INSTRUCTIONS FOR COMPLETING
THE MICTURITION TIME CHART
ICIQ Introduction
The scientific committee which met at the end of the 1st ICI in 1998 supported the idea that a universally appli- cable questionnaire should be developed, that could be widely applied both in clinical practice and research. The hope was expressed that such a questionnaire would be used in different settings and studies and would allow cross-comparisons, for example, between a drug and an operation used for the same condition, in the same way that the IPSS (International prostate symptoms score) has been used.
An ICIQ Advisory Board was formed to steer the deve- lopment of the ICIQ, and met for the first time in 1999. The project’s early progress was discussed with the Board and a decision made to extend the concept fur- ther and to develop the ICIQ Modular Questionnaire.
The first module to be developed was the ICIQ Short Form Questionnaire for urinary incontinence: the ICIQ- SF. The ICIQ-SF has now been fully validated and published1. Given the intention to produce an interna- tionally applicable questionnaire, requests were made for translations of the ICIQ-SF at an early stage, for which the Advisory Board developed a protocol for the production of translations of its modules. The ICIQ-SF has been translated into 30 languages to date.
In addition to the ICIQ-SF, ten modules have been adopted which are direct (unchanged) derivations from already published questionnaires. (Table below) WWW.ICIQ.net will be used to provide the validation status of the modules under development for urinary symptoms, bowel symptoms and vaginal symptoms.
Table 1. Fully validated ICIQ modules derived from previously developed questionnaires
ICIQ Modules Derived from For use in
ICIQ-MLUTS ICS maleSF [4] Men
ICIQ-MLUTS-LF ICS male[2] Men
ICIQ-FLUTS BFLUTS SF [5] Women
ICIQ-FLUTS-LF BFLUTS [3] Women
ICIQ-LUTSqol KHQ [6] Men and women
ICIQ-Nqol N-QOL [7] Men and women
ICIQ-OABqol OABq [8] Men and women
ICIQ-MLUTSsex ICS male [2] Men
ICIQ-FLUTSsex BFLUTS [3] Women
ICIQ-UIqol I-QOL [9] Men and women
*indicates a validated module
Annex 2 : International Consultation on Incontinence Questionnaire (ICIQ) -
ICIQ UI SF (Short-form)
REFERENCES
1. Avery K, Donovan J, Peters T, Shaw C, Gotoh M, & Abrams P. The ICIQ: a brief and robust measure for eva- luating the symptoms and impact of urinary incontinence. Neurourol.Urodyn. 2004; 23(4): 322-330.
2. Donovan J, Abrams P, Peters T, et al. The ICS-'BPH' study: the psychometric validity and reliability of the ICSmale questionnaire. Br.J.Urol. 1996; 77: 554-562. 3. Jackson S, Donovan J, Brookes S, et al. The Bristol
Female Lower Urinary Tract Symptoms questionnaire: development and psychometric testing. Br.J.Urol. 1996; 77: 805-812.
4. Donovan J, Peters T, Abrams P, et al. Scoring the Short Form ICSmaleSF questionnaire. J.Urol. 2000; 164: 1948- 1955.
5. Brookes ST, Donovan JL, Wright M, Jackson S, Abrams P. A scored form of the Bristol Female Lower Urinary
Tract Symptoms questionnaire: data from a randomized controlled trial of surgery for women with stress inconti- nence. Am.J.Obstet.Gynecol. 2004;191(1):73-82. 6. Kelleher C, Cardozo L, Khullar V, et al. A new question-
naire to assess the quality of life of urinary incontinent women. Br.J.Obstet.Gynaecol. 1997; 104: 1374-1379. 7. Abraham L, Hareendran A, Mills I, et al. Development
and validation of a quality-of-life measure for men with nocturia. Urology 2004; 63(3): 481-486.
8. Coyne K, Revicki D, Hunt R, et al. Psychometric valida- tion of an overactive bladder symptom and health-related quality of life questionnaire: The OAB-q. Qual.Life.Res. 2003;11:563-574.
9. Wagner TH, Patrick DL, Bavendam TG, Martin ML, Buesching DP. Quality of life of persons with urinary incontinence: development of a new measure. Urology 1996;47(1):67-72.
3 How often do you leak urine?(Tick one box)
never 0
about once a week or less often 1
two or three times a week 2
about once a day 3
several times a day 4
all the time 5
Annex 2 : International Consultation on Incontinence Questionnaire (ICIQ) -
ICIQ UI SF (Short-form)
Initial number DAY MONTH YEAR
Today’s date
DAY MONTH YEAR
1 Please write in your date of birth:
2 Are you(tick one): Female Male
ICIQ score: sum scores 3+4+5
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 ques- tions, thinking about how you have been, on average, over the PAST FOUR WEEKS.
4 We would like to know how much urine you think leaks.
How much urine do you usually leak (whether you wear protection or not)? (Tick one box)
none 0
a small amount 2
a moderate amount 4
a large amount 6
5 Overall, how much does leaking urine interfere with your everyday life?
Please ring a number between 0 (not at all) and 10 (a great deal)
0 1 2 3 4 5 6 7 8 9 10
not at all a great deal
6 When does urine leak? (Please tick all that apply to you)
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