What to Do When Bad Things Happen to Good Penises

26:46How do you tell the difference? Penile fracture, you immediately lose your erection and anything else, even with a pop, You may have just, you know, maybe it was your back too. Could have been just one of your vertebrae cracking because you're in the throes of it, but not a penile fracture. So really the fundamental what patients and what their listeners need to know is if they are having intercourse, they hear a pop or they feel a pop, they lose their erection. Within minutes, their penis will swell. And within minutes after that, it will become very, very discolored. So they will very much turn into a black and blue looking penis.

27:25And so something that you have to seek emergent care for. Some guys don't, and I will see them days to months later. Months? Months. Yeah, because, you know, there's, again, the overwhelming theme of this show is guys being more open about their health and their emotions and everything. And there's a shame factor. And I think if a guy does that, it's very difficult for him to go in, talk to some triage nurse in the emergency room about what happened, and then also talk to physicians and everybody else there. And so it's, again, medical professionals, we're used to dealing with this. This is a very common thing in our emergency rooms.

28:07So disavow yourselves of any shame, because if you do come to me in the chronic setting, you're most likely going to have significant scar tissue that's inhibiting normal erections, or you may even develop one of the other P's of the Pinocalypse, which is Peyronie's. And so we'll get into that here in a few minutes, but immediate surgical care, because we can often make a small incision, find where those two ends snapped, and just put a few stitches in, so you back up, Bob's your uncle. So it's not a end of the world thing if we actually get to it very soon. And most guys recover and have full function of their penises again without any long-term issues.

28:46But boy, if you don't get treated soon, it makes it much harder. And in fact, if a guy waits even a week after a penile fracture, surgical intervention is usually not very successful. And we just have to let it heal and see what happens. How long does that take to heal naturally? Months, you know, before all the swelling and everything goes down. And so again, if I see a guy, even if that is you, if you're listening now and you think you sustained a fracture in the last weeks to months, still make an appointment, go see your urologist. Because I usually will put these guys on PD5 inhibitors, potentially do a penile ultrasound, see what the state of things are.

29:23Certainly a physical exam to feel if I'm finding any plaques or any scar tissue. And so we can still be proactive because it takes about six months for any injury to fully heal, whether it's an orthopedic injury, whether it's a cut, whether it's a penile injury. And so during that six-month time period, there may be a role for adjuvant therapies, like, for example, shockwave therapies we just talked about. I've treated men for penile fractures that have not been immediately addressed and had some success with this as well. So it's never too late. We'll always figure it out. And just, you know, make sure that if it happens acutely, seek care.

30:00If it happens chronically or to one of your partners, have them seek care at whatever time in the diseased course because we can always intervene. So seeking care ASAP is crucial. Is there anything that they should absolutely under no circumstances do that might seem counterintuitive? Yeah, I mean, so there's a little bit of an interesting subcurrent that if you look at, there's the two main ways that penile fractures happen, and there's actually been pretty good literature on this, is one where you're not in bed, but you're in the backseat of a car, an elevator, on the side of a yacht. wherever that you're not normally making sweet, sweet love, penile fractures are more common.

30:47You want to hear something cool? No, terrible. I don't mean cool. You want to hear something crazy? You know, in the movies, like when somebody gets shot and nobody wants to get in trouble, but they don't want a guy to die, they just roll up to the side of the emergency room, kick the guy out, and then they take off. That happened to a patient of mine, I don't know, 15 years ago, where he was in the throes of passion with somebody that was not his wife in a hotel room. sustained an injury. And I think like barely did she let the car roll to a complete stop before she pushed him out on the doorsteps of the ER and then took off.

31:20And the social nature of what I had to do for this man to repair his fracture. First of all, it was a, it was a complete through and through fracture where he ruptured through his urethra. So he couldn't urinate and both corporal bodies. So I basically had to reconstruct his entire penis. I was actually on vacation and one My partner's called and said, Mills, there's no way I can do this. And so I come in to the ER and took about two hours or so to get all of the chambers realigned, fully reconstruction over a catheter. Meanwhile, you know, I thankfully knew from the emergency room that the person that dropped him off is no longer there and it was not his partner.

31:58Those are sort of the last words he said before he went under anesthesia and I started repairing him. So thankfully, socially, I didn't have to make that mistake and let him kind of have his comeuppance later. However, that manifested itself, not mine to judge. But yes, so the drive-by, the drive-by penile fracture dump in the ER, it's a real thing. But thank goodness he came in immediately, and I was able to fix him. So all kudos to the perp here that dropped him off. The sixth P. That's right, the sixth P. So that's, you know, maybe not having crazy jumping off the chandelier sex is a good way to keep your penis intact.

32:41And then alcohol. I mean, almost always alcohol is involved where you kind of dissociate. You don't feel normal triggers that, oh, that may have hurt. And then all of a sudden you went from that's uncomfortable to pop. So, yeah. So drunken sex sounds like a good idea. It never is. And then, yeah, just kind of be careful about your environment. That's it. keep your penis out of trouble. It's been good to you. Be good to it. I wish you were in a white lab coat right now. This is so, this is so like the more, you know, the more, you know, that's right. You know, I missed that afterschool special growing up.

33:11Think of, think if they would have done that then. And it was especially with like the voice of Morgan Freeman, some authority coming at you, you know, Orson Welles, Orson Welles. Yes. Yes. George Carlin would have been a good one. Anyhow, he would have not been able to do it straight. All right. So there's a penile fractures. Avoid. Not good. Not good. We made it through. We made it through that one. You made it through. Yeah. You kept your color. You're getting better at this. You know what? I'm getting my honorary medical degree by doing this. I'm starting to build up my tolerance. Attaboy.

33:44Attaboy.

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36:10So, phimosis, the pH of the five Ps. so this is where and obviously i shouldn't say obviously but in men that are not circumcised where your foreskin is unable to retract over the head of the penis is a phimosis and there's a physiologic phimosis in other words when boys are born the foreskin shouldn't really retract nor should parents try to retract it so if you're out there as a new dad and you're and and you decided to keep your son's foreskin then don't go and immediately try to pull his foreskin back because of listening to this episode, because there's a physiologic phimosis where that foreskin shouldn't retract until they're well into their four or five, six, seven year old.

36:51So it'll come naturally eventually when that skin releases, but for some it doesn't. And sometimes teenagers, if they've never been able to retract their foreskin, it can become a little bit of an issue because you will get dead skin cells that will slough under the head of the penis and build up scar tissue and build up debris that is difficult to clear. And it actually can cause adhesions where that foreskin will fuse to the glands. And then that becomes difficult because it's tough to pee sometimes. Because if that opening fuses shut, then you get what's called ballooning phimosis, where every time either a kid or even a guy pees, the pee has to trickle through the foreskin before it goes out through that very tiny aperture of the head of what we call the prepuce.

37:34And so that's no good. So we have to figure out how to fix that. And the other thing that happens is they develop these bands of tissue that are so tight that you can't retract the foreskin either. And so the most important thing for anybody listening that may be dealing with this is that if you're an adult and you are unable to fully peel your foreskin back, it's not good because A, it can cause infections. And B, one of the things that men that are not circumcised at birth is that there is actually another P, I guess not really a P, but a PC, there is a risk of penile cancer. If you can't pull your foreskin back, you can get tumors.

38:13And it's usually, it comes from the papillomavirus to the HPV that if you're not vaccinated against it, you can get a virus that can lead to what we call squamous metaplasia, which then can lead on to cancer. So the last thing that you want is to miss that when it's early and it can be treated. And so if you can't withdraw your foreskin back behind the head of your penis, that's phimosis, needs to be treated. And the other part of this is that there is a little band of skin called the frenulum, which attaches just underneath the urinary opening, what we call the meatus, to the shaft skin of the penis.

38:49And some guys will have tethered frenulums or short frenulums where no matter what they do, they're like, Mills, I'm doing everything you're saying and I still can't peel this all the way back. That's called frenulum brevi and that's what can lead to bad phimosis. That also needs to be seen and treated where sometimes we can do just a little release. Just like, you know, the saying tongue-tied is when the frenulum is too tight. When babies have to get a little frenular release in the tongue, you can be cock-tied as well, I guess. I'm not sure that's ever going to take off. But anyhow, yeah, I can see by your expression, it's definitely not going to take off.

39:22We'll just keep it at a frenulum breve. You can fix that one in post, right, Jordan? I'm keeping that. Yeah, you're keeping that. I know. This is why I got to be one take mils because you will not edit. And I'm okay with it. I mean, it keeps it natural and fluid. Anyhow, phimosis, not cool. Well, fire away with questions. So tell me what's in your head about all the things that can go wrong with phimosis because we're going to get to the next thing that's the most critical thing that could go wrong with phimosis, but fire away. I mean, this is a new one for me. I hadn't really heard of this until researching this episode.

39:56Are there, I mean, what are the non-surgical treatments? Are there steroid creams? Yeah, steroid creams and physical therapy, essentially, just, you know, when I see a guy that has it, he may not even know he has it. I may be seeing him for something else. And I say, hey, have you been able to pull this foreskin back? And he says, no, you know, actually I haven't been able to. Then I teach them with, yes, beta-methasone or a couple different, there's even stronger steroids out there, but those can help release some of the inflammation, cause the skin to be a little bit more supple. But you can't keep on long-term because those can lead to penile infections.

40:35So I usually do a six-week course of beta-methasone. There's actually medical devices. There's little ring expanders because I tell you, and maybe we should even talk about this whole idea of circumcision versus non-circumcision, either as kids or as adults, because there's a lot of religious overtones. There's a lot of social overtones of this. There's a lot of guys that either wish they weren't circumcised when they were born or wish they were. And so there's some parental issues. There's some genital mutilation issues that may be worthy of its own episode. But whatever the case, if a guy has phimosis, doesn't want a circumcision, because that's the surgical cure for this, then there are these rings that you can buy.

41:20They're like little gaskets. And you put a smaller one in every day and then stretch it, stretch it, stretch it. And I've actually seen some success with those because there is a tissue expansion quality to healthy skin. for guys that have severe advanced phimosis, they can get what we call metaplastic changes where that skin is totally inelastic and it'll never stretch. And it can lead to a pretty severe condition called lichen sclerosis, which then can lead to something even worse called BXO or Balanitis Xerotica Obliterans. Anytime you say Obliterans and penis in the same sentence, it's really pretty scary sounding.

41:57You definitely don't want to obliterans to penis, right? So BXO is the end sequellum of poorly retracting foreskin. That has to be treated surgically. There's not any amount of steroid cream that can make that go away. But yeah, you let into it. So for example, earlier this week, one of my surgeries I performed was on a 58-year-old guy that had really bad phimosis, tried everything, steroid creams, tried every kind of retraction exercise, but it was making it very difficult for him to have intercourse and sometimes to even urination. And so that's somebody that I had to do what's called a circumcision and frenuloplasty, where I took down that shortened frenulum, reconstructed him and made a very nice penis for him.

42:40I hope we'll see how he heals. But everything went great surgically, so he should do well. But again, at 58, lived with his foreskin this whole time, and it was time to go. We couldn't retract it. He was starting to get that lichen sclerosis. And had I not done something in the next month to year, he could have started developing BXO. So that's what we want to avoid because that skin is completely diseased. Can't sew to it. You can't do anything other than excise it. And I've seen BXO so bad, Jordan, where we actually have to do skin grafting and actually take off that skin and skin usually from the inner thigh, kind of the most hairless portion of the thigh that we can borrow that skin to reconstruct the penis.

43:21So that's a really big deal. We don't want to do that if we can avoid it. So, yeah, phimosis, not good, but not terrible. either. And if we can cure it non-surgically, then that's what we're going to try to do. Unless a guy comes in and says, look, to heck with it. I just, I just want this over this. I don't deal with this when I'm 70 or 85 years old. How common are adult circumcision surgeries? Boy, I had no idea. Common enough, you know, and my practice is a little more specialized to the point where I don't do a lot of these, but if it's a patient I'm seeing for something else, then obviously I'll take care of them.

43:53But I think they're relatively uncommon. Most of the time, if a guy gets through childhood adolescence without getting phimosis, then he's going to be okay. Sometimes I have had men, usually in their 20s, 30s, that really want purely a cosmetic circumcision that they just, and I really want to make sure they're doing it for the right reasons. You know, I've had guys come in and said they were with a partner that didn't want them to have foreskin anymore. And that, those are the guys I really try to dissuade from because, you know, if somebody is asking you to do something to alter your body permanently, you have to come up with a really good reason for it other than doing this for, you know, a partner that may not even be your forever partner.

44:31So cosmetic circumcisions, I'm a little less excited about doing unless it's completely a hundred percent his decision. Nobody's forcing him into that. And so, so there's a little more of a mental health component to those that I want to make sure we're doing it for the right reasons. But yeah, at most of the time there's, you know, which is why very, very few societies recommend routine circumcision because, you know, we're born with it for a reason. It has some protective issues or maybe some sexual reasons that having that extra foreskin is a good thing. And so, yeah, I'm not a routine circumciser or advocate for that in any way possible.

45:08It's a decision that, you know, guys need to make on their own unless there's a medical necessity for it. So that's phimosis, I imagine. Yeah. The opposite of phimosis is paraphramosis. Look at you, the fourth P. Yeah. And so paraphimosis is when you have phimosis, but it gets really bad to the point where you try to retract your foreskin. Again, if you're listening and you're sitting there thinking, man, I just, if I pulled a little harder, then I'll do what Mills told me. And the problem is that we talked about that phymotic band and it's a tightened piece of that shaft skin that when the penis is in its flaccid state and it's in its non-retracted state, it's usually okay.

45:45But if you try to pull back your foreskin and it gets stuck behind the head of the penis, it's that band that can actually cause pretty significant damage. it can actually inhibit blood flow to the head of the penis and cause what we call glandular ischemia, which if it isn't treated, can lead to what you call glandular necrosis, which is a horrible thing, where you actually can lose blood flow to the tip of the penis and potentially require some kind of emergent surgery to either restore blood flow or, you know, sometimes in the worst, worst possible scenario, the disaster striking scenario, can you lose a little bit of the tip of the penis.

46:20So paraphimosis, surgical emergency, or at least medical emergency. And so if anybody out there has foreskin, they retract it and they can't unretract it and they start to see pain and it starts to swell. It gets to the point where you have to do something somewhat forcible to re-retract it. And that's sometimes I've been called to the emergency room all hours of the night where I have to do something in the ER to immediately restore blood flow. It's something we call a dorsal slit where we just cut that phimotic band so that we can restore blood flow and then either formally do a circumcision or let that dorsal slit heal and then have them come back to fight another day for just more of a cosmetic appearance.

46:59But yeah, paraphimosis, really, really bad. If you're a parent and you have an infant that has that where you're not getting that foreskin back over, maybe you're changing diaper, you're cleaning the penis and it just retracts and it starts to get puffy and swollen and you see the head of the penis, you have to be able to go in and have that treated. Now, for parents out there that you see that, you can sometimes just gently hold pressure and squeeze the head of the penis to the point where that swelling gets down. And then you re-retract the foreskin. And that's the first thing a medical professional is going to do as well.

47:36So not that we're at all having a podcast where I'm saying this is medical advice. More of a suggestion to try as you have your pediatrician on speed dial or at least think about going to the emergency room. but paraphimosis also very very uncommon very uncommon because first you have to have foreskin second you have to have diseased foreskin and third you have to have enough laxity to be able to retract at the point where you get in trouble but certainly something that can happen so just remember that you heard it here and that that if that foreskin is not fully unretractable back to its normal state then you have to get some kind of medical attention this is a question born completely of ignorance as most of mine are, which is why I'm here.

48:18Love this. Makes it easy for me, Jordan. And I completely understand if this is something that you don't want to answer or want to answer on a separate episode. It sounds like there's a lot of things that can go wrong if you aren't circumcised. Oh, wow. Do you have opinions on circumcision at birth? Yeah, boy, that is a whole nother episode, I think, because we should bring in a pediatric urologist. We should, you know, there's a lot of, yeah, Yeah, the answer is, yeah, I have zero opinion. Otherwise, we'll have our email just flooded with people that will either hate me or love me. But there is no in between.

48:55Yeah, so my, you know, the answer is, if there's a cultural, religious reason to do it, then that's all I'm going to say for that. Is there a medical reason? This I can answer now, and then maybe we can unpack later. But if there's a, is there a medical reason? So the answer is two. So back in the bad old days of HIV, when we had no treatment for it and people were dying at an alarmingly high rate, we did find that the penis, the foreskin, was a reservoir for HIV. So there's some interesting studies, mostly out of sub-Saharan Africa, that showed that circumcising adult populations could dramatically decrease the spread of HIV.

49:38And so there are actually global initiatives to do that. And, you know, now that we have things like PrEP and some medications even to treat the antiretrovirals to treat HIV, not as much of a public health imperative to do that. That's number one. And number two, which again, we have modern medical solutions for is, as I was saying, the rate of penile cancer is almost unheard of in men that are circumcised at birth. Because as the foreskin will hide HIV as a reservoir, it also can hide HPV or the human papillomavirus. And there's a few strains of HPV that can lead to malignancy, that can lead to a squamous cell cancer, not only of the penis, but also of the cervix and also of the throat.

50:28And so head and neck cancers are exploding in people because of the HPV. So oral sex can lead to HPV transmission into the nasopharynx and the larynx and cause cancer of the head and neck. Now that we have a vaccine against HPV that's incredibly effective, those rates should go down to the point where this is a completely preventable disease in both men and women, regardless of who your sexual partners are, you're at equal risk, as well as I should say, anal cancers too are HPV. And so that also is something that we see in both men and women. So this is gender nonspecific and certainly a public health urgency.

51:12But with the advent of the HPV vaccine, those rates have gone down. But if you look at countries where they don't routinely circumcise their youth, there are endemic rates of penile cancer, mostly in South America, where that strain of HPV is so prevalent that almost anybody that's had multiple sexual partners will have been exposed to the more malignant variety of that virus. And so the good news about circumcising infants is that they are protected against penile cancer, but their partners are not necessarily protected against cervical cancer if they're having heterosexual relations. And so in some ways, it's kind of a false sense of security, not very giving or sharing, because still, you know, HPV and genital wards is what leads to cervical cancer, anal cancer, throat cancer, and penile cancer.

52:05So anyway, so it's sort of a false sense of security if you say, hey, I'm good, but, you know, but anybody that you have sex with may not be any of those other orifices that we talked about. And so, no, I mean, vaccine is probably the most important thing we can say about HPV prevention, as well as, you know, good, not vaccines for HIV, but good preventatives so that you can never really achieve a viral load. So those two arguments are kind of out for routinely circumcising because we have good medical therapies and preventative therapies for both of those conditions. So no, I do not believe that every kid should be circumcised, but when they do have a medical problem like we just talked about where they have an anatomic issue that can lead to phimosis and then that slippery slope down to the point where they have medical phimosis that can't be treated conservatively, then, yeah, but that would be circumcising thousands upon millions of guys to treat a relatively uncommon problem.

53:06That was an incredibly graceful and incredibly insightful answer. Thank you for that. We'll see how it goes. We'll see what the trolls say. But, yeah, so that's paraphimosis. And then the last one, again, I think, you know, we're going to hit really, really hard because this is a lot of the research and a lot of what I spend my days doing is taking care of something called Peyronie's disease. But it begins with P. It is one of the more devastating things that happened to perfectly good penises. And so I'm just going to foreshadow, we're going to give them an amuse-bouche, if you will. I don't think you will, actually.

53:38You probably shouldn't. But anyhow, it came out. Again, you won't fix it in post, I know. So it's too good. Yeah, every time I really say something that's going to get me in trouble, you say it's too good. I love it. so Peyronie's is where you get this plaque formation scar tissue in the tunic alboginia which now we've learned is what keeps our penis cylindrical and what keeps us in trouble for developing priapism because it becomes this impermeable fascia and it's also what snaps then it becomes hyperpermeable in penile fracture and in Peyronie's it's where scar tissue builds up an abnormal deposition of certain bad types of collagen.

54:19And again, I mean, the genetic basis of this, we know, we don't really know how to prevent it. It could happen to anybody. We could wake up tomorrow and all of a sudden, if you have a penis and you wake up in the morning with this condition, that could happen, could happen to any one of us. And so awareness is important because there are great therapies available for this. There's great, we really have to look at this as a mental health disease too, because anything that happens to our penis really messes with our psyche, messes with our identity as men and peronies for sure. Why? Because what happens is when you get this deposition of scar tissue in that tunic albogenia, instead of having a nice cylindrical, the penis you remember before you had the scar tissue, you end up either with a bend in it, you end up with a hinge where it loses its stability.

55:08So it makes intercourse more difficult. And what we almost never talk about, In fact, I've had so many men that have come to me and their doctors have told them, you're crazy. It's not true. It can't happen. Guys will lose penile length. That scar tissue will not expand. And so penile shortening happens to essentially 100 % of guys with Peyronie's disease. And so we have to address all of those through really a multimodal way. And there's lots of treatments out there. But again, for this episode, just know it's one of the five Ps. one of the terrible things that you have to perfectly good penises.

55:44And then, Jordan, we're going to build a whole series around Peyronie's because it's so common, 10 % of guys have it, and very few urologists, only about 1 % of urologists actively treat it. So it's a disease where you can suffer in silence, and it's a condition where you really need to find a very good team to help take care of you, and that's what we're going to figure out in episodes to come. I mean, you mentioned earlier so much of what we want to do on this show is take away the stigma around some of these issues. And I think it's really important to talk about. I know this is, you know, kind of one of the more, I don't know, taboo is the right word, but one of the more things, like I've never heard this spoken about so openly and I think it's important.

56:22The older I get, the more I practice urology and I'm still doing really finite, super focused surgeries. The more my practice really evolves very, I mean, I'm happy it's doing this, but it evolves into this huge mental health component of addressing the mind that is behind some of these disorders that guys suffer. And part of it is the lack of openness. I mean, you know, to date, I remember back to, again, your playground and talking about priapism and sort of, you know, I'm guessing, I just am guessing probably because of you had Bob Dole, who was an advocate, you know, I mean, an elder statesman.

57:04You had Raphael Palmeiro, who was, you know, a baseball player, maybe probably Hall of Famer. I don't know that I should, but, but, uh, you know, celebrity superstar baseball player talking about how they take Viagra to date, you know, we've not had any, any major public figure that wants to discuss Peyronie's and yet 10 % of guys are going to develop this. So there's plenty of men out there that have it. And again, you know, not my story to tell, but only that the more that we normalize this, the more, at least that we can have a space where we can talk about it and make sure that guys are getting in.

57:37Because it's amazing how many people will suffer with any one of these conditions, but certainly Peyronie's for years before they seek therapy. And so the goal is exactly what you said, you know, is to get it out there. And there are TV commercials now. I mean, the most, there's one FDA approved drug for this called Zyaflex. It's been out for 13 years. It's something, one of the drugs that actually kind of helped develop in the phase three trials. so I have a pretty deep history of this medication and it has gotten to the point where, you know, now you are watching. I was watching my beloved Dodgers play the other day and all of a sudden a commercial came on for the bent carrot.

58:13So we're gonna talk about that as well at some point, but it's out there. And so, yeah, I'm hoping this concept of disease state awareness allows more men to come in because even in my practice, which again is very well known for treating men with Peyronie's disease, I still see guys that are coming in because they saw the commercial. So however we get the message out there, we're getting the message out there. And I think that's critical. Thank you for all you do. I know that is something that is a huge specialty for you. And I'm excited to talk more about it. Yeah. Yeah. Where to begin. But this is a good place to begin is the foreshadowing of episodes to come.

58:51So stay tuned out there in the mailroom listenership. And I think we made it. I think we made it. You were upright the whole time. I was going to say, I was vertical. I can't believe it. I'm so happy. Yeah, I mean, if anything else, we're just, you know, we're training you. You were stealing you and therefore the audience. And now my mom really knows what I do for a living. So those are all good things that we've learned in this episode for years. She thought I was a cardiac surgeon. I just couldn't break it to her. But, you know, now's the time to be loud and proud here and say that, yes, mom, I am a Peroni specialist.

59:25This is what I do. Just in time for Mother's Day. Just as, yeah. Happy Mother's Day. All right. Maybe I'll cut that one. I don't know. Yeah. I mean, no, dude, look at, I mean, it goes right. It goes both ways. It goes both ways. All right. Well, we've had too much fun messing around for another episode of The Mailroom. But yeah, the five Ps of the Pinocalypse, know them. If it happens to you, never a joke. Seek the care you need for any of this stuff. That's the take-home message here. .

1:00:02Let's talk about it. Let's talk about it Seymour. . Let's talk about it. Let's talk about it Seymour. . . . . Let's talk about it in a minute.

1:00:51This program is intended for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Consult your health care provider for any medical or other related questions or concerns. The views and discussions aired on this podcast are those of Dr. Mills and do not represent the official positions of UCLA or UCLA Health.

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