One component in the assessment of patients with lower urinary tract symptoms is a screening questionnaire to better understand a patient’s disorder. This part of the process is especially important because the replication of symptoms during more invasive testing is critical for both diagnosis and treatment. However, there are many types of urodynamics incontinence screening questionnaires. Here, some of the available options will be discussed and summarized.
Questionnaire for Urinary Incontinence Diagnosis (QUID)
The QUID1 is a simple questionnaire that only contains 6 questions. The main purpose of this assessment is to distinguish stress urinary incontinence from urge incontinence. Here, women are asked to rate whether urine leakage occurs none of the time, rarely, once in a while, often, most of the time, or all of the time in the following six situations:
- Bending down/lifting up
- Undressing for the toilet
- When experiencing a strong urge to urinate
- Rushing to the bathroom
This test is useful for determining clinical trial outcomes, as well as when diagnosing urge or stress incontinence. In a trial containing 444 women with either urge incontinence or stress urinary incontinence, it was found that QUID scores correlated well with UDI-stress scores, as well as urinary diaries. Additionally, QUID stress and urge scores appropriately improved after treatment, leading researchers to conclude that the QUID has acceptable psychometric characteristics for measuring treatment outcomes. Ultimately, QUID is best used as a screening tool to distinguish between the two most common types of incontinence in women.
King’s Health Questionnaire
The King’s Health Questionnaire is unique in that it assesses quality of life for people who are experiencing urinary incontinence symptoms. There are three parts to this questionnaire. In the first part, general health and the impact of incontinence are examined. Patients are asked to rate their current health as “very poor,” “poor,” “fair,” “good,” or “very good.” In addition, they are asked how much their bladder problems affect their lives, from “a lot,” “moderately,” “a little,” or “not at all.”
In the second part of the King’s Health Questionnaire, patients are asked to rate how their lives are limited due to their bladder problems from “not at all,” “slightly,” “moderately,” and “a lot.” The following questions are asked:
- Does your bladder problem affect your household tasks?
- Does your bladder problem affect your job, or your normal daily activities outside the home?
- Does your bladder problem affect your physical activities?
- Does your bladder problem affect your ability to travel?
- Does your bladder problem limit your social life?
- Does your bladder problem limit your ability to visit and see friends?
- Does your bladder problem affect your relationship with your partner?
- Does your bladder problem affect your sex life?
- Does your bladder problem affect your family life?
- Does your bladder problem make you feel depressed?
- Does your bladder problem make you feel anxious or nervous?
- Does your bladder problem make you feel bad about yourself?
- Does your bladder problem affect your sleep?
- Does your bladder problem make you feel worn out or tired?
Next, patients are asked the following questions and asked to rate them as “never,” “sometimes,” “often,” or “all the time.”
- Do you wear pads to keep dry?
- Are you careful how much fluid you drink?
- Do you change your underclothes because they get wet?
- Do you worry in case you smell?
Finally, in the third portion of this extensive survey patients are asked how they are affected (i.e. a little, moderately, or a lot) based on the following:
- Urinary Frequency
- Urinary Urgency
- Urge Incontinence
- Stress Incontinence
- Nocturnal Enuresis
- Intercourse Incontinence
- Waterworks Infections
- Bladder Pain
Each answer is assigned a score, and the scores are added up to assess how the patients are affected by their incontinence. The King’s Health Questionnaire is a great way for physicians to assess symptoms while also determining their severity based on a quality of life measurement.
In one study2, the reliability and validity of the King’s Health Questionnaire was reviewed for patients with overactive bladder. The psychometric properties of the survey were examined for 1,284 patients who completed the questionnaire before and after 12 weeks of treatment in a double-blind randomized clinical trial of tolterodine for overactive bladder. Overall, internal consistency of the King’s Health Questionnaire was high, with item characteristics rated as good, and the majority of assumptions of summed scales were met. Researchers deemed this survey as externally valid and consistent. There were few problems noted with the questionnaire, except that the portion of the survey regarding personal relationships was complicated by the “not applicable” response. Overall, the validity of the King’s Health Questionnaire was supported for patients suffering from overactive bladder.
Michigan incontinence Screening Index
The Michigan Incontinence Screening Index3 was developed to overcome limitations of other screening tools. For instance, while other questionnaires measure type of incontinence or quality of life, prior to the development of the Michigan Incontinence Screening Index there was no tool available to discern type, severity, and quality of life concurrently.
In the Michigan Incontinence Symptom Index, patients are asked 10 questions and to rate their answer from a list of provided options. Each option has an associated point value, with more severe symptoms having a larger score. The first section covers stress urinary incontinence. Patients are asked to choose one of five answers, which are “never,” “rarely,” “occasionally,” “about half the time,” and “most or all of the time.” Each question is based on the patient’s experience in the past month. The questions are:
- How often has urine leakage occurred in association with any physical activity?
- How often has lifting light objects caused you to leak urine?
- How often has walking or light exercise caused you to leak urine?
The next section identifies urge incontinence, as well as its severity. Patients are asked three questions, and asked to rate their answers as “never,” “seldom,” “about once a week,” “about once a day,” or “more than once a day.” The questions here are:
- How often have you leaked urine because you could not wait to empty your bladder?
- How often has a sudden urge to urinate caused you to leak urine?
- How often have you leaked urine because you could not reach a bathroom in time?
The next two questions identify the patient’s ability to control his or her incontinence, as well as a quality of life measurement based on the amount of incontinence protection products that are used per day. The first question asks, “On average, what form of protection do you use to protect against wetness during the day?” The available answers are “none,” “Thin Pad or tissue,” “Medium/regular pad,” “Large/maxi pad,” or “Absorbent, disposable, undergarments.”
The next question in this section is, “On average, how many of these (pads, tissues, disposable undergarments) would you use to protect against wetness during the day?” The available answers are “none,” “1 per day or less, or only for security,” “1 per day and it is usually wet,” “2 – 3 per day,” “4 or more per day.”
Altogether, the aforementioned 8 questions are used to determine the severity of the patient’s incontinence, and a score is assigned. The next, and final, two questions are geared towards quality of life. The first question asks, “Overall, how often have you needed to change your daily activities because of your urinary incontinence?” with “never,” “rarely,” “sometimes,” “most of the time,” and “all of the time” being the available options.
The final question asks, “Overall, how big of a social problem has your urinary incontinence been for you during the past month?” with “no problem,” “very small problem,” “small problem,” “moderate problem,” and “big problem” as the available selections. These two questions are totaled to provide a “total bother score.”
The validity of the Michigan Incontinence Screening Index was measured to determine its validity as a screening tool for clinically relevant urinary incontinence4 in women. For this study, 214 women were evaluated and underwent clinical and urodynamic evaluation to determine type of urinary incontinence. High sensitivity and specificity scores for stress, urgency, and urinary incontinence were reported, proving this assessment to be valid as a screening tool for clinically relevant urinary incontinence.
The International Consultation on Incontinence Modular Questionnaire was first developed in 1998 by the International Continence Society and International Consultation on Urological Diseases. This questionnaire was developed after a distinct need was recognized for a universally applicable questionnaire that could be utilized across international populations in clinical practice and research.
Since its development, additional questionnaires have been added to address specific conditions. Here the standard ICIQ-Urinary Incontinence short form questionnaire will be discussed.
The ICIQ-UI short form has 6 questions, 3 of which are for filing purposes only and are un-scored. A total of 21 points are possible, with higher scores indicating greater severity of urinary incontinence. The first scored question asks, “How often do you leak urine?” with “never,” “about once a week or less often,” “two or three times a week,” “about once a day,” “several times a day,” and “all the time,” as possible answers.
The next question addresses how much urine the patient feels is lost. It states, “We would like to know how much urine you think leaks. How much urine do you usually leak (whether you wear protection or not)?” Here, four answers are possible: “none,” “a small amount,” “a moderate amount,” “a large amount.”
Finally, the third scored question regards the patient’s quality of life. This question asks, “Overall, how much does leaking urine interfere with your everyday life?” Here, the patient is asked to circle a number from 0 – 10, with 0 being “not at all,” and 10 being “a great deal.”
The un-scored question helps the physician determine the type of incontinence that is present. The question being asked is, “When does urine leak?” and the patient is given the following choices and asked to check all that apply:
- Never - urine does not leak
- Leaks before you can get to the toilet
- Leaks when you cough or sneeze
- Leaks when you are asleep
- Leaks when you are physically active/exercising
- Leaks when you have finished urinating and are dressed
- Leaks for no obvious reason
- Leaks all the time
In addition to this short form questionnaire, there are additional modules that can be completed, depending on the patient’s symptoms and the physician’s follow-up. These include:
- Urinary Symptoms for Males (ICIQ-MLUTS and ICIQ-MLUTS long form)
- Urinary Symptoms for Females (ICIQ-FLUTS and ICIQ-FLUTS long form)
- Urinary Symptoms Quality of Life (ICIQ-LUTSqol
- Urinary Symptoms Sexual Matters for Males (ICIQ-MLUTSsex)
- Urinary symptoms Sexual Matters for Females (ICIQ-FLUTSsex)
- Vaginal Symptoms (ICIQ-VS)
- Urinary Incontinence Quality of Life (ICIQ-UIqol)
- Nocturia (ICIQ-N)
- Nocturia Quality of Life (ICIQ-Nqol)
- Overactive Bladder (ICIQ-OAB)
- Overactive Bladder Quality of Life (ICIQ-OABqol)
- Long term catheter (ICIQ-LTCqol)
- Additional questionnaires are in the process of being finalized
The ICIQ is unique in that it also assesses sexual function, which is an aspect of incontinence rarely discussed. Furthermore, examination of this test for the validity, reliability, and responsiveness in other languages5 has been extensively studied, and researchers have found that this is truly an international tool.
Urogenital Distress Inventory
The Urogenital Distress Inventory (UDI-6) is a 6-item questionnaire that is designed to assess lower urinary tract symptoms in women.
This simple questionnaire has six yes or no questions with a follow up question of “If yes, how much does this bother you?” that can be answered with one of four selections: “not at all,” “somewhat,” “moderately,” and “quite a bit.” The questions are:
- Do you usually experience frequent urination?
- Do you usually experience urine leakage associated with a feeling of urgency?
- Do you usually experience urine leakage related to coughing, sneezing, or laughing?
- Do you experience small amounts of urine leakage (that is, drops)?
- Do you experience difficulty emptying your bladder?
- Do you usually experience pain or discomfort in the lower abdomen or genital region?
For the final question, an additional follow up states, “If yes, then is your pain relieved after emptying your bladder?”
Each answer is assigned a point total, and the scores are multiplied and scaled. A higher score indicates worse symptoms of incontinence.
The Urogenital Distress Inventory has been validated6 per its correlation with urodynamic symptoms. 128 women completed the UDI-6 and also underwent urodynamic assessment. Ultimately, it was determined that UDI-6 can provide predictive information regarding urodynamic findings in women, particularly in regard to stress urinary incontinence, bladder outlet obstruction, and detrusor overactivity.
International Prostate Symptom Score
Many of the aforementioned questionnaires are primarily geared towards women and issues of stress urinary incontinence or pelvic organ prolapse. However, the International Prostate Symptom Score questionnaire is specifically designed for men to assess problems with the lower urinary tract and prostate.
This questionnaire has 8 questions, with the first 6 answered by choosing “Not at all,” “less than 1 in 5 times,” “less than half the time,” “about half the time,” “More than half the time,” and “almost always.” Each answer has an assigned point total. The questions in this category cover:
- Incomplete emptying
- Weak Stream
The 7th question is in regards to nocturia. A score is assigned based on how many times the patient gets up in the middle of the night to relieve himself from none (0 points) to 5 times per night (5 points). Finally, a quality of life assessment is made, where patients are asked, “if you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?”
Options are “delighted,” “pleased,” “mostly satisfied,” “mixed,” “mostly dissatisfied,” “unhappy,” and “terrible,” with assigned point totals. Patients that score 1 – 7 for the first 7 questions have mild urinary tract symptoms; scores of 8 – 19 indicate moderate urinary tract symptoms; and 20 – 35 indicate severe symptoms.
However, the usefulness of IPSS has been questioned7 in men with urinary tract symptoms-benign prostatic hyperplasia. Data from 51 men were recorded and symptom severity was assessed via IPSS questionnaire and uroflowmetry tests. There was a negative correlation between IPSS and maximum flowrate, and no statistically significant correlation between IPSS and other uroflowmetry variables.
Overall, there are a number of questionnaires available for the assessment of lower urinary tract symptoms in both male and female patients. Some assessments, like the QUID, are able to distinguish between types of incontinence, while other questionnaires, like the King’s Health Questionnaire, are designed to examine a patient’s quality of life.
The Michigan Incontinence Screening Index is one tool that can assess symptoms while providing evidence for distinction between disorders, while also assessing quality of life. The ICIQ is broadly applicable for international use and can be customized with the addition of modules for complete patient care, particularly regarding sexual health. The IPSS and UDI are two tools that can be used exclusively for male or female patients, respectively.
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- Bradley, C. S., Rahn, D. D., Nygaard, I. E., Barber, M. D., Nager, C. W., Kenton, K. S., … Pelvic Floor Disorders Network. (2010). The Questionnaire for Urinary Incontinence Diagnosis (QUID): Validity and Responsiveness to Change in Women Undergoing Non-Surgical Therapies for Treatment of Stress Predominant Urinary Incontinence. Neurourology and Urodynamics, 29(5), 727–734. http://doi.org/10.1002/nau.20818 Link
- Reese, P.R., Pleil, A.M., Okano, G.J. et al. Qual Life Res (2003) 12: 427. doi:10.1023/A:1023422208910 Link
- Suskind, A. M., Dunn, R. L., Morgan, D. M., Delancey, J. O., Mcguire, E. J., & Wei, J. T. (2013). The Michigan incontinence symptom index (M-ISI): A clinical measure for type, severity, and bother related to urinary incontinence. Neurourology and Urodynamics, 33(7), 1128-1134. doi:10.1002/nau.22468 Link
- Suskind, A. M., Dunn, R. L., Morgan, D. M., DeLancey, J. O. L., Rew, K. T., & Wei, J. T. (2015). A Screening Tool for Clinically Relevant Urinary Incontinence. Neurourology and Urodynamics, 34(4), 332–335. http://doi.org/10.1002/nau.22564 Link
- Lim, R., Liong, M. L., Lau, Y. K., & Yuen, K. H. (2015). Validity, reliability, and responsiveness of the ICIQ-UI SF and ICIQ-LUTSqol in the Malaysian population. Neurourology and Urodynamics, 36(2), 438-442. doi:10.1002/nau.22950 Link
- Lemack, G. E., & Zimmern, P. E. (1999). Predictability of urodynamic findings based on the urogenital distress inventory-6 questionnaire. Urology, 54(3), 461-466. doi:10.1016/s0090-4295(99)00246-0 Link
- Oranusi, C., Nwofor, A., & Mbonu, O. (2016). Correlation between international prostate symptom score and uroflowmetry in patients with benign prostatic hyperplasia. Nigerian Journal of Clinical Practice, 0(0), 0. doi:10.4103/1119-3077.196120 Link