Chronic Pain Chronicles with Dr Karmy
Join Dr. Grigory Karmy M.D., a distinguished chronic pain management physician with over 20 years of experience, on a captivating journey through the world of pain relief in his podcast series. Delving into the latest regenerative medical treatments like PRP, stem cell injections, and prolozone therapy, alongside educational discussions on pain transmission and the latest medical innovations, Dr. Karmy shares invaluable insights and real-life stories, empowering listeners to find relief and regain control over their chronic pain.
Chronic Pain Chronicles with Dr Karmy
Episode 26: Platelet Rich Plasma-beyond arthritis and musculosceletal pain with Dr. Leonardo
Most people are familiar with athletes using platelet-rich plasma for injuries. Some of you may also know that it is used for osteoarthritis.
Did you know that the uses extend far beyond those two indications?
Join us for an in-depth interview with Dr. Leonardo, where we discuss newer uses of PRP ranging from erectile dysfunction to hair loss.
Watch the Video Interview here: https://www.youtube.com/watch?v=J6F-l4ro4Ac
If you have any questions for Dr. Karmy, feel free to email us at karmychronicpain@gmail.com
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he knew that he was a challenge, but he had some hope. And, at one point, I don't know how many p shots he may have had at that time. It might have been about like five or six, every two to three months, he reported that he actually had an erection, you know, and that was a big deal for him and, and me. And then, later on he said that he actually had an orgasm for the first time in, in maybe like a decade. And that was absolutely wonderful. Hello.. This is Dr. Karmy for Chronic Pain Chronicles, and today with us we have Dr. Leonardo. Hello. Hello. Good morning. Morning, Dr. Leonardo is somebody I have known for a very long time. He's a colleague at the clinic and he was actually the physician that brought platelet-rich plasma or PRP into the clinic, uh, about nine, 10 years ago. But he didn't stop there. He went on to introduce a number of other uses of PRP into the clinic. Uh, what's unique about PRP, compared to say drugs is that drug is typically a single chemical. So most drugs have maybe a single use at the most 2 uses. PRP on the other hand is, something, uh, that is made out of our own blood. Uh, you concentrate platelets and platelets don't just have one chemical. They have a soup of different chemicals. And I think in part because of that, PRP has a very wide range of uses. Perhaps in some cases it's one chemical in that soup that, uh, works. And in other cases, perhaps it's a different chemical in that soup that works. But be it as it may PRP seems to have a very wide range of uses. Dr. Leonardo, how did you become interested in PRP? And how did you I guess, uh, become interested in all the different uses for PRP? So, um, it started as early as maybe 2007 that I had exposure to PRP. At the time I was living in the United States working as an anesthesiologist, and our group worked with a lot of orthopedic surgeons and at the time , they're doing PRPI wasn't really sure what it was all about. And, I asked the orthopedic doctors and, , they gave me an explanation in terms of growth factors, which is pretty much the business end of healing and repair for platelets. And what they're trying to do is concentrate platelets and inject it back into the body to promote healing and repair. So when I , relocated to Canada, began working at Karmy Chronic Pain Clinic. This was 2013. I had asked you about it and it was still kind of new, really unknown, and we ended up getting, um, a PRP centrifuge around 2015. So it's been about 10 years. We weren't the first clinic, but we were one of the first clinics to take on PRP, and we used it primarily for treatment of musculoskeletal injuries. And it worked great for that. And, I came to discover that PRP had other indications that were pretty wonderful and, and unique at the time. Some of them include aesthetics, facial aesthetics, rejuvenating skin, also hair regrowth, and also, uh, to improve sexual function particularly, erectile dysfunction, and then also the equivalent for, the female genitalia in terms of rejuvenation, improving sensitivity, lubrication, and pleasure. So, it just kind of snowballed from there. I discovered Dr. Charles Reynolds. He's the one that invented the vampire procedures meaning vampire facelift, the vampire facial, vampire hair regrowth, the P Shot or the Prius shot, the orgasm shot or the OShot. And, I trained with him and I became Ontario's first physician trained by Dr. Ronalds in these procedures. And yeah, that's how it all started. Again, there's a wide range of applications. Let's maybe start with the one that I think is the most, attention grabbing and that's , things to do with sexual health. P shot for men or shot for women. There's no wound, there's no damage. It's PRP is trying to heal. How is PRP supposed to work for , sexual dysfunction, whether it's for men or women, or perhaps mechanism is different there? So, um, in terms of I guess decline in sexual performance, a lot of it has to do with decreased circulation to the genitalia. All right. Um, as we age atherosclerosis could be a problem where we have decreased blood flow, whether it's the corpus cavernosum of the penis and the glands, or even the analogous in terms of the female genitalia and the clitoris. So, PRP , again we're talking about growth factors. There are also other chemical signals from the platelets that signal the body to promote angiogenesis, basically creating new blood vessels. There are also cytokines that recruit stem cells to the injection site. So this in combination with the growth factors, we can really heal and repair tissue. Again, it's not an injury, but it's just kind of decline over the years. As, a fact of, of life in, in terms of aging for a number of patients. So we're improving circulation, we're recruiting stem cells, and we're regenerating tissue. I guess, what I find with PRP applications is often there is an attempt to make the effect bigger or stronger, whether it's by stimulating platelets to release small growth factors or release them faster, or whether it's trying to apply other devices that work complementary to PRP injection. Is that the case here as well? A lot of these therapies may or may not be enough in terms of monotherapy and there's so many factors that are involved. Okay? For one thing, patient selection. Most procedures work well with mild to moderate presentation. However, if you have a patient with really severe ed, chances are PRP as monotherapy is not going to help. Even in combination with other therapies, it may not help. I use the shim score, the sexual health index for men. Um, score. It's a questionnaire. Five questions. Patients reply with an answer from one to five, five being the highest level of function. One, pretty much no function. So the highest you can get is 25 outta 25. The lowest you can get is five out of 25. So for the patient scoring in single digits, like anywhere from five to nine, that is really severe and my conversation will then with them is gonna be a lot different than someone with mild to moderate presentation where the score is maybe 16 outta 25, 20 outta 25. So that's one thing. Patient selection. Another thing is basically the centrifuge. A lot of times in literature and even in in conferences people talk about PRP, like it's all one thing, and there's a variety of PRP systems out there. For one thing, there's single spin and double spin systems, and most clinics have single spin systems compared to double spin because they're less expensive and they're really easy. It's, and it's actually cheap. However, these devices aren't delivering as many platelets compared to double spin systems. And, um, there have been independent reports that substantiate this claim and often the double spin systems are delivering maybe three times as much as single spin systems where the single spin system would require a series of three. Typically for our treatments, assuming there's mild to moderate presentation, most of our patients do well with just one treatment, right? Then there's also protocol, alright? Anyone can just inject the penis, but to do it successfully in finding the target site, that's the skill. Alright, in terms of my practice, there's certain safeguards that I use to maximize the efficacy and the results. For one thing, when I inject the corpus cavernosum. I aspirate back on the syringe, and if I get a flash of blood with high confidence, I know that I'm intracavernosal. Another technique I could use is ultrasound guidance where I can direct the needle into the corpus cavernosum, and I see that the PRP is being delivered to the target organ. However, if you're doing this blindly, you could just be injecting away and completely missing the corpus cavernosum, and you have poor results. So lots of, variety and variations and reasons why, uh, there's success and, and maybe even failure. So that's monotherapy. There are all sorts of other therapies that are available that you can use in conjunction with PRP. One of them is ultrasound, shockwave therapy, and it's something that, , that I used , but, I've stopped recently within the last couple years or so. And, I thought they worked well together. I would never do ultrasound shock wave therapy as monotherapy just because treatment failure, highly dependent on how many doses. So if a patient comes in, you assess them and you think six treatments are going to work and it doesn't, maybe they actually needed nine. Maybe they actually needed 12 or 20. Who knows? It's kind of a tough sell if it didn't work for those six treatments to have the patient come back with hopes of success. Also, you, if you were a patient, do you wanna make an office visit that frequently? Six treatments in a matter of two to three weeks, and then having to repeat that sequence about three or four months later, or sometimes it's a protocol of 20. I as a practitioner, do not wanna have to keep scheduling a patient that much where our P shot it's pretty much a one and done approach. With more severe cases, they may have to repeat their treatment at about two to three months. But for most of my patients, with mild to moderate presentation, um, we've had a high success rate. And the procedure is out of pocket. It's not cheap. And if it's not working, I, I'm definitely going to hear back from the patient. And when we first started, we would always email and contact our patients at about the three month mark, uh, just to see how they were doing, if they wanted to come back for a follow up. And often, um, we had no reply. And often in this case, no news is actually good news again, because if they paid a fortune or not really a fortune, but if they paid a pretty penny for this procedure and it didn't work. I will hear from them. So for a period of about seven years or so, there were probably maybe five to seven patients where it just didn't really work out for them. And this is the mild to moderate group, right? With the severe patients I have a different conversation with them. I'm telling them, all right. You scored five outta 25. This could actually be zero out of 25. All right? You can put in a lot of money into this and still have absolutely no benefit. However, if you spend this money and it's a financial hardship for you, I would recommend that you don't do it. If on the other hand, it's not a financial hardship for you, it might be worth giving it a try. And sometimes we are actually pleasantly surprised. So I guess one group of patients that, uh, will often have issues are patients who had erectile dysfunction after the prostatectomy. What are your thoughts on p shot for patients post prostatectomy? It's very challenging. They would be considered , severe in presentation because, you know, the surgical site is the prostate. There might be nerve injury as well. And I'm not injecting PRP to the site of injury in that case, right. It's still intracavernosal where we're trying to improve blood flow. And, within the vicinity it may help stimulate the nerve endings. But again, it's far from the actual surgical site. Uh, however, I did have one patient, he actually traveled up from Buffalo several times. And, you know, he knew that he was a challenge, but he had some hope. And, at one point, I don't know how many p shots he may have had at that time. It might have been about like five or six, every two to three months, he reported that he actually had an erection, you know, and that was a big deal for him and, and me. And then, later on he said that he actually had an orgasm for the first time in, in maybe like a decade. And that was absolutely wonderful. And this was all pre pandemic. So, during the pandemic, I didn't see him anymore because the borders were pretty closed and I hadn't followed up with him, in, in quite a while. This is when, I was practicing in Mississauga. So this was again over five years ago or so. So it seems like, location is important, making sure you deliver PRP to the right area. And, also concentration of platelets is important. It's a little bit like an orthopedic medicine where they're starting to move in the direction of more is more. The more platelets you put in, the more likely you're going to have a positive outcome. Uh, they even have specific numbers nowadays that they recommend for, say, knee injections, which is five to 10 billion, uh, and shoulder injections, which is probably closer to 5 billion. What about O shot? Anatomy is a little different. What are your thoughts on O shot in terms of I am assuming again, quality of PRP matters. What else? So, with the OShot again, it's, it's multifactorial and we're treating a few different things, right? It could be sensitivity, it could be a lubrication problem, it could be dyspareunia. It could also be like in sclerosis. There are a variety of indications for the OShot and, in terms of lubrication , the injection site where we inject the PRP help stimulate and improve circulation to the glands that are responsible for lubrication. And, that is near the the urinary sphincter. So sometimes women who have stress incontinence. We'll also benefit from that just because of the location of the injection relative to the sphincter. So that was another indication that, um, I didn't mention previously, but we've had success with that. In terms of pleasure it's similar. The c clitoris is analogous to the glands and for a lot of erectile tissue, they function a lot better with improved circulation. Right. So again, if we're improving the circulation to the clitoris, we have much better stimulation. Injecting into the clitoris? Correct. There are two injections for the OShot, the clitoris, and also the anterior vaginal wall. So that sounds for both of them quite painful. I can't imagine having injections into my penis and clitoris is a very sensitive area. So how is that how are patients tolerating that? So, I'm an official trainer for Dr. Reynolds and the way that he teaches these are, use of topical anesthetics, right? Like a BLT cream, Zaca, lidocaine, tetracaine. Or sometimes you can use Lidocaine 30% on its own. And in terms of the P shot, oh, one other thing I, I didn't mention is my background is in anesthesiology. So, I, bring that to the table in terms of making my patients extremely comfortable. Right? So for the P shot it's basically taught with just the topical numbing and, i'd say that is adequate. I would say most patients, like 90% of patients, will experience maybe a pain score of anywhere from three to four outta 10. However, that's not good enough for me. So I perform , it's a, a superficial dorsal PL nerve block. It's not like your traditional a dorsal penal nerve block where you're down to pubic synthesis. I'm a little bit more superficial and it's more like a field block or so where I capture the fibers leading to the penis and it's, a dilute concentration, just lidocaine 1%. And, it provides a whole lot of comfort to the patients, to the point where they're experiencing maybe zero outta 10, maybe one or two outta 10 at most discomfort. But I would say 90% of the patients they return because it was not traumatic for them. And, a little, a little story. All right. So, , when I returned to Dr. Reynold's office in 2022 to become an official trainer for him, I also volunteered to be a model for the P shot. So the gentleman before me, they just used straight up topical numbing, and by the time they did his injection, he was screaming in agony. And it was kind of a tough sell for, you know, the attendees to like, okay, we're gonna do this now. So I demonstrated my supervisional dorsal penal nerve block on myself. Mm-hmm. And by the time they injected me, like I was a little curious. I was like, I, I, I have never done that to myself. Okay. But I don't want to be that guy. Okay. And I was like, you know, I was, I was like I hope this works. So when they injected me, I did not feel a thing. And there was a certain level of comfort. For the attendees to learn that technique, right. In terms of the OShot it's, it's similar. There's topical numbing and there's also a clitoral nerve block that's performed. And, I, I can teach that during, training, but I, I found that sometimes just the BLT cream alone is adequate for maximal comfort for the OShot, you know? But if, a patient has a history of just not responding well to local anesthesia or whatever, then i'll use that. And also ice that meaning the clitorial nerve block. So, so it sounds like pain is, people still feel something, but it's usually not excruciating pain. It's pretty mild from what you're describing. Yeah. Um, sometimes I'll have patients, come to me having seen another provider, like for the OShot, and they said it was extremely painful, or they recommended taking naproxen. Like in the morning I was like, whoa, whoa, whoa, whoa. That is all wrong. You do not take NSAIDs with your PRP and if you perform the OShot properly, there should be no pain at all. And then I perform the procedure and it was night and day. Now I throw around OShot p shot pretty liberally here, but I have to remind everyone that these are licensed trademark names and procedures. So only those who've actually trained with Dr. Reynolds or one of his trainers that are paying licensing fees can use these terms, right? Because if someone says, oh, I, I got a P shot down the street, and they're not a provider, they're not doing the same protocol as us, right? And, they, we cannot guarantee their results or their experience because it could be quite different than what we are doing. And I find that it is kind of night and day. So just my, uh, added comment there. Uh, let's maybe go to talk a little bit about the results. No treatment, at least in pain management, is ever effective for a hundred percent of the people. PRP, at least in my experience for musculoskeletal pain, I would say about 50 to 60% of patients have a good response and the rest don't if, if they do have a good response, usually it's not a permanent response usually, you know, it helps for maybe, uh, a year or two, but at some point it will wear off. So what is your clinical experience with P shot and O shot? Uh, well first I wanna go back to the musculoskeletal application. There are certain , pathologies that are a home run. In my book, right? Like, um, I was part of a tennis league and I treated a lot of tennis elbow and golfer's elbow, and that was, that was pretty much a home run. Same similar story with these patients where they've had physio for weeks, months of the time, and still it just, it didn't really make them feel like they were healed. And then they would get one PRP treatment from me and they stop their physio. They're, you know, they're on the court pretty much pain free and years have gone by. So that's pretty much a home run. You know, certain other pathologies, like shoulders and knees are a lot more complicated. The knees are weightbearing, the shoulder, there's so many ligaments, muscles, et cetera going on there that, um, you know, it may not be as successful as something as simple as tennis elbow or golfer's elbow. In terms of the P shot, as I mentioned to you before. That, over a course of about five years, there were maybe about five to seven patients where they weren't wowed with the results. Okay? And during that time span, I may have had about, I don't know, two, 300 patients or so. So that is a high success rate and my success rate is gonna differ from other providers just because one the system that I'm using it's double spin. And two, the protocol, right? Um, there, there's certain variations that I use to actually enhance what Dr. Reynolds teaches. And, when you train with me, I will teach how he does his procedure, and then I will teach how I do my procedure, right? And the difference here is I use a tourniquet, or it's basically a cock ring. Okay. After Intracavernosal injection of the PRP, I'm applying a lasso, which is basically a cock ring to keep the platelets within the corpus cavernosum 'cause remember, it's liquid at the time and we're injecting it into a vascular structure. So the fear is that it's just gonna go right into systemic circulation. So when I use a cock ring, I make sure that the PRP kind of, gels within the corpus cavernosum it'll coagulate and it's guaranteeing that it's coagulating within the corpus cavernosum. Dr. Reynolds in the past, used to use a hand vacuum, and cylinder system. It would give negative pressure to draw blood into the penis in hopes to keep the PRP within the corpus cavernosum. However you spent all this time to concentrate your platelets and then you're bringing and drawing blood into the injection site, diluting it. Um, the cock ring was, I felt a better solution where you're keeping it within the corpus cavernosum and you are not diluting the platelets. Right. Another thing is, my injection pattern , for Dr. Reynolds, he has two injection sites on both sides of the penis. Mm-hmm. And then one in the glands corona. Now, um, I have a lot of urology colleagues, uh, Dr. Reynolds, his background is in emergency medicine and he's an absolute genius in terms of developing this. However, when you look at the anatomy and my urology colleagues, you know, substantiate this, that when you inject it into, the glands corona, it's kind of wasted because it doesn't really contribute much in terms of. Uh, sensation and function because the nerve endings, they travel down the dorsum, the upper part of the shaft, and then they work their way down to the ventral side to the frenulum. And at the frenulum, that little triangle tip on the underside of the penis, it's highly vascular and densely populated with nerve ending. So I inject per frenulum on each side of the, of the frenulum. And that's something that Dr. Reynolds does not do. So that way we get better sensation. So is that meant to actually do something for the nerve endings and so we're not just trying to improve circulation, we're trying to do something for the nerve endings with this approach? Correct. All right. Because again, like , why do robbers rob a bank?'cause that's where the money is, right? So in terms of nerve endings, that's where the money is, right at the frenulum. And as, as guys are fully aware. It feels good there to be manipulated and, and touched there because of those nerve endings. So if we're injecting the PRP where the nerve endings are, you're gonna have a lot better circulation along with sensitivity. So what about, or shot, how are the results with or OShot compared to the results with P Shot? I don't think it's quite as successful. Okay. Just because again, it, it's multifactorial. There could be a lot of psychological components related to why there's success or failure with the OShot. Particularly if you're going in for a certain indication, right? For like something like Dyspareunia something like lubrication, it's a better result, right? Because it's more functional as opposed to emotional. Yeah, I would say that, if my success rate with P shot was about 95%, I think for OShot it's more on the lines of about 80, 75%, which is pretty much in line with, what Dr. Reynolds group has found. Okay. Where my P shot, I feel like it's better because I made adjustments with the protocol. Well, you sort of hit, an important issue that maybe we should explore a little bit more. And that is that most , sexual problems can have multiple causes. In other words, there's a psychological component. Sometimes it could be medications that they're taking that could be affecting things. So are there, um. other screening tools, whether it's, psychological assessment for psychological health that can be used to predict whether somebody would respond to some of these interventions. It's part of my, my consultation trying to, screen for the patient. So, again, like erectile dysfunction is multifactorial. There's a physical component and, I'll tell the patients, all right, consider it like plumbing. P shot is taking care of the circulation. That's the actual plumbing. However, what controls that flow of blood or water, it's the faucet. So what is the faucet? All right. It could be hormones, it could be stress levels, it could be other things in our life that control that flow. So in my consultation. I'll ask the patients, are you married? Are you single? Are you dating around? Okay, I'm married. All right. How long have you been married? The answer or the patient can be very different if it's 10 years versus they're a newlywed. Okay. Because 10 years, there's no performance anxiety there, right? Maybe if you're dating or a newlywed, there's a lot of pressure that could really affect performance Also I ask the patients, do you masturbate? Are you able to achieve an erection when you masturbate? Yes, I do. Are you able to climax? Yes. And then they have a sexual partner and then all of a sudden they can't get an erection, right? So there's definitely a psychological component. With that because they have more confidence when they're with themselves because they, they're not performing for anybody. So that's one way that I can screen. And for those who are dating and have performance anxiety, there's not so much I could really do for them. Right? Because P-Shot is fixing a physical problem. However, sometimes they go hand in hand. You know, let's say that you improve the, the, uh, the erectile quality, you're, you're improving the circulation. That may give you a little bit more confidence, alright? But it's a little bit more indirect and it's less of a, a, a win. I know that sometimes there's other tests that people will do to see, for example, if they have erections when they sleep. Apparently. If I understand correctly, most men have erections while they sleep. I suppose there's ultrasound testing of the circulation. Do these play a role or not really? Nocturnal erections are very important because when we sleep, um, that's our body's chance to really heal and repair. And what I'll often do for my patients is prescribe a low dose tadalafil, which is a generic form of Cialis, maybe three milligrams or six milligrams. Daily Cialis is five milligrams, so, um, the compounding pharmacy can't really make five milligrams. But they can, if they make it like lactose free or so, but they cannot compound the same exact brand name that is on the market. However, the reason why I prescribe the low dose tadalafil, , is I want them to take it at night. Alright? Just because it'll be active while they're asleep and they may have nocturnal erections, whether they know it or not. Okay. So that's how I use it in my practice just to, really improve nocturnal erections, not necessarily prescribing it for, performance, situational performance. In terms of using nocturnal erections as a predictor of success, I really don't do that. Again, it comes down to the shim score when they're awake and then often, they're not aware of their erections when they're asleep. Maybe when they wake up they, they are, you know, they'll tell me a doctor, you know, like, I used to have morning erections and now nothing at all. Alright. So that puts them in a little bit more severe category than someone who does have morning erections or are aware of it. This is something I wasn't aware of. It sounds to me like you feel like there's some benefit to having erections through the night. Absolutely. Because EE every time you have an erection, you are profusing the penile tissue. Okay. But at, at night, just in general, that's the time our body heals and repairs. Even with our skin, there's certain applications that we use for the skin that are recommended at night because of cell turnover. So similarly, the body's repairing itself, even the penis. Okay. And if we are perfusing and giving nutrients, oxygen, all the better are there some contraindications to using Cialis? I'm talking about low dose, and for most people they can tolerate that even with a cardiac history. However, um, if there's any cardiovascular disease or so, I'm a lot more cautious with prescribing for those patients. I don't have a lot of patients coming to me with severe cardiovascular disease and I'm not prescribing high dose Tadalafil or Cialis for you know, situational performance. Sometimes I do, but the concern with these PDE five inhibitors is the vasodilation, right? So if you have a high dose, it's gonna vasodilate the blood supply to your penis along with everywhere else in your body. And I will recommend to my patients if they are taking a high dose. Viagra or Cialis to hydrate. Well, because if you have lower extremity vasodilation in light of just, um, poor fluid status, whatever blood supply you have when it's active will pull down to your feet and legs away from your head and heart such that you're gonna get palpitations or you're gonna feel dizzy or lightheaded. So fluid hydration is key. Also avoiding alcohol.'cause that's gonna dehydrate you. And another thing is, I, I tell my patients, if you wanna have great sex, you have to put your best foot forward, right? We, we like to drink alcohol because it makes us nice and relaxed. However, it really kills erections, right?
And, and also having sex at 3:00 AM is gonna be a worse outcome than if you're having sex in the morning. All right?, Just another little tidbit. But yeah, in terms of, high dose Cialis or Viagra if the patients do become lightheaded or so, I just advise them, lie down and bend your knees. That way the blood returns to the head and heart away from the lower extremities. And then just kind of get up slowly, take small sips of water to really fill up the tank. However, if you've got, um, a great fluid status a lot of this can be prevented. So we talked a bit about response or percentage of patients who respond. What about duration of the response? What are you seeing? So, it's variable as well. And, I will tell my patients expect to come back on an annual basis and often they don't. Sometimes, they're coming back at maybe a year and a half or two years. And I was like, did it? And then of course, they didn't answer the, the follow up, how are you doing? We, we actually stopped sending follow up questions because a lot of times it was just unanswered, but sometimes they come back a year and a half, two years later. And I was like, well, how'd it work? It's like, it worked great. That's why I'm, I'm back. Of course, patients with really severe disease, they may have to come back, you know, twice a year or, they get two or three P shots separated two to three months apart from each other. And then their maintenance is going to be about 10 months to a year. So with pain management, I think the mantra is it should be multidisciplinary where you know, you can do an injection to maybe help people do other things like exercise, but often injections in isolation and not enough. Are there some lifestyle changes that patients can do themselves that either, help with some of that sexual dysfunction things, whether it's cognitive behavioral therapy, meditation, exercise or maybe will help make P-Shot O-S hot last longer?, The simple answer that patients hate to hear is diet and exercise. Right? But seriously you know, there are studies that demonstrate that , if you're more active, you're walking, I, I'm not sure what that threshold is, but you're improving your circulation, improving your erectile function and then diet. If you're eating a lot of fatty foods, that's just contributing to atherosclerosis and then your family doctor is gonna put you on a statin, right? And when patients are on a statin, it really affects hormone production because you have this hormone cascade that all starts from from fat and it's eventually converted down to your different sex hormones. So if you are interfering with your lipid production. You're going to interfere with your hormone production as well, and that's going to present in your erectile function. So in a perfect world, you know, you change your diet, low fat, you exercise, but that takes a lot of work. So if you can't do the work, then there's p shot, there's medication as well. And all the other things that you mentioned it's fair game, it's multimodal. Do whatever you can in your power and in your budget. Often, patients can't afford psychotherapy or cognitive behavioral therapy or so., But, all that matters. But I think in the end, most patients just want convenience. They want to go in, they want to get a procedure, and they want their ed fixed and, and that, and that's it. Sometimes I can help, sometimes not, right? Often we'll try the P shot first. If they've got fantastic erections, then, then it's a win. If not, then I'm going to dive a little bit further into their hormonal status. Often patients see their family doctors and they do a set of hormones and everything is normal, and that's all I ever hear. Then my doctor said it, it's normal, but, there's such a thing as optimization. So if this is the range of, of normal, say for testosterone and your patient scores right about here, yeah, that's normal, but it's kind of low normal. But why should we settle for low normal if we can be high normal, all right? And still within range, and you're going to, perform and feel a whole lot better. So, um, that's another thing that I would bring to the table if, you know, the single treatment didn't work. Yeah, there's a lot of, discussion about hormones for men and women. Unfortunately, often it's a bit of a double-edged sword. There are concerns about cancer strokes for some of the estrogen replacement. Oh, there's been a statement recently that that is no longer valid. That you know, estrogen replacement therapy is actually safe. That, that was something very old school and, no one was willing to prescribe estrogen to, to women because of those old studies. But of late they've dropped that black box warning. again, I think it, it is going to be an active area of debate and pendulum will likely swing in one direction and then in another. Right now, I think hormones are a little bit of a resurgence. As you said for a while, nobody would touch them, with, , testosterone. I guess the concern was, because prostate cancers have testosterone receptors, could you be increasing risk of prostate cancer or even just causing, , enlargement of prostate? Again, I don't follow the field closely. Any thoughts on, on that?, In terms of male hormones. I'll check a PSA for baseline and I'll monitor it. Every six months or, or annually, depending on risk. And just as long as everything is within normal range, you know, if testosterone levels are high, I'm gonna lower the dose to bring them back down to normal levels. And again, I will check the PSA , I'll have my patients, get a digital rectal exam from their family doctor. If the family doctor doesn't wanna do that, I will do that just to monitor them as well. That's all part of hormone management and testosterone replacement. But if you keep things within limits, um, you want your PSA below four, even if it's below four and there's a sudden increase, that's also a concern. So then I would maybe test a little bit more frequently or maybe back off on the dosing. Um, another thing is the prostate is analogous to the uterus, so it's going to respond to estrogen. So high estrogen levels are going to cause hypertrophy. So that's another marker , or hormone that I'll monitor. And often with these gentlemen that present with low T, their testosterone may actually be high normal, but their estrogen is also high normal. And there really should be a balance in favor of testosterone. Because if their the testosterone is on par with estrogen, it's still gonna come across as having low t meaning like low testosterone, regardless of whatever happen they're saying. It's not the absolute level, it's the balance between the two. Correct? Yeah. So there, there should be a balance in favor of testosterone over estrogen, right? And sometimes if estrogen gets too high. The patient will exhibit signs of BPH in large prostate. Okay, so let's move on to talking about skin. The skin on our face. There's skin on our scalp, uh, skin, on our scalp has hair follicles. I guess that's the difference. And skin. on our face not so much. And PRP is used for both. So, can you tell me a little bit about how PRP is used for those two indications? And what are you seeing in terms of results? So, in terms of face, , microneedling it's a technique where you use a device that has microneedles tiny little needles that make tiny little perforations, , in a short period of time, such that you can apply any kind of compound or medication to allow it to seep into the skin. So the vampire facial is microneedling with PRP. I've gotten great results with that. It's just that PRP has actually taken a backseat now to more sexier newer therapies like exosomes, right? And, , I haven't really done a comparison between exosomes and, and PRP in terms of micro needling. Um, exosomes are a lot easier because they're manufactured a lab and you just, draw it up in a, you know, in a syringe and apply to the face as opposed to going through the trouble of drawing blood and processing that. And I find that a lot of people that want PRP aesthetics have the worst veins imaginable. I don't know what that is or why that's the case, but anyway you know, patients get a nice healthy glow. There might be a little bit of skin tightening. It's not gonna be dramatic like a facelift or so, but there is benefit to that. You can microneedle the face period without any medication and still have benefit. Mm-hmm. Okay. It's gonna improve blood flow, but when you use something biologic like PRP or exosomes, it's going to take it a little bit further in terms of the results. And again, this is kind of subjective, the patients may notice where I don't notice, you know, patients like, oh my God, my skin looks so great. Sometimes it is very apparent. But it's not as, , I guess as apparent as maybe hair growth. So for PRP, for hair, I do it quite differently compared to, I think anyone else in Canada, unless I've trained them. And it again comes down to the centrifuge. When you use a dual spin centrifuge, you are delivering , more platelets than a single spin. A typical single spin blood draw is about 20 ccs. When I do PRP for the hair, I'm using 120 ccs. So you can bear 120 ccs to 20 ccs. I'm delivering six times the amount of platelets, right? And my device, my centrifuge is a little bit more efficient in terms of concentrating platelets. So I'm delivering a whole lot of therapy in one sitting. Where most clinics you need a series of three to be repeated every three to four months. Another series of three. I conducted a study where it was about 95% of my patients for a four year span benefited from PRP with just one treatment of mine, and they were turning for follow up at like year, year and a half, two, maybe even four years. And they still had better hair density compared to their baseline. A lot of clinics will say you need a series of three because of the cell cycles or, or the follicle cycles. There's like rest and, and a period of growth, et cetera. But that's really irrelevant. That's more relevant when it comes to laser hair removal because the laser has to capture the cells when they are actively dividing, right? However, for PRP it's irrelevant because you're improving the blood supply to the follicles. You're recruiting stem cells back into the follicles. Follicles actually contain stem cells in the bulge region and as we age, they either wither away or migrate. So PRP is a great way to recruit stem cells back into the follicles. So you're gonna benefit from those regardless of what cell cycle there is. There are certain limitations with PRP for hair. When I examine you during consultation, I'm gonna look for areas of skin that are shiny, maybe like along the hairline. If the skin is shiny or even like in the crown, it's too late. The follicles have fibrosis, they have scarred over, we're not gonna be able to recruit those. That would be the role of surgery. Basically hair transplant or FUE. But for the rest of the scalp, if I'm seeing a little bit of stippling or so, those are follicles that we can wake up and really improve hair density. Does it if it's women or men? It benefits both because again, circulation recruitment of stem cells. Right. Also, , well it goes hand in hand. DHT dihydrotestosterone is implicated in male pattern baldness and it's also implicated in female hair loss. When the follicles are sensitive to it, meaning that no matter how high the levels are, the follicles just don't function very well. Or if it's a high concentration of DHT, it's gonna affect hair growth, improve circulation, kind of dilutes that out, causing the DHT levels to fall. So again, it's, it's basically just, on the receiving end of improved circulation. So we talked about various applications,, and, there's a few more that I could have talked about, but , what about risks and side effects with all the procedures we talked about? PRP is, is very safe, right? Because it's autologous and the kits are sterile, so there is no contamination between patients. The risks with any injection techniques include bleeding, bruising, swelling, right? A lot of that is just cosmetic. For the P shot, I use tiny little needles. Rarely do they bruise, but if it bruises, it's temporary, no big deal. Um, the same thing with microneedling. All right. There might be some redness to the skin, but after a couple days, you're gonna be presentable. For the hair, there's really nothing in terms of poor aesthetic outcome afterwards. I did have, however, maybe two or three patients, three patients where there's a whole lot of swelling and it kind of involved maybe even , the brows and upper eyelids. And that again, is temporary, right? It doesn't happen all the time. But I I told the patient, oh, this is actually a good sign because we're actually changing physiology and you're gonna get a good response from this. That's about it. But, anywhere you stick a needle, there's risk of injury to the surrounding structure. Nerve endings perhaps, right? So if you know the anatomy of the penis, you know where to inject and where not to. Same thing with the clitoris. For the hair on the scalp, it's pretty safe, but I can't think of any , side effect or complication from PRP that was permanent or even a concern. It's a very safe technique in the right hands and if they're trained properly. Maybe let's end by talking a little bit about research and application of PRP outside of musculoskeletal problems with musculoskeletal problems, there's lots of research articles. Unfortunately, some of them,, contradict each other, which is why it's still an area that hasn't made its way into the guidelines. So usually cosmetics is sort of a poor cousin of musculoskeletal medicine in the sense that research articles are typically few and in few. And I know that you are primarily a hands-on clinician, so you have personal experience, you can draw on a very long personal experience. But, but do you have any sense for what the research is on any of these PRP applications? I just did a, a, a quick search recently and the evidence is really poor. Regenerative medicine has been under attack by some aesthetic physicians, et cetera just in general and some of the research. In terms of, in Intracavernosal, PRP, which is P shot, demonstrated that there was really not much of a difference between PRP and placebo, normal saline. Right. And I haven't looked at that study in depth, but again, you have to take these journal articles with a grain of salt because again, they lump PRP together, like it's all the same thing. So most of the research out there uses single spin PRP because it's cheap. Right. Why conduct, you know, a study with double spin PRP systems that are a lot more expensive when you can do research with something that is cheap? But I can tell you already, based on the musculoskeletal research out there, that there is quite a difference between double spin PRP and single spin PRP. So even though they say that there's not much of a difference compared to placebo, I, I really wanna challenge, how they conducted the study because again, they're not using my protocol, which leads to a really high success rate. I don't know how they're injecting the penis. How can they confirm that they're actually intercavernosal? All right. How long have these practitioners been doing this procedure as well? So there's still a lot of doubt and question for and against. that sort of, the two components,, there's a difference between something that has been proven not to work and something that just doesn't have very much research to determine whether it works or not. And unfortunately, in chronic pain, for example. Most treatments fall into the category of just, nobody did enough research to figure it out, but practically it seems to work on day-to-day basis. Certainly what I'm seeing with musculoskeletal medicine is, as I mentioned, there is these articles which show that PRP is no better than placebo. And then there were other articles which showed that PRP is quite effective. So then at some point, somebody did a meta-analysis where they looked at all these studies together and what they found was a fairly consistent pattern in that anybody who got PRP into the knee with more than, I think it was 3 billion platelets, has a positive outcome. And studies which used PRP with less than 3 billion. Platelets per knee had a negative outcome. So at least in musculoskeletal medicine, there's certainly a trend in that, when you get past a certain threshold of platelets, PRP seems to work and below that threshold, not so much. Anyway, thank you so much for taking the time to share your experience with us. My pleasure. Thank you. Disclaimer, when it comes to your health, always consult with your own physician or healthcare provider for personalized advice and guidance. The information provided in this podcast is for educational and informational purposes only and should not be considered medical advice or a substitute for professional medical care.
