Undisturbed and refreshing sleep is essential for good health, physical and mental functioning (1).  Disturbed sleep is less restorative and negatively affects the quality of life. There is a high prevalence of disturbed sleep in men with lower urinary tract symptoms (LUTS). But there are very few studies that quantitatively evaluated the effects of LUTS on sleep quality and daytime dysfunction. This original article assesses the quality of sleep and determines the predictors of disturbed sleep in men with LUTS using validated sleep questionnaires and bladder diary as assessment tools.

This observational cross-sectional study was conducted among men with LUTS who presented in the urology clinic from August 2020 to March 2021. Men with urinary tract infections and neurogenic LUTS were excluded from the study. International Prostate Symptom Scores (IPSS) was used to categorise patients into mild (IPSS 0 -7), moderate (IPSS 8 – 19) and severe (IPSS 20 – 35) symptom groups. International Consultation on Incontinence Modular Questionnaire-male LUTS (ICIQ-MLUTS) nocturia bothersome score was used to divide patients into mild bothersome (score ≤ 5) and severe bothersome ( score > 5) groups. Nocturia frequency from bladder diary was used to divide them into mild nocturia and severe nocturia groups (nocturia frequency ≤ 2 vs > 2). Sleep quality was studied using the validated sleep scores, Epworth Sleepiness Score (ESS) (2) and Insomnia Severity Index (ISI). Patients with ISI ≥ 10 and ESS ≥ 11 were interpreted to have clinical insomnia and increased daytime sleepiness respectively. The first uninterrupted sleep period, FUSP ( time from sleep onset to first nocturnal awakening) was obtained from the bladder diary and patients with FUSP ≤ 2 hours were classified as having reduced FUSP. STOP-BANG questionnaire was used to assess the risk of obstructive sleep apnea (OSA) in the study population. Sleep quality was assessed by comparing ESS, ISI and FUSP in different groups using appropriate statistical tools. The IPSS, nocturia frequency and bothersome scores, prostate volume and post voided residual volume were used as the variants for determining the predictors of disturbed sleep using univariate logistic regression analysis.

The study was completed in 88 patients. The mean age of the patients in the study was 62.8 ± 8.91.  Matching was done for the risk of OSA using STOP-BANG scores between study groups. There was statistically significant difference in the mean FUSP between nocturia severity groups ( U = 609, p = 0.001) and bothersome groups ( U = 593.5, p = 0.024),Mann Whitney test. The mean ESS scores showed a statistically significant difference among the 3 IPSS categories (Chi -square (2) = 6.136, p=0.047, Kruskal – Wallis H test). There was also a statistically significant difference in the mean ISI scores between nocturia severity groups (U = 691.00, p=0.035, Mann Whitney test) and IPSS groups (Chi-square (2) = 6.671, p=0.036). Patients with moderate IPSS scores had 7.5 times higher odds and patients with severe IPSS scores had 21.8 times higher odds of having clinically significant insomnia compared to mild IPSS categories. Patients with nocturia frequency ≥ 2 had 3.8 times higher odds of having a reduced first uninterrupted sleep period. Also, patients with severe bothersome nocturia had 2.76 times higher odds of having a reduced first uninterrupted sleep period. The results of the univariate logistic regression for the predictors of disturbed sleep in LUTS patients is summarised in figure 1.

The duration of FUSP is drastically reduced with increasing nocturia severity and nocturia bothersome. The restorative slow-wave sleep (SWS) occurs mostly in the first third of the sleep period and interruption during this period results in decreased sleep quality, sleep efficiency, and increased day time dysfunction (3). Therefore, the duration of FUSP is useful in measuring the impact of LUTS on the quality of life and nocturia severity and bothersome scores provide important clinical clues to assess it. Patients with higher IPSS scores and severe symptoms have higher ESS and ISI scores, which are validated scales to assess daytime sleepiness and clinical insomnia. Categorisation of patients into mild, moderate and severe LUTS based on the IPSS scores gives an insight into the sleep quality of these patients. Nocturia frequency, nocturia bothersome scores and IPSS scores can predict the presence of disturbed sleep in patients with LUTS.

Identification and management of disturbed sleep in patients with lower urinary tract symptoms are integral in improving their quality of life. IPSS is a versatile tool that can be used for the initial assessment of sleep quality in patients with lower urinary tract symptoms.  Measures to reduce nocturia frequency and severity can prolong the first uninterrupted sleep period, which is an important indicator of overall sleep quality in patients with lower urinary tract symptoms.

Bliwise DL, Wagg A, Sand PK. Nocturia: A Highly Prevalent Disorder With Multifaceted Consequences. Urology. 2019 Nov;133S:3-13. doi: 10.1016/j.urology.2019.07.005. Epub 2019 Jul 13. PMID: 31310770.
Broderick JE, Junghaenel DU, Schneider S, Pilosi JJ, Stone AA. Pittsburgh and Epworth sleep scale items: accuracy of ratings across different reporting periods. Behav Sleep Med. 2013;11(3):173-88. doi: 10.1080/15402002.2012.654549. Epub 2012 Dec 3. PMID: 23205491; PMCID: PMC5658128
Lentz MJ, Landis CA, Rothermel J, Shaver JL. Effects of selective slow wave sleep disruption on musculoskeletal pain and fatigue in middle aged women. J Rheumatol. 1999 Jul;26(7):1586-92. PMID: 10405949.