DEAR DR. ROACH: My husband, 79 years old, is getting up five or six times at night to urinate. The urgent care doctor said he doesn’t have an infection but doesn’t know what’s going on. He is taking Flomax, but that doesn’t seem to be helping. Who should he see? — E.L.O.
ANSWER: Urinating at nighttime (“nocturia”) is a common problem for men, but if this is a new or suddenly worsened problem, it requires evaluation. The first question is whether he is urinating a lot or a little. A male bladder typically holds about 500 cc (almost a quart), so if his bladder were full every time, he might be making as much as 2.5 liters a night. Nighttime urination is considered high-volume when it constitutes a third or more of total urine output for 24 hours.
High-volume nocturia can happen when there is too much of something to get rid of: sugar, in people with mellitus (“sugar diabetes”); salt, in people who eat too much salt at dinner; water, in people who drink a whole lot of water, especially at night; and occasionally in people with congestive heart failure. In heart failure, there is not enough blood flow to the kidneys during the day, so when the person is at rest, the kidneys have enough blood flow to get rid of the fluid that has accumulated during the day (often in the legs and feet).
Another cause of high-volume nocturia is diabetes insipidus, a problem with either the kidney or the control center in the brain, causing the kidney to excrete too much water. That control center uses a hormone called anti-diuretic hormone to regulate water excretion. Normally, it is high at night, so there is less urine output at night. Sometimes this normal variation is reversed, leading to excess urine output at night, even without diabetes insipidus. High-volume nocturia is most commonly evaluated by doctors in internal medicine, including kidney and heart specialists.
Low-volume nocturia is caused by a problem with the bladder or, in men, the prostate. Urologists are the experts in figuring out where the problem is and the best course of treatment. Many men get treated for prostate problems when the real issue is an overactive bladder.
DEAR DR. ROACH: My blood pressure drug, losartan, was recalled because of contamination issues with NDEA and NDMA; one is used to make liquid rocket fuel and the other is a byproduct in the manufacture of pesticides. How does this happen? Does the drug company share manufacturing facilities with companies that make these other products? — EG
ANSWER: I read some speculation by chemists on how the contamination could have happened, and it seems to me that one company made a new process for making losartan (and the related drugs irbesartan and valsartan) that, although cheaper and more efficient, allowed contaminants to form unrecognized.
Although not recognized until 2018, it could have been happening since 2012. Other companies changed their manufacturing as well, unaware of these toxic impurities. This is a real problem, not so much because of this current recall (where the contamination levels are very low), but because it shows the industry lacks enough oversight to quickly identify contamination in generic pharmaceuticals coming from multiple countries.