Mr C.  is a 67 y/o AA former smoker with hx of 30 pack years. He has a PMHx of obstructive sleep disorder, HTN, GERD, erectile dysfunction, HLD, Prostate cancer s/p radiation 2015 ℅ frequent night time urination x one month. His vital signs are stable and physical exam is unremarkable. He denies drinking alcohol but drinks 2 cups of coffee every morning, and takes a calcium channel blocker Nifedipine for HTN at bed time. He has a PMHx of OSA (recently started using CPAP), and prostate cancer s/p radiation, PSA is followed every 6 months his last PSA recorded at .13.

The paper I chose to back up the plan for my H&P was developed by a multidisciplinary group of experts on nocturia, including urologists, general practitioners and a geriatrician with a special interest in nocturia.

It was A non- systematic review of the relevant literature retrieved in the PubMed/Medline database.

The aim of the study was to raise awareness and increase recognition of nocturia as a medical condition and provide practical recommendations for its diagnosis and management.

They included this very easy to follow algorithm to understand the pathophysiology of nocturia:

Recommendations made by the authors on the treatment of nocturia were as follows:

• Treatment should be tailored to the causes of nocturia in the individual patient.
• Some medications can precipitate nocturia and, therefore, change of the drug or timing of drug use may be warranted.
• Lifestyle and behavioral modifications should be attempted before instigating other treatments, with a trial of up to 3 months, a reasonable time period over which to assess treatment response, unless bother is increasing and intolerable.
• Pharmacological therapies should be introduced after life- style modifications have failed or as adjuncts.
• Desmopressin is the pharmacologic treatment for nocturia due to nocturnal polyuria with the highest quality evidence to support its use, with a once-daily, low-dose, gender specific formulation indicated for nocturia due to nocturnal polyuria.
• Diuretics, α1-blockers, 5α-reductase inhibitors, PDE5i, plant extracts, antimuscarinics and the β3-agonist mirabegron all have potential utility to reduce nocturnal voiding frequency in patients with different causes of decreased functional bladder capacity, although the clinical impact of such treatments appears to be limited.
• Educating patients on the available treatment options and involving them in the decision-making process can help to increase adherence to medication and thereby improve patient functioning and QoL.
• After implementing therapy, its efficacy and effect on patients should be assessed, with consideration given to combining therapies/interventions in the light of an inadequate response.
• Patients with nocturia of undetermined cause not responding to lifestyle and medical therapy should be considered for specialist assessment.

For our patient the plan would be as follows:

• The patient would be provided with all materials needed to keep a bladder diary.
• Patient must be educated on how to use the diary, the importance of keeping a diary, to keep diary for 3-4 days, and bring back on their next appt.
• The patient should be educated on:

-the role of coffee, Nifedipine, and OSA in nocturia.

• The patient should be advised to:

-Minimize fluid intake at least 2 h before going to bed, particularly caffeine and/or alcohol

-Restricting total fluid consumption to <2 L/day

-Emptying bladder before going to bed

• Changes that can be made in the future if symptoms persist:

-Decreasing coffee intake

-changing medication time of Nifedipine from evening to morning

-increase hours/days of CPAP use

• The possibility of prescribing medication (new drug approved by FDA desmopressin a vasopressin analog) for symptoms if life style modification do not help decrease symptoms should be discussed with the patient.