Differences between Sleep Apnea and Sleep Enuresis

Sleep apnea

Sleep apnea, also called childhood obstructive sleep apnea syndrome, is characterized by episodic upper airway obstruction that occurs during sleep. Apnea is a medical term for suspension of external breathing. The airway obstruction may be complete or partial. Sleep disruption leaves some children with daytime somnolence, difficulty waking in the morning, and disturbed concentration. Complaints of nocturnal enuresis, nightmares, and morning headaches may also occur.

Types of sleep apnea

• Obstructive sleep apnea is the more common form and occurs when the throat muscles relax.
• Central sleep apnea occurs when the patient’s brain doesn't send proper signals to the muscles that control breathing.

Incidence of the sleep apnea

Obstructive apnea is believed to affect approximately 4% of men and 2% of women in the United States. It is estimated that about 18 million Americans have sleep apnea. Obstructive sleep apnea occurs two to three times more often in older adults.

The most common symptoms

The signs and symptoms of obstructive and central sleep apnea can vary which is making this type of sleep apnea more difficult to diagnose. The most common signs and symptoms of obstructive and central sleep apnea include:

• Excessive daytime sleepiness (hypersomnia)
• Loud snoring - Disruptive snoring may be more characteristic in obstructive sleep apnea, while awakening with shortness of breath may be more common in central sleep apnea.
• Observed episodes of breathing cessation during sleep
• Abrupt awakenings with shortness of breath
• Awakening with a dry mouth or sore throat
• Morning headache

Some additional symptoms that may accompany the sleep apnea are:

• unrefreshing sleep
• chest retraction during sleep in young children
• high blood pressure
• weight gain
• irritability
• change in personality
• depression
• difficulty concentrating
• excessive perspiring during sleep
• heartburn
• reduced libido
• insomnia
• frequent nocturnal urination
• restless sleep
• confusion upon awakening

What causes sleep apnea?

Obstructive sleep apnea

Obstructive sleep apnea occurs when muscles in the back of the throat relax.
These muscles support many structures such as the soft palate, uvula, tonsils and tongue. When these muscles relax, the patient’s airways are being narrowed or closed during the inhalation and breathing is momentarily cut off. The most important consequence is low level of oxygen in blood. The patients may sometimes make a snorting, choking or gasping sound. This pattern can repeat itself 20 to 30 times or more each hour, all night long. 

Central sleep apnea

Central sleep apnea is is far less common then the obstructive sleep apnea. It usually occurs when the patient’s brain fails to transmit signals to the muscles included in breathing process. The patients usually wake with shortness of breath. and are more likely to remember the awakening than people with obstructive sleep apnea.

Risk factors

Obstructive sleep apnea

• Excess weigh
• Enlarged tonsils or adenoids
• A naturally narrow throat
• Being male
• Age
• A family history of sleep apnea
• Use of alcohol, sedatives or tranquilizers

Central sleep apnea

• Stroke or brain tumor
• Neuromuscular disorders
• High altitude

Diagnosis of sleep apnea

There are three tests which are commonly used to detect sleep apnea:

Nocturnal polysomnography
During this test, the patient it attached to the equipment that monitors the heart, lung and brain activity, breathing patterns, arm and leg movements, and blood oxygen levels all through the night.

Oximetry
This screening method involves using a small machine that monitors and records the patient’s oxygen level during sleep. A simple sleeve fits painlessly over one of the fingers to collect the information overnight at home. 

Electroencephalogram (EEG)
This test monitors the patient’s brain waves and can reveal repeated awakenings associated with sleep apnea.

Possible complications

There are several complications that could occur in relation to someone who has sleep apnea:

• Cardiovascular problems
• Daytime fatigue. 
• Complications with medications and surgery
• Sleep-deprived partners

Treatment of sleep apnea

Therapies

Continuous positive airway pressure (CPAP)
If the patient was diagnosed with sleep apnea, he or she may benefit from a machine that delivers air pressure through a mask placed over the nose. Although this is a very good method of treating sleep apnea, many people find it uncomfortable.

Dental devices
There are certain dental devices which are designed to open the throat by bringing the jaw forward. They may be also used for relieving snoring and mild obstructive sleep apnea.

Surgery or other procedures

The goal of surgery for sleep apnea is to remove the excess tissue from the nose or throat that may be vibrating and causing the soring, or that may be blocking the upper air passages and causing sleep apnea. Surgical options may include:

• Uvulopalatopharyngoplasty

During this procedure, the tissue from the rear of the patient’s mouth and top of the throat is removed. Tonsils and adenoids are usually removed as well.

• Laser-assisted uvulopalatoplasty

This procedure involves the use of a laser to remove a part of soft palate and shorten the triangular piece of tissue hanging from your soft palate (uvula).

• Radiofrequency ablation

During this procedure a doctor uses radiofrequency energy to remove tissue from uvula, soft palate and tongue, which may help decrease snoring and the risk of sleep apnea.

• Tracheostomy

During this procedure, a surgeon makes an opening in the neck and inserts a metal or a plastic tube through which the patient can breathe.

Sleep enuresis – bedwetting

Sleep enuresis or nocturnal enuresis is a specific disorder which is characterized by the persistent bed wetting during the sleep without any organic pathological cause after the age of 4-5 years.
Most children are toilet trained during daytime between the ages of 2 1/2 to 5 years, and night training usually follows about six months later. It is also called Enuresis nocturna, nocturnal bed-wetting, primary enuresis, familial, functional idiopatic, symptomatic, or essential enuresis, night-wetting…

Prevalence

It is estimated that 15-20% of children wet their beds at age 5, about 5% at age 10, 2-3% at age 14 and 1-2% in young adulthood. It is slightly more common in younger boys than girls, but the ratio increases to 2:1 around age 11. 

Types of sleep enuresis

• Primary enuresis refers to inability to maintain urinary control from infancy.
• Secondary enuresis is a relapse after control has been achieved.

Possible causes of sleep enuresis

There are many theories as to what causes enuresis.

Genetic causes
There is no doubt that genetic or familial factors play an important part in many children. When both parents have, or have had enuresis, there is a higher chance that the children will have it too.

Emotional disturbances
Underlying emotional disturbances, behavioral (ADHD, dyspraxia etc.) and learning difficulties are all considered to play some role in the ethiopathogenesis of sleep enuresis.
 
Sleep and other disorders
Sleep depth arousal levels, a small bladder capacity, nocturnal polyuria, dysfunctional detrusor muscle or dysfunctional perineal muscles may all be the contributing factors.
Medical disorders like diabetes, urinary tract infection, sleep apnea or epilepsy as well as some psychiatric disorders can also cause it.

Stress
Stress and illness may also play a significant part.

Diagnosis and prognosis for bedwetting

There are specific criteria for diagnosing sleep aneuresis: there have to be at least two episodes per month in children 3 to 6 years old and at least one episode per month for older individuals. Sleepwalking can also occur during an episode. The doctor may check for signs of a urinary tract infection, constipation, bladder problems, diabetes, or severe stress.
There is no doubt that bedwetting usually goes away on its own. The problem is that, until it does, it can be embarrassing and uncomfortable for almost any child. That’s why parents play a major role and it's a good idea to reassure a child that bedwetting is a normal part of growing up and that it's not going to last forever.

Treatment of sleep enuresis

Although most of the times this condition resolves by itself,unfortunately, no one can tell how long it may take to reach that point. Approximately 20% of children cease the bed-wetting every year without treatment. Therefore, in the majority of cases, no treatment is necessary. The decision to treat a child should be made jointly by the family, patient, and a physician.
In general, treatment is used for relatively older children, those with secondary emotional problems, and children with more severe (frequent) enuresis. It is important to understand that no universally accepted treatment of enuresis is 100% successful. A full physical examination should be done to rule out other medical conditions. Various techniques can be used when other medical conditions have been ruled out.

The most common are:

• behavior modification,
• alarm devices,
• medications