Podcast Summary: "Erectile Dysfunction? Is It Blood Flow or Your Mind? Here’s How to Find Out!"

Rena Malik, MD Podcast
Host: Dr. Rena Malik, MD
Episode Date: January 2, 2026

Main Theme and Purpose

In this "Ask Me Anything" episode, board-certified urologist and pelvic surgeon Dr. Rena Malik answers real listener questions on sensitive urologic and sexual health topics. Dr. Malik demystifies testosterone therapy and prostate cancer risk, urinary incontinence in women, and how to distinguish between psychological and vascular causes of erectile dysfunction using diagnostic tools like the penile Doppler ultrasound. With evidence-based advice, Dr. Malik empowers listeners to take charge of their health and seek solutions to quality-of-life issues they're often too embarrassed to discuss.

Key Discussion Points & Insights

1. Testosterone Replacement Therapy (TRT) and Prostate Cancer ([00:47]-[05:01])

• Question:
  Is taking TRT going to cause cancer?

• Historical Belief:
  For years, it was believed testosterone therapy increased prostate cancer risk due to older studies.

  "Some of those fears have been taken through many years and sort of become convoluted." — Dr. Malik, [00:57]

• Current Understanding:

  • Men with low testosterone may actually be at higher risk for prostate cancer, based on observational studies.
  • The Traverse Trial (RCT): Compared men given topical testosterone to those without; no increased development of prostate cancer in the treated group.
  • Testosterone does not cause normal cells to become cancerous.

  “We now have randomized control trial data... and a better understanding of what happens when you give someone testosterone.” — Dr. Malik, [00:57]

  • Elevation in PSA levels after starting testosterone is expected—not a sign of cancer but due to receptor saturation.
  • TRT may accelerate growth if prostate cancer is already present, which is why regular PSA monitoring is critical.

• Skinny from Urology Community:

  • TRT does not cause cancer.
  • Cancer survivors can consider TRT after certain conditions are met (e.g., over a year cancer-free).

• Caveats & Risks of TRT:

  • Stroke, blood clots, possible worsening of sleep apnea.
  • Requires close physician monitoring with labs and symptom tracking.

  "It needs to be done under the guise of a physician... but just like anything else, it needs careful monitoring and is very safe." — Dr. Malik, [04:36]

2. Explanation of Randomized Controlled Trials (RCTs) ([05:01]-[06:05])

• Definition & Importance:
  Dr. Malik details why RCTs are the "gold standard" in clinical research, eliminating bias and providing reliable evidence.

  “Randomized controlled trials... allow you to eliminate a lot of biases. They allow you to compare apples to apples...” — Dr. Malik, [05:06]

3. Female Stress Urinary Incontinence—Why It Happens & What to Do ([06:05]-[13:17])

• Question:
  After laughing hard at a comedy show, a 44-year-old woman experienced significant urine leakage for the first time. Is this normal? Dangerous?

• Dr. Malik’s Breakdown:

  • Urinary incontinence affects 1 in 3 women.
  • Stress Incontinence: Leakage occurs with increased abdominal pressure (coughing, sneezing, laughing).
  • Pelvic Floor Muscles:
    • They act like a "hammock" supporting the urethra.
    • Factors weakening them: childbirth (vaginal or C-section), standing jobs, high-intensity exercise, neurologic conditions, collagen disorders.
    • With muscle weakening, urethra can't stay closed under pressure.

  "Think of the pelvic floor muscles like a hammock that holds some resistance underneath your urethra..." — Dr. Malik, [07:36]

• Treatment & Self-Management:

  • Kegel Exercises:
    • Visualize “sucking up a blueberry with the vagina.”
    • Start lying down, progress to sitting then standing.
    • Equally important: Relaxing between contractions.

  "Just like you're going to the gym, you're not going to just like hold isometrics for the whole time." — Dr. Malik, [08:38]

  • Role of Pelvic Floor Physical Therapy:
    • “It’s like going to the gym with a trainer rather than going... alone.”
    • Biofeedback and coaching can help perfect form.
  • Other Tools:
    • Pessaries (e.g., Poise Impressa) or vaginal supports.
    • Surgeries are available; no effective medications for stress incontinence.

• Key Point:

  • Not dangerous, but a quality-of-life issue.
  • Encouragement for women to seek help:

    "You will be happier and more confident... when you feel good in your body. If this is bothering you... please encourage you, go see a doctor, get help, because it will help and make your life better." — Dr. Malik, [11:55]

• Other tips:

  • Avoid constipation and chronic urine holding—both can worsen incontinence.

4. Penile Doppler Ultrasound: Blood Flow or Brain? ([13:17]-[18:42])

• Question:
  What is a penile Doppler ultrasound? Why/when is it used?

• Overview & Mechanism:

  • Diagnostic tool for erectile dysfunction (ED).
  • Assesses if ED is due to poor arterial inflow, venous leak, or both.

• Utility:

  • Especially useful if there’s doubt about vascular vs psychological causes, or when significant stress/anxiety may be contributing.
  • Also for penile curvature/plaque evaluation.

• Procedure Details ([15:05]):

  • Baseline ultrasound is performed.
  • Physician injects a small amount of medication into the penis to induce an erection.
  • Progressive doses until maximal rigidity is achieved (to mimic a natural "best" erection).
  • The test measures how quickly blood enters and leaves, and identifies venous leaks.

  “We want you to get the most rigid erection that you can get. So what we'll do is we'll inject, start a small dose, and we'll wait and see..." — Dr. Malik, [16:28]

• Important Patient Advisories:

  • Anxiety may blunt the test’s accuracy since it can prevent a strong erection even with medication.
  • The most common complications: Erection lasting too long (priapism), which is treatable if caught promptly.
  • Total procedure time ~30 minutes plus post-procedure monitoring.

• Why Not for Everyone?

  • Often, whatever the precise vascular problem, initial treatments are similar.
  • Clear identification can sometimes help decide if surgery is needed, as in severe venous leak.

  “Most important thing is realizing that your anxiety for this test can actually affect the test results.” — Dr. Malik, [15:45]

Notable Quotes & Memorable Moments

"You can absolutely give testosterone, no matter if you have a family history of prostate cancer. If you're concerned about prostate cancer, it's not an issue, but you do need to be followed."
— Dr. Malik, [04:07]

"Women tend to take care of everyone else first... And then eventually like 10, 20 years...are they like, oh, I finally should take care of myself? And I would say you will be happier and more confident... when you feel good in your body."
— Dr. Malik, [11:55]

"If you have a problem with your erections, part of it is bothering you in your head, right? You are stressed about it, you're anxious about it, you're thinking about it, and it makes it worse. It becomes a vicious cycle."
— Dr. Malik, [14:14]

Timestamps for Key Segments

• TRT & Cancer Risk: [00:47] – [05:01]
• RCTs Explained: [05:01] – [06:05]
• Female Urinary Incontinence: [06:05] – [13:17]
• Penile Doppler & ED: [13:17] – [18:42]

Final Takeaways

• Testosterone Replacement Therapy: Safe when monitored; does not cause prostate cancer, but ongoing vigilance is necessary.
• Stress Incontinence: Extremely common, treatable, and nothing to be ashamed of; don’t delay seeking help.
• Penile Doppler Ultrasound: Useful for unraveling complex erectile dysfunction, but psychological and physical causes often overlap—don’t underestimate the role of the mind.

Dr. Malik closes by encouraging listeners to prioritize their health and not put off simple interventions that can drastically improve their lives.