— Here are three issues you may want to address with a professional.
By Jancee Dunn< Urologists often deal with health problems that arise from two very intimate functions: peeing and sex. Because of this, “most urologists tend to have a lot of brevity and a bit of humor, because we know these are hard topics for our patients,” said Maria Uloko, a urologist at UC San Diego Health and assistant professor of urology at the University of California, San Diego School of Medicine.
In my experience (as both a patient and a health journalist), urologists will happily discuss the subjects that some of us laypeople tend to avoid: erectile problems, peeing too much, peeing too little, painful sex, dwindling or nonexistent orgasms, urinary tract infections and the list goes on.
Rachel Rubin, a urologist and sexual health specialist based outside Washington, D.C., said many people don’t share these issues with their doctor even if they are ongoing; they simply learn to live with discomfort. “They’ll tell themselves, ‘Well, that’s just aging. Suck it up,’” Dr. Rubin said. But, “if it bothers you and it matters to you, then it’s a medical problem with medical solutions.”
There are two parts of a urologist’s job. “There’s the serious illness stuff, like cancers,” said Nelson Bennett, a professor of urology at Northwestern University Feinberg School of Medicine, who specializes in male sexual function. “But there’s a big chunk of our practice that is basically quality of life. I tell my patients that no one dies of not having an erection, but they’re still suffering.” All of this may be why people who have seen a urologist (present company included) sometimes say the results are life altering.
Here are three issues you may want to address with a professional.
Erection problems
If you have erectile dysfunction, Dr. Rubin said: “Don’t be embarrassed. So do your friends.” Erectile dysfunction affects as many as 30 million men in the United States, according to the American Urological Association.
There are treatment options for almost every erectile problem, including oral medications, injectable medications, surgery and cognitive behavioral therapy, Dr. Bennett said.
Although it can be tempting to furtively order medications such as Viagra on direct-to-consumer websites, a practice that Dr. Bennett found, in a 2021 study, is dramatically increasing, he said there are several reasons to see a specialist instead. “We can actually begin to figure out why you’re having the problem, as opposed to just taking medication to cover it up,” he said. Some medications can also affect erections, such as antidepressants, which can cause orgasms to be delayed, or vanish altogether. And a urologist can screen for those, he said.
What’s more, erection problems can be a sign of heart problems down the road. Penis arteries, which are one millimeter in diameter, are very small, compared with heart arteries, which are 3 millimeters. “So if you’re clogging your small pipes first, you may have erectile dysfunction before you have your first heart attack,” Dr. Rubin said.
“Those are the guys you need to start looking at,” said Dr. Bennett, “because we know that erectile issues will predate cardiovascular issues by about 10 years.”
Painful sex
For older women, painful sex is a leading sign of genitourinary syndrome of menopause, or G.S.M., a term that in 2014 replaced the dispiriting phrase “vulvovaginal atrophy.” During perimenopause and beyond, as estrogen leaves a woman’s body, the tissues in the vulva, vagina and urinary tract become dryer, less supple and more sensitive. This process can cause recurrent urinary tract infections and incontinence, and sex can become excruciating, which takes many women by surprise, Dr. Rubin said. G.S.M. may affect up to half of postmenopausal women, according to a 2019 review, and is “unlikely to improve without treatment.”
What has been shown to work for conditions like G.S.M., Dr. Rubin said, are treatments like inserts with DHEA, a steroid that mimics hormones, lubricants and moisturizers; ospemifene, an oral medication that is approved by the Federal Drug Administration to treat G.S.M.; vaginal dilators; and low-dose topical vaginal estrogen.
“There’s not a cocktail party or children’s birthday party where I don’t recommend vaginal hormones,” Dr. Rubin said. (It is important, however, that you discuss any of these treatments with your own doctor first.)
Pelvic floor therapy is another option, Dr. Rubin added. “Pelvic floor therapists rehab your muscles, just like you would do rehab after a knee replacement.” And you don’t have to do it forever, she added. “Physical therapists are there to optimize your pelvis and send you out the door.”
Then there’s the D.I.Y. approach: a 2023 review found that vibrators were considered “an accepted modality” to treat vulvar pain. “I think doctors should be prescribing vibrators, which are health aids, just like eyeglasses or hearing aids,” Dr. Rubin added. “The more we normalize them and educate patients in exam rooms about them, the better.”
Bladder issues
You may know that bladder control loss afflicts women at various hormonal stages in their lives — pregnancy, after giving birth and during menopause — but “men are plagued by urinary incontinence, too,” Dr. Bennett said. A quarter to a third of Americans have incontinence, according to the American Urological Association.
There are two main types: “stress incontinence,” which means sudden leaking brought on by activities like coughing, sneezing or exercise, and “urgency incontinence,” a strong and immediate urge to pee, which sends you on a mad dash to the bathroom.
Some male patients will visit the bathroom 10 times a night because of a prostate issue, which leads to sleep deprivation, Dr. Bennett said.
Some treatments for urinary incontinence include medication, and for women, vaginal estrogen, but urologists also teach patients Kegel exercises, use electrical stimulation and employ pelvic floor physical therapy. (Men have a pelvic floor, too.)
Urologists, Dr. Uloko said, “are really glorified plumbers. We know how to fix the leaks.”
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