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Disorders of pelvic organ function (bladder and bowel), as well as sexual dysfunctions, can be manifestations of either pathology of the organs themselves (e.g., inflammation) or changes in nervous system control. By answering these questions, you will help to develop a diagnostic algorithm and select optimal treatment for you.
The gray section of the scale is to be filled out by (or is intended for) the physician. Download pdf
Full Name____________________________________________________________
Gender: Female Male Age______________
Date____________________
Bladder
No. | Question / POINTS | 0 | 1 | 2 | 3 | Total | |
1 | Frequency of urination during the day? | 3–7 times | 8–9 times | 10–11 times | (___) times | _/3 | |
2 | Frequency of urination at night? | Never | Once | Twice | (___) times | _/3 | |
3 | Do you experience irresistible urges to urinate? | Never | Rarely* | Occa-sionally* | Always* | _/3 | |
4 | Do you experience incontinence? | Never | Rarely | Occa- sionally | Always | _/3 | |
5 | If you experience urinary incontinence, under what conditions? (multiple answers possible) | Do not lose | Cannot hold with urge | With cough or standing | Involun-tarily while awake | Involun-tarily during sleep | No points |
6 | What volume of urine do you lose during incontinence? | Do not lose | Damp underwear | Wet underwear | Wet trousers or skirt | _/3 | |
7 | Do you experience difficulty initiating urination? | Never | Rarely | Occa- sionally | Always | _/3 | |
8 | Have you noted a weak stream prolonging urination time? | Never | Rarely | Occa-sionally | Always | _/3 | |
9 | Do you note intermittency of urination (start-stop, start-stop)? | Never | Rarely | Occasionally | Always | _/3 | |
10 | Do you have to strain to start urination? | Never | Rarely | Occa-sionally | Always | _/3 | |
11 | Do you experience a sensation of incomplete bladder emptying? | Never | Rarely | Occa-sionally | Always | _/3 | |
| Are you satisfied with your bladder function? | Satis-fied | Mostly satis-fied | Dissa-tisfied | Extre-mely dissa-tisfied | __ | |
Maximum 30 points. Question 5 helps to suggest the type of incontinence.
Bowel
No. | Question / POINTS | 0 | 1 | 2 | 3 | Total |
1 | How often do you have a bowel movement? | Once a day | ( __ ) times a day | Once every two days | Once every ( __) days | _/3 |
2 | Do you take laxatives? | Never | Rarely | Occa- sionally | Always | _/3 |
3 | Do you experience difficulty expelling stool? | Never | Rarely | Often | Always | _/3 |
4 | Do you have diarrhea? | Very rarely | Rarely | Often | Always | _/3 |
5 | Do you experience fecal incontinence? | Never | Rarely | Often | Always | _/3 |
6 | When do you not hold stool? | I hold | With urge | With cough or standing | Un-cons-ciously | No points |
7 | What volume of stool do you lose during incontinence? | Do not lose | Slightly soiled underwear | Heavily soiled underwear | _/2 | |
| Are you satisfied with your bowel function? | Satis-fied | Mostly satis-fied | Dissa-tisfied | Extre-mely dissa-tisfied | __ |
Maximum 17 points. Question 6 helps to suggest the type of disorder.
Sexual Function (Questions 4 and 5 - for men only)
No. | Question / POINTS | 0 | 1 | 2 | 3 | Total |
1 | Is your sexual desire reduced? | No | Slightly | Moderately | Seve-rely | _/3 |
2 | Has frequency of sexual intercourse decreased? | No | Slightly | Moderately | Seve-rely | _/3 |
3 | How often do you note reduction in orgasm? | Never | Rarely | In half of at-tempts | In most at-tempts | _/3 |
4 | (Men) How often do you note reduction in penis rigidity? | Never | Rarely | In half of at-tempts | In most at-tempts | _/3 |
5 | (Men) How often do you note ejaculation disorder? | Never | Rarely | In half of at-tempts | In most at-tempts | _/3 |
| Are you satisfied with your sexual function? | Satis-fied | Mostly satis-fied | Dissa-tisfied | Extremely dissatisfied | |
Maximum 15 points for men, 9 for women.
When did you first notice the onset of problems? (e.g., 2 years ago)
Bladder side___________________
Bowel side_____________________
Sexual function side_____________
Interpretation
Severity / System | Bladder (points) | Bowel (points) | Sexual Function (points) | |
|
|
| Women | Men |
None | 0 | 0 | 0 | 0 |
Mild | 1 - 10 | 0 - 6 | 1 - 3 | 1 – 5 |
Moderate | 11 – 20 | 7 – 12 | 4 – 6 | 6 – 10 |
Severe | 21 - 30 | 13 - 17 | 7 – 9 | 11 – 15 |
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