Pelvic floor disorders (PFDs), anxiety and depression are common conditions that have been shown to affect quality of life. The aim of this prospective cross-sectional study was to explore the prevalence of anxiety and depression as measured by the Hospital Anxiety and Depression Scale (HADS) among women with urinary (UI), anal (AI) or double incontinence (DI; urinary and anal incontinence combined) as compared to continent women.

Data on background information, medical history including HADS and pelvic floor disorders (PFDs) was collected among female participants in a large population-based health survey during the period October 2006 to June 2008. Women were categorized according to continence status; continent, UI alone, AI alone or DI. HADS Anxiety (HADS-A) and HADS Depression (HADS-D) subscores ≥8 have previously been defined as indicating mild symptoms of anxiety and depression, whereas subscores ≥11 have been defined as indicating moderate to severe symptoms.(1) Total HADS mean score and the prevalence of mild and moderate to severe anxiety and depression among women reporting various PFDs, were calculated. Multivariable logistic regression analyses with backwards selection were applied in order to explore the independent association between HADS A or HADS-D subscores as dependent variables, continence status and selected background variables.

Data on HADS were available on a total of 12954 women (99.7). Mean age was 49.7 years (SD:10.0). One in three (4135) had completed intermediate education, and 5% (628) had completed tertiary education. Ten percent were nulliparous (1288), the majority had one or two deliveries (mean 2.4; range 0-4) and half of the participating women were postmenopausal. More than 60% of the participants reported no PFD symptoms, whereas 8% reported DI and one in ten reported AI alone (Table 1). 
Among the 7850 women categorized as continent 13% reported HADS-A scores ≥ 8 points compared to 24% and 28% among women with AI and DI, respectively. Fifteen percent of women with DI reported mild symptoms of depression (HADS-D subscores ≥ 8 points) whereas one in ten of women with UI alone reported symptoms of mild depression (Table 1). Five and six percent of women with no incontinence symptoms or urinary incontinence alone reported moderate anxiety symptoms (HADS-A ≥ 11 points), respectively, compared to ten percent of women with AI or DI. Overall, less than five percent reported moderate or severe symptoms of depression (HADS-D ≥ 11 points). 
The multivariable logistic regression analyses showed that women reporting AI (OR:2.0; 95% CI:1.7,2.4) or DI (OR:2.5; 95% CI:2.1,2.9) had a statistically significant increase in risk of anxiety (HADS-A ≥ 8 points). Similarly, women with education at primary and secondary had twice the odds of anxiety when compared to women with university or college education. 
Women reporting DI had a nearly three-fold increase in odds of mild depression (HADS-D ≥ 8 points) compared to women with AI or UI alone who had a two-fold increase in odds. Compared to women with university or college education, women with primary education had a 90% increase in risk, whereas women with secondary education had 50% increase in risk of depression symptoms.

The results of the present study show that experiencing mild symptoms of anxiety and depression is common among women with PFDs, and that women experiencing DI have a higher prevalence of mild symptoms of anxiety and depression compared to women with UI or AI alone. Overall, the prevalence of moderate to severe symptoms of anxiety was higher than the reported prevalence of moderate to severe symptoms of depression, and the prevalence of anxiety and depression symptoms were higher among women with DI as compared to continent women or those reporting only one incontinence symptom. 
The association between anxiety and depression was strongly associated with increasing severity of PFDs, with increasing risks associated with co-existing UI and AI as compared to experiencing these symptoms alone.

The cross-sectional design of the present study prevents any conclusions to be made with regards to causality or whether these findings may be explained by any common underlying biological or neurological factors. However, considering that anxiety, depression and PFDs are all factors known to reduce quality of life, these results may suggest that health care professionals need to be aware of the higher prevalence of anxiety and depression among women with co-existing UI and AI compared to experiencing one symptom, and to take this into consideration when planning treatment and follow up of these patients