Dr. Rena Malik: Improving Sexual & Urological Health in Males and Females | Huberman Lab Podcast

Podcast Host: Dr. Andrew Huberman (Stanford Associate Professor - brain development, brain plasticity, and neural regeneration and repair fields).

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Podcast Guest: Dr. Rena Malik, M.D., (A board-certified urologist and pelvic surgeon, male and female pelvic medicine expert, and public health educator )

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Content may not be suitable for all audiences and ages.

Key Takeaways:

Kegels strengthen pelvic floor muscles and improve urinary incontinence (Segment 3).
Psychology, hormones, blood flow, and nerves affect sexual desire and arousal (Segment 5).
Sexual dysfunction affects men and women differently due to physical and psychological causes (Segment 7).
Hormonal, physical, and psychological causes cause erectile dysfunction. Medications treat erectile dysfunction (Segment 8).
Pornography and masturbation are addictions like cocaine and other drugs (Segment 13).
Different phases characterize the female sexual response cycle (Segment 15).

Summary

The guest featured in the current episode is Dr. Rena Malik, M.D., a highly skilled urologist and pelvic surgeon who holds board certification in her specialized field. Dr. Malik's extensive knowledge and experience in the area of male and female pelvic medicine have positioned him as a highly respected expert in this field. In addition, she has a robust knowledge base in the realm of public health education. The presenter aims to analyze the fundamental components that contribute to sexual and urologic dysfunction, as well as the corresponding therapeutic approaches. This study aims to conduct a comprehensive investigation of several approaches in order to revitalize, maintain, and improve pelvic floor function, while simultaneously optimizing neuronal and vascular systems associated with the genital regions. Furthermore, the participant will engage in a discourse regarding the factors that regulate and potentially augment sexual desire and arousal, methodologies for evaluating and managing erectile dysfunction, and the difficulties associated with vaginal lubrication and/or achieving orgasm. The speaker will also provide elucidation on the aspects of vaginal and penile health, encompassing strategies for the prevention of urinary tract infections (UTIs), alongside an examination of commonly prescribed medications that may induce sexual dysfunction in individuals of both genders. This episode encompasses various subjects, such as oral contraception, self-stimulation, adult material, prostate health, and hormonal well-being in both males and females.

(01). 00:07:45 Pelvic Floor: Urination & Sexual Function

The pelvic floor is comprised of a collection of muscles that provide structural support to the organs located within the pelvic region. The anatomical arrangement of the structure aids in the facilitation of various physiological functions, including urine, defecation, sexual activity, and the maintenance of posture. Maintaining the integrity of the pelvic floor is crucial for the efficient functioning of the human body and holds the potential to mitigate symptoms such as urine urgency, frequency, and incontinence. Pelvic floor dysfunctions possess the capacity to affect individuals across all genders, as they may arise as a result of many circumstances such as stress, excessive exertion, or incorrect body alignment. Pelvic floor dysfunction is characterized by an aberrant condition of muscular tone or strength in the muscles of the pelvic floor. The occurrence of tension can give rise to intricacies in the urinary process, leading to symptoms such as heightened urgency, augmented frequency of urination, or inadequate bladder voiding. Furthermore, this illness has the potential to affect sexual function, leading to discomfort during sexual intercourse, difficulties in achieving and maintaining erections, or issues with ejaculation. Moreover, the contraction of inflexible pelvic floor muscles has the ability to initiate lumbar discomfort and contribute to the occurrence of gastrointestinal irregularity. On the other hand, a compromised pelvic floor, frequently observed in women who have undergone childbirth or those with certain medical problems, can give rise to complications such as urinary incontinence. Understanding the importance of the pelvic floor is crucial for promoting general health and managing a range of discomforts and dysfunctions [1].

Figure 1. Pelvic floor muscles [2].

References

1. Pelvic floor. Available from: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pelvic-floor#:~:text=The%20pelvic%20floor%20muscles%20are,pass%20through%20the%20pelvic%20floor.

2. Understanding Pelvic Floor Therapy (PFPT)/Pelvic Floor Muscle Training (PFMT). Available from: https://www.acsm.org/blog-detail/acsm-certified-blog/2019/04/12/pelvic-floor-dysfunction-training-advice.

2. 00:14:13 What is a Healthy Pelvic Floor?

The identification of pelvic floor disorders might pose challenges due to the delayed manifestation of symptoms and their often unpredictable occurrence. In contrast to the visible musculature, the detectability of the level of tension or relaxation in the pelvic floor is limited. The diagnostic procedure involves performing pelvic examinations for female individuals and rectal examinations for male individuals. A pelvic floor therapist aids individuals in attaining optimal pelvic function, akin to the responsibilities of a fitness trainer in a gymnasium environment. The participants initiate the procedure by applying adjustments to their posture with the aim of decreasing the likelihood of experiencing muscular tension. When conducting an examination on male persons, the evaluation involves the manual examination of muscles located in the anal and perineal regions, which are positioned between the scrotum and the anus. Digital tools, such as kegel exercise probes, possess the capacity to aid persons who experience weakened pelvic floors. However, it is imperative to recognize that these tools should not be regarded as diagnostic instruments. The acquisition of a definitive assessment may present difficulties due to the absence of well-defined standards for differentiating between typical and atypical observations [3].

References

3. Healthy Pelvic Floor. Available from: https://www.nhs.uk/common-health-questions/lifestyle/what-are-pelvic-floor-exercises/#:~:text=To%20strengthen%20your%20pelvic%20floor,squeeze%20for%20a%20few%20seconds.

3. 00:19:44 Kegels, Benefits & Risks, Urinary Incontinence

The inception of utilizing Kegel exercises to enhance the strength of pelvic floor muscles was initially introduced in 1948, as stated by Arnold Kegel. The perineometer is a device utilized for the purpose of quantifying and documenting muscular contractions, with the intention of providing recommendations for workout regimens. It is recommended that patients actively involve the muscles responsible for regulating urination, with the exception of the actual act of urinating, as a proactive approach to prevent dysfunction. The descriptions encompass the actions of upward and inward traction. Apply a consistent force for a duration of 5 seconds, then release the force, and thereafter repeat this sequence many times. Commence the exercise routine by initially assuming a supine position, followed by a gradual transition to a seated position, and ultimately assuming an upright posture. Perform 10 to 15 repeats of this sequence throughout both morning and evening sessions. Engaging excessively in a particular activity can lead to the development of muscular tightness and decreased physiological functioning. The effectiveness of Kegel exercises has been established in the treatment of stress urine incontinence, pelvic organ prolapse, and post-prostatectomy urinary leakage. Some individuals may partake in the endeavor of seeking increased pleasure for certain goals; nonetheless, it is crucial to use caution in order to avoid undue exertion. It is advisable to consult with a urologist when encountering symptoms such as dysuria or urinary dysfunction [4].

Figure 2. Kegel Exercise and its benefits [5].

References

4. Kegel Exercises. Available from: https://my.clevelandclinic.org/health/articles/14611-kegel-exercises#:~:text=Kegel%20exercises%20can%20give%20you,like%20pregnancy%2C%20childbirth%20or%20surgery.

5. Kegel Exercises and its benefits. Available from: https://www.centerforurologiccare.com/patient-education/kegel-exercises/.

4. 00:24:08 Pelvic Floor Relaxation; Exercise & Pelvic Floor

When considering alternative approaches to address the effects of Kegel exercises, potential strategies encompass therapeutic massage, the utilization of vaginal dilators, and the administration of muscle relaxant suppositories such as valium or baclofen. Although a definite treatment is not provided, these interventions effectively mitigate symptoms. It is advisable to consult a physical therapist for guidance on engaging in activities aimed at "down training" the pelvic floor, such as the happy baby stance, which facilitates muscular elongation. The utilization of precise diaphragmatic breathing techniques during periods of physical activity holds great importance. The process of expelling air while exerting force is a physiological mechanism that aids in the stabilization of the pelvic floor. This is achieved by triggering contractions, which effectively offset the rise in intra-abdominal pressure. The intentional incorporation of breath-holding techniques during physical activities, such as crunches, has a noticeable impact on the operation of the pelvic floor. The proven effects of pelvic floor dysfunction on blood flow and neurological pathways, particularly the pudendal nerve, have been found to have adverse implications for sexual function and the perception of discomfort. The intricate characteristics of the situation are emphasized by the interaction among several components [6].

References

6. LEARN TO Relax Your Pelvic Floor Muscles. Available from: https://www.bidmc.org/-/media/files/beth-israel-org/centers-and-departments/rehabilitation-services/relax_your_muscles_sheet_2016_05_rev.pdf.

5. 00:28:03 Desire vs. Arousal, Erections: Psychology, Hormones, Blood Flow & Nerves

The relationship between desire and arousal does not necessarily follow a linear pattern. Arousal is characterized by physiological indicators such as the presence of erect nipples and increased lubrication. The concept of desire encompasses a need for closeness. It is commonplace for the experience of desire to occur subsequent to arousal, particularly among women. The evaluation of nocturnal penile tumescence in males serves as an indicator of erectile function. The presence of performance anxiety has the potential to exacerbate sexual dysfunction. Hypertension, diabetes mellitus, and tobacco use have an impact on the circulation of blood. Hormonal fluctuations exert a significant influence on sexual desire, with testosterone playing a pivotal role in individuals of all genders. Doppler ultrasounds are utilized to evaluate and analyze the circulation of blood. Nerve tests are hardly conducted as a result of their inherent difficulty. The process of aging is associated with a decline in sensory perception. In the broader context, engaging in conversations with patients holds significant importance, as it allows for a thorough knowledge of sexual disorders by taking into account many elements such as interpersonal connections, stress levels, and anxiety [7].

Figure 3. Arousal and brain response [8].

References

7. Goldey, K.L. and S.M. van Anders, Sexual arousal and desire: interrelations and responses to three modalities of sexual stimuli. J Sex Med, 2012. 9(9): p. 2315-29.

8. Poeppl, T.B., K. Sakreida, and S.B. Eickhoff, Neural substrates of sexual arousal revisited: Dependent on sex. 2020. 117(21): p. 11204-11205.

6. 00:37:07 Pelvic Floor: Medical Professionals & Physical Therapy

To ensure optimal management of pelvic floor issues, it is recommended to get an examination from a healthcare practitioner who possesses specialist knowledge and skills in this area, such as a urologist, gynecologist, or Physical Medicine Rehabilitation physician. It is advisable to consult certified specialists who have obtained relevant board certifications in the specialized areas of female pelvic medicine, sexual medicine for women, and sexual medicine for males. Pelvic floor physical medicine rehabilitation physicians are a limited resource, although they demonstrate a considerable amount of skill within their domain. Pelvic floor physical therapists might be seen as a feasible alternative, given that they hold the necessary accreditation and demonstrate significant expertise in treating patients of the corresponding gender. The accessibility of resources for identifying specialists is limited; yet, completing research may uncover advantageous options [9].

References

9. The Pelvic Floor. Available from: https://teachmeanatomy.info/pelvis/muscles/pelvic-floor/.

7. 00:40:15 Sexual Dysfunction, Erectile Dysfunction, Orgasm Difficulty

Sexual dysfunction manifests in diverse ways in both males and females, while certain parallels can be observed due to shared anatomical homologs. The clitoris exhibits similarities to the penis due to the presence of spongy erectile tissue that experiences engorgement in response to sexual stimulation. The aforementioned structure has a substantial anatomical complexity in the pelvic area and serves to facilitate the sexual response of individuals assigned to females at birth. In the male demographic, the presentation of erectile dysfunction is more easily discernible, but in females, difficulties associated with attaining orgasm are marked by heightened intricacy. The occurrence of female orgasmic issues is impacted by a variety of circumstances. It is noteworthy to mention that sexual dysfunction manifests in various manners within each gender. The correlation between male arousal and erections is a commonly seen phenomenon. Nevertheless, it is crucial to recognize that factors beyond mere desire can exert an influence on the incidence of erections. These elements involve several aspects including vascular, hormonal, neurologic, and psychological components. Females possess the capacity to assess their sexual encounters by considering many elements, including the presence of lubrication, discomfort encountered during sexual intercourse, and their ability to achieve orgasm [10].

Figure 4. Sexual Dysfunction in Patients with Neurologic Disorders [10].

References

10. Vodušek, D.B. and M.J. Aminoff, Chapter 30 - Sexual Dysfunction in Patients with Neurologic Disorders, in Aminoff's Neurology and General Medicine (Fifth Edition), M.J. Aminoff and S.A. Josephson, Editors. 2014, Academic Press: Boston. p. 633-656.

8. 00:43:13 Desire & Arousal Issues; Erectile Dysfunction, Viagra, Cialis (Tadalafil)

Hormonal considerations often play a significant role in the manifestation of challenges pertaining to female sexual arousal, particularly with regard to desire and lubrication. Hormonal factors have been identified as potential contributors to the incidence of erectile dysfunction, accounting for around 6% of documented instances. The involvement of the parasympathetic nervous system in the development of erections is widely acknowledged within the domain of medical research. The aforementioned physiological process is aided by the presence of nitric oxide, which serves as a catalyst for the indicated response. The initiation of nitric oxide release is triggered by a stimulus, such as antagonistic behavior or sensory cues related to vision or touch. Throughout history, there has been a notable inclination towards the investigation of male sexual response, a trend that can be attributed, at least in part, to historical biases and the comparative feasibility of studying it. Intracavernosal injections are a treatment modality that is commonly used to manage erectile dysfunction. This approach is considered non-invasive, as it does not require any surgical intervention. One of the main mechanisms by which intracavernosal injections exert their therapeutic effect is by enhancing the circulation of blood within the cavernous bodies of the penis. The administration of these injections involves the application of artificial substances, namely alprostadil, phentolamine, and papaverine, that mimic the physiological sequence of events that culminate in an erectile response. The commencement of the erectile cascade is triggered by the liberation of nitric oxide, which then induces the liberation of chemical substances such as cyclic guanosine monophosphate (cGMP). The injection of medications that inhibit phosphodiesterase type 5 (PDE5), such as Viagra and Cialis, can extend the duration of this process. Numerous other pharmaceutical substances function in a comparable fashion by enhancing the concentrations of cGMP or cyclic adenosine monophosphate (cAMP) within the signaling pathways [11].

Figure 5. Sildenafil inhibits phosphodiesterase type 5 (PDE5) [11].

References

11. Cruz-Burgos, M., et al., New Approaches in Oncology for Repositioning Drugs: The Case of PDE5 Inhibitor Sildenafil. 2021. 11.

9. 00:52:20 L-Citrulline, Supplements

Both L-citrulline and L-arginine possess the capacity to enhance the presence of nitric oxide, albeit in different ways. L-arginine is a more direct route, albeit with restricted bioavailability. On the other hand, it is worth noting that L-citrulline exhibits a process of transformation into L-arginine and exhibits a prolonged length of retention in the circulatory system. The utilization of these supplements in the field of sexual medicine has shown potential; however, concerns arise due to the lack of regulatory procedures in the supplement industry. While scientific research provides support for the effectiveness of dietary supplements, it is crucial to acknowledge that the composition of these supplements may not consistently correspond to the assertions made on their packaging. Healthcare practitioners face a considerable barrier in offering confident recommendations due to the heterogeneity in the quality of medical interventions [12].

References

12. Theodorou, A.A., et al., Acute L-Citrulline Supplementation Increases Nitric Oxide Bioavailability but Not Inspiratory Muscle Oxygenation and Respiratory Performance. Nutrients, 2021. 13(10).

10. 00:54:09 Erectile Dysfunction & Cialis; Prostate Health; Females

Vascular issues have been identified as a significant contributing factor to a considerable number of instances of male erectile dysfunction as they progress in age. Erectile dysfunction, a disorder that gets increasingly common with age, affects around 50% of guys aged 40 and older. The effectiveness rates of drugs frequently vary between 60% and 70%. Nevertheless, it is crucial to acknowledge that not all individuals manifest favorable reactions to medication as a result of several factors, including improper administration, dosage adjustments, and psychological factors. The efficacy and safety of Viagra, Cialis, and l-citrulline in improving blood circulation in women is currently under-researched, with scant available literature on the subject. Low-dose Cialis (tadalafil) is sometimes prescribed for daily use within a dosage range of 2.5-5 mg, with the objective of enhancing prostate health. The therapy modality under consideration exhibits the capacity to enhance erectile function and mitigate discomfort in the pelvic region. In the realm of female sexual health, several medications possess the capacity to mitigate issues pertaining to blood circulation, particularly in instances when there are observable challenges associated with the vascular system. The implementation of a trial period lasting around four weeks can provide significant insights into the effectiveness of the remedy indicated before [13].

Figure 06. Sildenafil also improves hippocampal brain injuries [14].

References

13. Should you take a daily erectile dysfunction pill? ; Available from: https://www.health.harvard.edu/mens-health/should-you-take-a-daily-erectile-dysfunction-pill.

14. Yazdani, A., et al., Sildenafil improves hippocampal brain injuries and restores neuronal development after neonatal hypoxia–ischemia in male rat pups. Scientific Reports, 2021. 11(1): p. 22046.

12. 00:58:58 Erectile Dysfunction in Young Men

According to Dr. Rena Malik, a renowned expert in the field, A considerable number of adolescent males frequently exhibit pelvic floor dysfunction within the clinical setting, despite adhering to prescribed guidelines and practices. The contemporary societal context characterized by high levels of stress and extended periods of sedentary behavior, particularly exacerbated by the COVID-19 lockdowns, has a discernible influence on the well-being of the pelvic floor. The potential effectiveness of regular exercise in mitigating the adverse effects of prolonged sitting remains uncertain. Implementing techniques such as increasing physical activity through walking or incorporating a standing desk into one's routine can be beneficial. The presence of stress-induced feedback loops might exacerbate the situation, as apprehensions regarding performance serve to further deteriorate the problem [15].

References

15. Rastrelli, G. and M. Maggi, Erectile dysfunction in fit and healthy young men: psychological or pathological? Transl Androl Urol, 2017. 6(1): p. 79-90.

13. 01:01:37 Pornography, Masturbation & Ejaculation; Healthy Sexual Behavior

Engaging in self-stimulation while seeing explicit sexual content might potentially contribute to one's well-being when practiced in the context of mutually respectful and fulfilling partnerships, as well as in conjunction with a sense of overall life contentment. The experience of shame can indeed present a significant concern in this context, and engaging in shared consumption of pornography may be considered a beneficial practice for certain couples. The phenomenon of pornography addiction is frequently characterized as the problematic utilization of pornography in scholarly literature, with a prevalence rate of approximately four percent among those examined in research studies. The activation of dopamine pathways by pornography, akin to other addictive habits, is observed; nonetheless, it is noteworthy that not all individuals encounter associated difficulties. In relation to adolescents, the depiction of sexual content in pornography has the potential to influence their understanding and expectations of sexual experiences. Insufficient provision of comprehensive sexual education might result in misconceptions regarding authentic sexual encounters and interpersonal connections. Engaging in open dialogues around sexuality is crucial for effectively resolving these concerns and surmounting societal stigmatization. It is imperative to acknowledge that there exists significant variation in natural sexual practices, which is contingent upon individual backgrounds, beliefs, and connections [15].

Figure 07. Sexual cues alter working memory performance and brain processing [16].

References

16. Sinke, C., et al., Sexual cues alter working memory performance and brain processing in men with compulsive sexual behavior. NeuroImage: Clinical, 2020. 27: p. 102308.

14. 01:08:22 Arousal Habituation, Masturbation, Addiction

Currently, there is limited availability of specific data regarding individuals' preferences for imaginative, visual, or aural stimuli. However, it is imperative to recognize that individuals possess the capability to become habituated to certain stimuli, hence posing challenges to their potential to adjust to conventional or actual circumstances. The occurrence of habituation to specific types of stimuli, whether they are visual or tactile in nature, has the potential to impact an individual's arousal response, potentially impairing their ability to experience arousal in the presence of a partner or during sexual intercourse. It is advisable to vary one's masturbation routine to mitigate the risk of developing undue reliance on a certain mode of stimulation. The practice of self-stimulation, commonly known as masturbation, can be seen as a valuable method for self-discovery, leading to several benefits including improved sleep patterns, elevated mood, and reduced levels of anxiety. It is crucial to prioritize the preservation of a balanced state and avoid excessive self-indulgence that may affect one's ability to fulfill daily responsibilities and maintain healthy relationships. The proliferation of online content, including pornography, has been a key contributing factor to its heightened prevalence. The emergence of technology has exerted a significant influence on modern dating and communication patterns. The younger population often demonstrates a stronger preference for online interactions over in-person conversations, a phenomenon that has the potential to impact their social skills and overall interpersonal relationships [17].

Figure 08. Brain Activation during Human ejaculation [17].

References

17. Holstege, G., et al., Brain Activation during Human Male Ejaculation. 2003. 23(27): p. 9185-9193.

15. 01:12:57 Female Arousal Response, Orgasm, Coolidge Effect

The sexual response cycle, as investigated by Masters and Johnson, comprises distinct phases within the arousal process. The initial phase is characterized by a state of heightened arousal, accompanied by increased heart rate, quickened respiration, the manifestation of sex flush, and the presence of vaginal lubrication. The occurrence of this event leads to the manifestation of the plateau phase, which is distinguished by a prolonged state of increased vigilance. The subsequent phase is commonly referred to as orgasm, which is distinguished by the occurrence of consistent contractions of the pelvic floor muscles, an intensified sympathetic nervous system reaction, and heightened sensations. Following this, a time of recovery occurs, which is marked by an absolute refractory period where subsequent experiences of orgasms or erections are unachievable. Subsequently, a period of relative refractoriness follows, during which the presentation of new stimuli has the potential to exceed the aforementioned refractory state. The Coolidge effect is a widely studied phenomenon that occurs in both males and females, highlighting the importance of dopamine in overcoming refractory periods. The central nervous system plays a prominent role in regulating sexual function, with dopamine and prolactin serving as essential components in this process. Dopamine possesses the capacity to override refractory periods, whereas prolactin assumes the role of generating these times. This observation underscores the profound influence of the brain on sexual behavior, hence solidifying its central importance in the realm of sexual medicine [18].

Figure 09. Masters and Johnson's female sexual response cycle [19].

References

18. Phases of the Sexual Response Cycle. Available from: https://scholar.valpo.edu/cgi/viewcontent.cgi?article=1061&context=psych_fac_pub#:~:text=In%201966%2C%20William%20Masters%20and,%2C%20and%20(4)%20resolution.

19. Lima, B., Erotic Cities: Instrumental Anthropomorphism in Prince’s Compositions. Journal of African American Studies, 2017. 21: p. 1-23.

16. 01:17:22 Priapism, Melanocyte Stimulating Hormone; Women & Low Libido Medications

In the realm of sexual medicine, the Food and Drug Administration (FDA) has provided authorization for centrally-acting pharmaceuticals specifically formulated to target diminished sexual desire in premenopausal women. This observation underscores the complex interplay between neurochemistry and sexual function, wherein the brain assumes a pivotal role in defining the nature of sexual encounters. Priapism refers to an extended duration of penile erection that lasts for a period beyond four hours. This condition is frequently attributed to the administration of injectable therapies or the usage of specific pharmaceutical substances. This particular circumstance needs urgent medical intervention in order to mitigate potential harm to bodily tissues. Frequent etiologies encompass intracavernosal injections and medical disorders such as sickle cell anemia. Bremelanotide (marketed under the trade name Vyleesi) is an FDA-approved medicine indicated for the treatment of hypoactive sexual drive disorder in women. This pharmaceutical agent functions as a melanocortin receptor agonist. The administration of the injectable is often recommended approximately 45 minutes prior to the intended sexual activity, and it has been observed to significantly enhance sexual desire. Additionally, it may be employed for off-label use in the treatment of delayed ejaculation in males. Flibanserin, also known by its brand name Addyi, is an additional pharmaceutical agent that exerts its effects on serotonin and dopaminergic neural circuits within the brain. When administered on a daily basis at a dosage of 100mg prior to sleep, this medication has been observed to reduce symptoms of hypoactive sexual drive disorder, exhibiting efficacy in approximately 45-60% of individuals. These pharmaceutical interventions provide beneficial alternatives for those who are encountering diminished sexual desire or anxiety connected to desire, and they selectively act on specific neural circuits to address these issues [20].

References

20. female sexual dysfunction. Available from: https://www.mayoclinic.org/diseases-conditions/female-sexual-dysfunction/diagnosis-treatment/drc-20372556.

17. 01:22:25 Libido & Individuality

The level of libido exhibits significant variation across individuals, and there is no universally prescribed or proscribed quantity. Certain individuals identify as asexual or exhibit satisfaction with engaging in sexual activities seldom. The primary concern lies in the individual's subjective experience of distress associated with their degree of libido. Research indicates that over 40% of individuals may experience sexual dysfunction, however, only approximately 12% report being significantly affected by it. This anxiety may arise from individual emotions or issues related to one's partner. Divergent sexual desires within romantic partnerships do not necessarily entail one partner being correct and the other incorrect; rather, it necessitates the identification of shared perspectives and the attainment of consensus. Open communication regarding desires and expectations in sexual interactions is of paramount importance [21].

References

21. Willoughby, B.J. and J. Vitas, Sexual desire discrepancy: the effect of individual differences in desired and actual sexual frequency on dating couples. Arch Sex Behav, 2012. 41(2): p. 477-86.

18. 01:26:18 Female Arousal, Vaginal Lubrication; Discharge, Odors & Douching

From a physiological standpoint, the human body undergoes preparatory changes in anticipation of penetration, regardless of whether it is initiated by a penis, sex toy, or finger. The cervix undergoes movement to accommodate, while the inner two-thirds of the vagina experience elongation, occasionally exhibiting a doubling in length. The process of adaptation takes place during the state of arousal, and it is important to note that the length of arousal might vary among individuals. The labia also undergo expansion to aid the process of penetration. The presence of lubrication is indicative of sexual desire, although there exists variability in the quantity produced among individuals. Various factors such as hormones, age, and drugs have the potential to impact the natural lubrication process. Notably, alterations in lubrication may manifest during periods of lactation or menopause. Arousing stimuli elicit clitoral engorgement and nocturnal tumescence. The color, viscosity, and quantity of normal vaginal discharge can exhibit variation. The marketing strategies employed in the feminine hygiene industry may contribute to the generation of unwarranted anxieties among consumers. However, it is important to acknowledge that different scents and pheromones do really have an impact on the process of attraction. It is imperative to dismiss any detrimental marketing claims, as it is essential to understand that regular vaginal discharge is a natural and healthy occurrence that is indicative of an individual's own physiological composition.

Figure 10. Female sexual Response [22].

References

22. Basson, R., Women's sexual function and dysfunction: current uncertainties, future directions. International Journal of Impotence Research, 2008. 20(5): p. 466-478.

19. 01:33:09 Vaginal Infections, Discharge; Vaginal Microbiome

Alterations in vaginal discharge, characterized by a consistency resembling cottage cheese, accompanied by itching or pain, may indicate the presence of infections such as yeast or mycoplasma. Mycoplasma has the potential to impact the urethra, leading to the manifestation of urinary symptoms. The vaginal region possesses inherent self-cleaning mechanisms, thus necessitating limited intervention in terms of cleansing. It is advisable to focus cleaning efforts primarily on the areas of the body that are covered in hair. Allow the flow of soapy water to rinse downwards, as the human body inherently regulates vaginal health [23].

References

23. Superti, F. and F. De Seta, Warding Off Recurrent Yeast and Bacterial Vaginal Infections: Lactoferrin and Lactobacilli. Microorganisms, 2020. 8(1).

20. 01:35:45 Female Orgasm, Vaginal Penetration, Stimulation, Clitoris, G-Spot

Various forms of stimulation, including clitoral, vaginal, G-spot, nipple, auditory, or visual modalities, can lead to the attainment of orgasms. A significant proportion of women, over 85%, indicate that clitoral stimulation is essential for attaining orgasm, rendering it the most reliable approach. The G-spot, located on the anterior wall of the vagina, is a location that has been reported to potentially provide pleasurable sensations in select individuals. The significance of effective communication on personal preferences cannot be overstated. However, engaging in talks related to sexual matters may provide difficulties due to limited knowledge and awareness of the topic. Diverse individuals exhibit pleasurable sensations and attain orgasms through a variety of unique methods. The significance of prioritizing pleasure and communication within partnerships cannot be overstated. Additionally, it is noteworthy to mention that the occurrence of cervical orgasms can be attributed to stimulation, commonly achieved through cervical or G-spot stimulation. Pelvic floor contractions are considered a distinct physiological response that accompanies the female orgasm [24].

Figure 11. Clitourethrovaginal complex anatomy in female orgasm [24].

References

24. Jannini, E.A., O. Buisson, and A. Rubio-Casillas, Beyond the G-spot: clitourethrovaginal complex anatomy in female orgasm. Nature Reviews Urology, 2014. 11(9): p. 531-538.

21. 01:42:31 Erection & Orgasm, Pelvic Floor Muscles

Erectile and clitoral stimulation encompass the physiological processes of increased blood circulation into the erectile tissues and the contraction of the Tunica, which serves to impede the outflow of blood. During orgasm, the muscles in the pelvic floor undergo contractions, hence enhancing their strength and density. The climax and orgasm are neurologically initiated occurrences that elicit diverse physiological and subjective responses, contingent upon individual sensory experiences. The feeling of orgasm can be characterized as a state of heightened mindfulness, providing individuals with a brief period of mental clarity and heightened awareness of the present moment. The range of sensations experienced during orgasm is influenced by the unique sensitivity of each individual's nerves [25].

Figure 12. Neurophysiology of Male Erection and Ejaculation [25].

References

25. Giuliano, F., Neurophysiology of Erection and Ejaculation. The Journal of Sexual Medicine, 2011. 8: p. 310-315.

22. 01:46:32 Dopamine-Enhancing Medication & Arousal Arc

Extensive study has been conducted on apomorphine, resulting in regulatory approval for its use in nations outside of the United States. Nevertheless, the utilization of this product in the United States is still restricted principally due to the lack of endorsement from the Food and Drug Administration (FDA). The pharmacological mechanisms behind the effects of medicines like phlebanserin are multifaceted, involving both stimulatory and inhibitory interactions with the dopamine system. An exemplary example is the antidepressant phlebanserin, which has been found to enhance sexual desire. In a similar manner, it is noteworthy to mention that the initial exploration of Viagra focused on its potential as a therapeutic intervention for hypertension. However, subsequent discoveries revealed its effectiveness in improving erectile function [26].

Figure 13. The role of dopamine-oxytocin-nitric oxide pathway in the erection [26].

References

26. Chen, L., et al., Male sexual dysfunction: A review of literature on its pathological mechanisms, potential risk factors, and herbal drug intervention. Biomedicine & Pharmacotherapy, 2019. 112: p. 108585.

23. 01:51:18 Menstrual Cycle & Libido

There exists empirical evidence indicating that libido tends to increase in the period preceding and during ovulation. This surge in sexual desire is believed to occur a few days prior to ovulation, as it aligns with the optimal fertility window. However, it is important to note that while data supports heightened libido during this time, there is a lack of evidence regarding a complete absence of interest in sexual activities [27].

References

27. Shirazi, T.N., et al., Menstrual cycle phase predicts women's hormonal responses to sexual stimuli. Horm Behav, 2018. 103: p. 45-53.

24. 01:52:49 Vaginal Penetration, Variation & Communication

This research study explored many types of stimulation techniques for women, including the use of rocking motion, external vaginal stimulation, clitoral pressure during penetration, and intentional clitoral stimulation. Engaging in research and sharing personal preferences with one's partner is of utmost importance, given that individuals possess the fullest grasp of their own selves. The facilitation of individuals' preferences and requirements is significantly enhanced by the presence of effective communication [28].

References

28. Borg, C., et al., Brain processing of visual stimuli representing sexual penetration versus core and animal-reminder disgust in women with lifelong vaginismus. PLoS One, 2014. 9(1): p. e84882.

25. 01:55:24 Sexual Interaction Communication, Sex Therapists

To mitigate any misunderstandings, it is advisable to engage in discussions pertaining to sexual preferences with one's spouse in a neutral setting that is distinct from the bedroom. Utilize first-person statements to articulate personal preferences and aversions, emphasizing subjective sentiments rather than attributing responsibility. It is important to acknowledge that engaging in these talks may necessitate numerous iterations and may not always proceed seamlessly. It is advisable to consider consulting a sex therapist in the event of encountering challenges in interpersonal communication pertaining to sexual matters. asect.org offers a range of tools and access to professionals, including the option of virtual sessions if required [29].

References

29. Sexual Communication. Available from: https://shcs.ucdavis.edu/health-topic/sexual-communication.

26. 01:58:45 Urinary Tract Infections (UTIs) in Male & Females; Prevention, Vaginal Estrogen

Urinary tract infections (UTIs) are frequently encountered among women, with a prevalence rate of up to 50% throughout their lifespan. Recurrent UTIs are defined as the occurrence of one or more UTIs within a six-month period or three or more UTIs within a span of three years. The male population exhibits a lower prevalence mostly as a result of possessing elongated urethras, so imposing restrictions on the passage into the bladder, consequently leading to an increased susceptibility to infections. The prevention of UTIs entails maintaining proper hydration by consuming a daily intake of two to three liters of fluids. Additionally, the utilization of vaginal estrogen, administered by creams, suppositories, or rings, is recommended as a preventive measure for UTIs. Vaginal estrogen has been shown to be a highly successful intervention for reducing the incidence of recurrent UTIs. This efficacy can be attributed to its ability to lower the vaginal pH, which is achieved by slowing the conversion of glycogen to lactobacilli. This process aids in restoring the pH level to its typical acidic state, which plays a vital role in the prevention of urinary tract infections.

The Women's Health Initiative has expressed apprehensions regarding the potential hazards linked to the usage of vaginal estrogen. However, no instances have been reported thus far suggesting a causal relationship between vaginal estrogen and the development of breast cancer, uterine cancer, or any other unfavorable occurrences. Vaginal estrogen is typically regarded as a safe and cost-effective treatment option, with noticeable effects typically observed within a span of approximately three months. Maintaining consistency is crucial, and the optimal approach for effectiveness is to apply the ring either twice a week during nighttime or three times a week. In order to achieve thorough voiding of the bladder, it is recommended that persons adopt a seated position, relax their muscles, lean forward, and make an attempt to urinate until they have completely emptied their bladder. This intervention has the potential to mitigate the occurrence of recurrent UTIs and curb the transmission of bacterial pathogens [30].

Figure 14. Urinary tract infections: microbial pathogenesis, host–pathogen interactions [30].

References

30. Klein, R.D. and S.J. Hultgren, Urinary tract infections: microbial pathogenesis, host–pathogen interactions, and new treatment strategies. Nature Reviews Microbiology, 2020. 18(4): p. 211-226.

27. 02:04:04 Male Urination Sitting; Spermicide, Cranberry, D-Mannose & UTIs

According to a recent survey conducted in Germany, it has been observed that individuals of German nationality have a higher propensity for adopting a seated position during urination. This behavior has been hypothesized to perhaps stem from a more relaxed state of the pelvic floor musculature. This intervention has the potential to alleviate symptoms associated with urinary bladder dysfunction and benign prostatic hyperplasia. Spermicides and cranberries have been identified as risk factors for urinary tract infections (UTIs) in females. The American Urological Association guidelines for the prevention of recurrent urinary tract infections in women include the incorporation of cranberry. The efficacy of a capsule containing 36 milligrams of proanthocyanidins (PACs) in mitigating the risk of UTIs has been demonstrated. The efficacy of D-mannose, a dietary supplement, has been the subject of scientific investigation. Probiotics represent an alternative choice; nonetheless, the current body of evidence about their efficacy is insufficient. The microbiome investigations conducted at the University of California, Los Angeles (UCLA) are currently examining the microbial communities present in individuals who exhibit an elevated susceptibility to UTIs or hyperactive blood. Excessive cleaning practices have the potential to disturb the composition and functioning of the microbiome, which may consequently increase the risk of UTIs. Pelvic floor dysfunction represents a prevalent concern, as it has the potential to induce enduring pain throughout the process of urinating [31].

Figure 15. Urinary Tract Infections in Women Cranberry, D-Mannose and NSAIDs in the Prevention [31].

References

31. Konesan, J., L. Liu, and K.J. Mansfield, The Clinical Trial Outcomes of Cranberry, D-Mannose, and NSAIDs in the Prevention or Management of Uncomplicated Urinary Tract Infections in Women: A Systematic Review. 2022. 11(12): p. 1471.

28. 02:11:33 Testosterone, Post-Menopausal Women & Libido

The evaluation of hormones, namely free testosterone, holds significant importance in the context of women experiencing diminished libido or reduced sexual desire. Research findings indicate that the application of testosterone cream results in its systemic absorption, leading to enhancements in sexual drive and an increase in the frequency of gratifying sexual experiences. Females exhibiting low levels of physiologic testosterone have the option to utilize off-label testosterone treatments, such as AndroGel tubes, as a means to enhance their sexual desire. Transdermal testosterone may be provided as a treatment option for women experiencing vestibulodynia, a condition characterized by activated Androgen receptors and discomfort resulting from reduced levels of testosterone. The application of a compounded cream containing mixed estrogen and testosterone to the vestibule over a period of time has the potential to alleviate pain and discomfort. The hormone receptors are situated in both the vaginal and cerebral regions, rendering them advantageous in the treatment of women experiencing both conditions [32].

Figure 16. Testosterone replacement therapy in postmenopausal women [32].

References

32. Uloko, M., et al., The clinical management of testosterone replacement therapy in postmenopausal women with hypoactive sexual desire disorder: a review. International Journal of Impotence Research, 2022. 34(7): p. 635-641.

29. 02:14:56 Kidney Stones: Prevention & Treatment

Kidney stones frequently occur as a result of many metabolic problems, including but not limited to dehydration and the presence of oxalate in urine. The prevention of kidney stones entails the implementation of many strategies, including the augmentation of fluid consumption to a range of two to three liters, the reduction of oxalate intake, and the incorporation of citrate-inhibiting foods such as fruits and vegetables into one's diet. Crystal Light, a beverage with a high citrate content, has the potential to assist in this matter. In order to manage kidney stones, individuals are advised to augment their fluid consumption, reduce their intake of oxalate, and incorporate citrate-rich foods such as fruits and vegetables into their diet. Moreover, it is advisable to reduce protein consumption due to the potential elevation of purine levels or the presence of purine-rich foods, which might contribute to an increased risk. In cases when kidney stones are not presenting any symptomatic manifestations, a strategy of observation can be employed, wherein the stones are monitored over a period of time. It is important to note that during this period, there is a possibility for the stones to increase in size or migrate into the ureters. In cases where there is an absence of infection or evidence thereof, a conservative approach involving the administration of pain medicine and Flomax may be employed. Prompt and timely treatment of an infection is of utmost importance since it has the potential to precipitate swift and severe sickness. The treatment of kidney stones typically encompasses three primary procedures: shock wave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy. The initial procedure entails making a little surgical cut and utilizing a specialized camera that employs ultrasonic lithotripsy with the purpose of fragmenting and extracting the stone. The second treatment modality entails the implementation of a particular incision technique combined with ultrasonic lithotomy for the purpose of stone extraction [33].

References

33. Peerapen, P. and V. Thongboonkerd, Kidney Stone Prevention. Adv Nutr, 2023. 14(3): p. 555-569

30. 02:19:14 Oral Contraception, Libido, Individuality, Intrauterine Devices (IUDs)

The topic of oral contraceptives is a subject of debate due to the presence of a significant amount of evidence about sexual dysfunction, specifically with decreased libido and difficulties in attaining orgasm. A study based on Reddit postings has indicated a correlation between the use of oral contraceptives and an increase in levels of sex hormone-binding globulin. The protein possesses the ability to interact with both testosterone and estrogen, hence diminishing the abundance of testosterone. This phenomenon can have significant implications for specific groups of women. However, there is still a lack of clarity concerning the particular group of women who may have this issue. Additionally, after the withdrawal of oral contraceptives, elevated levels of sex hormone-binding globulin (SHBG) continue to endure. The endocrine system has remarkable flexibility, and oral contraceptives have been found to be advantageous in enhancing sexual autonomy and preventing pregnancy, particularly in instances of polycystic ovarian syndrome (PCOS). The existing collection of scholarly work pertaining to female sexual respect is relatively less comprehensive in comparison to the vast research conducted on male sexual dysfunction. If individuals experience difficulties with oral contraceptives, it is recommended that they quit their use and consider alternative contraceptive methods, such as long-acting techniques like intrauterine devices (IUDs) [34].

Figure 17. Recent progress in advanced biomaterials for long-acting reversible contraception [35].

References

34. de Castro Coelho, F. and C. Barros, The Potential of Hormonal Contraception to Influence Female Sexuality. Int J Reprod Med, 2019. 2019: p. 9701384.

35. Yan, M., et al., Recent progress in advanced biomaterials for long-acting reversible contraception. Journal of Nanobiotechnology, 2022. 20(1): p. 138.

31. 02:26:52 Anti-Depressants, SSRIs & Low Libido

Serotonin is a pharmaceutical substance utilized in the therapeutic management of premature ejaculation and diverse sexual dysfunctions, with the objective of suppressing the orgasmic response. The effectiveness of the treatment depends on the dosage given and can be reduced by either decreasing the dosage or switching to an alternate antidepressant, such as Wellbutrin. Cialis and Viagra are both approved for the therapeutic management of erectile dysfunction. A notable association has been observed between erectile dysfunction and depression, wherein the amelioration of erectile issues may potentially help to the mitigation of depressive symptoms. The investigation into the association between depression and erectile dysfunction necessitates considerable focus and discussion among primary healthcare professionals. Trazodone is sometimes used off-label as a secondary or tertiary therapeutic alternative for premature ejaculation [36].

References

36. Jing, E. and K. Straw-Wilson, Sexual dysfunction in selective serotonin reuptake inhibitors (SSRIs) and potential solutions: A narrative literature review. Ment Health Clin, 2016. 6(4): p. 191-196.

32. 02:29:32 Prostate Health, Cialis, Urination Difficulty

The administration of low doses of tadalafil has been found to be an effective therapeutic intervention for individuals experiencing erectile dysfunction, specifically targeting males who are affected by psychogenic factors. The substance exhibits a half-life of 36 hours and is administered at a daily dosage of five milligrams. The intervention demonstrates efficacy in addressing both erectile dysfunction and promoting prostate health. The prevalence of benign prostatic hyperplasia (BPH), also known as an enlarged prostate, is substantial, affecting around 80% of men who reach the age of 80. Several factors have been identified as potential contributors to the development of an enlarged prostate, also known as BPH. These factors include genetic predisposition, increased activity of the prostate gland, and difficulties in initiating urination. Cialis facilitates the relaxation of the fibers and smooth muscle within the prostate, hence promoting improved urinary flow. Additional drugs such as Flomax or alpha-blockers may also provide therapeutic benefits. Certain irritants can potentially contribute to the maintenance of bladder health. Restricting the consumption of caffeine-containing substances, such as coffee, tea, and chocolate, has been shown to potentially ameliorate symptoms. The bladder lining can be irritated by alcohol, as evidenced by studies conducted on animal models. Certain individuals have the capacity to habituate or adapt to a specific dosage of caffeine, hence it may prove beneficial to restrict the use of coffee. Additional irritants encompass carbonated beverages, spicy foods, and acidic foods [37].

Figure 18. Prostate Health and caffeine-containing coffee [38].

References

37. Hatzimouratidis, K., A review of the use of tadalafil in the treatment of benign prostatic hyperplasia in men with and without erectile dysfunction. Ther Adv Urol, 2014. 6(4): p. 135-47.

38. Montenegro, J., et al., Bioactive compounds, antioxidant activity and antiproliferative effects in prostate cancer cells of green and roasted coffee extracts obtained by microwave-assisted extraction (MAE). Food Research International, 2021. 140: p. 110014.

33. 02:34:22 Bicycling, Genital Numbness, Erectile Dysfunction

Cycling necessitates the act of assuming a seated position on the perineum, which is the anatomical region located between the scrotum and anus in males, and between the vagina and anus in females. The pudendal artery and nerve play a crucial role in facilitating blood circulation and maintaining optimal nerve functionality. It has been shown that a significant proportion, approximately 50%, of avid cyclists encounter symptoms of genital numbness and erectile dysfunction. In order to mitigate this issue, it is imperative to utilize a bicycle seat that facilitates comfortable seating on the ischial tuberosities while simultaneously promoting proper posture. According to empirical research, individuals who adopt a forward-leaning posture and utilize small bicycle seats exhibit a higher propensity for experiencing physiological complications. In order to mitigate this issue, it is advisable to utilize a seat without a nose and a broader seat including cutouts. A further investigation revealed comparable rates of erectile dysfunction among those engaged in running, swimming, and cycling activities, implying that the occurrence of numbness may not be a significant concern [39].

Figure 19. Excessive Bicycling causes Erectile Dysfunction [40].

References

39. Sommer, F., et al., Impotence and genital numbness in cyclists. Int J Sports Med, 2001. 22(6): p. 410-3.

40. Erectile Dysfunction and Cycling. Available from: https://www.mansmatters.co.uk/erectile-dysfunction-and-cycling/.

34. 02:37:48 Anal Sex, Females, Sexually Transmitted Infections (STIs), Lubricants

The prevalence of anal intercourse is increasing within heterosexual relationships, with a notable rise observed among male-gay partnerships. The utilization of this method is deemed to be safe with regard to pregnancy prevention and has the potential to mitigate the risk of contracting sexually transmitted infections. Nevertheless, individuals frequently neglect to employ protective measures such as condoms, despite the fact that the anal tissue is characterized by its thinness and susceptibility to tearing. Experiencing trauma has the potential to result in hemorrhage, hence facilitating the transmission of sexually transmitted infections. In order to mitigate the risk of contracting sexually transmitted illnesses, it is crucial to employ lubricants that possess ISO osmolality in accordance with the anal pH. A range of lubricants can be found in the market, encompassing water-based, silicone-based, and oil-based variants. In order to mitigate the risk of trauma, it is imperative to use prudence and mindfulness when partaking in anal intercourse. Water-based lubricants are readily available, whereas silicone-based lubricants possess enhanced slipperiness and exhibit prolonged durability. Oil-based lubricants are not recommended for use in conjunction with condoms in freezing conditions. Individuals partake in anal intercourse for a multitude of purposes, including the desire to circumvent vaginal penetration, prevent pregnancy, manage menstruation, or engage in activities of a celebratory nature. Sexually transmitted diseases (STIs) are infrequent occurrences; yet, engaging in anal intercourse without exercising caution can increase the likelihood of their transmission. Enemas are frequently employed as a precautionary measure before engaging in anal intercourse in order to mitigate the risk of infections [41].

Figure 20. Sexually Transmitted Infections (STIs) [42].

References

41. Subbarao, N.T. and A. Akhilesh, Knowledge and attitude about sexually transmitted infections other than HIV among college students. Indian J Sex Transm Dis AIDS, 2017. 38(1): p. 10-14.

42. What is STD Disease?; Available from: https://www.geeksforgeeks.org/sexually-transmitted-infections-class-12-reproductive-health/.

35. 02:44:14 Libido, Behavioral Interventions, Supplements

Sexual dysfunction, which includes disorders like low testosterone levels and erectile dysfunction, sometimes emerges as a result of comorbidities such as hypertension and diabetes mellitus. Extensive study has been conducted on the Mediterranean diet and its implications for sexual dysfunction. Additionally, physical exercise, encompassing cardiovascular aerobic exercise and resistance training, plays a crucial role in reducing blood pressure and mitigating the risk of diabetes. In the context of surgical preparation for penile prostheses in males, it is conceivable that persons with diabetes may demonstrate alterations in their habits to enhance erectile performance. It is recommended to do individual experiments with supplements in order to choose the most efficacious alternative. To optimize testosterone levels and promote circadian biology, it is recommended to implement dietary enhancements, maintain adequate sleep, and engage in early morning light exposure. Discontinuing the practice of smoking and vaping may yield advantageous results as well. When confronted with cases of sexual dysfunction stemming from a biological etiology, it is crucial to assess the cardiovascular health of the affected individual. This phenomenon can be attributed to the significant finding that approximately 15 individuals who suffer from erectile dysfunction are thereafter susceptible to experiencing a cardiovascular event within a period of seven years. The aforementioned claim may be applicable to females, notwithstanding the lack of currently available evidence on the matter [43].

References

43. Ghamari, K., et al., Vitamin E and ginseng supplementation to enhance female sexual function: a randomized, double-blind, placebo-controlled, clinical trial. Women Health, 2020. 60(10): p. 1164-1173.

36. 02:49:15 Supplements for Libido

According to Dr. Rena Malik, l-citrulline has the potential as an ashwagandha for mitigating stress and enhancing sexual function. Additionally, Tongkat Ali has been supported by a reasonable amount of evidence in relation to these particular areas of interest. Nevertheless, it is important to exercise caution and manage one's expectations in light of the limited sample size and inherent biases present in these studies. It is imperative to recognize that the availability of high-quality scientific research may not always be guaranteed, and the allocation of financing for research in this domain may be inadequate [44].

References

44. Palacios, S., et al., Effect of a multi-ingredient based food supplement on sexual function in women with low sexual desire. BMC Womens Health, 2019. 19(1): p. 58

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Dr. Rena Malik: Improving Sexual & Urological Health in Males and Females | Huberman Lab Podcast

Dr. Rena Malik: Improving Sexual & Urological Health in Males and Females | Huberman Lab Podcast