This study investigated the relationship of personality, depression, somatization, anxiety with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH). The LUTS/BPH patients were evaluated with the International Prostate Symptom Score (IPSS), 44-item Big Five Inventory (BFI), the Patient Health Questionnaire-9 (PHQ-9), the PHQ-15, and 7-item Generalized Anxiety Disorder Scale (GAD-7). The LUTS/BPH symptoms were more severe in patients with depression (p=0.046) and somatization (p=0.024), respectively. Neurotic patients were associated with greater levels of depression, anxiety and somatisation (p=0.0059, p=0.004 and p=0.0095, respectively). Patients with high extraversion showed significantly low depression (p=0.00481) and anxiety (p=0.035) than those with low extraversion. Our exploratory results suggest patients with LUTS/BPH may need careful evaluation of psychiatric problem including depression, anxiety and somatization. Additional studies with adequate power and improved designs are necessary to support the present exploratory findings.
Lower urinary tract symptoms (LUTS) consist of storage (frequency, urgency, and nocturia), voiding (poor stream, hesitancy, and straining to void), and post-micturition (terminal dribbling and incomplete emptying) difficulties and are common among older men.
Despite the fact that LUTS and BPH (LUTS/BPH) are not considered life-threatening conditions, numerous large and well-designed cohort studies have demonstrated a diverse array of adverse impacts on personal and public health, including mental health.
Hence, we tried to investigate the relationship between depression, anxiety, somatisation, personality and LUTS/BPH in Korean patients, with the use of validated brief rating scales. It was hypothesised that depression, anxiety and somatisation would influence of symptoms of LUTS/BPH. In addition, personality traits may be associated with clinical characteristics including the severity of LUTS/BPH since one's personality profile may be a crucial factor to given stressors and/or diseases.
Male patients with LUTS/BPH were recruited at an outpatient clinic in the Department of Urology at Bucheon St. Mary's Hospital.
Principal inclusion criteria included men aged ≥40 years, a clinical diagnosis of LUTS/BPH was evaluated by medical history, assessment of symptoms and bother, a careful physical examination, digital rectal examination, and laboratory tests such as urinalysis and prostate-specific antigen (PSA) level. Few exclusion criteria were applied because the aims of the study were based on an observational approach. However, patients who exhibited the following symptoms were excluded for diagnostic stability: 1) PSA level >10 ng/mL, 2) a history or evidence of prostate cancer by prostate biopsy, 3) previous prostatic surgery, 4) neurogenic bladder by neurological disorders such as multiple sclerosis, Parkinson's disease, spinal cord injury and spina bifida, which was based on the results from physical examination focusing on both the status of the patient's neurologic system and pelvic anatomy, and neurologic examination focusing on mental status, strength, sensation and neuronal reflexes, and urodynamic evaluations, 5) bladder stone, 6) bladder neck contracture, 7) urethral stricture, 8) bladder malignancy, 9) acute or chronic prostatitis, 10) acute, chronic or recurrent urinary tract infections, 11) any possible causes presenting LUTS other than BPH, and 12) speech or language deficits and cognitive dysfunction.
The present protocol was approved by the Institutional Review Board of Bucheon St. Mary's Hospital.
This study utilised all the Korean versions of the International Prostate Symptom Score (IPSS) for severity of LUTS/BPH,
The BFI personality traits consist of the following: extraversion (E), agreeableness (A), conscientiousness (C), neuroticism (N) and openness (O). The BFI, which was developed based on the Five Factor Model (FFM), consists of 44 items for which higher scores represent higher levels of each personality trait.
Demographic and clinical variables are described and also compared according to each personality trait and other parameters using the Student's t-test, chi-square test with Yate's correction, or Fisher's test where appropriate. Statistical significance was two-tailed and set at p<0.05. All statistical analyses were conducted using the NCSS 2007® and PASSP® (Kaysville, Utah, USA).
Ninety three patients participated in the study. The mean age of the whole population was approximately 62 (61.7±8.0) years, and the majority of patients were married. More than half of patients exhibited comorbid medical diseases. The mean total score on the IPSS among all groups was approximately 17, indicating a moderate severity of LUTS/BPH symptoms.
There were no group differences in IPSS total scores, education level, family history of LUTS/BPH, economic status, duration of disease, medications, comorbidity, alcohol history, smoking history, or marriage status according to each personality domain (data available on request). These trends were also observed when we divide the patients according to presence/absence of depression, anxiety and somatisation (data available on request).
The LUTS/BPH symptoms were more severe in patients with depression (p=0.046) and somatization (p=0.024), respectively, while anxiety did not correlated with symptoms of LUTS/BPH (
Mean total scores on the PHQ-9, GAD-7, and PHQ-15 were 1.7, 1.7 and 1.6 fold higher, respectively, in high neuroticism (HN) compared to low neuroticism (LN) (p=0.0059, p=0.004 and p=0.0095) (
Patients with high extraversion (HE) showed significantly low depression (p=0.00481) and anxiety (p=0.035) than those with low extraversion (LE). Otherwise, there were no significant differences among the remaining variables between the high and low groups in the other personality domains (
According to our study, patients with depression and somatisation showed higher level of LUTS/BPH symptoms; anxious patients showed a numerically higher LUTS/BPH symptoms. Additionally, HN was associated with greater levels of depression, anxiety and somatisation. The proportion of depression and anxiety was also significantly higher in HN group than in LN. The mean PHQ-9 and GAD-7 total scores were significantly higher in LE group than in HE group. Other personality traits were not associated with other clinical characteristics in LUTS/BPH patients. The strength of the present study includes a comprehensive evaluation of the relationship between symptomatology of LUTS/BPH and depression, somatisation, anxiety and personality traits. Additionally, this study employed simple, quick, reliable, well-validated, and self-administered personality scales, which is easy to interpret, even in a busy routine practice.
Previous studies have mainly focused on the negative effect of LUTS on quality of life, overall perception of bladder problems, general health status and mental health.
When the personality traits of our patients were compared with norm levels from 56 nations, O, A, C and E were relatively low.
N is highly correlated with various psychological factors such as anxiety, depression, pessimistic attitudes, hopelessness, impulsivity, hostility, low self-esteem, anger and vulnerability to stress and chronic negative emotions.
The depression and anxiety symptoms were significantly higher in LE than in HE group. E was found to be highly correlated with self-efficacy as well as depression and anxiety.
However, other personality traits such as A, C, and O were not significantly associated with clinical characteristics in LUTS/BPH patients, although numerically lower tendency toward severe symptoms of LUTS/BPH in lower A, C, and O groups were consistent. A is associated with a greater amount of social support, the improvement of depression/anxiety, and better adaptive coping styles,
We failed to show a global relationship between all five personality traits and LUTS/BPH symptoms severity. This point should be more investigated in future studies. We may assume that the BFI may not be relevant or sensitive to find such relationship. Additionally, the intricate and interactive relationship between personality and the disease itself should not be excluded. Several studies have suggested that LUTS/BPH itself may potentially result in personality changes.
In conclusion, our exploratory results suggest patients with LUTS/BPH may need careful evaluation of psychiatric problem including depression, anxiety and somatization. Additional studies with adequate power and improved designs are necessary to support the present exploratory findings.
This study was partially funded by the Ministry of Health and Welfare, Republic of Korea (HI12C0003).
The IPSS total scores and severity distribution of LUTS/BPH by presence/absence of depression, anxiety and somatization
Data represent mean±standard deviation or number (%). IPSS: International Prostate Symptom Score, LUTS/BPH: lower urinary tract syndrome/benign prostate hyperplasia, mild (0-7), moderate (8-19) and severe (≥20) in IPSS; *p=0.046, †p=0.024 based on Student t-test; The criteria for depression (≥5 on Patient Health Questionnaire-9, PHQ-9), anxiety (≥5 on Generalized Anxiety Disorder Assessment item-7, GAD-7) and somatisation (≥5 on PHQ-15)
Clinical characteristics of the sample based on personality profiles (N=93)
Data represent mean±standard deviation. *p=0.0059, †p=0.0481, ‡p=0.0095, §p=0.004, ∥p=0.035 based on Student t-test. IPSS: International Prostate Symptom Score, Obs: obstruction, sto: storage, QoL: quality of life, PHQ: Patient Health Questionnaire, GAD-7: Generalized Anxiety Disorder Assessment item 7