Traumatic events experienced in a person’s life can have a lasting impact, and should always be considered in the context of clinical medicine. Medical post-traumatic stress disorder (PTSD) is a well-studied reality of modern medicine. In particular, uro-oncological diagnoses and procedures in the adult population have been linked to the development of PTSD (1,2). In urology, we routinely perform invasive procedures on a sensitive area of the body without sedation. Our observation is that patients with post-traumatic stress disorder (PTSD) express more concern regarding invasive testing and urologists may shy away from offering invasive urological procedures for fear of evoking PTSD symptoms. It is unclear what characteristics, such as the type of trauma experienced, influence patient perception of instrumentation. This study seeks to identify characteristics that best predict anxiety and pain when undergoing urologic testing. Equipped with this information, urologists could thereby better identify which patients would have a higher likelihood of an adverse reaction to an invasive test and better prepare for that possibility.

Prospective observational trial of 61 sequential patients (average age 55.1 years, 68% female) planned for cystoscopy, urodynamics, or prostate biopsy. Validated measures were completed by patients prior to and during their scheduled procedure. PTSD was assessed by the standardized PTSD checklist (PCL-5), type of trauma experienced by life-events checklist (LEC-5), anxiety levels before and during the procedure by the rapid anxiety assessment scale (RAA) and pain during the procedure (Wong-Baker scale). Patients were stratified into the following 3 groups according to responses on the LEC-5: (1) history of invasive bodily trauma which can include but not limited to surgical or medical management, or sexual abuse, (2) history of other significant trauma which can include fire, car accidents, natural disasters such as floods, or divorce, or (3) no experiences that would qualify the patient for either group 1 or 2.

PTSD patients were identified by a cutoff of ≥33 on PCL-5 as per the National Center for PTSD1 (n=12, all female). PTSD at baseline correlated with anxiety before [F(1,58)=22.26, p=0.00 r2=28%] and during the procedure [F(1,57)=20.84, p=0.00 r2=27%]. Level of pain during the procedure did not correlate [F(1,58)=2.95, p=0.091 r2=5%]. Type of trauma experienced did not correlate with diagnosis of PTSD [F(2,57)=0.53, p=0.595] nor RAA before [F(2,57)=1.52, p=0.23] or during the procedure [F(2,56)=3.04, p=0.06]. However, higher levels of pain correlated with type of trauma experienced [F(2,57)=3.98, p=0.024] with invasive bodily trauma (M=3.65, SD 2.74) significantly different from no trauma (M=1.60, SD 2.96) as shown in Figure 1. Post-hoc power analysis: With 12 patients in the PTSD group and 48 in the control group, the power was 86% to discover a difference at least as large as 1 within standard deviation.

PTSD correlated with increased levels of anxiety, but not the level of pain experienced during an invasive urological procedure. There was no evidence that increased patient worry resulted in increased pain experienced. History of invasive bodily trauma was, however, predictive of higher pain levels during the procedure.

These findings may inform counseling, preparation/relaxation techniques patients may seek with outside therapist, or help predict indication for sedation. Our recommendations include:
1. Note or screen for a history of PTSD and invasive bodily trauma.
2. Counsel patients that PTSD generally will lead to increased anxiety surrounding the test but not increased pain during the procedure.
3. For patients with PTSD resulting from invasive bodily trauma, acknowledgement that anxiety and pain may be greater. They should be given the opportunity to meet with a therapist prior to plan coping skills. 
4. At the very least, handouts for cystoscopy and urodynamics should address increased apprehension (but not pain) in those with general PTSD and increased anxiety and pain in those with a history of PTSD due invasive bodily trauma.
5. Trauma-informed care can put patients at ease.

Bill-Axelson, A., et al. (2011). "Psychiatric treatment in men with prostate cancer--results from a Nation-wide, population-based cohort study from PCBaSe Sweden." Eur J Cancer 47(14): 2195-2201.
Maddineni, S. B., et al. (2009). "Identifying the needs of penile cancer sufferers: a systematic review of the quality of life, psychosexual and psychosocial literature in penile cancer." BMC Urol 9: 8.