the measurement of nocturia and its impact on quality of...

e u r o p e a n u r o l o g y s u p p l e m e n t s 5 ( 2 0 0 6 ) 3 – 1 1

avai lab le at www.sciencedi rect .com

journa l homepage: www.europeanurology.com

The Measurement of Nocturia and Its Impact on Quality ofSleep and Quality of Life in LUTS/BPH§

Emmanuel Chartier-Kastler a,*, Andrea Tubaro b

aHospital Pitie-Salpetriere, Department of Urology, Boulevard de L’Hopital 83, 75013 Paris, Franceb La Sapienza University, Sant’Andrea Hospital, Rome, Italy

Article info

Keywords:Lower urinary tractsymptomsBenign prostatic hyperplasiaNocturiaSleepQuality of lifeMethodologyQuestionnaireHours of undisturbed sleep

www.eu-acme.org

Abstract

Nocturia is one of the most bothersome complaints in men with lowerurinary tract symptoms suggestive of benign prostatic hyperplasia(LUTS/BPH). This is probably due to the fact that nocturia interferes withthe quality of sleep which may have a significant negative impact on howthe patient feels the next day in terms of energy level, concentration andmood and ultimately his overall quality of life (QoL). Disturbed sleep dueto nocturia may even lead to increased long-term morbidity and mor-tality. More attention should therefore be paid to nocturia in clinicalpractice, in the initial evaluation of the LUTS/BPH patient, and in clinicalresearch, in the evaluation of the benefits of (new) LUTS/BPH treatments.In LUTS/BPH a number of methods are available to assess the frequencyof nocturnal voids and its impact on QoL, however, none were specifi-cally designed or developed for this purpose. In addition, there are nomethods evaluating the impact of nocturia on quality of sleep. Clearlythere is a lack of specific, sensitive and validated methods assessing theimpact of nocturia on quality of sleep and QoL. The recently developedvalidated Nocturia Quality of Life (N-QOL) questionnaire may be a usefultool for this. It appears that it is not only the frequency of nocturnal voidsbut also its timing that impacts on the bothersomeness of nocturia. Thehours of undisturbed sleep (HUS), defined as the time from falling asleepto first wakening to void, may provide a useful method to assess theimpact of nocturia on quality of sleep. Data from objective sleep assess-ment tools, such as actigraphy, combined with data from subjectivesleep diaries/logs may accurately estimate the HUS.

§ Proceedings of a Satellite Symposium at the WHO 6th International Consultation on NewDevelopments in Prostate Cancer and Prostate Diseases.

Please visit www.eu-acme.org to read and answer the EU-ACME questions on-line. TheEU-ACME credits will then be attributed automatically.* Corresponding author. Tel. +33 1421 77 129; Fax: +33 1421 77 160.E-mail address: [email protected] (E. Chartier-Kastler).

1569-9056/$ – see front matter # 2005 Published by Elsevier B.V. doi

# 2005 Published by Elsevier B.V.

:10.1016/j.eursup.2005.10.003


Fig. 1 – Prevalence (%) of most commonly cited reasons for

disturbed sleep maintenance in men aged 50–93 years

[8,10]. Reprinted from Eur Urol Suppl, 3(6), Asplund R.

Nocturia: consequences for sleep and daytime activities

and associated risks, 24–32, 2005, with permission from

the European Association of Urology.

1. Introduction

Lower urinary tract symptoms suggestive of benignprostatic hyperplasia (LUTS/BPH) is a commoncondition over the age of 40 years. In its treatmenturologists have focussed for many years mainly onimproving flow rate and voiding (‘‘obstructive’’)symptoms (e.g. slow stream, intermittency, hesi-tancy, straining, terminal dribble) and preventingthe progression to acute urinary retention (AUR).This could be achieved by removing the enlargedprostate by prostatic surgery (e.g. transurethralresection of the prostate (TURP)). However, in somecases, TURP did not result in complete relief ofsymptoms. It appeared that TURP relieved voidingsymptoms more rapidly and/or to a larger extentthan storage (‘‘irritative’’) symptoms (e.g. increaseddaytime frequency, nocturia, urgency) [1–4]. Inaddition, it was observed that failure of TURP wasoften due to persistence and/or deterioration ofstorage symptoms [2,4]. When looking at the urinarysymptoms experienced by LUTS/BPH patients, void-ing symptoms are most prevalent. However, storagesymptoms are generally considered as most bother-some by the patient as they may interfere with dailylife activities and negatively affect quality of life (QoL)[5]. It has been recognised that nocturia, i.e. thecomplaint that the individual has to wake at nightone or more times to void [6], with each void precededand followed by sleep [7], is one of the mostbothersome storage symptoms in patients withLUTS/BPH because it negatively impacts on thequality of sleep and QoL [8]. As patients with LUTS/BPH seek medical advice because they are botheredby their symptoms, more attention should be paid inclinical practice and clinical research to storagesymptoms and in particular to nocturia. The meansby which nocturia and its impact on quality of sleepand QoL are measured are essential in this respect.This paper reports on data presented during apresentation that was held during a satellite sympo-sium on the 6th International Consultation on NewDevelopments in Prostate Cancer and Prostate Dis-eases, held from June 24–27, 2005 in Paris, France thatspecifically focussed on nocturia and its impact onquality of sleep and QoL and the instruments tomeasure these items within the field of LUTS/BPH.

2. The impact of nocturia on quality of sleepand QoL

Nocturia is one of the most bothersome symptomsin patients with LUTS/BPH, not only for the patientbut also for his partner [9]. This is probably due to the

fact that nocturia is the major cause of disturbedsleep. In a Dutch epidemiological study amongelderly men aged 50–93 years, nocturia was themost common cause of sleep disturbance (Fig. 1)[8,10]. Increased severity of nocturia leads toincreased sleep disturbance such as frequent awa-kenings and poor sleep (Fig. 2) [11]. Furthermore, notonly does increased frequency of nocturnal voidsnegatively impact on the quality of sleep, it alsoresults in decreased perceived daytime vitality/energy and general feeling of well-being (Fig. 2)[11]. This is probably due to the fact that disturbedsleep with reduced daytime energy interferes withconcentration, mood and performance of daily lifeactivities [8,12]. For example, the sleep interruptionassociated with nocturia may induce cognitiveimpairment [8,13] and may lead to impaired pro-ductivity at work [8,14]. Nocturics also have anincreased use of healthcare services [15]. Thisindicates that nocturia not only imposes a burdenon patients and their partners, but that its costs forsociety may also be considerable [8]. Nocturia and/ordisturbed sleep not only decrease the QoL of patientswith LUTS/BPH, they can also have more seriousconsequences. Excessive fatigue and reduced con-centration due to lack of sleep is also believed to be amajor risk for road traffic accidents [8,16] andoccupational accidents [8,17]. Approximately 20%of all motor vehicle accidents are due to fatigue orfalling asleep [18,19]. There are also indications thatlack of sleep (due to nocturia) may increase the riskof morbidity (e.g. depression, cardiovascular diseaseand diabetes) and perhaps even mortality [8,20–23].

As nocturia has a significant negative impact onthe quality of sleep and the QoL of patients withLUTS/BPH, its measurement should be part of the

e u r o p e a n u r o l o g y s u p p l e m e n t s 5 ( 2 0 0 6 ) 3 – 1 1 5

Fig. 2 – Increased severity of nocturia leads to decreased sleep quality, daytime fatigue and decreased well-being [11].

initial evaluation of the patient with LUTS/BPH andin the assessment of the benefits of (new) LUTS/BPHtreatment. However, the question then rises on howto measure nocturia and its impact on quality ofsleep and QoL.

3. How has nocturia and its impact on qualityof sleep and QoL been measured in LUTS/BPHclinical research?

3.1. Clinical trials on nocturia in LUTS/BPH

When looking at clinical trials in the field of LUTS/BPH it should first be noted that little research hasbeen devoted to nocturia and its impact on quality ofsleep and QoL. Most of the studies performed werealso not specifically designed or powered to evaluatenocturia. The Veterans Affairs (VA) Cooperativetrial, including 1,040 LUTS/BPH patients with atleast 1 nocturnal void, showed that 1 year treatmentwith an a1-adrenoceptor (AR) antagonist or combi-nation therapy of an a1-AR antagonist and the 5a-reductase inhibitor finasteride reduced the fre-quency of nocturnal voids to a statistically signifi-cantly greater extent than either placebo orfinasteride [24]. In a pooled analysis of 3 double-blind trials in LUTS/BPH patients with �2 nocturnalvoids the 5a-reductase inhibitor dutasterideimproved the frequency of nocturnal voids statis-tically significantly more than placebo [25] but to acomparable extent as finasteride in the VA Coop-erative study [24]. Two Japanese studies showed thatboth medical therapy (mainly consisting of a1-AR

antagonists) and surgery reduced the frequency ofnocturnal voids in LUTS/BPH patients. Surgeryreduced the frequency of nocturnal voids to aslightly larger extent, however, patients treatedwith surgery also had a higher frequency ofnocturnal voids at baseline [26,27]. Other clinicalstudies have also evaluated the impact of medicaltreatment on the frequency of single symptoms ofLUTS/BPH including nocturia [28–31]. However,most of these studies were not primarily designedand powered to assess the impact of LUTS/BPHtreatment on nocturia and therefore some of themprobably failed to show statistically significantimprovements in the frequency of nocturnal voidsvs. placebo.

3.2. Measurement of the frequency of nocturnal voids

The trials discussed above measured the quantita-tive domain of nocturia, i.e. the frequency of gettingup at night to void. This is often assessed by meansof the nocturia question included in the Interna-tional Prostate Symptom Score (I-PSS) [32] (Fig. 3).For this question the patient has to indicate howmany times over the past month he most typicallyhad to get up to urinate from the time he went to beduntil the time he got up in the morning. This canrange from none (score 0) to 5 or more times (score 5)per night. However, the I-PSS questionnaire wasneither developed nor evaluated for the measure-ment of nocturia and may be subject to recall bias.Other questionnaires are available that measurefrequency of symptoms of LUTS/BPH and thatinclude a question on the frequency of nocturnal


Fig. 3 – The relationship between nocturia and its impact

on quality of life, and their measurement methods.

voids, e.g. the Boyarsky symptom score [33], theMadsen-Iversen Symptom Score [34], and theICSmale questionnaire [35]. However, these sufferfrom the same drawbacks as the I-PSS. Although notoften used in clinical trials, a voiding diary, on whicha patient has to indicate how many times and atwhat times he voided at night, may also be used tomeasure the frequency of nocturnal voids (Fig. 3).However, this may also be prone to recall bias.

3.3. Measurement of the bothersomeness of nocturia

Although no clinical trials in the field of LUTS/BPHhave evaluated the impact of nocturia on QoL, it isrecognised that nocturia is a very bothersomesymptom. There are a number of methods thatcould potentially be used to measure the qualitativedomain of nocturia, i.e. its bothersomeness. Theseinclude generic QoL questionnaires and diseasespecific QoL questionnaires (Fig. 3). One of the maingeneric instruments for measuring QoL is the ShortForm 36 (SF-36) [36,37]. This measures the overallphysical, psychological and social function bymeans of 36 questions in 8 domains (physicalfunctioning, role-physical, bodily pain, generalhealth perceptions, vitality, social functioning,role-emotional and mental health). The SF-36questionnaire has for instance been used in aSwedish survey to measure the effect of nocturiaon vitality/energy and social functioning [14]. Never-theless, this general non-disease specific question-naire may be too crude and not sensitive enough tomeasure the impact of nocturia due to LUTS/BPH onQoL or for instance LUTS/BPH treatment inducedchanges in nocturia and its impact on QoL.

A number of questionnaires are available thatevaluate the impact of LUTS/BPH on every day QoL.These include among others the BPH Impact Index

[38], the International Continence Society Quality ofLife questionnaire (ICSQoL) [39], the BPH HealthRelated Quality of Life (BPH-HRQOL) questionnaire[40] and the BPH specific Interference with ActivitiesScale [41]. However, these questionnaires do notlook specifically at the impact of nocturia but ratherat the impact of urinary symptoms in general on QoLand activities of daily living. One question on theimpact of LUTS/BPH on QoL has been included in theI-PSS: ‘if you were to spend the rest of your life withyour urinary condition the way it is now, how wouldyou feel about that?’. The score ranges fromdelighted (score 0) to terrible (score 6) [32]. However,this single question also measures the effect of thepresent urinary condition on QoL and is not specificfor nocturia. A questionnaire that assesses theimpact of several urinary symptoms on QoL is theSymptom Problem Index (SPI) [38]. It contains 7questions which are aimed at the degree to whichthe present symptoms are a problem for the patient.This questionnaire also includes an item on nocturiaasking the patient: ‘over the past month, how muchhas getting up at night to urinate been a problem foryou?’ with a score ranging from no problem (score 0)to big problem (score 4). However, this singlequestion was not designed nor evaluated formeasuring the impact of nocturia on QoL. TheDanish Prostatic Symptom Score (DAN-PSS-1)attempts to both quantify and qualify symptomsby combining a symptom score and a bother score[42,43]. The severity of each symptom and thedegree of bother is scored from 0 to 3. A weightedscore is then obtained by multiplying the symptomscore and bother score. Questions on the frequencyand bothersomeness of nocturia are included in thisquestionnaire but there is currently little data withthis questionnaire and the single questions onnocturia were not designed nor evaluated formeasuring the impact of nocturia on QoL.

3.4. Measurement of the impact of nocturia on

quality of sleep

Within LUTS/BPH no questionnaire specificallyevaluates the impact of nocturia on quality of sleep.In sleep research the impact of nocturia on qualityof sleep has mainly been investigated by means ofself-constructed, non-validated questionnaires [11,44,45].

It seems that although there are a number ofmethods available in the field of LUTS/BPH thatmeasure the frequency of nocturnal voids and itsbothersomeness, most appear to be not sensitiveenough nor are specifically designed and validated.In addition, there are no validated methods that


assess the impact of nocturia on quality of sleep.However, recently there have been a number ofinteresting developments in these areas, which willbe discussed in the following paragraph.

4. Recent developments in the measurementof nocturia and its impact on quality of sleep andQoL in LUTS/BPH

4.1. Questionnaires on nocturia and its impact on quality

of sleep and QoL

Recently 2 questionnaires were constructed thatfocus on the qualitative domain of nocturia, i.e. itsbothersomeness (Fig. 3). Abraham et al. [46] havedeveloped a validated questionnaire that specificallymeasures the effect of nocturia on quality of sleepand QoL: the Nocturia Specific Quality of Lifequestionnaire (N-QOL; Table 1). This is a 13-itemquestionnaire which consists of 3 domains/sub-scales: a sleep/energy domain consisting of 7 ques-tions (score range 0–28), a bother/concern domainconsisting of 5 questions (score range 0–20) and oneglobal QoL question (score range 0–4). It deals withdaytime energy, worry, productivity, sleep andvitality. This self-administered questionnaire takesabout 5 minutes to complete and has been proven tobe internally consistent and reproducible. It has alsobeen shown to correlate with the energy/vitalitydomains of the SF-36 [32] and with the sleep qualitydomain of the Pittsburgh Sleep Quality Index [47]. TheN-QOL has become one of the modules of theInternational Consultation on Incontinence Ques-tionnaire-Nocturia (ICIQ-N) that is currently underdevelopment [48]. The other 3 modules of the ICIQ-Nconsist of a nocturia domain (2 questions on thefrequency and bothersomeness of nocturia), a sexualdomain (6 questions) and a general health domain(6 questions from the SF-12 [49]).

4.2. The Hours of Undisturbed Sleep (HUS)

A potential new method to measure (the impact ofnocturia on) the quality of sleep are the Hours ofUndisturbed Sleep (HUS). It has been shown thatdeep, slow wave, restorative sleep occurs during thefirst hours of the night, while in the second part ofthe night, the lighter (less restorative) sleep pre-dominates. It is mainly a decrease in deep sleep thatcontributes to daytime fatigue. Waking up in thefirst 3–4 hours of the night during deep, slow wave,restorative sleep is therefore also more likely toleave a person groggy and tired during the followingday than waking up later at night [50,51]. It is

therefore not only the frequency of nocturnal voidsthat impacts on quality of sleep and QoL but also thetiming of wakening up to void (Fig. 3). Based on this,the concept of HUS was developed as a proxy forquality of sleep. HUS is defined as the time fromfalling asleep to first wakening to void and should lastat least 3–4 hours [52]. This concept was recently usedin a proof of concept, pilot study evaluating the effectof tamsulosin oral controlled absorption system(OCAS1) 0.4 mg once daily on nocturia, quality ofsleep and QoL in LUTS/BPH patients with nocturiaand disturbed sleep [52]. In this study the HUS wasmeasured by means of a diary, the frequency ofnocturnal voids was assessed by means of the I-PSSnocturia question [32] and by means of a diary andQoL was assessed by means of the I-PSS QoL question[32]. It was shown that the decrease in the frequencyof nocturnal voids correlated with an increase in HUSand QoL thus suggesting that there is a relationshipbetween the frequency of nocturnal voids, HUS andQoL [52]. There was an increase in HUS withtamsulosin OCAS1 0.4 mg once daily of 81 minutesvs. baseline. However, this was not statisticallysignificant vs. placebo, which was probably due tothe fact that this was a pilot study with a smallnumber of patients. In addition, it was discussed bythe authors that more appropriate measuring toolsthat more accurately assess the actual sleep patternsof the patients may have yielded better results sinceself-administered diaries on night-time behaviourmay contain inaccuracies [52]. Sleep logs/diaries,may be subject to recall bias and may overestimatesleep onset latency and underestimate sleep time[53,54]. Therefore it is generally recommended thatsubjective assessment of sleep should be comple-mented by an objective measurement. Polysomno-graphy (PSG) is the gold standard objective sleepassessment method. It is a diagnostic test duringwhich a number of physiologic variables are mea-sured and recorded during sleep, such as: brainelectrical activity, eye and jaw muscle movement, legmuscle movement, air flow, respiratory effort, elec-trocardiogram and oxygen saturation. However, it isan expensive procedure that many individuals findintrusive and burdensome. In addition, it can only beperformed in sleep laboratory and is therefore notsuitable for clinical practice.

Actigraphy is an alternative sleep assessmentmethod that measures body movements, by meansof a wrist-worn activity meter. It is based on theprinciple that there is reduced movement duringsleep and increased movement when the patient getsup for example to void. The time, the number andfrequency of awakenings/nocturia episodes can thenbe assessed. Advantages of actigraphy include its


Table 1 – The Nocturia Specific Quality of Life Questionnaire (N-QOL) [46]

Reprinted from Urology, 63, Abraham L, Hareendran A, Mills IW, Martin ML, Abrams P, Drake MJ, et al. Development and validation of a

quality-of-life measure for men with nocturia, 481–486, 2004, with permission from the European Association of Urology.

ease of use, its low cost, non-invasive nature andautomated sleep scoring and data storage which isalso possible in the ambulatory setting for a longer-time period. Comparison of actigraphy with PSG hasyielded agreement rates of about 90% in normalpeople without sleep disorders [55]. In patients withsleep disorders actigraphy slightly tended to over-estimate sleep efficiency and total sleep time incomparison to PSG [56]. In studies comparing datafrom actigraphy, a sleep diary and PSG, actigraphydata were more accurate than sleep diary data when

compared to PSG [54]. However, when data fromactigraphy and a sleep diary/log were combined totalsleep time and sleep efficiency did not significantlydiffer from PSG [57]. The authors recommend thecombined use of actigraphy with sleep logs inpatients with disturbed sleep [57]. The AmericanAcademy of Sleep Medicine considers actigraphyappropriate for the assessment of treatment effectson sleep. In addition, it was concluded that in sleep-disordered patients the combined use of actigraphyand subjective questionnaires has advantages [56].


The REMview is a relatively new method thatincludes an eyelid electrode to detect eye move-ments, a head cap or headband housing a sensor todetect head movements, and a small recordingdevice. It assesses wakefulness, rapid eye move-ment (REM) sleep and non-REM sleep [58]. However,REMview requires additional testing to show thatthat this device outperforms other available sleepassessment methods [58].

5. Conclusions

It is increasingly recognised that nocturia is one ofthe most bothersome symptoms of LUTS/BPHbecause it negatively affects sleep and QoL of boththe patient and his partner. Unfortunately, theimpact of nocturia on quality of sleep and QoL isnot yet a key element in the evaluation of patientswith LUTS/BPH and limited attention is given tomeasuring the frequency of nocturnal voids, itsimpact on quality of sleep and QoL in clinicalurological research. Indeed, clearly an unmet needexists for better evaluation of nocturia and itsimpact on quality of sleep and QoL. The recentlydeveloped methods for measuring nocturia and itsimpact on quality of sleep and QoL, i.e. the N-QOL,the ICIQ-N and HUS may become useful tools inthis respect. The information obtained by thesemethods will provide more insight into the extentto which a LUTS/BPH patient suffers from nocturia,the disturbing effect on his sleep and its bother-someness in daily life, and the potential of LUTS/BPH treatment to reduce the patient’s nocturiaand ultimately to improve his quality of sleep andQoL.

It appears that it is not only the frequency ofnocturnal voids that determines the impact on QoL,but that also the timing of wakening up to void isimportant. The HUS may therefore provide a usefulmethod for measuring the impact of nocturia onquality of sleep but it needs to be established how anincrease in the HUS translates into improved day-time energy and QoL of the patient. Data fromadvanced sleep assessment tools, such as actigra-phy, may complement subjective sleep dataobtained by sleep diaries/logs and provide anaccurate measurement of the HUS.

References

[1] Speakman MJ. Initial choices and final outcomes in

lower urinary tract symptoms. Eur Urol 2001;40(Suppl 4):

21–30.

[2] Hakenberg OW, Pinnock CB, Marshall VR. The follow-up

of patients with unfavourable early results of transur-

ethral prostatectomy. BJU Int 1999;84:799–804.

[3] Ichiyanagi O, Ishigooka M, Hashimoto T, Hayani S, Suzuki

Y, Nakada T. The American Urological Association Symp-

tom Index: early post-operative evaluation of irritative

and obstructive symptoms due to benign prostatic hyper-

plasia. Int Urol Nephrol 1997;29:441–7.

[4] Ignjatovic I. Symptoms and urodynamics after unsuccess-

ful transurethral prostatectomy. Int Urol Nephrol 2001;

32:655–8.

[5] Peters TJ, Donovan JL, Kay HE, Abrams P, de la Rosette

JJMCH, Porru D, et al. The International Continence

Society ‘Benign Prostatic Hyperplasia’ Study: the bother-

someness of urinary symptoms. J Urol 1997;157:885–9.

[6] Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten

U, et al. The standardization of terminology in lower

urinary tract function: report from the standardization

subcommittee of the International Continence Society.

Urology 2003;61:37–49.

[7] Van Kerrebroeck P, Abrams P, Chaikin D, Donovan J,

Fonda D, Jackson S, et al. The standardization of termi-

nology in nocturia: report from the standardization sub-

committee of the International Continence Society. BJU

Int 2002;90(Suppl 3):11–5.

[8] Asplund R. Nocturia: consequences for sleep and daytime

activities and associated risks. Eur Urol Suppl 2005;3(6):

24–32.

[9] Mitropoulos D, Anastasiou I, Giannopoulou C, Nikolopou-

los P, Alamanis C, Zervas A, et al. Symptomatic benign

prostatic hyperplasia: impact on partners’ quality of life.

Eur Urol 2002;41:240–5.

[10] Middelkoop HAM, Smilde van den Doel DA, Neven AK,

Kamphuisen HAC, Springer CP. Subjective sleep charac-

teristics 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 1996;51:M108–15.

[11] Asplund R, Aberg H. Health of the elderly with regard to

sleep and nocturnal micturition. Scand J Prim Health Care

1992;10:98–104.

[12] Abrams P. Nocturia: the major problem in patients with

lower urinary tract symptoms suggestive of benign pro-

static obstruction (LUTS/BPO). Eur Urol Suppl 2005;3(6):

8–16.

[13] Thomas M, Sing H, Belenky G, Holcomb H, Mayberg H,

Dannals R, et al. Neural basis of alertness and cognitive

performance impairments during sleepiness. I. Effects of

24 h of sleep deprivation on waking human regional brain

activity. J Sleep Res 2000;9:335–52.

[14] Kobelt G, Borgstrom F, Mattiasson A. Productivity, vitality

and utility in a group of healthy profesionnally active

individuals with nocturia. BJU Int 2003;91:190–5.

[15] Asplund R. Nocturia in relation to sleep, somatic disease

and medical treatment in the elderly. BJU Int 2002;90:

302–13.

[16] Carskadon MA. Sleep deprivation: health consequences

and societal impact. Med Clin N Am 2004;88:767–76.

[17] Akerstedt T, Knutsson A, Westerholm P, Theorell T,

Alfredsson L, Kecklund G. Work organization and unin-


tentional sleep: results from the WOLF study. Occup

Environ Med 2002;59:595–600.

[18] Radun I, Summala H. Sleep-related fatal vehicle acci-

dents: characteristics of decisions made by multidisci-

plinary investigation teams. Sleep 2004;27:224–7.

[19] MacLean AW, Davies DR, Thiele K. The hazards and pre-

vention of driving while sleepy. Sleep Med Rev 2003;7:507–

21.

[20] Asplund R, Henriksson S, Johansson S, Isacsson G. Noc-

turia and depression. BJU Int 2004;93:1253–6.

[21] Asplund R. Mortality in the elderly in relation to nocturnal

micturition. BJU Int 1999;84:297–301.

[22] Asplund R. Sleep and cardiac diseases amongst elderly

people. J Intern Med 1994;236:65–71.

[23] Kawakami N, Takatsuka N, Shimizu H. Sleep disturbance

and onset of Type-2 diabetes. Diabetes Care 2004;27:282–3.

[24] Johnson TM, Jones K, Williford WO, Kutner MH, Issa MM,

Lepor H. Changes in nocturia from medical treatment of

benign prostatic hyperplasia: secondary analysis of the

Department of Veterans Affairs Cooperative Study Trial. J

Urol 2003;170:145–8.

[25] Zinner N, Roehrborn C. Dutasteride treatment improves

nocturia in men with symptomatic benign prostatic

hyperplasia. Prog Urol 2005;15(Suppl. 2):26 (abs. 80).

[26] Homma Y, Yamaguchi T, Kondo Y, Horie S, Takahashi S,

Kitamura T. Significance of nocturia in the International

Prostate Symptom Score for benign prostatic hyperplasia.

J Urol 2002;167:172–6.

[27] Yoshimura K, Ohara H, Ichioka K, Terada N, Matsui Y,

Terai A, et al. Nocturia and benign prostatic hyperplasia.

Urology 2003;61:786–90.

[28] Abrams P, Schulman CC, Vaage S. Tamsulosin, a selective

a1c-adrenoceptor antagonist: a randomised, controlled

trial in patients with benign prostatic ‘‘obstruction’’

(symptomatic BPH). Br J Urol 1995;76:325–36.

[29] Lepor H. Phase III multicenter placebo-controlled study of

tamsulosin in benign prostatic hyperplasia. Urology

1998;51:892–900.

[30] Brawer MK, Adams G, Epstein H. Terazosin in the treat-

ment of benign prostatic hyperplasia. Arch Fam Med

1993;2:929–35.

[31] Andersen M, Dahlstrand C, Høye K. Double-blind trial of

the efficacy and tolerability of doxazosin in the gastro-

intestinal therapeutic system, doxazosin standard and

placebo in patients with benign prostatic hyperplasia.

Eur Urol 2000;38:400–9.

[32] Barry MJ, Fowler FJ, O’Leary MP, Bruskewitz RC, Holtgrewe

HL, Mebust WK, et al., The American Urological Associa-

tion symptom index for benign prostatic hyperplasia. The

Measurement Committee of the American Urological

Association. J Urol 1992;148:1549–57.

[33] Boyarsky S, Jones G, Paulson DF, Prout GR. A new look at

bladder neck obstruction by the Food and Drug Admin-

istration: Guidelines for investigation of benign prostatic

hypertrophy. Trans Am Assoc Genitourin Surg 1976;

68:29–36.

[34] Madsen PO, Iversen P. A point system for slecting opera-

tive candidates. In: Hinman Jr F, editor. Benign prostatic

hypertrophy. New York: Springer-Verlag; 1983, p. 763–5.

[35] Donovan JL, Abrams P, Peters TJ, Kay HE, Reynard J,

Chapple C, et al. The ICS-’BPH’ Study: the psychometric

validity and reliability of the ICSmale questionnaire. Br J

Urol 1996;77:554–62.

[36] Ware Jr JE, Sherbourne CD. The MOS 36-item short-form

health survey (SF-36). I. Conceptual framework and item

selection. Med Care 1992;30:473–83.

[37] McHorney CA, Ware Jr JE, Raczek AE. The MOS 36-item

Short-Form Health Survey (SF-36):II. Psychometric and

clinical tests of validity in measuring physical and mental

health constructs. Med Care 1993;31:247–63.

[38] Barry MJ, Fowler FJ, O’Leary MP, Bruskewitz RC, Holtgrewe

HL, Mebust WK. Measuring disease-specific health status

in men with benign prostatic hyperplasia. Med Care

1995;33:AS145–55.

[39] Donovan JL, Kay HE, Peters TJ, Abrams P, Coast J, Matos-

Ferreira A, et al. Using the ICSQoL to measure the impact

of lower urinary tract symptoms on quality of life: evi-

dence from the ICS-‘BPH’ Study. International Continence

Society–Benign Prostatic Hyperplasia. Br J Urol 1997;

80:712–21.

[40] Lukacs B, Comet D, Grange JC, Thibault P. Construction

and validation of a short form benign prostatic hypertro-

phy health-related quality-of-life questionnaire. Br J Urol

1997;80:722–30.

[41] Epstein RS, Deverka PA, Chute CG, Panser L, Oesterling JE,

Lieber MM, et al. Validation of a new quality of life ques-

tionnaire for benign prostatic hyperplasia. J Clin Epide-

miol 1992;45:1431–45.

[42] Hald T, Nordling J, Andersen JT, Bilde T, Meyhoff HH,

Walter S. A patient weighted symptom score system in

the evaluation of uncomplicated benign prostatic hyper-

plasia. Scand J Urol Nephrol Suppl 1991;138:59–62.

[43] Meyhoff HH, Hald T, Nordling J, Andersen JT, Bilde T,

Walter S. A new patient weighted symptom score system

(DAN-PSS-1). Clinical assessment of indications and out-

comes of transurethral prostatectomy for uncomplicated

benign prostatic hyperplasia. Scand J Urol Nephrol

1993;27:493–9.

[44] Asplund R, Aberg HE. Nocturnal micturition, sleep and

well-being in women of ages 40–64 years. Maturitas

1996;24:73–81.

[45] Kageyama T, Kabuto M, Nitta H, Kurokawa Y, Taira K,

Suzuki S, et al. Prevalence of nocturia among Japanese

adults. Psychiatry Clin Neurosci 2000;54:299–300.

[46] Abraham L, Hareendran A, Mills IW, Martin ML, Abrams P,

Drake MJ, et al. Development and validation of a quality of

life measure for men with nocturia. Urology 2004;63:481–6.

[47] Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ.

The Pittsburgh Sleep Quality Index: a new instrument for

psychiatric practice and research. Psychiatry Res

1989;28:193–213.

[48] Avery K, Hashim H, Gardener N, Abrams P, Donovan J,

Abraham L. Development and psychometric evaluation of

the ICIQ nocturia module: The ICIQ-N. Neurourol Urodyn

2004;23: Abstract 595.

[49] Ware Jr J, Kosinski M, Keller SD. A 12-Item Short-Form

Health Survey: construction of scales and preliminary

tests of reliability and validity. Med Care 1996;34:220–33.


[50] Stanley N. The Physiology of sleep and the impact of

ageing. Eur Urol Suppl 2005;3(6):17–23.

[51] Akerstedt T, Nilsson PM. Sleep as a restitution: an intro-

duction. J Int Med 2003;254:6–12.

[52] Djavan B, Milani S, Davies J, Bolodeoku J. The impact of

tamsulosin oral controlled absorption system (OCAS) on

nocturia and the quality of sleep: preliminary results of a

pilot study. Eur Urol Suppl 2005;4(2):61–8.

[53] Tryon WW. Issues of validity in actigraphic sleep assess-

ment. Sleep 2004;27:158–65.

[54] Vallieres A, Morin CM. Actigraphy in the assessment of

insomnia. Sleep 2003;26:902–6.

[55] Sadeh A, Hauri PJ, Kripke DF, Lavie P. The role of actigraphy

in the evaluation of sleep disorders. Sleep 1995;18:288–302.

[56] Ancoli-Israel S, Cole R, Alessi C, Chambers M, Moorcroft

W, Pollak CP. The role of actigraphy in the study of sleep

and circadian rhythms. Sleep 2003;26:342–92.

[57] Kushida CA, Chang A, Gadkary C, Guilleminault C, Carrillo

O, Dement WC. Comparison of actigraphy, polysomno-

graphic and subjective assessment of sleep parameters in

sleep-disordered patients. Sleep Med 2001;2:389–96.

[58] Edinger JD, Means MK, Stechuchak KM, Olsen MK. A pilot

study of inexpensive sleep-assessment devices. Behav

Sleep Med 2004;2:41–9.

the measurement of nocturia and its impact on quality of...

Documents