鄉下的妹子太便宜，一次四個都要了[12P]

stcar

good good support

dadiaoguang

谢谢

wyp5888

好图，谢谢分享。

wudaode

11

xxp13136

大家好心情

weihai

果您要查看本帖隱藏內容請

q2367975099

看看再说

金正恩

将计就计

zidantiao

真的很不错

kaifka

RESPONSE OF MICROPENIS TO TOPICAL TESTOSTERONE AND
GONADOTROPIN
RICHARD C. KLUGO* AND JOSEPH C. CERNY
- |/ g' n2 G3 _$ B  y% t! _From the Division of Urology, Henry Ford Hospital, Detroit, Michigan
ABSTRACT
Five patients were treated with gonadotropin and topical testosterone for micropenis associated
with hypothalamic hypogonadotropic hypogonadism. All patients received 1,000 units of gonado-
2 }! k, V3 k, Ytropin weekly for 3 weeks, with a 6-week interval followed by 10 per cent topical testosterone
cream twice daily for 3 weeks. Serum testosterone levels were measured and remained equivalent
for both modes of therapy. Average penile growth response with gonadotropin was 14.3 per cent
increase in length and 5.0 per cent increase of girth. Topical testosterone produced an average
: k. T+ z5 Y+ wincrease of 60 per cent in penile length and 52. 9 per cent in girth. The greatest growth response
occurred in prepuberal male subjects with a minimal response in postpuberal male subjects. This
) Y* W$ J" j) v% g% T  Y2 ^study suggests that 10 per cent topical testosterone cream twice daily will produce effective penile
+ l: e$ a  }) Q) Qgrowth. The response appears to be greater in younger children, which is consistent with previ-
4 X% ?0 m8 b6 T; C3 h# Bously published studies of age-related 5 reductase activity.
) k, ], l- c5 M9 M, I% J. Y, `Children with microphallus regardless of its etiology will
& H# w& f7 q& g, M3 @require augmentation or consideration for alteration of exter-
nal genitalia. In many instances urethroplasty for hypo-
spadias is easier with previous stimulation of phallic growth.
The use of testosterone administered parenterally or topically
2 h- H0 G  i* s' M4 O& Jhas produced effective phallic growth. 1- 3 The mechanism of
response has been considered as local or systemic. With this
in mind we studied 5 children with microphallus for response
to gonadotropin and to topical testosterone independently.
MATERIALS AND METHODS
2 f: X! G" a# ~* h6 a7 QFive 46 XY male subjects between 3 and 17 years old were
evaluated for serum testosterone levels and hypothalamic
  c% i+ g1 o1 [% @function. Of these 5 boys 2 were considered to have Kallmann's
' m% }7 i3 e# zsyndrome, 1 Prader-Willi syndrome and 2 idiopathic hypotha-
lamic deficiency. After evaluation of response to luteinizing
: f& @( C& J: y3 Xhormone-releasing hormone these patients were treated with
; j& l$ c9 l3 \+ `6 t7 W* \( Y1,000 units of gonadotropin weekly for 3 weeks. Six weeks
after completion of gonadotropin therapy 10 per cent topical
1 h3 X5 N% m. z  U% B7 y1 ttestosterone was applied to the phallus twice daily for 3 weeks.
6 L! v2 u* H; BSerum testosterone, luteinizing hormone and follicle-stimulat-
" J4 K. M& t7 u1 t1 X6 f" ^  ~ing hormone were monitored before, during and after comple-
tion of each phase of therapy. Penile stretch length was
- C: d! t  l: Q' i# X3 R. \obtained by measuring from the symphysis pubis to the tip of
1 S& N4 I9 h# W) C3 o( h! cthe glans. Penile circumferential (girth) measurements were
! I5 q$ G# w6 w+ \obtained using an orthopedic digital measuring device (see
# m+ ^( S- Y; G: b6 ffigure).
0 A( R( k; h' h& b. f0 m) H" \RESULTS
Serum testosterone increased moderately to levels between
3 w8 U8 Z9 b. S; ^9 V& D50 and 86 ng./dl. with gonadotropin stimulation. Serum testos-
9 U' X; [0 d# Y* e" Xterone levels with topical testosterone remained near pre-
5 I3 }1 G% y% |/ l  `9 ?% [' dtreatment levels (35 ng./dl.) or were elevated to similar levels
developed after gonadotropin therapy (96 ng./dl.). Higher
, Z; i  T* l+ oserum levels were noted in older patients (12 and 17 years old),
while lower levels persisted in younger patients (4, 8, and 10
years old) (see table). Despite absence of profound alterations
& ?- z' P& y0 {, L2 H7 ^" Fof serum testosterone the topical therapy provided a greater
Accepted for publication July 1, 1977. ·
4 U4 _5 V$ |% g, D+ u/ x2 JRead at annual meeting of American Urological Association,
4 q; p/ F1 I3 a( X; a5 cChicago, Illinois, April 24-28, 1977.
7 R; X# E3 v4 L) v7 L  G* Requests for reprints: Division of Urology, Henry Ford Hospital,
2799 W. Grand Blvd., Detroit, Michigan 48202.
improvement in phallic growth compared to gonadotropin.
: q: A& p8 g' J4 B$ l& PAverage phallic growth with gonadotropin was 14.3 per cent
increase in length and 5.0 per cent increase of girth. Topical
8 b: j/ p6 ^) A) ntestosterone produced a 60.0 per cent increase of phallic length
and 52.9 per cent increase of girth (circumference). The
) d) S, G+ H& |- F* S! p5 Rresponse to topical testosterone was greatest in children be-
1 h" Q" L( w7 j3 Q3 Z; \+ qtween 4 and 8 years old, with a gradual decrease to age 17
# t: p! N( z1 h  o; C$ xyears (see table).
7 @" l  n# G# C0 ?DISCUSSION
Topical testosterone has been used effectively by other
clinicians but its mode of action remains controversial. Im-
mergut and associates reported an excellent growth response
0 S( u; J9 @9 o2 Gto topical testosterone with low levels of serum testosterone,
2 O9 N' P* I2 {8 Nsuggesting a local effect.1 Others have obtained growth re-
# Y) `" D( e- O: n( R1 H6 qsponse with high. levels of serum testosterone after topical
+ Y0 ?& ]/ v% v3 vadministration, suggesting a systemic response. 3 The use of
gonadotropin to obtain levels of serum testosterone compara-
ble to levels obtained with topical testosterone would seem to
provide a means to compare the relative effectiveness of
topical testosterone to systemic testosterone effect. It cer-
tainly has been established that gonadotropin as well as par-
enteral testosterone administration will produce genital
growth. Our report shows that the growth of the phallus was
significantly greater with topical applications than with go-
nadotropin, particularly in children less than 10 years old.
& t( ~7 d, v. X0 u$ ^" ^" wThe levels of serum testosterone remained similar or lower
0 \( ^1 {- q0 K1 ]/ ?than with gonadotropin during therapy, suggesting that topi-
2 Q% M, W- Q( W* L. Vcal application produces genital growth by its local effect as
well as its systemic effect.
0 `% G! i) E* e4 a& |9 X$ XReview of our patients and their growth response related to
+ P9 T' f" o& W0 Wage shows a greater growth response at an earlier age. This is
9 H2 x4 q- h  e* j! A8 Mconsistent with the findings of Wilson and Walker, who
- Z9 n& c  K; M  S& freported an increased conversion of testosterone to dihydrotes-
tosterone in the foreskin of neonates and infants.4 This activ-
ity gradually decreases with age until puberty when it ap-
- [; D$ r7 h+ W# zproaches the same level of activity as peripheral skin. It may
. f) a; m& s, b; @  W  O0 hwell be that absorption of testosterone is less when applied at
7 m2 ]8 D1 e' g9 ^  `2 F* ], @6 Van earlier age as suggested by lower serum levels in children
- W( u) v( s" I& Xless than 10 years old. This fact may be explained by the
/ s: W3 m4 h+ w- t0 p1 Dgreater ability of phallic skin to convert testosterone to dihy-
- u/ p( L2 |% a% J1 @) g3 odrotestosterone at this age. Conversely, serum levels in older
8 w4 S" w- @/ I* U8 Lpatients were higher, possibly because of decreased local
' q+ a  \* U% z: T" a7 a667
668 KLUGO AND CERNY
; H# {6 k6 E2 {Pt. Age
(yrs.)
Serum Testosterone Phallus (cm.) Change Length
(ng./dl.) Girth x Length (%)
4
8
10
' D: ]' j; z( ?8 |; r12
0 \, r  L$ h4 B17
Gonadotropin
% k" F( r$ z1 G3 m6 Y71.6 2.0 X 3 16.6
50.4 4.0 X 5.0 20.0
22.0 4.5 X 4.0 25.0
84.6 4.0 X 4.5 11.1
! E" r- w! x- b  `85.9 4.5 X 5.5 9.0
Av. 14.3
& J7 B; q! m5 i; D' [4
/ K7 w8 F* O  ?: t8
10
4 |  b$ a: L: u+ Z1 }2 o12
17
Topical testosterone
0 ?4 G  }6 ~" d, l! i5 }' [- e34.6 4.5 X 6.5 85
) t- E( M+ A3 N; k/ g38.8 6.0 X 8.5 70
40.0 6.0 X 6.5 62.5
93.6 6.0 X 7.0 55.5
95.0 6.5 X 7.0 27.2
Av. 60.0
available testosterone. Again, emphasis should be placed on
early therapy when lower levels of testosterone appear to
provide the best responses. The earlier therapy is instituted
the more likely there will be an excellent response with low
serum levels. Response occurs throughout adolescence as
noted in nomograms of phallic growth. 7 The actual response
to a given serum level of testosterone is much greater at birth
% |# Q, f& r  rand gradually decreases as boys reach puberty. This is most
likely related to the conversion of testosterone to dihydrotes-
% q& l* w: B, K/ Etosterone and correlates well with the studies of testosterone
conversion in foreskin at various ages.
* M$ J9 ^2 c/ V6 Z0 t/ ^6 F7 jThe question arises regarding early treatment as to whether
. O2 {* Y- R" X* I4 x7 ~9 Rone might sacrifice ultimate potential growth as with acceler-
ated bone growth. The situation appears quite the reverse
with phallic response. If the early growth period is not used
when 5a reductase activity is greatest then potential growth
0 u( u& M& z& [8 B$ H3 S# rmay be lost. We have not observed any regression of growth
attained with topical or gonadotropin therapy. It may well
( B9 W3 l, U. U- I; f7 S7 \4 i5 Z* dbe that some patients will show little or no response to any
form of therapy. This would suggest a defect in the ability to
convert testosterone to dihydrotestosterone and indicate that
phallic and peripheral skin, and subcutaneous tissue should
2 ]0 w/ m& o: r1 xbe compared for 5a reductase activity.
  h6 K- `7 w4 w) XA, loop enlarges to measure penile girth in millimeters. B,
example of penile girth computed easily and accurately.
conversion of testosterone to dihydrotestosterone. It is in this
older group that others have noted high levels of serum
testosterone with topical application. It would also appear
that phallic response during puberty is related directly to the
. E! }* I3 b  n+ Cserum testosterone level. There also is other evidence of local
response to testosterone with hair growth and with spermato-
5 F9 `" S8 A- ]/ V  J8 d7 lgenesis. 5• 6
2 Z& i  R$ h1 QAdministration of larger doses of gonadotropin or systemic
testosterone, as well as topical applications that produce
$ |2 R' u4 o3 chigher levels of serum testosterone (150 to 900 ng./dl.), will
6 C0 @+ h1 h, Ralso produce phallic growth but risks accelerated skeletal
maturation even after stopping treatment. It would appear
# }. _( N0 E; B' i; b! }7 lthat this may be avoided by topical applications of testosterone
+ x- A  \7 N( k' ]0 gand monitoring of serum testosterone. Even with this control
! B$ d' [% w% [9 @& V% Hthe duration of our therapy did not exceed 3 weeks at any
time. It is apparent that the prepuberal male subject may
suffer accelerated bone growth with testosterone levels near
200 ng./dl. When skeletal maturation is complete the level of
serum testosterone can be maintained in the 700 to 1,300 ng./
3 T( L3 t( _( d7 V' U& Hdl. range to stimulate phallic growth and secondary sexual
changes. Therefore, after skeletal maturation parenteral tes-
tosterone may be used to advantage. Before skeletal matura-
tion care must be taken to avoid maintaining levels of serum
0 v# C" F6 n- o6 ftestosterone more than 100 ng./dl. Low-dose gonadotropin
depends upon intrinsic testicular activity and may require
prolonged administration for any response.
5 Y9 i) t, `8 [$ D+ ]+ l( XAlternately, topical testosterone does not depend upon tes-
ticular function and may provide a more constant level of
REFERENCES
8 Z/ i$ c+ w; T$ k; j% s, R. o! A: H1. Immergut, M., Boldus, R., Yannone, E., Bunge, R. and Flocks,
$ s! }4 {+ E5 h  w) i3 zR.: The local application of testosterone cream to the prepub-
ertal phallus. J. Urol., 105: 905, 1971.
2. Guthrie, R. D., Smith, D. W. and Graham, C. B.: Testosterone
* Z5 z, F" n, ltreatment for micropenis during early childhood. J. Pediat.,
83: 247, 1973.
3. Jacobs, S. C., Kaplan, G. W. and Gittes, R. F.: Topical testoster-
one therapy for penile growth. Urology, 6: 708, 1975.
4. Wilson, J. D. and Walker, J. D.: The conversion of testosterone
' z% e' y/ S' U/ d& }! u  zto 5 alpha-androstan-17 beta-01-3-one (dihydrotestosterone) by
6 G* w2 [" D: U6 B: v% ~skin slices of man. J. Clin. Invest., 48: 371, 1969.
5. Papa, C. M. and Klingman, A. M.: Stimulation of hair growth
by topical application of androgens. J.A.M.A., 191: 521, 1965.
1 O# m' d8 B) T6. Gittes, R. F., Smith, G., Conn, C. A. and Smith, F.: Local
) [' ]# L% V4 Q! t* |androgenic effect of interstitial cell tumor of the testis. J.
Urol., 104: 774, 1970.
% u6 E' e7 j/ _2 a& {7. Schonfeld, W. A. and Beebe, G. W.: Normal growth and varia-
+ z* \5 C& V1 @; `# [tion in the male genitalia from birth to maturity. J. Urol., 48: