Scandinavian Journal of Urology and Nephrology, 2010; 44: 304–314 ORIGINAL ARTICLE Sleep and health-related quality of life in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the general population and patients with inguinal hernia HELÉN MARKLUND1,2, ANDERS SPÅNGBERG1 & ULLA EDÉLL-GUSTAFSSON2 1 Department of Clinical and Experimental Medicine, University Hospital, Linköping, Sweden, and 2Department of Medicine and Health, Division of Nursing Science, Faculty of Health Sciences, Linköping University, Linköping, Sweden Abstract Objective. To determine whether there are differences in the quantity and quality of sleep, including sleep efﬁciency and insomnia, and health-related quality of life (HRQoL) between patients with lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO), men from the general population and patients with inguinal hernia. Material and methods. The designs were descriptive and comparative. The groups consisted of 239 patients aged 45–80 years who were referred to urological departments with LUTS suggestive of benign prostatic obstruction. The comparison groups consisted of 213 randomly selected men from the general population, stratiﬁed according to age and geographical region, and 200 patients with inguinal hernia. The setting was one university and two general hospitals. The method was self-administered questionnaires about demography, comorbidity, sleep and health-related quality of life. Further, patients with LUTS answered questions about urinary symptoms and disease-speciﬁc quality of life. Results. The prevalence of insomnia was 40%, 26% and 19% and the prevalence of sleep efﬁciency < 85% was 49%, 38.5% and 31% in the LUTS, general population and hernia groups, respectively. The median number of nocturnal micturitions was 2, 1 and 1. In the LUTS group (n = 216), 47% had IPSS 8–19 and 44% had ‡ 20 points. The HRQoL was signiﬁcantly impaired in patients with LUTS compared with one or both of the comparison groups (p values < 0.05). Conclusions. Patients with LUTS suggestive of BPO had signiﬁcantly impaired sleep, a higher prevalence of insomnia and signiﬁcantly impaired HRQoL compared with one or both of the comparison groups. Key Words: Benign prostatic hyperplasia, inguinal hernia, insomnia, lower urinary tract symptoms, quality of life, sleep disorders Introduction With age, the circadian regulation system changes, sleep changes in duration, fragmentation and depth [1,2] and sleep efﬁciency decreases [2,3]. Epidemiological studies indicate that 40–70% of the general population aged ‡ 65 years suffer from chronic sleep disturbances [2,4] and the prevalence of insomnia is estimated to be 30% . Difﬁculties falling asleep or maintaining sleep and early awakenings are common symptoms [1,2,4,5]. Nocturia is an important cause of sleep disruption, especially among the elderly and in patients suffering from chronic diseases such as heart failure [4,6–8]. The prevalence of nocturia in men aged ‡ 60 in the general population varies between 21% and 53% depending on different deﬁnitions [8–10]. This symptom is one of the most bothersome in patients with lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO) [11,12]. Before surgical treatment, men with LUTS/BPO reported poor sleep quality, short sleep duration and low sleep efﬁciency with increased day-time sleepiness compared to other urological patients . Patients with LUTS suggestive of BPO have a deterioration in disease-speciﬁc quality of life Correspondence: H. Marklund, Urologiska kliniken i östergötland, Universitetssjukhuset, SE-581 85 Linköping, Sweden. Tel: +46 13 224679. Fax: +46 13 224569. E-mail: [email protected] (Received 8 March 2010; accepted 20 April 2010) ISSN 0036-5599 print/ISSN 1651-2065 online 2010 Informa Healthcare DOI: 10.3109/00365599.2010.488246 Sleep and QoL in LUTS suggestive of BPO (QoL) [14,15]. In the general population, men with moderate/severe LUTS have lower health-related quality of life (HRQoL) in the Mental Health, Vitality, Role – Emotional and Physical Functioning domains of the 36-item Short Form (SF-36)  than men with no or mild LUTS [17,18]. Nocturia is a common symptom in patients with LUTS suggestive of BPO or BPO. It is therefore assumed that they have poor sleep . As no previous studies were found, the present researchers wanted to compare patients with LUTS suggestive of BPO with men from the general population. It was assumed that the presence of any disease might affect sleep or HRQoL in an unspeciﬁc way. Therefore an additional comparison group, patients with inguinal hernia, was included. Inguinal hernia is a common condition and the incidence up to the age of 65–74 is estimated to be 39.7% . Using the SF-36 , studies have shown that Physical Functioning, Bodily Pain and Role – Physical were the most affected domains in patients before hernia repair [21,22]. The aim of this study was to determine whether there are differences in the quantity and quality of sleep, including sleep efﬁciency and insomnia, and HRQoL between patients with LUTS suggestive of BPO, men from the general population and patients with inguinal hernia. A second aim was to identify factors related to their sleep quality and sleep efﬁciency. 305 refer patients to hospitals in other areas. For inclusion, the same urologist (AS) read all consecutive referral letters concerning LUTS and benign lower urinary tract disease. Inclusion criteria were age 45–80 years, LUTS and that the patient accepted the referral to the clinic. Exclusion criteria were indwelling catheter or clean intermittent catheterization (CIC), suspicion of prostate or bladder cancer, neurological diseases that might affect micturition and difﬁculties in understanding written information. The criterion for suspicion of bladder cancer was usually macroscopic haematuria. Prostate cancer was suspected if there was a high prostate-speciﬁc antigen (PSA) value, > 4.0 or > 6.5 mg/l, or a suspicious ﬁnding on digital rectal examination. When the study was performed, age-related reference PSA values were used. This means that patients aged ‡ 65 years with a PSA value between 4.0 and 6.5 mg/l may have been included. Patients with unknown PSA values were included when there was no suspicion of malignancy mentioned in the referral letter. The inclusion criteria were fulﬁlled by 507 patients. Out of these, 268 patients declined to participate or did not answer the reminders. Finally, 239 patients were included. Demographic variables and comorbidity are shown in Table I. The management of the patients after their examinations is shown in Table II. Comparison groups Material and methods This descriptive and comparative study is a part of a larger study in which patients with LUTS suggestive of BPO and randomly selected men from the general population and their partners answered questionnaires. In the following text, LUTS is synonymous with LUTS suggestive of BPO. The regional research ethics committee approved the study. Patients with lower urinary tract symptoms suggestive of benign prostatic obstruction The patients were referred because of a suspicion of BPO to the urological outpatients’ clinic at a university hospital and two general hospitals between 2002 and 2004. They had to live within the catchment areas of the hospitals and most of them had a frequency–volume chart and timed micturitions (a type of ﬂow-rate measurement)  included in the referral letter. These hospitals are the only ones within these geographical areas and it is very uncommon to Men from the general population. From 2007 to 2008, 564 randomly selected men aged 45–80 years and living in the catchment areas of the hospitals received a mailed questionnaire. The sample was stratiﬁed according to age and geographical region to match the patients with LUTS and it was obtained from the national population register, the SPAR database. Three-hundred and ﬁfty-one men declined to participate or did not answer the reminders. Seven men were excluded owing to prostatic disease or hernia. Finally, 213 men were included (Table I). As these men were selected at random, it was assumed that they had LUTS comparable to prevalence ﬁgures of LUTS in the general population. In a Swedish study, the prevalence of LUTS, International Prostate Symptom Score (IPSS) > 7, was estimated to be 23% . Patients scheduled for inguinal hernia repair. Between 2004 and 2007, 532 men aged 45–80 years were referred to the surgical outpatients’ clinic at a 306 H. Marklund et al. Table I. Demographic variables and comorbidity in patients with lower urinary tract symptoms (LUTS) and the two comparison groups. LUTSL (n = 239) General populationGP (n = 213) Inguinal herniaH (n = 200) Age (years) 67 (62–73) 67 (61.5–72) 65 (58–73) Body mass index (kg/m2) 26 (24–28) 26 (24–28) 25 (23–27) Fluid intake evening (ml) 300 (200–400) 300 (200–400) 300 (200–400) No. of micturitions/night 2 (2–4) 1 (1–2) 1 (1–2) pa (group differences) < 0.001 L > H < 0.001 L > GP, H Marital/residential status 80 76 75 Other Wife/partner 5 3 10 Single 15 20 15 70 68 71 Employed 25 30 35 Unemployed/sicklisted 10 7 11 Pensioner 66 63 55 0.035 GP „ H Bed partner Wife/partner Occupational status Comorbidity High blood pressure 36 30 26 Obstructive/asthma 12 10 11 Coronary heart disease 19 22 18 Diabetes 15 14 6 Psychiatric condition 6 3 2 Joint disease/pain 31 25 25 Gastrointestinal disease 22 15 20 8 4 – 34 25 19 Inguinal hernia Previous urological disease 0.021 H < L, GP 0.001 L > H Data are shown as median (Q1–Q3) or %.aOnly signiﬁcant p values are given. The c2 test was used for nominal and the Kruskall–Wallis test for ordinal data. When a signiﬁcant difference was found, the c2 test or the Mann–Whitney U test was used to compare the groups pairwise. Table II. Management of patients in the lower urinary tract symptoms group after their examinations. Management n Watchful waiting 67 BPO surgery 75 BPO drug therapy 47 OAB anticholinergics 29 OAB electric stimulation 1 Clean intermittent catheterization 5 Bladder or prostate cancer 9 Other benign disease (neurogenic, stricture, prostatitis) 6 Total 239 BPO = benign prostatic obstruction; OAB = overactive bladder. university hospital in the south-east region of Sweden and scheduled for surgical repair of an inguinal hernia. The exclusion criteria were a diagnosis of prostatic disease, bladder cancer, neurological disease that may affect micturition and difﬁculties understanding written information. Out of these, 332 men declined to participate or did not answer the reminders. Finally, 200 patients waiting for elective surgical hernia repair were included (Table I). Procedure A package of structured, self-administered questionnaires about demography, comorbidity, sleep, HRQoL and sexuality was used. The questions regarding sexuality were not analysed in this study. The patients with LUTS and inguinal hernia ﬁlled in the questionnaires at home before their consultation at the outpatients’ clinic. Two reminders about the questionnaires were sent over a 4-week period to the LUTS and hernia groups and one reminder was sent to the general population group. At the consultations, the patients underwent clinical examinations in accordance with the clinical routine at each hospital. The management of the LUTS patients after their examinations is given in Table II. Pressure–ﬂow studies were performed in only a minority of the patients. Sleep and QoL in LUTS suggestive of BPO There was no rationale to exclude patients after the consultations and to use a narrower deﬁnition of LUTS suggestive of BPO. Questionnaires Quantity and quality of sleep. The quantity and quality of sleep were assessed by six questions from the Uppsala Sleep Inventory (USI) [25,26] and 19 questions from the Basic Nordic Sleep Questionnaire (BNSQ)  (Tables III and IV). The questions referred to the past 3 months, with regard to sleeponset latency (SOL), time of going to bed/waking up, nocturnal sleep duration and pharmacological therapy. The questions regarding difﬁculties falling asleep, nocturnal and early morning awakenings, day-time symptoms, day-time napping and snoring were assessed on a ﬁve-point scale, from 1 (never) to 5 (every day or almost every day). Sleep quality was deﬁned as “how well have you been sleeping during the past three months?” rated on a ﬁve-point scale from 1 (well) to 5 (badly) [25–27]. Sleep efﬁciency (SE%) was calculated as the ratio of reported nocturnal sleep duration and time spent in bed multiplied by 100. A SE% of ‡ 85% is considered to be satisfactory . Clinical insomnia was deﬁned as difﬁculties falling asleep 3–5 days or more a week, SOL or wakefulness after sleep onset of more than 30 min, nocturnal awakenings more than 3 nights a week, awakenings ﬁve times or more a night, or early morning awakenings more than three times a week combined with one or more day-time symptoms. The requirement for day-time symptoms was that the subject had excessive morning sleepiness, day-time sleepiness, physical tiredness or non-restorative sleep 3–5 days or more a week [28,29]. Using a narrow 307 deﬁnition, insomnia denotes a set of sleep-speciﬁc symptoms in an individual who has adequate circumstances and opportunity for sleep . Health-related quality of life. HRQoL was assessed with the SF-36 , which consists of eight domains (Tables III and V). Each domain is transformed to a score from 0 to 100, with a higher score indicating a better HRQoL. Furthermore, two principal components were calculated, the Physical Component Summary (PCS) and Mental Component Summary (MCS). The questionnaire was analysed in accordance with the manual . Urinary symptoms and disease-speciﬁc quality of life. Selfreported urinary symptoms, urinary incontinence and disease-speciﬁc QoL were measured in patients with LUTS and the questionnaires are presented in Table III. Statistical analysis Medians, quartiles (Q1–Q3) and frequencies were used for descriptive statistics. Non-parametric analysis was used owing to non-normally distributed data. The analyses were performed in two steps. First, all three groups were compared and if the difference was signiﬁcant, the groups were compared pairwise. The two-way c2 test or Fisher’s exact test was used for nominal data, and the Kruskal–Wallis and the Mann–Whitney U test were used for ordinal data. Spearman’s rank correlation coefﬁcient (r) was used for correlations. Logistic regression (forward Wald analysis) was performed to determine variables related to sleep quality and sleep efﬁciency. The independent variables are shown in Table VI. A p value < 0.05 was Table III. Description of the questionnaires used in this study. Questionnaire No. of items/scale; score range Test of validity and/or reliability Quantity and quality of sleep 2/1–7, 1–3; 3/yes/no; 1/open question Validity [25,26]; reliability  Basic Nordic Sleep questionnaire (BNSQ)  Quantity and quality of sleepa 14/1–5; 5/open questions Validity ; reliability  Short Form-36 (SF-36)  Health-related quality of lifea 8 domains/0–100 Validity ; reliability  International Prostate Symptom Score (IPSS)  Self-reported urinary symptomsb 7/0–5; 0–35 Validity ; reliability [15,31] Linköping Incontinence Questionnaire (LIQ)  Self-reported urinary incontinenceb 1/0–5+; 3/yes/no; 0–5 Reliability  Symptom Problem Index (SPI)  Disease-speciﬁc quality of lifeb 7/0–4; 0–28 Validity ; reliability [15,32] BPH Impact Index (BII)  Disease-speciﬁc quality of lifeb 4/0–3 or 0–4; 0–13 Validity ; reliability [15,32] 1/0–6; 0–6 Validity ; reliability [15,31] Uppsala Sleep Inventory (USI) Measures a b [25,26] Bother question in IPSS  a b Disease-speciﬁc quality of life Measured in both the lower urinary tract symptoms (LUTS) and the comparison groups; bmeasured only in the LUTS group. 308 H. Marklund et al. Table IV. Sleep variables in patients with lower urinary tract symptoms (LUTS) and the two comparison groups. Single questions from BNSQb and USIc questionnaires Scale LUTSL (n = 239) General populationGP (n = 213) Inguinal herniaH (n = 200) pa Difﬁculties falling asleepb 1 (< 1/month) to 5 (> 5 days/week) 2 (1–3) 1 (1–2) 1 (1–2) Nocturnal awakeningsb 1 (< 1/month) to 5 (> 5 days/week) 5 (5–5) 5 (3–5) 4 (3–5) Early morning awakeningb 1 (< 1/month) to 5 (> 5 days/week) 2 (2–3) 2 (1–3) 2 (1–3) Excessive morning sleepinessb 1 (< 1/month) to 5 (> 5 days/week) 2 (1–3) 1 (1–2) 2 (1–2) Daytime sleepinessb 1 (< 1/month) to 5 (> 5 days/week) 2 (1–3) 2 (1–3) 2 (1–3) 0.001 L > H Physical tirednessb 1 (< 1/month) to 5 (> 5 days/week) 2 (2–4) 2 (1–3) 2 (1–3) 0.006 L > H Non-restorative sleepb 1 (< 1/month) to 5 (> 5 days/week) 2 (1–3) 1 (1–2) 2 (1–2) < 0.001 L > GP, H Daytime nappingb 1 (< 1/month) to 5 (> 5 days/week) 3 (1–4) 3 (1–4) 2 (1–4) 0.02 L, GP > H Sleep quality 1 (good) to 5 (bad) 2 (1–3) 2 (1–3) 2 (1–3) < 0.001 L > GP, H No. of nocturnal awakenings per nightb 1 (no awakenings) to 5 (‡ 5 times) 3 (3–4) 2 (2–3) 2 (2–3) < 0.001 L > GP, H Snoringb 1 (never) to 5 (every day) 3 (2–5) 3 (2–5) 3 (1–4) 86 (75–93) 88 (78–96) 7 (6–8) 7 (6–8) Sleep efﬁciency 0–100% Nocturnal sleep durationb h 89 (82–100) Time of going to bedb h:min 22:30 (22:00–23:00) 22:30 (22:00–23:00) 22:30 (22:00–23:00) Morning wakening timeb h:min 07:00 (06:00–07:30) 07:00 (06:00–07:30) 06:30 (06:00–07:00) < 0.001 L > GP, H < 0.001 L > GP, H 0.001 L < H 7 (6–8) 0.011 L > H < 0.001 L > GP, H Insomnia 40 26 19 Use of sleeping pills by prescriptionb 15 11 10 Sleep onset latencyb > 30 min 27 17 20 0.03 L > GP Awake during nightc > 30 min 46 37 31 0.003 L > H Sleep efﬁciency < 85% 49 38.5 31 0.001 L > GP > H Data are shown as median (Q1–Q3) or %.aOnly signiﬁcant p values are given. The c2 test was used for nominal and the Kruskall–Wallis test for ordinal data. When a signiﬁcant difference was found, the c2 test or the Mann–Whitney U test was used to compare the groups pairwise. bBasic Nordic Sleep questionnaire (BNSQ); cUppsala Sleep Inventory (USI). considered signiﬁcant. The power is 80% to detect the difference between 13% and 25% in a nominal variable. All analyses were performed using SPSS version 15.0 (SPSS, Chicago, IL, USA). Results External and internal missing values The withdrawal rate in the LUTS group (n = 507) was 54% (range 50–61% between the hospitals). Patients aged 65–75 years had a 6% lower withdrawal rate than the other age groups. The withdrawal rate in the general population group (n = 564) was 62% (range 61–65% between the geographical areas). The youngest age group, 45–60 years, had a 9–10% higher withdrawal rate than the other age groups. The withdrawal rate was 62% in the hernia group (n = 562), and the patients aged 75–80 years had a 10% lower withdrawal rate and the groups 45–60 years a 12% higher rate than the patients aged 60–75 years. All patients answered the sleep and the SF-36 questionnaires. The internal missing values per item varied from 3 to 32 for the 653 men. For comorbidity, the men were required to check yes and no boxes. Sleep and QoL in LUTS suggestive of BPO 309 Table V. Scores on the domains in the Short Form-36 (SF-36) questionnaire in patients with lower urinary tract symptoms (LUTS) and the two comparison groups. Norm for the general population (n = 460) Age (years) LUTSL (n = 239) General populationgp (n = 213) Inguinal herniaH (n = 200) 67 (62–73) 67 (61.5–72) 65 (58–73) 85 (70–95) 90 (75–95) 85 (65–95) 100 (25–100) 100 (75–100) 75 (25–100) < 0.001 GP > L, H 68 (41–100) 74 (52–100) 62 (41–84) < 0.001 GP > H 67 (47–82) 72 (58.5–87) 72 (52–87) < 0.001 GP > L 65 (50–80) 75 (55–85) 70 (50–80) 0.002 GP > L pa Range 65–74 Physical Functioning (PF) 0.005 GP > L, H 85 (65–95) Role – Physical (RP) 100 (25–100) Bodily Pain (BP) 74 (51–100) General Health (GH) 72 (52–87) Vitality (VT) 75 (55–90) Social Functioning (SF) 100 (87.5–100) Role – Emotional (RE) 100 (67–100) Mental Health (MH) 92 (76–100) Physical Component Summary (PCS) 47 (35–53) Mental Component Summary (MCS) 56 (48–59) 87.5 (75–100) 100 (87.5–100) 100 (75–100) < 0.001 GP > L 100 (67–100) 100 (100–100) 100 (67–100) 0.005 GP > L 80 (64–92) 88 (76–96) 84 (72–96) < 0.001 GP, H > L 48 (37–54) 51 (42–55) 44 (35–52) < 0.001 GP > H 51 (41–56) 55 (49–58) 55 (47–58) < 0.001 GP, H > L Data are shown as median (Q1–Q3).aOnly signiﬁcant p values are given. The Kruskall–Wallis test was used to compare the LUTS, population and hernia groups. When a signiﬁcant difference was found, the Mann–Whitney U test was used to compare the groups pairwise. A number of men only checked the yes boxes and the number of missing values thus appears to be between 46 and 90 (n = 653). Twenty-four patients with LUTS did not answer the IPSS, Linköping Incontinence Questionnaire (LIQ), SPI and BPH Impact Index (BII) questionnaires and the bother question in the IPSS at all (n = 239). The internal missing values per item varied from 0 to 10. Demography and comorbidity The patients with LUTS had a signiﬁcantly higher BMI and a higher frequency of previous urological Table VI. Insomnia and sleep quality in relation to urinary symptoms and disease-speciﬁc quality of life in patients with lower urinary tract symptoms (LUTS). LUTS all (n = 216) c IPSS : score 0–35 Mild: 0–7 p 19 (13–26) LUTS without insomnia (n = 115) 16 (11–25) LUTS with insomnia (n = 75) 21 (17–26) 9% 13% 4% Moderate: 8–19 p 47% 50% 42% Severe: 20–35 p 44% 37% 55% LIQd: score 0–5 Incontinence = score 1–5 0 (0–1) 39% 0 (0–1) 34% 0 (0–3) Test with vs without insomnia Correlation with sleep qualityb pa Spearman’s r, pa 0.002 0.01 r = 0.35, p < 0.001 r = 0.12, p = 0.09 46% SPIe: score 0–28 16 (11–21) 14 (8–19) 19 (12–22) < 0.001 r = 0.38, p < 0.001 BIIf: score 0–13 7 (4–8) 5 (3–7) 8 (5–10) < 0.001 r = 0.42, p < 0.001 Bother question in IPSSc: score 0–6 4 (3–4) 3 (2–4) 4 (3–5) 0.002 r = 0.28, p < 0.001 Data are shown as median (Q1–Q3).aMann–Whitney U test; bSleep quality question in the Basic Nordic Sleep questionnaire (BNSQ); c International Prostate Symptom Score; dLinköping Incontinence Questionnaire (LIQ); eSymptom Problem Index (SPI); fBPH Impact Index. 310 H. Marklund et al. Cumulative frequency (%) 100 80 60 LUTS n = 236 Population n = 210 Hernia n = 194 40 20 0 Badly Rather badly Neither well nor badly Rather well Well Sleep quality Figure 1. Cumulative frequency distributions of sleep quality in the three study groups. LUTS = lower urinary tract symptoms. diseases than patients with hernia. There was a small signiﬁcant difference in residential status between the hernia and general population groups. The frequency of diabetes was lower in the hernia group. Otherwise there were no signiﬁcant differences (Table I). Quantity and quality of sleep Most sleep variables were signiﬁcantly impaired in patients with LUTS compared to one or both of the comparison groups (Table IV). The patients with LUTS had a signiﬁcantly higher prevalence of insomnia (40%) than both comparison groups and significantly lower sleep efﬁciency (49%) than patients with hernia (Table IV, Figure 1 and Figure 2). In the logistic regression, the signiﬁcant independent variables for a low sleep efﬁciency were high age, being a pensioner in relation to being employed and belonging to the LUTS group (Table VI). Signiﬁcant factors for a worse sleep quality were joint disease/pain, belonging to the LUTS group, psychiatric condition and many micturitions per night (Table VI). Cumulative frequency (%) 100 80 LUTS n = 233 Population n = 208 Hernia n = 198 60 40 20 0 20 40 60 80 Sleep efficiency (%) Figure 2. Cumulative frequency distributions of sleep efﬁciency in the three study groups. LUTS = lower urinary tract symptoms. 100 Sleep and QoL in LUTS suggestive of BPO 311 Health-related quality of life Discussion Patients with LUTS were signiﬁcantly more impaired than men in the general population in all domains but Bodily Pain (BP) of the SF-36. Mental Health (MH) and Social Functioning (SF) were the most affected domains (Table V, Figure 3 and Figure 4). Compared to the hernia group, patients with LUTS were signiﬁcantly more impaired in the MH domain and less impaired in the BP domain. The Physical Functioning (PF), Role – Physical (RP) and BP domains were signiﬁcantly more impaired in patients with hernia than in men in the general population (Table V). In this study, sleep in patients with LUTS suggestive of BPO was assessed more thoroughly than in previous studies. One of the advantages is that speciﬁc, wellestablished sleep questionnaires were used, and the patients were compared with randomly selected men from the general population and patients with inguinal hernia. The ﬁndings indicate that LUTS has a negative impact on sleep and the patients were signiﬁcantly more affected in almost all sleep variables compared with the comparison groups. The patients with LUTS were especially affected by the frequency of nights with awakenings; they displayed day-time symptoms and reported a reduced sleep quality. The prevalence of insomnia in the LUTS group was nearly twice as high as in the comparison groups, while the prevalence in the latter groups was comparable to general population studies [5,35]. Nearly 50% of the patients with LUTS had a sleep efﬁciency < 85%, i.e. they spent more than 15% of their time in bed awake. To the authors’ knowledge, this is the ﬁrst study that has identiﬁed explanatory variables for poor sleep in patients with LUTS suggestive of BPO. It is already known that high age, joint disease/pain, psychiatric conditions and the number of nightly micturitions  are related to impaired sleep, and this study conﬁrms that the presence of LUTS suggestive of BPO is also such a factor. Employed men may have higher sleep efﬁciency owing to the fact that they have less time to spend in bed. In the LUTS group, the majority of patients had moderate to severe LUTS. The symptoms were bothersome and their disease-speciﬁc QoL was Urinary symptoms and disease-speciﬁc quality of life The LUTS patients had a signiﬁcantly higher number of nocturnal micturitions than the other groups. The median number of nocturnal micturitions was 2, 1 and 1. In the LUTS group (n = 216), 47% had IPSS 8–19 and 44% had > 19 points. The prevalence of the symptom urinary incontinence was 39% (n = 207) (Table VI). In the patients with incontinence the symptoms of continuous, stress and urge incontinence occurred in 8%, 26% and 74%, respectively. In the LUTS group, a higher IPSS score was positively correlated with insomnia. The sleep quality was signiﬁcantly correlated with the IPSS, SPI and BII scores and the bother question in the IPSS (Table VII). Cumulative frequency (%) 100 80 LUTS n = 222 Population n = 197 Hernia n = 188 60 40 20 0 0 20 40 60 80 Physical component summary (PCS) score Figure 3. Cumulative frequency distributions of the Physical Component Summary (PCS) score in the three study groups. LUTS = lower urinary tract symptoms. 312 H. Marklund et al. Cumulative frequency (%) 100 80 LUTS n = 222 Population n = 197 Hernia n = 188 60 40 20 0 0 20 40 60 80 Mental component summary (MCS) score Figure 4. Cumulative frequency distributions of the Mental Component Summary (MCS) score in the three study groups. LUTS = lower urinary tract symptoms. Table VII. Signiﬁcant explanatory factors for sleep efﬁciency and sleep quality using logistic regression, forward Wald analysis. Dependent variable b SE OR 0.041 0.017 1.04 0.017 –0.61 0.31 0.54 0.045 0.44 0.38 1.55 0.255 LUTS group 0.56 0.24 1.75 0.022 Hernia group –0.04 0.26 0.96 0.887 Constant –3.29 1.23 Independent variablesa Sleep efﬁciency (n = 460) b Age c2 p 38.27 < 0.001 Occupational status Employed Unemployed/sicklisted 0.013 Study group 0.017 0.008 Sleep quality c (n = 462) 37.31 Joint disease/pain 0.77 0.23 2.16 0.001 0.68 0.26 1.97 0.009 Study group LUTS group < 0.001 0.012 Hernia group 0.06 0.29 1.06 0.826 Psychiatric condition 1.22 0.58 3.37 0.037 0.17 0.08 1.19 –1.64 0.27 No. of micturitions/night Constant 0.035 < 0.001 a Tested independent variables are the study groups (categorical, reference = population group), age, occupational status (categorical, reference = pensioners), bed partner, ﬂuid intake evening, number of micturitions/night, single domains in the SF-36, high blood pressure, obstructive/asthma, coronary heart disease, diabetes, psychiatric condition, joint disease/pain, gastrointestinal disease and previous urological disease. bSleep efﬁciency is dichotomized into the values 0 (‡ 85%) and 1 (< 85%). cSleep quality question in the Basic Nordic Sleep questionnaire (BNSQ) is dichotomized into the values 0 (score 1 and 2) and 1 (score 3, 4 and 5).OR = odds ratio; LUTS = lower urinary tract symptoms. affected. The prevalence of incontinence was high, corresponding with previous ﬁndings, and indicates the importance of quantifying and classifying this symptom . Compared with the general population, the LUTS group was signiﬁcantly more impaired in all domains of the SF-36 but BP. These ﬁndings correspond with results from other studies with unspeciﬁed LUTS [17,18]. An important implication is that urinary problems inﬂuence many aspects of the HRQoL. In correspondence with previous studies [21,22], patients with inguinal hernia reported poorer HRQoL Sleep and QoL in LUTS suggestive of BPO in the PF, RP and BP domains and the PCS score. This was not found in the general population group. A limitation of this study is that the withdrawal rate was high. There may be many reasons for this: there were many questions to answer, there were detailed questions about the participants’ sexual life and there was a long wait from the referral to the visit at the outpatients’ clinic. The response rate also varied with age and geographical region. The variations were small and have probably not inﬂuenced the results. In this study, there is no adjustment of the p value due to multiple testing. The pattern of most variables that the LUTS group was impaired compared with the general population and hernia groups, and there were only small differences between the hernia and population groups, indicating that the signiﬁcances obtained were not caused by random variation. By omitting adjustment the risk of type II error is reasonably small. LUTS suggestive of BPO is a common and benign condition that often has a lower priority than other urological diseases. These ﬁndings indicate that patients with this condition need a higher priority owing to their sleep disturbances and affected HRQoL. This study conﬁrms the importance of evaluating sleep and HRQoL more systematically and providing supportive healthcare to patients with LUTS suggestive of BPO. 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