JCPM2021.10.06 PrematureEjaculation.3TypesOfWomen.WhyUseHAInsteadOfPRF?

Topics Discussed Include the Following…

*Premature Ejaculation treatment
*The Three Categories of Women Who Need Hormones
*What is Premature Ejaculation (how long is not long enough)?
*Why use HA instead of PRF sub q?

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

Relevant Research, Transcript, Relevant Links

Relevant Research

Abdallah, H., T. Abdelnasser, H. Hosny, O. Selim, A. Al-Ahwany, and R. Shamloul. “Treatment of Premature Ejaculation by Glans Penis Augmentation Using Hyaluronic Acid Gel: A Pilot Study.Andrologia 44, no. s1 (2012): 650–53.

Kwak, T. I., M. H. Jin, J. J. Kim, and D. G. Moon. “Long-Term Effects of Glans Penis Augmentation Using Injectable Hyaluronic Acid Gel for Premature Ejaculation.” International Journal of Impotence Research 20, no. 4 (July 2008): 425–28.

Martin-Tuite, Patrick, and Alan W. Shindel. “Management Options for Premature Ejaculation and Delayed Ejaculation in Men.Sexual Medicine Reviews 8, no. 3 (July 2020): 473–85.


Premature Ejaculation

Thank you for being here tonight. I had a request that we talk about premature ejaculation. So that’s the topic tonight. If you have an interest in that, hang with us. If you don’t, that’s the main topic, so you might want to go watch the news or something. And I hope you guys will jump in–I see some smart people on the call tonight. So I don’t want this to be about me.

I’ll show you some of the research I’ve looked at. I’ll tell you a story or two about the patients that I’ve treated, and then hopefully you guys will have some feedback. It has been something I’ve had an interest in. I’ll show you a quick thing, I threw this book together a few months ago.

It’s running pretty well. Even though this looks cool that [today] it’s number two, it’s number seven in men’s sexual health, whatever, you don’t get rich on that, but it does help. In the back of this book, it mentions the Priapus Shot® procedure, so hopefully, it helps people find us. And it gives one of the most, I think, effective tricks ever that I’ve never read in another book or in the research. I have no idea why no one has ever else ever written about this and I think it works better than anything.

How many of you ever had this happen? Like 20 years ago, when I was doing hormones and pellets before Suzanne Somers wrote the first book, I was doing testosterone pellets. And the lady gets her sex drive back, and then she comes in the office crying. I’m thinking of a particular woman in her mid-20s, married to an attractive, athletic, wealthy man in town, a gorgeous house, a pretty baby.

Everything’s perfect except she said, ” My sex drive is up, but I don’t even want to start a sexual activity because I know it’s going to be over so quickly.”

The analogy that popped into my head is, “If every time you cranked your Lamborghini you knew the engine was going to die before you got to the end of the driveway, you might still have a Lamborghini, but you’re just going to quit cranking the engine.

It sounds like a nuisance problem, but for many women, Premature Ejaculation (PE) is a major problem that breaks the marriage. The man starts to avoid the woman and it just breaks marriages.

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When I look at what’s written in the literature, which we’ll look at in a second, and hopefully you can get this thing, I purposely made it for free. If you’ve got a Kindle, you can read it for free. I’m not trying to hold out on you, I’ll cover it in a second. But I want to cover what I think is an overall plan that works and talk about what’s new about what’s happening with our PRP and what some of our providers are doing on the procedure side to help this problem.

So let’s just jump over. Oh, the other thing, and I’ll just tell you, I don’t want to give you TMI sort of thing, but the first time I had sex, it did last about maybe 30 seconds. But being the nerd that I am, I just read everything on the planet about it and came up with a system, and within a short time as a teenager, it was just a light switch, we can go all day or we can go 30 seconds, whatever you want. And I’m glad I had that experience because it made me figure it out.

And so I wrote … Okay, let me go back. I’m jumping around. Let me just go, I’m going to walk you through what’s worked for me. And when I wrote this other book, this one, this is actually the first, I’m almost embarrassed to call it a book. What happened was back 21 years ago when I’m doing hormones and this woman comes in and does that, and another woman, and another woman. And some of it was premature ejaculation, some of it was just man’s not interested. And if you remember, 21 years ago, only men doing hormones, women were taking Premarin and Prempro and Menthol back in the late ’90s, early 2000 that really only bodybuilders took hormones. So it was hard to get the men to come to see me after the women were fixed. Fixed doesn’t mean obviously their sex drive was back. That part was fixed and things were working and they lost 40 pounds, and now the man they love, or the woman, but the man, they love can’t keep up with them.

One of the hurricanes came through and it was the first time I’d been able to actually leave town because as an ER doctor, I was in the disaster committee, so I never got to evacuate. This is the one and only time I ever evacuated from a hurricane since I’ve lived at the Gulf, 1991. I watched Katrina from the back porch. I used to wonder why do people die and stay and die in hurricanes, it’s because they’re fun.

Hurricane sex is worth dying for almost.

I rode out Hurricane Sally on my little 43-foot yacht with my fiance. So yeah, hurricanes will kill you, but if they don’t kill you and rip up your town, they can be fun. I was bored. This is the only hurricane I left for and I was bored and so I wrote out what I would tell the husband of these patients, these women that were sad.

The Three Categories of Women Who Need Hormones

And remember women come in three flavors when they get hormones.

One flavor is they’ve been abused by their husband, so when they lose their weight and get their sex drive back, they’re leaving and there’s nothing you can do about it.

The other flavor is they have a very healthy husband and when they get their sex drive back and their figure back, they go live happily ever after, you never have to talk to the man.

But the third flavor is why lots of gynecologists are doing P-Shots® and doing hormones. It’s the woman who gets her sex drive and her health back and her figure back and her confidence back, and she loves the man, but he’s not healthy, and now he can’t keep up, but she doesn’t want to go to someone else, she wants him to catch up with her. That’s the troubling thing that happens.

And I’ve had women actually cry and say, “Just take me off the hormones because I love him so dearly, I’d rather just not have a sex drive. And he won’t come to see you, so just stop my testosterone.”

So I wrote this little book as a way to convince them to come to see me. And when I say I’m embarrassed to call it a book, I literally just wrote it out and put it in a three-ring binder and just gave copies to my patients.

And when the husbands and the women started saying, “Hey, this has changed our marriage,” I thought, well, I’ll just throw it on Amazon. And it ran as the best seller of sex books for about three, four years, 2004 through 2007, somewhere in there. And now it’s out there, I don’t publish it anymore, you just have used copies and there’s the PDF file of it. I’m going to give you the link right now. See, this was the web page back when I built my websites with Dreamweaver before WordPress. But there’s a PDF file if you just want to download this thing because the last part of it is about premature ejaculation. Let’s see if I can find it. Yep, this is it. So I’ll put the link in the chatbox. And there you go, you can download it (click)<–.

I got a little bit into my religious background in here [the book], but I think really it’s hard to talk about sex without talking about spirituality. So if that part bothers you, just throw it away. But the last part is where I talk about premature ejaculation. Okay? And it gives an outline. Now, I’ve recently expanded upon that and that’s what we’re going to now plunge into. But I’ve given you that PDF file, and now I’m going to walk through what’s … I’m making a bigger book. The book that I published was just one chapter in a bigger book coming.

So this is the first draft I’m showing you. And keep in mind, I have now treated thousands of people. I’ve decided to be a sex doctor and I’m still counting myself like I’m just an internist, is what I am, but I happened to have talked to thousands of people about sex. So one thing that happens that I don’t see talked about much by the sex therapist is just, when you have the guy that says, “I have an ejaculation early,” or, “I’m having sex and my erection goes away,” what you will find is often those guys are just aerobically not fit. Medium vigorous sex is the equivalent of walking upstairs. So part of the way I motivate men to get in shape is to tell them that, “Go walk up this flight of stairs, and at that point where you get short of breath and you want to take a break, that’s how long you’re actually good for with vigorous sex.”

And what I think happens is that as the person reaches their anaerobic threshold with vigorous sex, the blood just gets shunted away from the penis and they either have ejaculate because that means hard to have thoughtful control if you’re turning into anaerobe and you’re supposed to have oxygen in your brain. So they either ejaculate because they’re not focusing well or they just lose their erection. So the first part I think about premature ejaculation is that … and I’m going to tell you several things that are not in the book, but they work and I’m going to get around to the stuff about the procedure stuff that has to do with our platelet-rich plasma, hyaluronic acid, and how you can use that as a procedure in the penis. I’m getting to that. But if the man is short of breath, he has trouble breathing after a minute of sex, then you can inject HA all day long, he’s still going to lose his erection after a minute of sex.

What is Premature Ejaculation (how long is not long enough)?

Now that brings me to something else I should bounce back to which is, exactly what is premature ejaculation? So let’s look at, this was a review article, it was drawn in Sexual Medicine Reviews, which is put out by The Journal of Sexual Medicine. And let me just put this DOI number in the chatbox. And I want to see what I think as a man who actually talks to patients versus a researcher trying to gather data. Now, the people who gather data, don’t talk to husbands and wives, but it’s a different thing. So when you look at the definition of premature ejaculation, which we should think about, there’s this thing, well, if it lasts … they split it out here in this paper, so let’s just look at these bullet points. Ejaculation that always or nearly occurs prior to or within one minute of vaginal penetration from the first sexual experience. Or clinically significant … I’m going to give you what I think is the best definition in a second, and you’re not going to find it in a book. Or a clinically significant and bothersome reduction in latency time, often to about three minutes or less. Okay?

Then you got to number two, the inability to delay ejaculation on all or nearly all vaginal penetrations. Well, that’s kind of a vague, delay for how long and how do you know. And three, which is negative, personal consequences such as distress, bother, frustration, and/or they evoke avoidance of sexual intimacy. To me that was complex.

I guess you have to complicate it when you’re going to create quantifiable data. But my definition as a clinician is that are you able to have penis and vagina sex for as long as you or your lover may wish on that occasion? And there may be occasions when you’re running out the door and it’s almost like a kiss and you want a 30-second quickie. And there may be occasions when you’re off for the vacation for the weekend and you and your lover want to have the TV off and be in the bed until lunchtime, and then they leave the tray at the door because you want to keep going till dinner time.

I’m always going to have this disclaimer, I’m never claiming that just mindless, piston type of sex without any regard for the female is anything that anybody wants or should want, man or woman. But on the other hand, artful sexuality sometimes requires something way more than three minutes. And when you look at the research, what’s so frustrating about it or I think maybe even ridiculous about it is that the latency times are going from something like a minute to three minutes or three and a half minutes to six minutes. And I’m just telling you, or women will tell you that there are lots of times when the stars are right, and the music’s right, and six minutes is just getting started barely.

There was a study published in The Journal of Sexual Medicine that showed that our PRP causes the penis to grow in a small penis. But it’s still clinically not very useful because it’s taking a two-inch erection to two and a quarter-inch erection, which is not enough to make a difference in the marriage. So the definition that I like, which is just, you’re looking at a man and a woman, and the question is, can you give this woman sex for as long as she wants on any particular day? And if you can’t on the days you can’t, that’s premature. So you can’t really make a study about that, but you can actually achieve that result. And that’s what I’m about to show you. But that’s the typical definition. That’s the definition from the bible, basically, of sex, The Journal of Sexual Medicine, in the US.

Back to my outline, and hopefully I can give you guys a plan that actually works clinically, not just looks pretty in The Journal of Sexual Medicine. First, if they can’t breathe after five minutes of walking upstairs, I’m sorry, Bob, you’re not going to be having to sex longer than five minutes. It ain’t happening. I guess maybe if you’re in a hyperbaric chamber or something. But you’re not going to have vigorous sex longer than whatever you can walk upstairs, no matter what drug I give you. Okay? Let me take that back. I’ll just skip down. Unless maybe I give you a Trimix injection where even if you’re passed out from hypoxia, your penis is still stiff. That would be the one exception to that.

Now, this 30 seconds trick was the thing that I’ve figured out as a teenager. And again, I’ve never seen this in the research directly, but it’s there indirectly because there’s cause to innovation. And I put that research in that little book, let me give you a link to that while I’m thinking about it. Because you can read it for free on your Kindle. Let’s see. And this is what I’ve practiced for the past 40 plus years. Let’s see. Let me show you what I’m giving you the link to. This. And it works. For many people, assuming they can breathe. Again, all this is out the window if you can’t breathe. But assuming you have good endurance, which I did and do because I’ve always been an endurance athlete. And in high school, I was the two-mile runner, which means you don’t have to be fast, you just have to be able to not get short of breath.

Okay. So assuming you have that going for you, this next trick, which is in nobody’s book, as far as I know, except for mine, that I figured out as a teenager, is simply that there’s some cross innervation between the bladder and the ejaculatory sensation. So what I discovered or noticed about my own body, what I’ve taught a lot of men, is that if you have any urine at all in your bladder, it makes it much more difficult to avoid ejaculation. And a completely, totally completely empty bladder makes it much easier. Okay? That’s the summary of that whole little book that’s on Amazon, but there’s some nuances about it that are worth show. Just get that Kindle book for free to your people that have PE. And remember in the back of it, it tells them about the P-Shot. So I put it out there and not to make a fortune on the book, but to help people find the other things we’re able to do.

Now, the next thing again, I’ve never seen it in a book, but I call it the safe zone. And it’s basically that same sensation that you feel when you need to urinate, when you’re going down the highway, but you can’t stop, for whatever reason, you got to get to the meeting or whatever, and then the sensation goes away. But you were not allowed to urinate just somehow it attenuated. And then it comes back, it comes in waves, and when it comes back, it’s more strong, but there you go. I think this little paper right here supports that. No, this is something else, whatever. But the point I’m making is that when people do other things like interruption … and this, if you think about it is a form of interruption, except instead of stopping with your activity, you stop and you urinate. And you think, well, shoot, if I’m having to stop every five seconds or 30 seconds or a minute or whatever, this is not enjoyable.

But what really happens is you reach the safe zone. And for most guys, when I talk with them, this is no study, this is just talking to a few thousand people, most guys, probably it kicks in at about the five-minute mark, maybe 10, and then the urge just goes away and they can enjoy the sensation. It’s not like they have to think about yesterday’s meal or what they did. Take their mind … Who wants to have sex would not be thinking about sex. So they actually reach the zone where they can enjoy all the sensations and not have to worry about there’s no sensation or very attenuated sensation to ejaculate.

The sex positions, I go into this. Again, some of these is things that I’ve never read. What I see in the literature is mostly or what I see recommended by the sex therapist … You know I’m a contrarian if you’ve ever heard me talk for more than 30 seconds, but I’m not a [new guppy 00:20:40] either. So what I have found personally, and from counseling a few thousand men, is that what really better is not woman on top, and I think the theory is that man can be still and makes him less likely to have an orgasm, I have found that what works much better … because the woman can sometimes move when man’s not ready for him to, there’s also, if he’s ever had the experience at all, there’s also that worry about women coming down and fracturing hitting on the end of the thing. But more importantly, he doesn’t have control. And I’ve found that if the man is actually in any position where he’s standing and the woman is supine or prone, or doggy style, whatever, but if he’s able to stand the sensation and the urge to ejaculate goes down tremendously.

Which brings this thing, which is mostly, I call it advance interruption, but it’s just interruption, but you’re using all these other things. You’re not just stopping because you have the urge to ejaculate, you’re stopping and you’re doing the things I’ve mentioned already plus the other things I’m about to mention. And one of them is that, you have to think about your lover. And it’s amazing how many men are jealous or insecure about something in the bed, like a vibrator or whatever, all the different sex toys that you guys know other than his penis. Where something like that can help keep the mood going. And I usually tell my patients just to go to Amazon to buy their sex toys because it’s … But we will have our own brand eventually with our O-Shot brand. But for now, they go there, it comes in a box, it looks like books. An that can be used during the time the man is taking a break.

Of course, there’s always using other things. If he loves his lover, obviously he wants to taste her as well. And that goes on. But the idea of something other than his penis. And then this part, which is somewhat esoteric and harder to teach to people. But just the idea that what I handed to earlier, which is that sometimes three hours sex is not what your lover wants, and it’s a nuisance, but sometimes it is. And it’s not just about, of course the time, but this idea of lovemaking actually being an art, which I don’t hear doctors talk about much. We get clinical about everything, and I guess the course is hard to teach that. But if it’s truly an art, you never quit. And that’s part of what makes something an art, you never master it. You get good at it, but you’re never satisfied with where you are, and so you’re never satisfied with what you know about your lover and you’re never satisfied with … you’re satisfied but you always want something more through a better understanding and a better connection. So there’s this positive feedback loop.

What happens the other way, especially with women, and this is in research, is a negative feedback loop where if there’s a negative experience, it’s not just arousal, plateau, orgasm, refractory period, with women it’s much more complicated, especially. And it’s arousal, and if something goes sideways, then the next encounter, it’s harder to do the arousal part. But if it goes very well and whether it’s a 30 seconds encounter, this is from the research, 30 seconds encounter or vacation all day sex, if the counter is positive, there’s a positive feedback loop, so the next time it’s easier for her to be aroused…easier for her to have an orgasm.

This part is just some techniques I do think it helps to have. If you remember the Richard Gere movie where he plays the gigolo, you can’t be mindless, I don’t think, and control your ejaculate. Which is why I think alcohol is probably not the best if you want extended sex, at least for the man. And there are some tricks that I will teach in the upcoming book, and that you’ll see in the PDF file I gave you, for still enjoying the sensation, but focusing in the mind, such that you can enjoy, but yet ride the edge of ejaculation without ejaculation.

This part gets talked about a lot. You can see I haven’t even written about it. I mean, I have, but I haven’t even put this in the first draft of the book because it’s everything, right? You go get the [inaudible 00:25:42] cream and you spray your penis, and then you have less … it’s in the freaking condom machines at the gas station, right? It numbs your penis down. And they sell it on Amazon. And I don’t tell people to not do this, I actually tell people to do everything on this list and then back it off as they learn better their body and their lover’s body. And as you guys know, if you’re counseling women and men about sex, you can have people who’ve been married 40 years that don’t really understand each other’s body yet. So if you’re teaching them to do that eventually this is not needed, but it can be helpful at the beginning.

Now we’re at the part where I promised you I would talk to you some about our procedures and what’s happening, and then we’ll shut this thing down. And how it relates to the … Well, actually I want to get some feedback from you guys before I shut it down. But how it relates to premature ejaculations and our procedures. I’ll put the link and the little DOI number in here. So this is an old article, you can see 2011, so 10 years ago. And the reason I put it up here is just so you know, this is not a new idea to use an HA filler to somehow decrease the sensation and help extend sex. And the reason I use extend sex versus premature … And I’ll just put a link to this article in your chat box. I use extend sex rather than treating premature ejaculation is because that premature ejaculation definition is so vague, and going from three minutes to six minutes might be great on Friday before you head out to work but it may not do much to make things better on Saturday afternoon when you want the extended lovemaking.

Anyway, if you look at the results from here, this one, and then they had a follow-up study. Well, okay, here we go, so the intra-vaginal ejaculation latency time increased significantly. It went from 2.12 minutes to seven minutes. So you got an extra five minutes of sex. And maybe on some days, that’s enough for the woman to have the orgasm she wants, but a lot of days, maybe it isn’t. And I think what happens with a lot of women who come in with anorgasmia and they say, “I want an O-Shot so that I can have sex with penis in vagina sex.” Well, she might be one of those ladies that needs 30 minutes or an hour of activity before she has an orgasm. And you can give her an O-Shot all day long, but if she has a husband that goes for five minutes, it’s not happening. Which is why that’s one of the harder things for us to treat with an O-Shot, because we’re not controlling this part of the thing. So they drop back to about five minutes plus or minus three minutes. So it’s helpful.

Now the cool thing about it, and actually what I think a lot of people are doing it is the side effect is you have a larger glans, I’ll show you some pictures in a moment. And so you can envision that some people might use their supposed premature ejaculation as a reason to get treatment and expand the size of their glans.

Here’s a follow-up study where they injected, they used Perlane, which is similar to our Juvederm. And you can see the results of it at six months and at five years. There wasn’t much change at five years, side-effects were basically nil and satisfaction, you can see was somewhere around 70, 80%. And if you look at the time, here they’re measuring seconds, they went from a little over a minute to about six minutes. I don’t know, maybe that’s enough to make mama happy, but there’s a lot of mamas out there that six minutes is still not going to make them happy. Nowadays a lot of mamas, they don’t want daddy at all, right? Watch Game of Thrones and leave me alone. But I’m assuming they actually love each other and the woman wants intimacy. And there will be times when 30 seconds is beautiful, but I think with most women, they’re going to be times when six minutes just isn’t enough. So that’s why I’m not downplaying the results of this or that it might have an effect, but I wouldn’t count on this being the magic bullet that makes couples with premature ejaculation well.

Now, the nuance that we’re using, and probably the pre-people in our group that have done this the most, there may be others I don’t know of. But the ones that I know that have done this the most are George Ibrahim, he’s a urologist that taught at Duke, and Dr. Bill Song and Anne Truong. Those are probably the three I know of that are actually injecting and teaching injecting HA in the penis. You can also inject it in the shaft subdermally with the side effect causing increased girth. I don’t teach this. The reason I don’t teach it, even though I’ve done it to myself and it’s noticeable and it’s immediate, the increase in girth when you put it in the shaft, is that it’s hard to get it smooth and if you don’t know what you’re doing, you can cause a mess. So if you’re going to do this, I think you should go do a hands-on training with someone, preferably one of the people I just mentioned in the group. And if there are others on the call that are teaching this, let me know, and I’ll unmute you and you can tell us about your class.

Let’s see. So I think that covers everything I wanted to talk about. There’s of course a lot more with all these different topics, but that’s a basic outline. And frankly, of all the things that I’ve taught my patients over the years, the thing that’s helped the most is to tell them to go get in shape. Because you’re not going to have sex longer than you can walk up the stairs. And if you want to know how good you’re for sex, go find yourself the Empire State Building or something with lots of stairs in it and start walking and time yourself, there you go. So probably that my rule of thumb, which is work your way up to 21 to 25 miles on foot walking or jogging is going to do more to fix this than anything else we can do.

Next, I think my experience has been my little 30 seconds trick works well. Now, I didn’t mention the prescription drugs that’s covered in this one. I think I gave you all the DOI on that one, let me give you the link for it. This is the review article we talked about a moment ago, and I’ll just put that one in the chat box. They go into detail about the drugs. And you got the SSRIs. They also makes the mention oxytocin, and yohimbine. There used to be a medicine that was prescription called [Yokan 00:33:32] that actually worked very well, and that was a pharmaceutical grade yohimbine, and I’ve not been able to find a duplicate for that. And it works almost half the time. This was before we had by Viagra. But at the over-the-counter, it causes chills and all sorts of weird side effects with people. Anyway, they go over the drugs here. I have found I’ve never really needed the drugs with my patients. Doing the things that I just talked about, but probably the SSRIs are the ones that people use mostly.

Okay. I’m stopping. And I see a couple of questions. One is, inject only the glans? No. Well, I left that part out with our procedures. One of the things that Bill Song did, which I have tried, and it works well, and others in our group have done it, and it’s what it did to my own self, is that he saw me do a mixture of PRP with HA under in the tear trough. And by doing that mixture, you can get a smoother flow of the HA and less chance of lumpiness and a much more broader and even distribution and probably a longer, more effective result because the PRP recruits stem cells to the area that build on the HA, which we know from our wound care studies. The two studies I showed you were about just injecting the glans, but there are others out there about injecting subdermally in the shaft. Again, I’d recommend as simple as it looks that you hit up one of those three people I talked about to learn that technique.

But the thing that our group is doing, that’s innovative and you’re not seeing in the literature anymore, or anywhere is that mixture of PRP with the HA. So even if I were doing the shaft, most of us are mixing it 50/50. And it takes usually a lot of volumes, so if you’re going to inject five or six, 10 syringes of HA … Because if you do the math on it, simple math, right? Calculate the volume of a cylinder with a circumference of five inches, and then calculate with six inches, is a noticeable amount of volume. But if you take 10 Juvederm syringes or five or whatever you’re going to start off with, and then you take the same number of milliliters of PRP and using the right technique, you cause an emulsion, and then you inject that subdermally. And I would do the same thing with the glans. The worry about the glans of course, is there’s an actually intravascular space and there’s always that chance of PE from the HA, and you should just not be injecting HAs in the corpus cavernosum for that same reason. So that’s the possible nuance reported, that injecting the glans that I know of. But that’s the possible side effects.

Why use HA instead of PRF sub q?

Okay. The second question was, Sub-Q PRF instead of Sub-Q HA filler, and it helps a lot. You know the cool thing about PRF is … and a lot of people asking you about PRF and people love it. I’m not saying don’t do it, and it’s obviously cheaper than buying an HA, and PRF is going to help. To me, and at least my observation in the face, I’ve done a lot more face injections with HA than I have penises, you can design a shape with HA that stays. You can’t design a shape with … So to answer your question, what’s PRF, I went into that psalm and the short answer is that instead of platelet-rich plasma, you have platelet-rich fibrin, and it’s a quicker way. You’re basically making a clot that then you can … the dentist use it mostly to patch wounds and such. But I reviewed some of that literature, maybe three webinars ago. And is something that people are using.

I’m no one bias, and the verdict that was what was in the literature, the verdict’s still out about, do you activate, how do you activate, how do you make the PRP? That’s always the disclaimer and the criticism in the med analysis reviews, because there’s not a consensus about PRP what it is and PRP versus PRF. And so there’s just no way to get to a conclusion to that at the present moment with the research. And it becomes like arguing the difference between a Ford or a Chevrolet or whatever, a Lamborghini or Ferrari. So I don’t want to get too sidetracked about that. But back to using PRF versus HA. The reason people are putting HA in the penis is the reason it’s the fricking gold standard with the face.

I saw a woman today who came and went and cheated on me and got some Sculptra. And Sculptra is great for building volume, but you cannot control it. I can control to the millimeter when I have an HA filler in the mouth, I can control how I’m sculpting the cheek. I have absolute control. I don’t have absolute control with what the results is going to be three weeks from now with Sculptra or PRF. So I’ve found making the shape you want with an HA, which is going to be a solid structure. And there are those that are permanent, which you don’t use obviously until you get the hang of this, but there are those who are using the permanent fillers for the penis after they get the hang of it. But with an HA, you can create a shape. Maybe you want it wider at the base, or maybe you want it wider near the glans where it has the effect of a larger glans or some variations. You can actually become the Calvin Klein of penis shafts. But even if you’re not getting that esoteric with it, you have more control over making it smooth versus irregular and unpredictable.

You can tell I’m a big fan of HAs which is why I keep using them in the face and combining them with the PRP and all the research that involves PRP recruiting stem cells, or at least almost all of it involves the PRP. If you’re going to add a filler the PRP recruits themselves onto the scaffolding, which is the words that’s used in the wound care literature, onto the scaffolding of an HA and the effects can be really beyond belief. I don’t even like showing everybody my before and afters. Because when you’re treating scars and such and in the vampire breast lift, the results can be beyond belief.

Okay. If anybody else has a question, I’ll answer it as best I can. Or if you want to jump in. Okay. I see Julia has her hand up. Let’s see if she wants to jump in and teach us something. Hey Julia, I think … Let’s see. Let me try again. I’m trying to unmute you. All right. You’re un-muted if you want to go for it. Right there. Let me see, it looks like you’re on here. Nope. Maybe your mic’s not working. Let’s see.

Okay. I guess that’s it. Thank you guys. I’m always honored that you have an interest and I hope this has been helpful. Remember, you can go onto the websites and go to the search bar, if you put in PE, you’ll find not just this one once I get it posted, but at least three other times we’ve talked about it. And most other, we have over 400 videos, like the ultimate Wikipedia of PRP treatment. So jump in there and contribute, when you see something comment. And thank you, David. One of the smartest people I know. That’s always an honor to see that you have an interest in something I had to say. You guys have a great night and hopefully I’ll see you guys soon down here in Fairhope. Bye-bye.

Relevant Links

–>Next class to learn to inject the major joints (knees, elbows, shoulders, Achilles) with PRP<–
–>Apply for Further Online Training for O-Shot®, P-Shot®, Vampire Facelift®, Vampire Breast Lift®, Vampire Wing Lift®, or Vampire Facial®<–
–>Next Hands-on Workshops with Live Models, worldwide <–

–> IMPORTANT (ONLY) IF YOU ARE NEW TO THE CMA: Please take any relevant online tests so that we can immediately list you (and your clinic) on the directories and start supplying you with other helpful marketing and educational materials. Testing takes an hour at most (including watching the videos. If you want to expedite the testing, you can simply call the CMA headquarters (1-888-920-5311 9-5 New York time Mon-Thur; 9-12 Fri) and one of our business consultants will log you in and walk you through where to find the study materials and the tests. If you are already on the directories for the procedure(s) you provide, then you already took the tests or did hand-on training with evaluation by your instructor.

O-Shot® CBD Arousal Oil. O-Shot® providers order wholesale by logging into the O-Shot® membership site, or by calling CMA Headquarters.
Altar™–A Vampire Skin Therapy™. All CMA members can order wholesale by logging into the membership sites and going to Dashboard–>Supplies











Charles Runels, MD






Cellular Medicine Association

5 Things that Helped Me Last Week (2021 October 31-November 6)

5 Things that Helped Me Last Week (2021 October 31-November 6)

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…

George Lois was a marketing legend (one of the many things he blasted off was MTV). For a side gig, he also did the legendary covers of Esquire magazine through the 60’s and early 70’s. His iconic images are studies in how to create emotion and boldly speak the truth with an image. His editor, who was eventually fired from Esquire for his boldness (cancel culture is not new, ask Galileo), went on to start the TV show 20/20, and lived with the courage to print whatever Lois put on his desk; and those images made people angry, and they made people think.

The typical magazine cover now is covered with celebrity images, breasts and bottoms, and mindless blurbs that are safe from anger and revolution. If you thumb through Lois’ book of Esquire covers and read what Lois was thinking when he created his images, you see the secret thoughts of a creative genius who was also brave enough to listen to his gut…

Lois, George. George Lois: The Esquire Covers @MoMA. New York, NY: Assouline Publ, 2009.

2. Art—what is it? Any why even think about it?

When I was in college, I made a decision to not own a TV. Movies would be an option (my sons and I watched many movies), but I decided that a constant stream of TV pouring into the room felt like it was somehow making me less. I’ve always been a movie buff, but I like to GO to the movies and also liked it better when I had to drive to Block Busters and pick something out—in the same way not having junk food in my house makes it easier for me to stay lean, just not having a constant stream of TV & movies seemed to make it easier to hold on to the brain cells.

Until last week, I had not read a good explanation of what I’ve felt since 40 years ago when I made that decision about TV.

Ayn Rand was born and educated in Russia and from that background wrote one of the most influential books in the English language, Atlas Shrugged. From that perspective (knowing what communist Russia looked like), she frequently wrote about the difference between “freedom of the mind” which she saw people dying to achieve in Russia, and “freedom from the mind” which she saw in the drugs and pop culture of the 60’s.

Her Romantic Manifesto contrasts these two ideas in the area of art.
She also, maybe, more importantly, talks about why we need art.
I’m a fan of Eminem (who can not love his song about mom’s spaghetti being vomited when he’s nervous about his big chance) and other rappers, as well as a fan of Beethoven–so I’m puzzled by my choices. What IS art and how is it made and how do we choose what to consume?
Rand’s book the Romantic Manifesto is helping me sort it out (at 61 years old, I still don’t claim to have the riddle solved)…

Rand, Ayn. The Romantic Manifesto: A Philosophy of Literature. 2. rev. ed., 14. print.. Signet Books AE 4916. New York: Penguin Books, 1988.

3. Most important research I read this week —

The first time I saw the deep emotional response of my lover when she had an ejaculatory orgasm (two decades ago), I started reading all of the research and every popular book written about the subject. This led to injecting (ten years ago) my lover with PRP into the distal urethra (near the Skene’s glands) in an effort to enhance the ejaculatory orgasms I had already taught her to enjoy—vhooom…the O-Shot(R) was born.

Until then, PRP had not been injected around the periurethral space. The second woman (we can call her Jane) whom I treated had been abused by her x-husband and was left by that horror with scaring, severe dyspareunia, and near anorgasmia.

Knowing that PRP had been used to treat scarring, I treated her with the same procedure that I first used on myself (I created the P-Shot(R) first by injecting my own penis before creating the O-Shot(R)).

After the procedure, Jane’s dyspareunia resolved, she became orgasmic, and six months later was engaged to a high-school sweetheart.

She also called me a month later to say, “I can now run without leaking urine, so I’ve been running and have lost over ten pounds.”

Now, over ten years later, we have a growing and impressive list of research papers that have been published about the O-Shot(R) procedure. And, our Cellular Medicine Association has grown to include over 4,000 physicians (including many prominent urologists and urogynecologists) in over 50 countries.

I’m especially grateful to the editors of Female Pelvic Medicine and Reconstructive Surgery for publishing the following article showing that the O-Shot(R) does indeed help with stress urinary incontinence without the worries of other materials that have been tried (including fat, which caused 2 deaths by pulmonary embolism in one study)

Though the authors complicated our procedure by their apparent misunderstanding of how PRP travels when injected (they used 9 injection points where 1 does better), they still made the point that the procedure works and this article should be shoved under the nose of every physician and nurse practitioner who takes care of women…

Athanasiou, Stavros, Christos Kalantzis, Dimitrios Zacharakis, Nikolaos Kathopoulis, Artemis Pontikaki, and Themistoklis Grigoriadis. “The Use of Platelet-Rich Plasma as a Novel Nonsurgical Treatment of the Female Stress Urinary Incontinence: A Prospective Pilot Study.” Female Pelvic Medicine & Reconstructive Surgery 27, no. 11 (November 2021): e668–72.

4. App that made my life easier…

Though most of the world has swapped to “Zoom,” I still think GoToMeeting and GoToWebinar to help best when connecting with patients and with my staff (the staff of the Cellular Medicine Association liked working from home so much during COVID that we just kept it that way now that the pandemic has lessened).

I use this software 2 to 3 times a week and use the recordings to educate my patients and staff.

5. Quote I’m pondering —

C.G. Jung, The Undiscovered Self…

“Today, as the end of the second millennium draws near, we are again living in an age filled with apocalyptic images of universal destruction. What is the significance of that split, symbolized by the “Iron Curtain,” which divides humanity into two halves? What will become of our civilization, and of man himself, if the hydrogen bombs begin to go off, or if the spiritual and moral darkness of State absolutism should spread over Europe?

We have no reason to take this threat lightly. Everywhere in the West there are subversive minorities who, sheltered by our humanitarianism and our sense of justice, hold the incendiary torches ready, with nothing to stop the spread of their ideas except the critical reason of a single, fairly intelligent, mentally stable stratum of the population. One should not, however, overestimate the thickness of this stratum. It varies from country to country according to national temperament. Also, it is regionally dependent on public education and is subject to the influence of acutely disturbing factors of a political and economic nature”

Jung, C. G. The Undiscovered Self. New York: New American Library, 2006.


And, please give me feedback: hit “reply” and shoot me an email, or on our membership sites. 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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FORWARDED THIS MESSAGE? Learn more about the CMA here<—

Female Stress Incontinence–New Research that Every Gynecologist Should Read

Topics Discussed Include the Following…

*Metanalysis Review of Possible Injectables for Treating Urinary Incontinence in Women
*Urinary Incontinence—The Surprising Truth about Female Athletes
*Is Saline a Placebo?
*The muscle atrophy and nerve degeneration surrounding the female that occurs with aging
*Study Shows O-Shot® Methods Help with Female Stress Incontinence
*Tips for Injecting the Clitoris
*How to Learn the Basics of Writing Emails in Less than 30-Minutes

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

Relevant Research, Transcript, Relevant Links

Relevant Research

Athanasiou, Stavros, Christos Kalantzis, Dimitrios Zacharakis, Nikolaos Kathopoulis, Artemis Pontikaki, and Themistoklis Grigoriadis. “The Use of Platelet-Rich Plasma as a Novel Nonsurgical Treatment of the Female Stress Urinary Incontinence: A Prospective Pilot Study.Female Pelvic Medicine & Reconstructive Surgery 27, no. 11 (November 2021): e668–72.

Joseph, Christine, Kosha Srivastava, Olive Ochuba, Sheila W. Ruo, Tasnim Alkayyali, Jasmine K. Sandhu, Ahsan Waqar, Ashish Jain, and Sujan Poudel. “Stress Urinary Incontinence Among Young Nulliparous Female Athletes.” Cureus 13, no. 9 (September 2021).

Kim, Chul-Ho, Yong-Beom Park, Jae-Sung Lee, and Hyoung-Seok Jung. “Platelet-Rich Plasma Injection versus Operative Treatment for Lateral Elbow Tendinosis: A Systematic Review and Meta-Analysis.” Journal of Shoulder and Elbow Surgery, October 2021, S1058274621007242.

Kirchin, Vivienne, Tobias Page, Phil E. Keegan, Kofi OM Atiemo, June D. Cody, Samuel McClinton, Patricia Aluko, and Cochrane Incontinence Group. “Urethral Injection Therapy for Urinary Incontinence in Women.” The Cochrane Database of Systematic Reviews 2017, no. 7 (July 2017).


Oshiro, Takuma, Ryu Kimura, Keiichiro Izumi, Asuka Ashikari, Seiichi Saito, and Minoru Miyazato. “Changes in Urethral Smooth Muscle and External Urethral Sphincter Function with Age in Rats.” Physiological Reports 8, no. 24 (2021): e14643.

PANDIT, MEGHANA, JOHN O. L. DELANCEY, JAMES A. ASHTON-MILLER, JYOTHSNA IYENGAR, MILA BLAIVAS, and DANIELE PERUCCHINI. “Quantification of Intramuscular Nerves Within the Female Striated Urogenital Sphincter Muscle.” Obstetrics and Gynecology 95, no. 6 Pt 1 (June 2000): 797–800.

Platelet-Rich Plasma for Nerve Regeneration<–


Charles Runels: Welcome to the Journal Club with Pearls & Marketing 2021.10.27
Today, I was really proud to get a text from Red Alinsod, alerting me to a study that came out–a really strong article showing that our procedure helps with incontinence.[1]

We’ll come back to this study and I’ll give you a link to it, but I want to back up a little bit and talk about some of the background that I think helps make this study more insightful.

Oh, by the way, I’ll end this call with some ways to use this research. You wouldn’t think you could share. Some of the people new to the group may not have thought about the idea of sharing detailed medical research with your patients as a way to engage them and bring them to your office. There’s a way to do that. I’ll go over that at the end of the call.

Next Workshops with Live Models<---

Metanalysis Review of Possible Injectables for Treating Urinary Incontinence in Women

So 50 something pages and they review everything or the main things that have been injected around the periurethral area to help with incontinence and the various different materials that were used[2].

Of course, at the time this was put out, I think it was 2007. We were already doing the O-Shot® procedure.
I did the first O-Shot in 2010, so this was seven years after that, but we weren’t being noticed as much. So it was left out of their review, but some basic principles come out of this.

First of all, some of the things have been just pulled because of the side effects of it. For example, in a study of injectable fat, they had people, two people died in the study from pulmonary embolism.
So hopefully you guys are, are not even thinking about injecting fat around the urethra.

And then in with HA fillers, there’s was a higher incidence of complications. The same with calcium appatite (Coaptite®), several studies showing granuloma formation. This one’s still out and available, but then there are some principles.

First of all, in spite of the tendency, historically, to inject the proximal urethra near the bladder, these authors concluded after reviewing quite a number of different studies that mid urethra injections worked better. They didn’t look at distal urethra where we are injecting, but the proximal urethra or near the ureterovesical junction was not as effective.
So…a long way of saying the looking for something to inject around the urethra to help with incontinence has been ongoing for at least two decades, but the problem’s been finding something that works without noticeable sequela or serious side effects.

Urinary Incontinence—The Surprising Truth about Female Athletes

I also want to talk about this one. I, I think historically we tend to think of incontinence is something that is for people who’ve had babies, but, or for perimenopausal and older, this is one of the studies that of probably at least a dozen that sort of blow that one up, demonstrating that many female athletes who have high impact sports, volleyball, trampoline, running, having incontinence. And depending on the sport, it can be near 100%. I’ll put the link to this one in the chat box[3].

How to Use the Research to Find People Who Need You and Want to Pay You


I’ll just stop now and kind of give you a clue about how I turn this into something, to educate our patients.
So marketing really the best marketing is teaching people about their disease and then showing them how to treat the disease.

So that’s a recent article. And when it came out, I posted it. I made a video about the article, which I’ll show you how to do shortly, posted the video to a webpage and then put links to the research, and then had it transcribed. So we go into this in great detail in my workshops, but the basic idea is to do whatever software you use to film your discussion, film the article, as you discuss it, put that in a page and then put it on your website.

Now it needs to go further than that. If you just put a video up on a page on your website, it’ll probably sit there and be seen by not many people. I just posted this one today.

But I’ll shoot out an email tomorrow to bring people to here and this number will go up. So that email part of the deal and how and why I’ll show you that shortly, let’s go back to this.

Is Saline a Placebo?

I mentioned that fat, I’m going to put a link to this one. I mentioned that those people who died from the fat injection, there’s something else about this. And it was for pulmonary embolism, there’s something else about this study though, that’s worth noting the placebo arm had a 21% response rate and they quote the, the idea that, okay, you can have up to a 30% response rate from placebo.[4] To me, that seems like a stretch. When you’re doing things like this isn’t measuring libido with a survey; this is measuring the number of wet pads and, and leaking.

So I don’t think I’m alone in that assessment that maybe their placebo arm, which is saline, was not “doing nothing”, and that perhaps the hydro dissection was actually changing the tissue– as it has been shown to do in other studies.

If you look at the review article, I showed you previously, let me go back to that one. The one that was 50 something pages, it actually pointed that out and, and said, this is, yes, this review article. It made a point of the fact that, well, in this one article, in the fat study that the placebo arm had a 21% or saline had a 21% cure rate or much-improved rate. And so maybe there’s a mechanism we don’t understand. [5] That seems a little high for placebo for a study that’s measuring leaking urine.

So I think the reason for the placebo effect is worth thinking about with one of our lichen sclerosus studies and some of the orthopedic literature, that is a common limitation in PRP studies—what to use as a placebo.

And actually, in one of my favorite studies about Peyronie’s disease, Dr. Virag uses a positive control Xyflex as a positive control rather than use a placebo.

The muscle atrophy and nerve degeneration surrounding the female that occurs with aging

Two weeks ago, we talked about some of the anatomy and what might be happening to help explain why the O-Shot works. And this is one of those studies where they talk about PRP causing neurogenesis[6]. It also calls it.
Usually, when we think about nerve damage, we think maybe pudendal nerve damage from riding a bicycle or something, but DeLancey and others have published studies showing that in Cadaver studies that as women age, they actually lose some of the nerves and the sphincter mechanism around the urethra[7]. And they lose muscle fibers[8].
So we know PRP causes neurogenesis and it activates dormant cells within the muscle to cause myocytes to proliferate.[9]

And that’s been studied in the sports literature and used as a way to help recovery.[10] So with those two things together, it might help explain why our procedure is working. I’ll put a link to this one in the chatbox, too. So this is a, I think a rat study, but nope, this is, this might be one of those Cadaver studies. Anyway, let me put this in the chatbox. And then let’s look at the main paper that I’ve, I’m so excited about that I want you guys to, to know, and then let’s talk about how to educate your patients with it, and then we’ll call tonight. So this is the study. I’ll put the DOI number in the chatbox.

Study Shows O-Shot® Methods Help with Female Stress Incontinence

So these are MD PhD urogynecologist publishing in the journal of, of reconstructive surgery. So this is a high, high impact journal with a very conservative editor and the basic plan, what they did was they…they used it gel kits, not even a double spin centrifuge. They used a gel kit, a Regen kit, and which would give you about five CCs and injected the distal urethra. Thank goodness. But then it’s interesting. They did nine different injections at 10:00, 12:00, two o’clock at three different levels of urethra, one centimeter apart, distal median proximal. And then they were, then they were watched, they had two injections, four to six weeks apart, and then they just followed them for six months, 20 women with significant improvement.

And by the way, these women were chosen because they were women who had opted to have surgery for their incontinence. And so they were enrolled in this study and instead, so these were people who were bothered enough to have scheduled surgery.

And I would argue that again. I’m grateful they did the study, but my thinking is the authors probably have not injected the face, or they would know that injecting PRP a few millimeters from where the previous injection was, is probably NOT necessary. Because PRP is aqueous and spreads easily within a tissue plane, if you inject multiple sites only millimeters apart, it is like pouring water and then feeling like you need to pour water two inches away from where you previously poured it–when you could actually pour it in the one spot and it would spread.
they, they did NOT inject proximal urethra. Thank goodness.

Probably based on the previous studies and, and I’ve lectured the region companies, maybe they sell the most PRP kits of anyone and, and I’m acquaintances with the owner of the company and have lectured for them a couple of times in Venice, Italy (they’re based out of Switzerland).

And they’ve also published other really nice research. If you go to the O-Shot web page and look on the research tab, you’ll see where they’ve published. They sponsored a paper, Regen did that was published in menopause showing that PRP helps dyspareunia due to dryness and menopausal or post breast cancer patients who can’t be on hormones.
So I think they complicated the procedure, by doing more injections than what’s necessary, and they left off the clitoral injection, but otherwise, they did the procedure close to what we do as an O-Shot® procedure. They did the O-Shot without the clitoral injection. And they did more injections than what would’ve actually been needed to spread the PRP within the same area.

So you guys know we put four CCs in the anterior vaginal wall and four CCs into that space spreads. Well, it’s because it’s a, it’s not a round space because it’s a linear hydro dissection sort of distribution, it covers pretty much at least the front or the most distal half of the urethra and spreads laterally, probably a half a centimeter on each side.
So that’s my reason for why they complicated the procedure (and you can easily palpate the area after injection to confirm our method spreads the PRP as described), who knows someone eventually needs to do a study where the locations are varied and the amounts are varied, and try different PRP kits and there are an infinite number variables we could change how, by the way,|

They did activate the PRP as well with calcium chloride—which seems to help increase the chances that the procedure will work for sui. The research is pretty strong on that. We covered that about four weeks ago in journal club. Okay.

David Harshfield: Charles. The interesting thing is that, gosh, I guess 10 years ago, a lot of the journals are trying to sort of discredit PRP for instance, it’s so easy to use and whatnot, and they, they keep coming out of these trials.
This was an elbow trial in JAMA about, gosh, I don’t know, seven years ago I’ll find the link, but the title was PRP no better than placebo for lateral epicondylitis. And we happened to know the editor of JAMA. So we found the gallery proof and we looked into it. And Charles, they had three groups in a control group that got nothing in both the saline injection. They were calling saline the placebo, but sodium is a, is prolotherapy.

It’s different. We like using glucose because glucose is an insulator as far as electrical current. So forth, Sodium makes things speed up. So it’s a little painful, but it’s a treatment in the PRP and the so-called placebo saline were both way better than the controls. And then the punchline was PRP no better than placebo, trying to sort of discredit PRP but at any rate that’s when we figured out wows normal saline is it is a treatment (not a placebo).

Charles Runels: And actually we covered here. I was seeing if I could find it, but yeah, here we go. Here’s a study. Let me pull this up. We covered this a couple of weeks ago where someone did show PRP versus operative treatment for lateral, although tendonitis, the PRP was as good as surgery[11]. And that was published just within the past month.

So for you guys who don’t know, David Harshfield is an interventional radiologist. Who’s very, he’s, he’s published, he’s done research all the way back to the early days of Viagra and, and teaching and, and he’s connected with knowing he has his own group. And he’s very connected with understanding the guidelines of the FDA and such. So thank you for jumping in any other ideas or that you would comment on regarding this particular paper. To me, it just feels good that it made a at a high impact journal. Hopefully some people will, more people start paying attention.

David Harshfield…: I’m kind of interested now, Charles, because what we’re thinking now, platelets actually, all cells do the same thing. Neurons do just slower and platelets are looking like they’re going to be our little peripheral floating neurons. Think about that. So that when we inject them, they act like neurons. They have little secretory granules, just like a nerve would have neuro vesicles at the end to release acetylcholine for instance.
So they are doing a lot more things than what we thought, just, blood clotting and so forth. Platelets are cool, little creatures. They can do a lot of cool stuff

Charles Runels: And we can use them without the paperwork of the FDA because it’s autologous with minimal manipulation (so PRP is a body fluid, not a drug).

So thank you for that. I appreciate you jumping in there, David.

Tips for Injection the Clitoris

Keith asks, he says, when he injects the Corpus, the clitoral corpus cavernosum and Dr. Harshfield actually brought his ultrasound and we, he visualized it didn’t make it into our chapter about the O-Shot® in Red Alinsod and Christine Hamori’s book, you visualized the flow of PRP through the corpus cavernosum and saw a change in the waveform. And we just need to do our own, we need to publish those videos as just a separate case report or something.

But the question is when you do that injection, sometimes you see blanching or you’re seeing blanching and wondering if that you should back off. I know that some of the women have a really tiny, very tiny clitoris.
It’s maybe didn’t have too much volume, in that case, maybe you back off, but actually, I remember right, David, when you were doing that ultrasound, it was, it wasn’t until we had three or four CCs that we started to see it flow into the distal corpus cavernosum and the waveform changed to what you say that you’ve seen when the penis goes from flaccid to erect.

So, what’s you’re thinking about the volumes that we’re injecting into the clitoris?

David Harshfield: I think that’s, that’s the key right there, Charles, is that we, these girls that are so different and we didn’t understand the anatomy, remember Charles, because if you try to look at Grant’s Atlas, they can pretty much draw a penis on one page, and for the female anatomy it’s scattered throughout from this thing to that thing, the Corpus is on this page and 37 page later it’s clitoris and I don’t think we’d ever put it together. And when we also sounded those times with those girls, it was just like a man’s penis, the erectile tissue, the corpus cavernosum is a different size in us, but they act the same way. And it, it, I guess it would be much more volume intensive if you say that. And, but when you’re watching, while you inject, you can see where it goes. PRP has a real interesting phenomenon that it creates vasodilation.

And as most people know, to have an erection, you have to relax. It’s a parasympathetic thing, the smooth muscle relaxes, it slides in the way of the little outflow ducts. And then the erectile tissue feels with what, and then the ejaculation is a sympathetic thing totally different field, but when you’re filling these erectile tissues, I don’t think any of the women were even close to the same volume.

Charles, if I remember the, we were monitoring the, the flow and you’d have a really high systolic and diastolic flow to begin with. And as the Cavernosum filled up and the pressure increased, you just get a little systolic pump bump that diastolic flow would stop meaning there’s no. [inaudible] And women looked exactly to me as the men, men do.

Charles Runels: Yeah. That’s we really need to get that out so people can know. So I think that’s your answer. It depends on the size of the clitoris, Keith. Oh, I just put a link to the, to the paper that you was foreshadowed that you just heard David talk about, but this article that just came out, what was this it’s been within the past month showing that PRP versus operative treatment for lateral tendonitis was as effective as surgery.

David Harshfield: I mean, that was so much more honest study, Charles, because we’re comparing surgery versus biologic, not biologic versus prolotherapy. That was the same thing.

Charles Runels: Yes. And of course, people want to see a double-blind before they think before they want to acknowledge something. But I always like reminding them, there was no double-blind placebo control that I know of for birth control pills. And, and you can’t really do double-blind for many procedures. And there is a component of what we’re doing, which is, we’re saying the same thing. There’s a component.

The O-Shot® procedure isn’t a pharmacological thing where you’re injecting a drug, you’re physically hydrodissecting something. And that’s a procedure, which is why I think it matters how and where you inject it.
And then the hyrodissecion is combined with the cellular effects of what you’re doing (the PRP). But there’s really two things going on. Any comments about that idea?

David Harshfield: I think that it makes me laugh. I think there ought be a double blind control study on parachutes for these knuckleheads, at the think that everything needs a randomized control trial. We’re going to throw you out of an airplane and we’re going to find out if you need a parachute or not, you professors don’t get one.

Charles Runels: I like it.

David Harshfield: But you’re right, Charles. I mean, it goes to the quantum level.
Once you observe something, you change it in the quantum realm. So you back that all the way up to the macro, if you stick a needle in something thing and, and don’t even inject, you’ve changed micro environment.

So microtrauma, that’s how we’re healing. These folks now is we’re inducing little needle, dry needle, perfect example creates every time the needle goes into the tissues, there’s a little drop of blood on the skin. You can wipe that off, but the one on the inside of the skin’s there, it’s a miniature PRP shot. Even if you don’t inject anything.

How to Learn the Basics of Writing Emails in Less than 30-Minutes

Charles Runels: Okay. So let, let’s go over and I’ll show you what I was planning to show you about emails and then we’ll call tonight. That’s really the main study I wanted to show you. Let’s see. Here we go. And yeah. Okay. All right. So when you log into the first of all, there’s this reluctance, I think of doctors to try to sell something and I agree.

Here’s my here’s the philosophy. Just something to, to put in your brain that I think will help you when it comes to something where people need to pay you money for it is that you’re not trying to get anybody to do anything and try to teach your staff the same thing.

You’re not trying to get anyone to do anything. And if you have that mindset, it’s, it’s uncomfortable. It’s not what we want to do as physicians.

But what you can do, and I think which you’re responsible for doing. Patients don’t know about these procedures. And I think it’s the physician’s responsibility to teach people what we’re able to do for them if they don’t know. And then here’s the keyword offer to help that’s it.

So you teach them about their disease. You teach them different options that might be available to them, the risk and benefits, and then offer to help them. That’s all you’re doing. Now the problem that comes in when the thing that you’re one of the things that you think might help them takes an hour to explain, which is why our procedures can be exhausting if you’re trying to teach someone how they might help them.

So that’s how the digital can you with an email or a video that you send to your patients.

How to Use the Medical Research to Find People Who Need You

And I promised you a way to leverage this research. So what I would recommend you do is that, your patients are smart and they can Google things and they may not know every word, but whatever, they can still understand it. And, and make a more informed decision.

So I like actually sending an email, which I’m about to show you a quick way to do that. So if you go to just all the procedures, have this on them. And so if you log into the, to the website and then you go to the marketing page, then I have an a video there about how to write an email in 10 minutes. If it takes you longer than 10 minutes, you’re taking too long. You’re trying to write literature instead of writing notes.

And then here’s a free little book that will also help you (click)<—

And it’s put out by the same people that I use to send emails.
I used to have three different ways. I send emails, but this is the one that I like the best. And they give you some tips about writing emails.

But this video (on the membership sites), which is only 15 minutes long is really the key about how to relax and just get it done. If you’re a member, it’s on all the membership websites.

The idea would be that you send out an email and people want to know new, you’ll hear wall street journal, talk about the New England Journal, or you’ll see CNN mention something that came out in one of the medical journals. You can do the same thing; you can send an email to your people and say, “Hey, this research just came out that shows that PRP might help some women.” And. you always couch it with you can’t get everybody well, but there’s some new research. That’s the news that shows that we might be able to help some women who have incontinence. And here’s a link to the research. And if you’re interested to call me, that’s pretty much how you do it.

And then you can set that up to go automatically, but you shoot something like that out to your people every couple of weeks where you’re letting them know that you’re staying abreast of the current research, and you let them know when you bump into something that might relate to problems they have and how you might take care of them.

And then don’t forget the keyword is then you offer to help them and then…let it go. You’re not trying to get anybody to do anything; you simply start with teaching people about their disease and then offer to help.

If you do this and know your business, you won’t lack for people who are willing to pay you for your services.
And I think with that, let’s shut it down. Any other comments, David, I appreciate you jumping in with that, those ideas about how saline is not really a placebo.

David Harshfield: I love working with Charles cause you know, I do a lot of critical limb ischemia, for instance, trying to save limbs.

And we use PRP and you’re doing the same thing with these other structures. You’re trying to increase vascularization. I, one thing Charles a dawned me after a few years, being an interventionalist always was putting stints in things and I was a plumber and then occurred to me. What we’re doing is restoring the nerve and that’s, what’s creating increased flow both in and out; so that when we use PRP there, it’s restoring the nerve innovation in the local area. And that is going to fix all these other things.

Charles Runels: Beautiful. And you guys have a great night. I’m always honored to be able to share notes with you guys.

Good night.
Thank you, David.

[1] Athanasiou et al., “The Use of Platelet-Rich Plasma as a Novel Nonsurgical Treatment of the Female Stress Urinary Incontinence.”
[2] Kirchin et al., “Urethral Injection Therapy for Urinary Incontinence in Women.”
[3] Joseph et al., “Stress Urinary Incontinence Among Young Nulliparous Female Athletes.”
[5] Kirchin et al., “Urethral Injection Therapy for Urinary Incontinence in Women.”
[6] Sánchez et al., “Platelet-Rich Plasma, a Source of Autologous Growth Factors and Biomimetic Scaffold for Peripheral Nerve Regeneration.”
[7] PANDIT et al., “Quantification of Intramuscular Nerves Within the Female Striated Urogenital Sphincter Muscle.”
[8] Perucchini et al., “Age Effects on Urethral Striated Muscle I. Changes in Number and Diameter of Striated Muscle Fibers in the Ventral Urethra.”
[9] Moraes et al., “Platelet-Rich Therapies for Musculoskeletal Soft Tissue Injuries.”
[10] Middleton et al., “Evaluation of the Effects of Platelet-Rich Plasma (PRP) Therapy Involved in the Healing of Sports-Related Soft Tissue Injuries.”
[11] Kim et al., “Platelet-Rich Plasma Injection versus Operative Treatment for Lateral Elbow Tendinosis.”

Relevant Links

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–> IMPORTANT (ONLY) IF YOU ARE NEW TO THE CMA: Please take any relevant online tests so that we can immediately list you (and your clinic) on the directories and start supplying you with other helpful marketing and educational materials. Testing takes an hour at most (including watching the videos. If you want to expedite the testing, you can simply call the CMA headquarters (1-888-920-5311 9-5 New York time Mon-Thur; 9-12 Fri) and one of our business consultants will log you in and walk you through where to find the study materials and the tests. If you are already on the directories for the procedure(s) you provide, then you already took the tests or did hand-on training with evaluation by your instructor.

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Charles Runels, MD






Cellular Medicine Association



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?

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

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.

Relevant Links

–>Apply for Further Online Training for O-Shot®, P-Shot®, Vampire Facelift®, Vampire Breast Lift®, Vampire Wing Lift®, or Vampire Facial®<–
–>Next Hands-on Workshops with Live Models, worldwide <–

–> IMPORTANT (ONLY) IF YOU ARE NEW TO THE CMA: Please take any relevant online tests so that we can immediately list you (and your clinic) on the directories and start supplying you with other helpful marketing and educational materials. Testing takes an hour at most (including watching the videos. If you want to expedite the testing, you can simply call the CMA headquarters (1-888-920-5311 9-5 New York time Mon-Thur; 9-12 Fri) and one of our business consultants will log you in and walk you through where to find the study materials and the tests. If you are already on the directories for the procedure(s) you provide, then you already took the tests or did hand-on training with evaluation by your instructor.

O-Shot® CBD Arousal Oil. O-Shot® providers order wholesale by logging into the O-Shot® membership site, or by calling CMA Headquarters.
Altar™–A Vampire Skin Therapy™. All CMA members can order wholesale by logging into the membership sites and going to Dashboard–>Supplies











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.

Next Hands-On Workshops with Live Models<—

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


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
Find the nearest O-Shot® provider<–


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.

Relevant Links

Apply for Further Online Training for O-Shot®, P-Shot®, Vampire Facelift®, Vampire Breast Lift®, Vampire Wing Lift®, or Vampire Facial®<–
Next Hands-on Workshops with Live Models, worldwide <–


Altar™–A Vampire Skin Therapy™





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<—

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