University of Maryland Prostatitis Survey (REPOST) 
Author Message
 University of Maryland Prostatitis Survey (REPOST)

[
 Due to the importance of this survey it will be reposted in this
 newsgroup every five days until the December NIH prostatitis
 symposium. (Some service providers expire news articles in as
 few as two days. Frequent reposting reduces the possibility of
 it being completely missed by users of these systems.)
]

This message contains a prostatitis survey which is being posted to
appropriate locations on the world-wide Internet and to other
information provider services. A copy of this survey can be
obtained via electronic mail by sending a request to Internet
address:

A future survey is being contemplated and if produced will be
distributed in the same manner as this one.

*******************************************************************
*                   PROSTATITIS SURVEY  (1.0)                     *
*******************************************************************

This is a survey on prostatitis for Richard Alexander, M.D. at the
University of Maryland Medical Center. If you are a prostatitis
sufferer or know someone who is please help us conquer this disease
by filling out and returning this form. This survey will help us to
understand the symptoms patients who have been diagnosed with
prostatitis have to see if any patterns or clustering of symptoms
emerges. The success of this survey will depend upon large numbers
of men responding accurately and only once. The data will be
examined and may be used to help define what this disease is, from
the patients' perspective, at a meeting at the NIH in December,
1995 on prostatitis. Thank you.

*******************************************************************
*                          DIRECTIONS                             *
*******************************************************************

This survey is only for prostatitis. Please do not respond if you
have a diagnosis of prostate cancer or benign prostatic hyperplasia
(BPH).

All data is confidential. If you wish to remain anonymous simply
leave the name fields blank.

Some of the questions concern your personal habits, in particular
relating to {*filter*} activity. We would very much appreciate your
answering these questions frankly but if you are uncomfortable with
these questions then leave them blank. Please answer the other
questions as best as you can even if you choose to leave personal
questions unanswered.

When answering questions use your computer text editor to insert the
answers between the < and > markers. This allows computer
processing of your form. You don't have to worry about keeping or
removing the blanks surrounding your answer. You also don't have to
worry about upper or lower case letters. To illustrate, the
following are all valid responses to questions that require a Y or
N (meaning Yes or No) response:

<  Y   >
<   N>
< y >
<y >
<n>

Some system remailers will insert extra prefix strings (such as >)
in front of each survey line before you can reply. The computer
tallying your responses ignores these. You don't have to remove
them or be concerned about them.

Some questions require careful thought to pick the best applicable
response. Please do your best and if you get fatigued simply take a
break and continue on at a later time.

*******************************************************************
*                     RETURNING THE SURVEY                        *
*******************************************************************

Return the survey to Internet address:


When using your computer connection to submit your results be sure
to use e-mail to send to the above address instead of posting back
to the entire group where you got the survey. DO NOT ASSUME THAT
JUST REPLYING TO THIS MESSAGE WILL WORK. CHECK THAT THE DESTINATION
IS TO THE ABOVE PRIVATE E-MAIL ADDRESS AND THAT E-MAIL IS BEING
USED INSTEAD OF A POSTING REPLY GOING BACK TO THE GROUP.

You can optionally choose to receive an automated confirmation by
entering your electronic mail address at the bottom of the form.
The confirmation will consist of only the following single line:

     Your survey has been received.

If confirmation is not requested you will not receive any
notification or any other responses to your submission.

When sending back the survey return the complete form intact. (You
don't have to delete the leading information at the front.) Do not
rearrange the question ordering.

We ask that you return the survey via e-mail, but if you prefer you
may print it out and send the results via standard postal service
to the following address:

Richard B. Alexander, M.D.
Division of Urology
University of Maryland School of Medicine
22 S. Greene Street
Baltimore, MD 21201

*******************************************************************
*                          SURVEY ITEMS                           *
*******************************************************************

-------------------
- General
-------------------

[1] What is your age in years? (insert numbers between < and > of
next line)
<    >

[2] What is your race? (insert an X in the most appropriate answer)
<    > Caucasian (white)
<    > African descent
<    > Hispanic
<    > Native American
<    > Asian
<    > None of the above

[3] For how many years have you had the symptoms that led to your
diagnosis of prostatitis? (use 0 if less than a year)
<    >

[4] How much work have you missed due to your prostatitis? (insert
an X in front of the single best answer for you)
<    > None or not applicable
<    > A few days a year
<    > A few weeks a year
<    > A few months a year
<    > On permanent disability

---------------------
- Symptoms
---------------------

[5] Did your prostatitis come on suddenly or gradually? (put an X
in the most appropriate response)
<    > Gradually
<    > Suddenly
<    > Neither or not applicable

[6] Are your symptoms: (insert an X in the most appropriate answer)
<    > Present constantly
<    > Present at a low level all the time but get worse at times
<    > Come and go -- in between flare-ups I am normal
<    > None of the above

[7] Do your prostatitis symptoms vary during the day? (put an X
before one or all that apply)
<    > Lesser in the morning
<    > Greater in the morning
<    > Lesser during midday
<    > Greater during midday
<    > Lesser in the evening
<    > Greater in the evening
<    > Not applicable to me

[8] Please indicate all of your symptoms from the following list.
(put an X in front of all categories you experience leaving the
rest blank)
<    > Fatigue (tiredness)
<    > Myalgia (aches ands pains in muscles)
<    > Arthralgia (aches and pains in joints)
<    > Frequent need to urinate
<    > Difficulty getting urine out such as weak stream, straining,
       or it takes a long time to empty the urine out of your bladder
<    > Pain that occurs with urination or is made worse by urination
<    > Pain (other than with urination) that is somewhere in the
       pelvic area ({*filter*}, groin, testicle,{*filter*}, {*filter*} or
       thereabouts)
<    > Pain deep in the abdomen (belly)
<    > Pain in the lower back
<    > Pain in a location not in this list
<    > Other symptoms not on this list
<    > No symptoms or not applicable

[9] Please rank order your symptoms from most severe to least
severe. Start with 1 for the most severe, then 2 for the next and
so on until no more symptoms match your condition. Leave unmarked
any symptoms you don't experience. If none of the symptoms apply
then place a 1 in either of the last two categories.
<    > Fatigue (tiredness)
<    > Myalgia (aches ands pains in muscles)
<    > Arthralgia (aches and pains in joints)
<    > Frequent need to urinate
<    > Difficulty getting urine out such as weak stream, straining,
       or it takes a long time to empty the urine out of your bladder
<    > Pain that occurs with urination or is made worse by urination
<    > Pain (other than with urination) that is somewhere in the
       pelvic area ({*filter*}, groin, testicle,{*filter*}, {*filter*} or
       thereabouts)
<    > Pain deep in the abdomen (belly)
<    > Pain in the lower back
<    > Pain in a location not in this list
<    > Other symptoms not on this list
<    > No symptoms or not applicable

[10] Indicate in percent the amount of time you experience the
following pain levels (change the numbers, total should be 100%)
<  0%  > None
<  0%  > Mild
<  0%  > Moderate
<  0%  > Severe
<  0%  > Disabling

[11] If you have pain, where is the pain located (place an X in all
those categories which describe your pain location)
<    > Perineum (area between {*filter*} [{*filter*}] and{*filter*} [bowel
       opening])
<    > {*filter*}
<    > Left testicle
<    > Right testicle
<    > Left groin
<    > Right groin
<    > Base of {*filter*}
<    > Higher up in middle of {*filter*}
<    >{*filter*}
<    > Around {*filter*}area but deeper inside
<    > Deep in abdomen
<    > Tip of {*filter*}
<    > Lower back
<    > My pain location is not in this list
<    > I don't have pain

----------
Ten of the next eleven questions are to be answered with a special 0
to 5 number indicating one of the following responses:

0 - Not at all
1 - Less than 1 time in 5
2 - Less than half the time
3 - About half the time
4 - More than half the time
5 - Almost always

You may find it easier to write this scale down for reference while
responding to these questions.
----------

[12] Over the past month or so, how often have you had a sensation
of not emptying your bladder completely after you finished
urinating? (use the special 0 to 5 response)
<    >

[13] Over the past month or so, how often have you had to urinate
again less than 2 hours after you finished urinating? (use the
special 0 to 5 response)
<    >

[14] Over the past month or so, how often have you found you stopped
and started again several times when you urinated? (use the special
0 to 5 response)
<    >

[15] Over the past month or so, how often have you found it
difficult to postpone urination? (use the special 0 to 5 response)
<    >

[16] Over the past month or so, how often have you had a weak
urinary stream? (use the special 0 to 5 response)
<    >

[17] Over the past month or so, how often have you had to push or
strain to begin urination? (use the special 0 to 5 response)
<    >

[18] Over the last 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? (for this question place an X in the
one answer that best describes you)
<    > None
<    > 1 time
<    > 2 times
<    > 3 times
<    > 4 times
<    > 5 or more times

-------------------
- {*filter*} Effects
-------------------

[19] Do you have difficulties achieving an {*filter*}? (use the
special 0 to 5 response)
<    >

[20] Do your {*filter*}s last long enough for {*filter*}l/{*filter*}
penetration and ejaculation? (use the special 0 to 5 response)
<    >

[21] Before your prostatitis did you suffer from premature
ejaculation? (use the special 0 to 5 response)
<    >

[22] Since your prostatitis started do you suffer from premature
ejaculation? (use the special 0 to 5 response)
<    >

[23] Does it take you longer to ejaculate now than before you got
prostatitis? (Y or N)
<    >

[24] Have you noticed a change in color of your {*filter*} since the
onset of prostatitis? (Y or N)
<    >

[25] Sine you have had symptoms of prostatitis, has your volume of
{*filter*}: (place an X before only one)
<    > Seemed higher (more {*filter*})
<    > Seemed lower (less {*filter*})
<    > Not changed
<    > Don't know

[26] Do you find it harder to reach {*filter*} than before you got
prostatitis? (Y or N)
<    >

[27] Do you have pain before or after ejaculation? (insert an X in
one or two responses)
<    > Pain before ejaculation
<    > Pain after ejaculation
<    > No pain related to ejaculation
<    > Not applicable to me

[28] Since your prostatitis started have you noticed: (place an X
before only one)
<    > No change in the feelings and sensation of ejaculation
<    > A decrease in the feelings or sensation of ejaculation
<    > An increase in the feelings or sensation of ejaculation
<    > Not applicable to me

[29] Were you a {*filter*} (no {*filter*} activity with another person)
before your symptoms of prostatitis began? (Y or N)
<    >

[30] Was there a change in {*filter*} frequency shortly before the
start of prostatitis? (put an X in front of the response that best
describes you)
<    > Abstinence (no {*filter*} activity) before the onset
<    > A period of decreased {*filter*} activity before the onset
<    > A period of increased {*filter*} activity before the onset
<    > Not applicable to me

[31] Number of {*filter*} partners in the period preceding the start of
prostatitis. (put an X in one of the categories)
<    > 0
<    > 1
<    > 2-5
<    > 6-10
<    > Greater than 10

[32] Please indicate what type of {*filter*} activity you had in the
period before your onset of prostatitis. (insert an X in all
appropriate categories)
<    > None
<    > {*filter*} by self
<    > {*filter*} by others
<    > {*filter*}l {*filter*} with a female who had never given birth
<    > {*filter*}l {*filter*} with a female who had given birth
<    > {*filter*}{*filter*} with you as inserter
<    > {*filter*}{*filter*} with you as receiver
<    > {*filter*}sex performed on you

[33] How frequent was your {*filter*} activity before the onset of
prostatitis? (place an X in the most appropriate answer)
<    > None
<    > A few times a year
<    > A few times a month
<    > A few times a week
<    > Several times a week

[34] How frequent is your {*filter*} activity after the onset of
prostatitis? (place an X in the most appropriate answer)
<    > None
<    > A few times a year
<    > A few times a month
<    > A few times a week
<    > Several times a week

[35] Has your doctor documented bacterial infections in your urine
with cultures? (insert an X in the correct answer for you)
<    > Yes
<    > No
<    > Don't know

[36] Has your doctor documented bacterial infection in {*filter*} by
culture? (insert an X in the correct answer for you)
<    > Yes
<    > No
<    > Don't know

[37] Has your doctor documented white {*filter*} cell count findings
from penile fluid discharged during a finger rectal exam?
(Technically this is obtaining EPS [expressed prostatic fluid]
during a digital rectal exam [DRE]. The WBC below stands for White
{*filter*} cell Count and HPF stands for High Power Field. Place an X in
the appropriate answer.)
<    > Don't know
<    > Definitely never had such an exam done
<    > Doctor tried but no fluid obtained
<    > 10 WBC/HPF
<    > 10-20 WBC/HPF
<    > 20 WBC/HPF

[38] Has your doctor or any of your doctors told you that you have:
(put an X in front of all that apply)
<    > Inflammatory prostatitis
<    > Chronic prostatitis
<    > Bacterial prostatitis
<    > Abacterial prostatitis
<    > Non-bacterial prostatitis
<    > Idiopathic prostatitis
<    > Acute prostatitis
<    > Prostatodynia
<    > Epididymitis
<    > Prostatic cancer
<    > None of the above
<    > Not sure

------------
- Antibiotics
------------

[39] Have you taken antibiotic medication for the condition? (put
an X in the response which best represents you)
<    > No
<    > Briefly
<    > Many times with one or two agents
<    > Almost constantly with multiple different {*filter*}

[40] How long does your doctor put you on antibiotics when you are
on them? (put an X in front of none or the one most appropriate
answer)
<    > One or two weeks
<    > Usually a month
<    > Several months
<    > Indefinitely (no stop date)
<    > Varies from one antibiotic to another
<    > Not applicable to me

[41] Are you currently on antibiotics? (Y or N)
<    >

[42] Did you respond to any antibiotics? (put in X in the most
appropriate reply)
<    > No
<    > Somewhat
<    > Yes
<    > Not applicable

[43] Have you ever gone into complete remission (symptoms went
totally away) even if only for a short time while taking
antibiotics? (Y or N)
<    >

[44] Have you had periods where you were taken off of antibiotics?
(put an X in the response that best matches your history)
<    > Not used antibiotics
<    > Used them continuously
<    > Had one period of being off of them
<    > Had more than one period of being off antibiotics

-------------
- Doctor interaction
-------------

[45] How many doctors have you seen about your condition? (insert a
number)
<    >

[46] Are you satisfied with the treatments given you by your
physician? (put in X in the most appropriate reply)
<    > Yes
<    > Partially
<    > No

[47] Are you satisfied with the attitude of your doctor? (put in X
in the most appropriate reply)
<    > Yes
<    > Partially
<    > No

----------
- Other Factors
----------

[48] Have you had any psychological problems dealing with this
disease? (put an X before any one of the following responses)
<    > None
<    > Some minor depression
<    > Some major depression
<    > Thoughts of suicide

[49] Do you have any history of immunological disease such as
severe allergies to particles in the air, psoriasis, asthma, joint
disease or arthritis or a disease regularly cared for by a
rheumatologist?
<    > Yes
<    > No
<    > Don't know

[50] Are your symptoms related to a particular activity such as
driving, sitting for long periods, bicycle riding, running, walking
or some other physical activity? (put an X in front of the
appropriate response)
<    > Yes
<    > No
<    > Not sure

[51] Do you have relatives with prostatitis? (put an X in front of
the appropriate response)
<    > Yes
<    > No
<    > Not sure

[52] If you have any medical history or other information that you
think relates to your prostatitis please tell about it. For
example, perhaps some specific thing like bike riding or driving
irritates you most. Do certain foods aggravate your symptoms? Do
you have psoriasis or asthma and does this medical condition run in
your family? (write between the < and > below and insert extra
lines as needed)
<

[53] Have you tried treatments, medical or not, that seemed to help?
This includes anything you think is effective such as long walks,
special cushions, herbs, etc. If so, tell what these are and how
beneficial they have been. (write between the < and > below and
insert extra lines as needed)
<

[54] If you now have or have had in the past any significant
symptoms not covered by this survey please indicate here. (write
between the < and > below and insert extra lines as needed)
<

[55] Would you be willing in the future to give your name and
address for a patient registry? (Y or N)
<       >

*******************************************************************
*      OPTIONAL IDENTIFICATION (leave blank for anonymity)        *
*******************************************************************

First Name
<                          >
Last Name
<                          >

*******************************************************************
* OPTIONAL RECEIVED NOTIFICATION (if you want to be automatically *
* notified that your survey has been received)                    *
*******************************************************************

E-mail Address
<                          >

*******************************************************************
*    END OF SURVEY  (see earlier directions for how to return)    *
*******************************************************************



Tue, 12 May 1998 03:00:00 GMT
 
 [ 1 post ] 

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