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
- n  B' K- B% A/ S( f1 Q; w% B4 iRICHARD C. KLUGO* AND JOSEPH C. CERNY
' F: m$ x, o3 _2 XFrom the Division of Urology, Henry Ford Hospital, Detroit, Michigan
' j' w5 b- Y% W3 q. j( ~+ `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-
tropin 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
' y) A! E: N% Y+ \' L& c; Efor both modes of therapy. Average penile growth response with gonadotropin was 14.3 per cent
- Y8 o4 G$ ]) A# q/ |3 |/ x6 ^increase 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
# {/ X1 x- f- S8 _& r" q$ ]study suggests that 10 per cent topical testosterone cream twice daily will produce effective penile
growth. The response appears to be greater in younger children, which is consistent with previ-
- z7 \8 h2 Z" b7 }! yously published studies of age-related 5 reductase activity.
Children with microphallus regardless of its etiology will
' q$ \+ ^5 j7 g% M. j1 ]require augmentation or consideration for alteration of exter-
. r3 A4 v! M  S7 h( Q+ B" a! l7 znal genitalia. In many instances urethroplasty for hypo-
spadias is easier with previous stimulation of phallic growth.
( o6 I& O' R1 C# J' eThe use of testosterone administered parenterally or topically
: S2 h+ v. R" n, t1 N, L: G. \has produced effective phallic growth. 1- 3 The mechanism of
1 K  A2 Y2 A5 U7 Q3 q5 Xresponse 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
8 U1 Q# I4 T  \Five 46 XY male subjects between 3 and 17 years old were
evaluated for serum testosterone levels and hypothalamic
) N$ H' v1 O% f0 ~( n8 D) N& yfunction. Of these 5 boys 2 were considered to have Kallmann's
& h0 H9 S  n$ [+ jsyndrome, 1 Prader-Willi syndrome and 2 idiopathic hypotha-
lamic deficiency. After evaluation of response to luteinizing
+ `. x; _- r6 whormone-releasing hormone these patients were treated with
6 x. v. r, |' g, i6 p* d9 @1,000 units of gonadotropin weekly for 3 weeks. Six weeks
after completion of gonadotropin therapy 10 per cent topical
2 w0 X' d) V- Rtestosterone was applied to the phallus twice daily for 3 weeks.
6 b4 @4 u3 L( A. X& R1 ]" u$ ESerum testosterone, luteinizing hormone and follicle-stimulat-
6 @) ^' \4 n' m/ _% y' O8 Y+ p7 Xing hormone were monitored before, during and after comple-
tion of each phase of therapy. Penile stretch length was
4 n/ \: A7 ~- t2 H# Cobtained by measuring from the symphysis pubis to the tip of
the glans. Penile circumferential (girth) measurements were
obtained using an orthopedic digital measuring device (see
figure).
RESULTS
Serum testosterone increased moderately to levels between
50 and 86 ng./dl. with gonadotropin stimulation. Serum testos-
  S' r3 {8 [* q2 T, l( Z; rterone levels with topical testosterone remained near pre-
treatment levels (35 ng./dl.) or were elevated to similar levels
  c6 E+ m( p/ jdeveloped after gonadotropin therapy (96 ng./dl.). Higher
  c% \; p) p+ ~9 U% a& S, Rserum levels were noted in older patients (12 and 17 years old),
while lower levels persisted in younger patients (4, 8, and 10
/ W, ], _- b: X, ^' I1 zyears old) (see table). Despite absence of profound alterations
9 G4 R: K2 n/ o) {9 jof serum testosterone the topical therapy provided a greater
! v. |  Z# `- Q8 I2 jAccepted for publication July 1, 1977. ·
$ V# p, E$ R" O9 R% j( LRead at annual meeting of American Urological Association,
Chicago, Illinois, April 24-28, 1977.
* Requests for reprints: Division of Urology, Henry Ford Hospital,
2799 W. Grand Blvd., Detroit, Michigan 48202.
improvement in phallic growth compared to gonadotropin.
/ m! P$ B7 p5 H# k$ P1 ?Average phallic growth with gonadotropin was 14.3 per cent
2 x# S( \- N# S; h' _! t7 iincrease in length and 5.0 per cent increase of girth. Topical
0 C" l. u! f  w* {1 gtestosterone produced a 60.0 per cent increase of phallic length
and 52.9 per cent increase of girth (circumference). The
' z+ n' S' ?' W2 D+ K% d' ^* }response to topical testosterone was greatest in children be-
tween 4 and 8 years old, with a gradual decrease to age 17
years (see table).
DISCUSSION
Topical testosterone has been used effectively by other
  _, T5 G( I" j, `, R  q0 bclinicians but its mode of action remains controversial. Im-
* x8 f, P# F: g. s) A1 fmergut and associates reported an excellent growth response
to topical testosterone with low levels of serum testosterone,
suggesting a local effect.1 Others have obtained growth re-
sponse with high. levels of serum testosterone after topical
administration, suggesting a systemic response. 3 The use of
6 |  w1 y1 ~9 q5 a" R) Jgonadotropin 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
  p; a' @0 G1 |* m, g2 @( I' ~topical testosterone to systemic testosterone effect. It cer-
) _& N7 p& P. I) T' h$ r& `" m2 Etainly 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.
: _% S+ H0 a0 u, J6 o! Q, CThe levels of serum testosterone remained similar or lower
than with gonadotropin during therapy, suggesting that topi-
cal application produces genital growth by its local effect as
well as its systemic effect.
: C1 h; o1 G. I( BReview of our patients and their growth response related to
( O& P$ {( H& C$ n2 V0 Mage shows a greater growth response at an earlier age. This is
consistent with the findings of Wilson and Walker, who
reported an increased conversion of testosterone to dihydrotes-
: j1 ?+ c. U1 A' ~- c8 Utosterone in the foreskin of neonates and infants.4 This activ-
ity 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
6 i2 s" d4 o" n  a2 nless than 10 years old. This fact may be explained by the
2 X4 t" |' l2 |( A4 Z+ jgreater ability of phallic skin to convert testosterone to dihy-
  x. ]  g/ |8 E& \! @drotestosterone at this age. Conversely, serum levels in older
/ d: s6 M% r  P& n* F. T# f: Tpatients were higher, possibly because of decreased local
667
# L% z9 B, \  D668 KLUGO AND CERNY
/ N" T  K. G) r: G6 {; ^/ a3 h* {Pt. Age
: t% E/ i  ]/ M1 b9 I(yrs.)
) X* ?  \. {$ n+ {) J0 OSerum Testosterone Phallus (cm.) Change Length
(ng./dl.) Girth x Length (%)
* J: K8 V. r0 M4
6 o# t# t6 s) ~) c9 L# ]8
10
) r6 \0 F  c" A" l7 t12
- R+ X- V2 B  V% m$ l. R. \) q17
Gonadotropin
71.6 2.0 X 3 16.6
) O3 t; h& K/ V+ ?" R# E4 |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
85.9 4.5 X 5.5 9.0
; t1 @$ [8 h+ B! bAv. 14.3
+ W* q0 G8 U; ~4 T) y  t4
7 C4 @" J; _& \  i2 L$ e8
7 B1 L! \; @9 U10
12
/ q4 ~" O. V) [/ y0 D17
Topical testosterone
; E! J. O' Q: ]' w) H34.6 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
6 [3 l2 W& D7 t/ |& T8 _& d, tAv. 60.0
available testosterone. Again, emphasis should be placed on
1 z* E* u. m9 q6 u$ V# t% Eearly therapy when lower levels of testosterone appear to
; f5 t3 U( E; a/ E8 zprovide 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
/ }1 O+ }7 M) l8 Gnoted in nomograms of phallic growth. 7 The actual response
/ q0 b9 Y" d" vto a given serum level of testosterone is much greater at birth
and gradually decreases as boys reach puberty. This is most
likely related to the conversion of testosterone to dihydrotes-
9 l. e8 v: H) _" S7 ytosterone and correlates well with the studies of testosterone
  f8 U7 B' G( E2 F9 Q+ Mconversion in foreskin at various ages.
The question arises regarding early treatment as to whether
) v7 j- t. y/ bone might sacrifice ultimate potential growth as with acceler-
ated bone growth. The situation appears quite the reverse
5 ]0 O' @3 j* e2 A/ e' kwith phallic response. If the early growth period is not used
when 5a reductase activity is greatest then potential growth
3 j, [. S4 X' B5 w) w8 _may be lost. We have not observed any regression of growth
attained with topical or gonadotropin therapy. It may well
8 z% X$ H! o, S& F# t5 Vbe that some patients will show little or no response to any
+ O, c, h+ V5 Iform 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
/ N9 n, p$ c- E9 g% Sbe compared for 5a reductase activity.
A, loop enlarges to measure penile girth in millimeters. B,
. S: k, C  ~% l! Mexample 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
, _/ h( U+ P  p% k( B/ V+ z- V! {testosterone with topical application. It would also appear
that phallic response during puberty is related directly to the
* N! S! H" b; F) N; h% V0 N/ ^serum testosterone level. There also is other evidence of local
response to testosterone with hair growth and with spermato-
genesis. 5• 6
Administration of larger doses of gonadotropin or systemic
testosterone, as well as topical applications that produce
$ J* z# ?( R( L* X: P0 g$ mhigher levels of serum testosterone (150 to 900 ng./dl.), will
' Y6 |. x) P; T' @. ]0 palso produce phallic growth but risks accelerated skeletal
maturation even after stopping treatment. It would appear
that this may be avoided by topical applications of testosterone
/ c! o: K! X; B; L4 U9 \( Mand monitoring of serum testosterone. Even with this control
the 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
4 k3 j% @$ b" _1 W# N200 ng./dl. When skeletal maturation is complete the level of
serum testosterone can be maintained in the 700 to 1,300 ng./
dl. range to stimulate phallic growth and secondary sexual
+ B) C) q+ c0 ]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
testosterone more than 100 ng./dl. Low-dose gonadotropin
depends upon intrinsic testicular activity and may require
prolonged administration for any response.
Alternately, topical testosterone does not depend upon tes-
6 B2 P) [/ D0 ?0 t7 T( J. zticular function and may provide a more constant level of
3 h3 H0 @0 v, F9 KREFERENCES
1. Immergut, M., Boldus, R., Yannone, E., Bunge, R. and Flocks,
R.: The local application of testosterone cream to the prepub-
ertal phallus. J. Urol., 105: 905, 1971.
! j$ j2 ?/ t6 F7 X' r7 r2. Guthrie, R. D., Smith, D. W. and Graham, C. B.: Testosterone
2 a" y9 U7 L$ t$ ktreatment 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
8 D+ J  f" ]2 K) ^6 S: f% A! \3 wto 5 alpha-androstan-17 beta-01-3-one (dihydrotestosterone) by
, ~. y+ P3 q; W; b# x# eskin slices of man. J. Clin. Invest., 48: 371, 1969.
$ A- p" q# |9 B! c: ^) A* f$ L5. 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
androgenic effect of interstitial cell tumor of the testis. J.
Urol., 104: 774, 1970.
7. Schonfeld, W. A. and Beebe, G. W.: Normal growth and varia-
tion in the male genitalia from birth to maturity. J. Urol., 48: