The P-Shot and O-Shot
Dr Sherif Wakil outlines his pioneering use of platelet rich plasma for the effective treatment of male and female sexual dysfunction
Sexual dysfunction is a major public health concern with sexual health issues having a significant impact on interpersonal relationships and quality of life for both men and women. It’s estimated that one in 10 men has a problem related to having sex, such as erectile dysfunction with men over the age of 75 have a staggering 77.5% chance of suffering from erectile problems. While issues pertaining to male sexual dysfunction are more commonly talked about, sexual health issues also affect a surprising number of women.
According to the Sexual Advice Association, sexual problems such as Hypoactive Sexual Desire Disorder (HSDD), Female Sexual Arousal Disorder (FSAD), Female Orgasmic Disorder (FOD) and Dyspareunia (pain that interferes with sex), impacts around 50% of women, however, very few women discuss the sexual issues they are having with a physician. In fact, the percentage of women who do speak about it is as low as 14%, according to the American statistics, which also states that almost 40% of women suffer from one or more type of FSD to the point that is causing them psychological distress. Added to this is the fact that, although there are various treatments for erectile dysfunction in men, there are no virtually no FDA-approved treatments for sexual dysfunction in women. The only exception is Flibanserin, sold under the trade name Addyi, a medication which was recently approved for the treatment of pre-menopausal women with HSDD.
With a demand for safe and effective treatments in this field for both sexes, a new revolutionary, non-surgical treatment modality utilising PRP is opening up new and exciting possibilities. These treatments are known as The O-Shot and the P-Shot.
What is PRP?
Platelet rich plasma, usually referred to as PRP, has been used in various fields of medicine including cardiothoracic surgery, plastic surgery, sports injuries, wound healing, and rejuvenation with satisfactory results. Injections of PRP have also recently shown to be effective in treating sexual dysfunction. PRP is obtained from patient’s blood by high speed and sophisticated centrifugation. The resulting PRP can be activated with either calcium chloride or calcium gluconate.
It is imperative that PRP is injected within 10 minutes of activation otherwise it will clot. Various growth factors i.e. transforming growth factor (TGF), platelet derived growth factor (PDGF), vascular endothelial growth factor (VEGF) and insulin-like growth factor (IGF) are secreted from the alpha-granules of concentrated platelets activated by aggregation inducers. These factors are known to regulate processes including stem cell migration, attachment, proliferation and differentiation as well as to promote extracellular matrix (ECM) accumulation by binding to specific cell surface receptors. It has been shown that PRP may induce the synthesis of collagen and other matrix components by stimulating the activation of fibroblasts, this in turn rejuvenates the skin.
Centrifuge—single spin vs dual spin
Not all PRP is created equally. The quality of the PRP will depend on a number of factors, one being the type of centrifuge used. In terms of centrifuges we often talk about ‘single spin’ and ‘dual spin’, although we can also think about it in terms of ‘separation’ versus ‘concentration’ techniques. In order to truly concentrate the platelets a dual spin centrifugation system is needed. The initial spin removes the red blood cells from the plasma, resulting in a mixture of platelet rich plasma (PRP) and platelet poor plasma (PPP), which contains a relatively small number of platelets. A second spin is then necessary to create a finer separation which removes the PPP, leaving a higher concentration of platelets and resulting in PRP that falls within beneficial levels (six times baseline). The most effective solution should be no less than four to six times the concentrate.
The P-Shot is named after the Greek god of fertility, Priapus. It is indicated for erectile dysfunction, improvement in sensation and function, Lichen Sclerosus and Peyronie’s disease. It also helps increase size and girth when combined with an approved pump.
Causes of erectile dysfunction:
Erectile dysfunction can be caused by ageing, psychological conditions (such as anxiety), depression, neurological disorders (such as Parkinson’s disease), pelvic surgery and endocrine disorders e.g. diabetes and interactions with prescribed drugs. In 40% of the cases, the cause is atherosclerotic disease.
Treatment modalities for treating erectile dysfunction include:
• Psychological support e.g. counselling
• Pharmacological e.g. Phosphodiesterase type 5 (PDE-5) inhibitors which are usually the recommended first-line treatment for ED
• Testosterone replacement therapy for cases of androgen insufficiency
• Vacuum constriction devices
• Vasoactive drug injection therapy
• Surgical treatment: surgical implantations of penile prosthesis, which can either be inflatable or malleable.
All of the above could have risks and complications which vary in severity. These encompass side effects from PDE inhibitors such as headaches, flushing, dyspepsia and nasal congestion, unsatisfactory results from vacuum restriction11 and risks of complications from surgery.
The P-Shot procedure
Lasting approximately 40 minutes, the P-Shot procedure is quick and easy to perform. Local anaesthetic, preferably lidocaine, is applied to the glands and shaft of the penis.
Around 60ml of the patient’s blood is taken under proper aseptic precautions and placed in a special high-speed centrifuge to obtain 10ml of PRP. After sterilising the penis, the PRP is activated with a few drops of calcium chloride to trick the platelets in the plasma into thinking the body has been injured—by initiating fibrinogen cleavage and fibrin polymerisation—so they release growth factors. The harvested PRP is then injected into the corpus cavernosum in a very specific way according to the P-Shot protocol. Treatment can be tailored according to patient’s complaint and indication of the treatment.
The growth factor-rich plasma will lead to an initial increase in size. Growth factors trigger stem cells to increase blood flow and generate healthy tissue growth, which will continue for about three months. It will also help in regaining the sensitivity in diabetic patients by regenerating CN. If combined with an approved penis pump, treatment helps patients gain an increase in length and girth. Patients usually see an increase in the flaccid position within four to six weeks and in erect position in four to six months of continuous use of the pump following the P-Shot treatment. Some patients could have the P-Shot repeated in one year or less, since it is not ‘an antibiotic course’ and, as such, no limit exists to the number of treatments that should be given. Referring to it as a ‘vitamin shot’ for their penis, patients also report increased pleasure during sex, increased ability to achieve an erection and maintain it for longer.
Downtime and aftercare
The P-Shot has the advantage of carrying no downtime and zero to little discomfort. Patients can even exercise and have sexual intercourse on the same day. Typically, there are no side effects (except from a few drops of blood from the injection site and mild soreness). Rarely, bruising is reported or lumps are formed which tend to resolve themselves or with non-steroidal anti-inflammatory drugs. As this procedure uses the patient’s own blood, and is all natural, there is little risk of allergic reaction. Usually one injection is sufficient, however, some patients might need top-ups for sustained results or if their disease is severe. This usually depends on the patient’s age and lifestyle factors such as whether or not they are a smoker, or heavy drinker.
The following results have been reported by patients following PRP injection into the penis (The P-Shot) for male sexual dysfunction:
• Increased erection quality
• Heightened sensation and pleasure
• Increased firmness of erection
• Improvement to the symptoms of Lichen Sclerosus
• Improvement in Peyronie’s Disease
• Increased sexual stamina
• Healthier appearance
• Increased blood flow and circulation
• Increased length and girth when combined with the penis pump.
Most patients report an immediate increase in girth, which, as described above, is due to the injected plasma. This may slowly reduce over the next week as the plasma is reabsorbed by the body but will usually increase again over the next three to four weeks, due to the growth factors initiating the regenerative process. Firmness and strength of erection is noted after about four weeks and will continue to improve over the next three months. Immediate improvement in sexual function has been reported, which I believe may be in part due to psychological factors, however, optimum results are seen four weeks later. The effects of treatment continue to improve for up to three months and may last for 12 to 18 months.
Measurements of results
There are various ways to evaluate the effectiveness of treatment. The measurement of nocturnal penile tumescence and rigidity (NPTR) is a safe method of defining erectile function. Electro diagnostic methods include penile nerve conduction test, bulbocavernosus reflex responses and pudendal somatosensory evoked responses. Penile biothesiometry is promising for evaluation of penile sensation.
The erection hardness score is also a good way to assess improvement as well.16
0—Penis does not enlarge.
1—Penis is larger, but not hard
2—Penis is hard, but not hard enough for penetration
3—Penis is hard enough for penetration, but not completely hard
4—Penis is completely hard and fully rigid
These scales can be utilised to quantify the improvement in sexual function.
Many women suffer in silence about the issues they are experiencing in terms of low desire; low levels of sexual arousal or lack of feeling; difficulty in achieving orgasm and even more difficultly in achieving vaginal orgasm (orgasm from vaginal intercourse without clitoral stimulation); urinary incontinence or pain during sex, brought on by child-birth, the menopause and other factors.
Recently the first FDA-approved drug aimed at female sexual dysfunction was released. The drug is known as Flibanserin (sold under the trade name Addyi), but only targets one type of FSD—hypoactive sexual desire disorder (HSDD) in pre-menopausal women. HSDD is only one small factor that effects women with FSD. While taking Flibanserin may help with this one aspect, it does not address any of the other issues and, as such, is like filling a car with gas when the engine and cables do not work. There are also some undesirable side-effects attached to the drug, such as syncopal attacks as well as some inconvenience e.g. the patient is not allowed to drink alcohol during the period she is receiving the treatment.
Other treatment options for FSD
Calcium hydroxyapatite crystals can be used to treat USI, but they could have some side-effects, such as urinary obstruction, erosion and granuloma formation. Injections of hyaluronic acid to enhance orgasmic sensitivity lack data to support its use. Vaginal oestrogen and transdermal testosterone patches have been tried but testosterone can lead to side-effects such as acne, hirsutism and virilisation. The O-Shot is an all-natural procedure with a safer side-effect profile than previously offered treatments.
It is for these reasons and more that I believe in the benefits of the O-Shot.
The O-Shot, or ‘Orgasm Shot’ was invented in 2010 by Dr Charles Runels, MD (Alabama, USA) and is a method of injecting the vagina with PRP in a bid to regenerate the vaginal tissues and regain sensation.
The O-Shot is suitable for treating the following:
• Urinary stress incontinence (USI)
• Reduced sensation
• Decreased arousal
• Vaginal dryness
• Reduced sexual desire
• Lichen sclerosis
• Fissures post episiotomy
The O-Shot procedure
The O-Shot is a pioneering new non-surgical technique, which offers a quick, safe and simple solution for a variety of concerns associated with female sexual dysfunction. A strong topical anaesthetic cream is applied to the anterior vaginal wall and the clitoris after retracting the clitoral hood. The injection is then performed, according to the O-Shot protocol, which we have modified quite a few times to date in order to achieve the best results. With the experience that we have gained in injecting thousands of women, we do change the protocol according to each individual complaint and needs, so injecting a patient when the desired outcome is to increase sensation is different from injecting a patient with Lichen Sclerosus. Both of these techniques are also different from the way in which we would inject a patient with urinary incontinence and so on. For example, in the latter, we aim to change the vesicourethral angle with the volume injected in the anterior vaginal wall.
Following the treatment, there is no downtime. The patient can even resume sexual activity almost immediately after the procedure. From my experience, there is often an immediate improvement in sexual dysfunction and arousal, due to the volume effect of the PRP, which increases the friction during penetration. This may dissipate over a few days but then slowly improves again over the next three to five weeks, with full effect often achieved at around three months.
Potential side-effects may include (as with any injection) spot bleeding, bruising, tenderness, a warm or burning sensation in the area (this usually settles within minutes/hours), temporary localised numbness (due to the local anaesthetic effects) and hypersexuality or increased arousal, especially in younger women with previously normal or close-to-normal sexual function.
A pilot study of the effect of localised injections of autologous PRP for the treatment of female sexual dysfunction was published in 2014. 11 females, aged 24-64, presenting with complaints associated with female orgasmic disorder, hypoactive sexual arousal disorder, anorgasmia or dyspareunia, participated in the study. After receiving the O-Shot seven of the women treated (64%) demonstrated some degree of improvement (Table 1). Five of the seven women who started with elevated levels of sexual distress in the FSDS-R, in which the threshold of distress is defined as a score of 11 or more, dropped their scores to less than 11. Therefore, according to the test criteria, 71% of the women improved from being ‘distressed’ to being ‘not distressed’ after the procedure.
The effectiveness of PRP for the treatment of vulvar lichen sclerosus has been established by a study of nine patients with the disorder. Two patients were lost to follow-up. Of the remaining seven, four had decreased inflammation on post-treatment biopsies, one had no change, and two had ‘minimal’ increase in inflammation.
Another study demonstrated that PRP injections lead to decreased inflammation in vulvar lichen sclerosus without the potential side-effects associated with topical or systemic immunomodulators. King et al at the Center for Vulvovaginal Disorders, Washington, DC published an exploratory study designed to evaluate the efficacy and safety of autologous PRP injections for the treatment of vulvar lichen sclerosus. They concluded that the effectiveness of PRP is based on its high level of growth factors such as PDF, TGF-β, and EGF. These growth factors are important in modulating mesenchymal cell proliferation, and extracellular matrix synthesis during healing.
The vast majority of published literature shows that autologous PRP has minimal risk of scar tissue formation or serious adverse events. The results of this exploratory study suggest that PRP injections decreased histopathologic inflammation in women with vulvar LS without the potential side effects associated with topical or systemic immunomodulators.
With more than 30,000 procedures performed worldwide, the results of the O-Shot and P-Shot look promising. Being autologous, PRP is safe with minimal side-effects. It is good to know that now there is something substantial available in the ever-demanding field of sexual aesthetics. However, proper training of how to administer the O-Shot and P-Shot is of upmost importance for patient safety. As well as this, ongoing collection of data, which I am continuously involved in, is mandatory to provide the patients with the best care and achieve the optimum results.
Dr Sherif Wakil is the founder and medical director of DrSW Clinics. He has more than two decades of experience in heath care and has worked in leading hospitals in the UK and Middle East, including The Royal London Hospital NHS Trust and is now based on London’s Harley Street. Dr Wakil has performed more than 20,000 procedures and has introduced a number of new treatments to the UK and Europe, including the P-Shot and the O-Shot and the Vampire Breast Lift early 2014, He is the only trainer for these procedure in Europe and the Middle East.For the past few years Dr Wakil has been at the forefront of the non-surgical sexual aesthetics arena with his new sexual rejuvenation treatments and cutting-edge machines—so much so that he has been named ‘Dr O’.