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Male Chronic Prostatitis Symptoms Questionnaire

  • Personal Information

  • MM slash DD slash YYYY
    • Instructions:

    Please answer all of the questions in the following survey. These questions will ask you if you have certain bowel, bladder, or pelvic symptoms and, if you do, how much they bother you. Answer these by circling the appropriate number. While answering these questions, please consider your symptoms over the last 3 months. The PFDI-20 has 20 items and 3 scales of your symptoms. All items use a response scale from 0 to 4.
  • Pain

  • Urination

  • Quality of Life / Impact of Symptoms

  • Scoring the NIH-Chronic Prostatitis Symptom


    Pain: Total of items 1a, 1b, 1c, 1d, 2a, 2b, 3 and 4 = ____

    Urinary Symptoms: Total of items 5 and 6 = ____

    Quality of Life Impact: Total of items 7, 8 and 9 = ____

The National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI) captures the three most important domains of the prostatitis experience: pain (location, frequency, and severity), voiding (irritative and obstructive symptoms), and quality of life (including impact). This index is useful in research studies and clinical practice. (From Litwin MS, McNaughton-Collins M, Flowler FJ, et al: The NIH Chronic Prostatitis Index [NIH-CPSI]: Development and validation of a new outcome measure. J Urol 1999; 162:369-375.)