lower urinary tract symptoms ( luts ) and nocturia are highly prevalent in adult men and women in western societies.lower urinary tract symptoms are disease and genderunspecific and highly bothersome , decrease qualityoflife and are responsible for morbidity / mortality.bladder diaries can assess and quantify luts , can differentiate between the various causes , and are recommended by guidelines.drug treatment should target the underlying pathophysiology of luts and nocturia . lower urinary tract symptoms ( luts ) and nocturia are highly prevalent in adult men and women in western societies . lower urinary tract symptoms are disease and genderunspecific and highly bothersome , decrease qualityoflife and are responsible for morbidity / mortality . bladder diaries can assess and quantify luts , can differentiate between the various causes , and are recommended by guidelines . clarifies the amount of patients seeking help for luts and/or nocturia in five western countries.describes the time between symptom onset and first consultation , diagnosis and treatment.determines the reasons for physician consultations.evaluates assessment tools and the use of bladder diaries.describes the treatment pattern according to the type of luts.quantifies conservative and medical treatment of luts and/or nocturia . 
  clarifies the amount of patients seeking help for luts and/or nocturia in five western countries . describes the time between symptom onset and first consultation , diagnosis and treatment . determines the reasons for physician consultations . evaluates assessment tools and the use of bladder diaries . describes the treatment pattern according to the type of luts . quantifies conservative and medical treatment of luts and/or nocturia lower urinary tract symptoms ( luts ) affect a large proportion of the adult female and male population worldwide but are often underreported due to embarrassment , acceptance of luts as an inevitable part of ageing , or lack of knowledge about the condition.1 , 2 , 3 , 4 luts are unspecific for age and gender and have a multifactorial aetiology.5 , 6 early attempts to classify symptoms based around concepts of  prostatism  or benign prostatic hyperplasia ( bph ) in men and overactive bladder ( oab ) in women have long been recognised to be inadequate.7 , 8 , 9 neither oab nor bph produces a consistent set of symptoms in all patients.10 as luts can be highly bothersome and patients seek help for fast symptom relief,11 , 12 it is imperative that patients are assessed , labelled and treated correctly at the physician office . one symptom in particular , nocturia , seems to be consistently overlooked in clinical practice with regard to its specific aetiology , impact on qualityoflife and treatment , despite its high prevalence.13 the analysis of 43 trials of communitydwelling people demonstrated that 20.4%43.9% of women and 11.0%35.2% of men aged 2040  years have nocturia 1 times per night and 4.4%18% of women and 2.0%16.6% of men report about nocturia 2 times per night.14 the prevalence of nocturia rises dramatically with ageing . women or men aged > 70  years have nocturia 1 time per night in 74.1%77.1% and 68.9%93.0% , respectively , and 2 times per night in 28.3%61.5% and 29.0%59.3% , respectively . in a german epidemiological study investigating 5504 men aged 5080 years , 40.5% of participants had clinically important voiding and/or storage luts.15 of all individual symptoms , nocturia had the highest symptom bother and was the only symptom significantly associated with physician consultations during the previous 2  years.16 
  key instruments for diagnosing , quantifying and discriminating luts , with or without urinary incontinence , are patient history , symptom questionnaires and bladder diaries.17 , 18 however , only bladder diaries can objectively quantify the number of voids during day and nighttime as well as document drinking and micturition volumes . bladder diaries should be taken for 27  days and are recommended by international guidelines in patients with bladder storage symptoms or nocturia.19 , 20 , 21 without a bladder diary , it may be difficult to ascertain the correct diagnosis and , hence , the best possible treatment option(s ) . despite the recognition of nocturia by the international continence society and publication of a standardisation report , nocturia may be different and independent from other luts.22 during the last decade , nocturia has gained increasing interest in the literature but it remains to be determined whether this has also translated into a greater focus in clinical practice with regard to earlier diagnosis or specific treatment . the aim of this study was to investigate the quality and timing of the diagnosis and treatment of nocturia by means of a large database analysis of european and usamerican patients to obtain better insights into the management of nocturia in different western healthcare systems . data were drawn from the  lower urinary tract symptoms disease specific programme  ( lutsdsp ) , an observational , crosssectional , real world , multinational survey of physicians and their consulting patients in france , germany , spain , the uk and the usa . the survey was conducted by adelphi real world between february and may 2013 . participating physicians were identified by local fieldwork teams from public lists according to predefined selection criteria . primary care physicians ( pcps ) and urologists had to have a minimum of four patients diagnosed with bph and a minimum of three patients diagnosed with oab consulting each week . gynaecologists had to have a minimum of six patients diagnosed with oab consulting each week . physicians completed a patient record form ( prf ) for the next 14 prospective patients whose diagnosis included  bph ( pcps / urologists only ) ,  oab  and/or  nocturia / nocturnal polyuria . patients could have a single diagnosis or more than one , and the diagnoses were based on each physician 's subjective assessment after his / her normal diagnostic procedure . patients had to be aged between 18 and 89  years , currently being managed for luts ( but could be consulting for the first time ) , consulting as an outpatient , not pregnant and not suffering from luts as the result of a urinary tract infection . physicians completed the prf as soon as possible after the consultation providing relevant information gleaned during the consultation through observation of and/or discussion with the patient . questions included information available from medical records such as time since first symptoms , time since diagnosis and time since first treatment for luts . immediately after the consultation , each patient was invited to complete a patient selfcompletion ( psc ) form independently of the physician . the overall aim of the psc was to assess the degree of bother associated with luts , including waking to void . in addition , the study evaluated the previous use of bladder diaries during the normal diagnostic workup of patients at the physician office and , furthermore , each patient was requested to provide an estimate of the mean number of voids during the waking and sleeping hours over the past 7  days . the lutsdsp was conducted in accordance with the european pharmaceutical market research association 2012 code of conduct for international healthcare market research and the us health insurance portability and accountability act 199623 and as such ethical approval was not required . informed consent was obtained after physicians explained the study and patients reviewed the collection forms . physicians were reimbursed for their participation in the study by the local fieldwork partners at fair market rates and the fieldwork teams adhered to national data collection regulations . a full description of the methodology has been published previously.24 
  based on the clinical diagnoses of the physicians , patients were divided into one of the six groups : 
 men with nocturia onlymen with bph or oab onlymen with nocturia+bph or oabwomen with nocturia onlywomen with oab onlywomen with nocturia+oab . men with nocturia only men with bph or oab only men with nocturia+bph or oab women with nocturia only women with nocturia+oab . demographic data , patient and physicianreported number of voids ( during day and night ) , reasons for consulting a medical professional , type of medical physician visited , use of a bladder diary , time to consultation , diagnosis and treatment and type of treatment were recorded and evaluated in this study . a total of 627 physicians [ 261 pcps ( 41.6% ) and 366 urologists or gynaecologists ( 58.4% ) ] completed records for 8738 patients , of whom 5335 ( 61.1% ) completed the psc . a diagnosis was reported by physicians in 8659 cases ( 99.1% ) . of the total patient population with a diagnosis label , the mean age was 64.0 years and 5165 participants ( 59.6% ) were men ( table  1 and fig .  1 ) . the majority of patients ( 71% ) lived with a partner and was not employed ( 68% ) , with the majority of these being retired . eightyfive per cent of patients had comorbid conditions of which arterial hypertension ( 46% ) , hyperlipidaemia ( 26% ) and diabetes mellitus ( 19% ) were most frequently reported ( table  1 ) . patient demographics and number of day and nighttime voids reported by physicians or patients ; numbers are provided as meansd or in % , range in parentheses bmi , bodymass index ; prf , patient record form ; psc , patient selfcompletion ( form ) . * all percentages refer to the analysis sample with a reported diagnosis patients reported a mean of 7.5 daytime and 2.5 nighttime voids . physicians appeared to underrecord the number of daytime voids compared with patient reports in all male and female patient subgroups but were more likely to agree with the patient on the number of nocturnal voids . a total of 2244 patients ( 25.9% ) had a confirmed diagnosis of nocturia ( nocturia or nocturnal polyuria ; table  1 and fig .  1 ) although all patient groups had symptoms of nocturia , physicians indicated nocturia as part of the diagnosis in only 1316 men ( 25.5% of the male study population ) and 928 women ( 26.6% of the female study population ) . nocturia as part of the diagnosis was more likely when patients had a higher nocturia frequency ( 3.33.8 voids per night according to the psc form in subjects with vs 2.02.4 voids / night for those without nocturia in their diagnosis ) . the majority of patients ( 69% ) first consulted a pcp , of whom 48% were later referred to a specialist who made the diagnosis and initiated treatment . most patients initially consulted a physician because of worsening of luts frequency ( 43%58% ) or deterioration of luts severity ( 44%55% ; fig .  2 ) . women with oab were most likely to have first consulted a physician because of urinary incontinence . tiredness due to sleep disturbance was also an important indicator for seeking help with up to 25% ( women with nocturia+oab ) of patients diagnosed with nocturia consulting because of sleep loss . other reasons for consulting a medical professional were fear of other diseases ( 19%25% of men vs 16%19% of women ) or suggestion of a friend or relative ( 12%16% in men vs 11%15% in women ) . there was a tendency towards higher patient numbers with increasing luts severity [ nocturia only  ( bph)/oab only  nocturia+(bph)/oab ] . percentages were calculated excluding missing responses only 37% of all luts diagnoses were based on previous bladder diaries . among men diagnosed with only 35% had completed a diary before participating in the lutsdsp . a greater proportion of females with men with  bph or oab only  were the least likely group to have been diagnosed with a bladder diary ( 27% ) . in the subgroup of patients with nocturia of any type ( table  2 ) , pcps were particularly unlikely to have employed a bladder diary to make the diagnosis of nocturia and differentiate the underlying pathophysiology ( 34% ) . among specialists , urologists had employed a bladder diary to evaluate nocturia in 45% of patients , whereas gynaecologists were the most likely physician group to have used a bladder diary for diagnosis ( 60% ) . proportion of patients with any type of nocturia previously completing a bladder diary percentages were calculated excluding missing responses . for patients with a diagnosis of nocturia ( nocturia or nocturnal polyuria ) . in patient groups without nocturia as part of the diagnosis , 40% of the patients with at least one nocturnal void , who felt bothered by nocturnal voiding , were diagnosed using a bladder diary . this number was even lower in patients with 2 voids per night ( 37% ) . even among patients diagnosed with nocturnal polyuria approximately half of the female patients with nocturia ( 48% ) were not evaluated with a diary , while this proportion increased to 63% in men . overall , patients took approximately one year to consult a medical professional following the onset of luts ( table  3 ) . diagnosis was made approximately 12  weeks later , with small differences between the groups . it then took another 37  weeks until initiation of treatment , with a mean total of 106  weeks ( i.e. over 2  years ) between symptom onset and first treatment . among patient subgroups , women diagnosed with  oab only  experienced the longest time at every stage of the patient journey to treatment ( mean total time to treatment 131.4  weeks ) , while men with  bph or oab  had the shortest total time to treatment ( 89.6 weeks ; difference ~42  weeks ) . men and women with a mixed nocturia diagnosis waited for a mean of 105  weeks from symptom onset to first treatment , while those with a diagnosis had a slightly shorter time to treatment ( mean for men 93 weeks vs women 92 weeks ; difference ~12  weeks ) . duration from symptom onset until first consultation , diagnosis and treatment numbers are provided as meansd ( range in parentheses ) . including behavioural treatment . during the initial office visit to any type of medical professional , most patients were given advice on behavioural strategies , such as limitation of fluid intake , avoidance of alcohol or caffeine , and bladder training , but almost a quarter ( 23% ) of patients were not currently receiving any lifestyle advice or behavioural modifications ( table  4 ) . women with nocturia , with or without oab , were most likely to receive conservative treatments , most frequently pelvic floor muscle exercise or bladder training . 3 ) . in the  nocturia only  group , 19% of men and 22% of women were not receiving prescription drugs for their luts condition ( although they may have received behavioural advice ) at the time of the survey  the highest proportion of any diagnosis group . in the group of men with  nocturia+bph / oab ,  only 6% were not receiving prescription drugs for their luts condition . desmopressin was the only drug in the group of antidiuretics ; all other drug classes included several drugs . fdc , fixed dose combination ( dutasteride+tamsulosin = duodart , combodart ) regardless of the type of physician currently consulted and presence or absence of nocturia as part of the patients diagnosis , 59% of men received blockers and 76% of women received antimuscarinics . there was a clear treatment pattern , with almost half ( 46% ) of the men with nocturia+bph / oab  receiving the blocker tamsulosin and 37% of the females with  oab only  receiving the antimuscarinic solifenacin . among patients with nocturia only ,  18% of men and 15% of women used desmopressin ( melt or tablet ) , while 63% of men and women received another drug in addition to desmopressin , most typically an oab ( antimuscarinic ) or bph ( blocker ) drug , although these conditions were not part of their diagnosis . diuretics for the treatment of luts ( e.g. furosemide , torasemide ) were used in 20 patients ( 0.23% of the total study population ) and only in those with a total of 627 physicians [ 261 pcps ( 41.6% ) and 366 urologists or gynaecologists ( 58.4% ) ] completed records for 8738 patients , of whom 5335 ( 61.1% ) completed the psc . a diagnosis was reported by physicians in 8659 cases ( 99.1% ) . of the total patient population with a diagnosis label , the mean age was 64.0 years and 5165 participants ( 59.6% ) were men ( table  1 and fig .  1 ) . the majority of patients ( 71% ) lived with a partner and was not employed ( 68% ) , with the majority of these being retired . eightyfive per cent of patients had comorbid conditions of which arterial hypertension ( 46% ) , hyperlipidaemia ( 26% ) and diabetes mellitus ( 19% ) were most frequently reported ( table  1 ) . patient demographics and number of day and nighttime voids reported by physicians or patients ; numbers are provided as meansd or in % , range in parentheses bmi , bodymass index ; prf , patient record form ; psc , patient selfcompletion ( form ) . * all percentages refer to the analysis sample with a reported diagnosis patients reported a mean of 7.5 daytime and 2.5 nighttime voids . physicians appeared to underrecord the number of daytime voids compared with patient reports in all male and female patient subgroups but were more likely to agree with the patient on the number of nocturnal voids . a total of 2244 patients ( 25.9% ) had a confirmed diagnosis of nocturia ( nocturia or nocturnal polyuria ; table  1 and fig .  1 ) although all patient groups had symptoms of nocturia , physicians indicated nocturia as part of the diagnosis in only 1316 men ( 25.5% of the male study population ) and 928 women ( 26.6% of the female study population ) . nocturia as part of the diagnosis was more likely when patients had a higher nocturia frequency ( 3.33.8 voids per night according to the psc form in subjects with vs 2.02.4 voids / night for those without nocturia in their diagnosis ) . the majority of patients ( 69% ) first consulted a pcp , of whom 48% were later referred to a specialist who made the diagnosis and initiated treatment . most patients initially consulted a physician because of worsening of luts frequency ( 43%58% ) or deterioration of luts severity ( 44%55% ; fig .  2 ) . women with oab were most likely to have first consulted a physician because of urinary incontinence . tiredness due to sleep disturbance was also an important indicator for seeking help with up to 25% ( women with nocturia+oab ) of patients diagnosed with nocturia consulting because of sleep loss . other reasons for consulting a medical professional were fear of other diseases ( 19%25% of men vs 16%19% of women ) or suggestion of a friend or relative ( 12%16% in men vs 11%15% in women ) . there was a tendency towards higher patient numbers with increasing luts severity [ nocturia only  ( bph)/oab only  nocturia+(bph)/oab ] . only 37% of all luts diagnoses were based on previous bladder diaries . among men diagnosed with only 35% had completed a diary before participating in the lutsdsp . a greater proportion of females with men with  bph or oab only  were the least likely group to have been diagnosed with a bladder diary ( 27% ) . in the subgroup of patients with nocturia of any type ( table  2 ) , pcps were particularly unlikely to have employed a bladder diary to make the diagnosis of nocturia and differentiate the underlying pathophysiology ( 34% ) . among specialists , urologists had employed a bladder diary to evaluate nocturia in 45% of patients , whereas gynaecologists were the most likely physician group to have used a bladder diary for diagnosis ( 60% ) . proportion of patients with any type of nocturia previously completing a bladder diary percentages were calculated excluding missing responses . for patients with a diagnosis of nocturia ( nocturia or nocturnal polyuria ) . in patient groups without nocturia as part of the diagnosis , 40% of the patients with at least one nocturnal void , who felt bothered by nocturnal voiding , were diagnosed using a bladder diary . this number was even lower in patients with 2 voids per night ( 37% ) . even among patients diagnosed with nocturnal polyuria , approximately half of the female patients with nocturia ( 48% ) were not evaluated with a diary , while this proportion increased to 63% in men . overall , patients took approximately one year to consult a medical professional following the onset of luts ( table  3 ) . diagnosis was made approximately 12  weeks later , with small differences between the groups . it then took another 37  weeks until initiation of treatment , with a mean total of 106  weeks ( i.e. over 2  years ) between symptom onset and first treatment . among patient subgroups , women diagnosed with  oab only  experienced the longest time at every stage of the patient journey to treatment ( mean total time to treatment 131.4  weeks ) , while men with  bph or oab  had the shortest total time to treatment ( 89.6 weeks ; difference ~42  weeks ) . men and women with a mixed nocturia diagnosis waited for a mean of 105  weeks from symptom onset to first treatment , while those with a diagnosis had a slightly shorter time to treatment ( mean for men 93 weeks vs women 92 weeks ; difference ~12  weeks ) . duration from symptom onset until first consultation , diagnosis and treatment numbers are provided as meansd ( range in parentheses ) . including behavioural treatment . during the initial office visit to any type of medical professional , most patients were given advice on behavioural strategies , such as limitation of fluid intake , avoidance of alcohol or caffeine , and bladder training , but almost a quarter ( 23% ) of patients were not currently receiving any lifestyle advice or behavioural modifications ( table  4 ) . women with nocturia , with or without oab , were most likely to receive conservative treatments , most frequently pelvic floor muscle exercise or bladder training . 3 ) . in the  nocturia only  group , 19% of men and 22% of women were not receiving prescription drugs for their luts condition ( although they may have received behavioural advice ) at the time of the survey  the highest proportion of any diagnosis group . in the group of men with  nocturia+bph desmopressin was the only drug in the group of antidiuretics ; all other drug classes included several drugs . fdc , fixed dose combination ( dutasteride+tamsulosin = duodart , combodart ) regardless of the type of physician currently consulted and presence or absence of nocturia as part of the patients diagnosis , 59% of men received blockers and 76% of women received antimuscarinics . there was a clear treatment pattern , with almost half ( 46% ) of the men with nocturia+bph / oab  receiving the blocker tamsulosin and 37% of the females with  oab only  receiving the antimuscarinic solifenacin . among patients with 18% of men and 15% of women used desmopressin ( melt or tablet ) , while 63% of men and women received another drug in addition to desmopressin , most typically an oab ( antimuscarinic ) or bph ( blocker ) drug , although these conditions were not part of their diagnosis . diuretics for the treatment of luts ( e.g. furosemide , torasemide ) were used in 20 patients ( 0.23% of the total study population ) and only in those with this study included 8659 adult male and female patients who sought help for luts by a physician during a 4month data collection period . this was a representative crosssectional study in five western countries , describing the assessment and treatment patterns of luts in general and of nocturia in particular . only 5% of men and 9.2% of women sought help for nocturia as a single symptom , whereas nocturia concomitantly appeared with other storage and/or voiding luts in 20.5% of men and 17.4% of women . the majority of patients sought for professional help because of deterioration of luts frequency or severity . patients with a diagnosis of nocturia , alone or in combination with bph or oab , were more likely to have first consulted a medical specialist because of tiredness due to lack of sleep compared with patients without a diagnosis of nocturia . our study also demonstrated that all male and female patients , independent of any nocturia label as part of the diagnosis , had a considerable nighttime voiding frequency ; however , nocturia a part of the diagnosis was more likely when patients had a more severe nocturnal voiding frequency ( 2.02.4 voids per night in patients without vs 3.33.8 voids per night in patients with nocturia diagnosis ) , although the number of nocturnal voids was adequately captured by the physicians . although 40% of patients with 1 void per night and 37% of patients with 2 voids per night were bothered by nocturia , they were not particularly labelled with the diagnosis  nocturia ;  instead , nocturia in these patients was considered to be a part of the diagnosis timing of first consultation after appearance of luts ( nocturia ) as well as evaluation of the time from the assessment to initiation of luts ( nocturia ) treatment has never been described before . therefore , this observational study , for the first time , provides valuable information accordingly . the time from first symptom appearance to first physician consultation was almost 1  year for all patient subgroups but the time for patients with nocturia appeared to be slightly shorter , suggesting a clinically important increase in bother associated with this symptom . the time from the diagnosis to the initiation of first therapy , behavioural treatment and lifestyle advice included , was surprisingly long , ranging from 27 to 41  weeks . furthermore , the total time from first symptom appearance to first prescribed treatment was approximately 2 years , which also seems surprisingly long and underlines that luts are often considered an unescapable part of ageing by patients and suggests that physicians may underestimate the symptom burden , bother and decrease in qualityoflife associated with luts . only 37% of the luts patients were diagnosed and their symptoms differentiated with a bladder dairy . of these , 75% of patients ( n=1401 ) had 2 voids per night , but were not specifically diagnosed with nocturia . among the 63% of patients with luts who were diagnosed without a bladder diary , 70% of patients ( n=2207 ) had 2 voids per night , yet were not labelled with the diagnosis it has to be kept in mind that several communitybased studies determined a nighttime frequency 2 voids to be associated with substantial symptom bother and decrease in healthspecific qualityof life.16 , 25 furthermore , two longitudinal population studies demonstrated that a nighttime frequency 2 voids is associated with a significantly increased mortality rate during the next 5  years.26 , 27 this leads to the questions why so few physicians used bladder diaries and , when a bladder diary was used , why the physicians did not transfer the diary results to meaningful , pathophysiologybased treatments , especially considering that bladder diaries are recommended by several expert groups and guideline panels in case patients report about nocturia or bladder storage symptoms.17 , 20 , 21 a bladder diary for 27  days is the diagnostic tool of first choice to detect the underlying pathophysiology of nocturia , where global polyuria ( 24hour urine volume > 40  ml / kg body weight ) , nocturnal polyuria ( nocturnal urine volume > 33% of the 24hour urine volume ) or reduced maximum voided volume ( urinary frequency due to reduced anatomical or functional bladder capacity ) can be discriminated.22 , 28 the results of bladder diaries can be used to initiate treatment based on the pathophysiology of luts . the majority of physicians of this study obviously had not used bladder diaries or did not take the diagnostic and differential values of bladder diaries into consideration when determining the underlying causes of luts in general and nocturia in particular . therefore , education and training of physicians with regard to the use and interpretation of bladder diaries could improve the assessment and , consequently , treatment of patients with luts in the future . however , even within the group of patients with a diagnosis of  nocturnal polyuria ,  the diagnosis was based on a bladder diary in only 55% of the cases . more reassuring was the finding that attempts to limit fluid intake and that a high number of nighttime voids ( 3 voids per night at the time of diagnosis ) increased the chances of using of bladder diary . if targeted and effective management plans of nocturia are not applied early enough , subjects are of increased risk of falling , suffering of bone fractures , developing sleep disorders , diabetes mellitus or cardiovascular diseases , becoming disappointed or resigning to their condition , which all unnecessarily lower life expectancy and qualityoflife.26 , 29 , 30 , 31 , 32 , 33 
  most patients were recommended behavioural advice by the physician . however , 59% of all male patients still received blockers and 76% of all females received antimuscarinics regardless of the diagnosis . the high level use of blockers and antimuscarinics might reflect their low price and a trialanderror approach . specific drugs for the treatment of nocturnal polyuria were only rarely prescribed ( diuretics or antidiuretics ) , maybe reflecting the inadequate assessment of luts with bladder diaries , comorbidities , concomitant polypharmacy or the higher patient age . diuretics for the treatment of nocturia ( e.g. furosemide or torasemide in the afternoon ) increase urine secretion during the evening and reduce nocturnal diuresis . furosemide has shown to significantly reduce nocturnal voids and percentage of nighttime voided volume in men34 but , however , was rarely used in male ( 5.5% ) or female ( 1.9% ) participants of this study . until recently it was not recommended to use the antidiuretic drug desmopressin in patients aged 65 years because of the risk of developing hyponatremia . however , a new formulation of desmopressin has recently been approved in the european union and canada which now allows treatment of idiopathic nocturnal polyuria with this drug also in the elderly population but without the risk of hyponatremia . combined with a low use of bladder diaries , and longtime interval from initial visit to the doctor to medical treatment of symptoms , it seems that treatment of luts patients can still be optimised . limitations of the observational research and real world data collection approach used in the lutsdsp include selection and diagnosis of patients . although respondents are requested to collect data on a series of consecutive patients to avoid selection bias , in the absence of randomisation this is contingent upon the integrity of the participating respondent rather than formalised source verification procedures . moreover , diagnosis in the target patient group is based primarily on the judgement and diagnostic skills of the respondent physician rather than on a formalised diagnostic checklist , although patients are managed in accordance with the same routine diagnostic procedures representative of that clinical practice setting . a further limitation of the dsps is that being crosssectional , they can not be used to demonstrate cause and effect . to demonstrate this , an experimental study would be necessary  even analyses of large administrative databases do not allow for causal inferences to be made due to their design and the need for statistical control of confounding factors . these limitations need to be balanced against the methodological strengths that ensure the representative nature of the respondent sample within predefined parameters . moreover , the methodology takes into account the potential differences in customs and practices for the management of target illnesses across different cultures and countries . these observational studies are particularly useful for conditions , which may be embarrassing or where patients may unnecessarily resign themselves to accepting their symptoms as an unescapable part of ageing . data from this study show that patients with luts ( nocturia ) wait for a considerable time before seeking help ( approximately 1  year ) or ultimately receiving treatment for their condition ( approx . 2  years ) . therefore , luts patients could shorten or avoid a negative impact on their qualityoflife when they would visit a medical professional for their symptoms earlier . the main reasons of luts ( nocturia ) patients for consulting medical professionals are worsening of symptom frequency and severity as well as the appearance of embarrassing incidents and sleep impairment . although the majority of patients have nocturia , most physicians do not use bladder diaries to make the diagnosis or differentiate between the various causes , despite distinct recommendations in guidelines of various medical societies . physicians primarily use antimuscarinics or blockers regardless the diagnosis even in patients with nocturia . improved nocturia awareness among patients and physicians could help to improve the assessment , diagnosis and treatment . matthias oelke has been consultant , speaker and/or trial participant for apogepha , astellas , bayer , duchesnay , glaxosmithkline , ferring , lilly , pfizer , and recordati . p. anderson : protocol / project development , data collection and management , critical revision and approval of article . t. holmlarsen : protocol / project development , data analysis , drafting , critical revision and approval of article .
summaryaimsthe aim of this study was to investigate the quality and timing of the diagnosis and treatment of nocturia in reallife practice in european and usamerican patients to obtain better insights into the management of nocturia in different western healthcare systems.methodsdata were drawn from the  luts disease specific programme ,  a reallife survey of physicians and patients in france , germany , spain , uk and the usa . 
 physicians completed a patient record form for lower urinary tract symptoms ( luts ) patients . 
 patients filled out a selfcompletion form , indicating  among other items  information on the mean number of day and nighttime voids during the last 7  days , and questions on the management of luts in daily practice.resultsin total , 8659 patients were analysed . 
 the majority of patients initially consulted a physician because of worsening of luts frequency ( 43%58% ) or severity ( 44%55% ) . 
 only 37% of all luts diagnoses , regardless of the appearance or severity of nocturia , were based on bladder diaries . 
 patients took approximately 1  year to consult a medical professional following the onset of luts . at the initial visit 
 , most patients received advice on behavioural strategies . 
 regardless the type of luts and physician , 59% of men received blockers and 76% of women antimuscarinics.conclusionsdata show that patients with nocturia and luts accept their symptoms for a considerable period before they seek help or ultimately receive treatment . 
 they may therefore be enduring significant negative impact on their qualityoflife which could be avoided . 
 physicians rarely use bladder diaries and primarily use antimuscarinics ( women ) or blockers ( men ) . 
 improved awareness of nocturia among patients and physicians could improve the management of nocturia .