Posts Tagged ‘obstructive sleep apnea’

Sleep Apnea: Bad For Your Health (General, Sexual & Urinary)

February 6, 2016

Andrew Siegel MD   2/6/16

guy-32820_1280

(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.

 Diagnosing OSA

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.

Treating OSA

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,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

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.

Advertisements

Of Nighttime Urination, Sleep Disruption and Promiscuous Eating

March 29, 2013

Andrew Siegel, M.D.  Blog #100

Nocturia is a condition in which one awakens from sleep to urinate. Arising once or so to empty one’s bladder during sleep hours is considered normal; however, when it happens multiple times, it can be not only annoying but also sleep-disruptive. It is common in both men and women and increases in prevalence as we age.  It is primarily a kidney-driven urine production problem, as opposed to a bladder-driven urine storage issue.

As with many matters, nocturia is more complicated than it appears and is often multi-factorial.  That stated, it is important to reiterate that the most common underlying cause of nocturia is nocturnal overproduction of urine.  Although most associate the occurrence of nighttime urination with lower urinary tract conditions, in many cases the problem is actually due to the kidneys (upper urinary tract) and not the bladder and prostate (lower urinary tract).  Nighttime urine overproduction, a.k.a. nocturnal polyuria, may result from kidney issues, but also from cardiac or lung conditions. Nocturnal overproduction of urine at night has been implicated as a causal factor in over 80% of cases of nighttime urination.

Nocturia can certainly occur on the basis of lower urinary tract conditions, particularly with benign prostate enlargement or overactive bladder. Under these circumstances, the nocturnal urinary frequency is often on the basis of decreased bladder capacity (in which the bladder is incapable of storing normal volumes) or sometimes because of failure to empty the bladder (in which the bladder is always left partially full).  Additionally, any source of bladder irritation such as an infection, stone, cancer, etc., can irritate the lining of the bladder and cause nighttime urination.   Nocturia can be induced by extrinsic pressure on the bladder, seen with fibroids of the uterus and rectal fullness due to either gas or constipation, although it can be caused by the presence of any pelvic mass. Nocturia can also occur on a neurological basis since neurological diseases such as stroke, spinal cord injury, multiple sclerosis, Parkinson’s disease, etc., can affect urinary frequency during sleep. Even when nocturia is caused primarily by prostate enlargement, overactive bladder, bladder irritation or a neurological issue, etc., nocturnal overproduction can contribute to the process.

Why does nocturnal overproduction of urine occur?  It can result from a number of factors such as the mobilization of excess fluid stored in the lower extremities in people who have peripheral edema. Edema refers to fluid within the tissues–typically the ankles–that tends to accumulate with gravity over the course of the day. Upon assuming the lying-down position when sleeping, the legs are relatively elevated as opposed to standing and this tissue fluid returns into circulation, causing the kidneys to increase urine production.  In general, those with peripheral edema go to sleep with ankles (and perhaps legs) engorged with edema fluid and wake up with thinner legs, as the return of some of the fluid to the circulation and the subsequent increased urination rids them of this. Another underlying cause is excessive production of atrial natriuretic peptide due to sleep apnea or congestive heart failure.  Yet another possibility is an abnormality in the nocturnal secretion of anti-diuretic hormone.  This pituitary hormone functions to cause the kidneys to retain fluid; nocturia may occur because of an age associated decline in its secretion while sleeping. Other factors include excess fluid intake in the evening, especially caffeine-containing beverages, and the use of medications such as diuretics.   Systemic diseases such as diabetes mellitus, diabetes insipidus, and kidney insufficiency, can all cause nocturnal polyuria.

Sometimes nighttime urination occurs not because of any systemic illness or bladder, prostate, kidney or overproduction issue, but simply because of poor sleep. When sleeping poorly, one often gets up to urinate because the wakeful state makes one more conscious of their bladder being full, or alternatively, for an activity to occupy time during the insomnia. Any sleep disorder—insomnia, obstructive sleep apnea, restless leg syndrome, etc.—can result in poor quality sleep and often nocturia. The bladder is a convenient outlet for anxiety, which can induce urinary frequency.

The principal diagnostic tool for assessing nocturia is a voiding diary in which the time and the volume of urination are recorded for a 24-hour period.  There are 4 major findings that may occur: reduced bladder capacity; global polyuria; nocturnal polyuria; or a mixed pattern.  Typical bladder capacity is 10–12 ounces with 4–6 urinations per day. Reduced bladder capacity is a condition in which frequent urination occurs with low bladder capacities, for example, 3–4 ounces per void. Global polyuria is a condition in which bladder volumes are full and appropriate and the frequency occurs both daytime and nighttime. Nocturnal polyuria is nocturnal urinary frequency with full and appropriate volumes, with daytime voiding patterns being normal. A mixed pattern can be a more complex picture involving elements of the other patterns.

If fluid intake is found to be excessive, simple moderation of intake will be helpful, particularly with respect to caffeinated beverages and high fluid content foods such as melons and other fruits. Restricting liquid intake after dinner is often advisable. Minimizing high salt content foods and table salt can help prevent fluid retention. If edema is the issue, compression stockings worn during the day as well as elevating the legs during the day can be of value in getting some of the interstitial fluid out of the system. Diuretics taken during the late afternoon may decrease fluid accumulation.

Medications may be helpful, depending upon the cause of the nocturia.   Synthetic  antidiuretic hormone, aka DDAVP which is useful for childhood bedwetting, can be useful for adults with nocturia associated with nocturnal polyuria. Bladder relaxing medications as well as behavioral techniques and pelvic floor exercises can be beneficial for overactive bladder. Prostate relaxing and shrinking medications or surgical treatment can be helpful if an enlarged prostate is the cause.

Nighttime urination is one of the most annoying and bothersome of urinary symptoms given how sleep-disruptive it often proves to be.  Chronically disturbed sleep can negatively affect one’s quality of life and health.  It can result in daytime fatigue, increased risk of traffic accidents, increased incidents of fall-related nighttime injuries, and weight gain because of altered eating patterns. Insufficient sleep alters our internal biochemical environment and can profoundly disrupt our eating drives leading to patterns of “promiscuous eating.” Clearly, there appears to be a physiological basis for this fatigue-driven eating. Sleep deprivation or the need for sleep results in decreased levels of leptin, our chemical appetite suppressant, and increased levels of ghrelin, our appetite stimulant, in addition to increased levels of cortisol, one of the stress hormones. This sleep-deprived change of our internal chemical milieu can drive our eating. Therein lies the link between urology and nutrition/health/wellness that I am so fond of establishing.

Bottom Line: Nocturnal urinary frequency should be investigated to determine its cause, which may in fact be related to conditions other than urinary tract issues.  Nighttime urination is not only bothersome, but may also pose real health risks. Chronically disturbed sleep can lead to a host of collateral wellness issues.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.