Hypothesis / aims of study
Sleep quality and lower urinary tract symptoms are often connected. Following the literature, this study tried to see if nocturia was associated with Quality of sleep and QoL, while simultaneously studying other LUTS symptoms and their relation with the latter. For that, we will evaluate a group of men with BPH who are undergoing BPH surgery. This project's main focus is to evaluate the development of sleep quality and quality of life in patients with BPH that are going to undergo surgery. And to confirm if LUTS and Sleep quality are in fact associated with each other.
Study design, materials and methods
This study is an observational, prospective, longitudinal type of study and was carried out in consecutive patients with BPH who were referred for surgery (Open Prostatectomy or TURP).
Using a combination of 3 surveys and a uroflowmetry, data was collected in two different moments, before and after surgery.
Were included in this study all male patients who had an age between 40 and 80 years old, with a previous diagnose of BPH, documented symptoms, and who were scheduled for surgery.
All patients who had any kind of sleep disorders, psychiatric and/or neurologic disorders diagnosed where excluded from the study.
The patients performed a uroflowmetry and post-void residue and then were asked to answer 3 surveys: The Pittsburgh sleep quality index (PSQI) for measuring the quality and patterns of sleep; The International prostate symptoms score (IPSS) for accessing the symptoms related to BPH from the patient’s point of view; The International Consultation on Incontinence Questionnaire Nocturia Quality of Life Module (ICQ-NQoL) for evaluating the patient’s quality of life (QoL). One month after undergoing surgery, the patients were asked to come and once again perform the same protocol, (uroflowmetry plus surveys). To compare the results of the Pre-op versus Post-op we used the Wilcoxon test and the T-test. To measure the strength of association between variables we used the Pearson Correlation Coefficient and the Spearman Correlation Coefficient.
Results
From the initial 54 patients scheduled for surgery, only 24 turned out to be eligible to participate in the study, their ages ranging from 53 to 80 years old (average of 67.7 +/- 8.4). After surgery, there was an increase of 41% in the Qmax value, a decrease of -365% in the PVR value, a decrease of 50% in the nocturia episodes, and a decrease of 144 % in the IPSS score. There was a significant improvement seen on the quality of sleep and QoL, as it was obtained a decrease of 233% in the ICQ-NQoL score, an 80% decrease in the PSQI score, and an increase of 14% on the TSH.
9 participants (37.5%) still had a PSQI 2 score superior to 5 after surgery, which translates to poor quality of sleep. The sample was then divided between those who had a PSQI 2 score < 5 and those who had a PSQI 2 score ≥ 5.
When comparing the parameters' values in the 15 participants with a normal quality of sleep with the 9 participants with poor quality of sleep the last ones had a higher IPSS 2, ICQ-Nqol 2, PVR 2, Nocturia 2, and a lower THS 2. That means not only were the 9 participants still sleeping badly after surgery, but they were also still reporting to have persistent LUTS symptoms.
we notice that both variables IPSS 2 and Nocturia 2, obtained after surgery, presented a direct linear association with PSQI 2 and ICQ-NQoL 2 while also showing an inverse linear association with TSH 2. This means that when the IPSS 2 score and Nocturia 2 episodes increase, the PSQI 2 and ICQ-NQoL score tend to increase. At the same time when the IPSS 2 score and Nocturia 2 episodes increase, the number of hours the participants slept per night tends to decrease.
There was a strong linear association between IPSS 2 and PSQI 2 (Pearson Correlation = 0.66, graph (A)), while the linear association between Nocturia 2 and PSQI 2 was a moderate one (Pearson Correlation = 0.43, graph (D)). The same happened with the TSH 2 and ICQ-NQoL 2 variables, with IPSS 2 showing stronger correlation values.
Interpretation of results
The present study showed that BPH Surgery significantly improved not only LUTS symptoms but overall QoL and Sleep Quality with most of the variables presenting an improvement superior to 50%. More importantly, we stress the fact that PSQI and ICQ-Nqol scores decreased, 80% and 233 % respectively, which shows very significant improvement after surgery.
We can then conclude by looking at the data before and after surgery and its changes, that BPH surgery should be considered a factor involved in the recovery of sleep quality and QoL in patients with BPH that show poor quality of sleep and/or QoL.
In our study, the participants who had a PSQI 2 > 5 had an average of PSQI 2 and ICQ-Nqol 2 of 9(3) and 14(10) respectively, a significant difference when comparing to the average of 3(1) on the PSQI 2 score and 6(7) ICQ-Nqol 2 score on the rest of the participants. The participants who had a PSQI 2 > 5 also slept on average a 1:30 h less than the other participants with a PSQI 2 < 5. As in the present study, we simply explored the overall score of PSQI we cannot claim that certain components had a higher improvement than others. The incidence of a persistent poor quality of sleep after surgery was as high as 37.5 %, in these participants however, IPSS, Nocturia, Qmax, and PVR were also higher than those of participants presenting normal sleep quality after surgery. The difference between pre-op values and post-op values on the participants with poor sleep quality after surgery was minor when compared to the others, which may imply that insufficient improvement of LUTS with surgery leads to persistent poor sleep quality.
Finally, the present study suggest that the presence of LUTS other than nocturia could also be a factor in the existence of poor sleep quality, and should, therefore, be studied and evaluated. This was particularly seen with the higher correlations achieved with the IPSS 2 variable comparative with the Nocturia 2 variable, with a correlation of 0.66 and 0.43 respectively with the PSQI 2 variable, which was not exactly expected as most studies reported an association between sleep quality and nocturia, never converging on other LUTS symptoms evaluated with the IPSS. As it stands, based on these findings it is reasonable to state that not only nocturia appears to be a factor in poor sleep quality, other LUTS symptoms may also be responsible for a decrease in sleep quality and overall QoL. There must also be a common etiology underlying LUTS and poor sleep quality in patients with BPH.
Concluding message
In conclusion, the results found in this study once more support the concept that the presence of low quality of sleep and QoL are most likely associated with the presence of LUTS symptoms, including but not limiting to nocturia. Therefore, in addition to the standard assessment of urinary symptoms, evaluation of sleep quality and QoL should become a common practice in patients presenting BPH, and a factor for choosing the path of surgery instead of standard medication.