Topics Discussed Include the Following…

1. Importance of female sex muscles in sexual function (it’s not just about the pelvic floor).
2. The need to consider sexual function from a systems analysis.
3. PRP and a modified O-Shot® procedure could potentially treat muscle dysfunction.
4. Pelvic floor muscles and sex.
5. Combining the O-Shot® with surgical procedures and devices that strengthen muscle is possible.

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

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

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1. Transcript

(transcript as a pdf file)

Charles Runels, MD:

Thank you for coming to the journal club (with pearls & marketing), JCPM, tonight. It looks like a lot of smart people on the call. Hopefully, I can bow out and let you guys take over some of the discussion. I want to focus tonight on muscles. I don’t want to say pelvic floor muscles because I don’t like that description. It seems to indicate to me almost a derogatory term, and there are so many other muscles within the female pelvis that are not technically part of the pelvic floor. I see some surgeons on the call who have been dissecting the area much more than I have. So, I want to have you jump in and correct me if I say something erroneous or add to what I say.

But I want to explore not only some of the research regarding the muscles of the pelvis and how our O-Shot® might benefit (maybe even with some modifications of the procedure) but also look at the anatomy and think about how it fits into the overall system. Here’s a picture with which I’ve been playing around.

And it’s okay, you can laugh at it. It’s a very rough draft, but I hope it indicates something that’s going to be beautiful eventually. I’ve been looking at various professional medical illustrators to redo it. This is my present conception of the female orgasm system.

You know where I’m going with this, right? Because I’ve been dreaming about this for several years. I want a poster on my wall that encourages people to think in systems analysis when it comes to sex, just like they do with the respiratory system, pulmonary system, and nervous system. I see no other branch of medicine where people as prone to think everything’s a nail because they have a hammer. And they get a laser, or they get a radio frequency, or they learn about an O-Shot®, and I think more than any other branch of medicine, tend to forget the rest of the system and treat everything with their new thing.

A system has multiple components with feedback loops, with one influencing the other. But the thing the components have in common is they work together simultaneously for one purpose, which means that the sexual system or the orgasm system, whatever we decide to call it, will be different than the reproductive system.

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Hopefully, I’ll have a beautiful poster you guys can have (professionally illustrated). A system must be complete but not redundant, and it can go on infinitely more granular; for example, you could think about hormones. Well, if you talk about hormones, you could also talk about all the different thyroid hormones T1 through T4, and then you could get all the way down to the molecular level or the subatomic particle level.

So, when defining a system, where do you draw the line? I’m drawing the line at what I think are the first-level components that a clinician (or a clinician in partnership with other clinicians) should think about when trying to think about sexual function.

So, this is the picture (of the top levels) that I’ve come up with so far.

I know there’s the clitourethrovaginal complex, but I decided to tease out the urinary tract and the birth canal. There is also the pelvic floor, but there are also more specific sex muscles; that’s what I want to think about tonight—not just the pelvic floor but the other muscles. So, let me pull this up for you so you can look at it. I’m seeing people arrive. Crazy good group tonight. All right, so hold on a second. Let me show you a picture. And actually, I’ll start with a list of muscles. Let me pull this up.

(See the video)

Okay, got it.

I’m just going to breeze through this, and then I’ll eventually have multiple papers about muscle and how it responds to PRP. We’ll talk about pearls, our procedure, and how it might be modified. But first, I want to go through the list of muscles.

The most common sex-muscle problem that I see in my office is the woman suffering from a trigger point that causes dyspareunia. Usually, she can put her finger on where it hurts. It’s usually in the posterior vaginal wall, but not always. Traditionally, trigger point pain has been treated with triamcinolone trigger point injections, like in sports medicine. But let’s go through the list of muscles.

Got it ready for you here (see video)

Okay, so you got the pelvic floor muscles: levator ani (pubococcygeus, iliococcygeus, puborectalis).

But I want to come down here. These are not pelvic floor muscles. The vagina muscles, the clitoral complex. You have ischiocavernosus and bulbospongiosus, which cover the corpus cavernosi and the bulb of the clitoris (corpus spongiosum) and contribute to erectile function. These are striated muscles, not smooth muscles. And, of course, you got the gluteus muscle and hip adductors and the obturator, things that I think affect more movement, maybe not as directly to pleasure.

And then not on this list, of course, is the urinary mechanism where you have both strides and smooth muscle that encircles both the urethra and then, distally, the urethra and vagina. That’s a lot of muscles.

PRP is used to help athletic injury.

Before we even get to the pelvis, we’ve covered this a lot in the past, but I want to throw up a couple of papers that involve platelet-rich plasma and muscle injury and tendon injury. And when you think about this, think, well, if it works for the muscle of an elite athlete, well, where else do you have muscles that can be injured?

So look at this. Here’s a collegiate basketball player who wasn’t getting better, and you had a quadriceps tendon tear. It’s not like the orbicularis oris or the facial muscles where you have muscle connecting to skin. So one end is skin and the other insertion side is bone.

With the pelvic muscles, and I don’t mean just pelvic floor muscles, you have bone to bone. And so there’s tendons and there’s fascia just like an elite athlete. And of course, the rhetorical question that keeps me up at night is why do we have college athletes getting better treatment of their torn injured aging muscles, than does your mother, or your wife, or your sister who has trauma from various reasons, from childbirth to just sex and riding or bicycle?

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Okay, so in this study, they’re using an Arthrex device to obtain 4 CCs of PRP out of a 15-millimeter blood draw. And so it’s similar to some of the double centrifuge devices you guys are using. They like to brag that they use a light to separate it out and that somehow that’s more accurate. Maybe it is, maybe it isn’t, but it’s basically a double centrifuge, and they show in this athlete that he was not getting better until they injected PRP.

Here’s what I want to read this part in red that stood out to me. Okay, platelet clots may be beneficial in speeding up the treatment of tendon injuries, inducing cell proliferation, and promoting the release of growth factors. Whatever randomized control trials these were. They were unresponsive to other conservative treatments such as medications, rehabilitation, laser therapy, corticosteroid injections, and how many of those things are we using in vaginas that continue to hurt from dyspareunia for years or decreased sexual response. So, the same thing, we’ve got pelvic rehabilitation, we’ve got various modes of energy transmission, corticosteroid injections, whatever.

I’ll read this last part to you, and then we’ll go to… use of PRP for non-surgical management of tendinopathy and partial tendon continues to be studied, shows improvement across multiple domains to include pain, strength and sonographic appearance in a patient with a partial quadriceps tendon tear that failed to respond to conservative therapy. So imagine if you had a way to make the pelvic muscles not just the floor, those muscles involved with the sexual response to improve in strength and to attenuate pain.

You would have the Super Bowl vagina if you were given the same treatment as a Super Bowl NFL player. I admit this truly makes me angry that it’s taken this long for us to take muscle as a muscle, a tendon as a tendon. And it’s only our emotions that somehow make us resistant to using the same idea in the muscles of the vagina that might work in the muscle of the thigh.

Here are some of my favorite studies regarding PRP and the muscles.

Here (see references at the end of this article).

The recurring theme is that when you’re dealing with muscle injuries, as many of you know, you’re dealing with the replacement, with healing, with scarring and fibrosis. And so it’s not just healing; it’s healing in such a way that you maintain function. Of course, when you have someone making $100 million a year, then there’s more money involved in helping them get well than someone’s grandmother who happened to deliver five babies. But it doesn’t mean we can’t pull the technology. The whole reason I was all in with PRP in the beginning when it started leaking over into the aesthetic field and why I pulled it into the sexual medicine field as far as I know, being the first to do an O-Shot® or use it in the vagina, the penis is that I think just a basic principle is this.

Here’s just a basic rule you can follow: If you look to see what $100 million athletes and $100 million racehorses are doing today that’s not already in the medical journals, well, you are seeing medicine as it will be practiced 30 years from now, for normal mortals. Because they don’t have time to wait for the FDA, they just got to get that $100 million guy back out on the field. And if it’s not working, they’ll know it. So that’s what we’re looking at. And you can see these are the growth factors. Most of you know this already, but here are some of the growth factors that have to do with the replacement and treatment of scarring and the replacement of fibrotic muscle tissue with normal tissue (see video).

So you have… of course you get new blood flow and here they’ve looked at some of the ones that are being used mostly by people in our group are Magellan, Pure Spin, Insight. Some of you guys have the Angel system and then on the single-spin people, its Selphyl, Regen, and Eclipse. So that’s just one of many papers, and they all revolve around that same theme activating the pluripotent stem cells or satellite cells that are waiting for that PRP to differentiate into healthy muscle tissue.

So I’m just giving you an overview. Now, here’s a couple of, or three papers about the pelvis in general. Actually before I do that I do want to pull up a picture too. Hold one second.

This is a midline transsection of a cadaver (see video). And they’ve died for you in purple, the body, the glands of the clitoris, and the root of the clitoris. The root, if you look at the corpus spongiosum, was not visible, and neither is the corpus cavernosi because it’s midline. So then, if you go down away, let’s see where it’s up. Here. So now if you look… you’ve got an MRI view, and you can see glans, body of the clitoris, corpus cavernosi, corpus spongiosum, and overlying that, you have striated muscle overlying the corpus cavernosi, overlying the corpus spongiosum or the bulb. There’s the root, there’s urethra.

So back to this view, there’s an MRI view of it. So you’re seeing this whole space pretty much, from the urethra up towards the proximal body is filled with the root, or at least there’s a significant portion of it that fills the root.

Overlying that is muscle. So the question becomes, I think if the muscle actually contributes to the sexual response. Of course, when we’re doing our current injection, we’re injecting the anterior vaginal wall. The body of the clitoris, which we’ve shown is at least in immune patient that we visualize with ultrasound, it is indeed hydro-dissecting down the corpus cavernosum.

And I think it does when you get it right, but maybe we should also be doing something that approaches, maybe it goes in the perineal body so that we’re getting indirectly into multiple muscles. I don’t know..

Two other things. You guys know this already, but here’s a couple of physical therapies that are possible, that are being used by people in our group. Now I’ll come back, I haven’t shown you the research about the pelvic muscles in general. Hold on a second.

So this is combination muscle stimulator, electrical muscle stimulator combined with a vibrator on a little rabbit. And then this, there’s a button back here that inflates this until it’s touching the vaginal wall. So you can cause contraction of the stratum muscle of the vaginal wall. So it’s a pleasant way to get your kegels done. And these go retail for about 300 bucks. If you talk to the company, they’ll wholesale them to you as a physician. The company or the devices changed hands a few times and the company used to promote at some of the medical meetings, and I haven’t bought this product in a while, but we’ve got a pretty good stock of them.

It may be that this is something you might want to try in some of the anorgasmic patients combined with your O-Shot® procedure. But anyway, that’s one way.

Then some of you have an EMSELLA device, and many people find this to be… even though it’s an expensive device, they find it to be helpful and profitable, and it’s something that your staff can run without you being there. They need to make sure there’s no IUD or something that a big magnet is going to bother the patient. Very simple questions, and then they sit there, and nobody gets hurt with it.

So those are, I think, the two things I see people… oh, and intensive people make one without the vibrator component that may be less threatening to some women and still makes you do the Kegels, but it comes without the rabbit.

Anyway, so those are the two things that I see people in our group using with their patients to help on the muscle side. But I’m starting to wonder if we’re missing an opportunity by not modifying or adding to our procedure by injecting some of those muscles.

Okay, I have a couple more papers I want to show you. All right, so tying back into what we just said with the sports medicine, if you have pain with sports medicine and you jack up the thigh of your quarterback with prednisone to help the pain and you cause a muscle atrophy, not good. So you’re not going to get that. You give it to your grandmother or to somebody’s grandmother who has dyspareunia in the office, but you wouldn’t do that to the thigh of a quarterback. So why are we doing it to grandmother? I don’t know.

Stronger pelvis muscles are associated with better sex.

But this simply makes the point that, as you would expect, stronger muscles are not just about improving urinary symptoms; they help with sex. That’s it.

That’s the whole point of this brief article, all the references. And then I have about six more like that in here about how having a stronger pelvis… here’s another one… having a stronger pelvis leads to better sex, as you would expect. And these papers go back… this was 2019; they go back for almost a decade.

Okay, so what do we do with that? I’m going to be quiet now, see what comments or corrections you guys want to make and then we’ll call it a night. Let’s see who’s on the call?

Oh, I didn’t know. So Eric says that the Intensity are no longer in production. Wow. Maybe we need to bring one out. Our group’s big enough. We might need to patent our own device.

Let’s see who else is on here. Lots of people. I’m going to unmute you, Hunter. Hunter is one of our wizards with the P-Shot®.

Hunter Hanson, MD:

Hi.

Charles Runels, MD:

Hey, Hunter, thanks for jumping on.

Hunter Hanson, MD:

Oh, sure.

Charles Runels, MD:

I don’t know. I’m going to ask you a question. I don’t know if you guys know, but Hunter has probably done more P-Shots® than anybody literally on the planet Earth through his multiple clinics. After seeing what we talked about, of course we want to have muscles that are involved with sex as well. Do you have any ideas or words of wisdom you want to share after seeing what we talked about?

Hunter Hanson, MD:

I’m more of a listener. On the female side, I do an occasional O-Shot®, but that certainly is not the big focus of the business. Like you said, I’m doing P-Shots® every day.

Charles Runels, MD:

Yeah, you have six clinics now. how many clinics do you have now?

Hunter Hanson, MD:

I spun some off, but now I’ve been training in other locations. So I don’t have the clinics, but I’m instructing other people. I’ve got a couple of places, well, three in the country, that are doing what I’m doing.

Charles Runels, MD:

Beautiful.

Hunter Hanson, MD:

And then we’re going to be training another group, I think in next month, that are coming down from a northern state. I’ll make it more mysterious.

Charles Runels, MD:

Beautiful.

Hunter Hanson, MD:

I certainly support your idea about all the muscles that aren’t involved, and I’m wondering if just that single CC of PRP in the clitoral head should be augmented, and we should put more in the clitoris in more of the wings itself. We have a Vampire Wing Lift, but that’s more for the skin itself. I don’t think that’s in the glans.

Charles Runels, MD:

Yeah, we’re putting in the labia majora mostly where the lipocyte layer is; not necessarily where the spongiosum is. But part of the reason I pulled you up, I see a couple of… let’s see some neurologists and some other people that are down there. See you, Cedric. I’m going to pull you up here in a second, too. But to remind you, guys that are new to the group, before I ever injected a vagina, before I injected anybody else’s penis, I injected my own penis; I injected quite a number of penises, and the anatomy is the same as the clitoris (analogous tissue). So when you’re doing P-Shots®, it is a larger version of the clitoris.

So your ideas may be more valuable than you think. While I have you on the call, I get a lot, and I’ll go back to the clitoris and vaginas, but since I’ve got you on the call, I get a lot of questions about Peyronie’s. And we have the paper from Ronald Virag, who’s a legend in the urology space, where he showed PRP works better than Xiaflex for Peyronie’s, but he was using ultrasound guidance to inject the plaque. And my understanding the last time we talked was you’re getting great results just injecting into the penis itself without needing ultrasound guidance, combining it with a pump with great results. Is that right?

Hunter Hanson, MD:

Well, yeah, that’s correct. Years ago we’ve been together maybe 10 years now, isn’t that scary? But this all began-

Charles Runels, MD:

Who would have thought when that first class we did in Atlanta that things were developed like they did? The group was small, and we were young. The group was young, and the procedures-

Hunter Hanson, MD:

I collect 9 CCs of PRP out of a 60 CC blood draw. And initially, I would do two separate 9 CC syringes full of PRP. And what I would do would do a traditional shot with one of the 9 CCs of PRP. And then, I would inject more PRP directly into the curve or into what I would tell the patients would be the gristle in the area causing trouble. But what I found was that the double draw wasn’t that important. And if I just did a regular P-Shot® but did it multiple times, I had the same result.

So what I would tell people with Peyronie’s is that they should plan on three P-Shots® and I space them out. I only do a P-Shot® once every three to four months, and I do a series of three for Peyronie’s. And I tell people they can do it more often if they want, but many people are happy with those three.

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Why I do it four months apart is simply because it takes our body that long to completely respond to one of the PRP treatments. I explain to patients that it’s just like if you have a cut on your arm; you’d have a scab on your arm for a couple of months as it heals. And I’m considering the PRP is doing the same type of process. So I want each one of those PRP treatments to be completely done before I repeat it to save the patient money as well as to make the best result possible. So I do just a regular P-Shot® three times for Peyronie’s.

Charles Runels, MD:

If you look at that study that Virag did, and he was going once a week for six weeks, the study was a landmark study, and so I’m so grateful for it. But if you look at the wound care studies, the endpoint is usually at 12 weeks because that’s the soft tissue timeframe to look at healing a wound, which was done 10, 20 years before we started using that sexual medicine space. So I’m with you. I usually tell them, “Don’t even think about seeing much happening until around the third week, and the full effect in eight to 12 weeks.”

So spacing it out every four months gives time for things to work.

Hunter Hanson, MD:

The other thing that I do that most people don’t do is that I do a tremendous amount of Trimix injections for erection difficulties. So before someone gets a P-Shot®, I will inject them in the office with trimix and see what their erection looks like. Now on Peyronie’s, I will take pictures of the penis with a protractor so that we can see the amount of deformity, and then two months later, we do another injection, give them another erection with another protractor, and then we can see what changes occurred. And then we have some measurements.

We don’t have the patient just saying, “Yes, I’m happy,” or, “No, I’m not.”

Charles Runels, MD:

We got to put together some of that data and publish it because you’re documenting like crazy, and you’re getting better than what’s published in the literature. There was a study using a pump showing 51% over 12 weeks’ time. But my bet is you’re doing much better than that, combining the pump with your PRP. Do you know what your success rate is of people just-

Hunter Hanson, MD:

We do have data, but it certainly is buried, and I’m not that good at retrieving all that. It’s on our computers.

Charles Runels, MD:

I’ll put it to you a different way. We all have our money back if you’re not happy with what you’ve done. As far as I know, there’s no one in our group not following that policy. And I’d probably know it because about once every six months I’ll to a year I’ll get an angry email from a patient. But just in the past six months, how many people have you had to give their money back because their Peyronie’s weren’t happy with the result? What percentage do you think?

Hunter Hanson, MD:

We’ve never given money back because we show positive results based on the photographs. So we do have people that try, even with a regular P-Shot®, to say nothing happened. But that’s extremely rare. And I remember 10 years ago, I had a man that complained that he didn’t get a longer penis after a P-Shot®, but he got an inch better in diameter or circumference. He got an inch more in circumference. So it was a measurable change. We had documented changes; it’s just not the direction he wanted. I see that more often. I explain to patients now that when I’m doing a P-Shot®, I’m putting fertilizer in the penis, but I can’t tell them how many flowers will bloom.

Charles Runels, MD:

Well, you’ve done more, and I hope the gynecologists on the call realized they were hearing… I don’t know what the analogy for Peyronie’s is in the clitoris, but I know there can be damage, and well, there’s BXO.

Hunter Hanson, MD:

Peyronie’s in my experience and my research, the most common cause of Peyronie’s is a childhood injury of the penis that was thought to be inconsequential at the time, but it forms some scar tissue in the penis like a bicycle accident or something like that the child had. And it doesn’t light up until someone is in midlife when their testosterone drops.

And with a lack of testosterone, the penis will retract; it’ll pull in the gristle in the penis. And that’s a common problem that guys will say, “Hey, my penis is getting smaller,” and it’s because of their testosterone dropping.

So when the testosterone drops, it pulls in the gristle, and then that scar doesn’t pull in uniformly, and then they get a bend. So it’s something almost like diabetes where you’re going to be a diabetic, but it took you until you’re 40 to finally show it. The other reason people get Peyronie’s is that I tell people it’s from torquing. And I’m joking about that, but it’s for a sex where the female’s on top, where they can snap the penis and damage it.

Charles Runels, MD:

Yeah, I’m always paranoid when in that position because I know too much. Well, we’ll catch up with you in just a minute because there’s one of the… I’m hoping I’m pulling on the calling in a second, but Cedric Olivera, I hope I didn’t say that wrong, is one of the first board-certified urogynecologist has done some research with Delancy, if who you guys heard me brag about. And they documented that as a woman ages, she also loses nerve fiber, she loses… there’s atrophy just like with the men. In the paper, I remember a man loses somewhere around 50% of the endothelium of the penis by the time he reaches 65. So if we can reverse that or attenuate that with our PRP in the man, hopefully, we can with a woman as well. Keep your mic on, and I’m going to pull a couple of other people on the call. I’m going to go ahead and pull Cedric on the call, because he’s new to our group, but not new to the pelvis. Hold on just a second. I’m unmuting you, Cedric, as you jump in and teach me something. Are you there?

Cedric Olivera, MD:

Yeah, I’m here. Can you guys hear me?

Charles Runels, MD:

Yeah. Thanks for jumping on. You’re new to the group, some of it. We got some of our regulars on the call and some new people, but I’m embarrassed.

Charles Runels, MD:

I guess a week or two ago, I told you I’ve been literally staying up at night and getting up early in the morning trying to figure out not just where all the parts are, but it’s like I’m staring… I’ve lifted the hood on maybe the engine of a car or something, and I can learn all the parts but not know how they work together. And there’s a big mass of muscles down there. So knowing how they control urine is one thing, which is complicated enough, but knowing how it contributes to the sexual response and then using that knowledge to maybe direct some modifications or additions to our procedure, that’s the topic of the moment. If you don’t mind jumping first, tell us just a quick background on yourself and any comments or corrections or additions to what I’ve stumbled through as far as the muscle anatomy involved with sex. Go for it.

Cedric Olivera, MD:

So I guess the way I would approach that at this point is that first of all, I’d say I’m impressed with… even though I’m new to this whole process of O-Shot®, I’m really impressed with your level of detail, and I’m really impressed with the amount of science that you are trying to put forth in this field of medicine. So as a urogynecologist, we take care of patients with pelvic organ prolapse stress or urinary incontinence or the stress urge mix, potential and sexual dysfunction. But before now, I never really had a great way of treating sexual dysfunction.

So basically we asked FSFI, it was female sexual function index. Rebecca Rogers is the one that did the original paper. She’s a urogynecologist, I know her very well. And we talk about the sexual response cycle and desire, arousal, plateau, orgasm resolution, but we never really had good ways of treating things.

So desire, we say, well, you just increase sensate focus, more touch and kiss and caressing, et cetera. And if it’s an issue with dyspareunia, well you increase lubrication, but there was never really a good treatment for orgasm.

So now a lot of patients would come to me and they say, “Doctor, I want my vagina tighter.”

And so if the distance between the vagina and the anus known as the perineal body, which comprised of the bulbocavernosus muscle and the superficial transverse perennial muscles forming the perineal body, if that was short i.e. two centimeters as opposed to three or four, we could say, “Okay, we’ll do a perineoplasty. We’ll build those tissues up.”

And as I’m thinking about it, I haven’t done my first O-Shot® yet. It’s coming up in two weeks. But as I’m thinking about how this is working, and I’ve done MRI studies with John Delancy, et cetera, but as I’m thinking about how this is working, it’s fascinating because the pelvic floor muscles, let’s say the levator ani muscles, the puborectalis, the pubococcygeus, the iliococcygeus, when you do biofeedback on a patient with stress incontinence for example, or a kegels exercise also known as pelvic floor muscle training exercise, you place two fingers in the vagina, have them contract, you can feel the levator ani muscles lift your fingers up towards the anterior vaginal wall.

And so, in my mind what’s happening is that if a woman’s having sex and a penis is in the vagina and she does that same contraction, well all of a sudden it’s going to put pressure on that anterior vaginal wall i.e. the G-spot and right where those areas that we’re putting up the PRP.

So I think it’s fascinating that patients would want a tighter vagina because it probably puts more pressure against the anterior vaginal wall and the G-spot and allows them to have better orgasm. So I’m kind of interested to see what will happen when I start doing these O-Shots®, and see if… maybe the thing to do would be being able to measure and objectively quantify the size of the perineal body and then maybe an O-Shot® and a vaginal plasty or perineoplasty rather, where you tighten the vagina, put more pressure against the urethra.

Maybe that would be the ultimate thing to do. The other thing is that unfortunately many women have prolapse, and so you got to figure out how when you correct their prolapse, whether it’s through a pessary use or some surgery, and you put that vaginal apex where it’s supposed to be over the levator plate so that during coitus, it has mobility. Let’s say you do abdominal sacrocolpopexy, when you straighten out the vaginal canal and you un-kink the urethra, they’ve had kinking due to prolapse, they may have incontinence, but then that might be the best time to put the PRP, because you don’t want to put the PRP or do an O-Shot® in a woman with significant prolapse, you might put in retention.

So just some things where I’m thinking about even before I’ve started doing any of these procedures, but I think it’s fascinating. I think we’re definitely on the right track. I think you’re definitely incorporating science and thinking about it the right way. So kudos to you.

Charles Runels, MD:

Well, thank you for the good feedback.

Charles Runels, MD:

Thanks for jumping in. I’m going to pull… is your mic unmuted, Alex?

Alexandra Runnels, MD:

I think it is. Can you hear me?

Charles Runels, MD:

Yeah. Yes, we can hear. Cedric, that’s my wife, Alex. She’s a gynecologist who has been doing some of what you mentioned. She has an office here in Alabama and in Texas and has been doing… you’ll have to tell… I don’t want to speak for you, Alex, but she’s done some of what you’re talking about. Some of those surgeries combined with an O-Shot®. I’m telling you, I could easily list off a dozen landmark studies that are just waiting to be done. But before I turn loose, Alex, but I have right now a picture of the muscles pulled up to look at.

And the fascinating part to me is that they’re just right there. And as you just said, Cedric, no pressure against the anterior vaginal wall is necessary for most of the pleasure with the female. So I think as a sideline, it’s worth mentioning when you talk about making the vagina tighter, there seems to be a first impression, at least among some circles, that you’re just thinking about making it somehow more wonderful for the male. But it’s really about the female as much so because if you think about those posterior muscles just absent, there would be no pressure.

And so the Kama Sutras talked about just the right fit, not big or little penis or loose or tight vagina, but the right fit, so that there’s neither pain but lots of pleasure from the right amount of pressure. But then we got the men’s penis shrinking and the woman’s vagina becoming more lax. And in some of the studies you’ve actually done Cedric, you guys have counted nerves and counted muscle and you know that it’s going away. So then the thing becomes, well if you could stick a needle in there somewhere and make muscles stronger, either as you mentioned in the perineal body or maybe could you even do it, I guess maybe with ultrasound? Could you inject the ischiocavernosus, or the… anyway, so I’m rambling now, but you can see lots of studies just waiting to be done.

One more quick sideline before I turn your loose, Alex. So far that I know about, we’ve had three cases of urinary obstruction. And in every case, but two of the three, quite significantly more PRP was injected than what’s recommended.

Who knows? And maybe we could be… normally, we’re injecting four in the anterior vaginal wall. Maybe if we injected 10 in the anterior vaginal wall routinely, mostly would get better results with not much retention. However, we did have three people who had overflow obstruction, which resolved without serious sequelae. They had to be a good result. But one of them, it was an outrageous amount. One was just twice as much PRP as recommended and the other was apparently what we only recommend. Back to your question, Hunter, as far as just damage, correct me if I’m wrong, Alex or Cedric, but if you do bladder taps on a baby, so you might cause obstruction, but I don’t think you’re going to cause actual damage to the bladder if you happen to prick it with a needle. But run with it Alex, and tell me what you’re thinking from everything that’s been discussed so far.

Alexandra Runnels, MD:

Okay, well hi everybody, I’m Alex Runnels and lots of you know me and some of you don’t. I don’t think I know Cedric. But I have a lot of thoughts about what has been talked about tonight. Yes, the pelvic floor muscles and the muscles that make up the structures that ultimately converge to make the perineal body and the muscles overlying spongiosus and… they’re all very important. But I think the reason why they are so important that is not talked about is that something about the vagina function, and as far as in sexual function, that doesn’t really get talked about so much. And what it is, the vagina is designed to stretch very, very big and then shrink back down to very narrow, collapsed upon itself canal.

Whether we’re talking about a vagina that’s supported by bulky muscles, or attenuated muscles, or supported by… it’s a long vagina, a short vagina, whatever. Really in order for the vagina and the surrounding structures, the perineal tissue, the perineum, the labia, in order for all of that to work right in a female, it needs to be able to comfortably stretch a lot and then it’s got to be able to rebound well. And it needs the support of the muscles around it. Of course, you can’t have transected muscles or super atrophied muscles and expect to have much support.

When that happens, then things prolapse and that’s its own problem. But really it all comes really down to the connective tissue framework, or underlying connective tissue structure of not just basically of the muscles as well as not so much the skeletal muscles, but the muscular layers of the vagina itself and the submucosal tissue and the mucosal tissue of the vagina itself, as well as the supporting ligaments of the pelvis, whether we’re talking about the round ligaments, the cardinal ligaments, the pubic cervical ligaments, whatever ligaments we’re talking about. It really all comes down to the integrity of the connective tissue that makes all of it up. And in order for that connective tissue to stretch adequately and then rebound well and therefore have a comfortable, functional vagina, it needs to have really good blood flow.

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And the other component, well, there are lots of other components, age is a huge component because that connective tissue is made up of different types of collagen and elastin and the gags, the glycosemia… glycans, all that stuff that makes up the connective tissue, if it is a youthful person, the collagen turnover is quick. As we get older, collagen doesn’t turn over so quickly, and neither does elastin. The collagen fibers break, and the elastin that makes things elastic doesn’t turn over so well, especially if it’s not well vascularized.

And so blood flow to the entire structure is so critical, not just to the clitoris and to the erectile tissues of the labia, the bulbospongiosus, even around the urethra, the blood flow to that venous plexus that surrounds the urethra I think is so very critical for urinary continence.

But the connective tissue and the blood flow of the muscular structures of the pelvic floor too, those muscles can’t be healthy and strong and have the type of integrity that they need to support the penis and the vagina pushed up against the anterior vaginal wall if there’s not really that great of blood flow to it all. And that is a huge problem in so many women beyond a certain age starting in 40s, 50s, just like erectile dysfunction in men is mostly cardiogenic in nature. Well, for women it’s mostly cardiogenic in nature also. And if those structures that are made up of the framework. It’s like the frame of a house. You build a…

Charles Runels, MD:

Hey Alex, sorry to interrupt you, but can you address to the idea… are you always doing an O-Shot® when you do your surgeries? You mentioned some of the pelvic for the other. I see other urologists and gynecologists on the call and all of us refer to you guys for surgery. Talk some about how you’re combining the O-Shot® with what surgeries and what you’re thinking is with that. And then I’ve unmuted David Harshfield and Peter and others. So, y’all jump in if you want to. Your mic is unmuted, but talk to me a little bit about how you’re thinking about how you’re putting the O-Shot® because you did some perineoplasty or something the other last week and threw an O-Shot® in there. Talk to me.

Alexandra Runnels, MD:

Everybody that I do either a perineoplasty or labioplasty or any of those types of procedures always gets an O-Shot®, and then I inject PRP into the incision line and into the body of whatever I’ve thrown sutures in. And I have seen a huge difference. The ones that I didn’t do that to versus everybody else the healing is very different, much more robust healing, much more I feel like integrity to that surgical wound. I don’t do surgery anymore without including an O-Shot® with some extra PRP.

Also, the other thing that I do is when people don’t want or need surgery, I’ll do some things where I will… especially if they’re coming in for, say, they want a tighter vagina, or they want better sexual function, and they have little incontinence. And what I’ll do is I’ll have them sit on the EMSELLA and create a little action going on in the muscles of the pelvic floor and the perinatal body.

And then that day, after they’ve sat on the EMSELLA, I’ll do an O-Shot®, and I’ll inject PRP into their pelvic floor muscles, specifically the perineal body or the transverse perineal muscles and really whatever other muscles I can assess are maybe somewhat atrophied or have been involved in some damage in the past. And I think that that helps the PRP work better because the muscle has been aggravated a little bit, and there’s a better response if there’s been some something going on, versus sort of a… I’m not saying that it causes an injury, but I think it does help the PRP to get things going. And I see a good result with that. I see a much better result with that. And then they’ll do the rest of their EMSELLA series. Is that what you were asking?

Charles Runels, MD:

Yeah, that helps a lot. You guys should probably swap phone numbers. But I think that I’ve seen that study done of more rapid healing and, of course, all over the plastic surgery literature, but also was done with a hysterectomy. It’s been done with just it’s healing, is healing, is healing.

David, are you unmuted? David Harshfield? The thing I’m wondering is if you could do… so Dr. Harshfield is one of our radiologists. If there is one study I can see, it is maybe just injecting the muscles involved with erection. The bulbospongiosus, ischiocavernosus. I don’t know, I’m trying to think of a strategy. If you were going to think of… if you just had a magic wand and we do, because we have PRP and a needle, where would you put it, Cedric, if you’re going to do a study to improve sex by injecting the muscles involved with sexual arousal? Where would you put your needle and would you need an ultrasound or could you do it from surface anatomy?

Cedric Olivera, MD:

So can you hear me?

Charles Runels, MD:

Yes.

Cedric Olivera, MD:

So I haven’t thought about any of this, but as I was thinking about it as you guys were talking and I was looking at the anatomy, I’d be curious to know what would happen if we were to inject the perineal body, so that… I wonder how much more closure we can get i.e. tightening of the vagina from a nonsurgical standpoint just by injecting PRP into the perennial body.

Charles Runels, MD:

Just that one injection.

Alexandra Runnels, MD:

I do that.

Charles Runels, MD:

In all of your surgeries, Alex? I mean-

Alexander Runnels, MD:

I do the-

Charles Runels, MD:

But you’re combining with everything else. Have you ever done it as a standalone?

Alexandra Runnels, MD:

I also do it not in someone who’s not having surgery, who is coming in specifically for sexual function. And when I examine them, if they have somewhat of a lax or attenuated perineal body, then those are the patients that I do it on. And it’s not instantaneous, and it’s not overnight. And they do need to do some other things in combination with it, such as real kegels at home with something that makes them do them or an EMSELLA device or something like that. Because just like you can’t build muscle, you have to go to the gym to build muscle, even if you’re taking something supposed to support muscle growth. So you do need to stimulate that muscle a little bit. But I’ve had some very good results with injecting those muscles of the perineum for the purpose of tightening things up.

Hunter Hanson, MD:

I’ve got a question for the group. We use a vacuum device on the penis after a P-Shot®. Would we ever use a vacuum device on the vagina after an O-Shot®?

Alexandra Runnels, MD:

I have my patients use a vacuum device on the clitoris after an O-Shot® for the ones who have decreased sensation or decreased orgasmic function associated with their clitoris. I’ll do an O-Shot® and then have them use a clitoral suction device just like we use for the men with the pump. And I give them the same instructions: use it 10 minutes a day on a low setting, as long as they can stand it. And if they get to the point where they can’t stand the 10 minutes without having an orgasm, then great, we’ve gotten somewhere. But I have had a lot of success with that. It’s the same idea as pulling blood flow into the clitoris. And I’ll often have them use some transdermal topical or transdermal testosterone cream along with it and that works great.

Hunter Hanson, MD:

Good.

David Harshfield, MD:

Charles, we were… Alex, it’s good to hear your voice again.

Alexandra Runnels, MD:

Thank you. It’s nice to hear from you, too. David.

David Harshfield, MD:

Stay partial. We were looking at skeletal muscle restoration in the spine, and we were doing like a L4 facet for someone that had maybe a neurotonomy, or somehow the medial bundle branch had been burned. And they had atrophy of the multifidus muscle, which is not good in the spine, guys. It’s like the rotator cuff of the shoulder. That multifidus muscle is a little bitty thing, but it starts rotation. And you need that. Well, we’re trying to inject facets.

We think the facets are inflamed, whatever. The dad gum multifidus grows back. And then we said, okay, and I’m an interventional radiologist, so I’m doing a lot of limb ischemia. People with no blood flow to the extremity. And we’re doing blood flow restriction where you put this KAATSU, K-A-A-T-S-U, these little bands, high five pressure bands, and you trick the body into thinking that the limb is very ischemic.

You let just enough arterial flow in, no venous out, no lymphatic out, and you do that for about 10 minutes, and all these molecules are released in this ischemic leg, and it goes back to your bone marrow and your thymic gland and all that. And it induces growth of skeletal muscle. And so Charles, I’ve always wondered about the pump. If that’s not sort of what we’re doing with that. But in terms of when we inject, let’s just say PRP, what we’re I think doing, and we may not be thinking about this way, because we see different tissues are restored. But I think it’s primarily, that restoration of the nerve, subtends the skin, the muscle next door in a joint, it’s the cartilage, all the capsule, everything is taken care of.

And I learned this doing leg ischemia, injecting along the neurovascular bundles below the knee. You can see the anterior tibial artery in its nerve and the two veins. And you put a few drops of PRP or whatnot, every couple inches along that under also, and their blood flow comes back almost instantly, but certainly within a week.

And then the patient says stuff that’s weird, like, “Hey, Dr. Harshfield, I can feel my feet.”

I said, “Okay, great. What are you talking about?” “My feet were so numb, I couldn’t tell I had my shoes on.”

And I went, “Whoa. We were storing the nerve.”

Charles Runels, MD:

Yeah, the last time I looked, there’s 50, 60 papers about PRP causing neurogenesis in various locations. So when we do our O-Shot®, you guys know I’m always bragging somewhere in our computers we have video of me injecting a clear body while David Harshfield was doing ultrasound on the corpus cavernosi and showing a change in flow and wave form. If you are going to do, knowing what you know about the anatomy and you’ve got an ultrasound machine, and I said, okay, you got to put that needle in there and make muscles change to make sex better. Would you need your ultrasound or could you inject those? You showed cavernosus, bulbospongiosus from surface anatomy. I think you need an ultrasound, but maybe I’m wrong.

David Harshfield, MD:

I agree because the anatomy is so unique and different, person to person.

Charles Runels, MD:

Could you teach someone who’s an internist to do that or would they need the experience of Alex, or Cedric, or yourself to do that?

David Harshfield, MD:

That sounds interesting. If you want to do it, it’s like playing guitar. If you want to do it, you can do it.

Charles Runels, MD:

You just practice it?

David Harshfield, MD:

Yeah.

Charles Runels, MD:

Well, maybe this turns into a different procedure that you have to be a gynecologist or urologist who knows how to do it—a radiologist. Guys, we’re over the hour. I appreciate you being here and helping us think about what we’re doing. As you can see, a lot of times, I think we know what the research might show maybe years before we’re able to do it and show it, but hopefully it’s given you some practical ideas of taking care of your patients.

So thank you, David. Thank you, Alex. Thank you, Cedric. I’m excited about you being in the group. You guys have a good night.

Cedric Olivera, MD:

Charles, could I just say one thing?

Charles Runels, MD:

Yes, sir. Please.

Cedric Olivera, MD:

I would totally agree with what Alex said. The only addition I would make Alex, and maybe think about this is the effect of estrogen in the vagina after an O-Shot® potentially, which would increase vascularity, increase para basal cells, et cetera. A healthier milieu with estrogen added also.

Alexandra Runnels, MD:

Absolutely. I hear you and all about that. I’m all about some testosterone. I’m all about something else that I have not talked about, yet that has been the most dramatic thing I have seen yet in my almost 25 years of being a gynecologist that improves blood flow to the important parts of the female vagina and pelvis. And I don’t know if I’m allowed to talk about it yet, Charles.

Charles Runels, MD:

Well, we just got to do… yeah, I think it’s too early till we do some research. Maybe Cedric can help us do it. But yeah, thank you for bringing that up, because about the estrogen, because I think, again, maybe I’m wrong, but I’ve never seen a branch of medicine where we tend not to think or most we’re tempted to not think as much in terms of the whole system. And I think the sexual arousal orgasm system, whatever you want to call it, is at least as complicated and at least as deserving of attention as the gastrointestinal system. If I get a poster for how to have a bowel movement, I should have a poster about how to have an orgasm.

And best I can tell, if you take anything off of that picture I’m showing you right now, any part of that system has disease and forgotten parts there as sort of my wastebasket, miscellaneous for stuff like the spinal cord and the mouth and other parts that are involved with sexual function other than what’s normally thought about.

But I mean, any part of that can go wrong and you can get all the rest of it right and have bad sex. So I think it’s worth remembering the endocrine part of it as well. Okay.

Cedric Olivera, MD:

Would you add nipple and breast to be different structures? Just a thought.

Charles Runels, MD:

Yeah. And it’s somewhat arbitrary because if you think about it, what are you going to include, and what can you leave out? And maybe they should be different. What surprised me, Cedric, was how little when I go to the research and read about the breast, which Alex will tell you; maybe she shouldn’t tell you because it sounds so pathologic, but I’m up many mornings at 2:30.

Alexander Runnels, MD:

It’s pathologic.

Charles Runels, MD:

… staring at the pelvic floor. I spent a month trying to find anything of significance about the breast involved with sex, and almost everything printed has to do with sex after breast cancer. But not much about just, of course, the feedback loop with oxytocin and prolactin. Even though homo sapiens are the only species where the breasts are routinely involved in sexual relations. There is no other species, not apes, not chimpanzees, no other species where breasts are a part of sexual intercourse.

So yeah, it’s somewhat arbitrary about how it’s divided up, but I want this pretty poster eventually done by showing subcategories within each part of it. Urinary tract, I think would probably include Skene’s glands, or periurethral glands. And by Dr. Grothenberg’s definition, it would include the G-spot and then different pathologies. So there would be sub-categories and little sub-pictures drawn out from it.

So hopefully all of you guys can help me think about it. But surprisingly not that much about the breasts & sex: like in one study in looking at breastfeeding, increased arousal in one group and decreased arousal with sex in another group, and no difference in the other. And then there’s also quite a bit written about just women feeling guilty, feeling shame by the fact that they’re sometimes sexually aroused when they breastfeed their babies.

But it’s not talked about, I don’t think enough. And sometimes, they wind up aborting breastfeeding because of that shame. Anyway, you guys can tell I’m excited, and I’m always honored when you are on the call to help me think about it all. You guys have a good night. Bye-Bye.

David Harshfield, MD:

You too. Thanks, guys.

Alexandra Runnels, MD:

Thank you.

Charles Runels, MD:

Thank you, David. Thank you, Alex and Cedric.

2. References

1. Agarwal V, Gupta A, Singh H, Kamboj M, Popli H, Saroha S. Comparative Efficacy of Platelet-Rich Plasma and Dry Needling for Management of Trigger Points in Masseter Muscle in Myofascial Pain Syndrome Patients: A Randomized Controlled Trial. J Oral Facial Pain Headache. Published online November 28, 2022. doi:10.11607/ofph.3188
2. Aguilar-García D, Fernández-Sarmiento JA, del Mar Granados Machuca M, et al. Histological and biochemical evaluation of plasma rich in growth factors treatment for grade II muscle injuries in sheep. BMC Veterinary Research. 2022;18(1):400. doi:10.1186/s12917-022-03491-2
3. Bernuzzi G, Petraglia F, Pedrini MF, et al. Use of platelet-rich plasma in the care of sports injuries: our experience with ultrasound-guided injection. Blood Transfus. 2014;12(Suppl 1):s229-s234. doi:10.2450/2013.0293-12
4. Brækken IH, Majida M, Ellström Engh M, Bø K. Can Pelvic Floor Muscle Training Improve Sexual Function in Women with Pelvic Organ Prolapse? A Randomized Controlled Trial. The Journal of Sexual Medicine. 2015;12(2):470-480. doi:10.1111/jsm.12746
5. Bubnov R, Yevseenko V, Semeniv I. Ultrasound guided injections of Platelets Rich Plasma for muscle injury in professional athletes. Comparative study. :5.
6. Celenay ST, Karaaslan Y, Ozdemir E. Effects of Pelvic Floor Muscle Training on Sexual Dysfunction, Sexual Satisfaction of Partners, Urinary Symptoms, and Pelvic Floor Muscle Strength in Women with Overactive Bladder: A Randomized Controlled Study. The Journal of Sexual Medicine. 2022;19(9):1421-1430. doi:10.1016/j.jsxm.2022.07.003
7. Edenfield AL, Levin PJ, Dieter AA, Amundsen CL, Siddiqui NY. Sexual Activity and Vaginal Topography in Women with Symptomatic Pelvic Floor Disorders. The Journal of Sexual Medicine. 2015;12(2):416-423. doi:10.1111/jsm.12716
8. Ferreira CRG, Soares WM, da Costa Priante CH, et al. Strength and Bioelectrical Activity of the Pelvic Floor Muscles and Sexual Function in Women with and without Stress Urinary Incontinence: An Observational Cross-Sectional Study. Healthcare (Basel). 2023;11(2):181. doi:10.3390/healthcare11020181
9. Graca FA, Stephan A, Minden-Birkenmaier BA, et al. Platelet-derived chemokines promote skeletal muscle regeneration by guiding neutrophil recruitment to injured muscles. Nat Commun. 2023;14(1):2900. doi:10.1038/s41467-023-38624-0
10. Le ADK, Enweze L, DeBaun MR, Dragoo JL. Platelet-Rich Plasma. Clinics in Sports Medicine. 2019;38(1):17-44. doi:10.1016/j.csm.2018.08.001
11. Lutz RH, King JE, Sell TC, Early CL, Nguyen EM. Platelet-Rich Plasma Treatment of a Quadriceps Tendon Tear in a Collegiate Basketball Athlete. Curr Sports Med Rep. 2023;22(11):370-374. doi:10.1249/JSR.0000000000001115
12. Middleton KK, Barro V, Muller B, Terada S, Fu FH. Evaluation of the effects of platelet-rich plasma (PRP) therapy involved in the healing of sports-related soft tissue injuries. The Iowa orthopaedic journal. 2012;32:150-163. Accessed June 10, 2017. http://www.ncbi.nlm.nih.gov/pubmed/23576936
13. Moraes VY, Lenza M, Tamaoki MJ, Faloppa F, Belloti JC. Platelet-rich therapies for musculoskeletal soft tissue injuries. The Cochrane database of systematic reviews. 2013;12:CD010071. doi:10.1002/14651858.CD010071.pub2
14. Omodei MS, Marques Gomes Delmanto LR, Carvalho-Pessoa E, Schmitt EB, Nahas GP, Petri Nahas EA. Association Between Pelvic Floor Muscle Strength and Sexual Function in Postmenopausal Women. The Journal of Sexual Medicine. 2019;16(12):1938-1946. doi:10.1016/j.jsxm.2019.09.014

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Tag Words

club, discussion, muscles, pelvic floor, anatomy, systems analysis, sexual system, reproductive system, hormones, research, PRP, procedure, muscles, dyspareunia, triamcinolone, trigger point injections, athletes, tendinopathy, tendon injuries, growth factors, muscle injury, muscle function, sexual response, vaginal muscles, clitoral complex, erectile function, gluteus muscle, hip adductors, obturator, urinary mechanism, urinary tract, bladder, blood flow, connective tissue, nerve fiber, collagen, elastin, blood flow restriction, vacuum device, estrogen, breast, arousal, shame, breastfeeding, Hunter Hanson MD, Cedric Olivera MD, Alexandra Runnels MD, David Harshfield MD

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