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Riyadila Fajariza
 JOURNAL OF ENDOUROLOGY
Volume 26, Number 5, May 2012

Correlation Between Stress

and Kidney Stone Disease
Ricardo Miyaoka, M.D., Omar Ortiz-Alvarado, M.D.,
Carly Kriedberg, B.A., Shaheen Alanee, M.D.,
Ekkarin Chotikawanich, M.D., and Manoj Monga, M.D.
 Abstrak
◆ Latar Belakang dan Tujuan :
Prevalensi penyakit batu ginjal meningkat di seluruh
dunia, dan beberapa faktor mungkin terlibat. Penelitian
ini bertujuan untuk mengetahui hubungan antara stres
dengan terjadinya batu ginjal.
◆ Pasien dan Metode :
Secara prospektif mengevaluasi 200 pasien dengan
diagnosis batu ginjal dan mengisi kuesioner yang sudah
divalidasi untuk mengukur tingkat stres (Stres Perceived
Skala-10 [PSS-10]). Karakteristik yang berhubungan
dengan batu dan faktor-faktor stres dinilai. Variabel yang
signifikan pada analisis univariat digunakan sebagai
model yang mampu menjelaskan variabilitas dalam skor
PSS-10 pada pasien.
◆ Hasil :
Rerata skor PSS-10 adalah 15,3-1,1. Jenis kelamin
perempuan (P = 0,014), terjadinya kematian atau penyakit
serius anggota keluarga atau teman dekat dalam 6 bulan
terakhir dalam wawancara (P = 0,044), trauma psikologis
lainnya (P <0,0001) semua terbukti menjadi faktor yang
signifikan. Aspek terkait batu yang berhubungan dengan
stres adalah adanya gejala pada saat wawancara (P =
0,012) dan berlalunya dua atau lebih batu per tahun (P =
0,022). Kami mampu menjelaskan 34% variabilitas PSS-10
masing-masing subjek. Status pekerjaan adalah satu-
satunya variabel yang signifikan, tetapi jenis kelamin,
usia, dan kehadiran gejala pada saat administrasi
kuesionerdapat menjelaskan variabilitas
 Introduction

Dietary changes
The prevalence of urolithiasis is
increasing in modern,industrial,
and more affluent socioeconomic
nations. Other risk factors

Psychobiologic,
Stress Psychoneuroimmunologic,
and Behavioral pathways

Previous studies have suggested a link between

stressful life events and urolithiasis and its related
symptoms, although it is still unclear whether stress
acts as a causative factor or as a consequence of
painful and recurrent colic episodes
 Patients and Methods

July 2008 to August 2009 Institutional Review Board

This questionnaire also evaluated potential sources of stress

A prospective study of consecutive
patients seen at our multidisciplinary
Kidney Stone Clinic
All subjects responded to a self-administered
validated questionnaire regarding stress
(Perceived Stress Scale–10 [PSS-10])
within 6 months of the interview, such as employment status,
condition as primary wage earner for the family and primary
caregiver for children; occurrence of death, serious illness or
accident involving close relative or friend; change in marital
status or any other major psychological trauma (defined as
any event that provoked concern for over a week), as
suggested by Kreitler and colleagues

Participants completed a demographic questionnaire that

queried history of stone disease and management (symptoms
at the time of interview, time from last stone passage, total
number of stones passed, number of stones passed per year,
therapeutic procedures for stone removal), and
sociodemographic data (age, sex, race)
Inclusion criteria
◆ Age of 18 years or older, confirmed
diagnosis of urolithiasis, and
willingness to enroll.
Exclusion criteria
◆ Patients under 18 years of age
◆ Diagnosis of depression
◆ Use of antidepressants or anxiety
medication for any cause,
◆ Alcohol or drug abuse
◆ Pregnancy
◆ Cognitive incapability to fill out the
questionnaire.
 “
The Student t test was used to correlate stressful life events
and demographic features with PSS-10 scores. Multifactorial
analysis of variance was used to construct a model that was
able to explain the variability in PSS-10 score in our patients.
The variables that were significant on the univariate t tests
analysis were used to construct that model. Variables significant
at a P value of 0.05 or that contributed to the ability of the
model to explain PSS-10 variability were kept in it.
 Results

From July 2008 to August 2009, 210

patients were prospectively enrolled.
Ten patients were excluded in total. Four
had a diagnosis of clinical depression,
two did not have a sufficient
comprehension of the English language
to understand and fill out the
questionnaire, and another four failed
to adequately complete the PSS-10.
The mean PSS-10 score was 15.3 – 1.1.
◆ Table 2 summarizes
the PSS-10 total scores and their
correlation with sociodemographic
parameters and urolithiasis-related
aspects.Female sex (P = 0.014),
occurrence of death or serious illness of
a family member or a close friend within
the last 6 months of the interview (P =
0.044), occurrence of other
psychological trauma (P < 0.0001)
correlated significantly with higher PSS-
10 scores. Stone-related factors
associated with stress were presence of
symptoms at the time of interview (P =
0.012) and passage of two or more
stones per year (P = 0.022).
 Employment status was the only significant variable, but sex,
age, and presence of stonerelated symptoms at the time of
questionnaire administration had to be kept in to achieve a
model that explains the largest amount of variability. Larger
number of patients could have added significance to these
variables.

There was no significant difference noted in stress in those

with a recent stone passage history (< 1 month) compared
with those with a remote history of stone passage ( > 1 month,
P = 0.879). Disability, reported by 11% patients, did not impact
psychological stress (P = 0.465).
 Discussion

Stress was suggested to have a causative correlation with

urolithiasis by Walters in 1986.17 He hypothesized that stress Females had a significantly higher
would trigger the ‘‘fight or flight’’ reflex, leading to score in PSS-10 than men (P <
neuroendocrine activation that ultimately would enhance 0.0001). This is in accordance with
vasopressin secretion and finally produce hypertonic urine, other reports that suggest that
increasing the risk of calculi formation more than 90% of women report
moderate and higher levels of
stress in their lives
Najem and associates also suggested a causal relationship
between stress and urolithiasis as they interviewed patients to
determine stressful life events that took place up to 2 years
before their diagnosis. Although the authors propose that
evaluating stressful life events that preceded the diagnosis of
calculus clarifies the circular argument that stress led to
disease and disease led to stress, one might propose that the
timing of formation of asymptomatic stones is difficult to
pinpoint.
Sociodemographic Parameters Analyzed

• Unemployment (P = 0.0114)
• Occurrence of illness/ death (P = 0.0444)
• Other psychological trauma (P < 0.0001)
within the past 6months of the interview proved
to be relevant
Conclusions

◆ Passage of two or more stones per year and, most

importantly, presence of symptoms proved to be factors
related to elevated stress in patients with a diagnosis of
urolithiasis.
◆ Female sex, age, and unemployment may also contribute to
a stressed state in this population. Further studies are
needed.
◆ A causal relationship between stress and stones remains
elusive, yet evaluations of the impact of stress-reduction
techniques on stone recurrence may be warranted.