Understanding giggle incontinence: Causes, symptoms, and management

A recent review published in the journal Pediatric Research discusses the historical background and current understanding of giggle incontinence, which is a bladder storage disorder.

Study: Giggle incontinence: a scoping review. Image Credit: Pavlova Yuliia / Shutterstock.com

What is giggle incontinence?

Giggle incontinence is a type of daytime urinary incontinence characterized by uncontrollable episodes of urinary incontinence due to loud, powerful, or bursting laughter. Unlike enuresis, stress urinary incontinence, non-neurogenic voiding dysfunction, bladder and bowel dysfunction, or anatomical disorders causing incontinence, giggle incontinence lacks additional functional symptoms.

Historically, giggle incontinence has been mistaken for stress urinary incontinence and an overactive bladder. Moreover, giggle incontinence has been considered a particular type of laughter-induced daytime urinary incontinence that can be distinguished from laughter-induced stress urinary incontinence by its specific feature of complete emptying of the bladder.

The exact etiology of giggle incontinence is not fully understood. However, two main hypotheses indicate the involvement of the central nervous system and dysfunction of the detrusor and pelvic floor muscles.

The authors of the current review systematically searched various scientific databases and identified 26 studies on giggle incontinence published between 1959 and 2023. These studies were assessed to describe the historical background, current understanding, and challenges associated with giggle incontinence.   

Different types of urinary incontinence in children

Various terminologies have been used to describe giggle incontinence, including micturition induced by giggling, ambivalent laughter micturition, and enuresis risoria. To better understand giggle incontinence and develop appropriate treatments, it is important to distinguish the clinical consequences of giggle incontinence from those associated with stress urinary incontinence and an overactive bladder.

According to the International Children’s Continence Society (ICCS), stress urinary incontinence is characterized by the involuntary loss of urine due to activities that increase intra-abdominal pressure, such as sneezing, coughing, or laughter. Current estimates indicate that stress urinary incontinence affects 8-19% of children.

An overactive bladder is characterized by minor and frequent micturition, as well as other symptoms, including urgency, pollakiuria, and incontinence. This condition affects 5-12% of children.   

ICCS describes giggle incontinence as a rare disorder marked by significant voiding during or after laughter, while bladder function remains normal in its absence. The condition is characterized by laughter-induced uncontrollable urine loss that cannot be stopped until the bladder is completely emptied. However, the condition is not associated with any concurrent urological disorders.    

By analyzing 26 studies that reported a total of 351 giggle incontinence cases since 1959, giggle incontinence primarily affects females, with some cases reporting a family history of this condition. Giggle incontinence primarily affects children over five years of age and often improves or disappears with age.

Pathophysiology

A widely accepted hypothesis on the pathogenesis of giggle incontinence indicates the involvement of the central nervous system, similar to cataplexy, which is the loss of voluntary muscle control. Laughter acts as a stimulus to induce hypotonia and relaxation of pelvic floor muscles, thereby leading to uncontrolled micturition.

Mechanistic evidence links cataplexy with type 1 narcolepsy-associated laughter-induced muscle weakness. Most patients with type 1 narcolepsy are positive for the human leukocyte antigen HLA-DQB1*06:02, which may contribute to the familial tendency observed in some giggle incontinence patients.

Attention-deficit hyperactivity disorder (ADHD) is a common condition observed in about 23% of giggle incontinence patients. Existing evidence also links giggle incontinence pathogenesis with pelvic floor muscle dysfunction, as the proper functioning of these muscles is required for the closing of vaginal, urethral, and anal sphincters in response to increased intra-abdominal pressure. It has also been hypothesized that laughter-induced instability of the detrusor muscle can lead to giggle incontinence.

Diagnosis

A detailed voiding history is crucial for diagnosing diverse forms of daytime urinary incontinence. This will typically include a detailed patient history, maintenance of a voiding diary, analysis of urinary tract infection history, evaluation of toileting positions, and thorough physical examination of the abdominal, genital, and lumbosacral regions.

These procedures should be combined with lower urinary tract ultrasound, voiding residual analysis, and electromyographic flowmetry for an accurate diagnosis of lower urinary tract dysfunction. However, these examinations often provide normal results in patients with giggle incontinence.  

Existing evidence highlights a connection between giggle incontinence and overactive bladder waves. However, urodynamic studies have defined overactive bladder waves as sensitive hyperactive waves, whereas giggle incontinence waves are considered asymptomatic hyperactive waves. Laughter-induced asymptomatic hyperactive waves may justify the urgent and spontaneous urination in giggle incontinence patients and distinguish it from the sensitive hyperactivity waves observed in overactive bladder.

Treatment

Medications that are commonly used to treat neurodynamic lower urinary tract disorders include anticonvulsants, antidepressants, anticholinergics, α-adrenergic blockers, and electric shocks. Three therapies are currently being used to control incontinence, including standard urotherapy, biofeedback, and methylphenidate.

Previous studies have shown that six-month standard urotherapy can partially improve giggle incontinence in 33% of patients; however, this therapy failed to cure the condition. Patients who are unresponsive to standard urotherapy are typically advised to undergo specific urotherapy.

Studies using biofeedback for giggle incontinence patients have reported an efficacy rate of 73% after ten weeks of weekly sessions. Patients are often advised to continue biofeedback training alone or in combination with methylphenidate once continence is achieved.

Methylphenidate is a central nervous system stimulant that acts by influencing urethral smooth muscles and increasing dopamine activity in the brain. Methylphenidate has been found to completely resolve giggle incontinence symptoms in patients; however, the treatment may cause adverse side effects in some patients, including insomnia, tachycardia, hypertension, anorexia, weight loss, abdominal pain, headache, irritability, agitation, or anxiety.