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
7 B6 I7 p7 B  v' p  mRICHARD C. KLUGO* AND JOSEPH C. CERNY
3 a: j8 N" J! M* q2 jFrom the Division of Urology, Henry Ford Hospital, Detroit, Michigan
2 C) U* z/ [' `+ s8 y$ d' {' XABSTRACT
# L& K% {! x' m; ?5 R5 O$ lFive 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
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
0 X6 {% }) {) X, C1 \2 ^, Y8 doccurred 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
# ^! ]2 q; y8 X' ~growth. The response appears to be greater in younger children, which is consistent with previ-
ously published studies of age-related 5 reductase activity.
* z. |+ k; T6 e, M0 E- ?( fChildren with microphallus regardless of its etiology will
+ D  F% }* f: krequire augmentation or consideration for alteration of exter-
3 l4 D  W' Z7 g2 [+ b9 k" ^8 Rnal genitalia. In many instances urethroplasty for hypo-
2 a/ H( Y1 I! t3 G- Q# cspadias is easier with previous stimulation of phallic growth.
' a* ~" m* ]+ f6 i" i" {2 c5 eThe use of testosterone administered parenterally or topically
8 L" S+ l8 ?2 I1 ]& e; `1 h, phas produced effective phallic growth. 1- 3 The mechanism of
7 @  O4 w, F- {# q" hresponse 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.
: S& A! A! P2 \' ?5 d* c  P& IMATERIALS AND METHODS
Five 46 XY male subjects between 3 and 17 years old were
% G# D9 i) {, U0 yevaluated 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-
lamic deficiency. After evaluation of response to luteinizing
2 T; F( U' {  yhormone-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
3 ]+ D' M3 r7 Dtestosterone was applied to the phallus twice daily for 3 weeks.
/ o' @0 [8 `" L& c' RSerum testosterone, luteinizing hormone and follicle-stimulat-
ing hormone were monitored before, during and after comple-
3 e! P5 B. ?& q4 s. Z+ rtion of each phase of therapy. Penile stretch length was
obtained by measuring from the symphysis pubis to the tip of
# b- e- ^' ]: V; m+ @+ d( o1 ethe glans. Penile circumferential (girth) measurements were
5 C" Y1 @# d. I7 W* m# T( robtained using an orthopedic digital measuring device (see
! W6 _. a/ ?/ yfigure).
RESULTS
0 {$ V7 i8 }: W3 E! S9 C5 H. wSerum testosterone increased moderately to levels between
2 R# a' C% q9 r9 `5 ~50 and 86 ng./dl. with gonadotropin stimulation. Serum testos-
terone levels with topical testosterone remained near pre-
7 K, D7 W1 O1 c8 Ktreatment levels (35 ng./dl.) or were elevated to similar levels
developed after gonadotropin therapy (96 ng./dl.). Higher
6 a1 c, e' Q; c3 F7 T8 d. A# s% N0 t2 iserum 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
- D- `+ V2 y$ h/ f) bof serum testosterone the topical therapy provided a greater
Accepted for publication July 1, 1977. ·
/ ]( n) O8 E5 t# ^/ gRead at annual meeting of American Urological Association,
Chicago, Illinois, April 24-28, 1977.
3 X9 N! N, {- P/ G2 U$ z) N1 {* Requests for reprints: Division of Urology, Henry Ford Hospital,
2799 W. Grand Blvd., Detroit, Michigan 48202.
5 \# y7 O- M2 j( c7 f; ^improvement in phallic growth compared to gonadotropin.
7 H; f, b8 J) b: s+ i1 uAverage phallic growth with gonadotropin was 14.3 per cent
increase 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
response to topical testosterone was greatest in children be-
! g) n, T; s7 v/ Q2 `& [3 {% Ptween 4 and 8 years old, with a gradual decrease to age 17
years (see table).
DISCUSSION
Topical testosterone has been used effectively by other
( b4 V+ i" C4 u8 r7 _8 ^clinicians but its mode of action remains controversial. Im-
) Y" |( _3 S( s5 Pmergut and associates reported an excellent growth response
4 E; M5 S, t9 ~3 u8 `/ tto topical testosterone with low levels of serum testosterone,
6 k1 P9 O/ u! o! [% R1 osuggesting a local effect.1 Others have obtained growth re-
" s" R" N9 W% g' d  D1 s' [! D) v4 qsponse with high. levels of serum testosterone after topical
2 P* W; e9 x& ?; p' w0 e; q7 |administration, suggesting a systemic response. 3 The use of
/ o$ b" u9 ~' v+ d$ a- _! `4 Ygonadotropin to obtain levels of serum testosterone compara-
- F, w1 \# [: W, j8 |$ R$ Qble to levels obtained with topical testosterone would seem to
provide a means to compare the relative effectiveness of
' {9 z) r' _+ Htopical 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
! |; ^' g+ u0 R& k( g1 }significantly greater with topical applications than with go-
2 Z/ ^* M* b7 A0 ~% h; tnadotropin, particularly in children less than 10 years old.
# B% d$ R9 e& RThe levels of serum testosterone remained similar or lower
" G+ S4 K! G5 l9 Ythan with gonadotropin during therapy, suggesting that topi-
cal application produces genital growth by its local effect as
; X# |* X- M) ?$ p/ Mwell as its systemic effect.
. u2 F% e3 X: Z6 ^( L' t" Q& ?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
& w# ]5 R0 X5 c; f( m' C9 Yreported an increased conversion of testosterone to dihydrotes-
8 P* k) T& {/ u% i5 q, Wtosterone in the foreskin of neonates and infants.4 This activ-
, H0 w9 m8 S; Q) D4 n7 Z8 N6 hity 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
9 j8 g9 U# R/ t  q0 U6 l/ }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
) Y9 ]$ n3 }7 \patients were higher, possibly because of decreased local
- _. i+ u+ P  z! P! i0 ]; x$ J667
668 KLUGO AND CERNY
Pt. Age
' o1 I- L; R8 B(yrs.)
* H1 w. B- F& K; |9 ISerum Testosterone Phallus (cm.) Change Length
(ng./dl.) Girth x Length (%)
4
8
% \- O1 f# C8 k* K: u10
' C" R1 ?0 ~; E1 Y12
17
) T" Q4 _3 T5 P& x/ L! @. ]Gonadotropin
) A& ]7 c0 y  b71.6 2.0 X 3 16.6
50.4 4.0 X 5.0 20.0
22.0 4.5 X 4.0 25.0
& X; }# j# D+ x$ J7 y84.6 4.0 X 4.5 11.1
" {% w: r3 g' [$ Q0 ]; T3 V85.9 4.5 X 5.5 9.0
- b+ W# R+ o- Q2 YAv. 14.3
1 \% P, j: t) [1 w2 o7 w, N$ L4
8
6 O6 k5 z" |5 l0 S6 k10
12
17
( Z+ r$ [3 Q  M4 ^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
9 I1 ~5 G0 W+ m93.6 6.0 X 7.0 55.5
; c/ b* p$ Z$ C2 I95.0 6.5 X 7.0 27.2
% x9 ~' l$ j0 R" h1 o, ?Av. 60.0
, {/ m( D; I4 D% z6 vavailable testosterone. Again, emphasis should be placed on
early therapy when lower levels of testosterone appear to
. n  D1 a7 y1 S9 @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
% l' J  Y5 {; i! W* B$ N6 s5 r% tnoted 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
4 X# c; ]6 `* rlikely related to the conversion of testosterone to dihydrotes-
. c9 y; u3 `  N' b  w8 Ptosterone and correlates well with the studies of testosterone
# A/ x( V3 h/ R4 B. c$ k  Aconversion in foreskin at various ages.
& ^* A, S9 I. Q9 e9 \. oThe question arises regarding early treatment as to whether
one might sacrifice ultimate potential growth as with acceler-
3 S2 U7 T) B8 [4 q, z% s. Yated bone growth. The situation appears quite the reverse
with phallic response. If the early growth period is not used
/ C  H; U, R  F8 Rwhen 5a reductase activity is greatest then potential growth
9 C: W9 w5 D' `6 ?' {, zmay be lost. We have not observed any regression of growth
0 B: l! J0 I1 x7 ~  g& N. t1 cattained with topical or gonadotropin therapy. It may well
9 I7 R% Z2 y, R3 W2 W6 }! abe that some patients will show little or no response to any
form of therapy. This would suggest a defect in the ability to
/ z, \' C- Z; ^0 Q' Econvert testosterone to dihydrotestosterone and indicate that
phallic and peripheral skin, and subcutaneous tissue should
be compared for 5a reductase activity.
; l+ E' _3 j5 g- w$ YA, loop enlarges to measure penile girth in millimeters. B,
' W% d. W4 N/ X3 Mexample of penile girth computed easily and accurately.
9 w! u8 B+ G- j/ m+ b$ Pconversion of testosterone to dihydrotestosterone. It is in this
: J+ K) {2 e: i% s; P" A9 Rolder group that others have noted high levels of serum
testosterone 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
response to testosterone with hair growth and with spermato-
$ _- \9 W7 w! o( \genesis. 5• 6
. h/ c4 a2 }. LAdministration of larger doses of gonadotropin or systemic
( |7 x* `. e  v. x9 Ntestosterone, as well as topical applications that produce
higher levels of serum testosterone (150 to 900 ng./dl.), will
/ i7 m6 Z3 r7 u) M4 jalso produce phallic growth but risks accelerated skeletal
maturation even after stopping treatment. It would appear
' Y9 u- u! M( V3 z7 {; z- ^6 r7 M3 Y! nthat this may be avoided by topical applications of testosterone
and monitoring of serum testosterone. Even with this control
2 N. ^6 j6 U8 ethe duration of our therapy did not exceed 3 weeks at any
0 \- \- |+ d1 O' Otime. 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
serum testosterone can be maintained in the 700 to 1,300 ng./
  w0 a' J  l9 u; R) I; ldl. range to stimulate phallic growth and secondary sexual
changes. Therefore, after skeletal maturation parenteral tes-
9 S4 O' n6 [" w% D' N' m# ^+ ttosterone may be used to advantage. Before skeletal matura-
tion care must be taken to avoid maintaining levels of serum
; c! d0 G+ k1 W8 q" Wtestosterone more than 100 ng./dl. Low-dose gonadotropin
" P; k+ S  z2 q$ Bdepends upon intrinsic testicular activity and may require
' d5 h+ L, X( E% Bprolonged administration for any response.
* c6 t, Z7 a" u' R& I) NAlternately, topical testosterone does not depend upon tes-
( W8 X- W5 z0 S) R; B" m  Sticular function and may provide a more constant level of
* M$ y) c. i! ?8 T- D$ S0 sREFERENCES
+ Z$ K7 W% d# v0 m( o, m1. Immergut, M., Boldus, R., Yannone, E., Bunge, R. and Flocks,
' O1 {* n) Z# ^1 h/ C3 IR.: The local application of testosterone cream to the prepub-
4 A( w# ~3 e. v3 uertal phallus. J. Urol., 105: 905, 1971.
% }' X7 a/ a* c2. Guthrie, R. D., Smith, D. W. and Graham, C. B.: Testosterone
5 k4 g) D' F6 \& @  h7 K0 h6 z7 F3 Gtreatment for micropenis during early childhood. J. Pediat.,
83: 247, 1973.
+ k& y2 Y; ~) j5 x6 |3. Jacobs, S. C., Kaplan, G. W. and Gittes, R. F.: Topical testoster-
# G- Y* V/ h. I, [( c! |! o2 d/ Fone therapy for penile growth. Urology, 6: 708, 1975.
' H0 H6 D( I% w3 S, u7 Z% ]5 M4. 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.
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
$ D: M% ?, O, oandrogenic effect of interstitial cell tumor of the testis. J.
* n0 y3 N* R3 v( j1 uUrol., 104: 774, 1970.
( X& `8 q& W) X2 S8 z7. Schonfeld, W. A. and Beebe, G. W.: Normal growth and varia-
tion in the male genitalia from birth to maturity. J. Urol., 48: