Enuresis and obstructive sleep apnea in adults

Nocturnal Urinary Symptoms as Screening Tools for Obstructive Sleep Apnea

IMPORTANCE

Nocturnal lower urinary tract symptoms are part of obstructive sleep apnea (OSA), and urogynecology clinics may serve as OSA screening sites.

OBJECTIVE

This study's aim was to determine the accuracy of nocturia and nocturnal enuresis (NE) as screening tools for OSA in new patients at a urogynecology clinic.

STUDY DESIGN

Using a retrospective study design, we gathered information regarding diagnostic OSA testing, continuous positive airflow pressure use, and lower urinary tract symptoms improvement from women in a urogynecology clinic who were previously screened for OSA using validated questionnaires. Nocturia and NE were tested for sensitivity and specificity using positive OSA diagnosis by polysomnography as the gold standard.

RESULTS

Nocturia with a cutoff of ≥2 episodes per night had the best test characteristics-86.4% sensitivity (95% confidence interval [CI], 65.1-97.1) and 58.5% specificity (95% CI, 44.1-71.9) for an overall accuracy of 78.4% (95% CI, 67.0-89.8). Nocturnal enuresis with a cutoff of ≥1 episode per week had the best NE characteristics with 31.8% sensitivity (95% CI, 13.9-54.9) and 79.3% specificity (95% CI, 65.9-89.2) for an overall accuracy of 56.1% (95% CI, 41.2-71).

CONCLUSIONS

Lower urinary tract symptoms such as nocturia and NE are routinely assessed in urogynecology clinics, making them useful for OSA screening and referral. The present study found nocturia symptoms with ≥2 episodes per night to retain acceptable test characteristics in screening for OSA, whereas NE was found to have less acceptable test characteristics for OSA screening. Urogynecology clinics may utilize nocturia symptoms in clinical decision making for OSA referral.

Nocturic obstructive sleep apnea as a clinical phenotype of severe disease

Study Objectives

This study was done to find whether a history of nocturia is associated with severity of obstructive sleep apnea (OSA) and also whether patients with nocturia constitute a separate phenotype of OSA.

Materials and Methods

Retrospective chart review was done in consecutive OSA patients who were diagnosed in sleep laboratory of our institute. Detailed sleep history, examination, biochemical investigations, and polysomnography reports were taken for the analysis. Nocturia was defined as urine frequency ≥2/night.

Results

Of 172 OSA patients, 87 (50.5%) patients had nocturia. On multivariate analysis, a history of nocturia had 2.429 times (confidence interval 1.086-5.434) more chances of having very severe OSA (P = 0.031). Time between bedtime and first time for urination was significantly less in very severe OSA compared to severe OSA and mild-to-moderate OSA (2.4 ± 0.9, 3.1 ± 1.3, and 3.0 ± 1.1 h, respectively) (P = 0.021). Patients with nocturia were older (52.3 ± 11.9 vs. 47.6 ± 12.1 years; P = 0.012), had higher STOP BANG scores (P = 0.002), higher apnea-hypopnea index (AHI) (64.8 ± 35.9 vs. 43.9 ± 29.1; P < 0.001), and higher Epworth sleepiness scale (ESS) (9.2 ± 5.3 vs. 7.7 ± 4.4; P = 0.052) and were more likely to be fatigued during day (P = 0.001). Nocturics had higher body mass index (BMI) (P = 0.030), higher waist, and hip circumference (P = 0.001and 0.023, respectively). Nocturic patients had lower awake SpO₂(P = 0.032) and lower nadir SpO₂ during sleep (P = 0.002).

Conclusions

A history of nocturia (≥2/night) predicts very severe OSA (AHI >60). Nocturic OSA is a phenotype of OSA with more severe AHI, lower oxygen levels, higher BMI, and higher ESS. We believe nocturia can be used for screening in OSA questionnaires, which needs to be validated in further community-based studies.

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.

CPAP Treats Enuresis in Adults With Obstructive Sleep Apnea

ABSTRACT

Enuresis, or "bedwetting," in children is associated with obstructive sleep apnea (OSA), and often resolves with treatment of OSA. However, it is poorly understood whether a similar relationship exists in adults. We describe a case series of 5 adult patients in whom OSA was diagnosed by laboratory polysomnography, who presented with enuresis that resolved after treatment with continuous positive airway pressure (CPAP). All cases occurred in the setting of obesity, in addition to other known risk factors for urinary incontinence and enuresis. OSA was diagnosed as severe in all but one case, which was mild. One patient noted recurrence of enuresis that coincided with malfunction of his CPAP machine. There is growing evidence that CPAP therapy may alleviate OSA and enuresis in adults with both conditions. Clinicians should routinely ask about enuresis in patients suspected of having OSA. A systematic study of the association between enuresis and OSA in adults is warranted.

Association of obstructive sleep apnea risk factors with nocturnal enuresis in postmenopausal women

OBJECTIVE

The prevalence of obstructive sleep apnea (OSA) in women increases significantly after menopause. However, identifying at-risk women is difficult because they tend to underreport symptoms and their complaints may differ from those traditionally associated with OSA. We investigated whether OSA risk factors are associated with the presence of a "nontraditional" complaint, such as nocturnal enuresis, in postmenopausal women.

METHODS

A cross-sectional study of postmenopausal women aged 50 to 79 years who participated in the Women's Health Initiative Observational Study and clinical trials (1993-2005) at 40 clinical centers in the United States was performed. Multiple variable logistic regression analysis was used to determine the association of OSA risk factors with nocturnal enuresis.

RESULTS

A cohort of 2,789 women (1.7%) reported having nocturnal enuresis. Obesity (odds ratio [OR], 2.29; 95% CI, 2.00-2.62), snoring (OR, 2.01; 95% CI, 1.74-2.32), poor sleep quality (OR, 1.70; 95% CI, 1.52-1.91), sleep fragmentation (OR, 2.44; 95% CI, 2.14-2.79), daytime sleepiness (OR, 1.50; 95% CI, 1.33-1.68), and hypertension (OR, 1.13; 95% CI, 1.01-1.26) were associated with nocturnal enuresis. Each additional OSA risk factor in a predefined OSA score significantly increased the odds of having nocturnal enuresis in a dose-response fashion (OR of 1.38, 2.00, 2.80, 3.87, 5.10, and 7.02 for scores of 1-6, respectively) compared with no risk factors.

CONCLUSIONS

OSA risk factors are associated with nocturnal enuresis in postmenopausal women. Mechanisms relating nocturnal enuresis to OSA may include apnea-associated changes in intrathoracic pressure, leading to increased urine output. Questioning at-risk postmenopausal women presenting with nocturnal enuresis about other OSA risk factors should be considered.

Sleep apnea in children with refractory monosymptomatic nocturnal enuresis

BACKGROUND

Children with nocturnal enuresis (NE) are believed to have deep sleep with high arousal threshold. Studies suggest that obstructive sleep apnea-hypopnea syndrome (OSAHS) and NE are common problems during childhood. We sought to assess the prevalence of OSAHS in children with refractory NE and whether its severity is associated with the frequency of bedwetting.

METHODS

The study group comprised 43 children with refractory monosymptomatic NE and a control group of 30 children, both aged 6-12 years. All subjects underwent thorough neurological examination, one night of polysomnography only for the patient group, and a lumbosacral plain X-ray to exclude spina bifida.

RESULTS

The groups were well matched. Two subjects of the control group had mild OSAHS. The mean age of the patients was (9.19±2.4 years), 26 were boys, and 67% showed frequent NE (>3 days bedwetting/week). Patients with NE had significantly higher rates of OSAHS (P<0.0001); three patients had mild, 12 had moderate, and eleven showed severe OSAHS. There was no significant statistical difference among patients having OSAHS in relation to age, sex, or family history of NE. The frequency of bedwetting was statistically significantly higher in patients with severe OSAHS (P=0.003).

CONCLUSION

Patients with refractory NE had a significantly higher prevalence of OSAHS with no sex difference. The frequency of bedwetting was higher in patients with severe OSAHS.

Nocturia, sleep-disordered breathing, and cardiovascular morbidity in a community-based cohort

Background

Nocturia has been independently associated with cardiovascular morbidity and all-cause mortality, but such studies did not adjust for sleep-disordered breathing (SDB), which may have mediated such a relationship. Our aims were to determine whether an association between nocturia and cardiovascular morbidity exists that is independent of SDB. We also determined whether nocturia is independently associated with SDB.

Methodology/Principal Findings

In order to accomplish these aims we performed a cross-sectional analysis of the Sleep Heart Health Study that contained information regarding SDB, nocturia, and cardiovascular morbidity in a middle-age to elderly community-based population. In 6342 participants (age 63±11 [SD] years, 53% women), after adjusting for known confounders such as age, body mass index, diuretic use, diabetes mellitus, alpha-blocker use, nocturia was independently associated with SDB (measured as Apnea Hypopnea index >15 per hour; OR 1.3; 95%CI, 1.2–1.5). After adjusting for SDB and other known confounders, nocturia was independently associated with prevalent hypertension (OR 1.23; 95%CI 1.08–1.40; P = 0.002), cardiovascular disease (OR 1.26; 95%CI 1.05–1.52; P = 0.02) and stroke (OR 1.62; 95%CI 1.14–2.30; P = 0.007). Moreover, nocturia was also associated with adverse objective alterations of sleep as measured by polysomnography and self-reported excessive daytime sleepiness (P<0.05).

Conclusions/Significance

Nocturia is independently associated with sleep-disordered breathing. After adjusting for SDB, there remained an association between nocturia and cardiovascular morbidity. Such results support screening for SDB in patients with nocturia, but the mechanisms underlying the relationship between nocturia and cardiovascular morbidity requires further study. MeSH terms: Nocturia, sleep-disordered breathing, obstructive sleep apnea, sleep apnea, polysomnography, hypertension.

Nocturia, enuresis and snoring: an unusual combination in an adult?

A 41-year-old man was seen in a respiratory clinic with symptoms of snoring, sleepiness during the day, enuresis and nocturia. He was waking up a minimum of 6–7 times to micturate every night. He had a past medical history of hypertension. His medication included lisinopril, omeprazole and simvastatin. He denied significant alcohol intake. On examination he was obese with a body mass index of 32 kg/m2, his blood pressure was raised at 170/120 mmHg. Chest examination revealed clear lung fields and otherwise unremarkable general examination. His collar size was 45 cm. His blood tests suggested normal renal, thyroid, calcium and blood sugar profiles. The mid-stream urine did not show any evidence of urinary tract infection. He had an elevated score of 15/24 on the Epworth Sleepiness scale (a questionnaire tool to assess daytime sleepiness).

He subsequently had an overnight oximetry, which showed 4% oxygenation desaturation index of 80.6 per hour (Figure 1). This is consistent with severe obstructive sleep apnoea hypopnoea syndrome. He was commenced on continuous positive airway pressure with substantial improvement in his sleep apnoea symptoms, including nocturic frequency, and his enuresis is completely resolved.

Facial patterns and primary nocturnal enuresis in children

PURPOSE

Aims of our study are evaluating: (1) the prevalence of dolicofacial pattern among enuretic and control-group children, (2) the prevalence of an abnormal head posture in bedwetters, and (3) the correlation with sleep-related breathing disorders (SRBD) identified by polysomnography (PSG) recording. Nocturnal enuresis is a multifactorial disease, but has been related also to obstructive sleep-disordered breathing in both adults and children. Anatomical factors recognized to predispose to SRBD include adenotonsillar hypertrophy, neuromuscular disorders, craniofacial abnormalities associated with macroglossia, retrognathia or maxillary hypoplasia, and obesity.

METHODS

Two hundred seventy enuretic children aged 7-12 years (mean 9.62 ± 2.31) were compared with a control-matched group of 274 children. To screen nocturnal sleep habits, all subjects' mothers filled out the Sleep Disturbance Scale for Children. Among these scales, only SBD scale was taken into account. Sleep breathing disorders (SBD) scale is composed of three items: sleep breathing difficulties, sleep apnea, and snoring. Cephalic index was calculated for each patient in order to identify facial patterns. An overnight PSG was performed in 28 (15 males, 13 females), randomly chosen, enuretic children and in 38 healthy volunteer controls (18 males, 20 females) matched for age (8.73 ± 0.79 vs. 9.12 ± 1.23; p = 0.147) and sex distribution (chi-square = 0.062; p = 0.803).

RESULTS

Bedwetters show different sleep habits, higher prevalence of dolicofacial pattern, and abnormal head posture more than controls.

CONCLUSIONS

Our preliminary study support further investigation of usage of the cephalic index as a predictor of SRBD.

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.

Association between primary nocturnal enuresis and habitual snoring in children

OBJECTIVES

Nocturnal enuresis has been associated with obstructive sleep-disordered breathing mostly in hospital-referred adults and children. To investigate whether primary nocturnal enuresis is significantly associated with habitual snoring in the general pediatric population irrespective of subjects' age and sex, we studied children attending six randomly selected schools in a city in central Greece.

METHODS

A questionnaire regarding the symptoms of sleep-disordered breathing and the presence of nocturnal enuresis (bedwetting for at least one night per week) was answered by the children's parents.

RESULTS

A total of 1821 children (age 5 to 14 years; 896 girls) were included in the study. Of these, 135 (7.4%) were snoring more frequently than three nights per week (habitual snorers). The habitual snorers had a history of primary nocturnal enuresis more often than did nonhabitual snorers (7.4% versus 2%; odds ratio 4.00, 95% confidence interval 1.93 to 8.32). The association of primary nocturnal enuresis with habitual snoring remained significant after adjustment for age and sex (odds ratio 3.54, 95% confidence interval 1.68 to 7.44).

CONCLUSIONS

In a community sample of children, those with habitual snoring more often had primary nocturnal enuresis than did those without snoring.

Nocturic frequency is related to severity of obstructive sleep apnea, improves with continuous positive airways treatment

OBJECTIVE

The purpose of this study was to determine the relationship between nocturia and obstructive sleep apnea (OSA), and the effect of continuous positive airways pressure (CPAP) therapy on nocturic frequency.

STUDY DESIGN

This was a retrospective review of sleep studies including patients with and without evidence of OSA, before and during CPAP treatment (where relevant). Chi-squared tests compared nocturia prevalence according to sleep diagnosis, logistic regression determined predictors of nocturia, and regression analyses determined predictors of nocturic frequency.

RESULTS

In 196 eligible studies, predictors of nocturia included increasing age and diabetes mellitus; nocturia was equally likely to occur in patients with and without OSA. In patients with OSA and nocturia, nocturic frequency was related to age, diabetes, and severity of OSA (P < .001). Patients with OSA and nocturia who were treated with CPAP demonstrated a significant decrease in nocturic frequency (P < .001).

CONCLUSION

OSA severity predicts nocturic frequency. The role of testing in the triage of patients with nocturia remains to be determined.

Resolution of nocturnal enuresis in snoring children after treatment with nasal budesonide

Nocturnal enuresis has been associated with obstructive sleep apnea-hypopnea and may resolve after adenotonsillectomy. Nasal corticosteroids have improved symptoms and polysomnography findings in children with snoring. Two children with primary nocturnal enuresis, chronic nasal obstruction, and loud snoring underwent polysomnography. The apnea-hypopnea index was 4.9 and 7.3 episodes/hr, and the oxygen desaturation of hemoglobin index was 4.6 and 5.2 episodes/hr. After administration of budesonide, the frequency of snoring decreased, the polysomnography findings improved, and the enuresis resolved completely. Six months after treatment, both children were still dry at night. Administration of nasal corticosteroids is associated with resolution of enuresis in children with mild obstructive sleep-disordered breathing.

Enuresis in children with sleep apnea

OBJECTIVES

To test the hypothesis that the presence of nocturnal enuresis is related to the severity of sleep apnea, we examined the relation between the Respiratory Disturbance Index (RDI, apneas plus hypopneas per hour of sleep) and the presence and severity of enuresis.

STUDY DESIGN

All children 4 years of age and older who were referred to our sleep center for suspected sleep disordered breathing (SDB) were asked whether and how frequently they currently wet the bed. All patients underwent full overnight polysomnography (PSG). The relation between RDI and enuresis was examined by chi(2) analysis. A value of P <.05 was considered statistically significant.

RESULTS

Ninety boys and 70 girls were studied; 66 children (41%) described current enuresis. At all ages, enuresis was more prevalent in our patients than control patients in the literature. Children with an RDI of < or =1 had a significantly lower prevalence of enuresis (17%) than did children with an RDI >1 (47%) (P <.05). Fourteen percent of children with an RDI < or =1 had frequent enuresis, compared with 32% of children with an RDI >1 (P <.05). There was no significant difference in the prevalence of enuresis in children with an RDI 1 to 5, 5 to 15, or >15 (P =.92).

CONCLUSIONS

There is a high prevalence of enuresis in children with suspected sleep-disordered breathing. Children with an RDI >1 were at higher risk for enuresis than children with an RDI < or =1. This may be due to the effects of obstructive sleep apnea on arousal response, bladder pressure, or urinary hormone secretion.

Bedwetting--not always what it seems: a sign of sleep-disordered breathing in children

ISSUES AND PURPOSE

Nocturnal enuresis (bedwetting) can linger long into childhood. Sleep research has documented that nocturia and bedwetting are symptoms of obstructive sleep apnea (OSA) in adults and that bedwetting is predictive of OSA in children.

CONCLUSIONS

Nocturnal polyuria is a cardiovascular response to negative pressure breathing (inspiration against a closed glottis), which is characteristic of OSA.

PRACTICE IMPLICATIONS

Evidence of nocturnal polyuria and sleep-disordered breathing are important signs of OSA, a serious but treatable condition.

Compliance with CPAP therapy in older men with obstructive sleep apnea

OBJECTIVES

Factors specifically affecting compliance with continuous positive airway pressure (CPAP) in older patients with obstructive sleep apnea (OSA) have not been described. The purpose of this study is to determine which factors are associated with compliance and noncompliance in older patients, a growing segment of the population.

DESIGN

A retrospective chart review of older male patients prescribed CPAP therapy for OSA over an 8-year period.

SETTING

Veterans Affairs Medical Center.

PARTICIPANTS

All patients age 65 and older for whom CPAP therapy had been prescribed for treatment of OSA in the past 8 years.

MEASUREMENTS

Records of all older male patients prescribed CPAP therapy for OSA over the last 8 years were reviewed. Compliance was defined by time-counter readings averaging 5 or more hours of machine run-time per night.

RESULTS

Of 33 older male patients with OSA studied, 20 were found to be compliant and 13 noncompliant with nasal CPAP therapy. The mean age (+/- SEM) at the time of diagnosis of OSA in the compliant group was 68 (+/-1) years, whereas that of the noncompliant group was 72 (+/-1) years (P <.05). Of the compliant patients, 95% attended a CPAP patient education and support group, whereas only 54% of noncompliant patients attended (P =.006). Resolution of initial symptoms of OSA with CPAP therapy was significantly associated with compliance. Symptom resolution occurred in 90% of compliant patients and in only 18% of noncompliant patients (P <.0002). Factors that were significantly associated with noncompliance with CPAP were cigarette smoking, nocturia, and benign prostatic hypertrophy (BPH). Of noncompliant patients, 82% complained of nocturia, whereas only 33% of compliant patients complained of nocturia (P =.02). BPH was diagnosed in 62% of noncompliant patients and in only 15% of compliant patients (P =.004). Diuretic use was more common in the compliant group and, therefore, was not a cause of increased nocturia in noncompliant patients.

CONCLUSION

In older male patients with OSA, compliance with CPAP therapy is associated with attendance at a patient CPAP education and support group. Resolution of symptoms with therapy also appears to be associated with enhanced compliance. In addition, we found an association between nocturia and the existence of BPH in older men with OSA who are not compliant with nasal CPAP. Larger observational studies should be performed to confirm these findings, and, if so confirmed, then further studies to determine whether treatment of BPH in older men with OSA improves compliance with CPAP.

Nocturnal enuresis and upper airway obstruction

PURPOSE

The purpose of this paper is to investigate the relationship between nocturnal enuresis (NE) and upper airway obstruction (UAO) in pediatric population.

MATERIAL AND METHODS

This study presents the results of our experience with 321 children who underwent adenotonsillar surgery.

RESULTS

Among 321 children who were operated on, 111 (35%) had NE. Seventy-four of the 111 children who had NE have been evaluated postoperatively. After a follow-up period of 3 months 47 (63%) patients were free of their complaints, while three (4%) of them reported decrease in the frequency of NE and 24 had no change in their complaints.

CONCLUSIONS

We do suggest that UAO is probably a more common etiological factor in NE than previously recognised.

Intracranial hemorrhage associated with thrombolytic therapy for elderly patients with acute myocardial infarction: results from the Cooperative Cardiovascular Project

BACKGROUND AND PURPOSE

Intracranial hemorrhage is a serious complication of thrombolytic therapy for acute myocardial infarction, especially among the elderly, but little information exists on estimating risk. Better estimation of risk in individual patients may allow for withholding or using alternate therapies among those at highest risk.

METHODS

To quantify the risk and identify predictors of intracranial hemorrhage associated with thrombolytic therapy, we performed a retrospective cohort study using data from medical charts. The study involved nearly all acute-care hospitals in the United States. All Medicare patients discharged with a principal diagnosis of acute myocardial infarction during a 9-month period in 1994 to 1995 were included. The main outcome measure was intracranial hemorrhage among those treated with thrombolytic therapy.

RESULTS

The rate of intracranial hemorrhage was 1.43% (455 of 31 732). In a logistic model, age > or =75 years, female, black race, prior stroke, blood pressure > or =160 mm Hg, tissue plasminogen activator (versus other thrombolytic agent), excessive anticoagulation (international normalized ratio > or =4 or prothrombin time > or =24), and below median weight (< or =65 kg for women; < or =80 kg for men) were independent predictors. A risk stratification scale was developed on the basis of these factors: with none or 1 of the factors (n=6651), the rate of intracranial hemorrhage was 0.69%; with 2 factors (n=10 509), 1.02%; with 3 factors (n=9074), 1.63%; with 4 factors (n=4298), 2.49%; and with > or =5 factors (n=1071), 4. 11% (Mantel-Haenszel; P<0.001).

CONCLUSIONS

The rate of intracranial hemorrhage in older patients after treatment with thrombolytic therapy exceeds 1%. Readily available factors can identify elderly patients with acute myocardial infarction at high and low risk for intracranial hemorrhage associated with thrombolytic therapy.