Pad Testing 2020

Download as pdf or txt
Download as pdf or txt
You are on page 1of 5

Chapter

Pad Testing in the Assessment of

3 Urinary Incontinence in Women


Emmanuel Karantanis

3.1 Introduction
Pad testing, most often used as an objective assessment of urinary incontinence, involves
the use of pre-weighed continence pads to capture urinary leakage over a period of time. On
completion of the tests, the pads are then weighed to calculate the amount of leakage.

3.2 Why Are Pad Tests Performed?


Pad tests are most commonly used in the research setting but can be an important clinical
aid, especially in cases where it is uncertain that the ‘leakage’ is urinary in origin. Generally,
pad tests are employed:
 To provide objective confirmation of urinary incontinence before and after treatment.
 To measure objectively the quantity of urine loss as a measure of severity: a 24-hour pad
test loss of greater than 75 g represents severe incontinence in women with stress
urinary incontinence [1].
 As a general aid when determining the type of incontinence: women with pure stress
urinary incontinence have been shown to leak less than 100 g in 24 hours and those with
overactive bladder have more severe leakage [1]; however, there is significant overlap,
such that pad tests cannot be used to make an accurate diagnosis.
 To help to differentiate between urine and vaginal discharge in women who may have
excessive vaginal fluid loss: urinary incontinence is unlikely if less than 2 g of loss is
found on 24-hour pad test [2]; such tests should not be conducted with panty liners, as
they have a tendency to evaporate their fluid.

3.3 Types of Pad Test


Pad testing methods differ with regard to duration (ranging between 1 and 72 hours) and in
the activities undertaken during the test. The two most common methods used for pad
testing are 1-hour and 24-hour tests.

3.3.1 One-Hour Pad Testing


One-hour pad tests are performed in a clinical setting, under the supervision of a continence
nurse or doctor. They include a filling phase, during which the patient spends 15 minutes
drinking 500 ml of fluid. This is followed by a series of provocative manoeuvres, such as
coughing and jumping, to try to stimulate urinary leakage. Pads are weighed before and at the
end of the test. Pad loss greater than 1 g is designated as significant or a ‘positive pad test’ [3].

14
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 13 Apr 2020 at 16:26:12, subject to the Cambridge Core terms of
use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/9781108346351.005
3 Pad Testing in Assessment of Urinary Incontinence in Women

3.3.2 Twenty-Four-Hour Pad Testing


Twenty-four-hour tests are performed at home. Women are provided with a set of pads and
advised not to modify their normal drinking or activities. The aim of such tests is to
document leakage in a normal home environment. Pad loss greater than 4 g is designated as
significant or a ‘positive pad test’. The values for 24-hour pad test are classified as follows:
mild (4–20 g/24 hour), moderate (21–74 g/24 hour), and severe (>75 g/24 hour) incontin-
ence [3].

3.4 Performing a Pad Test


3.4.1 Equipment
There are three components needed to perform a pad test:
 pads;
 snap-lock bags (one per test) to keep moisture in (all pad wrapping and adhesives should
be placed in the bag to maintain an accurate post-test recording);
 weighing scales: scales accurate to 0.1 g should be used.

3.4.2 One-Hour Pad Test


The ICS Standardisation Committee has set out a standard protocol for the 1-hour pad
test [3].
1. Test is started without the patient voiding.
2. Pre-weighed pad or collecting device is put in place by the subject and the first 1-hour
test period begins.
3. Subject is given 500 ml sodium-free liquid to drink within a short period (maximum 15
minutes) and then the subject sits or rests for 15 minutes.
4. Half-hour period: subject walks, including stair climbing equivalent to one flight up
and down.
5. During the remaining period, the subject performs the following activities:
i. standing up from sitting, 10 times;
ii. coughing vigorously, 10 times;
iii. running on the spot, 1 min;
iv. bending to pick up a small object from floor, 5 times;
v. wash hands in running water, 1 min.
6. At the end of the 1-hour test, the pad or collecting device is removed and weighed.
7. If the test is regarded as representative, the subject is asked to void and the voided
volume is recorded.
8. If the test is not regarded as representative, the test is repeated, preferably without
voiding.

3.4.3 Twenty-Four-Hour Pad Test


The 24-hour pad test has not been standardised. The following is a description of the 24-
hour pad test as used by the author:

15
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 13 Apr 2020 at 16:26:12, subject to the Cambridge Core terms of
use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/9781108346351.005
3 Pad Testing in Assessment of Urinary Incontinence in Women

1. Women are provided with five incontinence pads (such as Tena Lady Normal™, SCA
Hygiene Products, Göteborg, Sweden; these pads are less evaporative than panty liners,
less absorptive than thicker pads and more accurately reflect the fluid deposited on
them).
2. Each pad is pre-weighed within a snap-lock bag. Women start the test in the morning
and change to a new pad every 4 hours during the day. Whenever a pad is removed, it
must be reinserted in its original snap-lock bag together with the wrappings and
adhesives that were originally weighed. At the end of the day, the women wear their final
pad for about 8 hours overnight and complete the test upon waking.
3. The pads are returned within 7 days, as they are shown to hold moisture if sealed [4].
4. Women do not need to undertake any particular provocative activities apart from their
usual activities. It is useful to perform any vigorous activities that usually produce
leakage activities while undertaking the test.
5. Twenty-four-hour pad tests are particularly informative when performed
simultaneously with a bladder chart.

3.5 Comparison of 1-Hour and 24-Hour Pad Tests


The 24-hour pad test has been found to be repeatable and more sensitive than the 1-hour
pad test in detecting urinary incontinence [5]. It requires fewer staff resources and less time
and has been correlated with subjective severity measures [1,6–8]. The upper limit of
normal for a 24-hour pad test is 2 g when using Tena Lady Normal™ pads. The report of
the fourth International Consultation on Incontinence 2016 suggested that the 24-hour pad
test was preferable because of the poor predictive value of the 1-hour pad test in the
diagnosis of female urinary incontinence [5].

Clinical Scenario 1
A woman has constant moistness in the vagina, causing her to wear a pantyliner. The
pantyliner tends to be damp but does not contain obvious significant amounts of urine.
Despite this, the patient insists the panyliner smells like urine. In this case, the cause of the
dampness could be urine or vaginal mucus. A 24-hour pad showing >4 g of loss would point
towards a urinary loss.
Tip. Encouraging the woman to take Vitamin B complex tablets during the 24-hour pad
test can be helpful because urine on the pantyliner ought to stain orange, and help confirm or
negate whether urine is the cause of the dampness.

Clinical Scenario 2
A woman who leaks only during sport has a normal urodynamic assessment. Pelvic floor
muscle training and the use of continence devices fail to control the leakage. The woman
wants to proceed with surgery, but there is no objective evidence of urinary incontinence.
In this case, a 24-hour pad test conducted during a weekend of sport together with a
bladder diary showing activity can confirm significant leakage during sport. Activity has been
shown to increase 24-hour pad weight gain in women complaining of stress urinary
incontinence [9].

16
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 13 Apr 2020 at 16:26:12, subject to the Cambridge Core terms of
use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/9781108346351.005
3 Pad Testing in Assessment of Urinary Incontinence in Women

3.6 Limitations of Pad Tests


 Not standardised.
 Results influenced by fluid intake, increased voiding difficulty, sweating, vaginal
discharge.
 Inability to measure compliance.
 No diagnostic accuracy.
 No correlation to severity.

3.7 Summary
Pad tests are of most value in the research setting before and after treatment, as an objective
endpoint of urinary incontinence. The activity undertaken by the women during a test may
influence the results such that a similar level of activity should be performed when pad
testing for comparison before and after treatment. Women’s compliance with 24-hour pad
tests decreases once cured. The same types of pad should be used for all patients before and
after treatment, as pads have different absorptive and evaporative qualities. The major
limitation of the pad test is the lack of diagnostic ability.

Learning Points
 Pad tests are most commonly used in the research and clinical settings as an objective
endpoint of urinary incontinence.
 Pad test methodology varies in duration and type of activities undertaken, with 1-hour
and 24-hour tests being the most common types.
 The same type of pad should be used throughout and Tena Lady Normal™ pads are the
most suitable absorptive type.
 A positive 1-hour pad test is urine loss greater than 1 g and a positive 24-hour test is urine
loss greater than 4 g.

References urinary incontinence. BJOG.


1996;103:162–7.
1. O’Sullivan R, Karantanis E, Stevermuer TL,
Allen W, Moore KH. Definition of mild, 5. Abrams P, Cardozo L, Wagg A, Wein A
moderate and severe incontinence on the (Eds). Incontinence 6th Edition. ICI-ICS.
24-hour pad test. BJOG. 2004;111:859–62. Bristol, UK: International Continence
Society; 2017.
2. Karantanis E, O’Sullivan R, Moore KH.
6. Costantini E, Lazzeri M, Bini V,
The 24-hour pad test in continent women
Giannantoni A, Mearini L, Porena M.
and men: normal values and cyclical
Sensitivity and specificity after one-hour
alterations. BJOG. 2003;110:567–71.
pad test as a predictive value for female
3. Krhut J, Zachoval R, Smith PP, et al. Pad urinary incontinence. Urol Int.
weight testing in the evaluation of urinary 2008;81:153–9.
incontinence. Neurourol Urodyn.
7. Karantanis E, Allen W, Stevermeuer TL,
2014;33:507–10.
Simons AM, O’Sullivan R, Moore KH. The
4. Versi E, Orrego G, Hardy E, Seddon G, repeatability of the 24-hour pad test. Int
Smith P, Anand D. Evaluation of the home Urogynecol J Pelvic Floor Dysfunct.
pad test in the investigation of female 2006;16:63–8.

17
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 13 Apr 2020 at 16:26:12, subject to the Cambridge Core terms of
use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/9781108346351.005
3 Pad Testing in Assessment of Urinary Incontinence in Women

8. Lose G, Jorgensen L, Thunedborg P. 24- 9. Painter V, Karantanis E, Moore KH.


hour home pad weighing test versus one- Does patient activity level affect 24-hr
hour ward test in the assessment of mild pad test results in stress-
stress incontinence. Acta Obstet Gynecol incontinent women? Neurourol Urodyn.
Scand. 1989;68:211–15. 2012;31:143–7.

18
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 13 Apr 2020 at 16:26:12, subject to the Cambridge Core terms of
use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/9781108346351.005

You might also like