Nowadays, urology has not only focused exclusively on the study of urological illnesses, conversely, the interest of an interdisciplinary study of the patient and the relationship between the pathologies they might suffer has grown. Depression and anxiety have been associated with lower urinary tract symptoms (LUTS) in several studies around the world (1). In our population, a prevalence of LUTS is estimated to be close to 84% (2), for this reason, is essential and as an objective of this study, determine the association between anxiety, depression and LUTS in a large Hispanic population.

A cross-sectional, population-based study was conducted in patients ≥18 years old to evaluate LUTS/OAB in Colombia (2). The estimated sample size was 1,060 (confidence interval of 95%, a statistical power of 80% and a precision of 3%). LUTS/OAB were defined according to the 2002 ICS and 2010 IUGA/ICS definitions and were assessed using Spanish validated questionnaires.  

The hospital anxiety and depression scale (HADS) was used to evaluate mental health, the scale is divided into two, one evaluates depression (HADS-D) and the other anxiety (HADS-A). Depression and anxiety were defined as a score ≥ eight on both HADS-D and HADS-A (3).  

Sociodemographic characteristics and relevant comorbidities were reported using frequencies for categorical variables, and measures of central tendency for continuous variables. The data is presented separately according to sex. Logistic regression was carried out to estimate the association of depression and anxiety with different LUTS. Variables that proved statistically significant (p<0.05) were included in a multivariate model. This analysis was performed using STATA 17 statistical software.

The prevalence of anxiety in women and men was 16.4% (n=87) and 7.2%(n=38), respectively. Depression in women was 19.2% (n=102) and prevalence in men was 10% (n=53).  The average age in men with anxiety was 40 years and in men with depression was 42 years. Also, the median age of women with anxiety was 38 years and in women with depression was 41 years. In addition, the median BMI in the four groups is classified as overweight (BMI 25 – 29,9).  

More than half of the women and men with anxiety were married or living with a partner, 55% (n=48) and 53% (n =20), respectively. Men with depression reported being single more often (51%, n=27).  

In terms of comorbidities, was observed a higher incidence of obstructive sleep apnea and anxiety or depression in men and women. Also, irritable bowel syndrome was present in 21% of both, women with anxiety and those with depression.  

Regarding lower urinary tract symptoms (LUTS), In the group of women diagnosed with anxiety it occurred more frequently symptoms such as urgency (66% n=57), nocturia (64%, n=56), increased urinary frequency (58% n=50) and sensation of incomplete voiding (49%, n=43). In the same way, these four same symptoms were the most prevalent in women with depression,69% (n=70), 70% (n=71), 60% (n=61) and 55% (n=56), respectively. On the other hand, men with anxiety reported to a greater extent symptoms like nocturia 68%(n=26), increased urinary frequency 58% (n=22) and urgency 50% (n =19); while depressed men had a higher incidence of nocturia and increased urinary frequency only, in 64% (n=34) on the latter two. As a result, the reporting of moderate and severe LUTS was higher in women and men diagnosed with these mental pathologies. Furthermore, more than half of men that suffer anxiety (67%, n=22) or depression (83%, n=35) developed sexual dysfunction (SHIM < 22). Moreover, some additional urinary symptoms were analyzed, such as OAB dry type, which was reported in more than half of the men and women with anxiety or depression; Nocturnal OAB and stress urinary incontinence were reported twice as often in female patients with depression or anxiety (Table 1). 

The bivariate analysis is shown in (Table 2). In the anxiety model (HADS-A ≥ 8), an association was found between the presence of overactive bladder (OAB) without urinary incontinence (OR=3.7; 95% CI=1.4-9.9 p=0.07) and moderate or severe LUTS in men (OR=3.8; 95% CI=1.0-13.6 p=0.03). In women, anxiety was associated with nocturia (OR=4.2; 95% CI=1.2-13.8 p=0.01) and stress urinary incontinence (OR=2.4; 95% CI=1.2-4.8 p=0.01). 

For the depression model (HADS-D ≥ 8), an association was found between sexual dysfunction (SHIM <22 points) (OR=4.3; 95% CI=1.5-12.2; p=0.005) and moderate or severe LUTS (OR=4.0; 95% CI=1.6-10.1; p=0.002) in men; while in women it was associated with stress urinary incontinence (OR=2.3; 95% CI=1.2-4.2 p=0.007), sensation of incomplete emptying (OR=1.7; 95% CI=1.0-2.8 p=0.03) and decreased frequency of sexual activity (OR=1.8; 95% CI=1.0-3.3 p=0.03).

This study demonstrates the clear relationship between symptoms of mental illness and LUTS. Within our population, we can highlight the susceptibility of the female gender to suffer from depression, anxiety, and LUTS concomitantly. The multivariate model of anxiety showed that in men and women, the most associated manifestations are symptoms of irritative voiding dysfunction, while in depression, in addition to presenting the previously mentioned symptoms, sexual dysfunctions were also found.

The associations found in this study are consistent with other international reports. It is essential to inquire about possible symptoms related to the mental sphere in the urology consultation due to the possible risks that mental illness entails to make appropriate referrals and subsequent management and integral care of these type of patients.

Lung-Cheng Huang, C., Ho, C.-H., Weng, S.-F., Hsu, Y.-W., Wang, J.-J., & Wu, M.-P. (2015). The association of healthcare seeking behavior for anxiety and depression among patients with lower urinary tract symptoms: A nationwide population-based study. Psychiatry Research, 226(1), 247–251. doi:10.1016/j.psychres.2014.12.05
Plata M, Bravo-Balado A, Robledo D, Trujillo CG, Caicedo JI, Cataño JG, et al. Prevalence of lower urinary tract symptoms and overactive bladder in men and women over 18 years old: The Colombian overactive bladder and lower urinary tract symptoms (COBaLT) study. Neurourol Urodyn. 2019;38(1):200–207
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