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
From the Division of Urology, Henry Ford Hospital, Detroit, Michigan
5 S% o6 j. V" u( R7 g: C/ C4 o) }ABSTRACT
+ B; |* ]0 d+ V0 S' k0 AFive patients were treated with gonadotropin and topical testosterone for micropenis associated
9 s# Y  B9 P3 V: s  T$ {with hypothalamic hypogonadotropic hypogonadism. All patients received 1,000 units of gonado-
$ U$ r' X* L7 `; H' B% h% [$ ?' H" Jtropin 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
& D) B/ `0 O' e* I7 {1 wfor 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
* O( r- P  d. W: z; T. T. `increase of 60 per cent in penile length and 52. 9 per cent in girth. The greatest growth response
- i! E( n) v, |& c' {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
$ I& R# ?5 P' k  Y' [growth. The response appears to be greater in younger children, which is consistent with previ-
( V5 w" m; m5 W4 K& aously published studies of age-related 5 reductase activity.
Children with microphallus regardless of its etiology will
require augmentation or consideration for alteration of exter-
7 j! \8 V8 b& n) P8 |7 Y3 Rnal 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
in mind we studied 5 children with microphallus for response
to gonadotropin and to topical testosterone independently.
4 [4 t+ Y9 x: f# v0 F6 bMATERIALS AND METHODS
& Z/ s# t! ]% ]5 I) ^7 \Five 46 XY male subjects between 3 and 17 years old were
+ A0 r$ P  r; b; e6 `* C3 s2 Q1 gevaluated for serum testosterone levels and hypothalamic
function. Of these 5 boys 2 were considered to have Kallmann's
* X5 E. |5 M5 }syndrome, 1 Prader-Willi syndrome and 2 idiopathic hypotha-
; r# ^4 E) `) I" M" w6 V+ Alamic deficiency. After evaluation of response to luteinizing
3 G) Q4 q, s7 h3 W) V* x0 _hormone-releasing hormone these patients were treated with
$ |; b) d6 j4 |1 O" U( l# w1,000 units of gonadotropin weekly for 3 weeks. Six weeks
- R$ X. f* o& ?' p. O' S1 @after completion of gonadotropin therapy 10 per cent topical
6 J1 q. r1 B# D, b; K0 _testosterone was applied to the phallus twice daily for 3 weeks.
Serum testosterone, luteinizing hormone and follicle-stimulat-
! I9 i  g) k) ~5 w( s! y! \) ~& ]. }ing hormone were monitored before, during and after comple-
tion of each phase of therapy. Penile stretch length was
0 X' t' R* L  M( _obtained 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).
- e, u8 ?1 K8 RRESULTS
, H) z0 r+ V7 U; d% p# ^+ gSerum testosterone increased moderately to levels between
50 and 86 ng./dl. with gonadotropin stimulation. Serum testos-
$ c0 e. w8 ]: _: I/ n6 lterone 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
! A9 P& h3 e* Z3 G" |" Xserum levels were noted in older patients (12 and 17 years old),
while lower levels persisted in younger patients (4, 8, and 10
% X0 D5 @" L4 T5 ~& Dyears 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,
$ z% H4 I6 {) }5 i5 t( ^& ?" D! rChicago, Illinois, April 24-28, 1977.
' o8 q+ ]4 P5 O  E3 f# l1 j* Requests for reprints: Division of Urology, Henry Ford Hospital,
2799 W. Grand Blvd., Detroit, Michigan 48202.
; h1 V4 r' C  ]& H7 T$ Kimprovement in phallic growth compared to gonadotropin.
" ~- A2 F/ ^$ p; q. |Average phallic growth with gonadotropin was 14.3 per cent
increase in length and 5.0 per cent increase of girth. Topical
, D: Y1 w9 Y8 etestosterone produced a 60.0 per cent increase of phallic length
1 i! W' D3 M8 T1 Cand 52.9 per cent increase of girth (circumference). The
" f* S8 b6 P1 W+ gresponse to topical testosterone was greatest in children be-
- }3 Q% D; X6 @) F! htween 4 and 8 years old, with a gradual decrease to age 17
' ?# a! o- R5 Xyears (see table).
DISCUSSION
) F& C. P8 X- T9 |% jTopical testosterone has been used effectively by other
clinicians but its mode of action remains controversial. Im-
mergut and associates reported an excellent growth response
3 A- v3 [7 h4 t" J" dto topical testosterone with low levels of serum testosterone,
6 j5 ~' B0 Q! z( Z5 y9 D/ wsuggesting a local effect.1 Others have obtained growth re-
. E- n* ^. A' u8 P7 P0 [sponse with high. levels of serum testosterone after topical
3 ~  s% T1 y. X) }9 [8 d8 {6 p$ c: qadministration, suggesting a systemic response. 3 The use of
gonadotropin to obtain levels of serum testosterone compara-
) Y! t; O% T+ u" B: b2 bble 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-
; Z* n1 E- w/ z$ j( ntainly 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-
1 m  Q' |) d) W: cnadotropin, particularly in children less than 10 years old.
9 _) e. X6 E) @0 I3 kThe levels of serum testosterone remained similar or lower
, t: G( F& H4 L' `/ o2 [, p) |: ithan with gonadotropin during therapy, suggesting that topi-
, u* E) q& G9 |6 G  e4 K+ ocal application produces genital growth by its local effect as
well as its systemic effect.
% s) E8 c6 ^8 g# ?! K& xReview of our patients and their growth response related to
: P9 U& b; h, @9 ~6 ^age 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-
% U( P  Z2 K, Y1 a( @* ytosterone 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
less than 10 years old. This fact may be explained by the
greater ability of phallic skin to convert testosterone to dihy-
2 N# G0 ]' R6 e, jdrotestosterone at this age. Conversely, serum levels in older
patients were higher, possibly because of decreased local
2 I9 W3 G7 G# ?! E0 U. ?5 W- \+ B667
; y7 j  `. j  w668 KLUGO AND CERNY
Pt. Age
(yrs.)
  `3 r2 p8 P; z; X6 h# V( E5 iSerum Testosterone Phallus (cm.) Change Length
# @8 T& H3 F* S# @: H3 t" x" \' X(ng./dl.) Girth x Length (%)
% b7 ^! q% E! N4 w# @4
$ r2 o' L5 K0 R0 h8
10
- [0 p2 A  Z+ x+ Y, P" Y12
; g$ t& w4 L5 Z6 r. N/ _4 i3 W17
$ N! M5 T* n% k. @0 t0 O; nGonadotropin
71.6 2.0 X 3 16.6
50.4 4.0 X 5.0 20.0
3 W1 e: B  [2 {! G22.0 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
8 O. X  N! X/ t! yAv. 14.3
4
% ^+ V# w7 q  C% W8
10
12
17
Topical testosterone
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
% K5 ], P% E8 u& P" h6 F$ s93.6 6.0 X 7.0 55.5
95.0 6.5 X 7.0 27.2
Av. 60.0
9 w- W7 [' _! |. N& a2 d# Davailable testosterone. Again, emphasis should be placed on
early therapy when lower levels of testosterone appear to
$ U. y8 q; [% X2 s1 ^provide the best responses. The earlier therapy is instituted
the more likely there will be an excellent response with low
) Y1 T9 v+ w( \1 U- l; ^serum levels. Response occurs throughout adolescence as
1 k! D* O3 u* n0 D% }3 \& vnoted in nomograms of phallic growth. 7 The actual response
& }/ d7 g' o/ Z+ X* }) }to a given serum level of testosterone is much greater at birth
and gradually decreases as boys reach puberty. This is most
; M- G9 R0 V* v5 `likely related to the conversion of testosterone to dihydrotes-
tosterone and correlates well with the studies of testosterone
conversion in foreskin at various ages.
- J3 S  w! q7 \2 k0 R6 h/ `The question arises regarding early treatment as to whether
" I4 p/ d: A# g' I- p( b- W' yone might sacrifice ultimate potential growth as with acceler-
ated bone growth. The situation appears quite the reverse
/ f" K+ v( W2 `2 pwith phallic response. If the early growth period is not used
when 5a reductase activity is greatest then potential growth
may be lost. We have not observed any regression of growth
attained with topical or gonadotropin therapy. It may well
7 }! `# t: p, w4 c2 a( jbe that some patients will show little or no response to any
1 \% g( I4 G8 r1 e1 Hform of therapy. This would suggest a defect in the ability to
8 ^! y& U7 Q5 M& |6 `convert testosterone to dihydrotestosterone and indicate that
phallic and peripheral skin, and subcutaneous tissue should
- T0 D  r, i+ bbe compared for 5a reductase activity.
$ ]2 }6 W, n0 i: w7 z! }A, loop enlarges to measure penile girth in millimeters. B,
$ q1 N. e' H, e( R$ l4 dexample of penile girth computed easily and accurately.
, C8 B3 k3 a; C7 ?conversion of testosterone to dihydrotestosterone. It is in this
older group that others have noted high levels of serum
: v2 i7 i' K" q( B- g/ T( gtestosterone 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
& J0 L) Q" [( ^8 j! {+ Tresponse to testosterone with hair growth and with spermato-
genesis. 5• 6
" A2 ]4 {% o+ X1 kAdministration of larger doses of gonadotropin or systemic
; R4 m7 s- f) r% n% H  Z2 i* vtestosterone, 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
maturation 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
suffer accelerated bone growth with testosterone levels near
200 ng./dl. When skeletal maturation is complete the level of
) ~7 f2 {3 |9 k4 i% dserum testosterone can be maintained in the 700 to 1,300 ng./
dl. range to stimulate phallic growth and secondary sexual
changes. Therefore, after skeletal maturation parenteral tes-
8 ]3 f: B4 M. g8 I5 W1 h9 w* ktosterone 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.
- u$ J( ]: @: b2 a) E, }Alternately, topical testosterone does not depend upon tes-
ticular function and may provide a more constant level of
4 ]2 A3 k' k" T; b" f* O/ f4 hREFERENCES
1 H7 b! M! I0 \2 L0 V( ?) H& }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.
2. 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-
one therapy for penile growth. Urology, 6: 708, 1975.
$ c2 x' b7 N( y4 _: k2 {$ t% F4. Wilson, J. D. and Walker, J. D.: The conversion of testosterone
6 z( ~# M" J: mto 5 alpha-androstan-17 beta-01-3-one (dihydrotestosterone) by
' i  O, ^; d' T# {3 \2 kskin 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.
6. Gittes, R. F., Smith, G., Conn, C. A. and Smith, F.: Local
$ I% u5 y1 C9 y5 z1 Eandrogenic 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: