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
6 r% l, d3 F& b% P" {RICHARD C. KLUGO* AND JOSEPH C. CERNY
From the Division of Urology, Henry Ford Hospital, Detroit, Michigan
ABSTRACT
Five patients were treated with gonadotropin and topical testosterone for micropenis associated
2 |+ ^# u. K/ S+ r, o( V$ Swith hypothalamic hypogonadotropic hypogonadism. All patients received 1,000 units of gonado-
" _* k) H1 ]8 w; o! A: Gtropin 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
( I; a2 T, H( Kincrease in length and 5.0 per cent increase of girth. Topical testosterone produced an average
increase 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
study suggests that 10 per cent topical testosterone cream twice daily will produce effective penile
# y% t* g1 w% N% igrowth. The response appears to be greater in younger children, which is consistent with previ-
ously published studies of age-related 5 reductase activity.
Children with microphallus regardless of its etiology will
require augmentation or consideration for alteration of exter-
6 K+ T2 H0 V; n6 b( Qnal genitalia. In many instances urethroplasty for hypo-
: j/ H; Q4 [( I* Qspadias is easier with previous stimulation of phallic growth.
  ?- T4 q/ S* k7 S6 TThe use of testosterone administered parenterally or topically
has produced effective phallic growth. 1- 3 The mechanism of
6 r" @# U% G$ A) j) E% ~response has been considered as local or systemic. With this
in mind we studied 5 children with microphallus for response
% t& z1 d$ J6 A2 x: E% c5 _. Oto gonadotropin and to topical testosterone independently.
MATERIALS AND METHODS
) k* \9 ?. q, Q6 I  t1 TFive 46 XY male subjects between 3 and 17 years old were
evaluated for serum testosterone levels and hypothalamic
4 k9 ]3 j- Y7 k/ t! ffunction. Of these 5 boys 2 were considered to have Kallmann's
' B/ J2 e! v: X! qsyndrome, 1 Prader-Willi syndrome and 2 idiopathic hypotha-
: M3 y2 j% M0 q% S, s9 f/ f& d0 Mlamic deficiency. After evaluation of response to luteinizing
hormone-releasing hormone these patients were treated with
1,000 units of gonadotropin weekly for 3 weeks. Six weeks
: `5 P8 f8 H7 s- D+ wafter completion of gonadotropin therapy 10 per cent topical
6 K/ k7 o/ j' r8 z& r% M2 vtestosterone was applied to the phallus twice daily for 3 weeks.
Serum testosterone, luteinizing hormone and follicle-stimulat-
. t  Y4 u7 V6 G- ?$ u8 r( q6 @* eing hormone were monitored before, during and after comple-
tion of each phase of therapy. Penile stretch length was
' s& Y, o$ t9 C! E  k8 g7 I" hobtained by measuring from the symphysis pubis to the tip of
the glans. Penile circumferential (girth) measurements were
. F8 r/ s( Y! W3 M# {# [2 Wobtained using an orthopedic digital measuring device (see
figure).
RESULTS
$ ^$ ?$ o6 l; D; X' k$ c1 w8 @Serum testosterone increased moderately to levels between
50 and 86 ng./dl. with gonadotropin stimulation. Serum testos-
3 u! J5 J& B3 rterone levels with topical testosterone remained near pre-
% L# a1 j4 @# ztreatment levels (35 ng./dl.) or were elevated to similar levels
developed after gonadotropin therapy (96 ng./dl.). Higher
serum 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
of serum testosterone the topical therapy provided a greater
Accepted for publication July 1, 1977. ·
Read at annual meeting of American Urological Association,
Chicago, Illinois, April 24-28, 1977.
; X' }6 l, [) L6 q' j* Requests for reprints: Division of Urology, Henry Ford Hospital,
. Z/ A/ ?# O7 c6 R/ u2799 W. Grand Blvd., Detroit, Michigan 48202.
improvement in phallic growth compared to gonadotropin.
7 t: \/ a0 @' o/ K. GAverage phallic growth with gonadotropin was 14.3 per cent
increase in length and 5.0 per cent increase of girth. Topical
testosterone produced a 60.0 per cent increase of phallic length
5 {& q, x0 G) w+ s& E. `" p8 |and 52.9 per cent increase of girth (circumference). The
response to topical testosterone was greatest in children be-
tween 4 and 8 years old, with a gradual decrease to age 17
! x; Z' u1 K# wyears (see table).
DISCUSSION
/ ^3 y. r7 E/ X0 P- k0 GTopical testosterone has been used effectively by other
clinicians but its mode of action remains controversial. Im-
mergut and associates reported an excellent growth response
! G- i9 U' t( _2 j$ w6 o9 Oto topical testosterone with low levels of serum testosterone,
suggesting a local effect.1 Others have obtained growth re-
  }7 h$ l6 R0 T$ }7 ssponse with high. levels of serum testosterone after topical
administration, suggesting a systemic response. 3 The use of
& y; g$ Q$ H. `/ z! cgonadotropin to obtain levels of serum testosterone compara-
ble to levels obtained with topical testosterone would seem to
5 G8 E2 u5 k# ]2 f. b- }. aprovide a means to compare the relative effectiveness of
+ W+ M$ p- X7 @& ]4 ^2 Rtopical testosterone to systemic testosterone effect. It cer-
$ `3 p8 t9 q' ]0 \. Otainly has been established that gonadotropin as well as par-
enteral testosterone administration will produce genital
4 D% m2 E6 C# Mgrowth. Our report shows that the growth of the phallus was
  B5 g) {  A- t4 T0 @0 {- y0 I, C0 Tsignificantly greater with topical applications than with go-
4 e! v; \4 V, [$ Nnadotropin, particularly in children less than 10 years old.
' S, H4 Q' [# t5 ?  _5 zThe levels of serum testosterone remained similar or lower
' N- Z: _- i3 z  E! [than with gonadotropin during therapy, suggesting that topi-
' I# k' C) E/ J/ x/ Lcal application produces genital growth by its local effect as
1 p) a8 @) f" g' Y: O. Dwell as its systemic effect.
Review of our patients and their growth response related to
4 w2 B9 m4 v+ b/ R3 hage shows a greater growth response at an earlier age. This is
) y. L) T* y* Vconsistent with the findings of Wilson and Walker, who
reported an increased conversion of testosterone to dihydrotes-
% n' z  J; c- g; Ltosterone in the foreskin of neonates and infants.4 This activ-
1 o. }7 w( L) b8 {. s" ?: Mity gradually decreases with age until puberty when it ap-
proaches the same level of activity as peripheral skin. It may
well be that absorption of testosterone is less when applied at
an earlier age as suggested by lower serum levels in children
less than 10 years old. This fact may be explained by the
greater ability of phallic skin to convert testosterone to dihy-
drotestosterone at this age. Conversely, serum levels in older
patients were higher, possibly because of decreased local
667
  q& V- y  j0 Y( I6 F" T/ @668 KLUGO AND CERNY
Pt. Age
(yrs.)
Serum Testosterone Phallus (cm.) Change Length
(ng./dl.) Girth x Length (%)
1 N0 Q  Z9 E7 R  D) B& K4
8
10
12
5 O5 _( Q+ `1 K6 C+ i' C17
6 a7 o! {7 l( z: e! n- a& ?Gonadotropin
0 K" q5 B  f; \% e7 ]71.6 2.0 X 3 16.6
6 T, `5 Z( E8 \* L, H: l50.4 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
85.9 4.5 X 5.5 9.0
Av. 14.3
4
% }3 T. D( q7 Y8
10
% W- h7 e% {5 H8 c, U12
17
; n* i7 A! K' CTopical testosterone
: \6 `& F8 D+ Z/ S34.6 4.5 X 6.5 85
38.8 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
2 e; m9 s) G) ]9 r1 R+ y6 r: fAv. 60.0
available testosterone. Again, emphasis should be placed on
) T2 W/ M7 s/ o2 s9 j- Yearly therapy when lower levels of testosterone appear to
/ s) o6 i( Y: m* g# oprovide the best responses. The earlier therapy is instituted
the more likely there will be an excellent response with low
! g" r: R8 m! ?3 y2 E1 fserum 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
and gradually decreases as boys reach puberty. This is most
1 B# D! y% \+ ^9 x* clikely related to the conversion of testosterone to dihydrotes-
tosterone and correlates well with the studies of testosterone
% g8 @0 X& K( y9 T+ U" N, Hconversion in foreskin at various ages.
5 p4 S$ t6 d, o6 FThe question arises regarding early treatment as to whether
one 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
5 R, H/ i8 q+ n* r) o, ]* mwhen 5a reductase activity is greatest then potential growth
' [+ Q1 s4 h* K! n7 |may be lost. We have not observed any regression of growth
) ~4 v2 l2 e& R! [( [! G) w& nattained with topical or gonadotropin therapy. It may well
be that some patients will show little or no response to any
9 E3 T* g6 k, x8 i+ V# _2 Lform of therapy. This would suggest a defect in the ability to
$ W7 ^$ l$ G) R  Uconvert testosterone to dihydrotestosterone and indicate that
phallic and peripheral skin, and subcutaneous tissue should
( J; Y1 t3 v+ M( c6 W: n! Ybe compared for 5a reductase activity.
8 N0 @' k1 B. ^' yA, 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
( h$ \# e, ?) Y. [- C% Y5 oolder group that others have noted high levels of serum
0 ]# o' _  ~1 z- B4 [1 m% r  M% Gtestosterone with topical application. It would also appear
9 i! j/ D/ N: qthat phallic response during puberty is related directly to the
% h3 l+ `# T4 N# _0 E+ i, ?serum testosterone level. There also is other evidence of local
response to testosterone with hair growth and with spermato-
genesis. 5• 6
! p0 S1 B7 H* }/ L' d, r! w8 x# W* QAdministration of larger doses of gonadotropin or systemic
testosterone, as well as topical applications that produce
higher levels of serum testosterone (150 to 900 ng./dl.), will
also produce phallic growth but risks accelerated skeletal
7 I! ~# k, h$ |0 ^4 C3 l1 ?' Smaturation even after stopping treatment. It would appear
that this may be avoided by topical applications of testosterone
2 D" C- P  h+ B$ e7 C" x6 Y+ Rand monitoring of serum testosterone. Even with this control
* L( G7 Y/ b! y' d8 v& x3 A. ^' Uthe duration of our therapy did not exceed 3 weeks at any
+ z+ n% Z9 P/ i1 u0 }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
6 e. _- V$ o8 m  z8 Bserum testosterone can be maintained in the 700 to 1,300 ng./
dl. range to stimulate phallic growth and secondary sexual
4 j7 v: H2 q1 }changes. Therefore, after skeletal maturation parenteral tes-
tosterone may be used to advantage. Before skeletal matura-
/ Y% Z$ d  I* W; C. ?tion care must be taken to avoid maintaining levels of serum
; `% c" g' F! `2 M; Ztestosterone more than 100 ng./dl. Low-dose gonadotropin
depends upon intrinsic testicular activity and may require
9 R8 `- h# S7 h8 F# Nprolonged administration for any response.
Alternately, topical testosterone does not depend upon tes-
ticular function and may provide a more constant level of
REFERENCES
1. Immergut, M., Boldus, R., Yannone, E., Bunge, R. and Flocks,
0 [1 U7 o+ _3 B  ~7 ]- f3 R1 [) cR.: 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
+ {" _4 D: H; l- _/ M+ {5 A, Utreatment for micropenis during early childhood. J. Pediat.,
83: 247, 1973.
3. Jacobs, S. C., Kaplan, G. W. and Gittes, R. F.: Topical testoster-
/ b. e% h9 r0 ?one therapy for penile growth. Urology, 6: 708, 1975.
4. Wilson, J. D. and Walker, J. D.: The conversion of testosterone
: \- ]1 U% U/ nto 5 alpha-androstan-17 beta-01-3-one (dihydrotestosterone) by
skin slices of man. J. Clin. Invest., 48: 371, 1969.
8 u! C# J- y  G2 T. o9 M5. Papa, C. M. and Klingman, A. M.: Stimulation of hair growth
by topical application of androgens. J.A.M.A., 191: 521, 1965.
6. Gittes, R. F., Smith, G., Conn, C. A. and Smith, F.: Local
' @: R  X3 d1 l) Iandrogenic effect of interstitial cell tumor of the testis. J.
) s+ H( g5 S/ J8 ^Urol., 104: 774, 1970.
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tion in the male genitalia from birth to maturity. J. Urol., 48: