Impact of comorbid depression on treatment adherence and long-term urinary function following surgery for benign prostatic hyperplasia

Abstract

BACKGROUND

Benign prostatic hyperplasia (BPH) - that’s BPH, by the way - is a pretty serious problem for older guys when it comes to their bladders. Surgery is the primary treatment for patients with moderate-to-severe symptoms. However, psychological comorbidities after surgery can cause some patients to experience decreased treatment adherence, which in turn affects the recovery of urinary function. Depression and BPH have a high overlap rate in the elderly population. However, the impact of depression on the postoperative recovery from BPH needs to be systematically verified.

AIM

To help find out what happens in the long-term with pee after surgery for prostate cancer. This will help to create special treatments for people with this problem.

METHODS

In this investigation, past information was gathered from 756 sufferers of BPH who had undergone surgical procedures at Wuxi Ninth People’s Hospital Affiliated to Soochow University, and the Second Affiliated Hospital of Nanjing Medical University, from January 2021 to January 2025. Patients were divided into two groups based on the presence of depression: Comorbidity (n = 65) and non-comorbidity (n = 691). The two groups were compared at 6 months and 12 months after surgery in terms of their demographic and clinical characteristics, how well they took their medication, and their urinary function. We used a special type of maths to work out what causes people to take their medicine. We also used a special type of maths to see how depression affects people’s ability to pee.

RESULTS

Patients with depression and comorbidities showed significantly lower medication adherence self-efficacy, more missed doses and follow-up visits, and poorer health behaviors than those without depression (P < 0.05). They also had higher International Prostate Symptom Score and lower Quality of Life scores at 6 and 12 months postoperatively, along with lower maximum flow rate and higher post-void residual urine volume (P < 0.05). Improvement in urinary function was less marked in depressed patients. Multivariate analysis identified depression [odds ratio (OR) = 3.215, 95% confidence interval (CI): 1.892-5.463)], age ≥ 70 years (OR = 2.108, 95%CI: 1.276-3.482), and primary education or below (OR = 1.983, 95%CI: 1.195-3.294) as independent risk factors for poor adherence. Hamilton Depression Rating Scale scores correlated positively with International Prostate Symptom Score, Quality of Life, and post-void residual urine volume, and negatively with maximum flow rate (P < 0.001).

CONCLUSION

The study found that depression can make it harder to stick to treatment and can also make it take longer to recover from surgery for BPH. The study also found that the more severe the depression, the less likely the patient is to recover well. The findings emphasise the significance of conducting depression screenings at the outset and of implementing comprehensive interventions for BPH patients who also have depression. This approach is intended to enhance adherence to treatment and to ensure the best possible postoperative urinary outcomes.

Key Words: Benign prostatic hyperplasia; Depression; Comorbidity; Treatment adherence; Urinary function; Retrospective study

Core Tip: This retrospective study found that comorbid depression is an independent predictor of poor treatment adherence among patients undergoing surgery for benign prostatic hyperplasia. Reduced adherence was associated with impaired long-term recovery of urinary function after surgery. These findings highlight the importance of routine psychological assessment and early identification of depressive symptoms in this patient population. Implementing targeted psychological and behavioral interventions may improve treatment compliance, enhance postoperative recovery outcomes, and support long-term urinary function rehabilitation in patients with benign prostatic hyperplasia.

INTRODUCTION

Benign prostatic hyperplasia (BPH), or BPH for short, is something that a lot of older men get, and the older you are, the more likely you are to get it. Epidemiological data indicate that more than half of men over 60 are affected, with this proportion rising to around 83% in those over 80 years old[1]. Symptoms of BPH include frequent urination, the need to urinate urgently, and progressive kidney problems. In severe cases, it can lead to urinary retention and kidney failure[2]. Surgical intervention remains the primary treatment modality for patients with moderate-to-severe BPH, and it is generally considered to be the most effective treatment option. The efficacy and safety of surgical management has been significantly improved by minimally invasive procedures such as transurethral resection of the prostate and transurethral plasma kinetic enucleation of the prostate[3,4]. However, it has been revealed through clinical observations that while good immediate surgical outcomes have been experienced by many patients, less optimal long-term recovery and limited improvement in urinary function have been experienced by some owing to various influencing factors.

Low mood, loss of interest and reduced energy are just some of the symptoms of depression, a common psychological disorder. It is also often accompanied by cognitive impairment and sleep disturbances. Depression is common among old people, and most men with BPH are older too, so it is not surprising that depression and BPH often happen at the same time[5]. Adherence to prescribed treatment regimens is crucial for determining the outcomes of patients with chronic diseases. For patients undergoing BPH surgery, it is vital to adhere to behaviours that promote urethral healing, bladder function recovery, and the prevention of complications[6]. These behaviours include consistent medication use, regular follow-up visits, and continued pelvic floor exercises. Depression can negatively affect these behaviours. This is because affected individuals may show reduced motivation. They may also have diminished confidence in recovery. Consequently, they may have poor adherence. This can be seen in things like missed medications or delayed follow-ups[7].

Most studies on how well people recover after BPH surgery have looked at improving surgery and stopping problems. However, there is a lack of well-designed research on the impact of depression on long-term urinary function, how people with depression respond to treatment, and the connection between depression and adherence to treatment. Understanding this relationship is clinically important for improving comprehensive management strategies for patients after BPH surgery. Therefore, this study retrospectively analyzed clinical data from patients with BPH who underwent surgical treatment to explore the effects of comorbid depression on postoperative adherence and long-term urinary outcomes, thus providing evidence to support the development of targeted clinical interventions.

MATERIALS AND METHODS

Study participants and eligibility criteria

We retrospectively collected clinical data from patients with BPH who underwent surgery at the Department of Urology at Wuxi Ninth People’s Hospital Affiliated to Soochow University and the Second Affiliated Hospital of Nanjing Medical University from January 2021 to January 2025. Inclusion criteria: (1) Patients meeting the diagnostic standards for BPH as outlined in the European Association of Urology Guidelines on Non-neurogenic Male Lower Urinary Tract Symptoms (include BPH) (2021 Edition)[8] and confirmed through digital rectal examination, prostate ultrasonography, routine urine tests, and other relevant assessments; (2) Age ≥ 50 years; (3) Transurethral resection of the prostate or transurethral plasmakinetic enucleation of the prostate with surgeries performed by experienced associate chief physicians and completed without intraoperative complications; (4) Availability of complete clinical records including preoperative comorbidities, surgery-related information, and postoperative follow-up data; and (5) Signed informed consent was obtained from the patients and their family members, and the study was approved by the Hospital Medical Ethics Committee. Exclusion criteria: (1) Presence of urinary system malignancies, such as prostate or bladder cancer; (2) Preoperative severe urinary dysfunction (e.g., neurogenic bladder and bladder neck contractures); (3) History of depression treated with antidepressants for more than one year before surgery; (4) Severe dysfunction of major organs including the heart, liver, and kidneys; (5) Other psychiatric disorders such as cognitive impairment and schizophrenia; (6) Development of severe postoperative complications (e.g., massive hemorrhage, urethral stricture, and urinary fistula) that could interfere with urinary function examination; and (7) Follow-up duration of < 12 months and incomplete follow-up records.

Patients with follow-up periods < 12 months and those with missing follow-up data were excluded. A total of 756 patients met the eligibility criteria, including 65 with comorbid depression (comorbidity group) and 691 without depression (non-comorbidity group). Depression was diagnosed according to the International Classification of Diseases, 11th Revision criteria[9] based on clinical history and symptoms and was confirmed by a Hamilton Depression Rating Scale (HAMD) score of > 17[10].

Data collection

Patient information was extracted from the electronic medical record systems and postoperative follow-up platforms of Wuxi Ninth People’s Hospital Affiliated to Soochow University and the Second Affiliated Hospital of Nanjing Medical University. The following data were collected.

Baseline clinical characteristics: Age, sex, level of education (primary school or below, junior high school, senior high/technical school, college degree or higher), marital status (married or unmarried/divorced/widowed), body mass index, smoking status (≥ 10 cigarettes/day for ≥ 1 year), and alcohol consumption (≥ 2 drinking occasions/week for ≥ 1 year).

Comorbid conditions: Hypertension (defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg or diagnosed before surgery with ongoing antihypertensive treatment); diabetes mellitus (fasting plasma glucose ≥ 7.0 mmol/L, 2-h postprandial glucose ≥ 11.1 mmol/L, or a confirmed diagnosis under treatment); and coronary heart disease.

Surgical variables: Type of surgical procedure, duration of surgery, and intraoperative blood loss.

Depression-related variables: HAMD scores were assessed one week before surgery and at the time of depression onset. Treatment adherence data were obtained from the postoperative follow-up records, medication dispensing logs, and scheduled follow-up registration systems. Urinary function data were collected using clinical and objective measurements.

Observation indicators

The study outcomes were categorized into four domains: General clinical characteristics, depression-related parameters, treatment adherence, and urinary function indicators.

General clinical characteristics: Demographic and baseline health information were the same as those described above. Depression severity was evaluated one week before surgery using the HAMD[11]. The timing of depression onset (before and after the BPH diagnosis) was recorded. Based on the HAMD scores, depression was classified as mild (17-24 points), moderate (25-35 points), or severe (> 35 points).

Treatment adherence indicators: Medication adherence self-efficacy at 6 months postoperatively was assessed using the Adherence Self-Efficacy Measure (ASMES)[12]. The medication omission rate (missed doses/total prescribed doses × 100%), follow-up examination omission rate (missed visits/total scheduled visits × 100%), and health behavior adherence rate (number of patients complying with recommended behaviors, i.e., pelvic floor muscle training, divided by total patients × 100%) were calculated.

Urinary function indicators: Urinary outcomes were measured using the International Prostate Symptom Score (IPSS)[13], Quality of Life (QOL) score[14], maximum flow rate (Q_max), and post-void residual urine volume (PVR). Examinations were performed one week preoperatively, and 6 and 12 months postoperatively.

Treatment adherence assessments: Treatment adherence was assessed 6 months after surgery using the ASMES. The ASMES scores range from 0 to 8, with higher scores indicating better adherence. Based on the total scores, the patients were classified into high (7-8 points), moderate (4-6 points), and low adherence (0-3 points) groups. The medication omission rate (missed doses/total prescribed doses × 100%), follow-up examination omission rate (missed visits/total scheduled visits × 100%), and health behavior adherence rate (number of patients complying with recommended behaviors such as pelvic floor muscle training divided by the total number of patients × 100%) were calculated.

Urinary function assessments: Urinary outcomes were monitored using the IPSS[13], QOL score[14], Q_max, and PVR. The IPSS was used to quantify the severity of lower urinary tract symptoms, with total scores ranging from 0 to 35, with higher scores indicating more severe symptoms. The QOL score assessed the impact of urinary symptoms on QOL and ranged from 0 to 6, with higher scores indicating a poorer QOL. Q_max was measured by urodynamic testing and expressed in mL/second; values ≥ 15 mL/second were considered normal. PVR was measured using B-mode ultrasonography and expressed in milliliters; PVR < 50 mL was considered normal.

Follow-up methods

A specialized follow-up team was established to conduct postoperative monitoring through outpatient visits, telephone interviews, and WeChat-based communications. Routine follow-up assessments were scheduled at 1, 3, 6, and 12 months postoperatively, focusing on medication adherence, implementation of health behaviors, improvement in urinary symptoms, and completion of relevant questionnaires and examinations. For patients initially lost to follow-up, additional tracing was conducted through family contact and community healthcare services to maximize follow-up completeness. The overall follow-up completion rate was 96.8% (732/756), with 95.4% (62/65) in the comorbidity group and 96.9% (670/691) in the non-comorbidity group. No statistically significant difference in follow-up rates was observed between the two groups (χ² = 0.213, P = 0.644).

Statistical analysis

Data were statistically analyzed using SPSS 26.0. Normally distributed continuous variables were expressed as mean ± SD and compared using independent-samples t tests or repeated-measures analysis of variance, while non-normally distributed variables were reported as median (interquartile range) [M (Q₁, Q₃)] and analyzed using the Wilcoxon rank-sum test. Categorical variables were presented as n (%) and compared using the χ² test or Fisher’s exact test. Variables with P < 0.10 in univariate analysis were included in multivariate logistic regression to identify independent risk factors for poor treatment adherence (ASMES < 7) in patients after BPH surgery. Pearson’s correlation analysis was used to examine the association between HAMD scores and urinary function indicators. P < 0.05 was considered statistically significant.

RESULTS

General clinical characteristics

Patients with comorbid depression were significantly older and more likely to have a lower educational level (primary school or below), unmarried/divorced/widowed status, hypertension, and diabetes than patients without depression (all P < 0.05). Body mass index was significantly lower in the comorbidity group (P < 0.05). No significant differences were observed between the two groups with respect to sex distribution, smoking status, alcohol consumption, presence of coronary heart disease, surgical approach, operative time, or intraoperative blood loss (all P > 0.05). The detailed comparisons are presented in Table 1.

Table 1 Comparison of general clinical characteristics between both groups, n (%)/mean ± SD.

Indicator	Comorbidity group (n = 65)	Non-comorbidity group (n = 691)	t/χ2 value	P value
Age (years)	72.35 ± 6.82	67.12 ± 5.94	6.732	< 0.001
Educational level			12.345	0.006
Primary school or below	28 (43.1)	185 (26.8)	-	-
Junior high school	22 (33.8)	276 (39.9)	-	-
Senior high/technical school	10 (15.4)	152 (22.0)	-	-
College degree or above	5 (7.7)	78 (11.3)	-	-
Marital status			8.217	0.004
Married	42 (64.6)	553 (80.0)	-	-
Unmarried/divorced/widowed	23 (35.4)	138 (20.0)	-	-
Body mass index (kg/m2)	22.15 ± 2.34	23.87 ± 2.56	5.128	< 0.001
Smoking history	21 (32.3)	218 (31.5)	0.021	0.885
Drinking history	18 (27.7)	195 (28.2)	0.008	0.928
Underlying disease			-	-
Hypertension	38 (58.5)	296 (42.8)	6.542	0.011
Diabetes mellitus	25 (38.5)	183 (26.5)	4.893	0.027
Coronary heart disease	16 (24.6)	152 (22.0)	0.287	0.592
Surgical method			0.154	0.695
Transurethral resection of prostate	36 (55.4)	385 (55.7)	-	-
Transurethral plasmakinetic enucleation of prostate	29 (44.6)	306 (44.3)	-	-
Operation time (minute)	68.23 ± 15.42	66.78 ± 14.95	0.689	0.491
Intraoperative blood loss (mL)	52.35 ± 18.67	50.12 ± 17.89	0.853	0.394

Depression characteristics in the comorbidity group

Among the 65 patients with comorbid depression, depressive symptoms developed before the diagnosis of BPH in 32 (49.2%) and after diagnosis in 33 (50.8%). Based on the preoperative HAMD scores, 38 patients (58.5%) had mild depression, 22 (33.8%) had moderate depression, and 5 (7.7%) had severe depression. The mean preoperative HAMD score in this group was 25.36 ± 6.82.

Treatment adherence between both groups

Six months postoperatively, the ASMES were significantly lower in the comorbidity group than in the non-comorbidity group, with a smaller proportion of patients demonstrating high adherence and a greater proportion showing low adherence (all P < 0.05). Patients with comorbid depression also had higher rates of medication and follow-up examination omissions, along with lower adherence to recommended health behaviors than those without depression (all P < 0.05). The detailed results are presented in Table 2.

Table 2 Comparison of treatment adherence between both groups, n (%)/mean ± SD.

Indicator	Comorbidity group (n = 65)	Non-comorbidity group (n = 691)	t/χ2 value	P value
ASMES	4.21 ± 1.35	6.89 ± 1.27	16.783	< 0.001
Treatment adherence grade (n)			89.215	< 0.001
High adherence (7-8 scores)	8 (12.3)	356 (51.5)	-	-
Moderate adherence (4-6 scores)	32 (49.2)	275 (39.8)	-	-
Low adherence (0-3 scores)	25 (38.5)	60 (8.7)	-	-
Medication omission rate (%)	28.35 ± 8.67	8.12 ± 3.45	23.564	< 0.001
Follow-up examination omission rate (%)	32.18 ± 9.24	7.56 ± 2.89	25.127	< 0.001
Health behavior implementation rate (%)	35 (53.8)	587 (84.9)	42.351	< 0.001

ASMES: The Adherence Self-Efficacy Measure.

Urinary function outcomes before and after surgery

Both groups showed significant improvements in urinary function at 6 and 12 months postoperatively compared to the preoperative baseline values. Specifically, the IPSS, QOL scores, and PVR significantly decreased, whereas the maximum urinary flow rate increased (all P < 0.05). Despite these overall improvements, the patients in the comorbidity group consistently had poorer urinary outcomes, with higher IPSS and QOL scores, higher PVR, and lower Q_max at both postoperative time points than those in the non-comorbidity group (all P < 0.05). The detailed results are presented in Table 3.

Table 3 Comparison of urinary function parameters between both groups before and after surgery, mean ± SD.

Indicator	Group	Pre-operation	6 months post-operation	12 months post-operation	F (group/time/interaction)	P (group/time/interaction)
IPSS score (points)	Comorbidity group	27.35 ± 4.82	15.62 ± 3.45a,b	12.18 ± 2.97a,b	6.681/7.564/5.194	< 0.001/< 0.001/< 0.001
	Non-comorbidity group	26.89 ± 4.67	9.87 ± 2.89a	6.35 ± 2.12a	-	-
QOL score (points)	Comorbidity group	5.23 ± 0.89	3.15 ± 0.67a,b	2.56 ± 0.54a,b	5.618/6.024/4.264	< 0.001/< 0.001/< 0.001
	Non-comorbidity group	5.18 ± 0.92	2.01 ± 0.53a	1.32 ± 0.41a	-	-
Qmax (mL/second)	Comorbidity group	7.89 ± 2.15	12.35 ± 3.24a,b	15.62 ± 3.87a,b	4.648/5.268/4.915	< 0.001/< 0.001/< 0.001
	Non-comorbidity group	7.67 ± 2.08	16.89 ± 3.56a	20.35 ± 4.12a	-	-
PVR (mL)	Comorbidity group	156.23 ± 45.89	89.35 ± 28.67a,b	65.18 ± 22.34a,b	11.264/14.261/10.264	< 0.001/< 0.001/< 0.001
	Non-comorbidity group	152.87 ± 43.65	56.78 ± 21.45a	38.25 ± 18.67a	-	-

^aP < 0.05 vs before surgery within the same group.

^bP < 0.05 vs the non-comorbidity group.

IPSS: International Prostate Symptom Score; QOL: Quality of Life; Q_max: Maximum flow rate; PVR: Post-void residual urine volume.

Comparison of the improvement amplitude of postoperative urinary function indicators

The magnitude of improvement was calculated as the difference between the urinary function indices measured 12 months postoperatively and those obtained preoperatively. The comorbidity group showed significantly less improvement in IPSS, QOL, Q_max, and PVR than the non-comorbidity group (all P < 0.001), indicating delayed recovery of urinary function in patients with comorbid depression. The comparisons are summarized in Table 4.

Table 4 Comparison of improvement in postoperative urinary function parameters between both groups.

Indicator	Comorbidity group (n = 65)	Non-comorbidity group (n = 691)	t value	P value
Improvement in IPSS score (points)	15.17 ± 4.23	20.54 ± 5.12	9.876	< 0.001
Improvement in QOL score (points)	2.67 ± 0.89	3.86 ± 1.05	10.234	< 0.001
Improvement in Qmax (mL/second)	7.73 ± 3.15	12.68 ± 3.89	12.567	< 0.001
Improvement in PVR (mL)	91.05 ± 42.35	114.62 ± 48.76	4.789	< 0.001

Large SD suggest substantial individual variability in post-void residual urine volume improvement, which may be influenced by factors other than depression. IPSS: International Prostate Symptom Score; QOL: Quality of Life; Q_max: Maximum flow rate; PVR: Post-void residual urine volume.

Multivariate logistic regression analysis of poor treatment adherence in patients after BPH surgery

Poor postoperative treatment adherence, defined as an ASMES score of < 7, was the dependent variable in the multivariate logistic regression model (1 = yes; 0 = no). The things that were studied were age, how much education people had, if people were married, how much body fat they had, high blood pressure, diabetes and depression. The investigation determined that concomitant depression, a minimum age of 70 years, and an educational attainment of primary school or below were standalone predictors of substandard treatment compliance following BPH surgery (all P < 0.05). The detailed results are presented in Table 5.

Table 5 Multivariate logistic regression analysis of poor treatment adherence in patients with benign prostatic hyperplasia after surgery.

Independent variable	Assignment	β	SE	Wald χ2	P value	OR	95%CI
Depression	Absent = 0, Present = 1	1.169	0.325	12.893	< 0.001	3.215	1.892-5.463
Age	< 70 years = 0, ≥ 70 years = 1	0.745	0.289	6.678	0.010	2.108	1.276-3.482
Educational level	College degree or above = 0, senior high/technical school = 1, junior high school = 2, primary school or below = 3	0.685	0.294	5.342	0.021	1.983	1.195-3.294
Marital status	Married = 0, unmarried/divorced/widowed = 1	0.452	0.301	2.256	0.133	1.572	0.896-2.751
Body mass index	≥ 24 kg/m2 = 0, < 24 kg/m2 = 1	0.389	0.312	1.554	0.213	1.475	0.821-2.643
Hypertension	Absent = 0, present = 1	0.321	0.298	1.168	0.280	1.379	0.786-2.421
Diabetes mellitus	Absent = 0, present = 1	0.295	0.305	0.938	0.333	1.344	0.759-2.381

OR: Odds ratio; CI: Confidence interval.

The relationship between how severe depression is and how well the kidneys are working

Pearson’s correlation analysis revealed a significant association between depression severity and postoperative urinary outcomes in the comorbidity group, with the results indicating that depression severity is a contributing factor to postoperative urinary problems in patients with comorbidity. Scores for the HAMD were linked to IPSS and QOL scores 12 months after the operation, and to PVR. But there was a link between HAMD scores and Q_max (all P < 0.001). These findings indicate that a higher depression severity is associated with more severe urinary symptoms, poorer QOL, and less favorable urodynamic parameters. Detailed correlation coefficients are listed in Table 6.

Table 6 Correlation analysis between depression severity and urinary function parameters.

Indicator	r value	P value
IPSS score	0.426	< 0.001
QOL score	0.451	< 0.001
Qmax (mL/second)	-0.389	< 0.001
PVR (mL)	0.367	< 0.001

IPSS: International Prostate Symptom Score; QOL: Quality of Life; Q_max: Maximum flow rate; PVR: Post-void residual urine volume.

DISCUSSION

Recently, increasing attention has been paid to the coexistence of BPH and depression, particularly in older men. Previous studies have shown that these conditions frequently overlap and that depressive symptoms may indirectly impair BPH treatment outcomes by influencing symptom perception, motivation, and health-related behaviors[15,16]. However, most existing studies have focused on cross-sectional assessments of comorbidity prevalence or short-term postoperative outcomes, with limited assessments of long-term treatment adherence and its relationship with functional recovery. Moreover, systematic analyses exploring the mechanistic pathways linking the severity of depression, treatment adherence, and postoperative urinary outcomes are scarce[17]. In routine clinical practice, postoperative management of BPH mainly focuses on physiological recovery, while psychological comorbidities are often under-recognized or addressed only after symptoms become clinically evident, due in part to a lack of evidence supporting proactive screening and intervention strategies[18]. This study aimed to examine the impact of comorbid depression on postoperative adherence and long-term urinary function in a large cohort of surgically treated patients with BPH (n = 756), thus providing evidence to support a more targeted biopsychosocial treatment approach.

The findings of this retrospective study indicate that comorbid depression is associated with poor postoperative recovery of urinary function, which appears to be mediated through multiple pathways, including reduced treatment adherence and potential dysregulation of neuroendocrine mechanisms. The study also found that people with more severe depression were more likely to have delayed functional improvement, suggesting that more severe depressive symptoms are linked to worse rehabilitation outcomes. These results are similar to those of Zhang et al[19], which shows that depression can make it harder to recover after BPH surgery. This study also provided evidence of a bidirectional relationship between BPH and depression, with the two conditions affecting each other in both directions. People suffering from chronic lower urinary tract symptoms, especially those who have to urinate frequently at night, are likely to experience ongoing sleep disturbances. These symptoms can be a contributing factor to depression and may result in emotional dysregulation through impaired serotonergic signaling[20]. Depressive disorders are often linked to physical symptoms like pelvic discomfort[21]. This can make patients feel more aware of their symptoms and can make urinary irritation after surgery worse. This creates a cycle where symptoms get worse and patients feel more emotional. Around half of the patients (50.8%) with depression as well as BPH went on to develop symptoms of depression after a diagnosis of BPH, underlining the part played by the symptoms of BPH in causing psychological distress. These findings show how important it is to include psychological assessments and specific treatments for patients with BPH in their care after surgery. It is more important to do this than to focus only on physical results.

In this study, 8.6% of patients with BPH (65 out of 756 patients) also had depression, which is a little higher than the estimated prevalence of depression in the general elderly population, which is thought to be around 5%-7%[22]. This finding suggests that BPH may contribute to the development of depressive symptoms. BPH is a chronic and progressive condition. It can cause persistent physical discomfort and QOL deterioration. Patients with depression and other health problems showed different types of problems, including more people over 70 years old, more people with a low level of education (primary school or below), more people who were not married, divorced, or widowed, and more people with high blood pressure and diabetes. These characteristics align with the established risk factors for late-life depression, which are known to contribute to the development of this condition. A lack of education may make patients less able to understand their disease, what to expect after surgery and how to recover. This can lead to feelings of uncertainty and helplessness. Not having support from family or friends can also make it harder to cope with mental health issues and increase the risk of depression. The findings emphasise the need for specific, preoperative screening strategies for high-risk groups using standardised tools (e.g., HAMD) in conjunction with structured clinical interviews for early identification. The degree to which patients with depression also have another condition varies a lot depending on how severe the depression is. In this study, patients with mild symptoms of depression got an average score of 5.12 ± 1.14 on the ASMES and 18.6% of them did not take their medication. Adherence was substantially lower among those with severe depression. Their mean ASMES score was 2.35 ± 0.87, and 52.3% of them discontinued their medication. In addition, 52.3% of them also stopped their rehabilitation exercises. These differences appear to be closely associated with impairments in executive function related to depression. Symptoms of depression that are mild in severity are primarily characterised by a decrease in motivation. This may be addressed through relatively straightforward measures such as the provision of reminders and conducting follow-up assessments. Patients suffering from severe depression frequently exhibit impaired executive function, which restricts their ability to formulate, initiate and maintain treatment-related actions. This underscores the importance of prompt engagement with mental health professionals to devise bespoke intervention plans. Cognitive distortion is commonly observed in patients with comorbid depression during the postoperative recovery process. Some patients wrongly thought that temporary changes in their urinary function were a sign that surgery had failed. This made them even less confident in the treatment, which in turn made them less likely to stick to it.

Following the operation, it is very important for patients with BPH to continue taking their medication as prescribed, to attend regular follow-up appointments, and to follow the recommended health behaviours. In this study, significantly poorer adherence was shown by patients with comorbid depression, with a mean ASMES score of 4.21 ± 1.35 being recorded, and less than 15% of patients achieving high adherence. Elevated rates of missed medications and missed follow-up visits were also recorded, reaching 28.35% and 32.18%, respectively. The presence of depression was associated with significantly lower values than those observed in patients without depression[23]. Another way of looking at this was to see what other things might be causing people to take their medicine. This showed that depression was the biggest thing that stopped people from taking their medicine (odds ratio = 3.215). This was more important than things like age and how much education people had. The reasons why people with depression are less likely to stick to their prescriptions seem to be many and varied[24]. Patients may lose faith in their rehabilitation goals and become less involved in treatment-related activities as a result of core depressive symptoms, which can include anhedonia and low motivation[25]. Similarly, the ability of patients to understand and execute complex postoperative regimens may be limited by depression-associated cognitive impairments such as reduced attention and memory dysfunction[26]. Furthermore, the stigma surrounding mental health disorders may prevent some patients from seeking psychological support, which can further disrupt adherence. The rate of implementation of health behaviours was only 53.8% in the comorbidity group, which also showed poor adherence to non-pharmacological rehabilitation measures. This finding suggests that depression adversely affects not only medication compliance. It also affects patients’ capacity to sustain essential recovery behaviours. Examples of these behaviours include pelvic floor muscle training and adequate hydration. Ultimately, depression can form a vicious cycle of “poor adherence, delayed rehabilitation, and emotional deterioration”. Surgical intervention for mechanical bladder outlet obstruction can be highly effective. However, patients with depression often experience a slower recovery in urinary function. At 12 months postoperatively, the IPSS remained elevated at 12.18 points and Q_max reached only 15.62 mL/second. Overall, smaller improvements in urinary parameters were consistently observed in the comorbidity group compared to the non-comorbidity group. Further correlation analysis revealed a moderate positive association between HAMD scores and IPSS and QOL scores, as well as a moderate negative association with Q_max. These findings suggest that depression severity plays a crucial role in predicting postoperative recovery of urinary function. Several mechanisms may explain this association. Adherence issues can directly impact the effectiveness of a treatment. For instance, missing doses of α-blockers can lead to inadequate urethral smooth muscle relaxation, while not including anticholinergics may hinder the management of overactive bladder symptoms, which can have a negative effect on urodynamic outcomes[27]. Secondly, urinary function may be influenced by depression through neuroendocrine pathways because detrusor contractility can be suppressed and urethral sphincter tone increased by higher sympathetic nervous system activity in depressive states, which can contribute to detrusor-sphincter dyssynergia[28]. Thirdly, the body’s ongoing response to chronic stress, marked by inflammation and elevated cortisol levels, can hinder the healing process, intensify urethral mucosal swelling, and extend the recovery period after surgery[29]. The lack of notable differences in urinary function before surgery between those with and without comorbidity supports the idea that the observed differences in postoperative outcomes were due to depression rather than pre-existing functional differences.

While the between-group differences in IPSS at 12 months (12.18 vs 6.35) were statistically significant (P < 0.001), it is important to consider their clinical relevance. The difference of 5.83 points exceeds the established minimal clinically important difference for IPSS, which is typically 3-5 points, indicating that the poorer urinary function experienced by the comorbidity group is not only statistically significant, but also clinically meaningful to patients. Similarly, the differences in Q_max and PVR, even when individual variations was taken into account, were likely to be perceived by patients as clinically meaningful impairments in urinary function.

This study has some limitations. First, the retrospective design and inclusion of patients from only two centers (Wuxi Ninth People’s Hospital Affiliated to Soochow University and the Second Affiliated Hospital of Nanjing Medical University) may have introduced selection bias and limited the generalizability of the results. These findings require validation through larger multicentre prospective studies. Second, the information about how strong and how long antidepressant treatment was not included in the analysis. This meant that it was not possible to assess the potential impact of depression management on postoperative recovery outcomes. Third, the follow-up period was limited to 12 months. This leaves the long-term effects of depression on outcomes unclear. These outcomes include disease recurrence and sustained functional recovery. Future research is needed. This should be primarily randomised controlled trials. These will evaluate the efficacy of different psychological and pharmacological strategies. The aim is to enhance rehabilitation in patients with comorbid depression. Fourth, our study identified depression as a significant predictor of PVR improvement. However, the considerable interindividual variability suggests that other unmeasured factors may also play crucial roles. These factors include preoperative detrusor function, the severity of bladder outlet obstruction, and individual differences in tissue healing. Therefore, the impact of depression on urinary function should be considered in the context of a multifactorial recovery process. Subsequent studies should encompass a more extensive array of urodynamic parameters to facilitate a more exhaustive comprehension. Fourthly, the researchers primarily used the ASMES to assess treatment adherence, but this scale is susceptible to recall and social desirability bias. We also collected information about how often medication was not taken and records from when people were being followed up. This helped us to check the findings. In the future, it would be good for studies to include objective measures, such as information about when people refilled their prescriptions, counts of pills, or electronic monitoring devices, to check that people are telling the truth about how often they take their medication.

CONCLUSION

This study concluded that depression is a common comorbidity among patients undergoing surgery for BPH and significantly impacts postoperative outcomes negatively. Poorer rehabilitation outcomes are the result of reduced treatment adherence and delayed recovery of urinary function, which are both associated with comorbidity depression. People who are over 70 years old and have not received a lot of education are more likely to not follow their prescriptions after surgery. These findings show that it is very important to regularly check for depression and to provide psychological support at the right time in the management of postoperative BPH. A combined, multidisciplinary approach to treatment that considers both physical and psychological aspects may improve treatment adherence, speed up recovery of urinary function, and enhance patients’ QOL.