鄉下的妹子太便宜，一次四個都要了[12P]

stcar

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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
" }' G+ [" M, F$ ?# i2 ~% M+ yGONADOTROPIN
RICHARD C. KLUGO* AND JOSEPH C. CERNY
From the Division of Urology, Henry Ford Hospital, Detroit, Michigan
% z9 x$ [1 D" H4 |ABSTRACT
) ]' p4 O0 E* ?9 P1 jFive 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
/ N3 H2 t; e  H) Ufor 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
+ U  L/ e- f& }) e- P% Tincrease of 60 per cent in penile length and 52. 9 per cent in girth. The greatest growth response
  C! ~( ~2 K: yoccurred 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
growth. The response appears to be greater in younger children, which is consistent with previ-
: J9 W6 m# v: O- Y( _' |, ^ously published studies of age-related 5 reductase activity.
Children with microphallus regardless of its etiology will
+ A: O/ L# [" Q) x1 y& Y3 H6 G, H, Lrequire 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
has produced effective phallic growth. 1- 3 The mechanism of
response has been considered as local or systemic. With this
! H  _" G' `3 D9 X: lin mind we studied 5 children with microphallus for response
to gonadotropin and to topical testosterone independently.
MATERIALS AND METHODS
% [/ L6 I% l) y3 sFive 46 XY male subjects between 3 and 17 years old were
* }. o3 p' R, r3 Mevaluated for serum testosterone levels and hypothalamic
& `8 Z  i9 M6 ^% T6 efunction. Of these 5 boys 2 were considered to have Kallmann's
# ?# b' e  R1 t  h7 q% bsyndrome, 1 Prader-Willi syndrome and 2 idiopathic hypotha-
+ n& H0 \% |6 ?1 u4 j. k! N- p4 Xlamic deficiency. After evaluation of response to luteinizing
hormone-releasing hormone these patients were treated with
( o) z! `1 I5 i  u" ~1,000 units of gonadotropin weekly for 3 weeks. Six weeks
' \* U2 Y+ Z8 f9 ?" _after completion of gonadotropin therapy 10 per cent topical
testosterone was applied to the phallus twice daily for 3 weeks.
  u$ l: r; W# ^Serum testosterone, luteinizing hormone and follicle-stimulat-
ing hormone were monitored before, during and after comple-
+ ~& m! C* j$ d7 c3 ttion of each phase of therapy. Penile stretch length was
! c/ s% ?$ F9 K2 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).
) r) }+ \/ b" }, DRESULTS
Serum testosterone increased moderately to levels between
+ j6 e' f. s9 K! T0 ?  A50 and 86 ng./dl. with gonadotropin stimulation. Serum testos-
/ Q% u/ {; J$ Z/ ]; Aterone levels with topical testosterone remained near pre-
treatment 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
1 e* i: Q, B" Bof serum testosterone the topical therapy provided a greater
Accepted for publication July 1, 1977. ·
Read at annual meeting of American Urological Association,
+ S1 v, A1 c( ]# J# G+ W* uChicago, Illinois, April 24-28, 1977.
* Requests for reprints: Division of Urology, Henry Ford Hospital,
/ i; d% F; F) j' P* b+ h2799 W. Grand Blvd., Detroit, Michigan 48202.
8 e7 }8 M, X  g5 gimprovement in phallic growth compared to gonadotropin.
% E; ^! E1 G# o, ^4 g0 DAverage phallic growth with gonadotropin was 14.3 per cent
increase in length and 5.0 per cent increase of girth. Topical
( I3 \9 a- _6 A8 p3 ]) Ttestosterone produced a 60.0 per cent increase of phallic length
and 52.9 per cent increase of girth (circumference). The
response to topical testosterone was greatest in children be-
6 a  S1 ]8 c- dtween 4 and 8 years old, with a gradual decrease to age 17
years (see table).
DISCUSSION
Topical testosterone has been used effectively by other
) c" V! B4 k! B' cclinicians but its mode of action remains controversial. Im-
( W2 L$ W  H) c/ ^mergut and associates reported an excellent growth response
to topical testosterone with low levels of serum testosterone,
+ q" s& P1 e) ]5 l; }6 v8 Asuggesting 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
gonadotropin to obtain levels of serum testosterone compara-
9 a' f6 ~% n( l6 b' [7 i+ Cble to levels obtained with topical testosterone would seem to
; V/ e$ K4 ~' g! v" D7 Sprovide 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-
. O+ _7 g; Y4 J( l2 L1 v- Uenteral testosterone administration will produce genital
growth. Our report shows that the growth of the phallus was
$ Z# z, N/ e: E; @) jsignificantly greater with topical applications than with go-
7 b$ v' A! g; n( vnadotropin, particularly in children less than 10 years old.
0 O9 Q& k+ v  A7 H3 tThe levels of serum testosterone remained similar or lower
( u9 k7 _% j. p  g/ Sthan with gonadotropin during therapy, suggesting that topi-
cal application produces genital growth by its local effect as
2 q2 R; [7 O, x' p" F7 B0 c+ [well as its systemic effect.
Review of our patients and their growth response related to
age shows a greater growth response at an earlier age. This is
. r$ }1 x6 j; D& m' G9 w! S% d; uconsistent with the findings of Wilson and Walker, who
% v. D- U4 K2 p) Ireported 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-
2 t/ u# z+ C# }1 t" c9 wproaches the same level of activity as peripheral skin. It may
5 O  w; C  o5 Z$ hwell 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
& `, w: D# E6 N  k7 J' j# _2 x4 \5 Zpatients were higher, possibly because of decreased local
667
, \  V/ _7 {3 K7 f, F& L668 KLUGO AND CERNY
+ b3 H$ L3 C4 x" zPt. Age
(yrs.)
Serum Testosterone Phallus (cm.) Change Length
(ng./dl.) Girth x Length (%)
+ ]/ ~4 R* r* D7 i$ O! o9 B8 J4
8 W! V! J+ {$ k: T# B  p5 _8
0 L  ^; T8 G" G6 x" [2 \- p10
6 ?' }1 U2 A* U6 m12
( i5 V( d; t% }! }3 V4 }* E17
Gonadotropin
8 a$ z: y" B" V; X7 p71.6 2.0 X 3 16.6
50.4 4.0 X 5.0 20.0
22.0 4.5 X 4.0 25.0
- o% }  c1 O& r6 f84.6 4.0 X 4.5 11.1
  {: q) {; h$ F- O8 K- }4 ^85.9 4.5 X 5.5 9.0
Av. 14.3
& G/ T" n( I! _; g6 Y4
% `8 h0 {; Y! r5 J$ \$ Q6 u8
10
12
* A7 }6 A! y- s+ i! F' v8 G: j3 C17
+ ~7 E1 \! d4 G- TTopical testosterone
34.6 4.5 X 6.5 85
# Y2 U4 e  ?0 z% {38.8 6.0 X 8.5 70
40.0 6.0 X 6.5 62.5
9 ~+ N% M( W; A2 j1 z  o( ^8 e( S( b+ ~93.6 6.0 X 7.0 55.5
7 r3 o' o9 O  C/ ?# Y95.0 6.5 X 7.0 27.2
Av. 60.0
available testosterone. Again, emphasis should be placed on
& `  U% R. E6 w+ ^$ J& q+ nearly therapy when lower levels of testosterone appear to
* o, g; f1 M$ h' k) v) jprovide the best responses. The earlier therapy is instituted
the more likely there will be an excellent response with low
9 `0 z& ^& P8 X3 |$ ]2 }serum levels. Response occurs throughout adolescence as
noted in nomograms of phallic growth. 7 The actual response
. E" u8 c0 U: {5 T9 g2 p' I- C0 h, Tto 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-
4 j& v1 b4 b7 Z! o. M. Etosterone and correlates well with the studies of testosterone
2 g1 q8 {5 A; a( u3 L- F8 u, Bconversion in foreskin at various ages.
& q  _/ t1 g. h; p/ C. `8 ZThe 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
7 l+ \, b# O4 P8 ]! hwith phallic response. If the early growth period is not used
7 g- b7 N1 P' J9 A$ z: m! u: lwhen 5a reductase activity is greatest then potential growth
1 X, y' ?! {* Imay be lost. We have not observed any regression of growth
attained with topical or gonadotropin therapy. It may well
be that some patients will show little or no response to any
' Y# a+ {9 v! n, i. ^form of therapy. This would suggest a defect in the ability to
, _' [  }9 v# Q8 kconvert testosterone to dihydrotestosterone and indicate that
phallic and peripheral skin, and subcutaneous tissue should
be compared for 5a reductase activity.
A, loop enlarges to measure penile girth in millimeters. B,
example of penile girth computed easily and accurately.
+ ?/ m9 C3 G& O: p! bconversion of testosterone to dihydrotestosterone. It is in this
0 t8 @" ?6 W: g9 w- ]older group that others have noted high levels of serum
$ B8 G3 o( }; X/ G; Ztestosterone with topical application. It would also appear
6 h! c9 t1 K3 H- f1 Z- kthat phallic response during puberty is related directly to the
/ D! A3 o2 o% r  wserum testosterone level. There also is other evidence of local
/ v5 a# C  E8 v# h" N- Q  ]response to testosterone with hair growth and with spermato-
( i7 |; }$ Q5 n: p' Sgenesis. 5• 6
Administration of larger doses of gonadotropin or systemic
6 l; a6 J9 S/ S/ W8 Gtestosterone, as well as topical applications that produce
) g1 W1 {0 Q4 s- R/ Mhigher levels of serum testosterone (150 to 900 ng./dl.), will
also produce phallic growth but risks accelerated skeletal
maturation even after stopping treatment. It would appear
+ y. B1 ?. r. A" Athat this may be avoided by topical applications of testosterone
2 D( }* g7 p! D1 ~2 q, `and 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
200 ng./dl. When skeletal maturation is complete the level of
9 z+ F3 H. |) O. D9 k3 Hserum testosterone can be maintained in the 700 to 1,300 ng./
3 H" s3 L3 E, }" Vdl. range to stimulate phallic growth and secondary sexual
* |4 k4 o0 N# d+ [0 M% kchanges. 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
  G( g( i# r  Y1 Qdepends upon intrinsic testicular activity and may require
  O# Q; n8 M* b! s6 W! L& s+ ~prolonged administration for any response.
" n' g8 i! P* Z6 M( x+ C- KAlternately, topical testosterone does not depend upon tes-
ticular function and may provide a more constant level of
8 u6 }7 J5 N0 p* [: ^$ ~REFERENCES
1. Immergut, M., Boldus, R., Yannone, E., Bunge, R. and Flocks,
R.: The local application of testosterone cream to the prepub-
/ W+ F; Y/ j$ m# o, }ertal phallus. J. Urol., 105: 905, 1971.
, N4 I* ~* A, `+ f0 E8 b2. Guthrie, R. D., Smith, D. W. and Graham, C. B.: Testosterone
treatment for micropenis during early childhood. J. Pediat.,
83: 247, 1973.
3. Jacobs, S. C., Kaplan, G. W. and Gittes, R. F.: Topical testoster-
% n0 ?8 a" V7 w9 D* X0 r( |one therapy for penile growth. Urology, 6: 708, 1975.
/ n: @0 _! p( z4. Wilson, J. D. and Walker, J. D.: The conversion of testosterone
to 5 alpha-androstan-17 beta-01-3-one (dihydrotestosterone) by
skin slices of man. J. Clin. Invest., 48: 371, 1969.
) }1 E1 L  h! [0 h! k3 B5. 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
! ?  q  j/ ~( ~5 B) I3 G" V. x/ \androgenic effect of interstitial cell tumor of the testis. J.
* k/ z6 @- r1 lUrol., 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: