Waking Up at Night to Urinate (Nocturia): What Causes It?

Waking up again and again during the night to go to the toilet can lead to broken sleep, daytime tiredness and, particularly in older people, falls at night. The medical name for this problem is nocturia, and contrary to popular belief it is not only caused by the prostate. In this article we explain the causes of nocturia, how it is assessed and what can be done.

What is nocturia, and how many times a night is it normal to get up to urinate?

Nocturia means waking up during sleep at night to pass urine. Each time you get up there must be sleep before and after; waking up in the morning and passing urine for the first time does not count as nocturia.

Getting up once a night to pass urine is very common, particularly after the age of 60, and causes no problems for most people. Getting up two or more times a night, however, generally disturbs sleep quality and calls for the cause to be investigated.

What causes frequent urination at night?

The causes of nocturia can be grouped under three main headings.

1. Producing too much urine at night (nocturnal polyuria)

The amount of urine the body produces at night has increased. In older people, passing more than a third of the daily total at night suggests this condition. Possible causes:

• Drinking a lot of fluids, tea, coffee or alcohol in the evening
• Water tablets (diuretics) taken in the evening
• Heart failure and swollen legs (oedema): Fluid that collects in the legs during the day returns to the circulation when you lie down and is turned into urine by the kidneys.
• Sleep apnoea: Pauses in breathing during sleep can increase urine production at night.
• A reduced effect with age of the hormone that decreases urine production at night (antidiuretic hormone)

2. Producing too much urine throughout the day

The total amount of urine has increased both during the day and at night. Diabetes, drinking excessively and certain kidney diseases fall into this group.

3. The bladder holding only a small amount of urine

• Benign prostate enlargement: The bladder cannot empty completely and fills up quickly. For details, see the enlarged prostate treatment page.
• Overactive bladder: Comes with a sudden feeling of urgency and sometimes urinary incontinence.
• Urinary tract infection, bladder stones or bladder pain syndrome

In addition, people who wake up for reasons such as insomnia, anxiety and pain also tend to go to the toilet while they are awake. In this case the real problem is not the urine but the sleep.

Nocturia in women

Nocturia is not only a problem for men. In women, overactive bladder, changes in the tissues of the urinary tract that come with the menopause, pelvic organ prolapse, recurrent urinary tract infections and pregnancy can increase night-time urination. The assessment and lifestyle advice are largely the same as for men; treatment is planned according to the cause found.

How does frequent night-time urination affect your health?

Nocturia is not just an annoying symptom; it can affect quality of life in many ways:

• Broken sleep: Deep sleep being interrupted again and again leads to daytime tiredness, poor concentration and low energy.
• Risk of falls: Particularly in older people, going to the toilet in the dark while still drowsy increases the risk of falls and fractures.
• Mood: Long-term lack of sleep can increase irritability and low mood.
• Your partner’s sleep: Frequent trips to the toilet often affect your partner’s sleep too.

In addition, nocturia may be the first sign of an as yet undiagnosed condition such as diabetes, heart failure or sleep apnoea. For this reason, rather than dismissing it as “just age”, it is advisable to look for the cause. Lighting the way to the toilet at night, removing slippery rugs and not getting up too quickly are simple measures that reduce the risk of falls.

How is the cause of frequent night-time urination found?

The most valuable tool in nocturia is the bladder diary (frequency-volume chart). For at least three days, you note down:

• The time and amount of every drink,
• The time and amount of every time you pass urine (using a measuring jug),
• The times you go to bed and get up.

This record largely shows whether the problem is caused by producing too much urine or by bladder capacity.

In addition, a urine test, blood sugar, kidney function, blood sodium level where necessary, PSA in men where appropriate, and the amount of urine left in the bladder after passing urine (measured by ultrasound) are assessed. If necessary, a cardiology or sleep assessment is requested.

What can be done to reduce getting up at night to urinate?

Treatment is aimed at the cause. For most people, lifestyle changes are tried first:

• Reduce your fluid intake in the 2–3 hours before going to bed.
• Avoid caffeine and alcohol in the evening.
• Empty your bladder just before going to bed.
• If your legs are swollen, rest with your legs raised for a while in the afternoon; use compression stockings if your doctor considers them suitable.
• If you take water tablets (diuretics), talk to your doctor without changing the time you take them on your own.
• Pay attention to your sleep routine; tell your doctor if you snore or feel sleepy during the day.

If these measures are not enough, depending on the cause, medicines for an enlarged prostate or overactive bladder, or medicines that reduce urine production at night, may be used. Because medicines that reduce urine production at night can lower blood sodium, particularly in older age, they require close monitoring with blood tests. For marked symptoms due to an enlarged prostate, surgical treatments are also among the options.

When should you seek emergency care?

• If you cannot pass urine at all, or have swelling and pain in the lower abdomen
• If you have a fever, shivering, pain in the side or visible blood in the urine
• If getting up at night to urinate comes with shortness of breath, a cough that gets worse when lying down, or swelling of the legs that is increasing quickly
• If excessive thirst, frequent urination and weakness have increased rapidly

When should you see a urologist?

A urological examination is advisable if you get up two or more times a night and this affects your sleep and daytime life, if your urine flow has become weaker, if you also pass urine frequently during the day, or if you have urinary incontinence. Bringing a bladder diary kept for a few days to your appointment speeds up the assessment.

Op. Dr. Mücahit Kabar sees patients in Bursa (Nilüfer), Turkey, at Özel Medicabil Nilüfer Hastanesi (weekdays 08:30–12:00, +90 444 8 112) and Özel Jimer Hastanesi (weekdays 13:00–17:00, +90 444 45 67). Appointments are booked through the hospitals’ online booking pages or appointment lines. Consultations are held in English or Turkish; the hospitals’ international patient departments can arrange interpreters for other languages. If you are travelling from abroad, you can send your questions and reports by WhatsApp to +90 541 622 54 82 before your visit. See the contact and appointment information for details.