What is the approach to managing nocturnal enuresis in a 25-year-old male with autism spectrum disorder (ASD)?

Management of Nocturnal Enuresis in a 25-Year-Old Male with Autism Spectrum Disorder

For adults with autism spectrum disorder and nocturnal enuresis, a comprehensive approach combining behavioral interventions, alarm therapy, and pharmacological treatment is recommended, with conditioning alarm therapy as the first-line treatment due to its 66% success rate and long-term efficacy.

Initial Assessment

• Perform a thorough medical evaluation to identify potential underlying causes, including urinalysis and possibly urine culture to rule out conditions like urinary tract infection or diabetes 1
• Assess for physical contributors such as constipation, enlarged adenoids/tonsils, sleep apnea, or neurological issues that may contribute to enuresis 1
• Evaluate for comorbid psychological conditions, as adults with ASD have higher rates of clinically relevant psychological symptoms that may impact treatment success 2, 3
• Keep a 2-week baseline record of wet and dry nights to establish patterns and measure treatment progress 1
• Consider morning urine specific gravity to help predict response to desmopressin treatment 1

Behavioral Interventions

• Implement supportive educational approaches as the foundation of treatment:
  • Explain the non-volitional nature of enuresis to caregivers to avoid punitive responses 1, 4
  • Establish a journal or chart to track wet and dry nights 1, 4
  • Involve the individual in changing wet bedding when appropriate to increase awareness 1, 5
• Implement fluid management strategies:
  • Reduce fluid intake, especially caffeinated beverages, before bedtime 1, 6
  • Encourage adequate hydration earlier in the day 6
• Establish regular voiding habits with scheduled bathroom visits throughout the day 6
• Address constipation if present, as this can contribute significantly to enuresis 1, 6

First-Line Treatment: Conditioning Alarm Therapy

• Conditioning alarm therapy has shown the highest success rate (approximately 66%) with long-term efficacy and should be the primary intervention 1, 6
• Use a modern, portable, battery-operated alarm with a written contract and thorough instruction 1
• Ensure proper implementation with frequent monitoring (at least every 3 weeks) 1
• Recognize that proper presentation and monitoring of conditioning treatment significantly affects success rates 1
• Consider that adults with ASD may adapt well to the routine nature of alarm therapy due to preference for sameness and structure 1

Pharmacological Options

• Consider desmopressin (DDAVP) if alarm therapy fails or is not feasible:
  • Administered orally in 0.2-mg tablets in doses of 0.2 to 0.6 mg nightly 1
  • Most effective for those with nocturnal polyuria 6
  • Limit evening fluid intake to 200 ml or less when using desmopressin to prevent water intoxication 6
  • Schedule regular drug holidays to assess whether medication is still needed 6
• Consider imipramine (1.0 to 2.5 mg/kg at bedtime) as an alternative, with documented 40-60% effectiveness, though relapse rates can be as high as 50% 1
  • Obtain a pretreatment electrocardiogram due to potential cardiac arrhythmia risk 1
• For patients with comorbid ADHD symptoms, atomoxetine may be beneficial in reducing wet nights 7

Special Considerations for Adults with ASD

• Recognize that incontinence rates are significantly higher in individuals with ASD compared to the general population (30% vs. 0.5% for nocturnal enuresis) 2, 8
• Adapt visual supports and structured routines to help with treatment adherence, as these work well with ASD preferences for sameness 1
• Address potential sensory sensitivities that might interfere with alarm therapy or other interventions 1
• Consider the psychosocial impact of enuresis, as it can significantly affect quality of life, social relationships, and self-esteem in adults 8
• Recognize that many adults with enuresis (50% of men and 35% of women) have never consulted healthcare providers about their condition, highlighting the importance of proactive assessment 8

Treatment Pitfalls to Avoid

• Avoid assuming the condition will spontaneously resolve in adults, as treatment is necessary and beneficial 8
• Do not rely solely on "lifting" or waking the individual during the night, as evidence suggests this may be less successful than other interventions 1
• Recognize that many adults with enuresis incorrectly believe the condition is untreatable (only 30% believe it is treatable) 8
• Avoid creating control struggles or implementing punitive measures, which can worsen the situation and create psychological distress 1, 4
• Don't overlook the need for regular follow-up to adjust treatment strategies and maintain motivation 6