To enable a complete assessment of your current symptoms, it is important for your physiotherapist to gain a thorough understanding of how your bladder is currently functioning. Therefore, it would be appreciated if you could complete the following Bladder Diary for 48hours.
Instructions:
Try to choose two days where you feel that you would most easily be able to complete the diary.
Aim to start when you first wake up the first day and continue for 48hours. You should finish by recording the first void after waking the second night (first time passing urine on the third day).
Bladder function section:
- Time
- Interval
- Urge to pass urine from 0-4
- 1= Sensation of some urine but no desire to void eg. could delay 1hour
- 2 = Mild-Moderate Desire to void eg. could delay 30min
- 3 = Strong Desire to Void eg. couldn’t delay >15min
- 4 = Urgent Desire to Void eg. unable to delay 5min
- Did You Leak on Way to Toilet?
- No
- Yes – S/A eg a few drops, 20c piece
- Yes – M/A eg underwear quite damp
- Yes – L/A eg wet outer clothes
- Volume of Urine Passed / Bowels Opened
- Urine: Measure the amount of urine in mls (“cc” on specipan measure).
- Bowels: Write “BO” (bowels opened).
- NB: When you go to the toilet to open your bowels you are not expected to measure the amount of urine you pass at the same time.
Fluid intake section:
1. Time: eg. 9.45am, 3.30pm
2. Type: eg coffee, water, juice, tea.
3. Amount: eg. 1 cup, 200mls.
Bladder diary:
Day 1: Date: Time Went to Sleep: Time Woke Up:
| Time | Interval | Urge (0-4) | Leakage | Urine Vol/BO |
| Time | Type | Volume |
Day 2: Date: Time Went to Sleep: Time Woke Up:
| Time | Interval | Urge (0-4) | Leakage | Urine Vol/BO |
Day 2: Date: Time Went to Sleep: Time Woke Up:
| Time | Interval | Urge (0-4) | Leakage | Urine Vol/BO |