We appreciate the opportunity to respond to the comments by Drs. Kalantri, Moons, and Rich. We agree that the accuracy of the 3IQ is modest. However, Dr. Kalantri considerably overstates the proportion of women with urge incontinence (43%, which is not two thirds) and stress incontinence (23%, which is not three fifths) who are misclassified by the 3IQ (see our Table 3). As we stated in our conclusions, the modest accuracy of the 3IQ is acceptable given that the risk for misclassification and inappropriate treatment by primary care is low.

In response to Dr. Moons, the 3IQ is meant to be a diagnostic test applied in women with urinary incontinence and is not meant to be a screening tool for case finding. We included the first question of the questionnaire because some women may have incontinence that occurs less than monthly, and current incontinence in the last 3 months seemed a reasonable threshold for continuing onto the next 2 questions to determine the type of incontinence.

No gold standard test is agreed upon. To determine the gold standard, we consulted with international experts and our investigators and did a literature review. We respectfully disagree with Dr. Rich's conclusion that urodynamics are required for the gold standard. For clarification, we did not exclude older participants (age range for participants in the Diagnostic Aspects of Incontinence Study [DAISy] was 40 to 94 years) and we excluded only patients with major neurologic disease. We contend that our cohort was, in fact, very generalizable to patients who should be treated by primary care.

We agree with Dr. Moons that prediction based on several risk factors might, in principle, outperform our assessment essentially on the basis of 2 questions. However, the risk factors that he cites from our earlier work are considerably more useful for predicting weekly incontinence rather than for classifying type of incontinence among women who are known to have it. In addition, more complicated diagnostic algorithms are less useful in primary care practice.

We suggest using a self-help booklet as the first line of treatment (1). We agree with Dr. Rich that further studies of adverse effects of medications for urge incontinence should be conducted to evaluate the effect on cognitive functioning. We also recommend further study to determine the clinical outcomes that would result from using the 3IQ.

Until those studies are performed, using the 3IQ in a primary care setting seems reasonable.