Continence Questionnaire

Part one · Everyone

Your details, and anything affecting anaesthesia.

Short, and the same on every form. The blood-thinner question matters most: several of the procedures I perform can be done without stopping them, but only if that is planned in advance.

Full name

Date of birth

Best contact number

GP practice

Are you taking any blood-thinning medication?

Warfarin, apixaban, rivaroxaban, edoxaban, dabigatran, clopidogrel, ticagrelor, aspirin.

Yes No

Have you been diagnosed with diabetes?

Yes No

Have you had previous urological surgery or pelvic radiotherapy?

Yes No

All other regular medications

Allergies

Part two · The leakage

How much you leak decides the operation.

It is worth being precise rather than modest here. If you can, count the pads over one ordinary day before answering — the amount, more than anything else, determines which of the two operations is right.

How many pads do you use in a typical 24 hours?

What sort of pads?

Light liner Shaped pad Pull-up None

When does the leaking happen?

Coughing, sneezing or laughing Lifting or exercising Standing up from sitting Simply walking about Continuously, whatever I am doing When I cannot reach the toilet in time At orgasm At night, in bed

Do you also get sudden, hard-to-defer urges to pass urine?

This matters because an overactive bladder is treated with medication first, not with surgery.

Yes No

How much does the leaking restrict what you do?

Part three · What came before

What was done, and what has been tried since.

Whether you had radiotherapy is the single most important answer here — it changes which operation will work, because irradiated tissue behaves differently.

What treatment did you have for prostate cancer?

Surgery to remove the prostate Radiotherapy Brachytherapy (seeds) Hormone therapy Surgery for a benign enlarged prostate None — my leaking is not related to prostate cancer treatment

How many months ago was that treatment?

Have you completed a proper course of pelvic floor physiotherapy?

A course with a specialist physiotherapist, rather than exercises handed to you on a leaflet.

Yes, completed Leaflet only No

Have you had any previous surgery or injections for the leaking?

Yes No

Have you had a urethral stricture, or difficulty passing a catheter?

Yes No Not sure

Do you have arthritis in your hands, tremor, or any difficulty with fine finger movements?

An artificial sphincter is operated by squeezing a small pump, so this is a practical question rather than a general health one.

Yes No

In one sentence, what would you most like to be able to do again?

Your summary