Acta Obstet Gynecol Scand 58: 91-94, 1979
M E N T A L FACTORS INFLUENCING RECURRENCE OF STRESS INCONTINENCE
A . Obrink, P. Fedor-Freybergh, M . Hjelmkvist and G . Bunne From the Department of Obstetrics and Gynaecology, Karolinsku Institrrtet, Strbhntsherg Hospirril, Stockliolni, Sweden
Abstracf. At a recent follow-up of 51 women operated on
for stress incontinence, there was an astonishingly high discrepancy between symptoms claimed by the patients and signs found by the physician. To examine the influence of certain mental factors on the recurrence of stress incontinence, the patients in the above-mentioned follow-up were tested with the Eysenck Personality Inventory test and the Sabbatsberg Depression Self-rating Scale test. The women with symptoms but no objective signs of stress incontinence showed a higher degree of both neuroticism and depression than the women of perfect health. Thus, in this group, it may be a question of aggravation of symptoms, which cannot be helped by a reoperation. Instead, these women might need psychiatric attention to relieve their psychosomatic symptoms.
Surgical treatment for stress incontinence is mostly successful, i.e. the social handicap is abolished. However, great efforts can often provoke urinary leakage postoperatively (8). Normally, this is not enough to require further medical attention. At a recent follow-up of 5 1 women operated on for stress incontinence with pubococcygeal repair ad modurn Ingelman-Sundberg, between 1955 and 1965, it became obvious that, sometimes, the patients’ own histories did not conform with the clinical findings (5). Two groups of women were remarkable; one because symptoms of leakage were claimed without signs and the other because symptoms were absent in spite of clinically apparent stress incontinence. The latter group does not pose a problem to the physician, whereas the former group does. Women in the former group insist on further treatment and Will not be content with the operation Performed, even though it seems totally successful from the physicians point of view. Therefore, it justifiable to seek a mental explanation for the discrepancy between signs and symptoms. Therefore, most women in the follow-up were also submit-
ted to two psychological tests, namely the Eysenck Personality Inventory test ( 2 ) and the Sabbatsberg Depression Self-rating Scale test (3, 4). These tests reveal the degree of neuroticism (disposition to react in a neurotic way) and the degree of depression respectively. Because of the diagnostic challenge and the risk of a hazardous reoperation solely based on the patient’s complaints, interest centred on those women who complained of stress incontinence but in whom no clinical signs of this could be verified. MATERIAL AND METHOD Thirty-three women, mean age 65 years, were examined 10-20 years after pubococcygeal repair for stress incontinence. Preoperatively, all patients had been thoroughly examined and severe, genuine stress incontinence had been diagnosed. At follow-up visit the patients’ histories were scrutinized regarding the degree and the duration of a possible recurrence of stress incontinence. A gynecological examination was performed and continence was checked with 250 ml saline solution in the bladder in the supine position. The women were divided into four groups (see Fig. 1): 1. free from symptoms and signs of stress incontinence 2. symptoms but no signs 3 . signs but no symptoms 4. both symptoms and signs The psychological examination included two tests. 1. The Eysenck Personality Inventory test (EPI). This test includes 57 questions to be answered with “yes” or “no”. The degree of neuroticism, introversion and extroversion can be estimated. Only the subscale for neuroticism was used in this study and the evaluation was done according to the Stanine score. We regard the socalled neuroticism in the Eysenck scale as a disposition of the isolated personality to react more or less neurotically in a situation of internal or external frustration. Whether this disposition is based on the constitution of the personality or whether it is flexible and variable in different situations is unclear. However, it seems as if neuroticism might be influenced by an altered situation or treatment (4).
92
A . Obrink et al. 3 3
RESULTS (Figs. 1 and 2 )
P A T I E N T S
\
SYMPTOMS OF INCONTINENCE ( 9 1
S I G N S OF INCONTINENCE [ 6
Group I (neither symptoms nor signs): 21 women concentrated in the middle of the scales for both neuroticism and depression. Group 2 (symptoms but no signs): 6 women showed a high score regarding both neuroticism and depression. Group 3 (signs but no symptoms): 3 women showed a low degree of both neuroticism and depression. Group 4 (both symptoms and signs): 3 women scored the same as group 2 .
I
arm ama
nunma \
\
mmm
/
SYMPTOMS AND S I G N S OF INCONTINENCE
Fig. I . Distribution of the tested patients regarding symptoms and signs of stress incontinence.
DISCUSSION The tests reflect not only the tendency to mental aberrations in basic personality but also the response to environmental stress factors. Therefore, in spite of a perfectly normal personality, a woman may have test results pointing to an increase in both neuroticism and depression in a situation of mental stress such as urinary leakage. This is probably what happened to the women with both symptoms
2 . Sabbatsberg Depression Self-Rating Scale (SDSRS) is based on 50 statements, each with four possible answers such as “never”, “seldom”, “often”, “always”. The statements might be formulated like this: “ I have a bad conscience without knowing why”. This test was performed at the medical examination and the data were computed and scored 1-25. It was thereby possible to make a semi-quantitative assessment in order to estimate the degree of depression.
=
WOMEN FREE FROM SYMPTOMS AN0 SIGNS
NUMBER OF WOMEN
lo
1
WOMEN WITH SYMPTOMS BUT NO SIGNS WOMEN WITH SIGNS BUT NO SVMPTOMS WOMEN WITH BOTH SYMPTOMS AN0 SIGNS
1
2
3
b
6
1
2
3
4 5
Fig. 2 . Degree of neuroticism according to EPI. Note the
difference between patients with and without symptoms of stress incontinence.
I
I
0
DEGREE OF MUROTICISM ( € P I )
Mental factors influencing recurrence
of stress incontinence
93
=
WOMEN FREE FROM SYMPTOMS AN0 SIGNS W M N WITH SVMPTWS BUT NO SIGNS WOMEN WITH SIONS BUT 110 SYMPTOMS
NUMBER OF WOMEN
WOMEN WITH BOTH SYMPTOMS A N 0 SIGNS
SAEEATSBERG OEPRESSION SELF-RATING SCALE ISDSRSI
Fig. 3. Degree of depression according to SDSRS. Note the difference between patients with and without symptoms of stress incontinence.
and signs (see Figs. I and 2 ) . As could be expected, the continent women without symptoms showed a normal pattern concerning both neuroticism and depression. Some women obviously had stress incontinence although they denied symptoms. These women had the lowest degree for both neuroticism and depression. The most likely explanation for this “dissimulation” is that these women had arranged their daily lives so that sudden efforts and thereby urinary leakage were avoided as much as possible. Those subjects free from signs of urinary leakage at stress even though symptoms were claimed, had a higher degree of both neuroticism and depression. Thus, these women were peculiar in the sense that no objective signs of incontinence could explain the test results. All of them were entirely continent, even under maximum effort with a full bladder; no downward rotation of the bladder neck region was seen. This does not, however, exclude incontinence of a very low degree such as a slight urinary leakage upon heavy straining in the standing position. As a matter of fact, this type of “stress incontinence” is very common in postmenopausal women in general and is present in a large percentage also postoperatively, as has been shown by simultaneous urethrocystometry ( 1 , 8). It is therefore highly
likely that this slight and very common form of urinary leakage is used by the patients in this group to gain advantages and resolve mental frustration. The point is that if the bladder neck is well elevated and a firm floor is established underneath the urethra postoperatively and leakage cannot be provoked, nothing can be gained by repeat operation (1, 7, 8). The exaggerated complaints of the patients will remain the same. In fact, there is a risk of more scarring and denervation as a result of renewed surgery, so that an obvious and socially embarrassing recurrence might appear ( 1 , 6). The treatment of choice for these women is without doubt psychiatric. CONCLUSION If a recurrence of stress incontinence cannot be verified clinically, and there are no signs of technical failure of the previous operation, it may be wise to hesitate to perform a repeat operation. Instead, the patients might be helped by psychiatric care to relieve neurotic and depressive symptoms. REFERENCES I. Bunne, G. & Obrink, A.: Influence of pubococcygeal
repair on urethral closure pressure at stress. Accepted for publication in Acta Obstet Gynecol Scand 1977.
94
A . Obrink rt 01.
2. Eysenck, N. H . J. & Eysenck, S . B. G.: The Manual for the Eysenck Personality Inventory. University of London Press, London, 1964. 3. Fedor-Freybergh. P., Hjelmqvist, M. & Zador, G.: Psychodiagnostic follow-up of Neovletta-a new low dose oral contraceptive. Acta Obstet Gynecol Scand, Suppl. 54, 1976. 4. Fedor-Freybergh. P.: The influence of oestrogens on the well-being and mental performance in climacteric and postmenopausal women. Acta Obstet Gynecol Scand, Suppl. 64, 1977. 5. Obrink, A,: Pubococcygeal repair ad rnodum Ingelrnan-Sundberg. A retrospective investigation with 10-20 years time of observation. Acta Obstet Gynecol Scand 56: 391, 1977. 6. Obrink. A , , Bunne, G., Ingelman-Sundberg, A. & Ulmsten, U.: The urethral pressure profile before, during and after pubococcygeal repair for stress incontinence. Acta Obstet Gynecol Scand57:49, 1978.
7. Obrink, A,, Bunne. G.. Ingelman-Sundberg. A.: Pressure transmission to the pre-urethral space in stress incontinence. Accepted for publication in Urol Res 1977. 8. Obrink, A., Bunne, G.: The margin to incontinence after three different operations for stress incontinence. Accepted for publication in Scdnd J Urol Nephrol 1977.
Anders Obrink Kvinnokliniken Sabbatsbergs sjukhus Box 6401 S-I1382 Stockholm Sweden
M E N T A L FACTORS INFLUENCING RECURRENCE OF STRESS INCONTINENCE
A . Obrink, P. Fedor-Freybergh, M . Hjelmkvist and G . Bunne From the Department of Obstetrics and Gynaecology, Karolinsku Institrrtet, Strbhntsherg Hospirril, Stockliolni, Sweden
Abstracf. At a recent follow-up of 51 women operated on
for stress incontinence, there was an astonishingly high discrepancy between symptoms claimed by the patients and signs found by the physician. To examine the influence of certain mental factors on the recurrence of stress incontinence, the patients in the above-mentioned follow-up were tested with the Eysenck Personality Inventory test and the Sabbatsberg Depression Self-rating Scale test. The women with symptoms but no objective signs of stress incontinence showed a higher degree of both neuroticism and depression than the women of perfect health. Thus, in this group, it may be a question of aggravation of symptoms, which cannot be helped by a reoperation. Instead, these women might need psychiatric attention to relieve their psychosomatic symptoms.
Surgical treatment for stress incontinence is mostly successful, i.e. the social handicap is abolished. However, great efforts can often provoke urinary leakage postoperatively (8). Normally, this is not enough to require further medical attention. At a recent follow-up of 5 1 women operated on for stress incontinence with pubococcygeal repair ad modurn Ingelman-Sundberg, between 1955 and 1965, it became obvious that, sometimes, the patients’ own histories did not conform with the clinical findings (5). Two groups of women were remarkable; one because symptoms of leakage were claimed without signs and the other because symptoms were absent in spite of clinically apparent stress incontinence. The latter group does not pose a problem to the physician, whereas the former group does. Women in the former group insist on further treatment and Will not be content with the operation Performed, even though it seems totally successful from the physicians point of view. Therefore, it justifiable to seek a mental explanation for the discrepancy between signs and symptoms. Therefore, most women in the follow-up were also submit-
ted to two psychological tests, namely the Eysenck Personality Inventory test ( 2 ) and the Sabbatsberg Depression Self-rating Scale test (3, 4). These tests reveal the degree of neuroticism (disposition to react in a neurotic way) and the degree of depression respectively. Because of the diagnostic challenge and the risk of a hazardous reoperation solely based on the patient’s complaints, interest centred on those women who complained of stress incontinence but in whom no clinical signs of this could be verified. MATERIAL AND METHOD Thirty-three women, mean age 65 years, were examined 10-20 years after pubococcygeal repair for stress incontinence. Preoperatively, all patients had been thoroughly examined and severe, genuine stress incontinence had been diagnosed. At follow-up visit the patients’ histories were scrutinized regarding the degree and the duration of a possible recurrence of stress incontinence. A gynecological examination was performed and continence was checked with 250 ml saline solution in the bladder in the supine position. The women were divided into four groups (see Fig. 1): 1. free from symptoms and signs of stress incontinence 2. symptoms but no signs 3 . signs but no symptoms 4. both symptoms and signs The psychological examination included two tests. 1. The Eysenck Personality Inventory test (EPI). This test includes 57 questions to be answered with “yes” or “no”. The degree of neuroticism, introversion and extroversion can be estimated. Only the subscale for neuroticism was used in this study and the evaluation was done according to the Stanine score. We regard the socalled neuroticism in the Eysenck scale as a disposition of the isolated personality to react more or less neurotically in a situation of internal or external frustration. Whether this disposition is based on the constitution of the personality or whether it is flexible and variable in different situations is unclear. However, it seems as if neuroticism might be influenced by an altered situation or treatment (4).
92
A . Obrink et al. 3 3
RESULTS (Figs. 1 and 2 )
P A T I E N T S
\
SYMPTOMS OF INCONTINENCE ( 9 1
S I G N S OF INCONTINENCE [ 6
Group I (neither symptoms nor signs): 21 women concentrated in the middle of the scales for both neuroticism and depression. Group 2 (symptoms but no signs): 6 women showed a high score regarding both neuroticism and depression. Group 3 (signs but no symptoms): 3 women showed a low degree of both neuroticism and depression. Group 4 (both symptoms and signs): 3 women scored the same as group 2 .
I
arm ama
nunma \
\
mmm
/
SYMPTOMS AND S I G N S OF INCONTINENCE
Fig. I . Distribution of the tested patients regarding symptoms and signs of stress incontinence.
DISCUSSION The tests reflect not only the tendency to mental aberrations in basic personality but also the response to environmental stress factors. Therefore, in spite of a perfectly normal personality, a woman may have test results pointing to an increase in both neuroticism and depression in a situation of mental stress such as urinary leakage. This is probably what happened to the women with both symptoms
2 . Sabbatsberg Depression Self-Rating Scale (SDSRS) is based on 50 statements, each with four possible answers such as “never”, “seldom”, “often”, “always”. The statements might be formulated like this: “ I have a bad conscience without knowing why”. This test was performed at the medical examination and the data were computed and scored 1-25. It was thereby possible to make a semi-quantitative assessment in order to estimate the degree of depression.
=
WOMEN FREE FROM SYMPTOMS AN0 SIGNS
NUMBER OF WOMEN
lo
1
WOMEN WITH SYMPTOMS BUT NO SIGNS WOMEN WITH SIGNS BUT NO SVMPTOMS WOMEN WITH BOTH SYMPTOMS AN0 SIGNS
1
2
3
b
6
1
2
3
4 5
Fig. 2 . Degree of neuroticism according to EPI. Note the
difference between patients with and without symptoms of stress incontinence.
I
I
0
DEGREE OF MUROTICISM ( € P I )
Mental factors influencing recurrence
of stress incontinence
93
=
WOMEN FREE FROM SYMPTOMS AN0 SIGNS W M N WITH SVMPTWS BUT NO SIGNS WOMEN WITH SIONS BUT 110 SYMPTOMS
NUMBER OF WOMEN
WOMEN WITH BOTH SYMPTOMS A N 0 SIGNS
SAEEATSBERG OEPRESSION SELF-RATING SCALE ISDSRSI
Fig. 3. Degree of depression according to SDSRS. Note the difference between patients with and without symptoms of stress incontinence.
and signs (see Figs. I and 2 ) . As could be expected, the continent women without symptoms showed a normal pattern concerning both neuroticism and depression. Some women obviously had stress incontinence although they denied symptoms. These women had the lowest degree for both neuroticism and depression. The most likely explanation for this “dissimulation” is that these women had arranged their daily lives so that sudden efforts and thereby urinary leakage were avoided as much as possible. Those subjects free from signs of urinary leakage at stress even though symptoms were claimed, had a higher degree of both neuroticism and depression. Thus, these women were peculiar in the sense that no objective signs of incontinence could explain the test results. All of them were entirely continent, even under maximum effort with a full bladder; no downward rotation of the bladder neck region was seen. This does not, however, exclude incontinence of a very low degree such as a slight urinary leakage upon heavy straining in the standing position. As a matter of fact, this type of “stress incontinence” is very common in postmenopausal women in general and is present in a large percentage also postoperatively, as has been shown by simultaneous urethrocystometry ( 1 , 8). It is therefore highly
likely that this slight and very common form of urinary leakage is used by the patients in this group to gain advantages and resolve mental frustration. The point is that if the bladder neck is well elevated and a firm floor is established underneath the urethra postoperatively and leakage cannot be provoked, nothing can be gained by repeat operation (1, 7, 8). The exaggerated complaints of the patients will remain the same. In fact, there is a risk of more scarring and denervation as a result of renewed surgery, so that an obvious and socially embarrassing recurrence might appear ( 1 , 6). The treatment of choice for these women is without doubt psychiatric. CONCLUSION If a recurrence of stress incontinence cannot be verified clinically, and there are no signs of technical failure of the previous operation, it may be wise to hesitate to perform a repeat operation. Instead, the patients might be helped by psychiatric care to relieve neurotic and depressive symptoms. REFERENCES I. Bunne, G. & Obrink, A.: Influence of pubococcygeal
repair on urethral closure pressure at stress. Accepted for publication in Acta Obstet Gynecol Scand 1977.
94
A . Obrink rt 01.
2. Eysenck, N. H . J. & Eysenck, S . B. G.: The Manual for the Eysenck Personality Inventory. University of London Press, London, 1964. 3. Fedor-Freybergh. P., Hjelmqvist, M. & Zador, G.: Psychodiagnostic follow-up of Neovletta-a new low dose oral contraceptive. Acta Obstet Gynecol Scand, Suppl. 54, 1976. 4. Fedor-Freybergh. P.: The influence of oestrogens on the well-being and mental performance in climacteric and postmenopausal women. Acta Obstet Gynecol Scand, Suppl. 64, 1977. 5. Obrink, A,: Pubococcygeal repair ad rnodum Ingelrnan-Sundberg. A retrospective investigation with 10-20 years time of observation. Acta Obstet Gynecol Scand 56: 391, 1977. 6. Obrink. A , , Bunne, G., Ingelman-Sundberg, A. & Ulmsten, U.: The urethral pressure profile before, during and after pubococcygeal repair for stress incontinence. Acta Obstet Gynecol Scand57:49, 1978.
7. Obrink, A,, Bunne. G.. Ingelman-Sundberg. A.: Pressure transmission to the pre-urethral space in stress incontinence. Accepted for publication in Urol Res 1977. 8. Obrink, A., Bunne, G.: The margin to incontinence after three different operations for stress incontinence. Accepted for publication in Scdnd J Urol Nephrol 1977.
Anders Obrink Kvinnokliniken Sabbatsbergs sjukhus Box 6401 S-I1382 Stockholm Sweden
