Nocturia and insomnia in a middle-aged male
History
For the past 6 months, John has been waking up 3-4 times per night to urinate. He reports difficulty falling back asleep after these episodes, often lying awake for 30-60 minutes. John estimates he gets only 5-6 hours of fragmented sleep per night. He feels tired and irritable during the day and has started taking afternoon naps.
Past Medical History
- Hypertension (controlled on lisinopril)
- Type 2 diabetes (diet-controlled)
- Benign prostatic hyperplasia (BPH)
Medications
- Lisinopril 10 mg daily
- Tamsulosin 0.4 mg daily for BPH
Social History
John is a non-smoker and drinks 1-2 glasses of wine with dinner. He typically goes to bed around 10 PM and gets up at 6 AM.
Physical Examination
- Blood pressure: 132/78 mmHg
- BMI: 27 kg/m²
- Unremarkable cardiopulmonary exam
- Mild enlargement of the prostate on digital rectal exam
What could John be suffering from and what do you recommend?
Assessment
John may be suffering from concurrent insomnia and nocturia. His nocturia is likely multifactorial, potentially related to his BPH, diabetes, and hypertension medication [1][2]. The insomnia may be both a cause and consequence of his nocturia, creating a vicious cycle of sleep disruption [3].
Obstructive sleep apnoea is a potential cause of John’s symptoms, and he has several risk factors. When you mention this, John says his wife doesn’t complain of him snoring.
Plan
- Sleep diary: John will keep a 2-week sleep and voiding diary to better assess his sleep patterns and nocturia frequency.
- Urinalysis and post-void residual: To rule out urinary tract infection and assess bladder emptying.
- HbA1c: To evaluate diabetes control.
- Review of medication timing: Consider moving lisinopril to morning if currently taken at night.
- Sleep hygiene education: Limit fluid intake in the evening, avoid caffeine and alcohol before bedtime, and maintain a consistent sleep schedule.
- Referral to urology: For further evaluation of BPH and potential medication adjustment.
- Consider cognitive behavioral therapy for insomnia (CBT-I) if sleep issues persist after addressing nocturia.
- Consider polysomnography for investigation of sleep disordered breathing.
Follow-up
John will return in 4 weeks to review his sleep diary and test results. If nocturia and insomnia persist, further interventions such as medication changes or referral to a sleep specialist may be considered [4].
This case highlights the complex interplay between nocturia and insomnia in older adults, emphasizing the need for a comprehensive approach to diagnosis and management.
Related courses
- Managing sleep to optimise men’s health
- Maximising male health: healthy living and the sleep advantage
References
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4055528/
[2] https://www.nature.com/articles/s41598-023-36707-y
[3] https://www.sleepmedres.org/journal/view.php?number=165
[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4877310/
Associate Professor Tim Moss BSc PhD is Health Content Manager at Healthy Male and holds an adjunct appointment in the Department of Obstetrics and Gynaecology at Monash University. He is listed among the top 2% of most influential scientists of all time in the field of obstetrics and reproductive medicine.
Tim joined Healthy Male in 2020 after 25 years of working in academia and medical research. Tim learned science communication at the Alan Alda Centre for Science Communication and the School of Journalism at Stony Brook University, and the SciComm Lab in the Department of Engineering at Massachusetts Institute of Technology.
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