Sleep and the Growing and Going Problem

by Warren Schlott, DDS

One of the most common complaints of men who sleep poorly is that they have an urge or a need to use the restroom many times during the night. This can lead to sleep fragmentation and excessive daytime sleepiness. Most often the cause is an enlarged prostate, also known as benign prostatic hyperplasia (BPH). While this condition is most often treated by an urologist, the sleep dentist should be aware of this condition as treating underlying sleep apnea may help the patient sleep better.

BPH is a condition in which the prostate gland enlarges and squeezes or blocks the urethra.1 The enlargement is not due to cancer. The prostate gland is a walnut-shaped gland that surrounds the urethra at the neck of the bladder, where the urethra connects.  The prostate gland grows during two phases in a man’s life. At birth, it is about the size of a pea.  At puberty the first growth phase doubles its volume. The second phase of growth begins around the age of 25 and continues most of a man’s life. There are two theories that may explain prostate growth.2

As men age, the total amount of active testosterone in their blood falls, which leaves a higher ratio of estrogen in the prostate. Studies have suggested that a higher proportion of estrogen increases the activity of substances that promote prostate cell growth. Another theory targets dihydrotestosterone (DHT) as the culprit in prostate growth. Research has shown that even with testosterone levels dropping, men continue to produce and accumulate high levels of DHT. It is thought that the accumulation of DHT encourages prostate growth. It has been found that men who do not produce DHT do not develop BPH. Regardless of the cause, benign prostatic hyperplasia is a common problem.

BPH is most common in men over the age of 50. Research suggests that up to 14 million men in 2010 had symptoms suggestive of BPH.3 Other studies indicate that 50% of men between the ages of 51 and 60 and up to 90% of men older than 80 have BPH.4  It appears that the risk factors for developing BPH include aging and a family history of the condition. Some have suggested that obesity, heart and circulatory disease, and type 2 diabetes, and erectile dysfunction can be additional risk factors. The “growing and going problem” can make life more difficult.

As the prostate enlarges, it pinches the urethra. This results in the bladder wall becoming thicker. Eventually, the bladder can weaken from trying to push urine through the blockage and lose the ability to completely empty itself. Symptoms can include urinary frequency (urination eight or more times a day), the inability to delay urination, trouble starting a urine stream, a weak or interrupted urine stream, dribbling at the end of urination, urinary incontinence (accidental loss of urine), pain during urination, a sense that the bladder is not empty, and nocturia.5 It rarely causes serious complications, but it can be bothersome and embarrassing. Treatment for BPH includes lifestyle changes, medications and surgery.6

Symptoms of mild BPH can often be mitigated by reducing fluid intake before going out in public or before sleep. Avoiding or reducing alcohol and caffeinated beverages may be beneficial. Reducing medications such as decongestants, antihistamines, anti-depressants, and diuretics is often recommended. Finally exercising pelvic floor muscles can help mild symptoms. If lifestyle changes are insufficient to manage symptoms, medications can be used.

There are three types of drugs used to treat BPH. The most common medications used are alpha blockers. These drugs relax smooth muscles of the prostate and bladder to improve urine flow. Examples of this type of drug include Flomax, Uroxatral, Hytrin, Cardura, and Rapaflo. For the significantly enlarged prostates, 5-alpha-reductase inhibitors are used. These drugs block the conversion of testosterone to dihydrotestosterone and may actually shrink enlarged prostates.  Proscar, Avodart, and Jalyn are examples. The third type of drug used is phosphodiestrase-5 inhibitors. More commonly used for erectile dysfunction, these drugs can reduce symptoms of BPH by relaxing smooth muscles of the urinary tract. Cialis is an example of this family of drugs. Even though any of these drugs can have significant side effects, they are the most popular choice of treatment. Surgery is the only other treatment option.

Surgical options can be minimally invasive or invasive.7 Minimally invasive procedures can include needle ablation, microwave thermotherapy, high intensity focused ultra sound, and electrovaporization. These surgical approaches can destroy prostate tissue or widen the urethra to relieve blockage.  Minimally invasive procedures can relieve BPH symptoms, but there is a risk that symptoms may return as the prostate continues to grow. Side effects from the surgery can be significant. The most common invasive surgery is known as TURP, transurethral resection of the prostate. This procedure involves uses a wire loop to remove enlarged tissue. TURP is considered the gold standard for treating blockages due to BPH. However, side effects including sexual dysfunction are common. Which treatment, or combination of treatments, that is best for the patient is decided by the urologist and patient.

Treating comorbid sleep apnea may help. BPH patients become creatures of habit.  They generally know the location of nearby restrooms and take advantage of them regardless of the urge to urinate. Restroom use becomes insurance against the uncontrollable urge to urinate. In other words, restrooms are used whether there is an immediate need or not. It is well known that patients can be wakened by arousals caused by among other things apneas, hypopneas, and airway resistance. If a BPH patient is wakened by arousal, he is most likely to use the restroom even if there is not an extreme urge. By eliminating the arousals, the BPH patient may be capable of sleeping longer without the need of restroom use. It is the author’s opinion the most BPH patients have arousals primarily during REM sleep and eliminating these arousals provides an invaluable service to the patient. Treating the arousals will not cure BPH, but it can help improve sleep quality, making his world a better place.

BPH patients who have not discussed their possible condition with a physician, and who have mentioned the frequent need to urinate during sleeping hours to the sleep dentist, should be referred to a physician, usually an urologist, for a diagnosis and treatment. Treatment of a diagnosed sleep disorder can help the patient.

In the course of treating sleep-disordered breathing, clinicians sometimes will find associated conditions such as benign prostatic hyperplasia. Read more about this topic in “A New Screening Tool Connects Comorbidities To Sleep Disordered Breathing.”  

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