Improving Sexual & Urological Health in Males and Females | Dr. Rena Malik
Dr. Rena Malik, a board-certified urologist and pelvic surgeon, discusses male and female urologic, pelvic floor, and sexual health. She covers topics like UTI prevention, pelvic floor dysfunction, erectile dysfunction, female arousal, and the impact of hormones, blood flow, and neural factors on sexual function.
Deep Dive Analysis
17 Topic Outline
Pelvic Floor: Anatomy, Function & Dysfunction
Kegel Exercises and Pelvic Floor Relaxation
Sexual Desire vs. Arousal: Psychological & Physiological
Erectile Dysfunction: Causes, Treatments & Young Men's Issues
Pornography, Masturbation & Arousal Habituation
Female Arousal, Orgasm & Clitoral Stimulation
Medications for Low Libido in Women
Vaginal Health, Lubrication & Microbiome
Brain's Role in Orgasm & Dopamine Pathways
Urinary Tract Infections (UTIs): Prevention & Treatment
Prostate Health & Urination Difficulties
Kidney Stones: Prevention & Management
Oral Contraception's Impact on Libido and Mood
Antidepressants (SSRIs) & Sexual Dysfunction
Cycling, Genital Numbness & Erectile Dysfunction
Anal Sex: Safety, Risks & Lubrication
Behavioral & Supplemental Approaches to Libido
8 Key Concepts
Pelvic Floor Dysfunction
This occurs when pelvic floor muscles are overstrained, becoming contracted and short, leading to symptoms like urinary urgency/frequency, incomplete bladder emptying, pain during sexual activity, constipation, and back pain. Conversely, a weak pelvic floor can cause issues like urinary incontinence.
Desire vs. Arousal
Desire refers to the psychological want or interest in sexual activity, while arousal is the physical, physiological response of the body and genitals (e.g., erections, vaginal lubrication, nipple engorgement). These two aspects do not always occur in a linear fashion, and arousal can sometimes precede desire.
Nitric Oxide in Erections
Nitric oxide is a molecule released by the endothelium in response to sexual stimuli, acting as the 'ignition' for erections. It initiates a biochemical cascade that increases cGMP, leading to blood flow into the erectile tissue and subsequent engorgement.
Coolidge Effect
This phenomenon describes how the introduction of a novel sexual partner can override the post-orgasmic refractory period in both males and females, allowing for renewed arousal and the potential for additional orgasm or erection, largely mediated by dopamine.
Vaginal Microbiome
The natural community of microorganisms, primarily lactobacilli, residing in the vagina. This microbiome maintains an acidic pH, which is crucial for preventing infections like UTIs and bacterial vaginosis, and can be disrupted by practices like douching.
Orgasm Gap
Refers to the significant disparity in orgasm rates between men and women, particularly in heterosexual encounters. While men report a 95% orgasm rate in first-time encounters, women in heterosexual relationships report only 45-50%, compared to 90% in homosexual female relationships, highlighting the importance of clitoral stimulation.
Priapism
A prolonged erection lasting longer than four hours that occurs in the absence of sexual arousal. This is considered a medical emergency because it can lead to decreased blood flow and permanent tissue damage or scarring if not treated promptly.
Hypoactive Sexual Desire Disorder (HSDD)
A condition characterized by a persistent or recurrent deficiency or absence of sexual fantasies and desire for sexual activity that causes marked distress or interpersonal difficulty. There are FDA-approved centrally acting medications, such as bremelanotide (Vyleesi) and flibanserin (Addyi), available for premenopausal women with HSDD.
10 Questions Answered
Most people cannot recognize this on their own, as it's a gradual change. A proper assessment requires an examination by a physician specializing in pelvic floor health (urologist, gynecologist, or physical medicine rehabilitation doctor) or a certified pelvic floor physical therapist.
While only 3-6% of erectile dysfunction (ED) is hormonal, a large percentage in older men is vascular (blood flow related). In young men (20s-30s), ED is often linked to pelvic floor dysfunction due to stress and prolonged sitting, compounded by psychogenic factors like performance anxiety and problematic pornography use.
While masturbation and pornography can be healthy, excessive or problematic use can lead to arousal habituation, where individuals become accustomed to specific stimuli and may struggle to achieve arousal or orgasm with a partner or through different methods. It can also contribute to unrealistic expectations about sex and relationship difficulties.
Clitoral stimulation is the most reliable form of stimulation for female orgasm, with approximately 85% of women requiring it to climax. Vaginal penetration alone is often insufficient, though some forms of penetration can indirectly stimulate the clitoris or its internal structures.
UTIs are common in women and less so in men, where they warrant investigation. Prevention includes adequate hydration (2-3 liters of water daily), vaginal estrogen for women with low estrogen, complete bladder emptying, and specific cranberry supplements (36mg soluble PACs) or D-mannose.
Oral contraceptives can lead to low libido in a subset of women by increasing sex hormone binding globulin (SHBG), which binds testosterone and estrogen, making them less available. This effect can persist for several months after stopping the pill, and some women also report depressive-like symptoms or apathy.
An enlarged prostate (BPH) is very common with age and can cause urinary difficulties like urgency, frequency, and weak stream. Management includes medications like low-dose daily Cialis (Tadalafil) or alpha-blockers like Flomax to relax prostate smooth muscle, and avoiding bladder irritants like caffeine and alcohol.
High-volume cycling can cause genital numbness in both men and women, and erectile dysfunction in men, due to pressure on the pudendal artery and nerve in the perineum. Using a wider, noseless bike seat and maintaining good posture can help prevent these issues, though some studies suggest ED rates in cyclists may not differ significantly from other athletes.
Anal sex carries a higher risk of sexually transmitted infections (STIs) due to the thin, friable anal tissue, making condom use and adequate lubrication crucial. The anus does not produce its own lubrication, and specific isoosmolar lubricants for anal pH are recommended to prevent trauma.
The most effective interventions involve managing comorbidities like high blood pressure and diabetes, adopting a healthy diet (e.g., Mediterranean), engaging in regular exercise (cardiovascular and resistance training), ensuring adequate sleep, and getting early morning light exposure to support circadian biology and hormone release.
22 Actionable Insights
1. Prioritize Foundational Health
Adopt a Mediterranean diet, engage in regular cardiovascular and resistance exercise (especially large muscle groups), manage blood pressure and diabetes, and ensure adequate sleep and early morning light exposure to boost testosterone. These foundational health practices are crucial for overall well-being and sexual function, and quitting smoking/vaping is essential as they impair erections.
2. Seek Pelvic Floor Specialist
If experiencing symptoms like painful urination, pain with erections/ejaculation, or difficulty emptying, consult a urologist or pelvic floor specialist for assessment. Ensure the therapist is certified in pelvic floor physical therapy and experienced with your specific gender’s anatomy.
3. Improve Sexual Communication
Discuss sexual preferences (likes/dislikes) with your partner in a neutral setting outside the bedroom, using ‘I’ statements to avoid blame. Understand that these are ongoing, multi-conversation processes that may require patience and potentially the help of a sex therapist (find one at AASECT.org).
4. Prevent Urinary Tract Infections
Drink 2-3 liters of water daily, ensure complete bladder emptying (sitting, relaxing, leaning forward, or double voiding), and avoid spermicides. For women with low estrogen, consider vaginal estrogen (cream, suppository, or ring) 2-3 times weekly, and a soluble cranberry supplement with 36mg of PACs daily or 2 grams of D-mannose daily may also reduce UTI risk.
5. Maintain Vaginal Health
Avoid douching and excessive cleaning, as the vagina is a self-cleaning organ, and such practices can disrupt its natural microbiome and pH, increasing infection risk. Only wash hair-bearing external areas with soapy water, and seek evaluation for new, strong, or fishy odors, or changes in discharge (e.g., cottage cheese-like), itching, or discomfort.
6. Manage Pornography Use
Understand that pornography is a produced product that can set unrealistic expectations for sexual encounters. To avoid habituation and potential difficulty with real-world arousal, vary your masturbation techniques and the types of stimulation you seek.
7. Relax a Tight Pelvic Floor
If you have a tight pelvic floor, consider massage, vaginal dilators, or muscle relaxant suppositories (Valium, Baclofen) for temporary relief. The most effective approach is working with a pelvic floor physical therapist who can teach specific exercises like ‘happy baby pose’ to lengthen and down-train the muscles.
8. Exercise Caution with Kegels
Overdoing Kegel exercises can lead to a tight pelvic floor and dysfunction, so if you experience adverse symptoms or are unsure, consult a pelvic floor physical therapist to ensure correct technique and necessity. Strengthening is beneficial for a weak pelvic floor, but detrimental if already strong or over-trained.
9. Perform Kegel Exercises Correctly
For weak pelvic floor, stress urinary incontinence, or pelvic organ prolapse, squeeze pelvic floor muscles (like stopping urine flow or lifting the penis) for 5 seconds, relax for 5, doing 10-15 repetitions, 1-3 times daily. Start lying down to focus on the muscles, then progress to sitting and standing as strength improves.
10. Optimize Prostate Health
For prostate health and urinary symptoms (urgency, frequency, difficulty emptying), consider medications like daily low-dose Cialis (Tadalafil) or Flomax as prescribed by a doctor. Additionally, pay attention to and potentially limit bladder irritants such as caffeine, alcohol, carbonated beverages, spicy foods, and acidic foods.
11. Prevent Kidney Stones
Increase fluid intake to 2-3 liters daily, reduce oxalate-rich foods (e.g., spinach, rhubarb, excessive nuts), increase citrate (e.g., fruits, vegetables, Crystal Light), and decrease high-purine protein intake (e.g., red meats). If you have a stone, get a 24-hour urine analysis to identify metabolic abnormalities for targeted treatment, and seek immediate medical attention for fever, chills, or blood in urine.
12. Improve Cycling Genital Health
To mitigate genital numbness, erectile dysfunction, or decreased arousal from cycling, ensure proper posture and use a noseless, wider bike seat that supports your ischial tuberosities. Avoid leaning forward (aero riding) and bike seats with cutouts, as these can increase pressure on the pudendal nerve and artery.
13. Practice Anal Sex Safely
When engaging in anal sex, always use a condom and adequate, isoosmolar lubrication, as the anal tissue is thin and friable, increasing STI transmission risk. Take your time, start with smaller items, and never force penetration to avoid trauma.
14. Understand Desire & Arousal
Recognize that desire (wanting to have sex) and arousal (physical signs like nipple erection or lubrication) are distinct and don’t always occur in the same order. It’s normal for arousal to precede desire, especially for some women, so understand both components of sexual response.
15. Consider Low-Dose Tadalafil
For men, daily low-dose Tadalafil (2.5-5mg) can be an effective treatment for erectile dysfunction, especially with psychogenic issues, and is also effective for enlarged prostate (BPH). It can be tried off-label for women with sexual dysfunction and vascular issues for at least a four-week trial, but always consult a physician.
16. Address Oral Contraceptive Side Effects
If experiencing low libido, pelvic pain, or other sexual dysfunction while on oral contraceptives, discuss alternative contraception methods like IUDs with your doctor. Oral contraceptives can increase sex hormone binding globulin (SHBG), reducing free testosterone and estrogen, which may persist for at least four months after discontinuation.
17. Manage SSRI Sexual Dysfunction
If experiencing sexual dysfunction from SSRIs, discuss with your doctor reducing the SSRI dose, switching to an antidepressant with fewer sexual side effects (e.g., Wellbutrin), or adding medications like Cialis or Viagra to manage symptoms if the SSRI cannot be changed.
18. Testosterone Cream for Women
For women with low libido and clinically low testosterone, consider off-label transdermal testosterone (e.g., 1/10th of an Androgel tube on a hairless area like the calf or buttock) to improve overall desire. For vestibulodynia (pain in the vaginal vestibule), a compounded estrogen-testosterone cream applied locally can reduce discomfort, but always consult a physician.
19. Explore Low Desire Medications
For premenopausal women experiencing low sexual desire disorder, discuss with a physician the FDA-approved injectable medication Vyleesi (bremelanotide), taken 45 minutes before desired sexual activity, or the daily oral medication Addyi (flibanserin) at 100mg before bedtime. Both can increase desire, but require a prescription and may be costly.
20. Manage Priapism Emergency
If you experience priapism (an erection lasting longer than four hours without sexual arousal), seek immediate emergency medical attention. This is a medical emergency that can lead to decreased blood flow and permanent tissue damage if not treated promptly.
21. Breathe Correctly During Exercise
Practice diaphragmatic breathing during exercise, exhaling on the effort (e.g., during a crunch or squat). This helps stabilize the pelvic floor by contracting it during increased intra-abdominal pressure, preventing strain and potential dysfunction.
22. Use Supplements Wisely
When trying supplements for sexual function, introduce them one at a time to identify their specific effects, and understand that benefits typically build over time rather than being immediate. Consult reputable resources like examine.com for evidence-based information on efficacy.
8 Key Quotes
Many people hear about the need to so-called strengthen their pelvic floor, but in fact, many people need to do the exact opposite. They need to learn to relax their pelvic floor in order to achieve proper urologic and sexual function.
Andrew Huberman
Pelvic floor, very simply, is basically a bowl of muscles that's connected to bones that hold up all your organs.
Dr. Rena Malik
Not having an erection does not mean you're not aroused. It may mean other things, but certainly that's part of it.
Dr. Rena Malik
We always say in sexual medicine that the brain is the most powerful organ for sex, not your genitals, but the brain, because it is so powerful.
Dr. Rena Malik
The vagina is a self-cleaning oven. You don't have to do anything.
Dr. Rena Malik
About 85% of women require clitoral stimulation in order to climax. So very few actually climax through just vaginal penetration alone.
Dr. Rena Malik
If you take something that works immediately, it's probably got a PDE5 inhibitor mixed in there.
Dr. Rena Malik
If you are developing true organic impotence, meaning that there's a biologic problem that's causing your sexual dysfunction, then it's really important to get your cardiovascular health assessed because about 15% of men who develop erectile dysfunction seven years later will have a cardiovascular event.
Dr. Rena Malik
3 Protocols
Kegel Exercise Protocol
Dr. Rena Malik- Identify pelvic floor muscles by attempting to stop the flow of urine (do not perform during urination).
- Squeeze the identified muscles 'up and in' for 5 seconds, then relax for 5 seconds.
- Perform 10-15 repetitions, once in the morning and once at night, potentially adding one more session during the day.
- Begin practicing while lying down, then progress to sitting, and finally standing as proficiency improves.
- Avoid overdoing Kegel exercises to prevent the development of a tight, short pelvic floor and subsequent dysfunction.
Urinary Tract Infection (UTI) Prevention Protocol
Dr. Rena Malik- Increase fluid intake to 2-3 liters of water daily to dilute bacteria in the bladder.
- For women with low estrogen (e.g., postmenopausal), use vaginal estrogen (cream, suppository, or ring) 2-3 times per week at night; note that it takes about 3 months to become fully effective.
- Ensure complete bladder emptying by sitting, relaxing on the toilet, possibly leaning forward, and attempting to urinate a second time after standing up and sitting back down.
- Consider taking 36 milligrams of soluble Proanthocyanidins (PACs) from cranberry in a capsule form once daily.
- Consider taking about 2 grams of D-mannose daily, which has shown effectiveness in small randomized controlled trials.
Communication for Sexual Interactions Protocol
Dr. Rena Malik- Initiate conversations about sexual preferences and desires outside the bedroom, in a neutral location, to avoid creating insecurity or animosity.
- Use 'I' statements (e.g., 'I like it when...', 'I don't like it when...') to express preferences without placing blame on the partner.
- Recognize that effective communication is an ongoing process that will likely involve multiple conversations, some of which may be challenging.
- If difficulties persist, consider seeking guidance from a sex therapist, who can be found through resources like AASECT.org, for facilitated discussions.