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Volume 15 No. 04
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Accepted Papers

Scientific Investigations

Overnight Urge Perception in Nocturia Is Independent of Depression, PTSD, or Anxiety in a Male Veterans Administration Population

Thomas F. Monaghan, BS1,2; Donald L. Bliwise, PhD3; Nicholas R. Suss, BS1,2; Matthew R. Epstein, BS1,2; Zhan D. Wu, BS1,2; Kyle P. Michelson, BA1,2; Christina W. Agudelo, MA1; Dennis J. Robins, MD1,2; Adrian Wagg, MBBS4; Jeffrey P. Weiss, MD1,2
1Department of Urology, SUNY Downstate Medical Center, Brooklyn, New York; 2Department of Urology, Veterans Affairs New York Harbor Healthcare System, Brooklyn, New York; 3Department of Neurology, Emory University School of Medicine, Atlanta, Georgia; 4Department of Geriatric Medicine, University of Alberta, Edmonton, Canada


Study Objectives:

The goal of this study was to compare the urge perception associated with nocturnal voiding at the time of voiding in individuals with and without depression, posttraumatic stress disorder (PTSD), or anxiety diagnoses to test the hypothesis that patients with such diagnoses are more likely to experience insomnia-driven convenience voiding during the sleep period.


A database of voiding diaries with urge perception grades (UPGs) from 429 adult males seeking treatment for nocturia at a Veterans Affairs-based urology clinic was analyzed. The UPG categorizes perception for urinating from 0 (out of convenience) to 4 (desperate urge). Diaries completed by males age 18 years and older showing ≥ 2 nocturnal voids were included. Those included (n = 178) were divided into two cohorts based on the presence (n = 62) or absence (n = 116) of one or more previously established mental health diagnoses (depression, PTSD, or anxiety). The chi-square test was used to determine significance between groups.


Patients with a mental health diagnosis were more likely to report convenience voiding compared to those without depression, PTSD, or anxiety (14.5% versus 0.8%, P < .01). However, most voids in both groups were associated with the perception of urinary urgency. There were no differences in urinary volumes or hourly rates of urine production between the groups.


A relatively small subset of urology patients experience nocturnal voiding because they are awake for reasons other than the urge to void. Mental health factors had a substantial, albeit minimal, effect. Most nocturia reflects urgency to urinate rather than voiding by convenience.


Monaghan TF, Bliwise DL, Suss NR, Epstein MR, Wu ZD, Michelson KP, Agudelo CW, Robins DJ, Wagg A, Weiss JP. Overnight urge perception in nocturia is independent of depression, PTSD, or anxiety in a male veterans administration population. J Clin Sleep Med. 2019;15(4):615–621.


Current Knowledge/Study Rationale: Management of both nocturia and insomnia often fails to consider one in the context of the other. During the hours of sleep, patients seeking treatment for nocturia with a concomitant diagnosis of depression, PTSD, or anxiety may be more likely than those with no mental health history to report nocturnal convenience voiding, defined as voiding despite “no urge or desire,” thus reflecting either impaired sleep maintenance or difficulty returning to sleep originating from other causes.

Study Impact: Most nocturia, however, appears to be related to true urgency to void, and multiple physiologic causes (eg, excess urine production at night due to sleep apnea, reduced levels of arginine vasopressin resulting in nocturnal polyuria, urologic conditions) should be sought for treating the condition.


Nocturnal voiding is one of the most common urologic complaints in the general population.1,2 According to the National Health and Nutrition Examination Survey, one in five adult males consistently awakens to void two or more times per night, and the elderly are particularly susceptible, with 56% of males age 75 years and older meeting the criteria for nocturia.3 Mostly because of its direct role in impairing sleep, nocturnal voiding increases the risk of falls and hip fractures in the elderly,4,5 and is associated with a wide range of systemic endocrine, metabolic, cardiovascular, and immunologic conditions.2

The association between nocturnal voiding and poor sleep has been well recognized in both urologic and sleep research.6 On one hand, urinary urgency is the most common cause of nocturnal awakenings in adults, and nocturia is an independent predictor of both insomnia and impaired sleep quality, as patients bothered by nocturia also report difficulty returning to sleep.79 On the other hand, in another study using sleep diaries, adults recruited with self-reported poor sleep (with no mention of urinary symptoms) were noted to have at least half of all nocturnal awakenings accompanied by a trip to the bathroom, suggesting that sleep dysfunction may predispose individuals to a higher frequency of nocturnal voiding episodes.6,10 Population-based research suggests that there indeed exists a bidirectional relationship between baseline poor sleep quality and nocturnal voiding.11

In the setting of a Veterans Affairs urology clinic, the complex interplay between nocturia and poor sleep is further complicated by a high burden of depression, posttraumatic stress disorder (PTSD), and anxiety, which are independently associated with both insomnia and nocturia.1216 The HIIJO-KYO population study of community-dwelling older adults in Japan observed a higher hazard ratio for incident depressive symptoms among males with nocturia, which persisted following adjustment for sleep disturbances.12 Conversely, in one study examining multiple predictors of poor sleep (but not examining nocturia), depression was the single strongest factor associated with insomnia.14 Waking for reasons other than the urge to void (eg, rumination, troubling dream experiences) may predispose individuals to a higher frequency of nocturnal voiding.2,13 Extensive polysomnographic evidence shows that individuals diagnosed with depression, PTSD, or anxiety objectively experience adverse changes in sleep architecture that reduce overall sleep quality and depth.16,17

In this study, we examined nocturia from a urological perspective, employing scales and physiologic measurements that are typically used in urological evaluation. For example, the urge perception scale is a valid and reliable instrument for grading urinary urgency.18 This scale, modified from the bladder sensation scoring system proposed by De Wachter and Wyndaele, is a five-level Likert item that captures the sensation accompanying each micturition.18,19 Patients are asked to describe their reason for urinating on a scale from zero (out of convenience) to four (desperate urge). A complete overview of urge perception grade (UPG) responses is provided in Table 1. Rated urgency for nocturnal voiding is a stable phenomenon among individuals.18

Urge perception score: responses to the question, “Why did you urinate?”


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Table 1

Urge perception score: responses to the question, “Why did you urinate?”

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Another valuable source of data employed in urology to evaluate a patient is the “voiding diary,” which is also referred to as a “frequency-volume chart.” This is a 24-hour record of when the patient voids, which also includes the measurement of the quantity of each individual void, as measured by the patient. The voiding diary yields data regarding urine output, bladder capacity, and urinary urgency, and can be used to identify the primary mechanism behind a patient's nocturnal voiding. The causes of nocturia have been subdivided into several distinct etiologies.2 More simply, urologists fundamentally recognize nocturia (versus nocturnal voiding secondary to poor sleep) as a mismatch between nocturnal urine output and bladder capacity, whereby some systemic process or genitourinary tract abnormality, resulting either in excessive nocturnal urine production or inadequate urine storage, causes the patient to awaken and urinate.2

Based on the voiding diary, a number of measurements can be established, which then serve to aid in the diagnosis of a given patient's condition. The term “nocturnal polyuria” is used to describe patients who have a high rate of nocturnal urine production (typically ≥ 90 mL per hour), and thus experience nocturia driven by urine overproduction.2,20 In contrast, a patient's maximum voided volume (MVV) in a 24-hour voiding diary directly reflects maximum bladder capacity, and patients with diminished bladder capacity (MVV < 200 mL) experience nocturia because of a reduction in functional storage capacity.2,20 In either case, the mismatch between nocturnal urine production and storage capacity will result in an elevated nocturia index (Ni). The Ni is calculated by dividing nocturnal urine volume (NUV) by MVV; a Ni > 1 indicates that urine production exceeds capacity, resulting in either nocturia or enuresis.2,20 (Table 2 includes a complete description of the measures typically derived from 24-hour voiding diaries.)

Overview of standard voiding diary parameters.


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Table 2

Overview of standard voiding diary parameters.

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Nocturnal convenience voiding is associated with several distinct characteristics in voiding diary measures. As may be intuitively expected, convenience voiding results in significantly smaller voided volumes compared to urge-driven voiding.21 Thus, patients who are voiding simply because they are awake would be expected to exhibit smaller nocturnal maximum voided volumes, defined as the largest urine volume produced during a single nocturnal voiding episode) compared to those who void only when urinary urgency interrupts sleep. In addition, because nocturnal convenience voiding occurs, by definition, below the bladder volume threshold at which the individual perceives urinary urgency, convenience voiding yields a relatively higher nocturnal bladder capacity index (NBCi). As described in Table 2, a NBCi > 0 indicates that nocturnal voids are occurring below the patient's own maximum bladder capacity, and the magnitude of NBCi is proportional to the difference between maximum bladder capacity (as evidenced by 24-hour MVV) and nocturnal voided volumes. Mechanistically, in patients whose nocturnal voiding is driven by other factors, the absence of excess nocturnal urine production, coupled with a relatively normal 24-hour MVV, is expected to result in a normal Ni (< 1.0).

Given the strong association between mental health and sleep dysfunction, researchers and clinicians often postulate that insomnia secondary to mental health status may be the root cause of nocturnal voiding in patients with a concomitant psychological diagnosis.14 The notion that urinary symptoms can be ascribed as secondary to impaired sleep in this population has major clinical implications because the treatment options for nocturia are distinct from those for sleep disturbance per se.2 This study analyzes urge perception associated with nocturnal voiding by mental health status to test the hypothesis that patients with a concomitant diagnosis of depression, PTSD, or anxiety are more likely than those with no mental health diagnosis to experience convenience voiding (ie, voiding without urgency) during the period of sleep. Additionally, we examined the extent to which specific measures associated with nocturnal voiding (eg, urine volume per void) might also be associated with mental health diagnosis.


Overview of Study Design and Procedures

The 24-hour voiding diary is an objective record of the timing, measured volume, and urge perception grade associated with every micturition in a 24-hour period. Patients who had established care for treatment of nocturia at a Veterans Affairs-based urology clinic from 2008 to 2017 were asked to complete a 24-hour voiding diary. After applying inclusion and exclusion criteria, patients were divided into two groups based on the presence or absence of a contributory mental illness, which included a diagnosis of depression, PTSD, or anxiety as documented in Veterans Affairs medical records.

Nocturnal UPGs were analyzed to identify nocturnal convenience voiding, defined as micturition without urgency to urinate rated at the time of voiding. In patients with no episodes of convenience voiding, voiding diary results were also analyzed to determine whether those individuals with mental health history demonstrated features (eg, higher urine volumes) known to occur in the setting of primary sleep disturbances (eg, sleep apnea). Subgroup analysis excluding patients with obstructive sleep apnea, congestive heart failure, edema, chronic kidney disease, or diuretic use was performed to determine if the results were similar upon removal of conditions known to be associated with nocturia.2

Approval for a voiding diary database was granted by the Veterans Affairs New York Harbor Healthcare System Institutional Review Board. Voiding diaries were obtained as a standard of care in the clinical evaluation and management of lower urinary tract symptoms, and no further research instruments were needed.22 Retrospective analysis was made possible through a waiver of informed consent.

Patient Population

The database contained voiding information from 429 male veterans. Patients age 18 years or older with a 24-hour voiding diary showing clinically significant nocturia (≥ 2 nocturnal voids) were included for analysis. Because some patients kept diaries for more than a single 24-hour period, only the first complete voiding diary showing two or more nocturnal voids was included from patients with multiple entries, resulting in data from 178 individuals for analyses after exclusions (see next paragraph).

Diagnoses of schizophrenia, bipolar disorder, and lithium-induced nephrogenic diabetes insipidus were excluded because of their known association with polyuria.23,24 Patients who were taking diuretics or had received a diagnosis of obstructive sleep apnea, congestive heart failure, chronic kidney disease, or edema were included upon initial analysis, and subsequently excluded for subgroup analysis, because of their known association with nocturia.2 Included individuals were divided into two cohorts based on the presence or absence of one or more mental health diagnoses as carried in Veterans Affairs medical records, which included depression, PTSD, and anxiety (Table 3). Of the 178 individuals included for analysis, 62 were found to have a mental health diagnosis, whereas the remaining 116 patients were placed into the group without a contributory mental health diagnosis.

Demographics, comorbid conditions, and treatment history for patients by mental health diagnosis status.


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Table 3

Demographics, comorbid conditions, and treatment history for patients by mental health diagnosis status.

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Statistical Analysis

Wilcoxon rank-sum tests and chi-square tests were used to analyze continuous and categorical variables, respectively. Continuous variables were reported as median (95% confidence interval) using Wilcoxon confidence interval estimates; categorical variables were reported as frequency (proportion). All tests performed were two-sided and a value of P < .05 was deemed statistically significant. As a check whether various urologic variables (other than urgency perception) derived from the frequency-volume charts might differentiate the group with depression, PTSD, or anxiety from those men without these diagnoses, we performed a multivariate regression analysis predicting group status.


In total, 573 episodes of nocturnal voiding were reported by the 178 individuals included in this study. Of those 62 with a mental health diagnosis, 15 (24.2%) had a diagnosis of depression, 24 (38.7%) had PTSD, 1 (1.6%) had anxiety, and 22 (35.5%) had received more than one of these diagnoses. Patients with a mental health diagnosis were significantly younger than those without a mental health diagnosis (67 years versus 71 years, P = .02). There were no further significant differences in demographics, comorbidities, or urological treatment history between cohorts (Table 3).

We averaged all voiding-related measures (eg, UPG, NBCi) to derive within participants means for each measure. An overview of the within-participants mean nocturnal UPGs by mental health status is provided in Table 4. Nine of the 62 patients with a mental health diagnosis reported a mean nocturnal UPG below 1 (UPG 0 to < 1), compared to 1 of 116 individuals without a mental health diagnosis (14.5% versus 0.8%, P < .01). There were no significant differences by mental health status for all other mean nocturnal UPG intervals (Table 4).

Frequency distribution of mean within participant's nocturnal UPG by mental health diagnosis status.


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Table 4

Frequency distribution of mean within participant's nocturnal UPG by mental health diagnosis status.

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Among patients who reported only urge-driven nocturnal voiding (ie, all nocturnal voiding episodes at a UPG ≥ 1; 52/62 [83.9%] patients with a mental health diagnosis and 113/116 [97.4%] patients without a mental health diagnosis), there were no significant differences by mental health status for any of the voiding diary parameters analyzed when tested univariately (Table 5) or multivariately (Table S1 in the supplemental material). Neither total urine volume (nocturnal urine volume), rate of urine production (nocturnal urine production), nor the urine volume relative to each patient's own bladder capacity (as evidenced by NBCi) differentiated the two groups. Together with the UPG data presented in Table 4, the fact that Ni exceeded 1.0 for both patient groups suggested that physiologic mechanisms of high nocturnal urine production relative to storage were identical in patients with and without mental health diagnoses.

Comparison of voiding diary parameters by mental health diagnosis status in patients with no nocturnal convenience voiding.


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Table 5

Comparison of voiding diary parameters by mental health diagnosis status in patients with no nocturnal convenience voiding.

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Subgroup analysis excluding patients with conditions known to be associated with nocturia comprised a total of 120 patients, of whom 39 had a mental health diagnosis, and 81 had no mental health history. This analysis demonstrated findings similar to that of the analysis of the full cohort: a significantly higher proportion of patients with a mental health diagnosis reported one or more nocturnal convenience voids (12.8% versus 1.2%, P < .01), but most patients experienced nocturnal voiding primarily because of urgency. Additionally, there were no differences in voiding diary parameters by mental health status.


Despite the fact that our real-world clinical urology population is elderly, has a high burden of comorbid conditions (Table 3), and is likely to incur poor sleep for a wide variety of reasons,25 nocturnal convenience voiding (ie, voiding without urgency) among patients with no mental health history was an uncommon occurrence, and was only slightly more common among those with a mental health history. These results imply that there may be some nocturia patients whose issues related to comorbid nocturia and poor sleep could be addressed by focusing on treatments for poor sleep per se, rather than nocturia. Indeed, at least one interventional study has demonstrated that improving sleep can reduce nocturia episodes.26

Considering the long-established association between mental illness and poor sleep,14 it is somewhat surprising that most individuals with a diagnosis of depression, PTSD, or anxiety reported only urge-driven nocturnal voiding, and that urologic measures in these patients (ie, average urine volumes, storage capacity) did not differ from the cohort without a mental health history. We hypothesized that patients who are voiding simply because they are awake would not be voiding at full capacity, and thus are expected to have a higher nocturnal bladder capacity index compared to patients with urge-driven nocturia. Moreover, because convenience voiding produces significantly smaller voided volumes compared to urge-driven voiding,21 we would have expected significantly smaller nocturnal maximum voided volumes in the setting of insomnia-driven nocturnal voiding. Our data did not support these hypotheses. The lack of differences in voiding diary parameters between the two groups (Table 5) implies that are no significant anatomical or physiological differences that would require a different approach to the management of nocturia in patients with or without a history of depression, PTSD, or anxiety.

Our study is not without limitations. We employed a retrospective study design, used a small sample, and obtained results from a single clinic setting, which could limit the generalizability of our results. Moreover, we relied solely on clinical diagnoses in identifying depression, PTSD, or anxiety, as we did not have additional diagnostic instruments, such as self-reported scales or interviewer-based rating scales. Additionally, 24-hour voiding diaries may not reflect true voiding dysfunction as accurately as diaries 3–5 days in duration.27,28 Despite these limitations, the First Uninterrupted Sleep Period, sometimes called “time to first void,” was similar in the sample to what we have noted in studies of other nocturia populations encompassing both men and women,29,30 and was approximately 2 hours.

The most significant limitation of our study is the absence of polysomnographic evidence, which would help us to understand whether the higher volumes of nocturnal urine produced in both patient groups is due to sleep apnea, which is known to be associated with both higher likelihood of nocturia and greater urine output.3134 Our results were similar when patients with a known diagnosis of sleep apnea were excluded, but the lack of contemporaneous measurement of sleep-disordered breathing on the nights of urine collection cannot entirely eliminate this possibility. However, it is important to note that the mechanisms leading to excess urine production at night are not limited to impaired breathing during sleep. For example, excess urine production at night likely reflects a circadian redistribution of urine production that may characterize nocturnal polyuria.35 There is ample evidence that the clinical syndrome of nocturia is related to such high levels of nocturnal urine production, possibly because of decreased nocturnal levels of arginine vasopressin.3638

In summary, despite the high burden of sleep disturbances among patients with depression, PTSD, or anxiety, the current voiding diary analysis demonstrated no mechanistic differences in the etiology of nocturia by mental health status. Thus, a mental health diagnosis should not challenge the severity or validity of a patient's nocturnal voiding symptoms, nor should it negate possible pharmacologic, behavioral, or surgical approaches to nocturia. Conversely, the presence of nocturia can affect the magnitude of benefit seen in cognitive behavioral therapy for insomnia.9 Our data strongly suggest that a more integrative treatment approach to disturbed sleep accompanied by nocturia, encompassing both sleep medicine and urological expertise, may be warranted.


Among patients seeking treatment for clinically significant nocturia, there exists a small subset of individuals, specifically in the setting of concomitant mental illness, who experience nocturnal voiding because they are likely to be awake for reasons other than the urge to void. Such nocturnal convenience voiding, however, was absent in most patients with a diagnosis of depression, PTSD, or anxiety, and voiding diary data from these patients indicates nocturia of likely organic origin, similar to that seen in patients without mental health diagnoses. Patients with high rates of nocturnal voiding and disturbed sleep may see particular benefit from a treatment plan involving specialty care in both urology and sleep medicine.


Work for this study was performed at the Department of Urology, Veterans Affairs New York Harbor Healthcare System, Brooklyn, NY. Dr. Bliwise has served as a consultant for Merck, Jazz, Ferring, Eisai, and Respicardia and speaker for Merck within the last three years, outside the submitted work. Dr. Wagg is a consultant or speaker for Astellas, Pfizer, and Essity AB, outside the submitted work. Dr. Weiss is a consultant for Ferring, Wellesley, Vantia, and Symptelligence, outside the submitted work. The other authors report no conflicts of interest.



actual number of nightly voids


maximum voided volume


nocturnal bladder capacity index


nocturia index


posttraumatic stress disorder


urge perception grade



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