Topics Discussed Include the Following…

1. What They Do Not Teach at Medical School (that you need to know about the clitoris)
2. The Frenulum of the Clitoris and Its Relation to the O-Shot® Procedure
3. The Extensive Hidden Clitoris (and the secret unpublished video)
4. Urethra to Clitoris Distance Matters
5. A Cross Section of Coitus
6. Pearls for the O-Shot® Procedure Relating to the Anatomy of the Clitoris
7. A Magic Ingredient that Makes Your Marketing More Fun and More Effective and More True
8. Study Aesop’s Fables if You Want to Communicate Well with Your Patients (really, read them)

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

1. Transcript, 2. Relevant Research, 3. Relevant Links

1. Transcript

Charles Runels, MD

Welcome to the Journal Club with Pearls & Marketing

What They Do Not Teach at Medical School (that you need to know about the clitoris)

Until this past week, I knew that teaching the anatomy of the clitoris was at one time not done, but I thought that oversight had been corrected; now, I think, “Maybe not so much.”

Look at the following chart, where researchers looked at the curriculum of 7 medical schools in the Chicago area. Out of the seven medical schools, only one of them was completely teaching the anatomy of the clitoris. Only one talked about how to do a genital-urinary exam in regard to female sexual dysfunction (Codispoti, 2023)

Here’s the chart.

You can look at the complete paper here (it’s open source)<—

I’ve been doing the O-Shot® procedure for over a decade and have taught literally thousands of doctors. I’ve looked at the anatomy, and (because it is both complicated and not as well described as other parts of the anatomy) there are times when I’m not sure I understand it. Still—only 1 out of 7 medical schools even attempted to describe the clitoris completely as part of their curriculum.

Only 6 out of 7 of the schools described the glans clitoris. Of course, anybody who owns a vagina or has been naked with a vagina, you can find that much, the glans—still, only six out of the seven schools mentioned that!

But then consider the corona, only one out of seven talked about it. So, now, I don’t feel so badly that after 10 years of looking and thinking about the clitoral anatomy, I’m still not sure I understand the anatomy as well as I would like. I’m certain I didn’t get any instruction about how to examine the clitoris in medical school—even though I think I attended an absolutely outstanding (the University of Alabama School of Medicine in Birmingham) which included a course on sexual function in the curriculum (not commonly done in the 1980s).

I think, in many ways, I’m now preaching to the choir because many of you are doing surgery on the clitoral area and the labia, but many of you are not and could be like me and want and need a better understanding of the clitoris. So, after going through a number of books and research papers, I found what I think is a jewel to help us: It’s called the Anatomic Study of the Clitoris and the Bulbo-Citoral Organ,which these authors coined that term (bulbo-clitoral organ). I think it is the best picture book of the anatomy of the clitoris. So, I wanted to dive into some of the helpful views that I saw of it.

I see David Harshfield jumped on the call. I see multiple gynecologists on the call, so I do not want to dominate this conversation, but I’ll give a picture show and tell some things that were eyeopening to me, and then I’ll try to relate it to our thoughts about doing our procedure, the O-Shot®.

The Frenulum

I was taught to do the clitoral block by Sophia Lubin, who, if you’ve been through the workshop or if you’ve watched our videos on how to do the O-Shot®, you know I’m a big fan of hers because until then, I was getting maybe a two out of 10 (pain scale) with most people using ice and BLT cream. But after she showed me that block, most of the time, I get a zero out of 10 pain.

Now, my wife (Alexandra Runnels Runels, MD, ACOG) and some of you have started using 30% lidocaine and do not need the block, but when I say inject the frenulum, if you’re going to do the block, you should know where the frenulum is.

Most people were never taught what the heck the clitoral frenulum is when they were in medical school. So I’m showing you a picture from this book of the different varieties; I think vaginas are like snowflakes and irises: they’re all beautiful, and they’re all different. But these photos show some of the variations in the frenulum and the glans clitoris. You can see there’s variations in the size in that view. There’s one size; let me see if I can blow this up where y’all can see it better. Hold on a second.

They show one glans that they call an “accordion glans.” And here’s the thinner side here, but the labium minora comes up, and it bifurcates, and one side becomes the frenulum, and the other side becomes the clitoral hood. No one ever taught me that in medical school.

And when we do our injections, you’re following the labium minora up until you get right there, where Sophia Lubin taught me, and you do a little bleb of lidocaine right there at that (like when you’re injecting your finger in the web when doing a digital block). You’re not injecting the clitoris; you’re injecting there.

But you see, the frenulum has all different configurations, and it’s important to know what that is. Okay, so that’s the first picture I wanted to show you.

Next Hands-On Workshops with Live Models<—

The Extensive Hidden Clitoris (and the secret unpublished video)

Next picture: I really liked this picture of the glans that shows the whole structure of the clitoris as well. So you have the glans clitoris, the body of the clitoris, and you have the dorsal nerve that comes in, and up here’s the pubic rami, and then you have the sheath that the nerve comes around, and the nerve lives in that sheath. And then you have the crux, you have the corpus cavernosi that go down and the bulb here and here. So that’s the whole thing.

And looking at that, you can see, wow, no wonder riding a bicycle isn’t so great for sexual function because look, there’s the bone, there’s the dorsal nerve, there’s the clitoris, corpus cavernosum.

And you can imagine riding a bicycle in a big race, maybe not so good for those structures.

Our first target for the O-Shot® procedure is the body of the clitoris and then it hydro-desect the material with PRP.

Dr. David Harshfield came to my office and did an ultrasound while I did an O-Shot® procedure. He can jump on the call and tell you what he saw. Hold on a second.

Are you there David? Can you hear me? I’m trying to get your mic unmuted.

If you’re talking, I can’t hear you. Anyway, I’ll try again in a minute.

The first time I did an O-Shot, I had already done a P-Shots® to many men and to my own penis. And I thought, “Wow, if I can inject into the body of the Clitoris and it will go down into both corpus cavernosi, that could be wonderful.”

When I injected and saw no swelling, no edema from the one CC injection, I thought, “Man, that might’ve really gone where I thought it went.”

Years later, David Harshfield came to my office and was able to demonstrate it. And I can’t get your mic unmuted. I’m going to try one more time.

Okay. You should be able to talk.

David Harshfield, MD:

Okay.

Charles Runels, MD:

There you are. So talk to me because you’re the radiologist, the anatomist, the stem cell expert. I don’t think people would even believe if I said all your credentials, but that was an interesting day; tell me, we must publish that video, but maybe we should do six more before we publish it. But talk about what you were thinking when you did the ultrasound and looking at this picture. How would you explain what we’re looking at?

David Harshfield, MD:

First of all, we didn’t really, I didn’t understand this anatomy. And if you look at Grant’s Atlas, Charles, the penis is always shown in total, but when the vaginal parts, the clitoris, they’re shown on different pages, chapters away.

Charles Runels, MD:

That’s a good point. I never thought about that. Right. Have to piece it together.

David Harshfield, MD:

There was a cartoon, and it was from someplace out in San Francisco and in a Gay Pride parade, and they had a balloon, a big pink balloon. Do you remember that? Charles City?

Charles Runels, MD:

I do remember that, yes.

David Harshfield, MD:

And I went, “Holy moley.”

Charles Runels, MD:

There’s the whole thing.

David Harshfield, MD:

Yes. And so we had really polite attendees that day and we were also on each other. And I have a little hockey puck-shaped transducers, 20 megahertz, very high resolution, and it fits perfectly in the vaginal introitus. So we were using it to see where we were injecting when we were doing the O-Shot® for urinary incontinence. And you could see the urethra there; it was very bright. You saw the spongiosa, the tissue around that.

You see the needle going right in a spot between the euro epithelium and the urethra. And then we would inject. And I had been doing a lot of penile doppler back in the day. There was a guy named Jerry Bookstein. So he and I, he was from UCSD and I’m from Arkansas and I met the VA all the time. So we’re imaging what? Impotence and alcoholic liver disease. So I became an expert at those things. And to your point, Charles, you do anything for two weeks solid, you’ll be as smart as any 10 people on earth in that area.

Charles Runels, MD:

Before we go further, I want to show another picture because you’re talking about two different things, and we did them both that day. So this was another one of the pictures I wanted to show because I’ve been looking at a lot of Delancey’s work, who, as you know, did a lot of autopsy studies (and I think understands the pelvic floor better than anyone). We’ve talked about him on the journal club a lot. In his work, he shows the wall of the vagina and the wall of the urethra becoming; they touch at the introitus and become separated as you get more proximal to the bladder. And in this micrograph they show the urethra is there, and then here’s the vaginal anterior vaginal wall. And then they show what they describe as a vascular space between the two. Not a big space, but not adjoining each other.

And so that’s where we were doing that anterior vaginal wall injection. So I’m still trying to figure out exactly what’s happening. I think we need to do some more imaging studies.

And then, if you remember, we kept going up on the volume and wound up shooting a total of five CCs in the clitoral body. And that’s when the waveform swapped from what you described as a flaccid penis to an erect penile waveform as we were injecting the body of the clitoris. So looking at both of those pictures, now take it away and tell me what you’re thinking.

David Harshfield, MD:

Okay, so having this extensive experience with doing penile injection is basically an erection is filling a bathtub, and you have three components of that. You’ve got to be able to fill it, the arterial inflow, and then it’s got to have a plug. The venous outflow has got to be occluded. And then when it’s filled, it’s got to maintain the pressure and all that. Those three things are based on a neurovascular discussion in the ejaculation sympathetic, you can do that with a flaccid penis, but you cannot have an erection without parasympathetic.

That’s the tricky part. And so what we learned when we were doing the injections, I was an interventional radiologist looking at opening blood vessels and things like that.

And when I first started doing stem cell injections for vascular problems of the lower extremity, within a few days, certainly weeks, these blood vessels opened and I thought, “Hey, we’re injecting stem cells around outside now of the blocked arteries and they’re re canalizing.”

No, they weren’t. I was such a knucklehead. The patients were telling me, “I can feel my feet, I can feel my feet.”

I go, “What are you talking about?” And they said, “I didn’t know if I had shoes on or not. And since you’ve been doing these injections, the vascular flow’s higher, but now I can sensation my foot.”

Charles Runels, MD:

That’s wonderful.

David Harshfield, MD:

We’re fixing the nerve, Charles. And so when we were doing the clitoris and finally figured out where the cavernosa so was in the women and these vascular bodies and how they’re anchored and watching this PRP just flow freely through these structures and suddenly the woman has an erection (on ultrasound) not as obvious as a male op, but on the dollar, it’s exactly the same thing, Charles.

The flow pattern, initially with a flaccid penis, you just have a little systolic blip as it starts to fill, and the same thing in the women’s corpora cavernosa, which makes a complete circle and touch at the posterior margin of the introitus.

I had no idea if those things were contiguous. And watching these channels fill the little first flow pattern would be these little systolic pulses. As we started doing the injection, now it became a very high systolic and diastolic flow. So you had increased systole ejection fraction, but then you had vasodilation. So high diastolic flow, it means we’re filling the bathtub. And then when the bathtub got full or these cavernosa tissues congested, the flow pattern went back to a systolic pulse and they had vascular congestion like an erection. And there was so much more volume you could put in the clitoris side.

I was just amazed.

Charles Runels, MD:

Yeah, I was too. That’s the most PRP I’d ever put into a clitoris. And I am hesitant to put more than we normally do in the anterior vaginal wall, but it was flowing easily, and it seemed to, as you visualized it, have some pretty dramatic effects. We really need to take more pictures and publish

Don’t go away because I have a couple more pictures I want your comments.

Urethra to Clitoris Distance Matters

So this one is one, there’s an MRI study we talked about that a lady radiologist did, and this has been talked about showing the correlation of urethra to clitoral distance with orgasm.

Actually, one of Sigmund Freud’s understudies had difficulty with this; she had anorgasmia and talked someone in doing surgery trying to change the distance.

And that’s what these pictures demonstrate.

Freud, as you know, was of the opinion that a clitoral orgasm was infantile, and as women matured, they had a vaginal orgasms. His student broke away from that idea and tried to make a case for the importance of the clitoral-urethral disatance; and that MRI study confirmed it, and that’s the point from these pictures, too.

Any comments about this, David or anybody else on the call?

By the way, Steven, all the references, including the book, I just copied pasted them all into the chat box. So if you copy-paste it out of the chat box into a document somewhere, you’ll have all the references. Any comments about this, David?

David Harshfield, MD:

Yeah, the anatomy, and I’ve always been interested in this, and when you’re a radiologist, and you’re looking at MRIs of the pelvis or the low back, and then they include some source images where you have all this anatomy and now we’re doing executive physicals where we look at the entire body on MR…there are all these anatomic uniqueness of all the genital-urinary system and so forth. The exploratory system, a lot of docs are looking for patients that have rectal prolapse, and there’s that anatomy, but this anatomy is very clear, Charles, to your point, and they’re all different. It’s just amazing when we were injecting those folks with urinary incontinence in doing the PRP, I’ve since done that on several patients, and they have a neural response and a lot I think of their urinary incontinence was that—it was a neural issue as well as soft tissue and birth canal damage, so forth.

Charles Runels, MD:

Yeah. As you might imagine, if you do a whole textbook on clitoral anatomy, it’s a passionate part of your philosophy, and the authors (Vincent, 2014) have an interesting prelude to the book where they talk about a time when in the British Academy of Medicine, the head of their society was recommending clitorectomies as a way to treat psychological problems in women.

So there’s been this all-over-the-map idea about this mystical little organ. And as we just looked at the research, only one out of seven medical schools in Chicago teach the complete anatomy of the clitoris.

A Cross Section of Coitus

Here’s one of my favorite diagrams in the book (Vincent 2014). This is a cross section of sexual intercourse showing what happens to the male and female anatomy during that activity.

You see two corpus cavernosi, you see the female at the top of the screen, and then the male penis.

And here’s what I’m trying to figure out. If you look at that picture and you think about the other part of that MRI study showing that the distance of the urethra from the clitoris and the size of the clitoris correlated with orgasmic probability: (1) the size of the clitoris going up meant more likelihood and (2) the distance going down, meaning more likelihood of orgasm.

And you can see that it’s almost like, well, we’re rubbing corpus cavernosi together.

And as the surgeons on the call would say, there’s almost no sensation of the vaginal wall. But the big mystery to me is if you think about what’s going on on the posterior side of the vagina, if it isn’t there, there’s no pressure.

And of course that could also happen from a mismatch. You guys know I never say “big penis,” or “little penis” or “loose vagina” or “tight vagina.” It’s about how things fit.

And if you have a mismatch in fit where there’s no pressure on the anterior vaginal wall, then there’s less stimulation.

But the thing that I’m wondering is, we’ve got our Emcella machine, we have your stem cells, now we have PRP injecting that we can put in the muscles of the pelvis, and I think we’re probably injecting the muscles of the urinary sphincter when we do the O-Shot® procedure.

So, if you are going to go in there and magically make some muscles stronger in order to improve sexual stimulation, and you could just touch that picture and make the muscle stronger, what would you do, David? Because then, of course, the next thing is, well, everything you’re touching with your finger, why don’t we touch it with a PRP syringe/injection and actually do that?

David Harshfield, MD:

The congestive tissue, you see the tube corpora cavernosa. It looks like a little eyeballs, two little eyeballs and then the little mouth, the penis part and the dorsal nerve and a vein are very important there. But most of-

Charles Runels, MD:

Right, so you’re talking about the male version now, right?

David Harshfield, MD:

Yep, yep.

Charles Runels, MD:

There’s our female corpus cavernosi up here in her pelvis. Keep going.

David Harshfield, MD:

And the penile artery are the little dots down the cavernosa and they enlarge until the cavernosa’s full. And then they start to get smaller and the waveform obviously changes. The women are doing the same thing. Now you think about timing of this thing, it’s really interesting. But as far as the musculature around the vaginal wall, there’s smooth muscle below the epithelium.

I don’t know how good we are at regrowing smooth muscle, but it’s sort of a different animal than skeletal muscle. We’re really good at doing back injections. Say the facets in the median bundle branch are painful and will melt it with a hot probe and kill it, which I used to do. I don’t do it anymore. But that was silly because now what we’ve done, you don’t hurt, but you don’t have this musculature. And the multifidus is that little muscle that’s really close to the spinous process between the facets.

It’ll atrophy.

Well, fast forward 20 years, I quit doing all that steroid stuff and that nerve ablation, and we are starting to do PRP for facet problems. The muscle going back, Charles, the multifidus, started to restore.

And again, I think we restored the nerve, but here’s the combination for how the muscle regrows. Smooth muscle, I don’t know how good we’re at that. I’m trying to think of an instance where we restored that with our injections. I mean we should, but it’s not, I think maybe as evident as skeletal muscle. It’s really obvious that there’s not much skeletal muscle down there except the pelvic floor.

Charles Runels, MD:

Yeah, it’s tricky. As you know, there’s some smooth muscle and some striated muscle involved in the urinary sphincter, but it’s mostly smooth muscle. See, I’m not a big fan of the word, the pelvic floor. I know that’s the word to use. That’s what’s in the textbooks. And so I’m not trying to correct you. I think it doesn’t give it justice. Somehow when you call something the floor, it loses its luster and its glamor, but without muscles to support what’s going on there in this missionary position—there would be no pleasure. So they’re facing each other (in the diagram) and having sex, but without muscles to support it all. There’s no really good stimulation.

And now, back to what we’re talking about, what are we doing with our procedure when we have a couple come in?

There’s some restoration of the volume of the penis. We just had another study (Brandeis, 2023) documenting that there’s some growth with our P-Shot® (especially when you combine it with a pump).

Then (looking at the other side of the male/female couple), if the clitoris acts like every other tissue, there’s neovascularization that happens there, but I still feel like we’re missing. It feels to me like there should be some way to design something in the muscle. I’m still searching for what’s the magic place where we could grow muscle (using our O-Shot®) to improve sex.

Maybe it’s some part of the pelvic floor with the magic place to strengthen somehow the pressure that’s going on there. Anyway, I don’t belabor that point, but don’t go away because I have more anatomy pictures.

David Harshfield, MD:

One thing too, Charles, people were using platelet-rich fibrin, and it’s sticker, it stays home. And it might be, and you and I talked about this before, and using that in lieu of hyaluronic acid, the Juvederm, the hyaluronic acid, and we’re learning how important this hyaluronic acid is in the fascial points. They have to slide and move and so forth.

So the question was, and we’ve talked about what we’re injecting, would fat work in the sense that it will restore volume, and would platelet-rich fibrin be more substantive as far as volume goes than our PRP? It tends to want to just run a little spaces and not really stay in one spot until it activates. And then the interest in what little spaces were talking about and using amnion type, perinatal type tissues.

Charles Runels, MD:

Yeah, I think all the different variations that you, I know you’ve got your IRB and so active in research and understanding beyond my understanding by far about what else we could be adding in or instead of the PRP, I don’t think we’ve even come close to understanding what all might be possible a few years from now.

Look at this picture. I think it shows a cross-section through the glans, the body of the clitoris, and the septum in the middle.

As you know, when I do the O-Shot, we usually just inject one side and it seems to fill and we documented flow down both sides. But as you know, when you do the P-Shot, you have to do both sides. But I just thought that was a nice picture. But the other one, this was the picture that became the float in the parade, right? There’s the whole beast, the nose, the spongiosum, and the whole thing dissected out. Any comments?

David Harshfield, MD:

Yeah, that’s beautiful. In fact, the pictures we have are awesome, and they’re labeled, I can’t remember what; I’ve got them somewhere. I’ll resend them to you. That picture is the first anatomic picture I’ve seen that depicts,. I just drew it in, remember?

Next Hands-On Workshops with Live Models<—

Charles Runels, MD:

I know. Those videos are beautiful, and all I did was squirt the PRP. I really wish you’d publish that. Along with those videos are still shots with some links where people go watch it explains what we do.

David Harshfield, MD:

Yeah, it’s eye-opening because when that stuff disappears from the needle, you’re going, “I hope it’s going into the corpus cavernosi.

Charles Runels, MD:

Right. I think it also explains though, what happens when it goes wrong. And this is part of why I wanted people doing our procedure to see it. Because again, after a decade of doing the O-Shot®, I just discovered this book, which I think explains what can be pieced together by looking through many other books. But by the time you read this book cover-to-cover and think about it, you have a really good idea about the anatomy.

So, here’s a side view. When we’re injecting the body of the clitoris, when you get it right, there’s no swelling. It does act like a wick and go down; here we go. That’s the picture I was looking for right there. When you’re looking down at the top (dorsal side) of the clitoris and the two corpus cavernosis splitting off, then they just transected it there.

And when you pull the hood back, and you inject into that the body, not the glands, but the body of the clitoris, if you see swelling around it, you’re not in the right place.

But when you look at the micrograph and see the architecture of it, I think you understand why this is not a structure you want to inject with your 18 gauge needle. An 18 gauge needle can double as a scalpel. This is something you do with your 27 gauge at the most and hopefully with a 30 gauge needle so that you’re not disrupting the architecture. The goal, of course, is to rebuild architecture, not lance it with what amounts to being a small scalpel.

What else would you say about this picture, David? Anything to add?

David Harshfield, MD:

A lot of this, and I think this last year, well, last two years really, we’ve been doing dissections on more live tissue. In the old days, the interstitial, and that’s what this is interstitial space, and that is now the 81st organ in the human body. It was 82 organs, 83 when you’re pregnant; the placenta is an organ. The 79th was the mesentery. We realized how important the gut was. So, I think interstitial space might be the 80th organ.

And that’s what we’re looking at. In this interstitium is where most of the nervous tissue is, and it has these little vacuoles, it contains stuff that’s like lymph, but that doesn’t communicate with lymph. And that’s, I think, what we’re doing here, Charles, that’s interstitial space contained within a certain structure.

And back to the point about smooth muscle, which is basically lining all this congestive, this vascular cavernosal type tissue, that smooth muscle. Maybe we are restoring smooth muscle. I just, I’ve never seen it like I see skeleton muscle; it’s so much easier to see. Maybe smooth is so small and single layer, it’d be harder to appreciate that you’ve restored it on the focal 20 megahertz. Fuji’s got a 60 megahertz transducer. We’re going to be able to see all kinds of stuff, Charles. When I get that thing, I’ll bring it down, and we’ll look.

Pearls for the O-Shot® Procedure Relating to the Anatomy of the Clitoris

Charles Runels, MD:

Yeah, let’s play with it. And I just unmuted my wife. As you know, she’s a gynecologist. She’s been doing and teaching her stuff along with surgeries. Do you want to add some stuff in, Alex?

David Harshfield, MD:

Alex, how are you doing?

Alexandra Runnels, MD:

I’m good, I’m good, David, thank you very much. I love listening to you talk about anatomy and radiology, and it’s fascinating. I’m looking forward to seeing what you’re going to come up with next.

Charles Runels, MD:

Talk to us about these pictures, Alex. What would you add? Talk in terms of the procedure; what pearls could you have as far as doing the procedure or pitfalls to watch for, mistakes you see happen in the people you teach based on the anatomy?

Alexandra Runnels, MD:

Well, I think that these pictures are great for highlighting how fragile that space is and how it’s actually not a very big space, and it’s very easy to get into the wrong tissue plane.

And I see people do that all the time. I do it. It happens pretty frequently because the anatomy of every vagina is different; like you said, what do you call them? Snowflakes. They’re all snowflakes. Everybody’s anatomy is so very different: the axis, Iof the body of the clitoris runs at a different angle in every woman, every size woman, every age woman, depending on all sorts of things about her anatomy. And because it’s buried, you can’t see it really. I mean, you can feel it sort of sometimes, and you can expose it by pulling the clitoral hood back enough to see where it probably is.

It’s mostly buried.

And I think that it is very easy to get into the wrong plane and then fill up the space between the body of the clitoris and the clitoral hood with PRP instead of into the cavernosi themselves. And nothing bad happens of course, as you know, but the patients, they usually complain, I think, a little bit more of pain or discomfort if that happens. And I don’t think they probably get as good of a result or treatment.

But I think that making people more aware of just this, what I’m talking about, I think is a good thing for people that are just maybe getting started doing this or maybe haven’t done that many. And think hard about where they’re directing their needle when it comes to trying to get that PRP into the clitoris.

Charles Runels, MD:

I put a picture up that’s relative to what you’re talking about, Alex.

There are some who still think we’re injecting the glans. And if you watch the video, I think maybe I should make it more plain because you can see the needle go into the body just behind the glans. But as it does it, the glands twist around facing you. And I think it may be misleading, but technically the idea behind it anyway is that just as when you do the P-Shot, if you’re injecting the glans, well you’re injecting the corpus spongiosum—that’s connected to the glans. And if you really want to fill the shaft of the penis, you need to inject the body or the shaft, the corpus cavernosi behind the glans.

So that’s the idea behind it. Who knows? Everything I’m saying tonight could be wrong, but at least for the past decade or so, most of us have been going for, as you just heard Alex say, putting the needle into the shaft of the clitoris or the body of the clitoris, not into the glans.

And then, if you look at the anatomy, you can see from what I’m showing you that would then lend itself to hydro-dissecting down into the corpus cavernosi.

What else would you add to that, Alex? That’s what you’re doing. You’re trying to have it go down. And this is where David Harshfield had his ultrasound. He was looking at flow here, I think. Did I say that right, David?

David Harshfield, MD:

Yeah. We didn’t know what the heck we were seeing until it filled. Smokes that communicate. It was a fun day; it was a great day.

Charles Runels, MD:

You think we could actually get that? Should we do more before we publish it? Because we’ve talked about it, I think, well, I know I have it in a file in my Dropbox. It seems a shame that it’s living there and not where people can marvel at it.

David Harshfield, MD:

I’ll go back and see how much I can find. Alex is going to have to participate. Me and you are like 12-year-old boys when we start fooling around with this. And so I think, “Okay, boys focus and get this analogy demonstrated properly.”

Charles Runels, MD:

I bought an ultrasound for my office, and of course, I don’t know what to do with it, but Alex does. So maybe you two could play and get something published. Let’s see who else has comments.

Alexandra Runnels, MD:

Yeah. That’d be fun, David.

Charles Runels, MD:

Alex, what other pearls do you have about injecting the body of the clitoris, and I think I’ve never met the doctor yet that was taught in medical school how to pull back the clitoral hood and examine for phimosis and adhesions. T

alk a little bit about that, and then let’s swap over to your pearls about injecting the anterior vaginal wall, either one of you.

Alexandra Runnels, MD:

Well, I guess as far as the clitoral hood and fibrosis, there’s often, even when someone isn’t presenting with a complaint of anything specifically about the hood or phimosis, it’s not uncommon to find somebody with the hood somewhat adherent with some mild adhesions between the glans and the hood.

If you can’t pull the hood completely back, then it can get a little bit trickier trying to get the needle into the body. But if there are some not very dense adhesions, those are something that you can easily tease away and not harm anything.

Charles Runels, MD:

Tease away. In what way? How would they do that?

Alexandra Runnels, MD:

Well, I’m thinking of doing it when I’m doing something surgically, but really you don’t need anything sharp. You’re just a little blunt-tipped mosquito nose hemostat or something like that. And you can just do blunt dissection just to separate, put the little tip of the hemostat between the hood and the glands, and just open it and gently open it a few times. Usually, you can gently dissect or dissect away those adhesions and pull the hood back.

Now I’m not suggesting doing that in someone who has very severe or severe scarring, but it’s not uncommon. I’m sure people on this call that I’ve done enough will admit, too, that plenty of women out there don’t realize how much their clitoral hood will pull back.

Charles Runels, MD:

Men are taught how to retract their foreskin and tend to their hygiene. Are women ever taught? Is that even a thing? Are they ever taught to pull back their clitoral hood and keep things mobile and not adherent?

Alexandra Runnels, MD:

I do not think so. In my lifetime, no.

Charles Runels, MD:

Okay. Well, there’s a book for somebody, the Woman’s Hand Guide to Clitoral Care or something. That’s a 50-page book that somebody puts on Amazon.

I’m not the one to write it. Somebody needs to do that who has a clitoris, I think.

Okay. Alex, give me your tips about how you do and teach the O-Shot and think about the anatomy. I’ll just clip back to this picture, thinking about the anatomy around the urethra and more tips about how to make sure you get the needle in the right place because I do think there’s a nuance to it.

I’ve had a lot of gynecologists go back (after our workshops) and tell me (these are surgeons that do amazing stuff, and I don’t even know the name of the tools they use), “Yeah, it’s like an IV. You learn it in five minutes, but you’d have to do a few times to get the knack of it.”

So tell me more about how to get the knack of it.

Alexandra Runnels, MD:

I think something else that helps me a lot is I like to feel the body of the clitoris between my fingers, between my thumb and my forefinger before I inject it. I like to stabilize it up against the pubic symphysis so that it doesn’t change orientation or angle when I approach it. And then I don’t want to squeeze too much because then I’ll impede the flow of the PRP.

But if I just gently have the body of the clitoris between my fingers and have it stabilized up against the pubic synthesis without changing orientation, then I can feel, not only see the PRP going in the right place (because it’s not swelling anywhere), but I can feel it flowing between my fingers and then I know it’s going in the right place.

And if I don’t feel that, then I will adjust my needle and readjust and change my positioning until I do get that.

And I don’t know if anybody else does that technique of feeling while injecting. I usually teach that if I’m teaching the procedure, but I don’t know if other people do that or not. But I find that that is a very helpful thing. Otherwise, you’re just, it’s almost like a shot in the dark if you’re not holding onto it and keeping it still.

Charles Runels, MD:

I like it. And it’s not something that I routinely do. Because I can usually see it, but I like it, because then you’re seeing it and feeling it. So you put your thumb and forefinger on either side of the body, the clitoris, and then instead of just pulling back the hood and popping the clitoris out, you’re actually still maintaining focus on where the body is and keep it more horizontal as you inject it and feel the flow go between your thumb and forefinger.

Did I get it right?

Alexandra Runnels, MD:

You did get it right. And I think one other reason I like that is that even if I can see that there’s no swelling going on, sometimes I won’t even believe it if I can’t feel it because I’ll think, “Well, maybe it’s not swelling, because I’m injecting at a deeper fascial plane and it’s not swelling where I can see it.”

So I’m just never convinced until I have a bunch of evidence.

Charles Runels, MD:

So swap over to the anterior vaginal wall now and talk to me about that; so we’re looking at the anterior vagina, and then you got the urethra, it’s a transverse section. So talk to me about how you are most likely to get your needle in the right place and avoid the wrong place when you do the anterior vaginal wall injection.

Because this is what we’re aiming for right there (see video). This was actually taken at the opening of the urethra, by the way, this transection.

Alexandra Runnels, MD:

You can see it’s only very few cell layers thick. There’s just not that much space there.

Charles Runels, MD:

Yes, thank you. Yes, I’m sorry to keep interrupting, but it makes you torn, right?

When you see a needle plunge two inches in, and you think, “Oh, well, you haven’t damaged anything, but I don’t know what you’re treating anymore.”

Alexandra Runnels, MD:

Well, that, and it’s not very comfortable for a urethra to get pierced with a needle. It’s painful, and you’re right, it won’t be very effective. You’re not getting in the right spot.

But yes, it’s just a few cells thick; it’s not very thick at all. And so the most important thing, I think, is just not getting a needle further than just past the bevel into the mucosal surface. And paying attention also, again, to the angles of things and what’s perpendicular to what, is the bladder hanging down?

They have a bit of a prolapse, or is it up high and tight? And those are important things because, just like starting an IV, you wouldn’t start an IV at a perpendicular angle. You’d be kind of tangential. So I think that’s important.

Charles Runels, MD:

Cheryl wants to know, do you prefer to be sitting, or how do you position your own self when you’re injecting the clitoris?

Alexandra Runnels, MD:

Oh, the clitoris? I have done all sorts of different things. If I am in my own chair and I have the patient positioned well (I positioned them myself), I’ll usually stay put and stay in my own chair when I inject the clitoris. Although if there’s anything difficult at all about the patient’s size, their habitus, or the anatomy, or anything, then I like to stand up and be on their right side. I get up out of the chair walk to the side of the bed and approach it in that direction. Because that really is a better angle to approach it. And if so, if there’s ever anything about it that makes it a little bit tricky, then that’s what I’ll do.

Charles Runels, MD:

Yeah, I think it gives you a better visualization. Anything else either one of you, David or Alex, you want to share? And then I’m going to plunge in and do about five minutes on a little trick about getting people to pay attention to your emails, and we’ll call it a night.

Alexandra Runnels, MD:

Well, I have all kinds of things that I could talk about, but not anything that I think we probably want to talk about right now. I’m thinking about all kinds of things about connective tissue layers and fascial layers of this.

Charles Runels, MD:

We have new stuff coming. I’m telling you guys, crazy new stuff coming. I know David has so many things. He could talk all day literally about all the different things other than PRP that are coming down the road. Is there anything else you want to mention before we swap over to marketing, David?

David Harshfield, MD:

This new ultrasound system, soft wave. And the bottom line, what we’re trying to do for tissue is it needs voltage.

To quote Jerry Tenet, “Voltage is healing.”

In fact, it’s really amperage, by the way, but we need electrons in tissue. How do we do that? Injecting PRP is a way. Massage is a way. There’s all these ways. They have a new ultrasound system that’s high-frequency ultrasound, but it’s called soft wave. Now, there’s a system out there called Radial, and it’s okay from what it does. We need this focused ultrasound, and it helps these adventitial spaces to get adhesions and so forth. In a lot of these chronic pain patients, the fascial layers aren’t sliding; they’re scarred.

And to Alex’s point with between the clitoral head, and that happens in the adventitial, and this sound can be used both in the penis and also in the women to help facilitate the restoration of this cavernous tissue. And we’ll talk more, I think, about that sometime down the road. I won’t show; I know Alex knows, but it’s a really neat little toy that you can use in addition to your injections and stuff like that.

Charles Runels, MD:

Beautiful. If you would, maybe we’ll have you on the call one night, and you can go into great detail about it. Is it available now?

David Harshfield, MD:

Yeah. And they want me to use it. I do a lot of traumatic brain injury and stuff like that. I’m the medical director now for the NFL Alumni Association, and we’re trying to figure out how to treat traumatic brain injury, mostly inflammation.

And by the way, a lot of this problem in the cavernosal tissue’s inflammatory, and there’s bacteria everywhere. It’s a low-grade infection-ish type of thing. So we’re looking at how do we get energy in here so the body can heal itself. They want me to do some transcranial stuff, and I want to do some, I’ll do that too, but I want to do this. I think that this is going to be real important for these folks to be able to use sound in this way in addition to the cellular, the biologics.

Charles Runels, MD:

Beautiful. Well, I’m always honored to have you on the call, David. And if I wouldn’t get accused of being biased, I’d have Alex on every call. I’m trying to temper it because, obviously, I am biased because she’s brilliant and has some ideas that I think she’ll be rolling out soon (and she is my wife).

Let me swap over to marketing.

A Magic Ingredient that Makes Your Marketing More Fun and More Effective and More True

And it’s just an easy little concept that I first heard in a book that I’ve not been able to get it in a book, but it’s on Audible, and it’s called Thomas Moore on Writing. It’s only about an hour and a half, two hours long, maybe plus or minus 30 minutes, about two hours long. Thomas Moore on Writing.

And Thomas Moore, the modern Thomas Moore, not the one a century ago, but the modern Thomas Moore was a priest. He went awol, and he has a degree in music and after he did the priesthood and he can write and read Greek and Latin in Hebrew, he got a PhD in music theory and then has years of experience working as a counselor.

His first bestseller book was Care of the Soul, but he has just a little simple recording about writing, which really has a lot to do with just living (not just writing).

I found it very profound, comforting, and beautiful.

One of his points is that people worry too much about clarity.

But the current big takeaway for our discussion today and what I found useful in all of my writing, especially in marketing, is just this: He says that he will read some things. and it’s all about the subject, and you can’t find the author anywhere in it. So you read, this would be the email or just this research that shows that PRP does this and this many people, it’d be what we just said, seven medical schools in Chicago were looked at, and only one of them teaches the full clitoral anatomy. And there’s nothing in there about anything but the facts.

And then the reverse of that would be all about the author, which would be a celebrity TikTok sort of thing, where there’s really no content at all. It’s just a written version of a selfie with no other redeeming factor unless you just want to follow a particular celebrity—who they went to bed with that night or how they’re able to balance a champagne glass on their booty. And that’s the other extreme.

But his ideal was that people really want to see the author along with the facts and ideas. And that is completely, absolutely, in my opinion, critical to your patients reading your stuff. Not your patients reading my stuff or my patients reading your stuff. But if you put yourself in there with the science, you have a winner.

I’ll give you a few examples. Before you send out your next email or go back and read your previous emails, or go read your webpage where you talk about the O-Shot® procedure.

Is there a picture of you?

Are you anywhere to be found in there?

And I don’t mean just you talking about the facts. So can I find something about you in it? I don’t think it needs to be about your hobbies. It just needs to be about your adventure in medicine. If I were going to make a poster or something to write on your arm that you can’t wash off for a week, it would be to put yourself in there with the science.

Be careful though. Your patients resent your hobbies. They like to see your family. That’s the only thing they want to know about you outside your ideas about medicine. They’ll resent your hobbies. They’ll resent anything other than your reading and thinking about medicine and travel to learn more about medicine and what you’re doing in your office to learn and practice medicine and your family.

So to give an example, and I don’t think Alex will mind me telling this story, but she had someone write an email for her that I read, and I thought, “Well, it kind of looks like an ad. I couldn’t see Alex in anywhere.” (It sold nothing.)

And I said to her, “Let me just kind of remind you of a way to do this.”

So I had her send me a picture, to text a picture of a body part she had done something to, and there was no way to identify the person. There was no identity to it.

But she told me the story of the person and her interaction with her and what happened.

So, I just wrote an email about that. It was a paragraph or two, including the picture.

Now you have a story about a woman who, to her patients, is their hero, telling about her adventure with that person (patient) and how it ended well.

And they will open the very next email and read that one too, and the one after and the one after.

Study Aesop’s Fables if You Want to Communicate Well with Your Patients (really, read them).

And so another thing to think about if you want to really write good emails is to find your kids’ old book. It’s stuffed on a shelf somewhere. Hope you didn’t throw it away. Remember when you read Aesop’s Fables to your children (maybe last night) where there’s a moral to the story? Make your emails like an Aesop’s Fable.

The woman came to my office, and this happened, and this happened, and then I did this. And the moral of the story is this, and it’s hidden in there, but now you have Alex in there, and you have another person in there, and something happened, and you can pull the research into it. But that’s the takeaway: put yourself in with the science (and make it a story).

Everybody on this call lives a life that most people wouldn’t believe.

And most of the people on this call, if your next-door neighbor tried to follow you around all day, they’d be in the hospital. You’re not sleeping as much as they are. You don’t watch as much TV as they do. You work longer hours, you are probably still doing some kind of exercise, probably having more sex than they are, and eating what to them is weird stuff at weird times. And they would literally be hospitalized if they followed you around for three days.

But your patients don’t know that.

Some of them might think you’re out playing golf, and that’s okay if you do that, but they don’t know the other 80 hours you worked that week and that you read 10 books this week and a stack of research papers. And so if you start letting them see that in your writing and your videos, and they will follow you and realize why you’re their hero and their doctor, and everything else you say will be magnified.

Now, you can communicate.

So the takeaway, the moral of the story of this Aesop’s Fable is that just go back and look at everything that you’ve done on your website. Look at every email you’ve written and every email that you write in the future and say, “Am I in there? Is there a story about me interacting in my adventure of practicing medicine and all the drama that goes with it that my patients can read and be proud of me?”

People hate to be advertised to, but they love to read letters and they love stories. So write letters about your adventure stories, and they will love you, and they will buy everything that’s appropriate for them to buy from you.

And you don’t always have to win. Nobody does, and you’re not very lovable if you do.

And that is all I got for tonight. I hope that was helpful. Thank you again, Alex, and thank you, David, for helping explain the anatomy.

Good night.

References

Related to the journals discussed

1. Runels C. A Pilot Study of the Effect of Localized Injections of Autologous Platelet Rich Plasma (PRP) for the Treatment of Female Sexual Dysfunction. J Women’s Health Care. 2014;03(04). doi:10.4172/2167-0420.1000169
2. Vincent M, Lepidi H. Anatomic Study of the Clitoris and the Bulbo-Clitoral Organ. Springer; 2014.
3. Manin E, Taraschi G, Berndt S, Martinez de Tejada B, Abdulcadir J. Autologous Platelet-Rich Plasma for Clitoral Reconstruction: A Case Study. Arch Sex Behav. Published online November 15, 2021. doi:10.1007/s10508-021-02172-9
4. Tognazzo E, Berndt S, Abdulcadir J. Autologous Platelet-Rich Plasma in Clitoral Reconstructive Surgery After Female Genital Mutilation/Cutting: A Pilot Case Study. Aesthetic Surgery Journal. 2023;43(3):340-350. doi:10.1093/asj/sjac265
5. Codispoti N, Negris O, Myers MC, et al. Female sexual medicine: an assessment of medical school curricula in a major United States city. Sexual Medicine. 2023;11(4):qfad051. doi:10.1093/sexmed/qfad051

Related to Bicycles and Sexual Function

1. Panara K, Masterson JM, Savio LF, Ramasamy R. Adverse Effects of Common Sports and Recreational Activities on Male Reproduction. Eur Urol Focus. 2019;5(6):1146-1151. doi:10.1016/j.euf.2018.04.013
2. Lui H, Mmonu N, Awad MA, et al. Association of Bicycle-Related Genital Numbness and Female Sexual Dysfunction: Results From a Large, Multinational, Cross-Sectional Study. Sex Med. 2021;9(3):100365. doi:10.1016/j.esxm.2021.100365
3. Litwinowicz K, Choroszy M, Wróbel A. Strategies for Reducing the Impact of Cycling on the Perineum in Healthy Males: Systematic Review and Meta-analysis. Sports Med. 2021;51(2):275-287. doi:10.1007/s40279-020-01363-z
4. Balasubramanian A, Yu J, Breyer BN, Minkow R, Eisenberg ML. The Association Between Pelvic Discomfort and Erectile Dysfunction in Adult Male Bicyclists. J Sex Med. 2020;17(5):919-929. doi:10.1016/j.jsxm.2020.01.022
5. Hermans TJN, Wijn RPWF, Winkens B, Van Kerrebroeck PEVA. Urogenital and Sexual Complaints in Female Club Cyclists-A Cross-Sectional Study. J Sex Med. 2016;13(1):40-45. doi:10.1016/j.jsxm.2015.11.004

Favorite anatomy papers by Delancey

1. Perucchini D, DeLancey JO, Ashton-Miller JA, Peschers U, Kataria T. Age effects on urethral striated muscle I. changes in number and diameter of striated muscle fibers in the ventral urethra. American Journal of Obstetrics & Gynecology. 2002;186(3):351-355. doi:10.1067/mob.2002.121089
2. Perucchini D, DeLancey JOL, Ashton-Miller JA, Galecki A, Schaer GN. Age effects on urethral striated muscle II. Anatomic location of muscle loss. American Journal of Obstetrics and Gynecology. 2002;186(3):356-360. doi:10.1067/mob.2002.121090
3. DeLancey JO. Correlative study of paraurethral anatomy. Obstet Gynecol. 1986;68(1):91-97.
4. DeLancey JO, Starr RA. Histology of the connection between the vagina and levator ani muscles. Implications for urinary tract function. J Reprod Med. 1990;35(8):765-771.
5. PANDIT M, DELANCEY JOL, ASHTON-MILLER JA, IYENGAR J, BLAIVAS M, PERUCCHINI D. Quantification of Intramuscular Nerves Within the Female Striated Urogenital Sphincter Muscle. Obstet Gynecol. 2000;95(6 Pt 1):797-800. Accessed October 20, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1192577/
6. DeLancey JOL, Trowbridge ER, Miller JM, et al. Stress Urinary Incontinence: Relative Importance of Urethral Support and Urethral Closure Pressure. J Urol. 2008;179(6):2286-2290. doi:10.1016/j.juro.2008.01.098
7. DeLancey JO. Structural aspects of the extrinsic continence mechanism. Obstet Gynecol. 1988;72(3 Pt 1):296-301.
8. DeLancey JO. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol. 1994;170(6):1713-1720; discussion 1720-1723. doi:10.1016/s0002-9378(94)70346-9
9. Cardozo L, Staskin D, eds. Textbook of Female Urology and Urogynecology. Fourth edition. CRC Press, Taylor & Francis Group; 2017.
10. LEWICKY-GAUPP C, BLAIVAS J, CLARK A, et al. “The Cough Game”: Are there characteristic urethrovesical movement patterns associated with stress incontinence? Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(2):171-175. doi:10.1007/s00192-008-0738-0
11. Pipitone F, Sadeghi Z, DeLancey JOL. Urethral function and failure: A review of current knowledge of urethral closure mechanisms, how they vary, and how they are affected by life events. Neurourology and Urodynamics. 2021;40(8):1869-1879. doi:10.1002/nau.24760

P-Shot® Research Showing Increased Size

1. Brandeis J, Lu S, Malik R, Runels C. (130) Increasing Penile Length and Girth in Healthy Men Using a Novel Protocol: The P-Long Study. The Journal of Sexual Medicine. 2023;20(Supplement1):qdad060.125. doi:10.1093/jsxmed/qdad060.125
   
2. Kumar CS. 265 Combined Treatment of Injecting Platelet Rich Plasma With Vacuum Pump for Penile Enlargement. The Journal of Sexual Medicine. 2017;14(1):S78. doi:10.1016/j.jsxm.2016.11.174

 

3. 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 <–

Dr. Runels Botox Blastoff Course<–

–> 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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