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Keywords:

  • anxiety;
  • depression;
  • health-related quality of life;
  • lower urinary tract symptoms;
  • pain;
  • psychiatric morbidity

Abstract

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

Background: This study aimed to evaluate the association of factors such as pain, lower urinary tract symptoms (LUTS), anxiety, depression and psychiatric morbidity on health-related quality of life (HRQoL) of patients with LUTS.

Methods: A total of 227 patients with LUTS were recruited into the study. The patients were assessed on pain, LUTS, anxiety, depression, psychiatric morbidity and health-related quality of life (HRQoL) using standardized questionnaires.

Results: The study showed that after adjustment, age, pain, anxiety, depression, psychiatric morbidity and LUTS contributed 31%, 13%, 45%, 16% and 48% respectively to the variability of the physical, mental, social, global and overall HRQoL.

Conclusion: Age, pain, psychiatric morbidity, anxiety and depression are associated with HRQoL among patients with LUTS.


Introduction

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

Lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia often cause bothersomeness, dissatisfaction and disturbances in daily activities and living.1–5 However, the majority of men do not seek medical or surgical treatment because they are unaware of the symptoms, which may be of little bother to them, or may be unaware that they are having LUTS.6–10 Most men assume that the condition is a result of the aging process and are able to tolerate the urinary symptoms, which may extend to the need for medical or surgical intervention.

Lower urinary tract symptoms can pose a psychological impact in terms of depression, anxiety and psychiatric morbidity.11 These psychological disorders may cause morbidity, affecting longevity and the overall quality of life (QoL) of men afflicted with LUTS, and their families.12

Age, pain, LUTS and psychological disorder have been suggested to affect health-related quality of life (HRQoL). This study served as to examine whether factors such as age, pain, LUTS and psychological disorder can be associated with HRQoL.

Methods

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

A total of 227 patients confirmed as having benign prostatic hyperplasia and LUTS were involved in this study. These patients were assessed on their pain, LUTS, anxiety, depression, psychiatric morbidity and HRQoL. This group comprised patients with various indications such as renal impairment secondary to bladder outlet obstruction, bladder stones, failure of medical treatment, urinary tract infections and patients who were on medical treatment such as doxazosin, terazosin and alfuzosin. Ethical approval was obtained from the hospital ethics committee prior to the commencement of the study. Subsequently, patients’ consent was obtained. The patients were assessed using the standardized questionnaires/inventories. The questionnaires and inventories used in the study were the visual analog scale,13 International Prostatic Symptom Score (IPSS),14 Beck Depression Inventory (BDI),15 State–Trait Anxiety Inventory (STAI),16 General Health Questionnaire 12 (GHQ-12)17 and Health-Related Quality of Life (HRQoL-20).18 All these questionnaires and their translated versions (using a back-translation technique)19 had been validated prior to the commencement of the study.

The STAI comprised two scales: state anxiety and 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 feels, respectively.

The BDI is a clinical inventory consisting of 21 items, which are rated on a four-point scale ranging from 0–3 in terms of severity where the higher scores indicate severity of depression and vice versa.

The GHQ-12 is rated on a Likert scale from 0–3 where the higher scores indicate high psychiatric morbidity. The total scores of GHQ-12 were formed by summing the 12 items where 0 indicates best mental health and 36 indicates worst mental health.

The IPSS has been widely used internationally to assess urinary symptoms or LUTS. The score is classified as mild (0–7), moderate (8–19) or severe (20–35).

The HRQoL questionnaire consists of 20 questions that are scored according to a 10 cm long visual analog scale with a negative pole (0 cm) and a positive pole (10 cm). Patients were asked to place a mark on the line to indicate their status. Each subject's response on the visual analog scale was measured to the nearest millimeter. The minimum and maximum scores for each question were 0 and 10, respectively.

The global HRQoL scale was calculated by summing the 20 visual analog scale scores for the physical/functional dimensions such as locomotion, sexual activity, appetite and sleeping (six questions), mental health status such as behavior, cognitive and emotional aspects (six questions), social life status such as activity, social participation and personal relationship (six questions) and global (overall) quality of life (two questions). The sum of the scores for each group of questions gave three corresponding subscores (minimum 0, maximum 60), and an overall score (minimum 0, maximum 200) was calculated by combining the three subscores and those of the two general questions. Three questions explored the patient's perceived sexual status: two were from the physical/functional subscore (sexual desire, quality of erection) and one from the social life subscore (satisfaction with sexual life). They were analysed separately by constructing a sexual score (minimum 0, maximum 30) from the responses to these three questions.

Statistical analyses were performed using SPSS version 11.5 (SPSS Inc., Chicago, IL, USA). Bivariate correlation was used to assess the strength of the relationship between variables studied. Multiple regression analysis was used to determine the predictors on the outcome.

Results

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

Social demographics

Most patients fell in the age group of 60–69 years (41.9%) followed by age group of 70–79 years (29.1%), 50–59 years (18.9%), >80 years (7.5%) and <50 years (2.6%). The mean age of this group was 66.58 years (SD = 8.60). Chinese (57.70%) formed the largest ethnic group followed by Indians (22.50%), Malays (17.60%) and others (2.20%).

Pain

Pain intensity is described in Table 1. Those who suffered pain were mainly those who were having bladder stones, urinary tract infection, or distension of the bladder secondary to LUTS.

Table 1.  Mean and standard deviation among the patients with lower urinary tract symptoms
ParametersnMeanSD95% CI
LowerUpper
  1. BDI, Beck Depression Inventory; GHQ, general health questionnaire; HRQOL, health-related quality of life; IPSS, International Prostatic Symptom Score; STAI, State–Trait Anxiety Inventory.

Age22766.58 8.6065.4567.71
Pain227 1.44 2.34 1.13 1.74
IPSS22716.70 7.7916.6717.71
STAI22778.0513.0576.3479.75
GHQ22711.70 4.4911.1112.29
BDI22710.29 7.33 9.3711.25
Physical22726.61 9.5325.0627.55
Mental22722.15 9.4720.9123.39
Social22726.9212.6425.2728.57
Global227 7.56 3.85 7.07 8.08
Overall HRQOL22783.26 3.8579.2687.27

Anxiety

The mean scores for anxiety are shown in Table 1. It was found that anxiety was slightly high correlated with depression (r = 0.67, P < 0.01); moderately correlated with psychiatric morbidity (r = 0.56, P < 0.01), mental health (r = 0.55, P < 0.01), overall HRQoL (r = 0.52, P < 0.01) and social status (r = 0.48, P < 0.01), and weakly correlated with pain and LUTS (r = 0.36, P < 0.01) and physical function (r = 0.30, P < 0.01).

Depression

The mean scores for depression are shown in Table 1. Depression was moderately correlated with social (r = 0.53, P < 0.01) and overall HRQoL (r = 0.57, P < 0.01) and physical function (r = 0.43, P < 0.01), and weakly correlated with pain (r = 0.19, P < 0.01), LUTS (r = 0.35, P < 0.01) and age (r = 0.26, P < 0.01).

Psychiatric morbidity

The mean scores for psychiatric morbidity are shown in Table 1. Psychiatric morbidity was moderately correlated with social (r = 0.46, P < 0.01) and overall HRQOL (r = 0.45, P < 0.01), LUTS (r = 0.46, P < 0.01), mental (r = 0.40, P < 0.01), and weakly correlated with pain (r = 0.25, P < 0.01) physical function (r = 0.30, P < 0.01), age (r = 0.26, P < 0.01) and physical function (r = 0.43, P < 0.01).

Prostate symptoms

The mean score of IPSS was illustrated in Table 1. Most patients were highly symptomatic in their LUTS based on the classification of the IPSS. Lower urinary tract symptoms have been found to moderately correlated with psychiatric morbidity (r = 0.46, P < 0.01), physical function (r = 0.42, P < 0.01), social status (r = 0.44, P < 0.01) and overall HRQoL (r = 0.44, P < 0.01), and weakly correlated with pain (r = 0.33, P < 0.01) and mental health (r = 0.31, P < 0.01).

Quality of life

Physical function was highly correlated with social status and overall HRQoL. Mental health was highly correlated with social status and HRQoL, and social status was highly correlated with HRQoL. Global status was highly correlated with mental health (r = 0.61), social status (r = 0.67, P < 0.01) and overall HRQoL (r = 0.76, P < 0.01); moderately correlated with physical function (r = 0.52, P < 0.01), depression (r = 0.46, P < 0.01) and anxiety (r = 0.45, P < 0.01); and weakly correlated with age (r = 0.21, P < 0.01), psychiatric morbidity (r = 0.32, P < 0.01) and LUTS (r = 0.21, P < 0.01).

Multiple regression analysis

Physical status

Adjusted analysis showed that only age (P = 0.0001), LUTS (P = 0.0001) and depression (P = 0.003) were significantly associated with physical function. Overall, the variability of physical function that can be explained by the explanatory factors after adjusting for confounding was 31.0% (Table 2).

Table 2.  Predictive factors on the physical function among patients with lower urinary tract symptoms
Independent variablesAdjusted
Unstandardized βStandard errorStandardized β95% CIP-value
  1. R2 = 0.31, Adjusted R2 = 0.30; F6 220 = 16.77, P < 0.0001.

Age  0.260.07  0.23  0.13–0.380.0001
Pain−0.170.24−0.04−0.65–0.310.48
Prostatic symptoms 0.400.08 0.33 0.24–0.560.0001
Psychiatric morbidity 0.00120.16−0.006−0.32–0.300.94
Anxiety 0.00160.06 0.02−0.10–0.130.78
Depression 0.320.11 0.25 0.11–0.530.003
Mental status

Adjusted analysis showed that only age (P = 0.0001) and LUTS (P = 0.0001) significantly contributed to the mental function outcome. The variability of mental function that can be explained by the explanatory factors was 13.0% (Table 3).

Table 3.  Predictive factors on the mental function among patients with lower urinary tract symptoms
Independent variablesAdjusted
Unstandardized βStandard errorStandardized β95% CIP-value
  1. R2 = 0.13, Adjusted R2 = 0.12; F6 220 = 10.94, P < 0.0001.

Age  0.20.07  0.18  0.06–0.330.005
Pain−0.0050.27−0.01−0.58–0.480.86
Prostatic symptoms 0.370.08 0.30  0.21–0.530.0001
Social status

Adjusted analysis showed that only age (P = 0.0001), LUTS (P = 0.0001), psychiatric morbidity (P = 0.05), anxiety (P = 0.008) and depression (P = 0.012) significantly contributed to the social function outcome. The variability of social function that can be explained by the explanatory factors was 45.0% (Table 4).

Table 4.  Predictive factors on the social function among patients with lower urinary tract symptoms
Independent variablesAdjusted
Unstandardized βStandard errorStandardized β95% CIP-value
  1. R2 = 0.45, Adjusted R2 = 0.44; F6 220 = 30.12, P < 0.0001.

Age  0.410.08  0.28  0.26–0.560.0001
Pain−0.10.29−0.02−0.67–0.470.73
Prostatic symptoms 0.380.1  0.24  0.19–0.570.00
Psychiatric morbidity  0.360.19  0.13  0.01–0.730.05
Anxiety  0.190.07  0.19  0.05–0.320.008
Depression  0.320.13  0.19  0.07–0.570.012
Global status

Adjusted analysis showed only anxiety (P = 0.02) significantly contributed to the global function outcome. These factors contribute only 16% of the variance in global status (Table 5).

Table 5.  Predictive factors on the global evaluation domains among patients with lower urinary tract symptoms
Independent variablesAdjusted
Unstandardized βStandard errorStandardized β95% CIP-value
  1. R2 = 0.16, Adjusted R2 = 0.11; F6 220 = 3.35, P < 0.005.

Age  0.0050.04  0.12−0.02–0.120.18
Pain−0.140.11−0.12−0.37–0.080.21
Prostatic symptoms  0.00020.05−0.01−0.10–0.090.96
Psychiatric morbidity 0.0050.08−0.06−0.20–0.110.55
Anxiety  0.0090.04  0.32  0.02–0.160.02
Depression  0.0050.05  0.11−0.06–0.150.38
Overall health-related quality of life

Adjusted analysis showed that only age (P = 0.0001), LUTS (P = 0.0001), anxiety (P = 0.001) and depression (P = 0.001) were significantly contributed to the overall HRQoL. Overall, the variability of the overall HRQoL that can be explained by the explanatory factors was 48.0% (Table 6).

Table 6.  Multiple regression findings of predictors and overall health-related quality of life
Independent variablesAdjusted
Unstandardized βStandard errorStandardized β95% CIP-value
  1. R2 = 0.48, Adjusted R2 = 0.46; F6 220 = 16.77, P < 0.0001.

Age  0.880.18  0.25  0.52–1.240.0001
Pain−0.780.68−0.06−2.12–0.570.26
Prostatic symptoms  0.970.23  0.25  0.52–1.410.0001
Psychiatric morbidity  0.470.44  0.07−0.40–1.340.29
Anxiety  0.560.17  0.24  0.24–0.890.001
Depression  0.980.3  0.24  0.40–1.570.001

Discussion

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

In this study, it was found that psychological disorders such as anxiety, depression, psychiatric morbidity and pain could adversely affect QoL in addition to the bothersomeness caused by LUTS. The majority of patients experienced slight depression and bothersomeness due to LUTS and pain, which affects their overall QoL. Age was found to contribute to the outcome where an increase in age causes deterioration in HRQoL. One of the reasons is that as age increases, prostatic symptoms also increase giving a high likelihood of deterioration in their quality of life.

Anxiety levels among patients are slightly high. Unsolved LUTS and bothersomeness caused by LUTS increased the anxiety level. Most of the anxiety is largely attributed to the symptoms and thoughts of how to overcome them. Patients tend to worry and increase their level of anxiety. This subsequently affects their overall QoL.

The majority of patients also experienced a slight increase in depression. This could be attributed to the fact that the LUTS had a great impact on their daily living and activities. Some are depressed because they have to undergo surgical treatment, and some due to failure of medical treatment. Similarly, the slight increment in psychiatric morbidity, bothersomeness, irritation and pain could be related to the LUTS.

Only age, LUTS and depression were significantly associated with the physical function. Most of the explanatory factors contributed 31% of the outcome. Older age, severe LUTS and high depression are the some of the causes for the deterioration in overall QoL. However, there are other factors that were not studied which may contribute 69% of the physical function outcome.

For mental status, it is not surprising to find that age and LUTS significantly contributed to the mental function outcome. This is due to the fact that the elderly patients are the ones who have high symptoms of LUTS and therefore, it is not surprising that these two factors affect their mental status. Nevertheless, all the explanatory factors contributed only 13% of the mental status outcome and another 87% could be attributed to other factors.

For social status, it was found that age, LUTS, psychiatric morbidity, anxiety and depression were associated with QoL (45%). This is simply because aging patients and who are having LUTS tend to be psychiatrically morbid, therefore, contributing to the deterioration of the QoL.

As for global assessment, only anxiety was significantly associated (16%) to the global function outcome. Anxiety is widely known to be associated with deterioration of satisfaction. However, there is 84% of the variance of global assessment that was not studied which could possibly contribute to the outcome.

As for overall HRQoL, it was noted that age, LUTS, anxiety and depression were the associated factors for overall HRQoL. This was not surprising because age, LUTS, anxiety, depression have been long associated with HRQoL where higher age, severe symptoms, and high anxiety and depression all lead to deterioration of QoL. However, only pain and psychiatric morbidity did not significantly contribute to the outcome. This could be because there is a small number of patients with pain and psychiatric morbidity but without deterioration in their QoL. All the explanatory factors contributed 48% of the overall HRQoL.

There are many factors that contribute to the overall QoL of patients with LUTS apart from its symptoms. Therefore, clinicians should pay attention not only to the patient's symptoms but to other outcomes such as anxiety, depression and psychiatric morbidity in order to improve their HRQoL.

In conclusion, this study showed that age, pain, LUTS, anxiety, depression and psychiatric morbidity are the determinants associated with the physical, mental, social, global and overall HRQoL outcome. However, there are other factors that were not studied here might also contributed to the HRQoL outcome.

Acknowledgment

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

The author wishes to thank the University of Malaya's Research and Development Management Unit for providing financial support.

References

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