Functional Clitoral Anatomy

Topics Discussed Include the Following…

*Materials for Injection Into the Vaginal Wall
*What are we injecting: G-Spot or O-Spot (what’s the difference)?
*The change in FSFI and FSD-R after the O-Shot® procedure
*Dr. Elizabeth Owings discusses the Functional Clitoral Anatomy

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

Transcript (relevant links at the bottom of the page)

Review of Materials for Injection into the Vaginal Wall

Charles Runels, MD (00:03):
Thank you guys for being here at the Journal Club with Pearls & Marketing (JCPM). And we have a very special guest tonight, Dr. Elizabeth Owings, who wrote a… She just clicked to me and said she got the wrong link. Okay. Let me send her another link or we’re not going to lose her. Hold on one second. Yeah. Okay. Just sent it to her again. Hopefully she’ll show up. Okay.

Charles Runels, MD (00:35):
So Dr. Owings, amazing, amazing physician who spent several months just studying the anatomy of the clitoris. It’s hard to believe it was actually left out of Grey’s Anatomy for a while. So Dr. Owings will be coming on in about 10 minutes. I’ve been spending a lot of time thinking about the functional anatomy, the way things that are and how we might improve our O-Shot®. Well, this paper just happened to come out, and it was actually brought to my attention by my fiance Alexandra, who’s a gynecologist out there in San Antonio. So thank you Alex, for showing me this.

Charles Runels, MD (01:11):
This came out, as you can see, it was come out in the past month and it was a nice review article that was published in Aesthetic Plastic Surgery about all the different materials that are being squirted into the vagina. Some of it you’ve seen, but having it all fit together in one paper with a very, I think, balanced view of it is helpful. I wanted to point out a couple of things, and you can download it. I’ve put it in the handout section. You just click on the little yellow flower it’ll pop up, and if you open it now, it’ll be still open when the webinar’s over. If not, it’s going to disappear.

Charles Runels, MD (01:55):
So here’s a couple of things that I noticed about this that I’d like to bring to your attention. First of all, this first little review paragraph just lists the things that have been published, and I’d like to point out that maybe multiple injections, I’m being a little picky here, but aren’t always needed. And when they talk about emboli, [inaudible 00:02:19] emboli, that happens, but it happens with HA, and that happens… Pulmonary embolism happens with fat. We haven’t had a pulmonary embolism. We’ve had one episode of blindness from PRP, and that was when it was injected near the eye. And so, except for that one episode, no one’s ever gone blind by injecting in the vagina, although pulmonary emboli have happened injecting fat and HA around the vagina.

Charles Runels, MD (02:51):
So anyway, there’s a nice little overview. I’m just going through it here, and you guys can point out, I’ll unmute the mic if you want to throw something in here. But they do point out that vaginal atrophy happens with estrogen levels being a main cause. Definitely a cause, it’s debatable how much, because there’s definitely a contribution from testosterone, as you guys know, not just estrogen. Many of you have discovered with testosterone creams also help the problem.

Charles Runels, MD (03:27):
And they’re about to quote one of the articles that are published together with some of the other people in our group. But one other thing before we get to that. On page 1232, they mentioned that… They started talking about the G-spot, and this becomes almost like a religion or a belief system more than science, I think. And although there was this study that came out in… Where this fellow, I can’t say his name. I met him. Really nice guy, at one of the [inaudible 00:04:04] courses, he did a series of dissections on cadavers and totally dissected out the G-spot. The reason I’m bringing this out is most people think that maybe it still hasn’t really been shown because there’s no specific tissue that anyone else has been able to find.

What are we injecting: G-Spot or O-Spot?

Charles Runels, MD (04:26):
The only reason I bring it out is that I think technically we’re not injecting the G-spot, and I want to make sure that we’re clear on that because… Hey, I see you, Elizabeth, thank you for jumping on. Because the G-spot, in my opinion, is a functional thing. That if you look at what Dr. Grafenberg talked about back in the fifties, and you really should do a Wikipedia read and then read all the references about Dr. Grafenberg. Amazing, amazing man, amazing story that I won’t get into now. But he thought the whole urethra was the most arousing erotic part of a woman’s body. The spot became more of a later idea. And I think it’s less established. I think most people were tending to talk more about the clitoral urethral complex, which is what Dr. Owings is about to talk about here shortly.

Charles Runels, MD (05:23):
But the G-spot is something that I think you find in the bedroom, I think it varies from woman to woman, and in the same woman, sometimes from moment to moment. But it’s in theory the place where the woman’s most aroused. And I think to point to it on an anatomy chart, it could be how you define it. You can decide that. You can decide your left ear lobe’s the G-spot if you want to, but I think the way Dr. Grafenberg talked about it, it was the most arousing place of the most arousing place. The most arousing spot along the path of the urethra, but really it’s nebulous.

Charles Runels, MD (05:58):
And that’s why with the G-Shot that was out and popular in the US a number of years ago, you had to quote map the vagina and find that place by stimulating the woman’s vagina. And in Europe, this is still done. In some of our offices it’s still done, but this is frowned upon by ACOG now, and you’re putting, I think, your license at risk if you do this in the United States with an HA in the anterior vaginal wall, because of the risk of granuloma. 1 in 40 in one study, that can cause obstruction, necessitating surgery to correct it.

Charles Runels, MD (06:34):
So the O-spot, we need a place to call our place where we put it. You can call it whatever. You can call it the Florida spot. I don’t really care, but calling it the most distal place in the peri-urethral area, between the anterior vaginal wall and the urethra most distal from the bladder, it’s a long-winded thing. So that is the description of it. I like calling it the O-spot. Nobody’s name’s involved, so there’s no ego.

Charles Runels, MD (07:09):
It’s just where we put our shot, and that you can point to on a map. So if you’re going to do the G-Shot, in my opinion, you need to spread the lady’s legs and find where she moans the most, which is… I’m saying it purposefully in a very offensive way, because some people think of it as offensive, even when you say it in a not offensive way. So I like to talk about, we don’t really map out the vagina when we do the O-Shot®, and we’re not looking for the G-spot when we do that. Okay. Now I just wanted to bring that out. Go read about Dr. Grafenberg. Couple of the things. I’m trying to keep to the schedule here. I’ve got about two minutes and I’m going to turn it over to Dr. Owings. There’s a lot more here. Let’s see.

The change in FSFI and FSD-R after the O-Shot® procedure

Charles Runels, MD (07:55):
If you go down to this little graph where they talk about the research we did, and just a couple of things to point out. It’s not apparent from this is that we published this little study. And what I did was I had a patient who used to work in getting universities ready for inspection by the FDA. After she retired from the FDA, where she was an inspector of research projects done by universities, after she retired, then she worked as a consultant on the other side to help people get ready for what she would have done when she worked for the FDA. I loved her, love her still. I saved her life with some stuff I was doing, and so she felt obligated. So I said, okay, let’s go through my charts. I don’t want to even touch the charts. And find women for whom we have a female sexual function index and a female sexual distress scale revised that was filled out plus or minus a few weeks around the 12 week mark. As you can see, 12 to 16 weeks. And we have one before and we have one at that time, because I think that’s when it probably maxes out. And just add it all up and let me see what it shows. My hands are going to be off.

Charles Runels, MD (09:10):
And she did it as meticulously as only an FDA person might do. And thankfully, it showed benefit. You realize I wasn’t even seeking people who were distressed. And ironically, of the two that showed increased distress on the distress scale, I called one of them because her distress scale had gone up, I think from a one to a two. It just bumped from zero distress, basically, to a little bit more distress. And when I asked her why her distress went up, she said, well, I’m having great sex, and now my boyfriend can’t keep up with her. So that was, that was her distress.

Charles Runels, MD (09:51):
The other woman had a divorce right after the shot, and her whole life was distressed. But the bottom line is that we showed some benefit. Obviously there was no placebo, and rightly so, he points that out. But I want you to know how those numbers were generated.

Charles Runels, MD (10:08):
This one, I think very well done. I think it’s complicating it. If you notice the people who were doing the procedures, like the recent one that made the cover of the journal Sexual Medicine, the people who were doing the sex procedures, who have never done this in the face, in my opinion, are complicating it. If you ever squirt PRP in the face, you’ll see, it’s like filling up a sponge. You wouldn’t feel obligated to stick the sponge, if it were small, in three or four different places. You would just put the needle in the sponge and it would fill without lots of sticks, which is what you see when you see PRP spread through the face.

Charles Runels, MD (10:47):
But not having witnessed that, I think some people complicate it, just my opinion. I may be proven to be wrong, but I don’t think you have to put multiple sticks. And I think most of what happens does go along, especially when you’re treating for stress urinary incontinence, but even when you’re treating for sex, because of the sensitivity of the urethra, I think anything away from 12:00 for sure, by the time you get to 2:00 and 10:00, perhaps benefits are rapidly declining. I’ve seen lectures about hyaluronic acid when I lectured in Europe, and many of you on the call now or listening later will know about this, because you live in Europe. We don’t have as yet an HA that’s approved for the vaginal space. The guy who invented [inaudible 00:11:42] came out with one that is, but the recommendation is that it only be used in the posterior vaginal wall for the same reason, I just mentioned. The G-Shot is not recommended, it’s condemned by ACOG, because when you put the HA in the anterior vaginal wall, some not happy things can happen. Where it’s safer in the posterior vaginal wall.

Charles Runels, MD (12:06):
The end point is often pH, which is interesting to us in the States. And you can see people are mixing it with PRP as we are doing in our wing lift. This, again, I think is something that hopefully will eventually be something we’re able to do here. There’s a region kit that comes with an HA as an activator that’s not cross-linked, that is supposed to be available here eventually.

Charles Runels, MD (12:34):
And then the collagen botulinum toxin, I’ll get back to fat as it does lead to embolism. When you get to stem cells, I don’t even like saying that on a microphone now because the FDA is so rambunctious about making sure we don’t talk about stem cells too much. So that’s it. Let’s see if there’s any other notes and we’ll turn this over to Elizabeth. Anyway, hopefully you guys will think about that, and… Oh, I know what else was going to show you. This last little part in the summary, and then I’ll shut this down. The references here are crazy good. So you might want to go through those when you have a Sunday afternoon. This part.

Charles Runels, MD (13:24):
Well, the bottom line is that instead of having one tool, the idea of combining tools is important. We definitely need to standardize it. The double-blind placebo needs to happen, but I think it might need to be a positive control, because saline is not a placebo. If you think about what happens when you power wash your driveway, I’m afraid there may be some disruption of tissue that makes it not a placebo. So in fact, our procedure is part biological by activating pluripotent stem cells with PRP-derived growth factors and cytokines. It’s partly a physical procedure when you’re hydrodissecting tissue. So it’s a little tricky doing a placebo-controlled trial, unless maybe you just stick the needle there. Anyway, I’m playing around with that. I actually stopped one study when I saw another study where the saline placebo worked almost as good as PRP and much better than you would have expected a placebo to work in a histological study.

Charles Runels, MD (14:30):
So I think now let’s unmute Dr. Owings and I have her beautiful pictures that she’s accumulated to help explain some of the function of the anatomy and how it relates to what we just talked about. Let’s see, I see two microphones, Elizabeth. I’m going to unmute them both. There you go. Should be live now.

Elizabeth Owings, MD (14:57):
Okay.

Dr. Elizabeth Owings discusses the Functional Clitoral Anatomy

Dr. Elizabeth Owings, MD

Charles Runels, MD (14:59):
You’re there. There’s something that’s causing an echo. So while she’s flipping that off, just to let you guys know, Dr. Owings is really a… I meet lots of smart people, but she’s one of those Renaissance ladies who has a music degree and plays the piano like Liberace or something, and she’s got so many fricking specialty trainings I can’t track them, and still looking for the new thing to think about. So thankfully some of those new things that she wanted to think about included our procedure. So let me see if I can make this… Yep. There it is. And I’ll just run through this whenever you tell me to, Elizabeth, and we can hear you now beautifully.

Elizabeth Owings, MD (15:47):
Okay. Terrific. Glad you can hear me. Just had two mics, because I didn’t know which one was going to link up right.

Charles Runels, MD (15:53):
[inaudible 00:15:53]. We got it now.

Elizabeth Owings, MD (15:55):
Perfect. So I guess I have been thinking about this. I’ve been thinking about this a lot. Any of you heard me give this talk, my third patient after I was trained in the O-Shot®… And I’ve got general surgery training and we do gynecology rotations and you learn about it in medical school. The third patient had lichen sclerosis. I had never seen it before to recognize it. Yes. Thank you, Charles. But this is a condition where the, the tissues just sort of adhesed together over the clitoris. You can actually feel it underneath there, but you can’t see it. And when you think about how to do an O-Shot®, it’s a bit perplexing and not something that you want to walk into.

Elizabeth Owings, MD (16:36):
My assistant had applied the lidocaine and I just came in to do the procedure. Very straightforward procedure, only it wasn’t. But it prompted me, I realized, I didn’t know nearly what I needed to know about the clitoris. I spent the next month, basically, downloading articles. I didn’t go back to the anatomy textbooks, because I’d already looked at them and they really weren’t helpful to me to really understand what was going on behind the scenes underneath the small, external portion of the clitoris, which is what anatomists tell us that the clitoris is, is just this tiny, external portion. And they’re thinking about… Do I have a pointer?

Charles Runels, MD (17:22):
I can give you the pointer. Hold on a second. Let me see if I can do that.

Elizabeth Owings, MD (17:26):
But just when they, in your anatomy books, they think of the clitoris is… Oh, there you are. Just this, the glans in the shaft. That’s all they think of as the clitoris. You may just want to point, Charles.

Charles Runels, MD (17:51):
Okay, I’ll point for you. All right. Let’s do that.

Elizabeth Owings, MD (17:54):
Okay.

Charles Runels, MD (17:54):
Take it back. Hold on one second. Got it. Okay. I’ll be your pointer.

Elizabeth Owings, MD (17:55):
Okay. Be my pointer. So the glans in the shaft is all it would be pointing at. That’s just that top, just the very, very, part of the glans and the shaft, but not the deep part is what they thought. So the deep part would be the legs of the clitoris that Charles is pointing to now. And you can’t see that from the outside. And so modern anatomists and ancient anatomists don’t really think of that as part of the clitoris. So it’s the easiest for me to understand it is starting with the sameness, the things that are the same about the female anatomy and the male anatomy.

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Elizabeth Owings, MD (18:32):
And so the male anatomy, almost everybody has seen an erect penis, an erect phallus. You’re familiar with the fact that it’s firm. It’s supposed to be firm when it’s erect, and what makes it from are these two tubes that fill with blood. When it happens normally, that’s wonderful. And then sometimes people have to take medications to make that blood flow happen. And then sometimes of course, people actually have to take an injection. It’s injected into the tube to make the blood flow in there to make the penis hard. If a man has a penile prosthesis, it’s basically implanted where these tubes are to make it erect.

Elizabeth Owings, MD (19:15):
Well, females have those same tubes. They’re just mostly on the inside. So this is the male, that Charles has pulled up for us. There we go. The big circles on the top, when I was in a microanatomy histology class, they told us to think of the cross section of the penis as looking like a monkey. Two big eyes, and those are those tubes that get hard. And then the part down at the bottom is the part that surrounds the urethra.

Elizabeth Owings, MD (19:43):
And so in the female… And there it is, there we go. That’s a nice picture of how these tubes are very wide open, ready to fill with blood, ready to become engorged. And they actually are joined and are one space towards the end of the penis, towards where the glans of the penis is. And they separate down at the base and in the deep parts of the penis. There’s another picture of it. You got that up at the top, there’s this combined space, there’s a septum, but it’s got a lot of space in there where fluid can flow back and forth. That’s why when you do a Trimix injection for the penis to become erect, you only have to inject in one spot. And that fluid in the medication is active throughout that whole space. When we do our PRP injections, very shortly after it’s injected, it becomes a platelet-rich fiber matrix. It turns into a clot, basically, on the inside, but not the bad kind, not the kind that causes problems. This is the kind that’s basically generating those healing factors so that the function is going to improve.

Elizabeth Owings, MD (20:54):
I just always like to include this slide, because you can see that even in the glans penis, you don’t think of it as a tube. And you’re looking at the microscopic section. There are these big spaces in it. And when you did your Priapus shot, when you did that injection in the tip of the penis, which is a completely separate space from those two tubes that become erect. But when you do that injection in the tip, it doesn’t raise a bleb, it doesn’t raise a wheel. This is a great picture so you can understand that there’s the spongy part that surrounds the urethra, that leads up to the glans, and it’s spongy, even in a very erect penis, the glans will have some give to it. Where the shaft of the penis will not. That’s that those tubes that I was talking about that become erect.

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Elizabeth Owings, MD (21:41):
The same thing happens in the clitoris. Those same tissues are all present. I love this picture, because this shows perfectly well where to put that shot. As soon as you see those side to side rugae in the vagina, just inside the hymen, even if you’re not sure if you’re looking at the hymen or not, if you see those lines going side to side, that’s the place where you put your O-Shot®. That is the O-spot.

Elizabeth Owings, MD (22:10):
The same thing on that right picture. You have a really good view now of where that O-Shot® goes, and then all of the deep tissues of the female that are all part of that clitoris. It’s all part of that clitoris complex. So it’s not just the tip, not just [inaudible 00:22:28]. So I just included this picture of me and my son out in front of a [Glendonhall 00:22:32] glacier, and there’s an iceberg down there. So just like they taught us about iceberg, most of it is under the surface. The same is true for the clitoris. Most of it is deep. The part that we see is a very, very small part of it. So go ahead into the next one.

Elizabeth Owings, MD (22:46):
And you can see this pretty well on the slide here. And if you think of this, what you’re looking at is maybe just a longitudinal section of the penis with a foreskin or prepuce surrounding the glans. Then that’s exactly what you’re looking at with the clitoris. And there are those two tubes that are going to make the clitoris hard just like the penis. It doesn’t stand up because of the way it’s constructed. A penis will stand up. The clitoris does not. It will become full and engorged, but it doesn’t stand up, just because of the way it’s constructed. We don’t need to look at that one. I like that next one though.

Elizabeth Owings, MD (23:25):
To just point out, this is a two year old child. This is fully developed. Just exactly like you would see in an adult. Go ahead to that next one. Again, great anatomical picture. The tip of the clitoris with the glans is what you would expect to see on the outside, with little shaft that’s going up. You might see that. But the vast majority of it is deep. So when you put an injection, not in the glans, but just behind the glans, you’re going into that tube, and the fluid will go all the way down. We’ve proven this on ultrasound. The fluid will go all the way down to the deep parts of the clitoris.

Elizabeth Owings, MD (24:04):
This is an MRI. This is a picture closest to the outside, and that’s why we call it the introitus and not the vagina on the line drawing right to the right. So these are 18 year old women who’ve never had a baby. And you can see where the vagina is. I love this MRI picture. Very clearly, you can see where the legs of the clitoris are deep, the glans and the urethral meatus right there with the introitus. That’s good. Just like that. Go ahead. There it goes.

Elizabeth Owings, MD (24:38):
A little bit deeper, the body of the clitoris they’ve got mapped out right there for you. And then the crura coming down side by side, and there’s the bulb of the clitoris. That is analogous to the corpus spongiosum in the male penis. And it’s there. I don’t think I’ve got the photomicrographs, but it exists all the way up to the glans of the penis, just like it does surrounding the urethra to the male. The urethra in the female just comes directly to the outside. It doesn’t have to track up to the glans like it does in the man.

Elizabeth Owings, MD (25:17):
There we go. And then deeper still, at the very top, you’ve got the mons. Right under that is the pubic symphysis, and right under that is the crus of the clitoris, and then the urethra. Under that, sort of with the transverse shape here, is the vagina itself. Go ahead to that next one.

Elizabeth Owings, MD (25:43):
This is one of my favorite views, because you really get an idea… They tilted it, it’s not exactly anterior to posterior. It’s tilted just a little bit so that you can see the entire body of the clitoris. You just get an idea of the glans at the tip, and then these deeper structures, all part of the clitoris that are surrounding the urethra and the vagina. And when you look at this picture, I think that’s when I realized anything that we do that makes those tissues more healthy and lens support to them… You expect your face to sag a little bit after 50 or 60 years, and probably every other tissue in your body is as well. So if you’re lending any support at all to these tissues, it’s going to support the urinary continence mechanism. It doesn’t make the muscle any tighter. It’s just lending support to these structures. They’re going to become not necessarily more engorged, but there’s just going to be more just basic tissue tone. Go ahead.

Charles Runels, MD (26:47):
Let me just throw one thing in there, Elizabeth.

Elizabeth Owings, MD (26:50):
Yes.

Charles Runels, MD (26:51):
We have an MRI study that’s listed on the reference page of the O-Shot® that showed where a female radiologist, she did MRIs just like this of women who have trouble with orgasm and women who easily orgasm, and there was a correlation with the size of the clitoris and the distance of the clitoris to the vagina. So the bigger the clitoris, and the closer to the vagina, the more it correlated directly with ability to orgasm. So just stressing I like this picture as well, because the idea of anatomy just being for surgeons maybe isn’t right, because we all have to think about how the parts work together. I think that this picture explains why just talking about a spot maybe as the main thing isn’t exactly so accurate.

Charles Runels, MD (27:47):
It shows where this clitoral urethral complex, it also points out why the answer to, if you’re going to treat urinary incontinence, do you still treat the clitoris? I think there’s two reasons why you do. One is, as you’ll see in these upcoming micrographs, but especially the one that Elizabeth just pointed out, there was some contribution to the clitoris to the continence mechanism. And then of course if you’re going to treat sex, do you still treat around the urethra, because of what we just talked about with Dr. Grafenberg. Of course you do that as well. So I always treat both, whether the complaint’s sex or incontinence. And I think, as you just pointed out, Dr. Owings, that picture tells a lot.

Elizabeth Owings, MD (28:36):
The other thing that I’ve noticed is even if people don’t complain, if something improves, when they see you again, they will let you know. So maybe urinary incontinence wasn’t the chief complaint, but when they come back in six weeks or six months or a year, maybe it’s time for another one, or maybe I had more than one patient that said, “Well, I thought I knew how good sex could be, but it was never as good as this. And I don’t know how good it can be. Let’s do it again. Let’s have another O-Shot®.” More than one, and not all young, healthy people. One of my earliest clients was a 65 year old woman, and she was just really excited with how positive her sex life could be. Thanks for moving me on here.

Charles Runels, MD (29:28):
That was an accident, actually. Finish your story. That was an accident.

Elizabeth Owings, MD (29:33):
That was the end of it. She did not have a lot of complaints. She just wanted some improvements in the sexual function characteristic, but urinary continence got better, and sex got a lot better. And when she came back, I actually treated her nipples, because at that point, I didn’t know if it would be beneficial or not. She did not have any problems with her nipples. She had normal sensation, had never had surgery on her nipples, but she had better sexual arousal from nipple stimulation. It was not just a part of her sexual response. In her words, it was off the chart. The party line for PRP is going to be two or three weeks for the start, and then three months for full effect. She hunted me down in the gym at six weeks, because we went to the same gym, and said, “That nipple thing is amazing. I had no idea that was possible.”

Charles Runels, MD (30:28):
Wonderful. It’s good [inaudible 00:30:29] that. And you and I can go all night, I love it, with stories, but I’ve had some men want their nipples done. And second point is that if someone comes in and talks about, I just want it for urinary incontinence, we all know it, but I think it’s worth bringing it out in the light that can we all agree that sometimes people lie about sex, or they’re embarrassed to talk about sex, and they might use it incontinence as a ticket to be there as we often have our patients do, but they’re just embarrassed to say about the sex part. So it’s another reason why I always treat the clitoris, even if they’re there for incontinence.

Elizabeth Owings, MD (31:08):
Well, exactly. And this is my slide of the title Why Girls Don’t Compare Parts. It’s just that the clitoris, which is the part that’s external is so small and so deeply hidden between the labia minora and the labia majora, there’s a prepuce there. It’s just hard to see. But the truth is, if you look at it, if this is what you do for a living and actually you are paying attention, it looks exactly like a little penis. How do you make it bigger? You give the woman testosterone. And that’s the sex change. Surgeons taught us that. I think it’s probably a slide later on.

Elizabeth Owings, MD (31:48):
I went ahead and looked at the gross anatomy. What do the surgeons who were doing the dissections, what are they seeing? What does it really look like underneath the skin? And so you can see there’s the glans of the clitoris and the clitoral body, which we’re used to seeing on the outside. And then those deeper structures that crus, the bulb, and the way they wrap around. Wrap around the urethra with the vaginal vestibule right underneath it. They’re just right there together. Go ahead. Same thing here, a little bit kind of from the side, the crus is sort of coming down. This long, long leg that comes down straight.

Charles Runels, MD (32:24):
I really like this picture. It really I think shows how everything’s laid on top of each other.

Elizabeth Owings, MD (32:28):
And the bulb actually comes a little bit forward, and the vaginal introitus is sort of all the way on the right side of the screen there with the bulb in the middle, and then the clitoral crus on the side there. That bulb is wrapped right around the vagina with the crus just outside of it.

Charles Runels, MD (32:49):
Beautiful.

Elizabeth Owings, MD (32:51):
It’s the same picture. They’ve just turned it a little bit further.

Charles Runels, MD (32:58):
So I just want to rant shortly. How many of our colleagues think about the vagina as just a simple tube that leads to the cervix where you can deposit some semen? And how many people are taught all the way through college that that’s kind of what it is. And yet, when you see the elegance of the functional anatomy and what’s happening when there’s a penis here or what’s happening when various sexual or non-sexual activities go on. Obviously we all know it’s much more complicated than that, but I think showing and talking about this with our patients is very helpful. And with our colleagues.

Elizabeth Owings, MD (33:41):
Right. So again, it’s just a little bit of a different view, but the same concept. These pictures, I like, because you really get an idea. If you take the urethra and you look at the tissues around it, what are you looking at? And the answer is, so the urethra is kind of that hole in the middle. It’s got a U in it, and around it, you may see this. It’s erectile tissues around it. That’s where the deep areas of the clitoris are directly overlying the urethra. And then on top of that is the layer of muscle. And when that muscle is what’s responsible for our urinary… Well, that, and all the other structures. There’s no muscle that wraps all the way around the urethra like there is in the man. I’ve got a slide about that later. In the woman it’s just this band of muscle that’s listed up at the top and this… Go ahead to the next one. There we go.

Elizabeth Owings, MD (34:38):
SM is muscle. That’s it. And I counted it, because I’m that person. It’s about 30 cell layers thick. It’s not very thick. If you buy broccoli, that’s got that big thick, rubber band around it, it’s about that width, and about that thickness. It’s very thin, it’s not nearly as strong as that rubber band is, but it’s just not a very big muscle. And that is responsible for sort of pinching off the urethra against the anterior vaginal wall. So anything that you’re doing that’s going to lend some support to those structures on the on the inside, whether it’s the anterior vaginal wall, placing a platelet-rich fiber matrix right in between those tissues, that’s what you did with that deeper injection and the O-Shot®, when you can even actually feel it. It feels like a Walnut in there. That is going to support those structures for urinary continence. And I believe that that’s why the effects for continence are almost immediate.

Charles Runels, MD (35:44):
Elizabeth, something that I haven’t talked about that I’ve been trying to find more reasoning and a clearer picture about is that if you go to the sports medicine literature, PRP has been talked about quite a bit. It’s still debated about how effective it is, but when you injure muscle, as you know from your many surgery residencies, that it can turn to atrophy, it can be infiltrated with adipocytes or scar tissue. And instead of growing new muscle back, you’re left with this weaker structure. But you have a lot of research now showing that PRP can activate these stem cells that live within the muscle, mostly in the periphery of the muscle, that are just waiting to be activated to regenerate when there’s injury or stress.

Charles Runels, MD (36:42):
I’ve started to wonder if perhaps some of what we’re seeing with our great results with incontinence in my person is both the bulk that you just talked about and perhaps that we’re actually making these intricate muscles that we’ve just lumped together as the pelvic floor, but actually there’s all these different intricacies that are almost like the mast of a ship or something, with ropes going lots of different directions and lots of different opinions about which is pulling what. But the fun thing is when you just flood the whole area with PRP, and then you do your kegels or not, or you do your [inaudible 00:37:23] or not, we could be doing sports medicine in this muscle inadvertently, and without maybe thinking about it except when you show us these pictures and we say, “Oh yeah. Well, the erectile tissue’s important, the muscles are important. The blood flow is important. The nerves are important in both stress and urge incontinence.” And thankfully we have a material that makes all those things better.

Elizabeth Owings, MD (37:50):
It’s true. I’ve been blown away from the very beginning about what’s possible with platelet-rich plasma, and you can go back and forth about platelet-rich, platelet-poor, activated, not activated, leukocyte-rich and leukocyte-poor. It doesn’t matter. Ultimately, I find myself asking, can a human being, various functions, various portions be made better than they were with this as an adjunct? And I think the answer is very often yes. It’s not necessarily predictable who or where, but very often, yes. And I’ve had this more than once. “It’s never been like this before.” And that’s a happy thing for me.

Elizabeth Owings, MD (38:30):
This picture, this line drawing is my line drawing of the… The cross section is through the urethra that you just looked at the slides of just a minute ago, so that you can see there’s a spot right in between where the urethra is. The one big blob on your left is sort of the bladder. Ureter is behind that, and the vagina sort of underneath that. And then there’s this tract in between, and Charles talked about hydrodissection and we know that when we put our PRP in there, there is going to be some hydrodissection just based on where that is. I don’t think that alone would explain any urinary continence improvement, but I don’t know. I definitely don’t have the data on that.

Elizabeth Owings, MD (39:12):
But what this picture is just shows the darker area of the urethra is where all that erectile tissue is that I tried to show you in the cross section. And then a little bit further than that, a little bit closer to the end of the urethra is where that muscle is. Now, a lot of people have proven this. Going further back in there with your platelet-rich plasma does not make a better continence procedure. You still want your O-Shot® to go in the O-spot. That’s where you want your PRP to go, is just inside the most distal portion of the urethra, underneath the urethra just inside the vagina, just at that most distal point. Climbing in deeper does not do you any good. It does not help the patient.

Elizabeth Owings, MD (40:09):
It’s a beautiful artistic rendition that my friend Kent Rush did for the book. There’s some good pictures, but you just get the idea again. The clitoral legs are on the outside, and the bulbs are right there around the vagina itself. Go ahead to the next one. Same song. Second verse. Keep going.

Elizabeth Owings, MD (40:31):
This is the male sphincter. There’s really a sphincter. That’s that deep magenta thing marked SS around the urethra that’s marked U. It is truly a sphincter. It’s a band of muscle that goes all the way around the urethra. Women don’t have that. And the good news for men though, the P-Shot®, it can actually help that work better as well. I’ve helped a lot of people with, they’re just not functioning well, especially after prostate surgery. I’m not sure these men are getting what I would consider informed consent, but I don’t know. Anyway, the problems I think are much more common than people are led to believe. You may say that the incidence of this or that side effect is only 20%, but if it happens to you, it’s a hundred percent. So anyway, next slide.

Charles Runels, MD (41:21):
[crosstalk 00:41:21] placebo controlled study that I pushed out in another email with rats. And of course, with rats, you don’t have to worry about a placebo effect, and you can harvest the penis. But this is the third one I’ve seen where they looked at that, or they tried to model prostate surgery with nerve injury and injected the penis with PRP, and the other group got saline and then harvested the penis, and they saw repair. So anyway, I’m hoping one day, at least by the time my grandkids are grown, that PRP will be routinely part of the rehabilitation protocol [inaudible 00:42:03] prostate surgery.

Elizabeth Owings, MD (42:04):
I agree. So this female corpus spongiosum, let me just tell you why I included this slide. There is still a pervasive myth. It’s been in the medical literature for decades, for well over 50 years, that there’s no corpus spongiosum, but the glans of the clitoris comes off the corpus cavernosum because there is no corpus spongiosum. Once you know what the deeper structures are, and you’ve seen some of these photomicrographs, that’s obviously not true.

Elizabeth Owings, MD (42:40):
Somehow, Charles, this is… It’s slid off sideways.

Charles Runels, MD (42:48):
Oh, I did something wrong. I don’t know what I did.

Elizabeth Owings, MD (42:52):
So what they’ve done is given this woman testosterone and all portions of the clitoris have hypertrophied, including the corpus spongiosum. So the glans is pulled up by a suture at the very, very top. Point it up at the top. That’s it, right there. And the long strand right there would be what in a male would be surrounding the urethra. That would be the corpus spongiosum. This is a photo micrograph. It’s hard, I wish I had the pointer, but the bottom line is the corpus cavernosum are these two big round things, but the corpus spongiosum is there through the entire length of the clitoris all the way up. It’s submucosal, meaning if you’re looking at the outside of the vulva, you won’t know it’s there. You would have to do a dissection, but it’s there. The whole way.

Elizabeth Owings, MD (43:51):
Go ahead with the next one. This is [Ashazinsky 00:43:55], the guy with the hardest name to say, who said he dissected these out. I think you can probably only do this in Poland. Eight consecutive cadavers. And he dissected out this thing he called the G-spot. There’s an ongoing debate. If you go to PubMed.org, and just put in G-spot and anatomy probably it’ll come up. Helena O’Connell, the lady who did, I think, some of the gross anatomy dissections, and maybe the MRIs too, I can’t remember. I think she was also a partner on that study. Has gone through and done all these dissections and said there’s no such thing as the G-spot. But the debate rages on.

Elizabeth Owings, MD (44:39):
So if you look at this nice picture he gave us, because this thing that he found, which looks sort of like a thrombosed hemorrhoid, it is deep inside the vagina and right near the bladder. And so that might make you think, well, this is going to work better for sex if I go really, really deep with my O-Shot®. And again, it doesn’t. It doesn’t work for sex, and it doesn’t work better for incontinence. I don’t know why.

Elizabeth Owings, MD (45:06):
There you go. Those were those pictures for the lichen sclerosis. You won’t harm anyone by putting PRP in that. That is actually the treatment. I thought I could learn this, and I really think they belong in a center of excellence. I refer everybody to Kathleen Posey in Mandeville, Louisiana on the north shore above New Orleans. Someone once listened to my lecture, what you’ve heard so far, and said, “Well, we know why women have urinary incontinence. It’s because when they have a baby that this is torn and that is torn.” Which it set my teeth on edge because it’s obvious to me that there are plenty of women who’ve never had a baby that have urinary incontinence. And if I go to PubMed and just type in urinary incontinence, and nulliparous, I get a whole couple of… I don’t even remember how many. You should go look at it. Articles about where people have looked at this.

Elizabeth Owings, MD (46:07):
So anyway, we’re biased. We think that if you’ve haven’t had a baby, then you shouldn’t have as much incontinence as if you have had a baby. If you’re in shape, then you should not have incontinence. And if you’re out of shape, then that’s more likely. And if you’re old, then you should have more than young. And that’s not quite what we found at all, if you look at all these reviews from 1% to 42%, depending on various factors. Heavy women seem to have it worse. Childhood bed wetters and people who engage in high-impact exercise are more likely to. Even women without babies who’ve had… Go ahead to the next one. So even we find that women 18 to 40 who’ve never had a baby, are active and have a low BMI may have up to 23% urinary incontinence. Go ahead.

Elizabeth Owings, MD (47:01):
30% in athletes versus 13% in controls. These are young women, roughly median age, 19. 372 athletes and 372 age match controls. Their risk factors were high-level sport, a history of urinary tract infections, had family history of urinary incontinence, and constipation. And I think the family history of urinary incontinence goes along with maybe some anatomic features. History of constipation, I think probably as well as high impact exercise goes along with increased abdominal pressure. You’ve got all this pressure. Just think about jumping on a trampoline, just like jogging. A woman with urinary incontinence may never jog again. She may just walk. So that’s something that you can use to reach people and reach their pain. If they’re changing their lifestyle because of urinary incontinence, that’s a big deal. Go ahead.

Charles Runels, MD (47:56):
I think you just made a big point. How much leaking do you have to have before it counts as incontinence? Sort of like the question, how big does a boat need to be before it’s a ship? It has to be so big you cannot carry it across land. Now it’s a ship, not a boat. And the answer to how much leaking before you have incontinence… For you guys on the call, I haven’t tried to define that… Is if it interferes with your hygiene or your lifestyle. So you have to start wearing a pad or change your clothes, obviously, hygiene. If you stop something that you normally like to do, like your gymnastics or cheerleading as a teenager, which is 1 in 20 teenagers, in college people, or you can’t sit through your meeting at work, you’re changing your lifestyle. That’s incontinence.

Elizabeth Owings, MD (48:44):
Yeah. So many of these are similar. Go ahead and see if you can find a sister study. It’s not too much further ahead. Yeah, sisters. I love this. So they took post-menopausal women, and one sister had never had a baby and one sister had had a baby, and they found that the incidence was exactly the same. 47 versus 49%. That is not statistically significantly different.

Charles Runels, MD (49:08):
Totally unsurprising, huh?

Elizabeth Owings, MD (49:11):
Yeah. And then sisters had a high concordance. They were very likely to have the same situation. If one had normal continence, then the other one probably did. And the same thing for incontinence. Go ahead. And then the elite trampolinists. So this was fun. So 80% of the… These were 12 to 22 year olds. Mean age was 15. 80% during training, they would leak about an ounce. Started after two and a half years of training.

Elizabeth Owings, MD (49:41):
And if they put a pad in and tested, they found that it was a hundred percent over the age of 15 were leaking during their training event. So it’s not a sphincter, that urinary incontinence mechanism. There are a lot of parts to it. It’s much more sort of like a siphon, like a valve and not a sphincter. Because it can be overcome, just like the valves and the veins in your leg can be overcome if there’s enough pressure. So that’s what I wanted to say there.

Elizabeth Owings, MD (50:12):
Thinking about this in the future and how to teach this and how to think about this, I’ve been thinking about models. I think that’s where I’m going to be going. The direction I’m going to be taking is making a form of model where some of these parts can be snapped together and then unsnapped so that you’ve got not just a visual, but you can actually hold things in your hand and go, “Oh, this is how this goes together.” With perhaps various stages in, because it’s the same, maybe at eight weeks gestation, it’s exactly the same. You can’t tell the difference, whether it’s a male or a female. They are the same at that point, from the standpoint of what the tissues look like. And these changes come over time. Lots and lots of influences, and over the weeks, between 7, 10 weeks or so, things are changing so that eventually you can tell the difference, which is a boy and which is a girl. Usually. Those ultrasound people get it wrong sometimes.

Charles Runels, MD (51:20):
I’ve never seen such a low dropout rate. You’ve held everybody’s attention. I think this is the best clitoral anatomy… and I’ve heard others… lecture I’ve ever heard. And could I just have an email that people could contact, because I know that you teach classes. Dr. Owings will do a one-off class if someone wants to go follow her around and see how she thinks about her business. She’s in several different cities with her practice, so there’s some menu there to choose from. Could I just type an email address into the chat box so they can reach out to you?

Elizabeth Owings, MD (51:55):
Sure. That’d be great. E as in Elizabeth, P as in Patricia, Owings, O-W-I-N-G-S @gmail.com.

Charles Runels, MD (52:03):
Okay.

Elizabeth Owings, MD (52:03):
Am I supposed to do that or are you going to do that?

Charles Runels, MD (52:06):
I just typed it in. It’s all there. Thank you so much for being on the call. Anything else you want to throw out there before I shut it down?

Elizabeth Owings, MD (52:12):
No. No. Just looking forward to hearing from everybody. Thank you so much for your attention.

Charles Runels, MD (52:16):
Thank you, Elizabeth. You have a wonderful night.

Elizabeth Owings, MD (52:22):
You too.


Relevant Links

Zheng Z, Yin J, Cheng B, Huang W. Materials Selection for the Injection into Vaginal Wall for Treatment of Vaginal Atrophy. Aesthetic Plast Surg. 2021;45(3):1231-1241. doi:10.1007/s00266-020-02054-w<-click-to-read<–
Runels CE, Melnick H, DeBourbon E., A Pilot Study of the Effect of Localized Injections of Autologous Platelet Rich Plasma (PRP) for the Treatment of Female Sexual Dysfunction. J Women’s Health Care 2014, 3:4
—>>>Click here to read. The introduction explains the science of the O-Shot®<–click<—


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