Dr. Rob King, an integrative men’s health physician joins me to discuss a wide range of conditions affecting men. He shares his innovative and effective treatment approaches for some common and not so common health issues. He also discusses the importance of disease prevention and shares his top strategies for doing so. Men aren’t always the most focused on their health, however, I hope after this episode you will be inspired to take control of your own health and make positive changes to improve it.
Selected Links from the Episode
- Dr. Rob King website
- Unstress episode with Professor Marc Cohen on toxicity
- Unstress episode with Patrick McKeown on Buteyko breathing
- Unstress episode with Rosalba Courtney on breathing
Dr. Ron Ehrlich: Hello and welcome to “Unstress” where we explore what stresses us as an individual and the planet as you all know the two are inseparable. This is Dr. Ron Ehrlich. We’ve covered issues surrounding women’s health and I believe that’s actually relevant to men as much as women because as you’re a man there’s a very good chance there will be some significant female in your life. Partner, mother, sister, daughter, family or friends. So, gaining an understanding of women’s health is important to understand each other better. A worthy goal if ever there was one.
Children’s health is interesting too even if you don’t have kids because kids are really the Canaries in the coal mine and things are not looking that good. So, today our subject is men’s health. And of course, for women out there stay tuned for all the reasons we wanted men focused on the subject of women’s health. Just filling in the pieces of the puzzle here.
Men aren’t always has focused on their health as they should be and certainly not as focused as women are, but needless to say, it’s very important and it might actually be one reason why women live a longer life. It may be. It’s a function of that focus on health. My guest today is Dr. Rob King an integrative men’s health physician who as you will hear delivers innovative and effective treatment approaches for some common and not so common health issues. As well as and importantly involved with the disease prevention strategies.
Now it’s interesting because Rob is an integrative practitioner. And yes, this is a recurring theme and is a common denominator for many of my guests. Why? Because as an integrative practitioner as much as possible they look for and then treat the cause of a health problem rather than suppress a particular symptom. And that can have far-reaching effects on other health problems within the same person. Thinking holistically the cause is often multifactorial with biochemistry nutrition, microbiology, psychology. All playing important roles. He also integrates the central role of the guard. Another recurring theme on a whole range of common conditions and diseases and men’s health is no different some of which today it was news to me I must admit. We covered quite a bit of territory here. Some things I was entirely unfamiliar with and others that have affected me personally. I hope you enjoyed this conversation I had with Dr. Rob King.
Welcome to the show Rob.
Dr. Rob King: Thank you very much, Ron.
Dr. Ron Ehrlich: Now Rob, men’s health. As a man and knowing many men we don’t often give as much thought to it as we should. What are some of the things that come into your practice that distinguish? What is tell us about your practice first of all and how you got into this?
Dr. Rob King: Okay, so, I started my training in sexual medicine and during my training, I found out about this new specialty. So, this happened about 15 years ago of men’s health. So, it’s already interesting to note that we’ve always talked about women’s health for a very long time and yet mental health has been having been largely ignored. So, this new specialty that was really driven from Europe actually. It was to include all the aspects of health that are unique to men so that is sexual dysfunction, absolutely very important. Prostate health again which is a very largely ignored problem and also andrology so everything to do with male hormones.
So, currently, if you have a problem in any one of those areas or in all three of those areas you would actually have to see three different specialists. So, the idea was to bring those three men’s health issues under the one specialty so that’s what men’s health is. And so, I thought that was a very interesting really interesting specialty to work in and basically, I took that as a step further by taking it to a degree of what we call integrative medicine. So, actually not just looking at those three subspecialties but also putting in the greater context of the man’s health.
So, my practice today is very much revolving around comprehensive health checks for men so that would include men who would come to me because they’re well and they want to stay well, and I am seeing younger and younger men who come for that so even I have a few patients in their 20s now who come for an annual or biannual every two-yearly health check. And I see some older men who’ve already got some health issues and they find they’re not getting necessarily the answers elsewhere so that I’d call that more health assessment. So, trying to improve their health. And that’s really the two broad categories of men I see.
Dr. Ron Ehrlich: And what with those older men? Because I think it’s interesting to see where they’re at because then we can go back and tell our younger men how to avoid some of the problems that the older men are facing. What are some of those common problems that older men are facing? And by older are we talking about what age group? And be careful how you answer this Rob.
Dr. Rob King: Yes, exactly. So, really generally 40 and older. However, I’m seeing health problems in younger and younger men so it’s even coming down to 35 really, we can actually start talking about older men and we know that the aging process actually does start around the age of 35. So, if you’re actually not looking after yourself you will accelerate the aging process which then really takes off in one’s 40s.
So, basically some of the important issues that I see, I see a lot of men who have who come to me for low libido so that may not be in the context of the health check by the way to the other, so they may come to me for specifically low libido. I see a lot of sexual dysfunctions such as erection difficulties, some premature ejaculation which is also very common. Also, another condition that I treat actually is something called Peyronie’s disease which is very common which is there’s not much awareness of that condition. It’s a scarring process that goes into the in the penis that leads to curvature of the penis. So, that’s also something I see quite a lot of in my practice.
Now the other issue is men having urinary difficulties. So, this is when we come to talking about the prostate. So, from about the age of 35 the prostate depending if you’re, if you’re overweight the prostate will start enlarging and by the age of 40 some men will start noticing a change in their urine flow that they’ll be going to urinate more frequently than they may start getting up at night to urinate more frequently. So, that’s also something I see a lot of.
Dr. Ron Ehrlich: Peyronie’s is something I’ve not I mean obviously we’ve heard of, but Peyronie’s I’ve not actually heard of that. Tell us just what kind of come back to those other ones too but you mentioned Peyronie’s and I have not heard of that.
Dr. Rob King: So that’s very interesting because it’s actually quite common so probably even up to about 10% of men will have Peyronie’s disease during their life. So, what it is it’s as I said some scar tissue that forms in the penis and then can start contracting and then causes a curvature. Now the causes of that are can be trauma during sex, diabetes is a very well recognised risk factor and it can vary from a slight curvature, generally, it’s an upward curvature. Anywhere in the shaft of the penis the bit shaft or the distal shaft and sometimes it can be so severe that from already appearance perspective can be very distressing for men but also it can also interfere with intercourse. So, and it can be painful at the beginning when the process actually starts. Some men actually wake up one morning and that’s why it’s a very unusual condition because it’s as if the scarring and the contraction of the scar tissue can happen very rapidly and some men will say “Well, I woke up one morning and suddenly looked at my erect penis with my morning erection and there was this curvature”. And it’s very interesting that you haven’t heard about it because I always say to everyone you know we need to raise the awareness of Peyronie’s disease because the treatment is also very difficult.
Now it can be corrected surgically. In my practice, I use I’m currently using shockwave therapy to address that scar tissue. Now the scar tissue forms in a like nodule or a plaque. As I said most commonly on the dorsum of the penis, so you get an upward curvature but sometimes also downward or sideways or sometimes a combination of those.
Dr. Ron Ehrlich: So, it’s mind-boggling. This is 10%? This is affecting 10%?
Dr. Rob King: Yes overall. That’s right.
Dr. Ron Ehrlich: Wow. And I mean the trauma, to wake up like that must involve some form of trauma to the penis which is kind of overactivity one form or another?
Dr. Rob King: Look it may be although most men that I’ve seen in the last 12 months have not you know and that’s also well documented that there’s no obvious trigger for it okay? So, I was going to say a lot of men in some men about a third of men actually resolves spontaneously, which is also interesting which is why those men may never report the fact they’ve had it. They prefer not remembering that they’ve had it and about a third of men it will stay you know stable from the day they first notice that, other men will actually start you actually worsen over a matter of weeks to months.
Dr. Ron Ehrlich: And dare I ask shockwave therapy sounds quite traumatic and almost well, is that done under local anesthetic, general anesthetic, we’re just sitting in the chair bottom? I’m cringing when I think of this but go on.
Dr. Rob King: Good question because shock wave therapy also is very effective for men with erection difficulties as well because what it can do and what is as far as the scar tissue is concerned for Peyronie’s disease we know that it helps the body or the immune cells and to actually break down the scar tissue and relay a normal tissue of actually removed that scar tissue and it could also make sure the tissue around it is normal. But it’s also very effective in men with erection difficulties because we know that it can also increase sorry trigger the generation of new small blood vessels in the penis and probably also has a regenerating effect on the what we call the cavernous tissue which is the part of the penis that engorges with blood.
So, to come back to your question about pain that’s an interesting one because yes, we actually set it at a level where it’s uncomfortable more, not painful and it’s a handpiece which is held up against the penis and in the situation of Peyronie’s disease up against the scar tissue, the area where you’ve got that fibrotic scar tissue nodule or plaque and I apply about really depends, up to ten thousand impulses. So, treatment might take a half an hour to forty minutes. And some men tolerate it very well and some men don’t tolerate it very well. So, it’s interesting that should ask me about some form of anesthesia because one patient was tolerating the treatment so poorly that actually we did a trial of applying some topical anesthetic and on the cane in particular.
And in fact, it made the pain even worse as if numbing the skin somehow enhance there was simply the pain response in the deeper you know, the deeper nerve endings. So, hence why if you read up on all the studies there’s never any mention of using a topical anesthetic. So, that’s shockwave therapy now again for erectile dysfunction particularly in diabetic men it works really well and of course, there are many causes of erection difficulties and you try and actually address those first, not just you know a man presented me with erection difficulties and just put them on shockwave therapy. That tends to be the last actually line of treatment but for Peyronie’s, it’s actually the only really non-invasive treatment we currently have. And if you read the studies some studies will say it does have some effect on correcting the curvature. Certainly, I can actually reduce the pain because as the scar tissues forming some men will get quite a lot of pain in their penis, so we know that’s effective particularly for pain.
And other studies we’ll say this actually no effect on the curvature. But my experience and again it’s always you know working at the coalface and see many patients that you really start learning these things is that there’s a huge difference in the presentation in men with Peyronie’s disease. So, you’ll have some men who just have one small nodule and therefore that will be very easy to treat. Some other men will have several nodules or even some large plaques that can be up to 5 millimeters thickness. So, I’ve seen some extreme cases that are not actually amenable to surgery and even though I may explain to the patient that the shockwave therapy is unlikely to work because of the volume and density of the scar tissue they still want to try because they know…
Dr. Ron Ehrlich: Because the alternative is surgery.
Dr. Rob King: Exactly. And most of those patients are not actually candidates for surgery because of the extent of the scar tissue.
Dr. Ron Ehrlich: Wow, Peyronie’s. I’m going to park that one on the side for a moment. But let’s get back to libido because you mentioned libido and I guess the question is what’s normal? I mean you know we all live in our own worlds and have our own images of what should be. How do we define normal libido?
Dr. Rob King: Okay. So, and there’s a huge really spectrum of what could be considered normal and so we I get a lot of men who are worried because they seem to not have as much sex drive which is the other term for libido as their friends, their male friends and that’s what I need to really explain to them this normal spectrum which is really from not having a lot of libidos which is actually perfectly normal and we talk about some men who even you know asexual, where their sex drive has always been very low, you can’t find any physical cause for that. So, we know that some men just naturally have a very low libido and other men have an extremely high libido and there’s everything in between. But again, we’ve you know we live in a very I suppose sexualized world to a large extent available pornography and a lot of men feel that their libidos are abnormal because again they feel they’re not interested as much as their friends.
And so, that’s really the spectrum so it’s very hard to define something that’s normal. In general, it’s a change, okay? So, if someone used to have a very high sex drive and then there’s a rapid change then you’d have to suspect it then that’s when something’s not normal but yeah there’s the spectrum again is very wide.
Dr. Ron Ehrlich: Yes. So, it’s this subjective assessment of the person saying “Hey, I once was like this and now I’m not anymore what’s going on?”
Dr. Rob King: Exactly.
Dr. Ron Ehrlich: Yeah. And what are some of the things that could be going on?
Dr. Rob King: Okay. So, interestingly if you look at younger men often having low energy levels, so fatigue is extremely common cause okay you cannot have good sex drivers you’ve got low energy or fatigue and that makes sense in evolutionary terms why would you only have sex drive and have babies if we’re actually not fit to look after them? So, that’s how you could explain that. So chronic fatigue is a very, very common cause and anxiety and depression are a very common cause. And again you’re not going to have good sex drive if you’re extremely anxious because that will cause to activate we call it a sympathetic system which is what we activate when you get stressed and that will close all the blood vessels that deliver blood to the penis. So, yes.
So, in summary, and younger men it’s fatigue, anxiety, depression and then in older men it can actually be the fact that they start having erection difficulties so they’re not performing very well and then they start getting what we call performance anxiety, so there is an erection and then they start “What’s the point of having sex? It’s not you know working very well”. So, that and then starts leading to low libido.
So, I generally will ask in those men actually what actually do you have erection difficulties often the answer will be yes, not always of course. But and I always ask are you able to tell me what came first the erection problems or the low libido. So, of course, low libido can be caused by declining testosterone levels. It’s fact it’s one of the first signs of declining testosterone levels together with low energy. So, you can see how there are so many things that interplay here. And so, it’s always extremely important to check testosterone levels in those men but as I explained to you it’s libido is far more than just testosterone.
But the interesting thing in younger men that’s why it’s always important to check testosterone levels even in younger men because it’s always, you know, we always think of all younger men is not going to have low testosterone, so it’s often not checked. But in men who have severe anxiety and I saw that actually around the time of global financial crisis classic picture of men in their late 20s who were worried about losing their job who were in debt etc. And in those men measuring the testosterone levels was really incredible because we would always expect men’s testosterone levels to be between anywhere between 20 and 35 nanomoles per litre and these men had levels as low as 4.
Dr. Ron Ehrlich: Wow.
Dr. Rob King: So, that’s actually the effect is the response if what we call the pituitary gland in the brain just stopped producing this hormone called luteinizing hormone that stimulates the production of testosterone. So, again it’s a natural response to a stressful environment.
Dr. Ron Ehrlich: So, this is this stress response which is often referred to as the HPA the hypothalamus pituitary adrenal axis.
Dr. Rob King: And there is the pituitary-gonadal axis.
Dr. Ron Ehrlich: Right. So, that then in a turn affects sex hormone, a lot of hormones around the body but sex hormones. Wow, that’s quite from 20 to 35 whatever that figure is that’s the normal range and these young men were showing up as four and this was as you were relating to stressful situations. Wow, interesting.
Dr. Rob King: And that’s some, that’s reversible so you remove the stress and the testosterone levels go up. Now the other interesting thing actually about talking about libido and testosterone is that testosterone levels actually have always said that testosterone levels decline in men with age but we actually know it’s one of the few functions that in a very healthy man testosterone, normal testosterone production keeps on is still normal into much later on in life.
So, yes, the testosterone levels in the male population are declining that’s in and the number one driver for that is actually being overweight and obese. That’s the number one driver of declining testosterone and testosterone in the male population. Why? Because visceral fat which is a fact we accumulate inside the abdomen converts testosterone to estrogen. So, the more visceral fat you have the more testosterone is taken and converted to estrogen. So, in these men you see their testosterone levels declining and estrogen levels rising.
Dr. Ron Ehrlich: Right, wow.
Dr. Rob King: So, that’s something, that’s very important can you know the cause of low libido, it’s classic and of course also a lot of older men do have issues with was with depression and anxiety of course and obviously sexual dysfunction. Erectile dysfunction is a major cause of low libido and older men because again what’s the point of trying to engage sexually with someone if it’s not going to work anyway? So, their interest in sex declines.
Dr. Ron Ehrlich: Yeah. Yes. So, okay stress lowering of obesity lowering. We hear a lot about endocrine disrupting hormone, like plastics out there in the environment I guess I’m guessing that must be a factor too.
Dr. Rob King: Well, I do talk to some our patients about that there are generally many other things that we can do anyway, and I said it’s very rare that I see lean older men actually. So, we always start the movie with the obvious which jumps you know the visceral fat loss and most of my patient’s testosterone levels start rising again. So, it may take you to know 6 months, 12 months but just to show that we can maintain normal testosterone levels late until later on in life. So, and testosterone is not just about sex drives very important for muscle health. So, maintaining our muscle mass so maintain our physical independence. Very important for the brain for tissues really brain function, bone health, skin health. So, it’s an extremely important hormone.
Dr. Ron Ehrlich: How do we test for that? Is that a saliva test? Is that a blood test? What is it?
Dr. Rob King: Okay. So, there was a time maybe about 8-10 years ago when saliva testing and hormones became very popular. I’ve personally don’t do it anymore because I find that actually if you know how to interpret the blood test you really get you to know, all the information you need. So, we do a morning fasting testosterone level and the patient needs to have fasted for 12 hours.
And there’s endless information on this online and it can be extremely confusing. I will always do as a screening test a total testosterone and that will already indicate to me whether there is you know, already a lower testosterone to work than what you would expect. And there are other things you can start checking so you can start checking the free testosterone, you can start checking on the proteins that carry testosterone in the blood, sex hormone binding globulin in particular. And also, very important to check oestrogens levels. So, I’ve checked the oestradiol.
E: Because if the estrogen is higher the testosterone is low?
Dr. Rob King: Often there is that inverse relation exactly.
Dr. Ron Ehrlich: Right, right.
Dr. Rob King: And I still will check DHEA in men even though that’s quite controversial in terms of…
Dr. Ron Ehrlich: So, that’s one of the omega-3 or essential…?
Dr. Rob King: No, so that’s DHA. So, DHEA is actually one of the male hormones. It’s produced in the cascade from cholesterol because we produce our androgens from cholesterol down to testosterone and estrogen, DHEA.
Dr. Ron Ehrlich: Now we’re not going to be testing on biochemistry here but enough to say.
Dr. Rob King: Yes. So, it’s weak and it was thought at one at one time it was important to normalise the levels but it’s difficult when you replace DHEA it gets very quickly converted to oestrone which is a very potent hormone. So, there are issues there. So, we really focus on the total testosterone, the free testosterone and then the pituitary hormones called LH and FSH to try and get an understanding given what is causing low testosterone. Because of course, you can also have damage to the testes and the cells that are producing testosterone so that’s what we call primary hypogonadism. So, low production of testosterone so that could be things like undescended testes, so, babies who were born without the testes haven’t descended into the scrotum, hasn’t…
Dr. Ron Ehrlich: How common is that?
Dr. Rob King: That’s some… I know it’s common. I can’t give you a percentage but certainly, it’s common. Now these days that gets corrected you know reasonably rapidly so then there’s no damage to the testes, but you’ll see some men who had you know delayed correction of that and that can affect the testosterone production trauma to the testes. Okay, so that can be even from sport also men who have radiation therapy to the pelvis including for prostate cancer that can also although these days it’s so well you know things have changed radically in the last 10 to 15 years with radiotherapy but certainly any in general radiation that area, of course, can damage those.
Dr. Ron Ehrlich: So, these tests these are part of a blood test really. I mean you’ve got to know what to order but in all the time that I’ve ever had a blood test done now Rob, I’m going to have to come and see if you’re sure because this is I’ve never had that tested. And that’s obviously quite that’s important I mean as you know these are all issues that affect many of us.
Dr. Rob King: Yes. So, I mean to answer your question in why often this doesn’t get checked is and this is when I come back to having said that I have extended my practice to integrative medicine. So, that’s when we really put all the pieces of puzzle together and that’s very different to how our medical system has evolved, okay, over time where we particularly since World War 2 our enthusiasm for science and pharmaceutical medicine really led us to believe that we could really solve all problems through pharmaceutical drugs that are really there to block certain things from happening. And then today there’s so many health but people you know people who do have more and more health problems and that’s in part due to the rise in body fat as we said earlier. So, yes, coming back to the integrative approach that’s different to the pharmaceutical approach in the sense that we actually look for the cause of the problem.
Okay. So, when I started doing health checks so that was in Sydney men’s health in Bondi Junction, so this is going back 2005 because I had an interest in preventive medicine then already. You know you start realising well when actually never taught how to do a health check and a preventive health check which you do because generally when you request for health check you go to your GP and ask for health check and it’s not just GPs but generally it will be you know the standard blood sugar, cholesterol, have your blood pressure checked. But the more I’ve learned about preventive medicine and health checks I’ll check a huge number of things and including testosterone and oestrogen levels.
Dr. Ron Ehrlich: Yeah, yeah, yeah.
Dr. Rob King: Even in younger men because it’s actually… testosterone levels actually a really good surrogate marker of health because basically any stress on the body whether physical or emotional is a good way of summarising will cause testosterone to decline. So, if I see a 25-year-old who has a level of about 15 as opposed to what we said about you know what we’d expect most men to be between 20-35, I’ll say “Look, something’s going on here. Let’s have a look”. Whereas we had a tendency in medicine to say “Well, look we just wait for things to break before we go look for the problem or check these things, okay?” And I think also as testosterone there’s been a big lack of understanding. It’s really only again in the last 15 years we’ve really taken interested in testosterone in men which is pretty incredible.
And so, I’ve actually was lucky to grow with that knowledge, okay? And hence… but unfortunately what you read on the internet is still very much you know a few years behind and that’s why people get very quiet, confused about it all but certainly, it’s a very, very important hormone to check. Besides, it’s got a mention in terms of the oestrogen levels as well. What is interesting when you see the oestrogen levels start to rise so again number one cause is rising visceral fat levels is that oestrogen actually can also cause the prostate, it’s probably one of the major drivers of the prostate gland, to start enlarging. Okay. So, then again is the correlation between being overweight and the onset of an enlarging prostate which will often then lead to increased frequency and getting up more often at night to urinate.
Dr. Ron Ehrlich: Which is a good segue into my next question which was related to the prostate. And before we embark on what some of the problems are, what is the prostate for?
Dr. Rob King: Okay, so, very interesting question because I would say that 99 percent of my patients have no idea why it’s… what it does. It’s also a conversation I have because with the comprehensive health check I always ask about urinary symptoms and for men you know important to start doing if a prostate check, Some men from 40 others from 45 but again they have no idea what it is. So, it is actually it has three main functions, it’s an endocrine gland which is interesting because it actually is the main organ that converts testosterone to dihydrotestosterone. So, about 4% of testosterone gets converted dihydrotestosterone and that’s a very potent androgen. So, a potent male hormone. And it also has a role in fertility in reproduction because the fluid it produces actually is designed to protect sperm in the vagina. So, there is a fertility side to it as well and also sexual because during orgasm the prostate contracts and contributes to sexual pleasure. So, very important. And again, we are a very little understanding in the knowledge of it.
Dr. Ron Ehrlich: And so, what are some of the issues that men face with their prostate?
Dr. Rob King: So, in younger men, a very common problem is an infection occurring in the prostate. Now when I say very common you have to distinguish what we call acute prostatitis and chronic prostatitis. So, acute prostatitis can be for instance a sexually transmitted infection such as chlamydia or gonorrhea that actually gets into the prostate and causes an infection and a strong inflammatory response and that’s quite a dramatic picture. But much more common is what we call chronic prostatitis which is much more subtle onset and I’m seeing again young and younger men who have this is and of course in older men, it’s particularly common where we think it probably starts with a low-grade infection that can be is probably transmitted through unprotected intercourse.
Okay. So, there are all sorts of bacteria we know that can actually lead to this low-grade infection. It can be bacteria such as Enterococcus that can cause surprisingly low-grade infections in the prostate and that’s because it’s a gut bacteria and of course a lot of gut bacteria in the area of say around the anal vaginal area. And so, that will often present with some subtle signs such as increased frequency of urination and some dull pain that they feel somewhere in their pelvis or in the perineum which is the area between the scrotum and the anus. And sometimes it resolves spontaneously and that’s why I’m saying it’s very common because I ask men about all these you know, whether they’ve had these issues in the past and lot of people a lot and will say they have. So, hence why it’s a lot more common what we actually realise in younger men. And then in some other men the problem will actually just get gradually worse over a number of years and you can actually even in some men in extreme cases ruin their lives because the pain becomes so severe, the urinary frequency is so severe, the urgencies you know is a real problem so they suddenly you know they need that urge to urinate and that urge comes is you know it’s irresistible. They need to get to the toilet very quickly.
So, and you could also get there are all sorts of other symptoms you can get you to know, some feeling of discomfort in the shaft that penis with the tip of the penis sometimes you can get you can get some discomfort in the needle aspect of the thigh. Sometimes it can radiate the lower back. And as I said a lot of people who live with this condition when it’s mild but as soon as it starts getting more pronounced particularly with the pain in the urinary frequency those are the men that I tend to see in my practice and they tend to find me by you know, doing a search on the Internet. That seems to be the way they find me for this in particular because of prostatitis as we call it. So, chronic prostatitis often referred to as simply prostatitis. It is probably one of the most poorly treated conditions in men and urologist don’t particularly like dealing with prostatitis. It really is a more medical condition in the sense there’s no real operation you can do and neurologist tent to be extremely busy everywhere in Australia. And so, prostatitis tends to be initially treated with antibiotics blindly and if the patient doesn’t get better after four-week treatment of antibiotics that four-week treatment may be repeated. And if there’s no improvement generally they’re told that there’s nothing more that can be done. So, I often see men who have been unable to find anyone to help them.
Now it really is a multi-dimensional problem in the sense that there are many predisposing factors to getting this condition, which again in my opinion if you can isolate bacteria in the urine doesn’t mean that it wasn’t initially triggered by an infection. Now some of the predisposing factors they’re going to make you more likely to get ongoing problems for this is pelvic floor problems, okay? So, that’s become a big understanding in the causes and aggravating factors in prostatitis are having either your pelvic floor muscles which again are those that are in our pelvis that if you want them to contain all the pelvic organs or contain the… you can think of it a bit of like a salad bowl.
Dr. Ron Ehrlich: Holding it all and toning it up, keeping it in place to function properly.
Dr. Rob King: Exactly. So, the really the key to treatment of prostatitis again to relieve this pains, frequency is really having a pelvic floor assessment because you can either have an over contraction of these muscles in which case you can even that can even lead to the prostate actually being pushed up into the base of the bladder which can explain why all these men will get the frequency in the urgency but also that means that the prostate is not able to drain properly, okay? So, in my opinion, a very strong contributing factor because it’s an organ that produces fluid as we said earlier.
Dr. Ron Ehrlich: Would that over contraction be a response to trauma in that area? It’ll be like a muscle going tightening and being traumatised.
Dr. Rob King: Okay. So, again it’s a really fascinating story because in fact probably one of the number one causes is stress, anxiety. Because the more anxious we are the less we tend to breathe properly, okay? So, that’s what we talked about developing room called apical breathing, so we actually don’t even lower our diaphragm anymore and our busy lives and stressful city lives. We tend not to breathe properly anymore and when we don’t breathe properly fill our lungs with air lower the diaphragm. When we lower the diaphragm our pelvic floor muscles relax. Okay. So, if you’re never breathing properly your pelvic floor will start becoming you know we call this hypertonicity so that become hyper contracted and that’s a very, very important cause of problems again in with men’s prostate and triggering urinary problems. But it can also contribute to erection difficulties because you’re also blocking off part of the blood supply because obviously, you’re causing pressure against very important arteries. And then you can also have the muscles that are not contracted enough so we call hypertonicity and that can happen from prolonged sitting.
Okay. So, again with our sedentary lifestyle very, very common and you often notice people who have prostatitis any symptoms we talked about. They’ll say they often get worse after periods of prolonged sitting, okay? So, either long car journey or having sat down at work all day.
So, I work in close collaboration with a men’s health physiotherapist. There are a few around. The very few who actually truly specialised in men’s health and actually experts in pelvic floor and that’s been extremely valuable collaboration because you cannot really get successful outcomes with prostatitis unless you’ve actually looked at what the pelvic floor is doing. And of course, there are all sorts of techniques to then help the muscles either improve the tonicity if there was hype you know if there were to muscles of to relax or and again help muscles that are to contractive pelvic floor muscles into contractor to help them relax and that’s often through breathing exercises.
Dr. Ron Ehrlich: Now you’ve just hit on so many topics that we’ve covered on this podcast before, but we’ve never related them to men’s health and prostate health. Fantastic. And as somebody who’s gone through prostate cancer and I’ll talk about that in a moment I want to ask you about it. I have had the experience of that physiotherapy that you’re discussing, and the importance of those exercises post prostate cancer treatment but we’re going to get onto that. This is fantastic and that breathing. And anyway great, great stuff. I’m learning so much here. It is fabulous.
Now, testosterone. Okay. So, a function of stress, a function of well the prostate, prostatitis. What about an enlarged prostate? So, I mean when we move does that is that a follow-on from being inflamed for too long?
Dr. Rob King: So, generally so the enlarged prostate so what we call benign prostatic enlargement or hypertrophy BPE or BPH. Yes, there’s another very common problem with the prostate. Now as I mentioned earlier probably one of the major drivers is oestrogen levels stimulating the growth of the prostate. And interestingly a lot of men who have prostatitis also have this enlarged prostate because as this prostate enlarges its architecture changes slightly. And again, in my opinion probably it impacts on drainage and therefore an organ doesn’t drain properly more likely to start having some inflammation there and if you have a few bacteria there that again will predispose them to or will favour you know, a low-grade infection to be unable to resolve itself. So, this enlargement of the prostate is very common. I mean about we said generally about 40% of men in their 40s will start noticing some change in their urination. So, that is you know increased frequency or the flow that the urine flow is not as strong as it used to be. And again, getting up to urinate at night once to twice is considered normal. These men will start noticing they’re getting up more frequently or if they didn’t get up at all in the past this stuff then having to get up.
So, BPH – Benign Prostatic Hyperplasia is an extremely common condition and it’s one of the conditions that urologist do treat and can treat very effectively once the prostate has got to such a size that men are having really extreme voiding difficulties.
Now when I see a patient who presents with these urinary problems we’ve just mentioned and an enlarged prostate now the way we diagnose that in and I do that in my practice is really through something that most men would not want to have is a digital rectal examination. Which actually in my view is one of the reasons what a lot of men put off their health checks. This is a fear of having that done. But hopefully we’ll have very cheap ultrasound machines one day we could actually do that through an ultrasound in the practice without having to do a rectal examination in terms of assessing the size.
Dr. Ron Ehrlich: So, just for those that have missed it, the digital rectal examination is… Go on,
Dr. Rob King: So, with the gloved fingers with the gloves sorry, hand you insert the right index into through the anus through the anal canal up into the rectum and you can actually feel the back of the prostate up against the wall of the of the rectum.
Dr. Ron Ehrlich: And men should be having that well, when from.
Dr. Rob King: Okay. So, again there’s no consensus around the world about this, it’s really important for listeners to understand there’s very little consensus about a lot of things. Okay, like this also we’re getting more towards a consensus about what is a normal testosterone level, what is testosterone deficiency versus what is not? But that’s you know we’re finally getting there. But for this, I think a good rule is if you do have a family history of prostate cancer, particularly if your first-degree relative whether that be maybe your father had prostate cancer at the age of less than 55 years of age then definitely screening should start at age 40. And if you don’t have a family strong family history of prostate cancer then I would definitely start at 45.
Now the advantage also starting to check the prostate from age 40 and 45 is that through this examination, of course, I you know, what you look for is a change in the consistency of the prostate whether it’s no longer symmetric or whether you feel any nodules. But I also do it to be able to see whether the man’s prostate has started to enlarge, or did you see they’ve already had this onset of this benign this BPH.
Because if they have I’ll say look if you’re not careful you know in 5 to 10-15 years, you may start having urinary problems, you may have then to have a prostate operation. Obviously not as dramatic is a radical prostatectomy which removes the whole prostate but still quite traumatic. Usually a TURP – Transurethral Resection of the Prostate.
So, it’s another galvanize that I think to encourage men to start losing weight because again I have seen that another correlation usually it’s very uncommon for lean men to have an enlarged prostate. It does happen, absolutely. There’s usually men who have high insulin levels because we think insulin is also a hormone that stimulates the growth of the prostate. So, it’s another reason why I always encourage men to have a prostate examination. I say look, yes prostate cancer obviously is very important, but let’s not forget to check whether your prostate has started to enlarge, okay? Because we think as well as the prostate is enlarging you know there are more cells dividing so that will increase you know. We know that it’s also an increased risk for prostate cancer for the down the track, but we were talking about prostatitis and then we now know that prostatitis also increases the risk of getting prostate cancer because chronic inflammation organ, any organ that has this chronic inflammation is at higher risk of you know cancer developing in you.
Dr. Ron Ehrlich: You mentioned your integrative approach, which is something that I know will sit very comfortably with a lot of our listeners. And I know you’re interested in gut health. We’ve talked about gut health in many other ways but tell us about gut health and men’s health and you’ve identified some of the issues, tell us what you see is the connections there.
Dr. Rob King: Yes. So, my interest in gut health started when I started doing health checks because every second to third man I was seeing for a health check would tell me they were having gut problems. Okay, so, would that be bloating, discomfort, a lot of flatulence constipation diarrhea. So, you know, generally look for a cause of that maybe quite simple but in men who are 45 or older you know we were always taught to say well look you have to really start being careful about the possibility of maybe bowel cancer being present or maybe and in fact an autoimmune bowel condition, inflammatory bowel disease.
So, I typically refer those men to a gastroenterologist I work closely with, just down the street from where we were sitting and often these patients would come back to me after having had a colonoscopy sometimes with gastroscopy and they would say that “Well, I’ve been told there’s nothing wrong you know they’ve got some yes probably some IBS and that’s it”. And so, these men would look at me and say “Okay, well, Rob what do we do?” And I would say “Well, what you mean what we do? I have just sent you to the gut expert”. So, that was my first realisation there was something really missing from our understanding of gut problems. And it was just the time when the gut we started talking about the gut microbiome so again probably going back about 13 years ago. And so, a bit like testosterone I managed to get on to that knowledge you know that explosion and knowledge back when it all started. And I always had an interest in microbiology anyway. And coming back to actually prostatitis I’d always heard that there was an association between men who had prostatitis and IBS as we have…
Dr. Ron Ehrlich: Irritable bowel syndrome, correct?
Dr. Rob King: Yeah. Which is generally the term we give to people who’ve got gut symptoms the way we’ve described but have got no abnormalities seen on colonoscopy or gastroscopy and all their boxes are normal, okay? So, that’s the general label we put you know basically we’re not quite sure what’s going on, but there doesn’t seem to be anything to worry about.
Dr. Ron Ehrlich: This is probably a good spot to just say that you mentioned the urologist and you mentioned the gastroenterologist and unless there is something very obvious and serious that they can operate on then patients are often dismissed as there’s no problem.
Dr. Rob King: That’s right.
Dr. Ron Ehrlich: Please continue because that’s true, isn’t it?
Dr. Rob King: Yes.
Dr. Ron Ehrlich: I mean that happens a lot.
Dr. Rob King: Unfortunately, yes.
Dr. Ron Ehrlich: Yeah.
Dr. Rob King: And so, over the last particular last eight years I’ve developed a very good knowledge and understanding about the gut microbiome. Now I just such an extent that it is one of my areas of interest and so I’ve actually also I put that on my website it’s one of my areas of interest. And that’s been probably the fastest growing part of my practice is men coming to see me with all sorts of different problems. So, either because they’ve had again constipation, the diarrhea, bloating that no one is able to help them with but also people with severe eczema, autoimmune diseases because we know now that the gut is the core organ in our body that drives a lot of diseases. Okay, so by rebalancing the gut microbiome and the way you do that currently, there are different tests that you can do to look at the population of bacteria in the gut. There are some people in Australia who send stool samples to the US for a technique called PCR testing. Unfortunately, they still remain very unreliable. You can send this stool sample to ten different laboratories and get ten different reports.
Okay. So, currently in Australia we have that we have a laboratory in Melbourne that’s I’ve been working for 30 years on gut bacteria and they are using the culture method which has its limitations but it’s already a fantastic tool that we can use to already look at some of the core families of bacteria in the gut and the imbalances that are present. And really to make this probably easier for our listeners so it’s a test that takes about two to three weeks because some of these bacteria are very slow to grow in the laboratory and then it would involve rebalancing these gut bacteria through really supporting or giving probiotics for those bacteria that are lacking and giving some local antimicrobials. So, sometimes I give a short course of antibiotics surprisingly but when you’ve got some overgrowth a certain bacterium to you that we know cause problems it’s a very effective way of treating doing a short course of anybody because you know what you’re targeting with minimal collateral damage. And that generally is a four-week core program if you want. And also a lot of nutritional advice to inform you know so it’s all about so we tend to forget that we’re not just feeding ourselves when we eat, we are actually feeding forty trillion bacteria in our gut and so our nutrition and it puts a whole new dimension on nutrition because I’m able to give some advice on what people need to eat and eat in order to either stimulate the growth of certain bacteria or remove certain foods that are actually stimulating the growth of unfavourable bacteria.
And so, by doing that because we you know, we know that 70% at least 70% of the immune system is in the gut because that’s the greatest boundary to any outside world and the inside of our body as far as you know, obviously the lungs are also is a big boundary but that’s air we’re talking about this boundary we’ll put food that gets digested and there needs to get absorbed. So, that explains why so much of the immune system is there to keep an eye on what’s coming in okay and what is being absorbed into the body from the gut.
So, that has led me to treat actually a whole range of problems as I said. You know some eczema is the reason we call in one very tricky condition to address but it definitely does help a lot. The problems often you see people who got had had these conditions for many years. So, the longer they’ve had a health problem you know the longer it takes to improve the situation, so you know, if you had a condition for a problem for ten to twenty years. You know it would only make sense if you’re you know to rebalance something like the gut. It would take you to know sometimes a year a bit longer for things to go back to you know to improve conditions like eczema.
Often people who don’t have those conditions who have very, very troublesome yet you know problems which the constipation is generally the diarrhea can get really rapid our improvement from the right treatment.
Dr. Ron Ehrlich: It’s interesting because of this…and it’s also referred to as the second brain. So, the impact of that food gut health and on mental health is quite profound as well and no doubt affecting prostate and all of these are the health issues that you’re trying to bring back under control.
Dr. Rob King: Yes. So, actually talking about an integrative approach. So, and I was saying that pelvic floor problems and addressing them are actually key to the success. In some men who have severe gut issues, we know they’re never that prostatitis is never going to get any, any better if we don’t address that they have a gut problem. So, for instance, a physiotherapist I work with he will identify people who have severe gut problems there very obvious and you know will refer them to me to work on their gut and then vice versa. I’ll send you to know people to him to deal with the pelvic floor.
So, there’s even that issues that the gut microbiome even has a role there for specific men’s health conditions such as this is prostatitis. So, it’s really, it’s really interesting.
Now also for mental health we know that some back here’s some changes in the bacteria associated with mental health problems or you have some back to your particularly E. coli very important in producing some synthesising making essential amino acids which are precursors to important hormones. Sorry, neurotransmitters such as dopamine and serotonin. And then we know that the overgrowth of certain bacteria such as streptococcus and enterococcus produce a lot of de lactic acid which could have some profound effect on some people’s brains.
Dr. Ron Ehrlich: Okay. Well, we did a program year a few weeks ago with the pediatrician talking about pandas which are the streptococcus, it’s a pediatric infection of streptococcus and dramatically affecting a person’s behavior. Like they could wake up the next morning and be OCD – Obsessive Compulsive Disorder. But let’s move on just to prostate cancer because you know other than this is something that I personally have has happened to me and I got a diagnosis of prostate cancer three years ago. Tell me what I mean you’ve mentioned all the things that people should be looking out for in prostate health and presumably they are things that should alert people to the possibility of it being even prostate cancer. What are some of the challenges I mean in terms of treatment options for prostate cancer you know, some of them have effect… I mean not some of them, they have an effect on sexual health, don’t they?
Dr. Rob King: Absolutely.
Dr. Ron Ehrlich: Yeah, what are some of those challenges?
Dr. Rob King: Okay. So, I mean all men after so one of the most common procedures for the treatment of prostate cancer is what we call radical prostatectomies removing the whole prostate gland the vesicles see and the seminal vesicles excuse me and even though the technique the surgical techniques have improved dramatically, unfortunately, losing one’s erections it’s still currently an unavoidable consequence of having radical prostatectomy. However, the techniques now preserved the nerves that actually travel around the prostate gland which is why probably you know 15 years ago you know, radical prostatectomies you know caused a lot of damage. So, now what they do is what they call you to know nerve preservation but there will still be some stretching those nerves during the operation which means which explains why men will you know 99.5% of the time will have no erections after the operation.
So, now with radiotherapy that tends to be usually delayed onset erection problems, but I tend to see a lot more men who’ve had a radical prostatectomy. So, I will see some of those men for what we call sexual rehabilitation after prostate cancer operation or penile rehabilitation. And that’s essentially helping the penis, the tissues in the penis remain healthy enough so to give times for the nerves to heal themselves itself you know when you damaged will be stretched in those it’s a process called pathological process called neuropraxia. So, you give times for those nerves to heal and what you do classically is you’ll give some medication such as commonly Cialis or Viagra which do help increase even if they’re not going to give an erection they do increase a little bit the blood flow into the penis.
And if after six weeks after the operation they’re not getting any sort of erectile response from the medication then you’ll start them on some injections, okay? Where I actually teach men how to give themselves an injection into the penis which sounds horrendous but it’s actually not as bad as it sounds. And that’s very important because that will give the man some erections you’re trying to get blood flow into the penis because obviously, you have to always think of the flaccid penis is being an organ and a relative state of you know, nutritional and oxygen deficiency.
So, you’re trying to create these artificial erections, so you actually get some nutrition to the penis and that’s how you actually maintain the health of the penile tissue whilst you’re waiting again for the nerves to heal themselves.
Dr. Ron Ehrlich: So, what are they injecting?
Dr. Rob King: Okay. So, the compound is actually called alprostadil, prostaglandin E1 and it works in a similar way to say the well better-known compounds drugs such as Viagra or Cialis. So, now the advantage of doing that is that also enable the men to have sexual intercourse if they wish to. So, that’s a real benefit of drugs.
Dr. Ron Ehrlich: So, that is within six or eight weeks of the operation.
Dr. Rob King: Correct. Yeah. And the sooner you start the better the outcome in terms of recovering sexual function it can take anything up to three years, but you know, it’s generally 12-18 months you know often up to two years. And again, the more you have the earlier the man has started the more likely the recovery is.
Now that very much depends on what the erectile function was before the operation. So, if they had a very good erectile function so the ability to get erections before all that prostate cancer problems started in the operation then they have a very good chance of recovering. They will often still need some support with medications that Cialis or Viagra. Others will often need to have those injections lifelong in order to achieve an erection that’s hard enough for intercourse. If that’s what that meant the patient wants but though they’re having the whole issue of sexuality after prostate cancer operation is obviously very big. There’s loss of that sexual intimacy and often men get so traumatised by the whole experience.
Dr. Ron Ehrlich: It’s a very challenging time. That’s for sure. But tell me if people if you had to leave our listener with you know, here we are as men listening to this and partners of men listening to this and saying this is what men should be doing to ensure their health is as good as it can be, what would be a couple of tips that you would leave our listener with?
Dr. Rob King: Well, certainly I say to all the men I see who are lean I say do never put on weight, okay? Because that’s probably your greatest you know, the most important aspect of your health. And often that means that doesn’t necessarily mean they’re going to have a good nutrition but often you know we’ll make them focus on the nutrition and we know that nutrition is also key obviously to good health and we know the good physical activity is very important. But the thing I really want to emphasise, and this is not to you know encourage people to come and see me in particular for a health check but probably one of the biggest misunderstandings out there is that we can support all our nutrition through diet alone. And this comes back to gut health you see because again like all other tissues our gut starts to age from you know about the age of 40 and if you actually look at the process of digestion and absorption of food it’s highly complex.
And so, it only makes sense that as we get older the ability of our gut and our bacteria and digestive enzymes to extract the nutrients from our food and actually it’s starts to decline. So, in fact, nutritional deficiencies become very common from the age of 35 and 40 because in fact the big misunderstanding out there is that we can actually maintain good nutrition to rely alone on. And that is absolutely correct until we’re 35 or 40 but I always remind everyone that in evolutionary terms most of us didn’t live past the age of 40 until not that long ago.
So, these were, never didn’t used to be problems but now that most of us are living you know to very much later on in life. You can really improve quality of life by optimising nutrition and by that, I mean that for instance my health check I’ll check for mineral deficiencies, vitamin deficiencies, and the hormonal deficiencies and particularly seen what the testosterone is doing and to actually correct those deficiencies. The extremely common vitamin b12 deficiency, in particular, is probably one of the most you know, we call that a hidden epidemic and integrative medicine because so many people are deficient in b12 and don’t know it because unfortunately, another problem is that we rely still too much on what is given to us by the pathologists which are called the reference range.
Now really what the reference range tells us in most cases is where 97% of the population sits. But we know the 97% of the population is not healthy and therefore the actually comparing one’s level to that reference range has actually become obsolete. And we know nutrition medicines where those optimal targets are and that’s what we need to aim you know to encourage you to know, patients to achieve that.
So, for instance you know a lot of my patients will be on vitamin b12 supplementation, certainly vitamin D is the big issues we all know. Also, around the age of 40, the ability of our skin to produce vitamin D when exposed to UV lights thus decline. So, hence why usually so it’s a 90 percent of my men above the age of 45 are in vitamin D supplementation, not everyone but most, why? Because the ability again of vitamin D levels decline naturally. And there’s also very little awareness of that out there.
So, hence that’s always an example I give if why supplementation becomes really important because you’re helping or giving your body certain nutrients and in this case vitamin D because you know when it’s no longer able to produce it itself.
So, of course, we don’t die overnight by starting having these deficiencies, but it accelerates the aging process.
Dr. Ron Ehrlich: Look, I just want to finish with one last question and this is taking a step back from your position in men’s health because we’re all patients, we’re all out there doing the best we can. What do you think people’s biggest challenges on their health journey through life in our modern world today? What do you think that is?
Dr. Rob King: So, I think lack of physical activity you know I still feel very depressed that our cities keep on still moving outwards you know and people using you know their cars to travel. So, I think a lack of physical activity is a big challenge because people are encouraged to commute long distances and sitting in their cars for long hours or commuting on trains. But also, I think the quality and also eating the right foods.
I think for me I tend to realise that we live in what we’ve called an obesogenic world and environment. Everywhere you look you see the food. Okay and I think it’s getting very hard for people to resist that temptation because it’s particularly in the city of Sydney. As I said you go out lunchtime you know there’s coffee carts with cakes and food stalls and food courts and everywhere you look again you’re constantly encouraged to eat. So, I think personally that that is very you know very big challenge but also the quality of our food.
Again, I always remind everyone we don’t grow our own food even though it looks fantastic on a plate. I believe that our food is becoming more nutritionally deficient despite what agribusiness may say about that and that’s something that people again don’t realise that I think is food is very nutritionally deficient. And since we’re talking a little bit earlier about environmental issues in plastics I believe you know, air pollution is finally now being recognised more and more as a major factor in our health. We know the air pollutions related to cardiovascular disease, all these microparticles that we absorb, and you know, lung cancers you know the incidence of lung cancer is rising. We hear more and more people who get lung cancer who have never smoked, okay? It’s a very common story out there.
So, I think living in a city is a big challenge. You know I would love myself to live out in a country grow my own food, breathe clean air but you know the reality of work and you know where our job and career opportunities are in the cities. And so, I think that’s probably one of the…
Dr. Ron Ehrlich: Yeah.
Dr. Rob King: And stress, working very long hours. Okay. So, I think yes, I mean the cost is we know of everything is very high and getting ones you know having our own home where we can live in is extremely expensive and so some people you know work very hard to achieve that now and that’s certainly high-stress levels as I think you’ve spoken about in the past is extremely detrimental to our health.
Dr. Ron Ehrlich: Rob, thank you so much. That was just fantastic. I’ve learned so much. Thank you for joining me.
Dr. Rob King: Thank you very much, Ron.
Dr. Ron Ehrlich: Wow, so much in this episode. It’s why I love doing this podcast, I learn so much. I hope you do too. Testosterone. Now in all the years, I’ve been getting blood tests it’s never been tested. Peyronie’s never heard of that at least as a disease and 10% of men, of course, the issue of prostate cancer is something I am sadly very familiar with and it’s been fascinating for me in my surgery in my practice talking to patients to hear the various stories from various men. Not to mention talking about it with family and friends. It’s very challenging, it’s very challenging. Particularly if you go for treatments. Well, surgeries and radiation you know, treatments always come with complications. So, it’s very challenging and it’s something that is important to be able to talk about.
Men can easily climb into the cave and not express how they’re feeling and it can get very complicated. Again, I’m putting my hand up here too. Urinary incontinence, erectile dysfunction of both things that strike at the heart of our own perception of ourselves but it’s also something that affects many people surprisingly as we get older. But what about stress affecting testosterone levels? Well, our breathing problems affecting pelvic floor which in turn affects prostate erectile function in urinary problems. It’s why breathing is a pillar of health on its own. But there are a few extra things that I need to add to my understanding of the importance of breathing.
And what about prolonged sitting? The sitting that you know, we’ve heard the expression “Sitting is the new smoking”. And this whole idea of making pelvic floor muscles too loose. So, you know, this is all tiny and really amazing with all these five pillars and five stress models.
So, the prostate is an issue for all men young and old, so do not ignore it. We’ll have links to Dr. Rob King’s website and we’re going to do some more stories on men’s health. So, until next time this is Dr. Ron Ehrlich. Be well.
This podcast provides general information and discussion about medicine, health, and related subjects. The content is not intended and should not be construed as medical advice or as a substitute for care by a qualified medical practitioner. If you or any other person has a medical concern, he or she should consult with an appropriately qualified medical practitioner. Guests who speak in this podcast express their own opinions, experiences, and conclusions.