这么漂亮的姐姐潮喷的好厉害，哗哗的流[12P]

long7857

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fengliu521

感谢分享内容刺激美女多多

kaifka

RESPONSE OF MICROPENIS TO TOPICAL TESTOSTERONE AND
7 M, v  V: S* Z% j/ pGONADOTROPIN
& `) b; V% N: ~- o5 d2 n) Y9 pRICHARD C. KLUGO* AND JOSEPH C. CERNY
0 ^# x0 U$ x% s: {! _& ?* b9 }From the Division of Urology, Henry Ford Hospital, Detroit, Michigan
ABSTRACT
+ n/ S) u( X( D9 oFive patients were treated with gonadotropin and topical testosterone for micropenis associated
  V3 m0 U. X6 awith 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
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
increase of 60 per cent in penile length and 52. 9 per cent in girth. The greatest growth response
) [8 u$ p+ E# W' {2 V8 b" [: p6 {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
growth. The response appears to be greater in younger children, which is consistent with previ-
ously published studies of age-related 5 reductase activity.
" }2 h* D6 X' v8 @3 Y: sChildren with microphallus regardless of its etiology will
require augmentation or consideration for alteration of exter-
nal genitalia. In many instances urethroplasty for hypo-
/ V) C# D7 N/ F: R2 |/ B4 lspadias is easier with previous stimulation of phallic growth.
: E6 {8 c% s$ }8 U2 P3 a) g2 t+ KThe use of testosterone administered parenterally or topically
& ~$ F# |. I2 i6 \; \6 zhas produced effective phallic growth. 1- 3 The mechanism of
  H2 _! N! i5 h& D, M; ]response has been considered as local or systemic. With this
% I& y9 K" q2 H# Bin mind we studied 5 children with microphallus for response
, V! q" z  {( z$ o2 Pto gonadotropin and to topical testosterone independently.
2 d& B  _0 Z: h  Y3 P6 L  z" YMATERIALS AND METHODS
Five 46 XY male subjects between 3 and 17 years old were
evaluated for serum testosterone levels and hypothalamic
function. Of these 5 boys 2 were considered to have Kallmann's
syndrome, 1 Prader-Willi syndrome and 2 idiopathic hypotha-
  A# I" F- u+ W" D; q/ h- }lamic deficiency. After evaluation of response to luteinizing
0 T1 k& {+ p# z2 G1 ]& R% g  |! A( ^hormone-releasing hormone these patients were treated with
1,000 units of gonadotropin weekly for 3 weeks. Six weeks
after completion of gonadotropin therapy 10 per cent topical
testosterone was applied to the phallus twice daily for 3 weeks.
7 p- Q: F: X8 s: `9 ]Serum testosterone, luteinizing hormone and follicle-stimulat-
  V" T% M5 A5 `2 a7 U! h; c6 Wing hormone were monitored before, during and after comple-
% \% k  |- H& I/ e0 E* Ktion of each phase of therapy. Penile stretch length was
obtained by measuring from the symphysis pubis to the tip of
the glans. Penile circumferential (girth) measurements were
1 D: E& s7 S6 D2 }2 t4 Wobtained using an orthopedic digital measuring device (see
* K% x9 N9 Y- ^) W; D- u3 Cfigure).
RESULTS
$ E8 v' B) r) x! V" b& C9 jSerum testosterone increased moderately to levels between
50 and 86 ng./dl. with gonadotropin stimulation. Serum testos-
terone levels with topical testosterone remained near pre-
9 j8 O; Z! `7 P) s  ?% R$ streatment levels (35 ng./dl.) or were elevated to similar levels
+ g" U& [) @. U& mdeveloped after gonadotropin therapy (96 ng./dl.). Higher
' y0 [3 T( H2 i: A2 S3 sserum 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
6 r% w$ k0 ~- O; ^. p7 u5 oof serum testosterone the topical therapy provided a greater
Accepted for publication July 1, 1977. ·
, {5 z! Q- z: b* i2 U: E2 _. KRead at annual meeting of American Urological Association,
& @8 N" F* a9 z. ?, {% E, J' _Chicago, Illinois, April 24-28, 1977.
* Requests for reprints: Division of Urology, Henry Ford Hospital,
1 P; `/ t9 _+ k. k2799 W. Grand Blvd., Detroit, Michigan 48202.
5 K0 x2 ]! W4 Z/ i( l$ gimprovement in phallic growth compared to gonadotropin.
Average phallic growth with gonadotropin was 14.3 per cent
# O& [4 w/ P- O) ?increase in length and 5.0 per cent increase of girth. Topical
. Y8 Q  ~4 p4 r; j6 Wtestosterone 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-
8 D2 \) [0 Y) @tween 4 and 8 years old, with a gradual decrease to age 17
years (see table).
DISCUSSION
6 [2 H% `8 r4 _) H) e% z4 {; NTopical testosterone has been used effectively by other
clinicians but its mode of action remains controversial. Im-
& l: l7 h) {7 [! e7 h0 ?- dmergut and associates reported an excellent growth response
* t; \% |4 p$ `5 r% [3 g6 }to topical testosterone with low levels of serum testosterone,
suggesting a local effect.1 Others have obtained growth re-
& M9 q; C) M6 T- ^& f3 w9 Esponse 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-
8 J& h' T8 h: l: W% I) K" g/ Vble to levels obtained with topical testosterone would seem to
  Z) `: D' L* G9 R. Dprovide 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-
enteral testosterone administration will produce genital
growth. Our report shows that the growth of the phallus was
# w  u+ B$ X. z$ Jsignificantly greater with topical applications than with go-
9 L* m' x+ g+ _% |3 y  d3 J% T* Nnadotropin, particularly in children less than 10 years old.
* [* G" ]$ _8 G. a9 K* O( fThe levels of serum testosterone remained similar or lower
! H6 C0 N! R( v/ _2 Z+ o# Y# n3 \; kthan with gonadotropin during therapy, suggesting that topi-
+ O) x( s: V; e" E( j3 ncal application produces genital growth by its local effect as
$ Y/ _7 C9 z1 l& \5 xwell as its systemic effect.
Review of our patients and their growth response related to
# ~  P! C3 C" Q5 J7 Oage 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-
tosterone in the foreskin of neonates and infants.4 This activ-
# C& l2 g/ B4 k+ }ity gradually decreases with age until puberty when it ap-
8 R- ]3 r$ n2 D7 ]  D, rproaches the same level of activity as peripheral skin. It may
& w* v5 `; }! \9 @& Y/ m) G- Xwell 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
4 {7 H5 I" ~  B$ n8 H5 Egreater ability of phallic skin to convert testosterone to dihy-
0 H# f6 |9 P5 x' F3 jdrotestosterone at this age. Conversely, serum levels in older
patients were higher, possibly because of decreased local
5 J+ f( E4 [; u' G" _667
9 q% u$ |- D0 S5 }# M4 C$ L  L5 l668 KLUGO AND CERNY
( g9 B! `! L  s8 U5 ^; y  cPt. Age
# m; M. z( t* c' w" ?  d(yrs.)
Serum Testosterone Phallus (cm.) Change Length
(ng./dl.) Girth x Length (%)
4
8
10
12
! {* A) [7 X: T9 j. G17
3 a* J" ]+ S" i/ }; }7 y  T1 e% R% EGonadotropin
( @* _$ V! Y1 r71.6 2.0 X 3 16.6
: H4 M* J7 L3 L- H2 K- d50.4 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
1 d9 f( M5 Q. ~4 @7 }" A( o85.9 4.5 X 5.5 9.0
  N& |2 q) q( V& o. kAv. 14.3
4
+ v, c6 ]. z: q6 T4 J; v& I6 b& K8
10
12
; h5 O9 H) b" G17
: G) }' E5 C4 h5 K# gTopical 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
  Y8 m# }* W+ ?' m# M; v7 B) b93.6 6.0 X 7.0 55.5
95.0 6.5 X 7.0 27.2
# o) Q3 P  `+ h0 @Av. 60.0
9 ^& J) X0 Z% w6 A" vavailable testosterone. Again, emphasis should be placed on
7 O  [! g$ V6 }* b& C9 Zearly therapy when lower levels of testosterone appear to
provide the best responses. The earlier therapy is instituted
% y% d; r5 Z6 n2 h- P; [! Hthe 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
to a given serum level of testosterone is much greater at birth
and gradually decreases as boys reach puberty. This is most
  ^7 S6 r" V0 ]- g$ c( h9 Qlikely related to the conversion of testosterone to dihydrotes-
tosterone and correlates well with the studies of testosterone
( F2 o4 Q2 n7 U0 ~& Z. A. O% F( econversion in foreskin at various ages.
2 G$ {$ q; g% ~3 c9 S1 {+ q& i: XThe question arises regarding early treatment as to whether
one might sacrifice ultimate potential growth as with acceler-
  L6 m# X( D5 R% n( A$ f9 ~2 Fated bone growth. The situation appears quite the reverse
% ]' o9 S, v2 R* B! }with 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
; W2 |1 j. ]. H9 E+ S( W* e3 D1 A; wbe that some patients will show little or no response to any
- `" t" b1 d) _form of therapy. This would suggest a defect in the ability to
/ c+ Z1 U' ^% g0 t9 cconvert testosterone to dihydrotestosterone and indicate that
phallic and peripheral skin, and subcutaneous tissue should
  Q4 i1 s" x6 b6 u. abe compared for 5a reductase activity.
; M3 n7 W% Y& U; OA, loop enlarges to measure penile girth in millimeters. B,
example of penile girth computed easily and accurately.
5 Q+ q( c+ D9 ?, I) H1 @5 ^conversion of testosterone to dihydrotestosterone. It is in this
% F% w$ P; g8 q3 L' U8 polder group that others have noted high levels of serum
4 L/ c! N4 V- a, S* s2 F; xtestosterone with topical application. It would also appear
6 A/ n6 F) U( I$ {' n6 a& Z/ sthat phallic response during puberty is related directly to the
serum testosterone level. There also is other evidence of local
response to testosterone with hair growth and with spermato-
* G1 I; ]: Y  O) M1 d, @7 m5 E/ Jgenesis. 5• 6
Administration of larger doses of gonadotropin or systemic
testosterone, as well as topical applications that produce
) T  k' Z8 {9 I( Q5 x& Khigher levels of serum testosterone (150 to 900 ng./dl.), will
also produce phallic growth but risks accelerated skeletal
* B& Z, x& b  s) h* I0 ?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
7 x9 H7 d% y6 _' a+ l5 D9 cthe 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 I* i, l200 ng./dl. When skeletal maturation is complete the level of
1 k6 j/ Z1 t7 E5 u$ C' zserum 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-
tosterone may be used to advantage. Before skeletal matura-
- I( R4 {! m# ^: T( J7 t/ c3 V# xtion care must be taken to avoid maintaining levels of serum
testosterone more than 100 ng./dl. Low-dose gonadotropin
/ N8 w8 p, [* j) `8 Odepends upon intrinsic testicular activity and may require
6 }( R6 `+ d# J! ~/ yprolonged administration for any response.
* n& k+ W' O" dAlternately, topical testosterone does not depend upon tes-
ticular function and may provide a more constant level of
1 U' S( o: `. n; LREFERENCES
1. Immergut, M., Boldus, R., Yannone, E., Bunge, R. and Flocks,
R.: The local application of testosterone cream to the prepub-
; L0 B( ^7 v# |# iertal 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.,
0 C/ s+ {$ {- k1 \) {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.
# S& \4 T: a; F$ i4. Wilson, J. D. and Walker, J. D.: The conversion of testosterone
- G! n+ L; w- G, u# Kto 5 alpha-androstan-17 beta-01-3-one (dihydrotestosterone) by
skin slices of man. J. Clin. Invest., 48: 371, 1969.
; c# O2 Y0 ^/ g% Q* N6 R; s5. Papa, C. M. and Klingman, A. M.: Stimulation of hair growth
by topical application of androgens. J.A.M.A., 191: 521, 1965.
. o1 W+ ]' R& ]: p$ q6. Gittes, R. F., Smith, G., Conn, C. A. and Smith, F.: Local
androgenic effect of interstitial cell tumor of the testis. J.
5 T2 ]+ P2 i4 K5 c+ S+ \* {. Q1 i* ^Urol., 104: 774, 1970.
7. Schonfeld, W. A. and Beebe, G. W.: Normal growth and varia-
  d9 |& x% J% ftion in the male genitalia from birth to maturity. J. Urol., 48: