Enhancing Sexual & Urological Health for All Genders | Huberman Lab 

Dr. Rena Malik, MD (@RenaMalikMD) is a urologist and expert in Female Pelvic Medicine & Reconstructive Surgery (FPMRS)/Urogynecology. She focuses on the care of patients with pelvic health issues such as urinary incontinence (loss of bladder control) and pelvic organ prolapse (vaginal bulge due to bladder, uterus, rectum or bowel dropping), neurogenic bladder, and urogenital reconstruction for stricture disease or fistulas of the lower urinary tract.

In this episode of Huberman Lab, Andrew Huberman and Rena Malik discuss causes and treatment of sexual and urological dysfunction, pelvic floor function and health, how to enhance desire and arousal, penile and vaginal health, UTIs, and much more! Host: Andrew Huberman (@hubermanlab)

Pelvic floor: a bowl of muscles connected to bones that hold up pelvis; function is key for urination, defecation, back and core stability, and sexual function Pelvic floor dysfunction can lead to increase of urgency and frequency of urination, difficulty emptying bladder completely Tense pelvic floor can cause pain with sex

Pelvic floor plays a role for men and women though we primarily hear about it for women Pelvic floor can be too weak or too strong with both cause problems Pelvic floor muscular shortening is gradual and isn’t obviously noticeable because we haven’t been trained to recognize it

Pelvic floor exam by specialist For men: physician can feel muscle through anus and perineum For women: physician feels pelvic floor muscles through vagina – assess for muscular function and coordination Men: be sure to go to a pelvic floor specialist who has worked with men – many have only worked with women

Kegels are strengthening exercises for the pelvic floor To perform Kegels, think about how you would tighten to muscles to stop the floor or urination (but don’t do it during urination) Cue for women: lift up and in Cue for men: think about lifting penis off the floor without touching When you start doing Kegels, start lying down, then sitting, then standing as you become proficient

Benefits of Kegels for those that need them: typically prescribed for urinary incontinence and for women with pelvic prolapse; for men with prostatectomy

Some people use Kegels to increase intensity of orgasm during sex but be careful not to overdo it because you can get a more tense pelvic floor To relax pelvic floor muscles, you can massage, take pharmaceuticals to alleviate symptoms, and/or work with pelvic floor specialist

People don’t often breathe correctly during exercise – diaphragmatic breathing is important! Exhale on the effort to contract pelvic floor and create stability Nerves and arteries run through pelvic floor so blood flow can decrease with dysfunction

For many, avoiding crunches with legs crossed will be necessary

A lot of people who squat and deadlift heavy experience sexual dysfunction, up to erectile dysfunction It’s important to disentangle dysfunction to better pinpoint cause: Comorbidities like diabetes, high blood pressure, smoking, can negatively affect blood flow to genitals Hormonal issues impact desire (predominantly modulated by testosterone) Aging desensitizes genitals Mental health, stress, and anxiety can also negatively impact sexual health

First, understand that the penis and clitoris are parallel sex organs Sexual dysfunction in males: erectile dysfunction (could be vascular, hormonal, psychological, medications) Sexual dysfunction in females: difficulty with orgasm, low lubrication, pain with sex

Hormonal issues are just a small percentage of sexual dysfunction (only about 3-6%) There needs to be a stimulus for arousal, this is why sex is often tied to aggression and high testosterone – the sympathetic nervous system comes online

Medication like Cialis and Viagra won’t be effective for all males: a large percentage of erectile dysfunction is vascular, especially as you age; success rate is 60-70% Be careful if you’re tempted to experiment with over-the-counter L citrulline – it can cause nasty cold sores and canker sores

For women, there is no robust experimentation of Cialis or Viagra use Most sexual health studies have been done on males, in part because it’s easier to see what’s happening in men since sex genitals are external

There is a strong case for low dose (2.5-5mg) daily Cialis for erectile dysfunction in men; could also potentially be useful for men with pelvic pain or possibly as prophylactic (though this is off-label) Could also be useful for women with pelvic floor dysfunction

Erectile dysfunction in otherwise healthy young men (in 20s and 30s): sitting for a long period of time can induce pelvic floor dysfunction; one hour of exercise doesn’t offset a day of sitting – use a standing desk or walk more There’s also a psychological component – the more you feel something doesn’t work, the more you stress about it Tadalafil is a great option for erectile dysfunction

Serotonin is the antithesis to orgasm; SSRIs are sometimes prescribed for men with premature ejaculation Erectile dysfunction and depression are interrelated but it’s not always clear which came first Trazadone can cause sustained erection and is used off-label for premature ejaculation

There’s a difference between watching porn, masturbating to porn, and masturbating to the point of ejaculation Growing theory that masturbating to porn to the point of ejaculation is impeding healthy, real-world relationships

Pornography is more accessible than ever and does activate the dopamine pathway, but this doesn’t mean addiction happens to everyone You can watch porn and have normal, healthy relationships but it’s a fine line – porn can create problems if you only become comfortable masturbating in that setting

We need to talk about sex to understand what is normal so people don’t turn to porn in an attempt to understand sex and apply it to regular life

Try and vary what you do: you can become habituated to certain sexual preferences to the extent that you cannot perform or finish without them

Steps of female sexual arousal response: (1) excitement: heart rate goes up, vaginal lubrication, flush; (2) plateau; (3) orgasm: sympathetic response, rhythmic pelvic floor contraction; (4) refractory time period/recovery Prolactin establishes the refractory period and dopamine overrides it (so you can reduce the refractory period if something is novel enough) – the brain plays a huge role in sex

Female sexual arousal response is to prepare for penetration – the vagina actually lengthens; inadequate preparation can lead to painful sex Some people make a lot of lubrication, some don’t; changes in lubrication occur with breastfeeding, after menopause

Women will Medications for low libido: there’s a newer drug for women with low sexual desire called Vyleesi which works on brain pathways to increase desire; Flibanserin is also available for low libido

There’s no right or wrong level of libido – it’s really about whether you or your partner are bothered by it Couples may need to work through mismatched libido

Women always make discharge (it does not have to do with arousal); viscosity changes over the cycle Douching can wipe our microbiome

“The vagina is a self-cleaning oven – you don’t have to do anything.” – Dr. Rena Malik Just wash hair-bearing areas and that’s it Transdermal testosterone (1/10 of male dose) can improve sexual desire but only indicated once you’ve eliminated other causes of low libido

There are different types of female orgasm The clitoris is the most reliable form of stimulation for female orgasm Very few women climax through vaginal penetration alone

Only about 45-50% of first-time encounters in heterosexual relationships result in female orgasm; close to 90% of first-time sexual encounters in homosexual relationships result in orgasm

The g spot is 2-3 cm in the anterior wall of the vagina and is analogous to the male prostate – not all women are aroused by g spot stimulation Take home: you need to talk to your partner! There are so many ways for females to have an orgasm

The only consistent thing about female orgasm is that there will be pelvic floor contractions so you know when it’s happening Libido increases prior to and during ovulation because it’s the optimal time for fertility

Types of clitoral stimulation: rocking, outer part of the vagina, pressure (from alignment), intentional stimulation

Have the conversation outside the bedroom, not right before or after sex – move the conversation to a neutral location where sex is not about to happen or just happened (so it doesn’t seem like something went wrong) Use “I” statements– I like this, I don’t like this

Keep in mind, it’ll be an ongoing conversation, not a one and done For professional help, check out the American Association of Sexuality Educators, Counselors and Therapists (AASECT)

UTIs are very common in men and women Women: 50% of women will get a UTI in their lifetime, and about 30% will have recurrent UTIs Men: urethra is longer so UTIs are less common so it should be investigated

Prevention: hydration (2-3L fluid per day), vaginal estrogen is an effective prevention for recurrent UTIs in postmenopausal women (takes about 3 months to kick in), make sure you completely empty bladder The Women’s Health Initiative made a stink about estrogen and breast cancer but the absorbed amount when used vaginally is so minimal, it doesn’t even reach premenopausal levels

Men – you might even need to sit down to empty your bladder effectively because the pelvic floor is most relaxed while seated compared to standing Spermicide increases the frequency of UTIs in females

Cranberry works for UTI treatment and reducing the risk of UTI You can take capsules as prophylactic D-mannose may also work as prevention but research is less concrete It’s a myth! Women, there’s no good data on wiping front to back and UTIs

Over-cleaning can disrupt the dermis and microbiome

Dehydration and metabolic abnormality can lead to kidney stones Diagnosis protocol: 24-hour urine analysis Prevention: increase fluid intake, decrease oxalate intake (spinach, nuts), increase citrate (like fruit or drinking crystal light), decrease protein

Kidney stones can be treated in various ways but you can get very sick, very quickly – see the doctor right away

Female contraception is a very polarizing topic Some women experience low libido and significant consequences of taking oral contraceptives and there’s no way to know prior to taking

“I do think there is oral contraceptive-related sexual dysfunction, usually low-dose estrogen contraceptives are the culprit.” – Dr. Rena Malik Oral contraception response is varied and highly individual

80% of men at 80 have an enlarged prostate An enlarged prostate can narrow the urethra (pee tube) – imagine drinking from a narrow straw (urethra sits on the prostate) Genetics play a large role in predicting who will have a large prostate

You can’t really prevent a large prostate but you can mediate effects Symptoms of large prostate: difficulty urinating, overactive bladder (increased urgency and frequency), difficulty emptying bladder, increased urination at night

Tips: limit caffeine intake, reduce alcohol intake, sometimes spicy foods can irritate the bladder

Bicycle seats: you’re sitting on the perineum – high-volume cyclers can have genital numbness and sexual dysfunction Find a bike seat that allows you to sit with good posture, without aero riding It’s actually not good to have a bike seat with cutouts because the pressure is unevenly distributed Don’t worry too much – you won’t imminently have side effects from riding

Anal sex has become more common among heterosexual couples The main issue is that people don’t use protection – anal tissue is thinner and you’re more likely to get an infection You have to use a lubricant with anal sex and an anal-specific lubricant

Prepare the anus for sex: start with a small object and move up Some people use anal sex to avoid pregnancy, some want to try something new with their partner

The biggest cause of sexual dysfunction is comorbidities – manage your health and exercise Improve diet, exercise, get good sleep, and view early morning light (for testosterone) Stop smoking! It’s an erection killer

Get erectile dysfunction checked out right away – it’s related to future cardiovascular events

How (not) to communicate new scientific information: a memoir of the famous brindley lecture ( BJU International ) Women’s techniques for making vaginal penetration more pleasurable: Results from a nationally representative study of adult women in the United States ( PLOS ONE )

A qualitative analysis of female Reddit users’ experiences with low libido: how do women perceive their changes in sexual desire? ( The Journal of Sexual Medicine ) Why Women Engage in Anal Intercourse: Results from a Qualitative Study ( Archives of Sexual Behavior )

Human Sexual Response by William H. Masters & Virginia E. Johnson

Examine The New York Times – “Half of the World Has a Clitoris. Why Don’t Doctors Study It?” American Association of Sexuality Educators, Counselors, and Therapists (AASECT) Huberman Lab episode – “How Smell, Taste & Pheromone-Like Chemicals Control You” (Coolidge Effect)

Huberman Lab episode – “Biological Influences On Sex, Sex Differences & Preferences” Rena Malik – “The Surprising Reasons Why Women Engage in Anal Sex”