Topics
*Lichen Sclerosus protocols
*P-Shot® with and without Praipus Toxin™ for erectile dysfunction and for premature ejaculation
Video Recording of Journal Club with Pearls & Marketing
Transcript
Charles Runels, MD:
Thank you guys for being on the call tonight. I will be taking notes with the rest of you. Several questions came up this week and I have some experience, but collectively we have the experience of almost 4,000 doctors. So I hope you will jump in and add what you've seen. I pulled papers regarding the questions and I have some ideas from taking notes from you guys and from the research, so we'll just jump right in.
The first question regards a study that, or actually a review that just came out in a Russian paper that I wanted to show you guys the... Let me just pull it up right now. They posed questions. Oh, by the way, after we do this, this won't take very long, then we'll jump into some questions that have come up about can we use our Botox procedure for premature ejaculation. So these are the papers that I've pulled in regards to that and then some about PRF science. Several of our people, quite a number of people have told me they've started using PRF. So I pulled a paper and how it relates to the muscle and how that might relate specifically to our O-Shot procedure. So let's start with this one about the O-Shot and lichen sclerosus from a Russian journal.
By the way, I put some of the papers. We have more than five and that's all the software will let me give you guys. I put five of, I think, the most interesting papers that we'll discuss tonight in the little handout section. If you click on the orange flower, it will pop up. It goes away after the webinar's over. So if you download them now, they'll be available when we're done. This article, I think, brings up questions that hopefully you guys will help us think about. I'm going to tell you what I'm hearing, what I think the research shows in regards to this.
They did analysis of the current studies regarding PRP for lichen sclerosus and couple of those papers are papers that we published and others. I think their questions are well-founded. They say, "We've listed the research, but even though it may be helpful for lichen sclerosus, here's the things we still need to figure out. When do you use topical steroids and when do you not? What about all the rest of the protocols that go with it? When do you decide to treat? When do you stop treatment? Basically, what's the algorithm for using PRP for lichen sclerosus and what's causing it to work and what is PRP?" That's really the questions. All of which have been asked here, but I'll tell you what I think looking at the research, what we know about it so far. Let me pull these up for you.
All right. There's quite a number of papers that have come out. I'll show you. If you just look at, here's some of my favorites for lichen sclerosus. Let's see. Here we go, right there. So, not shabby. I threw in here one about UVB because it relates to one of the ideas. I'm going to explain that some of us are doing. Lichen sclerosus, just like psoriasis just like eczema, responds to UVB. Oh, that's not it. We have this study where they took people that were not responding to clobetasol. One group just stayed on the clobetasol and the other group guy PRP mixed with micronized fat because there was two variables there, but whatever. It just showed this amazing result, clinically significant.
Now, one that did not show benefit and is the only one I can find that did not show benefit was this one. All the others have, and you saw the list, probably a dozen or more. This one were done by Andrew Goldstein. The placebo group, five of them had improvement, four no changes, so half of the placebo group improved. So there was no statistical benefits because as you guys know, if you're doing PRP for lichen sclerosus, I think it's probably about 70, 80% are responding to it. And so, if you have your placebo getting half or better, it makes it hard to show benefit. But the placebo was saline. What I want to point out, anytime you see not for IV drugs, saline is a true placebo. IV saline versus IV morphine, okay, that's a placebo. But for hydrodissection, that's a physical thing.
I have a collection of papers here that show that saline in that situation is not a placebo. So here's some of them in the dermatology literature showing the effect of saline, treating scars, helping with wounds because the hydrodissection itself causes a response. So again, not for IV saline versus IV drug, that's a placebo, but in this study, saline was used to irrigate this one. This randomized study, saline was used to irrigate. So it brings up the question, I think, more importantly, what part of our procedures is actually resulting from the hydrodissection?
Anyway, so I'm going to quickly run through what I'm hearing is working and what I'm recommending from what I'm seeing both of my patients from the literature and from the hundreds of doctors in our group that are treating lichen sclerosus with PRP. Most of them are doing the following. They're stopping this. They're stopping the clobetasol a few days to a week prior to the PRP treatment. Then they're irrigating that or hydrodissecting the area with PRP. They're usually not activating it. They're often doing an O-Shot along with it. And then in three weeks, if they're not better, I recommend if they're seeing no improvement, put them back on the clobetasol. They're a non-responder. Usually, within a week, they will tell you. I'm dramatic, but we better. If they're better, you bring them back three to six weeks later and repeat the procedure in the areas that are still active.
Always a biopsy before you do treatment so you've documented you're not treating squamous cell carcinoma and always a consent form because 10% of people with lichen sclerosus convert to squamous cell carcinoma. What we're doing is not immunizing against that. So in theory, if they're having less inflammation and it's going away, and some of our people are telling me they're becoming biopsy-negative, as in you can't find it anymore on biopsy, if you're seeing that sort of response, they could still get squamous cell carcinoma in theory. So you have a good consent form. If they don't respond after the first treatment, you give them the money back. You put them back on clobetasol. If they are responding, you repeat in whatever areas are still bothering them at six weeks.
I've been doing this. My wife has been doing this. Others in our group have been doing this for a synergistic effect. I just showed you the study, but some of us are adding in a UVB light. So I'll put them just very short time, five minutes. Unfortunately, most of us don't have a place to go be naked at the beach, and so this is the next best thing. It's made for those who are treating their... Remember, the psoralens with UV for psoriasis? Well, we're just having them use this along with the PRP for just three to five minutes daily and holding it over the area of involvement and you have a study to back that up. Then if they have a lot of sclerotic area, some are using either laser or microneedling to break up that sclerosus so they're getting a better result. Most people are needing repeat treatment for maintenance every nine months to a year and a half. That's pretty much our best answer so far to those questions I just showed you in that Russian study.
Okay. The next thing I was going to jump in and talk with you guys about... If anybody wants to add to that, please, I want you to do that. Just push the button, I'll unmute your mic, or you can just type your comments into the chat box or the questions and I'll... Yep, absolutely. Absolutely. So I'm going to unmute you, Red, so you can expand upon that. Hold on a second. Let's see. Heather has something too, so I'm not going to rush this. Two smart people have something to say. Hold on a second. All right. Go for it, Red. Talk to us about what you're doing with your protocol for lichen sclerosus.
Hey, Charles. How are you?
Charles Runels, MD:
Hey, thanks for jumping on tonight.
Red Alinsod, MD:
Oh, sure. I just finished a webinar and I saw you were talking about this stuff, so I thought I'd jump in. We were talking about lichen sclerosus in a prior webinar I did. Your treatment with PRP with HA that your vampire treatments, that's where I get my best results. Radiofrequency alone, laser ablation alone, and even PRP alone, I haven't found to be as good as when I mix the PRP with a hyaluronic acid. So my resistant patients, I go straight to this now, the PRP with HA. These patients who come in have been treated everywhere else with everything else, steroids and ablative CO2 lasers, I get really great responses with your vampire mix.
Charles Runels, MD:
Beautiful. Well, that's a great pearl. Are you adding in your ThermiVa or laser or something else along with it? When are you adding that in?
Red Alinsod, MD:
Yes. Yes. I'm adding it as a maintenance and it seems to make the treatment more enduring. So once I do these injections, it's a radiofrequency every six to 12 months. I'm getting symptom-free intervals of lichen sclerosus anywhere from, like you said, you mentioned nine months, but more likely 12 to 18 months. I'm getting long periods of remission and I'm not having to reinject on most of these if I maintain it with either RF or CO2 lasers. Obviously, I'm using RF because it's noninvasive and I'm not using the microneedling type of RF, although I think that would work just as good, if not better.
Charles Runels, MD:
What do you think about the idea of using that little handheld UV for maintenance after they go through the series of treatments?
Red Alinsod, MD:
That's brilliant. I haven't used that before, so I'm going to start using that and trying it out. I have the Amazon link here. I'm going to tell all my patients about it. It's brilliant. I haven't tried it yet.
Charles Runels, MD:
Well, thanks for jumping in. Heather had a couple of ideas too. I want to get onto this idea about our Botox and the idea that it may be helpful for premature ejaculation and how that might happen and how it might relate to gynecological indications. Let me unmute you, Heather. Hold on a second. Oh, just while it's on my mind guys, if you're a surgeon, you need to be doing the Gynflix thing. It's crazy amounts of material. What's the website, Red? You still there? Just type it in the chat box and I'll make sure everybody gets it. Let's see. Heather, let's see, where are you? So some of you guys know Heather, she has a great course on peptides and was way off into expertise with regenerative treatments and her pain treatments before we ever met. What's your reaction to what the whole lichen sclerosus? Give us some tips.
Good evening, Charles. Can you hear me?
Charles Runels, MD:
Hey, yes.
Heather Smith-Fernandez, MD:
Okay. My experience, so I'm able to process different formulations of PRP in my practice. One of the things I've learned over the last couple of years is autoimmune tissue does a lot better with no white cells, no red cells. You're almost better doing a more plasma-rich than a really strong PRP in case you get a reactionary... Post-procedure, they can be really sore if there's red cells or white cells in the mix. That's just been my reaction with a lot of autoimmune tissues when I've worked on skin things and even some of the lichen sclerosus. So I wonder if in that study they were paying attention to that. A more plasma-rich treatment may have a better result than, say, a PRP from the Arthrex machine. The old Angel machine had red cells in it, and that can be extremely irritating to tissue and may actually counteract what you're trying to do as opposed to a more pure spin with the pure spin technique, the insight and even the cell fill that has the PRF and the... It's not as concentrated of a PRP, but there's no red cells in it.
I think that in some cases maybe that makes a bigger difference because lichen sclerosus, as you know, is so hard to treat and PRP is one of the things that doesn't make it worse. Procedurally, even just doing a needle dissection without the anti-inflammatory substances that you're injecting with the PRP, I think that... I just know that back in the day, when I first started doing PRP in knees, the only PRP we had had red cells in it and these knees would just blow up. They were hot, painful, irritated, and just a few little broken red cells can make a big difference. I was looking at that thinking one study, I wonder what was going on with that PRP.
Charles Runels, MD:
Yeah. I know what they used. It was the Magellan kit, which at that time programmed otherwise, but at that time it did have red cells in it. Thanks for jumping in. By the way, I just put in the chat box the Gynflix website of Dr. Alinsod's. I mean, it's just shocking how much content there is there about vaginoplasty and printing all these amazing surgeries. I put your peptology.com.
Heather Smith-Fernandez, MD:
Oh, thank you.
Charles Runels, MD:
If you guys are wanting to do peptides on an expert level, very, very helpful. Right. Thank you. Let's jump in to now about the... Oh, to answer your question, someone typed in about what about the HA? If you live outside the US region has a kit that comes with HA, but there's a new kit coming out that Dr. Alinsod is testing. Hopefully, it'll be out soon. That also comes with ha that will be available in the states, which brings me... Thank you, Greg. Let's see.
Okay. All right. Let's jump into about the premature ejaculation. I really want you guys to help me out with this because I don't have experience with this, but I'm going to jump through the research and see and tell you what I think based on what our providers are saying and from my plowing through the research. Okay. So let's look at first... We'll come back to the PRF. Okay. This, I think, is important because we're talking about... Well, I think there's an analogy with migraines. So you guys have been on where we talked about treating migraines with Botox, but originally the idea was that by treating trigger points where the muscle is tense, that's going to help migraine pain. But then that model of migraines went away, but we knew Botox was helping. So it's actually indicated when the FDA indications for Botox is migraines.
So the question became, well, how is it working? I think this picture, I did put this one, I think, in your handouts, this I think is the best explanation for what's going on and it's just fascinating. It relates, I think, to the Botox in the penis and in Duane indications. Now, the current idea is that the Botox is actually migrating along the axon and affecting both the trigeminal ganglion and the nucleus, the caudate nucleus, so that it's basically acting like a gate similar to gate theory and it's blocking the signals from the meninges because they share that nucleus. So you're actually using the muscles almost like a port to be able to inject the ganglion, and that's the current theory about why Botox helps migraines.
Now, this idea was brought up in this study, which was one of the studies we talked about regarding Botox for erectile dysfunction and with the idea that the same thing might be happening... Of course, the Botox can relax smooth muscle, increasing arterial blood flow into the penis, but there's also some speculation that the same sort of thing is happening and were affecting the ratio of parasympathetic to sympathetic tone within the penis. Even in the wound care studies, there's studies demonstrating cell proliferation, adipogenesis, angiogenesis. So it's not just about blocking acetylcholine receptors. That's the part that poured the smooth muscle within the penis. There's much more going on changing that ratio. Now, how that relates to women, I'm really unclear. If there's anybody clear about that, jump on the call. When I go in the research, it seems confusing to me. There's still speculation about how it's working in men, but we now have three double-blind placebo perspective studies showing that it works.
Before we go further, I want you to show you this. These are the off-label uses of Botox because when someone says to me, "Well, we're not going to use it for ED because it's off-label," it's usually someone who's not in doing cosmetic Botox because people who do cosmetic Botox know there are a lot of off-label uses. These are the on-label uses for Botox right there in the cosmetic world. These are some of the off-label uses we're doing with it, obviously quite a bit, commonly an accepted practice. I wanted to show you this one, not that one, this one, even for bruxism... That's not it. Anyway, I've got one in here somewhere. Bruxism well known and yet it's off-label. There it is, nocturnal bruxism. I mean, if you ever try this, you'll never stop offering it to your patients because I just never have a patient say it doesn't help them. Multiple studies show that it works, but it's still off-label.
Why is it off-label? I don't know. I don't know. I mean, to me, I think there is some level of... My wife actually said this. I think it's kind of smart. Maybe there's some level of volition upon the part of the neuromodulator manufacturers of not wanting everything on-label. Keeping some things off-label allows some element of profit to be maintained. We all do things for free, but something that's off-label allows you to charge cash for it instead of paying 10% to a billing company and wait three months and praying that you actually get half the money you requested from your insurance carrier. So in a way, they're doing us a favor, I guess, on the business side by not making it on-label, but I just wanted to point out that there's a lot of work being done routinely every day using off-label Botox. So I find that to be a weak reason for not doing it if the science supports it.
This is the one I was referring to. Let's see about migraines. Okay. So if you jump into the premature ejaculation sphere, my bottom line is yes, this is the first I can find where it was talked about medical hypothesis. The studies followed this. They were talking about it. I mean, we all know what it looks like, but I'm just pull it up here for you. Let's see here. Here, they're rat studies and I'm about to show you some of them, but they're rat studies, let's see where you can see it, here, that postulate that injecting bulbospongiosus muscle actually injected this muscle in rats after they watched them have sex for a while and maintained and found a baseline. I'll show you the study in a moment. Then they injected this muscle and let them have sex again and found that they lasted longer and they were just as virile, and as far as frequency, they just went longer. And so, the idea was to inject this muscle. That was the speculation, which is part of what forces the ejaculate.
Of course, there's a female counterpart. Again, I'm not sure how that relates, but if you look at the numbers, they're a little bit disappointing. So let me just show them to you. Even though the results are positive, I think they're disappointing. Hold on a second. I'm going to show you this. Okay. Some of the best of these are in the handout page, but... Not that one. So you can see, this is the one I talked about where they let the rats have sex and they had sex longer, but they're not really getting to the Casanova stage. Even when you look at... Okay. Now we're in this one. If you start looking at the time they actually have sex, their premature ejaculation goes from less than a minute to the two and three-minute stage. That's what they consider to be successful. They're injecting the muscle instead of the corpus cavernosum.
Here it is, another one. So all these studies, they're showing what I consider to be an unacceptable... Even though it's in the literature, I think it's an unacceptable definition of premature ejaculation. So statistically, it's helping, but you're still in this... Okay. You doubled your time. You're having sex, you went from 45 seconds to two and a half minutes was what they showed. Even though that increased satisfaction, in my opinion, premature ejaculation is ejaculation before either of the lovers is ready to stop and injecting the muscle is not accomplishing that, but it does have effect.
So, here's the part that I need you guys help with. That's all I have as far as the studies go is that it works, but it's not turning them into porn stars. It's just making them somewhat improved and they're injecting the muscle. What I'm hearing from our group is injecting the corpus cavernosum is also helping, that I can't find discussed in the literature. And then when I first heard it, I thought, "Well, that doesn't really make sense." I slept on it and I thought, "And it makes absolute sense." Since erection is parasympathetic and ejaculation is sympathetic, if the reason Botox is helping erectile dysfunction, if the reason it's helping is partially by changing the ratio and increasing parasympathetic and decreasing sympathetic, that should both improve erectile function and make ejaculation less accessible in theory. So there needs to be a study. I can't find that study, but that would go along with what we're seeing for the ED.
So now we're going to be quiet, see if anybody has anything to add to that. But I will tell you guys that anecdotally, I'm hearing from quite a number of our people that premature ejaculation is improving just by doing our usual Botox injection, which is just doing basically the P-Shot procedure with Botox or alone or adding it to your PRP and having the P-Shot 100. Everybody is putting 100 units. I don't even see a reason for offering 50 since it lasted six months with 100, three months with 50. Some are adding more. I don't recommend that because I figure at 100 units every six months, I'm injecting something similar to what of anybody would get in their face. Usually, in the neighborhood of 200 to 300 units every three months would be the same as 100 units every six months.
We've gone over the LD-50. The LD-50 is so outrageously high. IV Botox, the LD-50 is the number of pounds in bottles. So if a man weighs 140 pounds, the LD-50 IV push is 140 bottles of Botox, which would be 140 times 100 or 14,000 units of Botox. At $10 a unit, that would be $140,000 worth of Botox to reach the LD-50. So I'm having trouble buying into the idea for multiple reasons that we don't do this because it's off-label. It's a safe dose that we have two decades of research showing people don't get hurt with... You can't find where people get hurt. Even those who get some sort of botulism type syndrome, it's people that had 200, 300 units and they still get over it and often get treated again. So you can't find people who get in botulism from 100 units of Botox. We have multiple ways we're using it off-label cosmetically. If that's okay, why not be able to use it for something as life-inhibiting as ED or premature ejaculation?
So now I'm going to be quite see what questions you have and who wants to talk. I'll unmute your mic if you want to jump in. Let's see. Huh? Yeah. Rat voyeurs. George, okay, if you don't mind, I'm going to let you just jump in here here and tell me what I've said wrong because I'm sure I must have said something that was out there and maybe not right. I'm a big fan of... George Abraham has been... He's well respected throughout the country in the urology world. If you don't mind, you don't have to, but I've unmuted you. I just want you to-
I'm here. Okay.
Charles Runels, MD:
... support, whatever makes sense. Tell me what we need to do. I want you to do the freaking research. We've got some budget and I think we need to do some research. We've funded some O-Shot studies. We need to do some P-Shot studies and maybe Botox is one of the things we do. I don't know. You're unmuted. If you want to talk, tell me what you think.
George Ibrahim, MD:
All right. Thank you. Because I was in the background, looking to try to figure out how to undo the mute thing. Are we talking about premature ejaculation or are we talking about right now?
Charles Runels, MD:
All of it. So for those of you guys who don't know, George has been in our group now for... I mean, he was one of the first in. He teaches classes. He's successful. He was a successful faculty at Duke urology and went into private practice and has been a teacher and lots of success in both business and medicine in many arenas. So when he talks, I listen to what he has to say. Yeah, don't mince words. Tell me the good and the bad about what you're doing and what you think the next studies ought to be.
George Ibrahim, MD:
For sure. You're way too kind and thank you for exaggerating my... Thank you. The ED part, I totally understand. I mean, the way the physiology works with erections and the inflow and outflow and if you've done your anatomy and went to that part of the class of med school, because I didn't go to hand or any other thing except urology stuff, but if you went to the part where it describes how erections really happen, you're relaxing the arterials that bring in the inflow. Once the inflow gets up to a certain degree, it compresses the outflow, and therefore you're going to have a better erection. So that part I get because the toxin does help dilating that inflow, I mean dilating the vessels that come in by keeping them from being in their usual state, which is more constricted.
So the ED aspect, completely understand. I don't understand how it helps the premature ejaculation part. Yeah, that's why I was tuning in, waiting to listen to. And then I'm going to say this note before, because you mentioned this earlier about why do we even talk about 50 units? Yeah, no way. My experience with this has been I'll start with my 100 and I'll have guys that don't have any response. Bring them back in, I'll add another 50 and boom. So I have not seen a graduated response with retraction and things like that. I've seen more of a light switch response that it had to get up to a certain dose and then boom, there it was.
Charles Runels, MD:
Crazy. So when are you bringing them back, George?
George Ibrahim, MD:
Never before two weeks.
Charles Runels, MD:
Okay.
George Ibrahim, MD:
Never. Usually, it's a month.
Charles Runels, MD:
All right. That makes sense. You inject 100 along with your P-Shot or alone, I guess?
George Ibrahim, MD:
Yeah. Yeah. Exactly.
Charles Runels, MD:
And then you bring them back at a month, give or take. If they're not seeing anything, you add in another 50. Is that right?
George Ibrahim, MD:
Half my clients are from well over several hours from out of town. If they are, I'll tell them upfront, "Look, I mean, it's up to you. You can roll your dice. I can do the usual protocol or I can do the 150 right here and now." If they're driving several hours, the math makes it in their favor just to do the extra.
Charles Runels, MD:
Sure. Yeah. I've even had a few people tell me they're using 200, but why use 200 if 100 works? So I like your graduated approach to see if they can get to go to 100 to do the thing. What do you think about this idea that maybe it's affecting the ganglion? It seems like a stretch, doesn't it? That's the only way I can make... Unlike if it's working, I've got to make up something, but-
George Ibrahim, MD:
I was watching it. I went, "Okay. That makes sense."
Charles Runels, MD:
Yeah, if is what it's doing. I don't know what we do next to figure it out, but meditate on it because I think we're long overdue. We've got some budget. I even have two nonprofits if the CMA can afford it and we broach the idea, but I think I probably dropped the ball, but meditate on if you would want to do this or the next thing. Anything else you would add? I think with that, all I've got left is a quick... Actually, no, stay on because I want to see what you think about this next thing too. All right. So, this is up your alley too. So I started looking at... As you know, I'm an internist, so I feel definitely at a disadvantage when it comes to talking about anatomy and so I tried to make up for that. I just went on Amazon and I bought every freaking book that I could find that had anything to do with pelvic floor anatomy and started diving in into the research.
The person that I've come to have the most attention towards was this guy, this DeLancey. O.L. DeLancey has published so much stuff and I'm trying to think, "Okay. What is it we're doing?" I always imagined this old netter picture that shows a space between the urethra and the vagina distal to the bladder, but actually in his dissection of cadavers, they're touch. So it makes me wonder when we're doing our O-Shot, are we actually injecting some of those layers of the urethra mucosas? They're longitudinal. They're circumferential. But here's what I think could be happening. Because what we're seeing is the best result seems to be injecting fairly shallowly distal to the bladder, I'm wondering if we might not be correcting this, age effects on urethral striated muscle. He actually just did sections on 25 cadavers and documented, which what you'd expect is when people age, they have left muscle there.
Now plot back at this, and this is just one of many studies showing that when you inject with whether you're using PRF or PRP, that you make the muscles. Those satellite cells that function like stem cells cause muscle proliferation and perhaps that might be what we're doing with our O-Shot. So again, I'm trying to maybe combine too many things together, but it maybe gives us support for why going shallow and distal is working because maybe we're doing that. And then it brings up, well, if that's what's happening, do we do ultrasound? I've been talking to people that sell ultrasound devices trying to figure out if we're actually making this muscle more hypertrophic, how would you document it with an ultrasound without doing an autopsy? Okay. I'm going to shut up. What do you think about that, George or anybody else on the call? What could you do? What kind of study could you do to test that idea?
George Ibrahim, MD:
Okay. This is where I totally respect where you're going with that and I go, "Hey, if I can do it, then I get results. Do I really care where that needle is if I'm sticking it right where I think I'm sticking it, meaning, if I'm in muscle, something superficial, distal?" Because the O-Shot works. Yes, I have a laser now that I do some radiofrequency stuff, but at the end of the day, I only have it because they basically gave it to me because I wasn't going to buy the machines because I was getting plenty of results just doing the O-Shot.
As a urologist, we're dumbfounded that a woman is continent. The urethra is so dang on. There's no real sphincter like there isn't with a man with the prostate and everything. It's so short, it blows us away. And then when she loses estrogen and things get atropic and they're not wet anymore, so there's no more croptation where things stick to each other because of wetness, which is a huge part of female cognize mechanism, it blows us away that any woman is anywhere near continent. So anything that bulks up that area and puts just the most minute amount of resistance helps. You put PRP up there. You induce new growth. You bring in hormones. You get the vaginal linings become thicker. You're going to see help with SUI. I'm always talking about stress incontinence, never urgent incontinence.
Charles Runels, MD:
Mm-hmm. I agree. I mean, if you think about what happens when you inject the face, this is so short. If you put a needle anywhere in here, it's going to hydrodissect all over the place. The idea is that maybe if it were further proximal to the bladder, it may not cover as much of what's distal to the bladder, but who knows? I guess part of the reason I'm asking, well, I know part of the reason I'm asking is we know we're getting crazy good results. I'm trying to figure out how do we demonstrate that? Because we're still just a minuscule number of people when you consider everyone who's taken care of urethras.
I heard a good quote today or yesterday that I've never heard before. The great physicist, Pascal, when he got his Nobel Prize, he said, "Well," he said, "science..." Because nobody really ever accepts a new idea. Just it takes the next generation to accept it as the old people die off. He said, "Science progresses one funeral at a time." I never heard that before, but I'm trying to make that not the truth with the O-Shot. So, what do you think? Would there be a way to demonstrate some changes?
George Ibrahim, MD:
Okay. That part, I can't tell you how to demonstrate it because we're going forward than I would. But as far as for those that are listening that may or may not be new to doing O-Shots, when I teach others how to do these things, the biggest, one of the first things when it comes to O-Shots is no, you don't go that far back. If you're more than two digits in with your finger, you're way too far. Air easily... I mean, you're going to get it. I mean, if you go too far... Because you can see things when your bladder neck opens up. You can't see my pointer, but I'm looking at the space between BW, the vagina and BN, where that space opens up, now, you want to get it where things are tight, which is-
Charles Runels, MD:
Yeah. Okay.
George Ibrahim, MD:
Yeah, there you go. That's where the continence mechanism is in a female.
Charles Runels, MD:
All right. I'm so glad you jumped in. Thank you, Red and Heather. We need to talk soon, George. We got to get some more studies going.
George Ibrahim, MD:
My pleasure. Thank you.
Charles Runels, MD:
Appreciate you being on the call. Think about this PE thing and see if maybe light bulb will go off and you call me and tell me what we need to do. Thank you, guys. Y'all have a good night. Bye-bye.
George Ibrahim, MD:
Bye-bye.
Questions regarding lichen sclerosus and the O-Shot
https://www.clinmedjournal.com/jour/article/view/468
Bocox® for premature ejaculation
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Gul, Murat, Kadir Bocu, and Ege Can Serefoglu. “Current and Emerging Treatment Options for Premature Ejaculation.” Nature Reviews Urology 19, no. 11 (November 2022): 659–80. https://doi.org/10.1038/s41585-022-00639-5.
Li, Zhong-Tai, Yan-Feng Li, Yong Zhang, Yong Luo, Tong Zhu, Ke Li, Qing-Xing Feng, and Jun Jiang. “Injection of botulinum-A toxin into bulbospongiosus muscle for primary premature ejaculation: A preliminary clinical study.” Zhonghua Nan Ke Xue = National Journal of Andrology 24, no. 8 (August 2018): 713–18.
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.
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PRF science.
Narayanaswamy, Ragunanthan, Bishnu Prasad Patro, Naveen Jeyaraman, Prakash Gangadaran, Ramya Lakshmi Rajendran, Arulkumar Nallakumarasamy, Madhan Jeyaraman, Prasanna Ramani, and Byeong-Cheol Ahn. “Evolution and Clinical Advances of Platelet-Rich Fibrin in Musculoskeletal Regeneration.” Bioengineering 10, no. 1 (January 3, 2023): 58. https://doi.org/10.3390/bioengineering10010058.