How can I tell if my pelvic floor is too tight or too weak?

It's difficult to self-diagnose, but symptoms like urinary urgency/frequency, pain with sex/erections/ejaculation, or constipation can indicate a tight pelvic floor. Urinary incontinence often points to a weak pelvic floor. A pelvic floor specialist (urologist, gynecologist, or physical therapist) can perform an examination to properly assess it.

What are Kegel exercises and who should do them?

Kegel exercises strengthen the pelvic floor, often prescribed for stress urinary incontinence or pelvic organ prolapse. They involve squeezing and relaxing the muscles used to stop urine flow, starting with 10-15 repetitions lying down. Overdoing Kegels can lead to a tight pelvic floor and dysfunction, so consult a physical therapist to ensure proper technique and necessity.

How can I relax a tight pelvic floor?

Women can try massage or vaginal dilators, and suppositories with muscle relaxants like Valium or Baclofen can offer temporary relief. Working with a pelvic floor physical therapist is ideal, as they can teach specific exercises to down-train the muscles, such as the happy baby yoga pose.

What are the common causes of sexual dysfunction in men and women?

Sexual dysfunction often stems from vascular problems (e.g., high blood pressure, diabetes, smoking), neurological issues, certain medications, and psychological factors like stress and anxiety. Hormonal imbalances account for only a small percentage (3-6%) of erectile dysfunction and are primarily linked to desire, not physical arousal.

What is the role of testosterone and estrogen in libido for both sexes?

Testosterone is crucial for desire (libido) in both men and women; women typically have more testosterone than estrogen. Sufficient estrogen is also vital for brain function and libido in both sexes. Suppressing estrogen (e.g., with aromatase inhibitors) can significantly reduce libido in men.

How do medications like Cialis and Viagra work, and are there similar options for women?

Cialis (Tadalafil) and Viagra (Sildenafil) are PDE5 inhibitors that prevent the breakdown of cGMP, a molecule essential for sustained erections by increasing blood flow. While less studied, these medications are sometimes tried off-label for women experiencing orgasm difficulties due to blood flow issues, often for a four-week trial.

Why are young men in their 20s and 30s experiencing erectile dysfunction?

A common cause in young men is pelvic floor dysfunction, often due to stress, anxiety, or prolonged sitting. This can lead to hyper-contraction of pelvic muscles, impeding blood flow. Psychological factors and the unrealistic portrayal of sex in pornography can also create a negative feedback loop, exacerbating performance anxiety.

What is problematic pornography use and how does it affect sexual health?

Problematic pornography use, not 'porn addiction,' affects a small subset of individuals. It can lead to habituation where normal stimuli are less arousing, making real-world sexual interactions difficult or unsatisfying compared to novel, aggressive porn scenarios. Varying masturbation techniques can help maintain sensitivity.

What is the female sexual response cycle, and why is clitoral stimulation so important?

The female sexual response cycle includes excitement, plateau, orgasm, and recovery. Physiologically, the cervix moves up, the vagina lengthens, and labia open to prepare for penetration. About 85% of women require clitoral stimulation to achieve orgasm, even during vaginal penetration, highlighting its primary role compared to vaginal-only stimulation.

How does vaginal hygiene affect the microbiome and UTI risk?

The vagina is a 'self-cleaning oven,' and excessive cleaning or douching can disrupt its natural microbiome (lactobacilli) and pH. This disruption can increase the risk of UTIs and bacterial vaginosis. It's best to only wash outer hair-bearing areas and let soapy water run down naturally.

What causes urinary tract infections (UTIs) and how can they be prevented?

UTIs are common in women due to a shorter urethra, but in men, they indicate a need for investigation. Prevention includes drinking 2-3 liters of water daily, using vaginal estrogen (post-menopause) to normalize pH, and ensuring complete bladder emptying. Spermicides also increase UTI risk.

How does oral contraception affect sexual desire and mood?

Oral contraceptives can increase sex hormone binding globulin (SHBG), which binds up testosterone and estrogen, potentially leading to lower libido. Many women also report depressive-like symptoms, anhedonia, and apathy. These effects can sometimes persist for months after discontinuation, leading to highly polarized views on their use.

What natural supplements can support sexual desire and function?

For mild libido enhancement, Tongkat Ali, Maca root, and Ashwagandha (for stress reduction) have some supporting data. L-citrulline can increase nitric oxide for blood flow. It's recommended to try one supplement at a time, consult a physician, and prioritize foundational health habits like diet, exercise, and sleep.

Key Moments

Improving Sexual & Urological Health in Males and Females | Dr. Rena Malik

Andrew Huberman

Science & Technology9 min read175 min video

Aug 14, 2023|2,036,745 views|34,718|1,615

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TL;DR

Dr. Rena Malik discusses male & female pelvic, urological, and sexual health. Covers pelvic floor, UTIs, hormones, arousal, orgasm, and common dysfunctions.

Key Insights

Pelvic floor health is crucial for sexual, urinary, and defecatory function in both men and women; over-tightness is as common a problem as weakness.

Sexual dysfunction is rarely purely hormonal (only 3-6% of ED) but often multi-factorial, stemming from blood flow, neural issues, psychological factors, and lifestyle.

Nitric oxide is the primary initiator of erections and clitoral engorgement, making blood flow critical and responsive to lifestyle and medications like PDE5 inhibitors.

Female orgasm often requires clitoral stimulation; misconceptions from pornography create unrealistic expectations and highlight the need for open communication.

UTIs are common in women, preventable by hydration, vaginal estrogen (post-menopause), and D-mannose, and are rarely caused by poor hygiene.

Oral contraceptives can negatively impact libido by increasing sex hormone binding globulin, reducing free testosterone, and may affect mood in some women.

Prostate health is vital for proper urination and sexual function, with low-dose tadalafil and lifestyle changes often used for managing enlargement and related symptoms.

THE CRITICAL ROLE OF PELVIC FLOOR HEALTH

The pelvic floor, a bowl of muscles connected to bones, supports all pelvic organs and is vital for urination, defecation, sexual function, and posture in both men and women. A healthy pelvic floor ensures normal function in these areas, while dysfunction can manifest as urgency, frequency, incomplete bladder emptying, painful sex, painful erections/ejaculation, and constipation. Many people are mistakenly told to strengthen their pelvic floor with exercises like Kegels, but an equally common, often unaddressed, problem is an overly tight or contracted pelvic floor, which requires relaxation rather than strengthening.

ASSESSING AND ADDRESSING PELVIC FLOOR DYSFUNCTION

Determining if the pelvic floor is too tight or too weak usually requires a specialist due to the difficulty in self-assessment. A pelvic exam for women and a rectal/perineal exam for men allows a physician or physical therapist to palpate muscles, assess tension or weakness, and evaluate coordination. Kegel exercises, designed by a gynecologist for strengthening, are beneficial for conditions like stress urinary incontinence and pelvic organ prolapse but must be performed correctly and not overdone, as excessive Kegels can lead to a tight pelvic floor. Conversely, a tight pelvic floor is addressed through massage, vaginal dilators, muscle relaxant suppositories, and physical therapy techniques like happy baby pose to elongate and relax the muscles.

THE NEUROVASCULAR AND PSYCHOLOGICAL LANDSCAPE OF SEXUAL FUNCTION

Sexual function is influenced by hormonal, blood flow (vascular), and neural factors, including brain signals for desire and arousal. Often, people attribute sexual dysfunction to hormonal imbalances, but only a small percentage (3-6% for erectile dysfunction) is directly hormone-related. Blood flow issues, often linked to cardiovascular health (high blood pressure, diabetes, smoking), are a major cause of dysfunction. Psychological factors like stress and performance anxiety can create a vicious cycle, exacerbating problems like erectile dysfunction. Differentiating between psychological desire and physical genital arousal is crucial for accurate diagnosis and treatment, as they do not always occur synchronously.

HORMONES AND LIBIDO: TESTOSTERONE, ESTROGEN, AND DOPAMINE

Testosterone is a key modulator of libido in both men and women; women actually have more testosterone than estrogen. Estrogen is also vital for libido in both sexes, and its suppression in men can significantly reduce sexual desire. Dopamine is associated with the desire response, while prolactin contributes to the post-orgasmic refractory period. The physiological arousal response, including erections and vaginal lubrication, typically involves the parasympathetic nervous system (rest and digest), while climax shifts towards the sympathetic nervous system (fight or flight). However, individual responses can vary, with some finding elements of excitement or even aggression stimulating.

PHARMACEUTICAL AND SUPPLEMENTAL INTERVENTIONS FOR SEXUAL HEALTH

PDE5 inhibitors like Viagra (sildenafil) and Cialis (tadalafil) work by preventing the breakdown of cGMP, a molecule essential for sustained erections by increasing blood flow. While highly effective for 60-70% of men with erectile dysfunction, they do not work for everyone, especially if psychological factors are dominant. L-citrulline, an over-the-counter supplement, increases nitric oxide availability, similarly promoting blood flow. For women, centrally acting medications like Bremelanotide (Vilisi) and Flibanserin (Addyi) are FDA-approved for hypoactive sexual desire disorder, acting on brain pathways to enhance desire. Low-dose daily tadalafil can also improve prostate health and assist with erectile function, even in men without specific ED issues.

PORNOGRAPHY, MASTURBATION, AND SEXUAL EXPECTATIONS

Problematic pornography use can lead to unrealistic sexual expectations regarding arousal and orgasm, particularly among young people who rely on it for early sexual education. While masturbation is a healthy form of self-exploration when not excessive or isolating, habitual use of specific stimuli (e.g., vibratory pressure) can lead to habituation, making it difficult to achieve arousal or orgasm with a partner during penetrative intercourse. It's crucial for individuals to vary masturbation techniques and for couples to communicate openly about desires and expectations to promote healthy sexual interactions.

UNDERSTANDING THE FEMALE SEXUAL RESPONSE AND ORGASM

The female sexual response cycle involves excitement, plateau, orgasm, and recovery. Physiologically, the cervix moves up, the vagina lengthens, and labia open in preparation for penetration. Lubrication is a key indicator of arousal, though not the only one, and is influenced by age and hormones. While some women experience orgasm through vaginal penetration, approximately 85% require direct clitoral stimulation to climax. The clitoris, homologous to the penis, extends deep into the pelvis and is the most reliable pathway to orgasm. The 'G-spot' refers to the Skene's glands, homologous to the male prostate, located in the anterior vaginal wall, which can be a source of pleasure for some women. Communication with partners about what is pleasurable is paramount.

FACTORS INFLUENCING FEMALE AROUSAL AND ORGASM

Female orgasm encompasses various forms, often described as graded or cumulative, distinct from the 'all-or-none' absolute orgasms. Factors like novelty, individual preferences, and even specific stimulation points (e.g., nipple, cervical) can induce orgasm. The brain is considered the most powerful sexual organ, initiating and modulating the entire sexual response. Dopamine release is strongly linked to orgasm, and prolactin to the subsequent refractory period. Contrary to some beliefs, arousal-based lubrication can occur independently of emotional desire, particularly in response to perceived penetration. Vaginal estrogen can also normalize vaginal pH and reduce UTI risk in low-estrogen states.

URINARY TRACT INFECTIONS (UTIS): PREVENTION AND TREATMENT

UTIs are very common in women (up to 50% lifetime incidence), while less frequent in men, where they warrant investigation of underlying issues. Prevention strategies include adequate hydration (2-3 liters of water/day), complete bladder emptying, and in post-menopausal women, vaginal estrogen. Cranberry (specifically 36mg of soluble proanthocyanidins or PACs) and D-mannose are effective supplements. Wiping front-to-back, swimming, or urinating after sex lack strong evidence for prevention. Over-cleaning or douching can disrupt the vaginal microbiome, increasing infection risk. UTIs in men often require investigation due to the longer urethra. Unaddressed UTIs, especially with obstruction, can lead to severe illness rapidly.

ORAL CONTRACEPTION AND SEXUAL SIDE EFFECTS

Oral contraceptives are a highly polarizing topic. While offering significant benefits like pregnancy prevention and management of conditions like PCOS, a subset of women reports negative impacts on libido and mood. This is theorized to be due to increased sex hormone binding globulin (SHBG), which reduces the availability of free testosterone and estrogen—hormones crucial for desire. These effects can sometimes persist for months after discontinuing oral contraceptives. Women experiencing sexual dysfunction from oral contraceptives may consider switching to alternative contraceptive methods like IUDs, which are generally safe and effective.

SSRIs AND SEXUAL DYSFUNCTION

Selective serotonin reuptake inhibitors (SSRIs) and other antidepressants frequently cause sexual dysfunction, including reduced libido, delayed ejaculation, and orgasmic difficulties. Serotonin, which SSRIs increase, can inhibit orgasm, and these medications are sometimes used off-label to treat premature ejaculation. Managing SSRI-induced sexual dysfunction typically involves dose reduction, switching to antidepressants with less sexual side effects (e.g., Wellbutrin), or adding PDE5 inhibitors like Cialis or Viagra. It's often difficult to disentangle the impact of depression itself from the medication's side effects on sexual function.

OPTIMIZING PROSTATE HEALTH

Prostate enlargement (BPH) is very common, affecting 80% of men by age 80, and can narrow the urethra, leading to urinary symptoms like urgency, frequency, nighttime urination, and difficulty emptying the bladder. Low-dose daily tadalafil effectively relaxes prostate smooth muscle to ease urination and can also enhance erectile function. General prostate health strategies include limiting bladder irritants like caffeine and alcohol, and ensuring complete bladder emptying (e.g., by sitting, especially for men). Lifestyle factors such as diet and exercise are foundational for overall prostate health.

BICYCLING AND PELVIC HEALTH

Cycling, particularly aggressive cycling postures (e.g., aero-riding) and narrow bike seats, can put pressure on the perineum, compressing the pudendal artery and nerve. This compression can lead to genital numbness (reported by up to 50% of high-volume cyclists) and potentially erectile dysfunction in men, and decreased lubrication/arousal in women. To mitigate risks, cyclists should use wider, noseless seats designed to distribute weight onto the ischial tuberosities (sit bones) and maintain good posture to avoid excessive pressure on the pelvic floor. The overall rate of erectile dysfunction may not differ between cyclists, runners, and swimmers, suggesting some risk might be population-general rather than cycle-specific.

UNDERSTANDING ANAL SEX

Anal sex is becoming more common, including among heterosexual couples, partly due to pregnancy prevention. However, it carries a higher risk of sexually transmitted infections (STIs) than vaginal intercourse because the anal tissue is thin and prone to trauma/bleeding. Consistent condom use and ample, appropriate lubrication (ISO-osmolar to anal pH) are essential. The anus lacks natural lubrication, and oil-based lubricants should be avoided with condoms. Reasons for engaging in anal sex vary, including prostate stimulation for men, G-spot or pelvic floor stimulation for women, novelty, or avoiding vaginal penetration (e.g., during menstruation). Proper preparation and gradual progression are vital to prevent trauma.

HERBS AND SUPPLEMENTS FOR SEXUAL WELL-BEING

While behavioral tools like diet (e.g., Mediterranean), exercise (cardio and resistance), adequate sleep, stress reduction, and morning light exposure are foundational for sexual health, some supplements show promise. L-citrulline and ashwagandha (for stress reduction) have reasonable data. Tongkat Ali is known for mild libido enhancement, potentially by freeing up testosterone or suppressing cortisol, and there is anecdotal evidence of its effectiveness in both men and women. Shilajit, an Ayurvedic herb, has some data supporting FSH increases. When considering supplements, it's recommended to try one at a time, expect gradual effects, and ensure they are sourced from reputable providers, always consulting a physician.

Mentioned in This Episode

●Supplements

●Software & Apps

●Companies

●Organizations

●Concepts

●People Referenced

Optimizing Pelvic, Urological & Sexual Health

Practical takeaways from this episode

Do This

Consult a pelvic floor physical therapist for diagnosis and tailored exercises if experiencing dysfunction.

Practice diaphragmatic breathing during exercise, exhaling on effort to stabilize the pelvic floor.

Identify desire and arousal components: assess both psychological interest and physical genital response.

For erectile dysfunction, try PDE5 inhibitors (e.g., Cialis/Viagra) as directed by a physician, but understand they are not always a complete solution.

For women with low libido, consider FDA-approved medications like Vyleesi or Addyi under physician guidance. Also, low-dose transdermal testosterone can be beneficial for post-menopausal women with low libido or vestibulodynia.

Engage in open and honest communication with sexual partners about likes, dislikes, and comfort levels outside the bedroom.

Increase daily fluid intake to 2-3 liters, preferably water, to prevent UTIs and kidney stones.

For recurrent UTIs, consider vaginal estrogen (post-menopausal), 36mg of soluble Pacs from cranberry extract, or 2 grams of D-mannose daily.

Ensure complete bladder emptying by sitting, relaxing, leaning forward, and potentially double-voiding.

Manage underlying health conditions like high blood pressure, diabetes, and heart disease, as they significantly impact sexual function.

Adopt a Mediterranean-style diet, incorporate regular cardiovascular and resistance exercise (especially large muscle groups), and prioritize good sleep.

Get early morning light exposure to support healthy testosterone and circadian rhythm.

For prostate health, consider low-dose daily Cialis (tadalafil) to relax smooth muscle and improve urinary flow.

When cycling, use a noseless, wider bike seat and maintain good posture to reduce pressure on the pudendal nerve and artery.

When engaging in masturbation, vary techniques and avoid excessive pornography use to prevent desensitization to real-world interactions.

For anal sex, always use condoms and adequate ISO-osmolar lubrication to prevent STIs and trauma.

Avoid This

Overdo Kegel exercises if your pelvic floor is already strong or tight, as this can cause dysfunction and pain.

Hold your breath during strenuous exercises, especially crunches, as this can strain the pelvic floor.

Rely solely on visual pornography for sexual education; it often presents unrealistic portrayals of sex.

Engage in over-cleaning of the genital area (e.g., douching), as it can disrupt the natural microbiome and lead to infections.

Ignore persistent pain or discomfort in the pelvic or genital area; seek evaluation from a specialist.

Disregard sexual dysfunction as merely an aging issue; it can be a 'canary in the coal mine' for cardiovascular problems.

Take oral contraceptives if experiencing significant sexual dysfunction (low libido, anhedonia) or depressive symptoms, without discussing alternatives with a physician.

Use spermicides, as they are a known risk factor for UTIs.

Drink excessive amounts of bladder irritants like caffeine, alcohol, or carbonated/spicy/acidic foods if experiencing overactive bladder symptoms.

Smoke or vape, as nicotine is a vasoconstrictor detrimental to sexual function.

Use gray market peptides due to contamination risks (e.g., LPS).

Take multiple supplements for sexual health all at once, as it makes it difficult to assess individual efficacy.

Common Questions

The pelvic floor is a bowl of muscles connected to bones that supports organs in the pelvis. It plays crucial roles in urination, defecation, sexual function, and posture. A healthy pelvic floor ensures normal function in these areas and prevents issues like back pain or incontinence.

Topics

Health & Longevity Neuroscience & the Brain Mental Health & Psychology Human Performance Mindset & Self-Improvement Erectile Dysfunction Hormone Balance Sexual Dysfunction Pelvic Floor Health Prostate Health Medicine & Clinical Female Sexual Health Urinary Tract Infections (UTIs)Relationships And Intimacy

Mentioned in this video

Supplements

Valium

A muscle relaxant that can be used in suppositories to help relax tense pelvic floor muscles, though it's more of a band-aid than a treatment.

Baclofen

A muscle relaxant that can be used in suppositories to help relax tense pelvic floor muscles, though it's more of a band-aid than a treatment.

L-citrulline

An over-the-counter supplement that increases nitric oxide availability, thought to improve blood flow to genitals. Cautioned due to potential side effects like cold sores.

Maca root

A supplement mentioned for its potential libido-enhancing effects, possibly through estrogen receptor modulation and dopaminergic tone changes.

D-mannose

A supplement (about 2 grams daily) shown in small trials to be effective in reducing UTI risk.

Shilajit

An Ayurvedic herb, with one study showing increases in FSH. Mentioned as harder to assess for quality and dosing.

Ashwagandha

An adaptogenic herb known for stress reduction, which has implications for sexual function and overall well-being.

Cranberry extract

An active ingredient in cranberry (36mg of PACs in soluble form) recommended in AUA guidelines for reducing the risk of recurrent UTIs.

Tongkat Ali

An Indonesian herb discussed for mild libido enhancement, potentially by freeing up testosterone and suppressing cortisol. Mentioned as having 'reasonable data'.

Drugs & Medications

Cialis

A PDE5 inhibitor medication used for erectile dysfunction and prostate health, working by preventing cGMP breakdown. It has a 36-hour half-life allowing for daily low-dose use.

Wellbutrin

An antidepressant that increases dopamine and norepinephrine, offering an alternative to SSRIs for individuals experiencing sexual dysfunction.

Vyleesi

An FDA-approved injectable medication for premenopausal women with hypoactive sexual desire disorder, acting as a melanocortin receptor agonist to increase desire.

Addyi

An FDA-approved daily medication for low libido in premenopausal women, acting on serotonin and dopaminergic brain areas to decrease hypoactive sexual desire disorder.

Tranilast

An alpha-blocker medication used for enlarged prostate that relaxes urethral smooth muscle, also used to help pass kidney stones.

Alpha-melanocyte stimulating hormone

A peptide hormone that can cause erections and tanning in men, and has a role in female libido, with an FDA-approved version called Vyleesi.

Viagra

A PDE5 inhibitor medication used for erectile dysfunction, which prevents the breakdown of cGMP, leading to longer-lasting erections. Originally studied for high blood pressure.

Concepts

Coolidge effect

The phenomenon where a novel sexual partner can override the refractory period in both males and females.

Nitric Oxide

The 'ignition' for erections, released by the endothelium in response to tactile or visual stimuli, initiating the erection cascade.

Vaping

A recreational activity involving nicotine, identified as a vasoconstrictor and detrimental to erectile function and general sexual health in both males and females.

Mediterranean diet

A dietary pattern identified as the best-studied in sexual dysfunction literature, supporting overall health and potentially improving sexual function.

Pudendal artery

An artery that runs through the pelvic floor, essential for blood flow to the genitals; dysfunction can lead to decreased blood flow and affect sexual function.

Pudendal nerve

A nerve that runs through the pelvic floor, essential for sexual function and sensation; dysfunction can lead to pain and decreased blood flow.

prolactin

Hormone associated with the refractory period where erection or orgasm can't occur, establishing the post-climax phase.

Problematic pornography use

Term used in literature instead of 'porn addiction', describing a small subset of people whose pornography use negatively impacts their life or relationships.

Organizations

American Urological Association

Organization whose guidelines recommend cranberry extract for prevention of recurrent UTIs in women.

Stanford School of Medicine

Academic institution where Andrew Huberman is a professor.

University of California, Los Angeles

Location where significant microbiome studies on UTIs and overactive bladder are being conducted.

American Association of Sexuality Educators, Counselors, and Therapists

Website (aasect.org) to find a certified sex therapist for individuals or couples struggling with sexual communication or dysfunction.

People

Justin Sonnenberg

Stanford colleague and expert in the gut microbiome, highlighting the importance of microbiomes on mucosal linings and the effects of over-cleaning.

Rena Malik

Board-certified urologist and pelvic surgeon, expert in male and female urological, pelvic floor, and sexual health. Guest on the podcast.

Andrew Huberman

Host of the Huberman Lab podcast and a professor of neurobiology and ophthalmology at Stanford School of Medicine.

Masters and Johnson

Researchers who studied the human sexual response cycle, defining phases like excitement, plateau, orgasm, and recovery.

Companies

Inside Tracker

A personalized nutrition platform that analyzes blood and DNA data to provide health insights and protocols. Sponsor of the podcast.

Roche

Company that makes high-quality eyeglasses and sunglasses, sponsoring the podcast.

Helix Sleep

Company that makes customized mattresses and pillows based on individual sleep needs, sponsoring the podcast.

GoodRx

A platform offering coupons for prescription medications, making them more affordable.

Examine.com

A resource website providing evidence-based information on supplements, often referenced for human studies and efficacy.

Mark Cuban's Pharmacy

An online pharmacy mentioned for offering affordable prescription medications, including vaginal estrogen.

Software & Apps

Happy Baby

A yoga pose recommended for stretching and elongating tense pelvic floor muscles.

Huberman Lab Premium Channel

A premium offering related to the Huberman Lab podcast, offering additional content in exchange for completing a survey.

Kegel exercises

Strengthening exercises for the pelvic floor, described as beneficial for urinary incontinence and pelvic organ prolapse but cautioned against overuse.

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