Bicycle riding and Erectile Dysfunction
When a man age 50 or more years presents to his health care provider with complaints of consistent or persistent inability to obtain and/or maintain a penile erection for satisfactory sexual activity, the contemporary thinking is that the diagnosis is likely biologic-based erectile dysfunction. This is especially true if the patient also has a history of diabetes, hypertension, high cholesterol, cigarette smoking, or myocardial infarction.
Fifty years ago, at the time of Masters and Johnson, most of erectile dysfunction was thought to be psychogenic in origin. However, based on more than 10 years of widespread publications, erectile dysfunction in older men with vascular risk factors has been found to be linked to an underlying biologic vascular condition in strong association with dysfunction of the lining cells of the arteries, called endothelial dysfunction.
In contrast, when a young male, age teens to 40 years, presents to a physician with complaints of erectile dysfunction, the former thinking still prevails and the diagnosis most likely to be considered is psychogenic-based erectile dysfunction.
Why do practitioners have such great difficulty accepting the existence of vasculogenic erectile dysfunction in younger men? Unfortunately, many physicians who evaluate younger men do not seek a history of blunt perineal trauma. Endothelial dysfunction resulting in focal arterial occlusive disease can be associated with a history of blunt trauma. Evidence for trauma-associated focal arterial obstructive pathology is well–established in the medical literature for several other arterial beds. Such arterial beds include the radial artery (construction workers), the axillary artery (crutch-related injuries) and the popliteal artery (football players).
The arterial bed to the penis, the distal internal pudendal, common penile and proximal cavernosal arteries, are all susceptible to blunt trauma by virtue of the anatomic relationship to the ischiopubic rami (one of the pelvic bones) within Alcock’s canal. These arteries can be injured during bicycle riding, and other sources of straddle injuries such as blows to the perineum during martial arts.
Penile erection results following stimulation of the motor nerves to the penis. During sexual stimulation, nitric oxide activates an enzyme that facilitates the synthesis of cyclic guanosine monophosphate. The elevated concentrations of cyclic guanosine monophosphate result in lowered intracellular calcium thus promoting penile smooth muscle relaxation. Biologic consequences of nitric oxide – cyclic guanosine monophosphate relaxation include increased arterial blood inflow, engorgement of the spongy erectile tissue, lengthening and enlargement of the corporal erectile tissue within the constrained wall called the tunica albuginea and eventual occlusion of the small veins draining the spongy erectile tissue (sub-tunical venules) with increased venous outflow resistance and trapping of blood in the erection chambers (corporal veno-occlusive function).
Penile erection is, in part, interfered with by multiple biologic factors including low testosterone, low thyroid and metabolic conditions such as diabetes, elevated body mass index, elevated waist circumference, abnormal lipids, elevated blood pressure, sedentary lifestyle, cigarette smoking and increased age. Such factors can damage or injure the lining cells of arteries, called endothelial dysfunction. Endothelial dysfunction ultimately can lead to reduced arterial blood inflow to the penis and reduced arterial systolic perfusion pressures during erection that leads to inadequate erections and diminished erectile hardness during sexual stimulation.
There is a puzzling resistance to acknowledge that a site-specific endothelial dysfunction may also occur following blunt trauma to the distal internal pudendal, common penile and proximal arteries. These critical arteries to erectile function lie in close proximity to the hard bony surface, the lateral aspect of Alcock’s canal, the ischio-pubic rami. Blunt trauma induced endothelial injuries may be classified as either non-denuded or denuded. While some non-denuded endothelial injuries may spontaneously heal, some progress to frank endothelial dysfunction, that over a variable time period, result in focal atherosclerosis, focal arterial lumen narrowing and reduced systolic arterial perfusion pressures to the penis. Denuded endothelial injuries that result following blunt trauma to the arterial wall often result in progressive occlusive arterial pathology over time leading to diminished systolic arterial perfusion pressures in the penis arteries and diminished erectile hardness during sexual stimulation.
There are data in the peer review medical literature of appropriate level of scientific evidence to an association of erectile dysfunction with those who ride bicycles.
Marceau et al studied a community-based population exceeding 1700 men age 40 – 70 years of age. The odds ratio for men developing moderate to severe erectile dysfunction who acknowledged riding more than 3 hours per week was 1.72. This analysis was performed where co-variates were factored, such as age, energy expenditure, body mass index, cigarette smoking, depression, cancer, high blood pressure and diabetes.
Schrader et al published a unique National Institute for Occupational Safety and Heath study of bicyclists involving determination of nocturnal penile tumescence activity as recorded by Rigiscan and perineal or nose pressure recorded by specialized pressure sensitive sheets placed over the rider’s saddle. Schrader reported a significant inverse correlation between the magnitude of nose pressure values and the percent sleep time in erection. Control subjects exhibited over 30% sleep time in erection whereas those who rode with nose pressures exceeding 1000 and 2000 units revealed less than 20% sleep time in erection.
Dettori et al reported on the erectile dysfunction characteristics of several hundred men who performed long distance bicycle rides. In those men who exceeded 328 kilometers, complained of current perineal numbness and used a saddle with a cut-out (that acted to lower surface area contact and increase perineal compressure pressures), a surprising 18% were found at risk for developing erectile dysfunction.
Cohen et al studied over 30 male cyclists and examined transcutaneous penile oxygen pressures. Compared to values obtained during standing cyclists who straddled on commercially available saddles with nose extensions as the Vetta Lite, Terry and Specialized exhibited significant reductions transcutaneous penile oxygen pressures.
Leibovitch et al performed a literature search of 62 articles in the peer review medical literature on bicycling and genito-urinary disorders. They reported that 13 – 24% of bicyclists in the literature claimed erectile dysfunction. They concluded that although bicycling is associated with established cardiovascular benefits, that bicycling was a not infrequent cause of injury to the genitourinary system.
Bacon et al reported that the risk of developing erectile dysfunction among the over 20,000 men in the Health Professional Follow-up Study who were healthy and had good or very good erectile function before the study, decreased as the subjects reported increasing metabolic energy transfer units (METS) during various exercise forms, including bicycling. The authors also performed a unique multivariate and total physical activity sub-analysis of the data by the various exercise forms. The risk of developing erectile dysfunction among healthy participants who had good or very good erectile function before the study (and no prostate cancer) revealed a reduction of the risk of erectile dysfunction a the highest tertile of physical activity jogging, running, swimming, tennis, rowing and squash/raquetball. Curiously, there was no risk lowering for bicycle riding.
Goldstein and co-workers reported in The Journal of Sexual Medicine a prospective study recording cavnerosal artery peak systolic velocity values using duplex Doppler ultrasound in men who lay supine, sat on the examination table, straddled a saddle, sat on a two-cheek noseless seat and then lay supine. In all subjects who straddled a saddle, peak systolic velocity values approached zero. All remaining interventions were associated with mean peak systolic velocity values that were not significantly different from each other and where the values ranged from 20 – 26 cm/sec. It was estimated that the compression pressure on the perineum while bearing body weight on a bicycle saddle exceeded 300 mmHg.
An additional study in The Journal of Sexual Medicine examined if noseless bicycle saddles would be an effective intervention for alleviating deleterious health effects, erectile dysfunction and groin numbness, caused by bicycling on the traditional saddle with a protruding nose extension. Ninety bicycling police officers from 5 metropolitan regions in the U.S. (Northwest, Southern, Desert West, Midwest, and Southeast) using traditional saddles were evaluated prior to changing saddles and then again after 6 months of using the noseless bicycle saddle. The findings showed that use of the noseless saddle resulted in a reduction in saddle contact pressure in the perineal region. There was a significant improvement in penile tactile sensation, and the number of men indicating they had not experienced genital numbness while cycling for the preceding 6 months rose from 27 percent to 82 percent using no-nose saddles. Use of the noseless saddle also resulted in significant increases in erectile function as assessed by the initial evaluation. With few exceptions, bicycle police officers were able to effectively use no-nose saddles in their police work and 97 percent of officers completing the study continued to use the no-nose saddle afterward. In summary, for the first time, a prospective study of healthy policemen riding bikes using wider no-nose bike saddles for 6 months revealed improved perineal sensation and improved erectile function. Changing saddles changed physiology.
In summary, ideally, when a cyclist straddles the bicycle and bears his/her weight on a bicycle saddle, the weight is supported directly on the pelvic sit bones (ischial tuberosities). If the bicycle saddle has a narrow seat alone, if the bicycle saddle has a narrow protruding nose, or if the bicycle saddle has both a narrow seat and a narrow protruding nose, there may be situations where the cyclist bears his/her weight directly on the groin. Bearing weight on the groin has been shown in multiple studies to compress the pudendal nerve and or its branches and the pudendal artery and or its branches. The pudendal nerves and branches, and the pudendal artery and its branches run through the groin are the primary sources of sensation and arterial blood inflow to the genitals. Pressure on these nerves and arteries over time may lead to a loss of sensation and a decrease in arterial blood supply to the genitals. These reductions in sensation and/or arterial blood flow can contribute to the sexual health problems that have been widely reported in the peer review medical literature associated with bicycle-riding sexual dysfunction. Some cyclists erroneously believe, it is normal and a useful sign of the intensity of the workout, that genital sensation is reduced. The fact is numbness is a warning that excessive pressure is applied to the groin and this should not be ignored and that dismounting from the bicycle is recommended.
To help prevent bicycle riding sensation and/or sexual changes, it is recommended that cyclists use a no-nose saddle. A no-nose bicycle saddle is designed to support the weight of the cyclist on the sit bones. A no-nose bicycle saddle does not have a narrow nose protruding forward under the groin region. A no-nose bicycle saddle is designed so that the important pudendal nerves and pudendal arteries serving genital sensation and genital blood flow are not compressed against any part of the saddle surface. Recent studies have demonstrated the effectiveness of no-nose bicycle saddles in decreasing groin pressure and improving the sexual health. Other efforts to avoid bicycle riding sensation and/or sexual changes, involve obtaining guidance from a trained bicycle specialist who can provide information concerning saddle height and angle adjustments. It would be wise to get off the bicycle saddle when possible.
If consistent and persistent sexual problems have already resulted from bicycle riding, and the sexual problems result in distress, detailed evaluation of psychologic and biologic causes should be sought. One goal of treatment in young men who have erectile dysfunction secondary to blunt perineal trauma is to restore erectile fuction. Psychologic counseling can help with anxiety, stress, and interpersonal issues. Erectile function can be improved with the use of vacuum constrictive devices, oral pills such as Viagra, Levitra and Cialis, penile self-injections, or intraurthral pellets of alprostadil. A penile implant can be placed. All of these treatment options do not restore normal erectile physiology
The goal of microvascular arterial bypass surgery is to create an alternative arterial inflow route around traumatic-induced obstructive arterial lesions in the arterial bed to the penis. The specific objective of the surgery is to increase the arterial perfusion pressure in the penis artery and to increase arterial blood inflow in patients with erectile dysfunction secondary to pure arterial insufficiency following blunt perineal, penile or pelvic trauma. Young men, without other systemic vascular risk factors, who have erectile dysfunction secondary to blunt perineal trauma such as following bicycle riding represent the ideal patient population for this vascular reconstructive procedure. The ideal candidate for the surgery has erectile dysfunction purely on the basis of arterial blockage. All young patients with a history suggestive of trauma-associated impotence (pelvic fractures and perineal trauma) should undergo a comprehensive history, physical examination and psychologic interview. They should have a routine endocrinologic evaluation to ensure adequate circulating levels of unbound, free testosterone. Duplex Doppler ultrasonography should be performed to provide diagnostic hemodynamic data (cavernosal peak systolic and end-diastolic velocities) and preoperative information such as presence of communicating branches from the dorsal to the cavernosal artery. Finally, vascular assessment by dynamic infusion cavernosometry should be considered to document the degree of arterial pressure gradients between the brachial artery and the cavernosal arteries and to further evaluate the veno-occlusive function. Following hemodynamic diagnosis, if the patient has pure arterial insufficiency a selective internal pudendal arteriogram should be performed to confirm the location of the obstructive lesion, most often in the common penile or cavernosal artery(ies), and select the best inferior epigastric artery.
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