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
. h. k# c6 {; N  eGONADOTROPIN
RICHARD C. KLUGO* AND JOSEPH C. CERNY
From the Division of Urology, Henry Ford Hospital, Detroit, Michigan
5 H" l% Y+ L1 F- p* q0 m5 G" K  FABSTRACT
$ }6 g7 D8 u" H+ mFive 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
7 ^0 D) a& |! @2 M+ b, mincrease in length and 5.0 per cent increase of girth. Topical testosterone produced an average
  x: R, H$ o; @. w( x* Qincrease of 60 per cent in penile length and 52. 9 per cent in girth. The greatest growth response
6 l8 |7 J+ o; i6 T6 H4 Aoccurred in prepuberal male subjects with a minimal response in postpuberal male subjects. This
) ^$ p: I& G, _study suggests that 10 per cent topical testosterone cream twice daily will produce effective penile
1 ^4 z1 ]% C) n) H  @# Vgrowth. The response appears to be greater in younger children, which is consistent with previ-
ously published studies of age-related 5 reductase activity.
Children with microphallus regardless of its etiology will
require augmentation or consideration for alteration of exter-
$ W6 o, v: |# M% Mnal genitalia. In many instances urethroplasty for hypo-
1 [4 v+ F- o  {  L! T4 J: {1 ?) n0 Wspadias is easier with previous stimulation of phallic growth.
4 j, h) ^) w; X/ p+ l- ?6 l0 z7 p( ?The use of testosterone administered parenterally or topically
, Z7 P( J4 Q0 l, S7 q( M$ fhas 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.
MATERIALS AND METHODS
5 \1 R, _& ~' ]$ T& z' K& G& v: UFive 46 XY male subjects between 3 and 17 years old were
evaluated for serum testosterone levels and hypothalamic
8 n" \( r( }, vfunction. 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
hormone-releasing hormone these patients were treated with
8 J$ U& Q* S5 q0 y& j3 |0 [, G) G1,000 units of gonadotropin weekly for 3 weeks. Six weeks
after completion of gonadotropin therapy 10 per cent topical
; T. o/ }/ q2 O; ]* i% r' v) z5 \testosterone was applied to the phallus twice daily for 3 weeks.
Serum testosterone, luteinizing hormone and follicle-stimulat-
/ }! n2 u+ r+ ?; H( E# v* n8 ping hormone were monitored before, during and after comple-
, U7 _) m1 O; b! 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
obtained using an orthopedic digital measuring device (see
figure).
  u6 L, b* s  }& fRESULTS
, z) e' v( B4 Y2 g1 ZSerum testosterone increased moderately to levels between
! a. R# a* i3 {$ O2 q50 and 86 ng./dl. with gonadotropin stimulation. Serum testos-
terone levels with topical testosterone remained near pre-
treatment levels (35 ng./dl.) or were elevated to similar levels
  M) d) X% L. |2 e6 n' ]1 z$ m) zdeveloped 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; p" w9 c7 c/ d0 rof serum testosterone the topical therapy provided a greater
Accepted for publication July 1, 1977. ·
Read at annual meeting of American Urological Association,
Chicago, Illinois, April 24-28, 1977.
& S1 W3 n2 z1 L$ V" ?: X5 f! }* Requests for reprints: Division of Urology, Henry Ford Hospital,
2799 W. Grand Blvd., Detroit, Michigan 48202.
improvement in phallic growth compared to gonadotropin.
. y0 P9 ~' l! C. u0 F# CAverage phallic growth with gonadotropin was 14.3 per cent
increase in length and 5.0 per cent increase of girth. Topical
$ |- t  j' q1 ]9 [' z9 jtestosterone 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-
tween 4 and 8 years old, with a gradual decrease to age 17
" c8 e0 i# I: }9 eyears (see table).
9 q3 q) W* g: A# _- x$ s( ZDISCUSSION
+ X  z% l0 X' G8 g. {/ ]- @Topical testosterone has been used effectively by other
0 @! K1 D. W0 D& G9 n, G7 f- ~clinicians but its mode of action remains controversial. Im-
mergut and associates reported an excellent growth response
) v% E6 L( r& S# w, hto topical testosterone with low levels of serum testosterone,
suggesting a local effect.1 Others have obtained growth re-
' s( Z) q' m, e' A) xsponse with high. levels of serum testosterone after topical
administration, suggesting a systemic response. 3 The use of
  T# W& V, y; @/ C( W7 n8 t  N' Kgonadotropin to obtain levels of serum testosterone compara-
ble to levels obtained with topical testosterone would seem to
provide a means to compare the relative effectiveness of
; H! T( m2 S$ F) x+ N+ Qtopical testosterone to systemic testosterone effect. It cer-
tainly has been established that gonadotropin as well as par-
3 T0 z9 u1 c5 Q+ d' G- U+ denteral testosterone administration will produce genital
& @4 U1 M) w( Wgrowth. 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
than with gonadotropin during therapy, suggesting that topi-
. L3 e1 p! Q  E$ E: `cal application produces genital growth by its local effect as
well as its systemic effect.
. F! c8 q$ A0 q2 D' SReview 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
reported an increased conversion of testosterone to dihydrotes-
2 r* }9 P- _4 ~  O; dtosterone in the foreskin of neonates and infants.4 This activ-
, Y, c7 A# ^( @, O1 Gity 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
8 t) b1 F- G( h" n8 w! K1 a9 Fless than 10 years old. This fact may be explained by the
4 q% w. ]. g6 |* ygreater ability of phallic skin to convert testosterone to dihy-
- T2 d" N/ w8 G& c/ K) V2 \drotestosterone at this age. Conversely, serum levels in older
5 |: N6 M+ `% `! u, B6 N0 T5 lpatients were higher, possibly because of decreased local
+ p+ @: L. {0 V+ Q+ p0 m; F% z667
668 KLUGO AND CERNY
% r. @! f; l6 d. }6 BPt. Age
(yrs.)
9 ~/ L3 j. [5 V" e. cSerum Testosterone Phallus (cm.) Change Length
(ng./dl.) Girth x Length (%)
4
8
. p7 X( }$ g7 [10
7 Y& s; z; R: ^  o, }, E12
) ^7 ?$ X# y" q6 s3 u& N& c: [. D17
. U4 a7 o; S, q/ @Gonadotropin
71.6 2.0 X 3 16.6
& p! z9 Q4 U  Q5 v% r% ^" _50.4 4.0 X 5.0 20.0
# L; [5 N& D, A7 h& ^22.0 4.5 X 4.0 25.0
, |( t1 Q4 z" H  F84.6 4.0 X 4.5 11.1
85.9 4.5 X 5.5 9.0
Av. 14.3
4
8
10
" L8 f7 Y* R1 V, ~12
# k+ x! Q# C4 }. [! [) O6 C3 l" O17
Topical testosterone
7 X4 z8 ^5 v' }- ~6 A8 c% e: w34.6 4.5 X 6.5 85
38.8 6.0 X 8.5 70
& n& N4 }" W2 i; V40.0 6.0 X 6.5 62.5
93.6 6.0 X 7.0 55.5
! M# \1 q; M4 H& o* b* Y  ~95.0 6.5 X 7.0 27.2
Av. 60.0
1 V: a3 o; K* Wavailable testosterone. Again, emphasis should be placed on
early therapy when lower levels of testosterone appear to
7 |( q0 g; E0 Cprovide the best responses. The earlier therapy is instituted
the more likely there will be an excellent response with low
; I' W' B. S8 Xserum 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
" @% X+ D; I+ c, u6 `/ r4 ^4 ilikely related to the conversion of testosterone to dihydrotes-
5 g2 F# [- U! A5 Q% I+ otosterone and correlates well with the studies of testosterone
conversion in foreskin at various ages.
* y! p9 a+ }" Y. t, dThe 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
with phallic response. If the early growth period is not used
' n$ p/ R  ]; ?. Rwhen 5a reductase activity is greatest then potential growth
" T0 K  E+ X6 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
form of therapy. This would suggest a defect in the ability to
convert testosterone to dihydrotestosterone and indicate that
phallic and peripheral skin, and subcutaneous tissue should
+ H% p8 N- p# i% Cbe compared for 5a reductase activity.
: p4 C0 c8 Z# V6 p6 V( e* JA, loop enlarges to measure penile girth in millimeters. B,
example of penile girth computed easily and accurately.
$ v$ q; m( _' A4 xconversion of testosterone to dihydrotestosterone. It is in this
+ f- _! }" @& N+ w2 Solder group that others have noted high levels of serum
  r1 X1 l. F' q; f0 R1 g2 B+ Y6 Vtestosterone with topical application. It would also appear
that phallic response during puberty is related directly to the
) ^1 K: z$ w4 w; Wserum testosterone level. There also is other evidence of local
! k4 `& K; d. r  ^- _  `) j& gresponse to testosterone with hair growth and with spermato-
0 R3 u8 l* q- J% k' s5 v* _& Dgenesis. 5• 6
  f) k# y  D: C  |- C) [3 `Administration of larger doses of gonadotropin or systemic
; s, k- P- `+ v( T) B5 D/ vtestosterone, as well as topical applications that produce
higher levels of serum testosterone (150 to 900 ng./dl.), will
: v/ i* s: x4 }+ _: `7 _! [9 t7 i1 |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
* S( o3 F3 X0 M- Ysuffer accelerated bone growth with testosterone levels near
200 ng./dl. When skeletal maturation is complete the level of
" O8 v- s/ h4 ^' n# U5 Nserum 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-
6 Y# |# m7 v$ gtosterone may be used to advantage. Before skeletal matura-
5 M: j& ]3 Y+ Ytion care must be taken to avoid maintaining levels of serum
2 X1 r; Y3 m$ C: {, ^% B" s7 i6 Qtestosterone more than 100 ng./dl. Low-dose gonadotropin
depends upon intrinsic testicular activity and may require
prolonged administration for any response.
& V; a8 I  H+ L9 p  SAlternately, topical testosterone does not depend upon tes-
ticular function and may provide a more constant level of
REFERENCES
7 \2 R6 A1 s7 @& D1. Immergut, M., Boldus, R., Yannone, E., Bunge, R. and Flocks,
9 a& p8 o" p# A" X4 {* J+ T/ wR.: The local application of testosterone cream to the prepub-
, A) M% l6 T  N$ uertal phallus. J. Urol., 105: 905, 1971.
$ O1 Q, P' e3 m2 m8 c; @0 w, o2. Guthrie, R. D., Smith, D. W. and Graham, C. B.: Testosterone
treatment for micropenis during early childhood. J. Pediat.,
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/ ]1 b  f+ h/ W! P" c. @  {. \3. Jacobs, S. C., Kaplan, G. W. and Gittes, R. F.: Topical testoster-
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, g/ ]7 S/ |% U& J: E3 V5 U4. Wilson, J. D. and Walker, J. D.: The conversion of testosterone
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& _$ i8 B, B( n3 R# z$ P' t- H5. Papa, C. M. and Klingman, A. M.: Stimulation of hair growth
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9 Q% @) r! u9 c1 hUrol., 104: 774, 1970.
6 ^+ Q! y& V. {7. Schonfeld, W. A. and Beebe, G. W.: Normal growth and varia-
. {2 X4 v/ P3 e$ ?- y1 s& _+ L) ktion in the male genitalia from birth to maturity. J. Urol., 48: