Diagnostic and therapeutic effects of a low-dose human chorionic gonadotropin (HCG) stimulation test in incontinent boys with bladder exstrophy/epispadias complex (BEEC)

Abstract

Purpose To evaluate the effects of a low dose HCG test on structural changes of the lower urinary tract and urinary incontinence in boys with a history of complete reconstruction of the BEEC. Material and methods From April 2000 to March 2005, 11 pre-pubertal boys with a mean age of 7.5 years (range 5-11 years) were included in our study. All patients underwent bladder neck reconstruction due to bladder exstrophy (n=7) or classical epispadiais (n=4). All boys had grade I-II incontinence following surgery and received 12 intramuscular injections of 250IU HCG during a 4 week-period. The prostate size, bladder capacity, and bladder neck diameter were estimated using 3D-sonography or pelvic MRI prior to and after injections. The structural changes, uroflowmetric studies, and incontinence scores were compared before and after the HCG test. Results The patients were followed up for 1.5 to 6 (mean 4) years. The total prostate size and bladder capacity increased and the bladder neck diameter decreased in all patients. In all children, the incontinence score improved; 6 boys became continent for a period of 3-6 weeks and 3 boys became continent in long-term follow-up through the puberty. No major side effect was found following treatment. All patients were treated with a combination of anticholinergic, alpha adrenergic, and imipramine or minimally-invasive endoscopic injection of a bulking agent. No patient required open surgical reconstruction of the bladder neck. Conclusions Our preliminary results suggest that the low dose HCG test is a safe and a valuable modality in the treatment and prognostic evaluation of boys with BEEC who suffer from low grade incontinence. The data also reveal the role of prostate enlargement following puberty in the improvement of urinary incontinence in BEEC patients. Moreover, chronic treatment of boys with HCG increases bladder capacity that may facilitate future reconstructive surgery. However no test-responder patients of the present series required open surgical intervention. To evaluate the effects of a low dose HCG test on structural changes of the lower urinary tract and urinary incontinence in boys with a history of complete reconstruction of the BEEC. From April 2000 to March 2005, 11 pre-pubertal boys with a mean age of 7.5 years (range 5-11 years) were included in our study. All patients underwent bladder neck reconstruction due to bladder exstrophy (n=7) or classical epispadiais (n=4). All boys had grade I-II incontinence following surgery and received 12 intramuscular injections of 250IU HCG during a 4 week-period. The prostate size, bladder capacity, and bladder neck diameter were estimated using 3D-sonography or pelvic MRI prior to and after injections. The structural changes, uroflowmetric studies, and incontinence scores were compared before and after the HCG test. The patients were followed up for 1.5 to 6 (mean 4) years. The total prostate size and bladder capacity increased and the bladder neck diameter decreased in all patients. In all children, the incontinence score improved; 6 boys became continent for a period of 3-6 weeks and 3 boys became continent in long-term follow-up through the puberty. No major side effect was found following treatment. All patients were treated with a combination of anticholinergic, alpha adrenergic, and imipramine or minimally-invasive endoscopic injection of a bulking agent. No patient required open surgical reconstruction of the bladder neck. Our preliminary results suggest that the low dose HCG test is a safe and a valuable modality in the treatment and prognostic evaluation of boys with BEEC who suffer from low grade incontinence. The data also reveal the role of prostate enlargement following puberty in the improvement of urinary incontinence in BEEC patients. Moreover, chronic treatment of boys with HCG increases bladder capacity that may facilitate future reconstructive surgery. However no test-responder patients of the present series required open surgical intervention.