










































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2022 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Prostatectomy, prostate cancer, urinary 
incontinence, surveys and questionnaires

None declared.

Funding Statement: This was a researcher-
initiated study that was supported by funding 
from Westmead Private Physiotherapy 
Services and The Clinical Research Institute.

Received on January 13, 2022 
Accepted on February 7, 2022 
This article has been peer reviewed.

Soc Int Urol J. 2022;3(3):124–130

DOI: 10.48083/TIWQ1657

124 SIUJ  •  Volume 3, Number 3  •  May 2022 SIUJ.ORG

ORIGINAL RESEARCH

Pad Weight, Pad Number, and Incontinence-Related 
Patient-Reported Outcome Measures After Radical 
Prostatectomy

Cecile T. Pham,1  Manish I. Patel,1,2 Sean F. Mungovan3,4 

1 Specialty of Surgery, Faculty of Medicine and Health, University of Sydney, Camperdown, Australia  2 Department of Urology, Westmead Private Hospital, Westmead, 
Australia  3 Westmead Private Physiotherapy Services, Westmead, Australia  4 The Clinical Research Institute, Westmead, Australia

Abstract

Objectives To evaluate the correlation between 3- and 6-week postoperative 24-hour pad weight, daily pad number, 
and the International Consultation on Incontinence Questionnaires for Male Lower Urinary Tract (ICIQ-MLUTS), 
ICIQ-Short Form (ICIQ-SF) and UCLA Prostate Cancer Index (UCLA-PCI) in patients undergoing robotic-assisted 
radical prostatectomy (RARP).

Methods This prospective study included patients undergoing RARP between February and November 2019. 
Patients completed a 24-hour pad test, assessing pad weight and number, and 3 validated patient-reported outcome 
measures (PROMs); the ICIQ-MLUTS, ICIQ-SF and UCLA-PCI, preoperatively and at 3 and 6 weeks postoperatively.

Results A total of 47 patients were included in the study. There was a strong correlation between 24-hour pad 
weight and the ICIQ-SF at 3 weeks (r = 0.71, P < 0.001) and 6 weeks (r = 0.68, P < 0.001). There was a strong correlation 
between 24-hour pad weight and ICIQ-MLUTS incontinence (r = 0.80, P < 0.01) and incontinence QoL burden (r = 
0.79, P < 0.01) at 6 weeks. There was a moderate correlation between the 24-hour pad weight and UCLA-PCI urinary 
function (r = 0.58, P < 0.001) and urinary QoL burden (r = 0.66, P < 0.001) at 6 weeks. The correlation between pad 
number and 24-hour pad weight was weak at 6 weeks (r = 0.34, P < 0.001).

Conclusion PROMs may be used as a substitute for the 24-hour pad weight test for post-prostatectomy incontinence 
(PPI) assessments in the early post-RARP period. The ICIQ-SF and UCLA-PCI urinary function and QoL scores 
correlate with 24-hour pad weight. However, the ICIQ-MLUTS incontinence and QoL scores provide the strongest 
correlation with PPI.

Introduction

Prostate cancer is a major public health concern and the second most commonly diagnosed cancer in men globally[1]. 
Organ-confined disease is treated surgically by radical prostatectomy (RP). Despite improvement in surgical 
technique, post-prostatectomy incontinence (PPI) affects 49% to 63% of patients in the early postoperative period 
(first 6 weeks)[2–5]. Estimates of the incidence of PPI and continence recovery time vary because of the lack of a 

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https://orcid.org/0000-0002-5954-565X
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mailto:manish.patel%40sydney.edu.au?subject=SIUJ
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universally accepted definition of continence, the variety 
of assessment methods used to determine severity of 
PPI, and variability in PPI assessment time points. In 
clinical practice, PPI is commonly quantified by patient-
recorded numbers of pads used daily. However, some 
studies have reported that the reliability of pad number 
may be limited by patient recall and poor correlation 
with the actual amount of urine loss[6,7]. Pad weight 
testing protocols are used for the objective measurement 
of PPI with testing durations ranging from 20 minutes 
to 72 hours[6,8–10]. Increasing the duration of the 
testing protocol to 48 or 72 hours increases reliability but 
has not been recommended, as it can result in decreased 
patient compliance[10]. The 24-hour pad weight test is 
considered the gold standard for objective measurement 
of urinary incontinence[11,12]. However, it can be 
burdensome and result in poor patient compliance. 
Moreover, it does not take into consideration other 
markers of urinary function, such as frequency of 
incontinence and voiding.

This has led to the development of accessible and 
validated patient-reported outcome measures (PROMs) 
for routine PPI assessments. However, there are limited 
data on whether PROMs for PPI assessment correlate 
with objective measures and whether they can be used 
as a reliable substitute for 24-hour pad weight. To our 
knowledge, no study has compared PROMs with the 
24-hour pad weight test in the 6-week period follow-
ing RP. Commonly used PROMs include the Interna-
tional Consultation on Incontinence Questionnaire for 
Male Lower Urinary Tract Symptoms (ICIQ-MLUTS), 
the ICIQ-Short Form (ICIQ-SF) and the Univer-
sity of California Los Angeles Prostate Cancer Index 
(UCLA-PCI). In this study, we evaluated the correla-

tion between 24-hour pad weight, daily pad number, 
and the ICIQ-MLUTS, ICIQ-SF and UCLA-PCI in 
patients undergoing robotic-assisted radical prostatec-
tomy (RARP). 

Materials and Methods
Patient selection
Patients undergoing RARP by a single surgeon at a 
high-volume robotic centre in a private metropolitan 
hospital were prospectively recruited between February 
and November 2019 during their initial consultation 
prior to surgery. Patients who had a history of pad usage, 
pelvic surgery or pelvic radiotherapy were excluded. 
This study was approved by the Western Sydney Local 
Health District Human Research Ethics Committee 
(ETH02769). All participants provided written informed 
consent.

Patient-reported outcome measures
The ICIQ-MLUTS is derived from the International 
Continence Society male short-form (ICSmaleSF) 
questionnaire and is used to evaluate male lower 
urinary tract symptoms across multiple domains, 
including incontinence, voiding, leakage frequency, 
and impact on quality of life (QoL)[13,14]. The ICIQ-
MLUTS is a 13-item questionnaire consisting of 5 items 
forming the voiding subscale, 6 items forming the 
incontinence subscale and 2 items regarding leakage 
frequency. Each item is scored from 0 to 4, and each 
subscale is calculated. The ICIQ-SF is an abbreviated 
version that evaluates frequency and severity of urinary 
incontinence[15]. It consists of 4 items regarding leakage 
frequency, volume, and impact on QoL. The first 3 items 
are scored from 0 to 5, 0 to 6 and 0 to 10, respectively, 
and they are added to produce a total score ranging from 
0 to 21. The fourth item allows the patient to report when 
urinary incontinence occurs and does not contribute to 
the overall score. The UCLA-PCI assesses the impact of 
treatment (surgery and/or radiotherapy) on QoL[16]. It 
is a 20-item questionnaire consisting of function and 
bother across 3 domains: sexual, urinary, and bowel 
function. The items are scored from 0 to 100, with higher 
scores representing better QoL, and an average score for 
each domain is calculated.

Data collection
At t he time of recr uit ment, each pa r ticipa nt’s 
demographic information, including age and body mass 
index (BMI), and information on prostate cancer disease 
characteristics, including prostate specific antigen (PSA) 
and histopathology, was collected. All participants 
were referred to an independent physiotherapy clinic 
one month prior to surgery for the prescription of a 
preoperative pelvic floor muscle training program[17]. 
All patients were reviewed by the physiotherapist at 
3 and 6 weeks postoperatively for a continence review 

Abbreviations 
BMI body mass index
ICIQ-MLUTS  International Consultation on Incontinence  

Questionnaires for Male Lower Urinary Tract
ICIQ-SF  International Consultation on Incontinence   

Questionnaire Short Form
ICSmaleSF International Continence Society Male Short Form
IQR interquartile range
PPI post-prostatectomy incontinence
PROM patient-reported outcome measure
PSA prostate specific antigen
QoL quality of life
RARP robotic-assisted radical prostatectomy
RP radical prostatectomy
SD standard deviation
UCLA-PCI  University of California Los Angeles  

Prostate Cancer Index

125SIUJ.ORG SIUJ  •  Volume 3, Number 3  •  May 2022

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that included prescription of a postoperative pelvic floor 
muscle training program, until continence recovery had 
been achieved. Referral for preoperative physiotherapy 
is standard of care; however, close postoperative 
physiotherapy follow-up is not routine.

The patients were asked to complete 3 validated 
PROMs, the ICIQ-SF preoperatively and at 3 and 6 
weeks postoperatively and the ICIQ-MLUTS and 
UCLA-PCI preoperatively and at 6 weeks postopera-
tively. At 3 weeks postoperatively, only the ICIQ-SF was 
conducted because of its brevity.

The patients were also provided with an analytical 
weighing scale (accurate to 0.1g) and asked to weigh each 
pad before and after use for 24 hours on 3 consecutive 
days prior to the 3- and 6-week postoperative assess-
ment. The 24-hour pad weight used in the analysis was 
the mean 24-hour weight of the 3 consecutive days.

Statistical analysis
Statistical analysis was conducted using IBM SPSS 
Statistics version 26 (IBM, Armonk, US). P-values < 0.05 
were considered statistically significant. Continuous 
variables were summarized as means and standard 
deviations or medians and interquartile ranges. The 
correlations between variables were assessed using 
Spearman’s rank correlation. The strength of the 
relationships was interpreted as follows: 0 to 0.19, very 
weak positive correlation; 0.20 to 0.39, weak positive 
correlation; 0.40 to 0.59, moderate positive correlation; 
0.60 to 0.79, strong positive correlation; and 0.80 to 1, 
very strong positive correlation[18].

Results
A total of 54 consecutive patients were recruited. Five 
patients were lost to follow-up, and 2 did not complete 
the PROMs. Thus, a total of 47 patients were included in 
the analysis. All patients underwent RARP. The patients’ 
demographic, clinical, and operative characteristics are 
summarized in Table 1. The median preoperative scores 
for the ICIQ-MLUTS incontinence domain, ICIQ-SF, 
and UCLA-PCI urinary function domain were 0, 1, and 
100, respectively (Table 2).

The mean 24-hour pad weight was 24.2 ± 42.6g (0g to 
200g) at 3 weeks and 7.6 ± 17.7g (0g to 77g) at 6 weeks. 
With continence defined as a 24-hour pad weight of ≤ 
1g, 38% and 70% of the patients were continent at 3 and 6 
weeks, respectively.

The daily pad number ranged from 0 to 5 at 3 weeks 
and 0 to 2 at 6 weeks. The pad number correlated 
strongly with 24-hour pad weight at 3 weeks (r = 0.64,  
P < 0.001) and weakly at 6 weeks (r = 0.34, P < 0.001).

The correlations between 24-hour pad weight and the 
PROMs are shown in Figure 1. There was a strong and 

statistically significant correlation between 24-hour pad 
weight and the ICIQ-SF at 3 weeks (r = 0.71, P < 0.001) 
and 6 weeks (r = 0.68, P < 0.001).

There was a strong and statistically significant correla-
tion between 24-hour pad weight and ICIQ-MLUTS 
incontinence (r = 0.80, P < 0.01) and incontinence QoL 
burden (r = 0.79, P < 0.01) at 6 weeks. There was a moder-
ate and statistically significant correlation between the 
ICIQ-MLUTS nocturia score and 24-hour pad weight  
(r = 0.44, P = 0.049) but no significant correlation 

TABLE 1. 

Demographic, clinical and operative characteristics 

Characteristic
Mean ± SD or 

n (%)
Median (IQR)

Age 65.2 ± 7.6 65 (59–71)

Ethnicity

Caucasian 34 (72.34)

Middle Eastern/
Mediterranean

10 (21.28)

Asian 3 (6.38)

BMI (kg/m2) 29.1 ± 4.2 28.3 (59–71)

PSA (ng/mL) 8.5 ± 7 6.8 (4.2–9.2)

Prostate weight (g) 41.2 ± 15.1 40 (30–50)

Gleason grade group

2 25 (53.19)

3 15 (31.91)

4 2 (4.26)

5 5 (10.64)

Clinical stage

T2 17 (36.17)

T3 30 (63.83)

D’Amico risk group

Intermediate 17 (36.17)

High 30 (63.83)

Nerve sparing procedure

Not performed 2 (4.26)

Unilateral 12 (25.53)

Bilateral 33 (70.21)

SD: standard deviation; IQR: interquartile range; BMI: body mass index; 
PSA: prostate specific antigen

126 SIUJ  •  Volume 3, Number 3  •  May 2022 SIUJ.ORG

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between nocturia QoL burden (P = 0.67) and the 
24-hour pad weight. There were no statistically signif-
icant correlations between 24-hour pad weight and 
the other ICIQ-MLUTS domains, including voiding  
(P = 0.73), voiding QoL burden (P = 0.41), leakage 
frequency (P = 0.64), and leakage frequency QoL burden 
(P = 0.44).

There was a moderate correlation between the 
24-hour pad weight and UCLA-PCI urinary function 
(r = 0.58, P < 0.001) and a strong correlation between 
24-hour pad weight and urinary QoL burden (r = 0.66, 
P < 0.001) at 6 weeks. There were no significant correla-
tions between 24-hour pad weight and the UCLA-PCI 
bowel function (P = 0.41), bowel QoL burden (P = 
0.83), sexual function (P = 0.61), or sexual QoL burden  
(P = 0.31) domains at 6 weeks.

Discussion
This study evaluated multiple methods of assessing PPI 
to determine the most accurate and reliable. Several 
assessment methods are currently used, including 24-
hour pad weight, pad number and validated PROMs. 
The 24-hour pad weight test is widely accepted as 
the gold standard for objective measurement of 
incontinence but can be burdensome for patients. 
Most studies require patients to seal used pads in 
containers to minimize evaporation until the pads are 
submitted for evaluation. This may be seen by patients 

as an unacceptable, unsanitary practice and may lead to 
poor patient compliance[19,20]. A recent study showed 
that if patients are motivated and well-instructed, pad 
weight compliance can be high[21]. To increase patient 
satisfaction and compliance, we provided patients with 
analytical weighing scales and clear instructions to 
allow them to perform the measurements themselves 
at home. Although this was well-received, pad weight 
measurements can still be a demanding and complex 
task for patients. To date, there is no consensus on the 
best substitute for the 24-hour pad weight test for PPI 
assessment.

Our study focuses on the early postoperative period, 
as technical modifications, improvements in surgical 
technique, and the increasing use of robotic surgery have 
accelerated continence recovery[4,5,22,23]. Definitions 
of continence in the literature regarding the early post-
operative period vary greatly. We defined continence 
as a 24-hour pad weight of ≤ 1g. According to this defi-
nition, 38% and 70% of our patients were continent at 
3 and 6 weeks, respectively. Our study demonstrates 
that PROMs are reliable substitutes for the 24-hour pad 
weight test for PPI assessment in the early postoperative 
period.

The use of the daily pad number as a substitute for 
24-hour pad weight remains controversial. Nitti et al.[24] 
reported a strong correlation between perceived pad use 
and the 24-hour pad weight. In our study, we found a 
moderate correlation between pad number and 24-hour 
pad weight at 3 weeks and 6 weeks postoperatively. This 
is in line with previous studies reporting that the pad 
number is not a reliable measure of incontinence[4,5,21]. 
Patients may change pads for a variety of reasons, 
including differing acceptable hygiene and pad wetness 
levels, convenience, and financial or physical access to 
pads. As previous studies did not evaluate pad number 
reliability specifically for PPI, our study serves to vali-
date this finding in a post-prostatectomy population.

PROMs rely on the patients’ own perceptions of their 
incontinence symptoms and their effect on QoL. 
Although many PROMs are used to assess incontinence, 
thus far, there is no universally accepted PROM. We 
assessed the correlation between 24-hour pad weight 
and both generic and condition-specific PROMs. 
Previous studies have attempted to define continence 
using such PROMs. Some have defined continence as 
an ICIQ-SF score equal to or less than the preoperative 
score[25]. Ito et al.[26] recently categorized ICIQ-
MLUTS scores amongst men seeking treatment for 
bothersome lower urinary tract symptoms as mild to 
moderate (incontinence score of 16 to 25 and bother, 
ie, QoL burden, score of 22 to 80) and moderate to 
severe (incontinence score of ≥ 26 and bother score of 
≥ 81) allowing LUTS to be expressed as categorical 

TABLE 2. 

Median and interquartile ranges for incontinence 
assessment methods 

Preoperative
3 Weeks 

Postoperative
6 Weeks 

Postoperative

24-hour pad 
weight (g)

Nil 6 (0–21) 0 (0–4.5)

Pad number Nil 1 (0–2) 0 (0–1)

ICIQ-SF 0 (0–0) 6 (4–9) 1 (0–6)

ICIQ-MLUTS 
incontinence 
score

1 (0–2) 2 (1–4)

UCLA-PCI 
urinary 
function 
score

100 (81–100) 75 (58–100)

PROM: patient-reported outcome measure; ICIQ-SF: International 
Consultation on Incontinence Questionnaires Short Form; ICIQ-MLUTS, 
International Consultation on Incontinence Questionnaires for Male 
Lower Urinary Tract; UCLA-PCI, University of California Los Angeles 
Prostate Cancer Index

127SIUJ.ORG SIUJ  •  Volume 3, Number 3  •  May 2022

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http://SIUJ.org


FIGURE 1. 

Scatter plot showing the correlation between 24-hour pad weight and (A) ICIQ-MLUTS incontinence score and 
bother (B) UCLA-PCI urinary function and bother (C) ICIQ-SF score at 6 weeks following RARP.  
(r = Spearman’s rank correlation coefficient, P = P value)

values. Whilst these banding ranges can provide an 
indication of an individual’s LUTS severity relevant to 
a broader cohort, they do not provide a clear correlation 
with 24-hour pad weight. Moreover, as these PROMs 
are subjective measures of incontinence severity, it 
is difficult to determine a definitive cut-off score for 
continence. For this reason, we used the PROM scores as 

continuous variables and Spearman’s rank correlation to 
evaluate their correlations with the 24-hour pad weight. 
Whilst all 3 PROMs strongly correlated with 24-hour 
pad weight, the strongest correlations were between 24-
hour pad weight and ICIQ-MLUTS incontinence and 
QoL burden. The brevity of the ICIQ-SF may account for 
its weaker correlation. Although questionnaires should 
ideally be relatively short and simple to use in routine 
clinical practice, this must not compromise their clinical 
accuracy.

Ultimately, the best assessment method for PPI 
depends on the clinical context. PROMs can be used 
as a convenient and reliable substitute for 24-hour 
pad weight, particularly for routine PPI assessment. 
However, 24-hour pad weight remains important for 
situations when objective assessment is required, such 
as the decision to proceed to invasive therapy for PPI and 
monitoring of treatment response.

Our study has several limitations. We assumed that 
24-hour pad weight is completely objective and did 

128 SIUJ  •  Volume 3, Number 3  •  May 2022 SIUJ.ORG

 ORIGINAL RESEARCH
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http://SIUJ.org


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Beyond 6 weeks, the proportion of incontinent men is 
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Conclusion
PROMs may be used as a substitute for the 24-hour pad 
weight test for PPI assessment in the early post-RARP 
period. ICIQ-SF and UCLA-PCI urinary function and 
QoL scores strongly correlate with 24-hour pad weight. 
However, the ICIQ-MLUTS incontinence and QoL 
scores provide the strongest correlation with PPI.

129SIUJ.ORG SIUJ  •  Volume 3, Number 3  •  May 2022

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130 SIUJ  •  Volume 3, Number 3  •  May 2022 SIUJ.ORG

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