Question:

I'm a 37-year-old cyclist. 2012 will hopefully be my 3rd year of cycling. I'm contacting you today to seek help with a saddle issue that is threatening to remove me from the sport. And the thought of not being able to ride my bike is heartbreaking.

Quick history: About a year ago, I started experiencing trouble with bowel movements. Unsure as to what was causing the issue, I scheduled an appointment with my Gastroenterologist. Upon examination, it was determined that I had a fissure (a tear in my intestinal lining). Treatment consisted of dietary changes -- more fiber, more water, more veggies, etc. AND to stay off the bike for a couple of weeks. After taking time off the bike, the problem went away -- to my relief. And I made the dietary changes. However, after returning to the bike, the issue arose again. And it persisted for the rest of the season.

In October 2011, when my riding was reduced (and stopped completely in November and December), my "going issue" completely cleared up. At the end of the 2011 season, I got fitted for a new saddle in hopes that I could go into 2012 without any issues. Unfortunately, that is not turning out to be the case.

I started ramping up my training in late January and into February. I was able to get in about 40-50 miles on Saturday (group ride), an hour on the trainer on Wednesdays and spin class on Thursdays. And as the riding increased (especially after last Wednesday's TABATA style intervals for an hour on the trainer), my problem returned in full force. Needless to say I became very discouraged.

In your history, have you ever heard of riders dealing with issues like mine? I still have trouble trying to understand how riding the bike causes an issue of this nature. Based on my limited knowledge, it just doesn't make sense. If you have heard of issues of this nature, are you aware of any remedies? Wider seat, softer seat, lower the seat, move up the seat? One other thing to note: I've had a professional bike fit...but the problem was there before the fit and remained after the fit.

I really hate to let this sport go and I was really hoping to participate in my first CAT 5 race later this year. Any insights you may be able to share would be greatly appreciated. – Shane W.

Dr. Richard Ellin Responds:

Shane, what you’re dealing with is a chronic anal fissure, which is actually not that uncommon. I don’t have any evidence that it is more common in cyclists, but it is a fairly common problem. Undoubtedly it started because of your bowel problems, but unless it heals fully in the early stage, it can become a chronic problem, as it has with you. I suspect it was not fully healed when the symptoms initially went away, and it became aggravated by resuming cycling.

According to UpToDate, a clinical support system for physicians, once a tear occurs, it begins a cycle leading to repeated injury. The exposed internal sphincter muscle beneath the tear goes into spasm. This can cause severe pain, and the spasm pulls the edges of the fissure apart, which impairs healing of the wound. The spasm can also lead to further tearing of the tissue during passage of bowel movements. This cycle can lead to the development of a chronic fissure.

The site of most fissures also typically has a poor blood supply, further impairing healing. With this understanding of the cycle of events, one can speculate that cycling for hours at a time might increase the pressure on the sphincter muscle, and reduce blood flow to the area, though I don’t believe this has been specifically studied.

The goals of treatment are to relax the sphincter muscle, relieve pain, and reduce the trauma of passage of stool. The treatment is, therefore, varied, and there is no clear consensus on what is the best treatment. It can involve medications, such as topical nitroglycerin, or oral amlodipine, diltiazem or bethanechol.

These all work by relaxing the sphincter and perhaps by promoting increased blood flow. Bulk laxatives and stool softeners usually help to reduce the pressure of defecation. Sometimes Botox is helpful. In cases that don’t respond favorably to the above, surgery can be done, though often this is not needed.

Shane, my recommendation to you is to seek out the care of a physician who specializes in anorectal disorders. Successful management of his problem will probably require repeated visits over several months. I cannot say for sure that your continued cycling is a contributing factor, but it is something you should question your specialist about.

Comment

Richard Ellin, MD, FACP, is a board-certified specialist in Internal Medicine who practices in Alpharetta, Georgia. He received his medical degree and completed residency at Emory University, and has been in practice with Kaiser Permanente for 26 years. He is also an avid cyclist.