Is there a connection between nocturia and obstructive sleep apnea (OSA)?

Absolutely! Although seemingly unrelated medical conditions, nocturia is commonly associated with OSA. [1,2]

A retrospective study [1] (n = 138) reported pathologic nocturia (≥2 urination events per night) in 47.8% of patients with OSA-hypopnea-syndrome. In this study, nocturia was linked to increasing age, 02 desaturation and severity of OSA. In another study (n=30), OSA (defined as apnea-hypopnea index [AHI] ≥5) was diagnosed in 66% of patients with nocturia with increasing nocturia associated with higher AHI.[2]

Recall that repetitive apnea episodes in OSA expose cardiovascular system to cycles of exaggerated negative intrathoracic pressure. [3] This causes myocardial stretching which is likely the reason OSA has been linked to elevated nocturnal atrial natriuretic peptide (ANP) levels. [4] In turn, ANP as an aldosterone inhibitor, increases salt and water excretion causing nocturia. Of interest, use of continuous positive airway pressure (CPAP) has been shown to normalize ANP levels [5] which may explain CPAP’s favorable impact on the frequency of nocturia based on a meta-analysis. [6]

Although the role of screening for OSA in nocturia remains unclear, OSA should be considered in the differential diagnosis of nocturia, especially in men and women younger than 50 years of age. [7,8]

Bonus pearl: Did you know that OSA has been associated with recreational MDMA (“ecstasy”) use, with severity of OSA correlating with lifetime MDMA exposure? [9]

Contributed by Fahad Tahir, MD, Mercy Hospital-St. Louis, St. Louis, Missouri

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References:

  1. Hajduk IA, Strollo PJ Jr, Jasani RR, Atwood CW Jr, Houck PR, Sanders MH. Prevalence and predictors of nocturia in obstructive sleep apnea-hypopnea syndrome–a retrospective study. Sleep. 2003 Feb 1;26(1):61-4. PMID: 12627734. https://pubmed.ncbi.nlm.nih.gov/12627734/
  2. Umlauf MG, Chasens ER, Greevy RA, Arnold J, Burgio KL, Pillion DJ. Obstructive sleep apnea, nocturia and polyuria in older adults. Sleep. 2004 Feb 1;27(1):139-44. doi: 10.1093/sleep/27.1.139. PMID: 14998251.https://pubmed.ncbi.nlm.nih.gov/14998251/
  3. Bradley TD, Floras JS. Obstructive sleep apnoea and its cardiovascular consequences. Lancet. 2009 Jan 3;373(9657):82-93. doi: 10.1016/S0140-6736(08)61622-0. Epub 2008 Dec 26. PMID: 19101028. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61622-0/fulltext
  4. Svatikova A, Shamsuzzaman AS, Wolk R, Phillips BG, Olson LJ, Somers VK. Plasma brain natriuretic peptide in obstructive sleep apnea. Am J Cardiol. 2004 Aug 15;94(4):529-32. doi: 10.1016/j.amjcard.2004.05.010. PMID: 15325948. https://www.ajconline.org/article/S0002-9149(04)00730-1/fulltext/
  5. Krieger J, Laks L, Wilcox I, Grunstein RR, Costas LJ, McDougall JG, Sullivan CE. Atrial natriuretic peptide release during sleep in patients with obstructive sleep apnea before and during treatment with nasal continuous positive airway pressure. Clin Sci (Lond). 1989 Oct;77(4):407-11. doi: 10.1042/cs0770407. PMID: 2530023. https://pubmed.ncbi.nlm.nih.gov/2530023/
  6. Wang T, Huang W, Zong H, Zhang Y. The Efficacy of Continuous Positive Airway Pressure Therapy on Nocturia in Patients With Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis. Int Neurourol J. 2015 Sep;19(3):178-84. doi: 10.5213/inj.2015.19.3.178. Epub 2015 Sep 22. PMID: 26620900; PMCID: PMC4582090. https://pubmed.ncbi.nlm.nih.gov/26620900/
  7. Lowenstein L, Kenton K, Brubaker L, Pillar G, Undevia N, Mueller ER, FitzGerald MP. The relationship between obstructive sleep apnea, nocturia, and daytime overactive bladder syndrome in women. Am J Obstet Gynecol. 2008 May;198(5):598.e1-5. doi: 10.1016/j.ajog.2008.02.024. PMID: 18455544. https://www.ajog.org/article/S0002-9378(08)00168-3/fulltext
  8. Moriyama Y, Miwa K, Tanaka H, Fujihiro S, Nishino Y, Deguchi T. Nocturia in men less than 50 years of age may be associated with obstructive sleep apnea syndrome. Urology. 2008 Jun;71(6):1096-8. doi: 10.1016/j.urology.2008.02.038. Epub 2008 Apr 8. PMID: 18400277.https://pubmed.ncbi.nlm.nih.gov/18400277/
  9. McCann UD, Sgambati FP, Schwartz AR, Ricaurte GA. Sleep apnea in young abstinent recreational MDMA (“ecstasy”) consumers. Neurology. 2009 Dec 8;73(23):2011-7. doi: 10.1212/WNL.0b013e3181c51a62. Epub 2009 Dec 2. PMID: 19955499; PMCID: PMC2790228. https://n.neurology.org/content/73/23/2011.long

 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

 

 

 

Is there a connection between nocturia and obstructive sleep apnea (OSA)?

My middle age patient complains of night sweats for several months, but she has had no weight loss and does not appear ill. What could I be missing?

Night sweats (NS) is a common patient complaint, affecting about a third of hospitalized patients on medical wards1.  Despite its long list of potential causes, direct relationship between the often- cited conditions and NS is usually unclear2, its cause may remain elusive In about a third to half of cases in the primary care setting, and its prognosis, at least in those >65 y of age, does not appear to be unfavorable 2,3.

Selected commonly and less frequently cited conditions associated with NS are listed (Table)2-9.  Although tuberculosis is one of the first conditions we think of when faced with a patient with NS, it should be emphasized that NS is not common in this disease (unless advanced) and is rare among hospitalized patients as a cause of their NS1,9.

In one of the larger study of adult patients seen in primary care setting, 23% reported pure NS and an additional 18% reported night and day sweats5; the prevalence of NS in both men and women was highest in 41-55 y age group. In multivariate analyses, factors associated with pure NS in women were hot flashes and panic attacks; in men, sleep disorders. 

Table. Selected causes of night sweats

Commonly cited Less frequently cited
Neoplastic/hematologic (eg, lymphoma, leukemia, myelofibrosis)

Infections (eg, HIV, tuberculosis, endocarditis)

Endocrine (eg, ovarian failure, hyperthyroidism, orchiectomy, carcinoid tumor, diabetes mellitus [nocturnal hypoglycemia], pheochromocytoma)

Rheumatologic (eg, giant cell arteritis)

Gastroesophageal reflux disease

B-12 deficiency

Pulmonary embolism

Drugs (eg, anti-depressants, SSRIs, donepezil [Aricept], tacatuzumab)

Sleep disturbances (eg, obstructive sleep apnea)

Panic attacks/anxiety disorder

Obesity

Hemachromatosis

Diabetes insipidus

References

  1. Lea MJ, Aber RC, Descriptive epidemiology of night sweats upon admission to a university hospital. South Med J 1985;78:1065-67.
  2. Mold JW, Holtzclaw BJ, McCarthy L. Night sweats: A systematic review of the literature. J Am Board Fam Med 2012; 25-878-893.
  3. Mold JW, Lawler F. The prognostic implications of night sweats in two cohorts of older patients. J Am Board Fam Med 2010;23:97-103.
  4. Mold JW, Holtzclaw BJ. Selective serotonin reuptake inhibitors and night sweats in a primary care population. Drugs-Real World Outcomes 2015;2:29-33.
  5. Mold JW, Mathew MK, Belgore S, et al. Prevalence of night sweats in primary care patients: An OKPRN and TAFP-Net collaborative study. J Fam Pract 2002; 31:452-56.
  6. Feher A, Muhsin SA, Maw AM. Night sweats as a prominent symptom of a patient presenting with pulmonary embolism. Case reports in Pulmonology 2015. http://dx.doi.org/10.1155/2015/841272
  7. Rehman HU. Vitamin B12 deficiency causing night sweats. Scottish Med J 2014;59:e8-11.
  8. Murday HK, Rusli FD, Blandy C, et al. Night sweats: it may be hemochromatosis. Climacteric 2016;19:406-8.
  9. Fred HL. Night sweats. Hosp Pract 1993 (Aug 15):88.
My middle age patient complains of night sweats for several months, but she has had no weight loss and does not appear ill. What could I be missing?