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| 發表人 | 討論主題 | 發表時間 | 討論數 |
| 王炯珵 | Methylphenidate對於咯笑尿失禁的治療 生理回饋治療咯笑尿失禁 |
2014/9/29 下午 05:21:05 | 1 |
| 原 文 | 題 目 | Methylphenidate for Giggle Incontinence Successful Treatment for Giggle Incontinence with Biofeedback |
| 作 者 | Berry, Amanda K., Stephen Zderic, and Michael Carr Richardson, Ingride, and Lane S. Palmer |
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| 出 處 | The Journal of urology 182.4 (2009): 2028-2032 The Journal of urology 182.4 (2009): 2062-2066. |
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| 出版日期 | October 2009 | |
| 評 論 |
我們的學術論壇，這麼多年來，大概都是只討論一篇研究論文，但是由於這兩篇研究，一篇寫藥物治療，一篇寫生理回饋治療，不把兩篇一起報告，總有不吐不快之感。 首先跟大家說明，Giggle incontinence目前並未有適當的中文翻譯，我姑且稱為「咯笑尿失禁」，這和大笑、跳繩、咳嗽後造成的「應力性尿失禁」不同，也和老人家因膀胱過動症造成的「急迫性尿失禁」不同，它專門是指約在國小國中這階段的學生，突然咯咯的笑(非大笑)時，居然會不自主地整個尿液從膀胱排出，造成社交上的尷尬，發生情形以女學生佔大多數(女、男比例約10:1)，雖然發生原因仍不清楚，但有人有研究，認為可能在大腦內的幽默中樞和排尿中樞，兩個原本不相關的神經控制點，彼此不知為何而有了連結所造成的。 第一篇研究，是來自美國費城兒童醫院，他們回溯性整理2004年至2008年的藥物治療經驗，「咯笑尿失禁」的定義是指只有在笑時會漏尿，且尿失禁的程度超過50%次數要濕到外面衣服，同時沒有其他情況如頻尿、急尿、困難尿或其他情況會漏尿。 治療方面，首先會教導小朋友每2小時固定去尿尿，同時如果要參加容易歡樂和笑的活動前，也先要去尿尿。如果沒效，則在每天約上午10點給予Methlphenidate(MPH)，每天每公斤0.2mg~0.5mg，因為MPH的作用時間約4小時，所以在社交活動時，可以減少漏尿。 結果顯示，在20位平均年齡12.4歲的小朋友有咯笑尿失禁，其中15位同意MPH的治療，12位經過2個月治療後，尿失禁次數從每天平均3次降到1次，9位完全治癒。在副作用方面，有2位食慾下降，1位困難入睡，但停藥後症狀都改善。 各位讀者唸到這裡，可能都會很好奇，到底MPH是甚麼藥?我怎麼都沒聽過呢?MPH事實上是個治療過動症、注意力不足的藥，和安非他命類似的中樞神經興奮劑，所以許多父母聽到醫師這樣解釋後，都會拒絕給小孩藥物治療了。那是否有其它好辦法呢?我們就往下看第二篇吧! 第二篇是來自於紐約長島(Long Island，New York)兒童醫院的研究，他們認為使用生理回饋骨盆底肌肉訓練，在過去可以用於治療小朋友尿道外括約肌的功能障礙、尿失禁、泌尿道感染和輕度的輸尿管膀胱逆流，而咯笑尿失禁可能是由於中樞神經系統導致尿道括約肌放鬆，所以使用生理回饋方法應該有助於改善尿失禁。 他們的方法，第一步是行為調整，在可能會笑的場所，如搭公車回家前先去排尿。第二步是定時排尿和重覆排尿(double voiding)及避免膀胱刺激物，如咖啡因等。第三步是排便處理，減少便秘；最後會使用電腦螢幕，一周或兩周一次，一對一教導兒童做骨盆底肌肉訓練一個月。 結果顯示，在12個(2男10女)平均11.6歲的有咯笑尿失禁病患中，經過平均4.5次的訓練後，6位可以完全治癒，而4位則有部分改善，2位則失去追蹤。所以結論是不吃藥的膀胱訓練方法，也可以改善咯笑尿失禁。 |
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| abstract |
Methylphenidate for Giggle Incontinence PURPOSE: Giggle incontinence or enuresis risoria is a socially embarrassing problem characterized by involuntary and complete bladder emptying in response to laughter. To our knowledge the cause of giggle incontinence is unknown, although a functional relationship to cataplexy was suggested. We retrospectively examined the effectiveness of methylphenidate for giggle incontinence in children. MATERIALS AND METHODS: We retrospectively reviewed the charts of patients referred to a pediatric specialty voiding center between 2004 and 2008 for wetting associated with laughter. Patients who met giggle incontinence criteria with no associated urgency or urge incontinence were offered a trial of methylphenidate. Wetting frequency was assessed before and during methylphenidate treatment. RESULTS: A total of 20 patients with a mean age of 12.4 years (range 7.5 to 15.5) met giggle incontinence criteria with no other wetting reported. Incontinence frequency was daily to less than once weekly. After a timed voiding trial 15 of 20 patients (75%) elected a methylphenidate trial, of whom 12 (80%) reported prompt and complete cessation of wetting. Treatment duration was 2 months to greater than 3 years. CONCLUSIONS: Giggle incontinence with no other urinary symptoms is a rare form of incontinence. Methylphenidate was a viable option for giggle incontinence but it was not accepted by all families. Successful Treatment for Giggle Incontinence with Biofeedback PURPOSE: Giggle incontinence is the involuntary and often unpredictable loss of urine during giggling or laughter in the absence of other stress incontinence. The pathophysiology is unclear, urodynamics are seldom helpful, and the efficacy of timed voiding and pharmacotherapy is limited. We postulated that improving sphincter tone and muscle recruitment using biofeedback techniques might be helpful in children with giggle incontinence. MATERIALS AND METHODS: The charts of 12 patients with giggle incontinence were reviewed. Giggle incontinence severity, voiding patterns, associated symptoms and medical history including prior treatment were reviewed. Children were evaluated with uroflowmetry-electromyography and ultrasound measurement of post-void residual urine. They were assessed by the ability to isolate, contract and relax perineal muscles. They were taught Kegel exercises and instructed to perform them at home between weekly-biweekly sessions. Clinical success was characterized as a full or partial response, or nonresponse as defined by the International Childrens Continence Society. RESULTS: The 10 females and 2 males were 6 to 15 years old. Only 1 child had a partial response to first line therapy with timed voiding and bowel management. Seven children were treated with anticholinergic agents and/or pseudoephedrine with a partial response in 3. The 9 children with refractory giggle incontinence underwent biofeedback with a median of 4.5 sessions per child (range 2 to 8). The 6 patients who underwent 4 or more sessions had a full response that endured for at least 6 months and the 3 with fewer than 4 sessions had a partial response. CONCLUSIONS: Patients with giggle incontinence can heighten external urinary sphincter awareness and muscle recruitment using biofeedback techniques. Treatment with education and pharmacotherapy only led to a partial response in some cases. Biofeedback supplemented this treatment or avoided pharmacotherapy when at least 4 sessions were performed. Biofeedback therapy should be incorporated in the treatment algorithm for giggle incontinence in children and it should be considered before pharmacotherapy. |
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