Overactive bladder (OAB) syndrome is defined by the International Continence Society as a sensation of urgency to urinate, often accompanied by frequent daytime and/or nocturnal urination, with or without urinary incontinence, in the absence of other identifiable diseases [1]. The presence of a urinary tract infection or any other obvious pathology excludes the diagnosis of OAB [1]. Large-sample studies indicate that OAB is common in both North America and European countries, with a reported prevalence of 12%–17% in various studies [2].

Although the pathophysiology of OAB remains a matter of debate, several factors appear to contribute to its manifestation. These include age-related changes, bladder outlet obstruction, bladder ischemia, neurological, myogenic, inflammatory, sex-related, and psychological factors [3]. Among these, research on psychological factors is increasing. A population-based cohort study demonstrated that the prevalence of psychiatric disorders is significantly higher in patients with OAB than in the normal population (14.2% vs. 10.1%), and that OAB is associated with a range of psychiatric conditions, including dementia, anxiety disorders, mood disorders, psychotic disorders, and sleep disorders [4]. Similarly, Melotti et al. [5] reported that moderate to severe depression and anxiety are common among individuals with OAB, with these symptoms intensifying alongside OAB severity. Several studies have suggested a bidirectional relationship between depression and OAB, where OAB may serve as a risk factor for depression, and depression may contribute to the development of OAB [6]. A similar bidirectional relationship appears to exist between anxiety and OAB, with some studies indicating that anxiety and a history of sexual trauma are closely linked to OAB [6].

Obsessive-compulsive disorder (OCD) is a prevalent mental disorder associated with significant disability. It is characterized by the presence of obsessions and/or compulsions. Obsessions are recurrent and persistent thoughts, urges, or images, often accompanied by anxiety, while compulsions are repetitive behaviors or mental acts that an individual feels compelled to perform in response to an obsession or to achieve a sense of completeness [7]. In addition to the psychiatric disorders mentioned above, numerous studies indicate that OAB is associated with OCD symptoms and that OCD influences body perception. Ahn et al. [8] found that OAB patients exhibited significantly higher obsessive and compulsive symptoms compared to healthy controls, and there was a positive correlation between OCD and OAB symptom severity. A similar relationship was observed in children with nocturnal enuresis, who displayed more OCD symptoms than healthy controls [9]. Body perception and sensation, concepts closely related to OCD, have been extensively studied. Several successful therapy techniques for OAB include interventions targeting body perception, further underscoring its role in OAB [10]. Interestingly, some studies describe a distinct obsession regarding bladder control, suggesting that intrusive images of losing bladder control may be linked to memories of stressful past events [11].

Similarly, while the relationship between OAB and OCD symptomatology has been documented, evidence linking OCD with somatization and increased bodily sensations in both clinical and nonclinical settings is relatively scarce. Barak et al. [12] reported in a recent study that patients with OCD exhibit significantly higher somatization scores, and certain subtypes of obsessions and compulsions appear to be more closely related to OCD. Likewise, Biby [13] demonstrated in a classical study that OCD and somatization show a relatively strong correlation among nonclinical participants. In a similar study from China, Liu et al. [14] found that somatization and OCD symptoms may represent a common, closely related reaction to stressors such as low job satisfaction.

In summary, while the roles of various psychological factors and psychiatric disorders in OAB have been extensively studied, research specifically addressing the roles of OCD and body perception in OAB remains limited. In this study, we aimed to investigate the roles of OCD, body sensation disorders, and somatization disorders in the pathophysiology of OAB. We hypothesize that subtle obsessive-compulsive symptoms, along with an increased sensitivity to physiological body sensations, may contribute to the etiology or chronicity of OAB.

This case-control study was conducted between January 2022 and July 2023. Ethical approval was obtained from the local Ethical Committee (FSMEAH-KAEK 2020/151). A total of 124 participants were included in the study, and consent forms were obtained from all participants. The case group consisted of 63 female patients diagnosed with OAB, while the control group included 61 age-matched healthy females. Only women were included to exclude pathologies such as benign prostatic hyperplasia, which are common in older men and may produce similar symptoms. OAB patients were selected from those who presented directly to the general urology outpatient clinic of our FSM-RTH for OAB symptoms or were referred from other primary care institutions. Patients diagnosed with OAB by a urologist, following a comprehensive urological history and general examination, were re-evaluated by the authors for inclusion in the study. OAB was diagnosed based on symptoms such as frequent urination (i.e., micturition occurring more frequently during waking hours than previously normal), nocturia (i.e., interruption of sleep one or more times due to the need to micturate, with each void preceded and followed by sleep), urge incontinence, and urgency. Prior to diagnosis, necessary tests were conducted to exclude infection, urinary tract stones, and other potential pathologies that could account for these complaints. Age, sex, years of education, and marital status were recorded for all participants. Patients with any known psychiatric or neurological disease, chronic medical conditions such as diabetes mellitus, urological conditions such as bladder stones or voiding dysfunction, a history of genitourinary surgery, use of medications with urological effects or side effects, or those who did not provide informed consent were excluded. Healthy control participants were selected from healthy hospital personnel who presented to our outpatient clinic for routine examinations, as well as patients who sought care for kidney cysts or general check-ups. These individuals had no records of any medical or psychological disorders.

The OAB Questionnaire-V8 (OABQ-V8) was used to assess OAB status, the Obsessive Beliefs Questionnaire-44 (OBQ-44) was used to measure obsessive beliefs, the Body Sensations Questionnaire (BSQ) evaluated fear of bodily sensations, and the Somatosensory Amplification Scale (SSAS) was used to assess somatization disorder.

The surveys were administered by an impartial assistant physician who was blinded to the patients’ disease status and escorted the patient to another room following examination.

In this study, data from a total of 124 female participants—63 from the OAB group and 61 from the control group —were analyzed in detail. The mean age of the case group was 42.21±11.33 years, while the control group had a mean age of 41.62±7.98 years. As shown in Table 1, no significant differences were observed between the groups in terms of age, marital status, or years of education.

As shown in Table 2, OBQ total scores were higher in patients with OAB (22.88±8.57 vs. 7.12±4.81, P<0.001) compared to the control group. Patients with OAB also scored significantly higher on the OBQ-44 total scale, with a mean OBQ44 total score of 167.32±45.76 versus 145.21±47.33 in controls (P=0.011). Significant differences between the groups were observed in other OBQ-44 subscales, except for the perfectionism/precision subscale. The mean score for the responsibility/ threat estimation subscale was 62.19±18.72 in patients compared to 53.48±20.61 in controls (P=0.014). Additionally, OAB patients scored higher on the importance/control of thoughts subscale (63.33±17.28 vs. 54.29±19.81, P=0.009). Although the OAB group had higher scores on the perfectionism/precision subscale (41.21 ±14.48 vs. 36.88 ±13.82), this difference was not statistically significant (P=0.092). Similarly, patients had significantly higher scores on both the SSAS (28.52 ± 7.81 vs. 24.78±7.86, P=0.011) and the BSQ (35.11±12.08 vs. 29.77±10.69, P=0.012) compared to controls.

Correlation analyses indicated that symptom severity, as measured by the OAB-V8, had significant albeit relatively weak positive correlations with the OAB total scores (r=0.321), the OAB-R/TE subscale (r=0.241), and the OAB-I/CoT subscale (r=0.191), excluding the perfectionism/certainty subcategory. Similarly, statistically significant positive correlations were observed between OAB scores and both the SSAS (r=0.242) and the BSQ (r=0.276), as shown in Table 3. Additionally, a positive, though not strong, correlation was found among OBQ, BSQ, and SSAS scores.

The findings from this study offer several insights into the psychological aspects of OAB. Notably, this study provides a new basis for understanding the psychological functioning of OAB patients, appearing to be the first in the literature to demonstrate that OAB is a clinical phenomenon closely related to OCD symptoms and somatization tendencies.

Current literature indicates that the etiology and precipitating factors of OAB remain incompletely understood, and that symptoms may vary among patient groups [2]. Studies have reported that patient satisfaction rates with current treatments are around 50% [2], suggesting that individuals with OAB benefit only partially from medical treatments, which in turn leads to low treatment compliance. Thus, a better understanding of the etiology of OAB is necessary for improved management. In our study, OCD scores were higher in OAB patients compared to the control group. We hypothesize that, in some patients, escalating obsessive behaviors may evolve into urination compulsions, thereby mediating somatization through gradual changes in body sensations over time.

The association of psychiatric disorders such as depression, anxiety, and traumatic experiences with OAB or urinary incontinence has been extensively studied [6]. Among these conditions, OCD appears to be particularly related to OAB. Various studies have examined these relationships. For example, using the Maudsley Obsessive-Compulsive Inventory, Ahn et al. [8] reported that OCD patients exhibited significantly more obsessive and compulsive symptoms compared to healthy subjects. It has also been reported that OAB patients have greater difficulty controlling the behavior subscale of the inventory, while showing no significant differences in orderliness, doubt, or fear of contamination scores.

These findings are consistent with our study, which also reported that OAB patients had significantly higher scores related to thought control—a concept closely related to controlling behavior—but not in terms of perfectionism or certainty scores. Similarly, Ng et al. [22] included the study by Ahn et al. [8] in their recent meta-analysis, noting that it was the only study on OCD and OAB conducted in adults, not in children. That meta-analysis also highlighted the potential close relationship between OAB and OCD, calling for further investigation. Another study by Allameh et al. [23] confirmed this association using the Yale-Brown Obsessive-Compulsive Scale. Consistent with our findings, OAB patients have been reported to exhibit more obsessive-compulsive symptoms, and a positive correlation between OAB and OCD symptoms has been observed. Additionally, Rezaeimehr et al. [24] demonstrated that OCD patients with lower urinary tract symptoms (LUTS) exhibited significantly more urological symptoms—especially stress incontinence—compared to individuals with LUTS but without OCD. Another study suggests that, based on these findings, LUTS and OAB should be classified as psychosomatic disorders and treated accordingly [25]. Somatosensory amplification is defined as the tendency to perceive somatic sensations as intense, noxious, and unpleasant, and it is closely associated with general stress and neuropsychiatric conditions such as anxiety and depression [26]. The SSAS serves as an indicator of somatization, and current literature suggests that high SSAS scores are linked with conditions such as anxiety, depression, and OCD [26]. Studies have demonstrated a close association between somatization and OCD symptoms [27]. In a study of 116 women, Reynolds et al. found that those with more severe OAB symptoms exhibited more somatic findings [28]. This relationship between increased body sensation, OAB, and OCD is a prominent finding of our study, as SSAS scores were associated with both OAB symptoms and OBQ total and subscale scores, albeit with relatively weak significance levels. Our findings of a positive correlation between OCD (OBQ) and SSAS scores suggest a potential relationship between these constructs in OAB patients. Therefore, we hypothesize that increased obsessive behaviors in OAB patients may evolve into a somatization disorder through gradual changes in body sensations over time. Unfortunately, no studies evaluating body sensations using the BSQ in OAB patients have been found in the literature. However, Vrijens et al. [29], using a similar measure called the Self-Consciousness Scale, reported that OAB patients exhibited significantly higher self-awareness of body sensations compared to healthy subjects.

They also reported that OAB patients exhibited significantly higher depression and anxiety scores compared to controls, although these scores were not clinically significant enough to warrant a diagnosis. Similarly, Blakey et al. [30], using the Anxiety Sensitivity Index —which contains items similar to the BSQ—found that OCD patients had a higher baseline sensitivity to somatic sensations. Houghton and colleagues also support the association between increased sensitivity to bodily sensations and OCD symptoms in their review focusing on children and adolescents with OCD [31]. These findings suggest a possible etiological role for increased bodily sensation in OCD pathology. Overall, our study serves as a reference point for integrating the concepts of OCD symptoms and heightened body sensations in OAB. Cognitive-behavioral theories posit that obsessions often cause anxiety or discomfort, prompting compulsions in response. The primary result of our study indicates that OAB patients may exhibit greater obsessive and somatization tendencies. We propose that the urge to urinate, combined with its transformation into the act of urination, may enhance the physical perception of bladder sensations, ultimately leading to a body sensation disorder and somatization disorder. As a secondary outcome, we suggest differentiating OCD subtypes based on their roles in the etiology of OAB; specifically, responsibility/threat estimation and thought importance/control may be more critical factors for OAB than perfectionism/certainty. This differentiation should be examined more comprehensively. In this context, the close relationship between these 2 dimensions and OAB may support the view that OAB is a psychosomatic condition, warranting a review of diagnostic tools and treatment options in light of this new perspective.

Regarding treatment options, the findings from our study may also have implications for managing OAB. The demonstrated close relationship between a urological condition like OAB and psychological conditions such as OCD, somatization, and heightened body perception encourages further examination of treatment strategies that address this relationship. In line with our hypothesis, which posits that obsessive-compulsive tendencies and somatization may serve as etiological and/or perpetuating factors for OAB, treating one aspect of the psychosomatic axis may help ameliorate the other. We view this relationship as dynamic and bidirectional; treating OCD and somatization may reduce OAB symptoms, and conversely, treating OAB may alleviate associated psychological problems. This hypothesis aligns with cognitive-behavioral therapy, whose main postulate is that changes in behavior can lead to cognitive changes, and vice versa [32]. We recommend that future studies examine the effect of treating one condition on the other. In fact, the authors of this study are planning a prospective study to investigate the impact of treating OCD symptoms on OAB.

Although the psychodynamic aspects of OAB have been explored in many studies, to our knowledge, this is the first study to examine the relationship between OAB and OCD, body perception, and somatization disorder simultaneously. Many studies have focused on a single aspect of OAB, but our study demonstrates that obsessions can evolve into compulsions related to urination, leading to changes in body perception over time, with the bladder eventually producing physical responses that contribute to somatization, and ultimately, OAB. In this way, our study not only reveals the relationship between these conditions but also sheds light on the pathophysiology of OAB.

First, the possibility of various unreported somatic problems in control subjects may have influenced study measures, particularly those related to somatization and body perception. To mitigate this risk, healthy hospital staff were included in the control group. Another limitation is that OCD often co-occurs with other psychiatric disorders. The selection of the control group, consisting of employees from the same hospital who presented for routine check-ups, may limit the generalizability of the findings. Given the qualitative nature of this study, which relied solely on patients’ responses to questionnaires without any clinical examination, the possibility of information bias—such as measurement error due to recall bias and selection bias—must be considered. Moreover, the hospital staff control group may not be representative of the general population of women without OAB. There are likely significant differences in the factors that may affect the development of OAB between these groups, and many confounding factors need to be addressed.

The current study concluded that patients with OAB may exhibit obsessive-compulsive features, leading to alterations in body sensation perception over time, and may be more prone to somatization compared to healthy individuals. The relatively strong statistical relationships among these parameters and the severity of OAB symptoms may offer new insights into the understanding of OAB syndrome. These findings, focusing on somatization and OCD in OAB, can serve as a reference point for improving the management of OAB syndrome; however, further studies are necessary to fully understand this complex psychosomatic relationship.