改善男性与女性的性健康与泌尿健康
摘要
泌尿外科及盆腔外科专科医师 Dr. Rena Malik 与 Andrew Huberman 就男女性功能及泌尿功能障碍的主要原因与治疗方法展开深度探讨。对话涵盖盆底解剖与功能、勃起与唤起障碍、性功能障碍的激素因素与血管因素及神经因素、尿路感染、前列腺健康，以及改善性健康与泌尿健康的实用方法。贯穿全程的一个核心主题是：许多广为流传的观念——例如激素是性功能障碍的主要驱动因素——在很大程度上是误区，而血流问题与盆底问题才更为普遍，也更具可干预性。
核心要点
- 大多数人需要放松盆底肌，而非强化它 —— 因压力、姿势不良或过度练习凯格尔（Kegel）运动导致的盆底过度紧张，比肌肉无力更为常见。
- 勃起功能障碍中仅约 3–6% 源于激素问题 —— 血管（血流）问题才是主要原因，在 40 岁以上男性中尤为突出。
- 睾酮驱动男女双方的性欲（性冲动）；雌激素对男女性欲同样重要，不应被抑制。
- 一氧化氮是勃起和生殖器唤起的关键触发因子 —— PDE5 抑制剂（Viagra、Cialis）通过阻止一氧化氮所启动的 cGMP 级联反应的分解而发挥作用。
- 低剂量每日服用 Cialis（2.5–5 mg） 可能对前列腺健康及盆腔区域血管功能有益，甚至具有预防性作用。
- 长时间久坐 是盆底功能障碍及年轻男性勃起问题中一个被严重低估的重要诱因。
- 习惯特定手淫方式或色情内容 可能削弱对真实伴侣的唤起反应——建议多样化刺激方式。
- 盆底物理治疗 是处理盆底张力过高（过紧）和张力过低（过弱）功能障碍的黄金标准。
- L-瓜氨酸 可提升一氧化氮的可用性，可能有助于支持勃起功能，但补充剂质量缺乏监管——建议通过 examine.com 等可信来源加以核实。
- 运动时采用横膈膜呼吸至关重要 —— 用力时呼气有助于稳定盆底，预防功能障碍。
详细笔记
盆底解剖与功能
盆底是一组碗状肌肉群，附着于骨盆，支撑所有盆腔器官。其主要功能包括：
- 排尿与排便控制
- 性功能
- 姿势稳定性
男性和女性均有盆底。功能障碍可表现为张力过高（过紧）或张力过低（过弱）两种类型。
盆底张力过高（过紧）的症状：
- 尿急、尿频或排尿不尽
- 便秘
- 性交、勃起或射精时疼痛
- 慢性盆腔痛或腰背痛
盆底张力过低（过弱）的症状：
- 尿失禁（咳嗽、打喷嚏、提重物时漏尿）
- 盆腔器官脱垂（主要见于产后女性）
- 男性前列腺切除术后漏尿
评估方法：
- 女性：经阴道触诊（髂尾肌、耻尾肌、肛提肌）
- 男性：直肠指诊及会阴触诊
- 全面评估需由盆底专科医师完成——无法可靠地自行诊断
凯格尔运动：谁该练，谁不该练
凯格尔运动通过反复收缩和放松用于中断尿流的肌肉来强化盆底。
推荐方案（适合人群）：
- 从卧位开始，逐步进阶至坐位，再至站位
- 每次 10–15 次，收缩保持 5 秒，放松 5 秒
- 每天 2–3 组（早、中、晚）
- 切勿在排尿过程中练习
适应症：
- 压力性尿失禁
- 盆腔器官脱垂
- 前列腺切除术后漏尿
- 增强高潮强度（娱乐性目的）
注意事项： 过度训练凯格尔运动会造成盆底张力过高，可能引发排尿疼痛、勃起疼痛及射精痛。一旦出现上述症状，应立即停止练习并就诊泌尿科。
放松张力过高的盆底
对于需要降低张力而非强化盆底的人群：
- 快乐婴儿瑜伽姿势 —— 拉伸并延长盆底肌肉
- 阴道扩张器（适用于女性）
- 含肌肉松弛剂的阴道或直肠栓剂（地西泮/安定、巴氯芬）—— 仅为症状管理，非根治手段
- 盆底物理治疗 —— 最有效的方法；治疗师将针对骨骼排列、姿势及定向放松练习进行综合干预
- 横膈膜呼吸： 吸气时盆底放松，呼气时盆底收缩——运动时正确呼吸可预防功能障碍
性功能障碍的三大成因
性功能障碍——无论是男性勃起功能障碍还是女性唤起/高潮障碍——应从三个维度进行评估：
-
激素因素
- 睾酮驱动男女双方的性欲（性冲动）
- 女性体内的睾酮含量高于雌激素
- 雌激素对男女性欲均有重要影响——抑制雌激素（如使用阿那曲唑）可能完全消除性欲
- 勃起功能障碍中仅有 3–6% 源于激素原因
-
血管因素（血流）
- 勃起功能障碍最常见的原因，尤其在 40 岁以上男性中
- 约 50–52% 的 40 岁以上男性存在不同程度的勃起功能障碍；患病率随年龄增长而升高（约 60% 的 60 岁男性受此影响）
- 风险因素：高血压、糖尿病、心脏病、吸烟/电子烟（尼古丁是血管收缩剂）
- 评估方法：阴茎或阴蒂的多普勒超声（收缩期峰值流速 = 动脉血流入；舒张末期流速 = 静脉血流出）
-
神经因素
- 外周神经敏感性随年龄下降
- 阴部神经和阴部动脉贯穿盆底——功能障碍可同时损害感觉和血流
- 心理因素（焦虑、表现焦虑）会形成反馈循环，加重功能障碍
一氧化氮与唤起级联反应
- 唤起刺激（视觉、触觉等）触发内皮细胞释放一氧化氮（NO）
- NO 启动 cGMP 生成 → 平滑肌松弛 → 血管舒张 → 充血（勃起或阴蒂/阴道唤起）
- 磷酸二酯酶（PDE5） 降解 cGMP，终止反应
- PDE5 抑制剂（Viagra/西地那非、Cialis/他达拉非）阻断 PDE5，延长 cGMP 作用，维持唤起反应
神经系统序列：
- 副交感神经（“指向”）→ 启动勃起/润滑
- 交感神经（“射击”）→ 驱动高潮/射精
- 高潮后：回归副交感状态（亲密交流、催产素、情感联结）
药物与补充剂干预
PDE5 抑制剂（Viagra/Cialis）：
- 勃起功能障碍的成功率约为 60–70%
- 治疗勃起功能障碍的剂量：15–20 mg（Cialis）
- 低剂量每日服用 Cialis（2.5–5 mg）： 用于前列腺健康、盆腔血流，以及对勃起组织可能具有的预防性抗纤维化作用
- 超适应症用于存在血管风险因素的女性，可能改善唤起/高潮——建议至少试用 4 周
- 注意：Cialis/他达拉非最初是为前列腺健康而研发，并非针对勃起功能障碍
海绵体内注射（Trimix）：
English Original 英文原文
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