Neobook — clinical reference

Enuresis and ADHD

Studies have consistently shown an increased prevalence of enuresis among children with ADHD. Systematic reviews and meta-analyses have found that the pooled prevalence of enuresis in ADHD patients can be up to 30%, significantly higher than the 5 - 10% reported in the general population.^[72]

There are controversies regarding the association of ADHD and enuresis and the multifactorial aetiologies, but several factors are thought to contribute:

Genetic predisposition

Both enuresis and ADHD have been shown to have a significant genetic component, with specific genetic variants increasing the risk of both conditions.^[73]

Neuroanatomical abnormalities

Functional magnetic resonance imaging (MRI) studies have identified differences in brain structure and function between ADHD patients with and without enuresis, including altered activity in regions involved in bladder control and arousal regulation.^[74]

Sleep disturbances

ADHD patients often experience sleep disturbances, which may contribute to enuresis by disrupting the normal sleep-wake cycle and increasing nocturnal bladder contractions.^[75]

Executive function deficits

ADHD-related deficits in executive function, including planning, organisation and self-regulation, may impede the development of adequate bladder control mechanisms.

Studies report an average of 14.9% of children with NE as having associated psychiatric disorders, with ADHD being the most prevalent.^[76] The child may have ADHD and other co-occurring psychological or developmental conditions, such as autism spectrum disorder or learning disabilities, which may complicate the management of enuresis. In general, patients with enuresis often present with comorbid symptoms of ADHD, including inattention, hyperactivity and impulsivity.^[77]

Research suggests that enuresis in ADHD patients is often associated with poorer treatment outcomes, including reduced response to pharmacological interventions and an increased risk of relapse. Early identification and management of comorbid enuresis in ADHD patients may help improve treatment outcomes and quality of life for these individuals. Educating patients and their caregivers about enuresis, ADHD and their comorbidity can help improve treatment adherence and reduce the stigma associated with both of these conditions. Vitally important situations when psychological therapy should be considered as part of the treatment plan are as follows:

Emotional distress and low self-esteem

The child may feel embarrassment, shame or guilt related to bedwetting, leading to social withdrawal and low self-worth.

Anxiety and depression

The child displays symptoms of anxiety or depression, such as excessive worry, ongoing sadness, irritability, or changes in sleep and appetite.

Trauma or significant life stressors

Enuresis can reoccur following a significant life event, such as losing a loved one, parental divorce, or moving to a new school or home. The child may have also experienced emotional or physical trauma.

Behavioural issues

The child exhibits behavioural issues such as aggression, defiance or attention difficulties, which may be linked to or worsened by the stress of enuresis.

Family dynamics and parental stress

The family may show signs of strain, such as parental frustration, sibling teasing, or misunderstandings about the condition, leading to conflict or lack of communication regarding the child’s enuresis.

Resistance to conventional treatments

The child does not respond to conventional treatments, such as alarm therapy or medication, or the enuresis persists despite these efforts.

Adolescent enuresis

Enuresis persists into adolescence, where peer relationships and social acceptance become increasingly important, and the adolescent may experience intense embarrassment or social isolation as a result of the condition.

When there is suspected ADHD, psychological interventions, such as cognitive-behavioural therapy, can be highly effective in addressing the emotional aspects of enuresis. When the parent is more stressed than the child in cases of enuresis, it is essential to address the parent’s emotional needs as part of the treatment plan.

By addressing the psychological aspects alongside the physiological ones, healthcare providers can offer more comprehensive care, helping children overcome the symptoms of enuresis and the emotional challenges accompanying it. Empathy, education and appropriate interventions can mitigate the psychological burden of enuresis, allowing children to regain their confidence and improving their overall quality of life.

Enuresis and adenotonsillar hypertrophy

Obstructive sleep disorders, characterised by snoring and increased respiratory effort due to upper airway obstruction (UAO), are prevalent in paediatric populations. UAO is a common concern, affecting ~27% of children, and is often attributed to nasal or oropharyngeal pathologies.^[78] Adenotonsillar hypertrophy is the most frequent cause of UAO, while other contributors encompass craniofacial malformations, septal deviation and allergic rhinitis.^[79,80] In this context, obstructive sleep apnoea (OSA) emerges as a common presentation in children with adenotonsillar hypertrophy, further complicating the clinical landscape.^[81,82]

Enuresis and OSA are prevalent sleep-related problems in children, sparking significant interest in exploring their potential relationship. Studies have illuminated the association between OSA and NE, with both conditions sharing an underlying sleep disturbance marked by altered arousal responses and fragmented sleep patterns.^[82] This interplay is rooted in the pathophysiological mechanisms operating, ultimately leading to increased intra-abdominal pressure and altered blood pressure, which in turn induce natriuresis and polyuria by affecting levels of ADH and atrial and brain natriuretic peptides.^[83]

Sans Capdevila et al. ^[84] conducted a study involving 17 646 children, revealing that habitual snorers, constituting 26.9% of the sample, had an increased prevalence of enuresis, predominantly among boys. In contrast, non-snorers displayed a lower prevalence of enuresis at 11.6%. Additionally, children with enuresis exhibited elevated brain natriuretic peptide levels, with marginal increases observed among children with OSA. Although evidence suggests that OSA may influence ANP levels and renal function, potentially leading to increased urine output, further research is necessary to understand these mechanisms fully.^[85]

Additional investigations

Ultrasound is recommended as the first line in the investigation of enuresis in this update.

In cases resistant to treatment, additional investigations are recommended to exclude SMSE and help guide management.^[86] Some of the investigations already done in the initial assessment, such as a detailed volume voided chart over 48 hours, may need to be repeated. The weight of night-time nappies should be added to the volume voided.^[86] Night-time urine production should be recorded over ~2 weeks to differentiate between high-volume urine production and night-time OAB.^[86]

Uroflowmetry is indicated if there is a history of previous bladder/urethral surgery. Uroflowmetry and post-void residuals are useful in the work-up of NMSE. Rectal wall distension can be measured on ultrasound to assess constipation, and this is useful in the initial assessment. A course of laxatives may also be given as a trial to investigate the possible role of a distended colon as a cause.^[87]

Functional MRI has not been shown to be helpful; the main concern is that the MRI is done when the child is awake, and enuresis happens during sleep.^[88] While routine urodynamics are not indicated, these tests may help guide treatment by potentially adding anticholinergics to the treatment regimen, or biofeedback may be helpful to the child.^[89] Telemedicine, with closer follow-up, should be considered, as this helped in the investigation and treatment of MSE during the COVID-19 pandemic.^[90]

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The South African Medical Journal_The South African guidelines on enuresis: 2024 update_November 2024; Vol. 114, No. 11