JCPM2024.06.18

The following is an edited transcript of the Journal Club with Pearls & Marketing (JCPM) of June 18, 2024, with Charles Runels, MD.  

>-> The transcript (download as pdf) of this live journal club here <-<

Topics Covered

• Botulinum toxin for premature ejaculation
• (BoNT for ED) vs. (BoNT for PE)
• A review of regenerative therapies
• A device to prolong sexual intercourse
• Building on Sand or on Rock—which of the marketing techniques is most solid?
• Do I have any recommended birth products (amnion, etc) to augment the PRP effects?

Charles Runels, MD
Author, clinician, researcher, and inventor of the Vampire Facelift®, Orchid Shot® (O-Shot®), Priapus Shot® (P-Shot®), Priapus Toxin®, Vampire Breast Lift®, and Vampire Wing Lift®, & Clitoxin® procedures.

Transcript

Welcome to the Journal Club. I have some beautiful papers that came out in the past week or two, one regarding premature ejaculation. There’s a new device out that’s been FDA-approved to help with premature ejaculation. We will also cover a review article about regenerative therapies in dermatology and a quick pointer on marketing.

My goal is to come in under 30 minutes, which will make it less of a commitment for you to be on the calls.

Botulinum toxin (BoNT) for Premature Ejaculation

The first paper I want to cover involves using botulinum toxin for premature ejaculation. First, we should define that. Most of the studies say that anything less than five, some say six minutes, some say less than one minute–less than that is premature ejaculation.

I prefer to have the definition that premature ejaculation (PE) is when ejaculation occurs before either partner wants it to occur. And that may be one minute or less on some days, and it may be several hours on other days.

See Figure 1 for a chart from an open-source article by Parnhem et al. that offers three definitions of premature ejaculation.^[1]

Why are we talking about BoNT for PE?

For background to discuss BoNT for premature ejaculation, I have in front of you now one of the double-blind placebo control studies looking at botulinum toxin’s ability to help erectile dysfunction (ED).^[2] 

This is the idea behind our Priapus Toxin® procedure.

As a quick reminder: it’s thought that this function for ED happens by both vasodilatation by relaxation of smooth muscle, but also possibly by endocytosis with the migration of the botulinum toxin to the ganglion with attenuation of sympathetic and secondary accentuation of the parasympathetic nervous system, which facilitates erection.^{[3] [4] [5] [6] [7] [8]}

Figure 1 shows how migraine prevention with BoNT is not by relaxation of muscles. It’s thought that the neurotransmitters in the ganglion that are shared by the afferents from the meninges are blocked by the same endocytosis we’re talking about.^[9]

We have another review from a couple of weeks ago; just because these are wonderful papers, there were two meta-analyses of platelet-rich plasma, one for Peyronie’s and ED and the other for erectile dysfunction.^[10] [11]

This one concluded that, yes, it’s ready for prime time.^[12] 

And this one still said, “Well, the verdict’s out.”^[13] 

But no one has yet to say (after their research), “Oh, this is crazy. It’s dangerous and does not work.”

There was only one even iffy study, and they did not follow our protocol (did not activate the PRP, used less PRP, and changed the injection technique compared with our P-Shot® procedure).^[14] 

So, where’s the finish line (where our P-Shot® becomes the standard of care and treating ED without considering regenerative processes is malpractice)?

I don’t know, but I think it’s time for mainstream because other than shockwave, it’s the only treatment we have that might slow down the mechanism causing erectile dysfunction in men, neurovascular disease.^[15] 

So, with all of that in mind, what would be the mechanism of action for using BoNT to treat PE vs ED?

BoNT for ED vs. BoNT for PE

This one came out within the past month, showing that BoNT for premature ejaculation (PE) does not work. But why was it studied, and where did they inject?

If we’re using botulinum toxin for erectile dysfunction, that is a different mechanism than using it for premature ejaculation. For premature ejaculation, it’s thought that because BoNT relaxes the bulbospongiosus muscle and the bulbospongiosus is involved in the expulsion of ejaculate (which comes mostly from the prostate gland), then that relaxation might decrease the urge to ejaculate.

If you go back and look starting 10 years ago, here are two different studies in rats, this one in 2014 and another in 2019; and in both of those studies, injecting the corpus spongiosum in healthy rats increased the time until ejaculation and did not affect the frequency of sexual encounters or sexual intercourse.^[16] [17]

This has been discussed for as long as 10 years, and that’s one of many studies. I’ll give you a bird’ s-eye view of some of the others I have, but there are many. It makes sense logically, and it worked in rats, so why would it not work in people?

And I’m coming to the new device, but why would this not work in people? I don’t know the answer, but I will explain my theory.

I’ve written about premature ejaculation or the reverse of that, how to have sexual intercourse for the way the Indians talked about it in the Kama Sutras, for as short or as long as both lovers might desire. I’ll show you the book I published in 2004, 20 years ago. 

Do not buy a used copy on Amazon; they usually cost a fortune. If you want my office to send you a copy, you can order it here.

There’s a PDF of this somewhere online that you can download for free. I know it’s out there being given away on multiple websites, but it’s OK.^[18]

The last half of this book describes my “Magic 9” Methods; I give nine different methods when combined or used individually to help a man achieve absolute control.

I started devising these nine in my late teens. I’ve been practicing them for over 40 years and have taught them to thousands of people; they work.

I’ve also published one of the nine methods in a different book, Extend Sex with ICU, the 30-Second Trick.

I bring it up because, as a physician, I’ve written and talked about it for 20 years, and as a person, I’ve read and thought about it for 40 years. I wanted you to know that I understand this subject deeply. Some ways can be learned to make ejaculation an at-will thing for whenever the person might want to make that the event.

Back to the research.

This is the paper that just came out. It’s open source, so I’m going to give you a link so you can download it.^[19]  I’ll tell you how to use this research to have more patients, even though it doesn’t work.

Best I can tell from reading and talking to thousands of people over the past 34 years is that sex is truly an art and just like an artist drawing a picture, if you look at Rodin’s studio, the greatest probably sculptor of all time, he had a lot of things that he discarded because he didn’t think they were good enough. So, just because you’re a great artist, that does not mean that everything comes out beautiful every time you put a brush to canvas or every time you put your chisel to marble or sit down at your piano.

It doesn’t.

However, there are techniques for sculpting, painting, and the art of lovemaking that make the likelihood of a masterpiece more likely.

In the education, both in the science and the therapy part of it, for most of our colleagues and most of our patients, is that sex education doesn’t go that far enough, not to the place of art; not much past the lecture they got from their coach in high school about how to put a condom on the penis. Thankfully, the internet is changing that for some, but I still find a lot of resistance even to talking about what’s known between physicians and their patients.

So this article, has just come out, and because it is now news if you share it on social media or you put it in an email, it gives you a reason to talk.

News gives you a reason to talk.

One of my marketing heroes is David Ogilvy, who said, “Always include the news.”

If I write you an email or do a social media post about premature ejaculation, it’s just out of the blue, but this is interesting information because it is news: Studies in rats show that relaxing the muscle that expels the ejaculate can lead to a prolonged encounter with rats, but in people, it doesn’t seem to work.

So what does work?

Everybody’s heard the squeeze technique. Ugg! I don’t like it and have never used it; it does not work well, and it’s like blowing your nose with a clothespin on your nose—not fun.

But surprisingly, one of the things that does work well is increased aerobic capacity. Here’s one of the studies that came out that demonstrates that.^[20]

Not only does aerobic capacity increase your control (treating PE), it also improves erectile function, seven on average on the SHIM score, which is what Viagra does, and that is also what our P-Shot® procedure does—seven.^[21]

Men (and their lovers) suffering from premature ejaculation think, “Why should improved aerobic capacity help you last longer?”

One reason is that even relaxing sex has some degree of physical exertion associated with it, and the average exertion is about the same as slowly walking upstairs. How long can your lover slowly walk upstairs before becoming dyspneic?

Picture him walking up the stairs of a tall building in New York City. How many floors would he go before wanting to stop or start panting?

That’s about how long he’s good in bed.

When I say good, I mean his body is comfortable.

At the point of even mild dyspnea, the blood gets shunted away from the penis.^[22] So once they reach near their VO2 max, in other words, they’re starting to be more tachypneic, then the blood gets shunted to the muscles and away from the penis. So they lose their erection, but they also, I think, lose their awareness of controlling the reflex to ejaculate. So that’s why I think that it’s one of the known factors in prolonging sexual intercourse, much more effective than injecting BoNT into the bulbospongiosus.

Improving VO2 max helps prolong sexual intercourse.^[23]

A device to prolong sexual intercourse

Now, what’s the new device to help prolong intercourse?

It’s being used in Israel now. Like many of the lasers you use, it came out of Israel, and like many of the lasers you use, it is the intellectual property of the Israelis. This is an electrical muscle stimulator like your Emsella machine, an electrical muscle stimulator called the in2.^[24]

The FDA approved it. I haven’t seen it in the US yet.

The mechanism of action is that the man does lots of Kegels triggered by the device, which helps prolong the time until ejaculation. That’s not a new idea, but this new device is being sold straight to the consumer. It is something I haven’t seen for men.

You may remember when we had the Intensity vibrator (which I think went out of production), which would cause Kegels in females, and then the one for urinary incontinence went by a different name. Still, it was an electrical stimulator of the muscle, the pelvic floor, to help a woman self-treat her urinary incontinence or improve her orgasmic capacity. This is the male version of that.

If you’ve got an EMSELLA machine, you could use this research; I’ll give you the link to it.^[25] You could use this article and this news to say that you have something even better in your office with electromagnetic muscle stimulation.

More about BoNT for PE vs for ED

It’s important to me that if you show up to this meeting, you take away new practical ways to take better care of your patients, or better ways to communicate with your patients and find the ones who need you, compel them to come to your office, and/or find reassurance that what you’re doing is still the correct thing to do. 

So if you’re doing, first of all, as a review, we do have strong research showing that botulinum toxin helps erectile dysfunction. And thanks to my amazing wife, we now have a beautiful article about botulinum toxin helping female sexual function, but not dyspareunia, better than any FDA approved drug on the market.

There’s a placebo, flibanserin, bremelanotide, botulinum toxin without, and botulinum toxin with PRP. Clitoxin® blows away everything else FDA and not FDA approved except swapping out serotonin uptake inhibitors with Wellbutrin (which is a two-variable change).^[26] That’s the only thing in the meta-analysis that performs better than the Clitoxin® procedure.

Remember what Faraday said, “You never prove anything; you just support something until someone disproves it.”

So we have strong support for botulinum toxin injected into the penis to help erectile dysfunction and injected into the clitoris to help female sexual function. For dyspareunia, it still works, but it would be injected into the pelvic floor or trigger points, or with vaginismus, into the vaginal wall.

But other than for dyspareunia, we showed that it helps to inject it into the clitoris, especially if you combine it with our O-Shot® procedure.^[27]

So when you talk about how injecting BoNT into the penis helps erection and into the clitoris helps female orgasm and your male patients say, ‘Well, would it help my premature ejaculation?’ how do your answer?

What I’ve given you today is research showing that it was hypothesized that it might work in rat studies, but now we have a good study showing that it did not work for people.

And then they aske, “Well, what can I do for my premature ejaculation?”

If you’ve been to Dr Song’s class, it has been shown to help if you put fillers subdermally or in the glans; those studies have been done.^{[28] [29] [30]}

I don’t teach that, but Bill Song in our group does, and others do. You can also tell them that aerobic exercise will help.

In this study of injecting the bulbospongiosus for premature ejaculation, they’ve given you a good way to find the muscle by topical anatomy, which is important I think because think about this: if botulinum toxin does not work, but EMT therapy does, then what are the further implications?

What do the athletes do with EMT therapy?

Those machines—you put them on your pectoralis or whatever—make your pectoralis jump around without lifting weights to strengthen it. That’s what the EMSELLA does to help women with the pelvic floor, and there’s quite a bit of research supporting that. But what do athletes do to facilitate and accentuate muscle growth and healing? They inject their muscles with platelet-rich plasma.

With this paper, they give you a beautiful way to map out where the bulbospongiosus is by surface anatomy; you might be able to do injections, you do your P-Shot® for erectile function, but then you put an extra cc or so in the bulbospongiosus on each side and then sit them on your EMSELLA machine if you have one. Or, hopefully, we’ll also get those use-at-home devices. But I think that picture and that idea in the minds of you guys could lead to more progression of something I haven’t thought of and maybe that no one’s thought of yet. So that picture, I think, hopefully, will put your mind to racing, and you’ll come up with new things.

According to many articles in the sports arena, if injecting a thigh muscle is okay in an NFL football player^[31] [32] then, injecting the pelvic floor should also be okay^[33] [34]; and we have research about that. Muscle is a muscle; injecting bulbospongiosus to help with premature ejaculation could also be a thing. So that study needs to be done.

A Review of Regenerative Therapies

In this paper, they did a systematic review of randomized control clinical trials in regenerative medicine.^[35] And then they have this menu of things that they determine, yeah, it works.

This is new research that supports what we’re already doing. Because it’s recent, you could use it as news to promote your practice; it’s been out within the last month.

You could publish it to your people and say, “See, this is more research showing that what we do works.”

Building on Sand or on Rock—which marketing techniques is most solid?

I have five minutes before the 30-minute time limit expires. I promised you I’d come in under 30 minutes.

The last thing about marketing I wanted to show you is this article from the Wall Street Journal.^[36] This came out a year or two ago, but the gist of it is that really, even in the days of social media, long form email still does the job in many ways better than anything else.

And more importantly, if you check out the very first sentence here: “Kids think it’s fussy and archaic.” But for brands, creators, and businesses of every kind, the emerging medium of choice to reach an audience is the only guaranteed delivery option the internet has left.”

Do you see that?

“The only guaranteed delivery option the internet has left” is email.

If you do a microneedling, you can usually get through on social media, but as soon as you start talking about sex and you’re a doctor, you will likely get banned.

I have been banned from Pornhub. I tried to put a G-rated video on OnlyFans trying to get, but I got banned from OnlyFans.

I’m telling you, you can have group sex online, but if you’re a physician and you try to talk about sex, I know you will be banned on all the social media accounts, not maybe the first time or the second time, but you’re building a house of cards because the first time someone who works for Google, who happens to be a 16-year-old intern living in someplace in whatever country, who struggles with the English language, but still, they see a couple of flags about what you’re doing, and boom, your whole account is gone, and you’ll not get anybody on the phone, and you’ll never get it back.

I lost a whole YouTube channel, 140-something videos, and many, many thousands of views. I had to start over.

So in my opinion, you might get away with it, you might be getting away with it, but if you’re building your business and it has to do with sexual medicine, and you’re building it on social media platforms; you are building a very fragile construction.

But, so far, except for MailChimp, get off of MailChimp because they’re the first to do it; they’ve started censoring politically, and one of our providers said they censored them for talking about platelet-rich plasma, except for MailChimp, no one is censoring email. And it’s a better way to communicate if you’re going to write for a deeper, long-form, or sometimes short-form communication.

You wouldn’t tweet a letter to your mother or your daughter; you would text them, or you’d write them an email.

And so I’ve been preaching, and those of you who’ve been in the group a while know I’ve been preaching about this a long time. But here’s where I feel like I’ve failed you in that when I talk about emails, I think I’ve spent maybe too much time talking about content and the mechanics of just writing an email and shooting it out, but I’ve never really gone deep into how to create a system of emails that are working together and going out on the same day. I wrote some of the emails that you read 10, 15 years ago, and 20 years ago. But many emails that I wrote don’t go out one time.

For example, when I sent out a notice about the Journal Club, that’s one time, and it’s gone; next week, we will do a different one.

But I have other emails going out about particular problems and procedures. It’s a whole system that I’ve never taken the time to explain because usually, when people have come to classes—not usually, always—it’s been enough to just lay down how to write an email: “Here’s how it works, and here’s why it’s important.”

But I’ve finally decided to do just a deep dive into a whole step-by-step map of how to create a system of emails. And those of you who’ve been in my office, you know I have a one exam room office and built my practice too. Okay, whatever; I made seven figures, but many of you make more than that, but this is three red-light towns with an internist. This isn’t a plastic surgeon on Rodeo Drive, and that’s with me and one staff member.

And then it crashed because the board didn’t like my hormone business. And then I did it again in the cosmetic business, and I couldn’t—not that I’m smart, but I could never have done it without email. I would still be begging insurance to pay me if I didn’t understand how to create a system of emails going out simultaneously, with different people receiving just the right message on the right day.

Now, so I’m doing a live five-week class. It’ll be a class, but there’ll be homework in between. Some of it we’ll do during class. If you’re new to all this, you’ve never written an email; I don’t know, maybe it’s not right for you; I could probably get you going. But if you’ve been in the group for a while, it’ll be a live course on Sundays, five weeks, recorded, and you’ll have access to the recordings for life. As long as there’s an internet, it’ll be there. And I’ll put a link to that in the chat box.

And then, unless there are some questions, we will call it a night because I’m five seconds over my 30-minute timeframe.

But I just put a link to that five-week course. I don’t think I’ll ever do it live again. I’ll eventually offer the recordings somewhere to those who do not attend.

I did a live course probably four or five years ago, and we focused more on e-mail content. We got a lot done, but I found out many of the people—actually, everybody in the group—never got around to creating the network automatic part of it.

So, let’s see if we have questions. If not, we’ll call it a night.

Do I Have a Recommended Birth Product to Augment the PRP Effects?

So Linda asked about Vitilab products with PRP for the O-Shot® or hair.

I haven’t seen it, and I do not recommend any amnion or exosome product. I do not want the FDA knocking on my door and I do not want to use or do anything that I cannot advertise or speak about openly.

Here’s what I know: Our procedures are evolving, and I’m always looking for something to make them work better. Remember back 10 years ago, we were adding, and some of us still do, but we were adding different things to PRP when we treated the hair, and then most of us figured out it worked fine without adding in the other stuff, the B12 and the vitamin D, and the other stuff that we added. But it doesn’t mean I’m not looking for a way to improve it.

But I do not want the FDA knocking on my door. And, I don’t buy into the idea that once you pass 50, your PRP’s useless. Maybe it doesn’t work as well, but if I get cut, I’m 64; if I get cut, my skin heals still, and that doesn’t mean I wouldn’t want it to heal faster by adding something. But, for now, I know of no birth product that I can talk about openly without fear of the FDA—so there is not one that I use (even though some sales reps might tell you otherwise).

Thank you. I hope that was helpful. Have a good night.

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Niu, Caoyuan, and Pekka Santtila. “Effects of Physical Exercise Interventions on Ejaculation Control.” Sexual Medicine Reviews 12, no. 1 (December 23, 2023): 106–13. https://doi.org/10.1093/sxmrev/qead042.

Ongün, Şakir, Selin Acar, Pelin Koca, Mehmet Uzut, Ahmet Adil Esen, Nergiz Durmus, and Omer Demir. “Can Botulinum-A Toxin Be Used to Delay Ejaculation: Results of an Ejaculation Model in Male Rats.” The Journal of Sexual Medicine 16, no. 9 (September 1, 2019): 1338–43. https://doi.org/10.1016/j.jsxm.2019.06.002.

Parnham, Arie, and Ege Can Serefoglu. “Classification and Definition of Premature Ejaculation.” Translational Andrology and Urology 5, no. 4 (August 2016): 416–23. https://doi.org/10.21037/tau.2016.05.16.

Ramachandran, Roshni, and Tony L Yaksh. “Therapeutic Use of Botulinum Toxin in Migraine: Mechanisms of Action.” British Journal of Pharmacology 171, no. 18 (September 2014): 4177–92. https://doi.org/10.1111/bph.12763.

“Research – Priapus ToxinTM.” Accessed December 17, 2023. https://priapustoxin.com/research/.

Runels, Charles. Anytime…for as Long As You Want: Strength, Genius, Libido, & Erection by Integrative Sex Transmutation. LifeStream Medical, 2004. http://www.runels.com/AnytimeOrder18934r7.htm.

Runels, Charles, and Alexandra Runnels. “The Clitoral Injection of IncobotulinumtoxinA for the Improvement of Arousal, Orgasm & Sexual Satisfaction- A Specific Method and the Effects on Women.” Journal of Women’s Health Care 13, no. 3 No. 715 (March 20, 2024). https://doi.org/10.35248/2167-0420.24.13.715.

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Turan, Yaşar, and Abdullah Gürel. “The Heart Rate Recovery Is Impaired in Participants with Premature Ejaculation.” Andrologia 52, no. 5 (June 1, 2020). https://doi.org/10.1111/and.13573.

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