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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
RICHARD C. KLUGO* AND JOSEPH C. CERNY
0 Q' W+ U) t9 A$ G0 ~+ NFrom the Division of Urology, Henry Ford Hospital, Detroit, Michigan
ABSTRACT
7 r* c. q* F3 {) I4 q  o6 xFive patients were treated with gonadotropin and topical testosterone for micropenis associated
; J7 A2 Z% u  v! o( ywith 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
; p' [$ x! i: A2 y" L: q& S* zincrease 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
occurred in prepuberal male subjects with a minimal response in postpuberal male subjects. This
6 C  }3 K$ n) U! b% Kstudy 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-
0 [3 J, t' V) {. d3 Mously published studies of age-related 5 reductase activity.
Children with microphallus regardless of its etiology will
7 L1 i5 N8 |/ |. a% Irequire augmentation or consideration for alteration of exter-
4 S% U/ d9 w* Q/ p; \nal genitalia. In many instances urethroplasty for hypo-
2 U4 \: q% q+ Y+ c) L0 }spadias is easier with previous stimulation of phallic growth.
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
6 E6 v' E& x3 Z3 x9 lFive 46 XY male subjects between 3 and 17 years old were
evaluated for serum testosterone levels and hypothalamic
- J9 S  g9 e) J5 F9 @+ E) N# h  efunction. Of these 5 boys 2 were considered to have Kallmann's
syndrome, 1 Prader-Willi syndrome and 2 idiopathic hypotha-
2 j, \* U9 g- W% M" N( h) Tlamic deficiency. After evaluation of response to luteinizing
hormone-releasing hormone these patients were treated with
: T% p0 Y, d' B) a& f/ T4 w# \- K7 e1,000 units of gonadotropin weekly for 3 weeks. Six weeks
* i3 i. r& w5 t0 ?" Bafter completion of gonadotropin therapy 10 per cent topical
testosterone was applied to the phallus twice daily for 3 weeks.
  t  T+ d  M. l8 L: sSerum 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
, X+ c2 Z' j; ]9 W- Eobtained by measuring from the symphysis pubis to the tip of
: h" L5 |( U; ~2 b# ~/ ^the glans. Penile circumferential (girth) measurements were
obtained using an orthopedic digital measuring device (see
figure).
9 }+ n3 T( b2 v, f( {. d- @RESULTS
4 L& J9 b( t  F5 `. n: _Serum testosterone increased moderately to levels between
( ]0 D7 }  t5 P/ e50 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
, G, J9 w3 L$ J6 J+ @1 {/ Vdeveloped after gonadotropin therapy (96 ng./dl.). Higher
9 u, |. f/ E% o. n* xserum levels were noted in older patients (12 and 17 years old),
# P+ l" o2 a0 C. C( p4 kwhile lower levels persisted in younger patients (4, 8, and 10
years old) (see table). Despite absence of profound alterations
+ ^% g' k# t6 eof serum testosterone the topical therapy provided a greater
Accepted for publication July 1, 1977. ·
; j! x  y/ [$ Q0 @% N( JRead at annual meeting of American Urological Association,
# ^7 S' Z- `7 w1 ?* {" s: T* wChicago, Illinois, April 24-28, 1977.
. E2 ]0 \9 D/ b0 v3 j. Q" p* Requests for reprints: Division of Urology, Henry Ford Hospital,
2799 W. Grand Blvd., Detroit, Michigan 48202.
0 V- [- }. c" x1 A* Z5 oimprovement in phallic growth compared to gonadotropin.
! ]9 l; F9 z( R) [/ n5 cAverage 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).
9 |) b9 W) [6 ZDISCUSSION
/ G" y7 _( l) G  cTopical testosterone has been used effectively by other
' W' Q/ _& Z7 k; S. \' H+ m( rclinicians but its mode of action remains controversial. Im-
& W  i' d% e+ q! fmergut and associates reported an excellent growth response
to topical testosterone with low levels of serum testosterone,
suggesting a local effect.1 Others have obtained growth re-
" e# S- g: z9 D+ Usponse 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-
) g6 u* B9 f6 s$ K  sble 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-
/ ]5 }& [. }$ p0 L* venteral testosterone administration will produce genital
( f' Q6 @. B2 p! mgrowth. Our report shows that the growth of the phallus was
0 i. a9 Y8 s. t; zsignificantly greater with topical applications than with go-
nadotropin, particularly in children less than 10 years old.
; h4 Q( T% A. l, o6 k/ LThe levels of serum testosterone remained similar or lower
* c9 v! k. g1 dthan with gonadotropin during therapy, suggesting that topi-
) e1 H+ K' M- \3 u0 ^cal application produces genital growth by its local effect as
well as its systemic effect.
& S; y; ], ?. r0 |' qReview of our patients and their growth response related to
; \, ]! h& Y  n$ V5 u* o' k' l9 Vage 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-
* C6 L( D) c# X* dity gradually decreases with age until puberty when it ap-
proaches the same level of activity as peripheral skin. It may
! R9 v, s$ r% W& [  X; hwell be that absorption of testosterone is less when applied at
6 r, ^7 G2 N8 t. r6 \* fan 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-
drotestosterone at this age. Conversely, serum levels in older
* a6 f' G" x$ W0 j% opatients were higher, possibly because of decreased local
9 @4 o- e/ d5 ~4 j2 Z" b* ?! l667
668 KLUGO AND CERNY
  J: W/ H5 v3 p9 Y' R( a; G9 uPt. Age
& I' C' N! }, ^5 `% E$ D(yrs.)
! }$ X" e5 A; m, \! jSerum Testosterone Phallus (cm.) Change Length
- i5 O6 _4 i1 A/ |(ng./dl.) Girth x Length (%)
6 g6 w8 D+ L. N8 m* f4 Y4
8
10
12
17
Gonadotropin
( ]  ~, ^) D& k' b2 H71.6 2.0 X 3 16.6
0 E! _4 P7 {7 J0 Q: w50.4 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
! F7 i7 o, n1 \. d8 E7 M85.9 4.5 X 5.5 9.0
Av. 14.3
3 m; q5 ~  |0 A! x4
8
10
12
17
/ |+ k: M3 C* g' S! B/ _2 O9 OTopical testosterone
/ a0 E* I5 X" d/ c% O! a34.6 4.5 X 6.5 85
38.8 6.0 X 8.5 70
# X6 ?. N' B3 y  S; ]1 P40.0 6.0 X 6.5 62.5
' J4 }5 S6 a( m: b' C( ~93.6 6.0 X 7.0 55.5
; K7 o6 x0 m0 T95.0 6.5 X 7.0 27.2
7 T/ h5 A* Q5 {' _( Y) oAv. 60.0
available testosterone. Again, emphasis should be placed on
early therapy when lower levels of testosterone appear to
% ]" [1 ^7 l1 Fprovide the best responses. The earlier therapy is instituted
7 a2 J) ^7 `& Athe 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
3 H" f4 L5 W9 y. W  m* U4 yand gradually decreases as boys reach puberty. This is most
likely related to the conversion of testosterone to dihydrotes-
# ]( }1 J  `) F6 A5 f( |/ Q0 ztosterone and correlates well with the studies of testosterone
1 l; M5 \0 C8 V2 a1 T% P6 Kconversion in foreskin at various ages.
1 |6 J3 r! x3 [2 L- [The question arises regarding early treatment as to whether
9 Z5 M% V; G8 {, E3 W. l" Y$ @one might sacrifice ultimate potential growth as with acceler-
; g) ^4 r2 C* B3 O) qated bone growth. The situation appears quite the reverse
with phallic response. If the early growth period is not used
when 5a reductase activity is greatest then potential growth
) Z+ {8 r$ k; D5 Hmay be lost. We have not observed any regression of growth
attained with topical or gonadotropin therapy. It may well
% b$ A; H4 r3 e4 P  J3 x% j3 Cbe that some patients will show little or no response to any
0 X9 {7 p5 ^! p4 j3 I- T+ Y$ Lform 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
- o/ p/ B; O, P2 c+ nbe compared for 5a reductase activity.
( O- g5 D" |- kA, loop enlarges to measure penile girth in millimeters. B,
" H0 A, d2 I# C. ^' eexample of penile girth computed easily and accurately.
conversion of testosterone to dihydrotestosterone. It is in this
, `7 w: S) M3 y. D) c& lolder group that others have noted high levels of serum
" y& s8 w4 _: n% ptestosterone with topical application. It would also appear
9 X( S  g- G* o# T" d3 [" M2 s/ [that phallic response during puberty is related directly to the
# g7 T+ o. L6 w. A& f& pserum testosterone level. There also is other evidence of local
response to testosterone with hair growth and with spermato-
genesis. 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
also produce phallic growth but risks accelerated skeletal
* [* C4 m$ ?+ qmaturation even after stopping treatment. It would appear
that this may be avoided by topical applications of testosterone
; ?# r4 }  x' ?and monitoring of serum testosterone. Even with this control
, T/ P; i" }- ]+ O0 `% uthe duration of our therapy did not exceed 3 weeks at any
% r. K4 |- ]' b% ltime. It is apparent that the prepuberal male subject may
  {5 V9 b6 p- L6 V8 f: L1 qsuffer accelerated bone growth with testosterone levels near
8 r/ m6 v1 Z7 l8 \200 ng./dl. When skeletal maturation is complete the level of
) S: [1 V" s2 o9 ~  _% a& H: v$ P2 _serum testosterone can be maintained in the 700 to 1,300 ng./
% d; `" S+ r- Pdl. range to stimulate phallic growth and secondary sexual
changes. 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
3 t( h( h4 x3 Y5 ]; @& l' ^4 @; h6 ~testosterone more than 100 ng./dl. Low-dose gonadotropin
) M+ ?5 Q2 e, g* u/ bdepends upon intrinsic testicular activity and may require
1 P1 |- {) ]9 c9 @5 l, _prolonged administration for any response.
* c9 {7 W! s& h) kAlternately, topical testosterone does not depend upon tes-
; v! V2 w9 Z( @/ }0 \/ [6 I, q( zticular function and may provide a more constant level of
REFERENCES
1. Immergut, M., Boldus, R., Yannone, E., Bunge, R. and Flocks,
+ c3 U6 I& r( q5 v0 Z* BR.: The local application of testosterone cream to the prepub-
, g! F) K7 Z, d2 l7 j) Oertal phallus. J. Urol., 105: 905, 1971.
2. Guthrie, R. D., Smith, D. W. and Graham, C. B.: Testosterone
( c6 `4 @* l  Ptreatment for micropenis during early childhood. J. Pediat.,
83: 247, 1973.
% S6 T/ d' w3 x; X/ o9 l7 _3. 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
  o" ^- w" f: Ito 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
androgenic effect of interstitial cell tumor of the testis. J.
Urol., 104: 774, 1970.
" l' @8 t* p5 b5 W* v  ?0 W. _7. Schonfeld, W. A. and Beebe, G. W.: Normal growth and varia-
tion in the male genitalia from birth to maturity. J. Urol., 48: