Every week, Hussain Al-Zubaidi, a GP, will see at least one patient who suffers from nocturia, the medical term for needing to get up in the night to pee. A weak bladder has long been known as a side-effect of getting older, and nocturia has been found to affect between 69% and 93% of men over 70. It is often related to benign prostatic hyperplasia, the swelling of the prostate and surrounding tissue that occurs with age.
“For many men over 60, this means that their ability to empty their bladder is poorer,” says Al-Zubaidi, the lifestyle and physical activity lead for the Royal College of GPs. “They take longer when standing over the toilet and generally they’ll retain urine, which means they’re much more likely to be triggered to wake up and go for a wee in the night.”
But Al-Zubaidi has begun to notice a worrying new trend – many of the patients coming to see him are men or women in their 20s and 30s. Some researchers have found that nocturia can affect up to 44% of men between 20 and 40. So what is going on?
One theory is that this is a consequence of modern lifestyles. “I think it’s mainly down to drinking habits,” says Al-Zubaidi. “People are often busier during the day, so they tend not to ‘fluid load’ in the morning, which is what we’re designed to do. In the evenings, they’ll drink more water because they’re thirsty, and then get really awakened in the early hours when their bladder is full.”
Such unhealthy drinking habits may be encouraged by our fondness for streaming platforms and social media. A recent study using data from the National Health and Nutrition Examination Survey in the US found that 32% of participants over the age of 20 had to wake up and urinate twice or more in the night. This risk was almost 50% greater in people who spent five or more hours a day watching videos in various formats.
“I wonder whether it’s having that time for yourself in the evening while you’re watching Netflix, and suddenly you’re better able to notice your thirst, respond to it and do something about it,” says Al-Zubaidi. “But by that point, it’s a bit too late in the day and you’re going to wake up in the middle of the night needing to pee.”
But there are plenty of other factors that can contribute to nocturia. Rebecca Haddad, a doctor at the Hôpital Rothschild in Paris who has previously specialised in research on nocturia and ageing, says that smoking, consuming too much alcohol and being physically inactive can all reduce bladder capacity, making the need to urinate more frequent.
“There is a link between physical activity and urine production during the day and at night,” she says.
In particular Haddad explains that spending too much time sitting during the day, or staring at screens in the evening, may change the body’s circadian rhythms and lead to a strange phenomenon known as nocturnal polyuria, where people pass normal amounts of urine during the day, but large volumes at night.
Life’s big hormonal shifts also explain why nocturia becomes more common with age. Haddad points out that while it is often perceived as a male condition, it is just as much of a problem for women, with one leading study, called EpiLUTS, of 30,000 people finding that 69% of men and 76% of women over the age of 40 lived with nocturia episodes that woke them at least once in the night.
“Nocturia is definitely about much more than just the prostate,” she says. “Menopause is one of the transitional periods that generally impacts its occurrence. Diminished levels of the hormone oestrogen may induce anatomical and physiological bladder changes, contributing to a reduction in functional bladder capacity. Excess nocturnal urine production can also be provoked by oestrogen depletion.”
Menopause can also impair sleep and lead to weight gain, a combination of factors that drives many cases of nocturia. People with obesity and postmenopausal women are far more prone to a condition called obstructive sleep apnoea (OSA), where your breathing stops and starts hundreds of times during sleep, reducing the amount of oxygen that gets into the bloodstream.
“The thinking is that when people are of increased weight, it puts strain on the heart,” says Al-Zubaidi. “And when people are also getting poor-quality sleep, the heart has to beat faster to keep your blood circulating with the oxygen that it has.”
Whenever the heart is working harder, it releases a hormone called brain natriuretic peptide, which increases urine production. “It’s basically trying to reduce the strain on the heart by removing some of the blood volume as urine,” says Al-Zubaidi. “There’s a huge proportion of the population who have undiagnosed OSA, and nocturia is one of the nine key symptoms that could point towards that. Although many people don’t connect the two.”
Because of the connections between the bladder and other bodily systems, nocturia can also be a sign of chronic conditions such as hypertension, type 2 diabetes and kidney impairment.
“Chronic kidney disease is a problem because the kidneys are no longer as effective at making concentrated urine, meaning that too much water may end up being peed,” says Prof Marcus Drake, a specialist in neurological urology at Imperial College London.
However, Drake says that people should not be unduly concerned unless there is a sudden increased severity in the problem, with no apparent behavioural cause. “It is more worrying if the person is also constantly thirsty, or if there are additional unexplained symptoms such as unsteady walking or excessive snoring.”
At the same time, having to get up during the night to go the toilet is not ideal for your health. We’re increasingly learning that poor sleep can have all kinds of negative consequences, not just for energy levels but also for the stability of blood-sugar levels and long-term cognition.
“When you have blood sugar that is regularly spiking, you’re more likely to retain weight, which causes obesity,” says Al-Zubaidi. “We also know that even after a single poor night’s sleep, you accumulate certain proteins in the brain that are linked to dementia in later life.”
When it comes to preventing nocturia, the best advice is probably to focus on scheduling most of your fluid intake earlier in the day. In particular, Al-Zubaidi advises not having more than 330ml of fluids within three hours of going to sleep. That’s the same amount as a typical can of soft drink, or a large glassful.
“You want to have at least a quarter of your daily fluid intake in that first hour to two hours, when your body is really requiring some hydration after sleep,” he says. “And then if you’ve been doing any exercise, try to replace that fluid there and then. We call it the golden hour – if you can do it within an hour of activity, it’s much, much better than going for a run, and then catching up three or four hours later.”
If you do have to get up in the night, try to get back to sleep as soon as possible. While it may be tempting to check your phone for notifications or scroll social media, the light from the screen will affect the levels of sleep hormones and make it harder to nod off again.
“Try to avoid switching on any lights when you go for a wee,” says Al-Zubaidi. “Your eyes should be adapted to the dark, given that you’ve woken up in the middle of the night. And then try to get back into bed as soon as possible. My final tip is that one of the key signals the body uses to go to sleep is a dip in temperature. So just turn the pillow round or have the duvet off when you get back into bed, and you’re much more likely to feel sleepy again.”
Five other reasons you might regularly wake during the night
1 Overheating During sleep, your core body temperature should dip by 1-2C, a common pattern across all mammals. However, if you’re too warm – something that can be triggered either by eating a large meal close to bedtime or by consuming alcohol or caffeine in the evening, because digestion increases your metabolic rate – you might struggle to reach deep sleep. Your duvet also might be too thick.
2 Stress A stressful day can mean that a complex network in your body known as the hypothalamic pituitary adrenal axis, which connects the brain and various glands, is still active when you’re trying to get to sleep. This means that cortisol, the main stress hormone, is far higher than your body expects it to be in the early hours of the morning. This can disrupt your natural sleep cycles.
3 Sleep apnoea Obstructive sleep apnoea, a condition that causes you to temporarily stop breathing, is estimated to affect 1.5 million people in the UK, becoming more common in people carrying excess weight. The resulting lack of oxygen activates a survival reflex that wakes you sufficiently to start breathing again, interrupting your sleep cycle. As a result, people with the condition tend to start their mornings feeling exhausted.
4 Heartburn Lying down for many hours in bed allows food and stomach acid to flow into the oesophagus, with this acidity slowly building throughout the night until you wake up with a burning sensation and discomfort. This can be triggered by smoking, eating large meals before bed, or consuming spicy, acidic or highly fatty foods, as well as drinking excessive amounts of alcohol and carbonated drinks.
5 Restless legs syndrome This surprisingly common condition affects 5-10% of adults in the UK and can have a variety of causes, from genetic predisposition to low iron levels in the brain. Some antidepressant or antihistamine medications can exacerbate the condition. Sufferers typically experience tingling or pulling sensations in their legs, with symptoms being more intense at night. The best remedies are thought to be daily exercise, a regular sleep schedule, stretching leg muscles before bed and taking a hot bath.
