A self-limited episode of urinary hesitancy, urinary retention, dysuria, erectile dysfunction, and raised PSA level following a moderate level of road cycling.

Manneken Pis, Brussels, Belgium
Photo: Pbrundel - Own work, CC BY-SA 3.0, Link

Although ulcerative colitis is my most serious active medical problem, and irritable bowel syndrome generally my most vexing on a day-to-day basis, the most prominent health issue I had to deal with since the start of the current local COVID-19 lockdown (aka Movement Control Order, MCO) period related to my urinary and erectile function—this certainly came from left field!

My symptoms had resolved completely by the first week of April, though the lingering worry was a mildly raised prostate-specific antigen (PSA) level on April 16, 2020. I had a repeat PSA test yesterday, i.e. June 3, 2020—I’m overjoyed the level is back within the normal age-adjusted range. With my urinary tract, membrum virile, and prostate all apparently functioning normally again, I thought I’d write up the episode to record my analysis of what might have happened in and around my perineum—originating from a moderate level of cycling—that led to my woes in the past few months.

My Urinary Symptoms

I’ll first describe my urinary symptoms.

Urinary hesitancy and urinary retention

In retrospect, the first symptom was a weaker-than-normal urine stream, beginning around late February or early March 2020. Over the course of about three weeks, this became increasingly more noticeable, accompanied by other symptoms of urinary hesitancy, e.g. delay in initiating a urine stream, difficulty maintaining a stream, weak stream. Unsurprisingly, the time needed to empty my bladder was also getting longer and longer.

By March 20, 2020, the urinary flow had weakened to short, small spurts and dribbling, with incomplete emptying of my bladder. And because I couldn’t empty my bladder completely, I had to go and pee at short intervals, i.e. I had urinary frequency.

Also, my symptoms were noticeably worse overnight. For about 5 days, from March 20–25, 2020, I would invariably experience extreme urinary hesitancy, i.e. taking 5–10 minutes to even start a stream (with some straining), producing a very weak stream (so not much of a urine flow), and inability to maintain a stream even with a lot of straining. From March 21, 2020, I used a plastic container to collect the urine I passed and measured its volume. On each trip during the day, I’d consider myself lucky if I passed more than 100 mL, or 3.38 fl oz. However, the amount was even less at night and the time taken to pass that small amount felt like ages. It really felt like I was forcing my urine through a tiny pinhole. Needless to say, I didn’t get much sleep on those few nights because of the frequent trips to the bathroom and constant uncomfortable feeling of fullness in my bladder (and anxiety over the possibility of the nanoscopic hole in my urinary tract would spontaneously close for whatever reason).

This turn of events was totally unexpected—I had presumed that my mild urinary hesitancy (during the initial phase of this entire episode) was part of ageing but having such difficulties in urination was clearly abnormal for a dude in his mid-forties with no history of urological problems.

There was a point in time, perhaps on the evening of March 21, 2020, that I considered the possibility of acute complete urinary retention, especially overnight. This led me to (a) search my store room for equipment to perform a suprapubic puncture, and because I couldn’t find the right equipment, (b) on March 22, 2020, to walk to the nearby pharmacy (which did not have the equipment either). So I decided to make do with whatever gear I already had on hand in case of an emergency. Fortunately, the need for a suprapubic puncture was never called for.

Pain on urination

On those days and nights when the urinary hesitancy was severe, I also experienced pain in my perineum and glans penis during and after urination. In fact, the post-void pain was more severe (Numeric Rating Scale (NRS): 7) than that while peeing. The pain was shooting and tingling in nature, and would typically last anywhere between 30 and 60 minutes post-void.

In addition to the pain above, I also felt a sense of constant fullness in my perineum that was not relieved with urination. It was “always there” no matter how much urine I managed to pass. I suspect this sensation was from my prostate but I have no way of confirming this.

Erectile Dysfunction

From about when my urinary symptoms started, i.e. late February or early March 2020, I also had erectile dysfunction. This problem continued until my urinary symptoms completely resolved, in the first week of April 2020.

Other Relevant Information

I didn’t have a fever. I could feel my bladder only partially being emptied post-void most of the time but I wouldn’t regard this sensation as pain. The urine appeared normal—the colour looked no different to what it has been in the past several months (clear light yellow); there was no cloudiness and no change in odour. I did not see any urethral discharge.

I did not notice any genital numbness. I had no change in my bowel habit, and sensation in my rectum, anus, and perianal region was normal. I did not have any urinary or faecal incontinence.

I’ve had all sorts of medical problems in the past, but they never included urinary tract infection or kidney stones. I have never had any sexually transmitted disease (STD) and had no reason to have one at this time. I don’t have diabetes mellitus or any other endocrine or metabolic disorder.

A possible contributing factor to my urinary symptoms was the anticholinergic drugs I was taking for my irritable bowel syndrome—Liblan (chlordiazepoxide + clidinium bromide) and amitriptyline. These two drugs were unlikely to have been the cause of my symptoms—I had been taking them for more than two consecutive years—but they could have made my symptoms worse. I stopped taking both drugs on March 22, 2020. There was no improvement immediately after I stopped taking them, but my urinary symptoms did not get any worse either.

Cycling: The Elephant :elephant: in the Room

As I thought about the possible cause of my symptoms, I couldn’t help wondering the part cycling played—it was certainly uncomfortable considering if my favourite pastime was the root of my present health issues.

:small_red_triangle:During cycling, the typical bicycle saddle makes contact with the perineum and exerts a pressure effect on the underlying structures, including branches of the pudendal nerve and the internal pudendal artery. The prostate sits above the perineum and may also be affected by a transfer of force from the contact between the saddle and perineum.

Cycling log

I hadn’t done particularly much cycling before my urinary problems began. I was out of town for work in the first week of March 2020, so no cycling that week.

The following information on my cycling in the month of March 2020 was ascertained from my Strava records:

Date Distance Average Speed Maximum Speed
March 9, 2020 (MON) @23:58hrs 31.96 km 28.5 km/h 40.7 km/h
March 12, 2020 (THU) @17:22hrs 4.10 km 22.0 km/h 45.7 km/h
March 12, 2020 (THU) @18:23hrs 7.78 km 24.6 km/h 42.5 km/h
March 13, 2020 (FRI) @00:05hrs 21.16 km 25.5 km/h 43.9 km/h
March 13, 2020 (FRI) @15:24hrs 4.89 km 26.8 km/h 41.4 km/h
March 13, 2020 (FRI) @15:47hrs 5.35 km 27.4 km/h 46.1 km/h
March 17, 2020 (TUE) @00:12hrs 31.92 km 29.5 km/h 45.0 km/h
Total distance in March 2020 107.16 km    

Below are the details that explain the data in the table.

On March 9, 2020, I went on a solo night ride (31.96 km).

On March 12, 2020, I rode my Giant TCR Advanced bike to the Giant Bicycles store, which happens to also be my local bike shop (LBS), to upgrade its wheels. I chose a set of Shimano Dura-Ace R9100 C40 clinchers.

A pair of Shimano Dura-Ace R9100 C40 Clinchers were installed on my bike at Giant Bicycles Malaysia.
:small_red_triangle:A new pair of clinchers was installed on my Giant TCR Advanced on March 12, 2020.
Photo: Giant Bicycles Malaysia

In the early hours the next day (5 minutes past midnight to be exact), I took my bike out for a ride. On that ride, the plastic spoke protector on the rear wheel kept coming off—this gave an irritating rattling sound. Whenever I put it back on, it fell off after a few minutes. This didn’t happen when I rode home from the bike shop the previous day. Because of the trouble with loose spoke protector that night, I called it quits mid ride.

The reason why the spoke protector didn’t stay on was quite obvious: it was designed for Giant road wheels which have round spokes, whereas the Shimano wheels have bladed spokes.

So I took the bike to the shop the same day (March 13, 2020) to get rid of the spoke protector. This explains the numbers for March 13, 2020 in the table above.

On March 17, 2020—one day before the local lockdown came into force—I went out for a ride (and broke some personal records).

I did not sit on the saddle between March 17, 2020 and May 20, 2020, due to the lockdown (which did not permit cycling outdoors) and for fear of aggravating my symptoms. From May 20, 2020, my symptoms became noticeably worse.

Unpadded cycling shorts

On both trips to my local bike shop on March 12 and 13, 2020, I wore a pair of God & Famous commuter shorts, which are unpadded. I prefer to wear these when I’m not doing “serious” cycling because they blend in more easily than my cycling shorts. This was probably a mistake because these G&F shorts, though my favourite, don’t offer any meaningful shock-dampening protection to my perineum.

Saddle in neutral position

In the first week of March, I also fiddled with the tilt angle of my saddle, and I believe it ended up in a neutral position (i.e. zero tilt), as opposed to a slight downward forward tilt it had since February 21, 2020. A neutral position was probably too high (compared to a slightly lowered saddle nose) for my speed-oriented style of cycling, and created too much pressure on my perineum when I was in the drops (where I spend at least 80% of my time). After one ride, I tilted the nose of the saddle downwards by 2°, i.e. back to where it was originally. I cannot be sure at this time but I suspect the 2° downward forward tilt has helped to relieve pressure on my perineum, especially when I am in an aggressive position. I’m tempted to lower the saddle nose by another couple of millimetres or so.

Lower bicycle stem height

My records indicate that I dropped my bicycle stem height by 17 millimetres on February 20, 2020. (I wouldn’t have looked this up if I wasn’t writing this article.) This too was probably a contributing factor to my trouble in the perineum. I might have had a neutral saddle position previously but with the drop in my stem height, it would have been prudent to have the front of the saddle tilted downward a little to lessen perineal pressure.

Selle SMP Dynamic Bicycle Saddle

Since we’re on the topic of my bike saddle, I think I should mention some details about it. I found the saddle that came stock with my bike quite uncomfortable—my ischial tuberosities would be sore, not only during each ride, but continue to ache for a few days afterwards.

My solution was changing the saddle to a Selle SMP Dynamic on February 21, 2020. This saddle is a lot more comfy compared with the Giant stock saddle—no more pain during or after the ride.

The middle cutout of this saddle is relatively wide and long, and its heavily contoured shape acts like a car bucket seat, limiting fore and aft movement on the saddle. Therefore, it seems unlikely there would be pressure on my perineum once I’m on/in the saddle.

:small_red_triangle:Top view of my Selle SMP Dynamic Saddle. The cutout in the middle is 18 mm wide.

:small_red_triangle:Side view of my Selle SMP Dynamic Saddle. The Eagle Beak tip is designed to alleviate perineal pressure.

However, I sometimes noticed the nose of the saddle pushing against my perineum, especially when dismounting. I put this down to poor technique, which I’ve corrected since March 13, 2020. I don’t know how much injury, if any, the occasional contact with my perineum caused to the underlying structures.

Anatomy

In writing up this article, I had to review some anatomy of the male pelvic viscera and their relationship with the perineum, where the saddle comes into contact. As shown in the diagram below, there is only a small amount of space, the ischioanal fossa, between the perineum and the urethra and prostate. The ischioanal fossae (there are two; one on the left and one on the right) are essentially fat pads—based on the subcutaneous fat on my body, I cannot imagine I have much in these two regions.

Pelvic viscera and perineum of male - midsagittal section.

:small_red_triangle:Pelvic viscera and perineum of male—midsagittal section.

The following video helped me better understand the anatomy of the branches of the internal pudendal artery and the pudendal nerve, structures that may be injured with excessive or prolonged pressure on the perineum.

:small_red_triangle:Annotated anatomy video: branches of the internal pudendal artery and pudendal nerve.
Video: Dr James Pickering, Faculty of Biological Sciences, University of Leeds. Source: YouTube

Differential Diagnosis

Before seeing a urologist on March 26, 2020, I naturally had a list of possible diagnoses to explain my symptoms (listed below not in order of probability):

1. Urinary tract infection. At first glance, it might have seemed I had a urinary tract infection (UTI). However, factors against a UTI included being male, no known obstruction, no instrumentation of the urinary tract (ever), and no urologic surgery.

2. Acute Prostatitis. If I had acute prostatitis, I would have expected more symptoms to suggest infection and I could possibly have experienced more severe and more constant pain in/from my prostate and a fever.

3. Urethritis. Inflammation of the urethra was another possibility. Again, the lack of signs of infection (as opposed to symptoms) pointed against this diagnosis.

4. Enlarged prostate. My symptoms could have been explained by an enlarged prostate. However, the rapid development of urinary symptoms made prostatic enlargement less likely.

5. Urethral stricture. It certainly felt like I had a urethral stricture. But I did not have any known risk factors, e.g. trauma or surgery, catheterization, radiation, enlarged prostate.

7. Kidney stone lodged in urethra. It was possible a kidney stone had lodged in my urethra, hence causing the symptoms I was experiencing. I had no known risk factors for kidney stones.

The main problem with all the diagnoses above was that they did not explain the erectile dysfunction that seemed to accompany the urinary symptoms.

8. Bicycle seat neuropathy. Also called cyclist syndrome, pudendal neuropathy, pudendal neuralgia, pudendal nerve entrapment syndrome, Alcock canal syndrome, and other terms, bycicle seat neuropathy is relatively common among cyclists. Though this condition is well documented in the medical literature, I have to admit I first heard of it on a Global Cycling Network (GCN) YouTube video on how to prevent saddle-related numbness and discomfort. In that video, GCN’s Daniel Lloyd offers some useful tips on how to alleviate pressure on the perineum while cycling. Bicycle seat neuropathy, which has different presentations, is believed to be caused by a pressure effect on the perineum from the saddle and subsequent injury—either ischaemic or compressive—to the pudendal nerve, or one or more of its branches. This condition would account for all my symptoms: the urinary dysfunction, the neuropathic pain in the perineum and glans penis, and the erectile dysfunction.

What I Did Before Seeking an Expert Opinion

By the evening of March 25, 2020, I had enough. DIY medicine can only take you so far. It was time to see a specialist to get this thing sorted out.

My symptoms were not getting any better, despite me being off the two anticholinergic drugs for a few days and drinking lots of water (in case I had a urinary tract infection, but in hindsight, doing this probably exacerbated my urinary symptoms). My sleep over several nights had been disrupted, and I was beginning to feel moody during the day.

Double Voiding: My Version

I discovered that peeing twice every time I felt the need to go to the loo helped me to empty my bladder better than trying to pass everything in one go. A few days after I started doing this, I learnt this technique is called double voiding. My version of double voiding took anything between 10 and 20 minutes between efforts to pee, this interval being longer than the conventional idea of double voiding. During intervals, I found doing something to take my mind off the incompletely emptied bladder, e.g. watching a YouTube video or resuming writing a report, extremely helpful. At the same time, the interval gave me the opportunity to recover from the straining I did on the first effort. I would continue to double void till the first week of April, when my symptoms resolved and the amount of urine passed per effort was at least 350 mL.

Urology Outpatient Appointment on March 26, 2020

On the morning of March 26, 2020, I saw a consultant urologist (Dr TCL) in his clinic.

As expected, he ordered a mid-stream urine (MSU) test. Surprisingly, the results came back within a few hours—this was likely because there were few patients in the hospital at that time, in turn due to the COVID-19 lockdown. My urine was normal, without any evidence of infection or presence of blood in the urine (haematuria).

A transabdominal ultrasound scan showed a normal-sized prostate gland.

My urologist thought the problem was “multi-factorial,” which included some injury to my prostate due to the cycling. He recommended I stopped cycling completely—this wasn’t going to be a problem at that time since road cycling was banned during the lockdown period. But there was little chance I would quit cycling for good, unless absolutely necessary.

He ordered a prostate-specific antigen (PSA) test—I would have this done together with blood tests scheduled on the same day as the outpatient appointment with my gastroenterologist about three weeks later–and prescribed terazosin (Hytrin), an α-blocker, 1 mg once a day at bedtime.

Progress

Over the next few days, all my symptoms seemed to gradually improve. I’m uncertain how much the small dose terazosin helped—I wasn’t suffering any adverse effect, so I didn’t mind taking it. I continue to do so on my doctor’s advice.

My symptoms disappeared completely by the first week of April 2020.

On the day I was due to see my gastroenterologist (16 April 2020), I had a few investigations done, including the PSA test. The PSA level was mildly elevated at 4.01 ng/mL (reference range 0–4). I wasn’t too concerned about that result, but according to my urologist, this level was higher than what the laboratory reference range suggested. He told me the upper limit of normal PSA levels for a guy my age is 2.5 ng/mL. So, though my urinary and sexual function was back to normal, my PSA was mildly elevated.

As mentioned at the beginning of this article, I had a repeat PSA test on June 3, 2020—the PSA level was 1.75 ng/mL, i.e. well within the age-adjusted normal range.

Steps I Took to Lower My PSA Level

Between the two PSA tests (a period of 48 days), I was determined to see the PSA level come down, mainly because it had a large bearing on whether I could safely continue road cycling. I took the following steps:

  • Abstinence from cycling. Other than a 10-minute ride to my local bike shop (LBS) on May 20, 2020 to upgrade the pedals on my bike, I have refrained from cycling, even when the lockdown restrictions were eased (Conditional Movement Control Order) from May 4, 2020. On May 20, 2020, when I did cycle to my LBS, I wore a pair of padded bike shorts under my G&F commuter shorts to protect my boy parts.

  • Avoidance of ejaculation for three weeks. Ejaculation, as I was informed, increases the PSA level. In retrospect, a three-week period of sexual abstinence was extremely conservative, but I wouldn’t argue with my urologist, given his experience and expertise, and my desire to get back on the saddle. Based on the material available on the Internet, the PSA level may be raised up to 48 hours after ejaculation.

  • Avoidance of straining when urinating. If there was an obstruction in my urinary tract distal the prostate, straining might excessively raise the intra-prostatic urethral pressure.

  • α-Adrenoreceptor antagonism. This should lower the intra-prostatic urethral pressure. I continue to take terazosin 1 mg once a day at bedtime and will do so until my next urology appointment in four months’ time.

  • Abstinence from vigorous exercise for 32 hours prior to the PSA test. My last workout before the test was a 10.30 km night run.

  • A tomato a day. I added one tomato, eaten raw, per day to my diet, in the hope the lycopene in the tomatoes would lower my PSA level.

  • Occasional soybean pudding. To add some soy in my diet, I have been eating soy bean pudding, a popular local dessert, once a week on average.

My Take on What Happened Down Below :eggplant: and Wrap-Up:

Summing up, this is what I believe happened:

  • I lowered my bike stem by 17 millimetres but did not check/adjust that the saddle angle.
  • Instead of a slight downward forward tilt, I mistakenly adjusted the saddle to a neutral position, i.e. no tilt. This heightened the risk of the saddle exerting more pressure on my perineum, either while riding or when I was dismounting. After one ~32km ride, I adjusted the saddle to give it a 2° downward forward tilt.
  • On two trips to my LBS in mid-March 2020, I did not wear padded shorts. Though these trips were short, the total time my perineum did not have any padded protection, while I was on my bike, was about 53 minutes.
  • I also had poor technique dismounting from my bike—the nose of my saddle often hit my perineum.
  • The pressure effect on the perineum—from the lack of downward forward tile of the saddle, insufficient padding of the perineum while cycling, and/or poor dismounting technique—caused injury to the right and left pudendal nerves, or one or more of their branches, either by compression of those nerves (or direct trauma to them) or by restricting their blood supply (via the pressure effect in the perineum).
  • The pressure effect also temporarily restricted or occluded penile perfusion, a major contributor to my erectile dysfunction.
  • The pressure effect on the perineum, through ischaemia or compression, injured the deep branch of the perineal nerve, which, in turn, is a branch of the pudendal nerve. The deep branch of the perineal nerve supplies the sphincter urethrae muscle (male external sphincter muscle of the urethra), which sits inferior to the prostate in the deep perineal pouch. The resultant malfunctioning of this muscle affected urination (micturition), in that the muscle was unable to relax when I attempted to pass urine.
  • An alternative scenario was a spasmodic urethral stricture, i.e. spasmodic contraction of the muscle fibres around the urethra, possibly from injury to the nerve supply and/or traumatic injury to the urethra (from the saddle pressing against the perineum).
  • The obstruction of urinary flow in the urinary tract, either due to abnormal contraction of the sphincter urethrae muscle or spasmodic urethral stricture, created back pressure as I strained to push the urine through the obstruction. This caused injury to the prostate, hence elevating my PSA level.
  • Pain in the perineum and glans penis during and after urination was probably referred from the prostate.
  • A period of abstinence from cycling allowed recovery of the damaged nerves and/or blood supply on or around the perineum, thereby facilitating return of normal urinary and erectile function.
  • The normalization of my PSA level was mainly due to restoration of normal urine flow through the prostatic urethra.

With the PSA test on June 3, 2020 showing a normal level, I got the all clear from my urologist to resume cycling (without me even asking!).

:traffic_light: :bicyclist: :three: :two: :one:

#Cycling #InactiveProblems