ORIGINAL RESEARCH—PATHOPHYSIOLOGY
ORIGINAL RESEARCH—PATHOPHYSIOLOGY: Bicycle Riding and Erectile Dysfunction: An Increase in Interest (and Concern)

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ABSTRACT

Introduction

From 1999 to 2004, there had been 21 publications from multiple medical specialties (sexual medicine, urology, neurology, cardiology, biomedical engineering, sports medicine, emergency medicine, and officials from the National Institute for Safety and Occupational Health) investigating the relationship between bicycle riding and erectile dysfunction (ED). In the previous 18 years, there have been 14 such studies.

Aim

The primary aim was to summarize accumulating data on the safety of bicycle riding based on medical evidence categorized by levels of evidence, including case reports, observational studies, case control studies, mechanistic studies, and population‐based epidemiologic investigations. The secondary aim was to address the concerns of bicyclists and propose measures to minimize the risk of ED associated with bicycle riding.

Methods

An English‐language medical literature review was made of publications in peer review journals from 1981 to 2004, including published abstract presentations at major medical meetings.

Main Outcome Measure

Ranked published epidemiologic data on bicycle riding and ED.

Results

Bicycle riding more than 3 hours per week was an independent relative risk (RR = 1.72) for moderate to severe ED. In case control studies, the prevalence of moderate to severe ED in bicyclists was 4.2% and 4% vs. age‐matched runners 1.1% (P ≤ 0.018) and swimmers 2% (P = 0.05), respectively. Therefore, bicycle riders should take precautionary measures to minimize the risk of ED associated with bicycle riding: change the bicycle saddle with a protruding nose to a noseless seat, change the posture to a more upright/reclining position, change the material of the saddle (GEL), and tilt the saddle/seat downwards.

Conclusions.

The mechanism is hypothetically related to the rider interaction with the bicycle saddle at the perineum–saddle interface. Straddling bicycle saddles with a nose extension is associated with suprasystolic perineal compression pressures, temporarily occluding penile perfusion and potentially inducing endothelial injury and vasculogenic ED. Huang V, Munarriz R, and Goldstein I. Bicycle riding and erectile dysfunction: An increase in interest (and concern). J Sex Med 2005;2:596–604.

Introduction

Our group began investigating the effects of bicycling on male erectile function in the 1980s. Patients seeking treatment for their erectile dysfunction (ED) by microvascular arterial bypass surgery (penile revascularization) frequently provided a history of either blunt penile, pelvic, and/or perineal trauma [1, 2, 3, 4, 5]. A subset of these men, concerned with their ED at a young age (teens to 30 year olds), provided a history of blunt perineal trauma associated with bicycle riding. Histories associated with chronic perineal compression were obtained from avid, competitive cyclists, weekend cyclists, and stationary bicyclists. Daredevil cyclists and preteen novice bicyclists offered histories associated with acute perineal compression related to falls onto the saddle nose or bicycle bar. Over the last 20 years, there appears to be an exponential interest and concern by bicyclists regarding the development of ED.

Other researchers have had similar observations. Since 1981, and particularly in the last 5 years, numerous health‐care professionals from different disciplines, including basic scientists, epidemiologists, engineers, and physicians that included researchers from the National Institute for Occupational and Safety Health (NIOSH), have investigated the association between bicycle riding and ED. The NIOSH investigated the effects of occupational bicycling on erectile function as a result of complaints of groin numbness from concerned police officers who rode in bicycle patrol units.

The overall aim of this literature review was to summarize the accumulating medical data concerning the cause‐and‐effect association between bicycle riding and ED. In epidemiologic studies there are levels of evidence to support the existence of a relationship between two variables (bicycle riding and ED). These include case reports (lowest form of evidence), observational series or small patient series, case control studies, mechanistic studies, and population‐based epidemiological investigation (highest level of evidence). In this literature review on bicycle riding and ED, studies were ranked by level of epidemiologic evidence. A secondary aim of this literature review was to address the concerns of bicycle riders and to propose measures based on evidence‐based literature to minimize the risk of ED associated with bicycle riding.

Section snippets

Case Reports

Case reports, in general, have limited scientific validity but do represent the first line of epidemiologic association in determining cause and effect between two variables. The first case report concerning the association between perineal compression and ED was written in the 4th century bc. Hippocrates wrote that many Scythians reported being impotent because “the constant jolting on their horses unfits them for intercourse.” He continued by saying, “. . . they are the most impotent men”[6].

Observational Series

Small patient series do not have a control population for comparison purposes and thus are subject to bias. Weiss in 1985 reported penile numbness or paresthesias (81%) during an 8‐day, 500‐mile cycling tour [14]. Andersen and Bovim in 1997 studied 260 participants in the 540‐km Norwegian annual bicycle touring race. Thirty‐three of 160 responding males (21%) had penile numbness or hypoesthesia after the tour, with 10 experiencing penile numbness for more than a week. ED was reported by 21

Case Control Studies

In 1997, Salimpour presented at the American Urological Association meeting in San Diego a case control questionnaire‐based study of 738 riders (mean age 44 years) from a local Boston bicycling club compared with an age‐matched (mean age 44 years) 277 runners from a local track and field club. The prevalence of moderate to complete ED (as defined by criteria used in the Massachusetts Male Aging Study) was 4.21% in the rider population and was significantly more common (P = 0.018) than in the

Mechanistic/Pathophysiologic Investigations

Mechanistic studies are important to provide a hypothetical explanation for the pathophysiologic basis of the association between two variables. Concerning bicycle riding and ED, it is hypothesized that straddling bicycle saddles are associated with excessive perineal compressive pressures at the perineal–saddle interface. Measurements that exceed systolic perfusion pressures, which temporarily occlude penile blood flow, have been recorded [21]. It is hypothesized that in some bicyclists

Population‐Based Epidemiological Investigation

To determine the extent, nature, and spectrum of an association between two variables, the highest level of epidemiologic evidence examines data in a population of random sampled, free‐living individuals who enter the trial free of biases that typically plague case control studies. The only population‐based epidemiologic study thus far that examined the association of bicycle riding and ED was carried out by Marceau et al. in 2001. The authors of that research evaluated data from the

Discussion

Riding a bicycle is a common mode of transportation used by more than 50 million people in the United States [36] and by an estimated more than 1 billion men and women around the world. Bicycle riding is also an excellent form of cardiovascular exercise. The average MET level and caloric cost for leisure and moderate cycling is 4.0 METs and 280 cal/hour and 5.7 METs and 400 cal/hour, respectively [37]. Aerobic exercise (energy expenditure of 7.5 kcal/minute) from cycling can halve the risk of

Conclusion

The association between bicycle riding and ED has been well documented in numerous case reports [6, 7, 8, 9, 10, 11, 12, 13], observational series [14, 15, 16], case control studies [17, 18, 19, 20], and population‐based epidemiologic investigations [35]. It is believed that ED secondary to bicycling may be explained by how the rider interacts with the bicycle saddle. Straddling bicycle saddles is associated with perineal compressive pressures that exceed systolic perfusion pressures,

Conflict of Interest

None.

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