Dr. Rena Malik, a highly esteemed urologist and pelvic surgeon, answers your pressing questions in this December AMA. In this ...

weak-erections-at-night-uti-after-sex-ama

Weak Erections at Night?! UTI after SEX?! | AMA

do you ever have erections that are harder than others at different times of the day I'm Dr Reena Malik urologist and pelvic surgeon and welcome back to the Reena Malik MD podcast today we're answering your questions on the ask me anything episode of the podcast if you want to be able to ask me anything you can join us at renam malik. supercast dcom where you'll be able to ask me anything as well as access adree and early episodes of the podcast now without further Ado let's get to it all right first question is it weird that I get erectile dysfunction at night I wake up with morning wood I have sex in the morning as well if my wife is home from work but sometimes she wants sex at night and I have a harder time getting hard at night can ED happen only at night for some men great question and the reason this is an interesting question is because there is a reason for this and the reason is hormones so typically testosterone which is a major sex hormone in our body is released in a pulsatile manner now what that means is that testosterone is released highest in the morning and then throughout the day it goes steadily down now there's a little bit of pulse going up in the middle of the day and then it goes down again and then throughout the night it replenishes or restores so at the end of the day your testosterone is at the lowest amount that you will have and for some people that may lead to issues with erections now hormonal causes are not the number one cause of erectile dysfunction often times you can have issues with erections due to a variety of different things and we've talked about these on this podcast and on this channel before these include things like vascular dysfunction so having decreased blood flow to the penis things like high blood pressure high cholesterol diabetes can all affect the blood vessels leading to issues with blood flow to the penis also issues with the nerve so if you have any problems like neurologic conditions that affect the nerve function going to the penis that can make it more difficult to get an erection also if you had surgery like a prostectomy or any other surgery that could affect the nerve function down there also certain medications like anti-depressants sometimes or even high blood pressure medications can make it difficult to get erections as a side effect of the medication and of course psychogenic so if you are stressed or concerned about getting erections or anxious about getting erections that can also affect the ability to get erections but in this case I suspect that the hormone are a large driver because you're able to get really great erections in the morning when your testosterone is at its highest but later it becomes more difficult now of course at the end of the day you're more fatigued you probably have more things on your mind because you've gone through the day and potentially more stressors have built up and so that can also make it more difficult to get an erection at nighttime for some people so hope that answers your question very good all right let's check question number two my Doctor is recommending me to have a prostatectomy I don't know enough about what a prostate does I know the surgeon told me a lot that day but the shock of him saying I need surgery made me draw a blank when I left the office what is my life going to look like if I get a prostatectomy I'm assuming I'll be able to pee better which is what made me see this Doctor Who diagnosed my prostate cancer but doesn't the prostate also affect sex will I still be able to have normal sex so you really just wants to know if he's going to have a good sex life after this prostatectomy yes so prostates first start with what is the prostate what is the function of the prostate so the prostate is a gland that sits underneath the bladder around the urethra or the P tube where urine comes out so it does have some function and the function is essentially to make sure that sperm are healthy and so it creates fluid that then nourishes sperm and also helps it Transit through the vaginal Canal now the vaginal canal pH is very acidic and so the prostate fluid makes sure the sperm can survive that acidic pH and get to the ovaries and eventually make a baby if that is so desired and so it's an important function but the unimportant or the more frustrating thing about the prostate is that as you age it grows in size and as this person mentioned it can have you can have difficulty with urination and that can be things like difficulty emptying your bladder maybe straining to pee maybe waiting for your stream to start or having sort of a stop and go stream sometimes it can mean waking up a lot at night or having to go very often or urgently like you can't delay got to go got to go or you're even having leakage and sometimes that's leakage after you finish urinating when you have a diagnosis of prostate cancer you have many options available to you depending on the grade of your cancer is it localized to the prostate and essentially deciding what is the best option for you now just because you have prostate cancer does not mean you need to have surgery and so I think this is an important thing to understand it depends on the aggressiveness or grade of your cancer or what we call a g glein grade group and based on that we make decisions can you go through the route of maybe watching it and getting regular biopsies that's something called active surveillance to see that it's not getting worse can you have surgery or can you have radiation or can you do nothing at all and there's also newer options including things like high intensity focused ultrasound as well as certain types of cryotherapy that can be used for prostate cancer as well but often times they are done in the context of a clinical trial and so if you have a a big academic center near you you may be able to enroll for a clinical trial now if you've talked to your doctor and decided for based on your type of cancer based on how aggressive it is that surgery is a great option for you then it goes on to say what happens to your bladder and to your erections because I know you're less concerned about the urinary stuff I just want to go through that simply is one that yeah if you're having those obstructive urinary symptoms like got to go got to go or you're waiting for your stream to start or your stream is sort of weak then removing the prostate can be helpful in those cases however because when you remove the prostate you also remove one of the urethal sphincter so the sphincter is what holds the urine in that this can create some incontinence or leakage and this is different than the kind of leakage like you got to go got to go can't make it and a little dribbles out or you finish peeing a little dribbles out this is actually leakage that occurs when you cough sneeze lift something heavy do any sort of activity that increases pressure in your belly and so this is something that guys obviously have never experienced in their lives and is very distressing for a lot of people now often times this happens for most guys at least in the first week after surgery and then progressively gets better and usually about 85 to 90% of people will be dry after prostectomy but that's usually can take up to 12 to 18 months after surgery to get completely dry now how do you get dry you can do things like keagle exercises to strengthen the other sphincter that's remaining to help you hold urine in and if you're still struggling then you can talk to your urologist about a multitude of different options that may help with that type of leakage now in terms of sexual function the reason that people develop erectile dysfunction after a prostectomy is because there's nerves right around the capsule of the prostate or the outside of the prostate they're very important for sexual function and when those are injured or removed with the prostate they can lead to erectile dysfunction now it depends on if your surgeon can do a nerve sparing prostectomy which nowadays is very very common so unless you have a tumor that is really pushing against the capsule or very very large or very very aggressive most people can get nerve sparing at least one side or if not both to help preserve those nerves now if you have a nerve sparing prostectomy your rate of having issues with erections goes down but on average when you look at people having any sort of prostectomy and look at their pre-surgical erectile function usually about 60 40 to 60% of them will maintain that sexual function after surgery but that does mean that 40 to 60% of them will have erectile dysfunction now the important thing is if you have surgery and you're very concerned about erectile function then there are sort of Rehabilitation programs that we do after surgery to sort of help you maintain erectile function so that can be taking a daily dose of tadalfil daily or even using injections to help maintain erections after surgery the other thing is you can use a vacuum erection device now vacuum erection devices I've talked about on on my YouTube channel where I talk about how they're used essentially for getting an erection but in this case in men who are about to undergo surgery for prostate cancer there is some data that using these maybe twice a day for 5 minutes or so can help you maintain length and the reason this is important important is because when you have a prostatectomy there is some degree of loss of length of the penis and this is because when you remove the prostate you're also removing part of the urethra or the P tube and then you have to sew those ends together so that then pulls back the penis a little bit and so men will experience some degree of shortening and so using that vacuum erection device even before surgery can help you maintain the size of your penis so you don't lose length or lose much less length after surgery so I hope that answers your question but again it's an important discussion to decide with your doctor what is the right option for you now that surgical risk factor radiation has its own risk factors and these other options also have their own risk factors so you want to make sure that you really understand all these options and take your time because prostate cancer is very slow growing for most people so you can take your time and get second opinions and talk to other doctors before you go ahead with prostatectomy or whatever treatment you decide to have for your prostate cancer so nerve sparing seems to be key there to avoid the Ed you know one of the related questions that we've seen um and in the past is um not just the concern for Ed but people come worry about volume loss with uh prostatectomies is that is there any concern for volume loss in terms of uh you know the ejaculate or when they ejaculate yeah that's a great question so when you remove the prostate we will actually have to cut the vast efference on both sides so you will no longer be able to have children now for most men at that age where they get prostate cancer this is not a major issue but important for you to know so one there'll be no sperm in the ejaculate and two a large volume of the prostate of the fluid that comes out for your ejaculate comes from the prostate and the seminal vesicles which are what essentially is creating a lot of the fluid and so once we remove that you're going to have very minimal ejaculate after prostate removal if any at all and so that is a no own consequence of a prostectomy that doesn't mean that your orgasm will change you will still be able to achieve orgasm and feel pleasure but you won't have the same ejaculate volume all right makes sense next question is from Marina every time I have sex I seem to be getting a UTI I'm in college now and I've started having regular sex for the first time in my life but every time I've had sex since I lost my virginity I've had a UTI this most recent time I thought it was an STD so I went to the clinic cuz I want to make sure that I wasn't missing something bigger but my test came back fine except the urine was positive for another UTI so I got antibiotics again am I always going to have UTI with sex yes great question so let's start Basics urinary tract infection is essentially a bacterial infection of the bladder typically it presents with symptoms like burning when you urinate feeling the urge to go that's stronger going more of often having a pain in the lower sort of where the bladder is what we call Super pubic pain and sometimes fever or pain in the kidneys or the flank or like sort of the side of the back now when you have UTI the good news is a large majority of the time they are what we call uncomplicated so they're not going to create a very big infection or make you very sick they're just going to make you very uncomfortable and for women getting a UTI is exceedingly common and getting recurrent UTI or two or more in 6 months or three or more in a year is also unfortunately relatively common why does this happen well in the case of Marina she's having UTI after sex now this happens very often and the reason this happens is not because you're getting it from your partner or your partner has some sort of infection it's because of the actual thrusting motion that occurs during sex now when you look at the urethra which is the tube that drains p in women is significantly shorter than men this is why women get UTI more often because bacteria can go in from the outside world particularly near the vagina and go in and the colon and rectum and go in through the urethra and back into the bladder and so because during that motion of sex it can make that bacteria move a bit more and get into the urethra a bit easier so what can you do now anyone who's suffering from UTI can afford to drink more fluids and the reason for this is when we look at studies of people that have drank more have added 1 and 1/2 lers of fluid to their daily fluid intake mean they're drinking almost a liter and a half more so a coke bottle and a half more of fluid throughout the day you're seeing that they actually reduce their UTI rate by 46% so it is you know you're sort of diluting any bacteria that's there and your body is pretty remarkable in fact 46% of people can treat their own UTI they just resolve on their own because our bodies are so magnificent that they sort of clear out bacteria on their all the time and urine is not sterile so previously there was some thought that urine is sterile but now as they've increased investigations in this which seems to be a pretty easy investigation to do it's not all sterile there is always some bacteria in the urine and so having bacteria is not dangerous unless you're symptomatic other things you can do particularly if you're H having them after sex is one is you can try to U make sure that you urinate before sex and sometimes even after now this is not evidence-based there is no evidence of support that urinating after sex actually prevents UTI but I'm sure many of you have heard this that oh you know your mom may have told you make sure you urinate after sex and for some people it really works so I tell people if it helps you by all means that's totally fine but there's no evidence to support it and so if it's like hey I just want to lie around and not get up and urinate and you know that's okay too now the other thing is avoiding constipation so because a lot of the bacteria comes from stool when you're constipated that stool is sitting very close to the opening or the anus and so that can then create more bacteria load that can then get into the urethra so making sure you're not constipated and treating your constipation can be very helpful so getting over the counter products or talking to your primary care doctor about treating constipation I also made a video many years ago about a recipe that I give my patients it's basically applesauce prune juice and fiber mixed together if you want to check that out I'll put the link in the description the other thing that you can do is make that when you're urinating you're not rushing so a lot of times we'll hover over a toilet because we think it's dirty we don't want to sit on it and once in a while of course that's okay but if you're doing it all the time then you are creating some sort of dysfunction in your pelvic floor because your pelvic floor is not relaxing and this is that bowl of muscles that you sit on when you urinate when you're urinating normally it should be relaxed to allow that sphincter to relax and urine to flow out easily but when it's contracted you're now pushing against contracted muscles to pee which makes it more difficult and allows you maybe to empty less well and then that urine that sits in your bladder becomes food for bacteria so sometimes I'll tell people to even sit pee stand up sit back down and pee again sometimes that may also mean leaning forward a little bit to make sure that your bladder is completely empty so that's also very very important now there is some evidence for women with recurrent urinary tract infections that cranberry supplements or cranberry juice can be helpful and based on literature we see that cranberry supplements with 36 mg of proano sanadin in a soluble form meaning that they're coming from the berry itself not the whole Berry but the inside of the berry so when people say whole Berry Products they're often including the skin and the stems of the product which are really not helpful and there's also newer evidence that using cranberry juice itself the 100% cranberry juice is also very effective in preventing recurrent UTI now in someone who's having UTI solely after sex you can also talk to your doctor about getting an antibiotic one dose of antibiotic that you take after sex to prevent from getting a UTI now of course there are risks with taking antibiotics chronically so something to talk to your doctor about and decide if that's what's right for you now for a lot of people it makes their lives a lot easier they feel secure and safe that they have this ability to do that and so they're not so stressed about always getting a UT particularly when they're traveling or out of the country and so definitely something to discuss with your doctor now the last thing I want to point out is that this is not because you're doing something wrong so this is not because you are unhygienic or not clean I think a lot of people get told when they have recurrent UTI that they're not wiping correctly wipe front to back and yes there that makes sense to wipe front to back but many many people wipe back to front and don't get UTI so I think ultimately it's really not a hygiene issue for the large majority of people in fact my recurrent UTI patients are the cleanest patients I know in fact they clean too much to the point where they can create irritation on their skin which can then mimic UTI symptoms so clean normally don't douche don't put anything in the vagina just use soap and water on the outside and let soapy water run down and obv use a sensitive soap and really that's all you need all right so stay hydrated take care of that constipation no hovering cranberry helps huh yeah and make sure you're emptying your bladder y if you want to check out the rest of this AMA make sure to check check out our membership at renam malik. supercast dcom so you one can see full length episodes of the amas as well as ask me anything and get access to adree episodes and early releases of episodes with the transcripts on supercast and as always we're going to take care of yourself because you're worth it

Dr.

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