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

Andrew Huberman opens the Huberman Lab podcast, which he describes as discussing science and science-based tools for everyday life, and identifies himself as a professor of neurobiology and ophthalmology at Stanford School of Medicine. The guest is Dr. Rena Malik, introduced as a board-certified urologist and pelvic surgeon and an expert in male and female urological, pelvic floor, and sexual health; the introduction also notes that she still sees patients daily at her Southern California clinic, has authored dozens of high-quality peer-reviewed publications, and provides zero-cost public education on her YouTube channel.

Huberman lays out the episode's scope: how to avoid UTIs (urinary tract infections), pelvic floor anatomy and function, the distinction between an overly tight and an overly relaxed pelvic floor, and sexual health as it relates to erectile function, vaginal lubrication, and orgasm. He flags a central misconception, that many people believe hormones are responsible for sexual dysfunction when hormone dysregulation accounts for only a very small percentage of cases, whereas pelvic-floor and blood-flow-related issues can account for a large number of cases in both males and females.

Huberman explicitly frames the content as medical and scientific, discussed from the standpoint of the clinician and biologist, and issues a content advisory that certain themes would not be suitable for young children, leaving parents and households as the arbiters and pointing listeners to the episode timestamps. He also states that the podcast is separate from his Stanford teaching and research roles and is part of an effort to bring zero-cost-to-consumer science information to the general public.

To reduce the shock response, Huberman names the relevant terms up front - penis, vagina, anus, prostate, libido, intercourse, oral sex, anal sex - and frames the exchange as a very frank discussion grounded in science and medicine. He contrasts it with how people typically learn about sexual health, from school, home, friends, overheard remarks, online sources, and pornography, and with education oriented toward fear of STIs and unwanted pregnancy rather than the healthy versions of sexual health; Malik responds that they have to talk about all of it.

So a pelvic floor, very simply, is basically a bowl of muscles that's connected to bones that hold up all your organs.

Malik describes the pelvic floor's functions as many: it helps with urination, defecation, sexual function, and posture, and a strong, healthy pelvic floor is associated with normal urination and defecation, great sex, and an absence of ailments like back pain. She stresses that dysfunction is not confined to women, stating that men also suffer from pelvic floor dysfunction, and that urologists deal with it often because it is so integral to the functions they care for.

Overstrain is likened to doing gym repetitions without rest, which would leave a muscle contracted and short; the pelvic floor can similarly become contracted, short, and tight all the time, sometimes unknowingly, as a function of stress, anxiety, overuse, or posture problems. Consequences for urination include urgency, frequency, a sudden desire that cannot be delayed, leakage, and in some cases difficulty urinating because the pelvic floor is so tense. Huberman adds the possibility of incompletely vacating the bladder and needing to urinate again five minutes later.

Malik clarifies that the sensation of not emptying completely is not always a failure of evacuation: tense pelvic floor muscles can stimulate the bladder so it feels like there is more to go, and the condition can present in a number of different ways. A too-tense pelvic floor can also produce pain with sex, erections, and ejaculation, constipation, and often back pain. A too-weak pelvic floor is attributed in women to childbirth, and in others to neurologic disorders or connective tissue disorders such as Ehlers-Danlos syndrome, commonly producing urinary incontinence or leakage.

Reported manifestations grouped by system in the discussion: urinary - urgency, frequency, leakage, difficulty urinating, or a feeling of incomplete emptying; sexual - pain with sex, erections, or ejaculation; gastrointestinal and musculoskeletal - constipation and back pain; weakness-related - urinary incontinence or leakage.

Asked how a person could tell a too-tight from a too-weak pelvic floor, Malik says most people cannot recognize it because it is gradual and it is not a muscle we were ever trained to recognize; people hear about Kegel exercises but little else. Assessment typically begins with an examination - a pelvic exam for women and usually a rectal exam for men - with palpation of muscles such as the iliococcygeus, pubococcygeus, and levator ani through the vagina, plus assessment of tenseness, tenderness, coordination, whether a person is squeezing or pushing, sensation, and laterality.

Huberman describes digital palpation and the digital prostate exam, observing that the practice has persisted for something like 50, 60, or maybe 100 years, comparable to the old-school practice of assessing glaucoma by touching the eyeball. Malik describes pelvic floor therapists who align the bones and the way a person sits and walks so muscles are not strained by pulling in different directions, likening the work to going to the gym with a trainer, while conceding she is not a pelvic floor therapist. For men, the perineal area is examined externally and the muscles can also be felt through the anus.

On self-assessment, Malik says at-home probes that teach Kegel exercises are not really meant to diagnose, and that nothing gives a baseline reading of whether a pelvic floor is normal or abnormal; she agrees a high-quality assessment means seeing a pelvic floor specialist, and Huberman concludes it is not something people could reliably intuit on their own.

Kegel is identified as a gynecologist, though Malik says she does not remember all the specifics. The exercise is described as using the muscles that stop urine flow - but explicitly not while urinating, because that can create dysfunction - squeezing and relaxing between sets; alternative cues include pulling up and in the vagina, or, for men, the feeling of trying to lift the penis off the floor without touching it.

The dosing Malik gives is specific: squeeze for 5 seconds and relax for 5 seconds, start with 10 to 15 at a time, lying down first, then sitting, then standing, with 10 to 15 repetitions in the morning and 10 to 15 at night, maybe one more midday, but not overdoing it. She warns that doing tons and tons of Kegels produces a tight, short pelvic floor and pelvic floor dysfunction, and encourages working with a pelvic floor physical therapist to do them correctly.

Prescribed indications she lists include stress urinary incontinence - leakage with increased intra-abdominal pressure such as a Valsalva, coughing, sneezing, lifting heavy things, or jumping on a trampoline - pelvic organ prolapse in women, and post-prostatectomy leakage in men; recreational use is noted because improved pelvic floor musculature can produce more intense contractions during orgasm. Huberman reports that trying Kegels quickly resulted in painful urination, so the best thing for his pelvic floor seemed to be avoiding them, and he underscores the cautionary note.

The take-home distinction is that strengthening helps a weak pelvic floor but can be detrimental if the pelvic floor is already strong and gets overtrained. Malik advises that anyone with symptoms such as painful urination, pain with erections or ejaculation, or difficulty emptying should stop and go see a urologist so the pelvic floor can be assessed.

For a tight pelvic floor, the anti-Kegel options Malik lists are massage, vaginal dilators, suppositories containing muscle relaxants such as Valium or baclofen, and physical therapy to down train the pelvic floor; she calls the suppositories more of a band-aid than a treatment and names happy baby pose as an exercise that stretches and elongates the pelvic floor muscles. Huberman recounts that ceasing Kegels and avoiding crunching movements with legs crossed relieved discomfort similar to what Kegels had caused.

Malik offers a mechanistic account: diaphragmatic breathing matters because when you inhale the pelvic floor relaxes and when you exhale it contracts, and holding the breath during crunches is part of the problem. She adds that the pudendal nerve and pudendal artery run through the pelvic floor, so dysfunction can cause decreased blood flow to the pelvic floor muscles - affecting sexual function - and nerve inflammation that causes pain.

Huberman proposes framing the whole discussion around three influences - the hormonal influences, the blood flow related influences, and the neural influences, including brain-derived signals of arousal or lack of arousal - and notes that an effort to strengthen the muscles can cut off blood flow. He reports consulting a couple of exercise physiologists who confirmed that people who squat and deadlift heavy, tense the pelvic floor during dumbbell curls, or do a lot of abdominal work described erectile dysfunction and pain during vaginal intercourse, which he interprets as a hypercontraction of muscles in that area impeding the functions they wanted.

The tension Huberman identifies is that many males lift weights to increase testosterone and also want healthy sexual function; testosterone is involved in libido and the male and female sexual response, yet the same behavior may be impeding their erections. He sets up the diagnostic problem of distinguishing blood-flow-related, hormone-related, and neural causes, including central signals of arousal versus peripheral innervation of the penis or vagina.

Malik says the first step is a specific history - are you getting aroused, are you having erections, are you masturbating - and Huberman interrupts to insist on distinguishing psychological desire from genital arousal. Malik agrees that desire and arousal do not always go in one direction, noting that telltale signs of arousal include nipple erection and, in females, more lubrication. Asked whether both male and female nipples become erect during arousal, she answers I believe so, and Huberman says I think so.

Malik describes the sex flush, some redness or warmth, as the body's response to arousal and stresses that not having an erection does not mean you are not aroused. She separates desire, whether one wants to have sex, from obligation, and says it does not matter if the desire comes after arousal, describing women whose desire follows being intimate and close with a partner and calling that normal and totally fine.

For men, asking about nighttime erections separates organ function at night from daytime psychogenic components. Malik describes a vicious cycle in which a problem with performance in the bedroom leads to stress, not being present or mindful during sex, and worry about whether one will perform; when it does not perform again the anxiety is through the roof and that is actually causing the sexual dysfunction.

For vascular causes, Malik points to comorbidities - high blood pressure, diabetes, heart disease, and smoking - all of which affect blood flow to the genitals negatively, pointing to a more vascular issue. She then states the figure that frames much of the episode: hormonal issues are very important for desire, but as far as sexual function in terms of erections, only 3% of erectile dysfunction is related to hormones.

there's only 3% of erectile dysfunction that's related to hormones.

Huberman confirms the 3% figure refers to pure erectile function as opposed to desire, and Malik clarifies that desire is predominantly modulated by the hormone testosterone for both men and women, adding that women have more testosterone in their bodies than they actually have estrogen. Elsewhere the hormonal share of erectile dysfunction is refined to 3 to 6%, or up to 6%, still described as a small percentage of the entirety of erectile dysfunction.

Vascular assessment tools Malik names include Doppler ultrasound of the penis and clitoris, peak systolic velocity to identify a problem with arterial inflow, and end-diastolic velocity for venous outflow. Nerve-function tests are very uncommonly done because the information mostly comes from clinical report; nerve problems can be very difficult to reverse, and aging reduces receptor sensitivity and responsiveness - a limitation she says overlays all of this - with the overall picture also shaped by relationship, stress, and anxiety.

Asked where to find a pelvic floor therapist or urologist, Malik recommends a physician who specializes in pelvic floor - a urologist, gynecologist, or physical medicine and rehabilitation doctor - and specific credentials: board certification in female pelvic medicine and reconstructive surgery for women, sexual medicine for men, and a pelvic floor physical therapist certified in pelvic floor physical therapy who has treated one's gender. She notes that in her training there were about 20 PM&R doctors around the country who really focused on this, so it is not a lot of people, and concedes there is no great resource, at least to her knowledge.

Huberman frames the access problem as shame or at least a lack of clarity about how one gets help for issues relating to the genitals, contrasting it with knowing where to go for a headache or an eye issue - neurologists for headaches that warrant them, ophthalmologists and optometrists for eyes - and thanks Malik because people do not hear often enough about where to access the best quality care for these things.

On constructing a male-female parallel, Malik states that the penis is the homologue of the clitoris and that the clitoris is essentially the same sort of spongy erectile tissue seen in the penis, which gets erect with arousal and extends very deep into the pelvis, so it is actually quite long rather than a small organ. Huberman adds the embryological parallel: the penis and clitoris are analogous structures, with male genital development involving regression of female genitalia and associated organs such as mullerian ducts, and what would become the ovaries becoming the testes.

Malik resists a one-to-one parallel: in men erectile dysfunction can be seen, whereas difficulty with orgasm in women is multifactorial, and sexual dysfunction presents differently in both genders. She notes that men's sole visual of arousal is erections, so it becomes ingrained that if there is no erection there is no arousal, though vascular, hormonal, neurologic, psychogenic, and medication-related causes can all affect erectile function; for women the assessable barometers are level of lubrication, whether sex hurts, and whether orgasm occurs. Huberman uses these anatomical and functional parallels to frame the discussion of hormonal issues.

Huberman reviews the public view that testosterone is pro-libido and pro-desire in men and women, that dopamine is associated with desire, and the misconception that estrogen is anti-libido or anti-male - which he calls frankly false, citing that men who take drugs like anastrozole to suppress estrogen, thinking it is all about high testosterone and low estrogen, oftentimes crush their libido, just abolish it. He references Dr. Kyle Gillett, Dr. Peter Attia, and Derek from More Plates More Dates in connection with a slowly growing but positive shift, and states that estrogen is great for brain function and for libido in men and women.

Huberman distinguishes psychological desire from genital arousal, associates prolactin with the refractory period during which erection or another orgasm cannot occur, and offers to describe what he was taught so Malik can correct it. His account: erection and vaginal lubrication are generated by the parasympathetic, rest-and-digest nervous system, with a shift toward the sympathetic nervous system as desire, arousal, and sex or masturbation progress; catecholamines - dopamine, norepinephrine, and epinephrine, also called adrenaline and noradrenaline - are released; the climax response, which may or may not include ejaculation, is of the stress system of the body; and the postcoital phase returns to parasympathetic tone, with odors, tastes, oxytocin, and vasopressin enhancing pair bonding. He concedes the model is exceedingly oversimplified and acknowledges that for some people alertness, edginess, or excitement can also stimulate erection or lubrication.

the way we're taught in medical school is point and shoot. So point is the parasympathetic nervous system.

Malik explains the model - point is parasympathetic, then sympathetic - and attributes the reported link between aggression or edginess and arousal to the need for a stimulus, a visual or tactile stimulus, that causes the release of nitric oxide from the parasympathetic nervous system. Huberman then asks about nitric oxide, previewing drugs that increase blood flow - Cialis, Viagra, and nonprescription items such as L-citrulline, arginine, and watermelon.

So nitric oxide is essentially the ignition for, what we say, for erections.

Malik says she discusses erections more often because of the data, citing a paper that counted articles retrieved by the words penis and clitoris: 50,000 about penis and 2000 about the clitoris. Huberman relays that this was a major section of the Instagram comments and offers two explanations - that urology and sexual health were dominated by men, or that it is easier to study - asking what is going on here.

Malik points to Freud, who thought the female sexual response was less valuable, though she hedges the term - I do not know if that is the right term - settling on it being sort of dismissed, while Huberman observes that he seemed to be obsessed with it. She agrees that there were more men in medicine and that the penis is easier to study because you can see it visually and inject it and see an erection response, describing Trimix injections given to people with erectile dysfunction to increase blood flow.

On intracavernosal injections, Malik says there are basically three brand names and that the practice, though scary to hear about, uses a very small needle, is very well tolerated, is not as painful as it seems, and is the most effective nonsurgical treatment for erectile dysfunction; the agents are usually one, two, or three medications, and she names alprostadil and papaverine before pausing at what is the third one. Huberman reacts to the idea of an injection in the penis and surmises a commenter will supply the missing drug.

Malik explains the cascade: nitric oxide is released by the endothelium in response to a visual-tactile stimulating cue and sets off the erection cascade, releasing c-GMP, which causes the erection and is degraded by phosphodiesterase. PDE5 inhibitors such as Viagra and Cialis inhibit phosphodiesterase and tend to prevent the breakdown of c-GMP, so erections last longer, and the injectable medications work similarly by increasing cGMP or cAMP in those cascades, with the caveat that for some of them we do not know exactly how they work.

On L-citrulline, Malik says these agents work by increasing the availability of nitric oxide rather than acting later down the pathway: L-arginine is the more direct pathway but has very low bioavailability, whereas L-citrulline converts to L-arginine and lasts much longer in the bloodstream, which is why people tend to use it. Huberman had described L-citrulline as an over-the-counter supplement in the arginine pathway, working similarly to Cialis or Viagra but perhaps not as potent, with a caution that it can give people vicious cold sores and canker sores and that not everyone tolerates it well.