The need for voiding diaries in the evaluation of men with nocturia [review; review, tutorial] [see comments]

              Jaffe et al • Original contribution JAOA • Vol 102 • No 5 • May 2002 • 261
In a study to assess the need for voiding diaries in the
evaluation of men with nocturia, 337 consecutive male
patients were asked to estimate their number of voiding
episodes per night. Patients were placed into seven sepa-rate
groups based on the number of estimated number of
voiding episodes. These patients used a voiding diary to
track their voiding habits for 1 week. The mean number
of voiding episodes recorded in the diaries were then com-pared
with the subjects’ original estimations. The esti-mated
number of voiding episodes correlated with the
mean number of diary-recorded voiding episodes 48% of
the time. Correlation was highest for patients reporting
few episodes per evening and lowest for those reporting
five or six episodes per night. The study findings suggest
that voiding diaries are essential in helping to determine
the actual number of voiding episodes per night and that
the need for a voiding diary becomes more important as the
perceived amount of nocturia increases.
(Key words: voiding diary, nocturia, benign prostatic
hyperplasia)
Nocturia is a common complaint that causes many
patients to seek urologic consultation. This symptom can
be the result of many conditions, but commonly, it is the
result of benign prostatic glandular enlargement that is often
associated with benign prostatic hyperplasia (BPH). Benign
prostatic hyperplasia is one of the most common disease
processes affecting the aging male.1 It can be expected in 1 of
10 men in their 40s and 7 of 10 men in their 60s.2-4 The Amer-ican
Urological Association (AUA) Symptom Index is rec-ommended
in the workup of all men with BPH and com-plaints
of nocturia.5,6 This questionnaire provides the
physician with a quantitative value that can be used to deter-mine
the severity of the patient’s initial symptoms and to
monitor results of treatment. Donovan et al7 demonstrated
that the International Continence Society (ICS) male ques-tionnaire
developed for the ICS-BPH study had high levels
of validity and reliability when used to assess men with
lower urinary tract symptoms (LUTS). One of the difficulties
with these questionnaires in the evaluation of an individual
with nocturia is that its usefulness is dependent on the
patient’s recollection of the actual number of episodes of
nocturia per evening. This estimate is biased with recall errors
such as memory lapse (forgetting an event entirely) and tele-scoping
(remembering an event but forgetting the exact
timing of the event).8
For many years, voiding diaries have been used to quan-tify
incontinence and monitor results of treatment in all age
groups with voiding difficulties secondary to neurologic,
anatomic, and surgical dysfunctions.9-11 We are unaware of
any research evaluating the usefulness of voiding diaries in
men with complaints of nocturia. We designed a prospective
randomized study to assess the need for voiding diaries in the
evaluation of men with nocturia. Our goal was to determine
whether a voiding diary is a useful tool in the evaluation of
men with complaints of nocturia.
Materials and methods
A total of 337 consecutive men with LUTS were asked to esti-mate
their number of voiding episodes per night, which was
defined as a need to urinate that awakened the individual
from sleep. These men were then placed into one of seven
groups (groups 0 through 6) based on their response. The
number designation of each group corresponded with the
patient’s estimated number of episodes of nocturia per night.
For example, an individual with an estimated nocturnal
voiding frequency of 1 was placed into group 1. When a group
contained 20 individuals, the group was considered filled and
no more patients were entered into that study group. The
total study group consisted of 140 patients who were equally
assigned to the seven groups as previously described. All men
signed informed consents that gave permission to use the
information from the voiding diaries for academic research. The
study was approved by the institutional review board.
The 140 members of the study group were then given a
voiding diary and asked to record their number of nocturnal
voiding episodes, quantity voided, amount of fluid consumed,
time they went to bed, and how many hours they slept each
evening. The men all completed the voiding diaries for 1 week.
The remainder of the 337 patients were not included because
each of the seven groups in the study group already contained
20 patients.
ORIGINAL CONTRIBUTION
The need for voiding diaries in the evaluation of men with nocturia
JAMISON S. JAFFE, DO; PHILLIP C. GINSBERG, DO; DANIEL M. SILVERBERG, MD; RICHARD C. HARKAWAY, MD
Dr Jaffe is general surgery resident at Albert Einstein Medical Center, Philadel-phia,
Pa, where Dr Ginsberg is chairman of urology and president of the
medical staff and Dr Harkaway is director of urologic oncology and co-director
of urology residency. Dr Silverberg is attending urologist at Allentown
Hospital, Allentown, Pa.
Correspondence to Richard C. Harkaway, MD, 5401 Old York Rd, Klein
Bldg, Suite 500, Philadelphia, PA 19141.
E-mail: Harks99@aol.com
262 • JAOA • Vol 102 • No 5 • May 2002
ORIGINAL CONTRIBUTION
The voiding diaries were all returned after 1 week to be
analyzed. The mean number of voiding episodes recorded in
the voiding diaries was determined by adding all the episodes
of nocturia for the week, dividing it by 7 days, and then
rounding the value to the nearest whole number. The mean
number of voiding episodes from the voiding diaries was
then compared with the subjects’ original estimations of noc-turia.
Results
All 140 patients enrolled in the study returned a completed
voiding diary. When the mean number of voiding episodes
recorded in the diaries was compared with the subjects’ orig-inal
estimates, the overall accuracy for the entire study group
was 68 (48.6 %) of 140. The accuracy of each group decreased
as the estimated number of episodes of nocturia per evening
increased. The accuracy for groups 0 and 1 was 13 (65%) of 20,
11 (55%) of 20 for group 2, 10 (55%) of 20 for group 3, and 7
(35%) of 20 for groups 4, 5, and 6 (Figure 1).
The number of patients who overestimated and under-estimated
on their initial estimation of frequency of nocturia
per evening was analyzed. As the group number increased, the
percentage of patients who overestimated increased whereas
the percentage of individuals who underestimated decreased.
The overestimation in groups 0 through 6 was 0 (0%) of 20 for
group 0; 3 (15%) of 20, group 1; 5 (25%) of 20, group 2; 6 (30%)
of 20, group 3; 9 (45%) of 20, group 4; 10 (50%) of 20, group 5;
and 10 (50%) of 20, group 6. The underestimation in group 0
was 7 (35%) of 20; 4 (20%) of 20 in groups 1, 2, 3, and 4; and 3
(15%) of 20 in groups 5 and 6 (Figure 2).
The mean voiding diary–recorded episode ranges that
were observed in each group increased as the original esti-mation
of the frequency of nocturia increased (Figure 3). The
range for those who estimated 0 episodes of nocturia was 0 to
2 (R3) compared with those in groups 5 and 6 whose esti-mates
had a range of 2 to 7 and 3 to 8 (R6), respectively. Patients
in groups 2, 3, and 4 had a range of 5 that was intermediate
when compared with that in groups 0 and 6.
Discussion
Our data show that most (51.5%) of the subjects were inaccu-rate
in their estimation of the number of episodes of nocturia
per night. The accuracy was highest for those patients reporting
few episodes of nocturia and lowest for those reporting 5 or 6
episodes per evening. Many authors have reported on voiding
diaries as being more accurate than information collected by
history alone.8,12-15 Voiding diaries also have been shown to
reduce the recall error that is commonly found in retrospective
interviews.16-18
Abrams et al19 suggest that patients tend to exaggerate
their urinary symptoms while being asked a history. However,
our study shows that even those patients with no LUTS (deny
any episodes of nocturia), who were expected to be the most
accurate, were only accurate 65% of the time. We also found
Jaffe et al • Original contribution
0
0
70
60
50
40
30
20
10
1 2 3 4 5 6
% Accurate
Estimated episodes of nocturia
Figure 1. Accuracy
results of estimates
of number of void-ing
episodes.
JAOA • Vol 102 • No 5 • May 2002 • 263
ORIGINAL CONTRIBUTION
to maintain the voiding diaries for only 1 week.
The variability and reproducibility of voiding diaries are
also an area of interest when analyzing their usefulness in the
management of patients with urinary disorders. In our study,
we are assuming that the mean number of diary-recorded
voiding episodes is an accurate assessment of the individual’s
long-term frequency of nocturia. Multiple studies have shown
that frequency of diurnal micturition, frequency of nocturnal
micturition, and the number of incontinent episodes are highly
reproducible from one week to the next with the use of a
diary.12,17
A point of confusion in the analysis of our data is the
overall average of the mean number of diary-recorded voiding
episodes for each group. It could be argued that a voiding
diary in the workup of an individual with nocturia is not nec-essary
when comparing the actual number of nocturnal voiding
episodes of each group versus the ideal number of voiding
episodes (frequency of nocturia that would have been observed
if the patients were 100% accurate) for each group (Figure 4).
Clearly, the two plots look very similar, which is misleading
as the overall accuracy for the study group was only 48.6%. The
similarity in the observed average of the mean number of noc-turnal
diary-recorded voiding episodes versus the ideal mean
number of diary-recorded voiding episodes was observed for
a few reasons. A wide range of mean number of diary-recorded
voiding episodes can be seen within each of the seven subject
groups. Within the broad ranges that were observed in this
that men who perceived their nocturia as more severe (higher
original estimation) tended to overestimate their nocturnal
voiding frequency, whereas those men who claimed not to
have as severe nocturia (lower original estimation) tended to
underestimate. The degree of underestimation and overesti-mation
may have a direct correlation with the quality-of-life
question on the AUA symptom-score questionnaire.
A problem that seems to arise universally in all studies
concerning any form of health diaries is compliance. In our par-ticular
study, the compliance rate was 140 (100%) of 140 patients
in the study group. Verbrugge8 reports that agreement to fill
out health diaries is high and attrition during the diary period
is low. However, in a study by Fantl et al,20 only 32% of patients
recorded details relevant to their symptoms in their written
diaries. Reported causes of noncompliance in completing the
voiding diaries are survey fatigue, poor motivation from staff
members, and inconvenience.8,21 Other studies have shown
that nonwhite patients and those patients seen for treatment
of pelvic organ prolapse (no urinary symptoms) were less
likely to complete their diaries.22 In other attempts to raise
compliance rates, computerized voiding diaries have been
developed. Studies have shown that computerized voiding
diaries lead to an increased volume of data and greater patient
compliance in reporting bladder symptoms compared with the
standard written voiding diary.21,23 We believe that our high
compliance rate can be attributed to easily understandable
written instructions, dedicated office nurses, and our request
Jaffe et al • Original contribution
0
0
60
50
40
30
20
10
1 2 3 4 5 6
% Overestimated/underestimated
Estimated episodes of nocturia
% underestimated
% overestimated
Figure 2. Compar-ison
of overestima-tion
versus underes-timation
of number
of voiding episodes.
264 • JAOA • Vol 102 • No 5 • May 2002
ORIGINAL CONTRIBUTION
Jaffe et al • Original contribution
0
0
7
6
5
4
3
2
1
1 2 3 4 5 6
Actual episodes of nocturia
Estimated episodes of nocturia
Actual mean voiding diary episodes
Ideal voiding plot
Figure 3. Range
of numbers of
actual episodes
of nocturia.
0
0
8
9
7
6
5
4
3
2
1
1 2 3 4 5 6
Mean voiding diary episode range
Estimated episodes of nocturia
Figure 4. Com-parison
of aver-age
of the mean
number of diary-recorded
voiding
episodes versus
ideal voiding
plot.
JAOA • Vol 102 • No 5 • May 2002 • 265
ORIGINAL CONTRIBUTION
5. Cockett AT, Aso Y, Denis L, Khoury S, Barry M, Carlton CE, et al. Proceed-ings
of the 2nd International Consultation on Benign Prostatic Hyperplasia
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Department of Health and Human Services, Agency for Health Care Policy and
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’BPH’ Study: the psychometric validity and reliability of the ICS male ques-tionnaire.
Br J Urol. 1996;77:554-562.
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study, the mode of each group was still equal to the estimated
frequency of nocturia. For example, within each observed
range, the most frequently occurring or repetitive value
observed was equal to the estimated frequency of nocturia.
Also, in groups 1, 2, and 3, there was an almost equal number
of men who underestimated and overestimated on their initial
estimation, thereby leading to an average of the mean number
of diary-recorded voiding episodes almost equal to the esti-mated
frequency of nocturia. As the result, the average of the
mean number of diary-recorded voiding episodes creates the
illusion that the subjects’ original estimations were more accu-rate
than reported.
Conclusion
Many patients with voiding dysfunction often have their ini-tial
treatment decisions guided by symptom-score question-naires.
One of the seven questions on the AUA symptom-score
questionnaire is about the number of voiding episodes
per night. These questionnaires give quantitative data but
weigh heavily on the patient’s memory. Knowing the actual
number of episodes of nocturia would allow the physician to
treat the patient more appropriately by avoiding both under-treatment
and overtreatment. For instance, a man who has
nocturia eight times per night is perceived to have more serious
disease than a man with nocturia three times per night regard-less
of the patient’s perception of the problem. Voiding diaries
also allow the physician to accurately monitor the individual’s
response to treatment. In other words, knowing a patient’s
frequency of nocturia may be helpful in determining whether
a treatment plan is actually working and whether his medi-cation
dose needs further adjustment. Our study suggests that
voiding diaries are essential in helping to determine the actual
number of voiding episodes per evening. We have also shown
that the need for a voiding diary becomes increasingly impor-tant
as the perceived frequency of nocturia increases.
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Jaffe et al • Original contribution