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South: 405.759.7719
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FEMALE NIH-CPSI

Pain or Discomfort

1. In the last week, have you experienced any pain or discomfort in the following areas?

a. Area between rectum and vagina (perineum)
b. Labia
c. Clitoris (not related to urination)
d. Below your waist in your pubic area
e. Below your waist in yourrectal area

2. In the last week, have youexperienced:

a. Pain or burning during urination?
b. Pain or discomfort during or after sexual climax?

3. How often have you had pain or discomfort in any of these areas over the last week?

Never
Rarely
Sometimes
Often
Usually
Always
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4. Which number best describes your AVERAGE pain or discomfort on the days that you had it, over the last week?

0
1
2
3
4
5
6
7
8
9
10

Urination

5. How often have you had a sensation of not emptying your bladder completely after you finished urinating, over the last week?

Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always or always 6. Now often have you had to urinate again less than two hours after you finished urinating, over the last week?

6. How often have you had to Urinate again less than two hours after you finishded Urinating.over the last week?

Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always

Imoact of $ymotoms

7. Now much have your symptoms kept you from doing the kinds of things you would usually do, over the last week?

None
Only a little
Some
A lot

8. How much did you think about your symptoms, over the last week?

None
Only a little
Some
A lot

Quality of Life

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?

Delighted
Pleased
Mostly satisfied
Mixed (about equally satisfied and dissatisfied)
Mostly dissatisfied
Unhappy
Terrible

In order to determine how effective your treatment is. we need to know how much pain is interfering in your normal activities. For the 7 areas listed below, please circle the number on the scale which describes the level of disability you have experienced in each area OVER THE PAST WEEK. A score of "0" means no disability at all, and a score of -10- indicates that all of the activities which you would normally do have been totally disrupted or prevented by your pain over the past week. Circle "0" if a category does not apply to you.

Family/Nome Responsibilities: This category refers to activities related to the home or family. It includes chores or duties performed around the house (e.g. yard work,
house cleaning) and errands or favors for other family members (e.g. driving the children to school.

0
1
2
3
4
5
6
7
8
9
10

No Disability
Mild
Moderate
Severe
Total Disability

Recreation: This category includes hobbies, sports, and other similar leisure time activities.

0
1
2
3
4
5
6
7
8
9
10

No Disability
Mild
Moderate
Severe
Total Disability

Social Activity: This category refers to activities which involve participation with friends and acquaintances other than family members. It includes parties, theater, concerts, dining out, and other social functions.

0
1
2
3
4
5
6
7
8
9
10

No Disability
Mild
Moderate
Severe
Total Disability

Occupation: This category refers to activities that are a part of or directly related to one's job. This includes non-paying jobs as well, such as housewife or volunteer worker.

0
1
2
3
4
5
6
7
8
9
10

No Disability
Mild
Moderate
Severe
Total Disability

Sexual Behavior: This category refers to the frequency and quality of one's sex life.

0
1
2
3
4
5
6
7
8
9
10

No Disability
Mild
Moderate
Severe
Total Disability

Self-Care: This category includes activities which involve personal maintenance and independent daily living (e.g. taking a shower, driving, getting dressed).

0
1
2
3
4
5
6
7
8
9
10

No Disability
Mild
Moderate
Severe
Total Disability

Life-Support Activity: This category refers to basic life-supporting behaviors such as eating and sleeping.

0
1
2
3
4
5
6
7
8
9
10

No Disability
Mild
Moderate
Severe
Total Disability

Urogenital Distress Inventory (UDI-6 Short Form): UDI-6

1) Do you usually experience frequent urination?

Yes
No

If yes. how much does this bother you?

Not at all
Somewhat
Moderately
Quite a bit

2) Do you usually experience urine leakage associated with a feeling of urgency; that is, a strong sensation of needing to go to the bathroom?

Yes
No

If yes. how much does this bother you?

Not at all
Somewhat
Moderately
Quite a bit

3) Do you usually experience urine leakage related to coughing, sneezing, or laughing?

Yes
No

If yes. how much does this bother you?

Not at all
Somewhat
Moderately
Quite a bit

4) Do you experience small amounts of urine leakage (that is, drops)?

Yes
No

If yes. how much does this bother you?

Not at all
Somewhat
Moderately
Quite a bit

5) Do you experience difficulty emptying your bladder?

Yes
No

If yes. how much does this bother you?

Not at all
Somewhat
Moderately
Quite a bit

6) Do you usually experience pain or discomfort in the lower abdomen or genital region?

Yes
No

If yes. how much does this bother you?

Not at all
Somewhat
Moderately
Quite a bit

If yes, then is your pain relieved after emptying your bladder?

Yes
No

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.

VULVAR PAIN FUNCTIONAL QUESTIONNAIRE (VQ)

1. Because of my pelvic pain

I can't wear tight-fitting clothing like pantyhose that puts any pressure over my painful area.
I can wear closer fining clothing as long as it only puts a little bit of pressure over my painful area.
I can wear whatever I like most of the time, but every now and then I feel pelvic pain caused by pressure from my clothing.
I can wear whatever I like; I never have pelvic pain because of clothing.

2. My pelvic pain

Gets worse when I walk, so I can only walk far enough to move around in my house, no further.
Gets worse when I walk. I can walk a short distance outside the house. but it is very painful to walk far enough to get a full load of groceries in a grocery store.
Gets a little worse when I walk. I can walk far enough to do my errands, like grocery shopping, but it would be very painful to walk longer distances for fun or exercise.
My pain does not get worse with walking; I can walk as far as I want to
I have a hard time walking because of another medical problem, but pelvic pain doesn't make it hard to walk.

3. My pelvic pain

Gets worse when I sit, so it hurts too much to sit any longer than 30 minutes at a time.
Gets worse whcn I sit. I can sit for longer than 30 minutes at a time, but it is so painful that it is difficult to do my job or sit long enough to watch a movie.
gets worse when I sit, but most of the time sitting is comfortable.
My pain does not get worse with sitting. I can sit as long as I want to.
I have trouble sitting for very long because of another medical problem, but pelvic pain doesn't make it hard to sit.

4. Because of pain pills I take for my pelvic pain

I am sleepy and I have trouble concentrating at work or while I do housework.
I can concentrate just enough to do my work, but I can't do more. like go out in the evenings.
I can do all of my work, and go out in the evening if I want, but I feel out of sorts.
I don't have any problems with the pills that I take for pelvic pain.
I don't take pain pills for my pelvic pain.

5. Because of my pelvic pain

I have very bad pain when I try to have a bowel movement. and it keeps hurting for at least 5 minutes after I am finished.
It hurts when I try to have a bowel movement, but the pain goes away when I am finished.
Most of the time it does not hurt when I have a bowel movement, but every now and then it does.
It never hurts from my pelvic pain when I have a bowel movement.

6. Because of my pelvic pain

I don't get together with my friends or go out to parties or events.
I only get together with my friends or go out to parties or events every now and then.
I usually will go out with friends or to events if I want to. but every now and then I don't because of the pain.
I get together with friends or go to events whenever I want, pelvic pain does not get in the way

7. Because of my pelvic pain

I can't stand for the doctor to insert the speculum when I go to the gynecologist.
I can stand it when the doctor inserts the speculum if they are very Careful. but most of the time it really hurts.
It usually doesn't hurt when the doctor inserts the speculum, but every now and then it doeshurt.
It never hurts for the doctor to insert the speculum when 1 go to the gynecologist.

8. Because of my pelvic pain

I cannot use tampons at all, because they make my pain much worse.
I can only use tampons if I put them in very carefully.
It usually doesn't hurt to use tampons, but occasionally it does hurt.
It never hurts to use tampons.

9. Because of my pelvic pain

I can't let my partner put a finger or penis in my vagina during sex at all.
My partner can put a finger or penis in my vagina very carefully, but it still hurts.
It usually doesn't hurt if my partner puts a finger or penis in my vagina but every now and then it does hurt.
It doesn't hurt to have my partner put a finger or penis in my vagina at all.
This question does not apply to me because I don't have a sexual partner.
Specifically, I won't get involved with a partner because I worry about pelvic pain during sex.

At Oklahoma Physical Therapy our mission is to offer physical therapy services to restore, maintain and improve the wellness of our patients. Our purpose is to provide physical therapy services to all patients who have impairments, functional limitations, disabilities or changes in physical function and health status resulting from injury, disease or other process.

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