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Psychosomatic Medicine 67:476-482 (2005)
© 2005 American Psychosomatic Society

ORIGINAL ARTICLES

Stress, Hostility, and Disease Parameters of Benign Prostatic Hyperplasia

Philip M. Ullrich, PhD, Susan K. Lutgendorf, PhD, Jane Leserman, PhD, Derek G. Turesky, BA and Karl J. Kreder, MD

From the Department of Rehabilitation Medicine, University of Washington, Seattle, WA (P.M.U.); the Departments of Psychology and Obstetrics and Gynecology (S.K.L., D.G.T.) and Urology (K.J.K.), University of Iowa, Iowa City, IA; and the Department of Psychiatry, University of North Carolina, Chapel Hill, NC (J.L.).

Address correspondence and reprint requests to Philip M. Ullrich, PhD, Department of Rehabilitation Medicine, box 359740, Harborview Medical Center, 325 Ninth Ave, Seattle, WA 98104. E-mail: pullrich{at}u.washington.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 LIMITATIONS AND CONCLUSIONS
 NOTES
 REFERENCES
 
Objective: Psychological factors such as stress are known to influence activity in the sympathetic nervous system and hypothalamic–pituitary–gonadal axis, systems that in turn have been implicated in the development of benign prostatic hyperplasia (BPH). Associations between psychological stress and prostate function have not been directly examined. The objective of this study was to examine associations among stress, hostility, and BPH disease parameters.

Methods: Eighty-three men diagnosed with BPH completed self-report and interview measures of stress and hostility followed by measures of urologic function.

Results: Higher lifetime stress was associated with lower prostate volumes and residual urine volumes (p’s < .05). By contrast, high recent stress and hostility were associated with greater residual urine (p’s < .05). Stress and hostility were not associated with self-report ratings of urologic symptoms.

Conclusions: Stress and hostility were associated with objective measures of urologic functioning among men with BPH. Results highlight the need for increased attention in research and clinical settings toward associations between psychological factors and urologic disease.

Key Words: stress • hostility • benign prostatic hyperplasia • prostate

Abbreviations: BPH = benign prostatic hyperplasia; LUTS = lower urinary tract symptoms; SNS = sympathetic nervous system; AUA = American Urological Association; mL = milliliters; ANCOVA = analysis of covariance; HSD = honestly significant difference; SD = standard deviation.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 LIMITATIONS AND CONCLUSIONS
 NOTES
 REFERENCES
 
The majority of men over 50 years of age are presumed to have some urinary symptoms attributable to benign prostatic hyperplasia (BPH (1)), suggesting that the condition should be considered normal in older men (2). For most men, benign prostate enlargement is limited and does not affect health or functioning (3). However, in BPH, growth of the prostate coupled with greater tension in prostatic smooth muscle can cause bladder outflow obstruction (3–5) with resultant lower urinary tract symptoms (LUTS (2,4,6)). The exact causes of BPH are poorly understood but processes involving both the hypothalamic–pituitary–gonadal (HPG) axis and the sympathetic nervous system (SNS) are thought to be involved.

Testosterone produced through HPG axis activity is believed to regulate prostate growth (4,7). Testosterone is converted to the hormone dihydrotestosterone (DHT) by an enzyme, 5{alpha}-reductase, found in prostatic cells (4,8,9). DHT can stimulate a variety of growth factors that encourage prostatic growth (4,8,9). This process underlies the use of 5{alpha}-reductase inhibitors (e.g., finasteride) for the treatment of BPH (4).

SNS activity has a role in both the growth and contractility of the prostate. Compared with cells on surrounding physical structures, the prostate has an abundance of alpha adrenoreceptors (5), making the organ sensitive to the catecholamines norepinephrine and epinephrine. The release of norepinephrine may result in accelerated prostatic cell growth (10,11) and an increase in prostatic smooth muscle tension (5,12). These factors underlie the use of alpha blockers to treat BPH (5,13). Alpha blockers bind to alpha adrenoreceptors, thereby interrupting SNS stimulation of the prostate (5,13).

A large body of evidence indicates that psychological stress influences activity of the SNS and HPG axes. When the SNS is activated in response to acute stressors, norepinephrine is released from nerve endings projecting from the spinal cord and affecting organs and tissues throughout the body (14,15). Persons under chronic stress show elevated norepinephrine levels (16). Acute and chronic psychological stressors have more variable effects on HPG axis activity and testosterone secretion. Studies have found both elevated (17,18) and depressed testosterone levels (19–22) associated with higher stress. One factor contributing to testosterone and the stress response is hostility. Hostility is defined as a character trait involving enduring negative attitudes and emotions toward others such as mistrust and anger, which might be expressed through aggression or irritation (23). High hostility has been associated with increased SNS and HPG activity in response to stress (24–27).

Thus, numerous studies indicate that SNS and HPG activity are sensitive to hostility and stressors of both acute and longstanding nature. Other research shows that SNS and HPG activity influence prostatic disease processes. These parallel lines of research suggest the possibility that psychological factors may be associated with prostatic disease processes. Psychologic factors are proposed to affect the prostate by contributing to the release of catecholamines from the SNS and the secretion of testosterone on the HPG axis. Catecholamines modulate the tension of prostatic smooth muscle, thereby contributing to bladder outflow obstruction. In addition, SNS activity directly modulates growth of the prostate. The HPG axis can be stimulated under stress, leading to an increase in testosterone secretions. However, stress can also inhibit the HPG system leading to decreased testosterone secretions that may subsequently ameliorate BPH conditions.

With one exception, associations between psychological factors and indicators of prostate conditions have not been directly examined. Stone and colleagues (28) found that greater stress was prospectively associated with higher prostate specific antigen (PSA) levels among a sample of healthy men. PSA is a valid measure of prostate size with higher levels of PSA reflecting accelerated growth of the prostate.

The primary goal of this study was to examine whether psychological factors, including trait hostility and indicators of psychological stress, are associated with BPH disease parameters. Higher levels of stress and trait hostility were hypothesized to be related to more severe BPH disease as reflected in higher prostate volume, greater residual urine retention, and urinary tract symptoms (LUTS). Furthermore, the combination of high trait hostility and greater stress was hypothesized to be associated with more severe BPH disease parameters.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 LIMITATIONS AND CONCLUSIONS
 NOTES
 REFERENCES
 
Sample
The present study was an ancillary project to the Medical Therapy of Prostatic Symptoms (MTOPS) study (29). Participants were recruited from the 119 patients enrolled in the MTOPS study at the University of Iowa Hospitals and Clinics site. The MTOPS study was a National Institutes of Health-funded multisite clinical trial (KJK) investigating the efficacy of two drugs (finasteride and doxazosin) commonly used to treat BPH. Participants had been diagnosed with BPH in the Department of Urology at the University of Iowa Hospitals and Clinics. Exclusion criteria were prior intervention for prostate disease, psychiatric diagnosis, history of alcohol or substance abuse, current hormonal treatments, PSA greater than 10 ng/mL, recent heart attack or stroke, cancer, prior pelvic surgery, known neurologic conditions, or bacterial prostatitis. At the time of recruitment for the present study, participants in the MTOPS trial had been receiving one of the following combinations of medications for 7 years: 1) finasteride and a doxazosin placebo, 2) doxazosin and a finasteride placebo, 3) both doxazosin and finasteride, or 4) A finasteride placebo and a doxazosin placebo. Patients were attending their sixth and final annual MTOPS follow-up appointment between April and September 2001, and were approached for participation in the present study at that time. All procedures for the present study took place on the day of the final MTOPS follow up. After informed consent, a registered nurse assessed postvoid residual bladder volumes and prostate volumes as part of the MTOPS trial. Immediately after these assessments, participants completed an interview measure of life stress. Immediately after the interview, self-report measures were completed. For use in secondary analyses, baseline data, including postvoid residual bladder volumes and prostate volumes, were gathered from MTOPS archival databases. Additional information on the sample and MTOPS study procedures are published elsewhere (29).

Measures
Recent Stress
A version of the Life Experiences Survey (30) adapted for older adults (31) was used to assess stressful events within the past 6 months. This scale includes 20 events rated by respondents on a five-point scale from 0 = event did not occur to 4 = occurred with severe distress. Retrospective checklist measures of recent life events have demonstrated reliability and validity (32). For example, Alzheimer caregivers show higher scores on the Life Experiences Survey than age-matched control subjects (31).

Total Lifetime Stress
Stress over the lifespan was measured using a semistructured interview (33) developed in studies of patients with HIV infection (34). The interview is designed to assess the occurrence and impact of disruptive, life-altering stressful events across the lifespan. In audiorecorded, standardized interviews, participants were asked to recall stressors over the lifespan beginning with childhood and proceeding through adulthood. Stressors were given severity ratings ranging from 1 to 4, with 4 indicating "severe" and 1 indicating "mild." Severe stressors are those in which threat to the participant or close others are substantial. Moderate stressors are not direct life-threatening but reflect some substantial loss. Mild stressors are typically short-term and resolvable. Ratings of stressors were summed to provide a single stressful life events score. The interclass correlation between raters was 0.89, indicating high reliability. For use in secondary analyses, life stress score was also calculated excluding stressors that had occurred during the time of the MTOPS trial.

Trait Hostility
Hostility was assessed using the hostility subscale of the Aggression Questionnaire (35). The hostility subscale shows good reliability with test–retest correlation of 0.72 and a Cronbach’s alpha of 0.77. Validity for the total scale and subscales has been demonstrated by showing correlations between the scales and peer ratings of aggressiveness and other related constructs (35).

Residual Bladder Volume
Postvoid residual bladder volume is one diagnostic marker for BPH. Residual volume was assessed after subjectively complete urination using the Bladderscan BVI 2000 portable ultrasound unit according to the manufacturer’s guidelines. Higher residual volume among men with BPH may indicate more severe disease, increased risk for urinary tract infection, and may aggravate urinary symptoms. Residual bladder volume measured by ultrasound shows a 0.97 correlation with volumes measured using urethral catheterization (36). Volumes >60 mL are considered abnormal (37,38).

Prostate Volume
Prostate volume was measured by transrectal ultrasound using the Bruel & Kjaer model 8551 multiplane transducer. Prostate volume is one of the most important prognostic factors in BPH, with increased volumes indicating more severe disease (39). Men with untreated BPH may have prostate volumes of 38 mL or greater (39). Interrater reliability of prostate volume measurements has been shown to be over 0.90 (39).

Lower Urinary Tract Symptoms
LUTS was measured using the American Urological Association (AUA (7)) symptom index (40), a 7-item questionnaire measuring the frequency of clinically important urinary symptoms (emptying, frequency, intermittency, urgency, weak stream, hesitancy, and nocturnal polyuria). Ratings are summed to give a total symptom score ranging from 0 to 35. Scores from 0 to 7 indicate mild symptoms, 8 to 19 moderate symptoms, and 20 to 35 severe symptoms.

Statistical Analyses
Pearson correlations and analyses of covariance (ANCOVAs) controlling for age with post hoc Tukey HSD tests were used to examine simple associations between study variables and to determine whether demographic characteristics and medication groups differed on key study measures. Chi-square tests were used to determine whether medication groups differed on demographic characteristics.

Hierarchical multiple regression procedures were used to examine relationships between variables of interest. Separate equations were conducted for each of the dependent variables. Age and medication group (dummy-coded) were entered into the equations in the first step as control variables. In the second step of equations, centered values of hostility and either recent or lifetime stress were entered into the equation. The interaction term composed of the centered (41) hostility and stress variables were added in the third step of the equation. This provided tests of direct and interactive effects of the stress measures and the hostility measure on residual urine volume, prostate volume, and LUTS. Only significant interactions are reported.

Three strategies were used to examine the possibility that MTOPS treatment group would affect hypothesized associations among stress, hostility, and BPH parameters. First, as noted earlier, MTOPS treatment group was converted into three dummy variables to serve as a control variable in regression analyses. Second, regression analyses were conducted to determine whether associations among stress, hostility, and BPH parameters would vary according to MTOPS treatment group. These analyses involved separate regression models for each dependent variable, i.e., total prostate volume, residual urine retention, urinary tract symptoms (LUTS). In these regressions, the interaction terms of the independent variables with each of the three dummy variables were examined as predictors of BPH parameters. Significant associations between interaction terms and the dependent variable would suggest that associations between the independent and dependent variables differ across MTOPS treatment groups. Finally, measures of BPH disease parameters attained before the start of the clinical trial were used as dependent variables in secondary analyses with independent variables being the life stress score recalculated to exclude stressors occurring during the time of the clinical trial.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 LIMITATIONS AND CONCLUSIONS
 NOTES
 REFERENCES
 
Sample Characteristics
Demographic characteristics of the sample are presented in Table 1. Most participants were retired, married, and educated beyond high school. The mean age of the sample was 68 and all participants were white. Of the 119 clinical trial patients available for recruitment, 83 (70%) participated in this study. The distribution of participants across medication groups closely approximated the proportions found in the entire sample. Of the 83 participants, 23% had received finasteride and a doxazosin placebo, 27% doxazosin and a finasteride placebo, 19% both doxazosin and finasteride, and 31% 2 placebos. Medication groups were not different on demographic characteristics, and demographic characteristics were not significantly associated with most psychological or urologic measures. Age was associated with prostate gland size (r = 0.28, p < .05) and total life stress scores (r = 0.33, p < .01). Descriptive statistics for urologic and psychological variables are presented in Table 2.


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  		TABLE 1. Demographic Variables (N = 83)

 

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  		TABLE 2. Means and Standard Deviations of Key Study Variables

 

Associations Among Total Life Stress, Hostility, and Benign Prostatic Hyperplasia Disease Parameters
Life stress had a direct negative association with prostate volume. Specifically, total life stress and hostility contributed an additional 5% of the variance in prostate gland volume (ß = –0.24, p < .05 for life stress; ß = 0.05, not significant for hostility) after controlling for age and medication group. The interaction of total life stress and hostility was not significant. Hostility was not associated with prostate volume (see Table 3).


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  		TABLE 3. Associations Among Life Stress, Hostility, and Total Prostate Gland Volume

 

Life stress was negatively associated with residual urine volume, whereas high hostility was associated with greater residual urine. Specifically, total life stress and hostility contributed 9% of the variance in residual urine (ß = –0.24, p < .05 for life stress; ß = 0.25, p < .05 for hostility) beyond the effects of the age and MTOPS medication group (see Table 4). The interaction of life stress and hostility was not significant. Life stress and hostility and the interactions of life stress and hostility were not significantly associated with LUTS. Life stress and hostility did not interact with medication group in explaining variance in BPH disease parameters. In analyses using baseline clinical trial data for BPH disease parameters and baseline life stress scores, results were little different from those using final disease parameter data and total life stress scores. As found in the primary analyses, life stress before MTOPS was not significantly associated with LUTS at baseline. Also, life stress at baseline was inversely related to baseline prostate volume (ß = –0.23, p < .05), and inversely related to baseline residual urine though this association was not statistically significant (ß = –0.15, p > .10).


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  		TABLE 4. Associations Among Life Stress, Trait Hostility, and Residual Urine Volume

 

To address the possibility that recent stress as measured by the LES may overlap with the interview assessment of life stress, timing of stressors identified in the interview was examined, and it was found that only 6 of the 426 total stressors identified by interview had occurred in the 6 months before the interview. Although this finding supports the discriminant validity of these measures, life stress analyses were reconducted with life stress scores excluding those few that occurred within 6 months. Results did not differ in direction or strength from those including all scores.

Associations Among Recent Stress, Hostility, and Benign Prostatic Hyperplasia Disease Parameters
Greater recent stress, greater hostility, and the interaction of these two variables were associated with higher residual urine volumes. After controlling for age and medication group, recent stress and hostility contributed an additional 8% of the variance in residual urine (ß = 0.24, p < .05 for recent stress; ß = 0.24, p < .05 for hostility). The product term of recent stress and hostility contributed an additional 15% of unique variance in residual urine (ß = 0.49, p < .001) (see Table 5).


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  		TABLE 5. Associations Among Recent Stress, Trait Hostility, and Residual Urine Volume

 

To interpret the interaction of recent stress and hostility, values one standard deviation above and below the mean for recent stress and hostility were substituted into the regression equation, generating the regression lines shown in Figure 1. Among participants with lower hostility, recent stress had a minimal association with residual urine volume (residual urine = 41.5 for low recent stress; 35.8 for high recent stress). In contrast, among persons with high hostility, recent stress showed a strong association with residual urine (residual urine = 32.2 for low stress; 111.4 for high stress). A simple effects analysis (41) confirmed that the simple main effect of recent stress on residual urine was significant for persons with high hostility (t = 3.36, p < .05), but not significant for persons with low hostility (t = –1.51, not significant). Among patients with high hostility and high recent stress, the predicted residual urine volume of 111 mL was far above what is considered a normal volume: ≤60 mL (37,38). Recent stress and hostility and the interactions of recent stress and hostility were not significantly associated with LUTS or prostate volume. Recent stress and hostility did not interact with medication group in explaining variance in BPH disease parameters.



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  		Figure 1. Associations between recent stress and residual urine volume by level of hostility.

 


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
LIMITATIONS AND CONCLUSIONS
 NOTES
 REFERENCES
 
This study examined associations of stress and hostility with BPH disease parameters. Greater stress across the lifespan was associated with lower prostate volume and lower postvoid residual urine volumes. However, greater stress in recent months and higher levels of hostility were associated with greater postvoid volumes. The association between recent stress and residual volumes was strongest among men with high hostility.

These findings suggest the possibility that greater stress across the lifespan elicits physiological responses on the HPG axis and in the SNS that result in smaller prostate size. It may be that greater life stress directly leads to downregulation of HPG activity and reduced testosterone output (15,42,43). Reduced levels of testosterone can cause the atrophy of prostatic tissue (4,7) and the reversal of prostate growth (44,45). Greater life stress may have the effect of reducing prostate size independent of HPG axis activity through reduced blood flow to the prostate (46,47).

Associations among recent stress, hostility, and residual urine volume provide support for a long-theorized and clinically observed association. As early as 1912, stress was suggested as a cause of urinary retention (48). Since then, multiple case reports have described concomitant stress and urinary retention (49–54). To explain these associations, researchers have posited that stress reactions increase urethral sphincter muscle tension, thereby inhibiting voiding and promoting the retention of urine (55–57). Controlled studies of associations between urinary retention and life stress have not been reported. However, it is conceivable that stressful life events may influence residual urine volume by increasing muscle tension throughout the body, including pelvic floor muscles. Tension in pelvic floor muscles compresses the urethra, effectively maintaining continence (56). Tension of pelvic floor muscles also affects the detrusor muscle such that increased contraction of the pelvic floor results in relaxation of bladder muscles (57,58), a condition conducive to storage rather than elimination of urine. Finally, contraction of pelvic floor muscles inhibits void-urge sensation (59). In summary, increased tension in pelvic floor muscles may alter void-urge sensations and dysregulate the balance of tension–relaxation among pelvic, sphincter, and bladder muscles, resulting in less complete voiding and greater residual urine volumes.

Greater recent stress may have been associated with higher residual urine volume as a result of the effects of stress on prostate contractility. Catecholamines released under stress (14,15) may increase the contractility of prostate muscle, thereby potentially exacerbating urinary outlet obstruction (5,60). In support of this position, the administration of exogenous catecholamines results in prostate contraction (61–63).

High hostility appeared to have synergistic effects with recent stress on urinary function. Men with high hostility may experience increased physiological reactivity under stress, leading to greater dysregulation of the balance of lower urinary tract muscle tension and relaxation, and increased prostate contractility. This interpretation is consistent with research suggesting that greater hostility is associated with increased norepinephrine (26) and cardiovascular reactivity to stressors (64). Greater hostility has been shown to relate to higher muscular reactivity when under stress (65).

Recent stress and total stress across the lifespan had contrasting associations with residual urine volume, and hostility did not interact with lifespan stress in analyses. These findings suggest that associations among stress, hostility, and urine retention may vary according to the duration of stressors. Selye (66) made similar arguments in describing the general adaptation syndrome in which stress responses involve the up- or downregulation of physiological systems according to the duration of the stressor. Results suggest that acute stressors and hostility may have influence on the musculature of the pelvis, bladder, and urethral sphincters. In contrast, the accumulation of stress across the lifespan may show greater influence on the prostate than on other genitourinary structures. Alternatively, contrasting findings between measures of recent and lifetime stress may reflect differences in the severity of the stressors assessed. The LES measures the occurrence of stressors such as arguments with family, long work hours, or change in spousal health, which are relatively minor compared with stressors captured by the life stress interview that tended to be disruptive, life-altering events. The interview’s tendency to capture more severe stressors is not surprising considering that the study’s older participants were asked to recall stressors from childhood through adulthood, and better recall can be expected for more severe events. Therefore, contrasting findings for the measures may suggest that duration and/or severity of stressors may determine what facets of genitourinary function are affected. Stressors of a more enduring and/or severe nature might be expected to generate alterations in prostatic function, whereas stressors of less duration and severity may show effects on musculature of the pelvis, bladder, and urethral sphincters.


   LIMITATIONS AND CONCLUSIONS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 LIMITATIONS AND CONCLUSIONS
NOTES
 REFERENCES
 
The cross-sectional, correlational design of the study precludes conclusions regarding the direction and nature of associations between study variables. It is conceivable that urologic functioning may have influenced patients’ responses on psychological measures. However, the finding that psychological measures were not associated with a subjective measure of urologic symptoms does not support this position. This study relied on retrospective assessments of stress, which is a common strategy with demonstrated reliability and validity (32). However, there is the possibility that findings would have differed with assessments of ongoing stressors. Although analyses controlled for current medications and were replicated using premedication stress and disease variables, a better sample for examining associations among stress, hostility, and urologic functioning might be patients newly diagnosed with BPH and untreated.

This study raises interesting questions regarding the clinical relevance of stress and hostility in BPH and related urinary dysfunction. In general, stress and hostility should be concerns for clinicians, because these factors may contribute to variation in what are considered objective measures of urologic functioning that weigh heavily in urologic treatment decisions. Also, psychological factors may play some role in the etiology of BPH and urinary dysfunction, may serve to moderate the effects of existing urologic treatments, and may help explain why signs and symptoms of BPH show so much variability over time.

These results justify increased attention in research and clinical settings toward associations between psychological factors and urologic disease. The present findings may be relevant to other syndromes involving the prostate and lower urinary tract functioning such as prostatitis, pelvic floor muscle dysfunction, or common urinary symptoms such as incontinence and urinary retention. The dearth of research regarding psychological factors and urologic disease represents a wide gap in our understanding of associations between psychological factors and health. Increased attention toward the psychology of urologic conditions can make important contributions toward our knowledge of these disorders with subsequent implications for patient care.

We thank Margery Fearing, RN, and Nathan Miller, BS, for their assistance in conducting this study.


   NOTES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 LIMITATIONS AND CONCLUSIONS
 NOTES
REFERENCES
 

This study was funded by National Institutes of Health grant DK49971 awarded to the fourth author (K.J.K.).

DOI:10.1097/01.psy.0000161208.82242.f8


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 LIMITATIONS AND CONCLUSIONS
 NOTES
 REFERENCES
 

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