Nocturia in sleep-disordered breathing

Nocturia and obstructive sleep apnea in spinal cord injured patients - a cohort study

PURPOSE

To describe the prevalence of nocturia and obstructive sleep apnea (OSA) in a cohort of spinal cord injury (SCI) patients and to describe their association. Additionally, to assess clinical and urodynamic data explaining nocturia and to evaluate the effect of OSA management with continuous positive airway pressure (CPAP).

METHOD

Retrospective analysis of data from patients with SCI followed in a tertiary care rehabilitation center with a specialized sleep and neuro-urology units. All adult SCI patients who underwent urodynamic assessment before polysomnography (PSG) between 2015 and 2023 were eligible. Subjective (nocturia) and objective data (urodynamic data, polysomnography, CPAP built-in software) were collated from the Handisom database (database register no. 20200224113128) and the medical records of SCI patients. Statistical testing used Mann-Whitney test for non-parametric variables, Fisher's exact test for contingency analysis and the Spearman correlation test to assess correlations. A p-value < 0.05 was considered significant. Statistical analyses were performed using GraphPad Prism v9.

RESULTS

173 patients (131 males, 42 females) were included. The majority of patients were paraplegic (n = 111 (64,2%)) and had complete lesions (n = 75 (43,4%)). A total of 100 patients had nocturia (57,5%). The prevalence of OSA (Apnea Hypopnea Index (AHI) ≥ 15/h) in the studied population was 61,9%. No correlation was found between nocturia and OSA. A significant difference was observed between patients with and without nocturia in terms of the presence of neurogenic detrusor overactivity (p = 0,049), volume at the first detrusor contraction (p = 0,004) and the bladder functional capacity (p < 0,001).

CONCLUSION

Nocturia and OSA are highly prevalent in patients with SCI, but no statistical association was found between these two disorders. A prospective study focusing on nocturnal polyuria will be needed to assess the impact of OSA on lower urinary tract symptoms in SCI patients.

Effect of nocturia in patients with different severity of obstructive sleep apnea on polysomnography: A retrospective observational study

Objective

Obstructive sleep apnea (OSA) is one of the etiologies of nocturia. We analyzed polysomnography (PSG) results to determine correlated factors related to nocturia in OSA patients with different severity.

Methods

Patients with suspected OSA were examined using PSG. They were divided into two groups based on the presence of nocturia. Nocturia was defined as a patient who needed to void at least once. Apnea-hypopnea index (AHI) was employed to classify patients according to degrees of severity: AHI<5 events/h, 5 events/h≤AHI<15 events/h, 15 events/h≤AHI<30 events/h, and AHI≥30 events/h, defined as normal, mild OSA, moderate OSA, and severe OSA, respectively. Demographic variables, PSG parameters, International Prostate Symptom Scores (IPSSs), and quality of life scores due to urinary symptoms were analyzed.

Results

In total 140 patients, 114 patients had OSA (48 had mild OSA; 34 had moderate OSA; and 32 had severe OSA) and 107 patients had nocturia. The total IPSS was significantly higher in nocturia patients in all groups except the group of severe OSA patients. With the increasing severity of OSA, more correlated factors related to nocturia were determined. In mild OSA patients, nocturia related to increased age (p=0.025), minimum arterial blood oxygenation saturation (p=0.046), and decreased AHI of non-rapid eye movement (p=0.047), AHI of total sleep time (p=0.010), and desaturation index (p=0.012). In moderate OSA patients, nocturia related to increased age (p<0.001), awake time (p=0.025), stage 1 sleep (p=0.033), and sleep latency (p=0.033), and decreased height (p=0.044), weight (p=0.025), and sleep efficiency (p=0.003). In severe OSA patients, nocturia related to increased weight (p=0.011), body mass index (p=0.009), awake time (p=0.008), stage 1 sleep (p=0.040), arousal number (p=0.030), arousal index (p=0.013), periodic limb movement number (p=0.013), and periodic limb movement index (p=0.004), and decreased baseline arterial blood oxygenation saturation (p=0.046).

Conclusion

Our study revealed that there were more correlated factors related to nocturia with increasing severity of OSA. This study helps in clinical education and treatment for OSA patients with different severity.

Sleep-Related Urologic Dysfunction

This article reports on the epidemiology, prevalence, and physiopathology of sleep-related urinary dysfunction, a new syndromic category proposed by the recently revised ICSD-3-TR classification. Sleep enuresis, whether primary or secondary, monosymptomatic or plurisymptomatic, will be reviewed in terms of risk factors, comorbidity, and diagnostic and therapeutic indications. A definition of nocturia and its impact on patients' health, quality of life, and mortality will follow. Finally, the impact of urge incontinence on various medical and neurologic disorders will be discussed. Special emphasis will be placed on the possible association of this parasomnia with several sleep disorders and poor, fragmented sleep.

Lower urinary tract symptoms in young-middle aged males with a diagnosis of obstructive sleep apnea syndrome

BACKGROUND

The aim of the current study is to measure the prevalence and the potential role of International Prostate Symptom Score (IPSS) score as a predictor of obstructive sleep apnea syndrome (OSAS) in male experienced lower urinary tract symptoms (LUTS).

METHODS

A cross-sectional web-based Italian survey was administered via Google Forms between July 17 and October 31, 2022. The urinary functioning was measured through the IPSS questionnaire. Specifically, we considered symptoms occurring more than "about half the time" (score ≥ 3) as bothering symptoms. Multivariable logistic regression models (LRMs) adjusting for age, body mass index (BMI), International Index of Erectile Function-5, IPSS, and hypertension were fitted to predict OSAS in the cohort of men responding to the survey and experiencing LUTS.

RESULTS

Overall, 58 (24.4%) patients had a confirmed diagnosis of OSAS. The overall median IPSS was 5 (inter quartile range [IQR]: 3-8), respectively. According to IPSS items, 24 (10%), 44 (18.4%), 12 (5%), 12 (5%), 12 (5%), 11 (4.6%), 63 (26.4%) patients exhibit incomplete bladder emptying, urinary frequency, intermittency, urgency, weak stream, straining, nocturia with a score ≥ 3, respectively. After multivariable LRMs predicting the developing OSAS, age (odds ratio [OR]: 1.09, p < 0.001), BMI (OR:1.12, p < 0.001) and IPSS total score (OR:1.08, p = 0.02) were independent predicting factors.

CONCLUSION

This analysis revealed that the IPSS total score, age, and BMI are independent predictors of OSAS in males. In this context, the use of IPSS in daily practice could be helpful in assessing the LUTS presence and in supporting physicians to identify a hidden sleep apnea condition.

"Nocturia and obstructive sleep apnea syndrome: A systematic review"

Lower urinary tract symptoms represent a significant public health problem worldwide, impairing patients' quality of life, especially in elderly people. Among LUTS, nocturia is assessed as the most experienced entity related to several disorders such as sleep disorders and/or obstructive sleep apnea syndrome (OSAS). Among OSAS patients, nocturia stands as a bothersome symptom that increases alongside with the OSAS severity. However, despite the nocturia and OSAS shared a long-acknowledged link, the causes, and the pathophysiology for development of nocturia in OSAS have remained largely unexamined. Generally, the patients with OSAS experienced nocturia due to easy waking or increased bladder filling. However, nor the effect of treatment on management of nocturia in OSAS patients are well-established.

More than sleepiness: prevalence and relevance of nonclassical symptoms of obstructive sleep apnea

PURPOSE OF REVIEW

The purpose of this review is to describe the nonclassical symptoms and manifestations occurring in patients with obstructive sleep apnea (OSA), both from a standpoint of prevalence and in terms of clinical relevance. Particular emphasis will be given to nightmares, comorbid insomnia, restless legs syndrome and periodic limb movement disorder, bruxism, morning headache, nocturia, acid reflux, chronic cough and dysphagia.

RECENT FINDINGS

A review of the recent literature suggests that nonclassical symptoms have a high prevalence, are underestimated, and can interact with quality of life. Although these disturbances may occur together by mere coincidence, they may interact reciprocally. However, the degree of symptoms is not always correlated with OSA severity.

SUMMARY

OSA is a heterogeneous disease with variable clinical manifestations. This review highlights the need for detailed evaluation of patients with OSA to diagnose other important sleep disorders and clinical manifestations, given their frequent association.

Predictive performances of 6 data mining techniques for obstructive sleep apnea-hypopnea syndrome

PURPOSE

This study compared the effects of 6 types of obstructive sleep apnea-hypopnea syndrome (OSAHS) prediction models to develop a reference for selecting OSAHS data mining tools in clinical practice.

METHODS

This cross-sectional study included 401 cases. They were randomly divided into 2 groups: training (70%) and testing (30%). Logistic regression, a Bayesian network, an artificial neural network, a support vector learning machine, C5.0, and a classification and regression tree were each adopted to establish 6 prediction models. After training, the 6 models were used to test the remaining samples and calculate the correct and error rates of each model.

RESULTS

Twenty-one input variables for which the difference between the patient and nonpatient groups was statistically significant were considered. The models found the abdominal circumference, neck circumference, and nocturia ≥2 per night to be the most important variables. The support vector machine, neural network, and C5.0 models performed better than the classification and regression tree, Bayesian network, and logistic regression models.

CONCLUSIONS

In terms of predicting the risk of OSAHS, the support vector machine, neural network, and C5.0 were superior to the classification and regression tree, Bayesian network, and logistic regression models. However, such results were obtained based on the data of a single center, so they need to be further validated by other institutions.

Oxidative Stress: A Putative Link Between Lower Urinary Tract Symptoms and Aging and Major Chronic Diseases

Aging and major chronic diseases are risk factors for lower urinary tract symptoms (LUTS). On the other hand, oxidative stress (OS) is one of the fundamental mechanisms of aging and the development of chronic diseases. Therefore, OS might be a candidate mechanism linking these two clinical entities. This article aims to summarize the studies on the prevalence of LUTS, the role of OS in aging and chronic diseases, and the potential mechanisms supporting the putative link. A comprehensive literature search was performed to identify recent reports investigating LUTS and OS in major chronic diseases. In addition, studies on the impact of OS on the lower urinary tract, including bladder, urethra, and prostate, were collected and summarized. Many studies showed LUTS are prevalent in aging and major chronic diseases, including obesity, metabolic syndrome, diabetes, cardiovascular disease, hypertension, obstructive sleep apnea, autoimmune diseases, Alzheimer’s disease, and Parkinson’s disease. At the same time, OS is a key component in the pathogenesis of those chronic diseases and conditions. Recent studies also provided evidence that exacerbated OS can cause functional and/or structural changes in the bladder, urethra, and prostate, leading to LUTS. The reviewed data support the concept that OS is involved in multiple risk factors-associated LUTS, although further studies are needed to confirm the causative relationship. The specific ROS/RNS and corresponding reactions/pathways involved in chronic diseases and associated LUTS should be identified in the future and could serve as therapeutic targets.

Association of Sleep Disorders with Nocturia: A Systematic Review and Nominal Group Technique Consensus on Primary Care Assessment and Treatment

CONTEXT

Sleep disorders affect responsiveness to sensory information and can cause nocturnal polyuria and reduced sleep depth; hence, these are potentially influential in understanding the mechanism of nocturia.

OBJECTIVE

To report the systematic review (SR) and expert consensus for primary care management of nocturia in sleep disorders.

EVIDENCE ACQUISITION

Four databases were searched from January to April 2020. A total of 1658 titles and abstracts were screened, and 23 studies potentially applicable were included for full-text screening. The nominal group technique (NGT) was used to derive a consensus on recommendations for management using an expert panel with public involvement.

EVIDENCE SYNTHESIS

Thirteen studies met the SR inclusion criteria, all of which studied obstructive sleep apnoea (OSA), with ten evaluating the effect of continuous positive airway pressure. The NGT consensus discussed the assessment of OSA with other key sleep disorders, notably insomnia, restless legs syndrome/periodic limb movements of sleep, and parasomnias, including non-rapid eye movement (non-REM) parasomnias and REM sleep behaviour disorder (RBD). The NGT considered that the use of screening questions to reach a clinical diagnosis is a sufficient basis for offering conservative therapy within primary care. Reasons for referral to a sleep clinic are suspected sleep disorder with substantially impaired daytime function despite conservative treatment. Suspected RBD should be referred, and if confirmed, neurology opinion is indicated. Referrals should follow local guidelines. Persisting nocturia is not currently considered an indication for referral to a sleep clinic.

CONCLUSIONS

Sleep disorders are potentially highly influential in nocturia, but are often overlooked.

PATIENT SUMMARY

People with sleep disorders can experience nocturia due to easy waking or increased bladder filling. We looked at published research, and information was limited to one form of sleep disturbance-obstructive sleep apnoea. We assembled a group of experts, to develop practical approaches for assessing and treating nocturia in the potentially relevant sleep disorders.

[Evolution of the USP and IPSS score after continuous positive airway pressure sleep apnea therapy at night]

INTRODUCTION

To assess the impact of nocturnal continuous positive airway pressure (CPAP) treatment of obstructive sleep apnea (OSA) on lower urinary tract (LUTS) symptoms.

MATERIALS AND METHODS

A prospective, monocentric study was conducted between June 2018 and August 2019. Patients with moderate to severe OSA with an indication for treatment with nocturnal CPAP in combination with SBAU were included. SBAUs and their impact were evaluated by completing two self-administered questionnaires (Urinary Symptom Profile (USP) and International Prostate Score Symptom (IPSS)) filled out during the night-time ventilatory polygraph or diagnostic polysomnography for OSA and after 4 months of CPAP treatment.

RESULTS

In 79 patients, after four months of CPAP treatment, USP scores for stress urinary incontinence and overactive bladder were significantly improved, respectively 0.65±1.38 vs 1.13±2.10 ; p<0.0001 and 3.24±2.58 vs 5.43±3.66 ; p<0.0001, IPSS and IPSS-Qdv were significantly improved, respectively 5.20±3.78 vs. 7.44±5.05 ; p<0.0001 and 1.93±1.26 vs. 2.27±1.56 ; p=0.002 as well as IPSS score items on pollakiuria, urgency and nocturia.

CONCLUSION

Treatment with CPAP significantly improved SBAU in four months. Testing urology patients for symptoms of OSA in urology patients seeking SBAU would allow referral of patients suspected of OSA to a specialist for diagnosis and management if necessary.

Obstructive sleep apnoea/hypopnoea syndrome: relationship with obesity and management in obese patients

Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is a disease characterised by upper airway obstruction during sleep, quite frequent in the general population, even if underestimated. Snoring, sleep apnoea and diurnal hypersomnia are common in these patients. Central obesity plays a key role: it reduces the size and changes the conformation of the upper airways, besides preventing lung expansion, with consequent reduction of lung volumes. Furthermore, obese people are also resistant to leptin, which physiologically stimulates ventilation; as a result, this causes scarce awakening during apnoea. OSAHS diagnosis is based on the combination of clinical parameters, such as apnoea/hypopnoea index (AHI), medical history, physical examination and Mallampati score. The first objective reference method to identify OSAHS is polysomnography followed by sleep endoscopy. Therapy provides in the first instance reduction of body weight, followed by continuous positive airway pressure (CPAP), which still remains the treatment of choice in most patients, mandibular advancement devices (MAD) and finally otolaryngology or maxillofacial surgery. Among surgical techniques, central is barbed reposition pharyngoplasty (BRP), used in the field of multilevel surgery.

Risk factors associated with nocturia in patients with obstructive sleep apnea syndrome

AIM

To evaluate the risk factors associated with nocturia in patients with obstructive sleep apnea syndrome (OSAS).

MATERIALS AND METHODS

Patients aged over 18 years who had been diagnosed with OSAS using polysomnography (PSG) from January to December 2019 were evaluated. The number of nocturia episodes had been assessed in a 3-day bladder diary. We analysed the age, sex, body mass index (BMI) score, apnea-hypopn ea index (AHI) score and severity, hypertension, diabetes mellitus, smoking and heart diseases in all patients.

RESULTS

A total of 124 patients with a mean age of 49.9 ± 11.6 years (range: 25-81 years) were included in the study. Ninety-two (75.8%) patients had nocturia. The mean number of nocturia episodes of patients with nocturia was 2.4 ± 1.3. To determine factors affecting the risk of nocturia, the logistic regression analysis was performed. Patient age and BMI scores were found as the most effective risk factors determining nocturia (P < .05). The odds of patient age were 1.06 (odds ratio: 1.12; 95% confidence interval: 1.01-1.11; P = .010) times higher for patients with nocturia. Every 1-unit increase in the BMI score increased the risk of nocturia 1.12 times. In the study period, 48 patients with nocturia had undergone the continuous positive airway pressure (CPAP) therapy or surgical treatment. The mean number of nocturia episodes of these patients was 2.3 ± 1.4 before treatment and 1.7 ± 2.2 after treatment, showing a significant decrease (P = .032). Although the total daily urine volume increased significantly with the treatment, the total night-time urine volume decreased significantly at night (P = .016 and P = .024, respectively).

CONCLUSION

The age and BMI score were the risk factors associated with nocturia in patients with OSAS.

Night-time frequency of urination as a manifestation of sleep-disordered breathing: the Nagahama study

AIMS

Sleep-disordered breathing (SDB) is a well-known risk factor for cardiovascular outcomes. Studies of patients with SDB have identified frequent night-time urination as a manifestation related to SDB. We aimed to clarify whether night-time frequency of urination is independently associated with SDB in a general population. We also investigated whether night-time frequency of urination can help presumptive diagnose SDB.

METHODS

Study participants consisted of 7151 community residents. Oxygen saturation during sleep was measured for four nights using a pulse oximeter. SDB was defined as ≥15 events per hour in which oxygen desaturation exceeded or equal to 3% during an actigraphy-determined sleep period. Night-time frequency of urination was recorded for one week using a sleep diary.

RESULTS

Significant positive correlations were evident between night-time frequency of urination and SDB (none, 5.8%; once/night, 14.1%; twice/night, 20.1%; thrice/night, 28.7%; >thrice/night, 44.1%, P < 0.001). This association was independent of possible covariates, including sleep duration (adjusted odds ratio: once/night = 1.50, twice/night = 2.15, thrice/night = 3.07, >thrice/night = 3.73, P < 0.001). Other factors significantly associated with SDB were age, sex, obesity, observation of sleep apnea, and short sleep duration. The area under the curve of the risk score for SDB consisting of these conventional six items (0.834) significantly improved (0.842, P = 0.001) when night-time frequency of urination was considered as a risk score item.

CONCLUSION

Night-time frequency of urination was associated with SDB. Our findings suggest that the urination frequency should be considered a manifestation of SDB even in a general population.

Obstructive Sleep Apnea Syndrome as a Potential Cause of Nocturia in Younger Adults

OBJECTIVES

To investigate the impact of age on the relationship between obstructive sleep apnea syndrome (OSAS), nocturia, and other lower urinary tract symptoms (LUTSs).

METHODS

This was a secondary analysis study based on data derived from a previously conducted prospective observational cohort study on OSAS and nocturia. We analyzed 90 subjects who were suspected of having OSAS. Prior to polysomnography, we assessed International Prostate Symptom Score-Quality of Life scores, Overactive Bladder Symptom Scores, and International Consultation on Incontinence Modular Questionnaire-Nocturia Quality of Life scores to evaluate LUTSs. Nocturnal urine volume, night-time frequency, and night-time urine electrolyte content were measured during polysomnography. Patients were divided into groups according to age and OSAS severity determined using apnea-hypopnea index (AHI) scores. Young patients were those aged <65 years and elderly patients, ≥65 years. A multiple linear regression with multiple imputations was performed to examine the association of night-time frequency with demographic, polysomnographic, and clinical characteristics.

RESULTS

In young patients, night-time frequency was significantly associated with nocturnal urine volume, AHI score, and total IPSS. However, night-time frequency in elderly subjects was not associated with demographic and polysomnographic characteristics. In order to compare the severity of OSAS, night-time frequency and urinary sodium content significantly increased only in young patients (P = .007 and .004, respectively).

CONCLUSION

OSAS is a strong candidate of causative factor for nocturia in younger individuals. When a younger patient complains nocturia without any urological disorders, OSAS should be kept in mind as a potential cause of nocturia.

The effect of continuous positive airway pressure on nocturia in patients with obstructive sleep apnea syndrome

OBJECTIVE

The prevalence of nocturia in patients with obstructive sleep apnea syndrome (OSAS) who received continuous positive airways pressure (CPAP) treatment was studied as well as the effect of CPAP treatment on nocturia.

METHODS

All patients that were referred to the pulmonology department of a large teaching hospital in the Netherlands and received a CPAP mask for OSAS were interviewed and invited to take part in the study (N = 274). After informed consent, all patients were asked about the number of nocturia episodes before and after CPAP.

RESULTS

In this prospective analysis, 274 patients (190 male and 84 female) were included. The mean age was 60.3 years (SE = 0.7). Sixty-four patients (23.4%) reported no nocturia episodes before CPAP and 210 patients (76.4%) reported ≥1 nocturia episode(s). Treatment of OSAS with CPAP reduced nocturia with one or more episodes per night in 42.3% of the patients. Clinically relevant nocturia (≥2 voids per night) was reduced from 73.0% to 51.5%. There were no statistically significant gender differences.

CONCLUSION

The prevalence of nocturia in patients diagnosed with OSAS is 75.8% in both sexes. After treatment with CPAP, almost half of patients experienced a decrease in the nocturia frequency of one or more voids. Clinically relevant nocturia was reduced with one-third after CPAP. CPAP not only reduced the number of voids during the night but also improved the associated quality of life.

Effect of Nocturnal Hypoxia on Nocturia in Patients With Obstructive Sleep Apnea

Purpose

To identify the association between nocturia and obstructive sleep apnea (OSA), we compared results of polysomnography (PSG) with the presence or absence of nocturia in patients with suspected OSA.

Methods

Patients underwent PSG for suspected OSA. The International Prostate Symptom Score and quality of life (IPSS/QoL) questionnaire was evaluated to assess voiding symptoms that may affect sleep quality. The results of PSG were compared between patient groups with or without nocturia.

Results

In logistic regression analysis, age (odds ratio [OR], 1.052; P=0.004), diabetes mellitus (OR, 6.675; P<0.001), mean O₂ saturation (OR, 0.650; P=0.017), oxygen desaturation index (ODI) 3 (OR, 1.193; P=0.010), and ODI4 (OR, 1.136; P=0.014) affected nocturia independently among the OSA-suspected patients.

Conclusions

Hypoxia caused by OSA affects the incidence of nocturia. Less desaturated OSA patients with nocturia may require more urological evaluation and treatment for nocturia even after the correction of OSA.

Continuous positive airway pressure improves nocturnal polyuria in ischemic stroke patients with obstructive sleep apnea

Objectives

To assess the effect of continuous positive airway pressure (CPAP) on nocturia in ischemic stroke patients with obstructive sleep apnea (OSA).

Methods

This was a prospective and non-randomized controlled study in which ischemic stroke patients with OSA being treated in a rehabilitation ward were enrolled. The participants who tolerated CPAP were classified as the CPAP group, while those who refused or could not tolerate CPAP were classified as the control group. The percentage change of nocturia before and after 2 weeks of CPAP therapy between the two groups were compared.

Results

A total of 44 participants were enrolled in and 35 participants (mean age= 59.8±11.7 years old; mean apnea hypopnea index=42.9±16.7/h) completed the study (control group: 14, CPAP group: 21). Overall, 69% of the participants had nocturnal polyuria and 69% of them had more than one nocturia episode per night. The baseline and initial nocturia characteristics did not differ significantly between the two groups. As compared to the control group, CPAP therapy significantly decreased the nocturnal polyuria index (mean percentage change: 9% vs −21% (P=0.005)) and nocturnal urine output (mean percentage change: 6% vs −26% (P=0.04)), but not the nocturia episodes or 24-hours total urine output.

Conclusion

Nocturia due to nocturnal polyuria is very common in post-stroke patients with OSA. Treating OSA by CPAP significantly reduces nocturnal polyuria, but not nocturia frequency, in ischemic stroke patients.

Links between lower urinary tract symptoms, intermittent hypoxia and diabetes: Causes or cures?

Bothersome lower urinary tract symptoms (LUTS) manifest as urinary frequency, urgency, incontinence and incomplete bladder emptying. Existing treatments ameliorate but do not eliminate most symptoms, leading to financial and personal burdens attributable to sustained medical therapies that may last a lifetime. The purpose of this review is to highlight evidence of causal associations between LUTS and several common comorbidities, including intermittent hypoxia (IH) concomitant with obstructive sleep apnea (OSA), obesity, metabolic syndrome and type 2 diabetes. Links between these conditions, including therapies targeted to co-occurring complications that have demonstrated benefits for LUTS, suggest compelling avenues of research and also underscore critical gaps in understanding the mechanisms underlying urinary dysfunction. These gaps are prominent in the IH field, where an acknowledged link between OSA and LUTS has gone largely uninvestigated. New tools, models, or reappropriation of existing ones, especially rodent models, is required to parse the associations between IH/OSA, LUTS and obesity/diabetes and to elucidate their underlying, and potentially shared, etiologies.

Nocturia in Women With Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is underdiagnosed in women compared with men. Women have a tendency to underreport or present with atypical symptoms such as behavior changes, insomnia, fatigue, and depression. Nocturia, waking up from sleep 2 times or more to void, has been shown to be associated with OSA, but it is not an included symptom in commonly used screening questionnaires in primary provider offices. About 50% of patients with OSA have nocturia, and treatment of OSA improves it. Recognition of nocturia as a relevant symptom of OSA is important for primary providers to provide timely referral for the diagnosis of OSA.

Continuous Positive Airway Pressure Adherence In Patients with Obstructive Sleep Apnea & Symptomatic BPH

Purpose To determine the short-term and long-term adherence rates with continuous positive airway pressure (CPAP) therapy in sleep apnea patients with benign prostatic hyperplasia (BPH) compared to matched controls. Methods A case-control retrospective analysis was performed in a veterans affairs hospital. All symptomatic patients with BPH (n = 107) ever started on CPAP therapy between 2006 and 2012 were compared with controls matched for severity of sleep apnea (AHI). Adherence measures were obtained at the third and twelfth month visits. The cases included symptomatic BPH patients on active medical therapy. Diuretic use among cases and controls, and severity of nocturia among the cases were also analyzed. Results The mean AHI among cases and controls was 35.6 ± 27.3 and 35.5 ± 31 (p = 0.96). The population was male and predominantly Caucasian. There was no statistically significant difference in percent days CPAP device use ≥4 h. between symptomatic BPH patients and controls at 3-month (51.6 ± 38 vs. 47.2 ± 36; p = 0.43) and 1-year (64 ± 40.5 vs. 64.7 ± 31.3; p = 0.90) visits. The use of diuretics in the cases and controls, and the severity of nocturia in the cases did not influence adherence with CPAP therapy. Conclusions BPH or diuretic use did not affect adherence with CPAP therapy in obstructive sleep apnea. Severity of nocturia did not have any influence on adherence among the cases. BPH, regardless of the severity of nocturia, and diuretic use does not influence CPAP adherence in patients with OSA.

Nocturia Improvement With Surgical Correction of Sleep Apnea

Purpose

To evaluate changes in nocturia after surgical correction of obstructive sleep apnea (OSA).

Methods

A total of 66 patients were included in the present study. All had been diagnosed with OSA syndrome by polysomnography and underwent uvulopalatopharyngoplasty (UPPP). Preoperative and postoperative lower urinary tract symptoms (LUTS), quality of life (QoL), and nocturia episodes were evaluated using the International Prostate Symptom Score (IPSS) and overactive bladder symptom score (OABSS) questionnaires. Three months postoperatively, telephone interviews were performed to determine the success of surgery, current LUTS, and nocturia episodes. Patients were divided into surgical success and failure groups. Surgical success was defined as snoring decrease more than 50% based on the patient’s subjective judgment.

Results

The response rate was 56% and success rate was 73%. In all patients, nocturia episodes significantly decreased from 1.7±1.1 to 0.8±1.2 (P=0.002). Mean IPSS score, OABSS score, and QoL scores were also significantly improved. The success group showed a significant decrease in nocturia episodes, and total IPSS, OABSS, and QoL scores. However, the failure group did not show significant changes in all parameters.

Conclusions

OSA correction improved nocturia as well as other LUTS. These improvements were not observed in the failure group. This study shows that OSA is a cause of nocturia and that other LUTS and nocturia can be improved by surgical correction of OSA.

Obstructive sleep apnea syndrome should be considered as a cause of nocturia in younger patients without other voiding symptoms

INTRODUCTION

This study aimed to evaluate urination frequency among patients with obstructive sleep apnea syndrome (OSAS) and the effect of continuous positive airway pressure (CPAP) treatment.

METHODS

We evaluated 138 men with moderate-to-severe OSAS by using polysomnography. Urination status was assessed at baseline and three months using the International Prostate Symptom Score and Overactive Bladder Symptom Score. Nocturia was defined as ≥2 nighttime urinations and patients were classified into Group A (<50 years old with nocturia), Group B (≥50 years old with nocturia), and Group C (patients without nocturia). OSAS severity and other urinary symptoms were also evaluated.

RESULTS

Patients with nocturia exhibited more severe OSAS, compared to patients without nocturia (apnea-hypopnea index [AHI]: 52.0 vs. 44.7; p=0.021). Group A had the worst AHI, but did not have additional voiding symptoms, compared to Group B (p<0.001). The number of urinations was significantly correlated with OSAS severity in <50-year-old patients (p=0.013). CPAP reduced the number of urinations in Group A (75% of patients) and Group B (90% of patients). Patients with and without improved nocturia exhibited significant differences in their baseline OSAS severity (AHI: 53.7 vs. 37.3; p=0.042).

CONCLUSIONS

OSAS severity was associated with the number of urinations in <50-year-old patients. CPAP decreased the nocturia frequency in 85% of patients with nocturia and was most effective in patients with severe AHI. However, additional studies should evaluate voiding volume in order to elucidate the mechanism of nocturia in patients with OSAS.

Prevalence of Sleep Disordered Breathing among Patients with Nocturia at a Urology Clinic

OBJECTIVE

We assessed the prevalence of sleep disordered breathing (SDB) and characteristics among patients who visited a urology clinic complaining of nocturia (URO group) and those who visited a sleep apnea (SA) clinic complaining of excessive daytime sleepiness (EDS) (SA group). Additionally, we evaluated the effects of continuous positive airway pressure (CPAP) therapy in the URO group patients with nocturia and SDB resistant to conventional therapy for nocturia.

METHODS

Questionnaires were used to assess EDS, nocturia and lower urinary tract symptoms in 34 URO group patients and 49 age-matched SA group patients. We also compared these factors in the male patients in both groups and the male and female patients in the SA group. Significant SDB was diagnosed as a 3% oxygen desaturation index (3%ODI) on pulse oximeter of >5/h. The treatment response was analyzed in six URO group patients treated with CPAP after not responding to the conventional medical treatment.

RESULTS

SDB was found in 91.8% of the SA group patients and 70.6% of the URO group patients. The level of EDS and lower urinary tract symptoms were similar in both groups. The SA group showed higher 3%ODI values, while the frequency of urination during bedtime was higher in the URO group. The frequency of nocturnal urination was reduced after CPAP in the subjects resistant to conventional therapy.

CONCLUSION

SDB is as prevalent in patients who visit a urology clinic complaining of nocturia as in those who visit a sleep apnea clinic. Patients who complains of nocturia must be assessed for SDB before starting therapy for nocturia.

The Efficacy of Continuous Positive Airway Pressure Therapy on Nocturia in Patients With Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis

Purpose:

To assess the efficacy of the continuous positive airway pressure (CPAP) on nocturia in patients with obstructive sleep apnea (OSA).

Methods:

A literature review was performed to identify all published clinical trials of CPAP for the treatment of nocturia. The search included the following databases: MEDLINE, Embase, and the Cochrane Controlled Trials Register. The reference lists of the retrieved studies were also investigated.

Results:

Five publications involving a total of 307 patients were used in the analysis, which compared the number of incidents of nocturia before and after CPAP treatment. We found that patients with OSA and nocturia who were treated with CPAP had a significant decrease in the frequency of nocturia and the volume of urine associated with it. The mean number of nocturia incidents (standardized mean difference [SMD], –2.28; 95% confidence interval [CI], –2.42 to –2.15; P<0.00001) and the associated urine volume (SMD, –183.12; 95% CI, –248.27 to –117.98; P<0.00001) indicated that CPAP was effective. Besides, the Epworth Sleepiness Scale (SMD, –5.88; 95% CI, –6.56 to –5.21; P<0.00001) and the CPAP apnea-hypopnea index (SMD, –31.57; 95% CI, –33.87 to –29.28; P<0.00001) indicated that CPAP significantly improved the quality of sleep.

Conclusions:

This meta-analysis indicates that CPAP maybe an effective treatment for reducing nocturia associated with OSA and improving the quality of life of such patients.

Nocturia is an independent predictive factor of prevalent hypertension in obstructive sleep apnea patients

OBJECTIVE

The aim of this study was to determine whether nocturia is an independent predictor for prevalent hypertension in obstructive sleep apnea (OSA).

METHODS

We analyzed data from a national prospective clinical cohort of OSA patients participating in the French national prospective registry. Anthropometric data, comorbidities, OSA severity, and number of voids/night were included in multivariate analyses to determine the independent variables associated with prevalent hypertension.

RESULTS

A total of 22,674 OSA patients were included, of which 11,332 were hypertensive. The prevalence of hypertension among OSA patients was about 1.3 times higher in patients suffering from nocturia at 61.45% versus 46.52% in hypertensive and non-hypertensive OSA patients (p <0.001). There was a significant positive relationship between hypertension and the severity of nocturia beyond two voids/night: two voids/night versus none: odds ratio (OR) = 1.270 (95% confidence interval (CI) = 1.175; 1.372), three voids/night versus none: OR = 1.422 (95% CI = 1.293; 1.565), and four voids/night versus none: OR = 1.575 (95% CI = 1.394; 1.781). The strength of the association was enhanced in patients over 64 years of age.

CONCLUSIONS

Nocturia is a strong independent predictor of prevalent hypertension in OSA. This association exhibited a "dose-response" relationship beyond two voids/night. The resolution of nocturia after continuous positive airway pressure (CPAP) treatment might be an important outcome to consider for the response of hypertension to CPAP.

Diagnosis and treatment of sleep apnoea in women with schizophrenia

BACKGROUND

Obstructive sleep apnoea (OSA) is often overlooked in the context of schizophrenia because its hallmark, daytime sleepiness, is so easily attributable to antipsychotic drugs. This is a special problem for women.

AIMS

To underscore the importance of diagnosing and treating OSA in women with schizophrenia.

METHODS

A review of the recent literature (search terms: Obstructive Sleep Apnoea; Schizophrenia; Women (or Gender); Obesity; Antipsychotics; Continuous Positive Airway Pressure (CPAP)) as it applies to a composite case vignette taken from the files of a specialty clinic that treats women with psychosis.

RESULTS

The rate of OSA in women who are both obese and postmenopausal is very similar to that of men. Family history, smoking, and the use of tobacco, alcohol and of antipsychotic medication increase the risk. Despite reluctance, patients with schizophrenia generally agree to undergo sleep studies. Compliance with CPAP is difficult, but can be aided by the physician and is, on the whole, relatively high in women. CPAP improves sleep parameters and may also improve cardiometabolic and cognitive indices, although this still needs to be more fully researched.

CONCLUSION

Schizophrenia and untreated OSA are both associated with high mortality rates in women as well as men.

Nocturia in older adults: implications for nursing practice and aging in place

Nocturia is a bothersome symptom that increases with age, resulting in sleep disruption, an increased risk of falls, and a greater likelihood of rating one's health as poor. It is often a symptom of conditions that cause low volume voiding, overproduction of urine across the day or only at night and a symptom of a sleep disorder. Nocturia affects quality of life and has an impact on aging in place, thus assessment and treatment are essential. Behavioral treatments should be explored first, keeping in mind what the affected older adult defines as the desired outcomes of treatment.

Obstructive sleep apnea syndrome

Obstructive sleep apnea (OSA) syndrome is a common but often unrecognized disorder caused by pharyngeal collapse during sleep and characterized by frequent awakenings, disrupted sleep and consequent excessive daytime sleepiness. With the increasing epidemic of obesity, the most important risk factor for OSA, prevalence of the disease will increase over the coming years thus representing an important public-health problem. In fact, it is now recognized that there is an association between OSA and hypertension, metabolic syndrome, diabetes, heart failure, coronary artery disease, arrhythmias, stroke, pulmonary hypertension, neurocognitive and mood disorders. Diagnosis is based on the combined evaluation of clinical manifestations and objective sleep study findings. Cardinal symptoms include snoring, sleepiness and significant reports of sleep apnea episodes. Polysomnography represents the gold standard to confirm the clinical suspicion of OSA syndrome, to assess its severity and to guide therapeutic choices. Behavioral, medical and surgical options are available for the treatment. Continuous positive airway pressure (CPAP) represents the treatment of choice in most patients. CPAP has been demonstrated to be effective in reducing symptoms, cardiovascular morbidity and mortality and neurocognitive sequelae, but it is often poorly tolerated. The results of clinical studies do not support surgery and pharmacological therapy as first-line treatment, but these approaches might be useful in selected patients. A better understanding of mechanisms underlying the disease could improve therapeutic strategies and reduce the social impact of OSA syndrome.

The impact of sleep apnoea syndrome on nocturia according to age in men

Study Type--Symptom prevalence (cohort) Level of Evidence 2b. What's known on the subject? and What does the study add? Sleep apnoea syndrome (SAS) can be a risk factor for nocturia, although whether the relationship between nocturia and SAS changes according to age remains to be addressed. SAS has a modest impact on nocturia frequency and the prevalence of pathological nocturia in young adults and middle-aged men. However, SAS may not be a risk factor for nocturia in the elderly, and age-related urinary diseases and voiding dysfunctions could over-ride the influence of SAS on nocturia in the elderly.

OBJECTIVE

• To assess the association between nocturia and sleep apnoea syndrome (SAS) according to age, as well as to determine the factors related to nocturia.

PATIENTS AND METHODS

• A total of 1757 men who had been referred to a sleep laboratory underwent polysomnography. • Nocturia frequency was assessed using a questionnaire, and pathological nocturia was defined as the need to void two or more times per night. • The Pittsburgh Sleep Quality Index (PSQI) and Beck Depression Inventory (BDI) were applied to all study subjects.

RESULTS

• Nocturia frequency was significantly correlated with age (r = 0.405, P < 0.001) and the apnoea-hypopnoea index (AHI) (r = 0.065, P < 0.01). • In those men aged <65 years, significant correlations were found between nocturic frequency and age, AHI, BDI and PSQI. • Multiple regression analysis showed that age (β = 0.303, P < 0.001), AHI (β = 0.107 P < 0.001) and benign prostatic hypertrophy (BPH; β = 0.069, P < 0.01) were associated with nocturia, and that the presence of pathological nocturia was predicted by BPH (odds ratio [OR], 2.77; P < 0.01), age (OR, 1.09; P < 0.001) and AHI (OR, 1.02; P < 0.001). • However, in men aged >65 years, nocturia frequency was significantly associated with BDI and PSQI, although no relationship was found between nocturia frequency and SAS parameters. • BPH was more frequently observed in elderly men with pathological nocturia than in those without pathological nocturia (OR, 2.18; P < 0.05).

CONCLUSIONS

• In the elderly, SAS may not be a risk factor for nocturia. • Age-related urinary diseases and voiding dysfunction may over-ride the influence of SAS.

Nocturia, sleep and daytime function in stable heart failure

BACKGROUND

The aim of this study was to evaluate nocturia severity and nocturia-related differences in sleep, daytime symptoms and functional performance among patients with stable heart failure (HF).

METHODS AND RESULTS

In this cross-sectional observational study, we recruited 173 patients [mean age 60.3 ± 16.8 years; female n = 60 (35%); mean left ventricular ejection fraction 32 ± 14.6%] with stable chronic HF from HF disease management programs in the northeastern United States. Participants reported nocturia and completed a 6-minute walk test (6MWT), 1 night of ambulatory polysomnography, and the SF-36 Medical Outcomes Study, Epworth Sleepiness, Pittsburgh Sleep Quality Index, Multidimensional Assessment of Fatigue, and Centers for the Epidemiological Studies of Depression scales. Participants reported 0 (n = 30; 17.3%), 1-2 (n = 87; 50.2%), and ≥3 (n = 56; 32.4%) nightly episodes of nocturia. There were decreases in sleep duration and efficiency, REM and stage 3-4 sleep, physical function, and 6MWT distance and increases in the percentage of wake time after sleep onset, insomnia symptoms, fatigue, and sleepiness across levels of nocturia severity.

CONCLUSIONS

Nocturia is common, severe, and closely associated with decrements in sleep and functional performance and increases in fatigue and sleepiness in patients with stable HF.

Quantitating nocturia: a study into the recording of solute and water excretion to determine causation

BACKGROUND

Nocturia is common but the clinical assessment of its severity and cause rarely involves any biochemical analysis. Investigating the cause of nocturia needs to be informed by the overall 24 h fluid and solute excretion patterns. The aim of this study was to establish a practical method of monitoring the renal excretion of water and solutes over a complete 24 h cycle.

METHODS

The excretion patterns of sodium, volume and osmoles were assessed in 89 healthy control subjects over a 24 h period by sampling each voiding from the 24 h collection and then using the total urine creatinine as the denominator. A group of 21 patients under investigation for sleep-disordered breathing (SDB: a group of disorders known to increase the risk of nocturia) were also studied to determine comparative excretion patterns.

RESULTS

Reference excretion patterns of sodium, volume and osmoles were described. Patients under investigation for SDB had overall a significant (P < 0.001) increase in urine sodium excretion at night (nocturnal natriuresis) matched by an increased osmotic excretion and accompanied by a significantly increased nocturnal urine volume (P < 0.001).

CONCLUSION

Breaking down a 24 h urine collection into voided aliquots provides practical information on the pattern of water and solute excretion. Such patterns may assist in identifying the underlying mechanism of significant nocturia in individual patients presenting with this symptom, and could be used as a method of monitoring treatment.

The effect of nocturia on sleep

Sleep plays a vital role in physical and mental functioning. It is increasingly recognized that disturbed sleep is a highly prevalent and chronic condition that merits greater awareness due to the wide-ranging and serious repercussions associated with it. Nocturia is one of the causes of sleep disturbance and has been shown to impair functioning, quality of life, health and productivity, with those experiencing two or more voids per night reporting significant 'bother'. Nocturia warrants full consideration as a significant target for intervention, aiming to reduce the burden of disturbed sleep on individuals, families and society. Currently, however, a definitive evaluation of the most relevant sleep endpoints in nocturia therapy is lacking. One endpoint often used is the duration of the initial sleep period, which when evaluated in combination with the number of voiding episodes per night, might be an indication of the severity of sleep disruption in patients with nocturia.

Nocturia

Nocturia is a common symptom in women which has profound negative impact on the quality of life. With the increase in aging population, nocturia is becoming an important clinical problem. A proper understanding of cardio-respiratory, metabolic, and neurological patho-physiology of nocturia is imperative for appropriate management of nocturia. When managing a patient with nocturia it is important to evaluate the patient as a whole rather than from urological perspective only. In this article we attempt to discuss the definition, etiology, clinical features and management of nocturia so that a comprehensive approach to management can be adopted when faced with a woman complaining of nocturia.

The relationship between sleep apnea and overactive bladder

Approximately 4% to 5% of middle-aged men are affected by obstructive sleep apnea (OSA) syndrome, which is known to cause urologic disorders, cardiovascular diseases, and an increased risk of stroke. The correlation between OSA, erectile dysfunction, and nocturia is well known; a recent study demonstrated the association between overactive bladder and urgency incontinence. This article discusses the current literature and therapeutic options, as well as our own experiences and consequences for affected patients.

The relationship between obstructive sleep apnea, nocturia, and daytime overactive bladder syndrome in women

OBJECTIVE

The purpose of this study was to corroborate the association between obstructive sleep apnea (OSA) and nocturia in a clinical sample of urogynecologic patients and to explore whether night-time urine concentration predicts the presence of OSA.

STUDY DESIGN

Patients with nocturia and control subjects underwent a home sleep study, completed validated nocturia questionnaires, and provided evening and morning urine specimens that were analyzed for osmolarity.

RESULTS

Twenty-one patients with nocturia (16 of whom also had daytime overactive bladder [OAB] symptoms) and 10 control subjects were studied. OSA was present in 17 of 21 women (81%) with nocturia: 13 women (81%) with OAB, 4 women (80%) with nocturia/no OAB, and 4 control subjects (40%; P < .001). The percentage of rapid eye movement sleep time was correlated inversely with nocturic frequency (rho = -.51; P < .004). The presence of diluted nighttime urine in a patient with nocturia was 88% sensitive for the presence of OSA.

CONCLUSION

We should consider a diagnosis of OSA in all patients with nocturia, even those patients with daytime OAB.