Methylphenidate and atomoxetine for treatment of nocturnal enuresis in a child with attention-deficit hyperactivity disorder

Optimising the management of children with concomitant bladder dysfunction and behavioural disorders

Bladder dysfunction and behavioural disorders in children are commonly concomitant; hence, it is difficult to treat each in isolation. Pharmacotherapy is common treatment for behavioural disorders, and these medications may have intended or unintended positive or negative bladder sequelae. This review identifies the literature regarding the effects of behavioural pharmacotherapy on bladder functioning and possible bladder management strategies in children with concomitant behaviour and bladder disorders to enable clinicians to better manage both conditions. A PROSPERO registered PRISMA-guided review of three major databases was performed. After an initial scoping study revealed significant heterogeneity, a narrative approach was undertaken to discuss the results of all relevant cases relating to children being treated with pharmacotherapy for behaviour disorders and outcomes related to bladder function. Studies were screened to identify those that described effects of commonly prescribed medications in children with behavioural disorders such as stimulants, alpha 2 agonists, tricyclic antidepressants (TCA), serotonin and noradrenergic reuptake inhibitors (SNRI), selective serotonin reuptake inhibitors (SSRI) and antipsychotics, and the findings and implications were summarised. The review identified 46 studies relevant to behavioural pharmacotherapy and bladder function (stimulants (n = 9), alpha 2 agonists (n = 2), TCAs (n = 7), SNRIs (n = 8), SSRIs (n = 8) and antipsychotics (n = 6). Six studies focused specifically on bladder management in children with behavioural disorders with concurrent behavioural pharmacotherapy. This review identifies useful factors that may assist clinicians with predicting unintended bladder effects following initiation of behavioural pharmacotherapy to facilitate the best approach to the treatment of bladder dysfunction in children with behavioural disorders. With this evidence, we have provided a useful decision-making algorithm to aide clinicians in the management of these dual pathologies.

The Treatment of Lower Urinary Tract Dysfunction via Treatment of Obsessive-compulsive Disorder in a Pediatric Patient

Lower urinary tract dysfunction in the pediatric patient can be associated with mental health issues, such as anxiety and obsessive-compulsive disorder (OCD). In fact, 20%-40% of pediatric patients with daytime urinary incontinence have concomitant diagnosis of mental health disease.¹ Here, we present a case of lower urinary tract dysfunction in the setting of OCD, with symptom resolution following appropriate treatment of OCD. This case report demonstrates the importance of clinicians including mental health disorders in the differential of children with voiding dysfunction.

Impaired selective attention in patients with severe primary monosymptomatic nocturnal enuresis: An event-related potential study

Objectives

Primary monosymptomatic nocturnal enuresis (PMNE) is a very common problem in school age children. It is thought that PMNE represents a maturational lag in the central nervous system of those children. We did this case control study to assess the selective attention and resource allocation in those children using the P300 wave of the Event-Related Potentials (ERPs) and its relation to disease severity.

Methods

Forty four patients with PMNE and twenty three healthy controls were included in this study. Patients were diagnosed according to the criteria of international children's continence society and were classified into two groups; patients with frequent wetting (≥4 episodes/week), and patients with infrequent wetting (<4 episodes/week). ERPs were recorded at Fz, Cz, and Pz locations using odd-ball paradigm. N200 and P300 peak latencies (ms), and N200/P300 peak to peak amplitudes (µV) were measured.

Results

We found significant increase of P300 and N200/P300 interpeak latencies, and significant decrease of P300 amplitudes in frequent wetting group "severe" PMNE compared to healthy controls and infrequent wetting group.

Conclusion

Abnormal selective attention and resource allocation were found in patients with severe PMNE. Measures to improve selective attention might be helpful in treatment of patients with severe PMNE.

Significance

Impaired selective attention might play a role in pathogenesis of severe PMNE and the need for the various measures to improve selective attention may be further studied as a therapeutic tool for patients with severe PMNE.

Methylphenidate-Induced Enuresis: 3 Case Reports

ABSTRACT

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder in children and adolescents. Methylphenidate (MPH) is one of the most widely used drugs in the treatment of ADHD. Enuresis can occur comorbidly with ADHD. However, enuresis is sometimes seen in patients with ADHD as an adverse effect of MPH treatment. In contrast, in some cases, MPH reportedly improves enuresis in patients with ADHD comorbid with enuresis. The literature is contradictory with regard to the relationship between MPH and enuresis. This report presents the cases of 3 children with ADHD who displayed enuresis during MPH treatment.

Effects of methylphenidate on the lower urinary tract in patients with attention deficit hyperactivity disorder and without voiding dysfunction

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is characterised by a range of symptoms, such as excessive mobility, difficulty in maintaining attention and inadequate impulse control. Methylphenidate (MPH) is widely prescribed as a treatment for ADHD. In the literature, studies investigating the effects of MPH on the lower urinary tract (LUT) are limited.

OBJECTIVE

The aim of the study was to evaluate MPH-induced LUT symptoms (LUTSs) in patients with ADHD without a diagnosis of voiding dysfunction (VD).

STUDY DESIGN

After ethical committee approval, volunteers aged 7-17 y were divided into two groups, with group 1 composed of individuals diagnosed with ADHD but not VD and group 2 (control) composed of healthy individuals. Lower urinary tract symptoms and quality of life, in addition to uroflowmetry test results and postvoiding residual volume (PVRV), were evaluated in both groups at baseline and again 4 wk later. The individuals in group 1 were treated with MPH after baseline screening. The dysfunctional voiding scoring system questionnaire was used for scoring LUTSs. Postvoiding residual volume was measured by ultrasound. Bladder capacity (BC) was calculated as the sum of voided volume (VV) and PVRV. The means of the maximum flow rate (Q max), mean flow rate (Q mean), VV, PVRV and BC were recorded.

RESULTS

After exclusions, there were 43 participants in group 1 and 39 participants in group 2. There was no significant difference between the mean age of groups (p = 0.727). Compared with the baseline, VV and BC increased significantly in group 1 (p = 0.001 and p = 0.002, respectively) at the 4-wk follow-up. There was no significant difference in these parameters in group 2.

DISCUSSION

This study demonstrated that VV and BC increased after MPH treatment in patients with ADHD without a diagnosis of VD. The mechanism underlying this effect is unclear, but it may be associated with dopaminergic and noradrenergic effects.

CONCLUSION

The findings of the present study can inform further studies on the mechanism underlying the effect of MPH on the LUT. In a future study, the authors suggest evaluating the effects of MPH in a urodynamic study in patients with ADHD diagnosed with VD.

Associations Between Psychiatric Disorders and Enuresis in Taiwanese Children: A National Population-Based Study

BACKGROUND

Psychiatric disorders such as attention-deficit/hyperactivity disorder may negatively impact drug compliance and the prognosis of enuresis. However, existing studies regarding associations between lifetime psychiatric disorders and childhood enuresis are primarily from Western countries, and studies from Taiwan are lacking.

METHODS

We conducted a population-based retrospective cohort analysis using the Taiwan Longitudinal Health Insurance Database 2010. A total of 1,146 children with enuresis (ICD-9-CM code: 307.6) and 4,584 randomly selected sex- and age-matched controls were identified between January 1, 1997 and December 31, 2011. Logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for the development of psychiatric disorders in the children with enuresis.

RESULTS

Enuresis was more common in the younger children, and the rate was significantly higher in boys (58.7%) than in girls (41.3%). A total of 171 patients (14.9%) in the enuresis group had at least one psychiatric diagnosis vs 259 (5.7%) in the control group (p<0.001). Multivariate analysis showed that the presence of enuresis increased the odds of developing major depressive/dysthymic disorder (OR=2.841, 95% CI: 1.619, 4.987), attention-deficit/hyperactivity disorder (OR=3.156, 95% CI: 2.446, 4.073), autism spectrum disorder (OR=2.468, 95% CI: 1.264, 4.822), anxiety disorders (OR=3.113, 95% CI: 2.063, 4.699), intelligence disability (OR=3.989, 95% CI: 2.476, 6.426), disruptive behavior disorders (OR=3.749, 95% CI: 1.756, 8.004), and tic disorder (OR=2.660, 95% CI: 1.642, 4.308).

CONCLUSION

Children with enuresis are likely to have psychiatric disorders, and physicians should consider this during their evaluation.

Children with nocturnal enuresis and attention deficit hyperactivity disorder: A separate entity?

INTRODUCTION

There is ongoing debate about whether nocturnal enuresis (NE) is affected by the presence of attention deficit hyperactivity disorder (ADHD) in children. Clarifying this relationship could categorize them as a separate entity, potentially requiring a different management from enuretic children without ADHD.

AIMS

To study whether (1) children with ADHD exhibited greater severity of enuresis and associated voiding symptoms compared with children without ADHD, (2) whether there was a difference in enuretic response to treatment between children with/without ADHD, (3) whether previously prescribed medication for ADHD affected severity of enuresis or voiding symptoms, and response to treatment.

METHODS

Data on all consecutive children seen with primary NE and ADHD and age- and gender-matched children with NE without ADHD over the course of 2 years were extracted from our database. Controls were identified using a random number generator to choose patients within each age/gender group. Changes in Dysfunctional Voiding Scoring System (DVSS) and Bristol scores were assessed before and after treatment for NE using repeated measures ANOVAs. Number of weekly wet nights was compared between the groups before and after the treatment of enuresis. Children with more than a 50% decrease in number of wet nights per week were categorized as responding to treatment.

RESULTS

Compared with controls, ADHD children (N = 95) had significantly more severe voiding symptoms, NE and constipation (Table). No significant differences were found between children on ADHD medication (63.2%) and those who were not on ADHD medication (36.8%) on any of the demographic and pre-treatment clinical parameters. Similar enuretic response rates to behavioral modification alone were seen in both study (13.5%) and control (12.8%) groups (p = 0.73). Response to pharmacological treatment was seen in nine patients with ADHD (42.9%) and in six (20.7%) controls, with pharmacological intervention being significantly more effective than behavioral modification for patients with ADHD (p = 0.012). Additionally, no difference was found between ADHD patients on and off ADHD medication in terms of response to enuresis treatment.

CONCLUSION

In children with primary NE, the presence of ADHD was associated with more severe NE, voiding symptoms and constipation. The severity of voiding symptoms and/or NE was unrelated to the use of stimulant medication. The response to behavioral modification was comparable in both groups. However, patients with ADHD were significantly more responsive to medication for NE compared with behavioral modification, indicating a possible benefit for earlier pharmacological treatment for enuresis in this population subgroup.

Atomoxetine ameliorates nocturnal enuresis with subclinical attention-deficit/hyperactivity disorder

BACKGROUND

Recent studies have shown that incontinence and attention-deficit/hyperactivity disorder (ADHD) coexist and there is an interaction between them. The treatment for nocturnal enuresis (NE) and ADHD, however, has not been established.

METHODS

At the first visit to the outpatient clinic, physical examination and history taking were carried out in 265 new patients with NE. After excluding the possibility of comorbid ADHD and related disorders, patients with monosymptomatic NE (MNE) were treated with desmopressin and/or alarm, and those with non-monosymptomatic NE (NMNE) were treated with anti-cholinergics and/or alarm. This 12 week treatment did not work in 65 patients, and they were re-assessed for comorbid ADHD. A total of 24 were diagnosed with ADHD, and they were treated with atomoxetine (1.8 mg/kg/day) in addition to ongoing therapy for NE.

RESULTS

After 8 weeks of atomoxetine, the average wet nights per months was significantly decreased: 18.5-4.6 in the MNE group (P = 0.001), and 22.1-12.4 in the NMNE group (P = 0.0251). Overall, atomoxetine was beneficial in 19 of 24 patients.

CONCLUSIONS

Atomoxetine may be a suitable option for refractory NE with comorbid ADHD.

Comorbidity of ADHD and incontinence in children

ADHD and incontinence are common childhood disorders which co-occur at much higher rates than expected by chance. The aim of this review was to provide an overview both of the comorbidity of nocturnal enuresis (NE), daytime urinary incontinence (DUI) and faecal incontinence (FI) in children with ADHD; and, vice versa, of the co-occurrence of ADHD in children with NE, DUI and FI. Most clinical studies have focussed on the association of ADHD and NE. Population-based studies have shown that children with DUI have an even greater risk for ADHD than those with NE. While children with FI have the highest overall comorbidity rates of psychological disorders, these are heterogeneous with a wide range of internalising and externalising disorders--not necessarily of ADHD. Genetic studies indicate that ADHD and NE, DUI and FI do not share the same genetic basis. The comorbidity is conferred by non-genetic factors. Possible aetiological and pathogenetic links between ADHD and incontinence are provided by neurophysiological, imaging and pharmacological studies. The co-occurrence has clinical implications: children with ADHD and NE, DUI and FI are more difficult to treat, show lower compliance and have less favourable treatment outcomes for incontinence. Therefore, both groups of disorders have to be assessed and treated specifically.