Thursday, May 26, 2011

Giggle Incontinence (Leaking with Laughing): It’s Not So Funny If It’s Happening to You

Giggle Incontinence was first reported in 1959 in children. Unlike adult women who leak urine with laughing, due to stress incontinence, in children the reason for GI is not entirely known. It has been proposed that perhaps it’s due to an overactive bladder, or some release of pelvic muscle control with extreme emotional discharge.

How Does It Happen?

Think of total loss of muscle control when an extreme emotion overtakes you: fear is good example. Under heavy emotional stress, control of the urethral sphincter or a spontaneous bladder contraction can occur leading to full on urination. Is it a brain reaction or a bladder reaction? It is not clear, but in a small subset of female children, extreme laughter can lead to full on urination and bladder emptying, not simply a little squirt of pee with a heavy laugh like mom.
Some industrious researchers in Korea set out to study GU in teenage girls, and tried to see what was happening to the bladder during urination before and after treatment. Past treatments for GI included overactive bladder medications.

They treated 9 teenage girls between the ages of 12 and 19 who had pure giggle incontinence with methylphenidate (Ritalin) for 1 year. All had resolution of their symptoms, and none suffered side effects of the medication. They noted high urethral pressures after treatment, and it took approximately 7 months to see full resolution.

What is the significance of such a study? It may be useful in children with ADD/ADHD who may be considered for Ritalin treatment. Treating children with medication is a complex and individualized issue. In the absence of ADD/ADHD and if GI is severe and debilitating or embarrassing for the patient, there is an available option, and this study adds to available evidence already.

Monday, May 16, 2011

What Makes Women Satisfied with Their Sling Surgery for Urinary Incontinence?

Stress urinary incontinence is a significant bother to women beginning in their 30s all the way into their 80s, as more and more women remain physically and sexually active into their later years. It can be very restricting in terms of odor, embarrassment, as well as interfere with exercise, and even sex. Approximately 30% of women in their 40-60s will report some urinary incontinence.

After fluid restrictions and Kegels fail to improve stress urinary incontinence, the most common and most successful procedure to correct it is the sling. There are a variety of sling types and different methods of placement. Slings have supplemented and replaced the older open surgical methods, and have become the technique of choice for surgeons as well as requested by many patients in consultation (often after their friends have had successful procedures). Tissue slings harvested from the patient’s own tissue used to be the most common way 15 yrs ago, but these days, mesh slings dominate the most common types of slings placed.

We know that the success rate of modern mesh slings is approximately 90% in the longest term studies (11 yrs follow up), and so you would say, “that’s great”. But, is being dry the only thing that makes the woman satisfied after such a surgery, and, are there things that would predict lower levels of satisfaction after the surgery? This quality of life question is very important.

A recent study published from researchers in Minnesota asked and answered this very question. The purpose of the study was to ass which pre-operative and post operative variables correlated with patient satisfaction after sling surgery for stress urinary incontinence. They used extremely stringent criteria for grading how satisfied the patients were after surgery, on a scale from 1 to 5, 5 being “completely satisfied”, and 4 being “somewhat satisfied”, while 1 was “completely dissatisfied”.

A total of 367 women returned surveys of 428 total women who underwent either a mesh sling or a sling from tissue harvested from their own body. At a median follow up period of 2.9 years, 61% answered that they were “completely satisfied”. Broken down, 65% of the mesh sling patients were completely satisfied, while 48.3% of the tissue sling patients were completely satisfied. Women with the mesh sling were twice as likely to be satisfied with their surgical outcome.

What pre-operative characteristics predicted less satisfaction? These would be higher age, higher BMI and having had a tissue sling performed. Of the patients completely satisfied, 90% said it was because they had resolution of their incontinence. For those who were less than satisfied, it was mainly for reasons of incomplete resolution of the incontinence, or development of a stronger urge to urinate, urge incontinence, or even the inability to empty the bladder. Some of these urinary symptoms predated the surgery, and others developed after the surgery.

Despite a high chance of success, no surgery is perfect. It can help many women regain their prior “normal” lives, but even if the sling works to prevent stress incontinence, patients should know that adverse effects on urination can occur. Interestingly, the women who received the mesh slings were more satisfied that those who received their own tissue for a sling. This is likely due to the extra bikini line incision that is required for harvesting tissue which is not required for mesh slings.