Association of Depression and Anxiety in Underserved Women With and Without Urinary Incontinence

International Urogynaecology Consultation chapter 1 committee 4: patients' perception of disease burden of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This manuscript from Chapter 1 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reports on the patients' perception of disease burden associated with pelvic organ prolapse.

MATERIALS AND METHODS

An international group containing a team of eight urogynaecologists, a physiotherapist and a statistician performed a search of the literature using pre-specified search terms in PubMed and Embase (January 2000 to August 2020). The division of sections within this report includes: (1) perception of POP and the relationship with body image and poor health; (2) a vaginal bulge as it impacts health and wellbeing in women; (3) the impact of POP on sexual life; (4) body image and pelvic floor disorders; (5) POP and mood; (6) appropriate use of treatment goals to better meet patients' expected benefits; (7) using health-related quality of life questionnaires to quantify patients' perception of POP; (8) The financial burden of POP to patients and society. Abstracts were reviewed and publications were eliminated if not relevant or did not include populations with POP or were not relevant to the subject areas as noted by the authors. The manuscripts were next reviewed for suitability using the Specialist Unit for Review Evidence (SURE) checklists for cohort, cross-sectional and case-control epidemiologic studies.

RESULTS

The original individual literature searches yielded 2312 references of which 190 were used in the final manuscript. The following perceptions were identified: (1) women were found to have varying perceptions of POP including shame and embarrassment. Some regard POP as consequence of aging and consider there is no effective therapy. (2) POP is perceived as a vaginal bulge and affects lifestyle and emotional wellbeing. The main driver for treatment is absence of bulge sensation. (3) POP is known to affect frequency of sexual intercourse but has less impact on satisfaction. (4) Prolapse-specific body image and genital self-image are important components of a women's emotional, physical and sexual wellbeing. (5) POP is commonly associated with depression and anxiety symptoms which impact HRQoL although are not correlated with objective anatomical findings. (6) Patient-centered treatment goals are useful in facilitating communication, shared decision-making and expectations before and after reconstructive surgery. (7) Disease-specific HRQoL questionnaires are important tools to assess bother and outcome following surgery, and there are now several tools with Level 1 evidence and a Grade A recommendation. (8) The cost of POP to the individual and to society is considerable in terms of productivity. In general, conservative measures tend to be more cost-effective than surgical intervention.

CONCLUSIONS

Patients' perception of POP varies in different patients and has a far-reaching impact on their overall state of health and wellbeing. However, recognizing that it is a combination of body image and overall health (which affects mental health) allows clinicians to better tailor expectations for treatment to individual patients. There are HRQoL tools that can be used to quantify these impacts in clinical care and research. The costs to the individual patient (which affects their perception of POP) is an area that is poorly understood and needs more research.

Is female urge associated with incontinence, somatosensory amplification, health anxiety and depression?

PURPOSE

Incontinence is a condition that can cause significant problems that can affect patients' quality of social, emotional, psychological and sexual life. The aim of this study was to evaluate the level of anxiety, health anxiety, depression and somatosensory amplification in patients with urge incontinence.

MATERIALS AND METHODS

The study group consisted of 58 patients that met the inclusion criteria. The control group consisted of 67 volunteer participants that did not have physical or psychiatric illness and incontinence complaints. All participants filled out sociodemographic data form, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Somatosensory Amplification Scale (SSAS) and Health Anxiety Inventory (HAI).

RESULTS

The mean duration of incontinence in patients with urge incontinence was 16.55 ± 10.03 months. The mean age in urge incontinence group and the control group were 40.98 ± 9.58 and 39.1 ± 7.89 years, respectively. The mean values of SSAS, HAI and BAI scores in the incontinence group were significantly higher than the control group (P < .001), but there was no significant difference between the groups in terms of BDI scores. The linear regression analysis indicated that HAI and BAI significantly affected SSAS (P = .025 and 0.019, respectively).

CONCLUSIONS

Anxiety, health anxiety and somatosensory amplification are more common in patients who report urge incontinence. For these reasons, we believe that psychiatric evaluation should be included in the diagnosis and treatment process of patients presenting with urgency and incontinence symptoms.

Association of urinary incontinence and depression or anxiety: a meta-analysis

Objective

We explored the relationship between urinary incontinence (UI) and depression or anxiety.

Methods

We searched the Cochrane Library, Embase, and PubMed for articles on the association between depression, anxiety, and UI. We calculated pooled 95% confidence intervals (CIs) and odds ratios (ORs).

Results

Twelve articles (31,462 participants) were included. The UI group had significantly higher depression and anxiety levels than the non-UI group (OR = 1.73, 95%CI: 1.64–1.82, I² = 75.5%). In subgroup analysis, depression and anxiety were significantly higher in participants with UI than in those without UI (OR = 1.95, 95%CI: 1.82–2.10, I² = 64.3% and OR = 1.54, 95%CI: 1.43–1.65, I² = 59.2%, respectively).

 In subgroup analysis by age, participants with UI had significantly higher depression and anxiety, regardless of age, than the non-UI group (OR = 1.59, 95%CI: 1.29–1.95, I² = 59.1% and OR = 1.98, 95%CI: 1.62–2.43, I² = 75.5%, respectively).

Conclusion

Patients with UI had significantly higher depression and anxiety levels than those without UI. Depression and anxiety were higher in patients with UI than in those without UI, regardless of age. Larger sample sizes and more high-quality studies are needed to validate our findings.

Depression, anxiety, and stress in women with urinary incontinence with or without myofascial dysfunction in the pelvic floor muscles: A cross-sectional study

AIMS

To compare the prevalence of psychological symptoms (depression, anxiety, and stress) in women with urinary incontinence (UI), according to the presence or absence of myofascial dysfunction (MD) in the pelvic floor muscles (PFMs).

METHODS

Cross-sectional study, with women with UI who are 18 years old and over. The diagnosis of MD was defined by the pain of any intensity during the palpation of PFM. All participants answered the International Consultation on Incontinence Questionnaire-Short Form and the International Consultation on Incontinence Questionnaire Overactive Bladder for urinary symptoms and the Depression Anxiety and Stress Scale-Short Form-21 to check for the presence and degrees of depression, anxiety, and stress.

RESULTS

Two hundred-thirty-four women with a mean age of 52.5 (±9.2) years were included. Almost half (51.7%) of women had MD. Women with MD showed higher mild and moderate anxiety scores (p = .005) and higher mild, moderate, and severe stress scores (p = .027) than women without MD. Depression scores were not associated with MD; however, women with and without MD reported severe or extremely severe depression, anxiety, and stress.

CONCLUSIONS

The risk for depression, anxiety, and stress is high among women with UI regardless of the presence of MD. However, women with MD had higher scores for anxiety and stress than women with UI without MD.

Affective Symptoms and Health-Related Quality of Life Among Women with Stress Urinary Incontinence: Cross-Sectional Study

PURPOSE

To evaluate the relationship between affective symptoms, clinical variables of uro-gynaecological history and health-related quality of life (QoL) among women with stress urinary incontinence (SUI) in comparison to healthy controls.

PATIENTS AND METHODS

In a cross-sectional study, 80 women 30 to 80 years of age diagnosed with SUI and 97 controls without symptoms of SUI provided sociodemographic data and answered the King's Health Questionnaire (KHQ) for assessing the QoL among individuals with urinary incontinence. Symptoms of anxiety and depression were assessed by Hospital Anxiety and Depression (HAD) scale with a threshold ≥7. A multiple regression was performed to reveal the cross-sectional predictors of affective symptoms and QoL among women with SUI.

RESULTS

Women with SUI had a significantly higher prevalence of symptoms of anxiety and depression than the controls (50% vs 11% and 29% vs 3.1%, respectively; both p<0.001) and worse health-related QoL on all domains of the KHQ. In multiple logistic regression models adjusted for sociodemographic and clinical variables of uro-gynaecological history, perceived symptoms of mild-to-severe depression were associated with a higher amount of leakage (OR=3.59; 1.04-12.4), older age (≥55 years old vs <55 years old) (OR=5.82; 1.47-23.1) and higher BMI (OR=1.13; 1.01-1.27). In addition, when controlled for all domains of the KHQ, perceived depressive symptoms were associated with the "emotions" domain of the KHQ (OR=1.06; 1.02-1.09). Perceived anxiety symptoms (independent of age) were related to shorter duration of SUI, low parity, absence of comorbidities and to higher scores on the "personal relationships" and "emotions" domains of the KHQ.

CONCLUSION

Women with SUI have a significantly poorer QoL than their counterparts without SUI. It was determined that one-half of women with SUI had anxiety symptoms, while one-third of women with SUI had depressive symptoms. In addition, this study indicated that QoL was associated with anxiety symptoms in middle-aged women and with depressive symptoms in older women, especially those with a shorter duration of SUI.

Characterizing anxiety at the first encounter in women presenting to the clinic: the CAFÉ study

BACKGROUND

Clinically based anxiety questionnaires measure 2 forms of anxiety that are known as state anxiety and trait anxiety. State anxiety is temporary and is sensitive to change; trait anxiety is a generalized propensity to be anxious.

OBJECTIVE

Our study aims to characterize the reasons for anxiety among women about the initial consultation for their pelvic floor disorders to measure change in participant state anxiety after the visit and to correlate improvement in anxiety with visit satisfaction.

STUDY DESIGN

All new patients at our tertiary urogynecology clinic were invited to participate. After giving consent, participants completed pre- and postvisit questionnaires. Providers were blinded to pre- and postvisit questionnaire responses. The previsit questionnaires included the Pelvic Floor Distress Inventory, the Generalized Anxiety Disorder-7, and the 6-item short form of the Spielberg State Trait Anxiety Inventory. Participants were also asked to list their previsit anxieties. The postvisit questionnaires comprised of the Spielberg State Trait Anxiety Inventory, patient global impression of improvement of participant anxiety, patient satisfaction, and the participant's perception of whether her anxiety was addressed during the visit. The anxieties listed by participants were then reviewed independently and categorized by 2 of the authors. A separate panel arbitrated when there were disagreements among anxiety categories.

RESULTS

Fifty primarily white (66%) women with a median age of 53 years (interquartile range, 41-66) completed the study. The visit diagnoses included stress urinary incontinence (54%), urge urinary incontinence (46%), myofascial pain (28%), pelvic organ prolapse (20%), and recurrent urinary tract infection (12%). Less than one-quarter of participants (22%) had a history of anxiety diagnosis. The average previsit Spielberg State Trait Anxiety Inventory score was 42.9 (standard deviation, 11.98) which decreased by an average of 12.60 points in the postvisit (95% confidence interval, -16.56 to -8.64; P<.001). Postvisit decreased anxiety was associated with improvements in the patient global impression of improvement anxiety (P<.001) and participants' perception that their anxiety symptoms had been addressed completely (P=.045). The most reported causes for consultation related anxiety were lack of knowledge of diagnosis and ramifications, personal or social issues, and fear of the physical examination. Participants reported that improvements in anxiety were related to patient education and reassurance, medical staff appreciation, and acceptable treatment plan. Participants who reported complete satisfaction demonstrated a greater decrease in the postvisit Spielberg State Trait Anxiety Inventory scores compared with the participants who did not report complete satisfaction (P=.045). Changes in the Spielberg State Trait Anxiety Inventory score were not associated with the Pelvic Floor Distress Inventory (P=.35) or Generalized Anxiety Disorder-7 scores (P=.78).

CONCLUSION

Women with the highest satisfaction after their initial urogynecology visit also demonstrated the largest decreases in anxiety after the visit. Changes in anxiety scores were not correlated with the Pelvic Floor Distress Inventory or with measures of generalized anxiety (Generalized Anxiety Disorder-7). Recognizing and addressing patient anxiety may help physicians better treat their patients and improve overall patient satisfaction.

Is the belief that urinary incontinence is normal for ageing related to older Canadian women's experience of urinary incontinence?

INTRODUCTION AND HYPOTHESIS

Many women consider urinary incontinence (UI) a normal part of ageing. This belief may contribute to delays in treatment seeking. This study examined the relationship among holding that belief, UI type and severity, impact on quality of life, management and healthcare seeking in a sample of older community-dwelling Canadian women.

METHODS

This was a secondary analysis of a controlled trial examining the impact of continence promotion workshops on UI self-management. All women who consented and provided baseline data were included in this analysis regardless of eligibility for the main study.

RESULTS

The sample included 4446 women (2022 with UI) of mean (SD) age 78.2 (9.0) years and BMI 26.6 (5.6). The belief that UI is normal for ageing was held by 2149 women [48.3% (83.7% of 1798 incontinent women)] and was not associated with age [adjusted odds ratio (OR) (95% CI): 1.00 (0.99, 1.01), p = 0.72] or perception of overall health. Women with this belief had more impaired QoL compared with the women who felt UI was not normal for ageing [mean (SD) 83.9 (19.4) vs. 87.4 (18.6) (p < 0.01)]. This belief remained unaffected by daily UI and pad use up to 2/day.

CONCLUSIONS

More than two-thirds of women thought UI normal for ageing. This belief was not associated with age or perception of overall health. More severe incontinence and greater quantities of pad use did not make women less likely to hold this belief.

Effect of generalized anxiety disorders on the success of pessary treatment for pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Our aim was to evaluate the impact of generalized anxiety disorders (GAD) on the effectiveness of pessary treatment for pelvic organ prolapse (POP) in postmenopausal women.

METHODS

One-hundred and ten women with symptomatic POP who underwent pessary treatment were enrolled in this prospective study. Subjective evaluations of pelvic floor symptoms were assessed using the Pelvic Floor Distress Inventory (PFDI-20) and the Pelvic Floor Impact Questionnaire-7 (PFIQ-7), both at baseline and at the 3-month follow-up visit after pessary use. GAD was measured by the Generalized Anxiety Disorder-7 (GAD-7). Independent samples t tests, Mann-Whitney U test, chi-square test, Fisher's exact test, and Wilcoxon signed rank test were used to analyze data.

RESULTS

Twenty-one patients (20.6%) had GAD at baseline. After 3 months of pessary use, PFIQ-7, PFDI-20, and GAD scores were significantly improved in all participants (P < 0.001). In the GAD-negative group, total PFIQ-7 and PFDI-20 scores, including all subscales scores, were significantly decreased from baseline to posttreatment (P < 0.05). However, in the GAD-positive group, both PFIQ-7 and PFDI-20 scores, including subscales, were also significantly decreased from baseline to posttreatment (P < 0.05), except for subscale Colorectal-Anal Impact Questionnaire (CRAIQ-7) of PFIQ-7 (P = 0.225), which represented the impact on quality of life (QoL) from bowel dysfunction.

CONCLUSIONS

Both groups of women with or without GAD showed significant improvement in QoL scores after 3 months of pessary treatment. GAD had no influence on the success of pessary treatment for POP.

Screening for general anxiety disorders in postmenopausal women with symptomatic pelvic organ prolapse

OBJECTIVE

This study aimed to investigate the prevalence of general anxiety disorder (GAD) among postmenopausal women with symptomatic pelvic organ prolapse (POP) and to identify its associated factors.

METHODS

A cross-sectional study was conducted among postmenopausal women with symptomatic POP. Sociodemographic data and medical histories were obtained. Participants completed the POP Quantification (POP-Q), the Pelvic Floor Impact Questionnaire-7 (PFIQ-7), and the Pelvic Floor Distress Inventory (PFDI-20) measures. Measures of GAD were obtained using the Generalized Anxiety Disorder-7 (GAD-7). The data were analyzed using independent sample t-tests, the Mann-Whitney U-test, χ² tests, Fisher's exact tests and logistic regression.

RESULTS

Of the 177 participants interviewed, 19.2% had symptoms of GAD. There were no statistically significant differences in the sociodemographic characteristics or the POP-Q stage between women with and without GAD (p > 0.05). GAD was significantly associated with higher PFDI-20 and PFIQ-7 subscale scores (p < 0.05). After multiple logistic regression analyses, only the PFIQ-7 subscale UIQ-7 (odds ratio = 1.025, 95% confidence interval 1.007-1.043, p = 0.005) and the PFDI-20 subscale CRADI-8 (odds ratio = 1.025, 95% confidence interval 1.004-1.047, p = 0.021), which represented the impact on quality of life from lower urinary tract symptoms and the distress caused by bowel dysfunction, were risk factors that were independently associated with GAD.

CONCLUSIONS

GAD is prevalent in almost one-fifth of postmenopausal women with symptomatic POP. GAD is not associated with the severity of the POP-Q stage but is associated with higher scores for lower urinary tract and bowel dysfunction caused by POP.

Urinary Incontinence and Its Association with Frailty Among Men Aged 80 Years or Older in Taiwan: A Cross-Sectional Study

AIMS

To evaluate the prevalence of urinary incontinence (UI) and its association with frailty among men aged 80 years and older in Taiwan.

METHODS

Residents living in four veterans retirement communities were invited for study and 440 men aged 80 years and older were enrolled. Comprehensive geriatric assessment was performed for them, which composed of Clinical Frailty Scale, Northern Health and Social Care Trust (HSC)-Continence Assessment Form, Charlson's Comorbidity Index (CCI), Barthel Index (BI), Instrumental Activities of Daily Living (IADL), Mini-Mental State Examination (MMSE), Geriatric Depression Scale-5 (GDS-5), and Mini-Nutritional Assessment-Short Form (MNA-SF).

RESULTS

In this study, the overall prevalence of UI was 19.1% (mostly urgency incontinence and functional incontinence). Univariate analyses were performed to evaluate the associations between UI and other variables. Frailty was more common among subjects with UI than those without (60.7% vs 32.3%, p < 0.001). Besides, subjects with UI had more comorbidity (CCI: 1.40 ± 1.15 vs 0.89 ± 0.89, p < 0.001), poorer physical function (BI: 65.77 ± 33.39 vs 84.12 ± 24.08, p < 0.001; IADL: 3.46 ± 2.64 vs 4.41 ± 2.25, p = 0.003), more depressive symptoms (GDS-5: 1.83 ± 1.78 vs 1.18 ± 1.36, p = 0.02), poorer cognitive function (MMSE: 16.57 ± 7.65 vs 19.37 ± 6.82, p = 0.001), poorer nutritional status (MNA-SF: 10.0 ± 03.03 vs 11.23 ± 2.24, p = 0.001), more polypharmacy (66.7% vs 45.2%, p < 0.001) and higher chance of stool incontinence (22.6% vs 1.7%, p < 0.001). Multivariate logistic regression showed that UI was independently associated with frailty, (odds ratio [OR] = 2.1; 95% confidence interval [CI]: 1.2-3.6; p = 0.012), stool incontinence (OR = 14.4; 95% CI 5.2-39.7; p < 0.001) and depressive symptoms (OR = 1.30; 95% CI 1.10-1.54; p = 0.002).

CONCLUSIONS

About one fifth of study subjects had UI (mostly urgency and functional incontinence type), which was significantly associated with frailty, stool incontinence and depressive symptoms. Further study is needed to evaluate the possibilities of reversing these geriatric syndromes by an integrated intervention program.