Sample Questionnaires for Several Recommended Outcome Measures for Women with Pelvic Floor Disorders




International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF)


(From Avery K, Donovan J, Peters TJ, et al. ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn . 2004;23:322.)




Urogenital Distress Inventory-6 (UDI-6) and Incontinence Impact Questionnaire-7 (IIQ-7)


(From Ubersax JS, Wyman JF, Shumaker SA, et al. Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Neurourol Urodyn .1995;14:31.)




Incontinence Quality of Life (I-QOL) Instrument


(From Patrick DL, Martin ML, Bushnell DM, et al. Quality of life of women with urinary incontinence: further development of the incontinence quality of life instrument [I-QOL]. Urology . 1999;53:71.)




Pelvic Floor Distress Inventory-Short Form 20


(From Barber MD, Bump RC, Walters MD. Short forms of two condition-specific quality of life questionnaires for women with pelvic floor disorders. Am J Obstet Gynecol . 2005;193:103.)




Pelvic Floor Impact Questionnaire-Short Form 7


(From Barber MD, Bump RC, Walters MD. Short forms of two condition-specific quality of life questionnaires for women with pelvic floor disorders. Am J Obstet Gynecol . 2005;193:103.)




Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12)


(From Rogers RG, Coates KW, Kammerer-Doak D, et al. A short form of the pelvic organ prolapse/urinary incontinence sexual questionnaire [PISQ-12]. Int Urogynecol J . 2003;14:164.)




International Consultation on Incontinence Questionnaire-Short Form


Many people leak urine some of the time. We are trying to find out how many people leak urine, and how much this bothers them. We would be grateful if you could answer the following questions, thinking about how you have been, on average, over the past four weeks .








Urogenital Distress Inventory-6




  • 1.

    Do you experience, and, if so, how much are you bothered by frequent urination?


  • 2.

    Do you experience, and, if so, how much are you bothered by urine leakage related to a feeling of urgency?


  • 3.

    Do you experience, and, if so, how much are you bothered by urine leakage related to physical activity, coughing, or sneezing?


  • 4.

    Do you experience, and, if so, how much are you bothered by small amounts of urine leakage (drops)?


  • 5.

    Do you experience, and, if so, how much are you bothered by difficulty emptying your bladder?


  • 6.

    Do you experience, and, if so, how much are you bothered by pain or discomfort in the lower abdominal or genital area?



Response levels for all items are: (0) not at all; (1) slightly; (2) moderately; (3) greatly.




Incontinence Impact Questionnaire-7


Has urine leakage and/or prolapse affected your:



  • 1.

    Ability to do household chores (cooking, housecleaning, laundry)?


  • 2.

    Physical recreation such as walking, swimming, or other exercise?


  • 3.

    Entertainment activities (movies, concerts, etc.)?


  • 4.

    Ability to travel by car or bus more than 30 min from your home?


  • 5.

    Participation in social activities outside your home?


  • 6.

    Emotional health (nervousness, depression, etc.)?


  • 7.

    Feeling frustrated?



Response levels for all items are: (0) not at all; (1) slightly; (2) moderately; (3) greatly.




Scoring


For both the UDI-6 and IIQ-7, obtain the mean value of all answered items (possible value 0–3) then multiply by 33⅓ to obtain the scale score (range 0–100).




I-QOL Instrument




  • 1.

    I worry about not being able to get to the toilet on time.


  • 2.

    I worry about coughing or sneezing because of my urinary problems or incontinence.


  • 3.

    I have to be careful standing up after I have been sitting down because of my urinary problems or incontinence.


  • 4.

    I worry about where toilets are in new places.


  • 5.

    I feel depressed because of my urinary problems or incontinence.


  • 6.

    Because of my urinary problems or incontinence, I do not feel free to leave my home for long periods of time.


  • 7.

    I feel frustrated because my urinary problems or incontinence prevents me form doing what I want.


  • 8.

    I worry about others smelling urine on me.


  • 9.

    Incontinence is always on my mind.


  • 10.

    It is important for me to make frequent trips to the toilet.


  • 11.

    Because of my urinary problems or incontinence, it is important to plan every detail in advance.


  • 12.

    I worry about my urinary problems or incontinence getting worse as I grow older.


  • 13.

    I have a hard time getting a good night of sleep because of my urinary problems or incontinence.


  • 14.

    I worry about being embarrassed or humiliated because of my urinary problems or incontinence.


  • 15.

    My urinary problems or incontinence make me feel like I am not a healthy person.


  • 16.

    My urinary problems or incontinence makes me feel helpless.


  • 17.

    I get less enjoyment out of life because of my urinary problems or incontinence.


  • 18.

    I worry about wetting myself.


  • 19.

    I feel like I have no control over my bladder.


  • 20.

    I have to watch what or how much I drink because of my urinary problems or incontinence.


  • 21.

    My urinary problems or incontinence limit my choice of clothing.


  • 22.

    I worry about having sex because of my urinary problems or incontinence.



All items use the following response scale
















1 = Extremely
2 = Quite a bit
3 = Moderately
4 = A little
5 = Not at all

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May 16, 2019 | Posted by in GYNECOLOGY | Comments Off on Sample Questionnaires for Several Recommended Outcome Measures for Women with Pelvic Floor Disorders
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