Abstract
A cross-sectional study based on the community was conducted to explore the association between sleep status and LUTS among middle and old-aged men. Male residents in Zhengzhou aged 40 or older were recruited. Participants received the Pittsburgh Sleep Quality Index questionnaire and the International Prostate Symptom Score questionnaire to evaluate sleep status and the severity of lower urinary tract symptoms (LUTS), respectively. Logistic regression analyses and linear regression analyses were performed to evaluate the relationship between sleep quality and sleep duration and LUTS. A total of 5785 participants were enrolled. Multivariable analyses showed a positive relationship between sleep quality and LUTS (β 0.716, 95% CI 0.647–0.784), and poor sleepers were significantly associated with moderate or severe LUTS (OR 2.486, 95% CI 2.095–2.950). U-shaped dose–response relationship revealed that sleeping less than 5.8 h/day and more than 7.9 h/day was related to moderate or severe LUTS and more than 7.9 h/day of sleep duration was associated with poor voiding and storage symptoms (P for nonlinearity < 0.001). Similar relationship was observed between sleep status and nocturia. It showed a significantly positive relationship between sleep quality and LUTS. U-shaped dose–response relationships between sleep duration and LUTS were observed.
Keywords: Sleep quality, Sleep duration, Lower urinary tract symptoms, BPH, Nocturia
Introduction
Lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) are one of the most common disorders for elderly men, and half of the men develop bothersome LUTS in their seventies [1, 2]. LUTS/BPH is a chronic benign disorder and not life-threatening; however, it is associated with increased risk of cardiovascular diseases and reported to affect sleep, mental health, sexual function, and a series of disorders [3].
Sleep is essential for the maintenance of human health. Sleep disruption is a frequent complaint for adults worldwide and affects 39% of the Asian population and more than one-half of elderly people [4]. Studies suggested that sleep disturbance was related to heart disease, stroke, diabetes, hypertension, falls, and decreased quality of life [5, 6], but sleep problems are often overlooked by the elderly because of the aging process. Previous investigations suggested that LUTS was associated with sleep disturbances [7–9], whereas the relationship between sleep quality and sleep duration and LUTS among elderly men remains inconsistent.
Therefore, we conducted a cross-sectional study based on community health centers to explore the associations between LUTS and sleep, including sleep quality and sleep duration, among men aged 40 or older in Zhengzhou city.
Methods
Study population
Data were obtained from the prostate cancer screening study in Zhengzhou, Henan Province. 7 districts or towns were randomly selected in Zhengzhou, and 2 or 3 communities or villages were selected from every district or town. A total of 15 investigation fields were identified and we were in cooperation with local primary health centers to conduct the survey. Residents who volunteered to be screened were included in the study. The inclusion criteria were male residents in Zhengzhou aged 40 or older without prostate cancer. After provided informed consent, a total of 6282 men participated in the study from October 2019 to March 2021. They completed baseline questionnaires and needed to provide blood samples for prostate cancer-specific antigen (PSA) tests and receive physical examinations and digital rectal examinations (DRE). Postvoid residual volume (PRV) was measured by abdominal ultrasound examinations. Prostate volume (PV) was calculated by 0.52 times length, width, and height which were measured by abdominal ultrasound examinations.
Exclusion criteria were individuals with a history of prostate cancer, bladder cancer, urolithiasis, or other severe illness; men who received surgical treatment or medication use including alpha-adrenergic antagonists (alpha-blockers) and 5-alpha-reductase inhibitors (5-ARIs) for prostate diseases; men with a level of PSA ≥ 10 ng/ml; and men with missing data. After exclusion, a total sample of 5785 men were in the present analysis. The study was approved by the Grass-roots Ethics Review Committee of Zhengzhou University.
Measures
Baseline characteristics
Eligible participants received face-to-face survey based on a baseline questionnaire. The characteristics of eligible participants were collected from the questionnaires, including age, living status (live with partners/live alone), educational level (junior high school or below/high school/bachelor or above), employed (yes/no), place of residence (urban residents/rural residents), physical activity (physical active: regularly exercised at least 150 min of moderate activity or 75 min of vigorous activity per week/physical inactive), sitting time (average sitting time for working or watching television per week), the history of hypertension (yes/no), hyperlipidemia (yes/no), diabetes (yes/no), and prostatitis (yes/no). Body mass index (BMI) was calculated as weight in kilograms divided by the square of height in meters (kg/m2).
Sleep quality
The sleep quality of participants was evaluated from the 19-item Pittsburgh Sleep Quality Index (PSQI) questionnaire. It was based on 5–19 items that were related to seven “component” scores: subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, sleep medication use, and daytime dysfunction. A higher PSQI score indicated worse sleep quality. A global PSQI score of ≤ 5 was defined as good sleep quality, while a global PSQI score > 5 suggests a poor sleep quality [10]. Sleep duration was categorized into five groups: < 7 h, 7–8 h, 8–9 h, 9–10 h, and ≥ 10 h.
Lower urinary tract symptoms
The International Prostate Symptom Score (IPSS) [11] questionnaire was used to evaluate lower urinary symptoms. IPSS total, IPSS voiding symptoms (weak stream, intermittency, straining, and incomplete bladder emptying), IPSS storage symptoms (frequency, urgency, and nocturia), and quality of life (QOL) scores were obtained from the 8-item IPSS. The higher the score is, the more severe the LUTS is. IPSS was divided into two groups: 0–7 (none or mild) and 8–35 (moderate or severe). IPSS voiding symptoms score and storage symptoms score were also categorized into two groups based on the median levels, respectively. Nocturia was defined as the complaint of two or more nocturnal voids based on the IPSS item 7 [12].
Statistical analysis
Mean (SD), and number with frequency (%) were used to describe continuous and categorical variables, respectively. The comparisons between groups were calculated by the Mann–Whitney U test and Chi-square test. To explore the association between sleep and LUTS, OR (95% CI) was calculated by logistic regression analysis for categorical variables, and β (95% CI) values were calculated by linear regression analysis for continuous variables controlling for potential confounders. Non-linear associations between sleep duration and LUTS using logistic regression models with restricted cubic spline analyses. All analyses were performed with R software (version 4.1.0). P < 0.05 was considered statistically significant.
Results
A total of 5785 participants were enrolled in the analysis and the median age was 61 ± 9 years. 26.7% (1547) of the participants had an IPSS score of 8 or higher which was defined as moderate or severe LUTS. The baseline characteristics by LUTS groups are represented in Table 1. It showed that men with moderate or severe LUTS were more likely to be older (65 years vs 59 years), living alone (4.2% vs 3.1%), lower educational level (65.3% vs 60.5%), unemployed (80.7% vs 87.5%), urban residents (48.9% vs 45.6%), less physical activity (74.1% vs 69.7%), and higher prevalence of hypertension (42.9% vs 32.4%), hyperlipidemia (17.1% vs 12.7%), diabetes (17.5% vs 11.5%), and prostatitis (18.2% vs 6.9%). In addition, higher levels of BPH-related indicators, including PV (16.3 ml vs 12.7 ml), PVR (28.0 ml vs 12.3 ml), and PSA (1.5 ng/ml vs 1.3 ng/ml), were observed among the individuals with moderate or severe LUTS. Compared with men with none or mild LUTS, those with IPSS score of 8–35 had poor sleep quality (PSQI: 4.1 vs 2.9; poor sleepers: 21.0% vs 9.5%; P < 0.001, Fig. 1, Table 2) and longer sleep duration (sleep duration: 8.1 h vs 8.0 h; more than 10 h/day: 10.2% vs 7.2%; P < 0.001). Similar results were observed for voiding symptoms and storage symptoms sub-scores.
Table 1.
Baseline characteristics of 5785 participants
| Total (n = 5785) | IPSS score | P valuea | ||
|---|---|---|---|---|
| 0–7 (n = 3940) | 8–35 (n = 1547) | |||
| Age, mean (SD), years | 61 (9) | 59 (9) | 65 (8) | < 0.001 |
| BMI, mean (SD), kg/m2 | 25.7 (3.3) | 25.7 (3.2) | 25.7 (3.5) | 0.835 |
| Live with partner, n (%) | 5586 (96.6) | 3818 (96.9) | 1768 (95.8) | 0.036 |
| Education, n (%) | < 0.001 | |||
| Junior high school or below | 3588 (62.0) | 2384 (60.5) | 1204 (65.3) | |
| High school | 1536 (26.6) | 1062 (27.0) | 474 (25.7) | |
| Bachelor or above | 611 (11.4) | 494 (12.5) | 167 (9.1) | |
| Employed, n (%) | 1935 (33.4) | 1578 (40.1) | 357 (19.3) | < 0.001 |
| Urban residents, n (%) | 2697 (46.6) | 1795 (45.6) | 902 (48.9) | 0.018 |
| Physical active, n (%) | 1671 (28.9) | 1194 (30.3) | 477 (25.9) | < 0.001 |
| Sitting time, mean (SD), h/week | 24.9 (13.5) | 24.9 (13.7) | 24.8 (13.3) | 0.693 |
| No. Hypertension, n (%) | 2069 (35.8) | 1277 (32.4) | 792 (42.9) | < 0.001 |
| No. Hyperlipidemia, n (%) | 817 (14.1) | 501 (12.7) | 316 (17.1) | < 0.001 |
| No. Diabetes, n (%) | 776 (13.4) | 453 (11.5) | 323 (17.5) | < 0.001 |
| No. Prostatitis, n (%) | 607 (10.5) | 272 (6.9) | 335 (18.2) | < 0.001 |
| PV, mean (SD), ml | 26.7 (14.2) | 24.9 (12.7) | 30.4 (16.3) | < 0.001 |
| PVR, mean (SD), ml | 6.4 (19.0) | 4.3 (12.3) | 10.7 (28.0) | < 0.001 |
| PSA, mean (SD), ng/ml | 2.2 (1.4) | 2.1 (1.3) | 2.4 (1.5) | < 0.001 |
| IPSS total score, mean (SD) | ||||
| Total score | 6.4 (6.3) | 2.9 (2.2) | 14.0 (5.6) | < 0.001 |
| Voiding symptoms | 3.1 (4.0) | 1.0 (1.5) | 7.6 (4.2) | < 0.001 |
| Storage symptoms | 3.3 (3.1) | 1.8 (1.6) | 6.4 (3.3) | < 0.001 |
| QOL | 2.6 (1.2) | 2.1 (1.1) | 3.5 (1.0) | < 0.001 |
| No. nocturia, n (%) | 3091 (53.4) | 1548 (39.3) | 1543 (83.6) | < 0.001 |
The bold in the table means statistically significant (P < 0.05)
SD standard deviation, IPSS International Prostate Symptom Score, BMI body mass index, PV prostate volume, PVR post-void residual, PSA prostate cancer-specific antigen, QOL quality of life
aThe comparisons between groups were calculated by Mann–Whitney U test for continuous variables and Chi-square test for categorical variables
Fig. 1.
The distribution of global PSQI scores by IPSS groups (0–7, none or mild; 8–35, moderate or severe). The comparisons between groups were calculated by the Mann–Whitney U test (P < 0.001)
Table 2.
Comparisons of sleep quality and sleep duration by LUTS groups
| Total (n = 5785) | IPSS total score | Voiding symptoms score | Storage symptoms score | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 0–7 (n = 3940) | 8–35 (n = 1845) | P value* | 0–2 (n = 3453) | 3–20 (n = 2332) | P value* | 0–2 (n = 3025) | 3–15 (n = 2760) | P valuea | ||
| Sleep quality (PSQI) | ||||||||||
| Continuous variable, mean (SD) | 3.3 (2.1) | 2.9 (1.9) | 4.1 (2.4) | 2.9 (1.9) | 3.9 (2.3) | < 0.001 | 2.83 (1.9) | 3.8 (2.3) | < 0.001 | |
| Categorical variable, n (%) | < 0.001 | < 0.001 | < 0.001 | |||||||
| Good (0–5) | 5024 (86.8) | 3567 (90.5) | 1457 (79.0) | 3126 (90.5) | 1898 (81.4) | 2758 (91.2) | 2266 (82.1) | |||
| Poor (6–21) | 761 (13.2) | 373 (9.5) | 388 (21.0) | 327 (9.5) | 434 (18.6) | 267 (8.8) | 494 (17.9) | |||
| Sleep duration | ||||||||||
| Continuous variable, mean (SD), h | 8.1 (1.4) | 8.0 (1.4) | 8.1 (1.5) | < 0.001 | 8.0 (1.4) | 8.1 (1.5) | < 0.001 | 8.0 (1.4) | 8.1 (1.5) | 0.001 |
| Categorical variable, n (%) | < 0.001 | < 0.001 | < 0.001 | |||||||
| < 7 h | 1703 (29.4) | 1210 (30.7) | 493 (26.7) | 1073 (31.1) | 630 (27.0) | 933 (30.8) | 770 (27.9) | |||
| 7–8 h | 1229 (21.2) | 865 (22.0) | 364 (19.7) | 768 (22.2) | 461 (19.8) | 676 (22.3) | 553 (20.0) | |||
| 8–9 h | 1523 (26.3) | 1025 (26.0) | 498 (27.0) | 899 (26.0) | 624 (26.8) | 785 (26.0) | 738 (26.7) | |||
| 9–10 h | 859 (14.8) | 558 (14.2) | 301 (16.3) | 476 (13.8) | 383 (16.4) | 419 (13.9) | 440 (15.9) | |||
| > 10 h | 471 (8.1) | 282 (7.2) | 189 (10.2) | 237 (6.9) | 234 (10.0) | 212 (7.0) | 259 (9.4) | |||
The bold in the table means statistically significant (P < 0.05)
LUTS lower urinary tract symptoms, SD standard deviation, IPSS International Prostate Symptom Score, PSQI Pittsburgh Sleep Quality Index
aThe comparisons between groups were calculated by Mann–Whitney U test for continuous variables and Chi-square test for categorical variables
Multivariable analyses (Table 3) showed a positive relationship between sleep quality and LUTS (β 0.716, 95% CI 0.647–0.784), and poor sleepers were significantly associated with moderate or severe LUTS (OR 2.486, 95% CI 2.095–2.950). Besides, 8–9 h (OR 1.185, 95% CI 1.006–1.395) or more than 10 h (OR 1.378, 95% CI 1.087–1.748) of sleep duration was associated with moderate or severe LUTS than 7–8 h of sleep duration. Nevertheless, it showed no linear relationship between sleep duration and LUTS. Similarly, it suggested a positive association between sleep quality and nocturia (β 0.120, 95% CI 0.104–0.136), and poor sleepers were related to nocturia (OR 1.554, 95% CI 1.311–1.842). However, there was no significant association between sleep duration and nocturia.
Table 3.
Associations between sleep quality, sleep duration and LUTS
| IPSS (8–35) | Voiding symptoms (3–20) | Storage symptoms (3–15) | Nocturia | |||||
|---|---|---|---|---|---|---|---|---|
| β/OR (95% CI)a,b | P value | β/OR (95% CI)a,b | P value | β/OR (95% CI)a,b | P value | β/OR (95% CI)a,b | P value | |
| Sleep quality (PSQI) | ||||||||
| Continuous variable | 0.716 (0.647–0.784) | < 0.001 | 0.411 (0.365–0.456) | < 0.001 | 0.304 (0.270–0.339) | < 0.001 | 0.120 (0.104–0.136) | < 0.001 |
| Categorical variable | ||||||||
| Good (0–5) | 1.000 | – | 1.000 | – | 1.000 | – | 1.000 | – |
| Poor (6–21) | 2.486 (2.095–2.950) | < 0.001 | 2.066 (1.749–2.441) | < 0.001 | 2.132 (1.795–2.533) | < 0.001 | 1.554 (1.311–1.842) | < 0.001 |
| Sleep duration | ||||||||
| Continuous variable | 0.032 (− 0.077–0.142) | 0.566 | 0.010 (− 0.062–0.082) | 0.784 | 0.022 (− 0.032–0.076) | 0.418 | 0.008 (− 0.017–0.033) | 0.527 |
| Categorical variable | ||||||||
| < 7 h | 1.014 (0.851–1.208) | 0.879 | 0.999 (0.849–1.175) | 0.999 | 0.965 (0.823–1.132) | 0.661 | 0.921 (0.787–1.077) | 0.302 |
| 7–8 h | 1.000 | – | 1.000 | – | 1.000 | – | 1.000 | – |
| 8–9 h | 1.185 (1.006–1.395) | 0.042 | 1.182 (1.015–1.375) | 0.031 | 1.141 (0.982–1.326) | 0.084 | 1.031 (0.889–1.195) | 0.690 |
| 9–10 h | 1.115 (0.917–1.357) | 0.274 | 1.213 (1.011–1.457) | 0.038 | 1.125 (0.938–1.349) | 0.203 | 1.143 (0.956–1.366) | 0.143 |
| > 10 h | 1.378 (1.087–1.748) | 0.008 | 1.471 (1.174–1.843) | 0.001 | 1.282 (1.022–1.608) | 0.032 | 1.114 (0.890–1.395) | 0.344 |
The bold in the table means statistically significant (P < 0.05)
LUTS lower urinary tract symptoms, SD standard deviation, IPSS International Prostate Symptom Score, PSQI Pittsburgh Sleep Quality Index, OR odds ratio, 95% CI 95% confidence interval
aβ (95% CI) values were calculated by linear regression analysis for continuous variables and OR (95% CI) were calculated by logistic regression analysis for categorical variables
bAdjusted for age, BMI, living status, education, employed, physical activity, sitting time, hypertension, hyperlipidemia, diabetes, prostatitis, PV, PVR and PSA
A U-shaped dose–response relationship between sleep duration and IPSS score was presented in Fig. 2. Sleeping less than 5.8 h/day and more than 7.9 h/day was related to moderate or severe LUTS (P for nonlinearity < 0.001, Fig. 2A). Furthermore, more than 7.9 h/day of sleep duration was associated with poor voiding symptoms and poor storage symptoms (P for nonlinearity = 0.001, Fig. 2B, C), and more than 8.1 h/day of sleep duration had linked to nocturia (P for nonlinearity < 0.001, Fig. 2D).
Fig. 2.
Associations between sleep duration and A IPSS total scores (8–35), International Prostate Symptom Score; B IPSS voiding symptoms scores (3–20); C IPSS storage symptoms scores (3–15); D nocturia. Logistic regression models with restricted cubic spline analyses adjusted for age, BMI, living status, education, employment, physical activity, sitting time, hypertension, hyperlipidemia, diabetes, prostatitis, PV, PVR, and PSA
Discussion
In this cross-sectional study of middle and old-aged men in Zhengzhou, we found a significant positive relationship between sleep quality and LUTS. Sleeping less than 5.8 h or more than 7.9 h/day was related to moderate or severe LUTS and more than 7.9 h/day of sleep duration had linked to poor voiding and storage symptoms. Similar results were observed between sleep status and nocturia.
Our results are consistent with previous studies which have reported that poor sleep quality may exacerbate LUTS, especially voiding symptoms [8, 13]. Also, it showed that LUTS, especially nocturia, is related to sleep disturbance [14]. Nocturia, the common lower urinary tract symptoms among older adults, are often coexists with sleep disturbance [15]. Several studies have revealed the positive relationship between subjective sleep quality and nocturia [14, 16], and a quantitative association between nocturnal voiding frequency and objective sleep quality [17]. However, the underlying mechanism is unclear. It has been proposed that sleep disorders were related to imbalances in metabolic, steroid hormonal, and chronic inflammation [18, 19]. Also, these factors may contribute to the development of BPH [20, 21]. In addition, frequent awakenings due to nocturnal urination or bladder irritation symptoms disrupt the circadian rhythm and lead to negative effects on sleep quality [15, 22]. Recent studies have revealed that there may be a bidirectional association between LUTS/BPH and sleep quality [13, 14], but further investigations are necessary.
In addition, previous studies have shown that short sleep duration is related to fatigue and impaired circadian rhythm [23]. Longer sleep duration means less time for physical activities and a higher calorie consumption, like fats and carbohydrates [24]. The cardiovascular risk factors have been mentioned to be related to sleep disturbance and BPH [1, 25]. The mechanisms may be that the damage of atherosclerotic vascular on pelvic vasculature supplying the bladder and prostate may contribute to prostate epithelial hyperplasia [26, 27]. It also has been suggested that cardiovascular diseases were associated with sleep duration [19]. Metabolic syndrome has been shown to cause the overactivity of neuroendocrine systems, which may lead to worsening LUTS/BPH [28, 29]. Also, a prospective study showed that improved sleep habits, like refraining from excess hours in bed, may reduce the nocturnal voiding frequency and improve quality of life [30]. Proper sleep plays an important role in the autonomic nervous system and metabolism and regulates the urinary smooth muscle tone [28, 31], which are closely associated with the occurrence and progression of LUTS.
The relationship between sleep disorder and LUTS is complex and unclear. In addition to the influence of physical, mental health also play important role in progression of disease, which is often overlooked. On the one hand, sleep problems are highly prevalent among patients with psychiatric disorders, such as insomnia and depression, anxiety, etc. [32, 33]. Poor sleep may adversely affect cognitive function, emotion, and interpersonal relationship [34, 35]. On the other hand, previous studies have showed that LUTS were significantly associated with impaired quality of life and increased psychological problems [36, 37], especially for work-shift workers [9]. Therefore, sleep disorders may contribute to psychiatric stress, which may promote the development of LUTS. Nevertheless, the mechanism still needs to be further explored.
We conducted this large-scale cross-sectional study based on the community population in Zhengzhou, Henan. There were also some limitations in this study. First, we used the PSQI score to evaluate patients’ subjective sleep quality, and there may be some deviations from objective sleep conditions. Second, the diseases histories of participants were self-reported, and the lack of other disorders related to sleep, like obstructive sleep apnea (OSA), may have confounding effect on the relationship. Third, the present study was a cross-sectional study and further longitudinal studies are needed.
Conclusion
Among men aged 40 or older in Zhengzhou city, sleep quality was significantly related to moderate or severe LUTS, regardless of voiding symptoms or storage symptoms. In addition, sleeping less than 5.8 h or more than 7.9 h/day was related to moderate or severe LUTS, and more than 7.9 h/day of sleep duration is associated with poor voiding and storage symptoms.
Acknowledgements
The authors are very thankful to everyone who participated in this study, especially Professor Zhang, for guiding the writing of my dissertation. We are very grateful to the staff of the urology department of the Third People’s Hospital of Zhengzhou for their help and support.
Author contributions
The authors’ responsibilities were as follows: CZ contributed completely to the writing of this paper. YG was involved in the study concept and design. XC and WS acquired and collate data of this study. CZ, GW, and BZ carried out data analysis and interpretation. WZ was in charge of study supervision. All authors read and approved the final paper.
Funding
This study was founded by Zhengzhou Finance Bureau (no. 201974).
Availability of data and material
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available because of privacy or ethical restrictions.
Declarations
Conflict of interest
All authors declared that they have no conflict of interest.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available because of privacy or ethical restrictions.