Nocturia is described as the frequency with which urine is passed during the primary sleep phase. Following the first urination, each subsequent urination must be accompanied by sleep or the intention to sleep.(1) It is included in lower urinary tract symptoms and reported as the most bothersome and the most common. Nocturia causes long term sleep deprivation and lowering someone’s quality of life. It leads to decreased work performance, difficulty sustaining focus, and mood changes. It increases with age and affecting both males and females. (1) Nocturia is commonly found in primary health care, managed by general practitioners (GPs). Thus, it is important for them to know how to diagnose and treat nocturia, including referral indications to specialist(s). The aim of this study is to review the management and diagnosis of nocturia among Indonesian general practitioners.

This study was a cross sectional study. We collected the data by distributing self-constructed online survey covering the overview of nocturia among GPs in Indonesia, between October 2021 to March 2022. The questionnaire consisted of 15 questions, including general personal information of the respondents and the characteristic of nocturia patients, diagnostic modalities and management approach for nocturia patients. The primary outcome measures were data on nocturia diagnostic tools and management practiced by Indonesian GPs. The secondary outcome was characteristics of nocturia patients tended by Indonesian GPs.

There were 252 GPs in this study who filled out the questionnaire from October 2021 to March 2022. 77.8% of respondents came across 1-5 nocturia cases per month, more commonly encountered in elderly men compared to women (65.5% vs 17.5%).  Most GPs were dealing with patient’s age range of 50-65 years old (57.9%). The most common symptoms were nocturia accompanied by voiding symptoms (46.8%) and nocturia with storage symptoms (21.8%), and patients usually had had these symptoms for 2-4 weeks (32.9%) before they sought help.  In terms of diagnostic tools, history taking and physical examination were routinely done, and most GPs implemented bladder diary (73%) and scoring system (62.3%). However, not many respondents used urinalysis or other further examinations, and only 46% referred their patients to urologist for further diagnosis. With regards to management, most GPs prescribed education and lifestyle changes (88.1%) and medication such as alpha blocker (19.8%) compared to desmopressin (13.5%). Only 65.5% of respondents would refer their patients to urologist for further treatment.

Nocturia is not an uncommon disease and mostly found in elderly men by GPs in Indonesia.  It has negative impact for the quality of life however most patients seen by the GPs had waited several weeks before seeking help. This treatment seeking behaviour might be due to of low awareness that nocturia is a medical condition. Most of the general practitioners already understand the standard diagnostic approach for nocturia and did initial treatment.  However, only small portions of respondents refer their patients to urologist or done more extensive examination.  According to this study, only 73% used bladder diaries to diagnose nocturia on a regular basis. It is probably due to the fact that bladder diaries are considered to be time consuming and compliance plays a huge role (2). Low usage of urinalysis could have been related to Indonesia's inequitable distribution of facilities for laboratories. Desmopressin should be the primary choice for nocturnal polyuria caused by reduced nocturnal vasopressin, which is the most common cause of nocturia. However, only a few GPs prescribed desmopressin for patients with nocturia. The use of desmopressin in clinical settings is still uncommon probably because lack of standardised desmopressin doses and hyponatremia as its side effect, which can be life-threatening in the elderly. (3)

General practitioners in Indonesia face a difficulty in dealing with nocturia. Though the diagnostic modalities mostly are already in line with available guidelines, there were only 52% and 73% of GPs who used urinalysis and bladder diaries, respectively.  Desmopressin was prescribed relatively less frequent to treat nocturia compared with alpha blockers. This lack of standardized approach highlights the prospective necessities to create awareness on nocturia and encourage Indonesian GPs to implement the current guideline available for nocturia.

Everaert K, Hervé F, Bosch R, et al. International Continence Society consensus on the diagnosis and treatment of nocturia. Neurourology and Urodynamics, 2019;1-21
Albers-Heitner, P., Berghmans, B., Nieman, F., Lagro-Janssen, T., & Winkens, R. Adherence to professional guidelines for patients with urinary incontinence by general practitioners: a cross-sectional study. Journal of Evaluation in Clinical Practice,20-8;14(5), 807–811
Bara Barakat, Knut Franke, Matthias May, Ulrich Gauger, Thomas-Alexander Vögeli. Efficacy and safety of desmopressin on frequency and urgency in female patients with overactive bladder and nocturia, current clinical features and outcomes: A systematic review. Asian Journal of Urology, 2022; 27-34

Continence 2S2 (2022) 100330
DOI: 10.1016/j.cont.2022.100330