ReviewAffective symptoms and the overactive bladder — A systematic review
Introduction
Depression and anxiety are classified as affective disorders according to the DSM-IV psychiatric diagnostic criteria [1]. According to a survey of the World Health Organisation, anxiety is globally the most common psychiatric disorder [2]. The lifetime prevalence of anxiety disorders in the US adult population is around 18% [2]. Depression has a high lifetime prevalence as well, ranging from 2 to 15% [3].
Overactive bladder (OAB) is defined by the International Continence Society (ICS) as a symptom complex of urgency, usually accompanied by frequency (voiding 8 or more times in a 24 hour period) and nocturia (awakening at night to void), with (OAB wet) or without (OAB dry) urinary urgency incontinence (UUI) [4]. Approximately 16–17% of the adult population is affected by OAB: 43% of adult women experience OAB symptoms ‘sometimes’ and 33% ‘often’ [5], [6]. The health care costs of OAB are high and around 12 billion USD per year [7].
Although high prevalence rate would suspect the opposite, OAB is often underdiagnosed and subsequently undertreated, mainly because of patients' reluctance to seek medical help [8]. Only 27% of people with OAB were receiving treatment in a large population based survey [6]. One possible reason for not seeking help in OAB may be caused by stigma perception [8]. Another is that people may assume that UI is part of the normal aging process [9]. In addition an inverse relationship between depressive symptoms and healthcare seeking in patients with OAB is reported [10].
A relationship between common affective disorders (e.g. depression and anxiety disorders) and lower urinary tract symptoms (LUTS) has been described as early as 1964 [11]. The importance of mental disorders in the aetiology of urgency incontinence was again emphasized more recently [12], [13]. In 2011 the International Consultation on Incontinence-Research Society (ICI-RS) organised a think tank on psychological factors and LUTS [14]. It was noted that not only OAB but also other LUTS may be associated with affective conditions, concluding that ‘the possibility of causation and or maintenance of lower urinary tract symptoms through psychological causes needs further research' [14]. At present there has been renewed interest in the matter, reflected by a quadrupling in publications found through PubMed/EMBASE search on the topic since 2000 (searched for anxiety, depression and lower urinary tract symptoms before and after 2000).
Despite this growing interest, the exact nature of the association between bladder symptoms and mental conditions, specifically affective disorders, remains unknown. A systematic review using strict definitions may inform the field regarding the strength of the associations between affective disorders and OAB and may possibly enhance insight in underlying pathophysiological mechanisms and treatment recommendations at the “bladder–brain-axis”.
The aim of the current study was to (i) review articles providing evidence on the association of affective conditions with OAB; (ii) to examine the direction and strength of the association; (iii) to gauge the possible influence of method and design factors in terms of occasioning bias or confounding; and (iv) to formulate considerations for future research.
Section snippets
Methods
This systematic review was registered in PROSPERO under number CRD42014006641 [15].
Results
Forty-three articles regarding 37 studies were included in the review. Thirty-two articles were about depression, 9 about anxiety (and depression) and two about anxiety only. Diagnosing OAB was carried out according to the ICS definition of OAB in 33 articles. In 10 articles, the ICS definition had not been used. Three of these articles were published before establishment of the ICS definition in 2002 [20], [21], [22]. Retrospectively these 10 articles adhered to the ICS definition and were
Discussion
To our knowledge, this systematic review is the first to give an extensive qualitative overview of the current literature on the association between OAB and affective symptoms. The aim of the current study was to (i) review articles providing evidence on the association of affective conditions with OAB; (ii) to examine the direction and strength of the association; (iii) to gauge the possible influence of method and design factors in terms of occasioning bias or confounding; and (iv) to
Conclusions
The results of this systematic review reveal a positive association between the co-occurrence of OAB and affective symptoms. Furthermore, there is evidence for the new onset of OAB in depressive subjects, but further research is necessary to examine the strength of the effect. However, many evaluated studies relied on a single survey instrument, failed to note longitudinal changes and lacked information allowing assessment of epidemiological criteria for causality. Affective dysregulation may
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Cited by (0)
- 1
Vrijens and Drossaerts contributed equally to this manuscript and share first authorship.
- 2
Chair Pelvic Care Centre Maastricht, Maastricht, The Netherlands.