Benefits of Sexual Activity on Psychological, Relational, and Sexual Health During the COVID-19 Breakout

Topics Discussed Include the Following…

Penile Rehabilitation post prostate surgery
Shock Wave Therapy
Benefits of Sexual Activity on Psychological, Relational, and Sexual Health During the COVID-19 Breakout
Peyronie’s disease treatments
Radiofrequency
Priapus Shot® (P-Shot®)
Safety in the Office with COVID
O-Shot® for Urinary Incontinence

Video/Recording of CMA Journal Club, Pearl Exchange, & Marketing Tips

Transcript

Charles:

About two years ago, I was teaching a workshop at my class and a urologist was there, who was head of the department at a prominent hospital/university. And in the process of talking about some of the procedures and some of the ideas in the group, I mentioned Dr. George Ibrahim. And when I did, the response I got was like I was talking about, I don’t know, St. Peter or [inaudible 00:00:51] or something.

Charles:

So, our guest today, Dr. Ibrahim, has a lot of respect. He was teaching urologist at Duke for quite a time and then opened a private practice. Like all of us, he was in the fire, paid his dues, and then none of us want to stop. And so he’s built up multiple located … I think he has two locations now where he does our procedures and continues to teach for us. But it’s really been interesting to learn from him because the combination of his ideas about urology and combined with his ideas about our procedures have been unique and helpful. So I think without any further delay, let me just pull him onto the call so he can answer some of the questions that have come up and talk about some of the ideas that have occurred to him during his work. So let me just get him on the call right now.

Dr. Ibrahim:

Fine. Hello Charles.

Charles:

There you are. Yes. Thank you again for being on our call today. Lots of people are on the call. I put out a sort of a teaser, let people know that you would be here. So, quite a crowd today. And a backlog of questions from people about things that I want your opinion about. Just so you guys know, Dr. Ibrahim and I spoke briefly yesterday, but most of the stuff that I’ll be asking, I’ll be as curious as anybody about what his thinking is. We haven’t had an in-depth discussion for a while. So, why don’t we just start off with the list I have here of topics that occurred to you that might be helpful. George teaches for us. And so he’s alert to the problems and the challenges that come when you introduce these procedures to your practice as well as to the science and the discussion that’s going on in the medical literature and among our group.

Charles:

So, I have this list of potential topics. You can just start wherever you want, and I know everyone will be interested in your ideas. I can list them all for you if you want. The first thing I had here was dyspareunia, if you want to start with that one, because it’s such a hard problem. To me, that’s the worst of the sexual dysfunctions for women because they can fake arousal or even accommodate lovingly without a high sex drive. And an orgasm sometimes is not necessary. Women with pain will start to avoid their lovers. So let’s start with that one since that’s such a tough one

Dyspareunia

Dr. Ibrahim:

Well, Charles, thank you too so much for your introduction. I do appreciate you give me a chance to be here with you. This is an honor, and I hope we can make everybody’s time worthwhile. So to get straight to your topic, I really think that without addressing a female’s hormonal balance at that time of her age, you’re not going to make much headway. Borrowing a history of breast cancer that’s ER positive, there’s really no reason to not optimize the female’s hormones, everything from the lubrication that it brings to bring it back, the vaginal walls and helping with the tissue paper aspect that you see once a woman goes through menopause. These are the kinds of things that I really think, unless you’re going to be able to do that, you’re going to have a hard time.

Dr. Ibrahim:

I do think that the O-Shot can help, but unless she’s got some [ } on board, and that can be done topically and regionally. It doesn’t have to be done systemically, but I think that’s one of the first thing that at least that’s what I always tell one of these kinds of women that have suffered from this problem.

Charles:

Yeah. I like to stress to people that so far in spite of several years of campaigning for it, I like to stress to people that it’s really all we’re doing, these [PRP/cellular] procedures, is just making that local tissue healthier, but there’s so many other parts involved in the sexual response from the spinal cord, to the psychology of our thoughts, to the hormonal [inaudible 00:05:24] you that has to do. Without hormones, we can’t even make collagen or have blood flow. Hormones make our heart pump. So, there’s this system, and I’ve been campaigning that we talk in systems analysis the way we talk about a neurological system and a cardiovascular system. And the reproductive system is not the same as the orgasm system or the sexual response system. So, stressing that to our patients so we’re not over promising them a magic shot, but helping them, although it can be like magic sometimes, but helping them understand there’s this whole system we have to think about.

Dr. Ibrahim:

Absolutely. And with testosterone going to zero in almost every one of the menopausal women I see are almost undetectable. There’s no way that there’s going to be any desire or lost. And while you might be able to help with the lubrication, without that mental stimulation or desire, it’s not going to be a fun experience. It might not be painful anymore, but it’s hardly enjoyable from what I hear from my patients.

Charles:

So talk to us about how you think about, so you first start with optimizing their hormonal status. And there’s so many … The diagnosis, I’m almost regretting now starting with this because the diagnosis of dyspareunia is so complicated. But, maybe a fairly quick overview of how you think about that diagnosis, everything from dryness with breast cancer to surgical problems, so that maybe at least give an outline for the people on the call.

Dr. Ibrahim:

I think that the biggest part of the pain that a woman [inaudible 00:07:06] has and comes to fear when it comes to sex after menopause, is that the vaginal epithelium has become so atrophic. And without a nice beefy, robust, lubricated, thicker vaginal wall, so the vaginal walls, any kind of sex is going to be painful. And that’s where I’m going with it all.

Charles:

Okay. So when you do your procedure with the O-Shot, because you know you can have the dryness for breast cancer or you can have a pelvic floor tenderness, you can have an episiotomy that’s tearing, not mentioning the things like ovarian cyst and uterine fibroids, but the things that we can address with an O-Shot, can you talk how you might vary the how you do the procedure with a woman who has tenderness that it’s in a particular spot versus just overall dyspareunia from say dryness?

Dr. Ibrahim:

What I’ll typically do, if she is in menopause and she has been away from any kind of estrogen production for a few years, I’ll try to see if she’s against doing systemic hormones to see if she would do around about three to four weeks of topical extra dial. A lot of folks like to use a combination of estriol and estradial. I think estradiol is much more powerful, but I try to get them to do about three to four weeks prior to doing an O-Shot, telling them that it’s going to make, the O-Shot’s ability to repair tissue and strength the things and all the magic that the O-Shot does, a lot more [inaudible 00:08:49] better blood flow in the face of the O-Shot if she can do some estrogen for a while ahead of time. So I’ll try to get you to do that for about a month. And then I’ll go ahead and do the O-Shot.

Dr. Ibrahim:

And oftentimes, especially in women that have been in menopause without being on estrogen, I will oftentimes warn them ahead of time, “Look, we’re going to see some results from one. It might be phenomenal, but don’t hold off on doing a second one within two to three months after the first one to augment the effect of the first one.” Especially, again, if she’s not been doing estrogen.

Charles:

Okay. So, I know you have an upcoming class and I want to put this in the chat box so you guys will have access to it before I forget to do this. And Dr. Ibrahim, as I mentioned, was a highly respected teacher of surgical procedures. And I’ve seen him teach there in his office. And he’s patient and articulate and cordial and inspiring. So I highly recommend his class if you’re looking for some hands-on work. And he’s squeezed it into one day by leaving out the aesthetics part and focusing really heavily on the sexual medicine for both men and women.

Charles:

I know this, in your course, you’ll talk some about radio-frequency and laser technologies. And I actually got a question today about Emsella. Maybe just expand upon your ideas about things to do along with when it comes to the machines. Because I know people are either have them or contemplating them. So radio-frequency, laser and magnets, could you talk about how you work those into your protocols?

Dr. Ibrahim:

Absolutely. And before I do that, I’m going to put the plug in for the workshop. It’s going to be March the fourth. We’ll just squeeze everything into one day. Fortunately, I’ve had COVID and my first vaccine, so has my physician’s assistant, and the majority of my staff. But, we’re going to do what we have to do. That all being said, I do use enhancement. Patients are given the option. Some patients only want to get another shot or a Priapus Shot®. Some have heard about some of these other methods. I’m not here to do a commercial for any particular device.

Combining Shock Wave with the P-Shot® Procedure (timing)

Dr. Ibrahim:

I chose a laser over radio-frequency but I’ve seen both of them were great. I just chose not to have two devices that accomplish basically the same thing. So, I use a laser, but I’ve no … It’s done essentially the exact same way as radio frequency. And I use that often when I’m doing my O-Shots. And then with men, even if they don’t want to sign up for an acoustic wave treatment series, are pretty much always we’ll do some acoustic wave treatment just prior to injecting them for their P-Shot because I think that the [inaudible 00:12:04] trauma that we’re producing and increasing the blood flow from that acoustic wave treatment absolutely helps keep the PRP in place and excite the growth factors to do the jobs that we’re hoping that they’re going to do.

Dr. Ibrahim:

That all being said, my staff loves doing these workshops. And we’ve missed it for all the travel restrictions this past year. And so we’re itching to get back in it because they have fun doing it. They love seeing me teach because I know that’s where I used to do it. You may say I’m always my most excited and happiest when I get to teach. And so it’s always a fun event.

Charles:

Beautiful. Yeah. So if you guys are interested in that, click the link now because the link goes away when the webinar’s over and then you’ll have that page open. So, you will sometimes do a shockwave therapy at least briefly, even if they haven’t asked for it, just prior to a P-Shot. Let’s say that they go for it and they say, “Money’s not an object, I live down the street, Tom’s not a problem,” what would be your Cadillac treatment for a man with, let’s start with Peyronie’s disease, what would be your protocol?

Charles:

Because here’s the thing, I get the questions all the time. We’re still working on getting enough research out there. We have some. People act like we have none, sometimes our critics. We actually have a pretty good list of papers now over the past five or 10 years, talking about our stuff. I’ll just give you the list for the Priapus Shot. And it’s not a thousand papers, but that’s a pretty impressive, I don’t know, it’s probably 20 papers out there talking about PRP in the penis now. But there isn’t this goal [inaudible 00:13:52]. It’s like if you run a 100 yard dash, you know when the race is over. But the effort to convince our colleagues that PRP is a viable option where it becomes standard of care for every urologist and every family practitioners treating Peyronie’s erectile dysfunction, there’s no discreet line that’s, okay, now we all start to do this.

Combination Therapies for Peyronie’s Disease

Charles:

So, even more so if you start combining, okay, what’s the best algorithm if you’re going to combine it with shockwave. And there isn’t no published study that says, “This is the best, and this is what the recipe should be.” So when I get those questions, I’m always curious to what your protocol would be for someone with unlimited funds, unlimited time, how would you treat Peyronie’s?

Dr. Ibrahim:

That’s a great question. And I’m thrilled that you told people we all have different recipes for cooking a pound cake, basically. Because the science isn’t out there and I’ll give you my rationale reasoning for doing it. They’re offered the choice off easily. Again, just the Priapus Shot® or the acoustic wave treatment combined with a Priapus Shot®, when they choose the combination, which the vast majority do. Part of that, the reason is we make it much more attractive for them to do it as a package financially. But more importantly, I know that we’re going to see a better end result, have a happier patient. And I’ve said this, especially in my aesthetics practice, nobody is ever upset by spending more than they plan to spend if they get a better result than they thought they were going to get.

Dr. Ibrahim:

And so with that in mind, and just assuming they’re planning on doing both acoustic wave and the Priapus Shot® at the same time, for Peyronie’s, right off the bat, tell them this is not going to be a one and done situation. “Peyronie’s, Mr. Jones, that’s going to be something that we’re looking at. I want you to be scheduled for at least two of the Priapus Shot®.” Again, there’s the financial incentive that it’s not two times one cost. And I will typically start by doing the acoustic wave treatment. And I identified the plaque for our medical assistants who are the ones who deliver the acoustic wave treatments. And they’ve been very, very well-trained because my grasp of the penile anatomy and everything. But I have them concentrate a lot of the acoustic energy on the plaque itself.

Dr. Ibrahim:

And typically, we’ll have them do three acoustic wave treatments in a row. Mostly depending on how far away they live, typically a week apart. And when they come back to their third or their fourth acoustic wave treatment, right after they’ve had the acoustic wave treatment, I’ll do the Priapus Shot®. And just if people are taking notes, men who have acoustic wave treatments do not need to be numbed, but if I’m going to be doing a Priapus Shot®, I’ll go ahead and place my penile block before they do the acoustic wave for one reason, impatient. This guarantees that the guy sat around for at least 20 minutes letting the block sink. Number two, if I missed one of the nerves, they’re able to tell the medical assistant, “My right side of my penis is completely numb but I can still feel it on the left, and she lets me know when I come back in there and augment it.”

Dr. Ibrahim:

So I’ll do the first Priapus Shot® in the middle of the acoustic wave treatment. And then I’ll do the last or the second Priapus Shot® following the same day of the final acoustic wave treatment and then see how they go from there, telling them ahead of time, we’re probably going to have to do some kind of maintenance afterwards, meaning maybe one acoustic wave treatment a month and maybe a Priapus Shot® once or twice a year, depending on how they are or what kind of results that they get from their Peyronie’s. And one more thing before I go much further. This is one of the times where I’m very insistent on the penile pump or the vacuum erection device.

Charles:

[crosstalk 00:18:10]. That was my question.

Penis Pump Tips

Dr. Ibrahim:

Yes. Okay. We have templates that every patient gets, and it has a video and it has their instructions because they’re going to forget 90% of what you tell them in the office. But the first line of the penile pump instruction is, this is frustrating. You’re going to feel like you need a third hand to hold down your scrotum while you hold the cylinder and the other hand holds the pump. You’re going to figure it out. But I always try to teach them how to use the pump. At the initial conversation, set the time that they show up for their [inaudible 00:18:46] wave treatment and a P-Shot, they have already used the pump. The last thing I want them to do is to go home after a Priapus Shot®, I’m not going to let them do it while they’re still numb. So then the next day they try to do it and if it’s the first time they’ve done it, they’re going to be a little sore. And so it’s much better to teach the guy how to use the pump and become proficient in it before you start your other treatments.

Charles:

Let me just jump in with a couple of amens here. First of all, I want those of you who haven’t seen this, I want you to see that there is a study from the British Journal of Urology that’s been out now for a decade that shows that people who had scheduled surgery for Peyronie’s disease, 51% of them canceled it with a pump alone. And so you’ve got some science to back that up, but there is some frustration with the pump. And George is the first that I’ve heard come up with a great idea that’s like a lot of great ideas, simple after someone thinks of it, is that oftentimes the complaints people have as side effects from the Priapus Shot, they’re really blaming the side effects of the Priapus Shot on their misunderstanding of the pump. So having them do that for a week or two or some amount of time before they get the shot helps them sort that out and less likely to think that the procedure went wrong. And that’s how you’ve done it for a while, right?

Dr. Ibrahim:

Absolutely. And ever since we started doing this way, the number of callbacks, I don’t like using the word complaints, concerns has dropped dramatically. Because there’s rarely a concern after a Priapus Shot®, but the pump, if they don’t use it correctly, they over … I literally take a black sharpie and mark out a good portion of the dial and say, “There’s no reason to ever go past this line.” You don’t even have to go all the way to this line, but don’t ever go pass it because some guys would think, “Well, if one’s better, then four must be even much better.” And they would overpump and then it would not be good.

Charles:

Yep. So, another, Dr. Ibrahim, on the call. I’m going to unmute him. He has a question. Actually, I’ve got a pretty good line of questions here. So, let me see, where do you get … Here we go. Dr. Ibrahim, you’re unmuted. If you want to go ahead and just ask your question. I can read it if you don’t have your mic on.

Dr. Ibrahim:

Okay. The only questions I see are links. So I don’t know what kind of question [inaudible 00:21:41].

Charles:

Well, I can read it to you. I’ll just read it out. It looks like maybe his mic is not working. He just wants to know the ideal candidate for the P-Shot, what medicines are you giving after the shot like you putting on daily Cialis or something, any over-the-counter things you’re doing? I think that’s it. So medicines afterward, over-the-counter things, and what’s your ideal candidate for the procedure?

Dr. Ibrahim:

I don’t mean this flippantly, but I think all of us, we all know if you start with a really good canvas, you’re going to be able to get a nice painting. The ideal candidate is the guy who barely needs half [inaudible 00:22:21], I’m assuming, the P-Shot. Somebody who’s got great vasculature, good blood flow, great neurologic issues going on, they’re not smoking, they’re not overweight. But that’s not reality really, but that’s the ideal candidate, is the one that he’s not up to the performance he was at 22 but he’s still doing a good job. That’s the kind of guy I love seeing walk in the door because that’s going to be the home run.

Dr. Ibrahim:

The much older guy, the 78, six, year old man with history of renal problems, terrible Batchelor disease, diabetes, [inaudible 00:23:01] and all that. As far as over-the-counter stuff, and that is not what I give them, it’s what I tell them not to do. We have another handout telling them no [inaudible 00:23:15] and we list as many as we can because people don’t know that Excedrin is aspirin. And telling them, none of those for a week ahead of time. And for at least a week, if not more, after we do the procedure.

Dr. Ibrahim:

As far as a low dose daily Cialis … Now that the PD5 drugs are generic basically, it’s a lot easier to tell somebody to do it. I typically ask them right off the bat, have they ever tried one of the other or any of them? And a good many will say, “Yeah, I tried Viagra and I couldn’t stand the headache, but Cialis tended to not work as well, but I didn’t have the … I was [inaudible 00:24:02],” or vice versa. And I will write for some [trockies 00:24:08] just because that’s what I got used to back when these drugs were not completely generic and you couldn’t really write for pill form and get away with it. So I do have trockies that have either and/or Cialis or sildenafil in them, that I will tell them, “This could help you with everything that’s going on here.” And the biggest part of that is helping to increase blood flow. And I do tell them, especially in the beginning, it’s not a homework assignment they have to do, or they can tell their wives, “Yeah, it’s a homework [inaudible 00:24:40].” They must do but I wanted to have as many erections as possible after a Priapus Shot® as they can have to stimulate the blood flow.

Charles:

Yeah. That’s my aftercare instructions too, go home and have sex. Let me just quickly rattle off what I tell people the easy and hard cases and you expand on it, correct it, a different opinion, whatever. This is not a place for everybody just to try to agree. We’re swapping ideas. I tell people, “Avoid the person that a thousand or a million times zero is still zero.” So I tell people, “Avoid treating or at least make it a small percentage of your treatment, so you don’t get to discourage, the person who can they do Viagra or they do TriMix and just nothing happens. They never get in the morning erection, they’ve had diabetes for 20 years because they probably have vascular disease all the way, iliacs to the heart, aorta, whatever. So, and all we’re doing is treating the penis.

Who NOT to Treat with the Priapus Shot® Procedure

Charles:

Although I have heard people say they get great results with some of these patients, keep them to a minimum so you don’t get discouraged. And if that’s your first three patients with a P-Shot, you’re going to be discouraged. I try to avoid the person whose main goal in life is to grow their penis to some significant amount more than what GOD gave them, because it’s hard to make that person happy. I want the person who has Peyronie’s … The thing is our easy list is still everybody else’s hard list. I want the person who has Peyronie’s because I have a high success rate. I want the guy who had prostate surgery, who’s now been dismissed by the surgeon. Here’s where I really want you to help refine my ideas or correct them or expand them.

Charles:

I want the guy who’s had prostate surgery, who had erections before the surgery, who’s now been dismissed by the surgeon and he’s not happy with what’s going on. And then add in the P-Shot to the usual penile rehabilitation of a pump and daily Cialis. And I want the guy who’s got an erection, but it ain’t what they used to be, but he’s got something. He takes Viagra. He takes TriMix or he’s trying to avoid getting started on it. And then with that person, I’m going to be able to maybe cut the dose in half. He’s okay if his penis gets a little bigger, but it’s not his main primary goal in life. Expand on that, especially the penile rehabilitation, where would you correct me or expand upon what I just said?

Dr. Ibrahim:

[inaudible 00:27:12] I’m going to start with the first thing you said about … The example I used with my staff, and not necessarily in front of the patient, but they get the idea of why I don’t take that patient home. The patient that walks in and they’re so excited to see me, “I’ve heard so much about you Dr. Ibrahim, nobody’s ever been able to help me with this. I’ve been to so many different dah, dah, dah, and nothing’s ever worked.” And I’m thinking to myself, “And you just met the next doctor that’s probably not going to work [inaudible 00:27:39].” And I’ll listen, but nine times out of 10, it might be somebody I choose not to take or I start from the very beginning with all the, I can give you no guarantees, dah, dah, dah, kind of deal.

Dr. Ibrahim:

The thing about size, I do feel that there’s too many folks that, I don’t want to say members of our club, but I’ve seen too many other providers that offer the Priapus Shot®. And the biggest thing on their website is how we’re going to magically increase the size of your penis instantly. And I let patients know when they’re coming to see me, I go, “You’ll notice I don’t make any mention on my website about increase in size whatsoever.” I go, “We might see an increase in flaccid size. We both know that there can be an increase in both erection and flaccid sizes, but I never use that, is, “That’s why I’m glad you came to see me. I want to help you gain more size.” [crosstalk 00:28:46] If it happens, I tell him, “We’re both going to be excited, but that’s not how I’m going to measure your success. We’re going to the prostate surgery.”

The P-Shot® after Prostate Surgery

Dr. Ibrahim:

Absolutely. I was a big prostate cancer urologist, but that was my forte. And I didn’t do it at the time. But if I was dropped back where I was teaching prostatectomies, men would go home with a penile pump for no other reason, to continue to get more blood flow because they’ll stop having those nocturnal erections a lot of times because of the damage to the nerves. Even when the nerves are spared, it’s going to take some time for them to fully recover. And a lot of times they’ll never recover because as I was taught way back when, when we didn’t do many nerve sparing, that the nerves are part of the prosthetic capsule and nerve sparing is cancer sparing.

Dr. Ibrahim:

So, today, especially with the robot, many more men are left with their neurological function intact. My biggest question I ask them at the beginning is, how has it been since your surgery? And if it’s anything less than six months, I go, “Okay, well, what I’m going to do for you is not going to hurt anything, but you might want to wait and see how you are at six months because you might get all your recovery back.” But the question is, do you get any kind of blood flow when aroused? And if they’re like, “Yeah, but it’s just [inaudible 00:30:19]. It’s not hard enough.” I go, “Okay. All right, good. I can work with that.”

Dr. Ibrahim:

But if the answer is nothing, then I tell them, “Okay, well, I’m going to be able to help you. There’s no question.” And by that, I’m not telling them yet because they don’t want to hear about injections, but I’m thinking in my head, “All right, I’ve always got TriMix in my bag.” But if the [pitch knob 00:30:40] doesn’t work or depending on what other kinds of [inaudible 00:30:46] they might have going on, I might just say, “Let’s just help you out and get right down to the business. And let me show you how to do these injections.”

Charles:

Yep. Okay. All right. Let’s see. My thing’s blowing up with questions here. I’m just going to look. Let’s see if Sarah’s microphone will work. She’s got three or four questions. If not, I can read the questions to you. Sarah, are you there? Okay. All right. Let me just read her questions. So do you have the patient pump the same day as the shot or have them wait until the next day?

Sarah:

Hey, [inaudible 00:31:25], can you hear me now?

Charles:

Yeah. Go for it.

Sarah:

Great. So, one is, how much time-

Charles:

Where are you Sarah? Just got a hell of a snow a little bit.

Sarah:

I’m in Denver. And Dr. Ibrahim and I were in a shockwave treatment or shockwave treatment together. I don’t know if you remember Dr. Ibrahim. Sat next to you. Anywho, my question was, when you do the P-Shots in the middle of your shockwave therapy, how much time after the P-Shot before resuming shockwave treatments. It seems like the protocol has changed over the years.

Dr. Ibrahim:

And I do remember that workshop. So, nice to hear from you again.

Sarah:

[inaudible 00:32:11].

Dr. Ibrahim:

So I heard a couple of different questions. One was, sounded like, when do we resume pumping after the P-Shot and then what was the one about … What did you say about the GAINSWave [inaudible 00:32:24]?

Sarah:

Do you have them take any time off after your first P-Shot prior to resuming your shockwave treatments?

Dr. Ibrahim:

Okay, good. I’m glad you asked that. I don’t. So if they’re set up for their acoustic wave every week and I do their acoustic wave treatment on the Wednesday that they’re coming in normally and I do their Priapus Shot® that same Wednesday that they’re scheduled to get both of them, the following Wednesday, a week later, they go ahead and they get their acoustic wave treatment. If it was two days earlier-

Sarah:

Okay. Thank you. [crosstalk 00:33:02] the function of the P-Shot to have that trauma, that soon after huh?

Dr. Ibrahim:

Well, typically because I’m doing the first of the Priapus Shots during the acoustic wave series of 56. That first one, I typically would do right in the middle of the series at number three or four. And then I don’t do the final one until after their last treatment.

Sarah:

Right. Okay. And do you do your shockwave treatment first and then the P-Shot after that on that third session?

Dr. Ibrahim:

Yes. I do the acoustic wave first with my rationale being that [inaudible 00:33:45] what trauma that we might be causing helps the Priapus Shot and its growth factors stay around the area and focus on the parts of the penis that we want to rehab.

Sarah:

Okay. Completely agree. In that same training that we went to in Florida for GAINSWave, at that time, they were saying, wait four to six weeks after that first P-Shot before resuming treatment. But, you don’t think that’s necessary before resuming shockwave treatment.

Dr. Ibrahim:

Correct. And I don’t have any literature to support what I’m saying. And I can’t imagine they’ve got any literature.

Sarah:

I don’t think they do [crosstalk 00:34:26].

Dr. Ibrahim:

I know that the results that I’ve had doing it the way that I described have been fantastic. And have I done hundreds of these doing the protocol that they showed us, I don’t know, it might’ve been just as good. But, I’m not going to mess around with what’s working for me. But, I’m an open mind. If somebody tells me that they have compared such durations and differences, I’m all ears.

Sarah:

Okay. And then regarding the second question about pumping, I [inaudible 00:35:01] Dr. Runels that you generally recommend, I think you would have them pump perhaps immediately after the P-Shot at the appointment and at that same GAINSWave treatment or training, they recommended differing pumping to the next day because of the potential of having some bleeding and that traumatizing the patient. What is your protocol, Dr. Ibrahim?

Dr. Ibrahim:

Okay. So when I learned it, when I was at Fairhope, we were pumping immediately afterwards. I’m doing a penile block on these guys now, so I don’t want them pumping until they’re not numb. Because, like we said, at the very beginning about the pump, one of its problems is the pump causing pain and bruising and issues. And if they’re totally numb, they don’t know what’s going on. I think, especially when I’ve done the acoustic wave prior to doing the Priapus Shot®, that there’s enough trauma now. And let’s just wait till the next day when they’re not numb to resume pumping.

Sarah:

Yeah. Interesting. I used to do the block and have completely for the last year, just continued that. I use a really good topical and the Pro-Knox and they do amazing. But, just throwing that in there.

Dr. Ibrahim:

In fact, I’d love for you to contact me and let me know the source of your topical, because as we all know, it’s not the lidocane or [inaudible 00:36:33] or benzocaine or whatever. It’s the base that makes the biggest difference in a lot of these pharmacies. That base is a closely guarded secret. I’ve got some great ones that work on the [inaudible 00:36:45] because I haven’t found a good one for the penis in your right. You might not have said it, but I’m thinking in my mind, “I’ve done thousands of penile blocks.” And the goal is to get near the nerve, but I’ve hit the nerve enough times to where I’ve caused some residual discomfort from doing the block.

Sarah:

I have too.

Dr. Ibrahim:

Yeah. Which-

Sarah:

But I actually learned the technique from the block from you from one of your videos. And yeah, I’ve gone through many derivations because I do aesthetics as well for topical numbing. And I’ve just within the last year found one that I feel like is a home run. So I’m happy to share that with you. And then my last question is, are you injecting any exosomes versus PRP in the penis?

Dr. Ibrahim:

I am. And that’s a topic that that Dr. Runels and I left off, especially, some of the agenda. I do.

Sarah:

Great. I do as well. So I’d love to chat with you offline about that.

Dr. Ibrahim:

Wait a minute, I will say this out loud. I am a huge fan. A huge fan.

Charles:

So, Sarah, just so you get an idea of what we’re thinking. There are things like the exosomes and STEM cells and things that I’m most afraid to pronounce out loud. And it has to be thought about in terms of, of course the way Dr. Ibrahim does in terms of where you are and who’s the person and what’s the powers that be is saying, and is there an IRB and all that. And so it’s the kind of thing that I like to keep those conversations less broadcast so that people don’t get the wrong idea and get in trouble by not following the same kind of guidelines that George is following. So, I think the best way to find out his ideas about that is to show up in his class. But I appreciate your questions very much. I’ve got a long list. I’m going to jump to the next person, but thank you for jumping on the call. Okay. Did I lose you?

Sarah:

Nope. Thank you so much.

How to Vary the Injection of P-Shot® When Treating Peyronie’s Disease

Charles:

All right. All right. So another, I think his mic isn’t working, but we’ve got another question here from Dr. Eric [Byman 00:39:17] who says that he would like to know how … And this is a frequent question. I’m glad you asked this Eric. How do you vary the way you’re injecting your PRP when you do the P-Shot and how you’re doing, I think you touched on briefly, how you’re doing the shockwave when you’re treating Peyronie’s or do you?

Dr. Ibrahim:

Okay. For me, yes. All right. If I was not treating a plaque specifically, I would deliver almost all the PRP along the … Yeah, I do between three to five max sticks on both sides depending on the endowment. And then a little bit in the glands. I think the glanular part of the Priapus Shot is more for sensitivity because obviously the glands does not play any role whatsoever in erections. It does get a little bit more [inaudible 00:40:20] a little bit bigger, but that’s not where the meat is. When it comes to Peyronie’s, I’m going to take maybe a third of the entire amount of PRP that I have. I’ll split what’s left after that third to do this half injections. And then I will directly inject the plaque two to three to four times, depending on its size, directly with the PRP.

Charles:

Okay. Thank you. So we have another question that I’ve never had before. A lot of these questions … By the way, I’m putting into the chat box the address of someone, let’s see, who is … Dr. Peter Metropolis just gave us the address and phone number for a pharmacy. Thank you, Peter. For someone who has a cream that he’s found to be helpful doing the Priapus Shots. So you guys might want to try that one. The question is, someone got a TriMix … Let me just see if I can unmute the person who asked this, because this is complicated. You may have follow-up questions. Okay. Dr. Lydia Dennis, let me unmute you because this is one I’ve never heard before. Dr. Dennis, there you go. You should be able to speak if your mic is turned on. If not, I can read this.

Charles:

Okay. I’ll just read the question. Six year old guy with erectile dysfunction, previously on TriMix. I’m not sure what that means. But, was he on it when he came to your office or he stopped when he came to the office, but he was previously got a P-Shot on January the seventh. And two weeks later, says the TriMix no longer works. The penile pain, no pain or bruising after the P-Shot still having spontaneous morning erections. I don’t know how to explain that. My first guess is that maybe he’s overusing the pump and he’s waking up with an erection, but his TriMix isn’t working. I don’t know. Can you think of a way to explain that one?

Dr. Ibrahim:

Okay. I pulled my TriMix out of my refrigerator and I know it was fresh. And I ask him how many units he’s doing at home. If it’s an inordinate amount, I might not start with that. But I’ll then inject it myself [crosstalk 00:43:03]. Because they say they inject and gosh knows, are they doing it right, where are they doing it, and has that TriMix been sitting out for how long, how old is it? Always, that’s part of another handout that we have, letting people know that TriMix begins to lose its power both with time and temperature. So you might’ve kept it cold but if it’s four months old, it’s not going to be nearly as potent as it was today. You opened the bottle the first time. If it lays out on the counter for three hours, same thing. It’s not going to be nearly as potent as when you pull it straight out of the refrigerator. So, before I believe that it’s not working, I’m going to try it myself. [inaudible 00:43:48]

Charles:

All right. So, I’m not sure Dr. Dennis’ mic is not working. So, hopefully that’s helpful and seems to make sense to me. When someone tells me for example that PRP cause damage, it’s like saying you suffocated on oxygen because PRP causes tissue to become healthier. So it doesn’t mean it’s not happening, it just means there’s something else going on that has to be figured out. It’s not likely the PRP has actually damaged something.

Dr. Ibrahim:

Yeah. It’s like the people who tell you they’re allergic to Benadryl or epinephrin. Okay. Well, we all know what’s happening there. You’re getting sleepy. Benadryl or epinephrin, your heart’s racing, but they’re not allergic to it. If somebody is blaming the P-Shot, well, it’s also the person that was having problems to begin with, but now you get to be the crutch and he can blame you for it rather than himself for his inability. And I’ll tell the person, “I’m doing the best I can. I know where I’m putting things. I get to teach other physicians. I’ve been doing this as urologist for forever, but I’ll be glad to give you a list of folks that do a similar procedure that I do. And they may be able to help because I don’t know if I can.” Because at the end of the day, we all know you can’t help everybody, especially if they’re looking for a reason for something not to work.

Charles:

So, I have enough left on your outline to keep us busy for many hours. I’m going to try to get through as much of it as it can. And again, I’m always grateful to pick your brain on the ratio of knowledge and experience to cordial and easygoing with you is out the roof than nobody else maybe that I’ve worked with. So I always enjoy picking your brain. All right. So next on our list is … But, if there’s something you feel like you want to jump in, go for it because I don’t want to structure it so much. You don’t have a chance to just run. We have experienced people on the call, but we also have quite a number that are new.

Charles:

So if you have any quick tips, maybe we could jump to that now. With the COVID things going on, your ability to continue to make a living, it’s really interesting. I’ll get some people that are in the group that are just prospering like crazy, more than ever, truly. And then others that are dropping out. Literally, it breaks my heart going broke and closing their office. And it just breaks my heart because think about the irony of that; a doctor closing their office because people are getting sick. That’s something wrong when that happens, but it’s happening. And so help us talk to that person. How can you continue to do business and prosper, even though people were getting sick? What an ironic question, but help us out with that.

Dr. Ibrahim:

That’s great. And this should be brought up for folks who aren’t doing some of these things. Part one, when patients start to cancel an appointment or want to reschedule because they’re worried about COVID, staff, they have been very well trained by my office manager on, “Mrs. Jones, please, this is going to be one of the safest places you can be.” First of all, everybody in the office is used to washing their hands before they see anybody. Wearing masks and gloves is part of what we do day in and day out. That’s before COVID ever hit and we had to worry about PPE. We already had it all.

Dr. Ibrahim:

Number two, you’re not going to be in a waiting room with other folks. In fact, you won’t wait at all. And you’re going to pull up into the parking lot. You’re going to give us a phone call. And then one of my staff will check them in over the phone, make sure that we have a current payment, credit card, usually. They will actually even run the credit card for the anticipated, what the visit is going to be for telling them that there might be an adjustment depending on what we end up doing up there so that they’re not going to have to sit around. Their followup is going to be scheduled either before they’re ever seen, or once they go back to their car. They’re on the phone, again, with the MA. So the contact that they’re having with us face to face …

Dr. Ibrahim:

Because there was a time in North Carolina when I was limited to, I can’t remember if it was six minutes or something that I could be in the room at one time. And patients began to love it. They would walk in. They walk straight back to the room. They’d get on the table. I’d say hello to them. This was not for brand new patients. Brand new patients is a different story, but these are people who we’ve already had a relationship with. And we just get right down to business. And I’d apologize for not being able to spend more time with them, but the new rules made it. So I had a bit of time I could be in the room.

Dr. Ibrahim:

Now things are relaxed and we can spend a lot more time, but a lot of patients began to love it. So, we continue now to check our patients in and out before they ever get either up in the office or they come in, they’ve already been checked in and then they go back to their car and we finished the checkout without them sitting in a room, without other people hearing about their business. The privacy aspect’s been a lot better. So, we’ve done very well. We had two months. It was horrible and I was worried about who’s going to … I’d have to let go. And I’m happy to say nobody was let go. The new method has been a phenomenal forced change that we’ve had to do and it’s come over very well amongst our patients.

Charles:

Thank you for that detailed explanation, because it really breaks my heart to see doctors going out of business because we have more sick people. And I’ve put up here something that makes sense, but I want people to know there have research to back up what makes sense. So here we have published. You can see this was in the January 1st issue of what you would expect. People who are stuck at home are getting depressed and there’s been multiple research papers out about that. They’re getting depressed, there’s more abuse, there’s more substance abuse and physical abuse and child abuse, but the people that are having sex are doing better.

Charles:

And I’ll put this up here because, especially in the beginning of COVID, but it continues to this day, people are almost embarrassed about talking about the fact that we take care of sexual problems as if somehow that become unneeded because people are sick with a virus. It seems to me it’s more needed than ever. We need comfort. We need love when things are tough and we’re the people that help make that happen. So can you expandable, have you seen some of that or what’s your idea about … My point is nobody needs to make an excuse about going to work and talking about sex, even though people are dying.

Dr. Ibrahim:

You know what, I’d never would’ve thought to bring that up, but you’re absolutely right. Just to carry out that in, on the aesthetic side, now that everybody’s doing Zoom meetings and they’ve got 4k and high-def cameras looking at their face from two feet away, anything and everything above the nose, people who are doing that have never done it. Because the other is what you just said about the sex part, with so many families that have both spouses working, but now they’re both working from home and they found themselves in an environment where sex is okay at two o’clock in the afternoon, they want to do it. And a lot of couples coming in together. In fact, I’ve never had more couples at one time. Usually it’s one of the partners, almost always the female, that gets started and then the other one comes in after the fact. But I’m seeing more and more new patients enter as couples to optimize their sexual intimacy together because they’re spending so much more time together. And yeah, that is something that I would not have thought to bring up, but I see it a lot now.

Charles:

So we only have seven minutes left. Thank you for hanging with us for the whole hour. I got two questions that have been sent to me. Well, first of all, this is something I know that you’ve had a lot of experience with surgically before there was ever an O-Shot. So talk to us about in seven minutes, your ideas about the O-Shot, where it comes into the treatment for stress and urgent continents. And then last, have you had any thoughts about the new magnet Emsella treatment?

Treating Stress Incontinence and How the O-Shot® Procedure Integrates with Mid-Urethral Slings

Dr. Ibrahim:

So let’s talk about the incontinence. First of all, you see the literature that talks about 51% of women over the age of, just making up, 40 something report incontinence. And whenever I give talks, I go, “That’s the biggest wrong number in the world.” If a woman has gone through menopause or she’s ever, let’s say 50, and she’s had one or more vaginal deliveries, they’re incontinent. But they’re all used to it. Their mother wear her pants when she caught the sneeze. Their best friend wears her pants when she’s jumping rope. And so, so many women don’t even complain about, “I have this today.” Healthy as hell, thin, fit, 50 year old woman, three vaginal deliveries. It’s on our form. I don’t care if you’re coming in for Botox. It’s one of the questions on the form. Do you leak when you cough, sneeze, laugh, job, et cetera, then in parentheses stress, urinary incontinence?

Dr. Ibrahim:

And she didn’t even think to mark it, but I looked at her history and her age and I just couldn’t conceive up. And sure enough, she says, “Oh yeah, whenever I do jump rope, which is like three to four times a week, I’m always leaking.” And I go, “Well, let’s talk about what we can do.” And so it’s far more common and I advise everybody to make sure it’s on your list of questions, because if you’re going to be part of your club and you’ve learned how to do the O-Shot, then I will address their incontinence at every single visit until they tell me either, I don’t want to hear you talk to me about my incontinence again, Dr. Ibrahim, or they go ahead and [crosstalk 00:54:34].

Dr. Ibrahim:

And [inaudible 00:54:34] is, is I have done enough slings, enough mesh, enough tax in my career. And [inaudible 00:54:42]. They were horrendous and they had brought with issues. If I had had the O-Shot when I was in residency, I would have done a third of the female vaginal incontinence procedures that I did as a resident. One-third. It would have knocked out probably at least half, if not two thirds, of the cases that I had done. Because so many women are completely dry after one or two O-Shots. Every one so far has been dramatically improved if not, parentheses, cured. And again, I thought of how long is that going to last? I don’t know. I don’t have that crystal ball. Some, they’ve never had to come back and some come back once a year and some in between. So-

Charles:

The other surgeons in our group will tell me that even if the woman chooses to go straight to a sling, they’re usually still almost always grateful that they were offered a non-surgical solution first. Because there’s this urban feeling that surgeons want to cut, but actually surgeons want to get people well. And sometimes that means surgery, but there seems to be an appreciation for a surgeon that has something other than a scalpel in their bag. And then if they choose to go straight to the swing, they’re happy that they were offered something else. And so I’m glad to hear you supporting that idea. And you’ve seen it even work with urgent continence. I’ve heard that, but it’s interesting that you’ve seen it as well.

Dr. Ibrahim:

So when somebody comes in, they might stress incontinence stress, even though we’d give them the examples. And I find out that it’s urge. You’re itching to go. You’re back of the cold section of the grocery store, and you’re looking for the bathroom and, “I got to go, I got to go.” And you wait yourself before you can get there. That’s urge incontinence. I’ve had some women say, “Look, I’ve had a friend. She had urge incontinence. You told her ahead of time. Look, I can’t promise you anything for urge.” I go, “But it’s not going to hurt it. And if anything, it might make sex better.” And if it helps her incontinence, both of us are going to be thrilled to pieces and damned if it didn’t help her incontinence. And so I can give you the anatomic reasons why stress incontinence is held by the other shot, but I have no idea how urge it is. And I’m not talking about the incontinence. I’m talking about the urgency, the neurologic feeling in the head and the bladder that have to go. It helps with that. And I have no idea how come.

Charles:

Yeah. I’ve got some, as I’m sure you do, some theories about that, but we’ll save that for the … I’m telling you guys, every time I’m in the room or on the phone with this man, I learn a lot. He’s innovative, but he knows the science as well as anybody on the planet. So if you’re looking for a hands-on class, I can’t tell you, you just need to go see him. So last thing and then we’ll close it down. What’s your ideas about the magnet that’s being used to help incontinence?

Dr. Ibrahim:

To be very quick and short about it, of course I download it and I do not own one.

Charles:

Okay. All right. So guys, I think that we better shut it down. And lots of people are busy and I’m always honored. Everybody’s busy. So I’m honored that you made the call, honored that Dr. Ibrahim made time for us, and I’ll make sure this recording is posted somewhere soon. You should get an email automatically, but if you don’t just look forward on the membership site soon for the video and the transcript. Thank you for being on the call Dr. Ibrahim. I’m always grateful to you.

Dr. Ibrahim:

Thank you so much, Charles. I do appreciate your kind words and I appreciate your comments on the workshop.

Charles:

Yes, sir. Bye-bye.

Dr. Ibrahim:

Bye.

Dr. Ibrahim’s Next Workshop<—

Dr. Ibrahim is Western North Carolina’s only physician certified by the American Academy of Anti-Aging Medicine. He has been specifically trained in the use of bio-identical hormones, having passed both written and oral exams. A former Duke University Clinical Professor of Urology, Dr. Ibrahim’s experience with hormonal balancing goes back decades.

George Ibrahim, MD is a well known, board-certified urologist who has been professor at Duke University.