Prostate Symptom 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 · Prostate and urinary symptoms

The International Prostate Symptom Score.

Seven questions about the last month, plus one about how you feel. It produces a number between 0 and 35, which matters because it turns a vague sense of getting worse into something we can measure again after treatment and compare honestly.

1. Over the past month, how often have you the sensation of not emptying your bladder completely after you finish urinating?

2. Over the past month, how often have you had to urinate again less than two hours after you finished?

3. Over the past month, how often have you found you stopped and started again several times while urinating?

4. Over the past month, how often have you found it difficult to postpone urination?

5. Over the past month, how often have you had a weak urinary stream?

6. Over the past month, how often have you had to push or strain to begin urinating?

7. Over the past month, how many times did you typically get up to urinate between going to bed and getting up in the morning?

If you had to spend the rest of your life with your urinary symptoms exactly as they are now, how would you feel?

Part three · Background

What has already been tried, and what you want protected.

The last question changes which procedures I would recommend more than anything else on this form.

Are you taking any medication for your prostate?

Tamsulosin, alfuzosin or similar Finasteride or dutasteride A combination tablet Tadalafil daily A bladder medication for urgency None

Have you stopped any prostate medication because of side effects?

Yes No

Have you ever been unable to pass urine at all, needing a catheter?

Yes No

Have you seen blood in your urine?

Yes No

Have you had recurrent urine infections or bladder stones?

Yes No

Most recent PSA result, if you know it

How important to you is keeping normal ejaculation?

There is no right answer, and it genuinely changes what I would recommend. Some procedures preserve it and some almost always end it. Please answer honestly rather than diplomatically.

In one sentence, what would you most like fixed?

How bad is it, really? Let's put a number on it.

Your details, and anything affecting anaesthesia.

The International Prostate Symptom Score.

What has already been tried, and what you want protected.

Your summary