Diagnosis, Rehabilitation and Preventive Strategies for Pudendal Neuropathy in Cyclists, A Systematic Review

Abstract

This systematic review aims to provide an overview of the diagnostic methods, preventive strategies, and therapeutic approaches for cyclists suffering from pudendal neuropathy. The study defines a guide in delineating a diagnostic and therapeutic protocol using the best current strategies. Pubmed, EMBASE, the Cochrane Library, and Scopus Web of Science were searched for the terms: “Bicycling” OR “Bike” OR “Cyclists” AND “Neuropathy” OR “Pudendal Nerve” OR “Pudendal Neuralgia” OR “Perineum”. The database search identified 14,602 articles. After the titles and abstracts were screened, two independent reviewers analyzed 41 full texts. A total of 15 articles were considered eligible for inclusion. Methodology and results of the study were critically appraised in conformity with PRISMA guidelines and PICOS criteria. Fifteen articles were included in the systematic review and were used to describe the main methods used for measuring the severity of pudendal neuropathy and the preventive and therapeutic strategies for nerve impairment. Future research should determine the validity and the effectiveness of diagnostic and therapeutic strategies, their cost-effectiveness, and the adherences of the sportsmen to the treatment.

Full text

Journal of
Functional Morphology
and Kinesiology
Review
Diagnosis, Rehabilitation and Preventive Strategies for
Pudendal Neuropathy in Cyclists, A Systematic Review
Rita Chiaramonte 1, * , Piero Pavone 2and Michele Vecchio 1, 3, *


Citation: Chiaramonte, R.; Pavone,
P.; Vecchio, M. Diagnosis,
Rehabilitation and Preventive
Strategies for Pudendal Neuropathy
in Cyclists, A Systematic Review. J.
Funct. Morphol. Kinesiol. 2021,6, 42.
https://doi.org/10.3390/jfmk6020042
Academic Editor: Milos Ljubisavljevic
Received: 12 April 2021
Accepted: 7 May 2021
Published: 10 May 2021
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
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iations.
Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
1Department of Biomedical and Biotechnological Sciences, Section of Pharmacology, University of Catania,
95123 Catania, Italy
2Department of Clinical and Experimental Medicine, University Hospital “Policlinico-San Marco”,
95123 Catania, Italy; ppavone@unict.it
3Rehabilitation Unit, “AOU Policlinico G.Rodolico”, 95123 Catania, Italy
*Correspondence: ritachiaramd@gmail.com (R.C.); michele.vecchio@unict.it (M.V.);
Tel.: +39-(095)3782703 (M.V.); Fax: +39-(095)7315384 (R.C.)
Abstract:
This systematic review aims to provide an overview of the diagnostic methods, preventive
strategies, and therapeutic approaches for cyclists suffering from pudendal neuropathy. The study
defines a guide in delineating a diagnostic and therapeutic protocol using the best current strategies.
Pubmed, EMBASE, the Cochrane Library, and Scopus Web of Science were searched for the terms:
“Bicycling” OR “Bike” OR “Cyclists” AND “Neuropathy” OR “Pudendal Nerve” OR “Pudendal
Neuralgia” OR “Perineum”. The database search identified 14,602 articles. After the titles and
abstracts were screened, two independent reviewers analyzed 41 full texts. A total of 15 articles were
considered eligible for inclusion. Methodology and results of the study were critically appraised
in conformity with PRISMA guidelines and PICOS criteria. Fifteen articles were included in the
systematic review and were used to describe the main methods used for measuring the severity of
pudendal neuropathy and the preventive and therapeutic strategies for nerve impairment. Future
research should determine the validity and the effectiveness of diagnostic and therapeutic strategies,
their cost-effectiveness, and the adherences of the sportsmen to the treatment.
Keywords: bicycling; pudendal neuralgia; rehabilitation; systematic review
1. Introduction
Cyclists are particularly prone to trauma, infection, tumor, injury, and microtrauma
related to their sport [
1
]. Cavernosal and dorsal arteries and pudendal nerve could be
injured in many conditions, such as compression between the saddle and pubic bones or
pubic symphysis during cycling or within the Alcock canal medial to the ischial rami [
2
,
3
].
While cycling, the body weight on the seat could compress nerves, vessels, or both.
Repeated trauma to the perineum, prostatic disease in men, and pelvic pathology in females
can favor the onset of the disorder [
4
,
5
]. According to Silbert et al. [
5
], the compression of
the pudendal nerve could be related to the forward-leaning posture that presses perineum
anteriorly to the ischial spine. According to Andersen and Bovim [
6
], if ischemia of the
nerve by “compression posture” lasts less than 6 h, the block of nerve conduction is rapidly
reversible, while if the ischemic period persists beyond 8 h, the recovery requires weeks. It
could be related to a demyelinating block caused by direct pressure on perineum [6].
The pudendal neuralgia, caused by entrapment and compression of the pudendal
nerve, is characterized by severe, sharp pain along the course of the pudendal nerve [
7
],
genital numbness, erectile dysfunction (ED), and impotence [2,8].
Once afflicted, the cyclists are inclined to relapses; awareness of the problem could im-
prove the adherence to prevention and therapeutic strategies [
9
]. Cyclists should pay close
attention to any early warning symptoms and signs, such as pain, tingling, or numbness of
J. Funct. Morphol. Kinesiol. 2021,6, 42. https://doi.org/10.3390/jfmk6020042 https://www.mdpi.com/journal/jfmk

J. Funct. Morphol. Kinesiol. 2021,6, 42 2 of 10
the penis and/or perineum. Even in the absence of such symptoms, cyclists should follow
several pieces of advice.
Very few robust trials are present in the current literature, several of them not recent,
despite the actuality of the disorder. This disabling condition related to musculoskeletal
and neuropathic disorders often dictates to stop playing this sport, and this advice needs
to be extended. New research could make substantial changes in the diagnostic path, and
in taking charge. The therapeutically proposed solutions should not be directed to the
suspension of cycling, but to timely treatment to achieve a complete recovery, rehabilitation
from symptoms, and functional ergonomics.
The systematic review aims to provide an overview of the diagnostic methods, pre-
ventive strategies, and therapeutic approaches for the cyclists suffering from pudendal
neuropathy. The study defines a guide in delineating a diagnostic and therapeutic protocol
using the best current strategies. Moreover, an update on the topicality of this disorder and
on the disabling condition in those who practice this sport could increase the attention to
the problem to obtain a dedicated field of interest and prevent the disorder.
2. Methods
2.1. Search Strategy
A systematic literature search on the preventive strategies and therapeutic approaches
for the cyclists suffering from pudendal neuropathy was carried out. Pubmed, EMBASE,
the Cochrane Library, and Scopus Web of Science were searched. The review was conducted
from 1 May 2020 to 2 April 2021.
2.2. Selection Criteria and Data Extraction
Two independent reviewers (R.C. and M.V.) screened articles by title and abstract
for the following key terms: “Bicycling” OR “Bike” OR “Cyclists” AND “Neuropathy”
OR “Pudendal Nerve” OR “Pudendal Neuralgia” OR “Perineum”. We included original
articles (case reports, case series, observational and prospective studies) in English on
prevention and therapeutic strategies for pudendal neuropathy in healthy cyclists. Only
published data were included. We excluded animal studies and studies with participants
who had no peripheral perineum neuropathy and those different from cyclists. We also
excluded all duplicate studies.
The systematic review was executed according to the PRISMA checklist [
10
] and the
PICOS criteria [
11
] (population, intervention, comparison, outcome, and study design).
As shown in Table 1, the participants were cyclists, and the interventions were based on
prevention and rehabilitative or pharmacologic treatment. The comparator could be any
comparator, and the outcomes included clinical assessments, diagnostic scales, and nerve
conduction studies, as well as radiologic imaging.

J. Funct. Morphol. Kinesiol. 2021,6, 42 3 of 10
Table 1. Characteristics and outcomes of studies included in the systematic review.
Authors Study Design Participants Beginning of
Symptomatology Symptoms Diagnosis Treatment Outcomes
Andersen 1997 [6] Observational study 160 cm,
37.5 ±10.9 y After 540 km Penile numbness or hypaesthesia,
ED after the tour for h to m. Clinical diagnosis
Besides changing the body position on
the bike, restricting the training
intensity and taking ample pauses may
also be necessary in prolonged and
vigorous bicycle riding to prevent
damage to peripheral nerves.
22% reported numbness, 13%
impotence. It lasted for more
than 1 week in 11, and for more
than 1 month in 3 participants.
Bond 1975 [9] Case series 22 c After 40 miles or more Numb penis during and after
a ride. Clinical diagnosis
Tilting the peak of the saddle
downward, shifting their weight on
the saddle, stopping to rest, and
shifting to a higher gear and standing
up to pedal.
It is a benign disorder with
spontaneous resolution usually
occurring overnight.
Calvillo 2000 [4] Case report 1 c,
52 y After 10 min Anoperineal pain from 2 y. CT
Gabapentin 300 mg daily for 6 months
without any success.
Diagnostic bilateral pudendal nerve
block under CT guidance, injecting 4
mL of lidocaine with 1 mL of
triamcinolone (40 mg)
The use of CT to guide the
procedure allowed precision in
performing the procedure and in
making a differential diagnosis.
De Rose 2001 [12] Case report 2 c,
31.5 y
1 c: immediately after
a trauma ED for 2 m.
Intracorporeal blood gas
analysis, color Doppler
ultrasonography, and
selective pudendal
arteriography
Embolization of the fistula with
gelatin sponge
Cycling should be considered a
possible risk factor for arterial
priapism as it is for urethritis,
prostatitis, hematuria, testicular
torsion, scrotal and penile
numbness, and
erectile dysfunction.
Desai 1989 [13] Case report 1 c,
27 y After 32 km bicycle race Ipoaesthesia, loss of erections for
about three weeks. Doppler, EMG - Description of the case report.
Dettori 2004 [14] Prospective study 463 c After 320 km race Perineal numbness during the
ride, erectile dysfunction for 8 m.
International Index of
Erectile Function
Cyclists on a long-distance ride may be
able to decrease the risk of erectile
dysfunction by riding a road bicycle
instead of a mountain bicycle, keeping
handlebar height lower than saddle
height, and using a saddle without a
cutout if perineal numbness
is experienced.
Associations between erectile
dysfunction risk and riders.
Durante 2010 [8] Case report 1c,
41 y
After 6–11 h per week,
3 days a week of training
Penis pain 12–24 h after long
distance cycling and pain after
sexual intercourse. Hyperalgesia
was found during palpation of the
lesser sciatic notch and the
obturator internus muscle.
Pain intensity scale Treated twice a week for 4 w with ART
obturator internus muscle protocol.
Diagnosis and treatment of
pudendal nerve entrapment.
Goodson 1981 [3] Case report 1 c,
46 y After a 2-day, 180-mile ride
Diminished sensitivity to light
touch along the penile shaft,
numbness for 4 w.
Clinical assessment
Added seat padding or more
downward seat slanting is a
therapeutic recommendation.
Pudendal compression between
bike seat and pubic symphysis
can cause impairment of
sexual response.

J. Funct. Morphol. Kinesiol. 2021,6, 42 4 of 10
Table 1. Cont.
Authors Study Design Participants Beginning of
Symptomatology Symptoms Diagnosis Treatment Outcomes
Guess 2006 [15] Observational study
48 c,
22 hc,
33 y
Average of 28.3 ±19.7
miles/d, 3.8 ±1.5 d/w, for
an average of 2.1 ±1.8 h/r
Normal sexual function. VTs, SPEQ, FSDS -
Increasing VTs at the clitoris,
anterior vagina, and urethra
were associated with age. In
bicyclists, there were no
correlations between VTs and
miles biked per week, duration
of riding, or BMI
Guess 2011 [16] Case series 48 c,
35.98 ±6.90 99.24 ±74.11 miles/w Pain, numbness, and edema of
pelvic floor structures. VTs -
Cut-out and narrower saddles
negatively affect saddle
pressures in female cyclists
Oberpenning 1994
[2]Case reports 2 c
-- Numbness for 4–6 w.
Sonography of abdomen,
prostate and testes, MRI of
pelvis and lumbar spine,
Doppler sonography
The symptoms in the 2 patients
spontaneously resolved after 4 and
7 weeks, respectively, without specific
medical therapy.
Description of intermittent
genital hypesthesia that
occurred in cyclists after
long-term bicycle riding.
Partin 2012 [17] Observational study c,
22 runners >10 miles/w 62% genital numbness, tingling or
pain Clinical diagnosis, VTs Modifying the handlebar level
Correlation between bicycle
set-up and neurological
compromise in women cyclists.
Ricchiuti 1999 [18] Case report 1c,
44 y 3000 m/y ED, numbness EMG evidence of bilateral
pudendal nerve injury.
C decreased bicycling from 3000 to
approximately 1500 miles per year due
to the persistent symptoms.
This condition may be associated
with male ED if the penile blood
supply is compromised.
Silbert 1991 [5] Case reports 2 c
A: after switching to
triathlon bars and a narrow
firm seat.
B: after being hit by a car
and sustained a
perineal injury.
Penile numbness Clinical assessment
A: Symptoms resolved after the subject
returned to traditional drop bars and a
softer saddle.
B: After a period of not cycling, his
symptoms resolved completely.
Pudendal nerve pressure
neuropathy can result from
prolonged cycling, particularly
when using a poor
riding technique.
Solomon 1987 [19] Case report 1 c,
55 y11
After beginning to use a
stationary bike. Penile numbness and ED Clinical diagnosis Resolved once he stopped riding.
A relationship between sexual
dysfunction and bicycling may
be more common than
formerly suspected.
Cyclists, c; years old, y; erectile dysfunction, ED; electromyography, EMG; observational study, OS; hours, h; weeks, w; months, m; days, d; vibratory thresholds, VTs; Dennerstein Personal Experience
Questionnaire, SPEQ; Female Sexual Distress Scale, FSDS; magnetic resonance imaging, MRI; Active Release Technique, ART.

J. Funct. Morphol. Kinesiol. 2021,6, 42 5 of 10
3. Result
3.1. Description of the Studies
From 1975 to 2021, the database search identified 14,602 articles. After the titles and
abstracts were screened, the reviewers analyzed 41 full texts. Additionally, the reference
lists of relevant articles were screened for any other eligible articles to include for review.
The studies’ eligibility was assessed independently.
Twenty-six articles were excluded for the following reasons: 9 did not use the En-
glish language, 17 examined different neurological disorders from pudendal neuropathy.
Figure 1
shows the number of studies produced at each stage of the search. A total of
15 articles were considered eligible for inclusion (Figure 1and Table 1).
J. Funct. Morphol. Kinesiol. 2021, 6, x FOR PEER REVIEW 7 of 13
3. Result
3.1. Description of the Studies
From 1975 to 2021, the database search identified 14,602 articles. After the titles and
abstracts were screened, the reviewers analyzed 41 full texts. Additionally, the reference
lists of relevant articles were screened for any other eligible articles to include for review.
The studies’ eligibility was assessed independently.
Twenty-six articles were excluded for the following reasons: 9 did not use the English
language, 17 examined different neurological disorders from pudendal neuropathy.
Figure 1 shows the number of studies produced at each stage of the search. A total of 15
articles were considered eligible for inclusion (Figure 1 and Table 1).
Figure 1. Flowchart of the process of literature search and extraction of studies meeting the inclusion criteria.
3.2. Variations of Experimental Conditions Across the Studies
The methods used in each of the 15 selected articles for the prevention and treatment
of peripheral neuropathy of perineum in cyclists were described. The study groups were
homogeneous for relevant general clinical features, such as sport practice and localization
Figure 1. Flowchart of the process of literature search and extraction of studies meeting the inclusion criteria.
3.2. Variations of Experimental Conditions across the Studies
The methods used in each of the 15 selected articles for the prevention and treatment
of peripheral neuropathy of perineum in cyclists were described. The study groups were
homogeneous for relevant general clinical features, such as sport practice and localization
of the lesion, but not for clinical presentation, duration of symptoms, miles before starting
of symptoms, types of diagnostic measures, severity of symptoms, and therapy (Table 1).

J. Funct. Morphol. Kinesiol. 2021,6, 42 6 of 10
3.3. Summary of Findings
3.3.1. Diagnostic Examination
The systematic review showed preventive and therapeutic approaches for peripheral
neuropathy in cyclists and all the diagnostic methods used in the current literature.
Clinical evaluation related to the sport is considered enough for the diagnosis of
pudendal neuropathy due to cycling [3,5,6,9,13,17,19].
Several scales and instrumental diagnostics were used to diagnose the severity of the
disorders: Pain Intensity Scale [
8
], International Index of Erectile Function [
14
], Dennerstein
Personal Experience Questionnaire (SPEQ) [
15
], Female Sexual Distress Scale (FSDS) [
15
].
The diagnostic methods included nerve conduction studies and electromyography [
13
,
18
],
radiologic diagnosis with ultrasonography and doppler waveforms [
2
,
12
,
13
], computed
tomography [
4
], magnetic resonance imaging (MRI) [
2
], and diagnostic arteriography [
12
].
3.3.2. Bike Elements Related to Peripheral Neuropathy
The area of contact between the bicyclist and the bike is the cause of nerve compression.
Comfortable characteristics of the bicycle and practical recommendations are shown in
Table 2.
Bike
Bicycle characteristics associated with an increased risk of erectile dysfunction in-
cluded a mountain bicycle compared to a road bicycle [14].
Seat
Prolonged sitting on a hard, narrow, and upward-tilted seat contributes to the devel-
opment of impotence [
3
]. The narrow saddle is associated with a significant reduction in
penile blood flow and could be a source of blunt perineal trauma with consequent erectile
dysfunction [20]. The upward-tilted seat places greater pressure on the perineum [21].
Table 2. Comfortable characteristics of the bicycle and practical recommendations.
Practical Recommendations Characteristics of Bike Parts and Practical Strategies References
Bicycle parts: seat
Soft, wide [5]
Horizontal and not inclined seat [23,24]
Absent or flexible nose on the saddle [23,24]
Saddle without a cut-out [14,16,22]
Bicycle parts: handlebars Handlebar height lower than the saddle [14]
Avoiding triathlon bars [5]
Sportswear Padded biking shorts [25]
Rest Reduction of sport activity [2,5,12,20]
Advice Frequent breaks [2,5,9,18,19,23,24,26]
Shifting to a higher gear, and standing on the pedals periodically
[9,26]
Rehabilitation program Specific exercises for adjustments in technique and body posture
to a more upright position, stretching [8,23,24]
The use of cut-out saddles could increase the pressure along the area of the pudendal
nerves and vessels [
22
], with a higher risk of ED compared with a traditional saddle shape,
particularly in those who had perineal numbness [14].
According to Carpes et al. [
23
], the seat pressure was not different between men and
women. Using plain saddles, the men’s average seat pressure increased as the workload
increased. Using a holed saddle, the mean pressure increased as the workload increased

J. Funct. Morphol. Kinesiol. 2021,6, 42 7 of 10
both in men and in women [
23
]. This study [
23
] was not included in the systematic review
because the tested cyclists did not report any symptoms.
Handlebars
A height of the handlebars parallel with or higher than the saddle could increase the
risk of pudendal neuropathy compared to handlebar height lower than the saddle [
14
]. A
height of handlebars lower than the saddle could increase vibratory thresholds and cause
decreased genital sensation in the anterior vagina and labia [17].
The use of triathlon bars causes cyclists to move forwards the body with an excessive
pressure on the perineum and compression of the pudendal nerve [5].
3.4. Sex Influence
Most of the articles analyzed nerve impairment [
2
–
6
,
8
,
14
] and ischemic neuropathy
condition [9,12,13,18,19] in men.
Only a few articles analyzed the corresponding conditions in women [
15
–
17
]. There is
an association between bicycling and decreased genital sensation in competitive women
bicyclists, even if negative effects on sexual function and quality of life were not apparent
in young, healthy premenopausal cyclists [
15
]. A correlation between bicycle set-up and
neurological impairment was considered in female cyclists [
17
]. A study suggests that
cut-out and narrow saddles could negatively affect saddle pressures in female cyclists [
16
].
An association was highlighted between bicycling and decreased genital sensation in
competitive women bicyclists [
15
]. Correcting modifiable risks factors for pelvic floor
damage may serve as the most important next step in enhancing riding safety in women
cyclists [17].
4. Discussion
This systematic review gives an overview of all diagnostic methods used and pre-
ventive and therapeutic strategies essential for cyclists to avoid pudendal neuropathy.
The study describes the musculoskeletal and neuropathic disorders caused by careless
physical exercise contrary to what is generally reported in the literature, namely, the role
of physical exercise to prevent and treat musculoskeletal disorders. The role of correct
training in the musculoskeletal and neuropathic disorders is essential to avoid traumatic
and overuse-related symptoms. The execution of the athletic gesture should improve
performance and not cause related pathologies.
4.1. Diagnostic Approach
Pudendal neuralgia is a diagnosis of exclusion. The multidisciplinary team of Nantes,
France and Francophone Perineal Electrophysiology members in 2008 drew up the diag-
nostic criteria [27].
Clinical examination supports the definitive diagnosis [3,5,6,9,13,17,19].
Several scales were used to diagnose the severity of the disorders. Durante et al. [
8
]
used the Pain Intensity Scale, Dettori et al. [
14
] used the International Index of Erectile
Function [
28
], Guess et al. [
15
] used the Dennerstein Personal Experience Questionnaire
(SPEQ) [29] and the Female Sexual Distress Scale (FSDS) [30].
Four studies assessed the neuropathy compression with radiologic imaging [
2
,
4
,
12
,
13
].
Ricchiuti et al. [
18
] performed the electromyography that evidenced a bilateral pudendal
nerve injury. Guess et al. [
15
,
16
] determined the genital vibratory thresholds (VTs), but
they did not find any correlations between VTs and miles biked per week, duration of
riding, or BMI (body mass index) of cyclists [
15
]. Partin et al. [
17
] described a significative
association between increased VTs and decreased genital sensation in the anterior vagina
and labia.

J. Funct. Morphol. Kinesiol. 2021,6, 42 8 of 10
4.2. Cautions to Avoid Peripheral Neuropathy
Several articles highlight a spontaneous resolution with rest [
2
,
5
,
19
] and reduction of
sport activity [
18
], modifications of bike components [
3
,
6
,
9
,
14
], and following a rehabilita-
tion program [8,23,24].
The characteristics of the bike could influence the symptomatology related to pudendal
nerve compression. Dettori et al. [
14
] suggested to choose a road bicycle instead of a
mountain bicycle. Specific size and shape of saddle, handlebars, and the duration of rest
period affect the onset and the severity of the compression neuropathy. These limitations
of activity are often less accepted by athletes [6].
4.2.1. Breaks and Rest
The changes of the riding position during the training can alleviate symptoms [
5
,
9
].
During the training, frequent breaks, shifting to a higher gear, and standing on the pedals
periodically can take pressure off the genital area [
9
,
26
]. Several authors recommend a
period of rest during the race [3,9,26], exactly 20–30 s of rest every 20 min [23,24].
Reduction of activity [18] or rest [19] can reduce the symptoms after their onset.
4.2.2. Seat Arrangement
Bicycles should be fitted properly, and the saddle should be adjusted to the proper
height and angle to avoid nerve compression. The US Army equestrian saddle has a slot in
the center so that there is no pressure against the penis [
9
]. The therapeutic recommenda-
tions include a greater and wider seat padding, an absent or flexible nose on the saddle, a
gel saddle, a more downward seat position or slighter tilt downwards to avoid anterior
compression [
3
,
9
,
23
,
24
]. The seated weight should set down on the ischial tuberosities.
The seated height should permit a slight flexion during pedaling at the lowest point of the
pedal. Reducing the pressure on the perineum appears to be the solution, because in the
cyclists the repetitive sliding of the fascia lata could decrease penile perfusion [25].
A saddle without a cut-out could help in the cases of perineal numbness [14].
Alongside wide and padded saddles, padded biking shorts increase comfort and
protect the perineal soft tissue more than the other seat designs [26].
4.2.3. Handlebars
In addition to adjusting the seat, cyclists should attend to the handlebar position [
31
].
Maintaining height of the handlebar lower than the saddle could prevent nerve compres-
sion [14].
4.3. Rehabilitation and Physical Exercises
A specific program of exercises could help weight loss if necessary as overweight
could worsen nerve compression. Specific exercises are important for making adjustments
in technique and improving the body posture to a more upright position. Stretches and
rest for 3–10 days often promote recovery [23,24].
Durante et al. [
8
] presented the Active Release Technique (ART) for the treatment of
symptoms related to pudendal nerve entrapment [
32
]. The practitioners apply tension to
muscles and the patients actively contract and shorten the muscles and then stretch and
tense them [32].
4.4. Invasive Treatment
Treatment is related to the degree of discomfort and symptoms. Conservative mea-
sures are often enough. In cases of severe, intractable discomfort and dysfunction, more
aggressive and invasive treatment is necessary.
Calvillo et al. [
4
] used a CT-guided pudendal nerve block to temporarily relieve long-
standing perineal and scrotal pain in a cyclist. Surgical decompression of the pudendal
nerve could be a therapeutic option in cyclists for whom there was only temporary relief
after the nerve block.

J. Funct. Morphol. Kinesiol. 2021,6, 42 9 of 10
Several cases of high-flow priapism as a result of acute bilateral perineal trauma
sustained during bicycling have been reported [
12
,
33
]. They were treated successfully with
percutaneous arterial embolization [12,33].
4.5. Pharmacological Treatment
Symptomatic drugs might have beneficial effects, anti-inflammatory and nerve pain
medications or vasodilator drugs may be used in cases of ischemic neuropathy.
Gabapentin 300 mg daily for 6 months did not yield any success [4].
For the pudendal nerve block, under CT guidance, injection of 4 mL of lidocaine with
1 mL of triamcinolone (40 mg) relieves the symptoms for a longer period of time [4].
5. Study Limitations
In this systematic review, most studies are of low to moderate quality. Several studies
are case reports or have very small sample sizes, leading to questions regarding their
statistical power.
6. Conclusions
This research highlights all the preventive and therapeutic strategies towards obtaining
a guide for those who treat, train, and support cyclists with pudendal neuropathy. Increased
attention to the execution of the athletic gesture is essential to obtaining good sport results,
and especially to avoiding the possibility of training becoming the cause of musculoskeletal
and neuropathic disorders.
New bicycle designs pay attention to preserving the perineum, avoiding nerve com-
pression, reducing perineal pressure, and preventing impingement of the pudendal nerve.
However, nerve compression could be present, and its diagnosis and treatment are necessary.
The symptomatology related to pudendal neuropathy could affect experienced and
novice cyclists. Cyclists could develop a less severe disorder by maintaining better posture
on the bike and adhering to the advice on preventive measures. A conservative treatment
permits the recovery, rarely requiring invasive treatment.
Although the studies included in the systematic review on this topic present a mod-
erate or low level of evidence, they could lead to new original and innovative leaps in
the study the potential problem in more detail. Despite the range of tools available, ro-
bust trials are lacking, and the diagnostic and therapeutic approaches are often different.
More research is needed to determine the measurements of treatment adherence and cost-
effectiveness, the best diagnostic methodologies, and preventive and therapeutic strategies,
to delineate a definitive diagnostic and therapeutic protocol, including preventive tools,
such as improved bike models and new bike elements.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
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