SEARCH

SEARCH BY CITATION

Keywords:

  • anxiety;
  • depression;
  • lower urinary tract symptoms;
  • medical and surgical treatment;
  • psychiatric morbidity.

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

Background:  The present study aimed to evaluate the effects of treating lower urinary tract symptoms (LUTS) on anxiety, depression and psychiatric morbidity following one year of follow-up.

Methods:  A total of 297 patients were involved in this study. Patients were recruited into a surgical group (patients underwent transurethral resection of the prostate, n = 111), a medical group (underwent α-blockers treatment, n = 116) and a control group (renal stones patients with no or mild symptoms of severity, n = 70). Patients were assessed on anxiety, depression and psychiatric morbidity levels before and after treatment and were followed at 3, 6 and 12 months.

Results:  The study showed that before treatment for LUTS, most of the patients, especially the surgical group compared to the medical and control groups, were more anxious, depressed and psychiatrically morbid. However, after treatment, most of the patients in the surgical group experienced a great improvement in their anxiety, depression and psychiatric morbidity level when compared to the medical and control groups. The reduction or improvement of their psychological profile was due to the reduction or total withdrawal of LUTS after treatment.

Conclusion:  Both medical and surgical treatment improved patient LUTS and thus improved their overall anxiety, depression and psychiatric morbidity.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

Benign prostatic hyperplasia (BPH) is a common disease among elderly men and affects men over 50 years of age. The lower urinary tract symptoms (LUTS) secondary to BPH often cause bother, dissatisfaction and disturbance in daily activities and living. The majority of men do not seek medical or surgical treatment because they are unaware of the symptoms, which are no bother or less bother to them, and they may also be unaware that they are have LUTS.1,2 Most men assume that the condition is a result of the aging process and are able to tolerate the urinary symptoms, some of which may need medical or surgical intervention.3

Lower urinary tract symptoms secondary to BPH were found to be associated with sexual dysfunction in most men who had undergone surgical treatment like transurethral resection of the prostate (TURP). Transurethral resection of the prostate has been found to be associated with erectile dysfunction and retrograde ejaculation.4–8 The LUTS alone, together the effect of surgical procedure, had a psychological impact in terms of depression, anxiety and psychiatric morbidity.9 These psychological disorders may cause morbidity, affecting the longevity and overall quality of life (QoL) of men afflicted with LUTS and their families.10–13

Therefore, the present psychosocial study gives a clearer perception on how LUTS secondary to benign prostatic hyperplasia have an impact on QoL in terms of anxiety, depression and psychiatric morbidity level and how these psychological disorders can be overcome by treating LUTS.

This is essentially an observational study to assess the outcomes of anxiety, depression and psychiatric morbidity in cohorts of patients undergoing surgery and medical treatment for LUTS. It is merely a descriptive study and is not designed to make a comparison of merit of the two types of treatment.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

The patients were assessed at baseline and were followed up at 3, 6 and 12 months. Patients were assessed on their anxiety, depression and psychiatric morbidity. A total of 116 LUTS patients with mild and moderate symptoms were started on medical treatment (α-blockers: prazosin, terazosin, doxazosin and alfuzosin), 111 patients with LUTS (59 retention and 52 non-retention) confirmed of BPH underwent surgical treatment (TURP) and 70 renal stone patients with no or mild symptoms were involved in the present study, which was conducted at the University Malaya Medical Center, Kuala Lumpur. For the retention group, the patients were selected for TURP if they develop urinary retention and underwent catheterization. In the non-retention group, the patients who were selected for TURP were from various indications, such as renal impairment secondary to bladder outlet obstruction, bladder stones, failure of medical treatment and urinary tract infections. For the medical group, the patients were selected based on their symptomatic assessment, such as mild and moderate urinary symptoms, rectal examination, medical history and the severity of urinary symptoms which affected their QoL and were not on medical treatment for LUTS. Renal stone patients were chosen because of similar urological conditions for comparison purposes. Ethical approval was obtained from the hospital ethics committee prior to the commencement of the study and patient consent was subsequently obtained. The patients were assessed using standardized questionnaires/inventories and their translated versions, which was done using the back-translation technique.14 The questionnaires and inventories utilized in the study were the Beck Depression Inventory,15 the State Trait Anxiety Inventory16 and the General Health Questionnaire 12.17 All these questionnaires and their translated versions have been validated prior the commencement of the study.18–21

The State-Trait Anxiety Inventory (STAI) comprises of two scales: the transient state anxiety and the dispositional trait anxiety. The state anxiety and trait anxiety scales consist of 20 questions each describing how would one feel at a particular moment of time and how one generally feel, respectively.16

The Beck Depression Inventory (BDI) is a clinical inventory that measures cognitive, affective, somatic symptoms, neurovegetative and endogenous aspects of depression. The inventory consists of 21 items, which are rated on a four-point scale ranging from 0 to 3 in terms of severity where higher scores indicate a greater severity of depression and vice versa.15

The General Health Questionnaire (GHQ-12) is designed to detect psychiatric morbidity in community and clinical settings. It is rated on a Likert scale from 0 to 3 where the higher scores indicate high psychiatric morbidity. The total scores of GHQ-12 were formed by summing the 12 items with 0 indicating best mental health and 36 indicating worst mental health.17

International Prostate Symptom Score (I-PSS) is used to assess urinary symptoms or LUTS. The IPSS is classified into mild (0–7), moderate (8–19) and severe (20–35).

All patients were assessed at baseline, and at 3, 6 and 12 months using the same set of questionnaires. Statistical analyses were performed using SPSS version 10.0 (SPSS Inc., Chicago, IL). Statistical indices used in the present study were effect size index (ESI) and analysis of variance (anova).

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

Social demographic

Most patients on medication fell in the age group of 60–69 years (45.69%), followed by age group of 50–59 years (26.72%), 70–79 years (18.97%), those less than 50 years old (5.17%) and those above 80 years old (3.45%). The mean age of this group was 63.77 years (SD, 8.27 years). In the non-retention group, most of the patients fell within the age group of 60–69 years (40.38%), followed by 70–79 years (36.54%), 50–59 years (15.38%) and those above 80 years old (7.69%), with a mean age of 68.25 years (SD, 7.48 years). In the retention group, most of the patients fell within the age group of 70–79 years (42.37%), followed by 60–69 years (35.59%), 50–59 years (6.78%) and those above 80 years old (15.25%), with a mean age of 70.64 years (SD, 8.27 years) whereas the mean age for the control group is 50.00 years. A significant difference was noted in their mean ages between the groups (P < 0.005).

Chinese (61.21%) formed the largest ethnic group of the medically treated patients, followed by Indians (25.86%), Malays (8.62%) and Others (4.31%). Similarly in the non-retention group, Chinese formed the largest proportion (57.70%) followed by Malays (21.15%), Indians (19.23%) and Others (1.92%). In the retention group, Chinese again formed the largest proportion (50.85%), followed by Malays (32.20%) and Indians (16.95%), while in the control group, Indians formed the largest group. However, no significant difference was noted.

Anxiety

There was a significant difference in anxiety levels between the three groups. Patients prior to TURP were more anxious, as higher mean scores were noted in state anxiety, trait anxiety and in their overall anxiety than the medical and control groups (Tables 1,2).

Table 1.  Mean and SD of anxiety in patients with lower urinary tract symptoms in the medical, surgical and control groups
 State anxietyTrait anxietyOverall anxiety
MeanSDMeanSDMeanSD
Medical
 Baseline35.718.1038.045.9474.1112.84
 3-month34.878.6738.807.2573.5814.99
 6-month33.207.5337.836.7471.0013.60
 12-month31.777.3036.886.5268.6513.10
Overall surgical      
 Baseline40.797.1941.375.6382.1612.00
 3-month35.026.1738.055.6072.9810.86
 6-month32.895.7436.675.2469.7310.41
 12-month31.055.6335.345.3566.3810.41
Non-retention
 Baseline38.278.0740.196.7078.46 1.39
 3-month34.487.1037.696.8872.1713.11
 6-month32.336.2435.985.8968.5011.80
 12-month30.756.6135.276.5166.0212.71
Retention
 Baseline43.025.4842.414.2985.42 8.88
 3-month35.495.2338.374.2073.69 8.46
 6-month33.395.2737.274.5770.81 8.98
 12-month31.324.6435.414.1266.69 7.94
Control
 Baseline36.097.1337.936.3974.1612.25
 3-month36.147.4238.316.0874.4912.39
 6-month34.977.2737.565.9772.3611.90
 12-month33.336.5437.135.8670.4311.54
Table 2.  The effect size index (ESI) of anxiety in patients with lower urinary tract symptoms in medical, surgical and control groups
 ESI 3 monthsESI 6 monthsESI 12 monthsP-value
Medical
 State Anxiety0.100.310.490.001
 Trait Anxiety0.130.040.260.114
 Overall Anxiety0.040.240.420.006
Overall surgical
 State Anxiety0.801.101.350.001
 Trait Anxiety0.590.831.070.001
 Overall Anxiety0.761.041.310.001
Non-retention
 State Anxiety0.470.950.930.001
 Trait Anxiety0.370.630.730.001
 Overall Anxiety4.527.160.890.001
Retention
 State Anxiety1.371.762.140.001
 Trait Anxiety0.941.201.630.001
 Overall Anxiety1.321.662.110.001
Control
 State Anxiety0.010.160.390.067
 Trait Anxiety0.060.060.120.691
 Overall Anxiety0.030.150.300.169

Following 12 months of follow-up, there was a significant difference in the anxiety level in the TURP group (state anxiety, P < 0.001; trait anxiety, P < 0.001) and overall anxiety (P < 0.001) as compared to the medical group (state anxiety, P < 0.001; trait anxiety, P = 0.114) and overall anxiety (P < 0.01). As expected, no significant improvement was observed in the control group (Tables 1,2).

Depression

Before treatment, there was a significant difference in the depression levels between the three groups patients. patients prior to TURP, were more depressed than the medical and control groups. The TURP group had the highest percentage of major depression and higher mean scores compared to the medical and control groups (Tables 3,4).

Table 3.  Mean, standard deviation and effect size index (ESI) of the Beck Depression Inventory in patients with lower urinary tract symptoms treated medically, surgically and the control group
GroupsBaseline3 month6 month12 monthP-value
MeanSDMeanSDESIMeanSDESIMeanSDESI
Medical 7.695.537.395.620.056.145.500.284.594.640.560.0001
Overall surgical13.017.999.016.420.506.855.790.775.555.320.930.0001
Non-retention11.618.908.737.340.326.446.600.585.636.550.670.0001
Retention14.256.939.255.530.727.204.991.025.473.991.270.0001
Control 7.015.186.635.150.075.414.780.314.673.990.450.0150
Table 4.  The severity of depression (Beck Depression Inventory, BDI) in patients with lower urinary tract symptoms treated medically, surgically and the control group
BDIMedical n (%)Surgical n (%)Non-retention n (%)Retention n (%)Control n (%)
Baseline
 Asymptomatic (0–9) 72 (62.07) 38 (34.23)24 (46.15)14 (23.73)51 (72.86)
 Mild-Moderate (10–18) 39 (33.62) 47 (42.34)19 (36.54)28 (47.46)19 (27.14)
 Moderate-Severe (19–29)  5 (4.31) 24 (21.62) 8 (15.39)16 (27.12) 0
 Extreme Severe (30–63)  0  2 (1.80) 1 (1.92) 1 (1.69) 0
3-month
 Asymptomatic (0–9) 83 (71.55) 58 (52.25)30 (57.69)28 (47.46)51 (72.86)
 Mild-Moderate (10–18) 26 (22.41) 49 (44.14)20 (38.46)29 (49.15)18 (25.71)
 Moderate-Severe (19–29)  7 (6.04)  3 (2.70) 1 (1.92) 2 (3.39) 1 (1.43)
 Extreme Severe (30–63)  0  1 (0.9) 1 (1.92) 0 0
6-month
 Asymptomatic (0–9) 93 (80.17) 81 (72.97)39 (75.00)42 (71.19)58 (82.86)
 Mild-Moderate (10–18) 20 (17.24) 27 (24.32)11 (21.15)16 (27.12)11 (15.71)
 Moderate-Severe (19–29)  3 (2.59)  2 (1.80) 1 (1.92) 1 (1.69) 1 (1.43)
 Extreme Severe (30–63)  0  1 (0.90) 1 (1.92) 0 0
12-month
 Asymptomatic (0–9)103 (88.79) 92 (82.88)42 (80.77)50 (84.75)62 (88.57)
 Mild-Moderate (10–18) 11 (9.48) 17 (15.32) 8 (15.39) 9 (15.25) 8 (11.43)
 Moderate-Severe (19–29)  2 (1.72)  1 (0.9) 1 (1.92) 0 0
 Extreme Severe (30–63)  0  1 (0.9) 1 (1.92) 0 0
Total116 (100.00)111 (100.00)52 (100.00)59 (100.00)70 (100.00)

When comparing pre and post treatment, there was a significant improvement in the depression level in the TURP group compared to the medical and control groups (Tables 3,4).

The medical and surgical groups showed great improvement in depression following 12 months of follow-up. There are no changes in the control group since their LUTS symptoms were almost maintained (Tables 3,4).

Psychiatric morbidity

Similar patterns were observed in the psychiatric morbidity level. At baseline, the surgical group had higher psychiatric morbidity, but had subsequently improved 12 months after treatment (P < 0.0001). There were few changes in the medical and control group, as their symptoms were found to be relatively unchanged (Table 5).

Table 5.  Psychiatric morbidity (General Health Questionnaire) in patients with lower urinary tract symptoms treated medically, surgically and the control group
GroupsBaseline3-month6-month12-monthP-value
MeanSDMeanSDESIMeanSDESIMeanSDESI
Medical10.343.85 9.983.350.099.843.670.139.123.120.310.0630
Overall surgical13.134.6710.003.330.678.972.910.898.213.001.050.0001
Non-retention11.754.54 9.833.650.429.083.670.598.563.850.700.0001
Retention14.344.4710.153.040.948.882.041.227.901.951.440.0001
Control11.174.6510.203.530.219.872.890.289.243.060.410.0160

Prostate symptoms

It was found that before treatment, the surgical group had severe prostate symptoms when compared to the medical and control groups. Subsequently, the surgical group experienced remarkably reduction in LUTS after treatment, when compared to the other groups (Fig. 1).

image

Figure 1. The prostatic symptoms at baseline and at 3, 6 and 12 months. ◆, medical (n = 116); ▪, surgical (n = 111); ▵, control (n = 70).

Download figure to PowerPoint

Quality of life

The QoL of most patients who were depressed, anxious and psychiatric morbid was affected. The severity of prostatic symptoms affected their QoL and increase their anxiety, depression and psychiatric morbidity. Those with severe urinary symptoms, especially in the surgical groups, were more dissatisfied with their QoL (Fig. 2). Among the domains of QoL that were affected were their sleep, social activities and mental health. However, their QoL improved after treatment, due to the improvement of urinary symptoms, anxiety, depression and psychiatric morbidity.

image

Figure 2. Disease-specific quality of life at baseline and at 3, 6 and 12 months. ◆, medical (n = 116); ▪, surgical (n = 111); ▵, control (n = 70).

Download figure to PowerPoint

Transurethral resection of the prostate significantly improved the voiding symptoms and associated bother following one year of follow-up, while α-blockers reduced 21.0% of bother and LUTS by only 21.0%. Transurethral resection of the prostate relieved the filling symptoms, but not completely until the twelfth month. In the medical group, there was only minimal relief of filling symptoms and satisfaction. Although the control group did not have any treatment, there were slight improvements in the satisfaction/bother scores.

Complications

There were some complications noted at the first 3 months after surgery. Prostatectomy produces a number of short-term negative effects on patients. Three months after surgery, 10.81% of patients reported that they had one or more episodes of acute retention due to blood clots and 9.01% of patients had catheterization to relieve the pain; 27.03% reported postsurgical infection and the infection lasted two or more weeks for 7.21% of patients; overall, 24.32% reported a non-routine visit to a physician or urologist for a prostate problem (within three months of surgery) and 8.11% had re-admissions to the hospital for a prostate-related problem during that period.

There was evidence of minimal problems following the third month. 10.81% of the patients reported non-routine visits to their physician or urologist, while 3.60% were hospitalized for problems related to their prostate condition from the fourth to the twelfth postoperative month.

Incontinence and erectile dysfunction (ED) are two other complications of prostate surgery that were of long-term significance. Of the patients who had erections before surgery, 5.41% had ED three months postoperatively. Of the patients who reported they had no problem with dripping or wet pants prior to surgery, 5.41% reported it as a problem at 3, 6 and 12 months. A substantially greater number of patients reported these problems at one time or another, but not all at the three follow-ups.

Patients with mild symptoms and patients with acute retention demonstrated considerable differences in their responses to their condition. It is implicit that the severity of symptoms alone is not a valid index for the extent to which or the way in which those symptoms may affect the life of an individual patient. After three months of treatment, the symptomatic improvement assessed using IPSS was significantly greater with TURP than with α-blockers and was related to improvement in both filling and voiding symptoms.

Fifty percent of patients in the non-retention group with moderate to severe symptoms underwent surgical treatment. Those with retention showed great improvement in their urinary symptoms following TURP.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

In the present study, it was found that the psychological disorders, such as anxiety, depression and psychiatric morbidity could adversely affect QoL in addition to the bother caused by LUTS. The majority of patients experienced depression and bother due to LUTS and pain and this affected their overall QoL. However, there was a great reduction of depression scores following surgery due to the improvement of the patients’ urinary symptoms. The improvement was noted at 3 months, further improved at 6 months and was maintained at 12 months. In the medical group, the reduction in depression following α-blocker treatment was relatively low at the first 3 months, but further reduced at 6 months and 12 months.  This  could  be  due  to  a  lower  effectiveness  of medical treatment in reducing LUTS, which adversely affects the QoL as noted in other studies.1 The slight increment of severe depression levels in some patients following TURP could be due to the complications of TURP, such as retention due to blood clot, incontinence, erectile dysfunction, retrograde ejaculation and other social, personal and economic effects as noted in another study.12 In the medically treated group, some patients experienced a slight increased in depression because LUTS had did not at all or fully improve, or had worsened.

The anxiety level in all the groups, particularly the surgical group were found to be high prior to treatment. Following treatment, the surgical group tended to be less anxious due to LUTS improvement, which has been noted in other studies.21–24 Unsolved LUTS and bother caused by LUTS increased the trait anxiety in the medical group.

The low level of anxiety and sex-life satisfaction following surgical treatment may be due to the lifestyles of men who are no longer interested in having sexual activity at their current age, as was found in other studies.25–29

Most of the anxiety is largely attributed to the symptoms and the TURP operative procedure. Before patients underwent TURP, most of them tended to worry and, therefore, show a rise in the trait anxiety level, as well as state anxiety. Some worries were in regard to the surgical procedure and the effect of the surgical treatment. This subsequently affects the patients’ mental, social and physical health, which contributes to the unnecessary anxiety before surgery. In contrast, in the medical group, most of the patients were less worried.

After surgical treatment, patients experienced a great reduction in their anxiety level. This is largely due to the improvement of LUTS, which in turn improved their QoL and overcame their worries regarding surgery, which has also been noted in other studies.30,31 In the medical group, there was not as much of a significant improvement following treatment. Most of the patients on α-blockers complained of little improvement in their LUTS, which could be the reason why anxiety was yet to reduce remarkably.

The high level of psychiatric morbidity before treatment could be related to LUTS, bother, irritation and pain due to the enlarged prostate gland. A reduction of psychiatric morbidity was significantly noted after surgical treatment. This significant improvement in the surgical group could be due to the improvement of LUTS, pain, bother and the improvement of overall QoL, whereas in the medical group, there was no significant improvement in the psychiatric morbidity.

The majority of patients in the control group experienced relatively unchanged levels in their anxiety, depression and psychiatric morbidity after 12 months of follow-up, because they did not suffer any severe urinary symptoms or bother.

In surgery, some complications were noted. However, these complications occurred in only a small percentage and affected the QoL of only some of the patients. However, the majority of the patients indicated an improvement of QoL after surgery, thus improving their psychological symptoms due to LUTS.

In conclusion, the present study showed that LUTS contributed to the increase level of anxiety, depression and psychiatric morbidity before treatment. Before treatment, the surgical group was more depressed, more anxious and more psychiatrically morbid compared to the medical and control groups. Following treatment, the surgical group experienced a greater improvement in anxiety, depression and psychiatric morbidity. One could conclude that TURP patients were more relieved in terms of anxiety, depression and psychiatric morbidity, as well as overall QoL.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

The authors wish to thank the University of Malaya's Research and Development Management Unit for providing financial support. The authors also wish to thank the Psychological Corporation, USA and The Minds Garden, USA for allowing the use of the questionnaires and Dewan Bahasa and Pustaka, Kuala Lumpur for the verification of the translation of the questionnaires and inventories.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References
  • 1
    Garraway WM, Kirby RS. Benign prostatic hyperplasia: effects on quality of life and impact on treatment decisions. Urol. 1994; 44: 62936.
  • 2
    Tsang KK, Garraway WM. Impact of benign prostatic hyperplasia on general well-being of men. Prostate 1993; 23: 17.
  • 3
    Malaysian Medical Tribune. Fighting BPH the alfuzosin way. A fornightly medical newspaper. 60: 14. All media publications. 1998, 6.
  • 4
    Kawacirk I, Cerny J, Dusck P, Safarik L, Kohler O. Subjective symptoms before and after prostate surgery. The International Symptom Scoring System, I–PSS. Rozhl. Chir. 1995; 74: 3348.
  • 5
    McConnell JD, Roehrborn CG. Patient Selection and Symptoms Evaluation. In: Chisholm GD (ed.). Handbook on Benign Prostatic Hyperplasia. Merck, New Jersey, 1994.
  • 6
    Schou J, Holm NR, Meyhoff HH. Sexual function in patients with symptomatic benign prostatic hyperplasia. Scand. J. Urol. Nephrol. 1996; 179 (Suppl.): 11922.
  • 7
    Soderdahl DW, Knight RW, Hansberry KL. Erectile dysfunction following transurethral resection of the prostate. J. Urol. 1996; 156: 13546.
  • 8
    Thorpe AC, Cleary R, Coles J, Reynolds J, Vernon S, Neal SE. Written consent about sexual function in men undergoing transurethral prostatectomy. Br. J. Urol. 1994; 74: 47984.
  • 9
    Naughton MJ, Wyman JF. Quality of life in geriatric patients with lower urinary tract dysfunction. Am. J. Med. Sci. 1997; 314: 21927.
  • 10
    Blazer DG, Kessler RC, Mcgonagle KA, Swartz MS. The prevalence and distribution of major depression in a national community sample: the National Comorbidity Survey. Am. J. Psych. 1994; 151: 97986.
  • 11
    Maniam T. Psychiatric morbidity in an urban general practice. Med. J. Malaysia 1994; 4: 2426.
  • 12
    Vaillant GE, Vaillant CO. Natural history of male psychological health: XII. A 45-year study of predictors of successful aging at age 65. Am. J. Psych. 1990; 147: 317.
  • 13
    Wells KB, Stewart A, Hays RD et al. The functioning and well-being of depressed patients. Results from the medical outcome study. JAMA 1989; 262: 91419.
  • 14
    Brislin RW. Back translation for cross cultural research. J. Cross Cult. Psychol. 1970; 1: 185216.
  • 15
    Beck AT, Steer RA. Beck Depression Inventory: Manual. San Diego: the Psychological Corporation. Harcourt Brace Jovanich Inc., New York, 1986.
  • 16
    Spielberger CD, Gorsuch RL, Luschene A. The State-Trait Anxiety Inventory. University of South Florida, Tampa, 1986.
  • 17
    Goldberg DP, Williams P. User's Guide to the General Health Questionnaire. NFER-Nelson, Windsor, 1988.
  • 18
    Quek KF, Low WY, Razack AH, Loh CS. Beck Depression Inventory (BDI). A Reliability and Validity Test in the Malaysian Urological Population. Med. J. Malaysia 2001; 56 (3): 28592.
  • 19
    Quek KF, Low WY, Razack AH, Loh CS, Chua CB. Reliability and validity of the Malay version of the Beck Depression Inventory among urological patients. Malaysian J. Psychiatry 2001; 9 (1): 2934.
  • 20
    Quek KF, Low WY, Razack AH, Loh CS. Reliability and validity of the General Health Questionnaire (GHQ-12) among urological patients: a Malaysian study. Psychiatry Clin. Neurosci. 2001; 55: 509513.
  • 21
    Quek KF, Low WY, Razack AH, Loh CS, Chua CB. Reliability and validity of the Spielberger State-Trait Anxiety Inventory (STAI) among urological patients. A Malaysian study. Med. J. Malaysia 2001; 59: 26069.
  • 22
    Hodges WF. The effects of success, threat of shock and failure on anxiety. Am. Arbor. Mich 1967; 68: 5388.
  • 23
    Spence JT, Spence KW. The motivational components of manifest anxiety: Drive and drive stimuli. In: Spielberger CD (ed.). Anxiety and Behaviour. Academic Press, New York, 1966. pp. 291326.
  • 24
    Spielberger CD. The effects of anxiety on complex learning and academic achievement. In: Spielberger CD (ed.). Anxiety and Behaviour. Academic Press, New York, 1966b, pp. 36198.
  • 25
    Zohar J, Meiraz D, Maoz B, Durst N. Factors influencing sexual activity after prostatectomy: A prospective study. J. Urol. 1976; 116: 3324.
  • 26
    Bowers LM, Cross JJ Jr, Lyold FA. Sexual function and urological disease in the elderly male. J. Am. Geriat. Soc. 1963; 11: 647.
  • 27
    Freeman JT. Sexual capacities in the aging male. Geriatrics 1961; 16: 3743.
  • 28
    Kahn M. Sexual activity post-prostatectomy. Harefuah 1967; 5: 391.
  • 29
    Newman G, Nichols CR. Sexual activities and attitudes in older persons. JAMA 1960; 173: 335.
  • 30
    Quek KF, Low WY, Razack AH, Loh CS. The psychological effects of treatments for lower urinary tract symptoms. BJU Int. 2000: 86: 63033.
  • 31
    Quek KF, Loh CS, Low WY, Razack AH. Quality of life assessment before and after transurethral resection of the prostate in patients with lower urinary tract symptoms. World J. Urol. 2001; 19: 35864.