by Richard Ellin, MD, FACP
Question: I’m a 37-year-old cyclist. Next year 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, when my riding was reduced (and stopped completely in November and December), my “going issue” completely cleared up. At the end of the season, I got fitted for a new saddle in hopes that I could go into next year 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 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 his bowel problems, but unless it heals fully in the early stage, it can become a chronic problem. I suspect it was not fully healed when the symptoms initially went away, and it became aggravated by resuming cycling.
According to UpToDate, 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 his continued cycling is a contributing factor, but it is something he should question his physician about.
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 more than 26 years. He is also an avid cyclist.
I had this same thing happen. Had the surgery stayed off my bike for 2 weeks +. Started Regular long distance cycling. Year later bike toured across Canada with no problem. Don’t use any saddle cream. So yes you can heal an move on from this. Although 5 years before that I experienced bad saddle pain while on a 6 week bike tour in Austria. There the doctors I saw gave me pain killers an cream. Finished tgat trip. With no other saddle pain.
Hi Chris,
Really pleased to hear this. I have had a couple of operations for a chronic fissure including Botox injections as well as other interventions.
The latest op was 3 weeks ago and I am looking to get back on my bike to resume my Ironman training.
I am nervous as to what the effect will be but need to give it a go. I know It is a psychological issue as well as physical I have done a 3 mile run a few days ago and been swimming yesterday but the bike is still the one causing me the most concern.
I guess I need to give it a try.
Chris, why do you recommend not using saddle cream? I assume you mean a product like Assos.
Hi,
I also have a chronic fissure. For over 20yrs!! Had op about 10 yrs ago, but no joy. Have tried all the creams they recommend ( gtn, diltiazem), no joy. Now awaiting sigmoidoscopy and Botox injection. I too cycle a lot, but believe now this aggravates it ( fine on cycle, but following day flares up). Unable to keep
It under control now. My advice is ensure it’s completely healed before cycling, then build slowly and maintain a good fibre rich diet. One hard stool or constipated and could be back to square one. Believe it’s lifelong managing after healing.
Good luck
I dealt with a fissure initially misdiagnosed internal hemorrhoid in April – the symptoms are very similar. I was completing about 100-120 miles a week Peleton cycling from February through May. The pain (sharp, excruciating and burning) continued despite various treatments (lidocaine and increased fiber) and a colonoscopy confirmed the fissure. I saw a rectal surgeon in July who performed a lateral sphincterotomy which I’m told had the highest success rate for a chronic fissure. So far the bowel movement pain and post burning has subsided considerably and my life is returning to more normal… eating more, not afraid of a bathroom visit and more prepared to be away from the home. While fiber is essential, more so is what type and not loading up too fast. Plenty of water is critical when upping the fiber intake. I took a fiber supplement early on but stopped after 3 weeks since there were too many bathroom trips and for the fissure to heal more than two I won’t help the recovery. I returned simply to an all bran cereal and fruit breakfast and green vegetables/fruit everyday as additional fiber… since then it’s worked very well. I’m skeptical about the bike right now although dying to get on it. The recovery is about 8 weeks or so and I’ll try then with a gradual introduction based on the surgeons opinion and advice. I don’t think cycling caused my fissure but once the pain was there I’m sure I didn’t help it with continued riding. What I will say is don’t be afraid of seeking a specialist in this field … surgery doesn’t hurt and the pain is less after a week than prior.
I hope to avoid that surgery, getting my first botox injection soon. I guess I will stay off the bike for about 8 weeks. That is when the botox is the most active and that should be a good timeline for the fissure to heal.
I am a bit afraid of the LIS treatment, They say the chance of getting incontinent is very slim. But it would be difficult to measure the difficulties you face at an age of 70 or 80. Are you wearing a diper because you are old or is this 5-10 years earlier because of your LIS treatment? I bet the statistics fail to cover it since proof would be hard to gather.
Hope you are doing well
Great article and comments, Thank You!
I have been a competitive triathlete, surfer, cyclists and raced MTB for over 45 years now.
My pain was so severe that I had surgery at 11pm last New Years Eve at a great hospital in Managua, Nicaragua. The abscess had ruptured and was causing high fever and excruciating headaches. Since it was urgent they didn’t have time to drain and heal before doing the surgery and they just operated on the abscess and not the fistula. I healed very well and was back surfing within 2 weeks and running/yoga/tennis within 4 weeks and cycling within 8 weeks. Due to COVID my training has been somewhat limited but very consistent yoga/mtb every single day.
Last month an abscess returned with a vengeance (Saturday morning I was comfortably riding and that night rushed to the hospital) and we rushed to the hospital in San Jose, Costa Rica where they drained the abscess and put me on antibiotics for a week before operating on both abscess and fistula. I am 2 weeks into recovery after the surgery now and taking things slower than last time. The Dr said I could even get on the bike after 2 weeks but I plan to wait longer.
Both Surgeons said this had nothing to do with cycling. However, my dermatologist in San Jose, Costa Rica is also a cyclist and says he has seen a high percentage of his cycling patients with this same ailment, including his son in law who races professionally. He claims it is higher for MTB cyclists as there is more chance of getting dirty and infection. He recommended I get fitted for a seat to help prevent future problems.
I do have two other close friends with the same ailment, neither are cyclists but both are surfers.
Hope this helps others and would love to hear feedback.
Hi I have been diagnosed and awaiting treatment for an abscess and fistula how are you getting on
I did spin for 2 years and loved it. I had a fissure and a fistula and had surgery.
I have had diviticultis as a baby and had part of my Intestines removed,
I always have had bowel issues and have yet to heal.
If I ride my bike I feel bad pain in hours,
Chafing and cream needed. I feel your pain. Looking for suggestions too
I strongly recommend reading this book on healing anal fistulas naturally, it’s only 10 bucks on Amazon.
“How My Anal Fistula Healed Naturally: No surgery, seton, or magical herbs “https://www.amazon.com/dp/B07T2JTFRZ/ref=cm_sw_r_cp_api_0U-EFbEH4GZWB
I’ve been dealing with a chronic anal fistula/fissure for 4 months. After following the instructions in the book for 3 days and I feel better than I’ve ever felt in months. I can feel my body healing more each day.
The basic idea from the book was to do the following:
1. Ensure max of one non-constipated trip to the bathroom every day around the same time(requires diet lifestyle changes).
2. After each Bowel movement, make sure the area is 100% and disinfected! The problem is bacteria creeps into the fissure or fistula and causes infection, swelling and abscess. Causing it to be in this endless cycle and never healing. So it’s important to make sure it’s sparkling clean. The author recommends douching after each bowle movement to get everything out. Then apply an antibacterial ointment such as Neosporin inside the anus and in the case of fistula on the outside area too if it’s draining.
3. Stress reduction, this will be different for everyone. But the idea is to look I inward at what’s causing the most stress and come up with a plan for dealing with it. Weather it be yoga, counseling, therapy, time management, vacation or whatever. The bottom line is that increased stress can make matters a lot worse so look at ways of reducing it.
Thanks Simeon, I just bought the book. I’ve been on a 7 month journey of yoga/meditation/wim hof/easyMTB every morning and hope that combined with the book and a new bike seat will alleviate any FF’s (future fistula)
Great to hear that there is some hope on this. I was given glyceryl trinitrate (GTN) by the doctor. The side effects right after applying the cream is unpleasant, but I hope this will help healing. The doctor prescribed using this for 8 weeks… disappointed to know this can take ages to heal. Did anyone here got fully recovered only doing this treatment?
I could notice some swelling after cycling today and that’s why I was searching for anything which relates cycling to anal fissure.
Really interesting article and so glad that I’ve found this thank you.
I found some of the recounts here really helpful for physical tips and also in the mental capacity too which is really important I think.
I’m just finishing a 9 day stint in hospital right now actually after some Ulcerative colitis complications and a fistula surgery and although I’m on the path to healing I know it will be a while to get back in the saddle properly.
I think the key is to build up slowly in terms of exercise to promote blood flow, eat and take the right intake into my body in order to lessen the chance of healing issues down there and also to really try to distress as best as possible.
I’m going to be waiting until spring i think until I start riding properly as I really don’t want to relapse.
Get a proper saddle fit too and if all goes well apply this to my bikes to ensure a good fit and blood flow.
The killer is that I’ve just brought a new dream bike and have yet to sit on it yet! Looks good though lol.
All the best everyone.
I have recently experienced pain when getting back on to my MTB and after the normal Preparation H and high fibre treatment was not working I visited a specialist who diagnosed me with a perianal abscess which had burst and was in the process of healing. I am still in pain and unable to ride without the abscess swelling. Clearly this is a situation which is aggravated by riding due to the lower blood flow into this region of the body. what surprises me is why surfers shoud be affected by these problems.
Get a appointment with a surgeon I have same problem. I have anal fistula for 6 months that drained and recovered after using antibiotics but as I stopped usin antibiotics and start cycling problems came back. I visit a surgeon who told me the permanent solution of this is fistolomy. I agreed for fistolomy and after fistolomy I rest for 7 days after 7 days I was able to walk and do my everday works but doctor told me to not walk long distance and go for work atleast 2 weeks I was completely okay in 2 weeks and my doctor ask me to not do cycling for 6 weeks. It is now more than 1 year and I am completely Well I would suggest you to opt fistolomy to get rid of this problem completely
Hi all, thanks for the tips! I had a botox injection today so hoping that will do the trick over the next couple of months! I think I’ll give cycling a bit of a break for the time being but has anyone aggravated their fissure running? I spoke to the colorectal surgeon today who said I could start taking it easy again – mentally I’m struggling with no exercise, especially given the circumstances! I am apprehensive though as a I think a run really aggravated it in December!
I’m so happy to finally find these stories, I’ve been dealing with this pain for over a year,it was misdiagnosed by multiple doctors as enlarged prostate to internal hemorrhoids. But this past month I finally found a GI doc that said it was a fissure, I’ve been put on diet change and nifedipine cream which hasn’t helped much but I have real hope after reading this thank you.
Not great to hear! Don’t want to think anyone else is having this problem. I have been diagnosed with internal hemorrhoids and chronic fissure I have appointment with surgeon soon. Unfortunately all bikes seem to cause this issue; but I think the dehydratiion is a big contribution. I am at point where I can feel it tear on rides which is uncomfortable. What works for me Is good cycling shorts,hydration,konsyl d,and rest between flare ups. Anyone recommend a decent gel saddle?
The attached link may assist those who have an abscess.My surgeon has advised me to wait at least eight weeks before bike riding.
https://www.wikihow.com/Prevent-Perianal-Abscess-from-Returning
Well I feel a whole lot better knowing I’m not alone. A web search told me I was shit out if luck (no pun intended) after months of conservative treatment bit curing my issue. Said that surgery would make me shit my pants. So I’d resolved to never see a doctor and die either passing a stool or riding my bike. But thanks to all of you being so positive and forthcoming, I think I will see my doctor again so thanks.
Thanks So grateful blog For Sharing my coment
Again, thanks for sharing everyone. I am in the UK and have suffered from a chronic fissure for a few years (which I think came on really badly after intense interval training).
I had two botox injections in 2019, which didn’t work, so then a lateral sphincterotomy in December 2019, together with banding of haemorrhoids. Healing took a while, but soon returned to normal, with no side effects. Was able to cycle normally a couple of months later.
Sadly, the fissure he recurred about 2 months ago, after just one bad toilet experience. Clearly, those of us who suffer long term like this have to accept that it is a general weakness for life.
I am booked to see a consultant again and guess I will look into seeing whether another sphincterotomy is possible. I know there is a lot of caution attached to said operation, but honestly think the risks of incontinence are more aim at very elderly, and not for the likes of people on this thread, who am guessing are in pretty good physical shape.
I am also finally going to get a proper saddle fit and try the split saddle/cut out design. I raced competitively in France in my 20s and have enjoyed riding my bike for many decades so can’t quite face the thought of giving it up yet aged 48.
Good luck all!
Four plus years of fighting. About to call it quits on the sport.
I rode 200 plus miles a week on the road and some MTB when my issue started. Fissure led to creams and eventually my first abscess. Fistula formed. This happened over a long period of time and quality of life wasn’t great. The draining, pain, sitz bath etc drove me into a dark mental place.
Decided to have a fistulotomy, months later. Scary as hell procedure. Oxycontin barely touches the pain.
Healed it up. Waited eight full months to ride. Now have another abscess. Happened immediately after a bike ride from irritation/skin breaking. Likely turning fistula. Will likely have another surgery.
It’s not worth it for me. Which is very very sad to say. I did many races a year and MTB stage races like the Breck Epic and Pisgah. It’s nothing to take lightly as you can and may end up with extreme pain and lifestyle changes. You can also end up with a lot worse issues controlling your movements.
I went to the Goldman in ATL tried all the creams. Then went to Piedmont great team but didn’t trust their knowledge. Ended up with Dr. Culumovic at Prisma in GVL SC. He was the best option in my opinion. No bullshit Dr. straight to the point. Helps you quickly decide and get your quality of life back. Healing takes months to fix anything.
Botox isn’t a solution. Haven’t tried it but the best doctors will tell you botox and fibrin plugs are a joke.
I don’t have chrons, UC, IBD. Very rarely have been constipated and not a real issue for me.
I wish all the best of luck.
Once you have an issue it is a risk/reward situation. I wish I had stopped riding years ago. Healing doesn’t seem to happen well with the low blood flow. If someone had said they could cut off three of my fingers when this started or I could have this issue; I would have let them cut off my hand.
Interesting that you say that Botox is a joke, NHS stats show that it works or 7-10 people that had the procedure. I will still give it a shot. I will combine this with at least 8 weeks off the bike, I don’t ride competitively so my sessions aren’t that long anyway.