By filling in this form, you will help your doctor to assess if you have an enlarged prostate, and how badly it is affecting you. An enlarged prostate is a common and benign (non-cancerous) condition that often occurs in older men. (The results do not help to diagnose prostate cancer.)
1. The International Prostate Symptom Score (IPSS)
Please answer the following questions about your urinary symptoms.
Write your score for each question at the end of each row.
Write your score for each question at the end of each row.
| Over the past month, how often have you... | 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 | Your Score |
1. ...had a sensation of not emptying your bladder completely after you finished urinating? | 0 | 1 | 2 | 3 | 4 | 5 | |
2. ...had to urinate again less than two hours after you finished urinating? | 0 | 1 | 2 | 3 | 4 | 5 | |
3. ...stopped and started again several times when you urinated? | 0 | 1 | 2 | 3 | 4 | 5 | |
4. ...found it difficult to postpone urination? | 0 | 1 | 2 | 3 | 4 | 5 | |
5. ...had a weak urinary stream? | 0 | 1 | 2 | 3 | 4 | 5 | |
6. ...had to push or strain to begin urination? | 0 | 1 | 2 | 3 | 4 | 5 | |
| And finally.. | None | Once | Twice | 3 times | 4 times | 5 times or more | |
7. Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? | 0 | 1 | 2 | 3 | 4 | 5 | |
Add up your total score and write it in the box. | Total |
Supplementary question - Quality of life due to urinary symptoms.
If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? (Please tick which best describes how you would feel.)
0. Delighted
1. Pleased
2. Mostly satisfied
3. Mixed - about equally satisfied and dissatisfied
4. Mostly dissatisfied
5. Unhappy
6. Terrible
1. Pleased
2. Mostly satisfied
3. Mixed - about equally satisfied and dissatisfied
4. Mostly dissatisfied
5. Unhappy
6. Terrible
2. Assessment of sexual function
An enlarged prostate can sometimes affect sexual function.
These questions aim to assess if you have problems with your sexual function.
Write your score for each question at the end of each row.
These questions aim to assess if you have problems with your sexual function.
Write your score for each question at the end of each row.
| Can you obtain an erection? | Score |
| Yes, with normal rigidity ............. score 0 Yes, with slightly reduced rigidity ............. score 1 Yes, with much reduced rigidity ............. score 2 No, can not obtain an erection ............. score 3 | |
| If you have problems obtaining an erection, how big is the problem for you? | Score |
| No problem ............. score 0 Small problem ............. score 1 Moderate problem ............. score 2 Big problem ............. score 3 | |
| Do you ejaculate? | Score |
| Yes, with normal volume ............. score 0 Yes, with slightly reduced volume ............. score 1 Yes, with much reduced volume ............. score 2 No ............. score 3 | |
| If you experience reduced or no ejaculation, how big is the problem for you? | Score |
| No problem ............. score 0 Small problem ............. score 1 Moderate problem ............. score 2 Big problem ............. score 3 | |
| If you do ejaculate, do you ever experience pain or discomfort during ejaculation? | Score |
| No ............. score 0 Yes, with slight pain or discomfort ............. score 1 Yes, with moderate pain or discomfort ............. score 2 Yes, with severe pain or discomfort ............. score 3 | |
| If you experience pain/discomfort during ejaculation, how big is the problem for you? | Score |
| No problem ............. score 0 Small problem ............. score 1 Moderate problem ............. score 2 Big problem ............. score 3 |
Assessment
In general, an IPSS score of:
- 0-7 indicates mild symptoms
- 8-19 indicates moderate symptoms
- 20-35 indicates severe symptoms.
The answers to the supplementary question to the IPSS and the sexual assessment questions help your doctor to asses how badly your quality of life is affected by your symptoms.
References:
Barry MJ, et al. (1992). The American Urological Association symptom index for benign prostatic hyperplasia. Journal of Urology, 148: 1549–1557.
©EMIS and PIP 2005 Updated: November 2005 PRODIGY Validated
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