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! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Polyuria Resident Survival Guide Microchapters}}
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Polyuria resident survival guide#Overview|Overview]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Polyuria resident survival guide#Causes|Causes]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Polyuria resident survival guide#Approach to Polyuria|Diagnosis]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Polyuria resident survival guide#Treatment|Treatment]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Polyuria resident survival guide#Do's|Do's]]
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{{CMG}}; {{AE}} {{ZO}}
{{SK}} Approach to polyuria, Approach to dilute urine, Polyuria management, Polyuria work-up
==Overview==
==Overview==
* [[Polyuria]] is defined as [[urine]] [[output]] more than 2 L/24 hours, or 30 ml/kg/24 hours. There are 3 [[pathophysiologic]] causes of [[polyuria]]: increased [[thirst]] ([[idiopathic]], [[psychogenic]] [[polydepsia]], [[hypothalamic]] disease, and [[medications]]), [[central diabetes insipidus]] (DI) (decreased secretion of [[arginine vasopressin]] ([[AVP]])), and [[nephrogenic diabetes insipidus]] (DI) ([[renal]] resistance to [[AVP]]).<ref name="pmid12617410">{{cite journal| author=Moore K, Thompson C, Trainer P| title=Disorders of water balance. | journal=Clin Med (Lond) | year= 2003 | volume= 3 | issue= 1 | pages= 28-33 | pmid=12617410 | doi=10.7861/clinmedicine.3-1-28 | pmc=4953350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12617410  }} </ref>
* [[Polyuria]] is defined as [[urine]] [[output]] more than 2 L/24 hours, or 30 ml/kg/24 hours. There are 3 [[pathophysiologic]] causes of [[polyuria]]: increased [[thirst]] ([[idiopathic]], [[psychogenic]] [[polydepsia]], [[hypothalamic]] disease, and [[medications]]), [[central diabetes insipidus]] (DI) (decreased secretion of [[arginine vasopressin]] ([[AVP]])), and [[nephrogenic diabetes insipidus]] (DI) ([[renal]] resistance to [[AVP]]).<ref name="pmid12617410">{{cite journal| author=Moore K, Thompson C, Trainer P| title=Disorders of water balance. | journal=Clin Med (Lond) | year= 2003 | volume= 3 | issue= 1 | pages= 28-33 | pmid=12617410 | doi=10.7861/clinmedicine.3-1-28 | pmc=4953350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12617410  }} </ref>
* [[Nocturnal]] [[polyuria]] ([[NP]]), characterized by [[overproduction]] of [[urine]] at night (more than 20%-33% of total 24-hour urine volume depending on age). It can be caused by intake, [[urological]], [[nephrological]], [[hormonal]], [[sleep]], and [[cardiovascular]] factors. <ref name="pmid31586470">{{cite journal| author=Weiss JP, Everaert K| title=Management of Nocturia and Nocturnal Polyuria. | journal=Urology | year= 2019 | volume= 133S | issue=  | pages= 24-33 | pmid=31586470 | doi=10.1016/j.urology.2019.09.022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31586470  }} </ref>
==Causes==
==Causes==
===Life Threatening Causes===
===Life Threatening Causes===
 
*Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
*Polyuria does not have life-threatening causes.
===Common causes <ref name="pmid24490488">{{cite journal| author=Wieliczko M, Matuszkiewicz-Rowińska J| title=[Polyuria]. | journal=Wiad Lek | year= 2013 | volume= 66 | issue= 4 | pages= 324-8 | pmid=24490488 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24490488  }} </ref>  <ref name="pmid31586470">{{cite journal| author=Weiss JP, Everaert K| title=Management of Nocturia and Nocturnal Polyuria. | journal=Urology | year= 2019 | volume= 133S | issue=  | pages= 24-33 | pmid=31586470 | doi=10.1016/j.urology.2019.09.022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31586470  }} </ref>===
===Common causes <ref name="pmid24490488">{{cite journal| author=Wieliczko M, Matuszkiewicz-Rowińska J| title=[Polyuria]. | journal=Wiad Lek | year= 2013 | volume= 66 | issue= 4 | pages= 324-8 | pmid=24490488 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24490488  }} </ref>  <ref name="pmid31586470">{{cite journal| author=Weiss JP, Everaert K| title=Management of Nocturia and Nocturnal Polyuria. | journal=Urology | year= 2019 | volume= 133S | issue=  | pages= 24-33 | pmid=31586470 | doi=10.1016/j.urology.2019.09.022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31586470  }} </ref>===
* The most common causes of '''[[polyuria]]''' are:  
* The most common causes of '''[[polyuria]]''' are:  
**[[Psychogenic]] [[polydipsia]]
**[[Pregnancy]]
**[[Diabetes insipidus]] [[DI]] ([[central]] and [[nephrogenic]])
**[[Psychogenic polydipsia]]
**[[Central diabetes insipidus]] ([[CDI]])
**[[Nephrogenic diabetes insipidus]] ([[NDI]])
**[[Diabetes mellitus]] ([[DM]])
**[[Chronic kidney disease]] ([[CKD]])
**[[Chronic kidney disease]] ([[CKD]])
**Uncontrolled [[diabetes mellitus]] ([[DM]])  
**[[Urinary tract infection]] ([[UTI]])
**[[Interstitial cystitis]]
**[[Nephrolithiasis]]
**[[Primary hyperparathyroidism]]
**[[Familial hypocalciuric hypercalcemia]]
**[[Hypercalcemia]]
**[[Hypokalemia]]
**[[Sickle cell disease]] ([[SCD]])
**[[Stroke]] or [[neurological]] diseases
**[[Benign prostatic hyperplasia]] ([[BPH]])
**[[Stress incontinence]]
**[[Medications]]:
***[[Lithium]]
***[[diuretics]]
**[[Overactive bladder]]
**Drinking alcohol or caffeine


* '''[[Nocturnal]] [[Polyuria]]''' ([[NP]]) can be caused by different medical conditions including:
==Approach to Polyuria==
**[[Congestive heart failure]] ([[CHF]])
**[[Diabetes mellitus]] ([[DM]])
**[[Obstructive sleep apnea]] ([[OSA]])
**[[Peripheral edema]]
**Excessive nighttime fluid intake
**Abnormalities in [[antidiuretic hormone]] [[arginine vasopressin]] ([[AVP]]) [[secretion]] can cause [[overproduction]] of [[urine]] at night
**[[Nocturnal]] [[Polyuria]] [[Syndrome]], in the absence of any medical condition, it can be due to impaired [[circadian]] release of [[Arginine vasopressin]]([[AVP]]), which plays a key role in the control of [[urine]] production by increasing [[water absorption]] and [[concentration]] of [[urine]] at night


==Diagnosis==
Shown below is an algorithm summarizing the approach to [[polyuria]].<br>
<span style="font-size:85%">'''Abbreviations:'''
'''DI:''' Diabetes insipidus;


* [[Water]] [[deprivation]] [[test]] combined with [[desmopressin]] administration is the diagnostic '''gold standard''', it [[differentiate]]s between the causes of the [[polyuria]]‐[[polydipsia]] [[syndrome]].
</span>
===Hypotonic Polyuria===
{{Family tree/start}}
{{Family tree | | | | | | | | | | | | | A01 | | | | |A01='''Suspected hypotonic polyuria'''<ref name="pmid30779536">{{cite journal| author=Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dungan K | display-authors=etal| title=Endotext | journal= | year= 2000 | volume=  | issue=  | pages=  | pmid=30779536 | doi= | pmc= | url= }} </ref>}}
{{Family tree | | | | | | | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | | | | | | | B01 | | | | |B01='''Confirm presence of polyuria'''<br>'''>50ml/kg/24hrs or >3-4L/day'''}}
{{Family tree | | | | | | | | | | |,|-|-|^|-|-|.| | }}
{{Family tree | | | | | | | | | | C01 | | | | C02 |C01=Polyuria confirmed|C02=No polyuria/ or >800 mOsm/kg}}
{{family tree | | | | | | | | | | |!| | | | | |!}}
{{family tree | | | | | | | | | | D01 | | | | D02 | | | |D01='''Measure urine osmolality'''|D02='''Diabetes insipidus(DI)/Primary polydipsia ruled out'''}}
{{family tree | | | | | | | | | | |!| | | | | | }}
{{Family tree | | | | | | | | | | E01 | | | | | | |E01=<800 mOsm/kg}}                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
{{Family tree | | | | | | | | | | |!| | | | | | }}
{{Family tree | | | | | | | | | | F01 | | | | | |F01='''Hypotonic polyuria confirmed'''}}
{{Family tree | | | | | | | | | | |!| | | | | | }}
{{Family tree | | | | | | | | | | G01 | | | | | |G01=Measure serum Sodium and plasma osmolality}}
{{Family tree | | | | | | | | | | |!| | | | | | }}
{{Family tree | | | | | | |,|-|-|-|^|-|-|v|-|-|-|-|-|.| | | }}
{{Family tree | | | | | | H01 | | | | | H02 | | | | H03 | |H01=Low normal or low serum Sodium <150 mmol/L, plasma osmolality <280 mOsm/kg| H02=Normal serum Sodium/plasma osmolality|H03=High serum Sodium >146 mmol/L, plasma osmolality >300 mOsm/kg}}
{{Family tree | | | | | | |!| | | | | | |!| | | | | |!| | }}
{{Family tree | | | | | | I01 | | | | | I02 | | | | I03 | | | | |I01='''Primary polydipsia'''|I02='''Indeterminate diagnosis'''|I03='''Central or Nephrogenic DI'''}}
{{Family tree | | | | | | | | | | | | | |!| | | | | |!| | }}
{{Family tree | | | | | | | | | | | | | |)|-|-|-|-|-|'| | }}
{{Family tree | | | | | | | | | | | | | |!| | | | | | | | }}
{{Family tree | | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | }}
{{Family tree | | | | | J01 | | | | | | J02 | | | | J03 |-|-|-|-|-|.| |J01='''Water deprivation test'''|J02='''Baseline plasma copeptin'''|J03='''Hypertonic saline infusion test'''}}
{{Family tree | | |,|-|-|+|-|-|.| | | | |!| | | |,|-|^|-|.| | | | |!| | }}
{{Family tree | K01 | | K02 | | K03 | | |!| | | K04 | | K05 | | | |!| |K01=Urine Osm >800 mOsm/kg|K02=Urine Osm <300 mOsm/kg|K03=Urine Osm 300-800 mOsm/kg|K04=Plasma coprptin >4.9pmol/L|K05=Plasma coprptin <4.9pmol/L}}
{{Family tree | |!| | | |!| | | |!| |,|-|^|-|v|-|-|-|.| | | | | | |!| }}
{{Family tree | L01 | | L02 |-|-|'| L03 | | L04 | | L05 |-|-|-|-|-|'| |L01='''Mild primary polyuria'''|L02='''Desmopressin administration'''|L03='''>21pmol/L'''|L04='''<2.6pmol/L'''|L05='''>2.6pmol/L'''}}
{{Family tree | |,|-|-|-|^|-|.| | | |!| | | |!| | | }}
{{Family tree | |!| | | | | M01 | | M02 | | M03 | | | | | | | |M01=Urine Osmolality: 300-800 mOsm/Kg and <50% increase|M02='''Nephrogenic DI(partial or complete)'''|M03='''Complete Central DI'''}}
{{Family tree | |!| | | | | |!| | | | | | | | | | | | | }}
{{Family tree | |!| | | | | N01 | | | | | | | | | | | |N01='''Therapeutic trial with desmopressin'''}}
{{Family tree | |!| | | |,|-|^|-|v|-|-|-|.| | | | | | | | | | | }}
{{Family tree | |!| | | O01 | | O02 | | O03 | | | | | |O01='''Primary polydipsia'''|O02='''Partial Nephrogenic DI'''|O03='''Partial Central DI'''}}
{{Family tree |,|^|-|-|-|.| | | }}
{{Family tree | P01 | | P02 | | | | | | | |P01=Initial urine osmolality: 30 mOsm/kg and >50% increase after desmopressin:|P02=Urine osmolality <300 mOsm/kg or <50% increase}}
{{Family tree | |!| | | |!| | | | | | | | | | | | | | }}
{{Family tree | Q01 | | Q02 | | | | | | | | | | | | |Q01='''Complete Central DI'''|Q02='''Complete Nephrogenic DI'''}}
{{Family tree/end}}


* The [[c‐terminal]] [[portion]] of the larger [[precursor]] [[peptide]] of [[Arginine Vasopressin]] [[AVP]] ([[co-peptin]]), has been evaluated in the setting of [[polyuria]]‐[[polydipsia]] [[syndrome]], can be useful for the differential diagnosis. <ref name="pmid28967192">{{cite journal| author=Nigro N, Grossmann M, Chiang C, Inder WJ| title=Polyuria-polydipsia syndrome: a diagnostic challenge. | journal=Intern Med J | year= 2018 | volume= 48 | issue= 3 | pages= 244-253 | pmid=28967192 | doi=10.1111/imj.13627 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28967192  }} </ref>
===Polyuria===
Shown below algorithm for the diagnostic approach to polyuria based on the American Journal of Kidney Diseases.


==Approach to polyuria==
{{familytree/start}}
{{familytree/start |summary=polyuria diagnosis Algorithm.}}
{{familytree | | | | | | | | | A01 | | | | | |A01='''Polyuria'''<br>'''(Urine Output > 3L/d)'''<ref name="pmid26687922">{{cite journal| author=Bhasin B, Velez JC| title=Evaluation of Polyuria: The Roles of Solute Loading and Water Diuresis. | journal=Am J Kidney Dis | year= 2016 | volume= 67 | issue= 3 | pages= 507-11 | pmid=26687922 | doi=10.1053/j.ajkd.2015.10.021 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26687922  }} </ref>}}
{{familytree | | | | | | | | A01 |A01='''Polyuria'''<br> ❑ 24-hour urine volume >'''3'''L <br> ❑ 24-hour urine volume >50 ml/kg}}  
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | | | | | | | B01 | | | | | |B01='''Urine Osmolality'''}}
{{familytree | | | B01 | | | | | | | | B02 | | |B01='''Urine Osmolality >300'''mosmol|B02='''Urine Osmolality <300<ref>Robertson GL: Diabetes insipidus. Endocrinol Metab Clin North Am 24:549–572, 1995.</ref>'''mosmol}}
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | | C01 | | | | | C02 | | | | | C03 |C01=<div style="float: left; text-align: left;">'''Uosm <100mOsm/kg<br>(Water Diuresis)'''<br>*Psychogenic Polydipsia<br>*DI (central and nephrogenic)|C02=<div style="float: left; text-align: left;">'''Uosm =100-300mOsm (Mixed Polyuria)'''<br>*Partial DI(central and Nephrogenic)<br>*Simultaneous water and solute intake<br>*CKD|C03=<div style="float: left; text-align: left;">'''Uosm >300mOsm/kg<br>(Solute Diuresis)'''<br>*Hyperglycemia<br>*Azotemia<br>*High solute intake<br>intravenous fluids<br>enteral and parenteral nutrition<br>Exogenous supplements
{{familytree | | | C01 | | | | | | | | |!| |C01='''Solute diuresis'''<br> ❑ [[Glucose]] <br> ❑ [[Mannitol]] <br> ❑ [[Contrast media]] <br> ❑ [[High protein intake]] <br> ❑ [[Diuretics]] <br> ❑ [[Medullary cystic disease]] <br> ❑ [[Resolving ATN]] <br> ❑ [[Resolving obstruction]] }}
}}
{{familytree | | | | | | | | | | | | | |!| }}
{{familytree | | |!| | | | | | |!| | | | | | |!| }}
{{familytree | | | | | | | | | | | | | D03 |D03='''Water diuresis'''<br> ❑ [[Primary polydipsia]] <br> ❑ [[Diabetes inspidous]]}}
{{familytree | | |!|,|-|-|-|-|-|^|-|-|-|-|-|.|!| | | | }}
{{familytree | | | | | | | | | | | | | |!| | }}
{{familytree | | D01 | | | | | | | | | | | D02 | |D01='''Water Deprivation Test'''|D02=<div style="float: left; text-align: left;">'''24-Hour Urine Collection'''<br>'''(estimation of osmoles)'''<br>*Urine sodium<br>*Urine potassium<br>*Urine glucose<br>*Urine urea nitrogen<br>*Other osmoles}}
{{familytree | | | | | | | | | | | | | E02 | | |E02=Water restriction test '''OR''' administration of hypertonic saline 0.05 mL/kg/min for 2 h|}}
{{familytree | | | | | | | | | | | | | |!| | | }}
{{familytree | | | | | | | | | | | | | F01 | | | |F01='''Water restriction test'''
<br> ❑ Overnight fluid restriction should be '''avoided''' <br> ❑ Recommend the patient to stop drinking 2-3 hours before coming to clinic <br> ❑ Meaure urine volume every hour <br> ❑ Measure urine osmolality every hour <br> ❑ Measure plasma sodium concentration every 2 hours <br> ❑ Measure plasma osmolality every 2 hours |F02=F02}}
{{familytree | | | | | | | | | | | | | |!| }}
{{familytree | | | | | | | | | | | | | G01 |G01='''Test endpoints in adults:''' <br> ❑ Urine osmolality reaches normal value (above 600 mosmol/kg) <br> ❑ The urine osmolality is stable for 2 or 3 successive hourly measurements despite a rising plasma osmolality <br> ❑ Plasma osmolality >295-300 mosmol/kg <br> ❑  Plasma sodium is 145 or higher  }}
{{familytree/end}}
{{familytree/end}}


==Treatment==
==Treatment==
 
The management of polyuria depends on the underlying cause. Click on each [[disease]] shown below to see detailed management for every [[cause]] of polyuria.
'''[[Cranial]] [[diabetes insipidus]]''':
*[[Psychogenic polydipsia medical therapy|Psychogenic polydipsia]]
 
*[[Diabetes insipidus medical therapy|Diabetes insipidus]]
* [[Cranial]] [[diabetes insipidus]] ([[DI]]) can be managed by [[desmopressin]] [[orally]] or [[Intranasal]] (rarely used).
*[[Nephrogenic diabetes insipidus medical therapy|Nephrogenic diabetes insipidus]]
* [[Partial]] [[DI]] can be treated with a single nocturnal dose to [[prevent]] [[sleep]] loss due to [[nocturia]], but [[complete]] [[DI]] requires 2-4 daily doses.
*[[Diabetes mellitus type 1 medical therapy|Diabetes mellitus type 1]]
 
*[[Diabetes mellitus type 2 medical therapy|Diabetes mellitus type 2]]
'''[[Nephrogenic diabetes insipidus]]''':
 
* [[Withdrawal]] of [[lithium]] therapy usually leads to [[reversal]] of [[lithium-induced diabetes insipid]] ([[DI]]). It can [[persist]] for years after [[lithium withdrawal]], usually indicating that the patient has developed [[interstitial nephritis]] secondary to [[lithium]].
* [[Thiazide diuretics]] reduce [[urine output]] by up to 50%, and [[indomethacin]] has also been used. Results are frequently unsatisfactory, treatment is directed at sufficient fluid intake to replace urinary losses. <ref name="pmid12617410">{{cite journal| author=Moore K, Thompson C, Trainer P| title=Disorders of water balance. | journal=Clin Med (Lond) | year= 2003 | volume= 3 | issue= 1 | pages= 28-33 | pmid=12617410 | doi=10.7861/clinmedicine.3-1-28 | pmc=4953350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12617410  }} </ref>
 
'''[[Nocturnal]] [[Polyuria]]''':
 
* [[Lifestyle]] [[modifications]] are the first [[intervention]] for the [[management]] of [[nocturia]] and [[nocturnal]] [[polyuria]] ([[NP]]) but, as [[symptoms]] progress, pharmacotherapy may be initiated. 
* [[Antidiuretic]] [[treatment]] is necessary for patients with [[nocturia]] due to [[nocturnal]] [[polyuria]] ([[NP]]) because, in many patients, it treats the underlying cause (ie, insufficient secretion of antidiuretic hormone arginine vasopressin) that leads to overproduction of urine at night and has been shown to provide statistically significant [[reductions]] in [[nocturnal]] [[voids]].
* [[Desmopressin]] ([[synthetic]] [[analog]] of [[arginine vasopressin]]), is the only [[antidiuretic]] [[treatment]] indicated specifically for [[nocturia]] due to [[nocturnal]] [[polyuria]] ([[NP]]). <ref name="pmid31586470">{{cite journal| author=Weiss JP, Everaert K| title=Management of Nocturia and Nocturnal Polyuria. | journal=Urology | year= 2019 | volume= 133S |  bissue=  | pages= 24-33 | pmid=31586470 | doi=10.1016/j.urology.2019.09.022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31586470  }} </ref>


==Do's==
==Do's==
 
* Recommend diet modification, like avoiding any food that irritates the bladder including caffeine, [[alcohol]], carbonated drinks, tomato-based products, chocolate, artificial sweeteners, and spicy foods.
==Don'ts==
* Monitor fluid food intake, drink enough to prevent constipation and over-concentration of [[urine]], and avoid drinking just before bedtime.
 
* Recommend Kegel exercises to strengthen the muscles around the [[bladder]] and [[urethra]].
==References==
==References==
{{Reflist|2}}
[[Category:Nephrology]]
[[Category:needs review]]

Latest revision as of 04:18, 31 July 2021

Polyuria Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Zaida Obeidat, M.D.

Synonyms and keywords: Approach to polyuria, Approach to dilute urine, Polyuria management, Polyuria work-up

Overview

Causes

Life Threatening Causes

  • Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
  • Polyuria does not have life-threatening causes.

Common causes [2] [3]

Approach to Polyuria

Shown below is an algorithm summarizing the approach to polyuria.
Abbreviations: DI: Diabetes insipidus;

Hypotonic Polyuria

 
 
 
 
 
 
 
 
 
 
 
 
Suspected hypotonic polyuria[4]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Confirm presence of polyuria
>50ml/kg/24hrs or >3-4L/day
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Polyuria confirmed
 
 
 
No polyuria/ or >800 mOsm/kg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Measure urine osmolality
 
 
 
Diabetes insipidus(DI)/Primary polydipsia ruled out
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
<800 mOsm/kg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypotonic polyuria confirmed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Measure serum Sodium and plasma osmolality
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low normal or low serum Sodium <150 mmol/L, plasma osmolality <280 mOsm/kg
 
 
 
 
Normal serum Sodium/plasma osmolality
 
 
 
High serum Sodium >146 mmol/L, plasma osmolality >300 mOsm/kg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary polydipsia
 
 
 
 
Indeterminate diagnosis
 
 
 
Central or Nephrogenic DI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Water deprivation test
 
 
 
 
 
Baseline plasma copeptin
 
 
 
Hypertonic saline infusion test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine Osm >800 mOsm/kg
 
Urine Osm <300 mOsm/kg
 
Urine Osm 300-800 mOsm/kg
 
 
 
 
 
 
Plasma coprptin >4.9pmol/L
 
Plasma coprptin <4.9pmol/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild primary polyuria
 
Desmopressin administration
 
 
 
 
>21pmol/L
 
<2.6pmol/L
 
>2.6pmol/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine Osmolality: 300-800 mOsm/Kg and <50% increase
 
Nephrogenic DI(partial or complete)
 
Complete Central DI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Therapeutic trial with desmopressin
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary polydipsia
 
Partial Nephrogenic DI
 
Partial Central DI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial urine osmolality: 30 mOsm/kg and >50% increase after desmopressin:
 
Urine osmolality <300 mOsm/kg or <50% increase
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Complete Central DI
 
Complete Nephrogenic DI
 
 
 
 
 
 
 
 
 
 
 
 

Polyuria

Shown below algorithm for the diagnostic approach to polyuria based on the American Journal of Kidney Diseases.

 
 
 
 
 
 
 
 
Polyuria
(Urine Output > 3L/d)[5]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine Osmolality
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Uosm <100mOsm/kg
(Water Diuresis)
*Psychogenic Polydipsia
*DI (central and nephrogenic)
 
 
 
 
Uosm =100-300mOsm (Mixed Polyuria)
*Partial DI(central and Nephrogenic)
*Simultaneous water and solute intake
*CKD
 
 
 
 
Uosm >300mOsm/kg
(Solute Diuresis)
*Hyperglycemia
*Azotemia
*High solute intake
intravenous fluids
enteral and parenteral nutrition
Exogenous supplements
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Water Deprivation Test
 
 
 
 
 
 
 
 
 
 
24-Hour Urine Collection
(estimation of osmoles)
*Urine sodium
*Urine potassium
*Urine glucose
*Urine urea nitrogen
*Other osmoles
 

Treatment

The management of polyuria depends on the underlying cause. Click on each disease shown below to see detailed management for every cause of polyuria.

Do's

  • Recommend diet modification, like avoiding any food that irritates the bladder including caffeine, alcohol, carbonated drinks, tomato-based products, chocolate, artificial sweeteners, and spicy foods.
  • Monitor fluid food intake, drink enough to prevent constipation and over-concentration of urine, and avoid drinking just before bedtime.
  • Recommend Kegel exercises to strengthen the muscles around the bladder and urethra.

References

  1. ↑ Moore K, Thompson C, Trainer P (2003). "Disorders of water balance". Clin Med (Lond). 3 (1): 28–33. doi:10.7861/clinmedicine.3-1-28. PMC 4953350. PMID 12617410.
  2. ↑ Wieliczko M, Matuszkiewicz-Rowińska J (2013). "[Polyuria]". Wiad Lek. 66 (4): 324–8. PMID 24490488.
  3. ↑ Weiss JP, Everaert K (2019). "Management of Nocturia and Nocturnal Polyuria". Urology. 133S: 24–33. doi:10.1016/j.urology.2019.09.022. PMID 31586470.
  4. ↑ Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dungan K; et al. (2000). "Endotext". PMID 30779536.
  5. ↑ Bhasin B, Velez JC (2016). "Evaluation of Polyuria: The Roles of Solute Loading and Water Diuresis". Am J Kidney Dis. 67 (3): 507–11. doi:10.1053/j.ajkd.2015.10.021. PMID 26687922.
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