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Could nocturia be an indicator of an undiagnosed sleep disorder in male veterans?
Arun Rai, Tony Nimeh, Akshay Sood, Nannan Thirumavalavan, Portia E. Thurmond, Kazem M. Azadzoi, and Lori B. Lerner
Commented by Professor Antonella Giannantoni
Sleep-disordered breathing (SDB) is a pathologic condition characterized by pauses in breathing during sleep resulting in fragmented sleep and reduced oxyhemoglobin saturation. SDB is usually accompanied by snoring and excessive daytime sleepiness. Worth of noting: SDB is associated with cardiovascular and metabolic disorders and with lower urinary tract symptoms (LUTS).
In the present article Rai and co-workers aimed to determine if men presenting with nocturia and/or voiding complaints may have undiagnosed symptoms of SDB. The authors studied if an office-based screening of SDB by administering a common sleep questionnaire could help to identify those patients who should be referred to sleep medicine. A cross-sectional study was conducted at the Veterans Administration Boston Healthcare System Urology clinic. Men presenting with urinary symptoms were asked to complete the American Urological Association symptom score (AUA-SS) and the Berlin sleep questionnaire to evaluate their voiding complaints and sleep quality. The Berlin sleep questionnaire is a 10-item tool useful to identify symptoms known to be risk factors of SDB: snoring, sleep quality, hypertension, and body mass index (BMI). Between August 2012 and January 2013 a total of 618 questionnaires were collected. The multivariable analysis of the obtained data showed that elevated BMI, urinary frequency, and nocturia were significant and predictive factors for a positive Berlin score. Interestingly, the analysis revealed that the cutoff at which nocturia became a significant predictor of a positive Berlin score was at a score of ≥2. In the other multivariable analysis evaluating the predictors of nocturia, a positive Berlin score was found to be a significant and independent predictor of nocturia. Due to these results, the final suggestion of the authors was that urologists should consider administration of the Berlin score in their office, particularly in patients refractory to treatment for their voiding complaints, and if positive, consider referral to a sleep specialist.
This article reveals that it is important to consider not only the specific (urinary) symptoms of our patients but also their “whole entity”. The knowledge about nocturia and other urinary symptoms often shows that correlations and associations exist with other medical conditions. This is the case in the present article, in which a urologic complaint, nocturia, strictly links to a medical complaint, SDB.
To determine if men presenting with nocturia and/or voiding complaints may have undiagnosed symptoms of sleep-disordered breathing (SDB).
MATERIALS AND METHODS:
We conducted a cross-sectional study with men presenting to the Veterans Administration Boston Healthcare System Urology clinic between August 2012 and January 2013. Patients were asked to complete the American Urological Association symptom score and the Berlin sleep questionnaire to evaluate their voiding complaints and sleep quality. We performed univariable and multivariable statistical analyses to identify correlations between a positive Berlin score and voiding symptoms, with an emphasis on nocturia.
A total 618 completed questionnaires were included. More than 65% of patients reported nocturia. Of those reporting nocturia, 55% also had a positive Berlin score. The American Urological Association symptom score components of frequency and nocturia, as well as body mass index and hypertension, were shown to be significant independent predictors of a positive Berlin questionnaire, suggesting high likelihood of SDB. Conversely, a positive Berlin questionnaire was a significant independent predictor of nocturia, suggesting high degree of correlation between the 2 conditions.
Nocturia and other voiding symptoms, such as frequency, predict a positive Berlin score, and vice versa. Patients with a positive Berlin score may have an undiagnosed sleep disorder, the sequelae of which can lead to significant health consequences. If present, treatment of SDB can ameliorate voiding symptoms. Urologists should consider administration of the Berlin score in their office, particularly in patients refractory to treatment for their voiding complaints, and if positive, consider referral to a sleep specialist.