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
$ Q1 N/ O6 h" d* A. y& XGONADOTROPIN
RICHARD C. KLUGO* AND JOSEPH C. CERNY
/ m3 `; x# F9 m) Z9 E# [From the Division of Urology, Henry Ford Hospital, Detroit, Michigan
4 c) O$ E2 {6 C! p7 NABSTRACT
! q! i& |+ H, M2 }2 HFive patients were treated with gonadotropin and topical testosterone for micropenis associated
with hypothalamic hypogonadotropic hypogonadism. All patients received 1,000 units of gonado-
  C) C6 l# u1 ~/ @/ [- A6 Utropin weekly for 3 weeks, with a 6-week interval followed by 10 per cent topical testosterone
( A, ]1 E( I: p# [6 {- R/ |; kcream 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
, N* e( d3 f4 k- J0 iincrease of 60 per cent in penile length and 52. 9 per cent in girth. The greatest growth response
% ?# Q% I" ?3 V# [) ^! K6 j% Foccurred in prepuberal male subjects with a minimal response in postpuberal male subjects. This
% Z  X' B% k$ S  M2 rstudy 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-
* g# N/ ~5 u, J. Fously published studies of age-related 5 reductase activity.
Children with microphallus regardless of its etiology will
require augmentation or consideration for alteration of exter-
0 Z$ u4 y+ {: u+ w6 P- f1 V* c: I* |# Fnal genitalia. In many instances urethroplasty for hypo-
spadias is easier with previous stimulation of phallic growth.
7 }" c6 j' X1 uThe use of testosterone administered parenterally or topically
5 }) v4 [7 I  `* Z( z* {has produced effective phallic growth. 1- 3 The mechanism of
response has been considered as local or systemic. With this
  q+ T0 H/ G/ F  k  ain mind we studied 5 children with microphallus for response
to gonadotropin and to topical testosterone independently.
5 l1 b9 |  q+ P; zMATERIALS AND METHODS
$ i6 ~: M4 g6 `$ \0 }Five 46 XY male subjects between 3 and 17 years old were
, R) I& n5 a4 K3 t$ F% Q5 Levaluated for serum testosterone levels and hypothalamic
function. Of these 5 boys 2 were considered to have Kallmann's
  E& t1 R6 O6 Wsyndrome, 1 Prader-Willi syndrome and 2 idiopathic hypotha-
3 c1 `6 ?8 A! w% F' M) u8 C# W" g2 l: S# Ulamic deficiency. After evaluation of response to luteinizing
. ^; s- z- p" P+ v8 Fhormone-releasing hormone these patients were treated with
1,000 units of gonadotropin weekly for 3 weeks. Six weeks
7 B! [! u  y1 s& `' Lafter completion of gonadotropin therapy 10 per cent topical
testosterone was applied to the phallus twice daily for 3 weeks.
Serum testosterone, luteinizing hormone and follicle-stimulat-
/ o# ]. ?/ \7 i! {/ ying hormone were monitored before, during and after comple-
# a; ^7 {- `7 j' {- U8 Ption of each phase of therapy. Penile stretch length was
obtained by measuring from the symphysis pubis to the tip of
% }" e  H( Y( h3 v* T- k7 l7 Hthe glans. Penile circumferential (girth) measurements were
obtained using an orthopedic digital measuring device (see
figure).
7 x- O/ n. I. i% }RESULTS
+ |* W' o5 G7 {2 |, s7 R( h5 HSerum testosterone increased moderately to levels between
50 and 86 ng./dl. with gonadotropin stimulation. Serum testos-
terone levels with topical testosterone remained near pre-
/ K; H- A, n( a, W( ]& ltreatment levels (35 ng./dl.) or were elevated to similar levels
developed after gonadotropin therapy (96 ng./dl.). Higher
7 O, C$ z2 u, Xserum levels were noted in older patients (12 and 17 years old),
4 i# T  C9 r) s# M  fwhile 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,
! N8 i$ p/ u# }; \Chicago, Illinois, April 24-28, 1977.
* Requests for reprints: Division of Urology, Henry Ford Hospital,
' H; m+ Y, Q- @- B2799 W. Grand Blvd., Detroit, Michigan 48202.
; I0 S. y2 n6 I# o% Rimprovement in phallic growth compared to gonadotropin.
Average phallic growth with gonadotropin was 14.3 per cent
+ Z7 j& p  a; b3 L  |- Iincrease in length and 5.0 per cent increase of girth. Topical
testosterone produced a 60.0 per cent increase of phallic length
and 52.9 per cent increase of girth (circumference). The
7 C& d! |# P8 U3 }$ d% f; Jresponse to topical testosterone was greatest in children be-
tween 4 and 8 years old, with a gradual decrease to age 17
: u  f9 W; u" Z$ z: J. iyears (see table).
DISCUSSION
' `6 e- s) }$ W) e6 ?, ~2 sTopical testosterone has been used effectively by other
clinicians but its mode of action remains controversial. Im-
# N2 c7 j. X# z* F' Gmergut and associates reported an excellent growth response
to topical testosterone with low levels of serum testosterone,
: x" T3 m; w9 Q; W& T, Osuggesting a local effect.1 Others have obtained growth re-
sponse with high. levels of serum testosterone after topical
; Q3 l% J. a# P  }3 p+ cadministration, suggesting a systemic response. 3 The use of
* v( C3 U* W5 q* C  ~gonadotropin to obtain levels of serum testosterone compara-
# y/ T& u2 U+ Q& ]6 v5 bble to levels obtained with topical testosterone would seem to
$ m* [2 J" h. U, R( T% }provide a means to compare the relative effectiveness of
% m2 n0 v8 O9 @% e9 Mtopical testosterone to systemic testosterone effect. It cer-
tainly has been established that gonadotropin as well as par-
enteral testosterone administration will produce genital
3 M$ _8 R+ b: b3 j8 E  `4 mgrowth. 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.
The levels of serum testosterone remained similar or lower
0 ]' W1 w9 g. hthan with gonadotropin during therapy, suggesting that topi-
) t! h# a9 z' \) E, Hcal application produces genital growth by its local effect as
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
consistent with the findings of Wilson and Walker, who
* t6 Q3 \8 M9 W& o6 [reported an increased conversion of testosterone to dihydrotes-
3 {! \3 U4 I3 ?tosterone 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
% i, l' V- R0 |  P1 h: A) iwell 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
2 z# i, r. ?$ w/ M# Igreater 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
8 `; ]. k' Z1 z7 `  N2 `- S' _668 KLUGO AND CERNY
Pt. Age
; i  l5 `7 |$ p1 Z# P(yrs.)
0 g# n" ?, {- _, E& |/ tSerum Testosterone Phallus (cm.) Change Length
6 K. O  K3 _3 L: W9 ?(ng./dl.) Girth x Length (%)
' k0 f8 S/ ^( l1 C% i4
8
10
$ I2 {8 H  e7 _1 A7 ?12
/ a+ l$ X) e, v4 R6 ~, n17
) E- q. b1 i  oGonadotropin
$ \/ e# ?1 ?* Y6 Q( Q7 Q6 i! P71.6 2.0 X 3 16.6
6 E% [9 h/ w0 r3 l% U50.4 4.0 X 5.0 20.0
$ j# ?9 J6 M' W0 u7 U: p9 j: F) s% x22.0 4.5 X 4.0 25.0
# J$ ?5 {3 b; s* R* S2 H84.6 4.0 X 4.5 11.1
85.9 4.5 X 5.5 9.0
/ d9 k9 Q2 N) i' X- FAv. 14.3
) X  a; s7 K& {" \4
8
: c/ _8 ^2 {, n, W1 t10
. n$ b$ n/ I! m$ g12
# S+ r7 V3 S* [17
) H7 Y6 ?: p5 a2 _+ L7 Q/ W2 J, MTopical testosterone
( e1 `4 V, P1 ?, N% n1 {34.6 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
  \: k6 ?- |  Z0 j9 o3 t1 m7 s95.0 6.5 X 7.0 27.2
$ m, P# [+ U+ I  y5 @0 G. VAv. 60.0
available testosterone. Again, emphasis should be placed on
8 c- [4 [1 w9 Q5 E. p8 K' I* Aearly 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
3 y4 p, @, {" J! y; s0 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-
tosterone and correlates well with the studies of testosterone
: F: T" C6 c4 nconversion in foreskin at various ages.
+ `# [4 @4 _1 sThe 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
, ~8 a: q, W/ }' g# J/ rwith phallic response. If the early growth period is not used
6 [! x5 Q* N' b" m' \when 5a reductase activity is greatest then potential growth
* S0 J+ ~+ i# H% V) ], zmay be lost. We have not observed any regression of growth
& k9 T+ `5 J3 W9 ^+ Oattained with topical or gonadotropin therapy. It may well
: [" V+ L8 D2 Y9 ~be that some patients will show little or no response to any
) a5 A/ F0 A+ ^5 K% G/ u  Cform of therapy. This would suggest a defect in the ability to
9 f1 r, U: u/ q3 [convert testosterone to dihydrotestosterone and indicate that
* J4 E8 C* p# Y( W" d& Wphallic and peripheral skin, and subcutaneous tissue should
. p3 S1 f, S# G, l7 c8 cbe compared for 5a reductase activity.
A, loop enlarges to measure penile girth in millimeters. B,
8 U* N$ p9 ?' r- v9 jexample of penile girth computed easily and accurately.
9 K' X5 l' W# `* F7 e6 |conversion of testosterone to dihydrotestosterone. It is in this
+ k# X( I" O, Jolder group that others have noted high levels of serum
) S% e! h9 ?9 s7 Mtestosterone with topical application. It would also appear
that phallic response during puberty is related directly to the
serum testosterone level. There also is other evidence of local
% I9 r7 O# `" e$ u! }7 gresponse 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
8 F0 l/ e5 J9 Y1 _, F, bhigher levels of serum testosterone (150 to 900 ng./dl.), will
, s+ n; ]1 e2 U, P) W7 P) Palso produce phallic growth but risks accelerated skeletal
- s1 i4 t# O4 Nmaturation even after stopping treatment. It would appear
that this may be avoided by topical applications of testosterone
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
# @6 y$ H" k& Z6 C. T4 e' e# tsuffer accelerated bone growth with testosterone levels near
# y8 B0 y; N1 b" ~% Q4 B200 ng./dl. When skeletal maturation is complete the level of
serum testosterone can be maintained in the 700 to 1,300 ng./
' |  B% h; ^9 F* K( r* \dl. range to stimulate phallic growth and secondary sexual
changes. Therefore, after skeletal maturation parenteral tes-
tosterone may be used to advantage. Before skeletal matura-
% n, t$ J) a1 Ition care must be taken to avoid maintaining levels of serum
testosterone more than 100 ng./dl. Low-dose gonadotropin
6 b+ q9 J# L' p: jdepends upon intrinsic testicular activity and may require
. g2 h3 S& |2 W, h9 K# Aprolonged administration for any response.
Alternately, topical testosterone does not depend upon tes-
* s4 B+ L! X  p; i  x9 X- Bticular function and may provide a more constant level of
REFERENCES
1. Immergut, M., Boldus, R., Yannone, E., Bunge, R. and Flocks,
R.: The local application of testosterone cream to the prepub-
/ J4 C; N/ f( `& ?7 J; uertal phallus. J. Urol., 105: 905, 1971.
2. Guthrie, R. D., Smith, D. W. and Graham, C. B.: Testosterone
9 e; t" T4 n. n5 O  dtreatment for micropenis during early childhood. J. Pediat.,
  M3 m$ w& j5 y+ d0 M9 x' U& R% M. p8 r83: 247, 1973.
3. Jacobs, S. C., Kaplan, G. W. and Gittes, R. F.: Topical testoster-
+ v" s5 N" @6 l( V0 hone therapy for penile growth. Urology, 6: 708, 1975.
4. 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.
* L. a* ^8 p! K; }. ^, b  Y! z5. 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-
+ Y; N1 k1 @/ x4 {( g" Jtion in the male genitalia from birth to maturity. J. Urol., 48: