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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
GONADOTROPIN
; r3 Q: W8 z7 t# _/ x" ARICHARD C. KLUGO* AND JOSEPH C. CERNY
From the Division of Urology, Henry Ford Hospital, Detroit, Michigan
0 \3 x2 h( D# N% K# v- y* j$ vABSTRACT
Five patients were treated with gonadotropin and topical testosterone for micropenis associated
9 A2 W/ z+ l/ _with hypothalamic hypogonadotropic hypogonadism. All patients received 1,000 units of gonado-
8 f5 d8 b  R6 t1 q1 L: W9 O- Ttropin weekly for 3 weeks, with a 6-week interval followed by 10 per cent topical testosterone
  v' [3 v/ n( w9 u+ C) _7 o+ ~/ `! scream 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
  F! |( u/ T& A9 eoccurred in prepuberal male subjects with a minimal response in postpuberal male subjects. This
5 ]# _, o8 G3 l& m6 a9 j( p/ Ystudy 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-
; X: a, b5 z3 J6 }# _ously published studies of age-related 5 reductase activity.
/ F6 K1 m, w: V% M4 UChildren with microphallus regardless of its etiology will
3 m, X: W5 R' v1 B: |6 Hrequire augmentation or consideration for alteration of exter-
nal genitalia. In many instances urethroplasty for hypo-
/ d; u7 o4 D+ ~, rspadias is easier with previous stimulation of phallic growth.
! H, n, c* u& u6 z! V+ [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.
MATERIALS AND METHODS
Five 46 XY male subjects between 3 and 17 years old were
evaluated for serum testosterone levels and hypothalamic
2 h7 i$ |$ V/ W5 Mfunction. Of these 5 boys 2 were considered to have Kallmann's
syndrome, 1 Prader-Willi syndrome and 2 idiopathic hypotha-
4 I) ^, ^6 M9 j% i/ _2 k3 k( Ylamic deficiency. After evaluation of response to luteinizing
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.
* {# a0 {* X4 E" i' {  BSerum testosterone, luteinizing hormone and follicle-stimulat-
ing hormone were monitored before, during and after comple-
tion of each phase of therapy. Penile stretch length was
9 U3 k+ p- q$ Z6 N5 Pobtained by measuring from the symphysis pubis to the tip of
the glans. Penile circumferential (girth) measurements were
$ d( \7 I: `+ g* {: o2 Vobtained using an orthopedic digital measuring device (see
figure).
: `4 K* o. G6 wRESULTS
Serum testosterone increased moderately to levels between
50 and 86 ng./dl. with gonadotropin stimulation. Serum testos-
terone levels with topical testosterone remained near pre-
. B% p. ~' q2 ptreatment 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),
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
/ L3 ~+ C2 O' }- N( K4 YAccepted for publication July 1, 1977. ·
$ k2 }, y5 t' rRead at annual meeting of American Urological Association,
Chicago, Illinois, April 24-28, 1977.
) G  d# W, G; [- w# p6 j7 D: j* Requests for reprints: Division of Urology, Henry Ford Hospital,
2799 W. Grand Blvd., Detroit, Michigan 48202.
improvement 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
response to topical testosterone was greatest in children be-
tween 4 and 8 years old, with a gradual decrease to age 17
years (see table).
DISCUSSION
) p( a0 y2 ~6 |; q* m' c/ i; g8 @% tTopical testosterone has been used effectively by other
7 h9 z+ x3 b: b1 N5 E4 m* Hclinicians but its mode of action remains controversial. Im-
mergut and associates reported an excellent growth response
to topical testosterone with low levels of serum testosterone,
5 A6 o  [7 y2 `& rsuggesting a local effect.1 Others have obtained growth re-
. ]7 f# R: v# A$ Esponse with high. levels of serum testosterone after topical
/ T( a! Y& U6 `# Yadministration, suggesting a systemic response. 3 The use of
gonadotropin 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
, {, A. S) O: \& Q; K6 P- Mtopical testosterone to systemic testosterone effect. It cer-
& M5 P1 g, ^: r9 [( Htainly has been established that gonadotropin as well as par-
2 V( g, D4 A3 H$ V1 B. M" n6 henteral testosterone administration will produce genital
& o4 }4 w9 i* v9 bgrowth. Our report shows that the growth of the phallus was
1 [3 a% l" n' U, q, C5 Hsignificantly greater with topical applications than with go-
% e# ^$ O* @' }8 F& P: dnadotropin, particularly in children less than 10 years old.
The levels of serum testosterone remained similar or lower
1 ], M' n( L3 P9 g2 [7 G! Kthan with gonadotropin during therapy, suggesting that topi-
cal application produces genital growth by its local effect as
" V7 x/ {9 S/ a9 F/ owell as its systemic effect.
! d0 u7 {9 s5 OReview of our patients and their growth response related to
age shows a greater growth response at an earlier age. This is
( Y# J% b9 u' S  Q, f4 C7 ?5 Lconsistent with the findings of Wilson and Walker, who
7 E9 s  p# q# h& W. X9 Mreported an increased conversion of testosterone to dihydrotes-
tosterone in the foreskin of neonates and infants.4 This activ-
  K. y# p" M& q* ?ity gradually decreases with age until puberty when it ap-
proaches the same level of activity as peripheral skin. It may
7 \4 \( e6 u# d) g+ G. Y, Bwell be that absorption of testosterone is less when applied at
5 D1 c9 W. b" a& r* Han 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-
- `+ `: _& w# D) l$ \: Sdrotestosterone at this age. Conversely, serum levels in older
patients were higher, possibly because of decreased local
667
, ?0 L6 N. X* o# G" y+ `6 }+ y, V3 O668 KLUGO AND CERNY
( w: r6 X& M. A  FPt. Age
; ~7 j( t2 R/ x& e& P(yrs.)
Serum Testosterone Phallus (cm.) Change Length
; Y; e8 I" T! T; }% S1 o: N(ng./dl.) Girth x Length (%)
  c/ \' B, [' N% F3 e+ H1 L4
8
1 U! d2 X$ I; C' F6 [9 Y; Q/ x10
0 \4 U/ z: @! i) A, o) a12
+ s: C. y% v0 j7 E* c" [) x: b17
Gonadotropin
9 ~% H* J( C! {4 r/ `/ a71.6 2.0 X 3 16.6
: [0 @. j3 Z2 Q% M  Q8 ~* f50.4 4.0 X 5.0 20.0
22.0 4.5 X 4.0 25.0
- t7 Q2 `7 ]4 F0 B# @" B84.6 4.0 X 4.5 11.1
85.9 4.5 X 5.5 9.0
) y( `! f( M3 U  R  X" q# o2 r( @Av. 14.3
6 Z7 q1 @; U( d' s4
0 j' Z' ~# H' S8 t2 P; N8
9 u( E6 [& z6 a2 m10
9 R. ]* L0 g; I+ \# J9 c12
" I$ T/ d( w0 H3 Y" B9 e0 x; w9 U17
9 {, c( V0 S! ^Topical testosterone
4 ?1 V5 N3 K" }: g5 d# t+ J' K34.6 4.5 X 6.5 85
38.8 6.0 X 8.5 70
40.0 6.0 X 6.5 62.5
93.6 6.0 X 7.0 55.5
5 x$ b) m3 c: R" M# Y# z+ X" |95.0 6.5 X 7.0 27.2
Av. 60.0
% b+ ?3 N+ v! \available testosterone. Again, emphasis should be placed on
early therapy when lower levels of testosterone appear to
" a2 E6 [6 {2 Q* H! S  rprovide the best responses. The earlier therapy is instituted
. c. N+ @. ]: U" K# mthe more likely there will be an excellent response with low
7 K- w* [' w8 G7 H# j' M% S- }, ~+ h3 G. |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
% `: p$ L, _; u) wlikely related to the conversion of testosterone to dihydrotes-
# w, K* O( y( G  o' Wtosterone and correlates well with the studies of testosterone
conversion in foreskin at various ages.
+ r) n- N: ?4 j: t4 T7 {The question arises regarding early treatment as to whether
4 D. z* u  q/ a/ Rone might sacrifice ultimate potential growth as with acceler-
0 w0 Y4 Y. ~  }9 v1 wated bone growth. The situation appears quite the reverse
. @- N& S) k7 `% P$ B* cwith phallic response. If the early growth period is not used
when 5a reductase activity is greatest then potential growth
9 S8 W7 y6 v; ~may 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
; g9 I' _7 h) i# Ibe compared for 5a reductase activity.
A, loop enlarges to measure penile girth in millimeters. B,
example of penile girth computed easily and accurately.
/ y3 L& g5 ~7 cconversion of testosterone to dihydrotestosterone. It is in this
2 k$ O- z3 {7 V$ |8 y1 ?- t3 ^older group that others have noted high levels of serum
. r' R( E& l- v) z" v1 i% F. L. R* o; rtestosterone with topical application. It would also appear
# W4 b) U& w% j# u; A7 b: nthat phallic response during puberty is related directly to the
+ `+ V( d9 s$ n* b  qserum testosterone level. There also is other evidence of local
response to testosterone with hair growth and with spermato-
' U1 h/ R$ o2 T/ d* Y2 Ggenesis. 5• 6
3 c+ Z( e: e6 ^; M+ O3 gAdministration 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
- B/ P- g# }2 s! J$ dalso produce phallic growth but risks accelerated skeletal
maturation even after stopping treatment. It would appear
+ m; p( b+ s# Y+ C! J8 v! [that this may be avoided by topical applications of testosterone
. g, ?5 {8 ?$ q4 r- \" O& p# Dand 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
9 r; N: v; N! \# W% tsuffer accelerated bone growth with testosterone levels near
- o% v' ~6 J* k200 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
changes. Therefore, after skeletal maturation parenteral tes-
, M$ }0 Q) y6 d4 E- t5 Gtosterone may be used to advantage. Before skeletal matura-
' R$ \" S1 @5 g& ?! w( v( \tion care must be taken to avoid maintaining levels of serum
  y) y7 U6 g$ ?% D  M9 rtestosterone more than 100 ng./dl. Low-dose gonadotropin
depends upon intrinsic testicular activity and may require
9 Y: T2 [$ u- e7 Rprolonged administration for any response.
; y" C3 s7 A+ y$ t# v% FAlternately, topical testosterone does not depend upon tes-
ticular function and may provide a more constant level of
/ x+ g; a; U% F9 y8 XREFERENCES
1. Immergut, M., Boldus, R., Yannone, E., Bunge, R. and Flocks,
- \+ y4 [, }+ K, n: d4 F2 rR.: 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
/ p4 C) x. r7 z* Ttreatment for micropenis during early childhood. J. Pediat.,
* |8 ]9 z# t" H% ?4 r/ R$ h83: 247, 1973.
2 h: r7 {* o: t! _, L# e# f. O3. Jacobs, S. C., Kaplan, G. W. and Gittes, R. F.: Topical testoster-
one therapy for penile growth. Urology, 6: 708, 1975.
4. 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.
" C" L5 p" L* z5 N/ T5. Papa, C. M. and Klingman, A. M.: Stimulation of hair growth
by topical application of androgens. J.A.M.A., 191: 521, 1965.
" c& I8 a$ h" G, |7 b6. Gittes, R. F., Smith, G., Conn, C. A. and Smith, F.: Local
! M" W4 a& M8 b1 N8 t) ^androgenic effect of interstitial cell tumor of the testis. J.
4 l. M! `& Q0 M( v% i/ x) MUrol., 104: 774, 1970.
7. Schonfeld, W. A. and Beebe, G. W.: Normal growth and varia-
; d  ?8 E: H# j! }+ v) Ztion in the male genitalia from birth to maturity. J. Urol., 48: