Pelvic Dysfunction Screening Protocol Cozean Pelvic Dysfunction Screening Protocol This screening tool was developed to help patients and practitioners determine if pelvic floor dysfunction may be present. 1 / 10 I sometimes have pelvic pain (in genitals, perineum, pubic or bladder area, or pain with urination) that exceeds a ‘3’ on a 1-10 pain scale, with 10 being the worst pain imaginable. Yes No 2 / 10 I can remember falling onto my tailbone, lower back, or buttocks (even in childhood) Yes No 3 / 10 I sometimes experience one or more of the following urinary symptoms Accidental loss of urine Feeling unable to completely empty my bladder Having to void within a few minutes of a previous void Pain or burning with urination Difficulty starting or frequent stopping/starting of urine stream Yes No 4 / 10 I often or occasionally have to get up to urinate two or more times at night Yes No 5 / 10 I sometimes have a feeling of increased pelvic pressure or the sensation of my pelvic organs slipping down or falling out Yes No 6 / 10 I have a history of pain in my low back, hip, groin, or tailbone or have had sciatica Yes No 7 / 10 I sometimes experience one or more of the following bowel symptoms Loss of bowel control Feeling unable to completely empty my bowels Straining or pain with a bowel movement Difficulty initiating a bowel movement Yes No 8 / 10 I sometimes experience pain or discomfort with sexual activity or intercourse Yes No 9 / 10 Sexual activity increases one or more of my other symptoms Yes No 10 / 10 Prolonged sitting increases my symptoms Yes No Your score is 0% Restart quiz
