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Keywords:

  • LUTS;
  • depression;
  • BPH

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Study Type – Symptom prevalence (cohort)

Level of Evidence 2b

What's known on the subject? and What does the study add?

Depression plays an important role in pathogenesis of BPH. Our study shows that prostatic symptoms can be helpful in the screening for depression.

OBJECTIVE

  • • 
    To evaluate the relationship between lower urinary tract symptoms (LUTS) and depression in men through validated questionnaires.

PATIENTS AND METHODS

  • • 
    Healthy male workers (n= 673) were invited to a free health check-up.
  • • 
    Patients underwent a detailed medical examination.
  • • 
    All participants completed the International Prostate Symptom Score (IPSS) questionnaire and the Beck Depression Inventory (BDI).

RESULTS

  • • 
    Under multiple logistic regression analysis (adjusted for total testosterone and age), a significant effect of IPSS on BDI score was observed: mild depression (BDI score >9): odds ratio (OR) 1.092, 95% confidence interval (CI) 1.056–1.129; P < 0.001; moderate-to-severe depression (BDI score >19): OR 1.093, 95% CI 1.031–1.159; P= 0.003; and severe depression (BDI score >29): OR 1.176, 95% CI 1.048–1.320; P= 0.006.

CONCLUSIONS

  • • 
    In healthy men, LUTS are significantly associated with depression.
  • • 
    The treatment of LUTS is very important for the mental health of older men.

Abbreviations
BDI

Beck Depression Inventory

OR

odds ratio.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Lower urinary tract symptoms are highly prevalent among older men. BPH is related to ageing, but it remains difficult to develop a standardized clinical definition for BPH, since prostate enlargement is not always related to clinical symptoms. It has been reported that 40% of men in their fifth decade and 90% of men in their ninth decade have BPH [1].

Depressive disorders are a very common group of diseases, with an overall prevalence of 2–15% [2]. Depression can have a severe impact on the overall health, personal and family life of patients, as well as on health economics [3]. According to the National Institute of Mental Health, the US lifetime prevalence of depression is 16.5% [4]. Depression is expected to become the second leading cause of disease burden by the year 2020 [5].

Depression plays an important role in the pathogenesis of many chronic diseases, such as chronic obstructive pulmonary disease, inflammatory bowel disease, arthritis, asthma, diabetes and congestive heart failure [6]. This relationship also exists between depression and many urological diseases, such as incontinence [7,8] and urolothiasis [9]. Recent studies have analysed the impact of BPH on depressive symptoms [10,11]. In the current study, we examined a homogeneous population of men with no apparent prostatic or psychiatric diseases. We took different variables from the IPSS and tried to find a correlation with depressive disorders, using a validated depression screening tool.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

The Androx Vienna Municipality Study was a voluntary health status programme that was offered to male manual workers in the Vienna Municipality employed in the areas of energy supply and public transport. The Androx Vienna Study Group consists of urologists and psychiatrists as well as experts in male endocrinology and internal medicine. Details of the Androx Study have been described previously [12].

Two validated questionnaires were used to examine the two medical conditions LUTS and depression, the IPSS and the Beck Depression Inventory (BDI). Participating individuals also underwent a complete medical check-up and a psychological evaluation.

The IPSS is a widely recognized screening tool for the assessment of LUTS. It contains seven questions about different LUTS and one question about quality of life. We further sub-categorized the seven questions about LUTS into those that assess obstructive symptoms (questions 1, 3, 5 and 6) and those that evaluate irritative symptoms (questions 2, 4 and 7). The answer to question 8 (quality of life) was also evaluated separately.

The BDI is a 21-item self-reported measure intended to evaluate the existence and severity of symptoms of depression. It was first described in 1961 [13]. According to the BDI, mild depression is designated by a score of 10–19, moderate depression by a score of 20–29 and severe depression by a score of 30–63. In the present study, patients were classified according to the severity of depressive symptoms.

To evaluate the correlation between age and IPSS and between the BDI and IPSS, a local linear regression curve was generated on a scatter plot. In addition, we used the Mann–Whitney U-test to assess the correlation between the irritative or obstructive IPSS and a pathological BDI score. P-values were calculated using the Monte-Carlo-Simulation method. Multiple logistic regression analysis was performed to demonstrate the impact of LUTS on depression. Correlations between different variables were assessed using Kendall's τ coefficient. A P-value <0.05 was considered to indicate statistical significance. All calculations were conducted using SPSS 16.0 statistical software.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

A total of 673 patients (mean [sd] age: 51.5 [4.5] years) were included in the study. Patients with obstructive (2.0 vs 7.0, P < 0.001) and irritative (2.0 vs 6.0, P < 0.001) LUTS were found to have significantly higher BDI scores than those with no such symptoms (Table 1). Quality of life differed between patients with a BDI ≤ 9 and those with a BDI > 9 only in the upper quartile of the quality-of-life score (Table 2).

Table 1. Correlation between storage and voiding LUTS and depression, as assessed using the IPSS and BDI scores
 No symptomsSymptoms present P
  1. *Sum of questions 1, 3, 5 and 6 of the IPSS. †Sum of questions 2, 4 and 7 of the IPSS.

Storage IPSS *    
 N108143 
 Median age (quartiles), years51.0 (47.0–54.0)53.0 (49.0–56.0)<0.001
 Median BDI (quartiles)2.0 (0.3–4.0)6.0 (3.0–9.0)<0.001
Voiding IPSS    
 N23783 
 Median age (quartiles), years51.0 (47.0–54.0)53.0 (50.0–56.0)<0.001
 Median BDI (quartiles)2.0 (1.0–5.0)7.0 (3.0–9.0)<0.001
Table 2. Correlation between quality of life and depression, as assessed using the IPSS and BDI score
 BDI score ≤9BDI score >9 P
  • *

    Question 8 of the IPSS.

n 57796 
Median quality of life* as a result of urinary symptoms1.0 (0.0–1.0)1.0 (1.0–3.0)<0.001

Figure 1 comprises scatter plots showing significant correlations between age and IPSS (P < 0.001), age and irritative IPSS (P < 0.001), age and obstructive IPSS (P < 0.001) and IPSS and BDI (P < 0.001).

image

Figure 1. Scatter plots showing the significant correlations (P < 0.001) between A, age and IPSS, B, age and obstructive IPSS questions (sum), C, age and irritative IPSS questions (sum), and D, IPSS and BDI. Regression curves were generated using local linear regression analysis.

Download figure to PowerPoint

Table 3 shows the impact of IPSS on BDI under multiple logistic regression analysis. The risk of any depressive disorder (i.e. BDI > 9) increased by 9.2% with each additional point on the IPSS, the risk of moderate-to-severe or severe depression (BDI > 19) increased by 9.3% with each additional point on the IPSS, and the risk of severe depression (BDI > 29) increased by 17.6% with each additional IPSS point.

Table 3. Correlation between IPSS and BDI using multiple regression analysis. The models were adjusted by τ and age, which did not show a significant impact on BDI
Dependent variablePredictorOR95% CI P
Depressed (BDI score >9)IPSS1.0921.056–1.129<0.001
Moderate-severe or severely depressed (BDI score >19)IPSS1.0931.031–1.1590.003
Severely depressed (BDI score >29)IPSS1.1761.048–1.3200.006

Table 4 shows the correlations between pairs of variables, measured using Kendall's τ coefficient. Each pair of variables has a positive Kendall's τ coefficient, indicating that the ranks of both variables increase together.

Table 4. Correlations between age and BDI and various components of the IPSS
 Kendall's τ P
Age and IPSS 3 groups0.134<0.001
BDI and IPSS 3 groups0.236<0.001
Age and Irritative IPSS questions (sum)0.126<0.001
Age and Obstructive IPSS questions (sum)0.108<0.001
BDI and IPSS Q1: Incomplete emptying0.207<0.001
BDI and IPSS Q2: Frequency0.185<0.001
BDI and IPSS Q3: Intermittency0.147<0.001
BDI and IPSS Q4: Urgency0.15<0.001
BDI ∼ IPSS Q5: Weak stream0.185<0.001
BDI and IPSS Q6: Straining0.113<0.001
BDI and IPSS Q7: Nocturia0.156<0.001
BDI and IPSS Q8: Quality of life as a result of urinary symptoms0.277<0.001
BDI and IPSS0.266<0.001
BDI and Irritative IPSS questions (sum)0.216<0.001
BDI and Obstructive IPSS questions (sum)0.229<0.001

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

The present study investigated LUTS and depression in a homogeneous cohort of healthy men, and found an association between those two symptom complexes.

Depression is an important global public health issue and was rated the fourth leading cause of disease burden in 2000. It accounted for 4% of total disability-adjusted life years [14]. With a lifetime incidence of 2–15% [2], it was the leading reason for disability among people aged 15–44 years in 2004 [15]. It is also responsible for the greatest proportion of disease burden attributable to non-fatal health outcomes, accounting for almost 12% of total years lived with the disability worldwide [6,16,17].

Depression is often a comorbidity of other chronic diseases and can worsen their associated health outcomes. Furthermore depression, naturally, also changes a patient's subjective view of his/her disease. In patients presenting with chronic diseases that include depression, the depression is often not diagnosed because the diagnostic and therapeutic process is directed towards the other chronic diseases.

Studies have documented a significant association between depression and incontinence in older patients [7,8], but little is known about the association between LUTS, BPH and depression. Wong et al. [10] carried out a large study including 1980 men aged 65–92 years. Patients had to complete a specifically designed questionnaire. The investigators were able to show a significant association between moderate-to-severe LUTS and clinically relevant depressive disorders. Johnson et al. [11] evaluated whether the severity of nocturia differed with the state of depression. Compared with non-depressed patients, depressed patients had more severe LUTS.

The association between LUTS and depression could be attributable to several different mechanisms. Obviously, quality of life is decreased in patients with moderate and severe LUTS, sometimes to such an extent that a patient can develop depressive symptoms. Eckhardt et al. [18] showed that the bothersomeness of LUTS, including incomplete emptying of the bladder and frequency, correlated strongly with wellbeing and quality of life. In addition to the obvious functional impact of LUTS, urological diseases in general are viewed very negatively by patients and family members. The study by Gannon et al. [19] showed that men held very negative views about what it meant to have a prostatic disease and viewed such diseases as being associated with old age. Men are often ashamed to have a urological disease and feel embarrassed and anxious about it [20]. The effect of LUTS on a patient's mood could also be explained by the sleep deprivation caused by nocturia [11,21].

In comparison with previous studies, we used a healthy and younger population. The subjects were all working and had similar economic circumstances. The questionnaires were filled out voluntarily. None of the patients had obvious signs of LUTS at the time. We were therefore able to show the usefulness of different prostatic symptoms in screening for depressive symptoms. In contrast to the study by Johnson et al. [11], which examined the relationship between the single symptom of nocturia and depression, we evaluated the relationship between every single item of the IPSS and depression individually. We also tried to distinguish between irritative and obstructive symptoms. As shown in Table 4, each of the symptoms had an impact on depressive symptoms; however, none stands out as a superior predictive factor.

We are aware of the fact that our tool for the diagnosis of depression is merely a questionnaire, but it was our intent with this study to test the value of LUTS in the screening for depression and vice versa, so this can be considered a minor limitation. Another limitation is that we can explain the impact of LUTS on depression with the help of different mechanisms, but we cannot quantify the impact that depression has on the development of LUTS. It has already been shown that depression can cause LUTS by way of influencing different hormonal systems [22].

Despite these limitations, we feel that the present study emphasizes the important relationship between LUTS and depression. It offers an insight into the relevance of clinically moderate and severe symptoms of prostatic disease, and shows that an association with depression exists in all stages of LUTS.

In conclusion, LUTS increase the risk of developing a depressive disorder. If a patient presents with either LUTS or depression, he should be screened for the other disease. Cooperation between urological and psychiatric institutions is crucial, as is the involvement of the general practitioner.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES