Fiona Stanley Fremantle Hospitals Group - Continence Prolapse Assessment Form

Australian Pelvic Floor Questionnaire

Bladder section Urinary frequency - How many times do you pass urine in the day? [0] up to 7 [1] between 8-10 [2] between 11-15 [3] more than 15 Nocturia - How many times do you get up at night to pass urine? [0] 0-1 [1] 2 [2] 3 [3] more than 3 times Nocturnal enuresis - Do you wet the bed before you wake up? [0] never [1] occasionally – less than 1/week [2] frequently – once or more/week [3] always – every night Urgency - Do you need to rush/hurry to pass urine when you get the urge? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily Urge incontinence - Does urine leak when you rush/hurry to the toilet/Can you make it in time? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily Stress incontinence - Do you leak with coughing, sneezing, laughing, exercising? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily Weak stream - Is your urinary stream/flow weak/prolonged/slow? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily Incomplete bladder emptying - Do you have a feeling of incomplete bladder emptying? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily Strain to empty - Do you need to strain to empty your bladder? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily Pad usage - Do you have to wear pads? [0] none – never [1] as a precaution [2] with exercise/during a cold [3] daily Reduced fluid intake - Do you limit your fluid intake to decrease leakage? [0] never [1] before going out/socially [2] moderately [3] daily Recurrent UTI - Do you have frequent bladder infections? [0] no [1] 1-3/year [2] 4-12/year [3] >1/month Dysuria - Do you have pain in your bladder/ urethra when you empty your bladder? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily Impact on social life - Does urine leakage affect your routine activities (recreation, shopping, etc.) [0] not at all [1] slightly [2] moderately [3] greatly How much of a bother is your bladder problem to you? [0] no problem [1] slightly [2] moderately [3] greatly Other symptoms (blood in urine, pain etc.) Bowel section Defaecation frequency - How often do you usually open your bowels? [2] < 1/week [1] < every 3 days [0] > 3/week or daily [0] > more than 1/day Consistency of bowel motion - How is the consistency of your usual stool? [0] soft [0] firm [1] hard/pebbles [2] watery [1] variable Defaecation straining - Do you have to strain a lot to empty your bowels? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily Laxative use - Do you use laxatives to empty your bowels? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily Do you feel constipated? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily Flatus incontinence - When you get wind/ flatus, can you control it or does wind leak? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily Faecal urgency - Do you get an overwhelming sense of urgency to empty bowels? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily Faecal incontinence with diarrhoea - Do you leak watery stool when you don’t mean to? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily Faecal inc. with normal stool - Do you leak normal stool when you don’t mean to? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily Incomplete bowel evacuation - Do you have the feeling of incomplete bowel emptying? [0] never [1] occasionally – < 1/week [2] frequently – > 1/week [3] daily Obstructed defaecation - Do you use finger pressure to help empty your bowel? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily How much of a bother is your bowel problem to you? [0] no problem [1] slightly [2] moderately [3] greatly Other symptoms (pain, mucous discharge, rectal prolapse etc.) Prolapse section Prolapse sensation - Do you get a sensation of tissue protrusion in your vagina/lump/bulging? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily Vaginal pressure or heaviness - Do you experience vag. pressure/heaviness/dragging sensation? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily Prolapse reduction to void - Do you have to push back your prolapse in order to void? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily Prolapse reduction to defaecate - Do you have to push back your prolapse to empty your bowels? [0] never [1] occasionally – < 1/week [2] frequently – ≥ 1/week [3] daily How much of a bother is the prolapse to you? [0] no problem [1] slightly [2] moderately [3] greatly Other symptoms (problems sitting/ walking, pain, vag. bleeding) Sexual function section Sexually active? Are you sexually active? no < 1/week ≥ 1/week most days/daily If NOT, why not: no partner partner unable vaginal dryness too painful embarrassment other Sufficient lubrication - Do you have sufficient lubrication during intercourse? [1] no [0] yes During intercourse vaginal sensation is: [3] none [3] painful [1] minimal [0] normal/pleasant Vaginal laxity - Do you feel that your vagina is too loose or lax? [0] never [1] occasionally [2] frequently [3] always Vaginal tightness/vaginismus - Do you feel that your vagina is too tight? [0] never [1] occasionally [2] frequently [3] always Dyspareunia - Do you experience pain with intercourse? [0] never [1] occasionally [2] frequently [3] always Dyspareunia where - Where does the pain occur? no pain at the entrance of the vagina deep inside/in the pelvis both Urinary leakage with intercourse - Do you leak urine during sex? [0] never [1] occasionally [2] frequently [3] always How much of a bother are these sexual issues to you? Not applicable [0] no problem at all [1] slight problem [2] moderate problem [3] great problem Other symptoms (coital flatus or faecal incontinence, vaginismus etc.)

How many children? How many were vaginal births? How many caesarean sections? Any babies larger than 4 kgs? Yes No Any forcep deliveries? Yes No Where you pushing for longer than 2 hours or shorter than 30 mins for any of your deliveries? Yes No Did you have any large vaginal tears when you delivered your baby? Yes No Unsure

Surgical History

Have you had any surgeries? Yes No

outline below what surgeries and what year below

Medical History

Have you had cancer? Yes No

If yes please explain

Any family history of cancer? Yes No

If yes please explain

Have you had regular pap smears? Yes No Have you had any history of abnormal cells? Yes No Have you had a mammograph/breast scan? Yes No

If yes please outline the most recent result and year

Have you had any colonoscopies? Yes No

If yes please outline the most recent result and year

Do you suffer from cystitis/ pain when passing urine? Yes No Do you suffer from blood in your urine? Yes No Do you suffer from thrush more than twice a year? Yes No Do you have any problems with itch around the vagina? Yes No Have you been diagnosed with a sexually transmitted infection? Yes No

If yes please outline

Are you still menstruating? Yes No

If yes is it heavy or light?

Are you on any contraception? Yes No

If yes please outline

Have you been diagnosed with endometriosis? Yes No Have you been diagnosed with polycystic ovaries? Yes No Do you suffer from irritable bowel syndrome? Yes No Have you been diagnosed with diabetes? Yes No Have you been diagnosed with a thyroid condition? Yes No Have you been diagnosed with high blood pressure? Yes No Have you been diagnosed with a heart problem? Yes No Have you been diagnosed with depression? Yes No Have you been diagnosed with anxiety? Yes No Do you suffer from sinusitis? Yes No Do you suffer from hayfever? Yes No Do you suffer from low back pain? Yes No Do you suffer from pelvic or hip pain? Yes No Do you have any other medical conditions? Yes No

If yes please outline

Are you a smoker? Yes No

If yes please outline how many cigarettes a day

Medications

Do you take any medications? Yes No

If yes please list below

Exercise

Do you do any general exercise? Yes No

If yes please outline

Have you ever been taught how to do pelvic floor muscle exercises? Yes No Could you stop your flow of wee/urine if you tried? Yes No Haven’t tried Can slow it

Fluid intake

How much do you drink in a day in cups? How many cups water? How many cups caffeine? How many cans soft drink? Do you drink alcohol? Yes No

If yes please outline how many standard drinks per week

How many cups other fluids (e.g. milk, herbal tea, milo)?

The Pelvic Health Distress screening tool

Everyone experiences painful situations at some point in their lives. Such experience may include headaches, tooth paint, joint, muscle or pelvic pain and/or pain with sexual intercourse. We are interested in the types of thoughts and feelings that you have when you are in pain and how you cope with the pain.

If you do not suffer from pain change this to your condition for example incontinence (leakage of urine or faeces) or prolapse.

I often feel overly stressed [0] Never [1] Rarely [2] Sometimes [3] Often [4] Always I feel nervous, anxious or on edge [0] Never [1] Rarely [2] Sometimes [3] Often [4] Always I worry a lot about my health [0] Never [1] Rarely [2] Sometimes [3] Often [4] Always I feel down, depressed or hopeless [0] Never [1] Rarely [2] Sometimes [3] Often [4] Always I take little interest or pleasure in doing things [0] Never [1] Rarely [2] Sometimes [3] Often [4] Always I worry whether something serious is wrong [0] Never [1] Rarely [2] Sometimes [3] Often [4] Always I can't seem to keep the pain out of my mind [0] Never [1] Rarely [2] Sometimes [3] Often [4] Always I pay close attention to my pain [0] Never [1] Rarely [2] Sometimes [3] Often [4] Always I can confidently participate in my normal activities despite my pain [0] Never [1] Rarely [2] Sometimes [3] Often [4] Always I feel helpless in being able to reduce or cope with the pain [0] Never [1] Rarely [2] Sometimes [3] Often [4] Always I am afraid of the pain [0] Never [1] Rarely [2] Sometimes [3] Often [4] Always I try to avoid anything that causes or worsens my pain [0] Never [1] Rarely [2] Sometimes [3] Often [4] Always I have had a stressful or traumatic life event that has had a negative impact on me [0] Never [1] Rarely [2] Sometimes [3] Often [4] Always Are you currently or have been previously sexually active? Yes No

I have avoided sexual intimacy because of my pain [1] Never [2] Rarely [3] Sometimes [4] Often [5] Always I can confidently say no to sexual activity if I don't want it [1] Never [2] Rarely [3] Sometimes [4] Often [5] Always

DASS

Each option indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

0 Did not apply to me at all - NEVER
1 Applied to me to some degree, or some of the time - SOMETIMES
2 Applied to me to a considerable degree, or a good part of time - OFTEN
3 Applied to me very much, or most of the time - ALMOST ALWAYS

I found it hard to wind down [0] Never [1] Sometimes [2] Often [3] Almost always I was aware of dryness of my mouth [0] Never [1] Sometimes [2] Often [3] Almost always I couldn’t seem to experience any positive feeling at all [0] Never [1] Sometimes [2] Often [3] Almost always I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion) [0] Never [1] Sometimes [2] Often [3] Almost always I found it difficult to work up the initiative to do things [0] Never [1] Sometimes [2] Often [3] Almost always I tended to over-react to situations [0] Never [1] Sometimes [2] Often [3] Almost always I experienced trembling (eg, in the hands) [0] Never [1] Sometimes [2] Often [3] Almost always I felt that I was using a lot of nervous energy [0] Never [1] Sometimes [2] Often [3] Almost always I was worried about situations in which I might panic and make a fool of myself [0] Never [1] Sometimes [2] Often [3] Almost always I felt that I had nothing to look forward to [0] Never [1] Sometimes [2] Often [3] Almost always I found myself getting agitated [0] Never [1] Sometimes [2] Often [3] Almost always I found it difficult to relax [0] Never [1] Sometimes [2] Often [3] Almost always I felt down-hearted and blue [0] Never [1] Sometimes [2] Often [3] Almost always I was intolerant of anything that kept me from getting on with what I was doing [0] Never [1] Sometimes [2] Often [3] Almost always I felt I was close to panic [0] Never [1] Sometimes [2] Often [3] Almost always I was unable to become enthusiastic about anything [0] Never [1] Sometimes [2] Often [3] Almost always I felt I wasn’t worth much as a person [0] Never [1] Sometimes [2] Often [3] Almost always I felt that I was rather touchy [0] Never [1] Sometimes [2] Often [3] Almost always I was aware of the action of my heart in the absence of physical exertion (eg, sense of heart rate increase, heart missing a beat) [0] Never [1] Sometimes [2] Often [3] Almost always I felt scared without any good reason [0] Never [1] Sometimes [2] Often [3] Almost always I felt that life was meaningless [0] Never [1] Sometimes [2] Often [3] Almost always

Continence Prolapse Assessment Form

Continence/Prolapse Assessment Form