1. International Neurourology Journal 2015;19:286-292 Men With Severe Lower Urinary Tract Symptoms Are at Increased Risk of Depression Won Sik Jeong 1, Hong Yong Choi 1, Ji Won Nam 2, Shin Ah Kim 3, Bo Youl Choi 2, Hong Sang Moon 1, Kyu Shik Kim 1 1 Department of Urology, Hanyang University College of Medicine, Seoul, Korea 2 Department of Preventive Medicine, Hanyang University College of Medicine, Seoul, Korea 3 Center for Farmer’s Safety and Health, Dankook University Hospital, Cheonan, Korea This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons. org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2. International Neurourology Journal 2015;19:286-292 INTRODUCTION Lower urinary tract symptoms (LUTS) comprise a set of common, bothersome symptoms in middle-aged and elderly men. Recent research suggests that depressive symptoms may influence the symptoms of benign prostatic hyperplasia (BPH). We performed a community-based cross-sectional study to evaluate the correlation between LUTS and depression.

3. International Neurourology Journal 2015;19:286-292 The survey was conducted in a rural community during four periods in August 2009, 2010, 2011, and 2012. Two validated questionnaires were used to examine LUTS and depressive symptoms. These included the International Prostate Symptom Score/quality of life (IPSS/QoL) and the Korean version of the Center for Epidemiological Studies-Depression scale (CES-D-K). Patients were categorized in the depressive symptom group if their CES-D-K score was >16 points. MATERIALS AND MRTHODS

4. International Neurourology Journal 2015;19:286-292 A total of 711 men were included in this study. Thirty-five participants (4.92%) were found to have depressive symptoms. There was a positive correlation between depressive symptoms and LUTS severity (P<0.001). As compared to the mild LUTS group, the odds ratio (OR) of depression was 2.868 (95% confidence interval [CI], 1.293–6.362; P for trend<0.001) in the moderate LUTS group, and 4.133 (95% CI, 1.510–11.313; P for trend<0.001) in the severe LUTS group. In a model considering multiple variables such as age, education level, smoking, and exercise, the OR in the moderate LUTS group was 2.534 (1.125–5.708, 95% CI, P for trend=0.005), while that in the severe LUTS group was 3.910 (95% CI, 5.708–11.154; P for trend=0.005). In addition, depression was related to voiding symptoms. RESULTS

5. International Neurourology Journal 2015;19:286-292 Men with severe LUTS are at higher risk of depression than those with less severe urinary symptoms. The severity of voiding symptoms worsens depression. More aggressive urological diagnosis and treatment is needed in patients with severe LUTS, due to the impact on depressive symptoms and QoL. CONCLUSIONS

6. International Neurourology Journal 2015;19:286-292 Table 1. Patient characteristics Values are presented as mean±standard deviation or number (%). DEP, depressive symptom. CharacteristicTotal (n = 711)DEP (n = 35)Non-DEP (n = 676)P-value Age (yr)65.25 ± 9.6068.23 ± 8.5265.09 ± 9.460.057 Educational status 0.039 High school or higher 31710 (28.6)307 (45.4) Middle school 1404 (11.4)136 (20.1) Elementary or below 25421 (60.0)233 (34.5) Marital status 0.149 Married 66130 (85.7)631 (93.3) Single 505 (14.3)45 (6.7) Smoking status 0.142 Never 1985 (14.3)193 (28.6) Ex-smoker 35520 (57.1)335 (49.6) Current smoker 15810 (28.6)148 (21.9) Drinking status 0.112 Never 1275 (14.3)122 (18.0) Ex-drinker 10910 (28.6)99 (14.6) Current drinker 47520 (57.1)455 (67.3) Body mass index (kg/m 2 ) 0.274 < 23.0 26517 (48.6)248 (36.7) 23.0–24.9 17110 (28.6)161 (23.8) ≥ 25 2758 (22.9)267 (39.5) Regular exercise 0.041 Yes 2667 (20.0)259 (38.3) No 44528 (80.0)417 (61.7) Chronic diseases Hypertension 0.456 No 42819 (54.3)409 (60.5) Yes 28316 (45.7)267 (39.5) Diabetes 0.040 No 60826 (74.3)582 (86.1) Yes 1039 (25.7)94 (13.9)

7. International Neurourology Journal 2015;19:286-292 Table 2. Selected characteristics according to lower urinary tract symptom severity Characteristic LUTS severity P-valueP for trend Mild (0–7)Moderate (8–19)Severe (20–35) (n = 468)(n = 183)(n = 60) Age (yr)63.01 ± 9.3069.1 ± 8.6870.97 ± 8.54< 0.001 Educational status 0.0440.002 High school or higher 237 (50.6)65 (35.5)15 (25.0) Middle school 96 (20.5)32 (17.5)12 (20.0) Elementary or below 135 (28.8)86 (47.0)33 (55.0) Marital status 0.0870.045 Married (n = 661) 442 (94.4)168 (91.8)51 (85.0) Single (n = 50) 26 (5.6)15 (8.2)9 (15.0) Smoking status 0.0240.807 Never (n = 198) 142 (30.3)36 (19.7)20 (33.3) Ex-smoker (n = 355) 218 (46.6)103 (56.3)34 (56.7) Current smoker (n = 158) 108 (23.1)44 (24.0)6 (10.0) Drinking status 0.4740.272 Never (n = 127) 89 (19.0)30 (16.4)8 (13.3) Ex-drinker (n = 109) 64 (13.7)32 (17.5)13 (21.7) Current drinker (n = 475) 315 (67.3)121 (66.1)39 (65.0) Body mass index (kg/m 2 ) 0.2630.569 < 23.0 (n = 265) 161 (34.4)73 (39.9)31 (51.7) 23.0–24.9 (n = 171) 119 (25.4)44 (24.0)8 (13.3) ≥ 25 (n = 275) 188 (40.2)66 (36.1)21 (35.0) Regular exercise 0.0760.029 Yes (n = 266) 196 (41.9)54 (29.5)16 (26.7) No (n = 445) 272 (58.1)129 (70.5)44 (73.3) Chronic diseases Hypertension 0.904 No (n = 428) 287 (61.3)105 (24.5)36 (60.0) Yes (n = 283) 181 (38.7)78 (27.6)24 (40.0) Diabetes 0.8960.691 No (n = 608) 397 (84.8)158 (26.0)53 (88.3) Yes (n = 103) 71 (15.2)25 (24.3)7 (11.7) Values are presented as mean±standard deviation or number (%). All results are adjusted for age except age variable. P-values were calculated using the general linear model for continuous variables and Cochran-Mantel-Haenszel test for categorical variables.

8. International Neurourology Journal 2015;19:286-292 Table 3. Correlation between depressive symptoms and LUTS severity Variable Age-adjusted modelsMultivariable models OR(95% CI)OR(95% CI) IPSS components, score/total score a) Feeling of incomplete emptying 1.1951.022–1.3991.2131.034–1.424 Frequency 1.2171.018–1.4541.2010.999–1.443 Intermittency 1.1970.994–1.4431.1370.939–1.378 Urgency 1.3361.140–1.5671.3081.114–1.536 Weak stream 1.2371.055–1.4491.2071.026–1.420 Straining 1.3371.141–1.5671.3091.115–1.537 Nocturia 1.2371.056–1.4001.2081.026–1.421 Quality of life score 1.0490.817–1.3460.9970.771–1.288 LUTS severity a) Mild (0–7) (n = 468) 1Reference1 Moderate (8–19) (n = 183) 2.8681.293–6.3622.5341.125–5.708 Severe (20–35) (n = 60) 4.1331.510–11.3133.9105.708–11.154 P for trend < 0.001 0.005 Continuous, 1 score/total score 1.0741.033–1.1161.0681.026–1.112 Voiding symptoms b) Nonvoiding symptoms (n = 446) 1Reference1 Voiding symptoms (n = 265) 2.6941.295–5.6052.6611.267–5.588 Continuous, 1 score 1.111.051–1.1721.1061.047–1.169 Storage symptoms c) Nonstorage symptoms (n = 537) 1Reference1 Storage symptoms (n = 174) 2.4411.195–4.9842.0420.975–4.275 Continuous, 1 score/total score 1.0971.003–1.1991.0740.979–1.178

9. International Neurourology Journal 2015;19:286-292 P-values for trend were determined using multivariable logistic regression analyses. LUTS, lower urinary tract symptom; OR, odds ratio; CI, confidence interval; IPSS, International Prostate Symptom Score. Multivariable model: a) Adjusted for age (continuous), education status, marital status, smoking status, and regular exercise. b) Adjusted for age (continuous), education status, marital status, and regular exercise; voiding symptoms: urgency, frequency, nocturia. c) Adjusted for age (continuous), education status, marital status, body mass index, and regular exercise; storage symptoms: hesitancy, straining, feeling of incomplete emptying, intermittency, weak stream. Table 3. (continued)

10. International Neurourology Journal 2015;19:286-292 Fig. 1. Patient selection process. CES-D, Center for Epidemiological Studies-Depression scale.

11. International Neurourology Journal 2015;19:286-292 Fig. 2. Prevalence of depressive symptoms according to lower urinary tract symptoms (LUTS) severity. Results are adjusted for age (categorical variable). P-values and P for trend were calculated using Cochran-Manel-Haenszel test for categorical variables. P=0.002, P for trend<0.001. DEP, depressive symptom.