Andrew Siegel MD 2/6/16
(Thank you Pixabay for image)
This is an important topic, an issue that the medical community is just getting wind of (pardon the pun) with respect to how common a problem it is and how significant its consequences are. Obstructive sleep apnea (OSA) negatively affects all aspects of health, including sexual and urinary function. Many patients with OSA present with urological symptoms that are not genital/urinary in origin, their root cause being the OSA. When the OSA is treated, the urological symptoms improve dramatically.
Obstructive sleep apnea (OSA) is a chronic medical disorder that adversely affects one’s sleep, health and quality of life. It is characterized by repeated complete or partial interruptions of breathing during sleep due to mechanical obstruction of the upper airway passage. Muscle relaxation during sleeping—including those muscles that support the tongue and throat—results in the soft tissues in the throat sagging and collapsing under the force of gravity, pulling the airway closed and causing intermittent suffocation. This reduces or halts breathing and causes below-normal levels of oxygen in the blood, giving rise to insomnia and restless sleep with frequent awakenings. OSA sufferers wake up fatigued and have excessive daytime sleepiness, which correlates with an increased chance of motor vehicle accidents, “fatigue” eating and sleep deprivation-related cognitive impairment and mood disturbances.
OSA is present in about 25% of men and 10% of women in the USA. It is more prevalent with aging and with obesity. Snoring in a loud and exaggerated fashion is typical, and snorting and gasping for air is characteristic. Other manifestations of OSA are a dry mouth and throat and abnormal daytime breathing patterns–particularly loud, shallow mouth breathing. It is not uncommon for those with OSA to have anatomical irregularities, including a thick neck, enlarged tonsils and palate and jaw abnormalities.
Obesity and OSA share much in common, both chronic diseases that give rise to serious medical issues affecting quantity and quality of life. OSA results in hypoxia (lack of oxygen supply), an unhealthy state since every cell, tissue and organ in our body depends upon oxygen to fuel proper function. A spectrum of serious medical issues can result, including headache, impaired glucose metabolism/type 2 diabetes, depression, chronic kidney disease, peripheral neuropathy, glaucoma and cardiovascular disease. OSA is detrimental to endothelial cell function, the specialized cells that line arteries, and OSA-related cardiovascular disease includes high blood pressure, heart attack, stroke, congestive heart failure, arrhythmia and atrial fibrillation. OSA increases the risk of premature mortality.
OSA is associated with urological issues including decreased sex drive, low testosterone levels, sexual dysfunction in both men and women, overactive bladder and frequent nighttime urinating (a.k.a. nocturia).
OSA and Urination
Many with OSA have urinary symptoms because of the OSA and not because of problems with their bladder, prostate, kidneys, etc. They often end up in a urologist’s office because their primary symptoms are urinary. The two most prevalent urinary issues associated with OSA are nighttime urination and overactive bladder.
Nocturnal urine production by the kidneys is based upon many factors including fluid intake as well as the production of certain hormones. The two key hormones involved are anti-diuretic hormone (ADH) and atrial natriuretic peptide (ANP). ADH is a pituitary hormone that regulates water excretion by the kidney, restricting urine production so that humans maintain their blood volume. ANP is the opposite—a diuretic that increases water excretion by the kidney, causing abundant urine production, as well as inhibiting ADH.
Here is what happens with OSA: Vigorous efforts to breathe against an obstructed airway result in negative pressures in the chest. This increases the volume of venous blood that returns to the heart, causing distension of the right heart chambers (atrium and ventricle). The heart responds to this distension as a false sign of fluid volume overload, with a hormonal response of secreting ANP. As a result of the ANP secretion, high volumes of urine are produced during sleep, resulting in sleep-disruptive nocturia. There may be as many as 6 or more nighttime awakenings to urinate. When OSA is treated it results in a significant improvement, if not complete resolution, of the sleep disruptive nocturia.
In contrast to nocturia, overactive bladder is more of a daytime issue. Its symptoms include the sudden and urgent desire to urinate (a.k.a. “gotta go”), urinating frequently, and possibly urinary leakage (urgency urinary incontinence). The cardinal symptom of OAB is urgency, the sudden and compelling desire to urinate that is difficult to postpone. Studies have shown a direct relationship between the severity of OSA and the severity of OAB symptoms.
OSA and Sex
Sexual issues are common among men and women with OSA. Men typically experience a loss of interest in sex, low testosterone and difficulties obtaining and maintaining erections. Women can experience a loss in sex drive and other symptoms of female sexual dysfunction. Neurological testing of patients with OSA-related erectile dysfunction has shown an absent or impaired bulbo-cavernosus reflex, which is a measure of pelvic floor muscle response to sexual stimulation. The extent of impairment is directly proportional to the severity of the OSA. Essentially, this is peripheral neuropathy—nerve damage that negatively affects sexual function.
Despite growing awareness of OSA, 90% of those with the disorder are undiagnosed and untreated. The diagnosis is made with overnight sleep studies, performed under the care of a pulmonologist, an internist who specializes in lung problems. This study records sleep stages, heart rhythm, leg movements, breathing patterns and oxygen saturations. OSA is defined as a complete cessation of airflow lasting more than 10 seconds (apneic episodes). The degree of OSA is based upon the number of episodes per hour of breathing cessation:
- Mild OSA: 5-15 apneic episodes per hour
- Moderate OSA: 15-30 apneic episodes per hour
- Severe OSA: more than 30 apneic episodes per hour
As an alternative to overnight sleep studies that require an overnight stay in a sleep lab, home sleep testing machines are now available.
Since many with OSA carry the burden of extra pounds–which contributes in a major way to the problem–the first-line treatment is lifestyle improvement. This includes healthy eating, weight loss, exercise, smoking cessation, etc. Additionally, alcohol and other sedative medications (that can further interfere with breathing) should be avoided. Positional therapy–avoiding the supine position and instead sleeping upright–can be helpful as well.
Continuous positive airway pressure (CPAP) is the most common and effective treatment for OSA and is considered the gold standard. This is an apparatus that maintains the airway and airflow, preventing apnea and the negative consequences of lack of oxygen. The problem with CPAP is that it is a somewhat cumbersome device that some people tolerate poorly. Alternatively, oral appliances that are fitted by a dentist can be effective, are less cumbersome than CPAP and do not require an electrical source. A procedure under investigation is the implantation of a hypoglossus nerve stimulators, which can help prevent some of the involved muscles from sagging and causing obstruction. On occasion, surgery such as uvulo-palato-pharyngoplasty performed by an ear/nose/throat surgeon is needed to help alleviate the obstructed breathing passage.
Bottom Line: OSA causes reduced levels of oxygen in the blood and therefore diminished oxygen supply to all cells in the body. Oxygen is vital for cellular function, and similar to the mechanical choking of one’s neck from OSA, so the cells, tissues and organs of the body “choke” in response to insufficient oxygen. The symptoms of OSA are due to the collateral damage from this lack of oxygen with impaired nerve and blood vessel function being particularly detrimental. Many urological issues can develop as a result of OSA, including sleep-disruptive nighttime urination, overactive bladder and altered sexual function. Fortunately, OSA is a treatable condition.
A shout-out to my friend and dentist extraordinaire who has expertise on OSA and the use of oral appliances: Warren Boardman, DDS, Bergen County Center for Snoring, Sleep Apnea & CPAP Intolerance, 75 Chestnut Street, Ridgewood, NJ, 07450, 201-445-4808
Wishing you the best of health,
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Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.
Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.