Topics Discussed Include the Following…

*The Most Common Criticism of PRP-Related Research
*Proposed methods of classifying PRP
*Should you or should you not activate the PRP with Calcium?
*What exactly happens when you inject PRP?
*Exercise pre PRP
*Why activate sometimes and sometimes not?

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Relevant Research, Transcript, Relevant Links

Relevant Research

Hamilton, Bruce, Johannes L. Tol, Wade Knez, and Hakim Chalabi. “Exercise and the Platelet Activator Calcium Chloride Both Influence the Growth Factor Content of Platelet-Rich Plasma (PRP): Overlooked Biochemical Factors That Could Influence PRP Treatment.” British Journal of Sports Medicine 49, no. 14 (July 1, 2015): 957–60.

Sheean, Andrew J., Adam W. Anz, and James P. Bradley. “Platelet-Rich Plasma: Fundamentals and Clinical Applications.” Arthroscopy: The Journal of Arthroscopic & Related Surgery 37, no. 9 (September 2021): 2732–34.

Toyoda, Toshihisa, Kazushige Isobe, Tetsuhiro Tsujino, Yasuo Koyata, Fumitaka Ohyagi, Taisuke Watanabe, Masayuki Nakamura, et al. “Direct Activation of Platelets by Addition of CaCl2 Leads Coagulation of Platelet-Rich Plasma.” International Journal of Implant Dentistry 4 (August 1, 2018): 23.

Ulasli, Alper Murat, Gokhan Tuna Ozturk, Bagdagul Cakir, Gulsemin Erturk Celik, and Fatih Bakir. “The Effect of the Anticoagulant on the Cellular Composition and Growth Factor Content of Platelet-Rich Plasma.” Cell and Tissue Banking, August 28, 2021.


Thank you guys for being here. I know there are many smart, very smart people—not just smart, but well-informed people regarding tonight’s subject. And so I promise you, I don’t claim to be the know-it-all, and I don’t claim to be able to give you a definite black and white answer. For example, we know two plus two equals four in this universe. I can’t give you an answer that definite concerning tonight’s subject (activation of PRP), but hopefully I can show you some of the ideas that have guided my thinking over the past decade of doing and teaching procedures with PRP. And hopefully, you can integrate those ideas into your practice, watch what happens, and then teach me something better.

If you have comments, I will definitely keep an open mic at the end of my presentation, which should take only about 15 minutes, showing you my favorite ideas in the literature, and then I hope you’ll jump in and tell me what you’re thinking.

All of the research with PRP is definitely growing logarithmically.

You can see here’s the research articles by year with platelet-rich plasma. Of course, we’re not through with 2021 yet. And all of the articles, without exception, where there’s a med analysis and all of the primary research with clinical trials, they all end in the same way in that we don’t have a good apples-to-apples comparison, a good definition of what platelet-rich plasma is.

The Most Common Criticism of PRP-Related Research

Every week when I get ready for this little webinar, I have dozens of new articles to look through to try to see what could be most helpful to our group, and all the articles have that criticism, which is justified. And you can see there’s talk, there’s always talk on the basic science level about how we make the platelet-rich plasma.

You can see there are people talking about making it with different devices.

So one of my favorite things I’ll show you right off the bat is this little infographic. Actually, I can give you the link before we shut down the webinar tonight, but this is a little infographic that was done by some guys who reviewed the research concerning orthopedics.

I don’t know if you’ve tried this yet. But next time you’re in a room full of dentists, ask them about platelet-rich plasma and everyone in the room will know what it is. And most of them will either have a centrifuge or one of their partners has a centrifuge, and they make use of it in their practice.

All the orthopedic surgeons will know what it is. But even a decade after introducing the O-Shot® procedure and the Priapus Shot® procedure, it’s still difficult to find urologists and gynecologists who understand exactly what the tool (PRP) is, much less the variables involved in preparing and using it.

Proposed methods of classifying PRP

So a lot of what I’m looking at each week in the way of new research, I’m pulling from the dentistry literature and the orthopedic literature. And so these guys have proposed ways to classify PRP.

  1. Is it leukocyte-poor or leukocyte-rich?
  2. What’s the concentration?
  3. How did you activate it?
  4. Endogenous versus exogenous?

And then, there you go. So their proposed PAW classification.

Now, I’ve always leaned towards activating it. Part of that is I was first introduced to the Selphyl kit, which as far as I know is still the only kit that actually comes with calcium chloride to activate the plasma before you… Well, to activate it in the syringe before you inject it.

Now, there’s a couple of things to note here that are not scientific that have to do more with just the much needed but also needed to be understood restrictions by the FDA. So for example, a kit other than Sephyl® was brought to my office by the salesperson who swore to me all about how the kit was self-contained.

And I suggested that I would like to activate the PRP with calcium chloride. He agreed that there was research to back up that idea and promptly went to his vehicle and came back with a calcium chloride vile, but he was not able to talk about that. He was not able to speak about the calcium chloride until I brought it up because it was off label for his centrifuge.

So just understand that when you’re speaking with a salesperson, most of these people are wonderfully ethical people who understand their kit, but they also are bound by the law to be careful what they can even say, and rightly so. So that limits the way the science is discussed by the people who are often educating the clinician salesperson for a particular kit.

Should you or should you not activate the PRP with Calcium?

So knowing that, let’s look at some of the science that’s been influential for me. Let’s see, I’ll just put this DOI link right now in the chatbox, so you can pull it up and have it before the meeting shuts down, so there you go. If you click on that, it’s in the chatbox. You’ll have this article. It will also be posted on the membership site later. But I liked this article for a couple of reasons.

One, is if you just suffer through the introduction, much of it you’ll already know, but having it put together, I think it’s the best display of the question, which is, “should you activate or not?”

And this particular study, they brought into the picture, how is exercise affecting it (PRP)? But the way they pose the study is worth just going through word for word, at least the part I’ve highlighted here.

So in this introduction, they say, “A recent…” Just bear with me because I want you to hear this word for word. “A recent med analysis on the efficacy of the widely-used autologous platelet-rich plasma, 14 musculoskeletal indications showed conflicting evidence.”

Okay. So this is really ubiquitous. All of the med analysis show conflicting evidence. And so the point they’re making though is, they think predominantly because of the shortcomings in the standardization of the study protocols and the confounding factors affecting the platelet application. So there’s so many variables. If you go back to this, if we’re all studying, say, how to inject the knee and you have leukocyte-poor versus leukocyte-rich, at least three different common ways of activating it, and then you have different concentrations of blood. Then even in the same patient, you can see that there’s multiple ways you could create your plasma and get different results.

So and extracellular elements, optimal concentrations of platelets, leukocytes, release growth factors, dose, timing, and activation: all of those are variables every time we do a procedure.

What exactly happens when you inject PRP?

So platelet-derived growth factors, PGF, are stored in alpha granules found within platelets. So even the people in our group, I think this should be in your bone marrow if you’re injecting PRP because this is about to tell you very clearly what it is you’re doing. Are stored in alpha granules found in platelets and are released in a selective manner upon activation. So it’s got to be something activated, whether it’s after you inject it or before is up for debate.

But until it’s activated, you’re not doing anything.

It’s why your plasma can sit at room temperature, in theory, in a container for three or four hours before you actually use it because it’s not activated.

Platelets, let’s see. Platelet activation is dependent on specific platelet membrane, glycoproteins binding to ligands, kinase activation and cytoplasmic calcium influx from both the dense tubular system and the extracellular milieu and may be initiated in vivo, here we go, by a range of factors including thrombin, calcium, collagen and shear stress.

Example of a variation in technique

Now, last week, or a couple of weeks ago, we reviewed a double-blind placebo control study done out of the University of Aristotle in Greece, where they injected the Corpus cavernosum with PRP. And in that study, their idea was to very slowly, over four or five minutes, per Corpus cavernosum, inject the PRP, obviously trying to prevent any activation at all until it was within the tissue. So that is one way of thinking versus activating it, which was my postulate before you inject it.

Who knows what’s the right thing? But I’m getting to my logic.

So what really happens?

Each platelet contains about 80 alpha granules, which, in addition to growth factors, contains adhesive proteins, the chemokines, fibrinolytic proteins and procoagulant molecules. In vitro calcium and thrombin are routinely utilized to induce growth factor release from European clinical practice. Pre activation is widely used; Regen makes a kit that includes thrombin, a way to make thrombin.

And they also make a kit that comes with an HA, non-cross-linked hyaluronic acid, which can activate PRP. Regen makes the kit that includes HA, we can’t get those yet in the US, as far as I know, I think they’re coming soon.

Selphyl® makes a kit that as I said, comes with a small aliquot of calcium chloride to add pre-injection.

However, evidence and consensus on the therapeutic requirement for pre-injection activation is lacking. That’s true, there’s no good consensus. So I’ll show you what my thinking is, and you can come up with your own consensus.

Exercise pre PRP

First thing of this study was to evaluate the effect of exercise on platelet rich plasma. You can see the list, basically all the stuff.

The second aim was to study the effect of the activating agent, calcium chloride on the growth factor, concentration-relation to different exercise states.

So they took these guys. If you look at the methods up here, they took the guys at 10 healthy men, and they had them do an hour of sub-maximal exercise. They drew the blood pre, post, and 18 hours afterwards, and then prepared the PRP and looked at it in vitro.

In this study, the exercise actually decreased the VEGF, which we’re very interested in, right? We want new blood flow, neovascularization, which the VEGF helps with. And that seemed to go down with exercise, which is conflicting with other studies. But then the calcium chloride activated the growth factors, but there was a different spectrum… And you can see up here, “activated with calcium chloride results, significant increase of PDGF and IGF-1.

There wasn’t a big change in the VEGF with the calcium chloride. So what does all that mean?

I think the next one will help put it together. So in this study, which came out of the dental literature… So just keep that in mind,

the calcium chloride did increase some of the growth factors and it changed the spectrum, there are other studies that show that same idea.

For example, when you activate with HA you get an increase in the VEGF.

What they’re leading up to is there could come a time to a part of the protocol for each procedure, whether it’s the knee versus a P-shot® versus the face.

We could be more specific about which growth factors we want and therefore change how we’re activating.

Based upon that idea, what I’m doing thus far is more simple than that, and it’s explained by this. The first idea that I get from this is that there is an increase in the amount of growth factors, reliably, the amount of growth factors that are released by adding the calcium chloride. At least in vitro, you’re going to reliably get an increase.

The question is, is that going to be more or more effective if that’s done in your syringe pre-injection versus letting it happen after you inject it?

What I just showed you is what the research talks about. What I’m about to tell you is my opinion.

My opinion is that the calcium chloride is literally a few drops and it assures me that those platelets have been activated rather than hoping they are activated to that full extent by my injection, through the sheer forces and the exposure to the collagen through the needle, where to me that feels less reliable.

Okay. Now the next part though, I think tells you another reason why I like activating with calcium chloride, and then I’ll tell you why. Even though I like it, I don’t always do it. I’m not going to make you suffer, you can read all this yourself, but I want to point out a couple of things. And again, this is from the dental research and the dentists were doing this at least 10 years before it was ever really used much cosmetically.

There were a few pioneers who were doing it, some of them in our group, but most were not thinking about it cosmetically until 10 years after the dentist thought about it. So let’s just, a little bit of the background because it helps us understand. Unlike sir Claude, who played a rich fibrin, because I get this question a lot,..

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“should we use PRF versus PRP?”

Well, the dentists use PRF quite a bit because it makes a gel and you can pack a wound with it for better handling efficiency and minimizing loss of growth factors to diffusion. PRP and some other derivatives in liquid form are usually clotted by addition of exogenous coagulation factors, such as thrombin and or calcium chloride. In other words, if you’re not going to make PRF if you want it to stay where you put it, and according to these authors, maybe you should think about either thrombin or calcium chloride.

The reason I don’t usually go for the PRF is I feel like there’s less research to back it up. And the handling of it feels less consistent to me because what we’re doing is through a needle, not packing a wound. And so venipuncture is performed with anticoagulants.

This is back to some of the science and the sodium citrate or acid citrate dextrose, ACD solution, it coagulates the calcium, that’s why it doesn’t form a clot. So adding the calcium back is undoing the mechanism of the anticoagulant in the two, in which you drew the blood.

So that’s worth thinking about, it’s logical but it’s maybe something I hadn’t really thought about specifically until I read this. So behind the clot formation, there’s an intrinsic coagulation pathway, and this takes you back to your basic science. You guys remember factor seven and all that, and calcium helps do all that.

So on a screen, there’s a chart down here. I think that shows us better, but let’s skip down here in contrast to calcium. When an alternative coagulation factor say thrombin is added to the situated PRP, the resulting fiber and fodder fibers are thin and often fuse together. In this study, we attempted to associate platelets from the coagulation pathway and evaluate the possible direct action of calcium.

What these guys did is then this was in vitro. They looked at what sort of structure was being built using electron microscopy. Basically when you put in what their conclusion was, if this were… If we were building a house, the calcium chloride provides more strong steel rebar to support the structure of the platelet-rich fibrin matrix than does thrombin.

This is the diagram I was looking for. So here’s the thrombin cascade that we’re talking about, where the glass surface activates it. And here’s calcium chloride which just does it for you.

Why activate sometimes and sometimes not?

So why do I use it sometimes and not others? If I’m doing an O-Shot® where I’m trying to create a firm, basically a liquid lift or liquid sling that changes the orientation of the urethra and helps with incontinence or creates healthier tissue, and I want it to stay in that place. I like adding the calcium chloride, so I get a stronger structure or a stronger platelet, rich fibrin matrix that happens more quickly. I get a clot and it stays where I want it to be more reliably, I think. And I think these two studies or these two descriptions, maybe they’re better just talked about as descriptors of the behavior of platelets. Back up that idea that you get a more reliable structure.

So how could that change how those procedures are done? If you look at the study, I mentioned earlier, their choice was to use a constrictor band and slowly inject over 4 minutes per Corpus cavernosum without activating —they were attempting to not activate the platelets; but then keep a constrictor band in place for 20 minutes.

During which time you’d get some mild hypoxia, which would cause some activation. In theory, you would get some activation and staying of the growth factors within the penis.

The downside to that as we discussed is that you’re avoiding the half of the Corpus cavernosum that lies deep to the base of the penis, looking from the outside or the pubic symphysis pubis there’s… Goes back along the pubic rami like with the female, so all that’s not treated. And we know by treating the face that by injecting the plasma, you can see it doesn’t go flat.

It stays expanded because you’re forming a matrix in there, which perhaps would change the way some of the urologists and gynecologists think about this PRP if they could see the behavior in the face. You don’t use a constrictor band to keep it in the face when you inject it.

So my preference is to activate it: One, because I know I’m reliably getting all the platelets to release their alpha granules; two, because I feel like I’m more reliably getting a fibrin matrix; and I prefer the PRP over a PRF because again, I think it’s more reliable and I can handle it more accurately through a needle.

I like to always use the calcium and the O-Shot® and the P-shot® because I’m trying to get the material to stay in a specific place.

I don’t always use CaCl (although many of our providers do) with hair and with the face because adding the calcium, whether it’s chloride or gluconate, and the gluconate does hurt less and works as well.

But adding the calcium can increase the pain in the face and the scalp, Also, in the face and scalp I want it to spread. I want it to spread more throughout the scalp and throughout the face where more ubiquitous covering of that tissue.

Wherewith the P-shot® and the O-Shot®, I’m trying to keep it more local.

When treating the breast, when treating loss of sensation in the nipple, I also like to use calcium for the same reason: so it stays right under the areola; but if I’m just injecting the fatty tissue of the breast, I don’t use calcium because I want it to spread.

Now, all that could be wrong, but that’s the way I think about it. If you look at the research and the references, then I think I’m that backed up by that. But I started this by telling you, “I can’t give you a definite right.”

And as was pointed out, you can find lots of research about PRF. And there are many people that are going to jump up and down and say that everything I just said was wrong, which is okay. What really needs to happen is we do research where we do, a hundred P-shots®, one way and 100 P-shots® in another way. And that’s my thinking, so let’s see…

What else do you guys have questions or comments? I’m happy to unmute anybody’s microphone if you want to talk about it…(silence) You just click the little button, I’ll unmute you and you can tell me where I’m wrong or where I need to be educated.

The problem with teaching something for 10 years is you start to believe everything you’re saying, which obviously… Everything I’m saying will eventually proven to be, there’s a better way, but this is my best understanding at the moment.

The other thing I’ve noticed is that when someone tells me they’re consistently not getting good results, not so much with hair, I don’t hear it or with the face, but especially with the O-Shot®, oftentimes all I have to do is have them start activating the PRP and they’ll start seeing better results.

Let’s see, I’m looking at some of the questions…(silence) When it comes to who I’ll treat and who I won’t treat it. The guiding principle I use is, could this person have surgery? If they would not be a candidate for surgery, let’s say high dose corticosteroids, or even if really heavy smoker, you can make an argument there. They’re not going to respond as well. If they have hepatitis C or HIV, absolutely, I would treat them, if they have just like… I would do surgery on them and have many times in the ER. If they’re on anticoagulants, I’ll still treat them… You can still have an IM injection if you’re on anticoagulants, but I’ll just warn them, they may have more bruising. And let’s see, but if they’re on other anti-inflammatory agents or smokers. Just like for the same reason, you have more poor wound healing if you have facial plastic surgery, our procedures don’t work as well.

For a while, I wouldn’t do them at all. Now I will do them, but always with a disclaimer that their results may not be as noticeable. And I think with that, I’ll shut it down, I’m always honored that you guys have an interest in what we’re noticing. Again, I’m bringing to you… Not just, as I mentioned, not just my ideas, but what I’ve gathered from our 4,000 plus members. And indirectly, like I said, I’ve often had probably a dozen times, had someone who said, “Hmm, my O-shots® are just not working.” And when I found out they weren’t using calcium and they started adding that in, they became more consistent.

The other thing is, the question comes up as it’s still minimal manipulation if you add the calcium chloride. And yeah, we actually had one of the head people who, the FDA on a lecture that was on a different webinar, and that question was asked. They do consider adding calcium chloride it’ll still be minimal manipulation because it’s still autologous. It’s still homologous because, in a person’s body, the platelets are activated in a similar way. So you’re not doing something the body wouldn’t normally do with the platelets. Okay. I think with that, we’ll shut it down. Thank you, guys. I hope you have a good night and I will put links to all this in the email that goes out and on membership sites. Bye-bye.

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Charles Runels, MD






Cellular Medicine Association


5 Things that Helped Me Last Week (2021August23-29)

For Members of the Cellular Medicine Association


Here are 5 things that helped me last week…

1. Idea/business book that helped me last week…

Propaganda, Bernays 1928. I just had to pull this one out again. No one would ever say, “Hey, let’s make a plan where we have our enemy make a circle around us; also, we can let the enemy mix with civilians so if they do something dangerous, we can’t shoot back.”

But, if things went unexpectedly, and that scenario happened, Bernays would have said, let’s reframe it with propaganda: “We have a common interest with our enemy; our enemy who surrounds us is now our “partner” to help keep us safe.”

When in reality, we are safe as long as we do what our “protection” demands.

The word “Propaganda” eventually got a bad reputation (Bernays wrote this book in 1928). But, Bernays (who was Sigmund Freud’s nephew) pioneered the idea and wrote some of the seminal works about influencing public opinion.

We covered another one of his books a few weeks ago (Crystallizing Public Opinion). Read them both if you want to find a good feel for the basics of propaganda.

Like any influence, propaganda can be used for good or bad. Whatever your political disposition, it’s best if you learn to recognize when it’s being used, study it, and then think of ways to use the same techniques to influence people to practice good health practices.

2. Video that encouraged me last week…

I interview or at least converse with other physicians almost daily. But, I found this interview with Brenda Scaggs really snuck up on me and touched me. Brenda worked as a forensic nurse during her ER years to help women who had been raped. Now, she’s come up with a wonderful way of Helping women who have suffered from genital mutilation. The first part of the video is me going over the research; skip that part if you want (the research is listed below the video). But, do not watch the last part of this video unless you want to be touched by Brenda’s story about how she helped a woman who had her clitoris cut off when she was 8 years old (along with her friends).

3. Most important research I read this week —

We’ve been using the P-Shot® to help men who have failed the usual post prostate surgery penile rehabilitation. Not all recover, but many do. The following article interestingly makes a positive case for what we do, and the has the usual and expected criticism that the variety of ways that people isolate PRP makes comparative studies difficult. And, then uses as an argument against the strategy that people are making money doing it. I’m always interested when “commercialization” is used as a criticism. Another way of saying the same thing is “Unless insurance pays for it, then it’s probably not good medicine.” Any physician who struggles to get insurance to pay for needed therapies knows the folly of this attitude; yet, most physicians still use what’s financed by insurance as a guide to what works. Anyway, that’s a side topic—but the following review article about cellular therapies to help after prostate surgery still encouraged me since the discussion has at least begun. Remember, it takes 20 years for a new medical procedure to be widely accepted…so we have another 9 years at least before the P-Shot® will be routine as part of the Penile rehabilitation protocol post-prostatectomy. Here’s a link to the article…Chung, Eric. “Regenerative Technology to Restore and Preserve Erectile Function in Men Following Prostate Cancer Treatment: Evidence for Penile Rehabilitation in the Context of Prostate Cancer Survivorship.” Therapeutic Advances in Urology 13 (January 1, 2021): 17562872211026420.

4. App I Used Every Day

For the past 5 years at least, I kept my literature searches organized in Mendeley. But, recently, I found FREE software that makes both the importing and the documenting in a written paper both your footnotes and bibliography easier than ever. I love this software: Zotero. If you’re writing in Word, you can literally click and drag into the paper and the references are formatted in whatever format you desire.

5. Quote I’m pondering —

Walt Whitman Speaks, Walt Whitman…

“The woman who has denied the best of herself—the woman who has discredited the animal want, the eager physical hunger, the wish of that which though we will not allow it to be freely spoken of is still the basis of all that makes life worthwhile and advances the horizon of discovery. Sex: sex: sex; whether you sing or make a machine, or go to the North Pole, or love your mother, or build a house, or black shoes, or anything—anything at all—it’s sex, sex, sex: sex is the root of it all: sex—the coming together of men and women: sex: sex.”


And, please give me feedback: hit “reply” and shoot me an email, or on our membership sites.

Have a great week!


P.S. The last book I launched could be of help to your patients who suffer from premature ejaculation: Extend Sex: The 30-Second Trick. You’ll notice that my trick makes use of the functional anatomy, even though I did not know the anatomy when I dreamed this up 40 years ago.

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Topics Discussed Include the Following…

*Female genital mutilation-non-surgical treatment options
*Scar remodeling and nerve regeneration from the O-Shot® procedure
*Talking with women who have suffered sexual pain.

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

Members of the Cellular Medicine Association have access to transcripts and further instructions about treatment strategies/options.

Brenda Scaggs, RN
Columbus Plastic Surgery
5005 Arlington Centre Blvd
Columbus, OH 43220
United States
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Alves, Rubina, and Ramon Grimalt. “A Review of Platelet-Rich Plasma: History, Biology, Mechanism of Action, and Classification.” Skin Appendage Disorders 4, no. 1 (January 2018): 18–24.

Botter, C, D Sawan, and M Sidahmed-Mezi. “Clitoral Reconstructive Surgery After Female Genital Mutilation/Cutting: Anatomy, Technical Innovations and Updates of the Initial Technique.” AJO-DO Clinical Companion 18 (2021): 996–1008.

Chung, Eric. “Regenerative Technology to Restore and Preserve Erectile Function in Men Following Prostate Cancer Treatment: Evidence for Penile Rehabilitation in the Context of Prostate Cancer Survivorship.” Therapeutic Advances in Urology 13 (January 1, 2021): 17562872211026420.

Number 5, STL Volume 24. “Platelet-Rich Plasma (PRP): Current Applications in Dermatology.” Accessed August 26, 2021.

Sadat Seidu, Anwar, Haruna Danamiji Osman, Kingsley Appiah Bimpong, and Kwame Afriyie. “Case Report Female Genital Mutilation/Cutting Resulting in Genital Tract Obstruction and Sexual Dysfunction: A Case Report and Literature Review,” 2021.

Sánchez, Mikel, Eduardo Anitua, Diego Delgado, Peio Sanchez, Roberto Prado, Gorka Orive, and Sabino Padilla. “Platelet-Rich Plasma, a Source of Autologous Growth Factors and Biomimetic Scaffold for Peripheral Nerve Regeneration.” Expert Opinion on Biological Therapy 17, no. 2 (February 1, 2017): 197–212.

Seidu, Anwar Sadat, Haruna Danamiji Osman, Kingsley Appiah Bimpong, and Kwame Afriyie. “Female Genital Mutilation/Cutting Resulting in Genital Tract Obstruction and Sexual Dysfunction: A Case Report and Literature Review.” Edited by Daniel Martin. Case Reports in Obstetrics and Gynecology 2021 (August 10, 2021): 1–4.

Sharif Mohamed, Fatima, Verina Wild, Brian D. Earp, Crista Johnson-Agbakwu, and Jasmine Abdulcadir. “Clitoral Reconstruction After Female Genital Mutilation/Cutting: A Review of Surgical Techniques and Ethical Debate.” The Journal of Sexual Medicine 17, no. 3 (March 2020): 531–42.

Wu, Yi-No, Chun-Hou Liao, Kuo-Chiang Chen, and Han-Sun Chiang. “Dual Effect of Chitosan Activated Platelet Rich Plasma (CPRP) Improved Erectile Function after Cavernous Nerve Injury.” Journal of the Formosan Medical Association, March 27, 2021.

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Cellular Medicine Association




Here are 5 things that helped me last week…

1. Idea/business book that helped me last week…

Thinking with Concepts

In 1979, in college, I took a course in embryology. With great excitement, I thought, “Now, I’ll finally figure out how babies grow!” Two weeks into the course, I felt a deep sense of disappointment: I realized that the course described in great detail what happens in the uterus, but with no explanation of why/how. There’s a great temptation to think that because we name something, or draw a picture of it, that we explained it. But a name, a concept noun, does not explain. Richard Feynman discusses this idea of concepts in a video where he tells how his father encouraged him to think by telling him (when observing a ball) that the name for the occurrence is momentum, but why it occurs is not known.

Those not trained in science usually think that we, as physicians, know and can do more than we can because we know the names of lots of diseases and can draw pictures of what the etiology looks like under the electron microscope.

Thinking with Concepts, the first chapter gives a list of methods to realize when you’re dealing with a fact, like the capital of the US is DC, and when you’re dealing with a concept, like inertia or cell differentiation—and how to think about each.

2. “Health” book that encouraged me last week (and remembering mothers of children with cystic fibrosis)—

Savage Factors, Peak Physical, Mental, & Sexual Performance Through the Practices of Ancient Civilizations.

One of the great medical innovations of mankind has been vaccines. One of the corollary dangers, however, of vaccines has been the false assumption that vaccines can completely compensate for an unhealthy body. Before we had so many antibiotics and antiviral medications, when my father was a child during the days of polio, mothers and grandmothers preached staying very well and practicing health practices so the body could defeat infection.

The fear: hospitalization with severe COVID-19 from which no medication and no ventilator can save you, that fear, that’s what every mother fears for her child with cystic fibrosis—they know a severe life-threatening pneumonia will very likely attack their child. So of course, they get their children vaccinated. But, you know what else they do? If you look here (click), you’ll read what I’ve seen first hand, the first advice of those mothers is “Help your child stay as healthy as possible.”

I don’t mind that Fauci preaches masks and vaccines; I’m puzzled that I never hear him preach, “Stay as healthy as possible,” or warn truthfully that “If you are obese, your chance of dying from COVID is increased one-hundred fold.”

Instead, physicians who talk about staying as healthy as a way to prevent COVID risk being labeled anti-vaccine and losing their license.

Though I’ve often been unkind to my body, I’ve been a Jack Lalanne fan and a Paul Bragg fan most of my life, but after reading this article about hormesis (click) a few years ago, the idea of hormesis seemed important, so I wrote a book for my own reminders about ways to stay healthy. After losing, last week, a dear friend and local cardiologist to COVID, l reread the book to remind me what I should be doing to stay healthy: Savage Factors, Peak Physical, Mental, & Sexual Performance Through the Practices of Ancient Civilizations.

3. Most important research I read this week —

Histopathology and Ultrastructural Findings of Fatal COVID-19 Infections on Testis

We all learned in medical school about mumps causing orchitis and leading to low testosterone or infertility, but we have not thought as much about it as an outcome from COVID. Not only can COVID infect the testes, but there are reports of it causing Peyronie’s.

Knowing this helped me last week while thinking about men who trust me with their health.

4. App I Used Every Day

Evernote. We use it at the office to communicate with each other and to store our company documents. And, I use me personal account to scan research and just about everything.

5. Quote I’m pondering —

Freeman Dyson, in Disturbing the Universe, describing his observations of Bomber Command during World War II (he was a mathematician who was involved in thinking about the war and weapons)…

“The Lancaster a magnificent flying machine, made into a death trap for the boys who flew it. A huge organization dedicated to the purpose of burning cities and killing people, and doing the job badly. A bureaucratic accounting system which failed utterly to distinguish between ends and means, measuring the success of squadrons by the number of sorties flown, no matter why, and by the tonnage of bombs dropped, no matter where. Secrecy pervading the hierarchy from top to bottom, not so much directed against the Germans as against the possibility that the failures and falsehoods of the Command should become known either to the political authorities in London or to the boys in the squadrons. A commander in chief who accepted no criticism either for above or from below, never admitted his mistakes and appeared to be as indifferent to the slaughter of his own airmen as he was to the slaughter of Germans civilians. An Operational Research Section which was suppose to give him independent scientific advice but was too timid to challenge any essential element of his policies.”

Does the news ever seem to you to be “copy and paste” from the history of previous generations? How odd that we are surprised.


And, please give me feedback: hit “reply” and shoot me an email, or on our membership sites, or on our weekly Journal Club with Pearls & Marketing. Which bullet above is your favorite? What do you want more or less of from the CMA? Other suggestions? Please let me know!

Have a great week!


Charles Runels, MD

P.S. The last book I launched could be of help to your patients who suffer from premature ejaculation: Extend Sex: The 30-Second Trick.
You’ll notice that my trick makes use of the functional anatomy, even though I did not know the anatomy when I dreamed this up 40 years ago.

Next Hands-On Workshops with Live Models<—

FORWARDED THIS MESSAGE? Learn more about the CMA here<—

Keloid & Female Genital Mutilation…Treatment

Red Alinsod, MD

Dr. Red Alinsod discusses the non-surgical and surgical treatment of female genital mutilation.



Dr. Charles Runels discusses the treatment of Keloid with Botox® & with the Vampire Facial® procedure (and how that compares with triamcinolone)

Surgeons can apply to study Dr. Alinsod’s surgical techniques<–

Physicians & Nurse Practitioners Can Apply to Learn Vampire Facial®, Vampire Facelift®, and O-Shot® Procedures<–

PRIVATE: Members of the Cellular Medicine Association can access links to the research quoted and to a transcript of the video in any language within the membership sites (to be posted on Monday)<–

Next Joint Injection Class<-=0

Business Consultant

Business Consultant



This is primarily a sales job helping us grow our team of physician providers. We are looking for someone with a strong background in telephone sales. It can be done remotely from any secure and fast internet connection through our software: Zendesk.

Because of our rapid growth, we see an immediate need for determined individuals to join our mission-driven team. If you find yourself interested in customer service, customer support technology, or the health/beauty industry, then you will find this job fascinating and rewarding. Though the primary outcome is sales, this is accomplished by a strong need to serve physicians and their patients for better outcomes–resulting in sales that benefit all parties. Business Consultants of the Cellular Medicine Association primarily serve as an essential link between our engineering team, fulfillment, and our physician team (our teachers and in-house physician, Dr. Runels), and our user community of very brilliant, innovative, brave, and motivated physicians.

The Client Success Team responds to customer (physicians, patients, and industry leaders) inquiries and provides user guidance through the software and telephone interactions.

We are looking for individuals with a positive attitude, problem-solving skills, and excellent written and verbal communication skills. A successful candidate will be comfortable helping strangers, have a friendly demeanor and will be willing to go the extra mile. We are a technology company, so technical experience is a plus. However, all representatives go through our new hire training course before being exposed to customer issues, so individuals of all levels of technical skill levels are encouraged to apply. We are proud to offer an intuitive software tool, so if you can smile and navigate a keyboard (type 55 words or minute or more…test yourself here), then our team is waiting for you!


Our office researches, markets, license,  & legally protects procedures that improve beauty and sexual health. If talking about either of those two subjects (including men having sex with men and women having sex with women) makes you uncomfortable, then this job will make you unhappy. We recognize the importance of sex in most relationships and make no apologies for researching and discussing ways to improve the lives of people by improving their sexual function.

Here’s more about our company and its mission (to improve health, sex, and family worldwide) <–

Benefits (click)<–


Provide friendly and efficient service to the worldwide Cellular Medicine Association community

Conduct Client Success calls to onboard new clients while providing proactive support and education through implementation

Respond professionally to inbound phone calls, tickets, and chats (including urgent situations)

Identify and escalate issues appropriately to the Technical Support, Billing, and Fulfillment team.

Provide dispatch for all incoming inquiries

Monitor and control numerous concurrent tasks

Proactively and independently work to meet targets and goals

Identify ways to improve the customer experience

Identify ways to increase the efficiency of the team

Must be available for a regular schedule of 40 hours a week, spanning weekends and holidays (as our customers need us all over the world); shifts may include evening or early morning hours but you will have four weeks off for vacation.

Patience and an ability to manage stress

Professional and approachable in correspondence

Strong communication and interpersonal skills

Ability to work under pressure and adapt quickly to adverse situations

Technical aptitude and the ability to learn quickly

Must be fluent in English

Preferred Skills

Knowledge of and experience in measuring and improving customer satisfaction

Familiarity with ticketing systems

Physical Demands

Must be able to remain in a stationary position for long periods of time. The person in this position needs to occasionally move about inside the office to access file cabinets, office machinery, etc. Constantly operates a computer & telephone and other office productivity machinery.

The person in this position frequently communicates with customers to answer their inquiries and guide them through the software. Must be able to easily exchange accurate information over the phone in these situations.

Send resume to Put, “application” in the title

5 Things that Helped Me Last Week (2021August1-7)

For Members of the Cellular Medicine Association


Here are 5 things that helped me last week…

1. Popular Magazine that Helped Explain to Women What We Do —

“Beyond Kegels: The Pelvic Floor Is Finally Getting the Attention It Deserves” Much gratitude to Cindy Barshop (who was interviewed for this article in Vogue) for her brave efforts to help women. The phrase “pelvic floor” has always felt less glamorous than what the muscles deserve (we usually don’t hold the floor of something in the highest of esteem). But, of course, without the pelvic floor functioning properly, neither continence nor sex works as well. Instead of thinking in terms of a general mass of muscles, women seem to find it more helpful to talk about the specific sections of the “floor” that serve the various functions. I’ve started using the terminology “G-spot support muscles” or “GSSM” for those muscle most contributory to sexual arousal. This idea of specific sections of the pelvic floor also help explain why our O-Shot® procedure works (click)<—.

2. Marketing/business/thinking book that helped —

The Lifetime Learner’s Guide to Reading & Learning (Hoover, 2017) This author is a monster…he lives in a 33 room house so that he can keep is library of 57,000 plus books. I think that qualifies him to make some reading suggestions (both books to read, and tips about what to read). He claims that only about 30% of what’s in his books is on the internet. I don’t know what the real number is, but I know that few people are inspired by a thumb drive on a shelf. And quite a bit that lives on the shelves of my home and office cannot be found online.

3. Most important research I read this week —

Materials Selection for the Injection into Vaginal Wall for Treatment of Vaginal Atrophy This very nice review article of most everything that’s been in injected into the vagina to help it work better puts an up-to-date and balanced view on where the science is now. They get a few things confused about our O-Shot® procedure, but still they give it a fair and favorable nod. More up-to-date research about the topic can be found here<—

4. App I Used Every Day

I almost always start any writing project using Ulysses (including this email), then I move whatever I wrote over into where it’s going to be launched or further developed.

5. Quote I’m pondering —

“It’s time to let the secret out: Mathematics is not primarily a matter of plugging numbers into formulas and performing rote computations. It is a way of thinking and questioning that may be unfamiliar to many of us, but is available to almost all of us.”—John Allen Paulos (from his A Mathematician Reads the Newspaper).

I have often been aghast at how many talking heads on the news just blatantly twist the numbers. I suppose that there is the possibility of an honorable lie, but still, when I look at the numbers and know I’m hearing a lie, it somehow makes me feel like something is physically crooked and clouded. For example, in the early days of COVID, Dr. Fauci was quoting a mortality rate from COVID of 4%, but at the time those numbers were only from people who were hospitalized; no one knew at that time the incidence of COVID in the general population (including the millions not in the hospital). Had he qualified his mortality rate to mean “4% mortality in hospitalized patients,” I would have not felt betrayed—but he did not say that. So, with great disappointment, I knew that he knew what he said was not true (or at least impossible at the time to know to be true), so from then on, I knew he would lie to frighten me.

Here’s an article about how wrong Fauci was about the math early on (nothing of course about how a freshman statistics student could have known he was wrong, or that he’s too smart to not know).

I’m not talking politics, I’m not talking about whether to wear a mask, or get vaccinated—I’m talking math, and how seldom do even smart people remember the ideas behind the math.

Richard Feynman said, The experts who are leading you may be wrong.” And, “Another of the qualities of science is that it teaches the value of rational thought as well as the importance of freedom of thought; the positive results that come from doubting that the lessons are all true.”

Plugging numbers about COVID into formulas terrified people with wrong conclusions instead of notifying the people who most need to be warned (read this to see<click<).

I still seldom see anyone, Fauci included point out the huge increase in mortality from COVD with even mild obesity. Looking at the math, dropping BMI from high to normal would be more protective to an individual than wearing a mask.

Hence, my favorite quote for last week: “It’s time to let the secret out: Mathematics is not primarily a matter of plugging numbers into formulas and performing rote computations. It is a way of thinking and questioning that may be unfamiliar to many of us, but is available to almost all of us.

Reminds me of yet another quote that’s haunted me (this one from Thomas Jefferson), “If a nation expects to be ignorant and free, in a state of civilization, it expects what never was and never will be.”


And, please give me feedback: hit “reply” and shoot me an email, or on our membership sites, or on our weekly Journal Club with Pearls & Marketing. Which bullet above is your favorite? What do you want more or less of from the CMA? Other suggestions? Please let me know!

Have a great week!


P.S. The last book I launched could be of help to your patients who suffer from premature ejaculation: Extend Sex: The 30-Second Trick. You’ll notice that my trick makes use of the functional anatomy, even though I did not know the anatomy when I dreamed this up 40 years ago.

Next Hands-On Workshops with Live Models<—

FORWARDED THIS MESSAGE? Learn more about the CMA here<—


Topics Discussed Include the Following…

*Materials for Injection Into the Vaginal Wall
*What are we injecting: G-Spot or O-Spot (what’s the difference)?
*The change in FSFI and FSD-R after the O-Shot® procedure
*Dr. Elizabeth Owings discusses the Functional Clitoral Anatomy

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


Review of Materials for Injection into the Vaginal Wall

Charles Runels, MD (00:03):
Thank you guys for being here at the Journal Club with Pearls & Marketing (JCPM). And we have a very special guest tonight, Dr. Elizabeth Owings, who wrote a… She just clicked to me and said she got the wrong link. Okay. Let me send her another link or we’re not going to lose her. Hold on one second. Yeah. Okay. Just sent it to her again. Hopefully she’ll show up. Okay.

Charles Runels, MD (00:35):
So Dr. Owings, amazing, amazing physician who spent several months just studying the anatomy of the clitoris. It’s hard to believe it was actually left out of Grey’s Anatomy for a while. So Dr. Owings will be coming on in about 10 minutes. I’ve been spending a lot of time thinking about the functional anatomy, the way things that are and how we might improve our O-Shot®. Well, this paper just happened to come out, and it was actually brought to my attention by my fiance Alexandra, who’s a gynecologist out there in San Antonio. So thank you Alex, for showing me this.

Charles Runels, MD (01:11):
This came out, as you can see, it was come out in the past month and it was a nice review article that was published in Aesthetic Plastic Surgery about all the different materials that are being squirted into the vagina. Some of it you’ve seen, but having it all fit together in one paper with a very, I think, balanced view of it is helpful. I wanted to point out a couple of things, and you can download it. I’ve put it in the handout section. You just click on the little yellow flower it’ll pop up, and if you open it now, it’ll be still open when the webinar’s over. If not, it’s going to disappear.

Charles Runels, MD (01:55):
So here’s a couple of things that I noticed about this that I’d like to bring to your attention. First of all, this first little review paragraph just lists the things that have been published, and I’d like to point out that maybe multiple injections, I’m being a little picky here, but aren’t always needed. And when they talk about emboli, [inaudible 00:02:19] emboli, that happens, but it happens with HA, and that happens… Pulmonary embolism happens with fat. We haven’t had a pulmonary embolism. We’ve had one episode of blindness from PRP, and that was when it was injected near the eye. And so, except for that one episode, no one’s ever gone blind by injecting in the vagina, although pulmonary emboli have happened injecting fat and HA around the vagina.

Charles Runels, MD (02:51):
So anyway, there’s a nice little overview. I’m just going through it here, and you guys can point out, I’ll unmute the mic if you want to throw something in here. But they do point out that vaginal atrophy happens with estrogen levels being a main cause. Definitely a cause, it’s debatable how much, because there’s definitely a contribution from testosterone, as you guys know, not just estrogen. Many of you have discovered with testosterone creams also help the problem.

Charles Runels, MD (03:27):
And they’re about to quote one of the articles that are published together with some of the other people in our group. But one other thing before we get to that. On page 1232, they mentioned that… They started talking about the G-spot, and this becomes almost like a religion or a belief system more than science, I think. And although there was this study that came out in… Where this fellow, I can’t say his name. I met him. Really nice guy, at one of the [inaudible 00:04:04] courses, he did a series of dissections on cadavers and totally dissected out the G-spot. The reason I’m bringing this out is most people think that maybe it still hasn’t really been shown because there’s no specific tissue that anyone else has been able to find.

What are we injecting: G-Spot or O-Spot?

Charles Runels, MD (04:26):
The only reason I bring it out is that I think technically we’re not injecting the G-spot, and I want to make sure that we’re clear on that because… Hey, I see you, Elizabeth, thank you for jumping on. Because the G-spot, in my opinion, is a functional thing. That if you look at what Dr. Grafenberg talked about back in the fifties, and you really should do a Wikipedia read and then read all the references about Dr. Grafenberg. Amazing, amazing man, amazing story that I won’t get into now. But he thought the whole urethra was the most arousing erotic part of a woman’s body. The spot became more of a later idea. And I think it’s less established. I think most people were tending to talk more about the clitoral urethral complex, which is what Dr. Owings is about to talk about here shortly.

Charles Runels, MD (05:23):
But the G-spot is something that I think you find in the bedroom, I think it varies from woman to woman, and in the same woman, sometimes from moment to moment. But it’s in theory the place where the woman’s most aroused. And I think to point to it on an anatomy chart, it could be how you define it. You can decide that. You can decide your left ear lobe’s the G-spot if you want to, but I think the way Dr. Grafenberg talked about it, it was the most arousing place of the most arousing place. The most arousing spot along the path of the urethra, but really it’s nebulous.

Charles Runels, MD (05:58):
And that’s why with the G-Shot that was out and popular in the US a number of years ago, you had to quote map the vagina and find that place by stimulating the woman’s vagina. And in Europe, this is still done. In some of our offices it’s still done, but this is frowned upon by ACOG now, and you’re putting, I think, your license at risk if you do this in the United States with an HA in the anterior vaginal wall, because of the risk of granuloma. 1 in 40 in one study, that can cause obstruction, necessitating surgery to correct it.

Charles Runels, MD (06:34):
So the O-spot, we need a place to call our place where we put it. You can call it whatever. You can call it the Florida spot. I don’t really care, but calling it the most distal place in the peri-urethral area, between the anterior vaginal wall and the urethra most distal from the bladder, it’s a long-winded thing. So that is the description of it. I like calling it the O-spot. Nobody’s name’s involved, so there’s no ego.

Charles Runels, MD (07:09):
It’s just where we put our shot, and that you can point to on a map. So if you’re going to do the G-Shot, in my opinion, you need to spread the lady’s legs and find where she moans the most, which is… I’m saying it purposefully in a very offensive way, because some people think of it as offensive, even when you say it in a not offensive way. So I like to talk about, we don’t really map out the vagina when we do the O-Shot®, and we’re not looking for the G-spot when we do that. Okay. Now I just wanted to bring that out. Go read about Dr. Grafenberg. Couple of the things. I’m trying to keep to the schedule here. I’ve got about two minutes and I’m going to turn it over to Dr. Owings. There’s a lot more here. Let’s see.

The change in FSFI and FSD-R after the O-Shot® procedure

Charles Runels, MD (07:55):
If you go down to this little graph where they talk about the research we did, and just a couple of things to point out. It’s not apparent from this is that we published this little study. And what I did was I had a patient who used to work in getting universities ready for inspection by the FDA. After she retired from the FDA, where she was an inspector of research projects done by universities, after she retired, then she worked as a consultant on the other side to help people get ready for what she would have done when she worked for the FDA. I loved her, love her still. I saved her life with some stuff I was doing, and so she felt obligated. So I said, okay, let’s go through my charts. I don’t want to even touch the charts. And find women for whom we have a female sexual function index and a female sexual distress scale revised that was filled out plus or minus a few weeks around the 12 week mark. As you can see, 12 to 16 weeks. And we have one before and we have one at that time, because I think that’s when it probably maxes out. And just add it all up and let me see what it shows. My hands are going to be off.

Charles Runels, MD (09:10):
And she did it as meticulously as only an FDA person might do. And thankfully, it showed benefit. You realize I wasn’t even seeking people who were distressed. And ironically, of the two that showed increased distress on the distress scale, I called one of them because her distress scale had gone up, I think from a one to a two. It just bumped from zero distress, basically, to a little bit more distress. And when I asked her why her distress went up, she said, well, I’m having great sex, and now my boyfriend can’t keep up with her. So that was, that was her distress.

Charles Runels, MD (09:51):
The other woman had a divorce right after the shot, and her whole life was distressed. But the bottom line is that we showed some benefit. Obviously there was no placebo, and rightly so, he points that out. But I want you to know how those numbers were generated.

Charles Runels, MD (10:08):
This one, I think very well done. I think it’s complicating it. If you notice the people who were doing the procedures, like the recent one that made the cover of the journal Sexual Medicine, the people who were doing the sex procedures, who have never done this in the face, in my opinion, are complicating it. If you ever squirt PRP in the face, you’ll see, it’s like filling up a sponge. You wouldn’t feel obligated to stick the sponge, if it were small, in three or four different places. You would just put the needle in the sponge and it would fill without lots of sticks, which is what you see when you see PRP spread through the face.

Charles Runels, MD (10:47):
But not having witnessed that, I think some people complicate it, just my opinion. I may be proven to be wrong, but I don’t think you have to put multiple sticks. And I think most of what happens does go along, especially when you’re treating for stress urinary incontinence, but even when you’re treating for sex, because of the sensitivity of the urethra, I think anything away from 12:00 for sure, by the time you get to 2:00 and 10:00, perhaps benefits are rapidly declining. I’ve seen lectures about hyaluronic acid when I lectured in Europe, and many of you on the call now or listening later will know about this, because you live in Europe. We don’t have as yet an HA that’s approved for the vaginal space. The guy who invented [inaudible 00:11:42] came out with one that is, but the recommendation is that it only be used in the posterior vaginal wall for the same reason, I just mentioned. The G-Shot is not recommended, it’s condemned by ACOG, because when you put the HA in the anterior vaginal wall, some not happy things can happen. Where it’s safer in the posterior vaginal wall.

Charles Runels, MD (12:06):
The end point is often pH, which is interesting to us in the States. And you can see people are mixing it with PRP as we are doing in our wing lift. This, again, I think is something that hopefully will eventually be something we’re able to do here. There’s a region kit that comes with an HA as an activator that’s not cross-linked, that is supposed to be available here eventually.

Charles Runels, MD (12:34):
And then the collagen botulinum toxin, I’ll get back to fat as it does lead to embolism. When you get to stem cells, I don’t even like saying that on a microphone now because the FDA is so rambunctious about making sure we don’t talk about stem cells too much. So that’s it. Let’s see if there’s any other notes and we’ll turn this over to Elizabeth. Anyway, hopefully you guys will think about that, and… Oh, I know what else was going to show you. This last little part in the summary, and then I’ll shut this down. The references here are crazy good. So you might want to go through those when you have a Sunday afternoon. This part.

Charles Runels, MD (13:24):
Well, the bottom line is that instead of having one tool, the idea of combining tools is important. We definitely need to standardize it. The double-blind placebo needs to happen, but I think it might need to be a positive control, because saline is not a placebo. If you think about what happens when you power wash your driveway, I’m afraid there may be some disruption of tissue that makes it not a placebo. So in fact, our procedure is part biological by activating pluripotent stem cells with PRP-derived growth factors and cytokines. It’s partly a physical procedure when you’re hydrodissecting tissue. So it’s a little tricky doing a placebo-controlled trial, unless maybe you just stick the needle there. Anyway, I’m playing around with that. I actually stopped one study when I saw another study where the saline placebo worked almost as good as PRP and much better than you would have expected a placebo to work in a histological study.

Charles Runels, MD (14:30):
So I think now let’s unmute Dr. Owings and I have her beautiful pictures that she’s accumulated to help explain some of the function of the anatomy and how it relates to what we just talked about. Let’s see, I see two microphones, Elizabeth. I’m going to unmute them both. There you go. Should be live now.

Elizabeth Owings, MD (14:57):

Dr. Elizabeth Owings discusses the Functional Clitoral Anatomy

Charles Runels, MD (14:59):
You’re there. There’s something that’s causing an echo. So while she’s flipping that off, just to let you guys know, Dr. Owings is really a… I meet lots of smart people, but she’s one of those Renaissance ladies who has a music degree and plays the piano like Liberace or something, and she’s got so many fricking specialty trainings I can’t track them, and still looking for the new thing to think about. So thankfully some of those new things that she wanted to think about included our procedure. So let me see if I can make this… Yep. There it is. And I’ll just run through this whenever you tell me to, Elizabeth, and we can hear you now beautifully.

Elizabeth Owings, MD (15:47):
Okay. Terrific. Glad you can hear me. Just had two mics, because I didn’t know which one was going to link up right.

Charles Runels, MD (15:53):
[inaudible 00:15:53]. We got it now.

Elizabeth Owings, MD (15:55):
Perfect. So I guess I have been thinking about this. I’ve been thinking about this a lot. Any of you heard me give this talk, my third patient after I was trained in the O-Shot®… And I’ve got general surgery training and we do gynecology rotations and you learn about it in medical school. The third patient had lichen sclerosis. I had never seen it before to recognize it. Yes. Thank you, Charles. But this is a condition where the, the tissues just sort of adhesed together over the clitoris. You can actually feel it underneath there, but you can’t see it. And when you think about how to do an O-Shot®, it’s a bit perplexing and not something that you want to walk into.

Elizabeth Owings, MD (16:36):
My assistant had applied the lidocaine and I just came in to do the procedure. Very straightforward procedure, only it wasn’t. But it prompted me, I realized, I didn’t know nearly what I needed to know about the clitoris. I spent the next month, basically, downloading articles. I didn’t go back to the anatomy textbooks, because I’d already looked at them and they really weren’t helpful to me to really understand what was going on behind the scenes underneath the small, external portion of the clitoris, which is what anatomists tell us that the clitoris is, is just this tiny, external portion. And they’re thinking about… Do I have a pointer?

Charles Runels, MD (17:22):
I can give you the pointer. Hold on a second. Let me see if I can do that.

Elizabeth Owings, MD (17:26):
But just when they, in your anatomy books, they think of the clitoris is… Oh, there you are. Just this, the glans in the shaft. That’s all they think of as the clitoris. You may just want to point, Charles.

Charles Runels, MD (17:51):
Okay, I’ll point for you. All right. Let’s do that.

Elizabeth Owings, MD (17:54):

Charles Runels, MD (17:54):
Take it back. Hold on one second. Got it. Okay. I’ll be your pointer.

Elizabeth Owings, MD (17:55):
Okay. Be my pointer. So the glans in the shaft is all it would be pointing at. That’s just that top, just the very, very, part of the glans and the shaft, but not the deep part is what they thought. So the deep part would be the legs of the clitoris that Charles is pointing to now. And you can’t see that from the outside. And so modern anatomists and ancient anatomists don’t really think of that as part of the clitoris. So it’s the easiest for me to understand it is starting with the sameness, the things that are the same about the female anatomy and the male anatomy.

Elizabeth Owings, MD (18:32):
And so the male anatomy, almost everybody has seen an erect penis, an erect phallus. You’re familiar with the fact that it’s firm. It’s supposed to be firm when it’s erect, and what makes it from are these two tubes that fill with blood. When it happens normally, that’s wonderful. And then sometimes people have to take medications to make that blood flow happen. And then sometimes of course, people actually have to take an injection. It’s injected into the tube to make the blood flow in there to make the penis hard. If a man has a penile prosthesis, it’s basically implanted where these tubes are to make it erect.

Elizabeth Owings, MD (19:15):
Well, females have those same tubes. They’re just mostly on the inside. So this is the male, that Charles has pulled up for us. There we go. The big circles on the top, when I was in a microanatomy histology class, they told us to think of the cross section of the penis as looking like a monkey. Two big eyes, and those are those tubes that get hard. And then the part down at the bottom is the part that surrounds the urethra.

Elizabeth Owings, MD (19:43):
And so in the female… And there it is, there we go. That’s a nice picture of how these tubes are very wide open, ready to fill with blood, ready to become engorged. And they actually are joined and are one space towards the end of the penis, towards where the glans of the penis is. And they separate down at the base and in the deep parts of the penis. There’s another picture of it. You got that up at the top, there’s this combined space, there’s a septum, but it’s got a lot of space in there where fluid can flow back and forth. That’s why when you do a Trimix injection for the penis to become erect, you only have to inject in one spot. And that fluid in the medication is active throughout that whole space. When we do our PRP injections, very shortly after it’s injected, it becomes a platelet-rich fiber matrix. It turns into a clot, basically, on the inside, but not the bad kind, not the kind that causes problems. This is the kind that’s basically generating those healing factors so that the function is going to improve.

Elizabeth Owings, MD (20:54):
I just always like to include this slide, because you can see that even in the glans penis, you don’t think of it as a tube. And you’re looking at the microscopic section. There are these big spaces in it. And when you did your Priapus shot, when you did that injection in the tip of the penis, which is a completely separate space from those two tubes that become erect. But when you do that injection in the tip, it doesn’t raise a bleb, it doesn’t raise a wheel. This is a great picture so you can understand that there’s the spongy part that surrounds the urethra, that leads up to the glans, and it’s spongy, even in a very erect penis, the glans will have some give to it. Where the shaft of the penis will not. That’s that those tubes that I was talking about that become erect.

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Elizabeth Owings, MD (21:41):
The same thing happens in the clitoris. Those same tissues are all present. I love this picture, because this shows perfectly well where to put that shot. As soon as you see those side to side rugae in the vagina, just inside the hymen, even if you’re not sure if you’re looking at the hymen or not, if you see those lines going side to side, that’s the place where you put your O-Shot®. That is the O-spot.

Elizabeth Owings, MD (22:10):
The same thing on that right picture. You have a really good view now of where that O-Shot® goes, and then all of the deep tissues of the female that are all part of that clitoris. It’s all part of that clitoris complex. So it’s not just the tip, not just [inaudible 00:22:28]. So I just included this picture of me and my son out in front of a [Glendonhall 00:22:32] glacier, and there’s an iceberg down there. So just like they taught us about iceberg, most of it is under the surface. The same is true for the clitoris. Most of it is deep. The part that we see is a very, very small part of it. So go ahead into the next one.

Elizabeth Owings, MD (22:46):
And you can see this pretty well on the slide here. And if you think of this, what you’re looking at is maybe just a longitudinal section of the penis with a foreskin or prepuce surrounding the glans. Then that’s exactly what you’re looking at with the clitoris. And there are those two tubes that are going to make the clitoris hard just like the penis. It doesn’t stand up because of the way it’s constructed. A penis will stand up. The clitoris does not. It will become full and engorged, but it doesn’t stand up, just because of the way it’s constructed. We don’t need to look at that one. I like that next one though.

Elizabeth Owings, MD (23:25):
To just point out, this is a two year old child. This is fully developed. Just exactly like you would see in an adult. Go ahead to that next one. Again, great anatomical picture. The tip of the clitoris with the glans is what you would expect to see on the outside, with little shaft that’s going up. You might see that. But the vast majority of it is deep. So when you put an injection, not in the glans, but just behind the glans, you’re going into that tube, and the fluid will go all the way down. We’ve proven this on ultrasound. The fluid will go all the way down to the deep parts of the clitoris.

Elizabeth Owings, MD (24:04):
This is an MRI. This is a picture closest to the outside, and that’s why we call it the introitus and not the vagina on the line drawing right to the right. So these are 18 year old women who’ve never had a baby. And you can see where the vagina is. I love this MRI picture. Very clearly, you can see where the legs of the clitoris are deep, the glans and the urethral meatus right there with the introitus. That’s good. Just like that. Go ahead. There it goes.

Elizabeth Owings, MD (24:38):
A little bit deeper, the body of the clitoris they’ve got mapped out right there for you. And then the crura coming down side by side, and there’s the bulb of the clitoris. That is analogous to the corpus spongiosum in the male penis. And it’s there. I don’t think I’ve got the photomicrographs, but it exists all the way up to the glans of the penis, just like it does surrounding the urethra to the male. The urethra in the female just comes directly to the outside. It doesn’t have to track up to the glans like it does in the man.

Elizabeth Owings, MD (25:17):
There we go. And then deeper still, at the very top, you’ve got the mons. Right under that is the pubic symphysis, and right under that is the crus of the clitoris, and then the urethra. Under that, sort of with the transverse shape here, is the vagina itself. Go ahead to that next one.

Elizabeth Owings, MD (25:43):
This is one of my favorite views, because you really get an idea… They tilted it, it’s not exactly anterior to posterior. It’s tilted just a little bit so that you can see the entire body of the clitoris. You just get an idea of the glans at the tip, and then these deeper structures, all part of the clitoris that are surrounding the urethra and the vagina. And when you look at this picture, I think that’s when I realized anything that we do that makes those tissues more healthy and lens support to them… You expect your face to sag a little bit after 50 or 60 years, and probably every other tissue in your body is as well. So if you’re lending any support at all to these tissues, it’s going to support the urinary continence mechanism. It doesn’t make the muscle any tighter. It’s just lending support to these structures. They’re going to become not necessarily more engorged, but there’s just going to be more just basic tissue tone. Go ahead.

Charles Runels, MD (26:47):
Let me just throw one thing in there, Elizabeth.

Elizabeth Owings, MD (26:50):

Dr. Owings’ book to explain the clitoris. A great educational/marketing tool for physicians.

Charles Runels, MD (26:51):
We have an MRI study that’s listed on the reference page of the O-Shot® that showed where a female radiologist, she did MRIs just like this of women who have trouble with orgasm and women who easily orgasm, and there was a correlation with the size of the clitoris and the distance of the clitoris to the vagina. So the bigger the clitoris, and the closer to the vagina, the more it correlated directly with ability to orgasm. So just stressing I like this picture as well, because the idea of anatomy just being for surgeons maybe isn’t right, because we all have to think about how the parts work together. I think that this picture explains why just talking about a spot maybe as the main thing isn’t exactly so accurate.

Charles Runels, MD (27:47):
It shows where this clitoral urethral complex, it also points out why the answer to, if you’re going to treat urinary incontinence, do you still treat the clitoris? I think there’s two reasons why you do. One is, as you’ll see in these upcoming micrographs, but especially the one that Elizabeth just pointed out, there was some contribution to the clitoris to the continence mechanism. And then of course if you’re going to treat sex, do you still treat around the urethra, because of what we just talked about with Dr. Grafenberg. Of course you do that as well. So I always treat both, whether the complaint’s sex or incontinence. And I think, as you just pointed out, Dr. Owings, that picture tells a lot.

Elizabeth Owings, MD (28:36):
The other thing that I’ve noticed is even if people don’t complain, if something improves, when they see you again, they will let you know. So maybe urinary incontinence wasn’t the chief complaint, but when they come back in six weeks or six months or a year, maybe it’s time for another one, or maybe I had more than one patient that said, “Well, I thought I knew how good sex could be, but it was never as good as this. And I don’t know how good it can be. Let’s do it again. Let’s have another O-Shot®.” More than one, and not all young, healthy people. One of my earliest clients was a 65 year old woman, and she was just really excited with how positive her sex life could be. Thanks for moving me on here.

Charles Runels, MD (29:28):
That was an accident, actually. Finish your story. That was an accident.

Elizabeth Owings, MD (29:33):
That was the end of it. She did not have a lot of complaints. She just wanted some improvements in the sexual function characteristic, but urinary continence got better, and sex got a lot better. And when she came back, I actually treated her nipples, because at that point, I didn’t know if it would be beneficial or not. She did not have any problems with her nipples. She had normal sensation, had never had surgery on her nipples, but she had better sexual arousal from nipple stimulation. It was not just a part of her sexual response. In her words, it was off the chart. The party line for PRP is going to be two or three weeks for the start, and then three months for full effect. She hunted me down in the gym at six weeks, because we went to the same gym, and said, “That nipple thing is amazing. I had no idea that was possible.”

Charles Runels, MD (30:28):
Wonderful. It’s good [inaudible 00:30:29] that. And you and I can go all night, I love it, with stories, but I’ve had some men want their nipples done. And second point is that if someone comes in and talks about, I just want it for urinary incontinence, we all know it, but I think it’s worth bringing it out in the light that can we all agree that sometimes people lie about sex, or they’re embarrassed to talk about sex, and they might use it incontinence as a ticket to be there as we often have our patients do, but they’re just embarrassed to say about the sex part. So it’s another reason why I always treat the clitoris, even if they’re there for incontinence.

Elizabeth Owings, MD (31:08):
Well, exactly. And this is my slide of the title Why Girls Don’t Compare Parts. It’s just that the clitoris, which is the part that’s external is so small and so deeply hidden between the labia minora and the labia majora, there’s a prepuce there. It’s just hard to see. But the truth is, if you look at it, if this is what you do for a living and actually you are paying attention, it looks exactly like a little penis. How do you make it bigger? You give the woman testosterone. And that’s the sex change. Surgeons taught us that. I think it’s probably a slide later on.

Elizabeth Owings, MD (31:48):
I went ahead and looked at the gross anatomy. What do the surgeons who were doing the dissections, what are they seeing? What does it really look like underneath the skin? And so you can see there’s the glans of the clitoris and the clitoral body, which we’re used to seeing on the outside. And then those deeper structures that crus, the bulb, and the way they wrap around. Wrap around the urethra with the vaginal vestibule right underneath it. They’re just right there together. Go ahead. Same thing here, a little bit kind of from the side, the crus is sort of coming down. This long, long leg that comes down straight.

Charles Runels, MD (32:24):
I really like this picture. It really I think shows how everything’s laid on top of each other.

Elizabeth Owings, MD (32:28):
And the bulb actually comes a little bit forward, and the vaginal introitus is sort of all the way on the right side of the screen there with the bulb in the middle, and then the clitoral crus on the side there. That bulb is wrapped right around the vagina with the crus just outside of it.

Charles Runels, MD (32:49):

Elizabeth Owings, MD (32:51):
It’s the same picture. They’ve just turned it a little bit further.

Charles Runels, MD (32:58):
So I just want to rant shortly. How many of our colleagues think about the vagina as just a simple tube that leads to the cervix where you can deposit some semen? And how many people are taught all the way through college that that’s kind of what it is. And yet, when you see the elegance of the functional anatomy and what’s happening when there’s a penis here or what’s happening when various sexual or non-sexual activities go on. Obviously we all know it’s much more complicated than that, but I think showing and talking about this with our patients is very helpful. And with our colleagues.

Elizabeth Owings, MD (33:41):
Right. So again, it’s just a little bit of a different view, but the same concept. These pictures, I like, because you really get an idea. If you take the urethra and you look at the tissues around it, what are you looking at? And the answer is, so the urethra is kind of that hole in the middle. It’s got a U in it, and around it, you may see this. It’s erectile tissues around it. That’s where the deep areas of the clitoris are directly overlying the urethra. And then on top of that is the layer of muscle. And when that muscle is what’s responsible for our urinary… Well, that, and all the other structures. There’s no muscle that wraps all the way around the urethra like there is in the man. I’ve got a slide about that later. In the woman it’s just this band of muscle that’s listed up at the top and this… Go ahead to the next one. There we go.

Elizabeth Owings, MD (34:38):
SM is muscle. That’s it. And I counted it, because I’m that person. It’s about 30 cell layers thick. It’s not very thick. If you buy broccoli, that’s got that big thick, rubber band around it, it’s about that width, and about that thickness. It’s very thin, it’s not nearly as strong as that rubber band is, but it’s just not a very big muscle. And that is responsible for sort of pinching off the urethra against the anterior vaginal wall. So anything that you’re doing that’s going to lend some support to those structures on the on the inside, whether it’s the anterior vaginal wall, placing a platelet-rich fiber matrix right in between those tissues, that’s what you did with that deeper injection and the O-Shot®, when you can even actually feel it. It feels like a Walnut in there. That is going to support those structures for urinary continence. And I believe that that’s why the effects for continence are almost immediate.

Charles Runels, MD (35:44):
Elizabeth, something that I haven’t talked about that I’ve been trying to find more reasoning and a clearer picture about is that if you go to the sports medicine literature, PRP has been talked about quite a bit. It’s still debated about how effective it is, but when you injure muscle, as you know from your many surgery residencies, that it can turn to atrophy, it can be infiltrated with adipocytes or scar tissue. And instead of growing new muscle back, you’re left with this weaker structure. But you have a lot of research now showing that PRP can activate these stem cells that live within the muscle, mostly in the periphery of the muscle, that are just waiting to be activated to regenerate when there’s injury or stress.

Charles Runels, MD (36:42):
I’ve started to wonder if perhaps some of what we’re seeing with our great results with incontinence in my person is both the bulk that you just talked about and perhaps that we’re actually making these intricate muscles that we’ve just lumped together as the pelvic floor, but actually there’s all these different intricacies that are almost like the mast of a ship or something, with ropes going lots of different directions and lots of different opinions about which is pulling what. But the fun thing is when you just flood the whole area with PRP, and then you do your kegels or not, or you do your [inaudible 00:37:23] or not, we could be doing sports medicine in this muscle inadvertently, and without maybe thinking about it except when you show us these pictures and we say, “Oh yeah. Well, the erectile tissue’s important, the muscles are important. The blood flow is important. The nerves are important in both stress and urge incontinence.” And thankfully we have a material that makes all those things better.

Elizabeth Owings, MD (37:50):
It’s true. I’ve been blown away from the very beginning about what’s possible with platelet-rich plasma, and you can go back and forth about platelet-rich, platelet-poor, activated, not activated, leukocyte-rich and leukocyte-poor. It doesn’t matter. Ultimately, I find myself asking, can a human being, various functions, various portions be made better than they were with this as an adjunct? And I think the answer is very often yes. It’s not necessarily predictable who or where, but very often, yes. And I’ve had this more than once. “It’s never been like this before.” And that’s a happy thing for me.

Elizabeth Owings, MD (38:30):
This picture, this line drawing is my line drawing of the… The cross section is through the urethra that you just looked at the slides of just a minute ago, so that you can see there’s a spot right in between where the urethra is. The one big blob on your left is sort of the bladder. Ureter is behind that, and the vagina sort of underneath that. And then there’s this tract in between, and Charles talked about hydrodissection and we know that when we put our PRP in there, there is going to be some hydrodissection just based on where that is. I don’t think that alone would explain any urinary continence improvement, but I don’t know. I definitely don’t have the data on that.

Elizabeth Owings, MD (39:12):
But what this picture is just shows the darker area of the urethra is where all that erectile tissue is that I tried to show you in the cross section. And then a little bit further than that, a little bit closer to the end of the urethra is where that muscle is. Now, a lot of people have proven this. Going further back in there with your platelet-rich plasma does not make a better continence procedure. You still want your O-Shot® to go in the O-spot. That’s where you want your PRP to go, is just inside the most distal portion of the urethra, underneath the urethra just inside the vagina, just at that most distal point. Climbing in deeper does not do you any good. It does not help the patient.

Elizabeth Owings, MD (40:09):
It’s a beautiful artistic rendition that my friend Kent Rush did for the book. There’s some good pictures, but you just get the idea again. The clitoral legs are on the outside, and the bulbs are right there around the vagina itself. Go ahead to the next one. Same song. Second verse. Keep going.

Elizabeth Owings, MD (40:31):
This is the male sphincter. There’s really a sphincter. That’s that deep magenta thing marked SS around the urethra that’s marked U. It is truly a sphincter. It’s a band of muscle that goes all the way around the urethra. Women don’t have that. And the good news for men though, the P-Shot®, it can actually help that work better as well. I’ve helped a lot of people with, they’re just not functioning well, especially after prostate surgery. I’m not sure these men are getting what I would consider informed consent, but I don’t know. Anyway, the problems I think are much more common than people are led to believe. You may say that the incidence of this or that side effect is only 20%, but if it happens to you, it’s a hundred percent. So anyway, next slide.

Charles Runels, MD (41:21):
[crosstalk 00:41:21] placebo controlled study that I pushed out in another email with rats. And of course, with rats, you don’t have to worry about a placebo effect, and you can harvest the penis. But this is the third one I’ve seen where they looked at that, or they tried to model prostate surgery with nerve injury and injected the penis with PRP, and the other group got saline and then harvested the penis, and they saw repair. So anyway, I’m hoping one day, at least by the time my grandkids are grown, that PRP will be routinely part of the rehabilitation protocol [inaudible 00:42:03] prostate surgery.

Elizabeth Owings, MD (42:04):
I agree. So this female corpus spongiosum, let me just tell you why I included this slide. There is still a pervasive myth. It’s been in the medical literature for decades, for well over 50 years, that there’s no corpus spongiosum, but the glans of the clitoris comes off the corpus cavernosum because there is no corpus spongiosum. Once you know what the deeper structures are, and you’ve seen some of these photomicrographs, that’s obviously not true.

Elizabeth Owings, MD (42:40):
Somehow, Charles, this is… It’s slid off sideways.

Charles Runels, MD (42:48):
Oh, I did something wrong. I don’t know what I did.

Elizabeth Owings, MD (42:52):
So what they’ve done is given this woman testosterone and all portions of the clitoris have hypertrophied, including the corpus spongiosum. So the glans is pulled up by a suture at the very, very top. Point it up at the top. That’s it, right there. And the long strand right there would be what in a male would be surrounding the urethra. That would be the corpus spongiosum. This is a photo micrograph. It’s hard, I wish I had the pointer, but the bottom line is the corpus cavernosum are these two big round things, but the corpus spongiosum is there through the entire length of the clitoris all the way up. It’s submucosal, meaning if you’re looking at the outside of the vulva, you won’t know it’s there. You would have to do a dissection, but it’s there. The whole way.

Elizabeth Owings, MD (43:51):
Go ahead with the next one. This is [Ashazinsky 00:43:55], the guy with the hardest name to say, who said he dissected these out. I think you can probably only do this in Poland. Eight consecutive cadavers. And he dissected out this thing he called the G-spot. There’s an ongoing debate. If you go to, and just put in G-spot and anatomy probably it’ll come up. Helena O’Connell, the lady who did, I think, some of the gross anatomy dissections, and maybe the MRIs too, I can’t remember. I think she was also a partner on that study. Has gone through and done all these dissections and said there’s no such thing as the G-spot. But the debate rages on.

Elizabeth Owings, MD (44:39):
So if you look at this nice picture he gave us, because this thing that he found, which looks sort of like a thrombosed hemorrhoid, it is deep inside the vagina and right near the bladder. And so that might make you think, well, this is going to work better for sex if I go really, really deep with my O-Shot®. And again, it doesn’t. It doesn’t work for sex, and it doesn’t work better for incontinence. I don’t know why.

Elizabeth Owings, MD (45:06):
There you go. Those were those pictures for the lichen sclerosis. You won’t harm anyone by putting PRP in that. That is actually the treatment. I thought I could learn this, and I really think they belong in a center of excellence. I refer everybody to Kathleen Posey in Mandeville, Louisiana on the north shore above New Orleans. Someone once listened to my lecture, what you’ve heard so far, and said, “Well, we know why women have urinary incontinence. It’s because when they have a baby that this is torn and that is torn.” Which it set my teeth on edge because it’s obvious to me that there are plenty of women who’ve never had a baby that have urinary incontinence. And if I go to PubMed and just type in urinary incontinence, and nulliparous, I get a whole couple of… I don’t even remember how many. You should go look at it. Articles about where people have looked at this.

Elizabeth Owings, MD (46:07):
So anyway, we’re biased. We think that if you’ve haven’t had a baby, then you shouldn’t have as much incontinence as if you have had a baby. If you’re in shape, then you should not have incontinence. And if you’re out of shape, then that’s more likely. And if you’re old, then you should have more than young. And that’s not quite what we found at all, if you look at all these reviews from 1% to 42%, depending on various factors. Heavy women seem to have it worse. Childhood bed wetters and people who engage in high-impact exercise are more likely to. Even women without babies who’ve had… Go ahead to the next one. So even we find that women 18 to 40 who’ve never had a baby, are active and have a low BMI may have up to 23% urinary incontinence. Go ahead.

Elizabeth Owings, MD (47:01):
30% in athletes versus 13% in controls. These are young women, roughly median age, 19. 372 athletes and 372 age match controls. Their risk factors were high-level sport, a history of urinary tract infections, had family history of urinary incontinence, and constipation. And I think the family history of urinary incontinence goes along with maybe some anatomic features. History of constipation, I think probably as well as high impact exercise goes along with increased abdominal pressure. You’ve got all this pressure. Just think about jumping on a trampoline, just like jogging. A woman with urinary incontinence may never jog again. She may just walk. So that’s something that you can use to reach people and reach their pain. If they’re changing their lifestyle because of urinary incontinence, that’s a big deal. Go ahead.

Charles Runels, MD (47:56):
I think you just made a big point. How much leaking do you have to have before it counts as incontinence? Sort of like the question, how big does a boat need to be before it’s a ship? It has to be so big you cannot carry it across land. Now it’s a ship, not a boat. And the answer to how much leaking before you have incontinence… For you guys on the call, I haven’t tried to define that… Is if it interferes with your hygiene or your lifestyle. So you have to start wearing a pad or change your clothes, obviously, hygiene. If you stop something that you normally like to do, like your gymnastics or cheerleading as a teenager, which is 1 in 20 teenagers, in college people, or you can’t sit through your meeting at work, you’re changing your lifestyle. That’s incontinence.

Elizabeth Owings, MD (48:44):
Yeah. So many of these are similar. Go ahead and see if you can find a sister study. It’s not too much further ahead. Yeah, sisters. I love this. So they took post-menopausal women, and one sister had never had a baby and one sister had had a baby, and they found that the incidence was exactly the same. 47 versus 49%. That is not statistically significantly different.

Charles Runels, MD (49:08):
Totally unsurprising, huh?

Elizabeth Owings, MD (49:11):
Yeah. And then sisters had a high concordance. They were very likely to have the same situation. If one had normal continence, then the other one probably did. And the same thing for incontinence. Go ahead. And then the elite trampolinists. So this was fun. So 80% of the… These were 12 to 22 year olds. Mean age was 15. 80% during training, they would leak about an ounce. Started after two and a half years of training.

Elizabeth Owings, MD (49:41):
And if they put a pad in and tested, they found that it was a hundred percent over the age of 15 were leaking during their training event. So it’s not a sphincter, that urinary incontinence mechanism. There are a lot of parts to it. It’s much more sort of like a siphon, like a valve and not a sphincter. Because it can be overcome, just like the valves and the veins in your leg can be overcome if there’s enough pressure. So that’s what I wanted to say there.

Elizabeth Owings, MD (50:12):
Thinking about this in the future and how to teach this and how to think about this, I’ve been thinking about models. I think that’s where I’m going to be going. The direction I’m going to be taking is making a form of model where some of these parts can be snapped together and then unsnapped so that you’ve got not just a visual, but you can actually hold things in your hand and go, “Oh, this is how this goes together.” With perhaps various stages in, because it’s the same, maybe at eight weeks gestation, it’s exactly the same. You can’t tell the difference, whether it’s a male or a female. They are the same at that point, from the standpoint of what the tissues look like. And these changes come over time. Lots and lots of influences, and over the weeks, between 7, 10 weeks or so, things are changing so that eventually you can tell the difference, which is a boy and which is a girl. Usually. Those ultrasound people get it wrong sometimes.

Charles Runels, MD (51:20):
I’ve never seen such a low dropout rate. You’ve held everybody’s attention. I think this is the best clitoral anatomy… and I’ve heard others… lecture I’ve ever heard. And could I just have an email that people could contact, because I know that you teach classes. Dr. Owings will do a one-off class if someone wants to go follow her around and see how she thinks about her business. She’s in several different cities with her practice, so there’s some menu there to choose from. Could I just type an email address into the chat box so they can reach out to you?

Elizabeth Owings, MD (51:55):
Sure. That’d be great. E as in Elizabeth, P as in Patricia, Owings, O-W-I-N-G-S

Charles Runels, MD (52:03):

Elizabeth Owings, MD (52:03):
Am I supposed to do that or are you going to do that?

Charles Runels, MD (52:06):
I just typed it in. It’s all there. Thank you so much for being on the call. Anything else you want to throw out there before I shut it down?

Elizabeth Owings, MD (52:12):
No. No. Just looking forward to hearing from everybody. Thank you so much for your attention.

Charles Runels, MD (52:16):
Thank you, Elizabeth. You have a wonderful night.

Elizabeth Owings, MD (52:22):
You too.

Relevant Links

Zheng Z, Yin J, Cheng B, Huang W. Materials Selection for the Injection into Vaginal Wall for Treatment of Vaginal Atrophy. Aesthetic Plast Surg. 2021;45(3):1231-1241. doi:10.1007/s00266-020-02054-w<-click-to-read<–
Runels CE, Melnick H, DeBourbon E., A Pilot Study of the Effect of Localized Injections of Autologous Platelet Rich Plasma (PRP) for the Treatment of Female Sexual Dysfunction. J Women’s Health Care 2014, 3:4
—>>>Click here to read. The introduction explains the science of the O-Shot®<–click<—
Altar™–A Vampire Skin Therapy™




Cellular Medicine Association

5 Things that Helped Me Last Week (2021July25-31)

For Members of the Cellular Medicine Association


Here are 5 things that helped me last week…

1. Medical Text Book that Helped —

Pelvic Floor Dysfunction: A Multidisciplinary Approach, 2006. Looking at the history of bulking agents for stress urinary incontinence, SUI (Chapter 121) to think about what’s going on with our O-Shot® procedure and how it compares with what’s been used historically. Bulking agents for SUI were first introduced in 1938. Agents tried in the US include bovine glutaraldehyde, cross-linked collagen, autologous fat, carbon-coated beads. In other countries, the list extends to silicon, polytetrafluorethylene paste, calcium hydroxylapatite, hyaluronic acid, and injectable micro balloons. The chapter helps define what the ideal agent would look like: hypoallergenic, nonimmunogenic, not cost-prohibitive, easily handled and stored, ease of injection into the correct location, no migration of the material. I did not introduce the O-Shot® procedure until 4 years after the book was published. But, the history of the effort to find the “ideal bulking agent” as outlined in this book is a great checklist to check if we now perhaps have it…and how it can be improved.

2. Marketing/business book that helped —

WHATEVER IT TAKES, Master the Habits to Transform Your Business, Relationships, and Life (Bornancin, 2021) At first I thought, I’ve heard all this already, but he puts his personal tweak on what I knew already to both remind me and to supercharge the idea. For example, how he handles vacations (I also start to fidget after 3 days) and extra money (he recommends having “No extra money) pages 206-208 were interesting and helpful to me.

3. Most important research I read this week —

Dual effect of chitosan activated platelet rich plasma (cPRP) improved erectile function after cavernous nerve injury We’ve been seeing our Priapus Shot® procedure be of help for penile rehabilitation post prostate surgery for a decade now. This is the third paper I’ve seen that addresses how the PRP may be affecting regrowth of function…but this is the best one. One could almost argue that it’s becoming below standard of care to not offer PRP post prostate surgery—very low risk and relative cost combined with very high possible benefit. Other papers supporting the idea can be found here. Drs not yet doing the Priapus Shot procedure can find training here.

4. App I Used Every Day

I use “focus” to keep from getting sucked into my computer and losing track of time. The app makes use of the principles in the Promdoro technique. Here’s the app.

5. Quote I’m pondering —

“If you don’t take weekends off, and you don’t take vacations, you still have seven evenings a week of unlimited time to do whatever you want, every night of the week anytime after…Girls don’t put on high heels and makeup until nighttime.”

—Gene Simmons (from his SEX MONEY KISS). Many don’t realize the Simmons claims to have NEVER been drunk or had “anything that looked like cool-aid” up his nose. His mother, Flora Klein, survived the Holocaust because she was a hairstylist who took care of a commandant’s wife’s hair (and by living on scraps). Simmons may have been outrageous as a musician, but he’s also a hardcore, brilliant businessman who self-promoted KISS and multiple licensed intellectual properties until he became the 6th richest musician ever. He claims to have never taken a vacation.

You can substitute “children don’t get home from ball practice,” or “wife or husband doesn’t come home from work,” for “girls don’t put on high heels and makeup” if that makes the quote work better for you.

I know he’s outrageous, but he’s brilliant and anyone with a mother with that background is probably going to be intense and solid in important ways.

And, please give me feedback: hit “reply” and shoot me an email, or on our membership sites, or on our weekly Journal Club with Pearls & Marketing. Which bullet above is your favorite? What do you want more or less of from the CMA? Other suggestions? Please let me know!

Have a great week!


P.S. The last book I launched could be of help to your patients who suffer from premature ejaculation: Extend Sex: The 30-Second Trick. You’ll notice that my trick makes use of the functional anatomy, even though I did not know the anatomy when I dreamed this up 40 years ago.

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Next Hands-On Workshops with Live Models<–

Research regarding acne scars<–

New research regarding the injection of ovaries with PRP<–

Homologous vs Autologous 

Cellular Medicine Association<–