Lower urinary tract symptoms (LUTS) comprise a set of common, bothersome symptoms in middle-aged and elderly men. Recent research suggests that depressive symptoms may influence the symptoms of benign prostatic hyperplasia (BPH). We performed a community-based cross-sectional study to evaluate the correlation between LUTS and depression.
The survey was conducted in a rural community during four periods in August 2009, 2010, 2011, and 2012. Two validated questionnaires were used to examine LUTS and depressive symptoms. These included the International Prostate Symptom Score/quality of life (IPSS/QoL) and the Korean version of the Center for Epidemiological Studies-Depression scale (CES-D-K). Patients were categorized in the depressive symptom group if their CES-D-K score was >16 points.
A total of 711 men were included in this study. Thirty-five participants (4.92%) were found to have depressive symptoms. There was a positive correlation between depressive symptoms and LUTS severity (P<0.001). As compared to the mild LUTS group, the odds ratio (OR) of depression was 2.868 (95% confidence interval [CI], 1.293–6.362; P for trend<0.001) in the moderate LUTS group, and 4.133 (95% CI, 1.510–11.313; P for trend<0.001) in the severe LUTS group. In a model considering multiple variables such as age, education level, smoking, and exercise, the OR in the moderate LUTS group was 2.534 (1.125–5.708, 95% CI, P for trend=0.005), while that in the severe LUTS group was 3.910 (95% CI, 5.708–11.154; P for trend=0.005). In addition, depression was related to voiding symptoms.
Men with severe LUTS are at higher risk of depression than those with less severe urinary symptoms. The severity of voiding symptoms worsens depression. More aggressive urological diagnosis and treatment is needed in patients with severe LUTS, due to the impact on depressive symptoms and QoL.
Depression is one of the most prevalent diseases worldwide, especially given its relationship with various chronic diseases. It is associated with an increased suicide rate, and is the cause of serious medical and social problems [
Nocturia is one risk factor among LUTS for depression because it disturbs sleep at night [
Several studies have recently reported that BPH and subsequent LUTS increase the incidence of depression and decrease the quality of life [
This study was performed on a rural population (Yangpyeong, Gyeonggi-do) during August 2009, 2010, 2011, and 2012. The study included men over 40 years old. Multiple other parameters were analyzed, including education level, marital status, smoking, drinking, obesity (body mass index), regular exercise, and chronic disease (hypertension, diabetes). The correlation between depression and the degree of LUTS was investigated. In addition, during a live interview, participants completed a living habits-related questionnaire including demographic parameters.
All of the participants were instructed to complete the International Prostate Symptom Score/quality of life (IPSS/QoL) and Korean version of the Center for Epidemiological Studies-Depression (CES-D-K) Questionnaires for analysis of LUTS and depression.
The Institutional Review Board (IRB) of Hanyang University Guri Hospital reviewed and approved this study (2013-01-046).
Patients were classified in the depressive symptom (DEP) group if their CES-D-K score exceeded 16 points.
The CES-D is a questionnaire that can be used to diagnose depression based on 20 items [
The Cochran-Mantel-Haenszel test was used to analyze categorical variables. Independent t-tests and the general linear model were used to analyze continuous variables. In an analysis excluding age, P-value and P for trend correcting for age are presented. Logistic regression analysis was used to assess the correlation between LUTS and DEPs. The age correction model and multivariable model are presented. Variables that were correlated with LUTS were selected for calibration of the multivariable model. Statistical analyses were performed using two-way tests with α-error=0.05. Analyses were performed using the statistical package SAS 9.2 (SAS Institute Inc., Cary, NC, USA).
A total of 895 patients were initially included. Seven were excluded because they did not complete the questionnaire. In addition, 173 participants who did not complete the CES-D-K questionnaire and 4 who had missing informations in educational or marital status were excluded (
A total of 468 patients experienced mild symptoms (IPSS score, 0–7), 183 had moderate symptoms (IPSS score, 8–19), and 60 had severe symptoms (IPSS score, 20–35). Depending on the age, there were significant correlations (P<0.001) between LUTS and relevance of demographic parameter, obesity, exercise, chronic disease (hypertension, diabetes) was not represented statistically (
There was a significant positive correlation between the prevalence of DEP and LUTS severity. In a group with mild LUTS, the prevalence of depression was only 2.8%. With moderate LUTS, the prevalence was 8.2%, and in the severe LUTS group, it was 11.7% (P for trend<0.001) (
This cohort study analyzed the association between LUTS and depression in men over 40 years old from a rural Korean community. As the severity of LUTS increased, the risk of depression also significantly increased.
Depression is one of the most common mental illnesses, and is increasing in prevalence. Given the correlation with suicide, this is a public health issue deserving of worldwide attention. A cross-sectional study of 229,595 adults in 2009 found that the prevalence of DEP and depression was 11.0% and 3.7%, respectively [
Urinary incontinence and overactive bladder are two urologic diseases that are relevant to depression. These two diseases are also closely related to age. These conditions also disturb sleep, which can affect quality of life for the patient and family members [
Several studies have demonstrated that LUTS relevant to BPH is closely related to age, depression, and quality of life. The relationship between LUTS and depression was not apparent in all cases [
In a Taiwanese population, 2% of patients diagnosed with BPH developed depression; this risk was 1.87 times higher than that of people without BPH [
Nocturia causes insomnia, affects patients emotionally, and is directly related to depression [
Pietrzyk et al. [
This study is based on a local community population by a research institute so that consistent follow-up is possible. An additional study targeting the same cohort should be possible through ongoing follow-up. In addition, as an objective examination for BPH and depression is in progress, more information can be determined by comparing research and clinical findings based on objective indices.
This study has several limitations. For instance, we were not able to assess causality or the predictors relating LUTS and depression. In addition, this study was based on a small sample of patients. Our results probably cannot be generalized to the entire Korean male population. Future prospective studies may clarify the relationship and causality between LUTS and depression. These data would emphasize the importance of the correlation, and the need for screening and LUTS treatment.
In conclusion, men with severe LUTS have a higher risk of depression than do those with mild and moderate LUTS. The severity of voiding symptoms worsens the DEPs. Given its potential influence on depression and quality of life, there is a need for more aggressive urological diagnosis and treatment of LUTS.
The Institutional Review Board of Hanyang University Guri Hospital reviewed and approved this study (2013-01-046).
No potential conflict of interest relevant to this article was reported.
Patient selection process. CES-D, Center for Epidemiological Studies-Depression scale.
Prevalence of depressive symptoms according to lower urinary tract symptoms (LUTS) severity. Results are adjusted for age (categorical variable). P-values and P for trend were calculated using Cochran-Manel-Haenszel test for categorical variables. P=0.002, P for trend<0.001. DEP, depressive symptom.
Patient characteristics
Characteristic | Total (n = 711) | DEP (n = 35) | Non-DEP (n = 676) | P-value |
---|---|---|---|---|
Age (yr) | 65.25 ± 9.60 | 68.23 ± 8.52 | 65.09 ± 9.46 | 0.057 |
Educational status | 0.039 | |||
High school or higher | 317 | 10 (28.6) | 307 (45.4) | |
Middle school | 140 | 4 (11.4) | 136 (20.1) | |
Elementary or below | 254 | 21 (60.0) | 233 (34.5) | |
Marital status | 0.149 | |||
Married | 661 | 30 (85.7) | 631 (93.3) | |
Single | 50 | 5 (14.3) | 45 (6.7) | |
Smoking status | 0.142 | |||
Never | 198 | 5 (14.3) | 193 (28.6) | |
Ex-smoker | 355 | 20 (57.1) | 335 (49.6) | |
Current smoker | 158 | 10 (28.6) | 148 (21.9) | |
Drinking status | 0.112 | |||
Never | 127 | 5 (14.3) | 122 (18.0) | |
Ex-drinker | 109 | 10 (28.6) | 99 (14.6) | |
Current drinker | 475 | 20 (57.1) | 455 (67.3) | |
Body mass index (kg/m2) | 0.274 | |||
< 23.0 | 265 | 17 (48.6) | 248 (36.7) | |
23.0–24.9 | 171 | 10 (28.6) | 161 (23.8) | |
≥ 25 | 275 | 8 (22.9) | 267 (39.5) | |
Regular exercise | 0.041 | |||
Yes | 266 | 7 (20.0) | 259 (38.3) | |
No | 445 | 28 (80.0) | 417 (61.7) | |
Chronic diseases | ||||
Hypertension | 0.456 | |||
No | 428 | 19 (54.3) | 409 (60.5) | |
Yes | 283 | 16 (45.7) | 267 (39.5) | |
Diabetes | 0.040 | |||
No | 608 | 26 (74.3) | 582 (86.1) | |
Yes | 103 | 9 (25.7) | 94 (13.9) |
Values are presented as mean±standard deviation or number (%).
DEP, depressive symptom.
Selected characteristics according to lower urinary tract symptom severity
Characteristic | LUTS severity |
P-value | P for trend | ||
---|---|---|---|---|---|
Mild (0–7) | Moderate (8–19) | Severe (20–35) | |||
(n = 468) | (n = 183) | (n = 60) | |||
Age (yr) | 63.01 ± 9.30 | 69.1 ± 8.68 | 70.97 ± 8.54 | < 0.001 | < 0.001 |
Educational status | 0.044 | 0.002 | |||
High school or higher | 237 (50.6) | 65 (35.5) | 15 (25.0) | ||
Middle school | 96 (20.5) | 32 (17.5) | 12 (20.0) | ||
Elementary or below | 135 (28.8) | 86 (47.0) | 33 (55.0) | ||
Marital status | 0.087 | 0.045 | |||
Married (n = 661) | 442 (94.4) | 168 (91.8) | 51 (85.0) | ||
Single (n = 50) | 26 (5.6) | 15 (8.2) | 9 (15.0) | ||
Smoking status | 0.024 | 0.807 | |||
Never (n = 198) | 142 (30.3) | 36 (19.7) | 20 (33.3) | ||
Ex-smoker (n = 355) | 218 (46.6) | 103 (56.3) | 34 (56.7) | ||
Current smoker (n = 158) | 108 (23.1) | 44 (24.0) | 6 (10.0) | ||
Drinking status | 0.474 | 0.272 | |||
Never (n = 127) | 89 (19.0) | 30 (16.4) | 8 (13.3) | ||
Ex-drinker (n = 109) | 64 (13.7) | 32 (17.5) | 13 (21.7) | ||
Current drinker (n = 475) | 315 (67.3) | 121 (66.1) | 39 (65.0) | ||
Body mass index (kg/m2) | 0.263 | 0.569 | |||
< 23.0 (n = 265) | 161 (34.4) | 73 (39.9) | 31 (51.7) | ||
23.0–24.9 (n = 171) | 119 (25.4) | 44 (24.0) | 8 (13.3) | ||
≥ 25 (n = 275) | 188 (40.2) | 66 (36.1) | 21 (35.0) | ||
Regular exercise | 0.076 | 0.029 | |||
Yes (n = 266) | 196 (41.9) | 54 (29.5) | 16 (26.7) | ||
No (n = 445) | 272 (58.1) | 129 (70.5) | 44 (73.3) | ||
Chronic diseases | |||||
Hypertension | 0.904 | 0.904 | |||
No (n = 428) | 287 (61.3) | 105 (24.5) | 36 (60.0) | ||
Yes (n = 283) | 181 (38.7) | 78 (27.6) | 24 (40.0) | ||
Diabetes | 0.896 | 0.691 | |||
No (n = 608) | 397 (84.8) | 158 (26.0) | 53 (88.3) | ||
Yes (n = 103) | 71 (15.2) | 25 (24.3) | 7 (11.7) |
Values are presented as mean±standard deviation or number (%). All results are adjusted for age except age variable. P-values were calculated using the general linear model for continuous variables and Cochran-Mantel-Haenszel test for categorical variables.
Correlation between depressive symptoms and LUTS severity
Variable | Age-adjusted models |
Multivariable models |
||
---|---|---|---|---|
OR | (95% CI) | OR | (95% CI) | |
IPSS components, score/total score |
||||
Feeling of incomplete emptying | 1.195 | 1.022–1.399 | 1.213 | 1.034–1.424 |
Frequency | 1.217 | 1.018–1.454 | 1.201 | 0.999–1.443 |
Intermittency | 1.197 | 0.994–1.443 | 1.137 | 0.939–1.378 |
Urgency | 1.336 | 1.140–1.567 | 1.308 | 1.114–1.536 |
Weak stream | 1.237 | 1.055–1.449 | 1.207 | 1.026–1.420 |
Straining | 1.337 | 1.141–1.567 | 1.309 | 1.115–1.537 |
Nocturia | 1.237 | 1.056–1.400 | 1.208 | 1.026–1.421 |
Quality of life score | 1.049 | 0.817–1.346 | 0.997 | 0.771–1.288 |
LUTS severity |
||||
Mild (0–7) (n = 468) | 1 | Reference | 1 | Reference |
Moderate (8–19) (n = 183) | 2.868 | 1.293–6.362 | 2.534 | 1.125–5.708 |
Severe (20–35) (n = 60) | 4.133 | 1.510–11.313 | 3.910 | 5.708–11.154 |
P for trend | < 0.001 | 0.005 | ||
Continuous, 1 score/total score | 1.074 | 1.033–1.116 | 1.068 | 1.026–1.112 |
Voiding symptoms |
||||
Nonvoiding symptoms (n = 446) | 1 | Reference | 1 | Reference |
Voiding symptoms (n = 265) | 2.694 | 1.295–5.605 | 2.661 | 1.267–5.588 |
Continuous, 1 score | 1.11 | 1.051–1.172 | 1.106 | 1.047–1.169 |
Storage symptoms |
||||
Nonstorage symptoms (n = 537) | 1 | Reference | 1 | Reference |
Storage symptoms (n = 174) | 2.441 | 1.195–4.984 | 2.042 | 0.975–4.275 |
Continuous, 1 score/total score | 1.097 | 1.003–1.199 | 1.074 | 0.979–1.178 |
P-values for trend were determined using multivariable logistic regression analyses.
LUTS, lower urinary tract symptom; OR, odds ratio; CI, confidence interval; IPSS, International Prostate Symptom Score.
Multivariable model:
Adjusted for age (continuous), education status, marital status, smoking status, and regular exercise.
Adjusted for age (continuous), education status, marital status, and regular exercise; voiding symptoms: urgency, frequency, nocturia.
Adjusted for age (continuous), education status, marital status, body mass index, and regular exercise; storage symptoms: hesitancy, straining, feeling of incomplete emptying, intermittency, weak stream.