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Speaker A: 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 doctor Reena Malik. Doctor 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, Doctor 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 Doctor 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 neurovascular, 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 Doctor 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, peer 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 Doctor 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 element. Element is an electrolyte drink with everything you need and nothing you don't. That means plenty of salt, magnesium, and potassium. The so called electrolytes and no sugar, salt, magnesium, and potassium are critical to the function of all the cells in your body, in particular to the function of your nerve cells, also called neurons. In fact, in order for your neurons to function properly, all three electrolytes need to be present in the proper ratios, and we now know that even slight reductions in electrolyte concentrations or dehydration of the body can lead to deficits in cognitive and physical performance. Element contains a science backed electrolyte ratio of 1000 milligrams. That's 1 gram of sodium, 200 milligrams of potassium, and 60 milligrams of magnesium. I typically drink element first thing in the morning when I wake up in order to hydrate my body and make sure I have enough electrolytes. And while I do any kind of physical training and after physical training as well, especially if I've been sweating a lot, if you'd like to try element, you can go to drinkelement. That's lmnt.com Huberman to claim a free element sample pack with your purchase. Again, that's drinkelement lmnt.com Huberman Today's episode is also brought to us by waking up. Waking up is a meditation app that includes hundreds of meditation programs, mindfulness trainings, yoga, NidRa sessions, and NSDR non sleep deep rest protocols. I started using the waking up app a few years ago because even though I've been doing regular meditation since my teens and I started doing yoga Nidra about a decade ago, my dad mentioned to me that he had found an app turned out to be the waking up app, which could teach you meditations of different durations and that had a lot of different types of meditations to place the brain and body into different states and that he liked it very much. So I gave the waking up app a try and I too found it to be extremely useful because some sometimes I only have a few minutes to meditate, other times I have longer to meditate. And indeed, I love the fact that I can explore different types of meditation to bring about different levels of understanding about consciousness, but also to place my brain and body into lots of different kinds of states depending on which meditation I do. I also love that the waking up app has lots of different types of yoga Nidra sessions. For those of you who don't know, yoga Nidra is a process of lying very still but keeping an active mind. It's very different than most meditations, and there's excellent scientific data to show that yoga Nidra and something similar to it called non sleep deep rest, or NSDR, can greatly restore levels of cognitive and physical energy, even with just a short ten minute session. If you'd like to try the waking up app, you can go to wakingup.com huberman and access a free 30 day trial. Again, that's wakingup.com huberman to access a free 30 day trial. And now for my discussion with doctor Reena Malik. Doctor Reena Malik, welcome.

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

Speaker A: 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 STI's 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?

Speaker B: Yeah, absolutely.

Speaker A: 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, you know, 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.

Speaker B: I love it. We got to talk about all of it.

Speaker A: 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, 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.

Speaker B: Absolutely. So a pelvic floor, very simply, is basically a bowl of muscles that's connected 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 functions and those organs. 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. 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 issues. 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.

Speaker A: Is so tense or perhaps to incompletely vacate the bladder.

Speaker B: Correct.

Speaker A: Like, you go to urinate and then you go back to your desk, or then five minutes later, you have to urinate again.

Speaker B: Exactly.

Speaker A: Something of that sort.

Speaker B: Well, 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.

Speaker A: 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 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 I said, we're going to be direct today. Would this be tensing up one's anus, 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.

Speaker B: 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. Right. Like, 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 don't really know how to 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 sort of a 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.

Speaker A: How does that exam go?

Speaker B: So it's essentially palpating the muscles and also looking at the function. So we'll say for.

Speaker A: So digital palpation, that's a medical technology for fingers are called digits. So 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, basically been the practice for, what, 50 years, 60 years, maybe a hundred 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 here?

Speaker B: Yeah. So for women, you can feel the pelvic floor muscles through the vagina. So you can feel the iliococcygous, the pubococcus, the levator ani. Those are all names of different muscles in this bowl.

Speaker A: This is the physician who can feel them with their fingers.

Speaker B: Correct. And 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 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, 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.

Speaker A: Can there be dysfunction in laterality? Like the pelvic floor is pulling up into the right or up into the left?

Speaker B: Absolutely. So 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. 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. 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 the way you sit and walk to make sure that you're not straining those muscles by pulling in different directions.

Speaker A: 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?

Speaker B: 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 as sensation.

Speaker A: Okay, so perineal area. So from the outside of the body, the region between the scrotum and the anus?

Speaker B: Yes.

Speaker A: Okay. So it sounds to me like if people want to get a. 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.

Speaker B: 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 read, you know, 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?

Speaker A: Let's talk about Kegels. First of all, who's Kegel?

Speaker B: 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. 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 like the vagina or for men, sometimes you'll say it's like the feeling that you're trying to lift your penis off the floor without touching it. So those are kind of you.

Speaker A: It's a good way to describe it, yeah.

Speaker B: So those are kind of the ways that you can describe those muscles. And so you can squeeze for 5 seconds and relax for 5 seconds and do them in repetitions and they're just like any sort of exercise you do. You don't want to start doing 100 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 ten to 15 at a time.

Speaker A: Ten to 15 repetitions. So yeah, let's talk sets and reps.

Speaker B: So yeah, ten to 15 repetitions in the morning, ten 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 can. 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.

Speaker A: What are some of the benefits of kegels for those that need them?

Speaker B: 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. 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.

Speaker A: 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.

Speaker B: Yes.

Speaker A: 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.

Speaker B: It can be. It can be if you overtrain it, just like if you over treat 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.

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

Speaker B: 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 that can help as well. Although they're not treatments, they're more of a band aid, but they can help with the symptoms that you're having, and then you can also. I think the best thing is to work with the physical therapist, because they can teach you certain exercises that will help down train the pelvic floor. For example, one of the ones I tell my patients is like, happy baby pose. It actually stretches and elongates the pelvic floor muscles. So doing these exercises regularly will help you lengthen the pelvic floor muscles.

Speaker A: One thing that I've experienced extremely pain from and that stopping was one of the best things that ever happened for my pelvic floor, was to not do any kind of crunching movement with my legs crossed. I would go to these yoga classes at one point in my life, and they'd have everybody do these crunches. And I've always done some abdominal work here and there during the week if I'm being diligent. But they would have us cross our feet, and that seemed to lead to some pelvic floor discomfort that was similar to what I had experienced when I did the kegels. So, again, for me, ceasing the kegels was one of the best decisions I ever made. I only did them for a short while. I was like, okay, this is clearly not for me. And I guess that's another point that tell me if you agree or not that if you hear about something online or on this podcast or anywhere else, and you try it, and it seems to be sending things in the wrong direction, either you're doing it wrong, or it might not be the right thing for you.

Speaker B: Exactly.

Speaker A: I think all too often we hear this thing is great, and people jump on that bandwagon, and then they end up worsening their problems or developing problems where they didn't have them previously. But is there anything about the anatomy of the neuromuscular connections or vasculature of the pelvic floor that would provide support for my experience there? That doing crunches with legs crossed is essentially, is it possible that it's creating asymmetries in the pelvic floor? And now I'm sure I'm angering yoga teachers and crunch Anistas everywhere. You know, hey, if it's a question of your pelvic floor or a few extra delineations in your abs. You know where my vote's going.

Speaker B: So there's a couple things here that we should dive into. One is that people don't often breathe correctly during exercise, right. And so diaphragmatic breathing is really important, which is like a deep breath that expands the diaphragm, not kind of shallow breathing, but just in your mouth and throat. And that is actually when you, you know, when you do any sort of exercise, your trainer will tell you, exhale on the effort. Right. And there's a reason for that, because when you inhale, your pelvic floor relaxes. When you exhale, your pelvic floor contracts. And so it actually, that contraction stabilizes the pelvic floor. So whatever intra abdominal pressure you're causing to increase from the exercise, whether it's a squat or a crunch or whatever, you're increasing your abdominal pressure. Your pelvic floor is then contracting to help stabilize that. Part of the reason people tend to hold their breath during crunches, they don't do the appropriate breathing. And so that can be part of it. The other thing that can happen with certain things is that there are nerves and arteries, particularly the pudendal nerve and the pudendal artery, that run through the pelvic floor. So when you get pelvic floor dysfunction, you can cause decreased blood flow to the pelvic floor muscles, which can affect sexual function. And you can get nerve inflammation as well, that can also cause pain. And so this is kind of how it all comes together.

Speaker A: I'm so glad that you mentioned blood flow. I think our entire discussion today should be framed up, at least in the back of our minds and the minds of our listeners and viewers as involving at least three things. Anytime we're talking about erectile function or dysfunction or pelvic floor function or dysfunction or vaginal lubrication or lack thereof, we need to think about the hormonal influences, the blood flow related influences, and the neural influences, including the neural influences that come from the brain, the signals of arousal, for instance, or lack of arousal, and so on. So we won't be overly systematic in our parsing of all this, but I think what you just mentioned raises a really important point, that sometimes in an effort to do something that's good for the muscles, like strengthen the muscles, one will cut off blood flow. In fact, one of the more common questions I got, and I consulted with a couple of exercise physiologists about this, and they confirmed that a lot of people who squat and deadlift heavy in the gym or even who just tense their pelvic floor when they're doing things like dumbbell curls or other exercises. And especially people who seem to do a lot of abdominal work reported to me in the questions that they experienced things like erectile dysfunction, that they experienced things like pain during vaginal intercourse, that essentially they had created some sort of what sounds to me like a hyper contraction of the muscles in that area that were impeding all the things that they wanted as either side effects or direct effects of exercise, because many people are exercising for aesthetic reasons and health reasons, but nowadays it seems especially on the male side. But we'll also talk about the role of testosterone on the female side. A lot of males lift weights in order to increase their testosterone and for reasons that are obvious, also want to have healthy sexual function. And here they are doing this thing that's very good for increasing testosterone if they're doing it correctly. And testosterone is involved in libido and the male sexual response, and the female sexual response, of course, but they are impeding their erections. So you can start to see how there are probably a lot of confused and maybe even distraught people out there. They're trying to do all the right things and they're setting up roadblocks and even sending themselves backward in some cases. So the question is, how does one know whether or not something like, let's say, low lubrication or pain during vaginal intercourse or loss of erectile strengthen or some sort of erectile dysfunction, whatever it may be, because it can take on different forms. As we'll talk about, how does one know if it's blood flow related, hormone related or neural related? And if it's neural related, how does one know if it's an issue of lack of appropriate signals from the brain over suppression or lack of arousal from the brain, or whether or not it's some peripheral neural thing of innervation of the penis or vagina?

Speaker B: So I think there's. There's a lot that we can go into here, but essentially, first you wanna find out, like, very specifically, what is going on. Are you getting aroused? Are you having erections? Are you masturbating? Like, there's all these questions that will help us go down the route.

Speaker A: Sorry to interrupt. When you say aroused, for sake of this discussion, I just wanna make sure that we distinguish between psychological arousal, the desire to, I guess here we also have to be precise. Arousal to engage in intercourse, arousal to desire, essentially, that I think people would learn to recognize. Or are we talking about arousal as the response of the genitals correct.

Speaker B: So desire and arousal, this is a very important concept. Doesn't always go in one direction. Sometimes you can feel arousal, meaning you have the telltale signs of arousal. Your nipples get erect, you have more loops, lubrication. If you're a female.

Speaker A: Do both male and female nipples get erect during arousal?

Speaker B: I believe so.

Speaker A: I think so, too.

Speaker B: I believe so. You know, you maybe get the sex flush, right? You get some redness or warmth feeling. That's your body's response to arousal. And sometimes that can be an erection, and sometimes that's not. Not having an erection does not mean you're not aroused. It may mean other things, but certainly that's part of it. And then desire. Do you want to have sex? Do you have, like, when you think about your partner or whoever you want to engage with, is there a desire to actually do that? Right? Or is it just more of obligation or other things? And it doesn't matter if the desire comes after arousal. For some women in particular, we see that they may not have the desire right away, but they want to be intimate or close with their partner, and so they'll start just being close with them, and then arousal will come. And then, oh, yeah, I like this. So then the comes after, and that's normal. That's totally fine. So you want to kind of parse that out. And then for men, you can ask, are you getting erections at night? Because that will tell us the function of your organ at night versus during the day, where you have also psychogenic components. Right. You can really get in your head about erections when you have a problem in the bedroom. With performance, it becomes a vicious cycle. Right. You have a problem the next time you're really stressed, you're not present, you're not mindful in the moment with sex, and you're thinking about, oh, my God, am I gonna perform okay? Am I gonna perform okay? And then it doesn't perform again, and you're just. It's getting worse and worse, and the anxiety is through the roof, and that's actually causing your sexual dysfunction. So I think it's important first to identify those issues and then also for blood flow. A lot of times we can assess based on, well, what other comorbidities do you have. Do you have other issues ongoing that may be affecting your blood flow? Most common, high blood pressure, diabetes, heart disease. And if you smoke, all of those things will affect blood flow to the genitals. And so that will point out negatively, negatively? Negatively. So that will point us to a more vascular issue. Hormonal issues are very important for desire. And as far as sexual function, in terms of erections, there's only 3% of erectile dysfunction that's related to hormones. So it's. Absolutely.

Speaker A: But that's pure erectile function.

Speaker B: Correct.

Speaker A: As opposed to desire.

Speaker B: Correct. Psychological muscle desire is predominantly modulated by the hormone testosterone for both men and women. In fact, a lot of people don't know this, but women have more testosterone in their bodies than they actually have estrogen. So testosterone is very important for both men and women for a variety of reasons. Using that discussion with the patient will help you identify where you're headed in terms of what you need to focus on for treatment. There are certain things you can use to assess blood flow. You can do doppler ultrasounds of the penis as well as the clitoris to see if there is good blood flow. You can assess the peak systolic velocity, which will tell you if there's a problem with arterial inflow, versus the end diastolic velocity, which will tell you if there's a problem with venous outflow. And so that can assess those things. Some tests you can do for nerve function, although they're very uncommonly done, because mostly we can kind of get that through clinical report. And unfortunately, if you're having nerve problems, sometimes it depends on what's causing them, but sometimes they can be very difficult to reverse, and that's kind of a problem. We know that as people age, their sensation becomes less so just through aging, the nerves, the receptors become less sensitive, and so you will generally have less responsiveness to the same sensations you did when you were younger. And so that kind of overlays all of this. So it's complex, but really a lot of it comes from the discussion you have with your patient or you kind of really doing a deep dive in what's going on, really thinking about each of those aspects, and also what's going on in your relationship and what's going on in your life. Stress, anxiety. How are those playing a role?

Speaker A: I'd like to take a quick break and acknowledge one of our sponsors, athletic greens. Athletic greens, now called ag one, is a vitamin mineral probiotic drink that covers all of your foundational nutritional needs. I've been taking athletic greens since 2012, so I'm delighted that they're sponsoring the podcast. The reason I started taking athletic greens, and the reason I still take athletic greens once or usually twice a day, is that it gets me the probiotics that I need for gut health. Our gut is very important. It's populated by gut microbiota that communicate with the brain, the immune system, and basically all the biological systems of our body to strongly impact our immediate and long term health. And those probiotics and athletic greens are optimal and vital for microbiotic health. In addition, athletic greens contains a number of adaptogens, vitamins and minerals that make sure that all of my foundational nutritional needs are met. And it tastes great. If you'd like to try athletic greens, you can go to athleticgreens.com hubermanda. They'll give you five free travel packs that make it really easy to mix up athletic greens while you're on the road, in the car, on the plane, etcetera. And they'll give you a year's supply of vitamin D. Three k, two. Again, that's athleticgreens.com Huberman to get the five free travel packs and the year's supply of vitamin D. Three k, two. Gosh, lots there to unpack. And I'm glad you mentioned the relationship itself, because there are all sorts of things that can impact the arousal response, novelty. Not everyone's in a committed relationship. Whether or not people are engaging in a lot of masturbation to the point of ejaculation or climax or not, pornography, et cetera, we will get into that. It's a vast space to explore. Before we go any further, I want to make sure, however, that we cue people to where and how they could find a really good, let's say, pelvic floor therapist and where they could find a really great urologist to do the sorts of exams and perhaps the sorts of treatments that we've talked about. Because at least as far as I understand, much of what people want to learn on this podcast is how things work and what happens when things break down, but also how to resolve those issues. So let's say somebody wants to check out their pelvic floor, figure out what's going on there. Maybe they're having issues, maybe they're not. If they are male or female, where do they go? Is there a place online that has a great list of some of the best ones in one's area? Can it be done over telemedicine? Yeah. How does one go about that?

Speaker B: Yeah. So in terms of your pelvic floor, it's good to get assessed by a physician who specializes in pelvic floor. Now that could be a urologist, that could be a gynecologist or even a physical medicine rehabilitation doctor, specializes in pelvic floor health. So typically you'll see in urology, you'll look for people who are board certified in female pelvic medicine and reconstructive surgery. If you're a woman, if you're a man, maybe sexual medicine, someone who specializes in sexual medicine, would be a good place to look for a gynecologist. Again, you want to look at someone who has interest in this area, who does manage pelvic floor. And then in terms of pelvic floor physical medicine rehabilitation, at least when I was in training, there was about 20 PMR doctors around the country who really focused on this. It's not a lot of people. If you can go to a pelvic floor physical therapist and you have one near you, that's great as well. You do want to make sure that one they do are certified in pelvic floor physical therapy and that they have taken care of your gender. So if you have male anatomy, then you want to go to someone who's actually seen men, because a lot of the pelvic floor physical therapists tend to treat a lot of women. And so that's kind of what I tell my patients, generally speaking. There's no, at least to my knowledge, no great resource. And maybe we'll look that up and see if we can find a.

Speaker A: That's very helpful. Thank you. Because again, going back to what I said at the beginning of our conversation, I think there's a lot of shame, or at least a lack of clarity as to how one gets help for issues that relate to the genitals. Because if you have a headache or you're having an eye issue, sort of nowhere to go. Hopefully your headache doesn't warrant going to a neurologist. But it might. Eye stuff tends to be ophthalmologists, optometrists. So I don't think we hear often enough about where to access the best quality care for these things. So thank you for that. In thinking about sexual dysfunction, I'd like to have that conversation more or less in parallel, if we can, around male sexual dysfunction and female sexual dysfunction. And I want to make sure that before we do that, that I'm creating the correct parallel construction. As they say, erectile dysfunction in males is clearly a form of sexual dysfunction. What is the parallel to erectile dysfunction in females? Is it lack of vaginal lubrication and lack of relaxation of the vagina to have non painful intercourse? Is it even possible to have a parallel conversation about these two things?

Speaker B: So it's different in some circumstances. There are homologues, so the penis is the homologue of the clitoris, so the clitoris is essentially the same sort of spongy erectile tissue that you see in the penis. It gets erect with arousal, and it actually extends very deep into the pelvis. So it's not just a small little organ. It's actually quite long. And so you can. In men, you can have erectile dysfunction because you can see it, but in women, you may have difficulty with orgasm. And it's not exactly a parallel, but difficulty orgasming in women is multifactorial, and we can get into that. But I think there, they're different. And I think also sexual dysfunction presents differently in both genders. So when you talk about men, they're very. The one visual they see of arousal is erections. And so it becomes very ingrained in your psyche that if I don't have an erection, I'm not aroused. Right. But there's a lot of reasons that you might not have an erection. That we've sort of touched on vascular problems, hormonal problems, neurologic problems, psychogenic issues, and other medications you're taking. There are issues that can affect erectile function. And so that can be part of it where you might feel like you have low desire because your arousal is not there. And that becomes a little bit confusing for women. What they can assess is their level of lubrication if sex hurts and if they get an orgasm. And so those are kind of the ways you can look at it.

Speaker A: Thank you for fleshing all of that out. Years ago, I worked on sexual differentiation and in particular, the role of hormones in sexual differentiation. And indeed, as you described, we learned because we were taught, and I think people still generally agree, that if one looks at the embryological origins of the penis and the clitoris, they are essentially analogous structures. And that a lot of male genital development involves, literally the regression, the disappearance of the female sexual genitalia and associated organs, mullerian ducts and things like that, and what would become the ovaries become the testes, et cetera, et cetera. Those are anatomical parallels. But what you just described for us very beautifully is the sort of functional parallels as it relates to sexual function and dysfunction. So I'm hoping with that framing that we can knock down a few of these pins in a little less time, because there's a lot to tackle here. First off, I'd like to address the hormonal issues. You mentioned that only 3% of erectile dysfunction, and by extension, can we say, also female issues with sexual arousal, are hormonal in origin. Is that right?

Speaker B: So with desire. Yes, they are hormonal in general and arousal in terms of lubrication, if you're using that as a barometer, yes. You can see less vaginal lubrication due to hormones, and I guess I would say three to 6% more. Up to 6% we see of erectile dysfunction is hormonal. It's a small percentage of the entirety of erectile dysfunction.

Speaker A: Okay. So I think in looking on the landscape of social media and podcasts and just in the common mindset, we've all come to believe that testosterone is pro libido. It's pro desire in men and women. I think now people are starting to appreciate that it's pro desire in women as well, but certainly in men, and that dopamine is also associated with desiree. And the general public tends to have this view of estrogen as being sort of anti libido or anti male, which is frankly false. In fact, and I've covered this on the podcast with Doctor Kyle Gillette and with Doctor Peter Attia and another fellow youtuber, Derek from more plates, more dates, has talked a lot about the fact that if people, if men, excuse me, take drugs like anastrozole to suppress their estrogen, thinking that, oh, it's all about having high testosterone, low estrogen, oftentimes they crush their libido, just abolish it, which has led to a slowly growing, but I think, positive shift in how people are thinking about estrogen. Estrogen is great for brain function. Estrogen's great for libido in men and women. Correct. And that is a revision of, I think, how most people think of the male sexual response. It's more in keeping with how people think about the female sexual response. Oh, estrogen in the female sexual response. That makes sense. But what we're trying to do here is clarify some of the misconceptions. Now, the reason I mentioned dopamine is that my understanding is that dopamine is involved in the, excuse me, the desire response. We will distinguish desire, the psychological arousal, from genital arousal, physical arousal, and that prolactin is associated with the refractory period during which erection can't occur. Another, perhaps, orgasm can't occur in females, et cetera. But my understanding is that's also not that simple. And we need to take a step back, perhaps, and just talk about the physiological underpinnings of the desire and arousal response. So I'll tell you what I was taught, and then you can tell me where it's wrong, I hope. I was taught that the erection response and the vaginal lubrication response is generated by the parasympathetic nervous system, the relaxed, the rest and digest aspect of the nervous system. Hence why some people can get psychogenic sexual issues of lack of erection or lack of vaginal lubrication. But that there are individuals out there for whom a lot of alertness, maybe even, and this is a controversial thing, but for some people, even some sense of aggression or kind of edginess or excitement, adrenaline, in other words, can stimulate erection or vaginal lubrication. So it gets tricky. It's not like the textbooks. It's not like they taught us in high school, as far as I know. I was taught that the arousal response in males and females is initiated by a parasympathetic sort of relaxed tone. And that as sexual desire and arousal and sex or masturbation progresses, that it shifts more towards the sympathetic nervous system, which has nothing to do with emotional sympathy and has everything to do with arousal. The catecholamines, dopamine, norepinephrine and epinephrine, also called adrenaline and noradrenaline, are released. And that the climax response, which may or may not include ejaculation, we have to separate that out, is one that is really of the stress system of the body. And then in the post coital or post ejaculatory or post climax phase, then there's a shift back to the parasympathetic nervous system. That's where the pillow talk and the exchange of odors and tastes and other molecules is known to enhance pair bonding through things like oxytocin, vasopressin and so on. And what I just described is exceedingly oversimplified, I realize. But is that more or less how the physiology works?

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

Speaker A: All the male audience will like that one.

Speaker B: And then, you know, you go on to the sympathetic nervous system. But it makes sense. And the reason that I think you're hearing about this aggression or these things that are leading to arousal is because there needs to be a stimulus, right? A visual stimulus, a tactile stimulus, some sort of stimulus that you're getting that is then causing the release of nitric oxide from the parasympathetic nervous system. And that could be, for some people, aggression or some form of that, right?

Speaker A: Tell people about nitric oxide, because we'll get into this. When we talk about drugs that increase blood flow, cialis, viagra, and also non prescription drugs, things like l citrulline, arginine and watermelon, for that matter. So I read on the Internet.

Speaker B: So, yeah, so nitric oxide is essentially the ignition for what we say for erections. The ignition for erections. The reason I talk about erections more often is when you look at the data. In fact, there was a paper on this where they looked at the number of articles that came up when you put in the word penis and the number of articles that came up when you put in the word clitoris. And it was 50,000 about penis and 2000 about the clitoris.

Speaker A: Okay, we have to. This was actually a major section of the comments on. When I asked for questions on Instagram and comments on comments and. Yeah, how come? Why not? Et cetera. Is that because the urology and sexual health field was dominated by men? That's going to be the presumption. Or is it because it's easier to study somehow or, I mean, what's going on here?

Speaker B: Yeah, I think there's been a lot of, I mean, you can go back to, like, freud, where he thought that the female sexual response was less valuable. And so there are some reasons less valuable, I guess. I don't know if that's the right term, but.

Speaker A: Oh, no, no, I'm not challenging your term.

Speaker B: I just meant, you know, it was.

Speaker A: He seemed to be obsessed with it. Right.

Speaker B: But it was more about the male sexual response than the female sexual response. And so in general, yes, there is, you know, there were more men in medicine. There was more. And it is easier to study. Right. You can't study the clitoris quite as easy as you can study the male penis response. Cause you can see it visually. You can inject it and see an erection response. Right. We do this for people who have erectile dysfunction. They'll take medications that increase blood flow, like Trimix. And you'll inject it into the penis and you'll see an erection. So you can actually Trimix. Trimix. So there's, it's.

Speaker A: The entire male audience just went, wait, what are you injecting into the.

Speaker B: So there are three basically brand names of intracavernosal injections that we use for erectile dysfunction.

Speaker A: I hear injection and penis. And I think, I'd say, I like to think that it reflects a natural male response. I sort of taken aback. I don't know, maybe there's a pelvic floor contractions in there someplace.

Speaker B: So it is scary to hear about. It's a very small needle. It is very well tolerated. I've done it to patients in the office and they look at me and say, you're done. It's not as painful as it seems. And when you are not having erections and you've tried multiple things, people get to the point where they're willing to try that. And so it is very effective. It is the most effective non surgical treatment we have for erectile dysfunction. And it's usually either one medication, two medications or three. So you can have alprostadil, papavrine and what's the third one?

Speaker A: That's okay, we can look at. Someone will put it in the comments, surely they will. What is it designed to do? A vasodilator of sorts.

Speaker B: So they work in different mechanisms, but similar to the medications that we have. PDE five inhibitors. PDE five inhibitors work in the erection cascade. Basically what happens, let's actually, let's take it back to the nitric oxide thing and we'll get there. So nitric oxide essentially is released by the endothelium in response to a visual tactile stimulant stimulating cue. Right? And so your body releases nitric oxide side, which then sets off the cascade for the erection. And so that releases cgmp, which is, which causes the erection, and it's degraded by phosphodiesterase. And so medications that inhibit phosphodiesterase, like Viagra and cialis, tend to prevent the breakdown of that cgmp, so you have longer lasting erections. And so similarly these medications work sort of similar to that. Some of them, we don't know exactly how they work, but they work by increased increasing cgmp or camp that are involved in those cascades.

Speaker A: And what about l citrulline? I hear about lcitrulline use. It's an over the counter supplement and it's in the arginine pathway. And my understanding is that it works similarly to things like Cialis Viagra, but is perhaps not as potent. I also just cautionary note out there, l citrulline can give people vicious cold sores and canker soreshenk. Vicious. You hear about this on the Internet. It's been verified by grotesque images that you do not want to google for, and not everyone tolerates it well.

Speaker B: So these actually work by increasing nitric oxide. So they're not in this, they're not later down the pathway, they're actually increasing the availability of nitric oxide. So l arginine is the more direct pathway, but it's very low bioavailability. L citrulline converts to l arginine but it lasts much longer in the bloodstream, which is why people tend to use l citrulline now in sexual medicine. These supplements, while there has been some studies on them and they are effective, there's no regulation on the supplement industry, so we can recommend them. But we just can't say that for sure that the supplement is exactly what's said on the bottle. We see lots of studies where they'll say, I read one about melatonin and there's a variation of melatonin from what's on the bottle to 400% times more. That's the struggle that we as medical doctors have. I know we get a lot of slack for it, that we don't talk about supplements, but it's really the challenge there is finding the quality supplement a.

Speaker A: Great site, which I have no relationship to except that I mention them all the time, is examine.com, which has references to human studies and where there's a lot of efficacy shown and we'll get into some side effect issues. Does can't address quality by brand issues, but thanks for mentioning that. What percentage of males who take cialis, aka tadalafil or viagra, for erectile dysfunction get relief from that? Because you mentioned only 3% of erectile issues in males are hormonal in origin. But what percentage are likely to be blood flow related in origin?

Speaker B: So a large percentage are blood flow related. That doesn't mean that the medication will be effective for everyone. If you look at the large percentage are, are vascular in nature, right? That's the number one cause as men age. So we know that about 50% of 52% of men over the age of 40 will have erectile dysfunction. And that continues to increase as you age. So 50% of 50 year olds, 60% of 60 year olds, and so on and so forth. So it's very, very common. And the success rate in the studies is about 60% to 70%. So when you give someone a medication, they will have sustained erections that are sufficient for penetrative intercourse, which is the way we kind of discuss erectile dysfunction in studies and with patients is about 60% to 70%. So not everyone will have success. But not all of that is because the medication doesn't work. Sometimes people are not taking them correctly. Sometimes people need to try different doses. And then there's still this issue of your brain is still active, and so if you're having anxiety or having other issues or stress in your life, that can have an effect on your ability to create an erection. So there's lots of factors that go into it, but generally speaking, they are effective and they do work quite well and they're tolerated pretty well.

Speaker A: And 60% to 70% is not a small number. That's a significant number. That's the majority by a significant margin. Is there a basis for the use of cialis tadalafil, viagra, l citrulline in females?

Speaker B: So, yeah, there's not a lot of data on this, but certainly, if you have surmised that there is a blood flow issue and they're having difficulties with orgasm, it's certainly something you can try off label. And certainly people do try these medications off label to see if they improve sexual function for women. But there's not a whole bunch of robust, randomized, controlled trial studies on women with. With these medications.

Speaker A: A little bit later, we will talk about prostate health specifically, but I'm just going to make a note here that nowadays there's increasing use of low dosage cialis tadalafil. So rather than. What I found online was that the erectile dysfunction treatment dosage of cialis Adelphil is somewhere in the 15 to 20 milligram range. What we're talking about here is daily use of 2.5 to five milligrams of cialis tidal fl for prostate health. And I learned in researching for this episode that tadalafil cialis was actually developed as a drug for the treatment of prostate health, to essentially increase blood flow of the prostate, to increase prostate health, not for the treatment of erectile dysfunction. So I found that to be somewhat interesting, and a lot of people are now starting to use that. I also learned that if you dive into the guts of the Internet, one can find that now there's a growing use of combined low dosage cialis and apomorphine, which is a pro dopaminergic agent. And we'll get back to dopamine a little bit later. But is there any basis for low dosage, say, 2.5 to five milligram daily use of cialis tidalafil in females?

Speaker B: Yes. So, well, let's talk about it. For males and females, I think low dose daily cialis is excellent for erectile function in men, even.

Speaker A: Is that true? Even. Sorry to interrupt, but is that true even for men that are not experiencing erectile dysfunction?

Speaker B: It's not indicated for that purpose, but there's a thought that, you know, it's increasing blood flow to the area. So people, I've personally used it for men who have pelvic pain to help with increasing blood flow, you can also use it potentially as a preventative. So some people have kind of thought, okay, it's increasing blood flow, it's preventing fibrosis of that erectile tissue. That can happen with age or other vascular problems. So it may be beneficial for that as well. Although again, that's off label and not something that we generally promote. As far as for women, there's again, it can help with blood flow. So if you're having issues. So if you have a female who's having sexual dysfunction and she's got a signs of vascular problems, like she's got diabetes, high blood pressure, she smokes, and yes, it's certainly reasonable to try and see how they do. Usually want to give at least a four week trial to see if there's any benefit with those medications.

Speaker A: Great, thank you for that. Why is it that I get so many questions about erectile dysfunction from males who are in their twenties and thirties? Because everything you said up until now was mainly focused on men 40 years and older. Is it from lack of physical activity, overuse of nicotine? By the way, vaping, as far as we know, vaping and smoking, bad for erectile function and perhaps sexual health in males and females generally. Because nicotine is a vasoconstrictor. Nicotine does have certain benefits, and I covered this in an episode on nicotine. Neurocognitive benefits in the elderly in particular. But it is a vasoconstrictor, so it runs against all of the sexual arousal stuff that we're talking about. But okay, let's assume that a male in their twenties or thirties is sleeping enough six to 8 hours a night, is exercising, isn't doing anything to punish their pelvic floor in the gym, they're not doing legs crossed kegels while doing crunches or something while inhaling on the crunch. That was a quiz, by the way, folks, for earlier topics covered, let's assume they're eating pretty well. The majority of their foods are coming from non processed or minimally processed foods. They're doing a little meditation each day. They're engaging in hopefully healthy relationships, they're not masturbating like crazy to porn. And let's assume that they are, you know, not on any SSRI. Why are all these 2030 year olds on the Internet asking mainly you? They mainly run to you, but also to my direct messages about their erectile issues.

Speaker B: So I will say I have seen a lot of young men in my clinic and I will say that they very often have pelvic floor dysfunction. So that even though they're doing all the right things, they do. I mean, we're in a stressful society, so you can try all the things to be to decrease your stress. But a lot of us are sitting long periods of time, especially during COVID I mean, people sat for months, right, years, like, just sitting at their home computer. And so, you know, exercising 1 hour is not going to offset the day full of sitting. And so all of those things can affect pelvic floor function. So my theory is that that's probably the more common cause.

Speaker A: So walk more. Yeah, I've actually heard that.

Speaker B: Standing desk.

Speaker A: Yeah, yep. Yeah, walk more. Standing desk. Okay, so. And then my guess is that there's some psychogenic feedback loop.

Speaker B: Absolutely.