Bicycling-related urogenital disorders

EUROPEAN UROLOGY REVIEW

Purpose
Bicycle riding is one of the most popular means of transportation, recreation, fitness and sports among millions of people of all ages who ride on road and off road, using a variety of bicycle types. It is also a readily available form of aerobic non-impact exercise with established cardiovascular beneficial effects. Bicycles are also a common source of significant injuries. This review focuses upon the specific bicycling related overuse injuries affecting the genitourinary tract.

Materials and Methods
MEDLINE search of the literature on bicycling and genitourinary disorders was performed using multiple subject headings and additional keywords. The search yielded overall 62 pertinent articles. We focused primarily on the most prevalent related disorders such as pudendal nerve entrapment, erectile dysfunction and infertility. The potential effect of bicycling on serum PSA level was also discussed in depth in view of its recognized clinical importance. Infrequent disorders, which were reported sporadically, were still addressed, despite their rarity, for the comprehensiveness of this review.

Results
The reported incidence of bicycling related urogenital symptoms varies considerably. The most common bicycling associated urogenital problems are nerve entrapment syndromes presenting as genitalia numbness, which is reported in 50–91% of the cyclists, followed by erectile dysfunction reported in 13–24%. Other less common symptoms include priapism, penile thrombosis, infertility, hematuria, torsion of spermatic cord, prostatitis, perineal nodular induration and elevated serum PSA, which are reported only sporadically.

Conclusions
Urologists should be aware that bicycling is a potential and not an infrequent cause of a variety of urological and andrological disorders caused by overuse injuries affecting the genitourinary system.

“Bicycling is a readily available, economical and efficient form of aerobic non-impact exercise with established cardiovascular beneficial effects. On the other hand, bicycles are also a common source of significant injuries…….. this review focuses upon the specific bicycling related overuse injuries affecting the genitourinary tract. Urologists should be aware that bicycling is a possible and not an infrequent cause of a variety of urological and andrological disorders caused by overuse injuries affecting the genitourinary system.”

Incidence
“The reported incidence of bicycling related urogenital symptoms varies considerably. Some disorders are reported only as occasional case reports, while others, mainly those associated with perineal compression, are reported very frequently.”


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Mechanisms of pudendal nerve compression
“Pedaling while sitting on a slim hard saddle and being constantly subjected to repetitive impacts generates extreme perineal pressure, which indirectly compresses the pudendal nerves, and increases the friction within Alcock canal. The constant pressure and the consequent loss of the ability of smooth gliding movements of the nerves expose them to repetitive trauma. The importance of neural gliding and movement of the nerve has been recently emphasized in the clinical management of patients with multilevel nerve compression. ”
“Another vulnerable location is outside the bonny pelvis. Direct pressure of the nose of the saddle against the perineum and the symphysis, further provoked by the forward leaning of the cyclist, pinch the pudendal nerves just where they emerge below the pubis. Additionally, the movements of the pedaling legs in the forward sitting position stretch the pudendal nerves over the sacrospinal and the scacrotuberous ligaments, leading to strain of the nerves. The pathophysiological significance of nerve stretching is well established and it is the underlying principle of the neural tension test which is used to diagnose specific compression neuropathies.”

Penile blood flow during cycling
“Cutaneous penile oxygen pressure, which is believed to correlate with penile blood flow, decreases significantly during cycling. The extent of the decline in blood flow was correlated with the cycling position and the type of the saddle.”
“Standing up while cycling improved penile oxygenation back to its normal level before cycling . Although cycling in the seated position invariably compromised penile perfusion, the type of the saddle significantly affected its extent.”
“With increasing levels of bicycle riding exposure, males are found to have significantly more urologic complaints, perineal pain or numbness.”

Management and prevention of pudendal neurovascular compression syndromes
“The optimal prevention scheme is comprised of two strategies: changing the riding style and schedules as well as modifying the design of the saddle and its positioning.”

Perineal soft tissue lesions
“Repeated chronic microtrauma of the perineum is the result of continuous contact with the saddle and bumping of the perineum against it. These repetitively contuse the perineal structures and may cause a variety of soft tissue lesions including calluses that form over the ischial tuberosities, chafing that may result in saddle sores and ulcerations. The combination of chafing, sweating and tight biker’s suits can cause skin irritation, perineal folliculitis and furuncles.”

Women too…
“Sexual and urinary symptoms associated with bicycle riding exist also in female bicyclists. The anatomical course of the pudendal artery and nerve within Alcock canal and its orientation medial to the pubis is homologous in males and females. Hence, similar types of sexual and urinary dysfunction may occur when these structures are compressed during bicycling.”

Ilan Leibovitch
Department of Urology, Meir Medical Center, Affiliated to Sackler School of Medicine, Tel Aviv University, 59 Tchernichovski st., Kfar Saba, Israel
Yoram Mor
Department of Urology, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
http://www.hobsonseats.com/articles/viciouscyclliingleibovitich2005.pdf