original research  
Do anxiety, stress, or depression have any impact on pain  
perception during shock wave lithotripsy?  
1
2
1
1
2
Muammer Altok, MD; Abdullah Akpinar, MD; Mustafa Güne  
ş
, MD; Mehmet Umul, MD; Kadir Demirci, MD;  
1
Ercan Baş, MD  
1
2
Süleyman Demirel University, Faculty of Medicine, Department of Urology, Isparta, Turkey; Süleyman Demirel University, Faculty of Medicine, Department of Psychiatry, Isparta, Turkey  
Cite as: Can Urol Assoc J 2016;10(5-6):171-4. http://dx.doi.org/10.5489/cuaj.3445  
Published online May 12, 2016.  
ment it with the aid of fluoroscopy or ultrasound. Adverse  
effects of SWL are well known. The most important adverse  
effect during the procedure is pain perception, which has  
been suggested to be related to many factors (stone size,  
stone location, shock frequency or voltage, skin aperture of  
the shock wave, the type of the SWL device, etc.).3  
The significance of anxiety, stress, and depression on pain  
perception during SWL is not clear. The aim of this study  
was to evaluate the effect of anxiety, stress, and depression  
on pain perception during SWL. Additionally, we evaluated  
the relationship between pain perception during SWL and  
the level of anxiety, stress, and depression.  
Abstract  
,4  
Introduction: The most important adverse effect during shock wave  
lithotripsy (SWL) is pain perception. In this study, we evaluated  
the effect of anxiety, stress, and depression on pain perception  
during SWL.  
Methods: From November 2013 to December 2014, 189 consecu-  
tive patients undergoing SWL for kidney stones were evaluated pro-  
spectively. Patient characteristics (age, sex, body mass index [BMI],  
urologic intervention history, the presence of a double-j catheter,  
and stone-related parameters) were also recorded. Anxiety, stress,  
and depression states were assessed before the first procedure using  
the Depression, Anxiety, and Stress Scales (DASS-42), which is  
a self-report scale. The degree of pain perception was evaluated  
with a 10-point Visual Analogue Scale (VAS) at the end of the first  
SWL session.  
Results: There were no statistically significant differences in terms  
of VAS scores during SWL between patients with and without  
anxiety, stress, or depression (p >0.05). Furthermore, no statisti-  
cally significant relationships were found between VAS scores and  
patient age, sex, side of the stone, presence of a double-j stent,  
number of stones, and SWL experience (p >0.05).  
Methods  
Between November 2013 and December 2014, a pro -  
spective study was conducted with consecutive patients  
allocated in order of application, who underwent SWL for  
kidney stones. The sample size was calculated based on  
5
a previous study by assuming an a error of 0.05, a 1-b  
error of 0.2 (power of 80%) and an effect size I pl:0.51.  
Power calculations determined that a total sample size of  
2
0 patients would be sufficient. The study was approved  
by the local ethics committee and informed consent was  
obtained from all patients. Patient data, including age, sex,  
body mass index (BMI), urologic intervention history (previ-  
ous SWL, operation), the presence of a double-j catheter,  
and stone-related parameters (size as maximum diameter,  
number) were recorded before the procedure.  
Conclusions: According to our findings, anxiety, stress, or depres-  
sion seemed to have no impact on pain perception during SWL.  
Introduction  
TM  
Diclofenac sodium 75 mg (Dikloron , Deva, Istanbul,  
The development of shock wave lithotripsy (SWL) in 1980  
significantly changed the management of urinary tract  
Turkey) was administered intramuscularly 3045 minutes  
before the SWL session for pain control. After the appli -  
cation of diclofenac sodium, the patient’s anxiety, stress,  
and depression states were assessed using the Depression,  
Anxiety, and Stress Scales (DASS-42), a self-report scale  
administered before the first procedure. All patients under-  
went 13 sessions of SWL in relation to treatment responses  
1
stones. It is currently accepted as the primary treatment  
2
option for urinary stones.  
SWL produces high-energy shock waves through an elec-  
trical discharge. The shock waves are transmitted through  
the tissues and focused onto a renal/ureteral stone to frag-  
CUAJ • May-June 2016 • Volume 10, Issues 5-6  
2016 Canadian Urological Association  
E171  
©
aꢀtꢁk ꢂt ꢃꢀ.  
Results  
in our department using an ELMED Multimed Classic litho-  
tripter (ELMED, Ankara, Turkey) electrohydraulic system.  
SWL treatment was initiated with at a 7 KV energy level  
and progressively increased to 1621 KV while consider-  
ing the pain perception of the patient. At a frequency of 60  
shock waves per minute, 2500 shock waves were applied  
for each patient at every session. Additional analgesics were  
not administered during the procedure.  
We included 189 patients in this study. Demographic  
data, stone-related parameters, and patients’ characteristics  
including VAS, anxiety, stress, and depression scores are  
shown in Table 1.  
The comparison of VAS scores and anxiety, stress, and  
depression statuses according to the DASS-42 scale are  
described in Table 2. There were no statistically significant  
differences in terms of VAS scores during SWL between  
patients with and without anxiety, stress, or depression  
(p >0.05, Table 2).  
Exclusion criteria for this study were the presence of any  
untreated urinary infections, nonsteroidal anti-inflammatory  
drug intolerance or allergy, psychiatric drug consumption  
(
such as antidepressants and anxiolytics), the inability to  
complete the DASS-42 form or evaluate pain with the visual  
analog scale (VAS), and absolute contraindications for SWL  
The comparison of the severity of anxiety, stress, and  
depression, and VAS score are shown in Table 3. There was  
no statistically significant difference between the anxiety,  
stress, and depression subgroups according to VAS scores (p  
>0.05, Tables 3, 4). Furthermore, no statistically significant  
relationships were found between VAS scores and patient  
age, sex, side of the stone, presence of a double-j stent, num-  
ber of stones, and SWL experience. The VAS score seemed  
to increase with increasing BMI and stone size; however,  
statistical significance for this was not detected (Table 5).  
(
pregnancy, bleeding diatheses).  
The degree of pain perception was evaluated with a  
6
1
0-point VAS at the end of the procedure. Only the VAS  
results of the first SWL session were evaluated. Statistical  
analysis was performed using the Statistical Package for the  
Social Sciences version 12.0 software program (SPSS 12.0  
for Windows; SPSS Inc., Chicago, IL, U.S.). Continuous  
variables were presented as a mean (± , standard deviation  
[
SD]). The distribution of numerical variables was analyzed  
separately in each group to establish nonparametric require-  
ments. We performed chi-square tests to compare categori-  
cal variables. The significance of differences between groups  
was estimated using the Mann-Whitney U test and differ-  
ences were analyzed. Bivariate comparisons were examined  
using Kendall’s correlation coefficients (r) and values were  
corrected for ties. Two-tailed hypothesis tests were used for  
statistical analysis and all of these differences were consid-  
ered significant at p <0.05.  
Discussion  
Pain during SWL is thought to be related to two different  
origins. First, is the effect of the shock waves on the cuta-  
neous and subcutaneous structures (skin, muscle, ribs, and  
subcostal nerves). The second is related to the kidney and  
to increases in intrapyelic pressure, distention of the renal  
capsule, or obstructions caused by fragmented stones. The  
type of SWL machine, shock wave voltage and number,  
skin aperture, stone size, stone location, sex, age, and BMI  
are thought to affect pain perception during SWL.1  
However, published data on this subject are contradictory.  
,3,4,7-12  
Table 1: Patients and stone characteristics (n=189)  
Age ± SD  
43.92 ± 13.98  
1
3
7
3
Vergnolles et al, Tokgoz et al, and Berwin et al reported  
that female patients have significantly higher pain percep-  
tion and require more analgesic treatments. Alternatively,  
Sex (%)  
Female  
Male  
59 (31.2%)  
130 (68.8%)  
4
11  
BMI ± SD  
27.22 ± 4.20  
Salinas et al and Tailly et al reported that there was no  
Side of stone (%)  
Right  
Left  
89 (47.1%)  
100 (52.9%)  
Table 2. The presence of anxiety, stress, depression, and  
VAS score  
Double-J stent status (%)  
Yes  
No  
Number (%)  
VAS score ± Sꢀ  
p value  
32 (16.9%)  
157 (83.1%)  
All patients  
189 (100%)  
4.62 ± 1.45  
Anxiety  
No  
Yes  
Stone number ± SD  
Stone size (mm) ± SD  
SWL session no ± SD  
VAS score ± SD  
1.41 ± 1.04  
10.5 ± 3.91  
2.3 ± 0.86  
115 (60.8%)  
74 (39.2%)  
4.55 ± 1.37  
4.74 ± 1.57  
0.458  
Stress  
No  
Yes  
4.62 ± 1.45  
7.35 ± 7.05  
10.95 ± 8.84  
6.73 ± 7.96  
136 (72.0%)  
53 (28.0%)  
4.64 ± 1.47  
4.58 ± 1.41  
0
.786  
.995  
Anxiety score ± SD  
Stress score ± SD  
Depression  
No  
Yes  
VAS: Visual Analogue Scale.  
Depression score ± SD  
BMI: body mass index; SD: standard deviation; SWL: of shock wave lithotripsy; VAS: Visual  
Analogue Scale.  
140 (74.1%)  
49 (25.9%)  
4.64 ± 1.48  
4.59 ± 1.38  
0
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CUAJ • May-June 2016 • Volume 10, Issues 5-6  
Pꢃꢄꢅ pꢂꢆꢇꢂptꢄꢁꢅ duꢆꢄꢅꢈ ꢉꢊꢁꢇk wꢃvꢂ ꢀꢄtꢊꢁtꢆꢄpꢉy  
Table 3. Comparison between the severity of anxiety,  
stress, and depression, and VAS score  
Table 4. Correlation between anxiety, stress, and  
depression levels, and VAS score  
VAS score  
Number (%)  
Mean ± Sꢀ  
VAS score  
Number (%)  
p value  
±
Sꢀ  
r
p
Anxiety (n=74)  
Mild  
Moderate  
Severe  
Anxiety  
No  
Yes  
22 (29.7%)  
26 (35.1%)  
26 (35.1%)  
4.55 ± 1.85  
4.73 ± 1.46  
4.92 ± 1.47  
115 (60.8%)  
74 (39.2%)  
3.04 ± 2.35  
14.04 ± 6.69  
0.019  
0.027  
0.793  
0.776  
0.402  
0.260  
0.831  
Stress  
No  
Yes  
Stress (n=53)  
Mild  
Moderate  
Severe  
136 (72.0%)  
53 (28.0%)  
6.52 ± 4.52  
22.32 ± 6.93  
0.067  
-0.151  
0.309  
0.156  
20 (37.7%)  
19 (35.8%)  
14 (26.4%)  
5.05 ± 1.76  
4.53 ± 1.07  
4.00 ± 1.04  
Depression  
No  
Yes  
140 (74.1%)  
49 (25.9%)  
2.89 ± 2.77  
17.69 ± 7.78  
0.107  
-0.137  
0.110  
0.220  
Depression (n=49)  
Mild  
Moderate  
Severe  
16 (32.7%)  
21 (42.9%)  
12 (24.5%)  
4.75 ± 1.34  
4.62 ± 1.50  
4.33 ± 1.30  
SD: standard deviation; VAS: Visual Analogue Scale.  
was used to detect anxiety or depression.13,16,17 The STAI is  
a self-report form, does not have a cutoff point for detect-  
ing the presence of anxiety, and only measures the level of  
SD: standard deviation; VAS: Visual Analogue Scale.  
significant relationship between pain perception and sex.  
3
18  
Berwin et al reported that BMI is related, while Vergnolles  
anxiety. HADS is also a self-report form and has a cutoff  
1
3
7
et al and Tokgoz et al reported that BMI in not related to  
point,but it evaluates the level of anxiety and depression;  
however, subgroup evaluations are not possible.19 Unlike  
these studies, we used the DASS-42 form in our study. The  
DASS-42 form is also a self-report form and includes 42  
1
1
pain perception. Tailly et al reported that stone size and  
3
number are related to pain perception, unlike Berwin et al  
who reported that there is no significant correlation between  
pain and stone size and the number of stones.  
Pain is a subjective description. Other than pathophysi-  
ological factors, psychological and social factors may also  
Table 5. Descriptive statistics for patient and stone  
characteristics  
1
4,15  
The relationship between pain  
affect pain perception.  
and anxiety in SWL patients has been evaluated in a few  
VAS Score  
Mean ± Sꢀ)  
Variables  
p value  
0.402  
0.308  
0.183  
(
1
2,13  
Franceschi  
Age  
0–39  
studies and the results were controversial.  
et al reported that anxiety cannot be predictive of pain.  
1
2
4.78 ± 1.65  
4.55 ± 1.20  
4.34 ± 1.40  
4
0–59  
59  
Sex  
Female  
Male  
BMI  
8.5–24.9  
5–29.9  
30  
Alternatively, Vergnolles et al investigated an anxiety and  
depression status effect on pain perception during SWL  
treatment in 164 patients and reported that depressed and  
>
4.73 ± 1.50  
4.58 ± 1.43  
1
3
anxious patients experienced more pain. In the current  
study, we investigated the effect of existing anxiety, stress,  
and depression before the SWL treatment on pain percep-  
tion during the SWL session. To our knowledge, this is the  
first study that has evaluated anxiety, stress, and depression  
at the same time in a large patient series; it is also the only  
study to evaluate the stress factor and its relationship to  
pain. In our study, no significant relationships were detected  
between pain perception and anxiety, stress, or depression  
among the subgroups.  
1
2
>
4.31 ± 1.29  
4.69 ± 1.55  
4.85 ± 1.37  
Side of stone  
Right  
Left  
4.76 ± 1.43  
4.50 ± 1.46  
0
.172  
.950  
Double-J stent status  
Yes  
No  
4.63 ± 1.48  
4.60 ± 1.43  
0
Stone number  
We only evaluated anxiety, depression, and stress levels  
before the first SWL session and VAS was only evaluated in  
the first SWL session. In the previously mentioned studies,  
this topic was unclear. These previous studies suggested  
that anxiety and pain perception increased in accordance  
1
2
>
4.56 ± 1.49  
4.52 ± 1.20  
5.21 ± 1.31  
0.108  
0.240  
2
Stone size (mm)  
7 mm  
8–14 mm  
14 mm  
<
4.41 ± 1.44  
4.61 ± 1.50  
4.91 ± 1.29  
7
with the increase in SWL session numbers. Therefore, the  
>
evaluation of anxiety, depression, and VAS status for every  
session, especially in the same patients, can cause conflict-  
ing results due to the cumulative experience.  
In similar studies, the State-Trait Anxiety Inventory (STAI)  
or Hospital Anxiety and Depression Scores (HADS) form  
Urologic background  
No  
SWL  
4.60 ± 1.35  
4.65 ± 1.66  
0
.941  
BMI: body mass index; SD: standard deviation; SWL: of shock wave lithotripsy; VAS: Visual  
Analogue Scale.  
CUAJ • May-June 2016 • Volume 10, Issues 5-6  
E173  
aꢀtꢁk ꢂt ꢃꢀ.  
questions. The advantage of this form is that it evaluates  
anxiety, stress, and depression simultaneously. Also, it has  
cutoff points for detecting the presence of anxiety, stress,  
and depression, and can evaluate their severity within sub-  
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0
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1
,3,4,7-13  
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in BMI and stone size; however, statistical significance was  
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pain perception. The second limitation is that the DASS-42  
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Conclusion  
Based on our findings, we can conclude that existing anxi-  
ety, stress, or depression before the SWL treatment may not  
be related to pain perception during the SWL session.  
Competing interests: The authors declare no competing ꢀnancial or personal interests.  
This paper has been peer-reviewed.  
2
1. Kim H, Neubert JK, Rowan JS, et al. Comparison of experimental and acute clinical pain responses in  
humans as pain phenotypes. J Pain 2004;5:377-84. http://dx.doi.org/10.1016/j.jpain.2004.06.003  
Correspondence: Dr. Muammer Altok, Süleyman Demirel University, Faculty of Medicine, Department  
of Urology, Isparta, Turkey; muammeraltok@sdu.edu.tr  
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