Systematic review and meta-analysis: relationships between attention-deficit/hyperactivity disorder and urinary symptoms in children


Lower urinary tract symptoms (LUTS), e.g., urinary frequency, pressure, urgency, and overactive bladder syndrome, are commonly reported in children with attention-deficit/hyperactivity disorder (ADHD). Understanding the co-occurrence of these conditions has implications regarding clinical approaches, treatments, and improved quality of life. We conducted a systematic review and meta-analysis to examine the relationships between LUTS and ADHD in children. We searched for articles published between January 1990 and July 2019, in PubMed, CENTRAL, and PsycNet. Two authors independently screened all articles and extracted data. We performed random-effect meta-analyses for ADHD with pooled outcomes for LUTS. We identified 119 relevant articles in the literature and 18 articles fulfilled the inclusion criteria for the systematic review, of which, 5 articles had sufficient data for meta-analysis. Examining ADHD among individuals with LUTS, the odds ratio was 2.99 (95% CI 1.13, 7.88, p < 0.001), compared to controls. In multiple studies, the mean overall score for LUTS, using a standardized measure, was significantly higher in patients with ADHD in comparison to controls, and the severity of ADHD was positively associated with the severity of LUTS. Younger age in children was correlated with a higher LUTS score. Different subtypes of urinary incontinence demonstrated differences in behavioral problems and psychiatric comorbidity. Sex differences in LUTS were not consistent across articles. Our results indicate clinically significant associations between ADHD and LUTS in children. Because LUTS and ADHD are common disorders in children, clinicians should be aware of these associations as they inform optimal assessment and treatment strategies.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2

Availability of data and materials

Data are available in the literature and are also from the authors upon request.

Code availability

Open access software was used for the analysis.


  1. 1.

    Mohammadi MR, Zarafshan H, Khaleghi A et al (2019) Prevalence of ADHD and its comorbidities in a population-based sample. J Atten Disord.

    Article  PubMed  Google Scholar 

  2. 2.

    Danielson ML, Bitsko RH, Ghandour RM et al (2018) Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents, 2016. J Clin Child Adolesc Psychol 47:199–212.

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Polanczyk G (2007) The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry 164:942.

    Article  PubMed  Google Scholar 

  4. 4.

    American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders (5th ed.).

  5. 5.

    Tistarelli N, Fagnani C, Troianiello M et al (2020) The nature and nurture of ADHD and its comorbidities: a narrative review on twin studies. Neurosci Biobehav Rev 109:63–77.

    Article  PubMed  Google Scholar 

  6. 6.

    Gnanavel S, Sharma P, Kaushal P, Hussain S (2019) Attention deficit hyperactivity disorder and comorbidity: a review of literature. World J Clin Cases 7:2420–2426.

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Burgu B, Aydogdu O, Gurkan K et al (2011) Lower Urinary tract conditions in children with attention deficit hyperactivity disorder: Correlation of symptoms based on validated scoring systems. J Urol 185:663–668.

    Article  PubMed  Google Scholar 

  8. 8.

    Duel BP, Steinberg-Epstein R, Hill M et al (2003) A survey of voiding dysfunction in children with attention deficit-hyperactivity disorder. J Urol 170:1521–1524.

    Article  PubMed  Google Scholar 

  9. 9.

    Özen MA, Mutluer T, Necef I et al (2019) The overlooked association between lower urinary tract dysfunction and psychiatric disorders: a short screening test for clinical practice. J Pediatr Urol.

    Article  PubMed  Google Scholar 

  10. 10.

    Yousefichaijan P, Sharafkhah M, Rafiei M, Salehi B (2016) Attention-deficit/hyperactivity disorder in children with overactive bladder; a case-control study. J Ren Inj Prev 5:193–199.

    Article  PubMed  Google Scholar 

  11. 11.

    Austin PF, Bauer SB, Bower W et al (2016) The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children’s Continence Society. Neurourol Urodyn 35:471–481.

    Article  PubMed  Google Scholar 

  12. 12.

    Sampaio AS, Fraga LGA, Salomão BA et al (2017) Are lower urinary tract symptoms in children associated with urinary symptoms in their mothers? J Pediatr Urol 13:269.e1-269.e6.

    Article  Google Scholar 

  13. 13.

    Vaz GT, Vasconcelos MM, Oliveira EA et al (2012) Prevalence of lower urinary tract symptoms in school-age children. Pediatr Nephrol 27:597–603.

    Article  PubMed  Google Scholar 

  14. 14.

    Nijman RJM (2004) Role of antimuscarinics in the treatment of nonneurogenic daytime urinary incontinence in children. Urology 63:45–50.

    Article  PubMed  Google Scholar 

  15. 15.

    Franco I (2016) Overactive bladder in children. Nat Rev Urol 13:520–532.

    CAS  Article  PubMed  Google Scholar 

  16. 16.

    Collis D, Kennedy-Behr A, Kearney L (2019) The impact of bowel and bladder problems on children’s quality of life and their parents: A scoping review. Child Care Health Dev 45:1–14.

    Article  PubMed  Google Scholar 

  17. 17.

    von Gontard A, Equit M (2014) Comorbidity of ADHD and incontinence in children. Eur Child Adolesc Psychiatry 24:127–140.

    Article  Google Scholar 

  18. 18.

    Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 62:1006–1012.

    Article  Google Scholar 

  19. 19.

    Booth A, Clarke M, Dooley G et al (2013) PROSPERO at one year: an evaluation of its utility. Syst Rev 2:4.

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Schwarzer G, Carpenter JR, Rücker G (2015) Meta-Analysis with R (Use R!), 1st edn. Springer, Berlin

    Google Scholar 

  21. 21.

    Viechtbauer W (2010) Conducting meta-analyses in R with the metafor. J Stat Softw 36:1–48.

    Article  Google Scholar 

  22. 22.

    Wells GA, Shea B, O’Connell D et al (2011) The Newcastle-Ottawa Scale (NOS) for assessing the quality if nonrandomized studies in meta-analyses. Ottawa Hospital Research Institute, Ottawa, ON. Accessed 14 Feb 2021

  23. 23.

    Herzog R, Álvarez-Pasquin MJ, Díaz C et al (2013) Are healthcare workers intentions to vaccinate related to their knowledge, beliefs and attitudes? A systematic review. BMC Public Health.

    Article  PubMed  PubMed Central  Google Scholar 

  24. 24.

    Blaivas JG, Tsui JF, Mekel G et al (2015) Validation of the lower urinary tract symptom score. Can J Urol 22:7952–7958

    PubMed  Google Scholar 

  25. 25.

    Sureshkumar P, Jones M, Caldwell PHY, Craig JC (2009) Risk factors for nocturnal enuresis in school-age children. J Urol 182:2893–2899.

    Article  PubMed  Google Scholar 

  26. 26.

    Von Gontard A, Moritz AM, Thome-Granz S, Freitag C (2011) Association of attention deficit and elimination disorders at school entry: a population based study. J Urol 186:2027–2032.

    Article  Google Scholar 

  27. 27.

    Joinson C, Heron J, von Gontard A (2006) Psychological problems in children with daytime wetting. Pediatrics 118:1985–1993.

    Article  PubMed  Google Scholar 

  28. 28.

    Oliver JL, Campigotto MJ, Coplen DE et al (2013) Psychosocial comorbidities and obesity are associated with lower urinary tract symptoms in children with voiding dysfunction. J Urol 190:1511–1515.

    Article  PubMed  Google Scholar 

  29. 29.

    Schast AP, Zderic SA, Richter M et al (2008) Quantifying demographic, urological and behavioral characteristics of children with lower urinary tract symptoms. J Pediatr Urol 4:127–133.

    Article  PubMed  Google Scholar 

  30. 30.

    Sureshkumar P, Jones M, Cumming R, Craig J (2009) A population based study of 2,856 school-age children with urinary incontinence. J Urol 181:808–816.

    Article  PubMed  Google Scholar 

  31. 31.

    Wolfe-Christensen C, Veenstra AL, Kovacevic L et al (2012) Psychosocial difficulties in children referred to pediatric urology: a closer look. Urology 80:907–913.

    Article  PubMed  Google Scholar 

  32. 32.

    Yang TK, Guo YJ, Chen SC et al (2012) Correlation between symptoms of voiding dysfunction and attention deficit disorder with hyperactivity in children with lower urinary tract symptoms. J Urol 187:656–663.

    Article  PubMed  Google Scholar 

  33. 33.

    Zink S, Freitag CM, von Gontard A (2008) Behavioral comorbidity differs in subtypes of enuresis and urinary incontinence. J Urol 179:295–298.

    Article  PubMed  Google Scholar 

  34. 34.

    Golding J, Pembrey M, Jones R (2001) ALSPAC—the avon longitudinal study of parents and children. Paediatr Perinat Epidemiol 15:74–87

    CAS  Article  Google Scholar 

  35. 35.

    Niemczyk J, Equit M, Braun-Bither K et al (2015) Prevalence of incontinence, attention deficit/hyperactivity disorder and oppositional defiant disorder in preschool children. Eur Child Adolesc Psychiatry 24:837–843.

    Article  PubMed  Google Scholar 

  36. 36.

    Achenbach TM, Ruffle TM (2000) The child behavior checklist and related forms for assessing behavioral/emotional problems and competencies. Pediatr Rev 21:265–271.

    CAS  Article  PubMed  Google Scholar 

  37. 37.

    Farhat W, Bägli DJ, Capolicchio G et al (2000) The dysfunctional voiding scoring system: quantitative standardization of dysfunctional voiding symptoms in children. J Urol 164:1011–1015.

    CAS  Article  PubMed  Google Scholar 

  38. 38.

    Jellinek MS, Murphy JM, Little M et al (1999) Use of the pediatric symptom checklist to screen for psychosocial problems in pediatric primary care: a national feasibility study. Arch Pediatr Adolesc Med 153:254–260.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  39. 39.

    Kodman-Jones C, Hawkins L, Schulman SL (2001) Behavioral characteristics of children with daytime wetting. J Urol.

    Article  PubMed  Google Scholar 

  40. 40.

    Post WM, Ruiz-Zapata AM, Grens H et al (2020) Genetic variants and expression changes in urgency urinary incontinence: a systematic review. Neurourol Urodyn 39:2089–2110.

    Article  PubMed  PubMed Central  Google Scholar 

  41. 41.

    Qu HC, Yan S, Zhang XL et al (2014) Urinary nerve growth factor levels could be a biomarker for overactive bladder symptom: A meta-analysis. Genet Mol Res 13:8609–8619.

    CAS  Article  PubMed  Google Scholar 

  42. 42.

    Seth JH, Sahai A, Khan MS et al (2013) Nerve growth factor (NGF): a potential urinary biomarker for overactive bladder syndrome (OAB)? BJU Int 111:372–380.

    CAS  Article  PubMed  Google Scholar 

  43. 43.

    Sheng W, Zhang H, Ruth KH (2017) Could urinary nerve growth factor be a biomarker for overactive bladder? A meta-analysis. Neurourol Urodyn 36:1703–1710.

    CAS  Article  PubMed  Google Scholar 

  44. 44.

    Guney E, Ceylan MF, Kara M et al (2014) Serum nerve growth factor (NGF) levels in children with attention deficit/hyperactivity disorder (ADHD). Neurosci Lett 560:107–111.

    CAS  Article  PubMed  Google Scholar 

  45. 45.

    Liu DY, Shen XM, Yuan FF et al (2015) The physiology of BDNF and its relationship with ADHD. Mol Neurobiol 52:1467–1476.

    CAS  Article  PubMed  Google Scholar 

  46. 46.

    Griffiths DJ, Tadic SD (2008) Bladder control, urgency, and urge incontinence: evidence from functional brain imaging. Neurourol Urodyn 27:466–474.

    Article  PubMed  Google Scholar 

  47. 47.

    Gor RA, Fuhrer J, Schober JM (2012) A retrospective observational study of enuresis, daytime voiding symptoms, and response to medical therapy in children with attention deficit hyperactivity disorder and autism spectrum disorder. J Pediatr Urol 8:314–317.

    Article  PubMed  Google Scholar 

  48. 48.

    Niemczyk J, Equit M, Rieck K et al (2018) EEG measurement of emotion processing in children with daytime urinary incontinence. Z Kinder Jugendpsychiatr Psychother 46:336–341.

    Article  PubMed  Google Scholar 

  49. 49.

    Kuizenga-Wessel S, Koppen IJN, Vriesman MH et al (2018) Attention deficit hyperactivity disorder and functional defecation disorders in children. J Pediatr Gastroenterol Nutr 66:244–249.

    Article  PubMed  Google Scholar 

Download references


DEG, MJ, JDB, BM receive support from the Beatrice and Samuel A. Seaver Foundation; additional support from the Mindworks Charitable Lead Trust (DEG); the Stanley Center for Psychiatric Research (DEG).

Author information




BM had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: OA, JDB, DEG, CMH, MJ, LRK, BM. Acquisition, analysis, or interpretation of data: OA, AB, JDB, DEG, MJ, LRK, BM, CGM. Drafting of the manuscript: AB, JDB, DEG, MJ, LRK, BM, CGM. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: BM. Obtained funding: DEG. Study supervision: OA, DEG, LRK.

Corresponding author

Correspondence to Dorothy E. Grice.

Ethics declarations

Conflicts of interest/competing interest

The authors declare that they have no conflicts of interest.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 103 KB)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Mahjani, B., Koskela, L.R., Mahjani, C.G. et al. Systematic review and meta-analysis: relationships between attention-deficit/hyperactivity disorder and urinary symptoms in children. Eur Child Adolesc Psychiatry (2021).

Download citation


  • Attention-deficit/hyperactivity disorder
  • Lower urinary tract symptoms
  • Overactive bladder