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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
' z8 ~6 r( S/ _7 I4 P4 E2 u( sGONADOTROPIN
1 b' K$ A6 _7 }: W9 z2 _RICHARD C. KLUGO* AND JOSEPH C. CERNY
' l, b  l; e( H3 D1 T0 bFrom the Division of Urology, Henry Ford Hospital, Detroit, Michigan
ABSTRACT
+ J* f( A) ~5 _+ R5 I8 RFive patients were treated with gonadotropin and topical testosterone for micropenis associated
6 J( r6 s' M* x5 Q, S! ], F+ L& `1 Jwith hypothalamic hypogonadotropic hypogonadism. All patients received 1,000 units of gonado-
$ p9 e1 a5 d0 {* X4 \tropin weekly for 3 weeks, with a 6-week interval followed by 10 per cent topical testosterone
5 f3 q, W4 a9 |7 Bcream twice daily for 3 weeks. Serum testosterone levels were measured and remained equivalent
$ @  u* ]# W, d- Wfor both modes of therapy. Average penile growth response with gonadotropin was 14.3 per cent
9 k6 ^/ n; g' q: Y3 Vincrease 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
7 B$ Z5 s( l& e% Z& N- v; ioccurred in prepuberal male subjects with a minimal response in postpuberal male subjects. This
% t2 }1 r6 {. ?  H8 C0 m2 A* ustudy 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.
0 B; t; ?' u" c# w1 QChildren with microphallus regardless of its etiology will
9 K( [0 m) Q' prequire augmentation or consideration for alteration of exter-
4 o, t  U9 J/ ]: `) ]* }9 onal genitalia. In many instances urethroplasty for hypo-
* u6 K! b9 B* _' I+ Kspadias is easier with previous stimulation of phallic growth.
The use of testosterone administered parenterally or topically
. s4 q+ i* U1 c3 \7 Q* N* jhas produced effective phallic growth. 1- 3 The mechanism of
) B4 d+ r  f8 e, N) M6 x; tresponse has been considered as local or systemic. With this
  b+ C" W! K1 F9 tin mind we studied 5 children with microphallus for response
2 E8 `0 y% P0 I7 o0 G% mto gonadotropin and to topical testosterone independently.
6 @5 ^+ C' b1 l. wMATERIALS AND METHODS
Five 46 XY male subjects between 3 and 17 years old were
4 R2 b5 ?: Z5 G! l) l& N' uevaluated for serum testosterone levels and hypothalamic
function. Of these 5 boys 2 were considered to have Kallmann's
% f5 q# e8 R' F8 e* S* Fsyndrome, 1 Prader-Willi syndrome and 2 idiopathic hypotha-
lamic deficiency. After evaluation of response to luteinizing
" p/ p; T' z' G0 G9 phormone-releasing hormone these patients were treated with
1,000 units of gonadotropin weekly for 3 weeks. Six weeks
* a0 R# X0 X+ ?5 O9 Pafter completion of gonadotropin therapy 10 per cent topical
testosterone was applied to the phallus twice daily for 3 weeks.
. z( J; Z+ O+ C# ZSerum testosterone, luteinizing hormone and follicle-stimulat-
ing hormone were monitored before, during and after comple-
7 X  A7 Z7 u1 Ption 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).
- I8 F8 l0 N5 g9 q/ y( s1 @RESULTS
5 q1 z6 \6 N: G; CSerum testosterone increased moderately to levels between
50 and 86 ng./dl. with gonadotropin stimulation. Serum testos-
$ ]) _. W- d0 qterone 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
serum levels were noted in older patients (12 and 17 years old),
) {* {+ q6 g1 i% N# ~while 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
, R) h$ |; A$ I$ q! _5 `# v: A& ]Accepted for publication July 1, 1977. ·
. J5 s: ?$ v$ e- q* a" jRead at annual meeting of American Urological Association,
* a0 N1 p. o9 |( b0 c5 AChicago, Illinois, April 24-28, 1977.
9 g: d) ^) @. G5 |* Requests for reprints: Division of Urology, Henry Ford Hospital,
2799 W. Grand Blvd., Detroit, Michigan 48202.
- I2 [5 Y* O6 t1 Y9 L) c2 }& e; l" Ximprovement in phallic growth compared to gonadotropin.
Average 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
" `6 M9 k( W0 |9 gresponse to topical testosterone was greatest in children be-
& S1 |! T) z, ^# @5 n% Ftween 4 and 8 years old, with a gradual decrease to age 17
years (see table).
6 {, i7 B: h# ^$ B# R* I! m+ MDISCUSSION
Topical testosterone has been used effectively by other
clinicians but its mode of action remains controversial. Im-
  W% P& y/ p" G  C9 F; omergut and associates reported an excellent growth response
3 d$ F+ q, z$ P; e7 uto topical testosterone with low levels of serum testosterone,
/ t: O' @; |  ]& L4 T; I: ]* Lsuggesting a local effect.1 Others have obtained growth re-
sponse with high. levels of serum testosterone after topical
administration, suggesting a systemic response. 3 The use of
" U0 C) c" E* g  |  L: Rgonadotropin to obtain levels of serum testosterone compara-
  C3 J: z& Y7 r$ Mble 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-
tainly has been established that gonadotropin as well as par-
' x2 ?4 D" p8 }6 C3 n7 U- genteral testosterone administration will produce genital
$ A+ v  h5 y0 C# T' R; K6 }7 egrowth. Our report shows that the growth of the phallus was
significantly greater with topical applications than with go-
) p8 a+ w* g9 Tnadotropin, particularly in children less than 10 years old.
+ v4 J5 X% x1 \3 l# J) VThe levels of serum testosterone remained similar or lower
$ `4 c3 l) Z. D3 g& I- zthan with gonadotropin during therapy, suggesting that topi-
: x4 [4 \, b! L0 y1 xcal application produces genital growth by its local effect as
well as its systemic effect.
5 c' z6 P# P8 u: O/ _Review of our patients and their growth response related to
4 M# G$ `% u3 a- w/ g' hage shows a greater growth response at an earlier age. This is
9 s$ A- F9 g7 i' u2 Fconsistent 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-
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
4 w- p. p( ^# L3 j7 |: l4 l2 {an earlier age as suggested by lower serum levels in children
' ~, B$ \6 w: L: W5 Wless than 10 years old. This fact may be explained by the
8 C( x1 v- H, ^4 y! }+ |; ggreater ability of phallic skin to convert testosterone to dihy-
7 ^/ R+ @. t" H! j  qdrotestosterone at this age. Conversely, serum levels in older
patients were higher, possibly because of decreased local
667
7 i- _5 }; ?0 }$ T! p/ ]668 KLUGO AND CERNY
* E4 ]4 Y2 l) w9 e8 d' wPt. Age
(yrs.)
Serum Testosterone Phallus (cm.) Change Length
* J+ B; J9 Y3 S( ]' a/ g(ng./dl.) Girth x Length (%)
( l8 M) Y6 o: t3 S7 t4
4 R( Z! S) u' N% @: Y8
( P& Y6 J5 X$ ]10
3 _. {! I- \) R9 \0 d+ H! G# A+ c& G12
17
Gonadotropin
  Z6 s" q  F6 l+ f' p  T. ]5 [0 l71.6 2.0 X 3 16.6
  k6 U. L; a, Y0 {+ p50.4 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
85.9 4.5 X 5.5 9.0
( |- e# N" C& k- wAv. 14.3
4
8
10
12
17
' Z5 d) d5 x2 Y9 o' uTopical testosterone
34.6 4.5 X 6.5 85
. e* |4 k. v6 j% ?5 O38.8 6.0 X 8.5 70
/ |- X7 z% G1 O+ \. z$ g7 g40.0 6.0 X 6.5 62.5
93.6 6.0 X 7.0 55.5
; U# y6 X* x7 F95.0 6.5 X 7.0 27.2
Av. 60.0
8 b) ^1 X1 r, ?7 s2 zavailable testosterone. Again, emphasis should be placed on
: I7 @& I8 {; p7 ]( R9 i# Qearly therapy when lower levels of testosterone appear to
provide the best responses. The earlier therapy is instituted
0 F" M; [' y; ^% I# \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
9 R# Q5 f; F" Y2 Pto a given serum level of testosterone is much greater at birth
and gradually decreases as boys reach puberty. This is most
3 y7 S( s8 b8 {6 c' F" M) ~: n6 ^likely related to the conversion of testosterone to dihydrotes-
, d. n5 Q* p* t6 U( S  S7 ttosterone and correlates well with the studies of testosterone
; e! r! d, S, U2 N0 M" a5 |) Pconversion in foreskin at various ages.
8 X( }. i4 n$ v4 ~8 YThe question arises regarding early treatment as to whether
$ p2 x% Q/ I5 p7 w+ ~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
3 I5 v" Q7 G4 g/ u6 Y; a( a# Gwhen 5a reductase activity is greatest then potential growth
* }5 Z( C4 U. e$ I4 y: q  P2 dmay be lost. We have not observed any regression of growth
0 Y5 R0 o2 g+ Z' |, [- Iattained 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
: |5 I- N3 Y, _0 _; R8 n6 l/ z- O% f- aconvert testosterone to dihydrotestosterone and indicate that
  r8 I# G# q7 Zphallic and peripheral skin, and subcutaneous tissue should
be compared for 5a reductase activity.
8 u/ |. _) O6 a( lA, loop enlarges to measure penile girth in millimeters. B,
example of penile girth computed easily and accurately.
conversion of testosterone to dihydrotestosterone. It is in this
older group that others have noted high levels of serum
testosterone with topical application. It would also appear
! {9 e3 l( l3 Kthat phallic response during puberty is related directly to the
! P% O  ~- _) o" Lserum testosterone level. There also is other evidence of local
2 p- u; H7 _7 u7 kresponse to testosterone with hair growth and with spermato-
2 X) p& `5 l2 z) Cgenesis. 5• 6
Administration of larger doses of gonadotropin or systemic
testosterone, as well as topical applications that produce
higher levels of serum testosterone (150 to 900 ng./dl.), will
, Z) L# [, k# V5 x+ H: ualso produce phallic growth but risks accelerated skeletal
maturation even after stopping treatment. It would appear
" G% m% [; R. Z7 H& ^that this may be avoided by topical applications of testosterone
and monitoring of serum testosterone. Even with this control
/ ], ?' h$ ~8 E8 A0 @2 Cthe duration of our therapy did not exceed 3 weeks at any
time. It is apparent that the prepuberal male subject may
. {4 x2 u: w- v8 M  y, o" vsuffer accelerated bone growth with testosterone levels near
  S+ ~' A7 O5 D200 ng./dl. When skeletal maturation is complete the level of
serum testosterone can be maintained in the 700 to 1,300 ng./
dl. range to stimulate phallic growth and secondary sexual
% q8 K4 }0 q! c& D- m& N! k/ Uchanges. Therefore, after skeletal maturation parenteral tes-
tosterone may be used to advantage. Before skeletal matura-
tion care must be taken to avoid maintaining levels of serum
5 _( I, e" `2 p4 }4 \testosterone more than 100 ng./dl. Low-dose gonadotropin
" W/ A  w* e0 R% v/ J- Wdepends upon intrinsic testicular activity and may require
prolonged administration for any response.
Alternately, topical testosterone does not depend upon tes-
$ C+ S$ h1 T6 a' x, j! \ticular function and may provide a more constant level of
5 T1 ~9 G. {  M" jREFERENCES
1. Immergut, M., Boldus, R., Yannone, E., Bunge, R. and Flocks,
R.: The local application of testosterone cream to the prepub-
% i, S( `* O: l6 O! D  oertal phallus. J. Urol., 105: 905, 1971.
2. Guthrie, R. D., Smith, D. W. and Graham, C. B.: Testosterone
0 o# o: v+ H4 C2 Y$ T& M) Vtreatment for micropenis during early childhood. J. Pediat.,
83: 247, 1973.
3. Jacobs, S. C., Kaplan, G. W. and Gittes, R. F.: Topical testoster-
- g/ M3 J: m& {: Bone therapy for penile growth. Urology, 6: 708, 1975.
4. Wilson, J. D. and Walker, J. D.: The conversion of testosterone
* M5 D  R2 D9 g( J6 \to 5 alpha-androstan-17 beta-01-3-one (dihydrotestosterone) by
skin slices of man. J. Clin. Invest., 48: 371, 1969.
. _8 `; ]$ V; s" m0 {4 ?/ u5. Papa, C. M. and Klingman, A. M.: Stimulation of hair growth
4 }3 O* ^: }, \1 g7 u* k' V& Nby topical application of androgens. J.A.M.A., 191: 521, 1965.
: F+ l" }: p1 Y# U4 p6. 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-
tion in the male genitalia from birth to maturity. J. Urol., 48: