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% [5]. 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 [13].
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) [16] 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 [19]. 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% [20]. Using the SF-36 [16], 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) [23] 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% [24].
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
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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) [27] (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 [28]. 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 [29].
Health-related quality of life. HRQoL was assessed with
the SF-36 [16], 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 [30].
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 [33]
Basic Nordic Sleep
questionnaire (BNSQ) [27]
Quantity and quality of sleepa
14/1–5; 5/open questions
Validity [27]; reliability [34]
Short Form-36 (SF-36) [16]
Health-related quality of lifea
8 domains/0–100
Validity [16]; reliability [16]
International Prostate
Symptom Score (IPSS) [31]
Self-reported urinary
symptomsb
7/0–5; 0–35
Validity [31]; reliability [15,31]
Linköping Incontinence
Questionnaire (LIQ) [15]
Self-reported urinary
incontinenceb
1/0–5+; 3/yes/no; 0–5
Reliability [15]
Symptom Problem
Index (SPI) [32]
Disease-speciﬁc quality of lifeb
7/0–4; 0–28
Validity [32]; reliability [15,32]
BPH Impact Index (BII) [32]
Disease-speciﬁc quality of lifeb
4/0–3 or 0–4; 0–13
Validity [32]; reliability [15,32]
1/0–6; 0–6
Validity [31]; reliability [15,31]
Uppsala Sleep
Inventory (USI)
Measures
a
b
[25,26]
Bother question in IPSS [31]
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.
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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.
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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 [36] 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 [15].
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.
In conclusion, patients with LUTS suggestive of
BPO had signiﬁcantly impaired sleep quality and
sleep efﬁciency and a higher prevalence of insomnia
than men in the general population and patients with
inguinal hernia.
Acknowledgements
This study was supported by a grant from the Medical
Research Council of Southeast Sweden 2004–2008.
We are grateful to the Department of Urology, Ryhov
County Hospital, Jönköping, and the Department of
Surgery, University Hospital, Linköping, for their
cooperation in this study.
Declaration of interest: The authors report no
conﬂicts of interest.The authors alone is responsible
for the content and writing of the paper.
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