Evaluation and Treatment in Urology for Nocturia Caused by Nonurological Mechanisms:Guidance from the PLANET Study

Patients with nocturia are commonly referred to urology clinics, including many for whom a nonurological medical condition is responsible for their symptoms. The PLanning Appropriate Nocturia Evaluation and Treatment (PLANET) study was established to develop practical approaches to equip healthcare practitioners to deal with the diverse causes of nocturia, based on systematic reviews and expert consensus. Initial assessment and therapy need to consider the possibility of one or more medical conditions falling into the “SCREeN” areas of Sleep medicine (insomnia, periodic limb movements of sleep, parasomnias, and obstructive sleep apnoea), Cardiovascular (hypertension and congestive heart failure), Renal (chronic kidney disease), Endocrine (diabetes mellitus, thyroid disease, pregnancy/menopause, and diabetes insipidus), and Neurology. Medical and medication causes of xerostomia should also be considered. Some key indicators for these conditions can be identified in urology clinics, working in partnership with the primary care provider. Therapy of the medical condition in some circumstances lessens the severity of nocturia. However, in many cases there is a conflict between the two, in which case the medical condition generally takes priority on safety grounds. It is important to provide patients with a realistic expectation of therapy and awareness of limitations of current therapeutic options for nocturia.Patient summaryNocturia is the symptom of waking at night to pass urine. Commonly, this problem is referred to urology clinics. However, in some cases, the patient does not have a urological condition but actually a condition from a different speciality of medicine. This article describes how best the urologist and the primary care doctor can work together to assess the situation and make sensible and safe treatment suggestions. Unfortunately, there is sometimes no safe or effective treatment choice for nocturia, and treatment needs to focus instead on supportive management of symptoms

Transesophageal echocardiographic demonstration of resolution of mitral vegetations after warfarin in a patient with the primary antiphospholipid syndrome

A 16-year-old girl with multiple cerebral infarcts was reported to have a normal transthoracic echocardiogram, but transesophageal echocardiography revealed vegetations on the atrial surfaces of both mitral leaflets at their line of closure. Blood cultures were negative, and prolonged treatment with intravenous antibiotics produced no echocardiographic improvement in the appearance of the vegetations. A diagnosis of primary antiphospholipid syndrome was made subsequently, although test results for this condition had initially been normal. Serial transesophageal echocardiograms showed complete resolution of the vegetations but some persistent thickening of the mitral leaflets, after warfarin therapy for 9 months. We suggest that in patients with culture-negative endocardial vegetations, specific tests should be performed for the primary antiphospholipid syndrome and a therapeutic trial of warfarin should be undertaken before contemplating heart surgery