It is not uncommon for cyclists to openly refer to saddle sores. But usually that is where the descriptions end. An understanding nod, a painful grimace, followed by silence as if to say “please spare me the gory details”. After years of suffering several #flapmash episodes, I feel there is value in sharing some details that may help to prevent or manage saddle sore issues others may have. This blog will be explicit (don’t worry it doesn’t contain any images of my genitals). So move on if you are the prudish type, or read on if you want to find out more.
For starters, let’s make a distinction between saddle sorenesss and saddle sores.
Saddle soreness (to me) is discomfort, pain or numbness in any area of your body that is in contact with the saddle. So that can be your sit bones, butt cheeks, inside of your upper thighs, or more delicate parts such as your groin, outer labia, inner labia or even your clitoris.
When I mention saddle sores I mean a variety of skin irritations and issues that go beyond pain or discomfort. Saddle sores vary in nature. Many saddle sores start with just a bit of chafing. The classic saddle sore is either an infected hair follicle (known as folliculitis) or a boil (known as a furuncle). Small sores caused by infected follicles usually heal up pretty quickly, but untreated boils can quickly reach scary proportions. They may develop into an abscess, a deep skin infection that may be filled with, or drain, pus and are hard to get rid off without antibiotics. There is no need to be overly graphic in this blog, but a quick google will throw up some interesting images if you feel the need for some illustrations.
Not every little bump “down there” is a saddle sore. Yet, when exposed to the heat, pressure and friction of long bike rides, any lump and bump can eventually develop into similarly infected abscesses.
My personal issues with saddle soreness and saddles sores have mostly been these three types:
1) Labial hypertrophy
Or in layman’s terms: swollen, enlarged labia (outer labia in my case, but it can happen to your inner labia too) due to pressure and reduced blood flow (especially when riding in an aggressive time trial position for 24 hours or more) resulting in lymphatic drainage and pain.
This made me wonder whether I was unlucky to have exceptionally large or awkwardly shaped labia. A quick glance at ‘The Great Wall of Vagina’ confirmed that while we are of course all shaped differently, and I am a little asymmetric, my vulvar area is nothing out of the ordinary.
Further clarification through Cobb Saddles’ excellent analogy of “innies” and “outies”, did however reveal that I am more of an outie with larger outer labia.
The consultant gynaecologists I recently saw for my ongoing flapmash issues is an expert in vulvar issues and also confirmed that there is nothing abnormal about my labia that would explain the issues I have had or would call for labiaplasty (surgery to reduce the size of your labia).
So far, I have found a number of ways to reduce the swollen labia issue:
- sit in a more upright position (when possible);
- ensure a bike fit that allows pressure transfer to the sit bones rather than the labia; and
- use a saddle with a cut out, although recent research seems to suggest a central cut-out can actually exacerbate the swelling of the labia through it rather than relieve pressure, as designed…
I have tested the Infinity Saddle, which is effectively one big cut out, but found it to be unsupportive and uncomfortable unless I sat in one specific upright position which in turn gave me poor power transfer.
So far, the best saddle for me has been the Cobb Max , but I am afraid the hunt for something that suits better still has not ended yet.
The Specialized Power Mimic saddle, with its multi-layered design flexible TPU (thermoplastic) and memory foam, was recently launched as the latest revolution in women’s saddle design. However, I have read mixed reviews about it. Once my new bike arrives (hopefully in January), I am planning to get a bike fit which incorporates saddle pressure mapping and hopefully I will have a chance to test if the Mimic is indeed the magic saddle for me. Having tried many different saddles, I can’t help feeling a little sceptical.
I would love for someone to launch a truly bespoke approach to saddle design. As illustrated by the Great Wall of Vagina we are all shaped differently; we have different riding positions and styles; and, at least in my case, I am sitting differently on my saddle from one day to the next depending on what lumps and bumps I am battling with. Saddle pressure mapping technology is now widely used in bike fitting. 3D printing is mainstream. Victoria Pendleton already had a bespoke saddle made out of the same silicone used for breast implants. Surely we are just one step away from saddles that are truly bespoke?
Of all the bespoke cycling kit one can think of (e.g. I saw bespoke helmets at Rouleur Classic), I believe there really is a market for bespoke saddles. How many saddles does the average cyclist try during their cycling life? In my time in cycling (which only commenced in 2011) I must have tried out at least 5, possibly 10 different saddles. I bet some people who read this blog have tried out even more. Of course a bespoke saddle would come at a higher price, but I would happily pay more to sit comfortably, and it can hardly be more than the cost of all discarded saddles together.
2) Infected follicles
I have regularly battled with infected follicles, but often this was initiated by ingrown hairs from shaving my bikini line and then exacerbated by heat and friction from long rides.
Thanks to widely referenced research and advice by British Cycling, many female cyclists are now more aware of the dangers of pubic hair removal.
If we are to believe the image presented in the media, then all women should be bare as children forever and a day, be it for their own pleasure or to please others, but there is clear evidence that hair removal damages the epidermis and increases the risk of ingrowing hairs and follicle infections. Sadly, I have often fallen foul of thinking ‘oh damn this bush, I will just remove this little bit here …’ only to be punished for my vanity shortly after.
Yet despite following British Cycling advice (wearing kit that properly fits, tilting the nose of my saddle ever so slightly down, refraining from hair removal and only trimming the hairs, using Doublebase gel as a chamois cream and Dermol 500 as a soap substitute and antibacterial shower gel), I kept on getting infected hair follicles, which would turn into abscesses after longer rides.
My worst experience of this kind was the infection I had after Le Mans 24 hour in 2013. My right outer labia had become so inflamed that I was totally lopsided, with the right labia looking like something that should belong to an elephant rather than a human. By the time the infection had caused big red circles to spread on the skin of my inner thigh and all the way up my belly, it was time for a doctor’s visit, quick trip to A&E, followed by an emergency operation in a French hospital. Back then, the French logged it as a Bartholin’s cyst. But the Bartholin gland is located much nearer to the opening of the vagina than the area where I was operated… Plus they definitely did not remove the Bartholin gland; I would know if they did! The operation itself was pain-free and done under full anaesthetic, but the recovery was slow and required daily wound care, including injecting iodine into the open wound.
I haven’t had a single issue on my right outer labia since, but have had various infected lumps on the left, each time requiring a course of antibiotics to heal. After numerous such incidents – one of the worst ones was after the mad Zwift distance record which left me with a gaping staph hole in my groin and a red ring 10-20cm down my inner thigh – I have become increasingly concerned about the impact of multiple courses of antibiotics. The abscesses also never fully healed. It felt like a lump of subcutaneous scar tissue remained and always caused new issues.
3) Blood filled boils
These red boil-like lumps started to appear about a year or two ago and have been my biggest nemeses. They would appear out of nowhere. It didn’t matter whether I did a long or a short ride and even occurred during periods when I didn’t ride my bike at all. They popped up on various locations on my left outer labia, often in the build up to my period, but at other times too.
Generally, it would start with a hard subcutaneous lump (rice grain to pea size) that I could wiggle about, which would then quickly over the course of a few hours become more swollen and painful to the touch. They never had a typical ‘head’ on them and weren’t the kind of lumps you could squeeze. Give it another day and it would grow to the size of a marble. Yet another day and it would be a small quail egg. If I dared doing a long ride on it, I would end up with a full golf ball.
If I was lucky, the skin on the angry painful lump would break of its own accord and start to drain. It never leaked obvious white or yellow pus. Just a little bit of clear liquid at first, followed by bright red blood. At this point I could help drain the lump by squeezing the blood out. Yet, no matter how long I squeezed for, there would always be more blood and the lump never emptied completely.
If I wasn’t so lucky, multiple applications of Tyrosur gel, magnesium sulphate paste or tea-tree oil over several days would eventually draw liquid to the surface and the skin would burst. Once drained (or at least partially drained) the lumps would shrink back from golf ball to quail egg to marble to pea and (if I gave it enough time) rice grain, but never completely disappear.
These flipping flapmash episodes were doing my head in. My training was disrupted. Every ride felt like Russian roulette. Sometimes my labia emerged unharmed. Sometimes the lumps would start to swell during the ride or race. And sometimes I would start with a big angry red swollen lump already (e.g. my last LEJOG record attempt) and would be guaranteed a big uncomfortable infected abscess by the time I climbed off the bike. It even got to the point, where I would beg the doctor to already supply me with the antibiotics before such events, so that I could take the antibiotics as soon as it occurred and didn’t have to suffer extra time waiting for an appointment and prescription. Such painful madness!
Anyone I would talk to would always point out all the obvious things I was already doing:
- bike fit
- suitable saddle
- bike shorts without seams that properly fit and are well-worn in (I have tried quite a few)
- not using underwear when riding (obvious but I guess still worth pointing out)
- building up slowly to more time in the saddle
- refraining from shaving pubic hair
- chamois cream with antibacterial properties (again I tried quite a few!)
- standing up out of the saddle from time to time
- taking care of hygiene
- washing with Dermol lotion
- airing my bum as soon as possible after a ride,
- sleeping without underwear or tight clothing, etc.
As long as the LEJOG record attempt was hanging over my head, I didn’t want to allow myself prolonged time off the bike or time to get it properly looked at and sorted. I feared (correctly) that it would require an operation and a lot of time off the bike, which I couldn’t afford at that point in time.
Bye-bye flapmash ?
As soon as I made peace with failing my record attempt, I started looking for a gynaecologist who could help me with my issues. Based on recommendations from experienced long distance riders Judith Swallow and Dave Minter, I got an appointment with Dr. Deborah Boyle, consultant gynaecologist at the Royal Free Hospital and Lister Hospital. She knows a lot about vulvar abnormalities and had worked with female cyclists before, so I felt in good hands. I had to wait a few weeks for the post-LEJOG abscess to heal and also for my insurance authorisations to be in place.
Dr Boyle’s verdict was that she couldn’t be totally sure what it was until she would open me up. It could indeed be a case of lingering scar tissue from previous saddle sores that just kept on getting inflamed again, but it could equally be a skin condition. One thing was for sure: the problem would not go away unless she removed some of the affected skin tissue at least.
The operation was done under full anaesthetic on the 8th of October at the Royal Free Hospital. Unlike my French adventure 5 years earlier, I didn’t need to stay overnight. Even though it was only for a few hours, the hospital took great care of me with a private room, nice food and fancy inflatable leg compression devices due to my DVT history.
I guess either the anaesthetic wasn’t as strong as the one in France (which could well have been the case given the French even offered me morphine as a pain killer!) or I wasn’t as fatigued to start with (having done bugger all for weeks rather than being in a post solo 24 hour race zombie status). Either way, I was slightly disappointed when waking up from my general anaesthetic that it hadn’t been the amazing deep sleep I had been looking forward to.
Forgive my layman’s description. For those who wondered, I didn’t have a flap reduction. The bad lumps under my skin were removed in two or three places and sent to the lab for testing. The wound was not left open like in France, but instead closed with two layers of dissolvable stitches. This made moving about and sitting down much easier. Five years ago, I could only lay down or sit on a pillow. This time, I could have gotten myself home, if it wasn’t for the hospital and my family insisting on someone picking me up after the operation and the potential side effects of the general anaesthetic. Showering was easier too.
The recovery didn’t require the pharmacy load of pain killers and antibiotics I was prescribed after the operation in France. A British common sense approach of only taking pain killers if I was in pain seemed much more appropriate. After some initial panic because some of the dissolvable stitches gave way after just 2 days and provided a rather deep look into my flesh, the wound healed slowly but nicely.
The main difficulty was that I couldn’t do any physical activity. If you have a wound on your leg, you can still do things with your arms and vice versa. But with a wound in your groin or on your labia, there is tension on the wound with every step you take and even sitting with my legs slightly too far open would cause issues. I could only wear loose harem pants and I was getting grumpier by the day.
Following the disappointment of failing yet another attempt at the LEJOG record (and the pressure of preparing for it for such a long time), this setback and uncertainty about whether the operation had cleared my flapmash problems once and for all, or if I was battling a chronic skin condition that would at best hinder or at worst stop my cycling forever, now made me feel rather depressed. I tried to enjoy other things such as time with family, reading books etc, but dealing with uncertainty and having patience are not my virtues…
In 2013 I tried to get back on the bike after 3 weeks, only to have to sit out two more weeks because the wound reopened. This time, I was able to do some gentle yoga again after 2 weeks (which did much to improve my mood!). I tried to run after 3 weeks (which is another long story and left me with buggered big toe joints..). After 4 weeks I was able to do some gym work. I waited 5 weeks before I got back on the bike, but found that I had to wait another week or two as the young skin was still very sensitive and fragile.
Hidradenitis Suppurativa ?
The hospital test results from the removed skin tissue came back a few weeks after the operation, but didn’t show anything conclusive. Phew, at least it wasn’t cancer.
The only known skin condition that matched my symptoms somewhat was Hidradenitis Suppurative (HS), a chronic and painful skin condition, that in very simple terms can be described as inverse acne. Many people get acne on their face; others get blocked hair follicles near sweat glands in their groin or armpits, under their breasts or on their bum. In the early stage HS presents itself as painful red lumps, looking like boils and cysts. In the later stages of HS there will be tunnel formation under the skin that leak pus and wounds will not heal easily anymore. Over time, more scarring will occur.
HS is more common in women, but generally begins around puberty age. Smoking and obesity are linked to HS, but the condition can also affect non-smokers of normal weight. It isn’t contagious and only runs in the families of about one-third of those with the condition. As far as I know, nobody in my family has or had HS, but there are studies that found coexistence of HS with other autoimmune disorders, such as Hashimoto’s thyroiditis (an autoimmune thyroid disease leading to low thyroid hormone levels), which does run in my family.
To be very clear: I am not saying that I have HS. Dr Boyle couldn’t make a diagnosis whether I had HS or not. Usually those symptoms would be more widespread (i.e. with lumps appearing not just on one labia, but also in other areas near sweat glands). Based on my description of my symptoms and my comparison with images on the internet (health warning, later stage HS is scary stuff!), it could be HS. But there is no specific test on which a HS diagnosis can be made. Dr Boyle would only be able to tell with more certainty if it was HS or not, if I managed to see her on a day when an actual blood filled lump was present (which is tricky as she only has consultations twice a week and the occurrence of my symptoms has been irregular).
If it is HS, then there is no cure, just treatment of the symptoms, ranging from warm flannels, to painkillers, to antibiotics (which I really don’t want any more of), to laser treatment, surgery (similar to what I just had) or steroid injections into the boil. However, relapse of symptoms is not uncommon.
If it is HS, then prevention methods include:
- Stress management (relevant for all sorts of reasons but not always possible with my job)
- Avoiding tight clothing (long live skirts and bring back those Hammer pants!)
- Weight loss and stopping smoking (I don’t smoke, but a little weight loss can’t do much harm)
- Washing with antibacterial lotions such as Hibiscrub which contains 4% chlorhexidine (I have used this in the past)
- Antibiotic tablets, taken preventatively (no thanks)
- Immuno-suppressive injections and various tablets to alter the immune system (again, no thanks)
If it is indeed HS, then you may understand it causes some emotional stress, embarrassment and frustration in addition to the discomfort and issues with cycling.
If it isn’t HS and was just a rather long period of bad luck that has now been fully ‘cut out’, then I would be very happy indeed !!!
Change of diet
There is limited information about HS, but there is some evidence to suggest diet can help to suppress HS. If you can get access, this is one of the best academic articles I could find about the link between HS and a ‘Western’ diet with lots of dairy products and highly refined simple carbohydrates. If you are interested in the detail, but can’t access the article, feel free to send me a message and I can send you a copy.
Even if what I have (or had) isn’t HS, these dietary changes are still good for general health. It means avoiding:
- White flour
- Refined sugar or processed high glycemic index foods
And eating plenty of:
- Fruits and vegetables
- Fatty fish, at least twice a week (I love fish!)
- Unsaturated fats (avocado, olive oil, nuts and seeds)
In short, it is about stopping the dairy whey/sugar > hyperglycemia > elevated insulin > hypoglycemia > hunger > sugar dietary cycle which will correct the chronic hyperinsulinemia, insulin resistance, and all its downstream problems. I may write some more about dietary changes in a future blog, but in the meantime this book is pretty eye-opening as is this one.
Although my overall diet was relatively healthy, I have always had a sweet tooth, so cutting out the tons of chocolate I used to consume isn’t a bad thing anyway, especially with the scary Jebel Shams climb coming up as part of BikingmanOman …
So far, work hasn’t been too hectic and I have pretty much stuck to the new diet, with the exception of some bubbly and some excellent Dresden stollen and Trou Normand at Christmas. I haven’t had any new flare ups or boils since the operation and resuming my cycling (touch wood). Perhaps I will slowly relax my diet again, or at least make exceptions for holidays and celebrations, but overall I am pretty happy with a diet that avoids dairy, refined sugar and yeast. I was already a big fan of Rawvelo sports nutrition products, but with these diet changes their vegan, natural sports bars, gels and hydration mixes without refined sugars make even more sense.
Change of skin care
If I haven’t scared you off yet with my infected labia stories, I reckon I may as well fill you in on my new skin care regime too.
Have you ever wondered why a growing number of people have sensitivities, allergies and other skin issues? Part of the answer may be that we are simply too clean now. Indoor lifestyles (i.e. lack of exposure to dirt) and a plethora of personal care products have removed the bacteria that were historically able to look after our skin.
You may call me a mad hippy, but at the moment I am willing to try anything to make sure I never get these painful bloody lumps again! I have removed all soaps and started using a product called MotherDirt which restores the skin with these good bacteria. You can read more about the science behind it here and here.
Time will tell if it is a complete scam, but so far, my skin responds well to the products (which are bloody expensive…). I tried to go complete ‘cold turkey’ by no longer using deodorant for a while, but quickly came back from that decision. I guess I am only half a hippy after all. Not using deodorant is just a step too far for me and makes me feel uncomfortable, especially given the amount of sports I do and how much of a heavy sweater I am. I did however find a paraben free, mineral protective deodorant.
Onwards and upwards
Right now, my overall fitness level isn’t too shocking anymore, but my cycling specific fitness is still pretty low and climbing back out of a very deep through. I am conscious of building it back up slowly though. My labia have survived up to 3 hours on the turbo without any damage. My longest ride on the road so far was just shy of 100 miles, albeit at a relatively modest pace. The big test will be the Poor Student 200km Audax on the 5th of January, followed by an early season warm-weather mini training camp in Tenerife later in January, and the ultimate test: the 1050km non-stop unsupported BikingMan Oman race at the end of February.
If I survive all of that without any new flapmash issues, the future for longer unsupported bike races looks bright… Already, I am amazed by being able to sit on my saddle in comfort for the first time ever.
Add a new titanium (!) bike into the mix that is not as stiff as my current bikes (the Scott Foil and Specialized Shiv TT are both known to be among the stiffest frames…) and one that runs on tubeless, and my cycling should become a lot more comfortable (and comfort equals speed!). I know a titanium bike is a bit extravagant, but it is an investment for life and my labia will thank me for it…
As an aside, I am also doing some exercises for imbalances in my glutes and hip flexors. Riding the other day with Peta McSharry, an excellent sports massage therapist and long distance cyclist, she noticed (and filmed) how often I move my bum quite a bit to the right on the saddle during the pedal stroke. I was astonished no bike fitter ever noticed this, and I have seen some very good fitters. It is less apparent on the turbo and even less so in the TT position, but may well explain why no amount of bike fits, different saddles or shorts will make any real difference, if my left labia is effectively rubbing over the saddle in all sort of ways. I am the problem, more so than the equipment that I am using!
Well done for making it to the end of this rather explicit blog. Sorry, but the Dutch are known not to shy away from taboos. I hope I haven’t alienated you too much and that some of my story may help you with your own flapmash issues or prevention.
Happy cycling !
PS: In March 2019 I was part of a panel session at the London Bike Show. If you missed it, you can listen to the full session by clicking on this Wheelsuckers podcast link.