Topics Discussed Include the Following…

How Botulinum Neurotoxin May Improve Erection

BoNT for a Decrease in Fibrosis

Pearls about How to Inject BoNT into the Corpus Cavernosum

What to Do When Your P-Shot® Procedure Does Not Work

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

Outline of This Page
1. Transcript
2. Relevant Links
3. Relevant Research

1. Transcript

Charles Runels:
Welcome to the Journal Club. Two things I think are worth covering tonight. One is I’ve been plowing… As you guys know, I’ve been finishing up a textbook about botulinum neurotoxin (BoNT), and one of the chapters involves our procedure using Botox or whatever neuromodulator you prefer for erectile dysfunction. And the current dogma is that after three I can find very good double on placebo-controlled studies that the drug is functioning to help erectile dysfunction by two things, mainly by relaxing smooth muscle the way Viagra does. And second, by basically a sympathectomy, by affecting the ganglion and increasing the relative amount of parasympathetic tone, decreasing sympathetic tone, which leads to an erection.

But as with many things, oftentimes we see with the research or with experienced results that are not explained by the current dogma, and then we go figure out why. That’s exactly what happened with Viagra. Until Viagra came along, it wasn’t a new idea to use a vasodilator or arterial dilator to improve erectile function.

I was at a lecture with Irwin Goldstein, who was one of the primary investigators of that drug, and he commented that even when Viagra hit the scene, it was such a new idea. It was hard to believe that you could dilate the arteries of the penis without significantly dilating the others, as in normal blood pressure medicine does the same thing, but without dilating the penis and arterial blood flow. So, to selectively do that was thought to be not possible.

Then when the new blood pressure antihypertensive medicine was under study, it didn’t work for hypertension, but accidentally, as you guys know this story, discovered that it worked well for erection. The point I’m making is the results demanded that researchers go back and think more deeply about the why and change their reasoning because the results did not match up with the why.

How Botulinum Neurotoxin May Improve Erection

And that’s probably happening with BoNT in the regenerative field. As I’ve plowed into the research that might back up more than what’s expected with BoNT or ED, I realized these studies were looking at those guys who did not respond to the highest doses of PDE5 inhibitors and even at the highest dose of Viagra after spinal cord injury and diabetes, longstanding diabetes, and comorbidities that made treating the erectile dysfunction not successful, the BoNT worked. So that’s better than you might expect.
So, I wanted to go through some other possible explanations that I’ve pulled from the regenerative literature about… We talked about neurogenesis already, some of the more prominent articles regarding how BoNT might help decrease fibrosis or scarring, or treat existing scars, and how it might improve vascularization with new arterial blood flow. Not just vasodilatation, but neovascularization. That’s the first topic with the research.

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I got another question, I was giving a lecture in Tampa this past weekend and bumped into one of our providers. And she had a question that I realized I hadn’t maybe answered as thoroughly as I should, which is when you have a healthy person, they’re not smoking, they’re 40-ish, they’re not elderly, and your P-Shot®, “Does not work”, what does that mean? What do you do? What do you check?

So I thought I would cover that and then we’ll call it a night, unless you guys have questions. Those were the main topics I have for tonight. I finally reached the end of the book, so the last part of the last chapter. So hopefully, I can get this reviewed. I’m going to do one last read through and then I’ll mail out copies, print copies to those of you who bought the online course. For those of you on the call or show up at the call, I’ll make a good deal for you guys if you want to buy the book. It’s going to be about 420 pages and 200-plus illustrations. So I think it’ll be a hopefully a useful reference.

BoNT for a Decrease in Fibrosis

Anyway, so let’s look at the decreased fibrosis part. This just shocked me. Most of these papers have been in the arena of using neuromodulators, I’ll say that. Whatever, I’m using BoNT as you realize, as a synonym for Xeomin, Dysport, Jeuveau, any of the botulinum toxins type A. And I was shocked, there’s actually a review article that says they looked at a thousand plus papers or a thousand papers to come up with the 40 or so that they reviewed for this review article by Carrero. Let me pull it over and show it to you. Let’s see. I didn’t realize that much had been written about the idea, and mostly in the arena of…

Looking at what happens with flaps and scars and with surgery. And when you look at it, there… Let’s see, hold on a second. Where’d it go? I’ll have to look in my own reference to find it. Hold on a second. Yeah. Anyway, so the studies… Huh. I don’t know how that fell off my list, but I’ll… There it is. Okay, let’s pull it up. This one. Okay, here we go.

Yeah, there it is. I had it. I’m just looking in the wrong place. This one had the name backward. All right, so they looked at a thousand papers to come up with the 30 or so that they reviewed, and then they came up with the ideas about why it might be working and it comes down to… And even for keloid, really shocking stuff that I didn’t realize. And when it comes down to there two possible causes, one is just decreased tension on the tissue. If you’re relaxing muscles surrounding the tissue, then there’s decreased tension on the tissue. I’m going to put the link to this one in the chat box so you guys can read it. One second.

And the other has to do with something we’ve talked about in these webinars before, that has to do with… Let me find it for you. I’m just going to copy paste this whole thing into the chat box. There it is. All right, I’m going to put the whole thing in the chat box. It has to do with collagen type. It changes Type I and Type III collagen production. And that’s along with the decreased tension on the scar itself, but it’s not… The science behind it, which goes back to 2008 and before, but it’s everything from flaps to breast surgery where it’s been demonstrated. Of course, we talked about this some in regards to Peyronie’s last week. But then when you put this all three of these together, when you have scars go down new blood flow and neurogenesis, you have three pretty dramatic ways of regenerating tissue.

So that’s kind of the final deal is that you have the hypoxia that comes, the hypoxia growth factor, hypoxia-inducible factor 1-alpha along with Type I and Type III collagen production being decreased, and the synergy of that seems to have an effect on keloid and remodeling, even scars that have aged. All right, so that’s the rejuvenation part of it.

Pearls about How to Inject BoNT into the Corpus Cavernosum

And then I wanted to show you some pictures that I sketched that have to do with that question of why did my P-Shot® not work. First about technique, and then some of the other pearls that I don’t think I’ve ever just said all at one time. So when it comes to injection technique, I think the first thing is to make sure you’ve got a firm grip with your thumb at 12 o’clock on the penis. So let me show you this picture.

So your thumb’s right at 12 o’clock on the gland’s penis. And so you know where the anatomy is, only scroll down and review the anatomy. I think this should be burned in your brain before you do a P-Shot®. So you have the skin and then you have Colle’s fascia, [inaudible 00:11:38] tissue, and then you have a Buck’s fascia, and then the tunica albuginea right there. So you have two little fascial planes and Buck’s fascia is the thick one that you’ll feel your needle pass through. In this [inaudible 00:12:00] tissue is where you’re putting filler when you use your HA procedures to improve the girth of the penis. And if you have a 27 gauge needle at a right angle to the axis of the penis, for most people, it’ll go right where you need to go. If it’s halfway out, which is what I tried to illustrate with this. If it’s halfway out or if it’s depressing the skin, for most people it’s the wrong depth.

Depth here, you may not even be in the corpus cavernosum. Here, you usually are perfectly positioned. Here, you may be pushing the urethra or at best just making it hurt worse. And then the second part about the technique is that the needle, if you can see if it changes from 90 degrees to the X of the penis, you’re changing the depth as the angle becomes smaller and it becomes your needle’s less deep. So 90 degrees to the penis at somewhere around two o’clock and full depth, but not depressing the skin with a half inch needle, whether it’s 30 or 27 gauge, whatever. A half inch needle puts you where need to be. And for most people, you divide the penis in thirds and you go at two o’clock and 10 o’clock on both sides. That seems to work the best.

What to Do When Your P-Shot® Procedure Does Not Work

And when people tell me they’re not getting results, that’s the first thing to think about, or one of the first things is just technique. Second, are you activating it? We’ve talked about this several times on Journal Club, but a lot of research showing now that activation really does make it something different. So, if you’re not activating with calcium chloride or calcium gluconate, then you’re doing something but you’re not doing our agreed upon P-Shot® procedure. Maybe it works, maybe it wont, but I don’t think you’re giving your patient the best benefit.

There was someone lecturing about PRP at this conference where I spoke last week, and it sounds like maybe the region people are going to come out with calcium chloride or calcium gluconate rather than include with their kits. As of now, Selphyl is the only one that includes something to activate the PRP.

I know there’s talk about it activating when you push it into the tissue, but it’s a different degree of activation than actually adding something in the material. The woman who one of our people was asking about the patient she was concerned about was a healthy person, but he was on… I think this was the clue to a patient that I don’t think I’ve stressed enough. He was on Viagra and he stopped the Viagra when he got the P-Shot®. To me that’s crucial, we hope that people that take our procedure, that take our P-Shot® are able to throw their Viagra away, but if they stop it at the same time you do the P-Shot®, that’s two different variables. The way I explain to the patient is before you start discontinuing things that might support your sexual function, build it up as good as you can make it, and then start seeing what you can do without.

That to me, seems the best way to go. If someone stops Viagra at the same time you do the P-Shot®, it’s confusing the issue. And I really don’t think I’ve stressed that enough, or TRIMIX or whatever else they’re doing or supplements, whatever they’re doing that they think is helping, they should keep it going. Then when their erections improve, they will know that it’s from your procedure. Then you can see about discontinuing or attenuating dosages, and usually you can drop it about half to maintain the same degree of erectile function or better. So, when you set that from the expectation at the beginning, I think you’re more likely to have a happy patient. From the very beginning, you tell them, “A win is not that you throw things away, but that we do the P-Shot®, we get you as sexually active and functional as we can, and then we can taper things off if we want after we have you to your best level.”

Next. And I just have two more. Next is the pump. We just saw a growth factor named hypoxic growth factor alpha-1. David Hartsfield has been on here and others talking about how hypoxia itself can promote growth factors that result in healthier tissue. There’s a study that shows that a vacuum device alone caused 51% men to cancel their Peyronie’s surgery. So I think the pump, in addition to keeping things pliable, probably does its own activation of platelets and contribution to growth factors. Again, you’ll have people that’ll say, “Well, if your such so great, why do I need to use the pump? Why do I need to keep taking my Viagra?” Well, if hormones were so great, why did Arnold Schwarzenegger have to pick up weights? There’s a synergy of all of it together. So that’s the metaphor I like to use.

A physical therapy combined with growth factors is much more powerful than either alone. Then when you achieve what you want, you do everything you can. Instead of testing my ability to get you well or testing my procedure to see if it can stand alone, quit trying to judge my ability to get you well or anyone component of it, and do everything you can, everything that I suggest that might be good for you to be as well as you can, and then taper off the parts of the therapy, the parts of the plan that you find less palatable. That’s the way I explain it to patients. And if they really want to be well, they’re more into, and should be, being as well as they can than proving… If they’re challenging the validity of what they’re paying me for a procedure because I happen to recommend other things along with the procedure, I’m probably not going to take that patient. Because in everything in medicine, we have multiple therapies, and we don’t combine multiple therapies in other arenas and complain that it’s taking more than one thing.

Also, you do have research. You talked about it a couple of weeks ago, which supports the idea that you should be using more than one therapy synergistically to help with erectile dysfunction. And more importantly, why would you just treat symptoms with something like Viagra that does not improve the health of the penis and not offer the person the option of doing something along with it that makes the penis healthier. I think that a point to make to your patients is, “Yeah, if your bag is working, that’s great. And if you have to cut it in half, well, I’m sorry, we didn’t get to throw it away,” but it doesn’t negate the effect or the promise of doing a procedure that’s been shown in every other tissue studied for the past two decades to improve the health of the tissue. Why would you not do that and just treat symptoms with your TRIMIX or your Viagra?

An Ethical Dilemma
And then of course, the next step to that is, why would you not do that as preventive therapy when you have a good erection to try to prevent the eventual need of something to support it? That’s more symptom-treating. That’s a bigger step. But at the very least, when we’re treating ED, I think we’ve got good support now in using one of the regenerative therapies. And that was outlined, just using regenerative therapies because treating symptoms and not doing that maybe is not the best medicine anymore. Here’s the algorithm that we went over, I think, three weeks ago where you could pick one or two of these, but more and more patients are demanding and doctors are providing multiple components. Some are symptomatic treatments like your intracavernosal injections of vasodilators and some of them are more regenerative, but no reason to do just one or the other.
Okay, the last thing is a little bit more esoteric, but I think it’s the last part of why did my P-Shot® not work. And then I’ll be done unless you guys have questions, but this is something that I also think happens quite a bit. Probably the best example I’ve seen of this is, one of our gynecologists told me after she did an O-Shot® and she called me and the patient was been home, took a couple of days after the shot, and she was complaining that the O-Shot® calls her to have back pain. So the gynecologist called me up and worried and said, “Can an O-Shot® call severe back pain?” I don’t think so, but have her come into the office and see what else she can find out. Well, turns out the woman, she was truly having musculoskeletal pain, her O-Shot® had worked so well, she and her husband were having very acrobatic type sex and she had just hurt her back. But was associating it because temporally, it was associated with the O-Shot®. In her mind, that’s what she attributed it to.

An Esoteric Reason Your P-Shot® Procedure May Not Work that Every Boxer Knows but Most Physicians Do Not Consider
So when I see something where someone thinks or P-Shot® has not done anything, I’m always curious what else might have changed? Did they stop a medicine? Did they start a medicine? Did they change their sexual practices? And this is where I think it’s maybe a little esoteric for some, but it’s only a few thousand years old. The idea of frequency of a man’s ejaculation and as the refractory period gets older, or… Excuse me, the refractory period gets extended as the man gets older, then the frequency of ejaculation would play a much bigger role than when the refractory period is 30 seconds when the guy’s 18. And the Chinese Dao, I’ll show you where this in a moment, I’ll show you where to buy this on Amazon. But they wrote 2000 years ago about an actual formula, and actually Sigmund Freud wrote an essay about how he thought that Leonardo DaVinci was partly superiorly intelligent because he was transmitting sexual energy.

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Every football player has heard the idea, every boxer practices the idea of avoiding playing your game during a refractory period. And I know about the studies and I’ll talk about those if you want, but the main thing is that I’ve actually had patients tell me they get the P-Shot® and they go home and whether it’s masturbating or with their lover, they have more frequent ejaculation. You can do the best P-Shot® in the world, but if the guy’s old enough that he’s ejaculating more frequently and is more likely in his refractory period, your P-Shot®’s not going to look so good. I’m on the page now where they’re giving away my book for free, which I kind of like. People are stealing it because I have links to my other websites on here and whatever.

I wish a million people would steal it. But I know that we’ve had, I guess we’re probably a couple of hundred thousand of these books we’ve shot out to people that I know about. But it’s electronic versions, not so many printed versions. It’s more like 50,000 or so, 80,000 somewhere in that range. But here’s the formula, divide your age by five. So if the man’s 40 divided by five, that would be eight days and you can have sex every day. But if he avoids having an orgasm more frequently than every eight days, intelligence, health, and sexual function improve.

Of course, that means that every sexual encounter does not end in ejaculation. And I don’t really even want to get too much into this tonight. I think maybe not everyone is ready to hear it and not everybody wants to hear it, but the main point of it is that if you do a P-Shot® and the person is either sexually more active or even if he doesn’t increase activity, but he’s already more active than what’s healthy for his sex drive and he’s basically in refractory period most of the time, then your P-Shot®’s not going to look so good.

I’ll put this in the thing. My book, I quit supplying it to Amazon. That’s out there, use copies or all over the price on how much they cost. Usually go for a $100 or so on Amazon, but no reason to do that. Just download the thing for free, and if that doesn’t work, shoot me an email and I’ll send you a PDF file.

But anyway, I give people a copy of my book or at least tell them about this formula, and tell them to have sex as much as they want, but try to space things out some so they’re not refractory and you’re more likely to get good results. So I think that’s enough for one night. We’ve covered some research. Actually, several ideas about how to make sure… Of course, hormones goes without mentioning, I think pretty obvious. And if you’re not expert at doing hormone replacement, make sure someone who has seen your patient probably the most overlooked is proactive, I think. But we covered all that last week. This was the main thing I wanted to bring out, the idea of technique and making sure… I call them the widows to pornography. I’m really not anti pornography, I just told men, “If you’re going to watch pornography, watch it with your lover so it doesn’t become a substitute for your lover.”
When you take the secrecy out of it, it loses its control over men, I think and quits becoming such a replacement. But if you haven’t seen it yet, I think if you ask about it or watch for it, you will see it if you’re taking care of women and their sexual function. If you know the right questions to ask, it’s really, I think a little bit disturbing how many women feel like they’re a widow to pornography. That’s the woman who knows her husband is masturbating to pornography and then he has no vitality left when he comes to his marriage bed. She knows about it and he may or may not know that she knows, but his behavior takes his sexuality away from his wife. And the same thing I think can happen even with your lover when you’re not thinking about that interval. Okay, let’s see if there’s any questions. If not, we’ll call it a night. Let’s see.

If someone has a penile implant and has nerve damage, can the P-Shot® help? Maybe, I just wouldn’t do it. If you happen to give a P-Shot® to someone who has an implant, and it doesn’t matter why, if the next day that implant goes flat, I don’t care if they got it caught in the car door. If for some reason it goes flat, there’s a good chance you’ll be held responsible. Of course, if you’re the surgeon that put the implant in, then you may have a better, or maybe you don’t have a better idea of where to put the needle, but at least you know how to fix things if you goof them up.

So, I would avoid that one like crazy, even though you might help, I just would not do it. And you’re right, I do inject around breast implants. You might be thinking about that, but there’s a lot more tissue there so that I can do it. And from across the room, if you watch me inject the breast, you’ll know I’m nowhere near the implant from across the room. That’s not the case with penile implants, so I just wouldn’t do it. Although it is a great idea.

And I don’t think anyone’s ever written about the same cycle in women. That was the next question. I’ve asked the sex therapists and women who are also physiologists or sex physicians or counselors, there’s a whole movement around the idea of controlling orgasmic energy for both men and women. I’m more of inclined to think that more orgasms could be better for women. I reserve the right to change that opinion. But I think women are usually energized by orgasm, at least to a certain extent, where men, as you know, go usually refractory. It can be made not to be refractory in men, but most men it’s refractory sort of thing and drains their energy. Or with women, not so much. Now I think if the woman’s ejaculatory, it’s a different thing. And ejaculatory orgasm for a woman, I think should be spaced out because it functions physiologically. Just my observation, that’s a different physiological response and I think that could be overdone. Let’s see, any questions. “Any experience with this implant?” Let me see what this is.

I think I got the wrong thing. I’m happy to pull you on the call, Stephen Luther, if you want to just… I’ll try one more time to pull it up. I can’t pull it up. Yeah, takes it to me and I’ll see if I can find it for the next webinar. And I think with that, we will call it a night. But thanks for the question, Stephen Luther. I can’t pull it up, but I’ll pull it up and ask around… Oh, yeah, yeah, yeah. I don’t have experience with the new, but I’ve met the guy… Thank you for clarifying. Really nice man, he was at one of where I spoke a couple of months ago. Let’s see. I spelled it wrong. Anyway, there’s basically a sheath that goes over the penis, and in the right hands, it seems to be working very well.

Some of the urologists in our group love them. Some of them are still afraid of them. I’m still on the fence until I see it out another year or two. But you’re right, that is the wizard and Dr. E-L-I-S-T. And I saw him lecture and he’s the wizard. If I were going to have it, he’d be the one I would go to. And in his hands, I think it’s a pretty amazing procedure. I wish I could tell you more, that’s all I really know. But I’ve seen him lecture, I’ve seen his pictures and I think in his hands, it’s a viable procedure, right? That’s about all I can say about it. I’ve not examined or treated anyone who has it. Yeah, that’s exactly right. Oh, cool. So you’re able to do a very cool… I’m going to unmute you if you don’t mind. See if you can tell us about it. If you want to talk, you’re unmuted.

Stephen Luther:
Okay. Yeah, it was an interesting patient who came in from out of town, and I didn’t know it ahead of time. And as I was numbing him up, of course then he tells me, and it was a sheath like you said, that just sits on top of the penis. And as I looked at that… I mean, he drove all the way in. He was insistent on having this P100. And so, I studied that pretty extensively. But as I lifted that up, it did expose the corpus cavernosum very effectively. And I was obviously unable to go at the 10 and the two position, but I was more able to go at the three o’clock and the nine o’clock position with that. But there’s no way to puncture that, it was just like a hard helmet, really. A sheath, like you said.

Charles Runels:
Not inflated. That’s a good pearl. I’ve not had a chance to treat one of these men, right? And many of our people, I always say 10 and two because it’s what seems to be easiest to teach. But there are people in our group who routinely do three and nine. I think a lot of the TRIMIX people aim for that as well. So, if you’re able to lift it up enough to do that, that’s a good tip for all of us. And you’re right, it’s not a inflatable device. So it seems if you happen to lightly touch it, seems like less of a disaster or no disaster.

Stephen Luther:
And it’s very hard. There’d be no way to pen it. It’d probably break your needle. It’s so hard.
Charles Runels:
Well, that’s handy. I’ll see if I can get the guy. He was lecturing at the International Society for Cosmetic Gynecologists when we were there last, and the Pelosi’s, it’s a really great meeting, and we had some conversation. I’ll get him to come on our call sometime and enlighten about how we might inject around it, because it could be a benefit. I can see. Any feedback? When did you treat him?

Stephen Luther:
Within the last two weeks, and followed up within five days. And he said everything was going great, and he brought his girlfriend in, and she got the O-Shot® at the same time. So, I think they were doing very, very well. He was very pleased.

Charles Runels:
Well, keep me posted. The BoNT for ED has been continuing to be surprisingly effective, so it’ll be fun to see what happens with him. Thanks-

Stephen Luther:
I can’t thank you enough for sharing that and all the literature you provide, it’s a wonderful opportunity to treat people.

Charles Runels:
I appreciate that. Thank you. Well, I feel like our group is strong and getting stronger, right? Of course, I don’t expect to make lots of money on this book, if any at all. And you may see me occasionally, push it out for brief times for free as a Kindle book. My hope is that when this comes out, because of the chapter about BoNT for ED and I mentioned the P-Shot® a lot. And of course the Vampire, I’m hoping I can use it for another educational tool to prompt the phone calls. But thank you for your always smart support. And I think with that guys, we will call the tonight. You guys have a great week and talk to you next time. Bye-Bye. Thank you, Stephen.

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