ABSTRACT

Objective:

Previous studies showed that nocturia has a negative effect on patients’ sleep quality. However, studies that focused on the sleep quality of patients’ partners are limited. In this study, we evaluated the impact of nocturia on sleep quality in patients with benign prostatic obstruction (BPO) and their female partners.

Materials and Methods:

We included 50 BPO patients with nocturia (group 1), 50 patients without nocturia (group 2) and their female partners. Lower urinary tract symptoms of the patients were evaluated by international prostate symptom score, serum prostate-specific antigen, uroflowmetry and urinary ultrasonography. The sleep quality of the patients and their partners were assessed by Pittsburgh sleep quality index (PSQI). The demographic and evaluation outcomes of the participants were recorded.

Results:

The mean age of the patients and their partners were 63±7.9 and 57.4±8.5 years, respectively, with no statistical significance. The patients and their partners in group 1 had significantly higher global PSQI compared with those in group 2. The percentage of poor sleep in patients and partners in group 1 was higher than that in group 2.

Conclusion:

Nocturia negatively affects the sleep quality of patients with BPO and their partners.

Keywords: Benign prostatic obstruction, nocturia, Pittsburgh sleep quality index, sleep quality

Introduction

Sleep is essential for restoration of the body and for maintaining energy (1). In recent years, awareness of various problems associated with sleep that are common among the population has been increased (2). Current evidences show that sleep quality affects health with disturbances in immune regulation (3), association with cardiovascular diseases and diabetes mellitus (4), daytime function (5), and quality of life (QoL) (6). Sleep disturbances can impact daytime functioning resulting in waking up tired in the morning, decreased work productivity, proneness to accidents, inability to concentrate and frequent daytime naps (7). Therefore, sleep disturbances are important to determine, since it is mostly modifiable risk factor. Determining the biological mechanisms underlying sleep disturbance may adverse bad health consequences and even prevent morbidity.

There are many reasons causing sleep disturbance including primary sleep disorders and physiologic, behavioral, and environmental factors requiring targeted diagnostic and treatment intervention (2). Nocturia is defined as “the number of times urine is passed during the main sleep period with each urination followed by sleep or the intention to sleep” by International Continence Society (8). Several medical conditions including benign prostatic obstruction (BPO), overactive bladder, diabetes mellitus, diabetes insipidus, and cardiovascular diseases may cause nocturia (9). Nocturia leads sleep fragmentation therefore, sleep quality of the patients is deteriorated. Several studies reported that nocturia negatively affected the sleep quality of the patients in both genders (10-12). Although there is no surprise that nocturia may also affect the sleep quality of the patients’ bed sharing partners, sleep quality of the spouses has been understudied. The current study aimed to evaluate the effect of nocturia on sleep quality in patients with BPO and their partners.

Materials and Methods

This prospective cohort study was approved by an institutional review board (E1-21-1781) and conducted in accordance with the principles of the Declaration of Helsinki. Between May 2021 and December 2021, male patients with lower urinary tract symptoms (LUTS) due to newly diagnose of BPO and their female partners who shared a bed with patients and accompanied their partners at visit were included in this study. All participants (patients and their partners) gave written informed consent. Both patients and their partners were asked to complete questionnaires at the first visit with the assistance of the authors.

The patients and their partners with a history of medical or surgical treatment for LUTS and/or BPO, urological malignancy, or diagnosed with diabetes mellitus, diabetes insipidus, or congestive heart failure, primary sleep disorders, and those with active urinary tract infection were excluded. In addition, patients had no partners or did not share a bed with their partners were not included in the study.

Evaluation of LUTS

In the current study, we used International Prostate Symptom Score (IPSS) questionnaire to evaluate LUTS. IPSS contains seven questions evaluating storage and voiding symptoms (13). The patient chooses 1 of 6 answers that are assigned from 0 to 5 points indicating the severity of the symptom. The total IPSS score ranges from 0 to 35 (asymptomatic to very symptomatic). IPSS is an self-administered questionnaire which is recommended to evaluate the patients with LUTS by European Association of Urology (EAU) (14). Nocturia frequency of the patients was determined by the seventh question of IPSS. The patients were divided into two groups. Patients with nocturia (n=50) were enrolled as group 1 and patients without nocturia (n=50) as group 2.

In addition to IPSS questionnaire, the patients were evaluated by digital rectal examination, uroflowmetry, urinary ultrasound, and serum prostate specific antigen level according to EAU recommendations (14). The patients with IPSS>7, prostate volume >20 mL, and maximum flow rate (Q_max) <15 mL/sec were included.

Evaluation of Sleep Quality

We used Pittsburgh sleep quality index (PSQI) (15) to determine the sleep quality of the patients and their partners. PSQI consists of four open and 14 rating scale questions (0 to 3). These items evaluate seven ‘‘component’’ scores including component 1: Subjective sleep quality, component 2: Sleep latency, component 3: Sleep duration, component 4: Habitual sleep efficiency, component 5: Sleep disturbances, component 6: Use of sleeping medication, and component 7: Daytime dysfunction. The sum of the seven components’ scores yields the global score. It is widely accepted that PSQI global score >5 indicates “poor quality sleep” (16). In clinical settings, PSQI is the most commonly used measurement tool of sleep quality which is strongly reliable and valid (16).

Both IPSS and PSQI that were applied to participants were validated Turkish versions of the questionnaires. The demographic, LUTS and sleep quality assessment outcomes of the participants were recorded.

Statistical Analysis

The Statistical Package for the Social Sciences (SPSS) v. 25 for Windows (SPSS Inc. Chicago, IL, USA) was used to perform the statistical analyses. Kolmogorov-Smirnov test was performed to determine the distribution of patients. Mann-Whitney U and chi-squared tests were performed to compare the groups. Logistic regression analysis was performed to study the relationship between nocturia and sleep problems. The comparison of sleep quality according to nocturia frequency was performed using Kruskal-Wallis test. A value of p<0.05 was considered to be statistically significant.

Results

The mean age of the patients and their partners were 63±7.9 (46-75) and 57.4±8.5 (39-71) years, respectively. Patients were divided into two groups. Group 1 consisted of 50 patients who had nocturia and group 2 consisted of 50 patients without nocturia. The comparison of the groups in terms of clinical and LUTS parameters were shown in Table 1.

Table 1

The assessment of sleep quality with PSQI showed that patients in group 1 and their partners had worse PSQI total scores compared with group 2 (p<0.001). The poor sleep quality rate of the patients and their partners in group 1 was significantly higher than group 2 [44 (88%) vs 19 (38%), p<0.001] and [39 (78%) vs 14 (28%), p<0.001], respectively. The assessment of sleep quality in patients was presented in Table 2 and in their partners in Table 3.

Table 2

Table 3

In patients, logistic regression analysis showed that subjective sleep quality [odds ratio (OR)=4.02, 95% confidence interval (CI)=1.74-9.28, p=0.001], sleep latency (OR=2.88, 95% CI=1.52-5.46, p=0.001), sleep duration (OR=9.43, 95% CI=3.31-26.82, p<0.001), habitual sleep efficiency (OR=4.84, 95% CI=2.35-9.97, p<0.001), sleep disturbances (OR=7.92, 95% CI=3.41-18.43, p<0.001), and total score of PSQI (OR=1.94, 95% CI=1.52-2.49, p<0.001) significantly related with nocturia while use of sleeping medication (OR=1.74, 95% CI=0.71-4.23, p=0.225) and daytime dysfunction (OR=1.11, 95% CI=0.59-2.12, p=0.743) were not. In the partners of the patients, logistic regression analysis revealed that subjective sleep quality (OR=3.06, 95% CI=1.48-6.31, p=0.002), sleep latency (OR=4.01, 95% CI=1.78-9.04, p=0.001), sleep disturbances (OR=2.66, 95% CI=1.34-5.28, p=0.005), and total score of PSQI (OR=1.64, 95% CI=1.27-2.13, p<0.001) had a significant relationship with nocturia. However, sleep duration (OR=1.57, 95% CI=0.61-4.02, p=0.350), habitual sleep efficiency (OR=1.05, 95% CI=0.57-1.94, p=0.876), use of sleeping medication (OR=1.61, 95% CI=0.58-4.45, p=0.361), and daytime dysfunction (OR=1.87, 95% CI=0.85-4.10, p=0.119) had no significant relationship with nocturia.

In group 1, total score of PSQI in patients and their partners according to the number of nocturia were differed insignificantly (Table 4).

Table 4

Discussion

In the current prospective study, we aimed to assess the effect of nocturia on sleep quality of patients with BPO and their partners. For the assessment we compared the BPO patients with and without nocturia and their spouses using validated self-reported questionnaires namely IPSS to evaluate LUTS and PSQI to evaluate quality of sleep. The patients with nocturia and their partners had higher PSQI score and poor sleep quality incidence compared to those without nocturia.

Benign prostatic obstruction is a common condition, with severe LUTS due to BPO being reported at a rate of approximately 25% in men aged ≥50 years (17). Nocturia is one of the most common LUTS in patients with BPO. Night-time voiding symptoms are more bothersome than day-time LUTS and sleep problems are the underlying causes of bother (18). A cross sectional study included 1.200 elderly men showed that nocturia independently increased the risk of poor sleep quality and poor sleep was associated with poor physical component of QoL and the mental component of QoL (19). Hernández et al. (20) found that nocturia was related to worse sleep quality in BPO patients. Another study that compared BPO patients with nocturia and without nocturia showed that patients with nocturia had a higher global PSQI scores. However, this difference was not statistically significant in the components namely sleep latency, sleep duration, use of sleep medication, and daytime dysfunction. The authors of the study stated that severe sleep disorders were more common in patients with nocturia than patients without nocturia (21). Bal et al. (22) found that nocturia was associated with increased daytime sleepiness. However, the authors could not show significant effect of the timing and frequency of nocturia on sleep quality (22). In our study, our results are consistent with previous studies and patients with nocturia had higher total score of PSQI and higher incidence of poor sleep. However, according to our results nocturia did not significantly affect use of sleep medication, and daytime dysfunction.

Symptoms of lower urinary tract and BPO negatively affect the health status of both patients and their partners (17,23). Mitropoulos et al. (24) reported that 28% of the partners of the patients with BPO suffered from sleep disturbances. Sells et al. (25) evaluated the morbidity in the partners of patients with BPO with a questionnaire that developed by the authors. They found that 76% of the partners were woken up more than once a night and 42% felt tired because of sleep disturbances. Another study supported these results and found that sleep disturbance was the most inconvenient morbidity in the partners of BPO patients (26). In a study by Shvartzman et al. (27) it was reported that approximately half of the partners of the patients with BPO regularly awaken at night due to nocturia. In this study 13% of the partners stated that they slept inadequately. Marklund et al. (28) compared the partners of men with LUTS and without LUTS in terms of quality of life and sleep quality. They used the questionnaire developed by Sells et al. (25) and sleep quality with the basic nordic sleep questionnaire (BNSQ) and Uppsala sleep inventory (USI). The answers for the questions focusing on awakenings and tiredness were significantly different between. However, according to BNSQ and USI quality of sleep did not differ between the groups. In the current study, we did not focus on other LUTS and assessed only the effect of nocturia on sleep quality. According to our results partners of the men with nocturia had higher global score of PSQI, components of subjective sleep quality, sleep latency, sleep disturbances and higher percentage of poor sleep compared to the partners of the men without nocturia.

Conclusion

Our results suggested that partners of the BPO patients with nocturia had worse sleep quality compared with partners of the BPO patients without nocturia. We believe that in clinical practice it should be focused on sleep quality of not only the patients with nocturia but also their partners.

Ethics

Ethics Committee Approval: This prospective cohort study was approved by an institutional review board (E1-21-1781) and conducted in accordance with the principles of the Declaration of Helsinki. Between May 2021 and December 2021, male patients with lower urinary tract symptoms (LUTS) due to newly diagnose of BPO and their female partners who shared a bed with patients and accompanied their partners at visit were included in this study.

Informed Consent: All participants (patients and their partners) gave written informed consent.

Peer-review: Internally and externally peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: Ç.Ş., A.A., İ.C.A., Concept: Ç.Ş., Design: Ç.Ş., Data Collection or Processing: Ç.Ş., A.A., İ.C.A., Analysis or Interpretation: Ç.Ş., M.Y.Ş., A.A., İ.C.A., H.F., Literature Search: Ç.Ş., M.Y.Ş., Writing: Ç.Ş., M.Y.Ş.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.

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The Effect of Nocturia on Sleep Quality in Patients with Benign Prostatic Obstruction and Their Female Partners