Take Care of the Skin Down there!
Managing saddle sores, anal fissures, and fistulas and how pelvic health physical therapy can help.
If you saw my posts earlier this week you saw that I rode my mountain bike for the first time in >3 years. It was everything I could have hoped for. The ride started cool as the sun burned off the morning fog. As I got on the trials it warmed up and I could feel the sweat and dirt coating my skin. I cautiously made my way around some rocky single track initially dismounting at the first big obstacle. Three years is a long time and my confidence started low. By the end I was cruising through rock gardens, clearing logs, and easing off the brakes on some nice descents. When I got home, I was smiling ear to ear and mentally planning a week-long bike back trip (that will not happen, but it was fun to think about). My legs felt just the right amount of wobbly and my butt was sore. I immediately showered and changed my clothes because sweaty shorts + dirt + prolonged reduced blood flow from sitting in a saddle+ bacteria = recipe for multiple uncomfortable pelvic floor issues. The takeaway from this blog/post is don’t ignore your saddle sore.
Riding bikes has so many amazing health benefits. For me, mountain biking is better than any meditation. I am so focused on the trail and the line that very few thoughts can break through. It is low impact, improves cardiovascular health, improves strength, exposes you to nature and sunshine, and so much more. There are, however, some uncomfortable sides to cycling. A bad bike fit can leave you with back, hip, neck, shoulder, hand, and foot or basically pain anywhere. In addition, your rectum and urethra, the two exit points of waste, are covered in tight shorts for extended periods. You also have thousands of hair follicles and glands that can be entrance points for bacteria. Add in the movement of the tissue with every pedal stroke and you are creating an opportunity for tissue tearing and/or potentially helping those pesky microbes work their way into the tissue where they can wreak havoc. I have personally experienced my share of infected hair follicles, rectal fissures, and hemorrhoids. I also know people who ended up with rectal abscesses that progressed to rectal fistulas. A fistula is an abnormal connection between organs. The abscess and infection damaged the tissue so significantly that they created a connection from the external tissue to the rectum. How did they let it get that bad? Likely, for a number of reasons.
First, the athlete mentality is to push through the pain.
Second, embarrassment about the nature of the pain.
Third, no one talks about these serious complications!
Fourth, shaming from other cyclists for taking time out of the saddle for a little saddle sore (reality check, it can be so much more than a saddle sore).
So, let’s stop all this nonsense. Let’s talk about these potential complications and not shame our friends when they need some time out of the saddle to heal.
As a physical therapist, I love prevention so Let’s start with prevention talk.
1) Get out of those dirty clothes when your ride is over! If you are doing a multi-sport event or a really long ride, stop and change your shorts! I started my triathlon career sitting in the same shorts from swim to bike to run and my skin suffered! I was a good athlete, but I wasn’t racing for any Olympic medals. Taking that extra 30 seconds to change shorts was so worth it.
2)Get a good pair of shorts. There are shorts made for male and female anatomy and they provide cushioning in different areas. Find a pair of shorts that are tight but not uncomfortably tight. Going to a cycling-specific shop and talking to a salesperson can help you identify which brand short might fit your build the best. Locally I love Mystic Cycle Center in Mystic CT.
3) Gradually build into your long rides. If you slowly increase your mileage it is much easier to identify and treat areas of pain. If for example, you are experiencing pain on your left sit bone and not on your right, you are potentially sitting harder on your left side. This could be a pelvic alignment issue, a biomechanical issue with your pedal stroke, or a bike fit issue. All of which can be addressed. If you continue to ride with that pain, you may be restricting blood flow to the area potentially leading to tissue injury and making yourself susceptible to infection. You are also likely moving to reduce the pain and you can cause other injuries from these reactive movement patterns. A good bike fit or physical therapy evaluation from an experienced cyclist (like me J) could be really beneficial.
4) Don’t ignore the sore spots! Generally, just keeping the area clean and dry and giving it time to heal if there is tissue damage is sufficient. If there is a breakdown in the skin, use a topical cream to prevent infection. I use a homeopathic anti-microbial ointment on all minor cuts that have calendula for tissue healing and olive oil for its anti-microbial properties. There are many pharmaceutical and homeopathic over-the-counter options to choose from. If your saddle sore is not getting better tell your doctor. If you are experiencing increasing pain, redness that is spreading, pus, or the tissue is hot those are all signs of infection and should not be ignored.
Treatment
If your saddle sore has not healed with rest and over-the-counter medication your medical treatment will vary depending on what you are experiencing. The following are some possibilities. I am not a medical doctor, so this information comes from experience and research and is not medical advice or all-inclusive of treatment options.
1) If the saddle sore or infection has progressed it may require draining and treatment with systemic antibiotics to prevent the infection from spreading. You should always complete the full round of antibiotics! Taking them until you feel better and then stopping contributes to the development of antibiotic-resistant organisms! If you are on an antibiotic, you can also talk to your doctor about supporting your digestive health with probiotics and nutrition as you will be taking out a lot of the good bacteria with the bad. Still much better than ending up septic with a systemic infection!
2) Anal fissures are tears in the anal sphincter. They can become chronic because there is a nearly constant tension in the tissue. Cycling contributes even more to that tension. Treatment options to heal from anal fissures include time out of the saddle, keeping the stool soft via diet and stool softeners, and relaxing the rectal and pelvic floor muscles via medication and/or muscular injections. I think a nice adjunct would be pelvic floor physical therapy. Many people unknowingly have hypertonic (overly contracted) pelvic floor muscles. Those who are in pain, like someone with an anal fissure, often have higher pelvic floor tension. Manual techniques to reduce the tension in the tissue and manual and electronic biofeedback can be very effective at reducing the tension in the system to allow the fissure to heal and potentially prevent future fissures from forming. Recent research also supports the use of pelvic floor physical therapy for anal fissures.
In extreme cases, a fissure will require surgery where they may make an incision in the sphincter to reduce the tension. It often helps it heal but can lead to incontinence later in life. Just another plug for pelvic floor physical therapy. If you have an injury to the anal sphincter learning how to optimize all the muscular systems involved in pooping can reduce the chance of becoming incontinent. Education on nutrition, bowel health, and having strong and coordinated secondary supporting structures (abdominal muscles and pelvic floor muscles) can be beneficial.
3) Fistulas. Well folks this is starting to get out of my wheelhouse, but I will discuss a few of the treatment options so you understand how serious these are. Fistulas can be very challenging to treat and almost always require surgery. So refer back to all the above points to not end up here. Surgery options include a fistulotomy where they cut the fistula open to allow it to heal. A second option is using a seton, which is a piece of thread that is left in the fistula to keep it open so it can drain and heal. A seton usually requires multiple surgeries with tighter and tighter setons to slowly cut through the fistula. A third technique is a flap procedure which is used when the fistula passes through the anal sphincter. Here the fistula is cut and scraped out and the hole in the anal sphincter is covered with a flap of tissue taken from the rectum. Other options include sealing the fistula with fibrin glue, laser, or ablation (and electrode burns the skin closed).
Here are some additional links on treating anal fissures and fistulas
So that was a lot, but the main takeaways are:
Take care of the skin down there!
Tell someone at the first sign that something is not healing right
Don’t make fun of your cycling friends or shame them for not riding because of a saddle sore. It may very likely be a lot more than just a sore.
Thank you so much for reading!
Happy riding!
Happy pelvic floors!
