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Get help for a long term urine problem

Get help for a long term urine problem

About the Patient’s Problem

What is your sex at birth?
If you’re not sure, it’s helpful to tell us whether it’s been days, weeks, months or years.

Assessing the type of urine problem

Have you read the NHS advice on urinary incontinence?
Do you leak urine when you cough, sneeze, laugh or stand? *
Do you get a sudden, intense urge to pee? *
Do you have to strain to pee? *
Do you feel that you can fully empty your bladder when you pee? *

Male urinary tract (IPSS)

Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating? *
Over the past month, how often have you had to urinate again less than two hours after you finished urinating? *
Over the past month, how often have you found that you stopped and started again several times when you urinated? *
Over the past month, how often have you found it difficult to postpone urination? *
Over the past month, how often have you had a weak urinary stream? *
Over the past month, how often have you had to push or strain to begin urination? *
Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? *
If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? *

Symptoms of possible cancer

Symptoms

Do you pass small trickles of pee very often? *
Have you had any blood in your pee? *
In the last month, has your appetite been poor? *
In the last month, have you lost weight without trying to? *
Have you recently started having pain in your bones or back? *
Have you had any blood in your semen? *

Symptoms of a neurological cause

Symptoms

Please let us know if you have any of the following symptoms:

Severe back pain *
Leg pain *
Numbness or tingling in a leg *
Numbness or tingling around your genitals or buttocks *
Weak legs *

Assessing the cause

Caffeine can make your bladder over-active. Caffeine is found in coffee, tea, cola and energy drinks

How many drinks containing caffeine do you have in a usual day?

Alcohol often causes problems with passing urine

Do you drink alcohol?

Alcohol consumption

One unit of alcohol

Amount of different types of drink representing one unit of alcohol

More than one unit of alcohol

Amount of different types of drink representing more than one unit of alcohol

How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *
How often during the last year have you found that you were not able to stop drinking once you had started? *
How often during the last year have you failed to do what was normally expected from you because of your drinking? *
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? *
How often during the last year have you had a feeling of guilt or remorse after drinking? *
How often during the last year have you been unable to remember what happened the night before because you had been drinking? *
Have you or somebody else been injured as a result of your drinking? *
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

File Upload

Please attach a photograph or scan of your bladder diary. You can also send photos if you think a photo would help our clinicians.
Maximum upload size: 8.39MB

Communication Preferences

How would you like us to deal with the problem? *
Video Consultation

Video consultations require you to have a smartphone, tablet, laptop or any computer with camera and microphone or headset. You will also require access to the internet, preferably over WiFi. If the practice decides on a video consultation you will be sent an email containing a link for the video consultation, so it’s best if you can receive your emails on that same device.

If the practice has a mobile number for you, we may send text messages to this number to inform you of an appointment time, or to allow you to book an appointment at a time of your choice.

Terms & Conditions *