www.kjurology.

org
http://dx.doi.org/10.4111/kju.2012.53.9.643

Infection/Inflammation

Depression, Anxiety, Stress Perception, and Coping Strategies in

Korean Military Patients with Chronic Prostatitis/Chronic Pelvic
Pain Syndrome
Sun Gook Ahn, Sang Hoon Kim, Kyu In Chung1, Kwang Su Park, Su Yeon Cho, Hyun Woo Kim
Departments of Urology and 1Neuropsychiatry, St. Paul's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea

Purpose: The objective of this study was to examine the psychological features and cop- Article History:
ing strategies of patients with chronic prostatitis/chronic pelvic pain syndrome received 13 April, 2012
accepted 12 June, 2012
(CP/CPPS).
Materials and Methods: The participants consisted of 55 military personnel suffering
from CP/CPPS and 58 military personnel without CP/CPPS symptoms working at the
Military Capital Hospital. The National Institutes of Health Chronic Prostatitis
Symptom Index (NIH-CPSI) was used to assess CP/CPPS symptoms. The Responses
to Hospital Anxiety and Depression (HAD) scale, Social Readjustment Rating Scale,
and Global Assessment of Recent Stress (GARS) scale were compared between the two
groups. The Weisman Coping Strategy Scale was used to assess coping ability with
CP/CPPS.
Results: The NIH-CPSI score of the CP/CPPS group was significantly higher than that
of the control group for all domains including pain, urinary symptoms, quality of life,
and summed score. The Anxiety and Depression domain of the HAD showed significant
differences between the two groups. There were no significant differences in the Social
Readjustment Rating Scale between the two groups, but the sum of the GARS score
was higher in the CP/CPPS group than in the control group. These were correlated with
the pain, quality of life, and sum domains of the NIH-CPSI. The Weisman Coping
Strategy Scale showed that intellectualization, redefinition, and flexibility were higher
in frequency in descending order, and that fatalism, externalization, and self-pity were
lower in frequency.
Conclusions: The CP/CPPS patients had depression, anxiety, and higher perception Corresponding Author:
of stress. In particular, these were closely related to the pain and quality of life of the Hyun Woo Kim
Department of Urology, St. Paul's
patients.
Hospital, The Catholic University of
Korea College of Medicine, 180
Key Words: Anxiety; Depression; Prostatitis; Psychological adaptation; Psychological
Wangsan-ro, Dongdaemun-gu, Seoul
stress 130-709, Korea
TEL: +82-2-961-4511
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, FAX: +82-2-958-2073
distribution, and reproduction in any medium, provided the original work is properly cited. E-mail: urokhw@catholic.ac.kr

INTRODUCTION tion or sexual disturbance, and psychological problems

such as depression and anxiety that have a negative impact
Chronic prostatitis/chronic pelvic pain syndrome (CP/ on health-related quality of life [4,5]. However, the etiology
CPPS) is a common male chronic pain condition. Its preva- of CP/CPPS is uncertain. Various theories have been hy-
lence ranges from 9 to 16% worldwide and from 5 to 25% pothesized, such as inflammation, pathogen and host-spe-
in Korea [1-3]. CP/CPPS presents with various voiding cific factors, pelvic floor tension myalgia, and differences
symptoms, perineal or suprapubic pain, erectile dysfunc- in systemic pressure sensitivity [6-8]. It has been sug-

Korean Journal of Urology

Ⓒ The Korean Urological Association, 2012 643 Korean J Urol 2012;53:643-648
644 Ahn et al

gested that there are significant psychological components dence of mental abnormalities, genitourinary disease, or
to this condition, because most CP/CPPS patients have de- chronic pain conditions. All participants gave written con-
pression and anxiety [9]. It has also been suggested that firmed consent and ethical approval was obtained before
stress is a potent factor in the development, prolongation, the study. The Korean version of the NIH-CPSI [17], a
and perpetuation of the symptoms in the condition known 9-item index, was used to assess CP/CPPS symptoms. The
generally as chronic prostatitis [10]. The severity of stress NIH-CPSI consists of three domains including pain, uri-
has been reported to depend on individual perception or nary symptoms, and quality of life. The Hospital Anxiety
subjective interpretation of causative factors rather than and Depression (HAD) [18] scale was used to determine the
on the contents or frequency of factors causing stress [11]. levels of anxiety and depression that the patients experi-
That is, individual coping strategies for each stress and cog- enced. It consists of two seven-item indexes, one for anxiety
nitive assessment of stress have been suggested to sig- and the other for depression, that are used to measure emo-
nificantly affect stress progression [12]. Coping strategies tional disturbance. This study used the standardized HAD
refer to cognitive and behavioral efforts that are used to sat- scales that Oh et al. [19] translated and validated in
isfy external or internal demands, and they have been Korean. The Global Assessment of Recent Stress (GARS)
known to act as regulators between stress and psycho- scale, which consists of eight items assessing the recent
logical disorders or physical diseases [13]. Therefore, in ad- 1-week stress perception [20] and that Koh and Park [21]
dition to stress frequency, differences in stress perception translated and validated in Korean, was used for stress
and coping strategies should be considered as factors caus- assessment. The Social Readjustment Rating Scale [22],
ing or deteriorating stress symptoms in patients with which consists of 43 items assessing the presence and fre-
CP/CPPS. quency of stress factors that are continuously painful to pa-
In Korea, several studies on psychological problems re- tients and the frequency of the recent 1-year stress events
lated to CP/CPPS have been conducted [14,15], but few and that Hong and Jeong [23] translated and validated in
studies on the relationship of coping strategies for stress Korean, was used to assess stress frequency. The Weisman
have been conducted. Accordingly, this study was con- questionnaire [24] that Koh translated in Korean [25] was
ducted to compare the psychological features and coping used to assess coping strategies for stress. It consists of 15
strategies of patients with CP/CPPS with those of a healthy coping strategies, and patients indicate on a 5-point Likert
control group, to investigate differences between the two scale the frequency with which they use each coping style.
groups, and to provide useful information for the treatment The results were analyzed to 3 categories dependent on
of CP/CPPS. whether the patients had coping strategies.

MATERIALS AND METHODS 3. Statistical analysis

T-tests were conducted to compare the demographic char-
1. Patients acteristics and each scale of the patient group with those
The subjects were recruited from the Military Capital of the control group. Pearson correlation coefficients were
Hospital urology clinic in Korea from June 2008 to August measured to investigate the correlation between CP/CPPS
2009. Fifty-five enlisted men diagnosed with CP/CPPS and symptoms and perception to stress in the patient group.
58 enlisted men without CP/CPPS working at the Military The results were considered statistically significant when
Capital Hospital were selected as the CP/CPPS and control p＜0.05. Statistical analyses were performed by using
groups, respectively. SPSS ver. 12.0 (SPSS Inc., Chicago, IL, USA).

2. Study design RESULTS

The patient group included patients diagnosed with
CP/CPPS via medical interview, digital rectal examina- 1. Demographic characteristics of the subjects
tion, urinalysis, and prostate secretion examination after The mean age of the 55 patients was 22.5±2.6 years. The
prostate massage or urinalysis after prostate massage patient group consisted of one married patient (1.8%) and
(VB3) after visiting the hospital owing to voiding symptoms 54 single patients (98.2%), and their mean level of educa-
and chronic pelvic pain. The definition of CP/CPPS was tion was 12.43±1.76 years. The mean age of the control
used as described in the National Institutes of Health group (58 subjects) was 21.7±2.1 years. The control group
(NIH) consensus [16]. All the men enrolled in this study consisted of 3 married patients (5.2%) and 55 single pa-
were required to have a National Institutes of Health tients (94.8%), and their mean level of education was
Chronic Prostatitis Symptom Index (NIH-CPSI) total 12.85±1.92 years. No significant differences in the demo-
score of 15 or higher, with symptoms persisting for at least graphic characteristics of the subjects were found between
3 consecutive months. Exclusion criteria included pyuria, the two groups (p＞0.05) (Table 1).
symptoms suggestive of benign prostatic hyperplasia, his-
tory of seizures, neurogenic bladder or significant abnor- 2. National Institutes of Health Chronic Prostatitis
malities on baseline blood tests, or any history of mental Symptom Index
illness. Control groups in this study had no history or evi- As shown in Table 2, the pain scores were 8.49±3.81 and

Korean J Urol 2012;53:643-648

Stress Perception and Coping Strategy in CP/CPPS Patients 645

TABLE 1. General characteristics of the subjects TABLE 3. Comparison of HAD scale scores
CP/CPPS Controls CP/CPPS Controls
Characteristic p-value p-value
patients (n=55) (n=58) patients (n=55) (n=58)
Age (yr) 22.5±2.6 21.7±2.1 0.074 HAD scale
Education (yr) 12.43±1.76 12.85±1.92 0.22 Anxiety 5.06±4.50 2.61±2.79 ≤0.001a
b
Marital status Depression 4.57±4.30 2.78±3.27 0.013
Single 54 (98.2) 55 (94.8) 0.618
Values are presented as mean±SD.
Married 1 (1.8) 3 (5.2)
HAD, hospital anxiety and depression; CP/CPPS, chronic prosta-
Religion 0.059
titis/chronic pelvic pain syndrome.
None 25 (45.5) 27 (46.6) a
:p＜0.01, b:p＜0.05.
Catholic 4 (7.2) 10 (17.2)
Protestant 22 (40.0) 12 (20.7)
Buddhism 4 (7.2) 9 (15.5)
TABLE 4. Comparison of stress perception
Values are presented as mean±SD or number (%).
CP/CPPS, chronic prostatitis/chronic pelvic pain syndrome. CP/CPPS
Controls
Stress items patients p-value
(n=58)
(n=55)
a
TABLE 2. Comparison of NIH-CPSI scores in patients and Work, job & school 3.90±2.25 1.34±2.17 ≤0.001
controls Interpersonal 2.90±1.67 1.25±1.65 ≤0.001a
Changes in relationship 2.41±2.29 0.92±1.58 ≤0.001a
CP/CPPS Controls a
p-value Sickness or injury 3.16±2.47 1.29±1.85 ≤0.001
patients (n=55) (n=58)
Financial 3.37±2.52 1.32±1.63 ≤0.001a
Pain score 8.49±3.81 0.67±2.03 ≤0.001a Unusual happenings 1.87±1.95 0.92±1.10 0.0017a
Urinary symptom 4.98±2.85 0.58±1.22 ≤0.001a Change or no change in 2.74±2.27 0.98±1.38 ≤0.001a
score routine
a
Quality of life 7.96±2.11 3.11±2.76 ≤0.001a Overall global 3.5±2.03 1.23±1.78 ≤0.001
a
impact score Sum 23.87±13.19 9.29±11.24 ≤0.001
Total 21.44±6.84 4.28±4.67 ≤0.001a
Values are presented as mean±SD.
Values are presented as mean±SD. CP/CPPS, chronic prostatitis/chronic pelvic pain syndrome.
a
NIH-CPSI, National Institutes of Health Chronic Prostatitis :p＜0.01.
Symptom Index; CP/CPPS, chronic prostatitis/chronic pelvic
pain syndrome.
a
:p＜0.01. TABLE 5. Comparison of frequency of stressors
CP/CPPS
Controls
0.67±2.03 in the patient and control groups, respectively. patients p-value
(n=58)
In addition, the urinary symptom scores were 4.98±2.85 (n=55)
and 0.58±1.22 and the quality of life impact scores were During preceding 1 yr
7.96±2.21 and 3.11±2.76 in the patient and control groups, Positive 0.67±0.63 0.54±0.62 0.27
respectively. The total scores of the aforementioned do- Neutral 0.80±0.80 0.52±0.61 0.038
mains were 21.44±6.84 and 4.28±4.67 in the patient and Negative 1.91±1.71 1.80±1.64 0.72
control groups, respectively. The scores were all sig- Values are presented as mean±SD.
nificantly higher in the patient group than in the control CP/CPPS, chronic prostatitis/chronic pelvic pain syndrome.
group (p＜0.01).

3. HAD scale jury,” “financial,” “unusual happenings,” “change or no

As shown in Table 3, the HAD scale was 5.06±4.50 and change in routine,” and “one-week overall global” were all
2.61±2.79 for the anxiety domain and 4.57±4.30 and significantly higher in the patient group than in the control
2.78±3.27 for the depression domain in the patient and con- group (p＜0.01).
trol groups, respectively. The scores were all significantly
higher in the patient group than in the control group (p 5. Social readjustment rating scale
＜0.01, p＜0.05). When the recent 1-year stress factors were classified into
positive, neutral, and negative events according to the
4. GARS scale characteristics of the events and compared with each other,
As shown in Table 4, the stress perception score and scale no significant difference in the frequency of positive, neu-
summation for 8 items such as “work, job & school,” tral, or negative events was found between the patient and
“interpersonal,” “changes in relationship,” “sickness or in- control groups (p＞0.05) (Table 5).

Korean J Urol 2012;53:643-648

646 Ahn et al

TABLE 6. Relationship between NIH-CPSI and GARS scale in TABLE 7. Coping strategies of CP/CPPS patients (n=55)
the CP/CPPS patients
No
Items Yes Uncertain No
NIH-CPSI response
Stress perception Urinary Quality of Intellectualism 81.8 10.9 5.4 1.8
Pain Total
symptom life Shared concern 61.8 20.0 16.3 1.8
Reversal of affect 69.1 16.3 12.7 1.8
GARS scale sum 0.337 0.208 0.458 0.426
Suppression 45.4 34.5 18.1 1.8
p-value 0.013a 0.132 ≤0.001
b
0.002
b
Displacement 43.6 34.5 20.0 1.8
NIH-CPSI, National Institutes of Health Chronic Prostatitis Confrontation 63.6 27.2 7.2 1.8
Symptom Index; GARS, Global Assessment of Recent Stress; Redefinition 74.5 20.0 3.6 1.8
CP/CPPS, chronic prostatitis/chronic pelvic pain syndrome. Fatalism 21.8 27.2 49.1 1.8
a
:p＜0.05, b:p＜0.01. Acting-out 58.1 23.6 14.5 1.8
Flexibility 70.9 21.8 5.4 1.8
Tension reduction 45.4 7.2 45.4 1.8
6. Correlation of NIH-CPSI with GARS scale in the patient Isolation 32.7 12.7 52.7 1.8
group Externalization 21.8 23.6 52.7 1.8
The pain, quality of life, and sum domains of the NIH-CPSI Compliance 23.6 32.7 41.8 1.8
were shown to have a significantly positive correlation with Self-pity 21.8 20.0 56.3 1.8
the total GARS scale score in the patient group (p=0.013, CP/CPPS, chronic prostatitis/chronic pelvic pain syndrome.
p＜0.001, and p＜0.001, respectively) (Table 6).

7. Coping strategies depression and anxiety could act as contributing factors to

In the CP/CPPS patient group, the most commonly used CP/CPPS. However, the causality of depression and anxi-
coping strategy was intellectualization, meaning “collec- ety with CP/CPPS was unclear in this study, and a further
ting as much information as possible,” which accounted for study is required.
81.8% (Table 7). Redefinition, meaning “accepting his/her The definition of stress is somewhat controversial owing
problems and looking for something to cope well,” and flexi- to the ambiguity of the term; some researchers define it as
bility, meaning “trying to compromise with other feasible external stimuli, and others define it as responses to ex-
alternatives” followed intellectualization. Meanwhile, ternal stimuli. Thus, the definition has not yet been
rarely used coping strategies included fatalism, meaning established. In fact, because stress varies depending on in-
“accepting problems inevitably and feeling frustrated”; ex- dividuals, it is difficult to accurately define and examine
ternalization, meaning “criticizing other people or objects”; it. Lipowski [28] reported that stress refers to meaningful
and self-pity, meaning “scolding him/herself and expiat- internal and external stimuli perceived by individuals and
ing,” which accounted for 21.8%, respectively. defined it as something that induces emotions and even-
tually causes physiological changes threatening indivi-
DISCUSSION dual health and survival. That is, this definition empha-
sizes that stress is more influenced by individual inter-
CP/CPPS is a common disease diagnosed at urological out- pretation and assessment than by the event itself. Thus,
patient clinics. Current treatment methods include al- to investigate the correlation of diseases with stress, not
pha-blocker therapy, nonsteroidal anti-inflammatory only the events causing stress in the daily living of in-
drugs, and antibiotics for the control of the patient’s pain, dividuals and their frequency but also the stress perception
but their efficacy is limited [26]. CP/CPPS manifests vari- assessment, responses to, and coping strategies for stress
ous symptoms, such as pelvic pain, urinary problems, sex- of the individuals should be considered. Accordingly, not
ual dysfunction, and psychological problems. These symp- only the frequency of stress that occurred in the CP/CPPS
toms are significantly distressing and sometimes bur- patients but also their perception level and coping strat-
densome to the patients. That is, although CP/CPPS may egies for stress and the correlations between them were in-
be an important stress source, stress management has vestigated in this study. The 1-week stress perception lev-
been little considered in Korea. Accordingly, this study was el; work, job & school; interpersonal; changes in relation-
conducted to investigate the stress perception, responses ship; sickness or injury; financial; unusual happenings;
to, and coping strategies for stress of CP/CPPS patients and change or no change in routine; overall global; and GARS
their correlation with the severity of prostatitis. scale summation scores were all significantly higher in the
The HAD scale is an instrument that is reliable and valid CP/CPPS group than in the control group. This result in-
for measuring the anxiety and depression of patients [27]. dicates that the perception of daily living stress is higher
When the HAD scale was compared in this study, both de- in CP/CPPS patients than in healthy people, and that
pression and anxiety scales were higher in the CP/CPPS CP/CPPS could act as a source of stress in daily living and
group than in the control group. This indicates that psycho- that stress perception could become a factor affecting
logical disorders are part of CP/CPPS symptoms, and that CP/CPPS. When the frequency of stress events accumu-

Korean J Urol 2012;53:643-648

Stress Perception and Coping Strategy in CP/CPPS Patients 647

lated in the CP/CPPS patients over 1 year was inves- who participated in this study were from a military hospital
tigated, no significant difference in the frequency of pos- and their age bracket was limited; thus, the subjects do not
itive, neutral, and negative events was found between the represent all CP/CPPS patients. 2) Psychiatric interview
patient and control groups (p＞0.05). That is, this compar- and assessment were excluded and self-reporting survey
ison showed that the CP/CPPS group had a high perception scales were used, which could have the bias of respondents
level to stress regardless of the stress frequency. and errors. 3) The Weisman coping strategy scale trans-
The NIH-CPSI has been accepted by the International lated into Korean has been used in several Korean studies,
Prostatitis Collaborative Network as a standard and valid but the Korean version has not yet been validated.
instrument for evaluating men with CP/CPPS symptoms A further prospective study is required on a large scale
[29]. When the results of the NIH-CPSI were compared be- to investigate the correlation of CP/CPPS with stress, de-
tween the CP/CPPS group and the control group, the pain pression, and anxiety and differences in coping strategies
score, urinary symptom score, and quality of life impact between CP/CPPS patients and a control group with the
score were higher in the CP/CPPS group than in the control consideration of additional factors.
group, and the mean total score was also higher in the
CP/CPPS group than in the control group. Furthermore, CONCLUSIONS
because the pain score, quality of life impact score, and total
score of the NIH-CPSI increased in the CP/CPPS group, a The CP/CPPS patients had symptoms such as depression
significantly positive correlation of the aforementioned and anxiety and had a high level of stress perception re-
scores with the total GARS scale was shown. In particular, gardless of the frequency of stress events. In particular, the
a higher positive correlation of 1-week stress perception stress perception of the CP/CPPS patients was closely asso-
level with the pain score and quality of life impact score was ciated with the pain and quality of life of the patients. In
shown compared with the urinary symptom score. A pre- conclusion, CP/CPPS is likely to be closely associated with
vious study reported that the pain intensity of the stress factors. Assessment of and control of stress factors
NIH-CPSI was a stronger predictor affecting quality of life are required in the treatment of CP/CPPS patients.
compared with the urinary symptom score [5], and that the
NIH-CPSI total score provided a good outcome measure of CONFLICTS OF INTEREST
prostatitis symptoms because the pain and quality of life The authors have nothing to disclose.
impact scores were more responsive to change, but the uri-
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