EDITORIAL
The A, B, C’s of The Journal of Sexual Medicine:
Awareness, Bicycle Seats, and Choices
Most of us have choices in life. Some choices are easier to make than others-where we live, what we do for a profession who we see as friends, what we do for recreation-but are our choices always the best for us? And can we tell before we make that choice what the outcome will be?
A decade ago an editor of a biking magazine came to me seeking treatment for erectile dysfunction. We wrote about the permanent effect on his penile arteries of chronic long distance bicycling on narrow bicycle saddles. The outcome of that article was his loss of employment and my continued commitment to better understand the pathophysiology and treatment of bicycle-riding erectile dysfunction[1-5]. After several years of personal ridicule by members of the bicycle industry, they finally “addressed” the concerns by producing a bike saddle with a cutout, another one with a split in the rear, and other styles “designed to be safe” for the genitalia and “doctor-approved.” Bicycle riders thought they were “playing it safe” using one of these new saddles, but they continued to present to offices like mine after every fundraising bicycle ride hoping to be candidates for penile microvascular arterial bypass surgery to cure an erectile dysfunction problem that had suddenly developed following the ride[2,5]. The fact is that the reduced surface area of the new saddles actually worsened the problem (by increasing the magnitude of the compressive pressure on the perineum[3,5,6]), and the doctor who approved some of the saddles had designed them as well.
In the meantime, evidence-based investigations in peer review publications continued to appear to help men and women make choices based on science. For example, healthy, premenopausal women bicyclists and runners were compared by multiva1iate analysis of genital vibratory thresholds. Those who rode bicycles exhibited significantly higher genital vibratory thresholds at the perineum, posterior vagina, and labia[7]. Additionally, perineal pressure was measured in men sitting on three different saddle designs with no protruding nose compared to a traditional sport or road racing saddle with a narrow protruding nose.
The traditional 1 sport or racing saddle with a nose extension was associated with greater than two times the perineal pressure titan the saddles without a protruding nose[8]. One study showed that when male cyclists were compared with nonbiking men, the percentage of sleep sessions recording an erectile event was significantly lower in cyclists vs. n oncyclists[9].For athletes looking to improve cardiovascu la r health by exercising, the risk of developing erectile dysfunction was examined among healthy participants who had good or very good erecti le function before the study. Various types of physical activity at the highest tertile of physical activity (as measured by metabolic energy transfer units [METS]) were associated with a decreased risk of developing erecti le dysfunction, with the exception of bike riding[10]. Another study showed that there was compression of arterial blood inflow while straddling a narrow saddle with a nose extension or narrow saddle with a cutout; but sitting on a wide, noseless two-cheek bicycle seat that supported the ischial tuberosities a llowed for the same blood flow as sitting on a chair[3]. Finally, 20 healthy men without erectile dysfunction had transcutaneous oxygen pressure measured at the penile glans while sitting on bicycle saddles with different widths and padding: a narrow heavily padded seat with nose extension, a narrow saddle with medium padding and a V-shaped groove in the nose extension, a narrow unpadded leather seat with nose extension, and a wide seat with medium padding a nd no-nose extension. The most important factor in preserving penile perfusion was saddle width with out nose extension that prevented compression of the perineal arteries[11]. Suddenly science gave bicycle riders choices-but would they make them?
Fast forward to today. Steve Schrader investigated tl1e saddles being used by bicycle riding policeman and discovered the same issues of numbness and erectile dysfunction that I see regularly in my patients. Read his results in “Cutting Off the Nose to Save the Penis.” So what if police departments offered their officers a choice, an option to ride on a “safe seat?” Would they make the choice, and what would that mea n in the long run? For the first time, we have in this issue a prospective srudy of healthy policemen riding bikes on the job, using wider, no-nose bike saddles for 6 months. Not only did their sensation improve, their erectile function also improved. Changing saddles changed physiology. This is a landmark study for our field that reflects both prophylaxis for those furure riders (and their parents) just thinking about the bicycle of their dreams, and modification of lifestyle showing improvement without any active treatment. While this study was performed in men without erectile dysfunction, it nevertheless reflects furure directions of our field. People have choices, but intelligent choices require education and science, and The Journal of Sexual Medicine continues to play a role in disseminating important scientific information in the field of sexual medicine.
As clinicians, we must firmly place those choices in the hands of our patients. However, it is our responsibility to provide the necessary information required by our patients to make those choices. For example, there has been a great deal of recent discussion on the list serve of the International Society for the Study of Women’s Sexual Health with regard to use of testosterone in women with sexual dysfunction and low testosterone levels, and its potential to increase breast cancer due to aromatization in breast tissue (12-14]. The citation was made to the Women’s Health Initiative (WHI) report. While the \:vi-II repon reflects the use in an older popu lation of conjugated equine estrogens (premarin) with and without synthetic progesterone, we have a choice to use bioidentical hormones instead where we can measure levels in the blood. Breast cancer patients fear estrogens in their bodies[15,16]. Women with breast cancer have a choice to use aromatase inhibitors to greatly decrease the likelihood of androgen conversion to estrogen. If a woman is distressed enough by her sexual dysfunction, she can choose to work barb with her oncologist and sexual medicine physician for treatment. But it is her choice. Alder et al. address this question in this issue of the JSM.
Also in this issue is a review by Morgentaler et al. on the use of testosterone in men with prostate cancer. There is growing discussion that having prostate cancer no longer means being sentenced to a life without androgens, and all the concomitant androgen deficiency health problems. While the use of testosterone in post­prostatectomy patients is controversial, it is again a conversation worth having with patients who should be able to make an informed decision. Our responsibility as clinicians, as in any other treatment scenario, is to inform patients of the pros and cons of use of any therapy.
In this issue you will also find the guidelines for erectile dysfunction by the British Society for Sexual Medicine. Guidelines are just that they allow us to make the choices based on the information we have. They are recommendations based on statistics, but each patient is an individual who deserves individual attention and education.
We make choices every day, as individuals, as members of a domestic unit, as clinicians or researchers, as JSM readers. To make a choice you must be in formed and open-minded enough to read the choices. Steve Schrader took the time to investigate bike seats used by police officers­government employees-and in the end was awarded a Bullard-Sherwood Research-to­Practice Award in the Interventions Category for “Health Effects of Occupational Cycling.” Congratulations to Steve, and to all those men and women who will benefit in the long run from Steve’s amazing, first-ever, award winning research effons proving th e positive benefits of choosing a \wide, no-nose bike saddle over a narrow saddle with a protruding nose.
To honor those men and women who live in places where they are unable to make choices, we need to appreciate our ability to have choices and ought to make those choices responsibly. In their honor, we choose to read your JSM regularly, write for it responsibly, review for it when requested to do so, and cite your JSM when appropriate. Our new and higher JSM impact factor is a wonderful tribute to us a ll making the JSM choice.
Irwin Goldstein, Editor-in-Chief
 
References
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2. Munarriz RM, LaSalle MD, Goldstein I. Penile revascularization for treatment of erectile dysfunction secondary to blunt perineal trauma. Urology 2003;6 1:222-3.
3. Munarriz R, Huang V, UberoiJ, Mrutla nd S, Payton T, Goldstein I.Only the nose knows: Penile hemodynamic study of the perineum saddle interface in Editorial men with erectile dysfunction utilizing bicycle saddles and seats with and without nose extensions. J Sex Med 2005;2 :612-9.
4. Huang V, Munarriz R, GJ ldstein I. Bicycle riding and erectile dysfunction: An increase in interest (and concern). J Sex Med 2005;2:596–604 .
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6. Schrader SM. Research on bicycle saddles and sexual h ealth comes of age.J Sex Med 2005;2:594-5.
7. Guess MK, Connell K, Schrader S, Reutman S, Wang A, LaCombe J, Toennis C, Lowe B, Melman A, M.ikhail M. Genital sensation and sexual function in women bicyclists and runners: Are your feet safer than your seat? J Sex Med 2006;3: 10 18.
8. Lowe BD, Schrader SM, Breitenstein MJ. Effect of bicycle saddle designs on the pressure to the perineum of the bicyclist. Med Sci Sports Exerc 2004;36: 1055-62.
9. Schrad er SM, Breitenstein MJ, ClarkJC, Lowe BD, Turn er TW. Nocturna l penile tumescence and rigidity testing in bicycling patrol officers. J androl 2002;23:927-34.
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11. Schwarzer U, Somm er F, Klotz T, Crem er C, Engelmann U. Cycl.ing and penile oxygen pressure: The type of saddle matters. Eur Urol 2002;4 1:139- 43, 27.
12. Traish A, Guay AT, RF Spark. Testosterone Therapy in Women Study Group. Arc the Endocrine Society’s Clinical Practice guidelines on and rogen therapy in women m.isguided? A comm en­ tary. J Sex i\1ed 2007;4: 1223-34.
13. Kingsberg S, Sh.ifren J, Wekselman K, Rodenberg C, Koochaki P, Derogatis L. Evaluation of the ctini­ cal relevance of benefits associated with transdermal testosterone trea tment in postmenopau sal women
with hypoactive sexual desire disorder. J Sex Med 2007;4:I 001-8.
14. Braunstein GD. Management of female sexual dysfunction in postmenopausal women by testosterone administration: Safety issues and controversies.J Sex Med 2007;4:859-66.
15. 5 Schwenkhagen A. Hormona l changes in menopause and imp}jcations on sexual health. J Sex Med 2007; 4:S220-6.
16. Goldstein I. Current management strategies of the postmenopausal patient with sexual health problems. J Sex Med 2007;4:S235-53.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
J Sex Med 2008;5 :1773-1775