A rare case of suspected perineal nodular induration

Getting to the Bottom of Saddle Sores: A Scoping Review of the Definition, Prevalence, Management and Prevention of Saddle Sores in Cycling

Objectives: To summarise and map the existing evidence relating to the definition, prevalence, prevention and management of saddle sores within the literature and highlight research gaps. Design: Scoping review. Data Sources: Three databases were searched using an appropriate search strategy agreed on by the authors with the aid of an experienced medical librarian; these databases were MEDLINE, EMBASE and Web of Science. Eligibility Criteria: To be included in this review, studies must have made specific reference to dermatological conditions that affect the saddle area, specifically arising from cycling, in either sex. Results: Seventeen studies were selected for inclusion. Saddle sores in males were the focus of thirteen studies, with only two reporting in females. Saddle sores were defined as connective tissue lesions affecting the skin in the saddle area, which can be both acute and chronic. Commonly cited preventions were chamois cream, high quality, well-fitting cycling equipment and good personal hygiene. Management in the early stages usually involves rest. Topical and intralesional steroids and lubricating creams are recommended treatments for small saddle sores, with surgical excision an option for larger, persistent saddle sores. However, surgery and steroid use may increase risk of recurrence. Conclusions: Saddle sores are an underrepresented, male-dominated issue within the literature. There is particularly limited evidence around treatment options, including topical steroids and surgical removal. Further well-designed observational studies and/or randomised controlled trials will help provide further evidence on prevalence, prevention and treatment available in the future.

"Bumpy" ride for the female cyclist: A rare case of perineal nodular induration, the ischial hygroma

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PNI is a pseudoneoplastic lesion caused by repetitive microtrauma.

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Shearing in perineal fascia stimulates fibroblastic proliferation.

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Reported almost exclusively in males, it can occur in females and is underdiagnosed.

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Cyclists and any saddle sport athletes (even seated lawnmowing) are at risk.

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Treatment is to remove the trigger; surgery can be considered in refractory cases.

Introduction

Cycling is known to cause groin pain, typically adductor/hamstring strains and “saddle sores” (skin abrasion, ulceration and/or folliculitis). Rarely does it result in pathological mesenchymal lesions.

Presentation of case

We report a case of a 52-year-old female avid cyclist with chronic groin pain. Activity alteration, bike fit, and saddle modification did not ameliorate her symptoms. MRI revealed no hamstring or bony abnormality but demonstrated low T1/high T2 signal in the right perineum inferior to the ischial tuberosity.

Discussion

Perineal nodular induration, or “cyclist’s nodule,” is a reactive fibroblastic and myofibroblastic pseudotumor almost exclusively reported in male cyclists. PNI can become so nodular that it has even been referred to as an accessory testicle or “the cyclist’s third testicle.”

Conclusion

We report an unusual case of PNI in a female cyclist and review the differential diagnosis of non-infectious soft tissue perineal pain in cyclists. Clinicians should be aware of this rare condition to avoid confusion with other mesenchymal lesions.