ORIGINAL ARTICLE: EPIDEMIOLOGY,CLINICAL PRACTICE AND HEALTH

Nocturia among elderly men living in a rural area in Egypt,and its impact on sleep quality and health-related qualityof life

Tomader Taha Abdel Rahman1 and Maha Mohammed El Gaafary2

1Geriatrics Department, and 2Community Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Aim: Nocturia is such a commonplace occurrence in the lives of many older adults that it is frequently overlookedas a potential cause of sleep disturbance. The aim of the present study was to evaluate the prevalence of nocturiaamong elderly men living in a rural area in Egypt, and its impact on sleep quality and health-related quality of life(HRQoL).

Method: This was a cross-sectional study. A total of 1200 elderly men participated in the survey. The PittsburghSleep Quality Index (PSQI) Arabic version and the short form-36 (SF-36) were used in this survey.

Results: The prevalence of nocturia in the studied participants (≥1 void/night) was 63.5%. With the criterion (≥2voids/night) the prevalence was 46.0%. Multivariate logistic regression analysis showed that nocturia is an indepen-dent risk factor of poor sleep quality (OR 5.08), and poor sleep is an independent risk factor of the poor physicalcomponent of QoL (OR 17.6) and the mental component of QoL (OR 3.2).

Conclusion: Nocturia is widely prevalent among elderly men living in a rural area in Egypt. The adverse effect ofnocturia on QoL is related to poor sleep. Geriatr Gerontol Int 2014; 14: 613–619.

Keywords: Egyptian, nocturia, prevalence, QoL, sleep quality.

Introduction

Among the elderly population, the phenomenon ofnightly awakenings for bathroom trips has become socommonplace that it can essentially be considered acultural “norm” or expectation. Multiple, overlappingcauses of nocturia in the aged population have beendescribed, including loss of bladder capacity, decreasedglomerular filtration rate, and nocturnal polyuria fromdecreased arginine vasopressin, incipient diabetes, con-gestive heart failure and/or diuretic use. Despite suchelucidation of underlying mechanisms, the significanceof nocturia for disturbed sleep remains unclear.1

Sleep is a vital element in a human’s general health.However, sleep can lose its “healing” function, espe-cially through aging. Sleep in the elderly is characterizedby less restorative sleep and more frequent awakenings.

One of the main causes of sleep impairment in thispopulation, besides aging, is nocturia. The lack of sleepas a result of frequent nocturnal awakenings can havedeleterious effects on general health status. Frequentnocturnal awakenings might induce diminished vitality,increased susceptibility for diseases, impaired cognitiveperformance, depression, sleep-related accidents onthe road and at work, and even a higher mortalityrate. Furthermore, patients who have nocturia have anincreased risk for falls and fractures; especially theelderly, who often already have impaired motor andcognitive functioning.2 Impairment of sleep as a result ofnocturia might not only result in daytime fatigue, butcould also enhance symptoms associated with comorbidchronic diseases. Improvement of nocturia in thesepatients will not only result in an increase in sleepquality, but it might also aid in reducing some symp-toms associated with chronic diseases.3 Hence, nocturiashould not be seen as just an age-related problem, butconsidering the substantial impact it can have on thequality of sleep and quality of life, it should be recog-nized as a condition that needs to be taken seriously.4

Therefore, the aim of the present study was to evalu-ate the prevalence of nocturia among elderly men living

Accepted for publication 25 July 2013.

Correspondence: Dr Tomader Taha Abdel Rahman MD, AinShams University Hospitals, Geriatrics Department, AbbasseaSquare, Cairo, Egypt, Post code: 11331 Cairo, Egypt. Email:tomelhagyn@hotmail.com

Geriatr Gerontol Int 2014; 14: 613–619

bs_bs_banner

© 2013 Japan Geriatrics Society doi: 10.1111/ggi.12145 | 613

in a rural area in Egypt, and its impact on sleep qualityand health-related quality of life (HRQoL).

Method

Design

The present study was a cross-sectional study. Theelderly men were given a survey privately in a personalinterview at their homes. The survey was carried outbetween January and December 2012. Older adults withpoor cognitive function were excluded from the survey.The present study was approved by the Ethical ReviewCommittee of Ain Shams University.

Participants

All elderly people (aged 60 years or more) living inNabarooh (a rural area in Daqahliyah governorate,Egypt) were invited to participate in the present survey,but we could not carry out interviews with women livingin this rural area to assess if there was a gender differ-ence because of Egyptian traditions and rituals in ruralareas. A total of 1200 elderly men participated, 31elderly men did not respond and seven elderly men wereexcluded because of poor cognitive function. Accordingto the Central Agency for Public Mobilization and Sta-tistics (CAPMAS), Daqahliyah is Egypt’s fourth popu-lous governorate with a population 5.6 million. InNabarooh, the total population is 55 265. There are3150 older adults, and 1238 of those are male.5

Definition

Nocturia is defined by the International ContinenceSociety as the interruption of sleep one or more times atnight to void,6 lasting for more than 6 months.

Survey instruments

All participants were subjected to the following afterthey gave consent: complete history taking (includingwhen nocturia started occurring and history of restlessleg syndrome), American Urological Association (AUA)symptom index,7 Geriatric Depression Scale (GDS),8

Pittsburgh Sleep Quality Index (PSQI) Arabic version9

and the short form-36 (SF-36).10

AUA7 has developed a questionnaire (AUA symptomindex) to help men determine how bothersome theirurinary symptoms are. This questionnaire was used inthe present survey to assess the history of nocturia andits frequency.

GDS8 is a 30-item self-reported assessment used toidentify depression in elderly. A normal score is 0–9.

The PSQI Arabic version9 is a questionnaire used toassess sleep quality and disturbances over a 1-month

time interval. A total of 19 individual items generateseven “component” scores. The sum of the scores forthese seven components yields one global score. A totalscore ≤5 is associated with good sleep quality.

SF-3610 is a 36-item questionnaire that measuresquality of life (QoL) across eight domains, which areboth physically and emotionally based. For eachdomain, a score ranging from 0 (worst measured health)to 100 (best measured health) was calculated. Scoreson the eight SF-36 scales were further aggregatedto produce physical component summary (PCS) andmental component summary (MCS) measurements ofhealth status. The PCS and MCS were also scored usingnorm-based methods according to the participants’ ageand sex.11

Data management and statistical analysis

Data were collected and analytical statistics were carriedout. The χ2-test was used to test the association betweencategorical variables. Student’s t-test was used tocompare the two groups’ means. Multivariate logisticregression analysis was carried out in the present study.All proposed factors to be introduced for multivariateanalysis, beside that they were all biologically plausible,were significant according to the findings obtained fromthe field data analysis. The level of significance wastaken at P < 0.050. All statistical manipulation wascarried out using the 15th version of SPSS (SPSS,Chicago, IL, USA).

Results

The present study included 1200 elderly men aged60 years and older. A total of 420 participants aged60–64 years, 360 participants aged 65–69 years, 270participants aged 70–74 years, 132 participants aged75–79 years and 18 participants aged 80 years and older.A total of 6.5% were educated >12 years, 15 % had 6–12education years, 32.5% were educated <6 years and therest were illiterate. In regard to marital status, 72.5%were married, 18.5% were widowed, 6% were divorcedand 3% were single. A total of 32.5% of participantswere diabetic, 55.5% were hypertensive, 23.5% hadischemic heart disease (IHD), 5% had heart failure, 6%had chronic obstructive pulmonary disease (COPD),5% were asthmatic, 1% had a previous history of stroke,29% had benign prostatic hyperplasia (BPH), 10.5%had a history of recurrent urinary tract infection (UTI),1% had a history of prostatectomy, 3% had chronickidney disease (CKD), 1% were incontinent, 39.5% hadconstipation, 1.5% had history of cancer, 3% hadchronic liver disease (CLD), 41.5% had visual impair-ment, 10% had hearing impairment, 3.5% weredepressed, 44.5% had osteoarthritis and 14% were

TT Abdel Rahman and MM El Gaafary

614 | © 2013 Japan Geriatrics Society

using diuretics. In the studied population, 22.5% weresmokers, 3.5% drank alcohol, 45% drank tea, 25%drank coffee, no one was taking psychoactive medica-tions and no one had a history of restless leg syndrome.

The prevalence of nocturia in the studied populationaccording to the definition by the International Conti-nence Society (≥1 void per night) was 63.5% (Table 1).

There were significant associations between nocturiaand age (P = 0.012), sleep quality (P = 0.003), PCS(P = 0.000) and MCS (P = 0.000). Also, there were sig-nificant associations between nocturia and participantswith comorbidities, such as diabetes mellitus (DM;P = 0.002), heart failure (P = 0.026), stroke (P = 0.038),BPH (P = 0.004), recurrent UTI (P = 0.005) and diureticusage (P = 0.009; Table 2).

The relationship between sleep quality and thestudied risk factors, assessed by univariate analysis,showed a significant association between sleep qualityand nocturia (P = 0.003), IHD (P = 0.004), BPH(P = 0.000), recurrent UTI (P = 0.009), diuretic usage(P = 0.005), and arthritis (P = 0.010). All significant andborderline significant (P-value ≤0.1) variables in the uni-variate analyses were introduced for multivariate logisticbinary regression analysis. The included model satisfiedthe highest likelihood ratio.

Multivariate logistic regression analysis showed thatnocturia (OR 5.08) and IHD (OR 3.5) were the inde-pendent risk factors for poor sleep quality in the studiedpopulation (Table 3).

The relationship between PCS and the studied riskfactors, assessed by univariate analysis, showed a sig-nificant association between PCS and sleep quality(P = 0.000), nocturia (P = 0.000), DM (P = 0.004), IHD(P = 0.000), heart failure (P = 0.002), COPD (P = 0.007),and arthritis (P = 0.000). Also, the relationship betweenMCS and the studied risk factors, assessed by univariateanalysis, showed a significant association between MCSand sleep quality (P = 0.036), nocturia (P = 0.000), DM(P = 0.002), IHD (P = 0.008), BPH (P P = 0.000), andrecurrent UTI (P = 0.009). All significant and borderlinesignificant variables in the univariate analyses wereintroduced for multivariate logistic regression analysis.It was shown that poor sleep quality (OR 17.6), DM (OR3.2) and IHD (OR 2.0) were the independent risk factorsfor poor PCS in the studied population. Also, poor sleepquality (OR 3.2), DM (OR 2.5) and IHD (OR 3.0) were

the independent risk factors for poor MCS in thestudied population (Table 4).

Discussion

Nocturia is a common condition, particularly in olderadults. In previous studies, the prevalence of nocturia(≥1 void/night) was reported in men to be 26.0–78.0%.12–14 When nocturia was defined as ≥2 voids/night, the prevalence in men was 23.0–60.0%.13–17 Theoverall prevalence of nocturia in the present study, asdefined by the International Continence Society (≥1void/ night), was 63.5%. With the criterion of ≥2 voids/night, the prevalence of nocturia was 46.0%. Compari-sons between prevalence studies of nocturia might bedifficult because of different definitions, researchdesigns and population samples. Early prevalencestudies used varied definitions of nocturia and whatmight constitute a problem, whereas later studies haveconformed to the International Continence Societydefinition.18

Clinical observations have shown that some chronicillnesses are associated with nocturia. The Tikkinenet al. study reported that being overweight or obese,having coronary artery disease or diabetes in womenand obesity in men, were significantly associated withnocturia in Finland.19 The Gourova et al. study showedthat cardiovascular disease, hypertension, diabetesmellitus/insipidus and cerebrovascular disease wereindependent risk factors for nocturia in men aged55–75 years in the Netherlands.20 The Boston AreaCommunity Health study showed that nocturia was sig-nificantly associated with an increasing body massindex, type 2 diabetes, cardiac disease and diureticsuse.21 However, in a community-dwelling elderly popu-lation study carried out in Sweden, there was no corre-lation between nocturia, and known and treatedhypertension, angina pectoris, congestive heart failureor diabetes mellitus.13 A similar finding was also notedby a Dutch study that nocturia was not associated withcardiovascular symptoms, hypertension or diabetesmellitus in men.22

In the present study, in addition to age – which has asignificant association with nocturia – several chronicillnesses were significantly associated with nocturia,such as DM, HF, stroke, BPH, UTI and diuretic usage.

Diabetes mellitus is significantly associated with noc-turia. The result is congruent with numerous previousstudies,19–21,23–25 but a few studies have disagreed.13,22 Theosmotic diuresis and global polyuria induced by hyper-glycemia in diabetes patients have been shown to be themajor causes of urinary storage symptoms.26 Thus, it islogical to hypothesize that the association between theeffects of hyperglycemia might, at least in part, affect theoccurrence of nocturia. In addition, the lack of arginine

Table 1 Prevalence of nocturia among elderly menliving in a rural area in Egypt

Positiven (%)

Negativen (%)

Nocturia ≥1 void per night 762 (63.5) 438 (36.5)Nocturia ≥2 voids per night 552 (46.0) 648 (54.0)

Nocturia, sleep quality and HRQoL

© 2013 Japan Geriatrics Society | 615

vasopressin (AVP) secretion and renal AVP resistanceinduced by diabetes might play a crucial role.27

Some earlier epidemiological studies reported signifi-cant associations of heart disease with nocturia,19–21

whereas others did not.13–23 A recent study carried outby Chiu et al. showed that patients with chronic heartfailure suffer from three or more episodes of nocturia, ascompared with the controls.28 Possible reasons, such aspostural diuresis at night or nocturnal polyuria as aresult of an increase in the atrial natriuretic peptide(ANP),29 could account for the association.

The relationship between stroke and nocturia is notwell established. There was a study that rejected theassociation of nocturia with stroke.23 However, a previ-ous study carried out by Asplund showed that strokewas significantly associated with nocturia.25 Also,Brittain et al. reported that stroke survivors had a higherprevalence of nocturia than the non-stroke popula-tion.30 The associations of stroke with nocturia could bepartially explained by the lack of the normal nocturnalrise of plasma AVP in the post-stroke patient,31 and theuninhibited detrusor contractions secondary to theneurogenic defect. However, the actual mechanismsbetween them are not completely clear.

BPH is often associated with problematic symptoms,such as nocturia, frequency, a sensation of not com-pletely emptying the bladder and a need to urinate soonafter voiding.7 This is due to detrusor hyperactivity.

UTI is a common presentation to urologists andfamily doctors. A UTI episode is always associated withnocturia.32 This is as a result of uninhibited detrusorcontractions secondary to inflammation.

Sleep is a vital element in a human’s general health. Inthe present study, multivariate logistic regression analy-sis identified that older adults complaining of nocturiaare fivefold more likely to develop poor sleep quality (i.e.getting a PSQI score more than 5) than those who arenot complaining of nocturia, and this ratio rangesbetween 2 and 13. As well as this, elderly patients withIHD are 3.5-fold more likely to develop poor sleep

Table 2 Relationship between nocturia and participants, comorbidities

NocturiaNegative(n = 438)

Positive(n = 762)

P-value

n % n %

DM Positive 66 16.9 324 83.1 0.002Hypertension Positive 186 27.9 480 72.1 0.168IHD Positive 72 25.5 210 74.5 0.277Heart failure Positive 0 0.0 60 100.0 0.026COPD Positive 12 16.7 60 83.3 0.240Bronchial asthma Positive 6 10.0 54 90.0 0.126Stroke Positive 0 0.0 12 100.0 0.038BPH Positive 60 17.2 288 82.8 0.004Recurrent UTI Positive 6 4.8 120 95.2 0.005Prostatectomy Positive 0 0.0 12 100.0 0.330CKD Positive 12 33.3 24 66.7 0.943Depression Positive 18 42.9 24 57.1 0.531Cancer Positive 6 33.3 12 66.7 0.960CLD Positive 12 33.3 24 66.7 0.943Diuretic usage Positive 18 10.7 150 89.3 0.009Arthritis Positive 156 29.2 378 70.8 0.449

BPH, benign prostatic hyperplasia; CKD, chronic kidney disease; CLD, chronic liverdisease; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; IHD,ischemic heart disease; UTI, urinary tract infection.

Table 3 Multivariate logistic regression model todetect independent risk factors affecting sleep quality

Sleep qualityP-value Odds ratio

(95.0% CI)

Nocturia 0.001 5.08 (1.901–13.478)IHD 0.003 3.5 (1.563–6.918)BPH 0.998 1.001 (0.276–3.625)Recurrent UTI 0.387 0.354 (0.034–3.618)Cancer 0.905 0.035 (0.000–5.973)Depression 0.689 0.000 (0.000–3.042)Diuretic usage 0.293 0.410 (0.078–2.158)Arthritis 0.085 0.513 (0.261–1.097)

BPH, benign prostatic hyperplasia; CI, confidence interval;IHD, ischemic heart disease; UTI, urinary tract infection.

TT Abdel Rahman and MM El Gaafary

616 | © 2013 Japan Geriatrics Society

quality than those without IHD ranging between 1.5-fold and sevenfold. Donald et al. reported that poorsleep was related to nocturia independently of othermedical conditions.33 Whereas Foley et al. showed thatsleep disturbances are related to cardiovascular diseases,such as IHD.34 It is not surprising that IHD can give riseto poor sleep quality because of nocturnal angina, asthere is a direct relationship between quality of sleepand pain.35 It has also been found that the use of betablockers, which are prescribed for patients with IHD,causes sleep disorders and nightmares as adverseeffects.36

Although nocturia has been shown to be “bother-some”, its true effect on HRQoL has not beenadequately assessed. Seki et al. reported an associationof nocturia with a reduced general QoL.36 This associa-tion was based on univariate analysis. In the presentstudy, this association was also reported based on uni-variate analysis. In multivariate logistic regression analy-sis, nocturia was reported not to be an independent riskfactor of poor HRQoL. Introducing both nocturia andsleep quality to multivariate regression for estimation oftheir independent effects on QoL showed that nocturiahad an insignificant P-value and an odds ratio of almost1; this means that it is not an independent risk factor forpoor QoL. Nocturia and sleep quality are covariates,they are significantly interrelated. Introducing both ofthem in the model for detection of QoL risk factorsshowed sleep quality to be the predominant factoraffecting QoL. Nocturia affects QoL through its effecton sleep quality, and the latter (sleep quality) has anindependent effect on QoL. Older adults complainingof poor sleep quality are 17.6-fold and 3.2-fold more

likely to develop poor PCS and MCS respectively (i.e.getting PCS and MCS scores less than the norms forage and sex) than those not complaining of poor sleepquality. This agrees with Van Dijk et al., who studied therelationship between nocturia, sleep quality and QoL,and reported that the adverse effect of nocturia on QoLis related to sleep disorders,37 and disagrees with otherstudies that suggest that sleep disturbance and nocturiaaffect QoL independently.38

The present study showed that older adults com-plaining of DM are 3.2-fold and 2.5-fold more likelyto develop poor PCS and MCS of QoL respectivelythan those not suffering from DM. DM is a chronicdisease. It has a negative impact on an individual’sperception of well-being and QoL. The ongoing threatof complications can be worrisome and depressing,and the impact of long-term complications leads tomajor changes in a patient’s ability to function in dailylife.39

The current study found that older adults complain-ing of IHD are twofold and threefold more likely todevelop poorer PCS and MCS of QoL, respectively,than those not complaining of IHD. A major conse-quence of IHD is its effect on QoL, when patients mustlimit their everyday tasks in an effort to prevent anginaattacks. The pain and anticipation of pain frequentlyprevents patients from pursuing hobbies and otheractivities that were once an enjoyable part of their lives.40

A limitation of the present study was that we couldnot carry out interviews with women living in this ruralarea to assess if there is gender difference. This limita-tion was a result of Egyptian traditions and rituals inrural areas.

Table 4 Multivariate logistic regression model to detect independent risk factors affecting quality of life

Physical component summary of QoL Mental component summary of QoLP-value Odds ratio (95.0% CI) P-value Odds ratio (95.0% CI)

Sleep <0.001 17.6 (5.420–57.201) 0.003 3.2 (1.521–6.914)Nocturia 0.981 0.995 (0.632–1.568) 0.630 1.033 (0.686–1.979)AUA symptom index 0.495 0.962 (0.861–1.074) 0.920 1.012 (0.885–1.121)Diabetes 0.001 3.2 (1.601–6.423) 0.013 2.5 (1.276–5.231)Hypertension 0.415 0.723 (0.328–1.576) 0.928 0.001 (0.000–4.259)IHD 0.002 2.001 (0.236–8.979) 0.003 3.047 (0.330–13.150)Heart Failure 0.525 0.196 (0.069–0.558) 0.326 0.111 (0.027–0.467)COPD 0.356 0.459 (0.085–2.471) 0.199 0.265 (0.047–1.236)Stroke 0.678 0.002 (0.000–0.333) 0.067 0.390 (0.142–1.069)BPH 0.235 0.539 (0.200–1.433) 0.098 0.419 (0.149–1.177)Recurrent UTI 0.479 1.712 (0.429–7.136) 0.148 3.185 (0.662–15.310)Visual impairment 0.112 0.546 (0.260–1.150) 0.998 1.102 (0.000–8.029)Depression 0.345 0.457 (0.086–2.470) 0.762 0.001 (0.000–1.300)Arthritis 0.138 0.576 (0.261–1.189) 0.330 0.681 (0.278–1.485)

AUA, American Urological Association; BPH, benign prostatic hyperplasia; CI, confidence interval; COPD, chronic obstructivepulmonary disease; IHD, ischemic heart disease; UTI, urinary tract infection.

Nocturia, sleep quality and HRQoL

© 2013 Japan Geriatrics Society | 617

As nocturia causes sleep insufficiency, and a resultingdecrease in PCS and MCS of QoL, patients who consulta doctor for nocturia should be treated adequately. Forthe same reason, it is worthwhile for doctors to rou-tinely check if patients who contact them for sleepingdisorders also have nocturia.

We can conclude that nocturia is widely prevalentamong elderly men living in a rural area in Egypt.Elderly men who felt bothered by at least one void/nighthad more sleep problems and a poorer QoL than thosewith no nocturia. The adverse effect of nocturia on QoLis related to poor sleep.

Disclosure statement

The authors declare no conflict of interest.

References

1 Miller M. Nocturnal polyuria in older people: pathophysi-ology and clinical implications. J Am Geriatr Soc 2000; 48:1321–1329.

2 Asplund R. Nocturia: consequences for sleep and daytimeactivities and associated risks. Eur Urol Suppl 2005; 3 (6):24–32.

3 Schneider T, Stanley N. Impact of nocturia on sleep andenergy. Eur Urol Suppl 2007; 6: 585–593.

4 Tikkinen KA, Johnson TM, Tammela TL et al. Nocturiafrequency, bother, and quality of life: how often is toooften? A population-based study in Finland. Eur Urol 2010;57: 488–498.

5 Central Agency for Public Mobilization and Statistics(CAPMAS). General Population and Housing Censuses.Final Report. Cairo, Egypt, 2006.

6 Van Kerrebroeck P, Abrams P, Chaikin D et al. The stan-dardization of terminology in nocturia: report from thestandardization subcommittee of the International Conti-nence Society. BJU Int 2002; 90 (3): 11–15.

7 Barry MJ, Fowler FJ Jr, O’Leary MP et al. The AmericanUrological Association symptom index for benign prostatichyperplasia. The Measurement Committee of the Ameri-can Urological Association. J Urol 1992; 148: 1549–1557.

8 Sheikh JA, Yesavage JA. Recent Finding and Development of aShorter Version. In Brinn TL(Ed).Clinical Gerontology: A Guideto Assessment and Intervention. New York: Hawarth Press,1992.

9 Suleiman KH, Yates BC, Berger AM, Pozehl B, Meza J.Translating the Pittsburgh Sleep Quality Index into Arabic.West J Nurs Res 2010; 32: 250–268.

10 Ware JE, Kosinski M, Gandek B. SF-36 ® Health Survey:Manual & Interpretation Guide. Lincoln, RI: Quality MetricIncorporated, 1993; 2000.

11 Ware JE, Kosinski M, Keller SK. SF-36 Physical and MentalHealth Summary Scales: A User’s Manual. Boston, MA: TheHealth Institute, New England Medical Center, 1994.

12 Van Dijk L, Kooij DG, Schellevis FG. Nocturia in theDutch adult population. BJU Int 2002; 90: 644–648.

13 Rembratt A, Norgaard JP, Andersson KE. Nocturia andassociated morbidity in a community-dwelling elderlypopulation. BJU Int 2003; 92: 726–730.

14 Seim A, Hoyo C, Ostbye T, Vatten L. Prevalence andcorrelates of nocturia in men – a large community basedstudy. Neurourol Urodyn 2003; 22: 451. Abstract 63.

15 Blanker MH, Bohnen AM, Groeneveld FP, Bernsen RM,Prins A, Ruud Bosch JL. Normal voiding patterns anddeterminants of increased diurnal and nocturnal voidingfrequency in elderly men. J Urol 2000; 164: 1201–1205.

16 Chute CG, Panser LA, Girman CJ et al. The prevalence ofprostatism: a population-based survey of urinary symp-toms. J Urol 1993; 150: 85–89.

17 Tan HY, Choo WC, Archibald C, Esuvaranathan K. Acommunity based study of prostatic symptoms in Singa-pore. J Urol 1997; 157: 890–893.

18 Myeong HJ, Du GM. Practical management of nocturia inurology. Indian J Urol. 2008; 24: 289–294.

19 Tikkinen KA, Auvinen A, Johnson TM et al. A systematicevaluation of factors associated with nocturia–thepopulation-based FINNO study. Am J Epidemiol 2009; 1(170): 361–368.

20 Gourova LW, van de Beek C, Spigt MG, Nieman FH, vanKerrebroeck PE. Predictive factors for nocturia in elderlymen: a cross-sectional study in 21 general practices. BJUInt 2006; 97: 528–532.

21 Fitzgerald MP, Litman HJ, Link CL, McKinlay JB. Theassociation of nocturia with cardiac disease, diabetes, bodymass index, age and diuretic use: results from the BACHsurvey. J Urol 2007; 177: 1385–1389.

22 Blanker MH, Bernsen RM, Ruud Bosch JL et al. Normalvalues and determinants of circadian urine production inolder men: a population based study. J Urol 2002; 168 (4 Pt1): 1453–1457.

23 Yoshimura K, Terada N, Matsui Y, Terai A, Kinukawa N,Arai Y. Prevalence of and risk factors for nocturia: analysisof a health screening program. Int J Urol 2004; 11: 282–287.

24 Hsieh CH, Chen HY, Hsu CS, Chang ST, Chiang CD.Risk factors for nocturia in Taiwanese women aged 20–59years. Taiwan J Obstet Gynecol 2007; 46: 166–170.

25 Asplund R. Nocturia in relation to sleep, somatic diseasesand medical treatment in the elderly. BJU Int 2002; 90:533–536.

26 Daneshgari F, Liu G, Birder L, Hanna-Mitchell AT,Chacko S. Diabetic bladder dysfunction: current transla-tional knowledge. J Urol 2009; 182 (6 Suppl): S18–S26.

27 Schneider T, de la Rosette JJ, Michel MC. Nocturia: anonspecific but important symptom of urological disease.Int J Urol 2009; 16: 249–256.

28 Chiu AF, Liao CH, Wang CC, Wang JH, Tsai CH, KuoHC. High classification of chronic heart failure increasesrisk of overactive bladder syndrome and lower urinary tractsymptoms. Urology 2012; 79: 260–265.

29 Aydur E, Dmochowski R. Medical conditions associatedwith nocturia. In: Weiss JPP, Blaivas JGG, Van KerrebroeckPEVEV, Wein AJJ, eds. Nocturia. New York: Springer,2012; 11–36.

30 Brittain KR, Perry SI, Peet SM et al. Prevalence and impactof urinary symptoms among community-dwelling strokesurvivors. Stroke 2000; 31: 886–891.

31 Sakakibara R, Uchiyama T, Liu Z et al. Nocturnal polyuriawith abnormal circadian rhythm of plasma arginine vaso-pressin in post-stroke patients. Intern Med 2005; 44: 281–284.

32 Shawn D, Jeyapandy TD, Anil K. Guidelines for the diag-nosis and management of recurrent urinary tract infectionin women. Can Urol Assoc J 2011; 5: 316–322.

33 Donald LB, Daniel JF, Michael VV. Nocturia and dis-turbed sleep in the elderly. Sleep Med 2009; 10: 540–548.

34 Foley D, Ancoli-Israel S, Britz P, Walsh J. Sleep distur-bances and chronic disease in older adults: results of the2003 National Sleep Foundation Sleep in America Survey.J Psychosom Res 2004; 56: 497–502.

TT Abdel Rahman and MM El Gaafary

618 | © 2013 Japan Geriatrics Society

35 Ahmed AI, van Mierlo P, Jansen P. Sleep disorders, night-mares, depression and anxiety in an elderly patient treatedwith low-dose metoprolol. Gen Hosp Psychiatry 2010; 32:646.e5–646.e7.

36 Seki N, Yunoki T, Tomoda T, Takei M, Yamaguchi A,Naito S. Association among the symptoms, quality of lifeand urodynamic parameters in patients with improvedlower urinary tract symptoms following a transurethralresection of the prostate. Neurourol Urodyn 2008; 27: 222–225.

37 Van Dijk L, Kooij DG, Schellevis FG, Kaptein AA, BoonTA, Wooning M. Nocturia: impact on quality of life in aDutch adult population. BJU Int 2004; 93: 1001–1004.

38 Zhang X, Zhang J, Chen J et al. Prevalence and risk factorsof nocturia and nocturia-related quality of life in theChinese population. Urol Int 2011; 86: 173–178.

39 Gautam Y, Sharma AK, Agarwal AK, Bhatnagar MK,Trehan RR. A Cross-sectional Study of QOL of DiabeticPatients at Tertiary Care Hospitals in Delhi. Indian J Com-munity Med 2009; 34: 346–350.

40 Trujillo TC, Dobesh PP. Traditional management ofchronic stable angina. Pharmacotherapy 2007; 27: 1677–1692.

Nocturia, sleep quality and HRQoL

© 2013 Japan Geriatrics Society | 619