










































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2022 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Nocturia, nocturnal enuresis, overnight 
ambulatory urodynamics, urinary symptoms, 
quality of life

None declared. Received on October 20, 2021 
Accepted on May 8, 2022 
This article has been peer reviewed.

Soc Int Urol J. 2022;3(4):202–208

DOI: 10.48083/RDTD8562

202 SIUJ  •  Volume 3, Number 4  •  July 2022 SIUJ.ORG

ORIGINAL RESEARCH

Overnight Ambulatory Urodynamics Change  
Patient Management Strategies and Improve 
Symptomatic Outcomes

Richard G. Axell,1 Habiba Yasmin,1 Kristina Aleksejeva,1 Eskinder Solomon,2  
Bogdan Toia,1 Mahreen H. Pakzad,1 Jeremy L. Ockrim,1 Tamsin J. Greenwell1

1 Department of Urology, University College London Hospital NHS Foundation Trust, London, United Kingdom  
2 Department of Urology, Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, United Kingdom 

This work was performed at University College London Hospital NHS Foundation Trust, London, United Kingdom

Abstract

Objectives To determine the diagnostic value of overnight ambulatory urodynamics (aUDS) and to assess if a 
urodynamic diagnosis of detrusor overactivity (DO) or nocturnal enuresis resulted in a change in patient management 
and an improvement in their urinary symptoms.

Methods A retrospective review of 25 consecutive patients (28% male) with a median age of 38 years (range 18 
to 86) having overnight aUDS for bothersome urinary symptoms of primarily nocturia and/or nocturnal enuresis 
following non-diagnostic conventional urodynamics between November 1998 and August 2018. Urinary symptoms 
were assessed before overnight aUDS and again after urological treatment following any changes in urodynamics 
diagnosis and treatment. Six patients were excluded as follow-up data were not available.

Results Twenty-four patients (96%) presented with nocturia and 20 (80%) presented with nocturnal enuresis. DO 
was demonstrated in 19 (76%) patients (mean pressure 69.1±53.3 cmH2O). UUI was demonstrated in 16 (80%) out 
of the 20 patients who complained of nocturnal enuresis. Of the 19 patients with follow-up data, following overnight 
aUDS a change in urodynamic diagnosis was made in 15 patients (79%); 16 patients (84%) also had their clinical 
diagnosis and subsequent management changed; and 15 patients (79%) reported an improvement in their urinary 
symptoms following these changes in diagnosis and treatment. There was a significant improvement in ICIQ-OAB 
(120±44 versus 32±53, P < 0.0001) scores following the changes to clinical management post-overnight aUDS.

Conclusion In our study cohort, change in primary diagnosis following overnight aUDS led to a significant change 
in treatment care pathway and resulted in significant improvement in urinary symptoms at follow-up.

Introduction 

Conventional urodynamics (UDS) are considered the gold standard investigation for lower urinary tract symptoms 
(LUTS)[1,2]. Conventional UDS require rapid bladder filling and are performed in an unnatural environment. 
In a sub-group of patients who have failed medical therapy, conventional UDS are unable provide a urodynamic 
diagnosis that correlates with the patient’s presenting symptoms of nocturia and /or nocturnal enuresis. Ambulatory 

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urodynamics (aUDS) are recognised by the International 
Continence Society (ICS) as an important second-line 
diagnostic tool for providing a definitive diagnosis in 
patients who had previously had a non-diagnostic or 
symptomatically contradictory conventional UDS[3]. In 
our specialist centre, aUDS can be performed overnight 
while the patient is sleeping. In contrast to conventional 
UDS, aUDS allows for natural (orthograde) bladder 
filling and a more natural environment. The patient 
can be catheterised and connected to the urodynamics 
recording equipment and then allowed to go to sleep so 
that their bladder function and any urinary incontinence 
can be assessed overnight and improve the likelihood of 
a diagnostic test.

The aims of this study were to determine the diagnos-
tic value of overnight aUDS in patients presenting with 
isolated symptoms of nocturia and/or nocturnal enure-
sis following non-diagnostic or symptomatically contra-
dictory conventional UDS and to assess if a change in 
patient diagnosis and/or treatment following overnight 
aUDS led to a symptomatic improvement in patients.

Materials and Methods
Study Population
Twenty-five consecutive patients (28% male) having 
overnight aUDS for bothersome urinary symptoms of 
primarily nocturia and/or nocturnal enuresis seen at 
our tertiary referral centre between November 1998 
and August 2018 were identified from our prospectively 
acquired database and retrospectively reviewed. None of 
the patients had an underlying neurological disorder or 
history of previous treatment with radiotherapy. Their 
median age was 38 years (range 18 to 86). All patients 
had previously had conventional pressure flow studies 
or video UDS (vUDS). All overnight aUDS tests were 
performed following multidisciplinary team review 
when conventional UDS were non-diagnostic or when 
the conventional UDS diagnosis was contradictory to 
the patient’s primary presenting symptom(s) of nocturia 
and/or nocturnal enuresis. None of the patients had any 
daytime symptoms and therefore daytime aUDS were 
not performed as this was felt to not be indicated and a 
waste of resources and time for all involved. Six patients 
were excluded because follow-up data were not available.

Before proceeding to conventional urodynamics (filling 
cystometry and pressure flow studies) all patients had 
received (as appropriate) lifestyle advice, continence 
therapist input re bladder training ± pelvic floor muscle 
exercise, medications (as indicated by clinical diagnosis). 
Those progressing to overnight aUDS wished to consider 
more invasive treatments for their isolated nocturia or 
nocturnal enuresis symptoms, and it is a requirement of 

our NHS system and NICE guidance that a urodynamic 
diagnosis is made before these more invasive treatments.

Urodynamics Procedures
aUDS stud ies were per formed as per t he ICS 
guidelines[1,3] using the MMS Solar LUNA module 
(Medical Measurement Systems, Gladbeck, Germany). 
A f low rate, post-void residual and urinalysis were 
performed before the test. After residual urine was 
measured, a 4.5fr bladder catheter (Mediplus 5716, 
Wycombe, United Kingdom) and a 4.5fr rectal balloon 
catheter (Mediplus 5410, Wycombe, United Kingdom) 
were inserted for the measurement of intravesical and 
abdominal pressures, respectively. A conductance leak 
pad sensor (Digitimer Pe-Que Sensor Pad, Welwyn 
Garden, United Kingdom) was used on all patients 
reporting symptoms of nocturnal enuresis. After zeroing 
the fluid filled pressure measurement transducers and 
flushing the measurement lines with saline, a cough was 
used to ensure good cancellation and accurate pressure 
measurement readings. The patients were then taken 
to a private ward side room and advised on the use of 
the LUNA module events buttons to mark urgency and 
leakage and to activate the flowmeter to record voiding 
The patients were encouraged to perform their normal 
nightly routine known to be provocative for their typical 
nocturia and/or nocturnal enuresis symptoms. The 
median study duration was 16 hours (range 13 to 18). 
The urodynamicist returned to the ward in the morning 
to remove the pressure lines and download the overnight 
aUDS data from the LUNA module. A cough was again 
used to ensure good cancellation before removal of the 
pressure lines and the patient was asked whether they 
had experienced their typical overnight symptoms 
during the test. The on-call urology specialist registrar 
was available for advice or to review the patient if there 
were any issues overnight—in particular, with the 
pressure lines.

All conventional UDS, vUDS and overnight aUDS 
studies were analysed by an experienced urodynami-
cist and reviewed at a multidisciplinary team meeting 
to ensure accuracy of diagnosis and to determine treat-
ment options.

Assessment of Urinary Symptoms
Urinary symptoms were assessed using ICIQ-OAB 
scores in all patients before and after the changes to 
clinical management post-overnight aUDS. ICIQ-
OAB scores were extrapolated from medical records in  
5 patients treated at UCLH prior to 2010. This 
extrapolation was based on the detailed history of 
day time frequency, nighttime frequency, urgency, 
and urgency urine leak, plus bother related to these 
symptoms available in the notes.

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FIGURE 1. 

An 18-year-old female patient presenting with daytime frequency, urgency,  
and nocturnal enuresis (2 pads per 24 hours) 

vUDS trace showing a reduced 326 mL capacity bladder limited by pain due to loss of compliance (end-fill pressure 
26cmH2O), with no DO or SUI demonstrated.

A

Whole overnight aUDS study trace

B

continued on page 205

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Statistical Analysis
Data are expressed as median IQR and P-values were 
calculated using a 2-tailed paired Student t test for 
pairwise comparisons of parametric data, unless 
otherwise stated. Categorical data are expressed as 
number (percentage) and compared with the Fisher 
exact test. P < 0.05 was considered statistically 
significant. Analysis was performed using SigmaPlot 
12.5 (Systat Software Inc, San Jose,US) statistical analysis 
package.

Results
Following overnight aUDS, all studies were evaluable 
(as determined by replication of the patients’ nocturnal 
symptoms and good quality trace) and a definitive UDS 
diagnosis of DO was made in 79% (n = 19) of 24 patients 
presenting with nocturia (mean DO pressure 69.1 
± 53.3 cmH2O) and in 90% (n = 18) of the 20 patients 
presenting with nocturnal enuresis. UUI (median pad 
weight gain 103 mL, IQR 45–205) was demonstrated in 
80% (n = 16) of the 20 patients presenting with nocturnal 
enuresis. Of the remaining patients, 5 had a diagnosis of 
sensory urgency confirmed and 1 patient was diagnosed 
with reduced functional capacity due to high PVRs.  
A change in the primary UDS diagnosis occurred in 
80% (n = 20) of patients following aUDS.

Sub-Group Analysis of 19 Patients With Post 
AUDS Treatment Follow-Up Data

All 25 patients attended for their initial post noctur-
nal aUDS review, at which time the outcome of the 
nocturnal aUDS was discussed along with their new 
clinical diagnosis and treatment recommendations. Six 
patients failed to attend for further follow-up, whilst 19 
proceeded with treatment recommendations and had 
ongoing follow-up data available for review. DO was 
demonstrated in 14 of the 15 patients who presented 
with nocturnal enuresis, and the final patient was found 
to have a reduced functional capacity due to high PVRs. 
Of the remaining 4 patients who presented with isolated 
nocturia symptoms, 1 was found to have DO, and the 
remaining 3 patients had a diagnosis of sensory urgency 
confirmed.

Therefore, 84% (n = 16) of this patient sub-group 
had their clinical diagnosis and management changed 
following aUDS. In the 15 patients who had DO demon-
strated, 3 were treated with a clam cystoplasty, 5 were 
treated with intravesical botulinum toxin injections, 
and the remaining patients were treated with combina-
tion medical therapy. Of the 3 patients with confirmed 
sensory urgency, 1 was treated with reduced f luid 
intake, 1 was treated with desmopressin, and the final 
patient was treated with cognitive behavioural therapy.  

FIGURE 1. 

An 18-year-old female patient presenting with daytime frequency, urgency,  
and nocturnal enuresis (2 pads per 24 hours), Cont’d

Extrapolated overnight aUDS trace showing high pressure DO (up to pp145cmH2O) and 220 mL leak

C

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The patient diagnosed with reduced functional capac-
ity due to high PVRs had their catheterisation technique 
reviewed by the urology clinical nurse specialist and was 
advised to catheterise more often.

These treatment changes led to a statistically signif-
icant improvement in the reported urinary symptoms 
of daytime frequency, nocturia, and nocturnal enure-
sis in 79% of patients (Table 1). There was a significant 
improvement in ICIQ-OAB (120±44 versus 32±53,  
P < 0.0001) scores following the changes to clinical 
management post-overnight aUDS (Table 2). Sixty-one 
percent (11 out of 18) of patients had resolution of their 
nocturia and 73% (11 out of 15) of patients had resolu-
tion of their nocturnal enuresis.

Discussion
This exploratory study is the first to demonstrate that 
overnight aUDS is an extremely useful final stage 
diagnostic tool in patients with isolated nocturnal 
symptoms in whom conventional or video urodynamics 
have been non-d iag nost ic or sy mptomat ica l ly 
contradictor y. All overnight aUDS studies were 
evaluable, and we were able to make a definitive 
diagnosis in all patients. DO was demonstrated in 79% 
of patients presenting with nocturia and/or nocturnal 
enuresis. UUI was demonstrated in 80% of patients 
presenting with nocturnal enuresis. Of the others, their 
original diagnosis of sensory urgency was confirmed 

in 5 patients, and 1 patient was found to have a reduced 
functional capacity due to high PVRs. The finding of 
reduced functional capacity and high PVRs was not 
identified on routine flow rate and post-void residual 
or conventional pressure f low studies and appears 
to have been a nocturnal phenomenon of unknown 
cause. Although there are no other overnight aUDS 
datasets for comparison, we reproduced patients’ 
symptoms in all studies, compared with published 
day time aUDS datasets, which reported rates of 
72% to 77%[4,5]. Equally, previous daytime aUDS 
studies have demonstrated that clinical outcomes are 
improved in 40% to 79%[4,6] following treatment 
modification. This is similar to the 61% of patients who 
had resolution of their nocturia and the 73% of patients 
who had resolution of their nocturnal enuresis following 
treatment modification.

Nocturia is defined by the ICS as the complaint of 
waking to pass urine during the main sleep period[7]. 
The prevalence of nocturia increases with age[8]: approx-
imately 50% of adults between the ages of 50 and 79 have 
nocturia, and it is estimated that men aged between 70 
and 79 get up at least twice per night to pass urine[9]. If 
there are 2 or more episodes per night, nocturia can be 
a significant problem[10], affecting both sleep onset and 
ability to return to sleep[11]. Nocturia is strongly associ-
ated with poor quality of life[12], mainly due to fatigue 
caused by sleep disturbances[11]. Nocturia is often 
multifactorial. It can be caused by reduced functional 

TABLE 1. 

Urinary symptoms pre- and post- changes in diagnosis and treatment following overnight aUDS 

Urinary Symptoms Pre-Overnight aUDS Post-Overnight aUDS P-Value

Isolated nocturia, n(%) 4(21) 0(0) –

Isolated nocturnal enuresis, n(%) 1(5) 1(5) –

Both nocturia and nocturnal enuresis, n(%) 14(74) 4(21) <0.001

TABLE 2. 

Urinary symptoms ICIQ-OAB score pre- and post- changes in diagnosis and treatment following overnight aUDS 

Symptom
Pre-Overnight 

aUDS ICIQ-OAB, 
(Mean±SD)

Post-Overnight 
aUDS ICIQ-OAB, 

(Mean±SD
P-Value

Isolated nocturia (n = 4) 80±46 0±0 –

Isolated nocturnal enuresis (n = 1) 120 80 –

Both nocturia and nocturnal enuresis (n = 14) 131±40 38±59 <0.001

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bladder capacity, increased nocturnal urine output, or 
can result from primary sleep related disorders such 
as obstructive sleep apnoea, which affects nocturnal 
urine production and consequently provokes nocturnal 
bladder symptoms[13]. Nocturnal polyuria should be 
excluded as a cause, as this can be an indicator of a wors-
ening underlying pathology[14]. Sleep disorders should 
also be excluded, as patients with a primary sleep disor-
der, such as restless leg syndrome, may awaken due to 
this and then void but recall only waking to void when 
presenting clinically[15].

Nocturnal enuresis is defined by the ICS as the 
complaint of involuntary voiding that occurs at night 
during the main sleep period[7]. Although nocturnal 
enuresis is considered as a physiological finding in chil-
dren less than 5 years old, it is abnormal in adults[16].  
In adults, the prevalence of nocturnal enuresis is 
reported as 0.5% to 3%[17–19]. Typically, an adult 
presenting with isolated symptoms of nocturia and/or 
nocturnal enuresis will be managed by a primary care 
physician following history, physical examination, blad-
der diary, and urinalysis. However, assessment (with 
uroflowmetry and post-void residuals, cystoscopy and 
urodynamic evaluation) and treatment by a urologist 
may be required for those with the very bothersome or 
persistent symptoms[20]. Hirasing et al. found that only 
12% of adult men and 29% of adult women present-
ing with nocturnal enuresis had concomitant daytime 
incontinence[19], meaning that about 71% to 88% of 
patients with nocturnal enuresis will have a non-diag-
nostic conventional daytime urodynamic assessment.

Annually at our centre we perform 75 to 100 aUDS 
studies and 1 to 2 overnight aUDS studies. The 25 
patients having aUDS were accrued over a 20-year 
period – and account for < 1% of our aUDS studies. 
During this time period, we have had 3 separate lead 
principal clinical scientists performing and interpret-
ing both our aUDS and our overnight aUDS using a 
standardised technique and reporting pro forma, with 
no loss of continuity of care, and 1 change of aUDS 
equipment to a more modern version of the previous. 
Although both aUDS and overnight aUDS are the most 
accurate urodynamic diagnostic tests available, it takes 
2 to 4 hours to perform an aUDS or 12 to 16 hours to 
perform an overnight aUDS (in addition to the cost of 
a ward side room overnight) and 1 to 2 hours to inter-
pret the results (versus 30 to 60 minutes in total for UDS/
vUDS). Within the United Kingdom health care system, 
invasive treatment options such as intra-vesical botuli-
num toxin and sacral neuromodulation are offered only 
following a proven urodynamic diagnosis of DO. We 
do not perform invasive urodynamic assessment prior 
to non-operative intervention, as per NICE guidance[2]. 
Overnight aUDS is neither cost- nor time-effective as a 

first-line assessment tool. It should therefore be reserved 
for patients with significantly bothersome isolated 
symptoms of nocturia and/or nocturnal enuresis 
contemplating invasive treatment in whom conventional 
and/or vUDS have been non-diagnostic or contradictory 
to patient symptomatology.

There are some limitations of this study. Whilst this 
was a retrospective study, we consecutively reviewed all 
patients who had an overnight aUDS over a 20-year time 
period, and this is the largest dataset presented world-
wide to date. Although sleeping with a urinary cathe-
ter in situ is not part of the natural environment, and 
tests were performed in a ward side room, our patient 
cohort tolerated this well, and all episodes of UUI corre-
sponded with large flooding leaks detected on the leak 
pad sensor. The patients reported that the urodynamic 
findings correlated with their typical nocturnal urinary 
symptoms and did not report that the 4.5fr urinary cath-
eter used during the aUDS influenced the test. Although 
overnight aUDS is a time-consuming and expensive test, 
aUDS in general have been shown to be well tolerated[21] 
with 85% of patients happy to attend for further studies. 
Only 18.6% of patients experience mild to moderate de 
novo dysuria and 1.1% experience asymptomatic bacte-
rial UTI following aUDS[22].

There was no daytime aUDS performed in this group 
for the reasons cited in the methods section of this paper, 
and therefore there is no ability to compare daytime 
aUDS findings with overnight aUDS findings. If daytime 
aUDS permitted diagnosis (which we felt highly unlikely 
in the absence of symptoms—which is after all the goal 
of UDS—to reproduce symptoms and assess the under-
lying pathophysiological cause), then overnight aUDSs 
would have been avoided.

Extrapolation of urinary symptoms detailed in 
the notes of 5 early patients to retrospectively form an 
ICIQ-OAB score is also a weakness. Whilst the notes 
were detailed in terms of daytime frequency, night-
time frequency, severity of urgency and urgency incon-
tinence, and bother, the actual ICIQ-OAB was not 
contemporaneously completed by the patient, and this 
may introduce a degree of inaccuracy into the extrapo-
lated score.

Overnight aUDS is a complex challenging test and 
as such should be performed only at specialist centres 
and reserved for highly selected patients with isolated 
nocturnal urinary symptoms following a non-diagnos-
tic conventional or vUDS.

Conclusion
This is the first study to show that overnight aUDS 
studies are a useful clinical assessment technique 
in patients with isolated nocturnal symptoms. DO 

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was demonstrated in 79% of patients presenting 
with nocturia and in 90% of patients presenting 
with nocturnal enuresis. Of patients presenting with 
nocturnal enuresis, 80% were also demonstrated to 
have a diagnosis of UUI. Following overnight aUDS, 
the clinical diagnosis and subsequent management 

pathway was changed in 84% of patients. This resulted in 
a significant improvement in symptomatic outcomes. A 
total of 61% of patients had resolution of their nocturia, 
and 73% of patients had resolution of their nocturnal 
enuresis.

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