How a Man Could Die While Urinating

Ron, one of my patients woke up in the middle of the night, felt the urge to urinate and got out of bed quickly to go to his bathroom. Ron urinated standing up, suddenly felt dizzy and the next thing he remembers is that he found himself on the bathroom floor at 2:00 am with a sore elbow and a bump on his head. Ron didn’t die, but he could have died.

Ron’s case is not an isolated one

Losing consciousness while or after peeing (called micturition syncope) predominantly affects men (approximately 66 to 74 percent) but can also affect women.

Micturition syncope can happen at any age, but there are two distinct peak incidences: younger patients with a mean age around 38 to 44 years, often related to alcohol intake (syncope often occurring before midnight) and older patient with a mean age around 65 years (syncope often occurring after midnight or in the early morning). [1]

Why could micturition syncope kill a person?

Micturition syncope is a rather benign condition, but the risk of death happens if a person, when fainting, hits his or her head violently on a sharp corner of furniture or on a hard floor, triggering a brain bleed which can lead to death.

In older people, fainting and falling can also cause a bone fracture. A hip fracture in an elderly person who lives alone could make it impossible for that person to get up from the floor. If the person is unable to call for help for days, that person might die.

What is micturition syncope due to?

The primary mechanism involves activation of receptors in the bladder when voiding. The bladder receptors send a message to the brain, creating a reflex activation of the vagal nerve, leading to lower heart rate (bradycardia) and dilation of the peripheral blood vessels, triggering a sudden decrease in blood pressure. This sudden decrease in blood pressure and heart rate lowers the amount of oxygen arriving to the brain, triggering the person to faint and lose consciousness. [2]

This drop in blood pressure and heart rate is more pronounced when men urinate standing up. And if they drink alcohol, this phenomenon gets even worse, due to the diuretic and vasodilating effect of alcohol.

If, in addition, people push and strain when urinating (it can happen when defecating also), they increase their intra-thoracic and intra-abdominal pressure. As a result, the amount of venous blood coming back to the heart decreases. In parallel, there is a decrease in arterial blood sent by the heart to the different organs, further lowering blood pressure and increasing the risk of syncope. [2]

How to prevent micturition syncope

Make sure you are well hydrated when you go to bed so that your blood pressure and heart rate are not too low. [3]
Make sure you didn’t have too much alcohol to drink before bedtime.
When you need to get up in the middle of the night to urinate, spend a few seconds sitting on your bed before standing up, so that your blood pressure doesn’t drop too suddenly. [3]
For men, when urinating in the middle of the night, urinate sitting down on the toilet and not standing up.
For men and women, avoid pushing when urinating or defecating in the middle of the night.
Older people should have a wireless medical alert device on them when they get up in the middle of the night to urinate. With such a device, they can call for help if they fall and cannot get up.
Some people sense when the syncope is about to happen. To prevent it from happening, lie down on the floor and put your legs up, or cross your legs and tense up the muscles of your lower body to increase your blood pressure. This last maneuver is called physical counter-pressure maneuver. [4]
For people on blood pressure medications, make sure you don’t take too many medications at bedtime so that your blood pressure is stable day and night.
Remember that micturition syncope is not dangerous by itself, but it tends to recur. What is dangerous is the risk of injury from the sudden uncontrolled fall.