Improving Sexual & Urological Health in Males and Females
Summary
Dr. Rena Malik, a board-certified urologist and pelvic surgeon, joins Andrew Huberman to discuss the major causes and treatments of sexual and urological dysfunction in both males and females. The conversation covers pelvic floor anatomy and function, erectile and arousal dysfunction, hormonal versus vascular versus neurological causes of sexual dysfunction, UTIs, prostate health, and practical tools for improving sexual and urinary health. A key theme throughout is that many widely held beliefs — such as hormones being the primary driver of sexual dysfunction — are largely myths, while blood flow and pelvic floor issues are far more prevalent and actionable.
Key Takeaways
- Most people need to relax their pelvic floor, not strengthen it — over-tightening from stress, poor posture, or excessive Kegels is a more common issue than weakness.
- Only ~3–6% of erectile dysfunction is hormonal in origin — vascular (blood flow) problems are the dominant cause, especially in men over 40.
- Testosterone drives desire (libido) in both men and women; estrogen is also important for male and female libido and should not be suppressed.
- Nitric oxide is the key trigger for erections and genital arousal — PDE5 inhibitors (Viagra, Cialis) work by preventing the breakdown of the cGMP cascade nitric oxide initiates.
- Low-dose daily Cialis (2.5–5 mg) may benefit both prostate health and vascular function in the pelvic region, even as a preventative measure.
- Sitting for prolonged periods is a major, underappreciated contributor to pelvic floor dysfunction and erectile issues in young men.
- Habituation to specific masturbation techniques or pornography can impair arousal response to real-world partners — varying stimulation is advisable.
- Pelvic floor physical therapy is the gold standard for both hypertonic (too tight) and hypotonic (too weak) pelvic floor dysfunction.
- L-citrulline increases nitric oxide availability and may support erectile function, but supplement quality is unregulated — verify through reputable sources like examine.com.
- Diaphragmatic breathing during exercise is critical — exhaling on exertion helps stabilize the pelvic floor and prevents dysfunction.
Detailed Notes
Pelvic Floor Anatomy and Function
The pelvic floor is a bowl-shaped group of muscles attached to the pelvis that supports all pelvic organs. It serves multiple functions:
- Urination and defecation control
- Sexual function
- Postural stability
Both males and females have a pelvic floor. Dysfunction can present as either hypertonic (too tight) or hypotonic (too weak).
Symptoms of a hypertonic (over-tight) pelvic floor:
- Urinary urgency, frequency, or incomplete emptying
- Constipation
- Pain with sex, erections, or ejaculation
- Chronic pelvic or back pain
Symptoms of a hypotonic (too weak) pelvic floor:
- Urinary incontinence (stress leakage with coughing, sneezing, lifting)
- Pelvic organ prolapse (primarily in women post-childbirth)
- Post-prostatectomy leakage in men
Assessment:
- Women: palpation through the vagina (iliococcygeus, pubococcygeus, levator ani muscles)
- Men: rectal exam and perineal palpation
- Full assessment requires a pelvic floor specialist — cannot be reliably self-diagnosed
Kegel Exercises: Who Should and Shouldn’t Do Them
Kegel exercises strengthen the pelvic floor by repeatedly contracting and relaxing the muscles used to stop urine flow.
Recommended protocol (for appropriate candidates):
- Start lying down, then progress to sitting, then standing
- 10–15 repetitions, squeeze for 5 seconds, relax for 5 seconds
- 2–3 sets per day (morning, midday, night)
- Do not perform during urination
Indicated for:
- Stress urinary incontinence
- Pelvic organ prolapse
- Post-prostatectomy leakage
- Enhancing orgasm intensity (recreationally)
Caution: Over-training Kegels creates a hypertonic pelvic floor and can cause painful urination, pain with erections, and ejaculatory pain. If any of these symptoms appear, stop and see a urologist.
Relaxing a Hypertonic Pelvic Floor
For those who need to down-train rather than strengthen:
- Happy baby yoga pose — stretches and elongates pelvic floor muscles
- Vaginal dilators (for women)
- Vaginal or rectal suppositories containing muscle relaxants (Valium/diazepam, baclofen) — symptom management, not curative
- Pelvic floor physical therapy — most effective approach; therapist will address bone alignment, posture, and targeted relaxation exercises
- Diaphragmatic breathing: Inhaling relaxes the pelvic floor; exhaling contracts it — proper breathing during exercise prevents dysfunction
Causes of Sexual Dysfunction: The Three Pillars
Sexual dysfunction — whether erectile dysfunction in males or arousal/orgasm dysfunction in females — should be evaluated through three lenses:
-
Hormonal
- Testosterone drives desire (libido) in both sexes
- Women have more testosterone in their bodies than estrogen
- Estrogen is important for libido in both men and women — suppressing it (e.g., with anastrozole) can abolish libido
- Only 3–6% of erectile dysfunction is hormonal in origin
-
Vascular (Blood Flow)
- The most common cause of erectile dysfunction, especially in men over 40
- ~50–52% of men over 40 have some erectile dysfunction; prevalence increases with age (~60% of 60-year-olds)
- Risk factors: hypertension, diabetes, heart disease, smoking/vaping (nicotine is a vasoconstrictor)
- Assessed via Doppler ultrasound of penis or clitoris (peak systolic velocity = arterial inflow; end-diastolic velocity = venous outflow)
-
Neurological
- Peripheral nerve sensitivity declines with age
- The pudendal nerve and pudendal artery run through the pelvic floor — dysfunction can impair both sensation and blood flow
- Psychogenic factors (anxiety, performance anxiety) create feedback loops that worsen dysfunction
Nitric Oxide and the Arousal Cascade
- Arousal stimulus (visual, tactile, etc.) triggers nitric oxide (NO) release from endothelial cells
- NO initiates cGMP production → smooth muscle relaxation → vasodilation → engorgement (erection or clitoral/vaginal arousal)
- Phosphodiesterase (PDE5) degrades cGMP, ending the response
- PDE5 inhibitors (Viagra/sildenafil, Cialis/tadalafil) block PDE5, prolonging cGMP and sustaining arousal response
The nervous system sequence:
- Parasympathetic (“point”) → initiates erection/lubrication
- Sympathetic (“shoot”) → drives orgasm/ejaculation
- Post-orgasm: return to parasympathetic (pillow talk, oxytocin, pair bonding)
Pharmacological and Supplement Interventions
PDE5 Inhibitors (Viagra/Cialis):
- ~60–70% success rate for erectile dysfunction
- Erectile dysfunction dosage: 15–20 mg (Cialis)
- Low-dose daily Cialis (2.5–5 mg): Used for prostate health, pelvic blood flow, and potentially preventative anti-fibrotic effects on erectile tissue
- Off-label use in women with vascular risk factors may improve arousal/orgasm — recommend a 4-week trial minimum
- Note: Cialis/tadalafil was originally developed for prostate health, not erectile dysfunction