Reviewed June 2019
Always need to pee at night? Lifestyle changes to help nocturia
Chances are, you’ve had to get up in the night to go to the loo before. While this is common among women, nocturia is defined as having to wake up from sleep once or more in one night due to the need to urinate.1 Even though waking up to pee even just once a night falls under the definition, it is usually considered significant if you have two or more such episodes per night.
Sometimes needing to pee at night may simply be due to certain lifestyle habits and sometimes there may be an underlying medical or urological condition. For this reason, it’s important to figure out why you have nocturia. Nocturia may occur when your body produces too much urine (polyuria), when an excess proportion of urine is excreted at night (nocturnal polyuria), or when the bladder just can’t hold it (reduced functional bladder capacity).
In order to determine what may be causing your nocturia, maintaining a bladder diary is helpful. Keep records for two to three days of what you drink, the amount you drink, and time you drink it, as well as the amount of urine passed, and at what time you had to wake up to urinate. This will help you and your doctor figure out what is going on. There are also certain lifestyle changes you can make to manage your nocturia and help you better understand your body.
Why do we urinate?
The human body tries to maintain the body fluid volume and concentration (osmolality) within a normal range using various mechanisms in which the kidneys and the anti-diuretic hormone (ADH) play major roles. Urination is important for removal of waste products and excess water from the body. The kidneys filter about 180 litres of fluid per day, but 99% or more of it is reabsorbed by the kidneys into the body, producing a urine volume of only about one litre per day.2 ADH acts in the kidneys to increase water reabsorption, which makes concentrated urine.
Caffeine, alcohol and prescription drugs
Drinking too much water, unsurprisingly, leads to increased urine production. So drinking less for several hours before you go to sleep can reduce or prevent nocturia. What you drink matters, too — alcohol and caffeinated drinks are known to cause increased urine production (diuresis). Alcohol is believed to cause diuresis by reducing ADH secretion from the pituitary gland.3 Caffeine acts in the kidney and increases the amount of fluid which filters through it. It also reduces sodium reabsorption by the kidneys, which impedes the water reabsorption as well. This increased filtration of fluid (more fluid present) and reduced sodium reabsorption (hinders water from being reabsorbed) leads to diuresis.4 So, cut down the intake of alcohol and caffeinated drinks, especially during the evening, to help reduce nocturia.
There are certain drugs collectively known as diuretics, used for conditions such as high blood pressure, heart failure, and liver disease, which act by causing diuresis — as the name suggests. Furosemide, thiazides, and spironolactone are some commonly used diuretics. Most diuretic drugs act on different sites in the kidney and cause reduced reabsorption of sodium, which leads to an increased urine output. Each drug has a different onset and duration of action. So if nocturia is a problem for you, discuss an ideal time to take the drug with your doctor, so that it causes minimal action at night.
Can nocturia be linked to anxiety and depression?
Nocturia is believed to be associated with mental health issues like anxiety and depression. Research evidence suggests a bidirectional association between depression and nocturia, but the link between anxiety and nocturia is less clear.5 Although the exact mechanism is not known, it is sometimes attributed to the fact that women with depression and anxiety often have sleep disturbances, and when they wake up from sleep, they make a bathroom trip to urinate. In this case it’s not the need to empty the bladder which wakes them up, hence it is not true nocturia. This occurs in other causes of poor sleep, like stress and ongoing pain. Resolving the primary issue with sleep may prevent night time urination in these cases. Try out breathing exercises, aromatherapy, or meditation to calm and relax your mind before sleep. Avoid late evening naps and heavy meals at night which may interfere with sleep.
Feelings of anxiety and depression can be brought on by a complex combination of hormonal, lifestyle, and emotional factors that can be tricky to identify and address. If you are experiencing persistent depressive symptoms, be sure to consult your GP for further advice as they may be able to recommend specific therapies that could help you, or work with you to help determine the cause.
Ageing, menopause, and nocturia
Women are more likely to experience nocturia as they get older. Among the numerous causative factors related to ageing some are specific to women. For one, the lack of oestrogen following menopause weakens the bladder and urethra.6 Around the same time, many women experience pelvic organ prolapse (protruding of pelvic organs into the vagina). Damage to pelvic floor muscles during previous vaginal child birth may predispose some women to this, and with the loss of hormonal support it becomes more evident after menopause. These may lead to urinary symptoms like nocturia and urinary incontinence. Practising pelvic floor exercises at home is helpful, while hormone replacement and surgery for prolapse may provide definitive relief.
Does my diet have anything to do with it?
Even though more emphasis is given to beverages, diet too can have an effect on nocturia. Recent research has found that reducing the salt content in diet can lead to reduced nighttime urination.7 Although scientific evidence is lacking, some food items like chocolate and artificial sweeteners are known to act as bladder irritants which may cause nocturia.8 It’s best to modify your diet accordingly, and see whether avoiding these items helps to relieve your symptoms.
Could it be due to an underlying medical condition?
Nocturia is associated with medical conditions like heart failure, cirrhosis (irreversible scarring of the liver), and nephrotic syndrome (a kidney disease). All these conditions lead to retention of fluid in the body and this excess fluid leaks out of the blood vessels and gets collected in various spaces in the body, most commonly causing swelling of feet and legs. When you lie down, this position leads to mobilisation of this pooled fluid back into the blood vessels.9 This increases blood flow to the kidneys at night, so that more water is filtered through the kidneys, causing diuresis. Simple measures like having naps in the afternoon, keeping the legs elevated during daytime, and wearing compression stockings are helpful to minimise this fluid accumulation, and thereby reduce nocturia.
Shortness of breath even during light exercise and when lying down, and cough with pink phlegm which wakes you up at night may indicate heart failure. Loss of appetite, easy bruising, itchy and yellow discolouration of skin may be features of cirrhosis. Swelling mainly around eyes and foamy urine may be due to nephrotic syndrome. Hence, in the presence of these associated symptoms it’s important to seek medical opinion for definite diagnosis and management.
Diabetes mellitus (often referred to as diabetes) is a common condition which leads to nocturia. In fact, it is one of the common presentations of undiagnosed diabetes, along with increased thirst and weight loss. When blood glucose levels are high, excess glucose is passed with urine, and more glucose in the urine stimulates more water to be passed with it. Good control of your blood glucose level is important for reduction of nocturia in this case. Diabetes insipidus — a rare condition where a large amount of urine is passed, and you often feel thirsty — is another cause for nocturia where either ADH is deficient or kidneys are insensitive to ADH, and treatment depends on the particulars of your condition.
In obstructive sleep apnoea, when one tries hard to breathe despite an airway blockage, there is a negative pressure build up within the chest cavity. That stretches the heart, releasing a hormone called atrial natriuretic peptide which causes diuresis.10 Weight reduction and sleeping on one’s side are beneficial basic measures to manage this.
Even though some may find it embarrassing, nocturia is a common condition and it can be very distressing. Often, simple lifestyle changes are the first line treatment for nocturia. However, it’s important to remember that nocturia is only a symptom, and not a diagnosis, so it is important to visit your GP who will be able to advise you on the best course of action.
Last updated June 2019
Next update due 2021
- Fine, N.D., Nocturia: consequences, classification, and management, F1000 Research, September 2017, vol 6: 1627, [online], https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5583737/ (accessed 2 July 2019)
- Barrett, E., et al., Ganong’s Review of Medical Physiology, 23rd edn., New Delhi, Mcgraw Hill, 2009, p 646
- Hobson, R.M., and Maughan, R.J., Hydration status and the diuretic action of a small dose of alcohol, Alcohol and Alcoholism, July-August 2010, vol 45, issue 4, pp 366-373
- Marx et al., ‘Mechanisms of diuretic effect of caffeine’, médecine/sciences, vol. 32, no. 5, 2016, pp. 485-490.
- Breyer, N., et al., ‘The Association of Depression, Anxiety and Nocturia: A Systematic Review’, The Journal of Urology, Vol. 190, no. 3, 2013, pp. 953-957.
- Dantas Varella, L.R., et al., Assessment of lower urinary tract symptoms in different stages of menopause, Journal of Physical Therapy Science, November 2016, vol 28, issue 11, pp 3116-3121
- Matsuo, T., et al., Effect of salt intake reduction on nocturia in patients with excessive salt intake, Neurourology and Urodynamics, February 2019, vol 38, issue 3, pp 927-933
- Wyman, J.F., et al., Practical aspects of lifestyle modifications and behavioural interventions in the treatment of overactive bladder and urgency urinary incontinence, International Journal or Clinical Practice, July 2009, vol 63, issue 8, pp 1177-1191
- The British Association of Urological Surgeons (BAUS), Nocturnal Polyuria, June 2017, Leaflet 16/021
- Ichioka, M., et al., Changes of circulating atrial natriuretic peptide and antidiuretic hormone in obstructive sleep apnea syndrome, Respiration, 1992, vol 59, pp 164-168