Perception of nocturia and medical consulting behavior among community-dwelling women
We investigated the perception of nocturia and possible explanatory factors for medical consultation among community-dwelling women. Between October 2004 and February 2005, women aged ≥40 years living in Matsu, Taiwan, who were identified as having nocturia in a previous epidemiological survey, were interviewed with a questionnaire eliciting information about nocturia-specific quality of life impact (N-QOL), perceptions of nocturia, and medical-consultation behavior. A total of 328 women completed this study. Of these, 187 (57%), 99 (30.2%), 30 (9.1%), and 12 (3.7%) reported one, two, three, and four or more nocturia episodes, respectively, per night during the past 4 weeks. Most women attributed nocturia to aging or excessive fluid intake and had a lack of medical information. Overall, only 13.1% had visited a doctor for this condition. Nocturia episodes [≥three vs <three, odds ratio (OR) 3.8], N-QOL score (OR 2.0, per 10-point decrement), linking nocturia to a disease (OR 2.9), and medical information (OR 2.2) were independent factors associated with medical-consultation, whereas the lack of knowledge that nocturia was treatable appeared to be an important barrier to medical-consultation. Only 62.8% of the women were offered treatment upon consultation, even though nearly half of those treated reported significant improvement. A few women with nocturia have sought medical help, which appears to be affected by a compendium of factors. This study suggests that more information about nocturia should be provided to health providers and patients to identify and meet their most essential needs.
KeywordsNocturia Perception Treatment seeking
Nocturia, defined by the International Continence Society subcommittee as a complaint that an individual has to wake from sleep to void , has only recently been recognized as a clinical entity rather than just being one of the lower urinary tract symptoms (LUTS) . It is a common reason for sleep disturbance in the general adult population and may subsequently result in adverse consequences, such as nighttime falls, perceptions of poor health, and reduced vitality and productivity [2, 3]. Nocturia affects both men and women to an equal extent, with prevalence estimates from 10 to 80% among studies, depending on the definition of nocturia episodes (from one to three per night) and the population surveyed [3, 4, 5, 6].
Recent research has shown that nocturia has a multifactorial etiology that includes overproduction of urine in the night (nocturnal polyuria), reduced storage ability of the urinary bladder, or a combination of both [2, 3]. Based on the underlying causes, current treatment strategies include lifestyle modification and pharmacological therapies. The former includes fluid restriction, compression stockings, and late afternoon naps with the legs elevated, which may reduce fluid buildup. The latter involves diuretics in the afternoon, bladder smooth muscle relaxants, desmopressin, and imipramine [3, 6].
Despite its prominence and negative consequences, nocturia is a poorly reported and infrequently diagnosed problem. Investigations on the perception of nocturia and help-seeking behavior, which may help identify and meet the needs for those who are most afflicted, remain sparse. Because nocturia in men is frequently presented and treated as one of the LUTS that are assumed to be prostate-related, it is difficult to discern the motivation and outcome of treatment.
In the present study, we investigated the perception of nocturia and medical-consultation behavior in a community-dwelling female cohort of individuals that underwent a survey for nocturia-specific quality of life (N-QOL) impact . Potential predictors for medical consultation and the outcome of treatment were explored.
Materials and methods
Between October 2002 and February 2003, all inhabitants aged ≥30 years in Matsu, a small city located in the northeast of Taiwan, were invited to participate in a comprehensive screening program on public health (Matsu Community-Based Integrated Screening supported by the Bureau of Health Promotion, Department of Health of Taiwan). A supplement urological survey aimed at investigating the epidemiologic aspects of nocturia and overactive bladder syndrome was included as part of this study program.
A total of 862 women (approximately 75% of the target population) completed the initial survey. The prevalence of nocturia and associated risk factors have been published elsewhere . Between October 2004 and February 2005, women who were aged ≥40 years and reported one or more nocturia episodes per night in the survey (n=351) were interviewed again by public nurses with a questionnaire designed to investigate the N-QOL impact, perception of nocturia, and medical-consultation behavior. Among these, 51 who participated in the initial survey were excluded either due to nonresponse (n=37) or the resolution of the nocturia (n=14). Moreover, we recruited 28 women who failed to participate in the initial survey and reported one or more nocturia episodes. Consequently, a total of 328 women completed this study.
The questionnaire consisted of three parts. The first part collected information on demographics, medical conditions, and nocturia characteristics. The second part contained a validated 12-item N-QOL questionnaire  assessing the N-QOL impact. The N-QOL score ranged from 0 to 100, with a lower score indicating poorer QOL. The details and results of the N-QOL impact have been previously described elsewhere . The final part of the questionnaire focused on the subject’s perception of nocturia, coping strategies, and medical-consultation behavior. A multiple-choice question asked the participants “do you think your nocturia is a result of or related to the following factors,” with response options such as excess fluid intake, disrupted sleep, a consequence of aging, and a consequence of certain diseases. The strategies they took to cope with nocturia, if ever they had any, were also queried. Subsequently, they were asked if they had ever received information about nocturia from the media or public medical campaigns (medical information).
Finally, they were asked if they had ever consulted a doctor for their nocturia. If the response was “yes,” they were asked about the result of the treatment (with response options of not offered treatment, not improved or getting worse, slightly improved, and significantly improved). For those who did not seek medical help, the reasons were elicited by a question with multiple choices. Response options included “nocturia was a normal aging process,” “the problem was too minor to seek a doctor,” “lack of awareness that nocturia was treatable,” “too embarrassed to see a doctor,” “have no time to see a doctor,” and “concerned about medical costs.”
Continuous variables were presented as the mean±standard deviation and were compared using the t test. Categorical variables were presented as a percentage and were compared using the chi-square test. Univariate analyses were performed to evaluate the effect of potential variables, including demographics (age, educational level, and employment status), medical conditions, nocturia episodes (one, two, three, and four or more), duration of nocturia, N-QOL score, coping strategies, perception of nocturia, and medical information on medical consultation. A multivariate logistic regression model was constructed to test the association between medical consultation and the factors that had a P value of <0.1 in the univariate analysis. For all analyses, a P value of <0.05 was considered statistically significant.
Characteristics of the study participants
n (% in parentheses)
Number of cases
Primary school or below
Middle to high school
College or above
Duration of nocturia (years)
Perception of nocturia and coping strategies among the participants
n (% in parentheses)
Do you think that nocturia is a consequence of
Excessive fluid intake
Fluid restriction after night meal
Keep the light on all night to prevent falls
Take exercise after dinner
Comparisons of variables between women who had or did not seek medical consult
Duration of nocturia (years)
Current employment (%)
Educational level (%)
Primary school or below
Middle school or higher
Two or more medical comorbidities (%)
Perception of nocturia (%)
Excessive fluid intake
A normal aging process
One or more coping strategies (%)
Medical information (%)
Significant predictors for medical consultation on multivariate logistic regression analysis
Nocturia episodes per night
N-QOL score (per 10-point decrement)
Linking nocturia to a disease
Reasons for not consulting a doctor (n=285)
Nocturia is a normal aging process
Too minor to seek help
Don’t know that nocturia can be treated
Have no time
Too embarrassing to seek help
Treatment costs too much money
Of the 43 women who had consulted a doctor, 37.2% were not offered any treatment. Only 27 (62.8%) had received definite treatments, from which 22.2% reported no improvement or worsening, 29.6% reported slight improvement, and 48.1% reported significant improvement.
Our results indicate that, similar to other LUTS, most women view nocturia as a consequence of aging, and only about one fifth of them have medical information on nocturia from the media or public medical campaigns. Moreover, only a few women (13.1%) with nocturia had sought medical help, which appears to be driven by a variety of factors, including increasing nocturia episodes, a lower N-QOL score, linking nocturia to a disease, and having medical information. Conversely, viewing nocturia as part of the normal aging process, viewing it as a minor problem, or being unaware that this problem is treatable are the main factors that preclude women from seeking medical help. Lastly, a considerable proportion of women did not receive treatment upon medical consultation, while nearly half of those treated reported significant improvement.
Self-belief on LUTS significantly affects the motivation of treatment-seeking [9, 10]. Thus, people who attribute their LUTS to aging are inclined to adapt to their problems with different strategies, and consequently, are less likely to seek medical help. Conversely, those who link their LUTS to a disease, such as cancer, are more likely to seek medical help . Consistent with these reports, most women (58.8%) in the present study attributed nocturia to aging and 41.5% adopted coping strategies. On the other hand, only a relative minority of women (16.8%) linked their nocturia to a disease, and they were about three times as likely to consult a doctor (Table 4).
Notably, only 20.4% of women stated that they had learned medical information about nocturia from the media or public medical campaigns. A prior study suggested that social influence, including medical information from media or advice from friends or relatives, is more important than symptoms of severity in driving people to seek medical help for their LUTS . Parallel with this finding, our results reveal that women who have had medical information on nocturia were 2.2 times as likely to consult a doctor.
In the present study, nocturia episodes and QOL impact are independent factors associated with medical consultation: women reporting three or more nocturia episodes were about four times more likely than those reporting fewer than three nocturia episodes, and a 10-point decrement of N-QOL score was associated with a twofold-higher likelihood of consulting a doctor. Our previous study showed that the extent of sleep disturbance after nocturia is also an important factor, predicting a lower N-QOL score . Apart from leading to adverse consequences, such as a reduction in productivity and vitality, dysphoric moods, and alterations in the immune system , sleep deprivation also has an impact on life expectancy. Asplund  reported that elderly people with three or more nocturia episodes had a greater mortality rate than those with fewer nocturia episodes. In the present study, 54.8% of women with three or more nocturia episodes never sought medical help. These women deserve medical attention, although some might have adapted themselves to this problem.
Few women (13.1%) had consulted a doctor for their nocturia. Comparisons of our data with those of others are difficult because, to the best of our knowledge, studies investigating treatment-seeking behavior for nocturia among community-dwelling women are lacking. One important factor accounting for this low rate of consultation was the low threshold used to define nocturia (one or more nocturia episodes per night), as proposed by the International Continence Society. Several studies, however, have shown that people with one nocturia episode are less likely to perceive the negative impacts [5, 7]. The rate of medical-consultation would have increased to 25.5% if only those reporting two or more nocturia episodes were taken into account.
Barriers that limit the use of medical care in this study cohort were explored. Apparently, viewing nocturia as a normal aging process, disregarding the severity of nocturia (60.7% for women reporting fewer than three nocturia episodes vs 47.8% for those reporting three or more nocturia episodes), is an important determinant. Alternatively, nocturia was too minor to be worthy of medical consult for women with fewer nocturia episodes (66.4% of those reporting fewer than three nocturia episodes). On the other hand, only 13.0% of those reporting three or more nocturia episodes admitted that their nocturia was too minor to seek help. Unlike that observed in other studies that investigated the treatment-seeking behavior for other LUTS, such as urinary incontinence , embarrassment did not appear to be an important factor precluding women from seeking medical help.
The lack of understanding of the causes, treatment, and cures of LUTS leads to poor conceptualization of the illness and may serve as a barrier to treatment-seeking . Among women reporting three or more nocturia episodes, 47.8% admitted that unawareness of available treatments was the reason for not seeking medical help. This finding, coupled with the fact that only 20.4% of women had information on nocturia from public media or medical campaigns, suggests that improvement in nocturia knowledge would likely increase the prevalence of medical consultation.
Recent studies have demonstrated the safety and efficacy of desmopressin in the treatment of nocturia [2, 6]. In a double-blind placebo-controlled study conducted on nocturic women, Lose et al.  demonstrated that 46% of patients receiving desmopressin vs 7% patients receiving placebo had a 50% or greater reduction in nocturia episodes. Furthermore, desmopressin significantly prolonged the duration between sleep and first void. In addition, in a small-scale study conducted on women with urinary incontinence, behavioral modification has also been shown to reduce nocturia episodes .
Although the treatment strategies offered to those who sought medical help were not explored in detail, 37.2% did not receive any treatment upon medical consultation. One likely explanation is that in some women, nocturia might be a by-mentioned complaint among other problems with higher priority. Consequently, it may have been overlooked or the patients may merely have been reassured by doctors. Another possibility, however, is that some doctors might have been unfamiliar with the diagnosis and treatment of nocturia. Given that a significant proportion of women reported beneficial results from the treatment, more updated information regarding nocturia should also be given to doctors and other healthcare providers.
There are several potential limitations that should be considered. First, in this study, medical-consultation behavior was queried over the past few years, whereas symptoms were queried over the past month. As a result, past physician visits might have modified some of the variables examined as predictors, such as nocturia episodes. Also, as this survey only investigated women reporting nocturia during the study period, a small number of women whose nocturia had been cured from previous treatments would have been eliminated from this study. Second, the city of Matsu is a small community, and therefore, the possibility of a cohort effect must be ruled out in a comparative study between different communities. Third, although reasons for not seeking medical help were elicited in the present study, the desire for receiving treatment was not assessed. It is well recognized that a substantial proportion of women with severe LUTS do not want treatment, even if it is very bothersome .
In conclusion, our study shows that currently, few women with nocturia seek medical help, which appears to be driven by complex factors. Given that only a minority of women had learned medical information about nocturia and that a significant proportion of patients were not offered any treatment upon medical consult, we suggest that more information should be given to both care providers and patients.
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