Evaluation of the home pad test in the investigation of female urinary incontinence

Efficacy and patient acceptability of the continence dish

INTRODUCTION AND HYPOTHESIS

The continence dish has been a treatment option since 2002 for women with stress urinary incontinence (SUI) who decline surgery, but few quantitative objective efficacy data are published. We aimed to determine the efficacy and acceptability of this device for pure SUI or mixed incontinence (MUI).

METHODS

Prospective interventional cohort study of 100 women with SUI or stress-predominant MUI who were interested to use the device; International Consultation on Incontinence Questionnaire (ICIQ) was primary outcome measure; 24-h pad test and Incontinence Impact Questionnaire (IIQ) were secondary outcomes. Acceptability was determined by device retention for 4 weeks, adverse events and ability to self-insert the device.

RESULTS

Of 100 suitable women, 9 were not actually fitted, and 27 did not complete (acceptability: 64/100). The rate of adverse events was 7.7%, with 62.5% of users able to self-insert the device: 22 (34%) had pure SUI; 66% had MUI. In SUI, 68% were 'dry' on ICIQ median value 4.0 (IQR 2.5-8.5); 88% were dry on 24-h pad test (median 0.0, IQR 0.0-8.5). The "dry rate" was lower in MUI: 36% for ICIQ (median 9.0, IQR 5.0-15.0) and 62% for 24-h pad test (median 6.2, IQR 0.95-19.7). A "good" response on IIQ occurred in 88% of SUI and 69% of MUI.

CONCLUSION

These new data showing strong objective benefits of the continence dish should be further validated by randomized trials, but this information should be made available to women seeking treatment options for SUI/MUI (particularly in view of concerns regarding mesh mid-urethral slings).

Pad test for urinary incontinence diagnosis in adults: Systematic review of diagnostic test accuracy

INTRODUCTION

The pad test is an assessment tool for urinary incontinence (UI) severity classification and therapeutic response monitoring. However, the reliability and reproducibility of this test have been questioned.

OBJECTIVES

To summarize the evidence regarding the accuracy measures and reproducibility of different pad test protocols for assessing UI.

METHODS

A systematic review of the diagnostic accuracy of this tool was performed (CRD42020219392). Eligibility criteria: Studies reporting data on the accuracy measures and reproducibility of the pad test when used for detecting UI in adult men and women.

DATA SOURCES

MEDLINE, Science Direct, Cochrane, Web of Science, LILACS, and Pedro.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened the articles, extracted the data, and evaluated the risk of bias (RoB) using the QUADAS-2 tool.

RESULTS

From 1048 studies, 18 studies were included. Eight of these reported accuracy data, and 12 reported reproducibility properties. A total of 1070 individuals were analyzed, whose mean age ranged from 20 to 90 years. The accuracy of the long-duration protocols was generally moderate to high (sensitivity, 60%-93%; specificity, 60%-84%). The 1-h protocols obtained higher accuracy values. The overall reproducibility was moderate to high (κ ≥ 0.66).

LIMITATIONS

The RoB was high and, due to different cutoff points adopted by studies, the bivariate model was not satisfied to perform a meta-analysis.

DISCUSSION

The 1-h pad test was more accurate but less reproducible when compared to the long-duration tests. Pad test results should be used with caution in clinical practice.

Longer is better than shorter: The added value of the seven-day pad test in the post-radical prostatectomy urinary incontinence

AIMS

To investigate the feasibility and reliability of the seven-day pad test (7DPT), the correlation between 7DPT and 24-hour pad test (24HPT), and International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) questionnaire, and the different categorization by the severity of each pad test. Pad weighting tests have been recommended in the evaluation of post-radical prostatectomy urinary incontinence severity, being considered the 24HPT gold standard. Some authors consider that the longer the testing, the better assessment. We propose a self-filled pad weight, the 7DPT.

METHODS

A prospective study of incontinent male patients after radical prostatectomy. We carried out the study in two phases. All patients underwent urodynamic study. The first phase evaluated the feasibility and reliability of 7DPT. The second evaluated the correlation between 7DPT, 24HPT, and ICIQ-SF questionnaire in a larger sample.

RESULTS

First phase: 32 patients were recruited. Test-retest reliability was excellent, with good agreement between mean 7DPT and 24HPT. The number of pads and mean 7DPT showed a good correlation. Second phase: 72 patients were screened, 51 (71%) met inclusion criteria. Mean 7DPT and 24HPT showed a strong association. Mean 7DPT and 24HPT correlated moderately with ICIQ-SF score. 7DPT and 24HPT agreement with ICIQ-SF groups was slight. As 7DPT captures better days with maximum urinary leakage, up to 12 patients would have been misclassified according to 24HPT (number need to treat for 7DPT was seven).

CONCLUSIONS

7DPT is a feasible and reliable tool to evaluate post-radical prostatectomy urinary incontinence, with a strong correlation with the 24HPT and moderate with the ICIQ-SF.

Effect of antibiotics on urine leakage in women with refractory detrusor overactivity: A phase IIb randomized trial

AIM

Because bacterial cystitis is common in women with refractory detrusor overactivity, the aim was to compare the efficacy of 6 weeks of rotating antibiotics versus placebo, in conjunction with an anticholinergic, in controlling the symptoms of urge incontinence.

METHODS

In a multicenter phase IIb double-blinded randomized placebo-controlled trial, women with urodynamically proven refractory detrusor overactivity were randomized in a 2:1 ratio of antibiotics versus placebo for 6 weeks, in addition to darifenacin for 6 months. Any woman with disabling cystitis symptoms was given appropriate antibiotics ("clinical override"). The primary outcome was the degree of urge incontinence change at 6 weeks and 6 months on 24-h pad test. Secondary outcomes were changes in leaks and voids per day measured on 3-day bladder diary and quality of life measures. Microbiological data were collected at all visits.

RESULTS

Although 278 women were screened, only 36 were randomized and 33 (91.7%) completed the trial. Leakage on 24-h pad test decreased at 6 months by 75 g in patients receiving antibiotics versus 35 g in placebo. Cure of urge incontinence occurred at 6 months in 10/21 (48%) of antibiotics versus 2/12 (17%) of placebo. Clinical override, necessitating treatment of cystitis, occurred in 41.6% of placebo versus 16.7% of the antibiotic group by 6 months.

CONCLUSION

Despite the small sample size, the study showed a significant reduction in pad leakage and leaks per day over 24 h in the active treatment group over a 6-month period. Nearly half of patients on placebo had disabling urinary tract infection symptoms that required clinical override treatment.

Patient pad count is a poor measure of urinary incontinence compared with 48-h pad test: results of a large-scale multicentre study

OBJECTIVE

To determine in a large population of community-dwelling incontinent patients the accuracy and determinants of pad count as a measure of urinary incontinence (UI), using data from a multicentre 48-h pad test study.

MATERIALS AND METHODS

Incontinent patients, who were provided with absorbent products for the period January 2012 to March 2016, volunteered to perform a 48-h home-based pad test and to fill in a diary with information on pad usage. Correlations between UI measures (48-h pad count and pad weight gain, mean pad weight gain per pad) were calculated. Logistic regression analyses were conducted to investigate patient-related and pad usage-related factors influencing pad count.

RESULTS

A total of 14 493 patients (median age 81 years) were included, with a total of 98 362 continence products used overall during the study period. The 48-h pad count showed a weak correlation with 48-h pad weight gain (R² = 0.12; 0.19 for men and 0.11 for women) and mean pad weight gain per pad (R² = -0.03). The weakest correlation was observed among patients using >6 pads/48 h (R² = 0.02). A statistically significant negative association between pad absorption capacity and pad count was observed. Patients using products with a shaped and rectangular design had 34% and 40% higher propensity to use more pads than those using briefs (P < 0.001), respectively.

CONCLUSIONS

The results of this very large observational study confirmed that pad count is a poor measure of UI severity. Pad count only measured 12% of the variability of UI volume and was affected by several patient-related and pad usage-related factors. Consequently, pad count should not be used instead of the pad test as an objective measure of UI when an accurate evaluation is required for research or clinical purposes.

Objectively improving appropriateness of absorbent products provision to patients with urinary incontinence: The DIAPPER study

AIMS

To objectively assess and enhance the appropriateness of continence products provision to sufferers from urinary incontinence (UI) managed with containment strategies.

METHODS

Incontinent patients of five Italian continence care services were included in this industry-supported study from 01/2012 to 03/2016. All patients/carers have been invited to perform a 48-h home-based pad test and to fill in a diary. The primary outcome was the product appropriateness defined as the use of a pad with maximum absorbent capacity (MAC) from 30% to 50% higher than the individually measured urine load. Pads provision was corrected accordingly. Meaningful factors affecting products appropriateness and patient's satisfaction with the new products were also assessed.

RESULTS

The study included 14 493 subjects (mean age 78 years; 26% males, 74% females) using overall during the study days 98 362 pads. Sixty percent of the products were found to be not appropriate. In most of cases, (75%) products were inappropriate because too large. Age and pad weight gain, followed by gender, body weight, waist circumference, level of autonomy and mobility, pad wearing time, skin health status, and health district were independently associated to the propensity to inappropriateness. After correction of products prescription, a significant reduction (-31%) of the use of largest products was observed. At 6 months evaluation, 88% of evaluable participants were satisfied with the new prescription.

CONCLUSIONS

Most of patients are provided with not appropriate containment products. The use of the 48-h pad test allows improving on an individual basis the appropriateness of products provision.

Assessing variability of the 24-hour pad weight test in men with post-prostatectomy incontinence

Purpose:

Decision-making regarding surgery for post-prostatectomy incontinence (PPI) is challenging. The 24-hour pad weight test is commonly used to objectively quantify PPI. However, pad weight may vary based upon activity level. We aimed to quantify variability in pad weights based upon patient-reported activity.

Materials and Methods:

25 patients who underwent radical prostatectomy were prospectively enrolled. All patients demonstrated clinical stress urinary incontinence without clinical urgency urinary incontinence. On three consecutive alternating days, patients submitted 24-hour pad weights along with a short survey documenting activity level and number of pads used.

Results:

Pad weights collected across the three days were well correlated to the individual (ICC 0.85 (95% CI 0.74–0.93), p<0.001). The mean difference between the minimum pad weight leakage and maximum leakage per patient was 133.4g (95% CI 80.4–186.5). The mean increase in 24-hour leakage for a one-point increase in self-reported activity level was 118.0g (95% CI 74.3–161.7, p<0.001). Pad weights also varied significantly when self-reported activity levels did not differ (mean difference 51.2g (95% CI 30.3–72.1), p<0.001).

Conclusions:

24-hour pad weight leakage may vary significantly on different days of collection. This variation is more pronounced with changes in activity level. Taking into account patient activity level may enhance the predictive value of pad weight testing.

Correlates among nocturnal agitation, sleep, and urinary incontinence in dementia

Family caregivers of elders with dementia often face the challenging behaviors of nighttime agitation, sleep disturbances, and urinary incontinence. To date, no study has examined the interrelationships of these behaviors in community-dwelling persons. This single group, descriptive study employs wireless body sensors to objectively collect data on nighttime agitation, sleep, and urinary incontinence in patients with dementia in their homes over a 5- to 7-day period. The aims are to (1) examine the feasibility and acceptability of the use of body sensors in community-dwelling persons with dementia; (2) describe patterns of nocturnal agitation, sleep continuity and duration, and nighttime urinary incontinence; and (3) examine the relationships among nocturnal agitation, sleep continuity and duration, and nighttime urinary incontinence. Data collection is in early stages and is still in progress. Challenges and advantages from preliminary data collection are reported.

Validity testing of the stopwatch urine stream interruption test in radical prostatectomy patients

OBJECTIVE

To assess convergent validity of the stopwatch urine stream interruption test (UST). Specific aims were to describe relationships among stopwatch UST scores and 4 common clinical indices of pelvic floor muscle strength: 24-hour urine leakage, confidence in performing pelvic muscle exercise, 24-hour pad count, and daily pelvic muscle exercise count.

DESIGN

Secondary analysis; instrumentation study.

METHODS

The final sample consisted of baseline stopwatch UST scores and measurements of comparison variables from 47 participants in a randomized clinical trial of 3 approaches to pelvic floor training for patients with urinary incontinence following radical prostatectomy. The sample size provided 80% power to detect correlations of moderate strength or higher. The stopwatch UST was conducted in an examination room at the study site by trained study personnel (MP, ADC, JP, SM). Measurements of comparison variables were obtained from 3 instruments: 24-hour pad test, Broome pelvic muscle self-efficacy scale, and 3-day bladder diary. Relationships among study variables were evaluated with Pearson correlation coefficients.

RESULTS

Stopwatch UST scores were moderately correlated with 24-hour urine leakage on the 24-hour pad test (r = 0.35, P < .05), the most robust comparison measure. Correlations between stopwatch UST scores and all other comparison measures were in the appropriate direction, although weak, and did not reach statistical significance.

CONCLUSION

Findings suggest that the stopwatch UST may be a valid index of pelvic floor muscle strength in men following radical prostatectomy. With further testing, the stopwatch UST could become a valuable clinical tool for assessing pelvic floor muscle strength in radical prostatectomy patients with urinary incontinence.

Vaginal weights for pelvic floor training: a multiple participant case report

Activity-related incontinence is a problem for women, many with limited access to specialty clinics and practitioners. Incontinence inhibits participation in health-promoting levels of physical activity. Vaginal weights are a treatment option available without a prescription for home use that may help some of these women. This multiple baseline across-participant case study investigated the use of weights in a 'hands-off' pelvic floor exercise program for pre-menopausal women. Three of four participants improved, but did not cure, their incontinence with use of the weights. A fourth participant was unable to successfully use the weights. Referral to a women's health physical therapist was suggested for her. Poor adherence was noted at follow-up in two of three participants, with the one who maintained practice demonstrating continued improvement and increased physical activity. Weights provide a low-cost exercise adjunct to women interested in a flexible and independent incontinence management program. For continued improvement, behavioral factors promoting adherence should also be addressed. Weights are one of the options for women wanting a low-cost solution for activity-related urinary leakage. Problems using the weights or failure to benefit from their use may be indicators of a need for more advanced evaluation by women's health specialists.

Validity of the incontinence severity index: comparison with pad-weighing tests

The incontinence severity index (ISI) consists of two questions, regarding frequency and amount of leakage. It categorizes urinary incontinence (UI) into slight, moderate, severe, and very severe. The purpose of this study was to test its validity. The index was compared with the results of pad-weighing tests performed by 200 incontinent women referred to a hospital clinic and 103 at a primary care incontinence clinic. Inconvenience was scored by a six-level Likert scale. Mean pad-weighing results (grams per 24 hours, 95% confidence intervals) were 7 (4-10) for slight, 39 (26-51) for moderate, 102 (75-128) for severe, and 200 (131-268) for very severe UI. Spearman's correlation coefficient for pad-weighing results and severity index was 0.58 (p<0.01), and inconvenience increased significantly with increasing severity. The ISI demonstrated good criterion validity against 24-h pad tests. Good construct validity was indicated by a clear link between ISI and inconvenience.

Systematic review and meta-analysis of methods of diagnostic assessment for urinary incontinence

AIMS

To evaluate the performance of all tests proposed for the diagnosis of urinary incontinence.

METHODS

A systematic review and meta-analyses of the published literature of methods for diagnostic assessment of urinary incontinence.

RESULTS

One hundred twenty-one papers were included in the full review [Martin et al., 2006]. The quality of reporting in the primary studies was poor which reduced the number of studies that could be included in the data analysis. The literature suggests that women with urodynamic stress incontinence (USI) can be correctly identified in primary care from clinical history alone with a sensitivity of 0.92 (95% C.I.: 0.91-0.93) and specificity of 0.56 (0.53-0.60). A clinical history for the diagnosis of detrusor overactivity (DO) was found to be 0.61 (0.57-0.65) sensitive and 0.87 (0.85-0.89) specific. Within secondary care imaging of leakage by ultrasound was found to be effective in the diagnosis of USI in women with a sensitivity of 0.89 (0.84-0.93) and specificity of 0.82 (0.73-0.89).

CONCLUSIONS

Clinical interpretation of the results of the review is difficult because few studies could be synthesized and conclusions made. The published evidence suggests that a large proportion of women with USI can be correctly identified in primary care from history alone. Ultrasound offers a useful diagnostic tool which could be used prior to, and possibly instead of, multi-channel urodynamics in some circumstances. If a patient is to undergo urodynamic testing, multi-channel urodynamics is likely to give the most accurate result. Further primary studies adhering to STARD guidelines are required on commonly used tests.

[A new approach to the transvaginal needle suspension technique after Raz. Technique and long-term results]

AIM

Our aim is to describe the surgical technique and to present a long-term evaluation of the results.

MATERIALS AND METHODS

A total of 53 patients with stress incontinence underwent a Raz transvaginal needle suspension operation with the introduction of a polypropylene mesh strip (15x1.5-2 cm) pulled under the suspension threads. The suspension threads occur on the endopelvic fascia in order to support the bladder neck and to permit the function of the polypropylene mesh strip, which, however, does not take part in supporting the bladder neck. The same urologist carried out 53 consecutive operations with clinical evaluation at 6 months, 1 and 5 years after surgery.

RESULTS

After 6 months, 51 of the patients (96.2%) reported remaining dry after increasing intra-abdominal pressure. Two (3.7%) still had stress incontinence symptoms. After 1 and 5 years, 47 (88.6%) were dry and urinated normally, with spontaneous disappearance of nightly enuresis in two and surgery for subvesicular obstruction in one.

CONCLUSIONS

The introduction of a polypropylene mesh strip in the suspension threads in cases using the trasvaginal suspension technique has good, long-term results for the treatment of patients with stress incontinence.

Comparative study of autologous pubovaginal sling and synthetic transobturator (TOT) SAFYRE sling in the treatment of stress urinary incontinence

PURPOSE

To compare short-term results of autologous pubovaginal sling and synthetic transobturator (TOT) SAFYRE sling in the treatment of female stress urinary incontinence (SUI).

METHODS

Twenty women referred for surgical treatment of SUI were assigned randomly to autologous pubovaginal sling or synthetic TOT sling. Inclusion criteria were primary treatment of SUI and urodynamic study showing SUI without detrusor overactivity. Pre- and postoperative quantification of the severity of incontinence was done by pad test and a validated questionnaire (King's Health Questionnaire).

RESULTS

There were no differences in patients' mean age, parity, body mass index, rate of postmenopausal state, pelvic floor defects and mean Valsalva leak point pressure in the preoperative urodynamic study. Mean operating time (21.1 +/- 3.8 vs. 69.5 +/- 23.7 min; P < 0.001) and hospital stay (28.8 +/- 8.4 vs. 44.4 +/- 5.8 h; P < 0.001) was shorter in the TOT than the autologous group. The postoperative pad test (39.4 +/- 12.5 vs. 8.4 +/- 5.2 g; P = 0.01) and the absent in the improvement in the quality of life were significantly higher in the TOT group.

CONCLUSION

Our initial results suggest that the synthetic TOT technique had worse effectiveness for treating female SUI compared to autologous pubovaginal sling.

Pelvic floor muscle training is effective in women with urinary incontinence after stroke: a randomised, controlled and blinded study

AIMS

The aim of this study was to evaluate the effect of Pelvic Floor Muscle Training (PFMT) in women with urinary incontinence (UI) after ischemic stroke.

MATERIALS AND METHODS

Three hundred and thirty-nine medical records of stroke patients were searched. Twenty-six subjects were randomised to a Treatment Group (14 subjects) or a Control Group (12 subjects) in a single blinded, randomised study. The intervention included 12 weeks of standardised PFMT. The outcome measures were: (1) diary recording the frequency of voiding, the number of incontinence episodes and used pads; (2) 24-hr home pad test; and (3) vaginal palpation of pelvic floor muscle evaluating function, strength, static and dynamic endurance.

RESULTS

Twenty-four subjects with urge, stress and mixed stress/urge incontinence, completed the study, 12 in each group. A significant improvement in frequency of voiding in daytime (Treatment Group/Control Group: 7/8 at pre-test, 6/9 at post-test (median values), P=0.018), 24-hr pad test (Treatment Group/Control Group: 8/12 to 2/8 g P=0.013) and dynamic endurance of pelvic floor muscle (Treatment Group/Control Group: 11/20 to 20/8 contractions of Pelvic Floor Muscle, P=0.028) was demonstrated in the Treatment Group compared to the Control Group. A significant improvement in frequency of voiding in daytime (decreased from seven to six, P=0.036), pelvic floor muscle function (P=0.034), strength (P=0.046), static endurance increased from 9 to 30 sec (P=0.028) and dynamic endurance increased from 11 to 20 contractions (P=0.020) was also demonstrated within the Treatment Group, but not in the Control Group.

CONCLUSION

PFMT had a significant effect in women with UI after stroke measured by diaries, pad tests and vaginal palpation.

Pelvic Floor Muscle Training With Biofeedback and Bladder Training in Elderly Women

OBJECTIVE

It is generally assumed that interventions used to treat urinary incontinence (UI) in young women could simply be applied to older competent and motivated women, but these assumptions have not been formally tested. The purpose of this study was to determine the feasibility of using physical therapies to treat UI in older women.

DESIGN

Twelve-week time series.

SETTINGS AND SUBJECTS

We recruited women older than 75 years with UI from an outpatient urology clinic and a waiting list for incontinence surgery.

METHODS

After a baseline evaluation, the women collected data on their incontinence symptoms and bladder habits for 3 weeks using the 72-hour voiding diary and the 24-hour pad test. They then received 6 physical therapy treatments consisting of a combination of bladder training and pelvic floor muscle training assisted with biofeedback for 6 weeks. This was followed by another 3-week period of data collection and a final evaluation.

RESULTS

Ten women participated in the study; 7 completed it. They were all comfortable with the treatment. They complied with the study demands in terms of attendance at treatment session (100%), data collection (96%), and completion of exercises at home (82%). The authors observed a decrease in the number of incontinent and urgency episodes.

CONCLUSION

This preliminary study demonstrates that some women older than 75 years are good candidates to undertake physical therapies for UI and follow study demands. Random controlled studies that include this population will provide evidence regarding the effectiveness of these therapies.

Pad tests and self-reports of continence in men awaiting radical prostatectomy: establishing baseline norms for males

AIMS

In this study, we report normal pad weight gain in a group self-reported continent men and compare the self-report data with the 24-hr pad test and the International Prostate Symptom Score (IPSS).

MATERIALS AND METHODS

Subjects awaiting radical prostatectomy were consecutively recruited. Exclusion criteria were a previous history of urologic surgery, reported urinary incontinence, or a medical problem which could affect bladder function.

RESULTS

Two hundred forty five men were enrolled. All were Caucasian, mean age 62.7 years, mean Gleason score 6.5, and mean PSA 8.3. At initial interview, all described themselves as continent of urine and 26 declined the 24-hr pad test because they were emphatic that they were continent. Of the 220 remaining, mean pad weight gain was 4.0 g on 24-hr pad test (SD 3.8; range 0-35.0 g), mean IPSS score was 7.23; 95 subjects scored > or = 8 (moderate), 13 scored > or = 20 (severe). The IPSS single Quality of Life (QOL) question and the 24 hr pad weight were not correlated; the summary IPSS score and pad weight had a correlation of 0.16 (P = 0.02) and the QOL question and the summary IPSS score had a correlation of 0.63 (P < 0.001). IPSS QOL scores were worse for those recording > or = 8 (P < 0.001).

CONCLUSIONS

The range of weight gain between 0 and 35 g suggests that self-report alone of urinary continence is an inaccurate measure of continence for research purposes. We propose that a pad weight gain of 8 g or less is indicative of urinary continence in men.

The relationship between clinical parameters and health-related quality of life as measured by the 15D in incontinent women before and after treatment

BACKGROUND

The purpose of this study was to correlate the clinical parameters with a health-related quality of life (HRQoL) measure and to describe the change of HRQoL caused by treatment and its modifying factors among urinary incontinent women.

METHODS

Eighty-two incontinent women, referred to a tertiary gynecologic department, underwent clinical evaluation to establish diagnosis and severity of urinary incontinence (UI) and completed the generic 15D HRQoL instrument. Sixty-nine women were re-evaluated 13 months after treatment.

RESULTS

Compared to age-matched female general population, the HRQoL of urinary incontinent women was significantly lower. Urge or mixed incontinence impairs HRQoL more than stress incontinence. The 15D scores correlated poorly with urodynamics, frequency/volume chart findings, and the amount of urine leakage. Among patients with stress UI (SUI), the HRQoL after treatment was the same as in the age-matched general female population. Among women with urge or mixed UI, the HRQoL improved significantly after treatment but did not reach the HRQoL level of women with SUI at baseline. In stepwise regression analysis, lower the 15D score at baseline and bigger the decrease in urine leakage, greater was the change in HRQoL for the better.

CONCLUSION

There was a modest correlation of incontinence severity measures with quality of life impairment. The challenge for the future will be to improve the success of treatment for women with urge UI. The generic 15D appears to be sensitive to detect change in HRQoL due to treatment of UI women.

Definition of mild, moderate and severe incontinence on the 24-hour pad test

The values for 'mild', 'moderate' and 'severe' urinary incontinence have not been determined for the 24-hour pad test. To define these values, a prospective observational study was performed on 110 women with the primary symptom of urinary incontinence. Consenting women performed two 1-hour pad tests one week apart, and seven 24-hour pad tests for seven consecutive days. The 1-hour pad test definitions for mild, moderate and severe were translated to centiles, and used to categorise the 24-hour test values. This revealed that the range for 'mild incontinence' was between 1.3 and 20 g, 'moderate incontinence' ranged from 21 to 74 g, and 'severe incontinence' was defined as 75 g or more in 24 hours. Severity of leakage was analysed in relation to urodynamic diagnosis, age, parity and pelvic floor muscle strength. Increasing severity was associated with increasing age and parity. Women with detrusor overactivity were most likely to have severe leakage. In conclusion, this study defines the three grades of severity for the 24-hour pad test, which may help to guide patients' choice between conservative and surgical treatment and is useful for stratified randomisation of controlled trial participants.

The repeatability of the 24-hour pad test

A prospective observational study was conducted in a tertiary urogynaecology unit in women with the primary symptom of urinary incontinence to assess the repeatability of the 24-hour pad test. One hundred and eight women undertook seven 24-hour pad tests over 7 consecutive days together with 7 simultaneous fluid and activity charts. The results were analysed collectively and according to urodynamic subsets. Repeatability was assessed by repeated measures analysis of variance and univariate analysis of variance for each urodynamic diagnosis group (USI, mixed and no USI). Variation between pad test weights over the 7 days was low, supporting good repeatability. The number of days of pad testing required to approximate the 7-day average was 3 days. However, a single 24-hour pad test correlated highly with the 7-day average (r=0.881) and was considered sufficient to gauge leakage severity.

Tension-Free Vaginal Tape and Laparoscopic Mesh Colposuspension for Stress Urinary Incontinence

OBJECTIVE

To compare objective and subjective outcomes after the tension-free vaginal tape procedure (TVT) with laparoscopic mesh colposuspension as a primary treatment for female stress urinary incontinence. Objective outcome measures were stress test and 48-hour pad test.

METHODS

In 6 departments of gynecology in Finland, including 4 university teaching hospitals and 2 central hospitals, 128 women with urodynamic stress incontinence were randomly allocated to 2 treatment groups. Seventy were treated with TVT and 51 by means of laparoscopic mesh colposuspension. There were 7 dropouts. Inclusion criteria were history of stress incontinence, positive stress test, and urodynamic conformation of stress incontinence. Exclusion criteria were age older than 70 years, previous incontinence surgery, more than 3 episodes of urinary tract infection within the last 2 years, coincident other gynecological surgery, body mass index more than 32 kg/m(2), urethral closure pressure less than 20 cm H(2)O, and residual volume more than 100 mL in preoperative urodynamic evaluation. Assessment took place before treatment and at 12 months postoperatively with the cough stress test, Urge Score, 48-hour pad test, King's College Health Questionnaire, Visual Analog Scale, and Urinary Incontinence Severity Score.

RESULTS

When negative stress test was used as criteria for cure, 85.7% of women in the TVT group and 56.9% in the laparoscopic mesh colposuspension group were objectively cured. Subject satisfaction was significantly better after the TVT procedure than after laparoscopic mesh colposuspension.

CONCLUSION

Treatment with TVT results in higher objective and subjective cure rates at 1 year than treatment by means of laparoscopic mesh colposuspension.

Objective assessment of urinary incontinence in women: comparison of the one-hour and 24-hour pad tests

OBJECTIVE

To compare the performance and clinical usefulness of the one-hour and 24-hour pad tests in terms of the relationship with reported symptoms and urodynamic diagnosis.

METHODS

341 women aged 40 years and over reporting lower urinary tract symptoms who were recruited to a nurse led continence service, and went on to receive urodynamics, a one-hour and a 24-hour pad test and completed a urinary diary.

RESULTS

For both pad tests, there was a significant difference in the amount of urine leaked between the different urodynamic diagnoses (p<0.0001, for the one-hour and p=0.001 for the 24-hour test). Women with sphincter incompetence leaked significantly more than women with detrusor instability, or those with no abnormality. There was a significant difference between the proportion of women dry on a one-hour pad test and those dry on a 24-hour pad test (26.0% versus 38.4%, difference 12.4%; CI 5.5; 19.4). There is a positive relationship between amount of urine leakage and symptom severity expressed in terms of number of incontinent episodes for both pad tests.

CONCLUSION

Both pad tests bore little relationship to the underlying urodynamic diagnosis but there was a positive relationship with symptom severity. The 24-hour pad test appears to be clinically a more useful too than the one-hour test. The two types of pad test are probably assessing incontinence in different ways. We suggest that the minimum data set should include structured questions, diaries and the 24-hour pad test.

Do objective urodynamic or clinical findings determine impact of urinary incontinence or its treatment on quality of life?

OBJECTIVES

To correlate the clinical and urodynamic parameters with two measures of incontinence-specific quality of life (QOL), to describe the changes in those measures after treatment, and to explore the factors determining these changes.

METHODS

A total of 82 incontinent women (mean age 52 years, range 28 to 80) underwent urodynamics testing and a 48-hour pad test. They also completed the frequency/volume chart, estimated the degree of bother from urinary incontinence using the visual analog scale (VAS), and completed a validated QOL instrument--the Urinary Incontinence Severity Score (UISS). Sixty-nine women were re-evaluated 13 months (range 6 to 21) after treatment.

RESULTS

A greater degree of disability from urinary incontinence as measured by the VAS correlated with a lower maximal urethral closure pressure (r = -0.29, P <0.01), greater detrusor pressure (r = 0.30, P <0.05), and amount of urine leakage (r = 0.46, P <0.001). The UISS correlated poorly with the urodynamic and frequency/volume chart findings. A greater amount of urine leakage was the best predictor of QOL impairment as measured by the UISS (beta 0.25; P = 0.034). The change in urine leakage best predicted the change in the UISS (beta 0.30; P = 0.024) and the change in the VAS (beta 0.48; P = 0.001).

CONCLUSIONS

The response to the question "How bothered are you by incontinence at this moment?" best reflects the severity of urinary incontinence measured objectively. Urodynamic parameters correlated poorly with incontinence-specific QOL measure. Of the clinical objective measures of the severity of urinary incontinence, the amount of leakage in the pad test was the best, although modest, predictor of QOL impairment. The change in urine leakage best predicted the change in QOL scores and VAS 1 year after beginning treatment.

Pad test by mail for home evaluation of urinary incontinence

AIMS

To present a simple, cost-effective, and convenient method of home pad test using the mail system and evaluating change in pad weight over time.

MATERIALS AND METHODS

A series of nine kinds of commonly available commercial brands of urinary incontinence pads ranging from thin liners less than 10 g in dry weight to large diapers weighing over 100 g each were assembled. Two or three of each variety were individually weighed on an OHAUS LS2000 Portable Standard scale accurate to +/- 1 g. The pads were then wet uniformly with 20 cc of saline, placed individually in sealable plastic bags, sealed, and reweighed. Random groups of three pads were mailed by standard 1st class mail to the Urocenter of New York. The sealed pads were reweighed at 8 and 14 days from the original wetting. Concurrently, ten incontinence pads soiled with urine were similarly examined to confirm that there would be no detectable difference between urine and saline for the purpose of the study. In the second part of the study, 20 pads of the same type (13 inch-long pads with absorbent gel) were divided into 4 groups of 5 pads; each group was uniformly wet with 5, 10, 20, or 50 g of saline. These pads were mailed and reweighed at 7 and 14 days from the initial wetting.

RESULTS

Twenty-four pads were used in the first part of the study. The dry weights of 22/24 (92%) of the pads were within 2 g of the average weight for their brand. At the first reweighing, 22 pads (92%) weighed within 2 g of their initial wet weights (Fig. 1). Only two pads on day 8 differed substantially from their initial weights: one pad appeared to have lost 4 g and another one 9 g. On day 14, 23/24 pads remained within 1 g of their day 8 weight and 1 differed by 2 g, and the total weight of the 24 pads on day 14 was only 4 g different from their initial weight (P = 0.71, Fig. 1). The soiled pads exhibited weight changes that were indistinguishable from the saline pads. The average cost of mailing the pads by 1st class mail was $4 and the average length of time in the mail was 5 days +/- 1 day. In the second part of the study, 18/20 pads had lost less than 1 g at 1 week, and at 2 weeks, 19/20 had lost less than 2 g when compared to their initial weights (Fig. 2). One pad had lost 3 g. Pads in the low volume groups (5 and 10 g) lost an average of 1.4 and 1.2 g, respectively, while pads in the high volume groups (20, 50 g) lost an average of 1.8 and 2 g at 2 weeks.

CONCLUSIONS

Dry pads of any single brand have a relatively standard weight that varies insignificantly between pads. Up to 2 weeks of delay in the weighing of individually sealed pads does not significantly affect the clinical measurement of weight at a variety of low (5 g) or high (50 g) volumes of simulated incontinence. Home pad test using the mail system is a feasible, inexpensive, and clinically accurate method of evaluating incontinence. Patients can be instructed in techniques for home pad test, allowing for greater compliance, and convenience for both physicians and patients.

Severe depression determines quality of life in urinary incontinent women

AIMS

The purpose of this study was to assess depression and anxiety in urinary incontinent women and to investigate factors influencing their self-perception of urinary incontinence severity.

METHODS

In this prospective study, 82 incontinent women estimated the severity of urinary incontinence using a visual analogue scale and completed a validated quality of life instrument: urinary incontinence severity score. Psychiatrists evaluated depression and anxiety using a structured interview of Hamilton Depression and Hamilton Anxiety Scales. Patients were classified on the basis of history and urodynamic evaluation into two diagnostic groups: stress urinary incontinence (n = 57) and idiopatic urge incontinence with or without stress incontinence (n = 25).

RESULTS

Major depression occurred in 44.0% of women with idiopatic urge (+/- stress) incontinence and in 17.5% women with stress incontinence (odds ratio (OR 3.69), 95% confidence interval (95% CI 1.30-10.49)). Twenty two patients had severe incontinence defined as Urinary Incontinence Severity Score > or =14 points (upper quartile) and 23 patients defined as visual analogue scale > or =9 (upper quartile). In logistic regression analysis, major depression (OR 5.57; 95% CI 1.19-26.11), urge incontinence diagnosis (OR 23.13; 95% CI 1.90-282.11), parity (OR 2.33; 95% CI 1.16-4.60) and high Urgency Score (OR 1.94; 95% CI 1.32-2.85) predicted Urinary Incontinence Severity Score above the upper quartile. Only the pad-test (OR 1.01; 95% CI 1.00-1.02) predicted visual analogue scale above upper quartile.

CONCLUSIONS

Major depression correlates with reduced incontinence specific quality of life. This data also suggests an association between depression and idiopatic urge incontinence.

Are urodynamic tests useful tools for the initial conservative management of non-neurogenic urinary incontinence? A review of the literature

OBJECTIVES

To summarise the evidence for the role of urodynamic tests in the diagnosis and classification of urinary incontinence.

METHODS

Reference lists in relevant papers were reviewed and MEDLINE searches conducted.

RESULTS

The mean sensitivity (specificity) of clinical history versus urodynamic tests was 0.82 (0.57) for stress incontinence, 0.69 (0.60) for urge incontinence/overactive bladder, and 0.51 (0.66) for patients with mixed incontinence. The proportion of women with a clinical diagnosis of urinary incontinence but with normal findings from urodynamic tests ranged from 3 to 8%. Overall sensitivity of urodynamic tests was about 85-90% in the diagnosis of urodynamic stress incontinence, but generally lower following diagnosis of urge and mixed incontinence. No relationship emerged between urodynamic test results and response to medical treatment.

CONCLUSIONS

This literature review shows that the sensitivity of clinical history versus urodynamic tests was 0.82, 0.69 and 0.51 respectively for stress, urge and mixed urinary incontinence. It also suggests that urodynamic diagnosis does not predict response to treatment. These data add to the ongoing 'urodynamics or no urodynamics' debate in the evaluation of urinary incontinence and show that urodynamic testing may not be helpful for patients receiving initial non-invasive therapy. These data are in line with the conclusions of the 1st and 2nd International Consultations on incontinence.

Validity and reliability of an interviewer-administered questionnaire to measure the severity of lower urinary tract symptoms of storage abnormality: the Leicester Urinary Symptom Questionnaire

OBJECTIVE

To develop a valid and reliable interviewer-administered questionnaire to measure the presence and severity of storage abnormality symptoms of incontinence, urgency, frequency and nocturia.

SUBJECTS AND METHODS

Subjects were 930 men and women aged >/=40 years, taking part in a randomized controlled trial of a continence nurse practitioner (CNP) service. Criterion validity was tested by comparing questionnaire responses to 24-h pad test and 3-day urinary diary. Responsiveness was assessed by comparing questionnaire responses before and after treatment. Questions about urgency were investigated for construct validity in patients taking part in the trial who underwent urodynamic investigation (243). Test-retest and inter-rater reliability was measured at approximately 6 days in subjects recruited to an associated epidemiological study (104 and 102, respectively).

RESULTS

The questionnaire responses showed significant associations with pad-test and diary measures. Questions about the severity of daytime incontinence performed better than those measuring night-time incontinence. The response categories of soaked, wet, damp and almost dry had better associations with the pad test than other measures of the severity of incontinence. Test-retest and inter-rater reliability was good for all questions, and all were responsive to change in symptoms, showing significant differences before and after treatment.

CONCLUSION

There is a clear need for standardization of measurement using well-validated instruments. This interviewer-administered questionnaire is valid, reliable and sensitive to change in a wide range of severity of symptoms, and in both men and women aged >/=40 years. The questionnaire provides a useful assessment tool for primary and secondary care in research and clinical settings.

Evaluating incontinence in women

Urinary incontinence in women has a multitude of presentations and can be a pure and simple entity or a complicated combination of overlying disorders. The diagnosis and work-up of the incontinent woman should proceed from the classic tools of medical treatment, as well as the history and physical exam, and should incorporate modern techniques of dynamic imaging. It is vital to remember that it is often not until a simple treatment has failed that we appreciate a patient's complex problem, and, for this reason, we advocate appropriate use of the available technologies in order to separate more carefully the straightforward disorder from the intricate and convoluted problems. A thorough investigation of the multiple dimensions of urinary incontinence in the female patient, using subjective and objective testing, is the key to diagnostic and clinical success.

A randomized trial of behavioral management for continence with older rural women

Urinary incontinence (UI) is a commonly underreported and underdiagnosed condition. The purpose of this trial was to implement and evaluate behavioral management for continence (BMC), an intervention to manage symptoms of UI with older rural women in their homes. Participants were randomized into BMC or a control group, and 178 were followed for between 6 and 24 months. The intervention involved self-monitoring, bladder training, and pelvic muscle exercise with biofeedback. The primary outcome variable-severity of urine loss-was evaluated by pad test. Secondary variables were episodes of urine loss, micturition frequency, voiding interval, quality of life, and subjective report of severity. Urine loss severity at baseline evaluation was not significantly different in the two groups. But using the generalized linear mixed model analysis, at the four follow-ups, severity of urine loss, episodes of urine loss, quality of life, and subjective report of severity were significantly different. At 2 years the BMC group UI severity decreased by 61%; the control group severity increased by 184%. Self-monitoring and bladder training accounted for most of the improvement. The results support the use of simple strategies based on bladder diaries before implementing more complex treatments.

Prevention of postpartum stress incontinence in primigravidae with increased bladder neck mobility: a randomised controlled trial of antenatal pelvic floor exercises

OBJECTIVE

To test whether supervised pelvic floor exercises antenatally will reduce the incidence of postpartum stress incontinence in at-risk primigravidae with bladder neck mobility, ultrasonically proven.

DESIGN

Single blind, randomised controlled trial.

SETTING

Antenatal clinic in a UK NHS Trust Hospital.

SAMPLE

Two hundred and sixty-eight primigravidae attending an antenatal clinic at approximately 20 weeks of gestation with bladder neck mobility, on standardised valsalva, of 5 mm or more linear movement. The median age was 28, ranging from 16 to 47 years.

INTERVENTION

Patients randomised to supervised pelvic floor exercises (n = 139) attended a physiotherapist at monthly intervals from 20 weeks until delivery. The exercises comprised three repetitions of eight contractions each held for six seconds, with two minutes rest between repetitions. These were repeated twice daily. At 34 weeks of gestation the number of contractions per repetition was increased to 12. Both the untreated control group and the study group received verbal advice on pelvic floor exercises from their midwives antenatally.

MAIN OUTCOME MEASURES

Subjective reporting of stress incontinence at three months postpartum. Pelvic floor strength, using perineometry, and bladder neck mobility measured by perineal ultrasound.

RESULTS

Of the 268 women enrolled, information on the main outcome variable was available for 110 in the control group and 120 in the study group. Fewer women in the supervised pelvic floor exercise group reported postpartum stress incontinence, 19.2% compared with 32.7% in the control group (RR 0.59 [0.37-0.92]). There was no change in bladder neck mobility and no difference in pelvic floor strength between groups after exercise, although all those developing postpartum stress incontinence had significantly poorer perineometry scores than those who were continent.

CONCLUSIONS

The findings suggest that antenatal supervised pelvic floor exercises are effective in reducing the risk of postpartum stress incontinence in primigravidae with bladder neck mobility.

Practical outcome measures for assessing efficacy of incontinence procedures

Standard treatment for urinary incontinence in women has evolved during the past few decades. Conservative measures such as pelvic floor exercises and biofeedback may be effective and have been advocated for the past several years. However, the availability of other methods that are potentially more invasive yet efficacious provides a wider range of choices for women with urinary incontinence. With these alternatives comes opportunity and responsibility to assess how successful these treatments are. This article explores current methods of analyzing outcomes of urinary incontinence treatments.

Evaluation of female lower urinary tract symptoms: overview and update

Female lower urinary tract symptoms are nonspecific, and a thorough clinical evaluation is required to establish the correct diagnosis. Such evaluation should consist of a structured micturition history or questionnaire, physical examination with full bladder, micturition diary, pad test and urodynamic evaluation. The urodynamic evaluation should consist at least of cystometry, detrusor pressure/uroflow study, simple ('free') uroflowmetry, assessment of the relative contribution of urethral hypermobility and intrinsic sphincter deficiency, and estimation of postvoid residual urine by ultrasound or catheterization. Recent studies regarding the role of pad tests, micturition diaries and urodynamic studies in the evaluation of female voiding dysfunction are presented. Factors that are associated with the use of transurethral catheter during pressure-flow studies and current controversies regarding the diagnosis of female bladder outlet obstruction are reviewed and discussed. Although the urodynamic study is considered to be the best diagnostic tool in assessment of lower urinary tract function, some practitioners believe that urodynamic evaluation is not routinely warranted and prefer to employ a symptom-based empirical management strategy. Lower urinary tract symptoms are nonspecific, however, and should be used mainly to identify what bothers the patient. Urodynamic studies define the underlying pathophysiology. We believe that treatment of the underlying pathophysiology facilitates better treatment of symptoms.

An ultra-short perineal pad-test for evaluation of female stress urinary incontinence treatment

We assessed the reproducibility and feasibility of a rapid perineal pad-test designed for evaluation of stress urinary incontinence treatment. In an experimental study, we included 34 women with genuine stress incontinence, 13 with urge incontinence and 10 non-incontinent volunteers for a repeated pad-test with a standardized bladder volume (300 mL) and a standardized physical activity during one minute. The pad was weighed before and after the exercise to estimate the volume of any leaked urine. In order to find out the percentage of unselected, incontinent women who had been able to perform a preoperative pad-test, we identified all 120 women operated on for stress incontinence during a one-year period in a separate retrospective analysis. In another retrospective analysis, we compared the subjective outcome of laparoscopic colposuspension with the outcome of the test performed before and after the procedure among 93 women with genuine stress incontinence. Among stress incontinent women, the median of the differences in leakage between the first and the second test was 8.5 mL (range 0-60 mL) and the repeatability coefficient was 33.6 mL. None of the 13 women with urge incontinence leaked during the tests. One of the 10 controls leaked (during both tests). Of the unselected women, 104/120 (87%) were able to perform the test. Reduction of leaking after surgery was significantly associated with subjective report of outcome (P < 0.0001). In conclusion, the described pad-test has an acceptable reproducibility and feasibility making it suitable for follow-up studies.