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1. I worry if I wet myself because of urinary loss.

2. I worry if I lose urine when I cough or sneeze.

3. I have to be careful to get up because of urine loss

4. I always must know where the bathroom is when I go to new places.

5. I feel depressed because I lose urine.

6. Because I lose urine I worry, and do not leave my house for long periods of time.

7. I feel frustrated because the urine loss stops me from doing what I would like to do.

8. I worry that others might feel the smell of urine on me.

9. The fact that I lose urine is always in my head.

10.I always have to go to the bathroom.

11. Because of urine loss I must plan things before hand and in detail.

12. I worry that the urine loss will get worse as I get older.

13. I do not sleep well because of urine loss.

14. I am afraid to be embarrassed or humiliated because of urine loss.

15. Urine loss makes me feel that I am not healthy.

16. Urine loss makes me feel hopeless.

17. I feel that I do not take more advantage from life because of urine loss.

18. I am worried that I will not make it to the bathroom.

19. I feel like I have lost control of my bladder.

20. I must be careful with the amount of liquids that I drink because of urine loss.

21. Urine loss limits the way I dress.

22. I am worried with urine loss during sex.


1 = very frequently

2 = moderately

3 = not much

4 = it is not applied


  • Behavior restrictions or action restrictions.

  • Psychological Impact

  • Social embarrassment