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Consequences of sleep interruption due to nocturia

By Prof. Donald Bliwise

Nocturia is generally considered clinically significant only if a patient awakes to void at least twice per night, but extreme cases of up to 15 voids a night have been reported. No wonder, then, that nocturia is often associated with chronic sleep disruption.

Although the effects of poor-quality or insufficient sleep are less severe than those of sleep deprivation, disruption of sleep adversely affects our quality of life, daytime activities, cognition, mental health or mood, and productivity. The cognitive and behavioural consequences of sleep disruption are likely to be obvious in the short term, in the days just after the disruption. Other consequences may become evident in the longer term.

The longer-term effects of poor or short duration sleep include vulnerability to metabolic and cardiovascular conditions (e.g. type 2 diabetes, heart disease, stroke) and perhaps even an increased risk of death. Other health outcomes thought to be linked to poor or short duration sleep include obesity, hypertension, and defects in the immune system. Indeed these latter effects may contribute to the adverse cardiovascular outcomes associated with poor or short duration sleep.

What do we mean by poor sleep?

During a “good night’s sleep”, the first half (3–4 hours) of the night includes periods of deep, slow-wave sleep. The second half is dominated by periods of rapid eye movement (REM). The importance of the earlier period of deep, slow-wave sleep is highlighted by studies showing that interrupting it reduces insulin sensitivity and attenuates the sleep-related decrease in blood pressure.

Patients with untreated nocturia generally wake for their first void about 2.5 hours after going to bed, thus reducing their crucial slow-wave sleep duration and shortening the so-called “first undisturbed sleep period”. This shortening of the slow-wave sleep period has been linked to reduction of sleep quality, duration, and efficiency and increase in daytime dysfunction in patients with nocturia.

Patients with primary nocturia wake because they need to void and not for some other reason such as sleep apnoea, snoring, restless legs syndrome or periodic leg movements. Sleep disturbance related to other factors such as anxiety and depression may also cause nocturnal awakenings and subsequent voiding. Be aware, however, that nocturia may occur as a consequence of nocturnal polyuria due to

  • impaired hormone-mediated fluid regulation, which can result from sleep disordered breathing (e.g. obstructive sleep apnoea)

  • disturbed arginine-vasopressin release

  • cardiovascular or metabolic conditions

  • diabetes (mellitus or insipidus).

When contemplating treatment, bear in mind that specifically targeting the nocturia with a medication such as desmopressin is likely to have a better effect on the patient’s sleep than using a sedative-hypnotic drug. The all-important “first undisturbed sleep period” may lengthen by as much as 25 minutes with a sedative-hypnotic medication but can be increased by up to 76 minutes with a successful nocturia treatment.

Faced with the patient whose sleep is disturbed because of nocturia, and even if the patient is not particularly bothered by the condition, we should properly evaluate the patient’s sleep and the causes and impact of the sleep disturbance.

References

Bliwise D. Consequences of interrupted sleep due to LUTS. Section 4.5, Assessment of clinical benefit, pp. 130-9. In Clinical Benefit in LUTS Treatment, ed. T. Holm-Larsen and J.P. Nørgaard. Elsevier, Amsterdam; 2015. 

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