Questionnaire for Incontinent Patients Name Date: Date of birth: weight: height: Vaginal deliveries: Caesarean Sections: profession: No Yes Sometimes Yes 50% or more Do you lose urine during sneezing or coughing?... during exercise?... walking?... squatting, bending or getting up from a chair? Amount/event: ( ) a few drops ( ) teaspoon ( ) tablespoon ( ) more Do you feel your bladder is not emptying properly? Do you have difficulty starting off your stream? Is it a slow stream? Does it stop and start involuntarily? Do you ever have an uncontrollable desire to pass urine? If so, do you wet before arriving at toilet? If so, how much urine do you lose? ( ) a few drops ( ) teaspoon ( ) tablespoon ( ) more how many times a day does that happen? -on good days: times -on bad days: times Do you have pain while passing urine? How many times during the night do you get up to pass urine? number: How many times during the day do you pass urine? number: In the morning do you wet immediately on getting out of bed? Did you wet the bed as a child, but not after puberty? Did your start after puberty? Are your worse before a period? Do you have small ( rabbit ) stools? Do you ever soil yourself (faeces)? Wind ( ) Liquid ( ) Solid ( ) Are you moist with urine most of the time? Are you leaving puddles on the floor? Do you lose urine in bed at night? Do you wear pad or liner on going out? Liner ( ) Pad ( ) Diaper ( ) Number/day: Number/night:
Impact on Quality of life: 1 = normal 2 = mild, no effect on lifestyle 3 = can t drink, must locate toilets on going out 4 = always wear pads, very restricted social life 5 = totally housebound Please write down number: Have you had a hysterectomy? (when: ) Have you already had colporrhaphies ( times) Have you had previous abdominal surgery for incontinence? (when? ) (what kind of operation?) Are you better since? Any other pelvic surgery? What/when: Do you have deep pain on intercourse? I don`t have intercourse Do you have a pain down at the bottom of your spine? Do you have a pain down at the bottom of your abdomen?
Questionnaire Correlation of with specific anatomic defects Do you lose urine during sneezing or coughing?... during exercise?... walking? Low midurethral pressure (MUP), lax posterior compartment... squatting, bending or getting up from a chair? In case of minimal SI it is named paradoxical leakage, exclude tethered vaginal syndrome after previous surgery. No surgery = lax PUL Do you feel your bladder is not emptying properly? Do you have difficulty starting off your stream? Is it a slow stream? Does it stop and start involuntarily? Do you ever have an uncontrollable desire to pass urine? If so, do you wet before arriving at toilet? Do you have pain while passing urine? How many times during the night do you get up to pass urine? How many times during the day do you pass urine? In the morning do you wet immediately on getting out of bed? Middle or posterior compartment, after excessive bladder neck elevation Exclude urinary tract infection Tethered vagina/pul defect Did you wet the bed as a child, but not after Defective PUL, defective collagen tissue puberty? glue between vagina and PCM Did your start after puberty? Are your worse before a period? Do you have small ( rabbit ) stools? Defective PUL and/or rectocele Do you ever soil yourself (faeces)? Defective PUL and/or anal mucosal prolapse, middle or posterior compartment defects Are you moist with urine most of the time? Are you leaving puddles on the floor? Do you lose urine in bed at night? Do you wear pad or liner on going out? Have you had a hysterectomy? (when: ) Low MUP, lax hammock, lax posterior compartment, tethered vagina Defective PUL, defective collagen tissue glue between vagina and PCM Posterior compartment defect (prevalence > 30%) Have you already had colporrhaphies ( Consider tethered vagina syndrome times) (prevalence < 5%) Have you had previous abdominal surgery for incontinence? ( Are you better since? Any other pelvic surgery? Do you have deep pain on intercourse? I don t have intercourse Do you have a pain down at the bottom of your spine? Do you have a pain down at the bottom of your abdomen?
correlation of defects
correlation of defects with complaints, signs and findings Anterior defect (excess laxity) Middle defect (excess laxitiy) (excess laxitiy) Severe SI Voiding difficulties Incontinence worse 1 week before period Urine loss on FI persisting after Pain (low abdomen, standing post IVS low sacral, dyspareunia) Post-stress instability Voiding difficulties always damp signs Nocturia Faecal incontinence Cystocele (FI) Nocturnal enuresis ATFP defect cured at puberty or wet since childhood signs Urodynamics signs Lax hammock Raised residual Excitation pain (vaginal and cervical) Positive pad test (SI) Slow emptying time Prolapse (uterus, enterocele) Positive midurethral Boney Funnelling on PNS UVJ prolapse at strain Urodynamics Positive PTR Tethered vagina Urodynamics (excess tightness) Raised residual Positive CTR with SI Slow emptying time Stress related DI uncommon (5%) Positive PTR iatrogenic may occur years after vaginal surgery/bns motor -DI getting out of bed often no major SI note: FNU (frequency, nocturia and urgency may occur with all defects) Not all criteria may be present in a particular defect
probability rates for each parameter Anterior defect (excess laxity) Middle defect (excess laxitiy) (excess laxitiy) Severe SI = 90% Voiding difficulties Incontinence worse 1 = 50% week before period = 80% Urine loss on FI persisting after Pain (low abdomen = standing = 90% post IVS 90%, low sacral = 50%, dyspareunia = 80%) Post-stress instability Voiding difficulties = 80% always damp = 80% signs Nocturia Faecal incontinence Cystocele (FI) Nocturnal enuresis ATFP defect cured at puberty or wet since childhood = 90% signs Urodynamics signs Lax hammock Raised residual = Excitation pain 50% (vaginal and cervical) Positive pad test (SI) Slow emptying time Prolapse (uterus, = 90% enterocele) Positive midurethral Positive PTR Boney = 95% Funnelling on PNS = 90% Tethered vagina UVJ prolapse at strain syndrome = 70% (excess tightness) Urodynamics Urodynamics Positive CTR with SI Stress related DI uncommon (5%) iatrogenic may occur years after vaginal surgery/bns motor -DI getting out of bed often no major SI Raised residual Slow emptying time Positive PTR note: FNU (frequency, nocturia and urgency may occur with all defects) Not all criteria may be present in a particular defect