Bed Wetting (Enuresis) and ADHD

Though not many people want to talk about it, ADHD has long been known to be associated with bed wetting, or enuresis.  Bed wetting is common in normal children, occurring in as many as 25% of 5 year olds.  Recent research has found that while children with ADHD are not more likely to have enuresis, they are more likely to achieve dry nights later in life.  Most researchers believe that ADHD and bedwetting (and sleep disorders) share a common final neurological pathway, such as delayed maturation, resulting in patients with one of the disorders also having symptoms of the others.  

Another related issue is that children with ADHD tend to be less responsive to treatment for bed wetting.  Patients with ADHD are thought to be less likely to stick to enuresis treatment programs.  The reason for this is unclear, since the burden of treatment usually falls to the parents, not the child.

Causes

It’s important to distinguish between ordinary bed wetting and bed wetting that is coming from some other medical problem.  Parents and pediatric providers should be on the lookout for red flag symptoms like:

Signs of a  sleep disorder—loud snoring or breath holding, enlarged tonsils, odd movements during sleep

Anatomical problems—urine coming from places it shouldn’t, misshapen spine, dimples near spine

Constipation or fecal soiling

Bed wetting that comes after a period of 6 months or more of continence

Weight loss or other signs of diabetes

Holding maneuvers—crossed legs

Pain with urination

Day time incontinence in an older child

These types of symptoms should prompt a doctor’s visit for a thorough evaluation before proceeding further with home treatment.

Treatments

Unfortunately, while treatment for bedwetting is usually successful in getting dry nights, it typically does not make symptoms of ADHD go away completely.  That being said, it’s still great to wake up to dry in the morning!

Behavioral.   Most children who struggle with enuresis should try behavioral methods as they are the most effective and there are little to no side effects.  These methods include using a behavior chart as a positive motivator and using a bed wetting/moisture alarm.  Many parents think that with an alarm their child should be able to wake and get to the toilet themselves.  This is the wrong way to use the alarm as most children will ignore the alarm.  The alarm is for the parents, who then must MAKE SURE their child gets up and uses the toilet, EVERY NIGHT.  The idea is to condition the child to wake up at that time of night when they normally wet the bed, but before they actually do it.  It often takes 6 months or longer for this method to work, and parents must be absolutely consistent.

Parents should ensure that their child is not taking excessive fluids just before bed.  If you have a child who just loves to gulp water before bedtime, try offering more fluids during the day.  Also, children can be afraid to go to the bathroom at night because of the dark.  Make sure the way is well lit, and that your child has a nightlight in their room.

Medical.  There are a number of medications that can be tried but few work after the patient stops using them.  Sometimes they are used with behavioral methods in order to improve patient confidence. 

Desmopressin(DDAVP)—Usually used only for special occasions such as sleepovers or overnight camp due to risks for lowered blood sodium with repeated use.  It also can be very expensive.  You may want to check with your insurance/use a coupon from GoodRx if possible.  Desmopression (DDAVP) is not a controlled prescription, so pharmacies will usually give prices over the phone.

Desipramine—can have cardiotoxic effects and is dangerous in overdose.  Usually only used in teenagers due to higher risk of unintentional overdose in smaller children.

Oxybutinin—used only in select cases.  Can make incontinence worse if used incorrectly.

Surgical.  Most children with enuresis are not helped by surgery unless they have some kind of urinary tract abnormality that can be remedied in this way.  However, intriguing new research is also showing that children with enlarged tonsils, ADHD, and enuresis can sometimes be helped by surgery to remove tonsils.  Tonsils usually get smaller on their own with age, so it isn’t certain whether tonsillectomy improves outcomes long term.  However, if your child has obvious difficulty breathing due to tonsils (ie. they snore loudly), a visit to an ENT may be in order.

Reference:

Walle, Johan Vande, Soren Rittig, Stuart Bauer, Paul Eggert, Daniela Marschall-Kehrel, and Serdar Tekgul. "Practical Consensus Guidelines for the Management of Enuresis." European Journal of Pediatrics 171.6 (2012): 971-83. Web.