Bilal Chughtai, MD

On average, humans spend one-third of their lives asleep. Sleep is a restorative physiologic state and is a vital factor in physical and mental health maintenance, memory consolidation, and immune defense enhancement 

 Although sleep quality is difficult to precisely evaluate, it is a widely used construct measured subjectively by validated questionnaires and objectively by polysomnography or actigraphy. Sleep duration is commonly used as a proxy for assessment of sleep health. Adults typically require 7 to 9 hours of sleep per night, but over 35% of adults report sleeping less than 7 hours per night, and nearly 30% sleep less than 6 hours 

Poor sleep has been associated with a number of serious adverse health effects, including obesity, type 2 diabetes, cardiovascular disease, and mortality 

 Recent evidence has further linked impaired sleep with urologic disease, notably erectile dysfunction (ED) and lower testosterone levels (table) 

 Nocturia has repeatedly been associated with poor sleep quality, and evidence suggests this relationship is bidirectional.

Second-generation male sling beneficial at 5-year follow-up

Targeted counseling regarding sleep hygiene improvements may positively affect several urologic disorders while also facilitating a host of overall health benefits. Here we discuss the significant impact of sleep on men with urologic disease.

The link between ED and sleep disorders is well established. Numerous studies have reported an increased incidence of ED in men with obstructive sleep apnea (OSA) ranging from 47% to 80%

 Insomnia has been identified as an independent risk factor for sexual dysfunction in older men, theorized to be related to decreases in testosterone 

 In a recent study, men working nonstandard shifts who reported poor sleep quality had higher rates of erectile dysfunction than men who subjectively slept better 

Both restless legs syndrome and periodic limb movements are associated with an increased prevalence of ED 

 although as with other sleep disorders the underlying relationship remains unclear. Given the high incidence of poor sleep in the overall population, increased attention has recently turned to the impact of poor sleep on erectile function in men without specific sleep disorders.

In a survey study, 377 men with a mean age of 46 years completed validated sleep and erectile function questionnaires and were queried about comorbidities, smoking status, shift work status, and caffeine and medication use 

 Multivariable regression analysis controlled for a number of dependent variables, including age, body mass index, and burden of comorbidity. The authors found that poor sleep quality was independently associated with worsening erectile function. Notably, erectile function in this same group improved after patients were given instructions on improving sleep hygiene.

Further research characterizing this association is needed, but it is apparent that sleep health is an essential consideration for optimizing sexual function in men.

Numerous studies in humans and animals have reported an association between impaired sleep and lower serum testosterone levels 

 Low testosterone has been associated with a number of adverse health effects, including decreased libido, depressed mood, sexual dysfunction, and poor concentration 

In a recent study, serum testosterone levels in 9,756 men aged 16-80 years were analyzed utilizing a multivariable regression model controlling for comorbidities and baseline demographics 

 The authors found an association between lower serum testosterone levels and impaired sleep, showing a decrease of 5.85 ng/dL in serum testosterone for each hour of sleep lost 

 Although it is unlikely that a decrease of 5.85 ng/dL in testosterone levels per hour of sleep lost will dramatically affect overall health, sleep improvement should still be an important part of the treatment algorithm to maintain or increase testosterone levels. 

Nocturia is a widely prevalent condition that increases with age. Nocturia is associated with lower quality of life and has been associated with a number of comorbidities, including falls and fractures, diabetes, obesity, coronary artery disease, depression, and increased risk of all-cause mortality 

 Although numerous studies have identified nocturia as an independent predictor of sleep disturbance 

 there is evidence suggesting that the relationship between nocturia and sleep disruption is not necessarily unidirectional. It is generally supposed that nocturia causes patients to awaken, but studies have suggested that poor sleep itself results in patients waking up and realizing they need to urinate.

Low T could hasten time to post-RP biochemical recurrence

On one hand, successful treatment of nocturia and overall lower urinary tract symptoms (LUTS) has been shown to lead to improvement in sleep quality, while another study reported that poor sleep quality was associated with incident LUTS, including nocturia alone 

 Sleep apnea in particular has been identified as potentially playing a causal role in some cases of incident nocturia, but even healthy adults may suffer from sleep disturbance that causes them to awaken and then void.

A broader consideration is the potential multidirectional association among sleep, urologic symptoms, and non-urologic disease. Conditions known to be negatively affected by poor sleep quality, such as diabetes and cardiovascular disease, have also been identified as contributing factors in urologic symptoms 

 Ultimately, assessment of sleep should be considered an essential aspect of care for patients with urologic disease, which includes providing counseling and appropriate referrals for sleep evaluations.

As leaders in men’s health, urologists can offer appropriate initial counseling on improving sleep hygiene. This includes practices such as routine exercise, avoiding stimulant use such as caffeine or nicotine before bedtime, following a regular bedtime routine, exposure to natural light during the day, and ensuring a good sleep environment 

 Good sleep hygiene can have a significant positive impact on health, both globally and urologically.

is associate professor of urology, Weill Cornell Medical College, New York.

 is professor of urology at the Icahn School of Medicine at Mount Sinai and director benign urologic diseases, Mount Sinai Health System, New York. Follow him on Twitter at 

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"Targeted counseling regarding sleep hygiene improvements may positively affect several urologic disorders while also facilitating a host of overall health benefits," write Hudson Pierce and Bilal Chughtai, MD.

Impact of poor sleep quality on urologic disease

In 2016, unintentional injuries were the third most common cause of death in men above the age of 20, ranking just behind heart disease and cancer 

 Further, unintentional injuries are the number one cause of death among people between ages 1 and 44 years and cost over $70 billion a year. For urologists, decreasing risk for unintentional injuries is one of the most impactful moments of a patient visit.

Unintentional injuries are generally preventable and fall into two categories: nonfatal or fatal 

 Men are about twice as likely as women to die from an unintentional injury, with the most common causes of fatal injuries being overdose, motor vehicle accidents (MVA), and falls. By contrast, the most common causes of nonfatal injuries are falls, inadvertent strike, and overexertion. We review the rates and trends of unintentional injury in men and provide simple recommendations for urologists-many of whom see a disproportionate number of male patients-to implement in their practice.

Yearly, an estimated 11 million men are treated in the emergency department for nonfatal unintentional injuries. The rate of nonfatal injury in adult men remained steady at between 9% and 10% from 2001 to 2015. Younger men had the most drastic decreases in nonfatal injuries, while men above the age of 45 experienced an increase in nonfatal injury rates, due to a number of causes including falls. This represents a large area for urologists to make an impact, as elderly patients are commonly seen for conditions such as nocturia, which is a risk factor for falls.
By comparison, increases in drug-related deaths resulted in an increase in the rate of fatal injury in adult men nearly every year from 2009 to 2016, when 98,462 men died secondary to unintentional injury. The rate of fatal unintentional injuries in men from 2001 to 2016 increased.

The rate of occupational injuries has steadily decreased since 2003, with overexertion and falls being the most common causes of nonfatal injury leading to disability. The industries with the highest rates of nonfatal occupational injury in 2016 were health care, construction, public safety, and manufacturing, according to the Bureau of Labor Statistics 

 Industries with the highest rates of fatal occupational injuries include agriculture, construction, transportation, and warehousing. Occupational injury deaths were most common in the 45- to 54-year-old and 55- to 64-year-old age groups.

Men are more likely than women to use nearly every illicit drug and, as such, screening is vital 

 Moreover, overdose is the number one cause of unintentional home death in almost every male age group 

 Overdose deaths were most likely to be caused by opioids, heroin, and cocaine 

 Rates of death were highest in Caucasians, followed by Native Americans and African-Americans 

The rate of annual fatal MVAs in men decreased between 1999 and 2016, and the number of nonfatal MVAs decreased in roughly the same time period. The number of nonfatal injuries from MVAs suffered by African-Americans dropped by half from 2001 to 2015, while Caucasian and Hispanic populations experienced more modest decreases in this time period. These findings have paralleled a dramatic decrease in the rate of driving under the influence (DUI) in males over the past 30 years, as defined by self-reported DUI, DUI-related arrests, and DUI-related fatalities 

 2018; 84:7-12). Despite this decrease, men accounted for 80% of all DUI episodes in 2012. Specifically, men between the age of 21 and 35 years accounted for 32% of all DUI episodes, though they represented only 11% of the population 

Falls were the most common cause of death from unintentional injury in men above the age of 60. Men are more likely to suffer a fall than women. Women are statistically more likely to suffer a nonfatal fall 

Nonfatal unintentional injuries from firearms remained at about 0.011% of the adult male population between 2001 and 2015, rising from 11,252 injuries to 13,335 injuries. The highest rates of injury in this duration were experienced by the 20- to 24-year-old age group followed by the 25- to 29-year-old age group. Fatal unintentional injuries from firearms decreased steadily during this time 

Why are men at higher risk for unintentional injuries? There are several proposed theories, one of which is that there are societal gender norms that promote risk-taking behavior in men. This may stem from the idea that maleness is often defined by strength and independence. These gender expectations have been found in children as young as 10 years old. Such gender socialization has historically been a factor behind the propensity of males to engage in high-risk behaviors, including drunk driving, drug use, and dangerous physical activities (J Adolesc Health 2017; 61:S12-8).
In addition to the gender socialization that takes root in adolescent males, men disproportionately occupy jobs in higher risk industries. These industries include construction, fishing, military, public safety, and mining. In two occupations-firefighting and mining-heroism and fearlessness in the face of dangerous work are ingrained in the workplace culture (Emotion, Space and Society 2008; 1:127-34), which serves to both reinforce gender socialization and also enable men to fulfill a classic male archetype of the financial provider (Labor 2006; 3:77-93).

In the context of this societal understanding and cultivation of gender, it is not surprising then that men in some of these high-risk occupations have come to normalize withstanding physical strain and pain as a necessary, if not rewarded, characteristic aspect of the job 

 2013; 3:3). These factors create an environment conducive to unintentional occupational injury in men by habituating workers to dangerous work and physical strain.

While gender socialization and norms may serve to heighten high-risk environments, substance use has played a significant role in the increased incidence of fatalities. Compared to women, men have increased dopaminergic stimulation in response to substances similar to alcohol, which is involved in the reward mechanism 

There also exists an intersection between masculine norms and alcoholism. Masculine norms such as risk taking have been shown to increase the likelihood of alcohol-related problems 

 2011; 36:906-11). More research is needed to further elucidate the role of gender in substance use disorder, specifically in regard to opioids.

What can be done to reduce unintentional injury? First, screening for alcohol and drug use can help identify high-risk patients and promote counseling on the harms of substance abuse. While obtaining a social history, high-risk professions can be identified, and patients can be reminded to use appropriate safety devices and follow workplace safety regulations. This can include wearing appropriate protective gear and exercising caution when operating heavy machinery. Patients should be encouraged to recognize and report unsafe and hazardous working conditions.
Urology visits provide a rare context in which this societally and occupationally reinforced gender environment may be relaxed. Men frequently overcome many of these barriers in the name of their health to discuss personal and often sensitive topics with their urologists. This offers a unique opportunity for intervention and engagement on these issues, which may have significant outcomes for reducing morbidity and mortality in this population.

Since urology practices tend to have a high proportion of elderly patients, these patients should be screened for fall risk and educated in fall prevention. Patients who suffer from conditions that lead to falls such as overactive bladder and nocturia can be screened and reminded to secure their home to reduce fall risk. This can include a few questions about proper lighting, uneven surfaces, and loose rugs on the floor. Health care providers can also provide pamphlets from the CDC’s National Center for Injury Prevention and Control to reduce injury 

 is associate professor of urology, Weill Cornell Medical College, New York.

is professor of urology at the Icahn School of Medicine at Mount Sinai and director benign urologic diseases, Mount Sinai Health System, New York. Follow him on Twitter at 

Urology visits afford a unique opportunity to discuss falls, drug use, and work accidents.

Bilal Chughtai, MD

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Impact of poor sleep quality on urologic disease

Unintentional injury in men: Trends and risk reduction