Original Articles Journal of
251
The 1-Hour Pad Test Is a Valuable Tool in
the Initial Evaluation of Women With
Urinary Incontinence
Andrew C. Peterson, MD,* Cindy L. Amundsen, MD,†
and George D. Webster, MB, FRCS‡
Abstract
Aim: The urinary pad weight test is an objective
measure of severity of urine loss. The purpose of
this study was an attempt to determine the corre-
lation among the 1-hour pad weight test, number
of pads used per day, reported magnitude of incon-
tinence, 24-hour pad weight, urodynamic parame-
ters, and quality-of-life questionnaires.
Methods: Women with urinary incontinence pre-
senting between July 2002 and January 2004 were
asked to participate. A complete history, physical
examination, 24-hour urinary pad test, 72-hour
voiding diary, urodynamics, 1-hour pad test, and
incontinence questionnaires were completed. The
1-hour pad test was performed with a standard
bladder volume, and all completed a walking route
as outlined in the 1988 International Continence
Society 1-hour pad test protocol.
Results: Fifty women, average age 57.2 years
(range, 26 –78 years) completed the study. Ten
(20%) complained of urge, 23 (46%) stress, and 17
(34%) mixed incontinence. Within each group, the
1-hour pad test weight correlated positively with
the 24-hour pad test (Pearson coefficient 0.763).
Questionnaires indicated the 1-hour test unmasked
a significant stress component of leakage in 17
(34%) of the women not otherwise detected. The
pad weights did not correlate with the any of the
other parameters with which it was compared.
Conclusions: The 1-hour pad weight test is an im-
portant objective tool in the evaluation of the in-
continent female and complements other modali-
ties of evaluation of incontinence, in particular,
the bladder diary. It has good use in unmasking
stress incontinence but underestimates those with
urge incontinence.
Key Words: incontinence, evaluation, urinary
pad test
(J Pelvic Med Surg 2005;11:251–256)
S tress and urgency incontinence occurs in
up to one third of older individuals and
management costs in the United States ap-
proximate $16 billion a year. Like with all
medical conditions, treatment options should
be guided by the severity of the problem. The
most recent International Continence Society
(ICS) guidelines for diagnosis and evaluation
of women with urinary incontinence include
pretreatment evaluation with a voiding diary,
history and physical examination, quality-of-
life questionnaire, some form of quantitative
measurement of urine loss such as a pad test,
and, occasionally urodynamics.1
Historically, urinary incontinence was
subjectively evaluated by degree of patient
complaint and by documenting the number
of pads used per day. The urinary pad weight
test is an objective, well-accepted quantita-
tive evaluation for the severity of inconti-
nence that is more accurate than the subjec-
tive assessment of urine loss.2 This, added to
the patient’s subjective history, gives the cli-
nician a sense of the magnitude of the disor-
der. There are multiple recommended uri-
nary pad weight protocols ranging from very
short testing periods of 1 minute to up to 72
hours.3–7 The longer the test period, the
more reproducible the results are reported to
become. However, the longer pad tests in-
crease the sensitivity and specificity of the
test at the risk of decreasing patient compli-
ance.8 This increased testing time may also add
other variables to the study such as loss of the
urine from the pads as a result of evaporation,
thereby underestimating the amount of incon-
tinence. Conversely, pad weight tests per-
formed for several days can collect weight from
sources such as vaginal secretions and menstru-
ation, artificially increasing the weight. When
DOI: 10.1097/01.spv.0000190323.15248.7b
PELVIC MEDICINE &
SURGERY
Volume 11, Number 5
September/October 2005
From the *Department of Sur-
gery, Uniformed Services Uni-
versity of the Health Sciences,
Bethesda, Maryland, and the
Department of Reconstructive
Urology, Female Urology and
Urodynamics, Department of
Surgery, Urology Service, Madi-
gan Army Medical Center, Ta-
coma, Washington; the †Divi-
sion of Urogynecology,
Department of Obstetrics and
Gynecology, and Division of
Urology, Duke University Center
Medical, Durham, North Caro-
lina; and the ‡Department of
Urologic Surgery, Department of
Surgery, Division of Urology,
Duke University Medical Center,
Durham, North Carolina.
Reprints: Andrew C. Peterson,
MD, Chief, Reconstructive Urol-
ogy, Female Urology and Urody-
namics, Department of Surgery,
Urology Service, Madigan Army
Medical Center, Tacoma, WA.
E-mail: andrew.peterson@amedd.
army.mil.
The views expressed in this article
are those of the authors and do not
reflect the official policy or position
of the U.S. Army, Department of
Defense or the U.S. government.
Copyright © 2005 by
Lippincott Williams & Wilkins
ISSN: 1542-5983/05/1105-0251
 Journal of Peterson et al
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Volume 11, Number 5
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performed correctly, the shorter tests may
avoid these variables and increase compliance
while providing an evaluation appropriate for
office use.
In this study, we establish the use of the
short, higher-compliance 1-hour pad weight
test in the evaluation of the incontinent fe-
male. We determine the correlation among
the office-based 1-hour pad weight test, the
home 24-hour pad weight test, number of
pads used per day, the patient’s reported
magnitude of incontinence, urodynamic pa-
rameters, and quality-of-life questionnaires.
MATERIALS AND METHODS
This study was approved by the Institu-
tional Review Board at Duke University and
met all requirements of the institution. Be-
tween July 2002 and January 2004, women
with complaints of urinary incontinence were
asked to complete a urogynecologic history,
focused pelvic examination, 24-hour urinary
pad test, 72-hour voiding diary, urodynamics,
1-hour pad test, Incontinence Impact Ques-
tionnaire (IIQ), and Urogenital Distress In-
ventory (UDI).9 All patients receive an intro-
ductory packet in the mail at the time of
scheduling the initial appointment with the
clinic. Instructions are included for the 24-
hour urinary pad test and the 72-hour voiding
diary. Both of these are brought with the
patient to the initial appointment. Power
analysis before initiation of the study was
performed indicating 50 patients would be
needed for statistical significance.
After the pelvic examination, the blad-
der was emptied by catheterization and filled
to 200 mL. The patient then completed a walk-
ing route performing activities outlined in the
1988 ICS 1-hour pad test protocol (Fig. 1).10
Pads were weighed on a laboratory scale and
the weight of a dry pad subtracted to calcu-
late the urine leakage. All patients completed
a questionnaire after the test to establish the
correlation of the leakage events with those
occurring during normal daily activities (Ap-
pendix 1).
We recorded patient demographics, pa-
tient history, including the major presenting
© 2005 Lippincott Williams & Wilkins
FIGURE 1. Patient walking route for the 1-hour
pad test as adapted from the 1988 International
Continence Society 1-hour pad test protocol.
complaint of stress, urge, or mixed inconti-
nence, the number of pads used per day,
patient comorbidities, and prior surgical or
medical treatment of incontinence. Multichan-
nel, video urodynamics were performed on the
initial clinic visit. We recorded urodynamic pa-
rameters, including maximum capacity, sensa-
tion, compliance, detrusor overactivity, leak
point pressures at cystometric capacity, de-
trusor pressures and maximum flow rate dur-
ing micturition, and postvoid residual. The
abdominal leak point pressure was recorded
using fluid-filled transduction catheters. We
recorded both the baseline abdominal pressure
and abdominal pressure at leakage counting
the difference between these values as the ab-
dominal leak point pressure.
All data was recorded in an Excel spread-
sheet (Microsoft Corp., Redmond, WA) and an-
alyzed using SAS Version 8.1 (The SAS Institute
Inc., Cary, NC). Multivariate analysis of these
data was performed.
RESULTS
Fifty women of average age (57.2 years;
range, 26 –78 years) completed the study.
Ten (20%) had as their primary complaint
urge incontinence, 23 (46%) stress, and 17
(34%) mixed incontinence on the preevalua-
tion questionnaires. The average pad use, the
24-hour pad test and 1-hour pad test results,
questionnaire results, and urodynamic pa-
rameters are shown in Table 1. When com-
pared (analysis of variance), the differences
in pad use and weights were not statistically
significant, and there was no correlation be-
 The 1-Hour Pad Test for Urinary Incontinence Journal of
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Incontinence
tween the number of pads used and the pad

5.2 (0–10)
8.3 (2–20)
5.0 (2–10)
Episodes
Bladder
Diary weights (Table 1). There also were no corre-
lations between the 1-hour pad weight and
any urodynamic parameters, the IIQ and UDI
TABLE 1. There Were No Statistically Significant Correlations Between the 1-Hour Pad Weight and Any Urodynamic Parameters, the IIQ and UDI

questionnaires, or number of pads used per

day (Table 1). The average time to complete
Urodynamics

60 (14–110)
111 (35–200)
80 (10–150) the 1-hour pad test was 54.4 minutes (range,
(cm H2O)

20 –75 minutes). All women were able to

ALPP

complete all of the activities outlined in the

walking route.
Analysis of the post-1-hour pad test
questionnaire shows which standardized ac-
39.0 (23–66)
59.2 (33–99)

tivities caused leakage. The majority of urine

42.8 (9–80)

loss sensed by those women who reported

IIQ

stress incontinence during the 1-hour pad

Questionnaire

test was during the running and coughing

portions of the route. Only 3 women, 11%,
with a prior subjective complaint of urge or
49.1 (11–77)
49.4 (27–77)
46.9 (22–66)

mixed incontinence had a significant amount

UDI

of loss with washing hands on the pad test,

and none of the women who reported iso-
IIQ indicates Incontinence Impact Questionnaire; UDI, Urogenital Distress Inventory; PPD, ; ALPP, .

lated stress incontinence leaked urine during

that activity. Within each group (stress, urge,
and mixed), the 1-hour pad test weight corre-
29.9 (4–106)
1 Hour (g)

26.0 (8–56)
36.2 (6–72)

lated positively with the 24-hour pad test (Pear-

*There was no significant finding of detrusor overactivity in any group on urodynamics.

son coefficient 0.763, P ⫽ 0.005) (Fig. 2). The

questionnaire following the 1-hour pad study
indicated that the 1-hour test unmasked a
stress component of leakage in 17 (34%)
women not detected by the 24-hour pad test.
82.7 (8–400)
108.2 (8–245)
85.6 (2–236)
24 Hour (g)
Pad Tests

Four of these 17 presented with urge incon-

tinence only, 7 with mixed incontinence, all
of whom significantly minimized the subjec-
Questionnaires, or Number of Pads Used per Day*

tive stress component on the prehour study

consultation, and 6 with isolated stress incon-
tinence. All 17 of these patients had very low
4.7 (0–10)

24-hour pad weights on initial evaluation

3.4 (0–8)

3.6 (0–8)
PPD

(stress component 5.3 g, urgency component

17.5 g, and mixed incontinence 3.42 g). All
stated that the standardized walking route
and activities in the 1-hour pad test elicited a
57.2 (26–78)
53.5 (48–58)
56.5 (41–72)

stress urinary incontinence component that

Age (yr)

may not have been detected otherwise be-

cause they had developed avoidance of spe-
cific activities causing them to leak urine.

DISCUSSION
Mixed
Stress

The benefits of the 1-hour pad test in

Urge

this study include short duration, standardiza-

 Journal of Peterson et al
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September/October 2005
FIGURE 2. Twenty-four-hour pad weights versus 1-hour pad weight. The 1-hour test results
correlated with the 24-hour results (Pearson coefficient ⫽ 0.763).
tion of both the bladder volume and the ac-
tivities performed by the patient, and ease of
completion. Because the pad weights in the
1-hour and 24-hour tests correlated well, this
suggests that a well-conducted and standard-
ized 1-hour test may be used to add to the
24-hour test in the evaluation of all women
with incontinence (stress, urge, and mixed).
In addition, it may reduce the problems of
compliance and associated variables of the
longer home pad test and may be used to
replace the 24-hour test in the evaluation of
women with pure stress incontinence.
Normal urine loss for different pad test-
ing protocols has been established.11,12 On av-
erage, a fluid loss of 0.26 g to 2.1 g in a 1-hour
pad test13,14 and up to 8 g in 24 hours is con-
sidered normal. The average loss of urine in our
study far exceeded these accepted values, indi-
cating this was a valid population selection
with well-documented urine loss in all groups.
Lose et al in 198911 studied the 1-hour
pad test and concluded the 24-hour pad test
was superior because of decreased reproduc-
ibility and an unacceptable variability of the
shorter test. Ryhammer,5 in a concise review,
compared 1-hour tests to 24-hour tests and
again concluded the 24-hour test was supe-
© 2005 Lippincott Williams & Wilkins
rior. Neither of these studies, however, con-
trolled for bladder volume or standardized
patient activities during the 1-hour pad weight,
like in our study, which may have added to
the inconsistent prior results. However, we
did observe that although patients may comply
with the 24-hour pad test, they often travel
from a far distance the day before the consul-
tation; therefore, the 24-hour pad weight test
in our study may not have represented the
average daily experience because of the
change in activity associated with travel. This
could explain why our study did not find a
correlation between the 24-hour study and
the 1-hour pad weight study in the patients
with stress urinary incontinence. Our study
revealed that a posttest questionnaire helped
us understand when the leakage episodes
occurred. The 1-hour pad weight test would
not be helpful in nonambulatory patients and
those who are cognitively impaired.
Interestingly, none of the typical incon-
tinence evaluation parameters such as num-
ber of pads per day, incontinence episodes
per day, and abdominal leak point pressure
correlated with the amount of loss of urine
on the pad weight test. Our observations
during the clinical evaluation of these pa-
 The 1-Hour Pad Test for Urinary Incontinence
tients suggest that this may be the result of
the patient’s ability to guard against either
stress or urge incontinence in the testing
situation, thereby protecting them while in
the artificial environment of the clinical/uro-
dynamic evaluation. During the standardized
activities as described in the ICS protocol,
with a known amount of fluid in the bladder,
the patient may be less likely to guard against
urine loss during the evaluation by using
avoidance tactics. Although we filled the
bladder of each patient to a volume of 200 mL,
some authors might argue that we should base
the fill volume on the functional capacity as
determined by the bladder diary. However,
we and others have found the average vol-
ume used when the later method is adopted
is always 150 to 300 mL, thereby supporting
our use of a midrange volume of 200 mL.15
After filling, each patient was allowed to
change clothing, rest, and read instructions
for the test, thus delaying walking for 10 to
15 minutes, reducing the risk that the fill
itself would be responsible for eliciting an
involuntary contraction and an urge inconti-
nence episode. Indeed, none of these pa-
tients had a sudden loss of urine before em-
barking on the walking route.
The 1-hour pad test did not reliably
reproduce incontinence in those patients
who reported only an urge component be-
cause only 11% of patients had a significant
amount of leaking during the 1-hour stan-
dardized test. This is not surprising because
the triggers for urge leakage are very unpre-
dictable, and the current protocol only in-
cludes one provocative activity, handwash-
ing. This finding suggests the 1-hour pad test
as implemented in this protocol addresses
mainly the stress component of urinary loss
and that a 24-hour pad weight may reflect
more accurately the leakage of a patient with
urge incontinence.
Another interesting finding in our study
lies with the 17 (34%) women who did not
report significant activity-related urinary in-
continence but had a significant amount of
stress leakage documented with the 1-hour
pad test. That is, approximately one third of
Journal of
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September/October 2005
patients with primarily urge leakage, and/or a
mild stress component at home, actually had
a significant stress component during this
test. This finding agrees with recent findings
by others.14
CONCLUSIONS
This study evaluates the use of the 1-hour
pad test to quantify urine loss with a standard-
ized “activity route” and bladder volume, and
correlation with a 24-hour test is good. It indi-
cates that a 1-hour pad weight test, performed
with a standardized bladder volume and re-
quired activities, may uncover a significant
stress where this might otherwise be underes-
timated. Future protocols should emphasize
“triggers” for urge incontinence, because our
protocol may underestimate this contribution.
The 1-hour pad weight test appears to be an
excellent objective tool to use in the evalua-
tion of urinary incontinence in those mobile
enough to perform the test and complements a
voiding diary to elicit all factors contributing to
urinary incontinence.
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