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

Welcome to the Huberman Lab Podcast where we discuss science and science based tools for everyday life. I'm Andrew Huberman and I'm a professor of Neurobiology and Ophthalmology at Stanford School of Medicine. Today My guest is Dr. Reena Malik. Dr. Reena Malik is a board certified urologist and pelvic surgeon. She is an expert in both male and female urological, pelvic floor and sexual health. During today's episode, Dr. Malik answers the most commonly asked questions about urinary pelvic and sexual health. For instance, how to avoid getting UTIs, urinary tract infections. We also discuss pelvic floor anatomy and function as it relates to overcoming an overly tight or an overly relaxed pelvic floor. This is a key distinction that most people aren't aware of. 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. So today you'll learn about that. You will also learn about sexual health as it relates to erectile function, as it relates to things like vaginal lubrication, as it relates to orgasm. We separate out very carefully the difference between psychological desire and arousal that occurs within the genitals themselves. And Dr. Malik highlights some important misconceptions about sexual dysfunction. For instance, that many people believe that hormones are responsible for sexual dysfunction, but in reality hormone dysregulation is responsible for only a very small percentage of sexual dysfunction. And yet pelvic floor and blood flow related issues can account for a large number of cases of sexual dysfunction in both males and females. So I assure you that today's discussion is going to illuminate many new areas of information, many new tools and protocols that I'm guessing most people have not heard of. We talk about the neural vascular that is blood flow related and muscular aspects of bladder function, prostate function, skenes glands. We talk about vaginal health as well as penile health. We talk about these things as it relates to different stages across the lifespan. It is a far reaching and in depth and practical conversation that I'm certain everyone will glean important takeaways from. Now, before we go any further, I do want to highlight that the content of today's episode is sexual in nature. We talk very directly about different types of sexual behavior and we talk about it from the standpoint of the clinician and biologist. So it is a medical scientific discussion. That said, we can't be aware of where this podcast is being played and who is listening. And I assert that there are certain themes within today's discussion that would not be suitable for young children. How young? Well, that is certainly not for us to discern. We realize that different parents and different households should be the arbiters of what sorts of information their children are exposed to or not. So my suggestion would be that if you have any concern whatsoever that the content of today's episode would not be appropriate to be heard by some member of your family, that you please listen to the podcast first, or at least check the timestamps where we've detailed what specific topics are covered and then to make your decision accordingly. I should mention that not only is Dr. Malik still an active clinician, she sees patients daily out of her clinic in Southern California, and we provided a link to that clinic in the show. Note captions she's also authored dozens of high quality reviewed publications in the fields of urology, pelvic health, and sexual health, and we've also provided a link to that bibliography in the show. Note captions and she is also a spectacular public educator. She provides zero cost content about sexual health, pelvic floor health, and urology as it relates to both men and Women on her YouTube channel. And there too, we've provided a link to Dr. Malik's YouTube channel in the show. Note captions to this episode before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is, however, part of my desire and effort to bring zero cost to consumer information about science and science related tools to the general public. In keeping with that theme, I'd like to thank the sponsors of today's podcast. Our first sponsor is Roka. Roka makes eyeglasses and sunglasses that are of the absolute highest quality. 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And as always, thank you for your interest in science. And now for my discussion with Dr. Reena Malik. Dr. Reena Malik, welcome.

Thank you. Thank you so much. It's an honor to be here.

I'm delighted to have you here. I'm a huge fan of your content. I find that you are able to deliver critical information about sexual health, urology, pelvic floor, libido, and so many other things that are of immense interest to people. But that ordinarily people don't really know where to get the high quality information. And coming to you for that information means they are going to get the highest quality information. I truly believe that because as everyone will soon hear, today we're going to have a very frank discussion, but one that's really grounded in science and medicine, around sexual health and related topics. These are topics that typically people learn about perhaps a little bit in school, maybe at home, from friends usually overhearing things, as opposed to direct exploratory conversation, online pornography. And at least in my experience growing up, there was education around sexual health, reproductive health, et cetera, that was more oriented toward the fear of things like STIs, fear of unwanted pregnancy, all of which of course is extremely important for people to learn about, but far less about sort of the healthy versions of sexual health. Right?

Yeah, absolutely.

So this is an especially important conversation. It's also one that I think has a backdrop that we should just acknowledge right off the bat that because the information is gleaned from multiple sources and because there are, let's just say, influences out there that relate to the morality of different practices, that there can be shame, there can be misunderstanding, there can be secrecy, and that further leads to misinformation. So I'm confident that today you can clarify things for us and we're going to stay out of those trenches. And the last thing I'd like to say is that because a number of terms will certainly come up that I think for some people, they're not used to hearing in general discourse. I'm just going to get them out of the way now. Penis, vagina, anus, prostate, what else is there? We're going to talk about libido. We're going to talk about intercourse, oral sex, anal sex. We're going to talk about all of that. So I just want to get that out there so that we can reduce the shock response.

I love it. We got to talk about all of it.

Great. So to start things off, in anticipation of this episode, I solicited for questions on social media, and I got thousands of questions, but there was a lot of overlap in the questions. So to start off, I'd like to talk about pelvic floor. Okay. Because both males and females have a pelvic floor. And my understanding is that there's a muscular component, there's a neuromuscular component, there's a blood flow component. What is a healthy pelvic floor? What does a healthy pelvic floor do? And then we can talk about some of the health issues that an unhealthy pelvic floor creates and some of the ways to ameliorate an unhealthy pelvic floor.

Absolutely. So a pelvic floor, very simply, is basically a bowl of muscles that's connected to. To bones that hold up all your organs. So basically, in your pelvis, there's all these muscles there, and their function is essentially many. It helps with urination, defecation, sexual function, it helps with posture. And so having a strong, healthy pelvic floor can mean that you're having normal urination, you're having normal defecation, you're having great sex, and that you are also not having ailments like back pain or issues related to those. Those functions and those organs. And so pelvic floor is so important in so many different aspects. And we deal with it a lot as urologists because it's so integral to these functions that we take care of. And so when you have an unhealthy pelvic floor, it can vary from person to person. And while you hear about it a lot in women, men also suffer from pelvic floor dysfunction or problems with the pelvic floor. So basically, pelvic floor dysfunction happens a lot when you're doing things. Like if you were to go to the gym and do repetitions of any sort of exercise and you didn't rest, then that muscle would become contracted and short. Very similarly, if your pelvic floor is overstrained, it can become contracted and short and tight all the time. And you may not know it. It may just be a function of stress, anxiety or overuse or posture problems, things of that nature that can affect your pelvic floor. And so this can lead to. Let's start with urination. You can have symptoms of urgency frequency, meaning you have to go a lot to the bathroom, or you have to go and have a sudden desire that you can't delay. Sometimes even have leakage. In some cases, it can make it difficult to urinate because the pelvic floor is so tense.

Or perhaps to incompletely vacate the bladder.

Correct.

Like you go to urinate and then you go back to your desk and then five minutes later you have to urinate again.

Exactly.

Something of that.

So it can be either that you're not emptying completely or that the pelvic floor muscles are so tense that they're stimulating the bladder. So it feels like there's more to go. So it's not always that you're not evacuating. It can present in a number of different ways. And then with sexual function, if it's very tense, you can have pain. So you can have pain with sex, you can have pain with erections, you can have pain with ejaculation. Sometimes it can be a lot of different kind of pain syndromes. And you're like, I have all these different things going on. And it's really just pelvic floor dysfunction. With GI function, you can definitely have constipation. And then often you can also have back pain. And so all of these things can happen when your pelvic floor is too tense. Sometimes your pelvic floor can be too weak. And that can be often because of. We see this in women a lot because of childbirth, delivering children. With some people who have neurologic disorders, they can have weak pelvic floors or connective tissue disorders like Ehlers Danlos syndrome, for example. These sorts of things can cause weakness to the pelvic floor, which can then cause very often what I see is like urinary incontinence or leakage, which can then create problems for people down the line.

Thank you for that. So first question, how does somebody know if their pelvic floor is too tight from a over contraction or chronic contraction of the muscles there versus too weak. And one of the challenges in having this conversation is, is that if we were talking about contraction of the calf muscle or the bicep, I think everyone intuitively knows because they've seen the shortening of the muscle is when the muscle is quote, unquote flexed and the lengthening of the muscles when it is relaxed. Is there a way to describe pelvic floor muscular shortening in a way that everyone can understand? Would this be like, like I said, we're going to be direct today. Would this be like tensing up one's anus and the opposite of the movement that one would do before initiating a bowel movement? And relaxation is sort of the pattern of pelvic floor muscular relaxation just prior to initiating a bowel movement.

So I will say most people can't recognize it because it's very difficult to notice. It's sort of gradual, and so it can over time become noticeable with these symptoms. But otherwise it's very difficult because it's not a muscle that we were ever trained to recognize. You hear about Kegel exercises, for example, and people talk about how to do them, but that's all you ever hear about the pelvic floor. And so you do not really know how to kind of do things in a way that protects your pelvic floor or how to even tell when it's too tight or not relaxing. And so that takes a sort of training. And so usually when people come to first, you get an examination to see if your pelvic floor is tight. So for women, it's a pelvic exam, and for men, it's usually a rectal exam.

How does, how does that exam go?

So, you know, it's essentially palpating the muscles and also looking at the function.

So we'll say for digital palpation, that's a medical technology. For fingers are called digits. So you, you know, I'm old enough to recognize what a digital prostate exam is. Right. The physician inserts their fingers through into the anus and feels the prostate to see whether or not it's swollen or not. And as I'm saying this, I'm realizing, you know, sometimes we think of medicine, quote, unquote, modern medicine, as so evolved. This has basically been the practice for what, 50 years, 60 years, maybe 100 years. In the same way that the old school practice for glaucoma, excessive eye pressure, was for the physician to just touch the eyeball. So, folks, for those of you that think that medicine has evolved much, it clearly has in many ways. But in any event, so a prostate exam goes as I just described, what would a pelvic floor exam for a male and a pelvic floor exam for a female involve at a kind of granular level.

Yeah. So for women, you can feel the pelvic floor muscles through the vagina. So you can feel the iliococcygeus, the pubococcygeus, the levator ani. Those are all names of muscles in this bowl.

This is the physician who can feel them with their fingers, Correct?

Correct. And you know, you could, too. You could put your finger in, but you don't have a reference of normal. Right. So you wouldn't know what a normal pelvic floor feels like versus a tight one versus a weak one. And so you can assess the tenseness based on, you know, palpation. You can also see if there's tenderness. And so you can assess that based on just a general physical examination. And then also you can observe. So I can say, contract your busk, squeeze your pelvic floor up and in. I can look and see are they squeezing or are they pushing? Are they coordinated or not? Right. Because that's a function of normal use of the pelvic floor. And sometimes you'll see that they're discoordinated. You can also assess for sensation in the area and things like that. That could be consequences of dysfunction.

Can there be dysfunction in laterality? Like the pelvic floor is pulling up and to the right or up and to the left?

Absolutely. So what? Typically, when you see a pelvic floor therapist. Now, I'm not a pelvic floor therapist, but these are the people who do the work. Right. They work with you on a prolonged basis to help you normalize the function of your pelvic floor. It's like going to the gym with a trainer. Right. They really work with you to get your pelvic floor functioning correctly. And the first step to that, a lot of pelvic floor therapists will just align your bones and your kind of the way you sit and walk to make sure that you're not straining those muscles by pulling in different directions.

And if a male goes to the physician to get a pelvic floor exam, there's obviously difficulty in putting fingers into the urethra. One would hope too small an opening. So how are they doing the pelvic floor exam? Is it external to the body or is it through the anus?

So some of it's through the anus. You can feel the muscles through the anus, and then you can feel the perineal area and feel the muscles there as well. Sensations.

So, okay, so perineal area. So from the outside of the body, the region between the scrotum and the anus?

Yes.

Okay. So it sounds to me like if people want to get a high quality assessment of whether or not their pelvic floor is healthy or not. They need to see a pelvic floor specialist that it's not the sort of thing that they could into on their own necessarily.

It would be difficult. I mean, so there are things you can buy online, like probes that you can insert in the vagina that will teach you how to do Kegel exercises and give you some readings. But they're not really meant to diagnose. They're usually something people use if they say, have a weak pelvic floor and they want to try to do it at home on their own. So there's nothing that's going to give you a baseline reading. Is this normal or abnormal?

Let's talk about Kegels, first of all. Who's Kegel?

So he is a gynecologist. I don't remember all the specifics, to be quite honest, but basically he came up with Kegels, which are a strengthening exercise for the pelvic floor. And so what it is, what we describe it to, for patients is we say you're going to. There's a few different ways to describe it. You're going to use the muscles that you use when you urinate, but try to stop the flow. But you don't want to do them when you're urinating because that can create dysfunction. You want to learn what the muscles are, and then you squeeze those muscles and relax in between sets, so to speak. And so you'll do. The other way people describe it is pulling up and in. In the vagina. Or for men, sometimes you'll say it's like the feel that you're trying to lift your penis off the floor without touching it. Right. So those are kind of using.

That's a good way to describe it.

Yeah. So those are kind of the ways that you can describe those muscles. And so you can squeeze for five seconds and relax for five seconds and do them in repetitions. And they're just like any sort of exercise you do. You don't want to start doing a hundred of them. Right. You want to do them. I tell them people, I tell patients, do them lying down so that you're only focusing on those muscles. You're not working on your posture, you're not doing anything else. And as you get better with them lying down, you then sit up and do them. And then once you're good with them sitting up, you can do them standing and start with 10 to 15 at a time, like once in a morning.

10 to 15 repetitions. So, yeah, let's Talk sets and reps.

So, yeah, 10 to 15 repetitions in the morning, 10 to 15 repetitions at night, maybe one more during the middle of the day. But don't overdo it, because just like anything, especially when you're starting out, you. And if you're doing tons and tons of Kegels, then you will get a tight, short pelvic floor muscles, and you will then develop pelvic floor dysfunction. So it's really important to kind of understand those mechanics, which is why a lot of people think they know how to do Kegels, but they really don't. And so I always encourage people, if you have the time and the resources, to go to a pelvic floor physical therapist so they can really work with you and make sure you're doing them correctly.

What are some of the benefits of Kegels for those that need them?

Yes, so they are typically prescribed for urinary incontinence, specifically stress urinary incontinence. So leakage that occurs when you have an increase in your intra abdominal pressure, like a valsalva or coughing, sneezing, lifting heavy things, jumping on a trampoline. So for those purposes, we use Kegels to strengthen the pelvic floor and also in women, pelvic organ prolapse. So when you have weakness of the pelvic floor that leads to a bulge that you can visibly see or feel in the vagina for men, we often prescribe them for people who have had a prostatectomy who then subsequently develop leakage after the prostatectomy. That is again, stress urinary incontinence. Now, a lot of people use Kegels recreationally because improving the pelvic floor musculature can lead to more intense pelvic floor contractions during orgasm, which can be more pleasurable. And so some people do it for those purposes. But again, I caution people not to overdo it because then you can lead to a more tense pelvic floor, which is not where we want to end up.

Yes. I will underscore that cautionary note. Years ago, I heard about Kegels. I was like, okay, I'll try it. Sounds all good, right? I only heard good things about Kegels, and what it quickly resulted in was painful urination. And I thought, this is weird. Everyone's saying Kegels are so great. And the best thing I could do for my pelvic floor, it seemed, was to avoid Kegels.

Yes.

And a little bit later, when we're talking about prostate, I'll explain at least what my experience was as it relates to the prostate. But I guess the take home message that I'm gathering from what you're telling us is that strengthening the pelvic floor is great if you have a weak pelvic floor. Strengthening your pelvic floor further, if you have a strong pelvic floor, can be detrimental.

It can be. It can be if you overtrain it, just like if you overtrain anything else. And so you just have to, if you really want to do Kegels, if you have any symptoms at all like you described, painful urination or the things I've described, like pain with erections, pain with ejaculation, pain, difficulty emptying, any of those symptoms, stop and go see a urologist so that they can kind of assess your pelvic floor.

What is the antichal. In other words, if somebody decides that they have a tight pelvic floor, how can they learn to relax their pelvic floor?

So there's a lot of different sort of things that you can do. So for women, you can do massage of the area. You can use vaginal dilators to help relax the muscles. You can take suppositories that have medications like Valium or Baclofen, which are muscle relaxants, and.