| | The Influence of Psychiatric Comorbidities and Sexual Trauma on Lower Urinary Tract Symptoms in Female VeteransReceived 28 March 2009 published online 22 October 2009. PurposeWe characterized the association of psychiatric comorbidities and sexual trauma with lower urinary tract symptoms in women. Materials and MethodsConsecutive women (121) referred for evaluation of lower urinary tract symptoms to a specialized urology clinic were given validated questionnaires including the Urogenital Distress Inventory-6 and Incontinence Impact Questionnaire-7. These data were then analyzed according to psychiatric comorbidities, history of sexual trauma, age, race and obstetric history. Baseline incidence of psychiatric comorbidity and sexual trauma was also compared to a control population (1,298) from which all patients were referred. ResultsWomen referred for evaluation of lower urinary tract symptoms had higher rates of psychiatric comorbidities (64.5% vs 25.9%, p <0.001) and sexual trauma (49.6% vs 20.1%, p <0.001) compared to those in the primary care clinic. Total survey scores for the Incontinence Impact Questionnaire-7 were significantly higher for patients with psychiatric comorbidities and sexual trauma (11.05 ± 0.84) compared to scores of patients with neither of these conditions (7.6 ± 1.02, p = 0.010). Stepwise multivariate regression analyses demonstrated that higher Urogenital Distress Inventory-6 scores were associated only with age younger than 50 years and history of miscarriage, and that higher Incontinence Impact Questionnaire-7 scores were associated only with psychiatric comorbidities and history of miscarriage. ConclusionsPsychiatric comorbidities and sexual trauma are prevalent in female veterans presenting for evaluation of lower urinary tract symptoms and psychiatric comorbidities are associated with greater quality of life impact. Abbreviations and Acronyms: IIQ-7, Incontinence Impact Questionnaire-7, LUTS, lower urinary tract symptoms, OAB, overactive bladder, PSY, psychiatric, ST, sexual trauma, UDI-6, Urogenital Distress Inventory-6 Psychosocial conditions including depression, anxiety disorders and sexual trauma have been identified as risk factors for overactive bladder and incontinence. However, the exact nature of these associations is unknown. OAB, defined by the International Continence Society as “urgency, with or without incontinence, usually with frequency and nocturia,”1 affects approximately 17% of the adult population worldwide.2, 3 Currently the only Food and Drug Administration approved medications for the treatment of OAB work by blocking muscarinic receptors. However, these medications have limited long-term treatment efficacy in some patients.4 Therefore, improved treatment strategies for OAB must focus on the identification of patient factors that predict therapeutic response. An area of particular concern in the treatment of OAB is the role of psychosocial factors and emotional influences in the production or perception of lower urinary tract symptoms. If in some cases these symptoms reflect a systemic anxiogenic state rather than an abnormality at the level of the detrusor muscle, then antimuscarinic therapies might be expected to fail. The association of psychiatric comorbidities and sexual trauma with LUTS has been previously identified. In a case-control study by Davila et al surveys were administered to female members of childhood sexual abuse survivor groups and control patients in a general gynecology clinic.5 The authors found that 72% of sexual abuse survivors reported incontinence vs 22% of controls. In addition, the sexual abuse group reported higher rates of emotional problems (71% vs 6%) and higher rates of psychiatric conditions (53% vs 6%). However, this and other studies have not characterized the associations in detail. Therefore, in this investigation we characterized the type, severity and quality of life impact of LUTS in patients with psychiatric comorbidities and/or sexual trauma. Materials and Methods  This study was approved by the institutional review board of the McGuire Veterans Affairs Medical Center. Patients presenting to a specialized clinic (LUTS clinic) for the treatment of women with OAB or stress incontinence had a complete history and physical examination. They were also asked to complete the UDI-6 to assess the type and severity of LUTS, and the IIQ-7 to assess quality of life impact. All patients were initially referred from a primary care women's clinic (primary care clinic) at the same institution. During an intake visit to the primary care clinic patients are screened for LUTS including urinary urgency, incontinence and frequency. In addition, all women in the primary care clinic are screened for sexual trauma by asking for their response to the question, “have you ever been forced to have sex against your will?” Information was recorded for all women who attended the primary care clinic in a single calendar year including age, race, pregnancies, live births, miscarriages, terminations of pregnancy, LUTS, psychiatric comorbidities and history of sexual trauma. Comparisons between the primary care and LUTS clinic populations were made to identify factors associated with LUTS. Within the LUTS clinic individual items and total scores on the UDI-6 and IIQ-7 surveys were analyzed in terms of patient data to further elucidate factors associated with LUTS. Categorical data were compared using chi-square and Fisher's exact tests, and continuous data were compared using unpaired Student's t tests or the ANOVA method. In addition, stepwise multivariate regression analysis was used to identify independent risk factors with p <0.05 considered significant. Results There were 1,298 patients evaluated in the primary care clinic of whom 120 (9.2%) reported urinary urgency, 182 (14.0%) reported urinary incontinence and 148 (11.4%) reported urinary frequency. A total of 308 patients in the primary care clinic reported symptoms of urgency, incontinence or frequency. Mean age of patients in the LUTS clinic (121 referred from the primary care clinic) was slightly older than that of patients in the primary care clinic (50.3 ± 1.0 vs 48.2 ± 0.4 years, p = 0.049) and there was a greater percentage of white women in the LUTS clinic (54.6% vs 37.7%, p = 0.003). In the LUTS clinic women experienced an average of 2.6 ± 0.3 pregnancies resulting in 1.7 ± 0.1 live births, and had an average of 0.5 ± 0.1 miscarriages and 0.3 ± 0.1 abortions. Rates of psychiatric comorbidity were significantly higher for women in the LUTS clinic (78 of 121, 64.5%) compared to women in the primary care clinic (368 of 1,298, 25.9%, p <0.001, fig. 1). Likewise rates of sexual trauma were significantly higher for women in the LUTS clinic (60 of 121, 49.6%) compared to the primary care clinic (285 of 1,298, 20.1%, p <0.001). Of 60 patients in the LUTS clinic who met criteria for sexual trauma the most common setting was during active military service (35%). In addition, 33% experienced sexual trauma during childhood and 22% experienced sexual trauma in more than 1 setting. Of 121 patients in the LUTS clinic 47 (38.9%) had a history of psychiatric comorbidities and sexual trauma, 31 (25.6%) had a history of psychiatric comorbidities only, 13 (10.7%) had a history of sexual trauma only and 30 (24.8%) had no history of psychiatric comorbidities or sexual trauma (fig. 2). Although the rate of sexual trauma was nearly 50% of the population (49.6% positive, 50.4% negative), the rate of psychiatric comorbidities was significantly higher in the 60 patients with a history of sexual trauma (47 of 60, 78.3% with psychiatric comorbidities vs 13 of 60, 21.7% without psychiatric comorbidities, p = 0.002). Total Survey Scores and Association With Psychiatric Comorbidity or Sexual Trauma Surveys were completed by 104 of 121 (86.0%) patients. Total survey scores for the IIQ-7 were significantly higher for patients with psychiatric comorbidities and sexual trauma (11.1 ± 0.8) compared to scores of patients with neither of these conditions (7.6 ± 1.0, p = 0.010). In addition, survey scores for patients with a history of psychiatric comorbidity only (10.5 ± 1.1) were also higher compared to scores of patients with neither of these conditions (p <0.05). However, scores for patients who only had a history of sexual trauma (9.7 ± 1.5) did not differ significantly compared to patients with neither of these conditions. There were no differences in total UDI-6 scores, suggesting that the severity (as opposed to the quality of life impact) of LUTS was not affected by these conditions (fig. 3). However, the interaction of these 2 conditions significantly affected total scores from the UDI-6 but not from the IIQ-7 survey (fig. 4). Individual Survey Scores and Association With Sexual Trauma or Psychiatric Comorbidity When survey data from patients with a history of sexual trauma (52) were compared to data from those with neither sexual trauma nor history of psychiatric comorbidities (27) there were no differences in any of the UDI-6 questions. However, scores for IIQ-7 question 1 (ability to do household chores 1.0 ± 0.2 vs 0.4 ± 0.2, p = 0.012), question 4 (ability to travel by car/bus more than 30 minutes from home 1.9 ± 0.2 vs 1.3 ± 0.2, p = 0.022) and question 6 (emotional health 1.6 ± 0.2 vs 0.9 ± 0.2, p = 0.001) were higher in patients with a history of sexual trauma (fig. 5). Likewise when survey data from patients with a history of psychiatric comorbidities (65) were compared to data from patients with neither sexual trauma nor history of psychiatric comorbidities (27), there were no differences in any of the UDI-6 questions. However, scores for IIQ-7 question 5 (participation in social activities 1.5 ± 0.1 vs 1.0 vs 0.2, p = 0.032), question 6 (emotional health 1.7 ± 0.1 vs 0.9 ± 0.2, p <0.001) and question 7 (feeling frustrated 2.2 ± 0.1 vs 1.7 ± 0.2, p = 0.031) were also higher in patients with a history of psychiatric comorbidities (fig. 6). Survey Scores and Associations With Other Patient Variables Individual and total survey scores were compared for patients older or younger than the mean age of 50 years. Age younger than 50 years was associated with higher scores for UDI-6 question 5 (difficulty emptying bladder 1.4 ± 0.2 vs 0.7 ± 0.1, p = 0.006), UDI-6 question 6 (pain or discomfort in lower abdomen or genital area 1.4 ± 0.2 vs 0.8 ± 0.1, p = 0.014) and UDI-6 total scores (11.2 ± 0.5 vs 9.7 ± 0.5, p = 0.035). White race was associated with higher scores for UDI-6 question 3 (urine leakage with physical activity 2.3 ± 0.1 vs 1.6 ± 0.2, p = 0.004) and for IIQ-7 question 1 (ability to do household chores 1.4 ± 0.1 vs 0.8 ± 0.1, p = 0.005). There were no associations with pregnancy (0 pregnancies vs more than 0), parity (0 live births vs more than 0) and history of pregnancy termination (0 terminations vs more than 0). However, a history of having 1 or more miscarriages was associated with higher scores for UDI-6 total score (11.9 ± 0.6 vs 9.8 ± 0.4, p = 0.006), IIQ-7 question 1 (ability to do household chores 1.2 ± 0.2 vs 0.6 ± 0.1, p = 0.005), IIQ-7 question 2 (physical recreation 2.1 ± 0.2 vs 1.3 ± 0.1, p = 0.002) and IIQ-7 total score (11.8 ± 0.9 vs 9.1 ± 0.6, p = 0.026). Univariate and Multivariate Analyses To determine if any additional patient factors were associated with a history of sexual trauma or psychiatric comorbidities, patient characteristics including age, race and obstetric factors were compared to history of psychiatric comorbidities or sexual trauma in a univariate fashion. There were no statistically significant associations. However, age younger than 50 years and history of pregnancy termination approached significance as associations for psychiatric comorbidities (p = 0.06), suggesting a possible link between these conditions. To determine if any patient factors were uniquely associated with higher total survey scores for the UDI-6 and the IIQ-7, stepwise multivariate regression analyses were performed using continuous variables (ie number of miscarriages, number of psychiatric diagnoses, patient age) or categorical (yes/no) variables (ie psychiatric history, history of sexual trauma, pregnancy, miscarriage, live birth or termination of pregnancy, age younger than 50 vs 50 years or older, nonwhite vs white race). For continuous variables higher UDI-6 total scores were associated only with number of reported miscarriages (p = 0.004). For categorical variables higher UDI-6 total scores were associated with any history of miscarriage (p = 0.007) and age younger than 50 years (p = 0.043). For continuous variables higher IIQ-7 total scores were associated with the total number of psychiatric diagnoses (p <0.001) and the number of reported miscarriages (p = 0.011). For categorical variables higher IIQ-7 total scores were associated with a history of psychiatric comorbidities (p = 0.014) and history of miscarriage (p = 0.007). Discussion This study demonstrates that psychosocial and emotional factors likely influence symptoms typically associated with OAB. The most important result was the high prevalence of psychiatric comorbidity (64.5%) and sexual trauma (49.6%) identified in women referred for the evaluation of LUTS. The finding that these rates were also higher compared to those of 308 patients in the primary care clinic with any voiding symptoms suggests that a referral bias might exist in that patients with more severe/bothersome symptoms may have been more likely to seek treatment. In addition, these data highlight the important distinction between patients with clinically significant LUTS and patients with any LUTS. Because all patients in the study were referred from a single source the possibility of an overrepresented prevalence in the source population was ruled out. However, a 20.1% prevalence of sexual trauma in the control population indicates the pervasiveness of this condition, and is in line with published data from female veterans (22%)6 and nonveterans (15% to 25%).7 Additionally, the most common setting for sexual trauma in the LUTS clinic was during active military service (35%). This finding is supported by data showing much higher prevalence rates (1 in 3 to 1 in 4) of sexual trauma for women during military service compared to the lifetime prevalence in civilian populations (1 in 6).6 Another important finding of this investigation was that women with LUTS experience greater quality of life impact from the symptoms but the severity of symptoms is not altered. Although sexual trauma itself did not change total quality of life scores in women with LUTS, several individual survey items were affected (mainly emotional domains). However, the relatively small sample of women with sexual trauma and no history of psychiatric comorbidities may explain this result. To rule out the possibility that factors other than psychiatric comorbidities and sexual trauma might be confounding the survey results, univariate analyses were performed, and did not identify significant associations with age, race or the obstetric variables of pregnancies, parity, miscarriages and terminations. On multivariate stepwise regression analyses the finding that psychiatric comorbidity was an independent risk factor for quality of life impact from LUTS (higher IIQ-7 scores) lends support to the findings in this study. However, the finding that a history of miscarriages is also an independent risk factor for greater quality of life impact from LUTS was surprising. This has not been identified elsewhere in the literature and may represent a skewed patient population. However, loss of pregnancy, whether induced or spontaneous, has been associated with higher rates of substance abuse and affective disorders.8 Furthermore, the possibility of hormonal or fertility issues impacting LUTS must also be considered as studies demonstrate higher rates of sexual dysfunction in women with LUTS9 and higher levels of certain sex hormones in men with LUTS.10 In terms of the severity of incontinence, the finding that age younger than 50 years and history of miscarriage were associated with higher total UDI-6 scores is not easily explainable. However, in a case-control study by Davila et al the mean age of women in the abuse group was younger than in the control group, which suggests that sexual abuse may be more common in or more readily disclosed by younger women.5 Studies on the influence of psychosocial and emotional factors on LUTS in women are limited. In a population based study including results from more than 3,000 women Litman et al found that only depressive symptoms correlated with LUTS (defined as American Urological Association symptom index greater than 8) on multivariate analysis.11 Johnson et al evaluated survey results from 825 women and found that a lifetime history of emotional abuse (24%) was common and was associated with higher rates of stress incontinence.12 Jundt et al recruited 243 women attending a gynecology clinic to complete a survey on physical and sexual abuse, and found that 22% of the patients met criteria for abuse but the highest rates of abuse were identified in women with OAB (30.6%).13 Sexual and physical abuse has also been found in association with organic and especially functional gastrointestinal disorders, and was shown to be associated with higher rates of chronic abdominal and pelvic pain.14 In addition, women with gastrointestinal disorders are more likely to have other somatic symptoms including depression. Furthermore, there is some evidence in animal models linking neurochemical causes of depression (serotonin levels)15 and anxiety (alterations in corticotropin releasing factor)16 to LUTS. Conclusions This is the first study to our knowledge to characterize the association of psychiatric comorbidities and sexual trauma with the type, severity and quality of life impact of LUTS in women using validated surveys. The prevalence of psychiatric comorbidities and sexual trauma is high in female veterans presenting for evaluation of LUTS. This study demonstrates that psychiatric comorbidities appear to impact quality of life related to LUTS but not the type or severity of symptoms. References 1. 1Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21:167. MEDLINE |
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2. 2Stewart WF, Van Rooyen JB, Cundiff GW, et al. Prevalence and burden of overactive bladder in the United States. World J Urol. 2003;20:327. MEDLINE 3. 3Temml C, Heidler S, Ponholzer A, et al. Prevalence of the overactive bladder syndrome by applying the International Continence Society definition. Eur Urol. 2005;48:622. Abstract | Full Text |
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4. 4Nabi G, Cody JD, Ellis G, et al. Anticholinergic drugs versus placebo for overactive bladder syndrome in adults. Cochrane Database Syst Rev. 2006;4:. 5. 5Davila GW, Bernier F, Franco J, et al. Bladder dysfunction in sexual abuse survivors. J Urol. 2003;170:476. Abstract | Full Text |
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11. 11Litman HJ, Steers WD, Wei JT, et al. Relationship of lifestyle and clinical factors to lower urinary tract symptoms: results from Boston Area Community Health survey. Urology. 2007;70:916. Abstract | Full Text |
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12. 12Johnson JK, John R, Humera A, et al. The prevalence of emotional abuse in gynaecology patients and its association with gynaecological symptoms. Eur J Obstet Gynecol Reprod Biol. 2007;133:95. Abstract | Full Text |
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13. 13Jundt K, Scheer I, Schiessl B, et al. Physical and sexual abuse in patients with overactive bladder: is there an association?. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18:449. MEDLINE |
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14. 14Drossman DA, Leserman J, Nachman G, et al. Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Ann Intern Med. 1990;113:828. MEDLINE 15. 15Lee KS, Na YG, Dean-McKinney T, et al. Alterations in voiding frequency and cystometry in the clomipramine induced model of endogenous depression and reversal with fluoxetine. J Urol. 2003;170:2067. Abstract | Full Text |
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16. 16Klausner AP, Streng T, Na YG, et al. The role of corticotropin releasing factor and its antagonist, astressin, on micturition in the rat. Auton Neurosci. 2005;123:26. Abstract | Full Text |
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Division of Urology, Virginia Commonwealth University School of Medicine and the Hunter Holmes McGuire Veterans Affairs Hospital, Richmond, Virginia  Correspondence: Division of Urology, Virginia Commonwealth University School of Medicine, PO Box 980118, Richmond, Virginia 23298-0118 (telephone: 804-828-5320; FAX: 804-828-2157)
Study received institutional review board approval. PII: S0022-5347(09)02057-6 doi:10.1016/j.juro.2009.08.035 © 2009 American Urological Association. Published by Elsevier Inc. All rights reserved. | |
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