*For medical professionals only
Many doctors have never seen it at all, and lack understanding of the underlying mechanisms and influencing factors, and need to have literature to fill in the gaps.
Written by | Yan Xiaoliu
Dr. Ma Jun, who specializes in brain science and the diagnosis of children's developmental and behavioral problems, can treat thousands of children who "can't hold their urine" every year.
Some are "stress urinary incontinence" when you sneeze, "nocturnal enuresis" when you are asleep, and "giggle incontinence" when you pee when you laugh. "The simple understanding is that you are laughing at the urine, and the amount of urine is very large." Dr. Ma Jun told the "medical community".
This accounts for only 0.36% of daytime urinary incontinence in children and is a rare subtype. As the chief physician of the Department of Developmental and Behavioral Pediatrics at the Shanghai Children's Medical Center affiliated to Shanghai Jiao Tong University School of Medicine, and the deputy head of the Shanghai Enuresis Expert Collaboration Group, Ma Jun can encounter three or four cases every year.
But he wrote a review specifically for these "minority children", which was published in the Chinese Journal of Pediatrics in July this year. "Giggling urinary incontinence treatment is tricky, and it is likely that there are problems such as comorbid mental disorders, and the adverse effects can be carried over into adulthood. Many doctors have never seen it at all, and lack understanding of the underlying mechanisms and influencing factors, and need to have literature to fill in the gaps. ”
"Joy and sorrow" urinary incontinence
"It came suddenly, and died on the spot," says Dr. Ma Jun, describing the scene of the incontinence episode.
He once treated a little girl who became ill for the first time at a long-awaited birthday party, in front of all the guests. There are also children who are having a good time in the playground and suddenly pee when they laugh. Since then, laughter has become their "curse", and the more they laugh, the more they pee, and they can't stop laughing.
According to the International Association of Child Continence, giggling incontinence is defined by a child who has an overreflex in the bladder and urins profusely immediately after laughing or laughing. Other times, everything is normal, and no organic lesions or anatomical problems can be detected, making diagnosis difficult.
Giggling urinary incontinence can be easily confused with stress urinary incontinence, overactive bladder, etc. According to the Chinese Expert Consensus on the Clinical Diagnosis and Treatment of Urinary Incontinence in Children (2024 Edition), the core difference between them is urine output.
"Stress urinary incontinence can be just a few drops that leak when you cough or sneeze. Overactive bladder is usually characterized by urinary frequency, urgency, and low urine output. But giggling incontinence causes complete urination, emptying almost the entire bladder. Dr. Ma Jun said.
A parent once complained in the clinic: "The child is already in primary school, and he can't control his urine." The pants/skirt can be soaked, and there is a pool of water under your feet, and you don't dare to take him/her out! ”
These are all characteristics of giggling incontinence. Foreign studies have shown that the disease mostly begins at the age of 5-7 years, and the school age is the most common. In February this year, the sub-journal Nature published a meta-analysis that the age of onset ranged from 8.4 to 16.2 years old.
Dr. Ma Jun pointed out that it takes time to improve the urination function. At the age of four or five, if you are unable to control your bowel and bowel movements day and night, it is considered to be a dysplasia of excretory function that does not match the overall developmental level, and a clinical diagnosis is required.
"Giggling urinary incontinence is a developmental, behavioral problem that may resolve with age and brain development. But some of them carry over into adulthood. Dr. Ma Jun said. Some women with urinary incontinence have a history of giggling incontinence in childhood.
He remembered a child who presented with a seriousness that did not match his age. The parents said that the child used to laugh and make trouble, but after being sick for a long time, he began to control himself, kept a straight face every day, forbade himself to laugh, and did not care about others.
According to the Chinese Expert Consensus on the Clinical Diagnosis and Treatment of Urinary Incontinence in Children (2024 Edition), up to 40% of children with urinary incontinence have psychological and behavioral disorders. Some may appear after urinary incontinence and persist. Many children have low self-esteem, low self-confidence, and psychological distress, which in turn puts them at risk of social isolation, peer conflicts, being teased, and classroom challenges.
"We can't wait for the child to heal itself. On the one hand, it may not be possible. On the other hand, this disease seriously affects social interaction and is not conducive to children's growth. Dr. Ma Jun pointed out.
Dr. Ma Jun (male) on the call. Photo source/provided by the interviewee
It is difficult to treat laughing urine with medicine
Nowadays, several specialties such as nephrology, urology, etc., are studying giggling urinary incontinence. The focus is on improving the function of the detrusor and pelvic floor muscles to achieve healing.
The Pediatric Urodynamics and Pelvic Floor Group of the Pediatric Surgery Branch of the Chinese Medical Association wrote the Chinese Expert Consensus on the Clinical Diagnosis and Treatment of Urinary Incontinence in Children (2024 Edition), which pointed out that the treatment is based on urination (toileting) training and supplemented by drug treatment.
The Chinese Journal of Pediatrics published a review by Ma Jun, which also supports the use of standard urological therapy, biofeedback training and other toilet behavior treatments.
The first thing is to develop habits such as drinking water and urinating regularly to help children learn to urinate again. Secondly, we should do a good job of "urination diary" and dig out the "high incidence places" and "early warning signs" of giggling urinary incontinence.
"Parents know that if they want to go to places where they can laugh (playgrounds) and do things that are easy to laugh at (watching comedy), parents have to send their children to the toilet in advance. The bladder was empty, and I couldn't pee even when I smiled. This is a targeted intervention. Dr. Ma Jun said.
Biofeedback training includes pelvic floor muscle training such as combined Kegel exercises. Studies have shown that the effective rate of treatment is more than 90%, and it is suitable for children over 5 years old, and the effect is better for boys than girls.
Foreign countries also use the principle of conditioned reflex to do electric shock training for children with giggling urinary incontinence. This involves attaching electrodes to the back of one of your child's hands or to urinate and applying harmless, painless electrical stimulation once the child's smile and urge to urinate are detected. After a few or dozens of stimulations, your child may develop a new antiuritic reflex.
A small sample study supported an 89% reduction in the frequency of wetting after 1 year of shock training, and no adverse effects were reported.
Dr. Ma Jun emphasized that no matter which treatment method is adopted, the premise is to complete a comprehensive examination and formulate an individualized treatment plan. It includes physical examination, urological ultrasound, urinalysis and urodynamic examination, screening for low self-esteem, anxiety and other adverse emotions, as well as improving brain imaging and brain function tests.
He believes that giggling urinary incontinence is related to congenital abnormalities in brain function and brain activity. Existing studies suggest that the disease may result from abnormalities in central nervous system control. When some children laugh, the voiding neural network is highly excited, resulting in overactive detrusor muscles and loose pelvic floor muscles.
"On the basis of neural voluntary movements, children may have poor conditioning." Dr. Ma Jun explained that after laughing at the pee, the parents blamed and punished in an attempt to deter the child and stop the bad behavior. As a result, the child is frightened, feels nervous, and laughing urine symptoms are more stubborn. Based on this, drugs that directly act on the urinary system generally have low efficacy and high recurrence rate.
There is also research to support that the combination of genetic and psychological factors can cause disease. For example, if you have daytime urinary incontinence in your family, anxiety and other emotions may spread, or the risk of giggling incontinence increases. According to the analysis of the sub-journal "Nature", the incidence of family history may reach 13%-16.7%.
However, the above are all clinical observations and inferences. To date, the specific mechanism of giggling incontinence remains unknown. "Some parents asked me if I had been retributed for this disease." Dr. Ma Jun lamented that for complex situations with unknown etiology and incomprehensible causes, parents will attribute it to "mysticism".
Dr. Ma Jun has a habit of taking notes. He often reviews his diagnosis and treatment ideas and plans during his walks, and then records them on the A4 paper he carries with him. Photo source/provided by the interviewee
Focus on urinary incontinence and comorbidities
Dr. Ma Jun treats children from all over the country, and most of them have a tortuous history of medical treatment. Most of the children who were able to adhere to treatment and follow-up were able to gradually improve and eventually return to normal after individualized intervention. The Nature article showed that 6 months of standard behavioral therapy improved giggling incontinence by 33%.
He told the "medical community" that he would be concerned about giggling incontinence, more because children may have multiple mood disorders at the same time.
"Developmental-behavioral pediatrics is concerned with how brain development dominates and influences various functions or behaviors in a person." Dr. Ma Jun told the "medical community" that some children are full after eating and grinding and eating two bites. Parents think it is digestion and malabsorption. But within the scope of the discipline, he knew that the brain had to take the blame for this.
According to the aforementioned Nature article, attention deficit hyperactivity disorder (ADHD), a common neurodevelopmental disorder in childhood, was observed in 23% of children with giggling urinary incontinence. Such children have weak self-control, are prone to excessive excitement, and infinitely amplify emotions. For example, they will laugh at a little thing.
In this case, the co-treatment of the two diseases needs to be considered clinically. "We have to judge the contradiction between priority and secondary. If the child's mental disorder is more severe, then take medication to control ADHD first, and then do behavior training and intervention in urination. Dr. Ma Jun said.
He already has the next step in mind: to accumulate some more cases of giggling urinary incontinence and then design some brain function studies. This includes the use of functional MRI and other techniques to observe how laughter, brain nerves, bladder activity, and urination are linked.
"We need rigorous scientific research to understand the pathological mechanism. This is important for understanding the brain, the functions of the human body, and the relationship between the two. ”
参考文献：[1].吴雨涵, 马骏. 儿童咯咯笑尿失禁的诊治进展. 中华儿科杂志. 2024,62(6):580-582. DOI:10.3760/cma.j.cn112140-20240122-00069[2].中华医学会小儿外科学分会小儿尿动力和盆底学组. 儿童尿失禁临床诊治中国专家共识（2024年版）. 临床小儿外科杂志. 2024, 23(3):201-209. DOI:10.3760/cma.j.cn101785-202302006-001[3]. Adrián A. González-Maldonado, et al. Giggle incontinence: a scoping review. pediatric research. 95,1720–1725 (2024). doi.org/10.1038/s41390-024-03065-y
QR code or click to open the web version of the doctor station to view~
Source of this article: Responsible editor of the medical community: Moon
*The Medical Profession strives to be professional and reliable in its published content, but does not make any commitment to the accuracy of the content; The parties involved are invited to separately check when adopting or using this as a basis for decision-making.
to learn more clinical skills