Relationship of Nocturia and Sleep Apnea | Neurology Sleep Centre | Dr. Manvir Bhatia
Channel: Neurology Sleep Centre
Date: 2023-02-27

Nocturia is a condition characterized by waking up from sleep for more than twice or more to empty their urinary bladder. It is a key feature of lower urinary tract symptoms(LUTS). Although it has very little effect on the general health conditions of some people, it has serious negative impacts on the sleep quality and Health related quality of life(HRQL). It is significant in various health complications including Obstructive Sleep Apnea(OSA), hypertension, obesity, renal disorders, diabetes mellitus, diabetes insipidus etc. It is mostly caused by benign prostatic hyperplasia, overactive bladder and reduced bladder capacity.  Nocturnal enuresis(involuntary urination while sleeping) is also linked with OSA.   

Obstructive Sleep Apnea(OSA) is a disorder in which the breathing starts and stops when the muscles of the throat relax and block the airway. This leads to characteristic symptoms like loud snoring, gasping for air in sleep, difficulty in staying asleep, excessive daytime sleepiness etc. It lowers the overall quality of life by causing irritability, lack of sleepiness, insomnia and tiredness. 

OSA, nocturia and sleep:
It has been observed that these three have a strong relationship. The mechanisms that explain the association of nocturia with OSA include:
Due to respiratory disturbance during sleep, if a negative pressure is continuously maintained in the thoracic cavity, the venous blood supply to the heart increases. This increases the secretion of  atrial natriuretic peptide in urine and plasma, thereby suppressing the secretion of antidiuretic hormone.   
Benign Prostate Hyperplasia(BPH)
Patients with BPH complain more about poor quality and disrupted sleep and this is much worse in the presence of OSA. Polysomnography results have shown that BPH patients experience nocturia majorly during the REM(rapid eye movement) stage i.e. the superficial stages of sleep. BPH patients experiencing nocturia showed excessive daytime sleepiness, severe insomnia and poor sleep quality. Administration of melatonin helped reduce the number of midnight awakenings. 

Overactive Bladder(OAB):
In a study conducted on 150 women with OAB, all of them complained of insomnia and most of them complained of a strong desire to void. The mean nocturia rate was 4.5. OAB often leads  to loss of bladder control, leading to a need to void urgently, which in turn causes poor sleep quality and excessive daytime sleepiness.  

Women, OSA and nocturia: 
Women are more affected by nocturia as compared to men. It has been observed that in women, snoring becomes increasingly prevalent after the age of 50. This age corresponds to the beginning of menopause, which has also been associated with the risk of OSA. Although, the exact mechanism of menopause leading to menopause is not yet known very well, yet it is suggested that women tend to gain more weight post menopause. This leads to an increase in BMI, neck circumference and central obesity.     

Children, OSA and nocturia:
Children with OSA tend to wet the bed more often as compared to children without OSA but this often goes unrecognized as compared to the other symptoms of OSA. Swollen adenoids and tonsils are very common in them. It is recommended to surgically remove the tonsils and adenoids of children above two years of age as it  has effectively cured bet wetting in 60% of them.     

Management of these conditions becomes very important to maintain a good quality of life. A few general steps to manage nocturia include:
Intake of drinks that increase urine output (like caffeine, alcohol) should be avoided in the evening.
Cutting down the consumption of salty food and snacks. 
Reducing the intake of overall fluids at least two hours before going to bed.
Using the restroom just before going to bed to better empty the bladder.
In the case of children, it becomes very important to educate parents about this condition and encourage them to be optimistic about its cure. 

Although from among the various sleep related parameters caused by OSAS, the ones that can predict nocturia have not been defined, yet we can conclude that OSA and nocturia are very closely related. Hence, it becomes very important to manage both the conditions. Nocturia can be managed by the use of medications which include bladder relaxants, antimuscarinic medications, beta-3-agonists, vaginal estrogen therapy( for women who have undergone menopause) and desmopressin(for those who have failed all the previous lines of treatment).  It should also be noted that nocturia does not necessarily mean that a person is suffering from OSA. 
 Hence, it becomes important to get oneself screened for the possibility of OSA and seek help for the management of the same from a health professional for effective management and treatment. 
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