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The reported incidence after radi- cal prostatectomy varies greatly pregnancy stages cabergoline 0.5 mg cheap, from 5% to over 60% (305) women's health clinic grafton order cheapest cabergoline, depending on the surgical technique pregnancy magazine order cabergoline 0.5 mg on line, the definition of incontinence and how it is quantified (306–307) menopause upset stomach cheap cabergoline express, who performs the evaluation of the incontinence (physician or patient) (308–309), and (because of spontaneous improvement) the time between the surgery and the evaluation. However, at 12 months post-surgery, the prevalence of incontinence is probably about 15%–20% (310). But importantly, this study provides a prospective assessment of the risk of relatively strictly defined incontinence, which seems to be about 15% after 1 year. However, it should be noted that even this definition does not strictly identify all men who are completely dry. It is also important to note that many studies report post-operative continence at 1 to 2 years. Patients who required a daily safety pad were significantly more regretful of their decision than patients who were completely dry. The true incidence of incontinence and voiding dysfunction after external beam radiotherapy and brachytherapy must take into account the morbidity associated with the occurrence and treatment. Perhaps androgen depriva- tion causes apoptosis of the external sphincter, leading to incontinence. Detrusor overactivity seen pre-operatively was not responsible for any case of incontinence post-operatively. Therefore, no pre- operative bladder function parameters predicted post–radical prostatectomy incontinence. Urethral pressure measures done pre-operatively do not seem to consistently predict continence after radical prostatectomy. Furthermore, at 6 weeks it was significantly lower in incontinent patients (11 ± 9 cm H2O) than in continent patients (35 ± 6 cm H2O); at 6 months, the corresponding figures were 23 ± 6 cm H2O and 42 ± 9 cm H2O, respectively. Those with low pre- operative values run a greater risk of not regaining continence after the radical prostatectomy. Several authors have reported on imaging parameters that may predict post-operative continence after radical prostatectomy. Most have studied incontinent patients, but a few have compared continent and incontinent patients. These comparisons of incontinent and continent patients suggest that intrinsic sphincter deficiency is a major contributor to post-prostatectomy incontinence. The majority of the literature is based on urodynamic observations in incontinent patients only (although some patients are difficult to classify because the authors use terms that are non-standard or use terms in non-standard ways). These studies showed that the prevalence of urodynamic stress incontinence ranges from 88% to 100%. Ficazzola and Nitti (331) also showed that the symptom of stress incontinence had a 95% positive predicative value and a 100% negative predicative value for the diagnosis of urodynamic stress incontinence. Three studies have shown a relatively high incidence of impaired bladder contractility or detrusor underactivity in men after radical prostatectomy. It is not clear however, that these men truly have impaired contractility (presumed to be a result of surgery) vs. Another recent retrospective study showed no increased risk of post-operative urinary retention after slings in men with a urodynamic diagnosis of impaired contractility; it should be noted, however, that selection bias cannot be ruled out, due to the retro- spective nature of this study (335). While few would argue that empiric treatment of urgency incontinence with behavioural therapy and/or pharmacological treatment is unreasonable, the treatment of sphincter dysfunction usually requires surgery after conservative therapy fails. Most experts feel that it is important to rule out conditions such as impaired compliance prior to artificial urinary sphincter or sling placement. Some have argued that impaired detrusor contractility or bladder underactivity may be a risk factor for urinary retention after sling procedures, as Valsalva voiding may not be possible after sling place- ment. In spite of these considerations, temporary urinary retention is seen in 5%–36% of men treated with a male sling, with sling over-tensioning and sling malposition being the main causes (341). All of these abstracts were screened, identifying 284 papers suitable for the purpose of this review. After evaluation of the full-text publi- cations of those 284 papers, 47 papers were used for this chapter. With regard to Qmax at uroflowmetry, the same study demonstrated that patients with a baseline Qmax <10. No evidence is available regarding predictors of failure during therapy with anti–muscarinic recep- tor antagonists or phosphodiesterase type 5 inhibitors. No evidence is available regarding predictors of failure during therapy with anti–muscarinic recep- tor antagonists or phosphodiesterase type 5 inhibitors. Lower Urinary Tract Symptoms in Men: Etiology, Patient Assessment, and Predicting Outcome from Therapy 111 2. However, the study is limited by its small sample size, which might have made the statistical analysis underpowered. However, the study is limited by its short follow-up duration, and it might be hypothesized that larger significant differences might have been identified with longer follow-up. A larger absolute reduction of volume in patients with larger prostates (categorized as <30 mL vs. Lower Urinary Tract Symptoms in Men: Etiology, Patient Assessment, and Predicting Outcome from Therapy 113 Monoski et al. However, Qmax at the 1- and 6-month follow-ups in men with pre-operative detrusor underactivity was significantly lower than it was in men without (371). What are the predictive param- tative outcomes in relation to the cost of the eters of treatment success for combination procedure. Clinical data suggest that no single param- eter can accurately predict the outcome of a specific therapy. Is it possible to construct well-validated, useful nomograms based on multiple independent parameters to predict the probability of success or failure in surgi- cal therapies? Lower Urinary Tract Symptoms in Men: Etiology, Patient Assessment, and Predicting Outcome from Therapy 115 2. Lower urinary tract symptoms: Etiology, patient assessment and predicting outcome from therapy. The standardisation of terminology of lower urinary tract function: Report from the Standardisation Sub-committee of the International Continence Society. The prevalence of lower urinary tract symptoms in men and women in four centres: the UrEpik study. Lower urinary tract symptoms in young men: Videourodynamic findings and correlation with noninvasive measures. Prevalence of prostatism in Japanese men in a community-based study with comparison to a similar American study. Prevalence of lower urinary tract symptoms in men aged 45-79 years: A population-based study of 40,000 Swedish men. Worldwide prevalence estimates of lower urinary tract symptoms, overactive bladder, urinary incontinence and bladder outlet obstruction. National community prevalence of overactive bladder in the United States stratified by sex and age. Risk factors for developing lower urinary tract symptoms suggestive of benign prostatic hyperplasia in a community-based population of healthy ageing men: the Krimpen Study. The association between vascular risk factors and lower urinary tract symptoms in both sexes. Relationship of lifestyle and clinical factors to lower urinary tract symptoms: Results from Boston Area Community Health survey. Determinants of seeking of primary care for lower urinary tract symptoms: the Krimpen study in community-dwelling men. Lower Urinary Tract Symptoms in Men: Etiology, Patient Assessment, and Predicting Outcome from Therapy 117 23. The International Continence Society Benign Prostatic Hyperplasia Study Group: the bothersomeness of urinary symptoms. The International Continence Society Benign Prostatic Hyperplasia Study: Background, aims, and methodology. Impact of symptoms of prostatism on level of bother and quality of life in men in the French community. Implications of the most bothersome prostatism symptom for clinical care and outcomes research. Normal voiding patterns and determinants of increased diurnal and nocturnal voiding frequency in elderly men.

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Liver cell function can be investigated by testing how quickly the blood clots (e breast cancer under armour discount cabergoline 0.25 mg fast delivery. A Doppler ultrasound may reveal the accumulation of fat or scar tissue womens health beaver dam wi purchase cabergoline 0.25mg on line, impaired blood fow women's health clinic nowra discount cabergoline 0.25 mg without a prescription, and obstruction of bile fow in the liver menstruation explained 0.25mg cabergoline with visa. Patients with elevated liver enzyme levels should have a full evaluation of their liver by a hepatologist or pediatric hepatologist. Patients should be immunized against varicella zoster virus (unless live virus vaccines are contraindicated), hepatitis A virus, and hepatitis B virus. The levels of antibodies against these viruses should be measured to insure that the patient has acquired immunity. Drugs that are toxic to the liver, including alcohol, should be avoided when possible. Levels of fat-soluble vitamins should be monitored on a yearly basis in patients with most forms of liver disease, particularly in cases where bile fow is reduced, known as cholestatic disease. If undiagnosed chronic abdominal pain exists, endoscopy for detection of potential sources of bleeding or infection may be required. In addition, diarrhea should be evaluated to detect opportunistic organisms, optimal nutritional status should be achieved, and the liver cell injury and/or function should be evaluated (see above) prior to the transplant. Pancreatic insuffciency—a lack of digestive enzymes made by the pancreas that results in impaired food digestion—is uncommon, but should be considered in patients with poor absorption of fat. Cholestasis may lead to poor absorption of the fat-soluble vitamins A, E, D, and K; therefore, levels of these vitamins should be monitored to determine whether vitamin supplementation is needed. Physicians participating in the long-term management of these patients must be aware of this risk. Good to Know Transferrin is a protein in the body that binds and transports iron in the blood. Transferrin saturation refers to the amount of iron carried by the transferrin protein in the blood. The levels of ferritin in the blood increase as the amount of iron in the body increases. The unsaturated iron binding capacity test reveals the amount of transferrin that is not being used to transport iron. A single transfusion unit of packed red blood cells contains 200-250 mg of elemental iron. The body is unable to excrete excess iron; thus, all iron obtained via transfusions must be deposited somewhere in the body. The organs most commonly affected by iron overload include the liver, pancreas, and heart. Patients with iron overload are generally asymptomatic; fatigue is the only commonly reported symptom. Patients often have an enlarged liver, which may be discovered by physical exam, and elevated blood levels of the liver enzyme aminotransferase. Cirrhosis is a rare but irreversible complication of iron overload; therefore, it is important to prevent liver fbrosis, the scarring process 92 Chapter 4: Gastrointestinal, Hepatic, and Nutritional Problems that occurs in response to liver injury that can lead to cirrhosis. Fibrosis may occur earlier than usual in patients with viral hepatitis (particularly hepatitis C), non-alcoholic fatty liver disease, and/or alcohol abuse. Diabetes, joint pain, and heart disease are common in patients with severe iron overload and liver disease. Heart disease may include cardiomyopathy (weakening and enlargement of the heart muscle), irregular heartbeats, or heart failure. Patients receiving blood transfusions should be screened yearly for iron overload. Screening is performed using blood tests to measure transferrin saturation, ferritin, and unsaturated iron binding capacity. Patients with highly elevated blood levels of amino acids, obesity, or those suspected of chronic alcohol consumption may need a liver biopsy to detect liver disease or to determine the extent of liver injury due to other causes. Patients who develop iron overload at an early stage in their blood transfusion history or who have a family history of primary iron overload should undergo genetic testing for hemochromatosis, an inherited disorder that causes the body to absorb too much iron. Free radicals are naturally produced in the body as our cells use energy, and may be produced in response to environmental factors such as pollution. Patients with iron overload should avoid vitamins or medications containing iron and vitamin C, but do not need to restrict their consumption of foods 93 Fanconi Anemia: Guidelines for Diagnosis and Management containing iron and vitamin C. Oral chelation should be chosen and monitored in consultation with a physician with some experience with these agents. Nutrition as Therapy Complementary and alternative therapies include any treatments and practices that have not been shown to be effective by evidence-based clinical studies. Complimentary therapies are used in conjunction with standard medical care, and alternative therapies are used in place of standard medical care. Many families view food, and by extension, dietary supplements, vitamins, and micronutrients, as natural and thus safe. The multi-billion dollar industry that produces complementary/alternative nutritional regimes lacks federal regulation and has a clear incentive to promote its products regardless of the degree of evidence of the effectiveness of these products. Many complementary/alternative nutritional regimes and supplements are directly harmful or, by displacing standard medical therapy, indirectly harmful. Controlled clinical trials of 94 Chapter 4: Gastrointestinal, Hepatic, and Nutritional Problems supplements are necessary to demonstrate effectiveness and limit the risk of toxicity. Products containing iron must be avoided to reduce the risk of exacerbating iron accumulation in the liver and other tissues. Vitamin C increases iron absorption; therefore, products containing vitamin C, such as multivitamins or fortifed fruit juices/drinks should be avoided. In large studies, both vitamin A and vitamin E supplements have been associated with an increased risk of some cancers; therefore, they should be avoided until further study indicates otherwise. Large doses of omega-3 fatty acids, commonly found in fsh oil supplements, can increase the risk of bleeding due to inactivation of platelets, blood cells that mediate blood clotting. Establishing a non-judgmental, but candidly informative discussion of complementary and alternative therapies offers the physician a chance to educate parents about their choices. Physicians and families can access information about complementary/alternative nutritional therapies at the website of the Offce of Complementary and Alternative Medicine of the National Institutes of Health, available at:. Pediatric neurogastroenterology: gastrointesinal motility and functional disorders in children. Rodriguez L, Diaz J, Nurko S (2013) Safety and effcacy of cyproheptadine for treating dyspeptic symptoms in children. Westaby D, Portmann B, Williams R (1983) Androgen-related primary hepatic tumors in non-Fanconi patients. A surgical procedure that creates a functional thumb by moving the index fnger and its nerves, arteries, tendons, and muscles to the thumb position. A so-called foating thumb that lacks bones and is composed of skin and soft tissue. Children with these anomalies might have a shortened or absent thumb, radius, or both, due to incomplete growth. Therefore, it is essential that all subspecialists communicate with the primary physician, usually the hematologist/oncologist, to coordinate care. There are no standardized treatment procedures for congenital hand and arm abnormalities; treatments must be tailored to each child and family. The decision process is multi-factorial and requires participation from the family, physician team, and a physical or occupational therapist. Initial Evaluation Children born with limb abnormalities should be referred to an upper extremity specialist within the frst few months of life. This physician should be comfortable with and profcient in the diagnosis and management of congenital limb anomalies. It is important for physicians to encourage this type of conversation; otherwise, parents often seek health information via the Internet, which can be a source of misinformation. A physical or occupational therapist can offer adaptive devices or techniques to help the child accomplish these tasks. Furthermore, radial defciency— incomplete formation of the radius—is associated with numerous syndromes, further emphasizing the need for a thorough investigation (Table 1). The most common types of thumb anomalies that occur in children have been classifed into fve types depending on the degree of underdevelopment (2):.

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Musculoskeletal and connective tissue disorders: Back pain menopause 43 buy generic cabergoline 0.5mg, bone pain menopause vegas show discount cabergoline 0.5 mg on line, heaviness in extremities women's health center kearny nj cheap cabergoline 0.25mg visa, muscle spasms womens health of blairsville discount cabergoline 0.25 mg with mastercard, pain in extremity. Reproductive system and breast disorders: Breast induration, breast mass, fibrocystic breast disease, genital discharge, hot flush, pelvic pain, vaginal candidiasis, vulvovaginal dryness. Drug-Drug Interactions Substances increasing the clearance of sex hormones (diminished efficacy by enzyme induction) Substances increasing the clearance of sex hormones include phenytoin, barbituates, primidone, carbamazepine, rifampicin, and possibly also oxcarbazepine, topiramate, felbamate, griseofulvin and products containing St. After the cessation of drug therapy, enzyme induction may be sustained for about 4 weeks. Antifungal: T ↓dienogest Induction of hepatic microsomal enzymes may decrease griseofulvin plasma levels of dienogest. Sedatives and hypnotics: T ↓dienogest Induction of hepatic microsomal enzymes may decrease benzodiazepines plasma levels of dienogest. Drug-Laboratory Interactions the use of progestins may influence the results of certain laboratory tests (eg, gonadotropin, endogenous hormones). The results of certain endocrine and liver function tests may be affected by progestin-containing products:  Impaired glucose tolerance;  Reduced serum folate concentration;  Change in plasma lipoprotein levels. The results of the above laboratory tests should not be considered reliable unless therapy has been discontinued for 2 to 4 weeks. Special Populations Renal Impairment There are no data suggesting the need for a dosage adjustment in patients with renal impairment. Missed Dose In the event of a missed tablet, a patient should take 1 tablet only as soon as possible and then continue to take the next tablet at her usual time the next day. A tablet not absorbed due to vomiting or diarrhea should likewise be replaced by 1 tablet. For management of a suspected overdose please contact your regional Poison Control Centre. Despite its low affinity to the progesterone receptor, dienogest has a strong progestogenic effect in vivo. Dienogest has no significant androgenic, mineralocorticoid, or glucocorticoid activity in vivo. When given continuously, dienogest leads to a hyperprogestogenic and moderately hypoestrogenic endocrine environment causing initial decidualization of endometrial tissue. Ovarian Function In a study in 20 healthy women, a daily dose of 2 mg dienogest has been shown to induce an anovulatory state after 1 month of treatment. The pharmacokinetics of dienogest are dose-proportional and linear within the dose range of 1 to 8 mg. There is minimal accumulation with repeated administration (accumulation ratio 1:24) and neither the time to maximum concentration nor the terminal half-life are altered compared to single-dose administration. The pharmacokinetics of dienogest are dose-proportional within the dose range of 1 to 8 mg. Ten percent (10%) of the total serum drug concentrations are present as free steroid; 90% are nonspecifically bound to albumin. Metabolism Dienogest is completely metabolized by the known pathways of steroid metabolism, with the formation of metabolites which are mostly inactive endocrinologically. The metabolites are excreted very quickly; therefore in plasma, unchanged dienogest is the dominating fraction. The terminal disposition phase is characterized by a half-life of approximately 9 to 10 hours. Dienogest is excreted in the form of inactive metabolites which are excreted at a urinary to fecal ratio of about 3:1 after oral administration of 0. Following oral administration, most of the drug is excreted in the urine within the first 24 hours. Race No clinically relevant interethnic differences among Caucasian and Japanese patients were observed with respect to the pharmacokinetics and pharmacodynamics of dienogest. However, no special risk for these patients is expected since dienogest is almost completely metabolized before excretion and the metabolites are pharmacologically inactive. Each tablet contains 2 mg dienogest and the following nonmedicinal ingredients: crospovidone, lactose monohydrate, magnesium stearate, microcrystalline cellulose, potato starch, povidone K 25, and talc. Practically insoluble in water and neutral within the physiologically relevant pH range. Patients with a confirmed diagnosis of endometriosis assessed by laparoscopy or laparotomy prior to treatment were included. A total of 198 patients with endometriosis were treated over a period of 3 months. Pain improvement was not related to the use of pain medication which actually decreased over time (see Table 6). Reduction of pelvic pain by at least 50% without a relevant increase of concomitant pain medication was achieved in 32. Note: Statistical analysis according to testing procedure described by Roehmel et al. After 6 months of treatment, reduction of pelvic pain associated with endometriosis by 50% or more was achieved in 82. Compared to progesterone, the relative binding affinity of dienogest was less than 20%. In human uterine cytosol, the relative binding affinity of dienogest to the progesterone receptor was about one order of magnitude less than that of progesterone. The progesterone receptor mediated activity (alkaline phosphatase induction) of dienogest was tested in human breast carcinoma T47D cells and revealed a 2-fold weaker progestogenic activity than progesterone. Equally strong effects on menstrual cycling and/or inhibition of ovulation were observed in the repeated-dose toxicity studies in other monkey species after oral dosing. Effects of dienogest on the differentiation and proliferation of human endometrial stroma cells were assessed in vitro. Dienogest induced a dose-dependent inhibition of cell proliferation in the presence of estradiol. A 100 mg/kg dose of danazol had a comparable effect on the endometrial implants but also decreased the bone mineral density. In rabbits, pregnancy was maintained at low dosages of dienogest, indicating that rabbits are very sensitive to the progestational activities of dienogest. Antiandrogenic, Androgenic and Anabolic Activities Dienogest possesses antiandrogenic activities. In the Hershberger assay in rats, dienogest showed clear antiandrogenic properties. Unlike other 19-nortestosterone derivatives, dienogest has no androgenic activity. Antiprogestational Activities Dienogest, itself, has no antiprogestogenic activity, but the major rodent plasma metabolite aromatic dienogest has antiprogestogenic activity. Therefore, in rodents dienogest can also act as an antiprogestin when given orally or subcutaneously. This finding of antiprogestogenic activity has no relevance for primates as this aromatic metabolite does not occur in relevant amounts in monkey or human plasma. Estrogenic and Antiestrogenic Activities Dienogest does not bind to the estrogen receptor. Dienogest itself has no estrogenic activity, but the major rodent plasma metabolite, aromatic dienogest, has estrogenic activity. Therefore, in rodents, dienogest acts as an estrogen when given orally or subcutaneously. This finding of estrogenicity has no relevance for primates as this aromatic metabolite does not occur in relevant amounts in monkey or human plasma. Dienogest-medicated rats failed to exhibit any changes in either urine volume or the urinary Na/K ratio, even when the dose was as high as 100 mg/kg orally. Dienogest exhibited only low binding to the mineralocorticoid and the estrogen receptors. The conclusion drawn from the detailed endocrinological characterization of dienogest is that this drug substance has a potent progestational activity on the endometrium and a medium antigonadotrophic activity. The estrogenic activity of dienogest observed in rats and mice was considered to represent a species-specific response related to the presence of an aromatic dienogest metabolite that occurs only in these species. General Pharmacodynamics In rats, dienogest did not influence general symptoms and behavior at doses up to 30 mg/kg. Effects on the central nervous system in mice, rats, and rabbits revealed effective doses after oral or parenteral administration as high as 100 mg/kg, with the exception of a slight decrease in body temperature in mice which was observed after 10 mg/kg injected intraperitoneally. Some temporary effects of dienogest on body temperature or kidney function in rats were noted at lower doses (≥ 10 mg/kg), which are at least 2 orders of magnitude above the intended therapeutic dose in humans.

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Similarly menopause yeast infection generic cabergoline 0.5 mg on line, two voiding episodes per night were associated with substantial impact on health-related quality of life compared with those without nocturia menopause depression anxiety purchase cabergoline overnight delivery, and at least three episodes of nocturia resulted in further impairment of similar magnitude (19) contemporary women's health issues for today and the future 4th edition pdf buy genuine cabergoline on line. These results indicate that two episodes of nocturia consti- tute a threshold beyond which nocturia has adverse effects on well-being breast cancer awareness images order cabergoline 0.25 mg free shipping, whereas 1 void per night does not identify subjects with interference from nocturia (19). An association of nocturia with depression has also been consistent across studies (80–82). However, untreated depression at baseline was predictive of incident nocturia (83). How much reduction in nocturia is needed to be clinically important has not been answered. As nocturia is associated with other factors that may affect bother and quality of life (comorbid conditions, lifestyle factors), not all bother is explained by number of voiding episodes. Hence, treatment for nocturia episodes may not relieve all impairment among subjects with nocturia (19). Sleep loss alters carbohydrate metabolism and endocrine function, and has been associated with incident diabetes (87,88). Additionally, falls constitute the greatest risk factor for fractures among the elderly (89). Nocturia is associated with an increased risk for both falls and fractures (90–96). Increased risk for mortality has been reported not only in the elderly, but also among younger men and women (33,93,97,98). In a Japanese study among the elderly, at least 2 voids per night was associated with a doubled risk for fractures and mortality (96). Data from the Krimpen study among older men (55–84 years of age) showed no association of nocturia with increased mortal- ity risk after accounting for confounding factors (99). In contrast, results of the Olmsted County Study in men 60 years and older showed an almost 50% increase in mortality risk after multivariate analyses (100). Increased risk for morbidity and mortality among younger age groups and among those without prevalent comorbid conditions may indicate nocturia as a marker for impend- ing morbidity (e. Although no research articles have been published on economic impact of nocturia, a few studies have investigated the impact of nocturia and associated sleep loss on work productivity. A study of 203 working adults in Sweden has shown reduced work productivity with nocturia. Compared with age- and gender- matched controls, those with ≥1 voids per night had significant work productivity and activity impairment, impairment in non-work activities, and reduced vitality and quality of life (103). The prevalence of nocturia is higher among young women than young men, but the prevalence increases more markedly with age in men. Incidence of nocturia increases with age, but signifcant short- term fuctuation in nocturia severity in individuals makes studies on incidence challenging. Two or more episodes of nocturia per night constitutes clinically meaningful nocturia severity in the general population, affecting quality of life and perceived health, while a single episode usually does not. Nocturia has been suggested to increase risk for falls, fractures, death, and impaired productivity. Approaches to identify intra-individual variation and other confounding infuences need to be considered. Longitudinal studies using high-quality methodology remain a priority requirement. Nocturia of twice or more per night may be a threshold of clinical signifcance in the general population. However, this threshold is not irrefutably established, and should not be extracted to sub-populations. Research into all grades of nocturia severity may yield information of clinical relevance. What has changed is the knowledge that nocturia has multi-factorial etiology, which is not always urological in origin. In normal adult urinary physiology, the amount of urine made at night is less than the functional bladder capacity during the daytime, and hence adults void more during the daytime and can sleep at night without having to wake up to void. Therefore, urine production and storage at night is based on two simple physiological events: the first is that the person needs to go to sleep and the second is that urine needs to be produced and stored in the bladder. If, for whatever reason, one or both of these two mechanisms are disturbed, then nocturia will result. Hence, by understanding this basic principle, it is possible to predict the pathophysiology of nocturia, which can be divided into two broad groups of non-patho- logical or pathological nocturia. Non-pathological nocturia essentially means waking up for a reason other than the need to pass urine and feeling the desire to pass urine once awake (105), resulting in a convenience void (106). This may be due to, for example, noises outside the house, partner snoring, baby crying, light in the room being switched on, etc. Pathological nocturia, on the other hand, results from medical factors affecting either the sleep pattern, or production and storage of urine. Alternatively, the reduction in capacity ium, carbonic anhydrase inhibitors work by may result from extrinsic compression by several diverse mechanisms relevant to noctu- pelvic masses or urogenital prolapse (108). Sleep disorders–including primary (insom- young (aged 21–35 years) and exceeding 33% nia, periodic leg movements, narcolepsy, of total 24-hour output in the elderly. Depression: In a Swedish population-based study (81), subjects with major depression (assessed by the Major Depression Inventory) reported substantially more nocturia than those without. Hypertension and coronary artery disease: the connection between nocturia and hypertension is not clear. No other significant associations for nocturia with angiotensin-con- verting enzyme inhibitors, beta blockers, calcium channel blockers, or loop and thiazide diuretics were found. While the treatment for hypertension may cause (10,125,126) or alleviate nocturia (127) in some cases, appropriate methods are of particular importance when assessing this relation. Earlier studies in men (38,123,124) did not find a relation between nocturia and cardiac disease. However, in these studies, an association between cardiac symptoms or disease and nocturia was found in the preliminary analyses before multivariate models. In more recent studies (98,102,121,128), coronary disease has been shown to be associated with nocturia. Neurological diseases: Most patients with multiple sclerosis have bladder dysfunction, which may also lead to nocturia (129). In studies conducted among elderly people, nocturia was associated with stroke and cerebrovascular disease (128–130). Two other studies also reported increased nocturia in the postmenopausal period (136,137), whereas another attributed this to aging rather than to menopausal transition (138). The menopausal period is often associated with sleep disturbances for other reasons including hot flashes, mood disorders, and increased sleep disordered breathing (139); therefore, individuals reporting nocturia may be awak- ening due to non-bladder causes. There are few studies evaluating the effect of menopausal hormone replacement therapy on nocturia. In Finnish and Swedish population-based studies, there were indi- cations for increased nocturia among women with menopausal hormone therapy, but the findings were statistically insignificant in the multivariate analysis (134,140). In a small, randomized trial (151), those with menopausal hormone therapy did not report less (or more) nocturia than those with placebo. This finding was confirmed in randomized, controlled trials of an estradiol vaginal ring (152) and vaginal estradiol on urinary storage symptoms after sling surgery (143). In the Krimpen study, average nocturnal urine production was slightly more than 60 mL/hr. The auth- ors suggested that nocturnal urine production exceeding 90 mL/hr is abnormal (144). However, the authors concluded that nocturnal urine production as an explanatory variable for nocturnal voiding frequency is of little value. Congestive heart failure, third spacing (venous insufficiency, nephrosis), or late-night diuretic administration are potential underlying causes. Using bioelectric impedance analysis, nocturnal urine volume has been shown to correlate with the difference in fluid volume in the legs (r=0. This is indirectly supported by the results of a non-randomized study, where the number of nocturia episodes decreased significantly from 3.

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