Position statement: a clinical approach to the management of adult non-neurogenic overactive bladder

We read with interest the recent position statement on the management of non-neurogenic overactive bladder (OAB) published in the Journal.1 This considered statement reflects recent guidelines from national and international urological societies, including the American Urological Association, the European Association of Urology, the International Continence Society, the Urological Society of Australia and New Zealand and the UroGynaecological Society of Australasia. In recognition of the often repeated phrase in urological research “the bladder is an unreliable witness”, there has been an increasing emphasis on addressing factors beyond the bladder when managing patients with OAB and lower urinary tract symptoms (LUTS).2 The authors of the MJA statement deal with this issue more than most by encouraging their readers to be mindful of known OAB risk factors and comorbid conditions. However, one condition in particular, obstructive sleep apnea (OSA), continues to be overlooked in the diagnosis and management of OAB and LUTS.

Our group has previously shown a substantial burden of undiagnosed OSA in a large sample of community-based men aged 40 years and over, with 53% of men without prior diagnosis shown to have some degree of OSA, of which 14% and 12% were found to have moderate and severe OSA, respectively.3 We also demonstrated an independent association between nocturia — the most frequent and bothersome of the OAB symptoms2 — and the presence of moderate to severe OSA, with such men showing a 52% adjusted risk increase for the presence of nocturia.3 Recent systematic reviews of continuous positive airway pressure in the treatment of nocturia indicated a mean standardised difference of −2.28 episodes per night (95% confidence interval, −2.42 to −2.15) between treatment groups in patients with nocturia.4 This difference is comparable to the efficacy observed with frontline treatments for this condition. Nocturia and other OAB symptoms are also known to be sentinel markers of cardiovascular disease,5 providing further motivation for dealing with known risk factors, such as OSA, in the management of OAB.

We believe that it would be helpful to include recommendations to assess for the presence of OSA in patients presenting with nocturia, either alone or in combination with other OAB-related symptoms.