Andrew Siegel MD 11/30/2019
Obstructive sleep apnea (OSA) is a hot topic in medicine because of its serious health consequences and the fact that it affects 1/3 of men and 1/6 women, most of whom do not realize they are afflicted. OSA negatively impacts many aspects of health, including sexual and urinary function. Many patients unaware that they have OSA consult a urologist because of urinary symptoms that are actually not urologic in origin, their root cause being the OSA. When OSA is treated, the urinary symptoms improve dramatically.
IF YOU OR YOUR PARTNER ARE OVERWEIGHT, HAVE A THICK NECK, SNORE AND ARISE SEVERAL TIMES AT NIGHT TO URINATE, YOU VERY LIKELY HAVE OSA. IF AFTER THAT BIG THANKSGIVING MEAL, ONE OF YOUR RELATIVES IS ON THE COUCH “SAWING LOGS,” THEY HAVE OSA UNTIL PROVEN OTHERWISE.
Obstructive sleep apnea (OSA) is due to collapse and mechanical obstruction of the upper airway during sleep. It occurs because of lax tissues that support the tongue and throat, which result in the throat sagging under the force of gravity, pulling the airway closed and causing intermittent suffocation. Repeated complete or partial interruptions of breathing during sleep cause subnormal levels of oxygen in the blood, insomnia, restless sleep and frequent awakenings. OSA sufferers often wake up exhausted and have excessive daytime sleepiness that may be responsible for motor vehicle accidents, “fatigue” eating, and sleep deprivation-related cognitive impairment and mood disturbances.
Thank you Wikipedia Commons; attribution: Habib M’henni (User: Dyolf 77)
OSA is present in about one in three men and one in six women in the USA, although 90% of those with OSA are undiagnosed and untreated. It is more prevalent with aging, obesity, and in people who have short, thick “bull” necks, enlarged tonsils and elongated palates and other jaw and cranio-facial abnormalities. 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.
Why the loud snoring? When air cannot move freely, the floppy and collapsed soft tissues vibrate causing the familiar annoying sounds that can cause couples to sleep in separate rooms.
Obesity and OSA share much in common, both chronic diseases that can have serious medical ramifications. OSA results in hypoxia (low oxygen levels), an unhealthy state since every cell, tissue and organ in our body is dependent upon oxygen for 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, cardiovascular disease and premature death. OSA is detrimental to the function of endothelial cells, 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 and Urology
OSA can contribute to decreased sex drive, low testosterone levels, suboptimal sexual function, and frequent nighttime urinating (nocturia) as well as overactive bladder.
Many with OSA have frequent sleep-time urination because of 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, when in fact, they really need to see a lung and breathing specialist called a pulmonologist.
Nocturnal urine production by the kidneys is based upon several factors including fluid intake and 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, functioning to restrict urine production in order to maintain blood volume. ANP is the opposite—a diuretic that increases water excretion by the kidney in order to reduce blood volume, causing abundant urine production, as well as inhibiting ADH.
So, how does OSA affect nocturnal urine production? The answer is really quite interesting.
With OSA, vigorous efforts to breathe against an obstructed airway cause negative pressures in the chest. The negative pressures suck venous blood from the abdomen and peripheral veins into the heart, causing distension of the right heart chambers (atrium and ventricle). The heart responds to this distension– which is read as a false sign of fluid volume overload–by secreting ANP. The ANP causes high volumes of urine production during sleep, resulting in sleep-disruptive, usually full-volume nocturnal urinations. There may be as many as 6 or more nighttime awakenings to urinate. When OSA is treated it results in a significant improvement of the sleep disruptive nocturia.
Another problem associated with OSA is overactive bladder. Its symptoms include the sudden and urgent desire to urinate, frequent urination, and possibly urinary leakage (urgency urinary incontinence). The key 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.
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, 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—impaired nerve function that negatively affects sexual function.
Diagnosing OSA
The diagnosis of OSA is made with an overnight sleep study 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 (apneic episodes) lasting more than 10 seconds. 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: > 30 apneic episodes per hour
As an alternative to an overnight sleep study that requires an overnight stay in a sleep lab, home sleep testing machines are now often used.
Treating OSA
Since many with OSA carry the burden of extra pounds–which contributes in a major way to the problem– first-line treatment is weight loss and other lifestyle modifications including healthy eating, 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 cannot tolerate. An oral appliance that is fitted by a dentist can be an effective alternative that is less cumbersome than CPAP and does not require an electrical source. One of the newest methods of treatment is hypoglossal nerve stimulator implantation. Electrical stimulation of the sagging muscles that cause the obstruction to breathing by virtue of this implantable “pacemaker”-like device can be a highly effective means of treatment. 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 is a common, under-diagnosed and under-recognized chronic condition that reduces levels of oxygen in the blood and can severely impair one’s health. Many genital and urinary issues can result from OSA, including sleep-disruptive nighttime urination, overactive bladder and altered sexual function. The good news is that OSA is a readily treatable condition.
Wishing you the best of health and a wonderful Thanksgiving weekend,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States and is the author of five books:
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Dr. Siegel’s other books:
PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food
MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health
Our Greatest Wealth Is Health 