24-hour pad test in the assessment of male patients with post-prostatectomy urinary incontinence

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ORIGINAL ARTICLE

Correlation between the 1-hour and

24-hour pad test in the assessment of male patients with post-prostatectomy urinary incontinence

Corrélation entre les pad-test de 1 et 24 heures dans l’évaluation de l’incontinence urinaire après prostatectomie

M. Soto González

^a

, I. Da Cu˜ na Carrera

^a^,∗

, E.M. Lantarón Caeiro

^a

, M. Gutiérrez Nieto

^a

, S. López García

^b

, A. Ojea Calvo

^b

aFacultyofPhysiotherapy,UniversityofVigo,Pontevedra,Spain

bUniversityHospitalComplexofVigo,Pontevedra,Spain

Received28February2018;accepted22June2018 Availableonline20July2018

KEYWORDS Urology;

Incontinencepads;

Physicaltherapy modalities;

Urinaryincontinence

Summary

Introduction.—Thisstudyisaimedatstudyingthecorrelationbetweenthe1-hourand24-hour padtestsforurinaryincontinencefollowingprostatectomy;thesecondobjectiveistocheck whethertheseveritylevelestablishedbybothtestsisadequateformaleurinaryincontinence.

Materialandmethods.—Thestudypopulationincludespatientswhohadundergoneprostate- ctomyatasinglecenterbetweenFebruary2015andDecember2016,using159measurements consistingof24-hourand1-hourpadtests,belonging45patients.Bothtestshavebeenper- formedaccordingtotheprotocolstandardizedbytheInternationalContinenceSociety.Once allthedatahavebeenobtained,thelevelsmarkedbyeachofthepadshavebeenestablished, andthestatisticalanalysishasstarted.

Results.—Therelationshipbetweentheamountsrecordedingramsbythetwotestishighly signiﬁcant(P=0.000),however,whencomparingtheincontinencelevelsestablishedbyeach test(mild,moderateandsevere),discrepancieshavebeenfound.Themedianofthesevere cases inthe 24-hourpad testwas 389.5 grams, andinthe 1-hour padtest was 92 grams.

∗Correspondingauthor.FacultyofPhysiotherapy,UniversityofVigo,CampusAXunqueiras/n,CP-36005Pontevedra,Spain.

E-mailaddress:[email protected](I.DaCu˜naCarrera).

https://doi.org/10.1016/j.purol.2018.06.011

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So,patient’slossvaluesarewellabovethecut-offpointdeﬁnedforsevereurinaryincontinence inboth24-hour(50grams)and1-hourpadtest(75grams).

Conclusions.—Thereisadiagnosticdiscrepancybetweenthe24-hourpadtestandthe1-hour padtestintermsofdeﬁnedurinaryincontinenceseveritylevels.Inouropinion,theselevels shouldberedeﬁnedformaleurinaryincontinencesincetheamountofurinelossiswellabove thethresholdestablishedforsevereincontinence.

Levelofevidence.—4.

MOTSCLÉS Urologie; Protections d’incontinence; Modalitésde physiothérapie; Incontinenceurinaire

Résumé

Objectif.—L’objectifdecetravailestd’étudierlacorrélationexistanteentrelesPadTest1h et24hetl’incontinencepost-prostatectomie.L’objectifsecondaireestdevériﬁersileniveau degravitédéﬁniparchaquetestestadéquatpourl’Incontinenceurinairemasculine.

Matérieletméthodes.—Quarante-cinqpatientsayantsubiuneprostatectomieauseindenotre centreentrefévrier2015etdécembre2016ontétéinclus.Chacundestestsontétéréalisés sousleprotocolestandardiséparl’InternationalContinenceSociety.Unefoistouslesdonnées obtenues,lesniveauxidentiﬁéspourchacundesPadtestsontétéétablisetl’analysestatistique apuêtrelancée.

Résultats.—Autotal,159padtestde1het24hontétéanalysés.Larelationentrelaquantité degrammesenregistréeparlesdeuxtestsestfortementsigniﬁcative(p=0,000)parcontre,en comparantlesniveauxd’incontinenceétablisparchacundestests(faible,modéréetgrave), des divergenceont étérencontrées. Lamédianedes casgraves dansle testde tamponde 24heuresétaitde389,5grammes,etdansletestdetamponde1heureétaitde92grammes.

Alors,lesvaleursdespertesprésentéesparlespatients sonttrèssupérieuresauseuildéﬁni pourl’incontinenceurinairesévère,autantdanslePadTest24h(75grammes)quedanslePad 1h(50grammes).

Conclusions.—IlexisteunedivergencediagnostiqueentrelePadTest24hetlePadTest1h encequiconcernelesniveauxdegravitédel’incontinenceurinairedéﬁnis.Nouspensonsque cesniveauxdoiventêtreredéﬁnispourl’incontinenceurinairemasculine,laquantitédeperte d’urineétanttrèssupérieureauseuilétablicommeincontinencegrave.

Niveaudepreuve.— 4.

Introduction

Post-prostatectomyurinaryincontinenceisamajorhealth problemthataffectsahighpercentageofmalepopulation [1].Severaldecadeshave passed since1971, whenJames etal.ﬁrstdescribedthepadtest asamethodtoquantify urinaryincontinence(UI)[2].Fromthatmomenton,thebest conditionshavebeensoughttoperformthistest,emerging thiswayothershort-termtestsof2and1hour;of40,20and even1minute;andalsolong-termtestsof24and48hours.

During this period of over 45 years, numerous studies havebeendeveloped,aimedatstudyingthevalidity,relia- bilityandsensitivityofthesetests;differentauthorshave found that the 1-hour pad test had a low sensitivity [3], showinglackofprecisioninthedetectionofurineloss[1]

andpoorreliability,evenwithidenticalbladdervolumesin thesamepatient[4].Inaddition,thebladderﬁllingvolume thatismostsuitablefor itsperformancehasnotyetbeen standardized.

Inspite oftheaboveobservations,itis consideredone ofthebestteststoestablishtheinitialdiagnosisofUI[5], beingevenmoresensitivethancertainurodynamictests[6].

Forthisreason,itisrecommendedtouseitalongwithother tools,suchasquestionnairesorbladderdiaries[7].

Ontheotherhand,the24-hourpadtestseemstohave adequatereliability[2],andinordertoachieveit,patients areadvisedtocontroltheirphysical activity[8,9],aswell astheirﬂuid intake.It seemsthat ifthese variations are small,theydonotaffect reproducibility [10].This test is recommendedtoassesstheresultsofatreatment[5].

However,difﬁcultiescontinuetoexist,becausethereis noconsensusamongdifferentauthorsastowhatisconsid- eredcontinence inthe24-hourpad test.Anotherpossible problemisthatthesetestswereinitiallydesignedasmeth- odsforassessingwomen’sUI,andsubsequentlyhave been usedfor men’sUI. Consequently,itwouldbenecessary to determinewhethertheseveritylevelis thesamefor both genders,sinceetiologiesareoften verydiverseandbeing

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Table1 Descriptivefeaturesofthestudiedvariables.

Variable Category Descriptivefeatures P-value(normality)

24-hourtest (grams) 248.41.82±349.16(range:1—1629) 0.000^a

1-hourtest (grams) 30.24±54.8(range:0—364) 0.000^a

24-hourlevel None 4(2.5%)

Mild 49(29.7%)

Moderate 29(18.4%)

Severe 78(49.4%)

1-hourlevel None 20(12.7%)

Mild 76(48.1%)

Moderate 31(19.6%)

Severe 31(19.6%)

aHighlysigniﬁcantat1%(P<0.01).

the damage of the structures different, especially when talkingaboutradicalprostatectomy(RP).

Therefore,theprincipalobjectiveofthisworkistostudy thecorrelationbetweenboth testsinUIfollowing RP,and asasecondaryone,tocheckwhethertheseveritylevelis adequateformen’sUI.

Material and methods Experimental method

All patients had undergone RP at a single center in Vigo between February 2015 and December 2016. The inclusion criteria was post-radical prostatectomy urinary incontinence.Theinformedconsentwasobtainedforeach patient and the study was conducted with the approval oftheResearchEthicsCommitteeofPontevedra,Vigoand Ourense.

There were used 159 measurements of both pad tests belongingto45patients,performed atdifferentmoments oftheir progress following RP.The catheter wasremoved 2—3weeksaftersurgeryandtheﬁrstmeasurementhasbeen carriedoutaweeklater.Thesecondmeasurementhasbeen carriedoutonemonthlaterandthethirdmeasurementtwo monthslater.Eachpatient’smeasurementswerecarriedout alwaysperformingthe1-hourpadtestthedayimmediately afterthecompletionof the24-hourpadtest (the24-hour padtestendsat8inthemorningandthe1-hourpadtestis doneapproximatelyoneortwohourslater).

BothpadtestswerecarriedoutaccordingtotheICSstan- dardizedprotocol[5].Asvaluesforthe1-hourpadtest,1to 10gramsisdeﬁnedasmild,11to50gramsmoderate,and

>50gramssevere;forthe24-hourpadtest,4to20gramsis consideredmild,21to74gramsmoderate,and>75grams severe[1,5].

Statistical analysis

Forthestatisticalstudy,IBMSPSSStatisticsV22.0wasused.

Thestatisticaltechniquesandtestsusedwere:

• common descriptors in quantitative variables: mean, standard deviation, minimum and maximum, and

goodnessofﬁttothemodelofthenormalGaussianbell usingtheKolmogorov-Smirnovtest;

• Spearman’s rank correlation coefﬁcients between two quantitativevariables;

• plausibilityratiobetweentwoqualitativevariables;

• Cohen’s Kappa association method to determine the degreeofdiagnosticagreement;

• to quantify discrepancy between two pad tests, a non-metric variable was generated, resulting from the differenceofassessmentobservedinthe1-hourpadtest whencomparedtothe24-hour padtest. To thisend, 0 (zero) wasassigned for level matching, and a negative signdifference(−1and−2)forthosesamplesthatinthe 1-hourpadtest diagnosedlesssevereincontinencethan the24-hourpadtest(ofonestageortwolevels).

The setsignificance levelis the usual5% (significant if P<0.05)exceptintheKolmogorov-Smirnovgoodness offit test,whereonlyseveredeviationsofthemodelareconsid- eredsignificant,i.e.at1%(P<0.01).

Results

A total of 158 measurementswere obtained, correspond- ingto45 patientswhohad undergoneRP.The descriptive summaryforthesevariablesisshowninTable1.

Thegramsobtainedbythe24-hourpadtestandthe1- hourpadtestcorrelatedsignificantly(P=0.000).Giventhat mostnormalitytestsweresignificant(P<0.01),theSpear- man’s rank correlation coefficient (0.861) was used (see Fig.1).

Ascanbeobserved,thecorrelation betweenthegrams recorded by the 24-hour pad test and thoserecorded by the 1-hour padtest is highly signiﬁcant. Therefore,there isaconnection betweenbothtestsintermsoftheweight ofurineleakedintothepad,inthesensethatthegreater weightinoneofthetestscorrespondstogreaterweightin theothertesttoo.

However,intermsofseveritylevel,takingthe158sam- ples tested at24hoursasstandard gold reference,itwas observedthattheresultsofbothtestspresentedcleardis- crepancies. For example: whereas the 24-hour pad test categorizedascontinent only 2.5%of the samples(n=4),

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Figure1. Correlationbetweenthe24-hourand1-hourpadtest ingrams.

the1-hour padtest didsowith12.7%(n=20)of thesam- ples.Followingthisline,therearealsoobviousdiscrepancies betweenthetwoprocedures(seeTable2).UsingtheCohen’s Kappaassociationmethodtodeterminethedegreeofdiag- nosticagreementbetweentheclassiﬁcationsgeneratedby eachtest, alowvalue (0.254)wasobtained,whichledus to determine that the agreement between the two tests waspoor. In fact, only 73samples, less than half (46.2%, CI:38.1%—54.3%)wereclassiﬁedinthesamecategory,and mostmatches werefoundin themild(33 samples,20.9%, CI: 14.2%—27.5%) and the severe level (31 cases, 19.6%, CI:13.1%—26.1%).Consequently,in theremaining85sam- ples(53.8%,CI:45.7%—61.9%)adiagnosticdiscrepancywas observed.

Figure2. Lossofurineincasesofsevereincontinenceineachof thetests.

Itwasfoundthatin59cases(37.3%ofthetotalamount, CI:29.5%—45.2%)the1-hourpadtestclassiﬁedthesamples intoa milder level thanthe diagnosis of the 24-hour pad test,andthatinother25cases(15.8%CI:9.8%—21.8%)the discrepancywasuptotwolevelsmilder.Onlyin 1sample thediagnosisofthe1-hourpadtestwasmoreseverethan inthe24-hourpadtest.

Fig.2showsthatthevaluesofurinelossthattheevalu- atedpatientshadwerewellabovethesevalues,especially inthecaseofthe24-hourpadtest.The medianofsevere casesinthecase ofthe24-hourpadtestwas389.5 grams

Table2 Comparisonofthe 1-hourand24-hour testresults. Degreeof agreement(Cohen’sKappa)andofdiagnostic discrepancy.

Resultsofthetests Degreeof

agreement

Discrepancy Diagnostic

classiﬁcation

1-hourpadtest 24-hourpadtest Value(1-hourpad test—24-hourpadtest)

Samples

Doesnothave incontinence

12.7%(20) 2.5%(4) 1.9%(3) −2 15.8%(25)

Mildincontinence 48.1%(76) 29.7%(47) 20.9%(33) −1 37.3%(59)

Moderate incontinence

19.6%(31) 18.4%(29) 3.8%(6) 0 46.2%(73)

Severe incontinence

19.6%(31) 49.4%(78) 19.6%(31) +1 0.6%(1)

Total 100%(158) 100%(158) 46.2%(73) +2 0.0%(−)

Diagnostic agreement

Cohen’sKappa coefﬁcient value=0.254

Total=53.8%(85)

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andthemaximumlossrecordedwas1629.Withregardtothe 1-hourpadtest,themedianwas92gramsandthemaximum lossvaluewas364grams.

Discussion

Consideringtheresultsobtained,itwasobservedthatboth tests were correlated in terms of urine loss in grams, in agreementwiththestudyconductedbyPetersonetal.,who obtainedgoodafﬁnitybetweenboth[11].

The incontinence levels deﬁned by each of the tests shouldbesimilarifthepadtestsarecorrelated.Neverthe- less,when comparing the resultsof both tests,a greater detectionof urine loss wasobtained using a 24-hour pad test,similarlytoMatharuetal.,whofoundstatisticallysig- niﬁcant differencesbetween the proportions of continent women in both tests,which determinedthat the 24-hour padtestwasclinicallymoreusefulthanthe1-hourpadtest.

Therefore,itsuseisrecommendedintheassessmentofUI, along with that of the bladder diary and a questionnaire [12].On the sameline ofresearch, Loseetal. alsocom- paredboth testsandfound nocorrelation betweenthem, concludingthatthe24-hourpadwasbetter,asitwasmore sensitivetoconﬁrmincontinence.However,duetoitslow reproducibility, this work cannot be used in comparative studies[13].

Itwasnotedthatthe24-hourpadtestreﬂectedagreater severityofsymptoms,whichcouldbeduetothefactthat the1-hourpad test didnotshow patients’actual amount ofurineloss.Inaddition,itseemstoshowagreatersensi- tivitywhenitcomestodetectingcontinence. Patientssay thaturinelosevaluescorrelatedwellwiththe24-hourpad testresults[14].Thus,the1-hourpadtestpresentedafalse negativerateof80%.SimilarresultswereobtainedbyThind andGerstenberg,whoprovedthatthecorrelationbetween bothtestswaslow,sopatientsclassiﬁed asincontinentin the1-hourpadtestwerealsoconsideredincontinentinthe 24-hourpadtest,butthe1-hourtesthadahighrate(36%) offalsenegatives[15].Inourcase,thisrateismuchhigher, butthiscouldbeduetothefactthattheirsamplewasmade upof women,and thecut-off point for continence was2 gramsof urinelossinthe1-hour padtest,and8gramsin the24-hourtest.

Therefore,the1-hourpadtestdoesnotseemtobethe mostappropriatetodiagnoseUI;anhourmaynotbeenough toassesstherealvolumeofurineloss.Infact,authorssuch asHaylen etal.defendedtheuse ofthe2-hour padtest, sincethecloserthepatientsaretothecystometriccapac- ity,themorelikelyitisthattheyareincontinent.Inother words,in 60minutesaftertheingestion, fewwould reach thebladderﬁllingcapacity;neverthelesstheywouldreach itin120minutes.Thiswouldachievereproducibilityofthe test, whichwould validatethe resultsobtained [16].It is true that in clinical practice, certain patients mentioned that, after performing the 1-hour pad test, they experi- enced episodes of notable urine losses on the way back home,whichcouldbeexplainedbywhathasbeenpreviously described.

However,inordertodeterminewhichpadtestisbetter, theyshouldbecorrelatedwithotherassessmentmethodsof urinaryincontinence.

Inmanystudies,thedeﬁnitionofUI iselusiveinterms of severity[17].Giventheseverityof incontinenceinour sample,it wasnotedthattheseveritylevelsofbothtests donotﬁtwiththerealityofmaleincontinence,beingwell abovethe threshold.The medianof the 24-hour padtest was389.5grams,avalue 5timeshigherthanthatconsid- eredsevere.Althoughlessevident,itwasalsoobservedthat the medianof the 1-hourpad test was92 grams,a value thatnearlydoublesthescoreconsideredsevere.Yokohama etal.conductedastudyinmenwhohadundergoneprosta- tectomy,andameanof680gramsofurinelosswasobtained inthe24-hourpadtest[18].Thoughthereisagreatcorre- lationingramsofloss,thatis,themorelossinonetestthe greaterlossintheotherone;ifwetalkabout theseverity level the testsnolonger correspondbecause theselevels couldnotbewelladjustedformaleurineloss.

This could be explained by the fact that most of the studies were performed on women, in whom UI is often associatedwiththeobstetric period,postpartumandfac- torssuchasage,whichcausemusclebutnotnervedamage astheygenerallydonotundergoanysurgicalintervention.

However,patientswithUIfollowingRPsuffereddamageto thesphinctermechanismduetothesurgicalprocedure.

In our opinion, the severity levels in men who had undergoneRP shouldberedeﬁned,sincethewaytheyare described today would placeonthe same level a patient with76gramsofurinelostandonewithover1600grams, as derived from our results. Sandvick etal. assessed the severityofUIfortheseverityindexandshowedthatthecor- relationindexishigherforfourseveritylevels,whichshould beconsideredin epidemiologicalstudies[19].Inaddition, Colladoetal.performedastudyonmenwhohadundergone RPanddeﬁnedtheseverityusingthe24-hourtestpadasfol- lows:mild<100grams;moderate100—399gramsandsevere

>400grams[20],whichismoreinlinewithourresults.Fol- lowingthesameidea,Tacíaetal.addedalevelofseverity, takingintoaccountthe‘‘verysevere’’UI[21],sincein1984 KlarskovandHaldsuggestedtoclassifyurinelossin4levels ofincontinence[22].

Limitations

The lackofvalidated questionnairesmeans thatthereare fewcorrelationsbetweenthepadtestsandothervaluation methods.

Thelackofreproducibilityassessmentisasigniﬁcantlim- itationofthepresentmanuscript.

Conclusion

In conclusion, although there is correlation in both tests regarding the amount in grams of urine generally lost by post-prostatectomymen,thereisadiagnosticdiscrepancy betweenthetwotestsintermsofseveritylevels,themost suitable being the 24-hour pad test, considering the high rateoffalsenegativesinthe1-hourpadtest.

In addition, the levels of severity established by both testsshouldberedeﬁnedfor maleincontinence,sincethe incontinencesuffered by thesepatients is well abovethe thresholdmarkedassevere.

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Disclosure of interest

Theauthorsdeclarethattheyhavenocompetinginterest.

References

[1]Drai J, Caremel R, Bubenheim M, Pﬁster C, Grise P. Lim- itedu Pad-Testcourtetdes questionnairesdanslévaluation delíncontinence urinaire post-prostatectomie. Prog EnUrol 2011:270—6,http://dx.doi.org/10.1016/j.purol.2010.08.009.

[2]Homsi C, Ferreira J, Bo K. The Pad test for urinary incontinence in women. J Physiother 2015;61:98, http://dx.doi.org/10.1016/j.jphys.2014.12.001.

[3]DevreeseAM,DeWeerdtWJ,FeysHM,DewulfM,AlaertsR, VereeckenR,etal.Functionalassessmentofurinaryinconti- nence:theperinealpadtest.ClinRehabil1996;10:210—5.

[4]Simons M, Yoong WC, Buckland S, Moore KH. Inadequate repeatability of the one-hour pad test: the need for a new incontinence outcome measure. Br J ObstetGynaecol 2001;108:315—9.

[5]Krhut J, Zachoval R, Smith P, Rosier P, Valansky L, Mar- tan A, et al. Pad weight testing in the evaluation of urinary incontinence. Neurourol Urodyn 2014;33:507—10, http://dx.doi.org/10.1002/nau.22436.

[6]LeeSU,LeeSH,KimH.Thecomparisonoftheabdominalleak pointpressureandthe1-hourpadtestinpatientswithstress urinaryincontinence.KoreanJUrol2006;47:847—51.

[7]Micussi M, Soares E, Lemos T, Brito T, Silva J, Maranho T.

Correlationbetweencomplaintsofstressurinaryincontinence andtheone-hourpadtestinpostmenopausalwomen.RevBras GinecolObstet2011;33:70—4.

[8]MalikRD,CohnJA,FedunokPA,ChungDE,BalesGT.Assess- ing variability of the 24-hour pad weight test in men withpost-prostatectomyincontinence.IBJU2016;42:327—33, http://dx.doi.org/10.1590/S1677-5538.IBJU.2014.0506.

[9]Painter V, Karantanis E, Moore KH. Does patient activity level affect 24-hr pad test results in stress- incontinent women? Neurourol Urodyn 2012;31:143—7, http://dx.doi.org/10.1002/nau.21169.

[10] Rasmussen A, Mouritsen L, Dalgaard A, Frimodt-Moller C.

Twenty-fourhourpadweighingtest:reproducibilityanddepen- dency of activity level and ﬂuid intake. Neurourol Urodyn 1994;13:261—5.

[11] Peterson AC, Amundsen CL, Webster GD. The 1-hour pad test is a valuable tool in the initial evaluation of women

with urinary incontinence. J Pelvic Med Surg 2005:11, http://dx.doi.org/10.1097/01.spv.0000190323.15248.7b.

[12]MatharuGS,AssassaRP,WilliamsKS,DonaldsonM,Matthews R, Tincello DG, et al. Objective assessment of urinary incontinence in women: comparison of the one- hour and 24-hour pad tests. Eur Urol 2004;45:208—21, http://dx.doi.org/10.1016/j.eururo.2003.09.006.

[13]LoseG,JargensenL,ThunedborgP.24-Hourhomepadweigh- ing test versus 1-hourward test inthe assessment of mild stress incontinence. Acta Obstet Gynecol Scand 1989;68:

211—5.

[14]Nitti V, Mourtzinos A, Brucker B, SUFU Pad Test Study Group. Correlation of patient perception of pad use with objective degree of incontinence measured by pad test in men post prostatectomy incontinence:

the SUFU Pad Test Study. JUrol 2014;3:836—42, http://dx.doi.org/10.1016/j.juro.2014.03.031.

[15]ThindP,GerstenbergTC.One-hourwardtestvs24-hourhome pad weighing testin the diagnosis of urinary incontinence.

NeurourolUrodyn1991;10:241—5.

[16]HaylenBT,FrazerMI,SutherstJR.Diureticresponsetoﬂuid loadinwomenwithurinaryincontinence:optimumduration ofpadtest.BrJObstetGynaecol1988;62:331—3.

[17]Robles JE. La incontinencia urinaria. Sist Sanit Navar 2006;29:219—31.

[18]Yokoyama T, Nishiguchi J, Watanabe T, Nose H, Nozaki K, Fujita O, et al. Comparative study of effects of extracor- porealmagneticinnervationversuselectricalstimulationfor urinary incontinence after radical prostatectomy. Urology 2004;63:264—7.

[19]Sandvik H, SeimA, Vanvik A, Hunskaar S. A severity index for epidemiological surveys offemale urinary incontinence:

comparisonwith48-hourpad-weighingtests.NeurourolUrodyn 2000;19:137—45.

[20]Collado A, Domínguez J, Rubio J, Gómez A, Casanova J, RamírezM,etal.Cuantiﬁcacióndelescapeurinariodurante 24h:unaaproximaciónmássensatadelaincontinencia,Vigo;

2012.

[21]Tacía KC, Ferreira U, Nardi PR, Matheus WE, Rodrigues N. Early versus delayed physiotherapy in the treatment of post-prostatectomymaleurinaryincontinence.ArchEspUrol 2006;59:773—8.

[22]Klarskov P, Hald T. Reproducibilityand reliability ofurinary incontinence assessment with a 60 min test. Scand J Urol 1984;18:293—8.