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uro.nocturia-eval.v1

Nocturia — chronic outpatient evaluation (nocturnal polyuria / reduced bladder capacity / 24-h polyuria / sleep / med / BPH / CHF / CKD / pregnancy / aging)

urologychronicadultgeriatricoutpatient
Start encounter →Print handoutPRODUCTION

Phase C wave-14 initial author (2026-05-15): SCAFFOLDED with full §5.5 depth — 11 phenotypes encoded as severity_triggers (nocturnal polyuria dominant, reduced bladder capacity, 24-h global polyuria, OSA-dominant, medication-induced, BPH-associated, CHF-associated, pregnancy physiologic, aging normal, behavioral evening fluid, CKD-related), 1 setting (outpatient primary), 6-PMID anchor set, 1 regimen axis with 8 steps (behavioral / med-timing / desmopressin / antimuscarinic-β3 / α-blocker / CPAP / CHF / comorbid routes), 5 sibling rows pointing at REAL existing engines (uro.bph.v1, uro.urinary-incontinence-eval.v1, cardio.acute-hf.core.v1, neph.ckd.core.v1, endo.dm2.core.v1). FVC-FIRST doctrine: 3-day frequency-volume chart is THE diagnostic artifact — differentiates nocturnal polyuria (NPi >33% / >20% young) from reduced bladder capacity from 24-h global polyuria; without FVC, phenotype is unknowable. DESMOPRESSIN-SAFETY doctrine: FDA Noctiva sex-specific dosing (female 0.83 mcg nasal lower than male 1.66 mcg due to higher hyponatremia risk); AVOID >65 yo (hyponatremia); baseline + serial Na at 1 wk + 1 mo + 3 mo + when ill; AVOID concurrent loop diuretic / SSRI; AVOID SIADH / CHF. Comorbid routing: BPH → uro.bph.v1; OAB → uro.urinary-incontinence-eval.v1; CHF → cardio.acute-hf.core.v1; CKD → neph.ckd.core.v1; DM → endo.dm2.core.v1; OSA → sleep medicine PSG + CPAP. Elderly safety: β3 (mirabegron / vibegron) or trospium preferred over oxybutynin IR (Beers); fall-prevention is dominant concern; deprescribing review. Medication-timing intervention: shift loop diuretic to morning ≥6 h before bedtime is high-yield + low-risk intervention often missed. Promoted SCAFFOLDED→INTEGRATED 2026-05-22 (shard-5 build campaign): all 6 prior placeholder PMIDs were mis-attributed (spinal myelopathy, VTE-obesity, aging white-matter, depression PRS [recycled], sympathetic ophthalmia, research ethics) and replaced with the live-verified AUA/SUFU OAB 2019 guideline (31039103); desmopressin/AASM-OSA/HF cited by name. RxCUIs corrected (7 wrong): solifenacin 1099767→322167, mirabegron 1455007→1300786, vibegron 2569961→2472254 (was menthol), desmopressin 3289→3251 (was dextromethorphan), silodosin 36117→720825 (was salmeterol), trospium 38400→236778 (was atomoxetine), onabotulinumtoxinA 861015→860189 (was metformin); tamsulosin 77492 RxNav-verified. Schema-blocked downstream: calc.fvc_24h, protocol.fvc_3day, panel.sleep_study, workup.psg_for_OSA, workup.serum_AVP — none yet in clinical-tools-registry.ts. Tickets surfaced in depth brief §6. Dossier registered in _registry.ts as part of this commit (Phase C wave-14 shard-3 scope).

Entry points (8)

  • symptom
    Patient reports ≥2 voids per night that wake them; ICS definition of nocturia (AUA OAB 2019)
    nocturia_two_or_more_voids_per_night
  • symptom
    Nocturia causing sleep disruption / daytime fatigue / falls in elderly — symptom-driven evaluation
    nocturia_with_sleep_disruption_or_falls
  • history
    Established BPH with nocturia component — α-blocker bridge + FVC for nocturnal polyuria overlap (uro.bph.v1)
    known_bph_nocturia
  • history
    Established CHF with nighttime supine-diuresis pattern — evening fluid restriction + diuretic timing (cardio.acute-hf.core.v1)
    known_chf_nighttime_diuresis
  • history
    Known DM with polyuria — endo.dm2.core.v1 pivot for glycemic control + 24-h polyuria phenotype
    known_dm_or_dm_polyuria
  • history
    Established CKD with concentrating-defect-related nocturia — neph.ckd.core.v1 pivot
    known_ckd_nocturia
  • history
    Snoring + witnessed apnea + morning headaches + daytime sleepiness → OSA workup (PSG)
    snoring_witnessed_apnea_morning_headaches
  • problem_list
    Medication review — loop diuretic evening dose / SSRI / TCA / CCB / lithium → adjust timing
    medication_review_nocturia

Required inputs (23)

  • agerequired
    demographic • used at FRAME
    Aging is a major contributor; >65 yo trigger for desmopressin hyponatremia caution (AUA OAB 2019; FDA desmopressin warning)
  • sexrequired
    demographic • used at FRAME
    Male: BPH overlay; female: OAB / mixed UI overlay; pregnancy phenotype
  • nocturia_episodes_per_nightrequired
    symptom • used at ENTRY
    ICS definition ≥1 voiding (any waking void counts); bother typically at ≥2; serial diary tracking (AUA OAB 2019)
  • frequency_volume_chart_3dayrequired
    symptom • used at INITIAL_WORKUP
    3-day FVC is THE diagnostic artifact — quantifies 24-h output, nocturnal output, nocturnal polyuria index (NPi = nocturnal output / 24-h output) (AUA OAB 2019)
  • evening_fluid_caffeine_alcohol_intakerequired
    history • used at CONTEXT
    Excessive evening fluid / caffeine / alcohol drives nocturnal polyuria — behavioral modification primary intervention
  • current_meds_diuretics_timingrequired
    history • used at CONTEXT
    Loop diuretic evening dose drives nocturia — shift to morning; SSRI / TCA / CCB / lithium / bisphosphonate timing adjustment (Beers / STOPP)
  • chf_or_volume_overload_statusrequired
    history • used at CONTEXT
    CHF nighttime supine-diuresis pattern — evening fluid restriction + morning diuretic + leg elevation late afternoon (cardio.acute-hf.core.v1)
  • dm_or_di_polyuriarequired
    history • used at CONTEXT
    DM / DI / hypercalcemia / SIADH cause 24-h global polyuria pattern; gates endo / neph workup (endo.dm2.core.v1; neph.ckd.core.v1)
  • ckd_concentrating_defect
    history • used at CONTEXT
    CKD impairs urinary concentration → fixed isosthenuria → nocturia from nocturnal polyuria; route neph.ckd.core.v1
  • sleep_disorder_history_OSArequired
    history • used at CONTEXT
    OSA causes nocturia via ANP release (negative intrathoracic pressure); PSG indicated; CPAP improves nocturia
  • bph_or_voiding_symptomsrequired
    history • used at CONTEXT
    BPH causes nocturia via reduced functional capacity + obstruction; α-blocker bridge; route uro.bph.v1
  • pregnancy_statusrequired
    history • used at CONTEXT
    Pregnancy physiologic nocturia from uterine pressure on bladder + increased GFR — reassurance + minor lifestyle measures
  • mental_health_depression_anxiety
    history • used at CONTEXT
    Depression / anxiety can affect sleep architecture and bladder perception; SSRI may be implicated (Beers)
  • allergy_or_hyponatremia_riskrequired
    history • used at TREATMENT
    Desmopressin requires baseline sodium + recheck at 1 wk; older / loop-diuretic / SSRI heighten risk (FDA warning)
  • sbprequired
    vital • used at TREATMENT
    Baseline BP for diuretic / α-blocker / β3 agonist initiation; orthostasis screening (AUA OAB 2019)
  • temp
    vital • used at RED_FLAGS
    Fever + nocturia → UTI workup (transient cause); rule out before chronic phenotyping (AUA OAB 2019)
  • post_void_residualrequired
    imaging • used at INITIAL_WORKUP
    PVR — high (>250 mL) gates BPH overlay + antimuscarinic caution (AUA BPH 2021)
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    Rule UTI + hematuria + glucosuria + casts; transient cause screen (AUA OAB 2019)
  • glucose_serumrequired
    lab • used at INITIAL_WORKUP
    Rule DM polyuria — glucose / HbA1c (endo.dm2.core.v1)
  • serum_sodium_baselinerequired
    lab • used at INITIAL_WORKUP
    Baseline for desmopressin safety + screen SIADH / hypernatremia (FDA desmopressin warning)
  • serum_calcium
    lab • used at INITIAL_WORKUP
    Rule hypercalcemia (polyuria from nephrogenic DI pattern) (workup.hypercalcemia)
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    Baseline renal function — CKD concentrating defect (neph.ckd.core.v1)
  • bnp_nt_probnp
    lab • used at INITIAL_WORKUP
    BNP for CHF screening if nighttime supine-diuresis pattern (cardio.acute-hf.core.v1)

12-phase flow (12)

  1. 1FRAME
    Adult / geriatric outpatient with chronic nocturia ≥2 voids/night with bother; identify dominant phenotype (nocturnal polyuria / reduced bladder capacity / 24-h polyuria / sleep / med / comorbid CHF / DM / DI / hypercalcemia / OSA / BPH / CKD / pregnancy / aging) (AUA OAB 2019)
    inputs: age, sex
    advance: engine scope confirmed
  2. 2ENTRY
    Nocturia episodes per night + bother + sleep disruption + falls risk (AUA OAB 2019)
    inputs: nocturia_episodes_per_night
    advance: entry captured
  3. 3CONTEXT
    Evening fluid / caffeine / alcohol intake; current meds (diuretic timing, SSRI / TCA / CCB / lithium); CHF; DM / DI / hypercalcemia; CKD; OSA; BPH; pregnancy; mental health (AUA OAB 2019; Beers)
    inputs: evening_fluid_caffeine_alcohol_intake, current_meds_diuretics_timing, chf_or_volume_overload_status, dm_or_di_polyuria, ckd_concentrating_defect, sleep_disorder_history_OSA, bph_or_voiding_symptoms, pregnancy_status, mental_health_depression_anxiety
    advance: context + comorbidity overlay complete
  4. 4RED_FLAGS
    UTI / hematuria → AUA microhematuria; hypercalcemia → workup; new-onset DM / DI → endo workup; hyponatremia screen before desmopressin; cauda equina red flags (saddle anesthesia, lower extremity weakness) → STAT neuro/spine (AUA OAB 2019)
    inputs: temp
    advance: no red flags OR routed
  5. 5INITIAL_WORKUP
    3-day frequency-volume chart (FVC) is mandatory; UA + glucose + sodium + creatinine; PVR; CMP / serum calcium; consider BNP if CHF suspected (AUA OAB 2019)
    inputs: frequency_volume_chart_3day, post_void_residual, urinalysis, glucose_serum, serum_sodium_baseline, serum_calcium, creatinine_egfr, bnp_nt_probnp
    actions: panel.ua, panel.renal
    advance: FVC complete + phenotype assigned
  6. 6BRANCHING_WORKUP
    PSG for OSA suspicion; serum AVP if water-deprivation test indicated (rare); cystoscopy if hematuria; urology if BPH overlay; neph if CKD (AUA OAB 2019)
    advance: branching diagnostics complete
  7. 7DIFFERENTIAL
    Nocturnal polyuria dominant (NPi >33% / >20% young), reduced bladder capacity, 24-h global polyuria (DM / DI / hypercalcemia / SIADH workup), OSA-dominant, medication-induced, BPH-associated, CHF-associated, pregnancy, aging-normal, behavioral evening fluid, CKD concentrating defect (AUA OAB 2019)
    advance: phenotype assigned
  8. 8RISK_STRATIFICATION
    Episode count + sleep disruption severity + falls risk + comorbidity overlay (AUA OAB 2019)
    inputs: sbp
    advance: severity + comorbidity overlay assigned
  9. 9TREATMENT
    STEP 1 — behavioral / lifestyle (evening fluid / caffeine / alcohol limit; leg elevation; compression stockings; nap if CHF; sleep hygiene). STEP 2 — medication review + timing adjustment (diuretic to morning). STEP 3 — phenotype-specific: desmopressin (≤65 nocturnal polyuria) OR antimuscarinic / β3 (reduced capacity / OAB) OR α-blocker (BPH) OR CPAP (OSA). STEP 4 — comorbid management routes (CHF → cardio.acute-hf.core.v1; DM → endo.dm2.core.v1; CKD → neph.ckd.core.v1). STEP 5 — pregnancy reassurance + minor lifestyle. STEP 6 — fall prevention (PT, lighting, bedside commode) (AUA OAB 2019)
    inputs: current_meds_diuretics_timing, allergy_or_hyponatremia_risk
    advance: phenotype-specific plan documented
  10. 10DISPOSITION
    Outpatient primary; uro/urogyn referral if refractory OAB / surgical BPH; sleep medicine if OSA; nephrology if CKD; cardiology if CHF (AUA OAB 2019)
    advance: disposition documented
  11. 11MONITORING
    FVC at 4 wk; episodes per night + bother; sodium at 1 wk + 1 mo + 3 mo on desmopressin; BP on diuretic / α-blocker / β3 (AUA OAB 2019; FDA)
    advance: monitoring plan documented
  12. 12FOLLOWUP
    Annual re-eval; deprescribing review on diuretic / desmopressin / antimuscarinic in elderly; reassess phenotype if symptoms change (AUA OAB 2019; Beers)
    advance: follow-up scheduled