Saddle sores, perineal (saddle region) pain, numbness, erectile dysfunction, vulvodynia (female genital pain), painful urination, painful frequent urination (small volumes “stranguria”), and painful intercourse. These are all common complaints in both male and female cyclists due to prolonged pressure and friction between the riders perineum and the saddle (Greenberg et al 2019). The exact incidence is not known but studies suggest that between 22-91% of all cyclists experience some or all of these symptoms (Baran et al 2021).
Clinically, I have been seeing a recent increase in these conditions. Typically male cyclists who develop perineal symptoms first notice numbness in the genital region, whilst women may notice labial pain as the first symptom.
I’ve seen quite a few cyclists ignore this & tell me “that’s just normal”. Actually, it’s not.
Numbness if often the first sign of bigger trouble and should not be ignored, as those who have failed to act upon the early warning signs have discovered when impotence was the result.
Why are cyclists so prone to perineal complaints since other endurance athletes like runners do not get these issues? There are two main reasons, the most important being the pressure on the “undercarriage” from your body weight on the saddle. If things are not set up correctly and/or the choice of saddle inappropriate, excessive pressure can be placed upon the pudendal nerve and artery and their various branches (more on this below) resulting in damage from repetitive overload. The second less common reason is that repetitive hip flexion during pedalling can cause a stretching / traction injury to the pudendal nerve in a minority of athletes who have an anatomical predisposition (such as a tight canal / narrow space for the nerve to glide during hip movement).
The traction type of injury more commonly occurs between the two pelvic ligaments mentioned. There is a large anatomical variation in this region of the body (meaning that the bony shape and angle of the ligaments vary between individuals), and these variations are often regarded as a predisposing factors in more severe cases.
For those who still don’t believe that saddle region symptoms are abnormal, consider this: there is a maximal pressure load that any region of the body can tolerate (for cyclists these durations are long, in the order of 1-6hrs daily). Excessive pressure or friction that exceeds this limit, repeated regularly, will cause damage whereas milder pressures will not. Pressure to the nerve directly, or ischemia (loss of blood flow) via pudendal artery compression, may reduce sensation (numbness) and over time lead to erectile dysfunction and a range of other perineal symptoms. This is why numbness or pain are early warning signs as the sensory component of the nerve is usually damaged first.
The most common type of pudendal nerve injury is known as “neuropraxia”, whereby the nerve remains intact, but its signalling ability is lost. The loss of conduction causes sensory loss (numbness) in the territory supplied by the nerve (in this case genitalia and pelvic floor regions) and may interfere with the sensation required for the erectile and ejaculatory reflexes. Pudendal neuropathy (nerve damage) is a recognised condition that often begins with the “minor” symptoms such as tingling, numbness or bladder complaints, and progresses to more generalised and more painful symptoms as nerve damage progresses.
Here are some of the typical symptoms:
Pain: about 50% of people report more pain when sitting (but not on the toilet seat). It is especially painful when cycling.
Pain Location: 85% have pain in perineum; 70% testicles / 40% labia; 30% penis / clitoris; 40% rectal (men) vs 70% rectal (women) in one surgical series (Popeney et al., 2007). Pain can also be felt in the coccyx and referred pain as far away as the feet.
Pain may be partially relieved in standing / walking.
Pain is typically worse as the day goes on, and less severe upon waking.
Numbness: genital region.
If you are having symptoms in the perineal (saddle) region, diagnosis requires an examination, and the differential diagnosis is challenging as many other conditions mimic pudendal neuralgia.
For cyclists with pudendal nerve pain, how is it treated?
The key issue is unloading the pudendal nerve & artery to permit healing.
This may initially require some rest off the bike and using a donut cushion for sitting during the day. The neuropraxia type of nerve damage (the mildest form) may settle within days in the early stages or may take up to 3 months for symptoms to resolve. The time frame can be substantially longer if the condition is chronic and untreated or undiagnosed for a long period of time.
Bike fit:
A poor bike fit can contribute to the problem, so sorting this out early makes sense. In terms of components, ergonomic saddles have been shown to improve blood flow and reduce compression both immediately and over 6 months resulting in greater comfort and absence of symptoms (Piazza et al 2019). Selecting a saddle that suits your individual anatomy is one of the key components of being able to ride again without symptoms. It may take a few trials of different saddles to find one that adequately unloads your pudendal nerves (read more here, here and here).
Saddle selection:
Saddle design does affect pelvic posture and tilt on the bike (Bressel & Larson 2003) and can alter blood flow in female (Piazza et al 2019) and male cyclists (Schwarzer et al 2002). Other elements of bike set up can influence perineal pressure including pelvic rotation and posture on the bike, handlebar position and crank length. Women appear to be more susceptible to lower handlebar positions with respect to perineal symptoms, perhaps due to proportionately smaller bodies, so taking a more conservative approach to positioning, at least when returning to cycling, is advisable (Liu et al 2021). Cyclists with more forward pelvic rotation require a different saddle design to those with less rotation. Thus, a change in position, a change in the cyclists flexibility, or changing the type of bike may require a different saddle (the extreme version is going from a mountain bike or a commuter bike to a time trial position).
There is no “one size fits all approach” for saddle selection and what is ideal today may change as your body changes in the future (read more here and here). Cycle Physio offers a range of ergonomic saddles to trial to assist in this regard, and expertise in assessing your body, pelvic rotation and spinal posture on the bike and can advise what saddles are more likely to be beneficial.
Other methods to reduce perineal pressure include wearing a thicker more appropriate chamois (Marcolin et al 2015), using wider tyres run at lower pressure (which increases pneumatic shock absorption), and endurance framesets which can absorb more road vibration.
Clinical treatment:
Clinical treatment modalities relate to expert level manual therapy to reduce inflammation around nerves, improve arterial flow and nerve glide. Most practitioners simply aren’t trained in this field. David Wadsworth has received training in treating these types of pelvic conditions and can assist in this regard.
The moral of the story here is don’t ignore genital numbness or pain. Ignoring symptoms can lead to sexual dysfunction (poor lubrication, arousal, pain, erectile issues). It is much easier and faster to sort out your bike fit, select a suitable ergonomic saddle and buy decent knicks with an endurance chamois, than it is to get nerve damage to heal.
References:
Baran C et al (2021): Cycling-Related Sexual Dysfunction in Men and Women: A Review. Sex Med Rev 2014;2:93–101.
Bressel & Larson (2003): Bicycle seat designs and their effect on pelvic angle, trunk angle and comfort. Med Sci Spt Ex
Greenberg DR et al (20149): Urogenital and Sexual Complaints in Female Club Cyclists—A Cross-Sectional Study. J Sex Med 2019;16:1381-1389.
Lui et al (2021): Association of Bicycle-Related Genital Numbness and Female Sexual Dysfunction: Results From a Large, Multinational, Cross-Sectional Study. Sex Med 2021;9:100365.
Piazza N et al (2019): The effect of a new geometric bicycle saddle on the genital-perineal vascular perfusion of female cyclists. Science & Sports 35:161-167.
Marcolin G et al (2015): Biomechanical Comparison of Shorts With Different Pads: An Insight into the Perineum Protection Issue. Medicine 94:e1186.
Popeney, C., Ansell, V., & Renney, K. (2007). Pudendal entrapment as an etiology of chronic perineal pain: Diagnosis and treatment. Neurourol Urodyn, 26(6), 820-827.