UUI), depression, systemic arterial hypertension (SAH), arthritis, and OSA with nocturia. Nevertheless, Yow et al.¹³13 Yow HY, Tiong JJL, Mai CW, Van Der Werf E, Zainuddin ZM, Toh CC, et al. Prevalence of nocturia among community-dwelling adults: a population-based study in Malaysia. BMC Urol. 2021;21(1):95. Disponível em: https://doi.org/10.1186/s12894-021-00860-1
https://doi.org/10.1186/s12894-021-00860... demonstrated associations with DM, CKD, and OAB syndrome. According to Madhu et al⁸8 Madhu C, Coyne K, Hashim H, Chapple C, Milsom I, Kopp Z. Nocturia: risk factors and associated comorbidities; findings from the EpiLUTS study. Int J Clin Pract. 2015;69(12):1508-16. Disponível em: https://doi.org/10.1111/ijcp.12727
https://doi.org/10.1111/ijcp.12727... ., there are associations with asthma, hysterectomy, menopause, uterine prolapse, urinary tract infection (UTI), irritable bowel syndrome, and cardiovascular disease.

In Brazil, Cruz et al.⁷7 Cruz R, Garcia-Rosa M, Faria C. Prevalence and associated factors in community-dwelling subjects - a population-based study. Rev Assoc Med Bras. 2020;66(6):830-7. Disponível em: https://doi.org/10.1590/1806-9282.66.6.830
https://doi.org/10.1590/1806-9282.66.6.8... identified an association between black skin color, increased risk of OSA, and the use of calcium channel blockers and nocturia, indicating that the symptom may be related to the effect of medications and reinforcing the complexity of its management in a context of multiple comorbidities and polypharmacy.

Considering the high prevalence of nocturia, its negative impact on survival and QoL, and the lack of specific studies with the female population with LUTS in Brazil, the present study investigated the prevalence and factors associated with nocturia in a sample of this population.

METHODS

The present study is an observational cross-sectional survey, individualized, and hospital-based. The research is in accordance with Resolution number 466/2012 and Resolution number 510/2016. The study, titled "Nocturia: etiology and impact on quality of life in users of the Unified Health System" (SUS - Sistema Único de Saúde), was approved by the Research Ethics Committee of the Faculdade de Medicina of the Universidade Federal Fluminense (opinion 5286801), with consent from the Research Ethics Committee of the Centro Universitário Arthur Sá Earp Neto (UNIFASE). All participants signed the Informed Consent Form.

The sample was convenience-based, consisting of women with LUTS attending the Urogynecology outpatient clinics of the Hospital Universitário Antônio Pedro (HUAP) and UNIFASE between 2021 and 2022. Women with preserved cognitive capacity were included, while those under 18 years of age, currently pregnant, with a history of pelvic radiotherapy, surgery for pelvic cancer, or neurological disease were excluded.

Anamnesis and physical examination were conducted as part of comprehensive gynecological evaluation, and the risk of OSA was estimated, given that it is a cause of nocturia and there is significant difficulty in access to polysomnography for patients attending both outpatient clinics.

The sociodemographic data analyzed included: data collection location – Niterói and Petrópolis (cities located in the state of Rio de Janeiro); age, dichotomized as under 60 years and 60 years or older; and education level, dichotomized as up to incomplete primary education and complete primary education or higher.

Regarding lifestyle variables, caffeine consumption was estimated by quantifying the consumption of coffee, mate, cocoa powder, soda, and chocolate, while tobacco consumption was estimated in packs/year¹⁴14 Pacheco AHDRN, Araujo DMR, Lacerda EMDA, Kac G. Consumo de cafeína por grávidas usuárias de uma Unidade Básica de Saúde no município do Rio de Janeiro. Rev Bras Ginecol Obstet. 2008;30(5):232-40. Disponível em: https://doi.org/10.1590/S0100-72032008000500005
https://doi.org/10.1590/S0100-7203200800... . Both were treated as continuous quantitative variables.

In the anamnesis, we sought to identify the presence of symptoms of pelvic floor dysfunctions. The main LUTS investigated was nocturia. Two possibilities were considered as outcomes of nocturia: one or more voids (nocturia 1), according to the definition of the ICS, and two or more voids (nocturia 2), due to a greater impact on QoL.

The other LUTS evaluated were: stress urinary incontinence (SUI), UUI, mixed urinary incontinence (MUI), OAB syndrome, hesitancy, slow stream, sensation of incomplete bladder emptying, and post-voiding incontinence. The other pelvic floor dysfunction symptoms evaluated were pelvic organ prolapse (POP), fecal incontinence, and constipation, defined by the Bristol stool scale and a frequency of less than three bowel movements per week¹⁵15 Aziz I, Whitehead WE, Palsson OS, Törnblom H, Simrén M. An approach to the diagnosis and management of Rome IV functional disorders of chronic constipation. Expert Rev Gastroenterol Hepatol. 2020;14(1):39-46. Disponível em: https://doi.org/10.1080/17474124.2020.1708718
https://doi.org/10.1080/17474124.2020.17... . The ICS¹⁶16 InternationaI Continence Society [Internet]. ICS Glossary; [acesso em 13 set 2023];[1 tela]. Disponível em: https://www.ics.org/glossary
https://www.ics.org/glossary... standardized nomenclature was used for defining LUTS and other pelvic floor dysfunctions.

In addition to pelvic floor dysfunctions, other comorbidities were investigated, namely: history of recurrent UTI, SAH, DM, heart failure, CKD, CVI, anxiety/depression, and other comorbidities. Anxiety and depression were addressed together, as they are often associated, and many participants were unable to provide precise diagnoses¹⁷17 Wilson H, Mannix S, Oko-osi H, Revicki DA. The Impact of Medication on Health-Related Quality of Life in Patients with Generalized Anxiety Disorder. CNS Drugs. 2015;29(1):29-40.Disponível em: https://doi.org/10.1007/s40263-014-0217-8
https://doi.org/10.1007/s40263-014-0217-... . The risk of OSA was assessed using the validated Portuguese version of the STOP-BANG questionnaire, which, for the analyses, was dichotomized into low and intermediate/high risk categories¹⁸18 Fonseca LBDM, Silveira EA, Lima NM, Rabahi MF. STOP-Bang questionnaire: translation to Portuguese and cross-cultural adaptation for use in Brazil. J bras pneumol. 2016;42(4):266-72. Disponível em: https://doi.org/10.1590/S1806-37562015000000243
https://doi.org/10.1590/S1806-3756201500... . Considering that the study was conducted in reference centers, which serve individuals with a high number of comorbidities, the variable was dichotomized into up to two comorbidities and three or more.

Among medications, the use of antidepressants, diuretics, calcium channel blockers, benzodiazepines, angiotensin II receptor blockers, beta-blockers, hypoglycemic agents, insulin, and angiotensin-converting enzyme inhibitors was investigated. Polypharmacy was considered as the concurrent use of five or more drugs¹⁹19 Delara M, Murray L, Jafari B, Bahji A, Goodarzi Z, Kirkham J, et al. Prevalence and factors associated with polypharmacy: a systematic review and meta-analysis. BMC Geriatr. 2022;22(1):601. Disponível em: https://doi.org/10.1186/s12877-022-03279-x
https://doi.org/10.1186/s12877-022-03279... .

During the physical examination, the body mass index (BMI) was calculated, with different cutoff points for participants under 60 years of age and those 60 years or older, and stratified into underweight/eutrophic, overweight, and obesity. The first two categories were grouped together due to the small number of participants underweight and because overweight and obesity are more relevant in evaluating nocturia²⁰20 Protocolo do Sistema de Vigilância Alimentar e Nutricional (SISVAN) [Internet]. Brasília, DF:Ministério da Saúde; 2008; [acesso em 28 ago 2023];[1 tela]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/protocolo_sistema_vigilancia_alimnetar.pdf
https://bvsms.saude.gov.br/bvs/publicaco... . POP was staged using the Pelvic Organ Prolapse Quantification (POP-Q) system. The anterior, posterior, and apical compartments of the POP-Q were stratified into up to stage II and from stage III onwards.

Frequency distribution tables were prepared for the sociodemographic, clinical, and lifestyle characteristics of the participants, and joint distribution tables were created for the outcomes of nocturia according to each of these characteristics.

Univariate logistic regression models were adjusted to estimate the odds of presenting one or more voids (nocturia 1) and two or more voids (nocturia 2). The explanatory variables considered in the statistical modeling were the sociodemographic, clinical, and lifestyle characteristics of the patients. For all univariate logistic regression models, crude odds ratios were estimated, along with their respective 95% confidence intervals and p-values from the Wald test.

Regarding the modeling strategy, only variables with an association with the outcome of nocturia in univariate analysis with a p-value ≤ 0.20 were considered in the multivariate analysis. Only variables that had a statistical association with the outcome (p-value ≤ 0.05) were kept in the multivariate analysis. It should be noted that in the multivariate analysis, non-significant variables were excluded in decreasing order of their p-value until obtaining a model with all significant variables at the 5% level. Adjusted odds ratios were estimated for these variables, along with their respective 95% confidence intervals.

DATA AVAILABILITY

The entire dataset supporting the findings of this study is available upon request to the corresponding author, Ingrid Antunes da Silva.

RESULTS

A total of 132 participants were included in the study, as shown in Tables 1 and 2. Of these, 71.2% had one or more voids, and 56.8% had two or more voids. 52.3% of the participants were aged 60 years or older, 45.5% had not completed elementary education, and 66.7% had three or more comorbidities.

For the outcome of nocturia defined as one or more voids, the multivariate analysis included education level, constipation assessed by the Bristol stool scale, recurrent UTI, DM, number of comorbidities, use of hypoglycemic agents, risk of OSA, MUI and OAB syndrome. At a significance level of 5%, the following variables remained associated with the likelihood of the patient having one or more voids: education level, number of comorbidities, and MUI.

In the multivariate analysis, patients with incomplete elementary education had approximately four times higher odds of presenting one or more voids (nocturia 1) compared to patients with at least completed elementary education (OR: 1/0.260 = 3.8; p-value = 0.003).

Patients with three or more comorbidities had approximately three times higher odds of presenting one or more voids compared to patients with up to two comorbidities (OR: 3.105; p-value = 0.008).

Patients with MUI had a 2.5 times higher chance of experiencing nocturia 1 (one or more voids) compared to those without MUI (OR: 2.533; p-value = 0.028) (Table 3).

For the outcome of nocturia defined as two or more voids, the multivariate analysis included age, education level, sensation of incomplete bladder emptying, fecal incontinence, constipation assessed by the Bristol scale, DM, number of comorbidities, use of antidepressants, oral hypoglycemic agents, and insulin, risk of OSA, SUI, MUI, OAB syndrome and caffeine consumption. In the selected multivariate logistic model, it can be observed that education level, OAB syndrome, and caffeine consumption remained associated with this outcome of nocturia.

Patients with incomplete elementary education had approximately three times higher odds of presenting two or more voids (nocturia 2) compared to patients with at least completed elementary education (OR: 1/0.324 = 3.1; p-value = 0.005).

Patients with OAB syndrome had approximately 2.8 times higher odds of presenting two or more voids compared to those without OAB syndrome (OR: 2.761; p-value = 0.018).

Regarding caffeine consumption, it is observed that for each 1 mg/day increase in caffeine consumption, there is a 0.5% reduction in the odds of the patient presenting two or more voids (OR: 0.995; p-value = 0.041) (Table 4).

DISCUSSION

The prevalence of nocturia defined as one or more voids (71.2%) was similar to that found in women in studies conducted in the general population in Salvador (BA) (71.2%) and in Niterói (RJ) (68.4%)⁷7 Cruz R, Garcia-Rosa M, Faria C. Prevalence and associated factors in community-dwelling subjects - a population-based study. Rev Assoc Med Bras. 2020;66(6):830-7. Disponível em: https://doi.org/10.1590/1806-9282.66.6.830
https://doi.org/10.1590/1806-9282.66.6.8... ,²²22 Moreira ED, Neves RCS, Neto AF, Duarte FG, Moreira TL, Lobo CFL, et al. A Population-based survey of lower urinary tract symptoms (LUTS) and symptom-specific bother: results from the Brazilian LUTS epidemiology study (BLUES). World J Urol. 2013;31(6):1451-8. Disponível em: https://doi.org/10.1007/s00345-013-1057-8
https://doi.org/10.1007/s00345-013-1057-... . Additionally, the prevalence of two or more voids (56.8%) was higher than that found in both studies and in the LUTS Brazil study (36.5%, 49%, and 32.4%, respectively)⁶6 Soler R, Gomes CM, Averbeck MA, Koyama M. The prevalence of lower urinary tract symptoms (LUTS) in Brazil: Results from the epidemiology of LUTS (Brazil LUTS) study. Neurourol Urodyn. 2018;37(4):1356-64. Disponível em: https://doi.org/10.1002/nau.23446
https://doi.org/10.1002/nau.23446... .

Such difference can be explained by the higher proportion of participants aged 60 years or older (52.3%) compared to other studies (20.8%, 43.3%, and 39.5%, respectively), as the prevalence of nocturia increases with age³3 Daugherty M, Ginzburg N, Byler T. Prevalence of Nocturia in United States Women: Results From National Health and Nutrition Examination Survey. Female Pelvic Med Reconstr Surg. 2021;27(1):e52-8. Disponível em: https://doi.org/10.1097/SPV.0000000000000792
https://doi.org/10.1097/SPV.000000000000... .

Additionally, unlike the mentioned population-based studies, participants attended in a university service usually have a higher number of comorbidities and are carriers of other LUTS, both factors associated with nocturia.

Nevertheless, Clemens et al.⁴4 Clemens JQ, Wiseman JB, Smith AR, Amundsen CL, Yang CC, Bradley MS, et al. Prevalence, subtypes, and correlates of nocturia in the symptoms of Lower Urinary Tract Dysfunction Research Network cohort. Neurourol Urodyn. 2020;39(4):1098-107. Disponível em: https://doi.org/10.1002/nau.24338
https://doi.org/10.1002/nau.24338... , evaluating American women in reference outpatient clinics, also observed lower prevalence rates of nocturia (49% for one void per night and 16.5% for at least two voids). This discrepancy may be partly related to different methods of assessing the number of nocturia episodes, which was self-reported by participants in the present study and assessed through a three-day voiding diary in the United States. Additionally, a higher level of education and income in that country may have contributed to a lower prevalence of nocturia.

Participants with education up to incomplete elementary level had a 74% higher chance of presenting one or more voids and a 68% higher chance of presenting two or more voids. Similarly, Cruz et al.⁷7 Cruz R, Garcia-Rosa M, Faria C. Prevalence and associated factors in community-dwelling subjects - a population-based study. Rev Assoc Med Bras. 2020;66(6):830-7. Disponível em: https://doi.org/10.1590/1806-9282.66.6.830
https://doi.org/10.1590/1806-9282.66.6.8... found nearly twice the chance of individuals with up to four years of education presenting two or more voids compared to those with five or more years of education. Daugherty et al.³3 Daugherty M, Ginzburg N, Byler T. Prevalence of Nocturia in United States Women: Results From National Health and Nutrition Examination Survey. Female Pelvic Med Reconstr Surg. 2021;27(1):e52-8. Disponível em: https://doi.org/10.1097/SPV.0000000000000792
https://doi.org/10.1097/SPV.000000000000... also found an association between lower education level and nocturia. Education level can serve as a marker for income level, as household expenses may lead to dropout rates, or as a marker for access to basic services such as education and healthcare. Reduced access to the healthcare system may influence the diagnosis and management of comorbidities associated with nocturia.

OAB syndrome was associated with a 2.8 times higher chance of experiencing two or more episodes of nocturia. OAB syndrome reduces nocturnal bladder capacity, which can be assessed through a voiding diary where information such as voiding times and volumes are recorded²³23 Nguyen LN, Randhawa H, Nadeau G, Cox A, Hickling D, Campeau L, et al. Canadian Urological Association best practice report: Diagnosis and management of nocturia. Can Urol Assoc J. 2022;16(7):E336-E349. Disponível em: https://doi.org/10.5489/cuaj.7970
https://doi.org/10.5489/cuaj.7970... . Additionally, the coexistence of OAB syndrome and other LUTS is common. Chan et al.²⁴24 Chan G, Qu LG, Gani J. Urodynamic findings in patients with nocturia and their associations with patient characteristics. Can Urol Assoc J. 2022;16(9):E455-E460. Disponível em: https://doi.org/10.5489/cuaj.7792
https://doi.org/10.5489/cuaj.7792... evaluated urodynamic studies conducted on 213 women with complaints of nocturia and identified, in 28% of cases, the simultaneous presence of detrusor overactivity, which may be present in OAB syndrome, and detrusor underactivity, a condition that can reduce bladder capacity due to elevated post-void residual.

The presence of MUI, characterized by the concomitance of UUI and SUI, was associated with a 2.5 times higher chance of experiencing one or more voids. UUI is one of the possible symptoms of OAB syndrome. OAB syndrome, in turn, has a complex pathophysiology and has been classified into different phenotypes, with the phenotype of interest being related to variation in urethral pressure during the bladder storage phase, which also presents with SUI²⁵25 Peyronnet B, Mironska E, Chapple C, Cardozo L, Oelke M, Dmochowski R, et al. A Comprehensive Review of Overactive Bladder Pathophysiology: On the Way to Tailored Treatment. Eur Urol. 2019;75(6):988-1000. Disponível em: https://doi.org/10.1016/j.eururo.2019.02.038
https://doi.org/10.1016/j.eururo.2019.02... . Since no association was found between pure SUI and nocturia, the association between MUI and nocturia may be due to a high prevalence of this phenotype in the studied population.

The presence of three or more comorbidities was associated with a nearly three times higher chance of experiencing one or more episodes of nocturia. In 2019, 23.9% of Brazilians who responded to the National Health Survey reported having SAH, and 7.7% reported having DM, two of the most prevalent comorbidities²⁶26 Gondim FSS, Campos MO, Flores TR, França GVAD, Medeiros ACD. Pesquisa Nacional de Saúde 2019: avanço no monitoramento da saúde dos brasileiros. Epidemiol Serv Saúde. 2022;31(spe1):e2021309. Disponível em: https://doi.org/10.1590/SS2237-9622202200001.especial
https://doi.org/10.1590/SS2237-962220220... . The loss of physiological nocturnal blood pressure dipping is related to a higher risk of nocturia²⁷27 Reyes PBG, Butcher K, Cotterill N, Drake MJ, Gimson A, Gogola L, et al. Implications of Cardiovascular Disease for Assessment and Treatment of Nocturia in Primary Care: Systematic Review and Nominal Group Technique Consensus. Eur Urol Focus. 2022;8(1):26-32. Disponível em: https://doi.org/10.1016/j.euf.2021.12.014
https://doi.org/10.1016/j.euf.2021.12.01... . Furthermore, DM can lead to glucosuria and increased urinary output if poorly controlled, as well as lower urinary tract dysfunctions²⁸28 Dawson S, Duncan L, Ahmed A, Gimson A, Henderson EJ, Rees J, et al. Assessment and Treatment of Nocturia in Endocrine Disease in a Primary Care Setting: Systematic Review and Nominal Group Technique Consensus. Eur Urol Focus. 2022;8(1):52-59. Disponível em: https://doi.org/10.1016/j.euf.2021.12.008
https://doi.org/10.1016/j.euf.2021.12.00... .

The consumption of caffeine showed a slight protective effect, with a reduction of 0.5% in the chance of presenting nocturia for each additional milligram consumed daily. In contrast to the findings of the present study, Le Berre et al.²⁹29 Le Berre M, Presse N, Morin M, Larouche M, Campeau L, Hu YX, et al. What do we really know about the role of caffeine on urinary tract symptoms? A scoping review on caffeine consumption and lower urinary tract symptoms in adults. Neurourol Urodyn. 2020;39(5):1217-33. Disponível em: https://doi.org/10.13140/RG.2.2.15502.31045
https://doi.org/10.13140/RG.2.2.15502.31... conducted a scoping review on caffeine consumption and LUTS in adults and found a trend of benefit in reducing caffeine consumption in LUTS overall. However, there is a scarcity of evidence regarding the specific effect of caffeine on nocturia, as well as the need to improve study designs to reduce the possibility of biases and standardize outcomes. Potential outcomes include the presence or worsening of mechanisms such as global polyuria and reduced bladder capacity based on data collected in voiding diaries.

Some limitations of the study should be acknowledged. Given the convenience sampling in specialty outpatient clinics, the prevalence of LUTS may be higher than in the general population. It was not possible to study the association of postmenopausal atrophy with nocturia, as a significant percentage of participants had a history of hysterectomy, making it difficult to determine the timing of menopause. The considered comorbidities were those reported by the patients, which may have introduced some imprecision in the prevalence of certain comorbidities. Additionally, it was not possible to classify participants as having compensated or decompensated diabetes, nor diagnose early-stage CKD, known to be associated with nocturia³⁰30 Ridgway A, Cotterill N, Dawson S, Drake MJ, Henderson EJ, Huntley AL, et al. Nocturia and Chronic Kidney Disease: Systematic Review and Nominal Group Technique Consensus on Primary Care Assessment and Treatment. Eur Urol Focus. 2022;8(1):18-25. Disponível em: https://doi.org/10.1016/j.euf.2021.12.010
https://doi.org/10.1016/j.euf.2021.12.01... .

Nonetheless this study constitutes a still limited group of Brazilian studies on the prevalence of nocturia and gains special relevance due to the largest national study on LUTS until then, the LUTS Brazil project, not having collected data from the state of Rio de Janeiro. Additionally, it is one of the first in the country to address factors associated with nocturia. In this sense, it investigated a wide diversity of associations, including sociodemographic, clinical, and lifestyle factors. Such an approach contributes to understanding which factors are most associated with nocturia in the Brazilian population, providing a basis for the development of approach protocols for women with LUTS.

Nocturia has an increasing prevalence in women as age increases and is associated with a greater number of comorbidities, which is also more common in elderly individuals. Therefore, it is essential for all professionals serving the elderly population, especially those with lower levels of education, to actively seek the presence of nocturia.

The treatment of comorbidities and the investigation of LUTS and the risk of OSA, with appropriate referral of individuals to specialized centers, can contribute to reducing the number of episodes of nocturia.

CONCLUSIONS

The prevalence of nocturia was consistent with Brazilian studies conducted in the general population and with a North American study conducted in a population treated in specialized LUTS outpatient clinics, while the prevalence of two or more voids was higher. Factors associated with a greater chance of presenting nocturia included lower education level, lower daily caffeine intake, OAB syndrome, MUI, and the presence of three or more comorbidities.

Consequently, it is highly relevant for all healthcare professionals serving the elderly population to investigate the presence of nocturia, aiming to implement measures to minimize its impact on QoL and mortality. Moreover, the identification of sociodemographic, clinical, and lifestyle factors associated with nocturia, carried out in a pioneering manner in a sample of the Brazilian population, can provide insights for the development of protocols for addressing women with LUTS.

New studies involving elderly individuals from the general population and the performance of laboratory tests to identify clinical conditions or decompensation of diseases that may lead to nocturia are necessary, as well as research on the impact of this symptom on QoL.

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