American Journal of Obstetrics and Gynecology (2005) 192, 66e73

www.ajog.org

A new questionnaire for urinary incontinence diagnosis in women: Development and testing
Catherine S. Bradley, MD,a,* Eric S. Rovner, MD,b Mark A. Morgan, MD,c Michelle Berlin, MD,e Joseph M. Novi, DO,c Judy A. Shea, PhD,d Lily A. Arya, MDc
Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa,a Division of Urology, Department of Surgery,b Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology,c and Department of Medicine Division of General Internal Medicine,d University of Pennsylvania, Philadelphia, Pa, and Departments of Obstetrics and Gynecology and Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oree
Received for publication April 14, 2004; revised July 10, 2004; accepted July 20, 2004

KEY WORDS
Questionnaire Urinary incontinence Reproducibility

Objective: The purpose of this study was to develop a questionnaire for urinary incontinence diagnosis in women and to test its reliability and validity, with incontinence specialists clinical evaluations as the gold standard. Study design: One hundred seventeen urogynecology outpatients with urinary incontinence symptoms completed the Questionnaire for Urinary Incontinence Diagnosis at enrollment and 1 week and 9 months later. Baseline clinical diagnoses were compared with Questionnaire for Urinary Incontinence Diagnosis diagnoses (criterion validity). Nine-month Questionnaire for Urinary Incontinence Diagnosis change scores were compared across treatment groups (responsiveness). Results: Clinical diagnoses included stress (n = 15), urge (n = 26), and mixed urinary incontinence (n = 72). Internal consistency and test-retest reliability estimates were good. Sensitivity and specificity were 85% (95% CI, 75%, 91%) and 71% (95% CI, 51%, 87%), respectively, for stress urinary incontinence and 79% (95% CI, 69%, 86%) and 79% (95% CI, 54%, 94%), respectively, for urge urinary incontinence. The Questionnaire for Urinary Incontinence Diagnosis correctly diagnosed urinary incontinence type in 80% of subjects. Questionnaire for Urinary Incontinence Diagnosis Stress and Urge scores decreased significantly in treated subjects.

Supported in part by a FOCUS Clinical Investigator Award for Research in Womens Health and by the 2001-2002 American College of Obstetricians and Gynecologists/Pharmacia Corporation Research Award on Overactive Bladder. Presented at the 22nd Annual Meeting of the American Urogynecologic Society, Chicago, Ill, October 25-27, 2001, and the 23rd Annual Meeting of the American Urogynecologic Society, San Francisco, Calif, October 17-19, 2002. * Reprint requests: Catherine S. Bradley, MD, MSCE, Department of Obstetrics and Gynecology, University of Iowa Hospitals & Clinics, 200 Hawkins Dr, Iowa City, IA 52242. E-mail: catherine-bradley@uiowa.edu 0002-9378/$ - see front matter 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2004.07.037

Bradley et al

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Conclusion: The Questionnaire for Urinary Incontinence Diagnosis, a new 6-item questionnaire for female urinary incontinence type diagnosis, is reliable and able to diagnose stress urinary incontinence and urge urinary incontinence in a referral urogynecology patient population with accuracy. 2005 Elsevier Inc. All rights reserved.

Female urinary incontinence is a very common problem that aects 28% to 35% of adult women.1 Urinary incontinence also has a signicant negative impact on a womans health-related quality of life.2 Given the importance of urinary incontinence on quality of life, there is increasing interest in the development and use of well-constructed questionnaires.3,4 Although several carefully developed and tested questionnaires that are specic to female urinary incontinence are available for use as screening tools, symptom indices, and quality of life measures,5-7 no well-tested instrument has been developed specically to aid in the diagnosis of dierent types of urinary incontinence (ie, stress and urge incontinence) in women. Stress and urge urinary incontinence, the most common conditions that cause female urinary incontinence symptoms, have dierent pathophysiologic mechanisms, epidemiologic characteristics, and treatments. Distinguishing between these types of urinary incontinence is important in clinical practice and for research purposes. The objectives of this study were to develop a psychometrically sound, symptom-based questionnaire that is intended to classify stress and/or urge incontinence type and to determine the questionnaires reliability, validity, and responsiveness to change in a population of women who are seeking incontinence care.

Second, the initial items that were developed and compiled by the investigators were reviewed by 10 expert reviewers (urogynecology and female urology specialists from various outside institutions). Each reviewer evaluated the items for language, content validity, relevance, and completeness by responding to a structured set of questions. The items were then revised with the use of their critiques. Last, the items were screened with 15 female patients who had urinary incontinence symptoms with the use of a cognitive think aloud technique.16 Subjects read each item and its response options aloud and then described the thought process that lead them to choose their response. The purpose was to identify ambiguous or misleading items. Patients were also asked whether they experienced any urinary incontinence symptoms that were not included among the items. Revisions were performed before proceeding with the pilot testing.

Pilot testing
Nineteen potential QUID items were administered to a convenience sample of urogynecology and female urology patients with urinary incontinence symptoms to evaluate individual item performance and reliability. The eligibility criteria and methods of administration were similar to that used in the nal study group. Individual items were evaluated by examination of endorsement patterns for response options and missing or not interpretable responses. Internal consistency among sets of items was evaluated with item-total correlations and the Cronbach a coecient. Test-retest reliability was evaluated with weighted k statistics. Items that did not meet the criteria were revised to produce the QUID instrument that was used in the larger reliability and validity study.

Material and methods

The Questionnaire for Urinary Incontinence Diagnosis (QUID) items were developed by a structured questionnaire development and testing process. The study was approved by the local Institutional Review Board.

Questionnaire development
The development phase of the questionnaire included 3 steps. First, potential items for the QUID were created and compiled with the use of the authors clinical experiences and an extensive literature review, which included published questionnaires and research ndings6-14 and previously reported urinary incontinence patient focusegroup recommendations.15 Items were chosen specically for their potential discriminatory value, and scaled responses were used, generally on the basis of symptom frequency. The questionnaire was intended to be self-administered and short and was eventually to include fewer than 10 items.

Questionnaire reliability and validity testing

The revised 20-item QUID was administered prospectively to new patients who were seen at the urogynecology clinic at the University of Pennsylvania Medical Center. Patients who were R18 years who had symptoms of urinary incontinence were eligible. Exclusion criteria included a history of current pregnancy or within 6 months after delivery, extraurethral urinary incontinence (ie, genitourinary stula), urethral diverticulum, and active urinary tract infection. Eligible subjects were consented and enrolled at their initial oce visit. They completed the QUID before they

68 saw the physician for the rst time. Demographic questions, questions about potential urinary incontinence risk factors, and the short Incontinence Impact Questionnaire (IIQ-7), a 7-item quality-of-life measure for women with urinary incontinence,7,17 were administered along with the QUID. The QUID was then readministered to the same subjects by mailed survey approximately 1 week after the initial visit. Subjects completed a clinical evaluation as recommended by their physician. In all subjects, this included a history, physical and pelvic examination, a cough stress test, postvoid residual volume assessment, and urinalysis. The history included incontinence, medical, reproductive, and surgical histories. The incontinence history was taken with the use of a standard form and included questions about urinary leaking, frequency, nocturia, urgency, pad use, and other voiding symptoms. Pelvic organ prolapse was graded according to Baden and Walkers18 halfway system. Multichannel urodynamic testing and other clinical tests were ordered only at the physicians discretion, on the basis of their usual clinical practice. All subjects were asked to complete a 48-hour home pad test and a 72-hour voiding diary. On the diary, the subjects were instructed to record all voids and leak episodes and to characterize each leak episode as stress, urge, or other. Three months after enrollment, a nal clinical diagnosis was assigned to each subject by 1 of the 3 participating attending physicians to be used as the gold standard urinary incontinence diagnosis. The physicians reviewed the entirety of the clinical information to arrive at the diagnoses, using a data form to capture and formalize the process. They were blinded to all questionnaire results. Nine months after enrollment, the QUID was administered again by mail, along with the IIQ-7 and several questions regarding the treatment for incontinence. Subject characteristics were described using frequencies and proportions or by the mean, median, SD, and range. Group comparisons were made with the Wilcoxon rank sum test for continuous data and the c2 or Fisher exact test for categoric data. Nonparametric tests were used because of data asymmetry. Probability values were considered signicant if they were !.05. Missing questionnaire responses were not imputed because of the small numbers. The individual item performance, internal consistency, and test-retest reliability analyses as described for the pilot group were repeated in the main study group. Items were selected to include in the nal QUID instrument, and a scoring system for the QUID was developed to diagnose stress and urge urinary incontinence by the questionnaire item answers. Items with good item analysis results (!2% missing or not interpretable responses) and good test-retest reliability (weighted k, R0.70) were considered for inclusion. The goal for internal consistency was a Cronbach a R80%

Bradley et al within stress and urge subscales. Univariate associations between responses to these items and the clinical diagnoses and item-total correlations were used to select the items that best predicted stress and/or urge urinary incontinence when compared with the subjects clinical diagnoses. These items were grouped into a stress subscale and an urge subscale. A simple, additive scoring system was used to produce a stress score and an urge score from these groups of items. The test-retest reliability of these scores was measured with intraclass correlation coecients. The coecient CIs were approximated with a Fisher z transformation.16 Independent, blinded comparisons of the QUID diagnoses of stress and urge urinary incontinence with the nal clinical diagnoses as a gold standard were performed (criterion validity testing). Receiver-operator characteristic curve analyses were used to identify optimal cut-points in the stress and urge scores to maximize the probability that a patient was diagnosed correctly, given the gold standard. Subjects whose stress and urge scores met both cutos were considered to have mixed urinary incontinence and were included in both analyses. Estimates of the questionnaires sensitivity, specicity, positive and negative predictive values, and accuracy (the proportion of cases correctly classied) for the diagnoses of stress urinary incontinence and urge urinary incontinence were calculated (with their 95% CI). To assess the questionnaires responsiveness to change, QUID stress and urge change scores were calculated by the subtraction of the scores at 9 months from the baseline scores. We hypothesized that subjects who had undergone surgery for stress urinary incontinence since enrollment and those who were currently continuing conservative treatments for stress and/or urge urinary incontinence (including pelvic oor exercises, biofeedback, bladder training, and antispasmodic medications) would have improved stress and urge scores at the 9-month time point. The IIQ-7 change scores were calculated in a similar manner to identify evidence for the change in urinary incontinence symptoms. The change scores were compared in the treatment and nontreatment groups with 2-sample unpaired t tests.

Results
Questionnaire development
More than 100 items were considered for use during the questionnaire development process. After revisions, 19 items, with 5 to 6 frequency-based response options each, were included in the pilot test.

Pilot testing
One hundred three women were enrolled in the pilot study group. The number of missing or not interpretable

Bradley et al responses per item ranged from 1.0% to 6.8%. Internal consistency of the stress and urge items was good (Cronbach a = 0.72 and 0.79, respectively). The testretest reliability of individual QUID items was variable, with weighted kappa statistics from 0.35 to 0.90 (median, 0.69; all P !.0001; complete pilot data are available on request.) After pilot testing, the questionnaire items were revised, and 20 items were included for further testing.
Table I Study group characteristics (n = 117)* Measurement

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Characteristic

Main study group

One hundred seventeen of 163 consecutive eligible patients (71.8%) agreed to participate. Table I shows the study group characteristics. Participants were similar to nonparticipants in terms of age and race. In addition to the standard evaluation, the subjects clinical workups included voiding diaries (n = 56), pad tests (n = 47), urodynamic testing (n = 47), and cystoscopy (n = 26). The clinical diagnoses that were assigned by the attending physicians were stress (n = 15; 12.8%), urge (n = 26; 22.2%), mixed urinary incontinence (n = 72; 61.5%), and other (n = 4; 3.4%). A wide range of urinary incontinence severity was demonstrated by the IIQ-7 scores, voiding diaries, and pad test results. The IIQ-7 scores ranged from 0 to 100 (median, 23.8). The number of incontinent episodes per day on the voiding diaries ranged from 0 to 18 (median, 2). The 48hour pad weight gains were !8 g in 19 subjects, 8 to 30 g in 12 subjects, and O30 g in 16 subjects (range, 0-865 g). Item analysis and internal consistency testing was performed with the baseline questionnaires. A median of 1.3% (range, 0-5.4%) of the responses per item was missing or not interpretable. Internal consistency (Cronbach a) of the items that pertained to stress and to urge urinary incontinence were 0.85 and 0.87, respectively. Test-retest reliability was measured in the 79 women (67.5%) who responded to the rst mailed questionnaire within 21 days of enrollment (median test-retest interval, 7 days). No signicant dierences were found between the responders and nonresponders in age, race, educational level, body mass index, duration of incontinence symptoms, and IIQ-7 score. Fifty-eight percent of the QUID items were answered identically, and 91% of the items were answered within 1 response category on both occasions. Weighted k statistics ranged from 0.66 to 0.93 (median, 0.80; all P !.0001). Three items that were intended to predict stress urinary incontinence and 3 items that were intended to predict urge urinary incontinence were selected to make up the nal QUID stress and urge subscales on the basis of item analysis, test-retest reliability, and strong associations with the clinical diagnoses (Table II). Each items possible responses were scored from 0 to 5 points. Scores were calculated in an additive fashion, which allowed possible QUID stress and urge scores to each

56 Age (y)y Body mass index (kg/m2)y 26.6 Parity (n)y 2 Race/ethnicity (n) Asian 2 Black 25 Hispanic 3 White 85 Education level completed: (n) !12 y 2 High school graduate 41 College graduate 45 Postgraduate degree 28 Postmenopausal (n) 61 Hysterectomy (n) 41 Duration of urinary incontinence symptoms (n) !1 y 18 1-5 y 59 O5 y 35 Current urinary incontinence medication (n) 14 Previous anti-incontinence surgery (n) 15 Pelvic organ prolapse (Rgrade 3) (n) 20

(22-87) (17.4-47.1) (0-8) (1.7%) (21.4%) (2.6%) (72.6%) (1.7%) (35.0%) (38.5%) (23.9%) (52.1%) (35.0%) (15.4%) (50.4%) (29.9%) (12.0%) (12.8%) (17.1%)

* Percentages may add to less than 100% when data are missing. y Median (range) for variables in the table.

range from 0 to 15. Subjects with missing item responses that were necessary for score calculation (5 and 4 subjects for the stress and urge scores, respectively) were not included in the analyses. The test-retest reliabilities of the calculated stress and urge scores were very good (0.91 [95% CI, 0.87-0.95] and 0.83 [95% CI, 0.75-0.89]). The optimal cuto values that were identied from receiver-operator characteristic curve analysis for the QUID diagnoses of stress and urge urinary incontinence were a stress score R4 and an urge score of R6. The QUIDs sensitivity and specicity were 85% (95% CI, 75-91) and 71% (95% CI, 51-87), respectively, for stress urinary incontinence and 79% (95% CI, 69-86) and 79% (95% CI, 54-94), respectively for urge urinary incontinence. Other test characteristics are shown in Table III. Women diagnosed with both stress and urge urinary incontinence by the QUID (stress score, R4; urge score, R6) were combined in a QUID-diagnosed mixed urinary incontinence group and were compared with those women who were diagnosed clinically with mixed urinary incontinence. For the detection of mixed urinary incontinence, the QUIDs sensitivity was 70% (95% CI, 57-80), and specicity was 86% (95% CI, 71-95). Fifty-seven of the 117 subjects (49%) completed the nal QUID at a median of 9 months after their initial enrollment (range, 6-15 months). Responders were not signicantly dierent from nonresponders in age, race,

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Table II The QUID Scoring Question Do you leak urine (even small drops), wet yourself, or wet your pads or undergarments. 1. When you cough or sneeze? 2. When you bend down or lift something up? 3. When you walk quickly, jog, or exercise? 4. While you are undressing to use the toilet? 5. Do you get such a strong and uncomfortable need to urinate that you leak urine (even small drops) or wet yourself before reaching the toilet? 6. Do you have to rush to the bathroom because you get a sudden, strong need to urinate? None of the time: score 0 Rarely: score 1 Once in awhile: score 2 Often: score 3 Most of the time: score 4

Bradley et al

All of the time: score 5

, , , , ,

, , , , ,

, , , , ,

, , , , ,

, , , , ,

, , , , ,

For scoring purposes, items 1, 2, and 3 contribute to the stress score; items 4, 5, and 6 contribute to the urge score. Each items responses range from 0 to 5 points.

Table III QUID test characteristics (with 95% CIs) for stress urinary incontinence and urge urinary incontinence, when compared with clinical diagnoses Stress urinary incontinence Sensitivity Specicity Positive predictive value Negative predictive value Accuracy Area under the curve 0.85 (0.75-0.91) 0.71 (0.51-0.87) 0.90 (0.81-0.96) 0.61 (0.42-0.77) 0.81 (0.73-0.88) 0.83 (0.74-0.92) Urge urinary incontinence 0.79 (0.69-0.86) 0.79 (0.54-0.94) 0.95 (0.87-0.99) 0.43 (0.26-0.60) 0.79 (0.70-0.86) 0.83 (0.75-0.92)

Comment
Several lower urinary tract symptom questionnaires for women have been developed and validated, which include symptom indices and quality of life instruments (such as the Bristol Female Lower Urinary Tract Symptom Questionnaire, the Incontinence Impact Questionnaire, and the Urinary Distress Inventory).6,7 None of these questionnaires were developed primarily to distinguish dierent types of urinary incontinence, and their diagnostic abilities for classifying subjects stress and urge incontinence have not been well tested. In 1982, Kauppila et al19 published a 10-question detrusor instability score that was intended to distinguish between patients with stress urinary incontinence and patients with urge or mixed urinary incontinence. The validity of this survey was later tested by a comparison of detrusor instability scores with a clinical evaluation (including urodynamic tests) in 250 Norwegian urogynecology patients.20 In this population, the diagnoses of the detrusor instability scores were 66% accurate for stress urinary incontinence and 68% accurate for urge incontinence. An English version of the detrusor instability score has not been tested to our knowledge, and reliability characteristics of the survey are unknown. A few studies have compared diagnoses that were obtained by surveys without validated scores or individual items taken from validated questionnaires with urodynamic or clinical diagnoses of female urinary

body mass index, education, duration of incontinence symptoms, initial IIQ-7 score, and clinical diagnosis that was assigned. Sixteen subjects had undergone surgery for stress urinary incontinence since their enrollment, and 19 subjects were actively continuing a conservative treatment for urinary incontinence. The treated group had IIQ-7 change scores that were signicantly better than the untreated group (15.0 vs 3.5; P =.02). The QUID stress and urge change scores were also signicantly better in the treated group (3.9 vs 0.1 [P !.001] and 2.3 vs 0.4 [P !.001], respectively) compared with the untreated groups change scores, which were close to 0.

Bradley et al incontinence.8,12,14,21 Lemack and Zimmern,21 in a retrospective study of 128 patients, compared single-item responses from the Urinary Distress Inventory, a quality-of-life measure that includes items about the presence and level of bother of specic urinary tract symptoms to urodynamic results. There were moderate correlations between answers to single symptom questions with stress and urge urinary incontinence diagnoses. Sandvik et al8 compared 2 diagnostic symptom questions to a urogynecologists nal clinical diagnosis in a prospective study of 250 subjects. With the 2 questions with yes/no answers, stress urinary incontinence was diagnosed with a sensitivity of 0.66 and specicity of 0.88, and urge urinary incontinence was diagnosed with a sensitivity of 0.56 and a specicity of 0.96. Kirschner-Hermanns et al12 compared the diagnostic accuracy of a nonvalidated questionnaire with urodynamic results in 132 women and men who were O65 years of age. They tested answers to 5 questions that used only 1 to 2 items for diagnoses and found a poor correlation between question answers and urodynamic results. No strategy (or proposed answer combinations) had O67% sensitivity for stress or urge urinary incontinence. Last, in a recent study from Japan, the authors modied a 1979 German survey and created a 15-item questionnaire with a very complex scoring system.14 In a prospective study of 198 patients who underwent routine evaluation for urinary incontinence, sensitivities were 0.83, 0.86, and 0.61 for stress, urge, and mixed urinary incontinence, respectively. Specicity values and condence limits were not reported, nor was psychometric data provided for the Japanese version. Our study expands on previous work in several important ways. The primary purpose of the QUID is to diagnose stress and/or urge types of urinary incontinence; our study design stressed psychometric testing of the items and the instrument. Our proposed scoring system is easy to understand and implement. The use of several items together to create stress and urge scores may allow us to diagnose stress and urge urinary incontinence with more balanced sensitivities and specicities. Overall, the QUID was able to classify approximately 80% of the subjects diagnoses correctly, and the positive predictive values in this population were very good (90% for stress urinary incontinence and 95% for urge urinary incontinence). Our results also suggest that the QUID is responsive to change; however, our response rate for the 9-month questionnaires was low (49%), which limited the significance of our ndings. It is reassuring that many characteristics of the nonresponders and responders were similar, but a more complete study is needed to conrm our results before we can conclude that the questionnaire is useful for measuring change in incontinence symptoms.

71 A potential concern with our study is the lack of a true gold standard diagnostic test. Because such a test is not available for urinary incontinence type, the validation of any diagnostic questionnaire for urinary incontinence types is challenging. Urodynamic testing is used widely to diagnose incontinence in clinical practice, although it is not recommended in the basic clinical evaluation of urinary incontinence by recent practice guidelines.3,22 Urodynamic testing is relatively expensive and invasive, which makes it impractical for use in larger epidemiologic studies. More importantly, components of urodynamic testing have varying degrees of reproducibility, sensitivity, and specicity.23-26 An expert panel that was convened by the 2nd International Consultation on Incontinence concluded that urodynamic testing by itself is not adequate to dene the cause of lower urinary tract dysfunction and must be integrated, if used, with symptom observation, a voiding diary, a patient history, physical ndings and other relevant components.27 Other researchers have also used clinical diagnoses as the gold standard when validating questionnaires.8,14 Limitations to the use of clinical diagnoses include potential subjectivity and diculty in standardization. We created a formal process in this study to assign the clinical diagnoses, which included a standardized basic clinical evaluation, in an attempt to minimize these potential problems. All subjects were evaluated by incontinence specialists who chose further testing on the basis of the subjects initial ndings. Thus, some of the subjects also had urodynamic test and voiding diary results that were available to aid in making their diagnoses. Our study design does not allow us to comment on how each of the urogynecologists used the available clinical data to determine their nal clinical diagnoses. These unknown factors may decrease the generalizability of our results. We decided a priori to use clinical diagnoses as our gold standard, rather than diagnoses that were obtained from urodynamic tests. Although not intended as an outcome for the study, the urodynamic test protocols were not standardized for these subjects, and only 40% of the women underwent urodynamic testing as a part of their clinical evaluation. Therefore, we have not reported the test characteristics of the QUID when they were compared with the urodynamic ndings alone. Furthermore, urodynamic testing has been shown in many cases to correlate poorly with clinical symptoms.28,29 This has been blamed on the bladder as a poor witness, but perhaps it is equally possible that a single short test cannot reliably capture real-life disorders that may be manifested more consistently by symptoms. Because the purpose of epidemiologic surveys is to identify bothersome symptoms, we feel that it is important for the questionnaire to correlate with symptoms and the diagnoses that are made when

72 considering those symptoms as part of a clinical evaluation. In future studies, it will be interesting to consider how QUID item responses and diagnoses compare with urodynamic ndings, bladder diaries, and other tests of bladder function. Another possible limitation of our study is the referral nature of the study population. The development and testing of this questionnaire in such a population may limit its applicability to other populations because of spectrum bias. Dierences in the spectrum of disease across a study population may alter the sensitivity and specicity estimates. For example, the sensitivity of the instrument may decrease if it is later applied to women who have a milder spectrum of urinary incontinence symptoms. In addition, even if the sensitivity and specicity of the QUID remain constant, the predictive values would be lower if used in a lower prevalence population. However, we do note that the range of IIQ-7 scores, the duration of incontinence symptoms reported, and the diary and pad test results demonstrate that a fairly wide spectrum of urinary incontinence symptoms and severity was present in this referral group. The potential uses of a well-constructed diagnostic questionnaire for female stress and urge urinary incontinence are great. Such an instrument could be used clinically in certain patient groups to help primary care physicians, including general obstetrician-gynecologists, to reach a diagnosis and to start a treatment plan in the absence of expensive and invasive diagnostic testing. In addition, a diagnostic questionnaire is potentially a powerful research tool. Most early epidemiologic studies of urinary incontinence did not dierentiate between different incontinence types, thereby lumping subjects with stress and urge urinary incontinence together. More recent studies distinguish between the 2 diagnoses, but the validity of their classication criteria is often uncertain and almost always unmeasured. An easy-to-administer questionnaire (such as the QUID) that can classify women into groups of stress and/or urge urinary incontinence with a known level of accuracy therefore could have great importance in facilitating population-based epidemiologic research in this area. We plan to validate the questionnaire scores in lower risk study populations as part of future studies. Finally, larger samples in future studies will provide more precise estimates of the QUIDs test characteristics.

Bradley et al
pact on quality of life and sexual life. Neurourol Urodyn 2000;19: 259-71. Assessment and treatment of urinary incontinence: Scientic Committee of the First International Consultation on Incontinence. Lancet 2000;355:2153-8. Lose G, Fantl JA, Victor A, Walter S, Wells TL, Wyman J, et al. Outcome measures for research in adult women with symptoms of lower urinary tract dysfunction. Neurourol Urodyn 1998;17: 255-62. Gunthorpe W, Brown W, Redman S. The development and evaluation of an incontinence screening questionnaire for female primary care. Neurourol Urodyn 2000;19:595-607. Jackson S, Donovan J, Brookes S, Eckford S, Swithinbank L, Abrams P. The Bristol Female Lower Urinary Tract Symptoms questionnaire: development and psychometric testing. Br J Urol 1996;77:805-12. Shumaker SA, Wyman JF, Uebersax JS, McClish D, Fantl JA. Health-related quality of life measures for women with urinary incontinence: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory: Continence Program in Women (CPW) Research Group. Qual Life Res 1994;3:291-306. Sandvik H, Hunskaar S, Vanvik A, Bratt H, Seim A, Hermstad R. Diagnostic classication of female urinary incontinence: an epidemiological survey corrected for validity. J Clin Epidemiol 1995; 48:339-43. Amundsen C, Lau M, English SF, McGuire EJ. Do urinary symptoms correlate with urodynamic ndings? J Urol 1999; 161:1871-4. Bergman A, Bader K. Reliability of the patients history in the diagnosis of urinary incontinence. Int J Gynaecol Obstet 1990;32:255-9. Bernstein I, Sejr T, Able I, Andersen JT, Fischer-Rasmussen W, Klarskov P, et al. Assessment of lower urinary tract symptoms in women by a self-administered questionnaire: test-retest reliability. Int Urogynecol J Pelvic Floor Dysfunct 1996;7:37-47. Kirschner-Hermanns R, Scherr PA, Branch LG, Wetle T, Resnick NM. Accuracy of survey questions for geriatric urinary incontinence. J Urol 1998;159:1903-8. Diokno AC, Dimaculangan RR, Lim EU, Steinert BW. Oce based criteria for predicting type II stress incontinence without further evaluation studies. J Urol 1999;161:1263-7. Ishiko O, Sumi T, Hirai K, Ogita S. Classication of female urinary incontinence by the scored incontinence questionnaire. Int J Gynaecol Obstet 2000;69:255-60. Fultz NH, Herzog AR. Measuring urinary incontinence in surveys. Gerontologist 1993;33:708-13. Streiner DL, Norman GR. Health measurement scales: a practical guide to their development and use. New York: Oxford University; 1995. Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl JA. Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory: Continence Program for Women Research Group. Neurourol Urodyn 1995;14:131-9. Baden WF, Walker TA. Surgical repair of vaginal defects. Philadelphia: Lippincott; 1992. Kauppila A, Alavaikko P, Kujansuu E. Detrusor instability score in the evaluation of stress urinary incontinence. Acta Obstet Gynecol Scand 1982;61:137-41. Klovning A, Hunskaar S, Eriksen BC. Validity of a scored urological history in detecting detrusor instability in female urinary incontinence. Acta Obstet Gynecol Scand 1996;75:941-5. Lemack GE, Zimmern PE. Predictability of urodynamic ndings based on the Urogenital Distress Inventory-6 questionnaire. Urology 1999;54:461-6. Fantl JA, Newman DK, Colling J, Delancey JOL, Keeys C, Loughery RM, et al. Urinary incontinence in adults: acute and

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