Archive for July, 2014

Advice From My Patient

July 29, 2014

Andrew Siegel, MD   Blog # 165

Last week I had the pleasure of being invited to lunch and to play a round of golf at a beautiful private course with two of my patients who are club members. One gentleman is in his 60s and the other in his 70s. I received some very excellent technical golf advice from the younger of the two, of which my game is in dire need of (my goal that afternoon being not to embarrass myself…I believe I achieved that!).

In addition to sound advice about my swing mechanics, as we approached an on-the-course restroom, my patient also gave me some sage life advice for the aging male: “Never pass up the opportunity to use the bathroom; never trust a fart; and never waste an erection.”

 As I later thought about his adage that involved seemingly disparate entities—the urinary tract, the intestinal tract, and sexual function—it occurred to me that the common thread was altered pelvic organ and pelvic floor muscle function. What he was really saying was that there are age-related changes of the function of the pelvic organs and the pelvic floor muscles.

Allow me to deconstruct his advice. “Never pass up the opportunity to use the bathroom,” implies the presence of urinary urgency and frequency, often signs of an enlarging prostate and/or overactive bladder. What he was recommending was “defensive voiding,” a technique of keeping the bladder as empty as possible on as regular a basis as possible to try to avert urinary urgency as well as urgency incontinence, a situation that occurs as the bladder leaks urine before its owner is able to get to the bathroom.

With “Never trust a fart,” he was expressing the point that a young man has a very “intelligent” anal sphincter, smart enough to distinguish between liquid, solid, and gas and that, with the aging process, the sphincter, well… becomes less clever. The aging anal sphincter is no longer always accurate in making the distinction between these three physical states, a critically important distinction, a mistake of which can lead to some embarrassing consequences.

Never waste an erection,” reveals the truism that at some point in life getting an erection at will is no longer an option. As we age, erectile dysfunction, or altered function, strikes most of us. When we are so fortunate as to get an erection—which for some men may be a rare occurrence—the opportunity should not be squandered and full advantage of the fortuitous moment should be made.

Pelvic floor muscle exercises can bolster the strength and tone of the pelvic floor muscles, which can improve sexual, urinary and bowel health. Such exercises improve overactive bladder responsible for urinary urgency, anal sphincter weakness responsible for not being able to trust flatulence as such, and erectile dysfunction, such that one’s ability to perform is more in one’s own hands and less up to the whim of nature.

The adage is totally relevant to the aging female as well, except for the part about “never wasting an erection.” Women, in fact, suffer with overactive bladder and anal sphincter issues at a higher prevalence than men. Pelvic exercises can help improve these issues, as well as female sexual issues. Dr. Arnold Kegel popularized pelvic floor exercises in females in order to improve their sexual and urinary health, particularly after childbirth, and his legacy is the pelvic floor muscle exercises that bear his name, known as “Kegels.” Kegel believed that in females, well-developed pelvic muscles are associated with few sexual complaints, and that sexual feeling in the vagina is closely related to muscle tone and can be improved through muscle education and resistive exercise.

Bottom Line: Keep your pelvic floor muscles fit and you just might be able to pass up the opportunity to use the bathroom, trust a fart, and not think twice about wasting an erection.

Andrew Siegel, M.D.

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: healthdoc13.wordpress.com

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; available in e-book (Kindle, iBooks, Nook, Kobo) and paperback  MalePelvicFitness.com

I can’t think of a more relevant occasion to repeat the book’s dedication:

This book is dedicated to my patients, many who have opened up their lives and hearts and have shared very personal and intimate details with me. They have been among my most important teachers and have given me a wealth of information that is not to be found in medical textbooks or journals. Meaningful, enjoyable, and rewarding relationships have been developed and nurtured over the years and it has been a privilege and an honor to be entrusted with their urological care. Engaging their confidence and respect through our interactions has proven to be one of the most satisfying and fulfilling aspects of being a physician.

Private Gym website where pelvic floor instructional DVD and resistance training equipment are now available  PrivateGym.com

 

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The Penis Is the Star of the Show, But Don’t Forget the Supporting Cast

July 26, 2014

 

Andrew Siegel, MD   Blog # 164

When it comes down to it, the penis is the star of the show, the lead performer, the anchor, and the host that gets all of the attention, credit and limelight. Like a rock star, he is expected to perform consistently—and when it is time for the show to begin, he usually roars onstage to give a 5 star performance; however, truth be told, often lurking deep within is the specter of a meltdown and total bombing of the act, and, for the less experienced performer, doom by stage fright.

What can help ensure his success? Behind every great performer is a cast of supporting players, a pit crew that encourage, boost and work diligently to guarantee a first-rate show. Without this crew, the penis would struggle with his solo act and fail miserably. Sadly, the entourage team gets little to no respect, even though they are essential in order for the penis to shine and stand at tall attention, confidently at center stage.

So, when the house lights dim, the emcee of the show is the penis, the one who rises to the challenge alone, engaging the crowd and timing his delivery flawlessly. The behind-the-scenes team has labored to make this happen. Let us now meet the members of this vital support group. The supporting cast members are the brain, nerves, arteries and the pelvic floor muscles, without which the demanding audience that seeks a stellar and satisfying performance would most certainly boo the penis off the stage.

The brain is the master control of the penis, instructing the nerves to deliver the message to the arteries to flood the penis with blood to assure a “stand-up” performance. These front-end team members have crucial functions in the preparation of the penis for the show, in order to get things rolling. On the other hand, the pelvic floor muscles are the members of the pit crew who work the back-end, responsible for maintenance of the “outstanding” performance of the penis, ensuring staying power in order to complete the act and its culmination in a loud round of applause from the enthusiastic crowd and perhaps cries for an encore.

The pelvic floor muscles are situated between the scrotum and the anus, known in medical terminology as the “perineum,” but better known in slang as the “taint,” because “it ain’t there (scrotum) and it ain’t there (anus).” Why should this nether region, located between “bottom of the balls and the butthole” garner any respect at all? Like New Orleans and Rio de Janeiro, with “checkerboard” neighborhoods boasting lavish mansions located adjacent to slum housing, so, too, this area is some very valuable human real estate that should never be sold short—for here reside the all-important cast members, the pelvic floor muscles, as well as critical-for-erection nerves and arteries.

The pelvic floor muscles form the floor of the pelvis, bridging the gap between the pubic bone and the tailbone, supporting the pelvic organs and surrounding the base of the star performer, thereby supporting rigid erections and ejaculation. If these members of the supporting cast went on strike, not only would organs plunge out of our pelvis causing us to be diapered like an infant, but also our star performer would be rendered in a perpetual state of flaccidity. He might be able to eek out a meager stand up routine, but his posture would be poor, his confidence lacking and he would be unable to finish the act to his and the audience’s satisfaction, inevitably failing.

Another muscle that works industriously behind the scenes, but gets little credit, is the diaphragm. It’s the heart and lungs that get all the respect and celebrity. The diaphragm is a crucial supporting cast member and its relationship to the lungs is similar to the relationship of the pelvic floor muscles to the penis.

The diaphragm and the pelvic floor muscles have much in common. The diaphragm and the pelvic floor form the roof and the floor, respectively, of our core muscles. The diaphragm separates the chest from the abdomen, while the pelvic floor muscles separate the pelvis from the perineum. The diaphragm supports the heart and lungs that rest on top of it, while the pelvic floor muscles support the pelvic organs that rest on top of them. The diaphragm has openings for the esophagus (the canal connecting the throat to the stomach) and the vena cava (the major vein of the body) and aorta (the major artery of the body), while the pelvic floor muscles have openings for the urinary tract and rectum.

The diaphragm descends when it contracts while the pelvic floor muscles ascend when they contract. A contraction of the diaphragm decreases pressure in the chest, causing inhalation of air, while relaxation of the diaphragm causes the exhalation of air; the diaphragm thus plays a critical role in supporting the function of the lungs, and without a functioning diaphragm, we would be hard pressed to breathe. Pelvic floor muscle contraction pinches closed the urethra and the rectum, maintaining control, while pelvic floor relaxation is necessary to urinate and move one’s bowels. Aside from urinary and bowel control, the pelvic floor muscles are responsible for erectile rigidity and are the motor of ejaculation. Via external compression on the inner part of the penis, they enhance rigidity by aiding closure of veins and elevating the blood pressure within the penis so that it is sky-high—a hypertensive penis—causing bone-like rigidity and a rock-star erection. Without well-toned and functioning pelvic floor muscles, one’s sexual, urinary and bowel health suffer dramatically.

In conclusion, for the smooth and flawless functioning of our star—and for the achievement of superstar status—it is critical to have top-notch, skilled, behind-the-scenes supporting cast members. To ensure that the supporting cast members do their best, they need to be well taken care of. In the case of the pelvic floor muscles, targeted exercise makes for a happy, healthy, and hard working support team—one that can go a long, long way in enhancing the capabilities of our star and preventing his performance from going south. Without the help of such a supporting cast, stellar status would be impossible to achieve.

The reason that the Oscars always run overtime is because the winning stars take endless minutes thanking everyone on their team, knowing they could never have risen to fame and glory without them!

Bottom Line: No penis “is an island,” and “it takes a village.” Respect the “pit team” that works behind the scenes to keep the penis performing like a star. Exercise is the best medicine, and pelvic floor muscles can and should be worked out just like other muscles of the body in order to achieve pelvic fitness. The Private Gym pelvic floor instructional DVD and resistance training equipment will give you the means of keeping the pelvic floor muscle support team in tip-top shape and help to ensure an impressive performance!

 

Andrew Siegel, M.D.

http://www.AndrewSiegelMD.com

 

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

www.healthdoc13.wordpress.com

 

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; available in e-book (Kindle, iBooks, Nook, Kobo) and paperback:

www.MalePelvicFitness.com

 

Private Gym website for pelvic floor instructional DVD and resistance training equipment: www.PrivateGym.com

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10 Ways To Know That You Are Doing Your Man Kegel Exercises Properly

July 19, 2014

Andrew Siegel, MD   Blog # 163

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There has been a great deal of hubbub on the topic of pelvic floor exercises for men this past week, with the publication of a review article in the Gold Journal of Urology reviewing the benefits of pelvic floor muscle training in males:

http://www.ncbi.nlm.nih.gov/pubmed/24821468

and with Tuesday’s New York Times article entitled Pelvic Exercises For Men, Too.

http://well.blogs.nytimes.com/2014/07/14/pelvic-exercises-for-men-too/?_php=true&_type=blogs&_r=0

and with the launch this week of the first comprehensive, interactive, follow-along exercise program that helps men strengthen the muscles that support sexual and urinary health www.PrivateGym.com.

The story was carried in the NY Daily News

http://www.nydailynews.com/life-style/health/men-kegels-new-device-article-1.1869335

as well as the San Francisco Chronicle, the Atlanta Journal Constitution, the Tampa Bay Times and many other media outlets, including Live With Kelly and Michael and Doctor Radio.

There has been some misinformation regarding the proper technique of pelvic floor muscle exercises, and I would like to set the record straight. On one of the radio shows I listened to, it was stated that kegel exercises are akin to “pushing down, grunting and doing the Valsalva maneuver (medical term for pushing and straining).”  The truth of the matter is that kegel exercises involve pulling in and up without grunting, just the opposite of straining. One strains to move their bowels, whereas when one kegels they accomplish the opposite—tightening up the sphincters to NOT move their bowels; in fact, doing kegels is a means of suppressing bowel as well as urinary urgency.

In the 1940’s, gynecologist Dr. Arnold Kegel popularized pelvic floor muscle exercises for females—particularly for women who had recently given birth—in order to improve urinary and sexual health. But Kegel exercises are NOT just for the ladies. Men have the same pelvic floor muscles as do women and they are equally vital for sexual and urinary health. The pelvic floor muscles form the floor of the all-important “core” group of muscles and contribute strongly to men’s ability to have control of their bladders and colons and are play a crucial role in erections and ejaculation. The pelvic floor muscles are what allow the blood pressure in the penis at the time of erection to be sky high—way above systolic blood pressure—allowing for bone-like rigidity. These muscles are also the “motor” of ejaculation.

Doing Kegel exercises properly is fundamental to reaping the benefits derived from getting your pelvic floor muscles in tip-top shape. So how do you know if you are contracting the pelvic floor muscles properly?

  1. You know you are doing your Man Kegels properly when you see the base of your penis retract inwards towards the pubic bone as you contract your pelvic floor muscles.
  1. You know you are doing your Man Kegels properly when you see the testicles rise up towards the groin as you contract your pelvic floor muscles.
  1. You know you are doing your Man Kegels properly when you place your index and middle fingers in the midline between the scrotum and anus and contract your pelvic floor muscles and you feel the contractions of the bulbocavernosus muscle near the scrotum and the pubococcygeus muscle towards the anus.
  1. You know you are doing your Man Kegels properly when you can pucker your anus (not the gluteal muscles) as you contract your pelvic floor muscles. As you do so, you feel the anus tighten and pull up and in.
  1. You know you are doing your Man Kegels properly when you get the same feeling as you do when you are ejaculating as you contract your pelvic floor muscles.
  1. You know you are doing your Man Kegels properly when you touch your erect penis and feel the erectile cylinders surge with blood as you contract your pelvic floor muscles.
  1. You know you are doing your Man Kegels properly when you can make the penis lift up as you contract your pelvic floor muscles when you are in the standing position.
  1. You know you are doing your Man Kegels properly if you can stop your urinary stream completely when you contract your pelvic floor muscles.
  2. You know you are doing your Man Kegels properly if you can push out the last few drops of urine that remain after completing urination when you contract your pelvic floor muscles
  3. You know you are doing your Man Kegels properly ifafter doing a pelvic floor muscle training regimen you start noticing improvements in erectile rigidity and durability as well as better quality ejaculations, ejaculatory control and improvement in urinary control.

Andrew Siegel, M.D.

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

www.healthdoc13.wordpress.com

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; available in e-book (Kindle, iBooks, Nook, Kobo); paperback now available:

www.MalePelvicFitness.com

Private Gym website where pelvic floor instructional DVD and resistance training equipment are now available:

www.PrivateGym.com

 

 

 

He Tried to Put the Soul Back in Medicine

July 12, 2014

Andrew Siegel MD Blog # 162

Dr. Arnold Relman died of melanoma on his 91st birthday on June 22, 2014. For 23 years he had been the editor of the New England Journal of Medicine. He was a man of strong convictions and an extremely outspoken individual who cared deeply about the “soul” of American medicine, which he thought had been compromised and violated because of economic concerns.

He was an ardent opponent of the profit-driven American health care system that he referred to as the “medical-industrial complex,” a multibillion-dollar business that he criticized for caring more about finances than for the sick. In 2002 he wrote a scathing article in The New Republic exposing Big Pharma for spending more resources on advertising and lobbying than on research and development. He also targeted profit driven hospitals and nursing homes, diagnostic laboratories, home care services, kidney dialysis centers.

He claimed “the private healthcare industry is primarily interested in selling services that are profitable, while patients are interested only in services that they need.” He first expressed his opinions on the economics of healthcare in 1980 and when interviewed in follow-up more than 32 years later in 2012 he observed, “medical profiteering had become even worse than he could ever have imagined.”

His proposed solution was a single-payer affordable insurance system financed by taxes—similar to Medicare—to replace the hundreds of private, high- overhead insurance companies, which he referred to as “parasites.” To control costs, he recommended that doctors be salaried rather than paid on a fee-for-service basis. He viewed Obamacare as a means of increasing health care access, but a very incomplete reform at best.

He stated “Many people think that doctors make their recommendations on the basis of scientific certainty, that the facts are very clear and there is only one way to diagnose or treat an illness. In reality, that’s not always the case. Many things are a matter of conjecture, tradition, convenience and habit. In this gray area, where the facts are not clear and one has to make certain assumptions, it is unfortunately very easy to do things primarily because they are economically attractive.”

Dr. Relman was responsible for requiring authors to disclose financial conflicts of interest—such as stock ownership or being employed as a consultant to the pharma company or device company that put out the product that was the subject of the article—that could and would affect the conclusions of the study. What he originated has become standard practice among peer-reviewed journals

He graduated at age 19 from Cornell University with a degree in philosophy and received his MD from Columbia at age 22, a brilliant, principled man with ethical ideals and a profound interest in public health and the absolute need for our health care system to be purified of tainted commercial interests.

Much if the information from this blog was obtained from the obituary of Dr. Relman written by Douglas Martin and published in the New York Times on Sunday, June 22, 2014.

Andrew Siegel, M.D.

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

www.healthdoc13.wordpress.com

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; available in e-book (Kindle, iBooks, Nook); paperback coming soon!

www.MalePelvicFitness.com

 

Bicycling and the Bedroom: Boom or Bust???

July 4, 2014

Please note that although the discussion that follows is specifically about cycling, it is relevant to any activity that places prolonged pressure on the saddle region of our bodies, including motorcycle, moped, and horseback riding. Also please note that this blog was published in an abridged version in the July 2014 edition of Masterlink, the newsletter of the Bicycle Touring Club of North Jersey.

Historical Trivia: Hippocrates reported sexual dysfunction among the wealthy residents of Scythia and judged excessive horseback riding to be the culprit.

Indisputable Fact: When sitting on a saddle, one places a much greater amount of body weight on the perineum (area between the genitals and anus where the genital blood and nerve supply lives) than one would otherwise, putting anatomy that is usually well protected into a vulnerable situation. The million-dollar question is whether or not this has the potential for a permanent injury.

Bottom Line: Cycling is an enjoyable recreational sport that provides a fabulous low-impact aerobic workout. It can result in outstanding cardiovascular health and fitness, the achievement of which is beneficial to sexual health. However, unlike running or swimming, cycling necessitates human interfacing with machine and contact points between the cyclist and the bike; these include the hands (on handlebars), feet (on pedals) and perineum (on saddle). Long distance cycling—in which prolonged time is spent in the saddle—can potentially adversely affect sexual function by causing compression trauma to the nerves, blood vessels, and muscles that support genital health and sexual function in both men and women.

As shocking as it seems, the male and female genitals are much more similar than one might imagine, as they share a common embryological origin. In embryological terms, the penis and the clitoris are the same structure, as are the scrotum and outer labia. The female is the default model that develops in the absence of testosterone; however, in the presence of testosterone, the clitoris becomes masculinized into the penis and the labia majora fuse to become the scrotum. Also virtually identical are the genital blood and nerve supply as well as the perineal muscles that support the genitals. What is different among the genders is the pelvic bone anatomy, with women having a much more open pubic arch and a wider distance between the ischial tuberosities (sit bones). Because of the perineal anatomical similarities among the genders, both men and women are susceptible to activity-related perineal trauma.

Healthy sexual functioning requires the on demand delivery of adequate volumes of oxygenated blood to the genitals. In terms of male sexual function, this penile surge of blood can occur within seconds and blood flow is increased by a factor of 40-50 times over baseline, a marvel of human engineering.1 Any compromise to blood flow may adversely affect a man’s ability to obtain and maintain an erection. With regard to female sexual function, blood flow compromise can negatively impact the ability to attain clitoral engorgement and vaginal lubrication.

The following is a simplified version of what happens in an arousing sexual situation, important foundational information for understanding why prolonged time in the saddle may potentially compromise sexual function. Under erotic circumstances, genital nerves release chemical mediators that increase arterial flow. Blood floods into the genitals and engorgement of the vascular sinuses of the penis and clitoris occur. As the process continues, the penis and clitoris become increasingly rigid. The bulbocavernosus and ischiocavernosus muscles of the perineum engage, their contractions further supporting penile and clitoral rigidity. In the female, the increased blood flow results in lubrication to the vagina. At the time of orgasm, the perineal muscles in both men and women contract rhythmically and in the male they facilitate ejaculation by propelling semen through the urethra.

Every tissue of our body is reliant on the nervous and the vascular systems for proper functioning. The nervous system is the electrical circuitry that provides sensation to touch, the ability for muscles to contract and thus motion, and the message to blood vessels to change in diameter. The vascular system is the lifeline of blood vessels that bring oxygen and nutrients to our tissues. The pudendal nerve is the main nerve of the genitals and is situated in the perineum. It provides sensation to the penis and clitoris, scrotum and labia, anal area and perineal skin, as well as motor function to the perineal and pelvic floor muscles. If the pudendal nerve gets traumatized it can cause numbness, a “pins and needles” sensation, and altered functioning of the perineal muscles. The pudendal artery is the main artery of the genitals and is also situated in the perineum, providing blood to the penis and clitoris, scrotum and labia, perineum and anus. It, too, must function properly as it is vital for sexual health.

Prolonged time in the saddle can compress and thereby “stun” the pudendal nerve and artery and can traumatize the perineal and pelvic floor muscles that support sexual function and are essential for penile and clitoral rigidity. Furthermore, the internal aspect of the penis and clitoris (the “root”) is anchored to the pelvic bones and is also subject to perineal compression as is the scrotum in men and the labia in women. The downward force of the cyclist’s weight while tilting forward on the saddle generates extreme pressure on the perineum that pinches the pudendal nerve and artery against the pubic arch.2 Both the duration and the magnitude of compression are factors in determining the degree of pudendal nerve and artery trauma.3 Pressure maps of the perineum demonstrate particularly high pressures on the saddle nose, under the cyclist’s pubic bone.4

Further compounding the issue is that there is a “steal” of blood flow from non-essential areas (including the genitals) to the muscles that are being utilized for the sport—in the case of cycling, the lower extremities being responsible for most of the work. Between the compromise to the penile and clitoral blood flow and the nerve supply, the direct effect of the compression of the perineal muscles and roots of the penis and clitoris, and the steal, there is a perfect storm for sexual dysfunction.5 Moreover, many cyclists are lean and their paucity of body fat does not provide much padding and insulation that could potentially offer some relief from saddle pressure. Over time, with repeated perineal stress to the pudendal nerve and artery, perineal muscles, and penile/clitoral roots, permanent damage may lead to sexual dysfunction.

Cycling-induced sexual dysfunction is a complex issue with multiple factors involved including the specifics of the geometry and hardness of the saddle, the anatomical variations of the individual, the amount of time spent in the saddle, the weight of the cyclist, the intensity of the cycling effort, and the particular style of sitting, which is nuanced and variable. Greater saddle width and the absence of a saddle nose have been demonstrated to be the most important factors in preventing arterial compression.6 If the saddle is not wide enough to support the ischial tuberosities (sit bones), then body weight is borne by the perineum. The wider saddles provide greater surface area that may allow the ischial tuberosities to bear more of the body weight.7,8 To reduce perineal compression, the back part of the saddle should be at least as wide as the distance between the two ischial tuberosities.9 However, too wide is no good because it may chafe the inner thighs. It is important for a saddle to be flat enough because if there is too much curvature, the center of the saddle can push up on the perineum and cause compression.

In addition to wide enough and flat enough, it is important that a saddle is firm enough. Gel saddles actually cause more trauma than unpadded saddles by virtue of the body sinking into the soft padding and the saddle thus squishing up into the perineum.10 The reduced surface area of saddles with a narrow cutout can actually increase the extent of the perineal pressure11 (on the edges of the cutout); however, for those cyclists who find that if they have a saddle that is sufficiently wide, flat and firm yet remains uncomfortable, they may need a cutout to help relieve some of the perineal discomfort.4

A horizontal or even downward-pointing saddle position has been associated with reduced perineal pressure.12 Heavier riders exert more pressure on their saddles than lighter riders.13 Lower handlebars may exacerbate perineal stress by forcing the rider to lean forward, putting more body weight on the perineum.14 Schrader15 did a study of male police officers recruited from several U.S. metropolitan areas who spent many hours a week in the saddle, testing the effectiveness of no-nose ergonomic saddles. After 6 months in a no-nose saddle, there was a significant reduction in saddle contact pressure with the perineum, improvement in penile sensation and better erectile functioning.

As a cyclist goes from sitting upright to the bent over aerodynamic position, the torso and pelvis rotate forward and the ischial tuberosities are lifted off the saddle surface, shifting more weight onto the perineum.4 This is clearly a superior position for time trials and triathlons, but inferior for one’s genital health. On the other extreme, when standing on the pedals, there is no perineal pressure and studies have shown that genital oxygenation is significantly increased.16,17 Interestingly, professional cyclists place less pressure on the saddle and appear to “float” over it.6 Mountain bikes have been associated with a greater degree of sexual dysfunction than road bikes,18 likely because of the additional perineal hammering and vibrational trauma from cycling over rough terrain; however, this is balanced to some extent by the use of suspension mechanisms, the increased time spent out of the saddle and more frequent dismounts.

The sexual dysfunction that may occur after a prolonged bike ride is often temporary, but can potentially become permanent if the perineum is subjected to chronic, sustained and repeated pressure trauma. It is much less likely to occur with recreational weekend cyclists and commuter cyclists who do not log in significant miles and more likely to occur in serious road cyclists and mountain bikers. It is estimated that 5% of men who cycle intensively have moderate to severe erectile dysfunction, and the number may be higher because many men are too embarrassed to discuss the issue or fail to make the connection between cycling and the resultant ED.13 Female cyclists have not been studied as closely as have male cyclists, but clearly cycling is potentially hazardous to a woman’s sexual health. Studies have shown that women cyclists as opposed to runners had significantly higher genital vibratory thresholds (reduced sensation) of the clitoris, perineum, vagina and labia.19

The first clue that trouble may be lurking is unusual sensations including genital numbness and tingling, symptoms commonly experienced by cyclists, correlating with time spent in the saddle.20 These are signs to shift position and perhaps assume a standing posture on the pedals to allow the symptoms to subside. Frequent subtle adjustments by shifting and shimmying and making an effort to sit on the ischial tuberositiesare helpful. Other measures one can take are wearing well padded cycling shorts and investing in a well-fitted seat tailored to the specifics of one’s anatomy. The saddle needs to be carefully adjusted and fine-tuned in terms of height and angulation to minimize perineal pressure

Dr. Arnold Kegel popularized pelvic floor muscle exercises in order to improve female sexual and urinary health after childbirth; his legacy lives on in these exercises that bear his name—Kegel exercises. Men have essentially the same pelvic floor muscles that women do and an equivalent capacity for exercising them, with a parallel benefit to urinary and sexual health. Cyclists can tap into their pelvic floor muscles to pump some “life” back into their compromised genitals after a long ride.5 Similar to using a bike pump to inflate tires so that they are well pressurized, with each contraction of the pelvic floor muscles, blood pumps into the genital tissuesto help “resuscitate” them. Performing Kegel exercises on a regular basis can help prevent perineal compression trauma by building bulbocavernosus and ischiocavernosus muscle strength and tone. Pelvic floor muscle exercises performed before, during and after cycling can help mitigate compression trauma. Most cyclists will periodically take a break from sitting in the saddle by standing up—this provides a perfect opportunity to take the pressure off the perineum and to do a few pelvic floor muscle contractions to restore genital blood flow.

Long distance cyclists may benefit from using oral medications for ED—including Viagra, Levitra, Cialis, and Stendra—to help maintain genital blood flow and oxygenation.21   These medications increase genital blood flow in both genders, and although research has only been reported in male cyclists, on a physiological basis there is no reason to believe why they would be any less effective in females.

Keys To Reducing Risk For Sexual Dysfunction

  1. Wear well padded cycling shorts.
  2. Be proactive—shift from sitting to standing every 10 minutes or so.
  3. When numbness and tingling occur, shift into an alternative position on the saddle and/or stand on the pedals.
  4. Sit back firmly on your ischial tuberosities and not on your perineum—as you shimmy from the saddle nose (which can really dig into your perineum) towards the back of the saddle (where you sit on your ischial tuberosities), you can feel your body engage properly.
  5. Invest in an ergonomic bicycle saddle tailored to the nuances of your anatomy—make sure it is wide enough to support your sit bones, firm enough so that your perineum doesn’t sink and flat enough so that you don’t slide and that it doesn’t wedge up under the perineum.
  6. Adjust seat and handlebar height and angle to minimize perineal compression.
  7. Do pelvic floor muscle contractions periodically while cycling and pelvic floor exercises when not cycling.
  8. If you start having sexual issues, seek help pronto…help is available!

Final word: Cycling is an awesome sport that occasionally may contribute to male and female sexual dysfunction, especially for serious cyclists who spend prolonged time periods in the saddle. Pay careful attention to your perineum, very valuable human real estate that contains structures that are vital to sexual health.

About the author: Andrew Siegel (www.AndrewSiegelMD) is a physician in practice at Hackensack University Medical Center who is board-certified in urology and female pelvic medicine/reconstructive surgery. He is a recreational cyclist who is a member of Bicycle Touring Club of North Jersey and is the author of three books, the most recent being Male Pelvic Fitness: Optimizing Sexual and Urinary Health. (www.MalePelvicFitness.com)

References

1. Pauker-Sharon Y, Arbel Y, Finkelstein A, et al. Cardiovascular risk

factors in men with ischemic heart disease and erectile dysfunction.

Urology. 2013;82:377-380.

2. Nanka O, Sedy J, Jarolim L. Sulcus nervi dorsalis penis: Site of

origin of Alcock’s syndrome in bicycle riders? Med Hypotheses

2007;69:1040–5.

3. Mackinnon SE. Pathophysiology of nerve compression. Hand

Clin 2002;18:231–41.

4. Damon Rinard: The Four And A Half Rules Of Road Saddles

http://www.cervelo.com/en/engineering/ask-the-engineers/the-four-and-a-half-rules-of-road-saddles-.html

5. Siegel, A. Male Pelvic Fitness: Optimizing Sexual and Urinary Health. Rogue Wave Press; 2014:55.

6. Schwarzer U, Sommer F, Klotz T, et al. Cycling and penile oxygen pressure: The type of saddle matters. Eur Urol 2002;41:139–43.

7. Lowe BD, Schrader SM, Breitenstein MJ. Effect of bicycle saddle designs on the pressure to the perineum of the bicyclist. Med Sci Sports Exerc 2004;36:1055–62

8. Munarriz R, Huang V, Uberoi J, et al. Only the nose knows: Penile hemodynamic study of the perineum-saddle interface utilizing saddle/seats with and without nose extensions. J Sex Med 2005;2:612–9.

9. Colpi GM, Contalbi G, Ciociola E, et al. Erectile dysfunction and amatorial cycling. Arch Ital Urol Androl 2008;80 (3):123-6.

10. Sommer F, Goldstein I, Korda JB. Bicycle Riding and Erectile Dysfunction:

A Review. J Sex Med 2010;7:2346-2358

11. Rodano R, Squadrone R, Sacchi M, et al. Saddle pressure distribution in cycling: Comparison of saddles of different design and materials. Proceedings of the XXth International Symposium on Biomechanics in Sports 2002:606–9.

12. Spears IR, Cummins NK, Brenchley Z, et al. The effect of saddle design on

stresses in the perineum during cycling. Med Sci Sports Exerc 2003;35:1620–5.

13. Blakeslee, S: Serious riders, your bicycle seat may affect your love life.

http://www.nytimes.com/2005/10/04/health/nutrition/04bike.html?pagewanted=all&_r=

14. Handlebar level can affect sexual health of female cyclists.

http://www.sciencedaily.com/releases/2012/07/120709121626.htm

15. Schrader SM, Breitenstein MJ, Lowe BD. Cutting off the nose to save the penis. J Sex Med 2008;5(8):1932-1940.

16. Cohen JD, Gross MT. Effect of bicycle racing saddle design on transcutaneous penile oxygen pressure. J Sports Med Phys Fitness 2005; 45(3):409-418

17. Potter JJ, Sauer JL, Weisshaar CL, et al. Gender differences in bicycle saddle pressure distribution during seated cycling. Med Sci Sports Exerc 2008;40:1126–34.

18. Dettori JR, Koepsell TD, Cummings P, et al. Erectile dysfunction after a long-distance cycling event: Associations with bicycle characteristics. J Urol 2004;172:637–41.

19. Guess MK, Connell K, Schrader S et al. Genital sensation and sexual function in women bicyclists and runners: Are your feet safer than your seat?

J Sex Med 2006;3:1018–27.

20. Andersen KV, Bovim G. Impotence and nerve entrapment in long distance amateur cyclists. Acta Neurol Scand 1997;95: 233–40.

21. Sommer F. Cycling and erectile dysfunction (ED): Can sildenafil prevent hypooxygenation of the penis during cycling? Pre- Bicycle Riding and Erectile Dysfunction J Sex Med 2010;7:2346–2358