insights

Underlying Conditions of Sleep Disruption in the Age of COVID-19

A man sleeping soundly in bed

Sleep disruption can be precipitated by a wide range of conditions, and prolonged sleep disruption—or insomnia—can lead to a variety of negative health effects. During the COVID-19 pandemic, stress levels have increased dramatically, and patients may be struggling with extreme cases of insomnia. But stress isn’t the only condition underlying sleeplessness.

Nocturia (frequent nighttime urination) is a common underlying condition that interrupts sleep throughout the course of the night. Globally, nocturia tends to be under-recognized by clinicians; however, the condition may improve with personalized treatment. Although nocturia is prevalent in the population and worrisome for patients and clinicians alike,1 studies suggest that treatment can greatly improve health-related quality of life.2 Yet, according to one poll, 62% of Americans do not know that this is a medical condition with potential treatment, and, perhaps more concerning, 66% of sufferers polled had not talked to a doctor about their symptoms.3

Many patients view nocturia as a natural part of aging, which may account for the sometimes very low reports of visits to clinicians—for instance, in one study focused on female Taiwanese patients, only 13% saw a clinician to discuss their nocturia.4 This creates an opportunity for primary care providers to step in with personalized, preventative medicine for long-term health.

Several episodes of nighttime urination are more likely to occur in certain groups without any underlying renal challenges:

  • Men with enlarged prostates (and it is one of the most bothersome symptoms)5,6
  • Individuals over the age of 60 (overall prevalence is 77% in both men and women)7,8
  • People with sleep apnea9

However, anyone may be affected by nocturia. Although definitions vary, most of the health effects are seen in patients who are waking up two or more times a night to urinate.10 As a multifactorial condition with many potential antecedents, triggers, and mediators, nocturia presents a challenge for personalized treatment.

Men’s health expert Geo Espinosa, ND, shares his thoughts and considerations on diagnosing and treating nocturia:

Undertreated & Risky

Patients identify nocturia as a major source of sleep disturbance,11 and the condition is correlated with increased risks of a range of conditions, including:

  • Depression12-15
  • Lower self-related health16,17
  • All-cause mortality18

In all likelihood, many of these correlations are due to the sleep disturbance associated with nocturia, particularly for early-night awakenings during slow-wave restorative sleep.19,20

Even in patients who report not being bothered by their nocturia, successfully reducing the number of nighttime awakenings improves overall health.21

Most sleep diaries do not include nocturia, but a commonly utilized tool in urology is a bladder diary. Studies show that prescription treatment for nocturia has low efficacy.22 Personalized lifestyle interventions may help to improve quality of life for these patients. Many patients will see symptom relief with simple modifications to liquid, caffeine, and alcohol intake, reductions in smoking, or exercise interventions.23-25 Some studies suggest that excessive sodium consumption may be associated with nocturia, and early experimental evidence in a small group of patients with high salt intake has shown reductions in nocturia.26 However, for others, underlying causes may not be as easily controlled.

What considerations may improve these patients’ quality of life?

Key Consideration: Benign Prostatic Hyperplasia

Nocturia is one of the most frequent urinary tract symptoms in men with benign prostatic hyperplasia (BPH), also called prostate gland enlargement.27 BPH is very common, affecting 50% of middle-aged men and 90% of men over 80 years.28 Yet only a quarter of men with BPH go on to develop benign prostatic obstruction, and many men with BPH are symptomless. For these reasons, other common causes of urinary tract problems need to be considered even if BPH is present.28 Over the years, treatment guidelines for benign prostatic hyperplasia have evolved, and surgery is rarely a frontline intervention anymore.28

The European Association of Urology’s guidelines for treatment of BPH recommend that clinicians “offer men with [lower urinary tract symptoms] lifestyle advice prior to or concurrent with treatment.”29 Since “watchful waiting” is recommended for many men,29 lifestyle recommendations may be highly important for health-related quality of life. This is particularly true because the evidence for pharmacologic treatments is limited, as a large 2019 systematic review and meta-analysis concluded.30 The review also found the evidence for lifestyle interventions limited, but many lifestyle interventions have extremely low risk and can improve many aspects of health.

Furthermore, prescription treatments for BPH have their own side effects. 5-alpha reductase inhibitors act by reducing the enzyme 5-alpha reductase, reducing the conversion of testosterone into dihydrotestosterone.31 However, as Dr. Espinosa alluded to in the video above, 5-alpha reductase inhibitors decrease the effects of testosterone throughout the body, which can have systemic effects.

In one systematic review, the authors estimated that 10% of BPH patients treated with 5-alpha reductase inhibitors had adverse sexual effects, and although for most men the prostate became smaller, the effect was “modest.”32 The most common side effect of 5-alpha reductase inhibitors is impaired sexual function, and it can be “debilitating,” so much so that some researchers recommend providing counseling before their use.33 Alpha blockers, which are often also prescribed to improve urine flow, also have sexual and other adverse effects.33

If liquid intake and smoking have already been considered, next steps can include:

  • Nutrition interventions: decreasing starch and red meat and increasing polyunsaturated fats and vegetables.34
  • Testing for and treating metabolic syndrome, which increases the likelihood of needing treatment for BPH.35
  • Inquiring about erectile dysfunction, which is common in patients with lower urinary tract symptoms and BPH.36,37

Key Consideration: Sleep Apnea

Sleep apnea alters the production of anti-diuretic hormone, causing more frequent urination.38,39 With aging, nocturia becomes more likely. However, age also increases the risk of sleep apnea. The connection between sleep apnea and nocturia is so strong that one article in the World Journal of Urology was titled “Obstructive sleep apnea syndrome should always be screened in patients complaining of nocturia.”9 In an Indian population, one study found that in patients with obstructive sleep apnea, 86% had hypertension, 59% were diabetics, and 80% experienced sleep disturbances, including nocturia.40 A 2020 meta-analysis suggests that men with obstructive sleep apnea (OSA) have a high incidence of nocturia; however, there was no significant relationship between OSA and nocturia in the women included in the studies.41

In women, menopause without hormone replacement therapy dramatically increases the likelihood of sleep apnea42 and sleep disorders in general.43,44 However, sleep apnea tends to be more common in men, with some older male populations having as high as 90% prevalence.45 In one urology clinic, assessment revealed that 90% of the patients with nocturia had sleep apnea; CPAP treatment reduced nocturia significantly in patients who had been resistant to other therapies.46

In other contexts, correction of the sleep apnea also reduces nocturia.47-50 To adequately address patients with either sleep apnea or nocturia, assessment for the other condition should be high on the list of priorities.

Key Consideration: Blood Pressure

Treatment of sleep apnea also reduces high blood pressure,51-53 which has been tied to nocturia as well. Whether nocturia alters blood pressure or hypertension increases nocturia is not entirely clear in the literature, but a connection has been established.54,55 In particular, it’s been suggested that when blood pressure does not dip at night in patients who perceive themselves to have poorer quality sleep, this may be related to nocturia.56 The variability of nighttime BP dipping metrics make that sign a challenge to use diagnostically,56 unlike tracking nocturia itself. An increase in the number of nighttime voids is correlated with circadian blood pressure abnormalities.54

Furthermore, BPH and hypertension may both be related to diet-induced hyperinsulinemia.57,58 A diet high in processed and high glycemic foods can cause insulin resistance and hyperinsulinemia. The renin-angiotensin-aldosterone system is altered. Insulin alters the sympathetic nervous system at the same time. All of these elements that can underpin development of BPH are also linked to hypertension.57 Shifting to a healthier diet may thus reduce BPH as well as hypertension.

Patients with hypertension are more likely to also have nocturia.59,60 In men with benign prostatic hyperplasia and hypertension, nocturia is much more common.61 This suggests that treatment of hypertension could beneficially affect not only cardiovascular health risks, but potentially nocturia symptoms. In at least one community study, focused on black men aged 35-49, nocturia was significantly correlated with undiagnosed, uncontrolled hypertension.62

Importantly, cardiac risks are elevated for women with nocturia.63 Like in men, nocturia in women can occur at any age, and can be a hallmark of an underlying condition or a standalone symptom.

Key Consideration: Metabolic Syndrome & Type 2 Diabetes

Both sleep apnea and hypertension are correlated with metabolic syndrome. In a 2018 study on men with BPH, metabolic syndrome also doubled the risk of troublesome nocturia.64 In younger men, the presence of nocturia may also indicate an increased likelihood of metabolic syndrome.65 A 2020 cross-sectional correlation study found that older women (aged >65 years) with type 2 diabetes had a significantly higher nighttime voiding frequency than younger women (>40 to <65 years) with type 2 diabetes.66 Screening for nocturia in women with type 2 diabetes may prove beneficial.

Patients with type 2 diabetes are also more likely to have nocturia or other lower urinary tract symptoms.67 In one study of 1,301 patients with type 2 diabetes, almost 60% reported nocturia.68 However, hypertension was more predictive.68 In women with type 2 diabetes, nocturia is common, and women with both conditions report impaired sleep.69 Importantly, when the time to first awakening is longer (allowing for deeper sleep), blood glucose measures can improve significantly.70 Nocturia may also be an early precursor to metabolic syndrome.71

Researchers have proposed that lower urinary tract symptoms in men with BPH, erectile dysfunction, and metabolic syndrome may have common underlying pathophysiology.72

To support patients’ cardiovascular health, a nighttime bladder diary may be a useful tool.

Takeaways

  • Nocturia affects a wide range of patients and causes many negative health effects.
  • Most patients do not know nocturia can be treated; screening is essential.
  • In patients with either sleep apnea or nocturia, screening for the other condition is beneficial.
  • Reducing frequency of nighttime urination can dramatically improve quality of life, as well as other health symptoms.
  • Lifestyle interventions and treatment of underlying problems are cornerstones to successful nocturia reduction:
    • Assess for sleep apnea.
    • Consider untreated hypertension.
    • Assess for metabolic syndrome.

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References
  1. Miranda Ede P, Gomes CM, Torricelli FC, et al. Nocturia is the lower urinary tract symptom with greatest impact on quality of life of men from a community setting. Int Neurourol J. 2014;18(2):86-90. doi:5213/inj.2014.18.2.86
  2. Van Dijk MM, Wijkstra H, Debruyne FM, De La Rosette JJ, Michel MC. The role of nocturia in the quality of life of men with lower urinary tract symptoms. BJU Int. 2010;105(8):1141-1146. doi:1111/j.1464-410x.2009.08969.x
  3. The medical condition 72 percent of Americans don’t know about is stealing sleep and disrupting lives, survey shows. P&T Community. Published September 12, 2018. Accessed April 25, 2019. http://www.ptcommunity.com/wire/medical-condition-72-percent-americans-don-t-know-about-stealing-sleep-and-disrupting-lives
  4. Chen FY, Dai YT, Liu CK, Yu HJ, Liu CY, Chen TH. Perception of nocturia and medical consulting behavior among community-dwelling women. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(4):431-436. doi:1007/s00192-006-0167-x
  5. DuBeau CE, Yalla SV, Resnick NM. Implications of the most bothersome prostatism symptom for clinical care and outcomes research. J Am Geriatr Soc. 1995;43(9):985-992. doi:1111/j.1532-5415.1995.tb05562.x
  6. A comparison of quality of life with patient reported symptoms and objective findings in men with benign prostatic hyperplasia. The Department of Veterans Affairs Cooperative Study of transurethral resection for benign prostatic hyperplasia. J Urol. 1993;150(5 Pt 2):1696-1700. doi:1016/S0022-5347(17)35870-6
  7. Bosch JL, Weiss JP. The prevalence and causes of nocturia. J Urol. 2013;189(1 Suppl):S86-S92. doi:1016/j.juro.2012.11.033
  8. Bing MH, Moller LA, Jennum P, Mortensen S, Skovgaard LT, Lose G. Prevalence and bother of nocturia, and causes of sleep interruption in a Danish population of men and women aged 60-80 years. BJU Int. 2006;98(3):599-604. doi:1111/j.1464-410X.2006.06390.x
  9. Misraï V, Charbonneau H, Attias D, Pathak A. Obstructive sleep apnea syndrome should always be screened in patients complaining of nocturia. World J Urol. 2019;37(12):2801-2802. doi:1007/s00345-018-2534-x
  10. Dmochowski R, Brucker BM, Cole E, et al. Economic burden of illness in adult patients with nocturia. J Manag Care Spec Pharm. 2019:25(5):593-604. doi:18553/jmcp.2019.18067
  11. Middelkoop HA, Smilde-van den Doel DA, Neven AK, Kamphuisen HA, Springer CP. Subjective sleep characteristics of 1,485 males and females aged 50-93: effects of sex and age, and factors related to self-evaluated quality of sleep. J Gerontol A Biol Sci Med Sci. 1996;51(3):M108-M115. doi:1093/gerona/51a.3.m108
  12. van der Vaart CH, Roovers JP, de Leeuw JR, Heintz AP. Association between urogenital symptoms and depression in community-dwelling women aged 20 to 70 years. 2007;69(4):691-696. doi:10.1016/j.urology.2007.01.017
  13. Drake M. Nocturia and depressive symptoms in older men. BJU Int. 2017;120(2):159. doi:1111/bju.13849
  14. Pietrzyk B, Olszanecka-Glinianowicz M, Owczarek A, et al. Depressive symptoms in patients diagnosed with benign prostatic hyperplasia. Int Urol Nephrol. 2015;47(3):431-440. doi:1007/s11255-015-0920-5
  15. Breyer BN, Shindel AW, Erickson BA, Blaschko SD, Steers WD, Rosen RC. The association of depression, anxiety and nocturia: a systematic review. J Urol. 2013;190(3):953-957. doi:1016/j.juro.2013.03.126
  16. Kobelt G, Borgström F, Mattiasson A. Productivity, vitality and utility in a group of healthy professionally active individuals with nocturia. BJU Int. 2003;91(3):190-195. doi:1046/j.1464-410x.2003.04062.x
  17. Robertson C, Link CL, Onel E, et al. The impact of lower urinary tract symptoms and comorbidities on quality of life: the BACH and UREPIK studies. BJU Int. 2007;99(2):347-354. doi:1111/j.1464-410X.2007.06609.x
  18. Bliwise DL, Howard LE, Moreira DM, Andriole GL, Hopp ML, Freedland SJ. Nocturia and associated mortality: observational data from the REDUCE trial. Prostate Cancer Prostatic Dis. 2019;22(1):77-83. doi:1038/s41391-018-0090-5
  19. Bliwise DL, Holm-Larsen T, Goble S. Increases in duration of first uninterrupted sleep period are associated with improvements in PSQI-measured sleep quality. Sleep Med. 2014;15(10):1276-1278. doi:1016/j.sleep.2014.05.013
  20. Stanley N. The underestimated impact of nocturia on quality of life. Eur Urol Suppl. 2005;4(7):17-19. doi:1016/j.eursup.2005.07.002
  21. Park K, Park HK, Kim SW, et al. Is it worth treating non-bothering nocturia? Results of a multicenter prospective observational study. World J Mens Health. 2018;36(3):248-254. doi:5534/wjmh.170003
  22. Drangsholt S, Ruiz MJA, Peyronnet B, Rosenblum N, Nitti V, Brucker B. Diagnosis and management of nocturia in current clinical practice: who are nocturia patients, and how do we treat them? World J Urol. 2019;37(7):1389-1394. doi:1007/s00345-018-2511-4
  23. Van Kerrebroeck P, Andersson KE. Terminology, epidemiology, etiology, and pathophysiology of nocturia. Neurourol Urodyn. 2014;33(Suppl 1):S2-S5. doi:1002/nau.22595
  24. Weiss JP, Bosch JL, Drake M, et al. Nocturia Think Tank: focus on nocturnal polyuria: ICI-RS 2011. Neurourol Urodyn. 2012;31(3):330-339. doi:1002/nau.22219
  25. Miot?a P, Dobruch J, Lipi?ski M, et al. Diagnostic and therapeutic recommendations for patients with nocturia. Cent European J Urol. 2017;70(4):388-393. doi:5173/ceju.2017.1563
  26. Monaghan TF, Michelson KP, Wu ZD, et al. Sodium restriction improves nocturia in patients at a cardiology clinic. J Clin Hypertens. 2020;22(4):633-638. doi:1111/jch.13829
  27. Oelke M, Fangmeyer B, Zinke J, Witt JH. Nocturia in men with benign prostatic hyperplasia. Aktuelle Urol. 2018;49(4):319-327. doi:1055/a-0650-3700
  28. Song Q, Abrams P, Sun Y. Beyond prostate, beyond surgery and beyond urology: the “3Bs” of managing non-neurogenic male lower urinary tract symptoms. Asian J Urol. 2019;6(2):169-173. doi:1016/j.ajur.2017.11.002
  29. Gravas S, Cornu JN, Drake MJ, et al. EAU Guidelines on Management of Non-neurogenic Male Lower Urinary Tract Symptoms (LUTS), incl. Benign Prostatic Obstruction (BPO). European Association of Urology; 2018. Accessed May 14, 2019. https://uroweb.org/wp-content/uploads/EAU-Guidelines-on-the-Management-of-Non-neurogenic-Male-LUTS-2018-large-text.pdf
  30. Karavitakis M, Kyriazis I, Omar MI, et al. Management of urinary retention in patients with benign prostatic obstruction: a systematic review and meta-analysis. Eur Urol. 2019;75(5):788-798. doi:1016/j.eururo.2019.01.046
  31. Kim EH, Brockman JA, Andriole GL. The use of 5-alpha reductase inhibitors in the treatment of benign prostatic hyperplasia. Asian J Urol. 2018;5(1):28-32. doi:1016/j.ajur.2017.11.005
  32. Vaughan ED. Long-term experience with 5-alpha-reductase inhibitors. Rev Urol. 2003;5(Suppl 5):S22-S27.
  33. Jiwrajka M, Yaxley W, Ranasinghe S, Perera M, Roberts MJ, Yaxley J. Drugs for benign prostatic hypertrophy. Aust Prescr. 2018;41(5):150-153. doi:18773/austprescr.2018.045
  34. Espinosa G. Nutrition and benign prostatic hyperplasia. Curr Opin Urol. 2013;23(1):38-41. doi:1097/MOU.0b013e32835abd05
  35. Yoo S, Oh S, Park J, et al. The impacts of metabolic syndrome and lifestyle on the prevalence of benign prostatic hyperplasia requiring treatment: historical cohort study of 130 454 men. BJU Int. 2019;123(1):140-148. doi:1111/bju.14528
  36. Calogero AE, Burgio G, Condorelli RA, Cannarella R, La Vignera S. Epidemiology and risk factors of lower urinary tract symptoms/benign prostatic hyperplasia and erectile dysfunction. Aging Male. 2019;22(1):12-19. doi:1080/13685538.2018.1434772
  37. De Nunzio C, Roehrborn CG, Andersson KE, McVary KT. Erectile dysfunction and lower urinary tract symptoms. Eur Urol Focus. 2017;3(4-5):352-363. doi:1016/j.euf.2017.11.004
  38. Ichioka M, Hirata Y, Inase N, et al. Changes of circulating atrial natriuretic peptide and antidiuretic hormone in obstructive sleep apnea syndrome. Respiration. 1992;59(3):164-168. doi:1159/000196049
  39. Yue Z, Wang M, Xu W, Li H, Wang H. Secretion of antidiuretic hormone in children with obstructive sleep apnea-hypopnea syndrome. Acta Otolaryngol. 2009;129(8):867-871. doi:1080/00016480802441762
  40. Hasan A, Uzma N, Swamy TL, Shoba A, Kumar BS. Correlation of clinical profiles with obstructive sleep apnea and metabolic syndrome. Sleep Breath. 2012;16(1):111-116. doi:1007/s11325-010-0463-z
  41. Zhou J, Xia S, Li T, Liu R. Association between obstructive sleep apnea syndrome and nocturia: a meta-analysis. Sleep Breath. Published online January 6, 2020. doi:1007/s11325-019-01981-6
  42. Bixler EO, Vgontzas AN, Lin HM, et al. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med. 2001;163(3 Pt 1):608-613. doi:1164/ajrccm.163.3.9911064
  43. Anttalainen U, Saaresranta T, Aittokallio J, et al. Impact of menopause on the manifestation and severity of sleep-disordered breathing. Acta Obstet Gynecol Scand. 2006;85(11):1381-1388. doi:1080/00016340600935649
  44. Baker FC, Lampio L, Saaresranta T, Polo-Kantola P. Sleep and sleep disorders in the menopausal transition. Sleep Med Clin. 2018;13(3):443-456. doi:1016/j.jsmc.2018.04.011
  45. Senaratna CV, Perret JL, Lodge CJ, et al. Prevalence of obstructive sleep apnea in the general population: a systematic review. Sleep Med Rev. 2017;34:70-81. doi:1016/j.smrv.2016.07.002
  46. Yamamoto U, Nishizaka M, Yoshimura C, et al. Prevalence of sleep disordered breathing among patients with nocturia at a urology clinic. Intern Med. 2016;55(8):901-905. doi:2169/internalmedicine.55.5769
  47. Park HK, Paick SH, Kim HG, et al. Nocturia improvement with surgical correction of sleep apnea. Int Neurourol J. 2016;20(4):329-334. doi:5213/inj.1632624.312
  48. Margel D, Shochat T, Getzler O, Livne PM, Pillar G. Continuous positive airway pressure reduces nocturia in patients with obstructive sleep apnea. Urology. 2006;67(5):974-977. doi:1016/j.urology.2005.11.054
  49. Miyauchi Y, Okazoe H, Okujyo M, et al. Effect of the continuous positive airway pressure on the nocturnal urine volume or night-time frequency in patients with obstructive sleep apnea syndrome. Urology. 2015;85(2):333-336. doi:1016/j.urology.2014.11.002
  50. Miyazato M, Tohyama K, Touyama M, et al. Effect of continuous positive airway pressure on nocturnal urine production in patients with obstructive sleep apnea syndrome. Neurourol Urodyn. 2017;36(2):376-379. doi:1002/nau.22936
  51. Miyazaki T, Kojima S, Yamamuro M, et al. Nocturia in patients with sleep-disordered breathing and cardiovascular disease. Circ J. 2015;79(12):2632-2640. doi:1253/circj.CJ-15-0654
  52. Wang AY. Sleep-disordered breathing and resistant hypertension. Semin Nephrol. 2014;34(5):520-531. doi:1016/j.semnephrol.2014.08.006
  53. Marcus JA, Pothineni A, Marcus CZ, Bisognano JD. The role of obesity and obstructive sleep apnea in the pathogenesis and treatment of resistant hypertension. Curr Hypertens Rep. 2014;16(1):411. doi:1007/s11906-013-0411-y
  54. Matsumoto T, Tabara Y, Murase K, et al. Nocturia and increase in nocturnal blood pressure: the Nagahama study. J Hypertens. 2018;36(11):2185-2192. doi:1097/HJH.0000000000001802
  55. Muiesan ML, Paini A. Nocturia and night-time blood pressure: an association too frequently overlooked. J Hypertens. 2018;36(11):2135-2137. doi:1097/HJH.0000000000001864
  56. Manning G, Rushton L, Donnelly R, Millar-Craig MW. Variability of diurnal changes in ambulatory blood pressure and nocturnal dipping status in untreated hypertensive and normotensive subjects. Am J Hypertens. 2000;13(9):1035-1038. doi:1016/s0895-7061(00)00261-2
  57. Kopp W. Diet-induced hyperinsulinemia as a key factor in the etiology of both benign prostatic hyperplasia and essential hypertension? Nutr Metab Insights. 2018;11:1178638818773072. doi:1177/1178638818773072
  58. Vikram A, Jena G, Ramarao P. Insulin-resistance and benign prostatic hyperplasia: the connection. Eur J Pharmacol. 2010;641(2-3):75-81. doi:1016/j.ejphar.2010.05.042
  59. Yoshimura K, Terada N, Matsui Y, Terai A, Kinukawa N, Arai Y. Prevalence of and risk factors for nocturia: analysis of a health screening program. Int J Urol. 2004;11(5):282-287. doi:1111/j.1442-2042.2004.00791.x
  60. Yokoyama O, Nishizawa O, Homma Y, et al. Nocturnal polyuria and hypertension in patients with lifestyle related diseases and overactive bladder. J Urol. 2017;197(2):423-431. doi:1016/j.juro.2016.08.087
  61. Gourova LW, van de Beek C, Spigt MG, Nieman FH, van Kerrebroeck PE. Predictive factors for nocturia in elderly men: a cross-sectional study in 21 general practices. BJU Int. 2006;97(3):528-532. doi:1111/j.1464-410X.2006.06029.x
  62. Victor RG, Li N, Blyler CA, et al. Nocturia as an unrecognized symptom of uncontrolled hypertension in black men aged 35 to 49 years. J Am Heart Assoc. 2019;8(5):e010794. doi:1161/JAHA.118.010794
  63. Kurtzman JT, Bergman AM, Weiss JP. Nocturia in women. Curr Opin Urol. 2016;26(4):315-320. doi:1097/MOU.0000000000000287
  64. De Nunzio C, Brassetti A, Proietti F, Deroma M, Esperto F, Tubaro A. Metabolic syndrome and smoking are associated with an increased risk of nocturia in male patients with benign prostatic enlargement. Prostate Cancer Prostatic Dis. 2018;21(2):287-292. doi:1038/s41391-017-0003-z
  65. Kupelian V, McVary KT, Kaplan SA, et al. Association of lower urinary tract symptoms and the metabolic syndrome: results from the Boston area community health survey. J Urol. 2013;189(1 Suppl):S107-S116. doi:1016/j.juro.2012.11.026
  66. Wang TT, Chung MH, Chien HY, Palmer MH, Liao CH, Liao YM. Nocturia in women with type 2 diabetes mellitus: a cross-sectional, correlation study. J Wound Ostomy Continence Nurs. Published online March 17, 2020. doi:1097/WON.0000000000000635
  67. Rohrmann S, Smit E, Giovannucci E, Platz EA. Association between markers of the metabolic syndrome and lower urinary tract symptoms in the Third National Health and Nutrition Examination Survey (NHANES III). Int J Obes (Lond). 2005;29(3):310-316. doi:1038/sj.ijo.0802881
  68. Chung MS, Chuang YC, Lee JJ, Lee WC, Chancellor MB, Liu RT. Prevalence and associated risk factors of nocturia and subsequent mortality in 1,301 patients with type 2 diabetes. Int Urol Nephrol. 2014;46(7):1269-1275. doi:1007/s11255-014-0669-2
  69. Chang CJ, Pei D, Wu CC, et al. Correlates of nocturia and relationships of nocturia with sleep quality and glycemic control in women with type 2 diabetes. J Nurs Scholarsh. 2017;49(4):400-410. doi:1111/jnu.12302
  70. Juul KV, Jessen N, Bliwise DL, van der Meulen E, Nørgaard JP. Delaying time to first nocturnal void may have beneficial effects on reducing blood glucose levels. Endocrine. 2016;53(3):722-729. doi:1007/s12020-016-0920-y
  71. Aoki Y, Yokoyama O. Metabolic syndrome and nocturia. Low Urin Tract Symptoms. 2012;4(Suppl 1):11-15. doi:1111/j.1757-5672.2011.00118.x
  72. Gorbachinsky I, Akpinar H, Assimos DG. Metabolic syndrome and urologic diseases. Rev Urol. 2010;12(4):e157-e180.

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