Survey

Urinary Incontinence Self-Assessment Survey

If you have a leaky bladder you are not alone. Urinary incontinence is a problem that affects millions of women. These are the most common types of urinary incontinence:

Stress urinary incontinence (SUI) is a medical condition that affects over 15 million women in the US. It involves involuntary leakage of urine during routine activities such as laughing, coughing, sneezing, sex, or exercise
Urge urinary incontinence (UUI) is another medical condition. It is due to inappropriate contractions of the bladder often resulting in a sudden unexpected urge to urinate
Women with mixed urinary incontinence (MUI) experience symptoms of both SUI and UUI

This short survey is designed to help you understand your urinary incontinence and whether the Renessa treatment for SUI might be right for you.

Many women don't want to undergo surgery for SUI. Others mistakenly accept SUI as a natural part of aging or childbirth. Renessa is a non-surgical treatment performed in the comfort of a doctor's office, or in an outpatient center, in a 45-minute to 1-hour visit. You can safely resume virtually all activities the same or next day.

This survey is confidential.


1.	Do you leak urine when you laugh, cough, sneeze, or exercise? Yes No

2.	Is your urine leakage associated with a sudden unexpected urge to urinate? Yes No

3.	How long have you had problems with leaking urine? Less than one year More than one year

4.	Have you discussed your urine leakage with a doctor? Yes No

5.	If yes, what treatment(s) did you receive? Please check all that apply. No treatment Kegel exercises Biofeedback Pessaries/Catheters/Plugs Bulking agents Renessa Surgery Other

6.	How often do you leak urine? Never Once a week or less Two or three times a week Once a day More than once a day

7.	Does your urinary incontinence interfere with your daily activities? Yes No

8.	What activities have you stopped or are inhibited about doing because of your urinary incontinence? Exercise Sex Social activities Travel

9.	Do you experience any of the following complications in association with your urinary incontinence?
	Skin problems, rashes, infections, sores Yes No
	Urinary tract infections Yes No
	Lack of exercise Yes No
	Less participation in social gatherings Yes No
	Disruption in your concentration at work Yes No
	Avoidance of sexual intimacy Yes No
	Embarrassment Yes No
	Depression Yes No

10.	On a scale of 1 to 5, how concerned are you about your urine leakage? Not concerned 1 2 3 4 5 Very concerned

11.	On a scale of 1 to 5, how interested are you in the Renessa non-surgical treatment performed in a doctor's office in a 45-minute to 1-hour visit? Not interested 1 2 3 4 5 Very interested

12.	On a scale of 1 to 5, how likely are you to seek the Renessa treatment within the next 3 months? Not likely 1 2 3 4 5 Very likely

13.	If you are not likely to seek treatment within the next 3 months please indicate the reason(s): Cost Lack of insurance Don't want surgery Other medical complications Don't have time Other

14.	Did you complete this survey for yourself or for someone else? Self Friend or relative

15.	What is your age, or if you are reviewing this site for a friend, what is her age? Less than 25 years 25 to 50 years 51 to 65 years 65+ years

16.	Are you aware that Renessa is covered by Medicare? Yes No

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