Obstructive sleep apnea (OSA) is a progressively prevalent condition characterized by recurrent episodes of partial (hypopnea) or total (apnea) upper airway collapse during sleep, resulting in reduced oxygen levels and sleep disruption resulting in symptoms such as daytime fatigue.¹ The prevalence of OSA varies depending on gender and age. The prevalence of OSA increases with age and is twice as frequent in males. In the United States, the prevalence of OSA stands at about 30% among men aged 30 to 49 years and 40% among men aged 50 to 70 years.² Several studies have reported that risk factors associated with OSA include small oropharyngeal airway, being overweight/obesity, and craniofacial anatomical abnormalites.^1,3 Furthermore, current data associate OSA with cardiovascular, metabolic, oncological, and neurocognitive effects, including hypertension, coronary artery disease, atrial fibrillation, stroke, cognitive impairment (especially affecting attention and executive function), nocturia, nocturnal gastroesophageal reflux, and a higher risk of developing cancer as well as its recurrence.^2,4

While not the only validated screener, the STOP-BANG is a simple tool to assess for the risk of OSA. The questionnaire includes 8 questions, STOP: snoring, tiredness, observed apnea during sleeping and high blood pressure, plus BANG: body mass index ≥ 35, age ≥ 50, neck circumference ≥ 17 inches (40 cm), male gender. Each question is scored as a yes or no. Patients are categorized as low OSA risk (score 0-2), intermediate risk (score 3-4), and high risk of OSA (score ≥5 or ≥3 yes responses plus body mass index ≥35, or neck circumference ≥17 inches). Research studies have reported that the STOP-BANG questionnaire has a sensitivity of 98% and a specificity of 28% to predict moderate to severe OSA.⁵

The standard objective test for OSA is overnight polysomnography in a sleep study center with the primary outcome being measurement of the apnea-hypopnea index (AHI; number of apneas plus hypopneas per hour of sleep). This test involves concurrent monitoring of both sleep and respiration. However, polysomnography in a laboratory procedure is cumbersome, expensive, and time-consuming. Thus, home diagnosis (a home sleep apnea test) has become increasingly used, especially since current data have shown its equivalence to lab-based polysomnography.^1,6 Based on this test, OSA can be categorized objectively as mild (AHI 5-14.9), moderate (AHI 15-29.9), or severe (AHI ≥30).

OSA has a significant influence on men’s health, notably contributing to the development of conditions such as erectile dysfunction (ED), low testosterone, and polycythemia, especially in the setting of testosterone therapy. Moreover, emerging data suggest that OSA may be correlated with poor erectile function recovery following radical pelvic surgery. Multiple reports have described an elevated incidence of ED in men with OSA, with rates varying from 47% to 80%.³ The current evidence demonstrates that men with OSA are at higher risk of ED compared to men without OSA. The causal relationship between OSA and ED remains incompletely elucidated, with hypotheses suggesting that the decrease in nocturnal erections may be a primary contributory factor linking OSA and ED. Nonetheless, other potential mechanisms linking ED and OSA include shared comorbidities, including diabetes, hypertension, low testosterone, and metabolic syndrome, as well as OSA-associated peripheral neuropathy and endothelial dysfunction. In addition, some reports have described that the treatment of OSA, reducing the nocturnal episodes of apnea/hypopnea, and improving blood oxygenation might improve erectile function, with a significant increase in validated erectile function scores (International Index of Erectile Function) after OSA treatment has been instituted.⁷ Based on our clinical observations and preliminary research, early findings indicate that 2-year erectile function recovery following radical prostatectomy is notably diminished in individuals with OSA.⁸

Patients with OSA, similarly, are at increased risk of low testosterone levels, and an inverse correlation has been demonstrated between the severity of the OSA and testosterone levels.³ It is worth noting that OSA is commonly associated with baseline polycythemia (hematocrit ≥50%) and rates increase when such men are started on testosterone therapy.^9,10 A recent study reported that the prevalence of polycythemia in men with OSA on testosterone therapy is almost double that of men on testosterone therapy without OSA.¹¹ Untreated polycythemia is associated with complications such as vascular thrombosis and cardiac sequelae. Accumulating evidence supports a clinical pathway in which men with polycythemia on testosterone therapy should be screened for OSA. In our clinical practice, candidates for testosterone therapy are screened for OSA with the STOP-BANG and potentially a home sleep apnea test even before starting testosterone therapy. With such a pathway we have seen polycythemia rates drop significantly.

In summary, the high prevalence of OSA in men, along with its associations with ED, potentially compromised erectile function recovery following radical pelvic surgery, reduced testosterone levels, and the occurrence of polycythemia in men on testosterone therapy, underlines the importance of OSA screening in men who are middle aged or older.

Funding Source: This study was funded by the Sidney Kimmel Center for Prostate and Urologic Cancers and the National Institutes of Health, and the National Cancer Institute to the Memorial Sloan Kettering Cancer Center through Cancer Center Support Grant (P30 CA008748).

Conflict of Interest Disclosures: The Authors have no conflicts of interest to disclose.