By Chiara Ghetti, MD

Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis

Dr. Ghetti reports no financial relationships relevant to this field of study.

SYNOPSIS: Women with major depression undergoing surgical treatment for stress urinary incontinence have worse condition-specific quality of life than non-depressed women. Postoperatively, depressed and non-depressed women have similar incontinence severity and quality of life.

SOURCE: Siff LN, Jelovsek JE, Barber MD. The effect of major depression on quality of life after surgery for stress urinary incontinence: A secondary analysis of the Trial of Midurethral Slings. Am J Obstet Gynecol 2016;215:455.e1-9.

The main objective of this study was to determine whether baseline major depression affects urinary incontinence severity and incontinence-specific quality of life after midurethral sling surgery. This was a secondary analysis of the Trial of Midurethral slings (TOMUS) study, a multicenter, randomized equivalence trial that assigned women with stress UI to either retropubic or transobturator midurethral sling surgery. The aim of the primary TOMUS analysis was to compare 12-month cure rates between each type of midurethral sling. The reported analysis included all TOMUS subjects who completed Patient Health Questionnaire (PHQ-9), underwent midurethral sling, and completed one year of postoperative follow-up.

The main outcome measures for this analysis included the PHQ-9, which has been validated for the diagnosis of depression in primary care and specialist medical outpatient settings. Subjective outcome measures also included the following validated self-report questionnaires: the International Consultation on Incontinence Questionnaire (ICIQ) measuring incontinence severity, Incontinence Impact Questionnaire (IIQ) and the Urogenital Distress Inventory (UDI) measuring incontinence-specific quality of life, and Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) measuring symptom-specific sexual function.

The analysis included 526 patients, and 79 women (15%) had major depression at baseline. Depressed subjects were more likely to be younger, obese, diabetic, and current smokers. They were less likely to be white, have education level higher than high school, or have “very good” or “excellent” health. At 12 months, only 4% of the population met criteria for major depression. At baseline, depressed subjects had higher urinary incontinence severity and worse incontinence specific quality of life. At 12 months postoperatively following midurethral sling, there was no difference in incontinence severity between subjects who were or were not depressed at baseline. Postoperative condition-specific quality of life was worse in women with depression at baseline; however, after adjusting for differences between the depressed and non-depressed groups, these differences were not statistically significant. Subjects depressed at baseline maintained worse sexual function following surgery compared to the non-depressed at baseline. After adjusting for differences between groups, multivariable analyses did not show an independent association between baseline major depression and postoperative incontinence severity or quality of life. However, an independent association was found between baseline major depression and 12-month sexual function.


Depression is very common and has been estimated to affect about 18% of people. Depression is known to affect overall physical health, surgical outcomes, and quality of life. It has been found to affect subjective outcomes following different types of procedures. It also has been shown to affect the perception of symptoms in patients with chronic illness. In women with pelvic floor symptoms, major depression has been associated with both incontinence and prolapse symptoms and has been associated with worsened condition-specific quality of life. In a study conducted in women undergoing surgery for pelvic organ prolapse, we found a significant decrease in depressive symptoms following surgery.1

This secondary analysis of women undergoing surgery for urinary incontinence also demonstrated a decrease in depressive symptoms following surgery. At 12 months following surgery for urinary incontinence, 83% of those with major depression at baseline no longer met criteria for depression. Interestingly, incontinence severity in women with baseline depression following surgery was no different than in non-depressed women. However, sexual function remained worse in women with baseline depression, despite overall improvement in depressive symptoms.

The main limitation of this study was that the authors did not evaluate whether women held a past or current diagnosis of depression or were in treatment for depression. In interpreting the findings, it is difficult to control for the natural history of the disease within these women followed prospectively for 12 months following surgery. In addition, it is not possible to establish causality in the associations between mood and incontinence symptoms and the effect of surgery on mood.

Despite several limitations, this study further adds to the body of literature investigating the complex relationship of mood and pelvic floor symptoms. Interestingly, depressive symptoms improve following surgery for urinary incontinence. These findings are similar to those found in women undergoing surgery for other pelvic organ prolapse. This study further highlighted the importance of identifying depressive symptoms in patients with pelvic floor symptoms and women undergoing surgery. The presence of depressive symptoms contributed to individual women’s quality of life and likely affected goals and expectations of surgery. Being aware of the presence of depressive symptoms in women with pelvic floor symptoms may allow providers to better individualize treatment goals.


  1. Ghetti C, Lowder JL, Ellison R, et al. Depressive symptoms in women seeking surgery for pelvic organ prolapse. Int Urogynecol J 2010;21:855-860.