Topics Discussed Include the Following…

*A Review of the Treatment Options for the Treatment of ED
*Is it Ethical to Ignore Regenerative Possibilities and Only Treat Symptoms?
*The Value of Pyramids & More Tips on Building Them in Your Practice

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

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

1. Relevant Research

2. Transcript

Welcome to the Journal Club. Today, some really interesting research to share with you. I’ve been plunging into exactly what it is about Botox that is making it so effective for erectile dysfunction. As you guys know, we rolled it out as a standard procedure combined with our P-Shot® or as a standalone.

It’s receiving lots of press. And the people that are offering it in our group are having great success with it, and it’s been a help to their patients as well as profitabile.

But I’m still not satisfied with my understanding of how exactly it is working. And I uncovered more information than I thought I’d share with you today, along with some ideas in marketing for those of you that are just getting started.

So, we’ll save the marketing for the end. I want to jump into this review article and then we’ll get into the Botox part.

A Review of the Treatment Options for the Treatment of ED

Published this month a review article about the various medications it’s used to treat erectile dysfunction.

It’s in your handouts if you want to download it. That will go away when I close down the webinar. So, if you click on it now, you’ll see it. The biggest point I wanted to make about this article is that you’re starting to see more and more talk about combination therapies.

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They make the case in this article that if the person tolerates them, everyone should be started with a PDE5 inhibitor, which makes sense. It’s the most convenient thing. But of course, not everyone can tolerate it, and the side effects are not benign if you happen to be one of those people who have the side effects. Even there’s a higher incidence of melanoma.

Which I was not aware of until I started really digging into the research. Not a huge increase, but a demonstrable increase in the instance of melanoma. But for our purposes, I’ll let you read the review. Most of it you’ll be familiar with.

What I wanted to bring out is that, this at the very end, this is critical I think for us.

You’re starting to see more and more of this in clinical practice. But this is the first time I’ve seen it written out in a review article:

“With the above advent of novel regenerative therapies such as shockwave or P-Shot® with PRP, both patients, and physicians have been more focused in looking for a restorative treatment rather than only treating the symptoms of impotence.”

The reason that’s such a game changer is that some might argue that if you’re Viagra or your Cialis works, why do a P-Shot® or why do your shockwave treatment? Or why do the Botox?

—>>>Because I’m about to give you some really strong research demonstrating that Botox may actually have a regenerative process going on as well.

Is it Ethical to Ignore Regenerative Possibilities and Only Treat Symptoms?

But let me put it to you a different way. Let’s say that you have a 45-year-old patient who’s just now starting to need his Viagra to be confident with his wife. And you treat the symptoms of Viagra or IC injections, intracavernous injections of Trimix or whatever it is you prescribe. This goes along with a higher instance of fibrosis, does nothing for the regenerative process, or slowing down the etiology.

Maybe you don’t withhold the Viagra, but why would you not offer this person a regenerative process in the early stages?

This is a big paradigm shift.

In other words, some have argued and still continue to argue that if treating the symptoms is sufficient, why do anything else? And this is the first time I’ve seen it written in a review article that, well, there is a reason why.

Because you might want to slow down or, even if you can, reverse the etiology, which is what we do.

So, let me pull up this thing out of this little document I’ve been working on and remind you of something we talked about last time. Hopefully, you guys will jump in and correct or add to what we’re saying here.

But this is the very last chapter of this textbook I’ve been doing about using Botox both for cosmetic and medical purposes. If you look at your email somewhere in there, it may be in your spam folder; you should have gotten this chart, this algorithm. And what it is a combination of research and a recent urology published suggested an algorithm that I expanded on based upon…

First of all, I felt like the internal medicine part of it could use a little bit of expansion. And then, I expanded on regenerative therapies. But if you look at this algorithm, you have lifestyle, of course which should be thought of as imperative since trying to have good sex when you’re not healthy is a losing battle eventually.

And then you have comorbidities.

And my wife pointed out to me today that one of the side effects of the ever-increasing popular comorbidities includes thinking about offending polypharmacy. And semaglutide and the Mounjaro are both known to decrease libido. So, if you have someone on those medications, which you most likely do, and you give them a P-Shot®, it’s an offending drug for sexual function.

Of course, pain medicines because they drop LH and FSH. And so, that to me, this is the base that should always be thought about. But what this article just pointed out is what we talked about in the past two journal clubs. Which is that, yeah, you pick one in concert with the patient.

But combination therapies should be thought about early, especially adding in regenerative therapies early on along with what you might normally do to help the symptoms. And yes, as you guys know, oftentimes these regenerative therapies make it such that you don’t need the symptom treaters.

Or if you’re on the symptom treater, you’re able to decrease the dosage in half. But why would you not do that?

So, I just wanted to point that out because this is the first time I’ve seen it in an article. It’s out this month and you have a copy of it in the handouts there. Now, the next part about how Botox might be working as regenerative therapy I think is really, this has been mind-opening to me. Because if you look at the research that’s been published about using Botox for erectile dysfunction, it’s talked about really just two possible mechanisms of action.

One is the relaxation of smooth muscle with increased arterial blood flow, which is exactly what Viagra and all the PDE5 inhibitors do. And then the next is a sympathectomy, which happens with Botox, with central migration. But the regenerative effects, although they haven’t been studied directly in the penis, it’s really very profound.

And I wanted to show you some of that research.

Again, what I’m showing is regeneration in regard to scarring, which would correlate with treating Peyronie’s disease, with neovascularization, with neurogenesis. All that has been demonstrated with the botulinum toxins. I mean, this goes way back.

I was so shocked by this. This was from 1968. I was eight years old in 1968. In mice, they injected the thigh muscle. And then they watched to see what happened with the nerves. And initially, this is my sketch. So I don’t have to get in trouble for stealing someone’s picture.

This is my sketch of their picture. I’ll show you the actual research here in a moment from 1968 and then 1972. I’m thinking, well, how does this going with the face with our cosmetic injections and with the penis or the clitoris if we wind up doing and going mainstream with Botox and the clitoris. But first you have this axon as it folds down into the myocyte.

And you have the axolemma or the myelin sheath. And then you have the Schwann cells or the glial cells that support the axon. What this represents is you have a hashtag of… Actually let me just show you. I want to just go show you their article. I can’t put it in my book, but I’ll show it to you on their research.

Let me pull this over for you. Hold on a minute. Let’s see. All right, here it is. This one. So, this was in ’72. And you can see I’ve made a copy of their diagram here. But I wanted to show you the original. This was in 1968 where they did this study where they injected the mice.

Let’s see, where did it go? Here it is. So, this is a normal axon with the dendrites, the motor in plate. You remember all that from your physiology. And then soon afterwards, so this is actual staining of the axon within the myocyte of the mouse. But look what happened. This is the same magnification.

And you have this extension of the axon. So, you get these little fibrils that start taking off. It’s an adaptation to the inability of the nerve conduction or the action potential. Remember that? Action potential can’t pass through the motor in plate. And so, the nerve adapts.

We don’t know why. It adapts by sending off. And you’ll see how this applies even to the spinal cord here in some recent research I’ll show you shortly. So, it takes off, and then it forms new knobs that fold out into the myocyte, new motor in plates. So, that by the time you’re done, you have this tangled web of axons that go everywhere.

And initially, the myocytes atrophy, but then they recover back to their normal size. So, this was done in ’68. Over half a century ago. And then this was their diagram in ’72 summarizing some of that, that I just showed you my sketch of it. Their cross-hatching represents the botulinum toxin.

And then you have the folding down of the dendrites. And this axon sprouts off and a new Schwann cell takes over to nourish it. And then you get new folds, new connections forming down here. And what starts off is you have an axon going to one myocyte and it winds up branching off all over the place.

So, not only do you have new axons formed. But you have a more substantial and expanded network where the axons from one nerve cell are actually contacting now an increased number of myocytes. So, this bottom line is, you squirt some Botox and you grow new nerves that actually function.

That is a huge idea that’s been around now for more than a half a century. Now, when you think about, well, how does that apply to wound healing and how does it apply to sexual function? Your mind wants to explode. And so, even though it’s not talked about as one of the possible ways Botox is helping erectile dysfunction, I’m just saying it might be.

That’s all. I’m just saying that it might be. So, that’s the article. What was I going to show you again? So, here’s a Xeomin article where they actually talk about using it for spinal cord injury. Here, I’ll put the link to this one in your chat box so you can read it. I’m not going to go over all the details.

But the point is, I just showed you a 50-year-old article. Now, I’m showing you one that’s very recent. Same idea using botulinum toxin to grow nerves. All right, let me put this in the chat box, and then I’ll show you this next one that I think applies to Peyronie’s disease. So, would this apply to ED secondary to longstanding erectile dysfunction, I mean to diabetes or longstanding, say injury from a bicycle or a prostate surgery?

I don’t know. But it makes sense that it might. So, here’s one where they talk about 13 studies that confirm the effects of botulinum toxin improving blood flow, and perfusion of cutaneous and myocutaneous flaps. They say 13. I found studies where they looked at from mice to people and showing in neovascularization post Botox injections.

You think neovascularization might help with sexual function in the penis or the clitoris? Here’s the thing, if you did a study looking at the thigh of a rat. And then you do a study looking at the back of the arm like Sclafani did with PRP. And he did that study back in 2011, I think it was.

Where he injected PRP in the tricep area of people, because we don’t mind biopsies there so much. Then he biopsied and demonstrate neovascularization, collagenesis, adipocytes multiplied and enlarged and neurogenesis. Demonstrate all that in people. Of course not so that we could then go treat the back of arms but it published in the plastic surgery journal insinuating that if it works in the back of the arm, it might work in the face.

To me, it’s more of a psychological than a physiological or scientific speed bump to not extrapolate that same idea from the back of the arm to the penis. Which is why when I read that research in 2010, 2011, whenever it came out, that and other studies, I took out my penis and injected it.

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Because I didn’t have any big psychological speed bump about extrapolating that research. The reason I bring that up is I think the same thing could be going on with Botox. Because you see people extrapolating the idea of growing nerves and growing blood flow for wound care, for spinal cord injury, for the face.

But there there’s really no physiological reason to not extrapolate it to the genitalia as well. All right, so I’ll send this one. So, there’s the link to the one I’m showing you now. And then this one was fun. This one shows scar prevention after breast augmentation.

I know we have a lot of amazing breast surgeons in our group. And so, injecting the scar and objectively demonstrating at nine months, look at this, at six and nine month follow up, the scars and the remodeling phase showed significant smaller scar widths and better surface textures in the Botox treated scars than an untreated control.

The big thing here of course is, what’s the dose? And if you look at the studies that were done in the rat back by Duchenne, he did close to the LD 50. So, this was a much higher dose than what would we would be given the LD 50 to people like he did to the rats. Of course they weren’t approaching LD 50 in these scars as well, but that’s the big thing.

We have this idea, this concept that has been around for more than half of a century. But yet we’re not sure exactly how it’s working. And so, we’re not sure exactly how to optimize it and make sure that it stays safe. Which is why I recommend that we stick with doses similar to what are done in the face.

100 units of Botox in the penis, that’s only 75% of what’s routinely done for migraines. So, it’s a safe dose. And is what was shown in the double-blind placebo perspective studies to be effective. So, here’s another one looking at scar prevention, basically remodeling.

And some of you do wound care and do surgery. So, whether you apply this, I’ll give you the link to this one too. And then I think I’m done, almost done. We have to do the marketing part. Let me just exit this over for you. Just send it in the chat box.

If you open that, it’ll be waiting when we finish this. So, so when you have something that helps scarring, that’s Peyronie’s disease. There was something huge about this one. Wait a minute. Yeah, this part. It seems that when you combine the Botox with stem cells, it improves the ability of it to work for scars.

Of course, unless you’re using IRB in our group, we’re not doing stem cells in the United States. I hope you’re not being tricked into doing that unless you’re under the umbrella of an institutional review board. But to me, stem cells, that’s the mechanism of action of PRP. Of course, we’re recruiting pluripotent stem cells from the area of injection and from the bone marrow from cytokines.

And so, logically, we don’t know. We haven’t done the study. But logically, if this study showed that mesenchymal cells improve the ability of Botox to help scarring, then combining the Botox with our P-Shot® should make it even more effective for Peyronie’s disease. So, we have a mechanism of action that’s been demonstrated now for more than 50 years.

It would be different if Botox was some drug that was just discovered. Since we have a 20-year safety history for the doses that we’re using, to me the biggest hang-up is just standardizing it. And getting of the idea that we’re treating genitalia instead of arms or scars from surgery. Anyway, I think that’s all I’ve got except for the marketing piece.

So, about how to build a pyramid. Because I know a lot of you are starting out. Uh-oh, someone said the audio cut out. I hope y’all are hearing me now. Because I’ve been going a long time. I hope I wasn’t talking to myself. Maybe it was a joke. Can you guys hear me okay? Good.

The Value of Pyramids & More Tips on Building Them in Your Practice

So, I want to jump over to the marketing piece. I see people starting new clinics and struggling. And again, I’m not the Mr. Guru money guy. But I have been teaching people about how to start a cash practice. I started one in 2003, 20 years ago. And I’ve been teaching people how to do it now for 13 years.

And so, I’d have to be stupid not to learn something from the people who reported to me what worked and what didn’t work. I’ve taught a class a month at least every month for 13 years. Not counting many travels to other countries and other states teaching as well. So, I don’t have to be smart, I’m just taking notes.

And if I could pick one idea to make sure you don’t go broke and that you actually eventually make noticeable amounts of money, it would be how to build your pyramid. But before I jump to that, let me see if there’s any questions or comments. Please correct me if I said something that didn’t jive, you think I was wrong.

Because I definitely don’t want to go around being stupid about something I’m being stupid about. So, let me see if anybody has… I don’t see any comments. So, I’ll jump to the marketing piece and talk about making a pyramid. Let’s see. Make it where you can see what I’m drawing here.

I hope that made sense to you. I’m going to start offering and highly suggesting Botox even more than ever as part of my P-Shot® procedure. Because now, basically I have three suggested mechanisms of action. Increased blood flow, decreased sympathetic activity, increased parasympathetic tone.

Which has been demonstrated in those double-blind placebo controlled studies by a bigger flaccid penis just because parasympathetic is increased. But third, I honestly, I admit it, I just didn’t know the robust and long growing body of research regarding the ability of botulinum toxin of all things to cause regeneration of nerve and blood vessels.

Anyway, let’s talk about building a pyramid and then we’ll call it a night. Let’s see. Yep, here we go. I’ve searched all over for something I can easily draw with on a computer, which I don’t really like doing. I’d rather just draw on a piece of paper. But so far, a sketchwow is what I’ve found is working for me these days the best.

All one word, sketchwow. Anyway, so let’s talk about the pyramid. And if you’ve been to my workshops, we spend a whole day on marketing. I’m not sure I’ve ever really done this profit model, talked about it to satisfaction. But first, I would tell you, you never quit thinking about this profit model.

Because it’s a continuous construction and destruction. Let me explain. All right, so what the idea of the pyramid is that you have this thing at the top that people pay you the most for. It’s the biggest most soul satisfying thing that you do. So, for surgeons, it’s their most soul satisfying, probably most profitable surgery that they do.

If I were an eye surgeon, this would be something I do to make blind people where they can see. Nobody ever complains about whatever that cost. I’m lecturing in Tampa this week and I was at the beach. And so, a sign to rent a jet ski for an hour is 170 bucks. A level five, which is supposed to take about 45 minutes, is 143 bucks.

So, that means that basically a level five visit with your primary care doctor with five organs failing and on 10 medications is worth to your insurance carrier the price of an hour sitting on a jet ski. So, anyway, I think we all should do things for free. But I don’t think we have to work and accept insulting amounts of money.

I would rather just do free than accept insulting amounts. But there’s something that you do that is this very soul satisfying thing. Now, for a primary care person, this might be your yearlong membership if you’re going all cash. It could be if you’re just looking at single procedures, maybe it’s your package of three treatments for hair.

Or it’s your trifecta where they get a O-Shot®, a breast lift and a facelift, something like that. The idea is that you have this free level that people get. Uh-oh, somebody says my audio’s out again. I don’t know. Hopefully you’re hearing me. It’s back.

I’m at a hotel, so that’s part of the reason. Hopefully if it goes out, it won’t stay out for long. So, you got a free level. But here’s the thing that I don’t really I think emphasize enough when I teach this. Well, let me finish talking about it. So, then you have a less than $50 level. We’ll just put less than up here.

You have less than $100 level, less than 500, 1,000, 3,000, 5,000. Those of you have seen this before, I think I’ve got something new for you. You got 10,000, this would be your packages. Or if you’re a surgeon, you’re getting to your more elaborate surgeries. And then you have up.

So, that’s your $20,000 surgery or your $50,000 membership. Now, this is where doctors like to think about. They want to spend lots of money advertising their most expensive thing. Marketing people and internet people and the Kardashians who are billionaires, focus on that part.

If you’re a Kardashian, you do things like balance the champagne glass on your booty. Or to have somebody take a picture of your body by the swimming pool. Or do stupid things on television. And people watch it for free. But when you get 100,000,000 subscribers, you realize you sell to one in a thousand of those people.

You still sold a lot of dollars’ worth of stuff even if you just sold a $10 item. So, they focus on free. Doctors don’t often focus on this. Free still has to be value. And actually I think the Kardashians are brilliant. They’re not stupid women. And they have monetized their audience brilliantly.

And they’ve given their audience entertainment. That’s what they gave them for free, entertainment. Some of us are entertainers. I am not. And I think most doctors don’t even looking at a camera. So, we talked about this last week.

I don’t think most doctors should try to be entertaining. What we can be is informative. So, free in my opinion is information that does one or two things. Write this down because in my opinion, if you send an email that doesn’t do one or two of these things, you’re going to go and spam. And they’re less likely to read your next email.

It should either inspire them to do what they already know how to do. Maybe it’s research, encouraging them to go walking even though they’ve known it. You have new research or new results from one of your patients. Something that inspires them or something that you did that inspires them or it informs them.

So, it either inspires to do what they know or it informs. But either way, it makes their life healthier and happier in doctor sorts of ways. You’re not advising them about what car to buy, who to vote for. You’re advising them about how to be healthy. And secondarily, know love and prosperity and all the things that you need health.

You can’t know love, at least on this atmosphere, if you’re six feet under. And you can’t really enjoy love if you’re in pain. So, teaching people how to be healthy is also teaching them how to find love and prosperity in my view. And that’s your free level. And the reason it’s in a pyramid is everybody that’s reads your email, that’s your free level.

Or your social media, in my opinion, it’s still email. But everyone doing that can’t afford the very top thing. But they might afford the less than 50, the less than 100. Let’s say that you’re just starting. This whole pyramid is built for one person. Let’s say that you’re a urologist.

Well, you take care of men and women. But I think you start off with this, what is it you want to do? Who is it you really want to take care of? And if you’re a urologist who wants to focus on doing some special surgery for women who have some horrible thing that happens with their bladder, then that’s the top of your pyramid.

If that’s what you want to do. But you don’t start haphazardly just throwing items to sell and do in your office. You start with, how do you want to spend your day? And if it’s you want to treat Peyronie’s disease and it’s a P-Shot® combined with Botox and hormones because that’s part of the treatment and all that, well then that’s a package that costs 10 grand and that’s up here.

But you don’t build that if you don’t want to treat men with Peyronie’s disease. Because what you’re really doing here is you’re creating your life too. So, for those of you who are going all cash, to me, your first thing to think of is who’s the person you want to talk to every day?

Is it the woman who’s menopausal? So, when I first opened my office as an internist after working in the ER for a decade, I said, “Well, I think this person for me is going to be the 40-year-old woman, 40 pounds overweight, who’s tired, can’t think straight and has trouble with sex. And her marriage is strained and her kids are wearing her out.”

I figured I love that person. I wanted to help her. And to me, that would be a pleasant thing to do to change her life because I knew the ripple effect would be wonderful. And I find that person to be interesting and rewarding when I’d change her life. So, I built a whole pyramid just for that person.

My emails were for her, my $50 products, my Botox was for her. My Juvéderm before I had Vampires was for her. The drugs I sold. The whole pyramid was her. My weight loss program, it was about her. Actually, the fillers didn’t come around until when I found out women didn’t want to lose weight after their face collapsed from losing weight.

So, I learned to do fillers. That was why I learned in the beginning. I was building a pyramid for a 40-year-old woman because that’s who I wanted to take care of. And then those women started bringing their husbands. So, I built a separate pyramid for the husband.

So, most of you have heard me explain what a pyramid is. I would just add to this that even if you’ve had a practice, you might rethink who’s the person that you’re building the pyramid for. Second, just like our house, when you build it, things fall apart. So, you might have a product that’s gone out of date.

You have a book that’s no longer published. You can’t get that item anymore that you used to sell, or you’re tired of doing that procedure. You need to replace it with something. And that also means you change your auto responder emails that are going out.

So, this needs constant attention. In my opinion, as long as you’re in practice, you’re constantly thinking about the pyramid that you’re building. I built one of these pyramids for people with type two diabetes and then I abandoned it. And it crumbled because I found it was very rewarding.

But it was really very difficult to pay the bills with it. The weight loss program was okay. But what I knew about how to take care of diabetes was very time intensive to get people off their medicines. And I became interested in what we do with PRP. Some of those products are still out there.

And people pay for them occasionally. But I haven’t paid attention to that pyramid. So, if I were making up things to do for the new person, I would first say, “What’s the person you want to take care of? What’s the thing you want to do that would be your most sole rewarding thing for them?”

And this pyramid represents a set of promises to that person. And then start sending out emails to them. In my opinion, a minimum is once a week. In my opinion, you ought to be sending almost every day because you’re reading every day.

Sending emails to this person about what you’re reading and what you’re doing to inspire them and inform them to have a better life. So, I think that’s all I want to say. If you’re out there practicing, you might want to read, look at your pyramid. And if you’re starting out, I would definitely think about this idea.

We talk about this in my workshops that I teach if you haven’t been to one. If you’ve been one of our other teachers, you can come to mine at half price. And of course our journal clubs. We talk about this a lot. So, if you just go to the marketing page on our membership sites, you’ll find a lot of stuff about how to do this.

Let me see if there’s questions. If not, we’ll shut it down for the night. I think we’ll call it a night. Always an honor. I hope this was helpful to you guys. I’m telling you, this thing with Botox is going to be a big thing for us. Obviously not my invention.

But I think our group is going to have a key role in teaching the world some of the nuances of how to use this neovascularization and neurogenesis properties of Botox in the sexual medicine arena. You guys have a good night. Thank you for showing up.

3. Relevant Links

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