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Patient Case

We present a 55-year-old woman has progressive multiple sclerosis (MS). She is paraparetic, unable to walk, and she presents with a transurethral catheter catheter placed 1 year ago to manage her urinary incontinence. She has a history of recurrent urinary tract infections and recalcitrant detrusor overactivity with urgency urinary incontinence. Several anticholinergic drugs have been previously administered to control her urinary incontinence, without any substantial benefit and with intolerable anticholinergic side effects. She has a normal renal function with a creatinine of 0.4 mg/dl. Her BMI is 23 Kg/m2.

This lady appears to be highly motivated to become dry and to remove the urethral catheter. On physical examination the patient is seated in a wheelchair, she shows a normal genitourinary examination with no urogenital prolapse, although the vagina and the vulva appear irritated.

On urodynamics, she has normal compliance up to 178 ml, with evidence of high pressure detrusor overactivity and urodynamic urinary incontinence, with detrusor external sphincter dyssynergia (DESD). The maximum cystometric capacity is 178 ml. On pressure flow-study, she is able to start spontaneous voiding, but with incomplete bladder emptying. The final urodynamic diagnosis is detrusor overactivity and DESD) with impaired detrusor contractility.

We chose Option b.

The patient undergoes urinalysis and culture to exclude the presence of urinary tract infection and then a treatment with intradetrusor Botox injection. Two hundred U of Botox diluted in 20 ml of normal saline are administered under local anaethesia in an outpatient basis. The urethral catheter is removed soon after the injections and the patient starts performing intermittent catheterizations. Follow up visits are scheduled, as usually, at 2 wks, 3 and 6 months after Botox injections. The patient is asked to complete a 3-days bladder diary before each control visit and to perform urinalysis and culture. A standardized questionnaire on urinary symptoms and quality of life (Incontinence-Quality of Life) is given at each control visit; the Visual Analog Scale to score satisfaction to treatment is completed by the patient during each follow up visit.

Fiftheen days after Botox injection, the mean frequency of daytime urgency episodes and of incontinence episodes are 3.3 and 0.6 respectively. Conversely, the mean frequency of nocturia episodes is 4.2. On urinalysis and culture, no urinary tract infection is detected. The level of patient satisfaction to treatment is quite high (VAS= 7), although she would prefer to have to perform less frequent cateheterizations during the night. In this respect, she complains of more fatigue and excessive daytime sleepines during the day due to her disturbed sleep, with the need to catheterize at least two or thee times during the night.

Option d. We assess the presence of nocturnal polyuria.

The requested information we ask to detect are: urine volume at each catheterization, drinking frequency and volumes, as well as the time at which the patient goes to bed and get up in the morning. The nocturnal volume includes the sum of all nocturnal micturition and the first morning micturition. We also asked this patient to collect 4 urine samples each day for 3 consecutive days (3 samples at differet times during the day, and the latter during the night) in order to investigate the following parameters: urine osmolality, sodium, urea, and creatinine concentrations.

As results, the mean 24-h urine volume is 1678 ml and the mean nocturnal urine volume is 779 ml; the comparison of night-time with day-time urine volumes values reveals an increase in free water clearance (from 0.1 to 0.6 ml/min) and a decrease in osmolality (from 524 to 421 mosm/Kg). Creatinine clearance appears lower at night-time compared to day-time (118 ml/miv n s 105 ml/min). Sodium clearance remains similar as during the day (0.9 ml/min vs 0.9 ml/min). This condition is suggestive for an excessive water diuresis. The reduced mobility of this lady during the day probably is the first reason inducing an increased water absorption during the night, with higher urine volume produced in the supine position. A reduced production of vasopressin during the night is also a frequently observed condition in patients with nocturnal polyuria.

We choose options a and d.

As first choice treatment, we suggest to this lady to use stocking and to rest with legs up for some hours during the day. Furthermore, the possibility to assume desmopressin is taken into account as second choice treatment in case of failure of the adopted corrective manouvres.

This lady will come back to control visit 15 days after the beginning of the proposed treatment.

Comments from the Editors

Management of chronic peripheral edema using compression stocking during the day is a crucial point to avoid or reduce the excessive urine production during the night in patients with a reduced mobility, as in this case. The principle of compression therapy is simple, involving the use of external pressure in the forms of bandages or wraps to move the fluid from the interstitial space back into the intravascular compartment.  Also an appropiate physical activity with repeat exercices has been observed to help in cases of peripheral edema and nocturnal polyuria.

The proposal to administer desmopressin is due to the detected nocturnal reduced osmolality and positive free water diuresis, which represent an indication of suppressed vasopressin in this lady. Treatment with a V2 agonist is useful in nocturnal polyuria patients with excessive water diuresis, who have positive nocturnal free water clearance and/or low nocturnal osmolality, which represents an indication of suppressed vasopressin. For these reasons, the use of diuretics in this patient should not be appropriate, but it can be proposed in the case of nocturnal sodium diuresis, to restore a normal sodium pattern. 

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