Depression and Urinary Incontinence

DEPRESSION and URINARY INCONTINENCE

Many women with uncontrollable urine loss find their symptoms significantly impact their quality of life. They don’t go anywhere without checking the location of the nearest bathroom. They worry about coughing or sneezing in public. If they wear pads, they wonder if they have a urine odor. When eating out, they don’t have a second beverage for fear it will provoke urine loss. They fear urine loss during sexual intimacy. The issues surrounding this problem follow them everywhere.

It is no wonder that women with urinary incontinence have a higher prevalence of depression than similarly aged women without urinary incontinence. In a research study conducted in Finland and published in 2003, major depression occurred in 44% of women with urge incontinence and 17.5% of women with stress incontinence, as opposed to approximately 6% of the general population. Why?

In years past, physicians have assumed that women with urinary incontinence are depressed because they isolate themselves, don’t go out as much, are embarrassed by the problem, or are too anxious about it. While this is true, it is only part of the issue. Research aimed at answering the question “why?” has uncovered additional explanations for the difference in rates of depression found in women with and without urinary incontinence.

Various theories of depression involve a person’s perception of helplessness, lack of control, and inability to cope. Activities out of the control of women like urinary incontinence are more likely to cause depression. Women with urge incontinence unpredictably lose larger amounts of urine with each leakage episode resulting in greater anxiety related to the perception of greater loss of bladder control. What if you “can’t hold it” when pumping gas in your car and leak urine down your leg at the gas pump? This explains why women with urge incontinence report greater degrees of depression and impact on qualify of life than women with stress incontinence. Women with stress incontinence who limit what they drink or avoid activities that predictably provoke urine leakage still tend to be more depressed than the general population, but not as depressed as women with urge incontinence. Remember, urinary incontinence likely causes secondary depression because of its negative impact in quality of life. Studies have shown that symptoms of depression improve after treatment of both urge and stress urinary incontinence.

Many cases of primary depression are the result of low levels of serotonin, a neurotransmitter (chemical messenger) found in the brain. The group of medications called selective serotonin reuptake inhibitors (SSRIs) increase the availability of serotonin, and decrease the symptoms of depression. Interestingly enough, SSRIs such as Paxil and Zoloft have the side effect of urinary retention. This led researchers to wonder if this chemical messenger, serotonin, has some role in bladder function. The association between depression and urge incontinence is consistent with the idea that a reduction in serotonin function predisposes to depression and contributes to bladder overactivity. Some women with urinary incontinence believe their incontinence is a natural consequence of being a female, having children, and living past menopause – a burden to bear. And if this causes symptoms of depression, they just are not strong enough to deal with their incontinence. Current research suggests the strong association between urinary incontinence and depression is not related to a negative response to loss of bladder control, but is the result of low levels of serotonin. With more research about neurotransmitters common to both depression and urinary incontinence, we may discover better ways of treating urinary incontinence. In fact, Duloxetine, a new SSRI, is being marketed for the treatment of stress urinary incontinence because it causes bladder relaxation and urethral sphincter contraction.

Before the advent of SSRIs, many people with depression were led to believe they simply were not trying hard enough to get well or they had some character flaw causing their symptoms. We now know that depression is a physical illness, with physical basis and specific treatment. The point to remember is this. If you are experiencing symptoms of depression, you are not alone! Between 17-44% of women with urinary incontinence also have symptoms of depression. The exact relationship between the two is uncertain, but it is there. Make sure to tell us, or your primary care physician, if you are experiencing symptoms of depression. Being depressed makes it even more difficult to cope and participate effectively in treatment. Your participation is essential to maximize positive treatment outcomes.

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