Stesura Seveso Archivio Italiano di Urologia e Andrologia 2022; 94, 2232 ORIGINAL PAPER No conflict of interest declared. Studies have shown that ED and numbness occur, respectively in up to 24% and 61% of selected groups of riders. However, most studies were conducted on long- distance/intensive cyclists, so there is little information about the true effects of cycling in the sexual life of ama- teur practitioners (6-11). With this study, we aimed to evaluate the effects of ama- teur cycling in erectile function using a comparative ath- lete group and a validated sexual questionnaire. METHODS Recruitment and sporting clubs’ outreach 199 amateur cyclists (cyclists that do not receive financial support or sponsorship) were recruited in person in sev- eral cycling meetings and completed an anonymous sur- vey. We chose four mountain cycling events with high participation. The comparison group consisted of 43 amateur foot- ballers (sport without perineal contact) recruited in per- son from two amateur clubs. Institutional review board approval was obtained. Survey predictor variables The two groups of athletes were characterized and com- pared regarding their age, body mass index, alcohol intake, smoking, medication (diuretics, high blood pres- sure drugs, excluding angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, anti-depres- sants, anti-anxiety drugs, antihistamines, Parkinson’s dis- ease medications, prostate cancer medications, 5a-reduc- tase inhibitors, chemotherapy), comorbidities (hypercho- lesterolemia, hypertriglyceridemia, arterial hypertension, myocardial infarction, stroke, diabetes mellitus, chronic kidney disease, chronic liver disease, thyroid disease, hor- monal disorder, neurological disease, spine injury, prostate disease, perineal radiotherapy, penile/perineal trauma, depression, anxiety disorder) and hours per week of sports practice. The cyclists (group 1) were specifically characterized in terms of road vs cross-country, rest breaks during cycling (by questionnaire), saddle, shorts, and the riding position. The effect of each of these char- acteristics on sexual function was assessed. Survey outcome variables To evaluate EF, the International Index of Erectile Function (IIEF-5) questionnaire was applied. The presence of Introduction: Cycling is a popular means of transport and recreational activity; bicycles are also a source of genitourinary injuries and there is the idea that cycling may have a significant impact on sexual function. The objective of this study was to evaluate the effect of amateur cycling on erectile function. Methods: We used a questionnaire comparing amateur cyclists (n = 199) and footballers (n = 43), regarding sexual related comorbidities and hours of practice per week. The cyclists were also characterized in terms of road vs cross-country, breaks during cycling, saddle, and shorts. To evaluate erectile function, the International Index of Erectile Function questionnaire was applied. Results: there was no difference in International Index of Erectile Function total score between groups. Age and presence of erectile dysfunction associated comorbidity were negative fac- tors in the International Index of Erectile Function score in cyclists but not in the footballers. Conclusions: Cycling is usually associated with perineal numb- ness, but that numbness did not lead to lower International Index of Erectile Function scores. In conclusion amateur cycling has no effect on EF. KEY WORDS: Cycling; Football; Erectile function; Perineal numbness. Submitted 9 April 2022; Accepted 4 June 2022 INTRODUCTION Cycling is a popular means of transport and recreational activity for many people in a wide age range. It is an eco- nomical and efficient form of aerobic non-impact exercise with well-established cardiovascular beneficial effects and with a positive effect on quality of life (1, 2). Bicycles are also a source of genitourinary injuries, that can be cate- gorized into acute traumatic injuries versus chronic over- use injuries (3). Exercise is a well-known preventer of erectile dysfunc- tion, in an Italian study patients with lower physical activity were associated with higher levels of erectile dis- function (4). Since the 80’s, there is the idea that cycling may have a significant impact on sexual function (includ- ing erectile dysfunction (ED), perineal numbness and chronic pain) (1, 5, 6). The most frequently proposed pathophysiological mechanisms for ED in cyclists are vas- cular and nerve injuries (related to nerve entrapment and vascular occlusion with continuous compression of the pudendal nerve and pudendal artery) (1). Erectile function in amateur cyclists Duarte Vieira e Brito 1, Mário Pereira-Lourenço 1, Jose Alberto Pereira 1, Miguel Eliseu 2, Carlos Rabaça 1 1 Portuguese Institute of Oncology, Coimbra, Portugal; 2 Urology and Renal Transplantation Department, Coimbra University Hospital Centre, Coimbra, Portugal. DOI: 10.4081/aiua.2022.2.232 Summary 233Archivio Italiano di Urologia e Andrologia 2022; 94, 2 Erection in cyclists numbness was also registered, although in a subjective way (“yes or no” question). Statistical analysis Data was analysed using SPSS 21. Demographic and medical variables were compared across athletic groups using Pearson chi-square and Mann-Whitney tests. The effect of cycling variables in EF was calculated with Mann-Whitney, Pearson chi-square and Kruskal-Wallis tests. A p-value of ≤ 0.05 was consid- ered statistically significant. RESULTS General characterization and comparison between the two groups is summarized in Table 1. The subjects in group 1 were older (38.1 vs 30.5 years old; p = 0.001), and less individuals consumed alcoholic beverages (60% vs 79%, p = 0.018). The remaining variables did not dif- fer between the 2 groups. There was also no difference in the IIEF-5 total score between groups (22.45 vs 21.70; p = 0.071). Group 1 showed better results in question 3 of the IIEF-5, which concerns the ability to maintain erection after penetration (4.49 vs 4.14, p = 0.014). Age and the presence of ED associated comorbidities were negative factors in the IIEF-5 total score in cyclists (p = 0.032 and p = 0.036, respectively) but not in foot- ballers (p = 0.120 and p = 0.623, respectively). No other variables influenced IIEF-5 in the cycling group or in the football group when evaluated separately (Table 2). The IIEF-5 total score ≤ 21 included 37.2% of cyclists and 26.6% of footballers (p = 0.164), with no difference regarding ED severity between the two groups (p = 0.173) (Table 3). Regarding cycling specific variables (Table 4), there was no relation between IIEF-5 and number of hours per week of practice (p = 0.666), type of shorts (p = 0.254), type of saddle (p = 0.611), frequency of resting pauses (p = 0.288) and predominant position of the trunk while cycling (p = 0.371). Table 1. General characterization and homogeneity. Cycling (n = 199) Football (n = 43) P ED associated comorbidities 76.8% 86.0% 0.208 Mean age (years) 38.1 30.5 0.001 Mean weight (Kg) 77.3 75.1 0.157 Mean BMI (Kg/m2) 24.9 24.4 0.255 Alcohol consumption 60.3% 79.1% 0.018 Smoking 34.2% 46.5% 0.112 BMI: Body Mass Index. Table 3. Erectile Dysfunction severity by sport modality. ED severity (IIEF-5 score) Cycling Football P Severe ED (1-7) n = 0; 0% n = 0; 0% Moderate ED (8-11) n = 3; 1.5% n = 0; 0% Mild-Moderate ED (12-16) n = 7; 3.5% n = 3; 7.0% 0.173 Moderate ED (17-21) n = 43; 21.6% n = 13; 30.2% No ED (22-25) n = 46; 73.4% n = 27; 62.8% ED: Erectile Dysfunction. Table 4. Effect of cycling related variables on erectile function. ED severity (IIEF-5 score) Cycling Football P Hours per week < 5 (n = 73) 22.18 0.666 5-8 (n = 75) 21.30 > 8 (n = 51) 21.67 Shorts Uncoated (n = 2) 23.00 0.254 Gel (n = 107) 22.40 Sponge (n = 77) 22.34 Saddle Hard (n = 29) 22.70 0.611 Gel (n = 105) 22.51 Sponge (n = 55) 22.32 Continuous exercise until pause * 30 min (n = 29) 21.90 0.288 60 min (n = 60) 22.49 120 min (n = 29) 23.28 No pauses (n = 92) 22.34 Modality Only cross-country (n = 136) 22.13 0.023 Cross-country + road (n = 63) 23.13 Perineal numbness Yes (n = 50) 22.54 0.508 No (n = 149) 22.42 Predominant position No (n = 64) 21.97 0.371 30º (n = 4) 21.75 45º-60º (n = 124) 22.77 90º (n = 7) 21.57 * Time from start until stopping for rest. Table 2. Effect of Erectile Dysfunction associated variables on IIEF-5 total score by sport modality. Cycling IIEF-5 P Football IIEF-5 P BMI < 25 Kg/m2 Yes 22.57 (n = 119) 0.423 21.80 (n = 30) 0.759 No 22.26 (n = 80) 21.46 (n = 13) Alcohol Yes 22.24 (n = 119) 0.363 21.35 (n = 34) 0.200 No 22.75 (n = 80) 23.00 (n = 9) Tobacco Yes 22.27 (n = 67) 0.159 21.00 (n = 20) 0.081 No 22.54 (n = 132) 22.30 (n = 23) ED associated medication Yes 23.00 (n = 34) 0.565 22.13 (n = 8) 0.987 No 22.30 (n = 165) 21.60 (n = 35) ED associated comorbidity Yes 21.79 (n = 57) 0.036 21.73 (n = 11) 0.623 No 22.71 (n = 142) 21.69 (n = 32) Age ≤ 20 22.67 (n = 9) 0.032 18.78 (n = 9) 0.120 21-30 23.08 (n = 37) 22.81 (n = 16) 31-40 22.88 (n = 78) 21.08 (n = 10) 41-50 21.67 (n = 55) 23.00 (n = 6) > 50 21.60 (n = 20) 21.50 (n = 2) BMI: Body Mass Index; ED: Erectile Dysfunction. Archivio Italiano di Urologia e Andrologia 2022; 94, 2 D. Vieira e Brito, M. Pereira-Lourenço, J.A. Pereira, M. Eliseu, Carlos Rabaça 234 Athletes that also practice road cycling had better IIEF-5 scores (p = 0.023). Perineal numbness during or after exercise was present in 25.1% (n = 50) of cyclists and 7.0% (n = 3) of footballers (p = 0.009). Athletes (both groups included) without per- ineal numbness (n = 189), with numbness during the exercise (n = 46) and with numbness only after exercise (n = 7) had an IIEF-5 score of 22.35, 22.46 and 20.43, respectively (p = 0.301). Regarding only cyclists, athletes without perineal numbness (n=149), with numbness dur- ing exercise (n = 46) and with numbness only after exer- cise (n = 4) had an IIEF-5 score of 22.42, 22.46 and 23.5, respectively (p = 0.752). DISCUSSION We choose amateur footballers as a control group for two main reasons: 1) the aerobic metabolism is used in 90% of movements in football players and cycling is an aero- bic sport (12, 13); 2) football might be the most practiced sport among Portuguese males. Our study shows that amateur cycling does not cause erectile dysfunction, when compared with amateur foot- ballers. Among cyclists, only age, presence of ED related comorbidities and the exclusive practice of cross-country cycling were related to lower IIEF-5 scores. Age is strongly associated with ED, being erectile function reduced in men particularly after the age of forty due to multiple causes (14). In a study analysing a Spanish pop- ulation, a culturally similar population to the one in our study, higher rate of ED was found when the IIEF-5 score was used versus direct questioning. A rate of 8.48% and 13.72% was found for men between 25-39 and 40-49 respectively, and rate almost doubled in men between 50- 59 years (15). In our population with a median age dif- ference of 8 years, the cycling group should in theory present with higher rates of ED that were not observed in our study. In the 80s, some case reports began to relate cycling with sexual dysfunction (1). In the 90s, Andersen et al. showed a relation between cycling and ED (13% of 160 cyclists who rode in a 540 km touring race, but only 1.9% lasted more than a month) (8). In fact, ED and perineal numb- ness are the most common described bicycle related sex- ual symptoms in literature, occurring, respectively, in up to 24 and 61% of selected groups of riders (6). In relation to the possible pathophysiology responsible for this asso- ciation, the most frequently proposed causes are vascular and nerve injuries. Sommer et al. described nerve entrap- ment and vascular occlusion related to continuous com- pression (compression of the pudendal nerve and puden- dal arteries through Alcock’s canal) as the more plausible cause (1). Rider/saddle interaction, namely the type of saddle, shorts, preferential riding position, cycling modality (low impact vs. high impact) and hours of practice can explain possible different rate of cycling related ED. We did not find ED differences between types of saddles or shorts, but we only evaluated coating. In literature, the saddle plays a major role in cycling related ED (6). The best saddle (for ED protection) seems to be a wide, unpadded, no nose saddle that allows proper placement of the sit bones (more weight on the ischial tuberosities and less on the perineal soft tissues) (1, 6, 16-21). A more horizontal or even downward-pointing position of the saddle has been associated with reduced pressure on the perineum (22). In relation to shorts, a study showed that the saddle is more important for compression than shorts pad, suggesting that cyclist should choose self-reported comfortable shorts (23). We also did not find ED differ- ences between the rider preferential position, although there is some literature evidencing that the rider’s posi- tion influences compression on perineal structures. Cycling in the seated position decreases perineal blood flow and this decrease is inversely related with body weight (1, 6, 10, 21). Cycling in a reclined position reduces compression, while leaning forward in the “aero” position (as the nose of the saddle bears almost all of the rider’s weight) decreases blood flow by approximately 70% (10). Adjusting the handlebars, stem length and angle, and crank, has shown to have beneficial effect on perineal pressure. Related to position, riders should cycle in a more upright position and changing a seat to a “standing” position (1). In our study, cyclists that only practiced cross-country had lower IIEF-5 score. Cross-country cycling (mountain bike) is associated with perineal numbness and incident ED, that can be explained by the vibrations associated with this modality (6, 9, 21). In our study, cyclists had more perineal numbness, but that numbness did not lead to lower IIEF-5 scores. Numbness in perineum, penis, scrotum or buttocks, usu- ally referred to as “genital numbness” is probably the most common and most recognized symptom of pudendal compression. Most of the times it is the only symptom or the earliest one to indicate compression syndrome. Genital numbness may occur unrelated to ED although cycling related ED is invariably associated with genital numbness, which may serve as a marker for increased risk for erectile dysfunction (24). As in our study, recent works failed to show cycling as a risk factor for ED. An internet survey on 3932 cyclists showed that low and high intensity cyclists had better sexual function than swimmers and runners (25). We also did not find IIEF-5 differences related to hours of practice per week (older studies, focused on elite long- distance riders, related intensive cycling with ED) (24). Marceau et al (7) investigated ED incidence in the gener- al population, in recreational cyclists (< 3 hours per week) and in intensive cyclists (> 3 hours per week). The ED incidence was 21%, 11% and 17%, respectively, showing that intensive cyclists may have worse erectile function than recreational riders (although both have bet- ter results than non-cyclists). A recent large-scale obser- vational study on 5282 cyclists, also did not find differ- ences in ED incidence between several intensity groups < 3.75, 3.75-5.75, 5.76-8.5, and > 8.5 hours/week) (26). We must understand that the practice of sport can influ- ence sexual behaviour, interfering with the hypothalamic- pituitary-testicular axis function. However, competitive sports can lead to both reproductive or sexual tract injuries, dysfunction that can be transient (genital pain, hypoesthesia of the genitalia, hypogonadism, ED, altered sexual drive, etc.) or permanent (hypogonadism, ED, 235Archivio Italiano di Urologia e Andrologia 2022; 94, 2 Erection in cyclists etc.), by direct action (traumas of the external genitalia, saddle-related disorders in cyclists, etc.) or indirect (exer- cise-related hypogonadism, drug abuse, doping, stress, etc.) (27). A recent systematic review and meta-analysis indicates that moderate-intense physical activity improves erectile dysfunction problems (28). Results of a cross-sectional study show a sexual function benefit for those exercising at least 18 metabolic equivalent (MET) hours of activity weekly, an amount translating to 2 hours of strenuous exercise such as running or swim- ming, 3.5 hours of moderate exercise, or 6 hours of light exercise (29). Our study has some limitations, namely its cross-section- al design (it does not evaluate the temporal sexual evolu- tion of the athlete), the low number of athletes in the con- trol group and age differences between groups with an average age difference of 8 years, as erectile disfunctions in strongly associated with age (although our older group did not present with higher rates of ED). We also did not evaluate all the important saddle characteristics (presence of nose, width, cut-outs) and we did not investigate cyclists that only practice road cycling. Another limitation was the higher percentage of alcohol and tobacco con- sumption in the football group, although when statisti- cally analysed no significant difference was found. The numbness outcome was self-reported and was inves- tigated with a non-validated question. The questionnaire utilized was not validated but being the questions made in person by the researcher, the subjectivity was reduced. 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Br J Sports Med. 2017; 51:1419-1424. 29. Simon RM, et al. The association of exercise with both erectile and sexual function in black and white men. J Sex Med. 2015; 12:1202-10. Correspondence Duarte Vieira e Brito, MD (Corresponding Author) duartevbrito@hotmail.com Mario Pereira Lourenço, MD mariolourenco88@gmail.com Jose Pereira, MD joseaclpereira@gmail.com Carlos Rabaça carlosrabaca@gmail.com Portuguese Institute of Oncology, Coimbra (Portugal) Casa da Aveleira, Pencelo Guimaraes (Portugal) Miguel Eliseu, MD duartevbrito@gmail.com Urology and Renal Transplantation Department. Coimbra University Hospital Centre, Coimbra (Portugal)