1. Pelvic Floor Health: Strengthening vs. Relaxing
- What it is: The pelvic floor is a bowl of muscles connected to bones that hold up organs, crucial for urination, defecation, sexual function, and posture.
- Key Distinction: Many people focus on strengthening their pelvic floor (e.g., Kegels), but often, people need to learn to relax their pelvic floor for proper urologic and sexual function.
- Signs of an Unhealthy Pelvic Floor:
- Too Tight/Contracted: Can result from stress, anxiety, overuse, or poor posture. Symptoms include urgency, frequency, leakage, difficulty urinating (or incomplete emptying), pain with sex/erections/ejaculation, various pain syndromes, constipation, and back pain.
- Too Weak: Often seen after childbirth, in individuals with neurological disorders, or connective tissue disorders. Symptoms commonly include urinary incontinence or leakage.
- Assessment: It is difficult to self-diagnose pelvic floor issues because it's not a muscle traditionally trained for recognition. A pelvic floor specialist (urologist, gynecologist, physical medicine rehabilitation doctor, or certified pelvic floor physical therapist) is recommended for examination and assessment. For women, this involves a pelvic exam; for men, a rectal exam.
- Kegel Exercises:
- Purpose: Primarily for strengthening a weak pelvic floor, such as for stress urinary incontinence (leakage from coughing, sneezing, lifting) and pelvic organ prolapse in women, or post-prostatectomy leakage in men. Some also use them for more intense orgasms.
- How to do them: Squeeze muscles used to stop urine flow (but not during urination), or "pull up and in the vagina," or "lift your penis off the floor without touching it". Squeeze for 5 seconds, relax for 5 seconds, 10-15 repetitions, 1-3 times a day.
- Caution: Do not overdo Kegels. Excessive Kegels can lead to a tight, short pelvic floor and worsen sexual or urological dysfunction. If symptoms like painful urination occur, stop Kegels and see a urologist.
- Relaxing a Tight Pelvic Floor ("Anti-Kegel"):
- Techniques: Massage the area, use vaginal dilators (for women), or suppositories with muscle relaxants (Valium, baclofen).
- Pelvic Floor Physical Therapy: The most effective approach for down-training (relaxing) the pelvic floor through specific exercises (e.g., happy baby pose).
- Breathing and Posture:
- Diaphragmatic Breathing: Crucial during exercise. Exhale on effort (contraction), as inhalation relaxes the pelvic floor and exhalation contracts it, stabilising it against increased intra-abdominal pressure. Holding breath during crunches can be detrimental.
- Posture: Good posture can significantly benefit pelvic floor health.
- Cycling and Pelvic Floor/Sexual Health:
- Risk: High-volume cycling can cause genital numbness (up to 50%) and erectile dysfunction (in men) due to pressure on the pudendal artery and nerve.
- Prevention: Use wider, noseless bike seats that distribute weight onto the ischial tuberosities. Aero riding (leaning forward) and narrow seats increase pressure. Cutouts in seats may not help and can even increase pressure around the opening.
- Benefit: Cycling is a valuable aerobic exercise, and studies show rates of ED are not necessarily higher in cyclists compared to runners or swimmers, suggesting general population rates may influence findings.
2. Sexual Health and Dysfunction: The Interplay of Brain, Hormones, Blood Flow & Nerves
- Holistic View: Sexual function involves hormonal, blood flow (vascular), and neural (brain and peripheral nerves) influences.
- Desire vs. Arousal:
- Desire: The psychological want to have sex, predominantly modulated by testosterone in both men and women.
- Arousal: The physical response of the genitals (erection, vaginal lubrication, nipple erection, sex flush). Desire and arousal don't always occur in that order; arousal can precede desire, especially in women.
- Misconceptions about Hormones:
- Low Hormones: Only a small percentage (3-6%) of erectile dysfunction is directly related to hormone dysregulation.
- Estrogen: Crucial for brain function and libido in both men and women. Suppressing estrogen (e.g., with anastrozole) can abolish libido in men.
- Neural Mechanisms:
- "Point and Shoot": Erection and vaginal lubrication are initiated by the parasympathetic nervous system ("point"), while climax is driven by the sympathetic nervous system ("shoot").
- Nitric Oxide (NO): The "ignition for erections," released by the endothelium in response to stimulation, leading to a cascade that causes cGMP production and erection.
- Dopamine & Prolactin: Dopamine drives desire and can override the refractory period. Prolactin establishes the refractory period after orgasm.
- Assessing Dysfunction:
- Males: Questions about nocturnal erections can indicate if the issue is physical or psychogenic (performance anxiety).
- General: Consider other comorbidities (high blood pressure, diabetes, heart disease, smoking) that affect blood flow.
- Tests: Doppler ultrasounds can assess blood flow to the penis/clitoris. Nerve function tests are uncommon but exist.
- Prevalence of ED: About 50-52% of men over 40 experience ED, increasing with age. Young men (20s-30s) also report ED, often linked to pelvic floor dysfunction (from prolonged sitting/stress) and psychogenic factors (performance anxiety exacerbated by pornography use).
- Pornography Use:
- Problematic Use: While not everyone who uses pornography has problems, "problematic pornography use" (estimated 4% in studies) can arise due to dopamine pathways, leading to seeking novelty and avoiding real-world interactions.
- Unrealistic Expectations: Pornography can create unrealistic expectations about sexual encounters, leading to shame and misunderstanding.
- Habituation: Over-reliance on specific stimulation (visual, vibratory) from pornography can lead to habituation, making it difficult to achieve arousal or orgasm from normal activities or with a partner.
- Action: Vary your masturbation methods, and if experiencing problematic use or shame, consult a sex therapist.
- Female Orgasm:
- Clitoral Stimulation: About 85% of women require clitoral stimulation to climax. There's a significant "orgasm gap" in heterosexual encounters compared to homosexual encounters, where 90% of women report orgasm in first-time interactions, likely due to a better understanding of female anatomy and physiology.
- Vaginal Penetration: Rarely leads to orgasm on its own, but can stimulate the clitoris (which extends deep into the pelvis) or other erogenous zones.
- G-spot: An erogenous zone (anterior vaginal wall, 2-3 cm in) located near the Skene's glands (homologous to the male prostate). Not universal, but some women enjoy G-spot stimulation.
- Cervical Orgasm: Possible through cervical stimulation.
- Orgasmic Diversity: Orgasm is a brain-initiated event, leading to varied experiences (graded or cliff-type, sleepy or energised, hypersensitive to touch). Pelvic floor contractions are a measurable physiological component.
- Treatments for Sexual Dysfunction:
- PDE5 Inhibitors (Viagra/Cialis): Effective for 60-70% of men with ED, primarily by preventing cGMP breakdown to prolong erections. Can be tried off-label for women with vascular-related orgasm difficulties.
- Low-Dose Daily Cialis (Tadalafil): 2.5-5 mg daily can improve ED by keeping blood flow on board, and is also effective for BPH (enlarged prostate) by relaxing smooth muscle.
- Centrally Acting Medications for Female Low Libido:
- Bremelanotide (Vyleesi): A melanocortin receptor agonist, injectable, taken 45 minutes before desired sex, lasts 24-48 hours. FDA-approved for premenopausal women with hypoactive sexual desire disorder (HSDD). Can be prescribed off-label for men with delayed ejaculation.
- Flibanserin (Addyi): Daily oral medication (100mg before bedtime) working on serotonin and dopamine pathways to decrease HSDD. Works in 45-60% of patients and requires consistent use.
- Testosterone for Women: Transdermal testosterone (e.g., 1/10 of male dose on hairless skin) can increase sexual desire in postmenopausal women with low libido. Compounded estrogen-testosterone cream can treat vestibulodynia (pain in the outer vaginal area).
- SSRIs: Can disrupt sexual function, especially desire and orgasm (serotonin is "anti-orgasm"). Strategies include reducing dose, switching to another antidepressant (e.g., Wellbutrin/bupropion, which impacts dopamine/norepinephrine), or adding Cialis/Viagra.
3. Communication and Relationships
- Open Dialogue: Critical for healthy sexual relationships. Discuss preferences, likes, and dislikes with your partner.
- Timing: Have sensitive conversations outside the bedroom (e.g., kitchen table, car) to avoid a sense of insecurity for your partner.
- "I" Statements: Frame discussions using "I like it when..." or "I don't like it when..." to avoid accusatory language.
- Professional Help: If communication is difficult, a sex therapist can provide guidance. Resources like AASECT.org (American Association of Sexuality Educators, Counselors and Therapists) can help find a certified therapist.
- Libido Variation: There's no "normal" amount of libido. It's subjective and depends on whether it causes distress for the individual or impacts their relationship.
4. Urinary Tract Infections (UTIs)
- Prevalence: Very common in women (up to 50% experience one UTI; 1/3 get recurrent UTIs). UTIs in men are less common and warrant investigation for anatomical or functional abnormalities.
- Prevention:
- Hydration: Drink 2-3 liters of fluid (ideally water) daily. "Dilution is the solution to the pollution".
- Vaginal Estrogen: For women with low estrogen (postmenopausal, postpartum), vaginal estrogen cream, suppository, or ring can restore vaginal pH to a healthy acidic level, promoting lactobacilli and reducing UTI risk. It's highly effective and safe with minimal systemic absorption.
- Complete Bladder Emptying: Sit on the toilet, relax, lean forward, and consider going a second time after standing up and sitting down again. Men can also try sitting to urinate if they have emptying issues, as it relaxes the pelvic floor.
- Spermicides: A known risk factor for UTIs.
- Cranberry: Effective if it contains 36 milligrams of soluble proanthocyanidins (PACs). Generic cranberry juice or whole berry supplements are often ineffective.
- D-mannose: Taking 2 grams a day can reduce UTI risk.
- Hygiene: Wiping from front to back has no strong data, but good hygiene is important. Overcleaning with douches or other products can disrupt the vaginal microbiome, altering pH and increasing risk for UTIs or bacterial vaginosis. The vagina is a "self-cleaning oven".
- Symptoms: Changes in discharge (e.g., cottage cheese-like), itching, or discomfort warrant evaluation. A strong, new, fishy odor can indicate an STI.
- Mimicking UTIs: Pelvic floor dysfunction can cause pain with urination that feels like a UTI, even when no infection is present.
5. Kidney Stones
- Causes: Dehydration and metabolic abnormalities (e.g., excess calcium or oxalate in urine).
- Prevention:
- Hydration: Increase fluid intake to 2-3 liters daily.
- Dietary Adjustments: Decrease oxalate intake (e.g., limit spinach, rhubarb, nuts) and increase citrate intake (e.g., fruits, vegetables, Crystal Light). Decrease purine-rich protein intake (e.g., red meats).
- Treatment:
- Conservative: For small, non-obstructive stones without infection: pain medication, and medications like Flomax (relaxes ureteral smooth muscle to aid passage).
- Urgent: If fever, chills, or signs of infection with a blocking stone (hydronephrosis), seek emergency treatment immediately to prevent severe illness.
- Procedures: Shockwave lithotripsy, ureteroscopy (camera and laser via urethra), percutaneous nephrolithotomy (incision in back for large/hard stones).
6. Anal Sex
- Increasing Frequency: More heterosexual couples are engaging in anal sex, partly to avoid pregnancy or during menstruation.
- Safety & Risks:
- STIs: Higher risk of sexually transmitted infections than vaginal intercourse because anal tissue is thin and friable, prone to trauma and bleeding, which facilitates transmission. Always use a condom.
- Lubrication: The anus does not produce its own lubrication. Always use adequate lubricant that is iso-osmolar to anal pH (specific anal lubricants are available). Avoid oil-based lubricants with condoms.
- Trauma: Always ensure consent, take your time, and never force. Start with smaller items and gradually increase girth to avoid trauma.
- Pleasure: The prostate (in men) and pelvic floor (in both sexes) are highly innervated, making anal stimulation a source of pleasure for some.
- Preparation: Some people use enemas or adjust their diet to ensure bowel evacuation, though there is not much robust data on this for infection prevention (mostly STI risk).
7. General Health and Lifestyle as Foundational Tools
- Prioritise Behavioural Tools: These are the foundation for sexual health, mental health, physical health, and performance.
- Diet: Mediterranean diet is well-studied in sexual dysfunction literature.
- Exercise: Both cardiovascular aerobic exercise and resistance training (especially large muscle groups) are beneficial.
- Sleep: Crucial for boosting testosterone and overall well-being.
- Stress Reduction: Important for pelvic floor health and overcoming psychogenic sexual issues.
- Early Morning Light Viewing: Helps regulate circadian biology and testosterone release.
- Avoid Harmful Habits:
- Smoking and Vaping: Nicotine is a vasoconstrictor and will "kill your erection" and negatively impact sexual health generally.
- Bladder Irritants: Caffeine (coffee, tea, chocolate, energy drinks), alcohol, carbonated beverages, spicy foods, and acidic foods can irritate the bladder.
- Supplements: While not a replacement for foundational behaviours, some supplements (e.g., L-citrulline, Tongkat Ali, Ashwagandha) have reasonable data for mild libido enhancement or stress reduction. Always try one at a time, expect gradual effects, and check for quality and research (e.g., examine.com). Be cautious of "grey market" peptides due to contamination risks.
- Cardiovascular Health: Erectile dysfunction can be an early warning sign ("canary in the coal mine") of developing cardiovascular problems. About 15% of men with ED develop a cardiovascular event seven years later.