Androlog Mail
Dr. Mark Bradley Noss presented a case of microphallus in a chubby 14 years
old boy whose hormone assays suggests that he didn't yet reach puberty. FSH
<1, LH <0.01, Total Testosterone 0.08 (normal 10-28).
This is a common presentation in Andrology clinics and is usually simply
delayed puberty. A 5 cm penis should reach normal size for age once puberty
sets in (7 cm + or - 2 cm at the age of 14), so your patient might really
qualify as a low normal rather than a microphallus. The infrapubic pad of
fat further augments the impression of a small penis in prepubertal
overweight boys. In one study, it was suggested that prepubertal androgen
supplementation didn't effect the final size after puberty sets in.
Reassurance is very important to allay the concerns of the child & parents
and avoid the development of dysmorphophobia. However, induction of puberty
might need to be considered at the age of 15 to avoid psychological problems
if the child notices that he is lagging his peers in the development of male
secondary sex characters.
There are several hormonal regimens either using Testosterone directly or
HCG to stimulate the Leydig cells to produce testosterone. Regarding the
question about clomid, it will probably be not effective since it needs a
mature & functional pituitary gland. If puberty doesn't set in spontaneously
by the age of 18-20, the case is considered as hypogonadotrophic
hypogonadism rather than simple delayed puberty.
An important note is that Testosterone replacement in hypogonadotrophic
hypogonadism will result in the development of male secondary sex characters
but the patient will remain sterile. The diagnosis might be missed later in
life when the patient presents for infertility treatment. Unfortunately I
see this quite often. On the other hand, replacement with HCG (LH action)
and FSH results in complete androgenization and fertility preservation in
almost all patients with true hypogonadotrophic hypogonadism. It would thus
be a pity to miss this diagnosis.
Kind regards,
Hussein Ghanem MD
Professor of Andrology, Sexology & STDs
Cairo University, Egypt
hmghanem@hotmail.com
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