1. In the last week, have you experienced any pain or discomfort in the following areas?
a. Area between rectum and vagina (perineum) YesNo
b. Labia YesNo
c. Clitoris (not related to urination) YesNo
d. Below your waist in your pubic area YesNo
e. Below your waist in your rectal area YesNo
2. In the last week, have you experienced:
a. Pain or burning during urination? YesNo
b. Pain or discomfort during or after sexual climax? YesNo
3. How often have you had pain or discomfort in any of these areas over the last week?
4. Which number best describes your AVERAGE pain or discomfort on the days that you had it, over the last week?
5. How often have you had a sensation of not emptying your bladder completely after you finished urinating, over the last week?
6. How often have you had to urinate again less than two hours after you finished urinating over the last week?
7. How much have your symptoms kept you from doing the kinds of things you would usually do, over the last week?
8. How much did you think about your symptoms, over the last week?
9. If you were to spend the rest of your life with your symptoms just the way they have been during the last week, how would you feel about that?
Scoring the NIH-Chronic Prostatitis Symptom Index Domains
Pain. Total of items 1a. 1b. 1c. 1d. 1c, 2a. 2b. 3. and 4 -= Urinary Symptoms: Total of items 5 and 6 = Quality of Life Impact: Total of items 7, 8 and 9 = Adapted from Litwin et al. J Urol. 1999;162:369-375
No= 0, Not at all= I, Somewhat= 2, Moderately= 3, Quite a bit= 4
Add all scores and multiply by 6 then multiply by 25 for the scale score
Missing items are dealt with by using the mean from the answered items only
Higher score = higher disability
Also see scoring of PFDI-20.
Uebersax JS, Wyman JF, Shumaker SA. McClish DK, Fantl AJ. Short forms to assess life quality and symptom distress for urinary incontinence in women: the incontinence impact questionnaire and the urogenital distress inventory. Neurourol and Urodynam 1995;14:131-139.
Grade A rating for symptoms of UI for women
Donavan J. et al Symptom and quality of life assessment. In Incontinence vol I Basics and Evaluation eds Abrams P, Cardozo L, Khoury S, Wein A. Health Publications Ltd Paris France 2005.