Our director of sports medicine, Dr. Andy Pruitt, who has decades of experience studying cycling ergonomics, is joined by cycling journalist and registered nurse Betsy Welch for a frank discussion about saddle sores, sexual dysfunction, and other female-specific saddle/chamois pathologies. They discuss both preventative measures as well as the longterm consequences.
The pair begins with an anatomy lesson, then discusses the different ways that saddle sores can develop, from ischemic pressure, air follicle irritation/infection, to abrasion/friction.
Next, they discuss female-specific pathologies, including vaginal and urinary discharge or leakage, vaginitis, urethritis, hygiene and grooming, and how that relates to saddle choice.
Finally, Pruitt and Welch detail the sexual dysfunctions that can arise from saddle-related pressure and pain, including transient genital numbness, clitoral numbness and scarring, and labial scarring and disfigurement.
Welcome to Fast Talk Laboratories, your source for the science of endurance performance.
Betsy Welch 00:20
Hello, I’m Betsy Welch, and I am happy to be here as a guest host of today’s workshop, in which Dr. Andy Pruitt and I will be talking about the female-specific saddle, chamois bike fit pathologies. I work as a senior editor and reporter for VeloNews, where I cover women’s cycling, gravel, mountain bike adventure. I also in a previous life was a registered nurse, I guess I should say, I still am a registered nurse, so today’s conversation is very near and dear to my heart as a cyclist, journalist, and healthcare practitioner. I’m really excited to be here with a leading expert in the field, Dr. Andy Pruitt.
Dr. Andy Pruitt 01:06
Thanks, Betsy. I’m thrilled to be here with you today, too. This is a topic that needs to come to the forefront and has been whispered in backrooms for a long time, but we want to get women’s saddle issues out to the forefront.
Betsy Welch 01:22
Yeah, and we kind of have a couple of specific topics that we want to cover, and I’m sure we’ll try not to get too tangential, but it might happen, since we’re both very into this topic. Maybe we can start with one of the common, I don’t know afflictions of any cyclist, male or female, but talk about how it pertains mostly to women, saddle sores.
Female Saddle Sores
Dr. Andy Pruitt 01:46
I know we talked about this in the men’s video, but there are pathologies that cross over and that are not specific to gender, and a pressure-related sore, right? So, if you sit on tissue, and if I take my nice pink palm, and I make a white spot, that’s called ischemia, right? And if I refresh the capillary blood out, then that tissue is starving, and that’s ischemia, and that’s a pressure sore, and the tissue kind of dies, for lack of a better word, and if you do that over and repeatedly, suddenly, that tissue is going to begin to slough off, and it may even rise into a boil or nodule, but that is a pressure-related thing. It’s got nothing to do with hair follicles, or a bad fit, it’s purely just pressure, right?
Betsy Welch 02:36
When people say, “I have a saddle sore,” it could be pressure-related?
Dr. Andy Pruitt 02:41
Betsy Welch 02:41
Dr. Andy Pruitt 02:42
Absolutely. It could be postural, right? They could get a pimple, just like you get a pimple on your face, you can get a pimple in your crotch. That’s a clogged pore, typically, where it’s backed up and can get infected or clogged, so that’s a type of a saddle sore. Folliculitis, right? So, a hair follicle that has been sheared off at the skin level, with friction, now that hair follicle can kind of grow around under the skin or the hair can actually grow around under the skin make a bump, it then can become infected. So, folliculitis or sometimes in men we call them beard bumps, they can happen anywhere, right? Where you shear off a hair follicle. So, there are multiple kinds of saddle sores and they don’t all mean that your fit is bad, they don’t all mean that your saddles are wrong, it might have more to do with grooming or chamois cleanliness.
Are Saddle Sores Inevitable?
Betsy Welch 03:42
I mean, is this the fate of any cyclist? Are you doomed to having some sort of saddle sore? Or are there things you can do to prevent them?
Dr. Andy Pruitt 03:54
Great question. I think that there are people who skate through their careers and go, “What’s wrong with these people with saddle sores?” Then there are other people who have once a month have a different kind of saddles sore.
Betsy Welch 04:05
Dr. Andy Pruitt 04:06
Betsy Welch 04:06
Dr. Andy Pruitt 04:07
And in your job, I bet you ride lots of different bikes with lots of different saddles, and there’s a theory about sharing stresses. So, I’m not a journalist, but I ride a lot of different bikes, and I’ve demoed thousands of saddles, and I developed this concept of shared stress, I kind of like the idea of riding different bikes with different saddles in a given time so that no one area then becomes Ischemic, no one area becomes chafed, so I like that idea. Now, most people have one bike and one saddle, so then how do we vary stresses? Chamois changes, right? So, there are people out there that have their favorite chamois, they wash and dry it or not, between every ride, and it’s the or not we should talk about, right? Make sure your chamois is clean, never wear it two days in a row, make sure to use gentle detergent, make sure you air dry it, blah, blah, blah, all those things that the manufacturer encourages you to do.
Betsy Welch 05:10
Dr. Andy Pruitt 05:11
With their high-tech shorts.
Betsy Welch 05:13
Yeah, I mean, you’re totally right on that I do ride a lot of different bikes with different saddles, different kits, oftentimes, I don’t take the time to fit the bike that well, so I’m putting that variable in the mix too. I will say, however, this is not like a one size fits all conversation, just across the board, we should put that out there, whereas I could get no saddle sores on a 10-day backpacking trip, my partner could be like, you know, bedridden with them.
Dr. Andy Pruitt 05:51
Debilitated, unable to sit on the saddle.
Betsy Welch 05:53
Dr. Andy Pruitt 05:54
Yes. I mean, I’ve known guys that have finished stage races, basically without ever sitting down, right? So, anyway, so I mean, making sure your bike is fit correctly, making sure your saddle choice, which is a different video, please check it out, saddle choice, getting fit correctly, all those things, you can be a biomechanical ten, and still suffer from the things that we’re talking about, right?
Betsy Welch 06:16
Dr. Andy Pruitt 06:17
Betsy Welch 06:18
So, what are some like, even though I’ve just said, it’s not one size fits all, I think there are certain things that everyone should do, hygiene, obviously, is an important way to avoid some of these issues.
Dr. Andy Pruitt 06:31
Absolutely. So, hygiene for yourself, right? I love the guy at the multi-day ride or even the long gravel ride, like we were at recently, where the guy was in his kit from 6 am till 8 pm, and it’s like, what is growing in there, right? I mean, so you want to get out of that kit as quickly as you can, you want to get your tissue cleansed as quickly as you can, and if you’ve used water-soluble or petroleum jelly lubricant, it makes it even more important to get those pores clean. I would highly recommend an astringent, an alcohol-based skin astringent in the air, especially if you’re gravel racing, there’s no quick shower, but you can get out of your kit and clean yourself with an astringent to get that skin prepped as best as possible. So, hygiene is crucial. Grooming, you know, shaving of the groin, the pubic hair, or waxing, or laser, they all have different impacts on the way the hair grows back or not. So, shaving can leave a stubble, and you’re more likely to get a saddle sore from hair follicle from shaving, than from laser, which removes the hair, but if you don’t want to do laser, then all-natural, the hair acts like ball bearings and actually is a friction reducer. So, hair, you know, historically is for protection over our areas.
Betsy Welch 08:00
Yeah, absolutely. I guess it’s just important for people to note that however you do groom your pubic hair, shaving it, waxing it, is going to put you at higher risk for folliculitis-type sores and things like that.
Dr. Andy Pruitt 08:16
Correct. I’m a big fan of petroleum jelly-based friction reduction, it’s still there at the end of the day.
Betsy Welch 08:25
So, like chamois cream is what you’re talking about?
Dr. Andy Pruitt 08:27
Betsy Welch 08:28
Dr. Andy Pruitt 08:28
That’s water-soluble, which you have to reapply in the middle of a long ride. So, the petroleum gel is still there, but it also makes cleaning your chamois harder and it makes it clean and you harder, but it lasts the duration of the ride, right? So, anyway, what about things that don’t crossover?
Betsy Welch 08:49
Between men and women?
Dr. Andy Pruitt 08:50
Yeah. That’s why we’re here, right?
Betsy Welch 08:52
Yeah, it is. I mean, I don’t know is it warranted to do just a quick little anatomy talk here?
Betsy Welch 09:01
Knock yourself out.
Betsy Welch 09:02
Well, I just want to share one anecdote about Dr. Pruitt, the first time I called him up to do an interview, you know, when you’re in healthcare, you get used to using layman’s terms, just because it’s easier for everyone and I think I just said like, I think I just said vagina but I used it incorrectly, what I was meaning to say was labia, but you get used to talking about the vagina or the penis, but he called me on it, and he was like, “What do you mean the vagina? That’s inside.” So, I think it’s important when we’re talking about the saddle, men and women, to just use the correct anatomical terms because like I already said the vagina is not external, so it really doesn’t have anything to do with bike fit, however, the labia, vulva, those are the terms we should be using. Is that right?
Dr. Andy Pruitt 09:52
Those are the external genitalia that is compressed or irritated with cycling, the vagina does play a role, however, in some of the issues that women bring to the sport that men don’t bring to the sport, you know, vaginal discharge and leakage, all those things then seep into your chamois, right? So, that kind of becomes a petri dish of bacteria, and that’s a contribution from the female genitalia that men don’t have, not the men don’t have urinary leakage, it’s just not in the heart of things, right? So, I think, for women, especially on a multi-day tour, where there may not be a port-a-John, right? So, I encourage women to have a little Kleenex in their back pocket, so that there’s less contribution to the things that accumulate in your chamois.
Betsy Welch 09:58
One of the things I was most looking forward to talking about, sort of, on behalf of a lot of my women friends who aren’t professional cyclists, they’re just women like me who love to ride, you know, they come to me a lot and say, “Oh, my God, it hurts, like riding my bike hurts,” or “Ever since I had kids, it’s uncomfortable,” or like, “Is something wrong with my labia?” It breaks my heart, because, you know, you don’t want to see someone give up cycling, because it’s painful, and it doesn’t have to be.
Cycling Doesn’t Have To Be Painful
Dr. Andy Pruitt 11:22
It absolutely does not have to be. There’s a myriad of saddle choices out there now, and there’s most likely one that would make them happy, right? So, wow, back in my clinical practice, I recall a number of women coming in with a popular saddle of that time, late 90s, and had a really ample cut out for the genitalia, and they would say, they would come in for a medical fit because of their saddle discomfort, but they say the first hour, I love this thing, everything’s great, and then they get off to go to the restroom or the first feed station, and they’re off the bike for 10 minutes, and they can’t get back on and they’re never comfortable again.
Edema vs. Ischemia
Dr. Andy Pruitt 11:24
What that made me start thinking about was edema versus ischemia, right? So, ischemia is that pressure, that’s what hurts them first when they first got onto their bike and it’s uncomfortable, that’s ischemia that’s the capillary blood flow being moved around, and they’ll settle in, and that typically will resolve at first, right? So, that’s ischemia. Edema is fluid seeks the path of least resistance. So, you’ve got this big ample cut-out in the saddle, and it feels great at first, and they park their genitalia in that little cut-out and off they go, and fluid seeks the path of least resistance. So, in this ischemic area around the outside, all that fluid is being pushed toward the middle of the labia.
Betsy Welch 12:46
Dr. Andy Pruitt 12:47
So, we’ve got a cut-out in the saddle, all that tissue has suddenly become an epidemic full of fluid and actually swells into this cut-out, then they get off, and that fluid and the tissue migrates because it’s no longer confined to the cut-out, it migrates to the lateral tissues, and never fits back into that cut-out.
Betsy Welch 13:11
This is why getting back on after that hour or whatever is so uncomfortable.
Dr. Andy Pruitt 13:16
So, the saddle without a cut-out, traditional old saddles without a cutout, some women found that to be very comfortable, never had an issue with edema, and that can be, and there’s still a lot of women out there riding closed saddles, without edema. If we were to line up 100 genitalia across here, there’s going to be 100 different kinds and varieties, the less tissue you have externally, the more apt you’re going to be successful on a closed saddle, right? The more tissue you have, that’s your labia minora the inside when this dangling out, right? The fleshier you are the more trouble you’re going to have with edema as those tissues fall into the hole. However, I did two years where the research into this to develop a patented saddle, and again, if I take all those genitalia choices, right? I’m going to call the one over here with no exposure a doll, right? There’s nothing there, even they had significant swelling over time into a traditional cut-out.
Betsy Welch 14:28
So, I think it’s important to pause right here because we still have saddles on the market, men and women, or unisex, with cut-outs. Is that okay given what you learned in your research? Should we be avoiding cutouts or can they be okay?
Dr. Andy Pruitt 14:46
They can be okay. Like I said, the doll over here is going to be probably quite successful in a closed saddle, and there are other women who take their lady minor and roll them and put them into their vagina, so they can ride comfortably, you know, they’re trying to avoid that edema into the cutout.
Dr. Andy Pruitt 15:08
Posture plays a huge role. So, if you are a lordotic or swayback woman, or man, but that’s a more common posture in women, their genitalia is going to hit the nose of the saddle quicker because the pelvis is already tipped forward. So, they have a lot more issues with the ischemia in the vulva, and the labia on the more external things, those tissues become ischemic, ischemia and edema, both create pain, and it’s very hard to discern between the two of them.
Betsy Welch 15:44
Ischemia, lack of blood flow. Edema, swelling.
Dr. Andy Pruitt 15:47
Correct, and they feel the same to the brain. So, the women are telling me with the cut-out, that they were feeling midline pressure. So, I use the pressure map over the top of the cut-out, and the pressure map was reading zero pressure.
Betsy Welch 16:03
Dr. Andy Pruitt 16:03
But they’re still saying to me, “I feel pressure.”
Betsy Welch 16:05
Dr. Andy Pruitt 16:05
And it was the edema. So, the brain reads the edema as pressure, because it is, it’s pressure building in the tissue. So, the brain was thinking a very similar thing, so that’s when we started putting a hammock-like material in the cut-out to give the genitalia just contact, it likes to be caressed.
Betsy Welch 16:26
Dr. Andy Pruitt 16:27
Yeah, yeah, it’s the same kind of thing.
Betsy Welch 16:29
Dr. Andy Pruitt 16:29
Just likes to be supported, in that you have homeostasis, if there’s just a correct amount of pressure, you’re not going to get edema and you’re not going to get ischemia. So, finding that saddle, again, that has, you know, a soft nose, the hammock material in the middle to kind of caress those tissues is going to go a long way.
Dr. Andy Pruitt 16:49
let’s go back to the labial ischemia for a second. This is what people I think, need to talk more about, I think, the vaginal discharge, you’re going to deal with those kinds of infections with your urologist or GYN, the scarred or enlarged labia is a whole new pathology that’s bubbling to the surface. So, both edema and ischemia create scarring. So, if the labia are pressurized enough on the nose of the saddle it is without blood flow, it will create a scar, and suddenly that soft, malleable tissue becomes hard. One of the examples I remember so distinctly was a woman that had been a high-level cyclist in her youth and gone on to be a physician, she had a right-sided labia, which had become so scarred, that she would actually park it in the cutout, that’s how she found relief.
Betsy Welch 17:52
Dr. Andy Pruitt 17:53
Put it in the cutout.
Betsy Welch 17:54
Dr. Andy Pruitt 17:54
Then straddled the rest of the saddle crooked, which led to back pain, which got her knee, right?
Betsy Welch 18:00
She figured out an adaptation, but then that adaptation then,
Labial Scarring and Disfigurement
Dr. Andy Pruitt 18:03
So, let’s talk about this labial scarring and disfigurement, which is truly an epidemic. I interviewed the manager of the best professional team in the world. I asked him, how many of his women had labial issues that had required any kind of intervention? He said, none. Until I interviewed each individual rider, over half of his team,
Betsy Welch 18:28
Dr. Andy Pruitt 18:28
had significant pathologies, and many of them had reconstruction. So, what I want to impress upon new cyclists is this does not have to happen, don’t let this happen. There are solutions for it, but it’s plastic surgery, there’s reconstruction, it’s a big deal. So, if you start to notice labial toughening that’s a point where you need to stop and get a better saddle a different fit and start monitoring that tissue change with your gynecologist.
Betsy Welch 19:00
So, yeah, that was going to be one of my questions to you, I mean, short of being part of one of your like, clinical studies, what can the average cyclist who doesn’t want to run into any of these problems but who is having discomfort, will a traditional bike fit take these things into account? Like I said, short of being a clinical study.
Dr. Andy Pruitt 19:26
I would start with a traditional retail bike fit.
Betsy Welch 19:28
Dr. Andy Pruitt 19:30
That’s a whole nother video on how you find your bike fitter, but I would start at that level.
Betsy Welch 19:36
Because they’re going to see how you sit, how your body is.
Dr. Andy Pruitt 19:39
Exactly, they’re going to examine you with your posture, etc., and they’re going to put you in a pretty good position. Now, if that doesn’t resolve the issue, then you need to seek out a medical field, and there are probably 50 adequate medical bike fitters in this country. That doesn’t sound like many, and there aren’t many.
Betsy Welch 19:57
Dr. Andy Pruitt 19:58
There’s a concentration of us here in the middle of Colorado, but most states don’t have that. So, you do have to seek a medical, qualified fitter to help you. Then you really need to start monitoring these tissue changes with your gynecologist for sure. In which we’ve kind of sidestepped sexual dysfunction.
Betsy Welch 20:19
Right. Well, let’s get right into it. I’m glad you bring it up because that’s another thing that comes up with me, the sort of de facto bike expert in girls is like, “Oh my god, aren’t you afraid that after 11-days bike packing the Colorado trail with no chamois, like, it’s not going to work anymore?”
Dr. Andy Pruitt 20:47
That’s possible. So, you know, women can suffer clitoral erectile dysfunction from contusion. It can be transient, it can be permanent, although it’s incredibly rare.
Betsy Welch 21:01
Wait, wait, let’s pause here because I feel like that could terrify people off the bike forever. I mean, how does that happen? I think we have to go back to genitalia and anatomy again. Where is,
Dr. Andy Pruitt 21:15
Where are these parts?
Betsy Welch 21:16
Yeah. And are they at risk from poor fit?
Dr. Andy Pruitt 21:21
So, wow. The vulva is the hood over the clitoris, the most interior aspect of female genitalia, and as we sweep back, we get the labia majora, which are the big fleshy cushioning, they’re there for protection, right? Then the labia minora are inside and usually extrude out between the majora, but it is pressure on the vulva and on the clitoris that would lead to true sexual dysfunction, either loss of sensation, loss of rectal ability, lack of orgasm, all those things would come from an injury, either neural or vascular in that area, no different than men. Although, men’s erectile disfunction happens at scarring in the penal artery, right? Where you have the exact same neural network and vascular network, it’s just aimed a little differently, but the injuries can be similar, no doubt.
Betsy Welch 22:26
You said contusion, so that’s a bruise, essentially. That would be the cause of lack of function?
Dr. Andy Pruitt 22:35
So, you as your kid, and you ride home from the swimming pool barefooted on your bike battles, and you slip off and,
Betsy Welch 22:42
Having a Conversation About Saddle Discomfort
Dr. Andy Pruitt 22:43
Bam. So, that’s the first time you did that, and mountain biking, cyclocross, all the other times that we get that bam, right? Full suspension bikes, that rear suspension recoils, that will come back to you, and if you’re not perfectly placed, the nose of that saddle is going to get you. So, a contusion is an abrupt injury, where ischemia is long-term, right? Long-term lack of blood flow, both lead to scarring. So, I don’t want to scare the cycling public, what I’m trying to do is for women not to be afraid to have this conversation, right? In the retail setting, I’ve encouraged every retail shop owner to have at least one woman on the floor, and so someplace where another female can come in, and at least start that conversation. If they introduce them to their fitter, who’s very capable of having this conversation great, but that’s better than the male high school kid that’s working at the shop, right? So, there are ways to have this conversation or go have it with your doctor, but what I’m afraid of with the doctor is he’s going to say, “Well stop riding your bike. How dumb are you?” That’s the wrong answer, right?
Betsy Welch 24:01
Dr. Andy Pruitt 24:02
It’s the wrong answer. No, the right answer is to find the right saddle, the right position, the right fit, and the right chamois to make you comfortable, and avoid this issue. The dead giveaway is when a woman says to me in social conversation, I only ride once a week. What are they saying?
Betsy Welch 24:21
Dr. Andy Pruitt 24:21
It hurts and it takes six days to let it heal before they want to ride again, or I only ride an hour because they don’t want to get back on again. Those are the keys when your friends or your colleagues are saying these things or a wife saying this to a husband that maybe they should have a conversation about saddle discomfort.
Betsy Welch 24:40
Yeah, no, I’m so happy we’re having this conversation for that very reason, and I encourage men and women, again, to know your body parts first, to know the opposite sex body parts, and understand that we’re all going to sit on saddles differently.
Betsy Welch 24:58
So, you know you I have access to the sort of the latest and greatest in saddles, chamois, fit, and resources, but not everyone does, and not everyone is sort of as obsessed with cycling as we are to spend that much money. If you had to give people one thing to start with to prevent dysfunction, to prevent these types of pathologies, where would you start? I mean, fit, saddle, chamois, saddle, chamois, fit, what’s the order of operation?
What To Start With To Prevent These Pathologies
Dr. Andy Pruitt 25:34
Well, those all go hand in hand, right? It’s really the fit first and finding by word of mouth, a reputable fitter in your community. I would encourage you to drive 100 miles, if the guy that keeps the name, guy, or gal name keeps coming up, is 100 miles from you, get in your car.
Betsy Welch 25:52
Dr. Andy Pruitt 25:52
It’s well worth it, right? So, fit comes first, but as part of that fit, is to choose the right saddle and get it in the right place. The saddle is the center of the fit universe, and if you change your saddle, then the whole fit needs to be kind of reconsidered as well. One of the things we tell retailers that if there’s somebody at the saddle wall when they’re doing the thumb test on the saddle, the discussion shouldn’t be on saddle choice it should be on fit, and then let the fit and the saddle choice go hand in hand. Don’t be afraid to do a saddle trial, right? Many of the retailers now will let you try a saddle for X number of days, and you can rotate through several of them to get the size right, to get the shape right, there’s a myriad of choices closed, open, the mimic with the little support through the middle, there’s a myriad of choices out there, one of them is going to work for you.
Betsy Welch 26:53
Yeah, well, you don’t have to settle with the saddle that comes on the bike, you don’t have to settle with your husband’s hand-me-down saddle, likely, neither of those are going to be the right saddle,
Dr. Andy Pruitt 27:04
Right. I guess one of my closings would be, get the fit, make sure the equipment is not the variable anymore. If you are noticing changes in your anatomy, changes in size, shape, whatever, or changes in function, don’t be afraid to go have the conversation. Now, be careful with who you have the conversation with, if you’re going to go to your non-sports general practitioner, and they’re going to freak out and tell you get off your bike, that’s not the answer, right? They need then to refer to the fitter, a fitter and a doctor that have a relationship is a really great thing to find, but if you start noticing changes in your genitalia, start noticing changes in function, then you need to consider something more. There’s an epidemic globally right now of labial reconstructions, many of them secondary to cycling.
Betsy Welch 28:02
And these can be prevented, right?
Dr. Andy Pruitt 28:06
Betsy Welch 28:06
Dr. Andy Pruitt 28:07
Betsy Welch 28:08
Well, thank you, Dr. Pruitt, it was a wonderful conversation. As always, I learn a ton every time we speak and I hope that you all did, too.
Dr. Andy Pruitt 28:16
I appreciate you being here Betsy, it’s been great. My last parting shot, though, is that if you’re having any of these issues, make sure you do talk to somebody, even if that starts at the retail, and then move to the physician, however you want to do it, make sure you talk to somebody. Thanks for joining us.