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Gynecomastia (Breast enlargement) in boys

Small genital & genital Enlargement 
 
  What is small genital
Causes of small genital
Diagnostic tests for Diagnosing cause of Small genital
Treatment Options for genital Enlargement
Response of Treatment
 

What is small genital? 

As we know average penile length is six inches (i.e. fifteen centimeter). When genital is somewhat smaller than this, is called small genital. And when it is too small than normal is called microgenital. This small genital size is found in approximately one percent of men .The small genital may occur as single disorder or in some persons it may be associated with thin genital. In some persons genital is very thin as in children. It makes them genitally unsure of himself and decreases their confidence. They feel inferiority complex in exposing themselves in public places as in swimming pools & sea beaches etc. Thus it must be consulted urgently, so that diagnosis and treatment can be started as soon as possible. For this you may consult at our Diabetes Thyroid  Hormone center for complete diagnosis & treatment. In majority cases proper diagnosis & hormone therapy of about one year duration leads to genital growth in size and normalization of genital in length & thickness. Thus you consult at our center where doctor have experience of treating such problems. In very-2 rare cases surgical intervention is needed in which case by microsurgery technique the genital enlargement is achieved in length (as well as in thickness i.e. girth if required). 

 

Causes of small genital: 

The following are the major causes of small genital & Thin genital: 

Male Hormones Disorder:

(1) Hypogonadotropic hypogonadism: (hypothalamic or pituitary deficiencies)
Hypogonadisms, Hypothyroidisms, Testosterone deficiency, hyperprolactinemias, 
Hypogonadotropics states: Hypothalamic - pituitary deficiencies: Idiopathic GnRH deficiency, Kallman syndromes, Prader-Willi syndromes, Laurence-Moon-Biedl syndromes, pituitary hypoplasia, Trauma, post surgical, postiradiation, Tumour (Adenoma, craniopharyngioma, other), Vascular (pituitary infraction, carotid aneurysm), Infiltrative (Sarcoidosis, histiocytosis, hemochromatosis)
Autoimmune hypophysitis, drug-induced hyperprolactinemia, untreated endocrinopathies, Diabetics Glucorticoid excess, Hypopituitarisms, Cushings disease, Addisons disease. 
Isolated gonadotropin deficiency (non acquired): Pituitary, Hypothalamic 
Associated with multiple pituitary hormone deficiencies: Idiopathic pan hypo pituitarism (hypothalamic defects), Pituitary dysgenesis, Following inflammation, Infiltrative or destructive processes (autoimmune, hemosiderosis),
Fertile eunuch syndrome, Idiopathic hypopituitarism, 

(2) Hyperogonadotropic hypogonadism: testicular failure, development defect, drugs, trauma, congenital defect, congenital adrenal hyperplasia, Chromosomal defect, testosterone hormone biosynthetic defect, Mumps orchitis leading to testicular atrophy, Primary testicular defect-disorders of testicular differentiation or inborn errors of testosterone synthesis, Klinefelter syndrome, Other X polysomies (i.e. XXXXY, XXXY)
Rainbow syndrome, 
(3) Partial androgen insensitivity
(4) Growths Hormones Deficiency
(5) Thyroids hormones deficiency
(6) Idiopathic small phallus:
In many patients all the hormone growth factor & every thing else is normal, still they have small genitalia. This occurs due to Decreased capacity of penile tissue to grow. This occurs due to defective morphogenesis of the genital in utero so that its growing capacity decreases later in life. This is also one of the common causes of small & thin genital.
(7) Chordee
 

Diagnostic tests for diagnosing cause of small genital

First of all we take detailed history then do thorough examination of whole body system including genitalia. On history & examination we get certain clue for likelihood of some of the above causes. Then we perform those relevant tests in that particular patient. Thus by doing some of below mentioned tests diagnosis of cause of small genital is made.
The following are the list of investigations; need to be done in the cases of underdeveloped small/ or thin genital

These tests includes: 

Complete male hormone profile. 
Thyroids test
Serum prolactin
SHBG
Ultrasound of testis
Growths Hormones analysis
DHT Level

Other tests which may be required depending on likelihood of the any of above causes.

Dynamic test: HCG test: To judge functional capacity of testis whether testis has the capacity to function normally or not. In this test we inject single injection of gonadotropin as intramuscular injection then three day later the rise in concentration of male hormone is seen to assess whether testis has capacity to function normally or not.
Response to antiestrogen clomiphene

LH, FSH rise in response to gonadotropin releasing hormone tests.

Chromosomal analysis is done to see the genetic structure of testis, because there are many chromosome disorders, which lead to small genital.
Gene Analysis
Capacity of generation of active testosterone i.e. DHT is tested. This DHT generation test is abnormal in some cases of small genital / thin genital /underdeveloped genital.

Tests to locate testis as ultrasonography or C.T. Scan abdomen is needed if testis is not palpable.
MRI / CT SCAN head: if suspecting hypogonadotropic hypogonadism.

Serum inhibin is tested which tells that whether testis is functioning or not.

Serum Iron, T.I.B.C. & ferritin concentration tested for hypogonadism due to hemochromatosis.
Combined Pituitary hormone tests are performed when suspecting pituitary disorder.

Molecular genetic studies done in some special cases.

Serum estrogen increased whenever testicular function is decreased.
Serum DHT is low in some conditions when generation of dihydrotestosterone is decreased.

Assessment of androgen receptor is done when needed
Dynamic tests as:
All above tests need to be interpreted by expert of hormone diseases with good
experience. Based on above test results diagnosis of cause of small /or thin genital is made. Once the cause is found then treatment becomes very easy with good results.


Treatment For genital Enlargement 


genital enlargement by Hormone Therap
y:Before starting treatment for enlargement of genital all above causes are investigated and proper diagnosis is made. Then we test whether genital enlargement is possible or not.. 

First We Test Whether genital Enlargement Is Possible Or Not. 

For this hormone therapy given for three months in form of male hormone injection, skin patches, or oral tablets. If genital enlarges in size i.e. it grows in size by more than 1.25 cm in these three months, it means genital of that patient has potential for further growth. Once it is decided by above test that genital has potential for further growth, in such patient further courses of hormone therapy is given. By few courses of hormone treatment genital enlarges by three to four inches. By this therapy genital girth also increases besides increase in length. This genital lengthening treatment is very effective in those patients's in whom initial genital increasing potential test shows that genital has capability for further genital growth. Thus all patients achieve fully normal genital i.e. good genital length & thick genital. As genital increases in size patient's confidence increases and feeling of well-being is achieved. 

How this treatment works: 

When we give below-mentioned hormones by any of the below-mentioned routes. The concentration of these hormones in blood circulation rises. This leads to binding of more hormones on androgen receptors of genital. After binding with receptors these hormones leads to certain changes in the genital tissue. This leads to multiplication of penile tissue leading to further growth. This continued multiplication of penile tissue leads to further genital growth. This continued multiplication of genital tissue under the effect of above mentioned hormone treatment continues till genital size normalizes. Usually in one-year time genital size as well as genital thickness i.e. girth normalizes. Unluckily most doctors have less knowledge about hormone treatment so that they neither investigate the patient nor give hormone or other medical therapy for penile growth. 

Treatment of Small genital

Various options of genital enlargement therapy are available for microgenital & small genital.This treatment can be either:
Hormone Therapy: availalable as pills, hormonal skin patches or injections

Surgical therapy: genital enlargement surgeries 


Hormone Treatment For genital Enlargement


We start medical treatment only when above tests shows that genital has capacity to enlarge. It is given in the form replacement of male hormone testosterone & other hormone as growth hormone, DHT hormone & growth factor replacement. These hormones can be given in the form of oral tablets, skin patches, ointments, gel or injections. 
As this treatment has no side effects, is economical and easy to take either as oral tablets, skin patches, or as gel or sometimes as injection of hormone.

The various Treatment options are: 

1) Male hormone testosterone replacement: The replacement of male hormone testosterone is one of the common treatments for genital enlargement. The various preparation of testosterone is:

a) Oral preparation, which is available in capsule form. It needs to be given one to three capsules daily. These have no side effects.

b) Tran dermal Testosterone given as scrotal patch. It is very effective & has no side effects. It can be also given as Testosterone gel, which can be applied on any part of the skin.

c) Sublingual Testosterone cyclodextrin is now available which is very fast acting & very effective is fast & better genital organ & secondary
Genital character development.

d) Local application of D.H.T. gel is new preparation for male hormone replacement. It is very effective for increasing penile size, & in cases of cure of genital development in boys. 

e) Injections of Testosterone esters: These include Testosterone enanthate & testosterone cypionate given intramuscular injections every 10 to 14 days.

f) Long acting testosterone as testosterone bucilate given once in 4 months.

g) Testosterones implants are now available which once injected remain effective for up to six months.

h) New human androgen receptor modulators they increase the effect of male hormone over androgens.

2) Growths Hormones Therapy: Growth hormone is given when somatotropin deficiency is found.

3) IGF-1 therapy: is given when somatomedin-c is subnormal.

4) DHT Therapy: is given in many patients. It is very effective in most patients. This treatment is also effective in many patients when all above treatment has failed. The other good thing about this is that it is available as skin gel so taking this is simple & has no side effects. This treatment is very effective in those in whom male hormone is unable to work due to inability to generate the final end product for testosterone efficacy due to 5 alpha reductase defects. In such patient replacement of final target hormone is replaced leading to good penile growth. In such situation even male hormone can be used in higher than usual doses leading to achievement of good penile enlargement. 

5) Gonadotropin therapy is also very effective in genital enlargement.

6) Gonadotropin Releasing Hormone Therapy is effective in many cases of under develop genitalia.

But unluckily many doctors do not take the problem seriously leading to patient not given proper treatment. Thus many patients remain having small size of genital & associated lifelong inferiority complex. 
 

Response of Treatment: 


When any of above treatment is started the response is very good & has no side effects. In one study when the above hormone started, genital size increases by 1.0 cm in first month & then 0.3 cm every month in later months. After few courses of above treatment genital enlarges by three to four inches in length & also in girth i.e. thickness. Thus the trial of treatment should be given to all adults with small genital before asking them to go for surgery. 

Side Effects: It has no side effects if given in proper disease and in-patients when it is really indicated. This it is absolutely safe in young patients below 50 years. 

genital Enlargement Surgery 
Surgical Treatment is required when medicine are not effective then there are various surgical procedures are there which can lead to long & thick genital. At our centre our micro surgeon performs all genital enlarging or girth increasing surgery.

genital lengthening surgeries are performed by specialist surgeon (microscopic surgery) when genital is significantly small medicines have failed. Sometimes it is performed to improve the performance & satisfaction of man.

Three types of surgeries are performed. 

(i) genital Lengthening Surgeries 
(ii) genital Girth increasing surgeries.
(iii) Chordee correction



Response of Treatment 


When any of above treatment is started the response is very good & has no side effects. In one study when the above hormone started, genital size increases by 1.0 cm in first month & then 0.3 cm every month in later months. After few courses of above treatment genital enlarges by three to four inches in length & also in girth i.e. thickness. Thus the trial of treatment should be given to all adults with small genital before asking them to go for surgery. 

Side Effects: It has no side effects if given in proper disease and in-patients when it is really indicated. This it is absolutely safe
 

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