Pregnancy carries substantial risk for developing lower urinary tract symptoms (LUTS). While certain factors related to labor, delivery, and maternal demographics have been studied as risk factors for postpartum LUTS, a broader approach is necessary to appreciate the additional impact of an individual’s psychological state and social environment. We investigated psychosocial factors during pregnancy that may predispose women to experiencing LUTS postpartum.

We conducted secondary analyses of data from a longitudinal study, Expect With Me, evaluating a group model of prenatal care at four sites in the United States from 2011-2016. Participants represent a diversity of ages, race/ethnicities, and socioeconomic status.

Demographic and psychosocial characteristics were measured during the second trimester of pregnancy and LUTS were assessed at 12 months postpartum. Participants completed a modified version of the Center for Epidemiologic Studies-Depression (CES-D) scale that excluded somatic symptoms associated with pregnancy; the Multidimensional Scale of Perceived Social Support; the Perceived Stress Scale; the Everyday Discrimination scale; and a Shift and Persist Strategies scale reflecting resilience. Presence of LUTS was measured with items adapted from existing measures of urinary frequency, urgency, stress incontinence (SUI), urgency incontinence (UUI), nocturia, and pain. Bivariate and multivariate logistic regressions were run to assess associations between A) mother characteristics (race/ethnicity, age, BMI, parity, delivery mode) and B) psychosocial factors during pregnancy, and LUTS at 12 months postpartum.

Of the 475 women who provided information on LUTS at 12 months postpartum, 61% of participants were black, 18% were white, 17% were Latina, and 4% identified as another race or multiple races. The majority (52%) were between 18 and 25 years old and 38% had a pre-pregnancy BMI of 30 or above. 51% were primiparous and 72% had a vaginal delivery. 
Overall, more than half of the women (57%) reported one or more LUTS. In bivariate analyses, black women and mothers who delivered by C-section were more likely to report nocturia (p < 0.05).  Depressed mood, social support, stress, and resilience were also associated with LUTS at 12 months. In multivariate analyses, women with high levels of depressed mood had greater odds of experiencing any postpartum LUTS than those with low-level symptoms (OR 2.50, p=0.007). High levels of perceived stress (OR 1.17, p=0.001) and everyday discrimination at baseline (OR 1.55, p=0.021) were associated with increased odds of nocturia, whereas high levels of social support (OR 0.89, p= 0.009) and resilience (OR 0.45, p=0.0006) were associated with lower odds of nocturia. Measured psychosocial factors were not associated with SUI or UUI at 12 months.

Our findings suggest that mothers who report higher levels of depressive symptoms during pregnancy are at increased risk of experiencing one or more LUTS one year postpartum. Additionally, mothers who experience stress and everyday discrimination are significantly more likely to report nocturia 12 months after delivery, while mothers with higher levels of social support and resilience have lower odds of nocturia. This study contributes to the growing evidence base documenting associations between depression and increased LUTS [1].  Moreover, it highlights the potential importance of other indicators of mental and emotional well-being on risk of LUTS. Further research on psychosocial and environmental stressors (e.g., discrimination) and protective factors (e.g., social support) and mechanisms by which they may influence postpartum LUTS is warranted.  

Nighttime voiding frequency may be attributable to a variety of factors in the postpartum period. Underlying causes of nocturia may include household environment, individual sleep hygiene, and bladder issues in addition to mental or physical comorbid conditions. Sleep loss from any cause is associated with increased risk of obesity, heart disease, memory issues, and reduced immune response [2]. The impact on sleep of increased postpartum nocturia could further compound existing physical and mental health issues [3], particularly in a vulnerable population. Our findings support further study of the underlying causes of postpartum nocturia, including qualitative analysis of nighttime voiding behaviors to identify opportunities for better screening and intervention.

As a distinct event that results in LUTS, pregnancy is a window to identify modifiable risk factors at the individual and community levels that may mitigate LUTS and related negative health outcomes. This study identifies novel associations between psychosocial factors and LUTS, and particularly nocturia, in women who have recently given birth. Pregnancy represents a period when women are well-connected with the health system and could be screened for and provided treatment recommendations to address factors associated with postpartum LUTS. A better understanding of LUTS etiology is essential to the development of meaningful guidelines for the maintenance of women’s bladder health postpartum and prevention of LUTS over the life course.

Asplund R, Marnetoft SU, Selander J, Akerstrom B. Nocturia and depression. BJU Int. 2004 Jun;93(9):1253-6. PMID:15180617
https://www.cdc.gov/features/sleep-heart-health/index.html
Coyne KS1, Wein AJ, Tubaro A, Sexton CC, Thompson CL, Kopp ZS, Aiyer LP.The burden of lower urinary tract symptoms: evaluating the effect of LUTS on health-related quality of life, anxiety and depression: EpiLUTS BJU Int. 2009 Apr;103 Suppl 3:4-11