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Bacterial vaginosis (BV) is one of the most common causes of abnormal vaginal discharge seen in females who are sexually active. Generally, one notices unpleasant symptoms, such as vaginal odor, itching, watery discharge or pain. At least half to 2/3 of ladies with BV may not be aware of their conditions as they can have no symptoms at all.
BV is a condition due to overgrowth of pathogenic bacteria Gardnerella vaginalis and other anaerobic bacteria following the loss of good vaginal lactobacilli.
Aside from affecting a female’s quality of life, BV is known to increase risk of STDs, and can affect a person’s reproductive ability-causing spontaneous abortion, premature delivery, and more.
Although BV is not classified as an STD, it is associated with sexual activities and seen in women with higher frequency of sexual intercourse or those with more numbers of sexual partners. Other risk factors for BV include:
Herpes Simplex Virus (HSV) is a common STD seen globally. HSV type 2 is one of the most common causes of sexually related genital ulcers. While one can present HSV-2 with genital blisters, pain, itch and ulcers, one can also be asymptomatic yet shedding the virus continuously. In fact, more than 80% of people with HSV-2 are asymptomatic shedders of the virus.
In this article, we explore the association between these 2 conditions — BV and genital HSV-2. The article is written in hopes of increasing awareness for both conditions, and encouraging readers to consider getting screened and treated for both conditions.
Although both conditions do not pose an immediate health threat, they can have long term health implications if left alone and untreated.
The relationship between BV and HSV-2 is a unique one. Those with BV are more likely to contract HSV-2 from their partners than someone without BV. Those with HSV-2 infections have a higher risk of acquiring BV compared to people without HSV-2 infections.
By nature, the vagina is a sterile microenvironment on its own, housing millions of healthy lactobacillus, self-sustaining in flushing out bad bacteria/ particles and generating good bacteria to maintain the internal pH ecosystem. The actual mechanism of how the lactobacillus in the healthy vagina protects HSV-2 infection remains much to be discovered.
There are studies that suggest the presence of good lactobacillus such as lactobacillus salivarius, Lactobacillus plantarum or Lactobacillus brevis in cell cultures reduce HSV-2 viral replication up to more than 90% and reduce acquisition of HSV-2 infection, suggesting the protective role of these good lactobacillus.
In bacterial vaginosis, there is an alteration of the vaginal flora with depletion of the good lactobacillus, and an overgrowth of anaerobic bacteria, including Gardnerella vaginalis bacteria.
Such hostile vaginal microenvironments, without the protective effect from good lactobacillus, will increase the risk of contracting STDs, including HSV-2 infections. Additionally, the occurrence of bacterial vaginosis is associated with women with a greater number of sex partner(s) and higher frequency of sexual intercourse. These can also be independent risk factors of encountering STDs including HSV-2 infection.
It is postulated that genital HSV-2 infection or even asymptomatic constant HSV-2 viral shredding, can lead to activation of the immune system in the vaginal mucosal. This, in addition to natural occurrences, such as female hormonal fluctuations and normal changes in the vaginal microbiome, can lead to an increased occurrence of BV.
The other possible explanation is due to the thriving Gardnerella vaginalis bacteria on iron. This is based on the understanding that BV tends to occur more commonly peri-menstrual (before and after) timing due to availability of iron. In genital HSV-2 infection/ persistent viral shedding, this can create a microenvironment with iron allowing the overgrowth of Gardnerella vaginalis bacteria.
Interestingly, in a vicious cycle, with the increased risk of BV, the person with genital HSV-2 can transmit/ infect HSV-2 virus even more as untreated BV can increase further viral shedding of HSV-2.
There are increasing clinical studies showing that both genital HSV-2 infections and BV increase the risk of acquiring Human Immunodeficiency Virus (HIV) and transmitting HIV. Hence, it is worth considering screening for HIV in one who has HSV-2 and BV.
In a HIV positive person, due to a persistently compromised immune system, one is predisposed to contracting genital HSV-2 has a higher risk of genital HSV-2 flare ups (tends to be more severe), a higher risk of genital HSV-2 reactivation, and in a negative vicious way, increases susceptibility to developing BV and further HSV-2 viral shedding — the cycle never ends.
If one is concerned of contracting genital HSV-2 infection or BV infection, please do not hesitate to reach out to your doctor.
While history and physical examination can facilitate the right diagnosis, HSV-2 viral infection can be picked up with herpes simplex virus PCR test or herpes simplex virus antibody blood tests. In the case of BV, vaginal swab can be beneficial in nailing down the diagnosis and future treatment. Your doctor will need to understand your health condition and concerns before being able to guide you on the tests to proceed with.
If there is concern of exposure to HIV or other STDs, it is worthwhile to consider a screening test, as having one STD may heighten your chances of contracting a second, third or fourth.
STDs commonly can be asymptomatic and left untreated can cause health complications, as well as unknown social implications to our loved ones.
Genital HSV-2 infection is managed with antiviral medication (such as Acyclovir, Valocyclovir, Fanciclovir). However, as genital HSV-2 infection is associated with invariable recurring viral shedding, recurring flare up of genital HSV-2 is common. Hence, some patients may opt for a longer term of suppressive antiviral medication to reduce flare ups, viral shredding and risk of infecting their sexual partner(s).
BV can be treated with antibiotics in the form of oral tablets or vaginal pessaries. As one of the main causes of depletion of healthy vaginal lactobacillus, probiotics play a beneficial role in reducing the recurrence of BV.
Every patient can have different clinical presentations, concerns, and lifestyles. It is always important to consult your trusted physician to come up with an individual realistic treatment plan to manage both conditions above.
Currently, there are ongoing clinical research studies for the questions above, with potential results. Having said that, as we now know the nature of both genital HSV-2 and BV infections, it is worth managing both genital HSV-2 infection and BV concurrently.
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Over the years, there has been evidence of the development of antibiotic-resistant STDs. This is rather alarming, as the cases of STDs are not reducing at any rate. In fact, it is continuously on the rise. A healthy genital microbiome is our first line defense against external pathogens, including STDs.
There are clinical studies showing the good bacteria that constitutes the healthy genital microenvironment have an immune mechanism, and may provide protection against STDs. Treatment targeting the genital microbiome may potentially reduce the risk of acquiring STDs.
In this article, we would wish to enlighten the readers on the female and male microenvironment, the importance of maintaining a good baseline genital health and reducing one’s risk against STDs.
The vaginal environment is mainly covered with healthy anaerobic bacteria — lactobacillus spp. In an equilibrium, the lactobacillus spp keeps the vagina sterile, lubricated, and able to clear off common pathogens.
Unfortunately, this healthy state is easily tempered with the depletion of healthy lactobacillus spp and overgrowth of bad anaerobic bacteria. One of the commonly heard pathogenic vaginal bacteria is gardnerella vaginalis which plays a vital role in a recurring female vaginal infection known as bacterial vaginosis (BV).
BV is known to be associated with poor quality of life due to the uncomfortable symptoms of BV, and association with poor reproductive outcome such as preterm labour and low birth weight of infants. Furthermore, the persistence presence of bad anaerobic bacteria predisposes one towards contracting STDs and spreading STDs to others.
The actual mechanism of the destabilisation of the vagina flora remains unknown.
Factors that can shift the microflora to bad anaerobic bacteria rather than lactobacillus spp include:
Intriguingly, the male genital region is less discussed. In comparison to the female genital anatomy, the male genitalia are ‘externally’ seen. Yet, the male genital also has its own healthy microflora.
The penis is mainly covered with similar bacteria seen on our normal skin such as Corynebacterium spp and staphylococcus spp. Occasionally, bad anaerobic bacteria (that can be associated in BV in females) can be found in the male genital region as well.
As predicted and logically, men with female partners with BV infection tend to have genital microenvironments that have more bad anaerobic bacteria, such as gardnerella vaginalis, while men with female partners without BV are likely to carry normal skin bacterias such as, Lactobacillus spp, Corynebacterium spp and staphylococcus spp on the penis.
The male foreskin can also affect the microbiome in the penis. As the foreskin provides a physical layer, it can also house many bad anaerobic bacteria. In a circumcised man, as the penis is exposed, the quantity of bad anaerobic bacteria is lesser, with predominantly skin bacteria found on the penis surface. It is known that circumcised men have lower risk of acquiring HIV, herpes infection, HPV infection and lower risk to trigger BV in their female partners.
The actual mechanism of how the female genital microbiome can protect one against STDs has been a common clinical research topic though there remain gaps in the knowledge.
The healthy vaginal lactobacillus spp provides a more acidic sterile environment that prevents pathogens from replicating as they thrive better in alkaline environments. Additionally, the lactobacillus spp can protect women from STDs by:
In males, the role of genital microbiome against STDs are not as straightforward. Nonetheless, there are medical studies that show susceptibility of contracting HIV with higher numbers of bad anaerobic bacteria in the male genital region.
Bad anaerobic bacteria can be pro-inflammatory and they can create an environment that is easily succumbed to external pathogens. Men with skin flora bacteria predominant over the genitalia and less anaerobic bacteria may have lower risk of contracting STDs and triggering BV in their female partners.
You may have higher risk of STDs if
As a female, the general risk of contracting STDs is higher than males due to:
You may have higher risk of STDs if
Although STDs can be associated with abnormal genital symptoms, very often, STDs can be insidious without any tell-tale signs. You are advised to seek medical advice with your doctor if you are concerned of possible exposure to STDs and contracting the infections from your partner(s). STDs do not resolve on their own and will require the right medication and right dose to clear off the infection(s).
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In Singapore, obesity is defined as a body mass index (BMI) of more than 27.5. Obesity has a deleterious impact on a person’s health — with an increased risk of coronary heart disease, stroke, high blood pressure, diabetes, osteoarthritis, depression, poor sexual function, cancer, and more.
The diet we consume is known to play a major role in the development of obesity. One that consists of mainly processed food and fast food which are high in calories and have minimal proper nutrients. Consuming this diet in the long run can lead to chronic surplus of calories intake, leading to weight gain. Currently, 38% of the people in the world is obese, and this trend is rising continuously.
In this article, we explore the association of obesity and common allergy medical conditions. This article is written in hope of highlighting the importance of managing weight to reduce risk of immunological conditions, hence improving one’s quality of life.
In obesity, there is excessive build-up of fat tissues in the body — a condition known as adipogenesis. The fat cells known as adipocytes increase in size and numbers. The adipocytes produce chemicals and hormones known as adipokines that regulate the body’s overall wellbeing. In obesity, as there are more and bigger adipocytes, more adipokines are produced, leading to disruption of the body's internal equilibrium.
Over time, with excessive adipogenesis, excessive adipocytes and adipokines production, the body is in constant oxidative stress and inflammation. It is postulated that this low grade inflammatory state of an obese person increases the susceptibility towards allergic conditions.
During the chronic inflammatory state of obesity, the gastrointestinal linings also undergo changes. The intestinal microbiome becomes less diverse, leading to a weaker intestinal barrier and increased permeability of food/ protein/ particles/ allergens through the intestine layer. The external proteins or allergens can pass through the intestinal linings into the blood circulation, leading to abnormal activation of the immune system and food allergies.
As obesity contributes to the development of food allergies;
Obesity is clinically shown to increase the risk of allergic rhinitis. However, this association is more seen in the paediatric group rather than in obese adults. Hormone and chemicals such as leptin and interleukin-1beta protein can be found in high levels in obese individuals. These proteins can activate the immune inflammatory response, increase susceptibility towards allergens and increase risk of allergic rhinitis.
It is also hypothesised that due to the pro-inflammatory state of obesity, the mucus membrane lining of the nose passage can be constantly swollen and inflamed, leading to increased permeability of the external allergenic particles which result in activation of the immune system and allergic symptoms in the form of rhinitis.
Interestingly, a person with allergic rhinitis has an increased risk of becoming obese due to hampering of physical activities following rhinitis symptoms or becoming sedentary due to side effects of medications (such as drowsy antihistamines) of rhinitis.
Due to the association discussed above between obesity and allergic rhinitis;
The relationship between obesity and asthma is stronger among the paediatric group with greater risk of developing asthma, more exacerbation of asthma, and harder to manage the condition.
The negative impact of obesity on causing respiratory inflammatory conditions such as asthma is through complex mechanisms. Firstly, there is an innate genetic susceptibility of having asthma. This is further coupled with low grade chronic inflammatory state in obesity, leading to structural changes of the respiratory tract. To make things worse, obesity is also implicated in hormonal changes and less microbiome diversity, leading to predisposition to environmental triggers (pollution/ allergens) of developing asthma.
High sugar and fatty diet in obesity can also reduce the lung function. As excessive fat tissues accumulate around the chest and abdomen, the movement of the lungs and chest wall muscles can be restricted, leading to increased work of breathing.
In a vicious cycle, the repeated use of corticosteroid in asthma or poorly controlled asthma can also cause weight gain. Restricted physical activities may be seen in asthma patients. Weight gain can occur over time with a sedentary lifestyle.
As obesity contributes to the asthma and related long-term comorbidities;
Obesity can affect the skin in a few possible ways. We know obesity promotes inflammatory processes in the body and can affect the hormones and chemical substances of the body.
People with obesity may have an impaired skin epidermis barrier due to increased sweating and increased blood pressure. The skin microbiome can be less diverse in a person with obesity, with more colonisation of Corynebacterium spp. There is less lipid content on the skin surface in an obese person, leading to faster skin dehydration, and increased risk of developing atopic dermatitis. Interestingly, one can have increased risk of developing atopic dermatitis if the mother is obese before pregnancy.
Weight loss has a beneficial effect in overall treatment of atopic dermatitis, hence promoting a healthy lifestyle and weight loss can complement the treatment of atopic dermatitis. Additionally:
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Allergic rhinitis (AR) is a common inflammatory airway disorder triggered by airborne-related allergens. While this is not a life-threatening medical condition, it can be debilitationg — affecting a person’s quality of life; causing poor quality of sleep, suboptimal work performance and social interaction impairment.
In this article, we want to understand the background science and immunology of allergic rhinitis and make sense of the current treatments available, including the exciting option of immunotherapy.
Allergic rhinitis is an upper airway disease resultant from sensitisation of allergens and proteins in the air during breathing. The classical symptoms involve the upper respiratory airway such as sneezing, nasal itch, increase nasal secretion, blocked nose and etc. Common inhalant allergens that can trigger allergic rhinitis include house dust mite particles, mould, animal dander, grass, birch and pollen, cockroach particles and more.
In allergic rhinitis, following exposure to allergens, the immune response undergoes 2 phases:
The inhaled allergen protein will be ‘carried’ and ‘presented’ by a type of specialised cells known as Antigen Presenting Cells (APCs) to the nearby lymph nodes. Lymph nodes are ‘checkpoints’ in our body that store immune cells.
The allergen proteins then trigger a cascade of inflammatory response from the immune cells. Immune cells that are commonly involved in this phase include T cells, B cells, IgE antibodies, mast cells, ILK-4, IL-13, histamine, prostaglandins, leukotrienes, TNF-alpha and etc.
Following 4-6 hours of exposure to allergen protein, there will be further chemical inflammatory response involving cells such as monocytes, granulocytes, protein elastase and etc.
*Understanding the involvement of immune cells is imperative as this becomes the target area of modern medicine in allergic rhinitis.
The surge of inflammatory response in the early and delayed phase can be translated to the clinical symptoms of allergic rhinitis such as acute sneezing, itching, runny and block nose. Symptoms tend to abate when the allergen is withdrawn or avoided.
Over time, with recurring exposure and recurring inflammatory immune response, repeated wax and wane of condition, remodeling of the affected airway can occur. This explains the association of chronic allergic rhinitis with more complicating ENT conditions such as nasal polyps, nasal hyperplasia, eosinophilic sinusitis and more.
Interestingly, allergic rhinitis can be associated with asthma and chronic rhinosinusitis. The actual cause of association remains not fully understood. However, in these conditions, when one is exposed to allergens, there are similar inflammatory immune response demonstrated.
Statistics show 10-40% of people with allergic rhinitis have concurrent allergic asthma, while 60-80% of asthma people have concurrent allergic rhinitis. In chronic allergic rhinitis, when there is repeated and resolution of airway inflammation, remodeling of the airway anatomy can result in chronic rhinosinusitis or nasal polyps and other ENT conditions.
The ideal treatment of allergic rhinitis is to eliminate the triggering allergen from the environment. This, unfortunately, even with strict lifestyle allergenic control is not achievable and not practical.
Current management of allergic rhinitis involved a holistic approach of combining modern medicine with lifestyle control of environmental allergen to alleviate the condition.
Despite current conventional treatment is beneficial in controlling symptoms of allergic rhinitis, one may find taking daily pills, nose sprays or nasal irrigation a challenge and burden to our daily living.
In addition, the symptomatic medications may even be limited in efficacy in some patients. To address these concerns, immunotherapy can be considered as a potential therapeutic option.
Not all patients with allergic rhinitis find conventional medical treatment useful. Allergen specific immunotherapy (AIT) may come in useful and serve as a safe alternative treatment. AIT is a desensitization treatment where the triggering allergen is repeatedly introduced to the affected person over time to modify the immune response, inducing desensitization and amelioration of allergic symptoms after exposed to allergen.
AIT is arguably to achieve immune tolerance against allergen in the affected person over time following repeated re-exposure. In immunology terminology, with repeated exposure to the allergen, the body is able to normalised its own immune and inflammatory cells, preventing them from being triggered by allergens. AIT also produces allergen-neutralising antibodies that prevent allergen from triggering allergic inflammatory response. In clinical setting,
Here, we can observe the treatment of allergic rhinitis has shifted from conventionally controlling symptoms with symptomatic medication to management and re-education of the immune response to an allergen, hence transforming the immune system that is exaggeratingly overactive to 'normal' immune reaction towards allergen protein.
It is worth to note that in order to consider AIT, it is mandatory to identify the specific culprit allergen that causes the symptoms. Thankfully, again with modern medicine and technology, many of the common allergens can be picked up with skin prick test or IgE RAST blood test.
Medical literature over the years has shown consistently that AIT is useful in alleviating allergic rhinitis symptoms and standard medication burden. Currently, AIT can be considered in allergic rhinitis patients with specific IgE allergy that present with significant symptoms that affect their daily life, sleep despite conventional pharmacological treatment.
AIT demonstrates effective management of allergic rhinitis with concurrent allergic asthma. AIT has shown clinical significance in reduction of both allergic rhinitis and asthma symptoms, asthma exacerbations and hospitalisation. AIT also shows good clinical improvement in those with allergic rhinitis and concurrent rhinosinusitis disorders.
Furthermore, AIT when introduced during the early phase of allergic disease can prevent progression of allergic rhinitis to asthma or new allergen sensitisation. This is particularly useful and a beneficial option for the younger group people with allergic rhinitis. This can also serve as a backbone theory in further research and medical advancement into immuno-desensitisation related treatment.
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This is a possible scenario that can be seen when a couple undergoes STD screening tests together and notice their results are “not the same”. Often, such medical results can create disharmony and distress between couples.
What does it mean when a couple’s STD results are different, and how can we proceed with such results?
Understanding the possibilities of a different STD results in comparison to your partner(s) is key to determine the next course of actions. Here we list down some of the common causes of discordance STD results.
This is unfortunately the commonest cause of discordance STD results. Commonly the tests results are different between the couple due to an increased risk of exposure to the infection in a couple or another, leading to the results differences.
This is a dicey situation where, arguably, it may mean that there is an 'unfaithful' polygamy going around, someone cheated in the relationship — which is possible. However, it is worth to note that STD infection can live in the body for years unless it is effectively treated with the right medication. Hence, discrepancies in results experienced by couples may merely mean that their partner may have had a 'past' rather than being 'unfaithful' in his or her current relationship.
One may not necessarily acquire STDs from intercourse with a person with STD, though the risk of contracting STDs is higher in those with a positive contact history. Some people can become infected and naturally clear off the infection due to better general immunity. One may have received treatment from another health condition (tooth infection/surgery etc) and inadvertently treated the STDs without realising it. In such scenarios, screening tests on the couples may result in different results.
While this is a possibility, generally, laboratory errors are not common as accredited and regulated medical laboratory has to undergo very stringent laboratory processing to ensure delivering accurate and quality results as this can affect the treatment plan of a patient . In Singapore, the medical laboratories need to be licensed, accredited and regulated by the Ministry of Health (MOH).
If you do get different STD results from your partner, here are some things you can do:
Having an open conversation without being judgmental and accusative is key in dealing with the situation of unexplained STD results. It is useful to always use logical approach than emotional impulsive approach in dealing with such results. It is worth finding proper time and space to discuss such results with your partner(s), rather than over text message or phone call leading to further misunderstanding and communication breakdown.
Exploring partner(s) current and previous sexual relationship can be useful in correlating the results and the past history of exposure. Rather than blaming, focusing on solution-based approach, consider to treat any infection(s) if need to avoid further co-spread of disease to one another.
If there remain unexplained answers to the differences in STD tests, you are advised to consult your physician/ clinic who offered the screening tests. Sometimes, bringing your partner along for the consultation may be useful to 'clear the air' on the spot.
Getting the right medical information regarding STDs is very important in correlating the clinical history and the tests results. This is advisable rather than doing self-research and over-reading on online platforms, causing unnecessary distress and alarm.
It is always important to correlate the test results and a person's clinical pictures. In this instance, you will require the expertise of your kind trusted healthcare providers. While most of the STD results, we can interpret ourselves based on 'normal' or 'abnormal' or 'reactive' or 'non-reactive', some of the STD results may not be as simple as a 'yes' and 'no' answer. Having a discrepancy results in comparison to your partner's results may be due to a previously treated or exposed infection.
In view of the possibilities of a false negative results as the tests may be done within the window period of the STD infection, one may consider repeat the tests again at a later date. It is prudent to check with your healthcare providers on the sensitivity and the time frame required for a particular test to ensure the results are reflecting a true clinical picture.
Different laboratories may offer different test kits with different sensitivity and window period. Some of the newer generation tests may be able to pick up an infection much earlier from the time of exposure.
While convenience is key, self-performing testing runs a risk of false results due to multiple reasons explained above. One may opt to head down to a physical clinic for proper consultation, evaluation, and appropriate sample test collection (if need) by your health providers. Currently, in Singapore there are a number of convenient, discreet, fuss-free clinics that can offer such services. Getting tested by your physician reduce the risk of inaccurate results due to sampling error.
Furthermore, your physician may be able to guide you on what are the relevant infectious tests to address your individual concerns, as STD tests are not merely just ‘HIV testing’.
Some may consider regular 3-6 monthly sexual health screening tests. Such practices are good as this will:
This article strives to facilitate patients who have results that differ from their sexual partner and are struggling to make sense of the results. We hope the article is able to help one way or another! Take care!
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Genital herpes infections are one of the most commonly known STDs. Hitherto, there is no cure for the disease — it is a lifelong viral infection.
Genital herpes is caused by herpes simplex virus (HSV). Both type 1 and type 2 of HSV can cause genital herpes. It is known that one may present with a chronic recurring flare up of herpes ulcers after contracting HSV infection. Active HSV infection with ulcers can be transmissible to sexual partners. To make things worse, HSV infection can also be transmitted from a person to another person even when one is asymptomatic due to the continuous shredding of the virus.
In this article we want to understand the pattern of shredding of HSV virus, hence correlating to one’s clinical presentation, and the relevance of episodic versus suppressive antiviral treatment.
The recurrence of HSV-1 genital herpes flare up tends to be lesser in comparison to HSV-2 genital herpes. Shedding occur commonly after infection but decreases rapidly from 12% at 2 months to 7% at 11 months post acquisition of HSV-1. The shedding of HSV-1 virus reduces quickly throughout the first year of infection, leading to the risk of asymptomatic disease transmission to sexual partner lower after the first year. Shedding of HSV-1 genital herpes in comparison to HSV-1 oral herpes is higher. Long term shedding of HSV-1 is less common, though it is not completely impossible.
Nearly all patients with known first episode HSV-2 genital herpes will have recurring episodes of genital herpes. Viral shedding in HSV-2 genital herpes is higher than HSV-1 genital herpes, hence HSV-2 genital herpes is associated with higher frequency of recurrence. Even in a person without active genital symptoms in long run, intermittent viral shedding still occurs in HSV-2 person.
The classical clinical presentation of genital herpes is recurring blisters or punched-out ulcers over the genital region. Having said that, often, in clinical practice, visual diagnosis can be difficult or even absent in many infected patients during the time of clinical assessment.
When the genital ulcers are present, the diagnosis of genital herpes and herpes subtypes can be confirmed with further tests.
When there is absence of genital ulcers, HSV serology antibody blood tests can be used to guide the diagnosis of HSV subtypes of genital herpes.
The evidence-based benefits of considering long term suppressive treatment for herpes infection:
In episodic antiviral treatment, one can start antiviral medication when they notice the first signs of herpes disease such as tingling, itching over the site of herpes outbreak. Early episodic antiviral can reduce the time of the recovery and reduce viral shedding hence reduce transmission to others.
In those patients who have frequent genital herpes outbreaks despite episodic antiviral treatment, long term suppressive antiviral therapy can be recommended. In HSV-2 genital herpes, chronic suppressive therapy is recommended in comparison to episodic therapy as most patients with HSV-2 genital herpes invariably has higher frequency of recurrence and have chronic intermittent shedding of the virus. Chronic suppressive treatment is also beneficial to patients with genital herpes and has a weaker immune system (concurrent HIV, cancer etc). While chronic suppressive antiviral treatment can be beneficial to frequent outbreak in patients with HSV-1 genital ulcers, as the recurrence rate is lower than HSV-2 genital ulcers, some patients may only require episodic treatment.
Your decision on antiviral treatment option can be discussed with your doctor. Aside from understanding your herpes disease progression, It is worth discussing you and your sexual partner(s) concerns and expectations with your doctor before deciding on which treatment to opt for.
When a person is having genital herpes with clinical presentations of ulcers and blisters, these open erosions and wounds can be channel for a partner’s genital or body fluid to enter the body. Hence, if the partner has other STDs, the person with active genital herpes has a higher risk of contracting other STDs as well.
Clinical statistics have shown HSV-2 genital herpes increases twice to thrice risk of a person acquiring HIV infection. If you are exposed to possible sexually transmitted disease, do reach out to your trusted healthcare staff for further medical screening and early treatment if required.
Genital herpes brought in its wake overwhelming emotions of shame, fear, anger, distress and helplessness. Most patients do go through all these phases following diagnosis of herpes.
In an attempt to understand further on the medical condition, patients commonly rampaged through multiple channels such as chatgroup, chatGPT, internet sources and etc. These further muddle one’s disease understanding and create more fear and anxiety.
One should be reassured that the overwhelming emotions are normal human reaction following diagnosis of the condition. It is imperative to understand that genital herpes is a medical condition that is controllable with effective treatment. Proper health education on genital herpes is very important for the patient in managing the disease and reducing the risk to transmitting the disease to their partner(s).
Medical counselling may be useful in coping and coming to terms with the diagnosis of herpes. Importantly, do reach out to your doctor to obtain the right information and debunk myths about herpes infection.
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The skin is the largest organ of the human body. Beyond the naked eyes, the skin is the home to millions of bacteria, fungi and viruses that are beneficial to us. When the skin is covered and colonised by these microorganisms, they behave as a protective barrier against invasion of external insults and pathogens.
When there is a disequilibrium of the microenvironment of these commensal microorganisms, the physical skin barrier can be disrupted, following more growth and invasion of pathogenic microorganisms. This can result in chronic inflammatory skin conditions or even more severe systemic medical conditions.
In this article, we discuss skin microbiomes and their associated with common skin conditions, making sense with current existing clinical treatment and exploring the potential role of understanding skin microbiomes in future treatment of skin diseases.
Our skin is made up of two main layers: the epidermis (the external layer) and dermis (the inner layer). The epidermis is made up of keratinocytes that are crosslinked together to function as a physical barrier against the external world.
We can sub-classify the skin areas broadly into 3 areas:
Common bacteria that can be seen in the oily area of a normal skin include propionibacterium acne spp. Fungi such as Malassezia spp and Candida spp can be found in oily regions of the skin as well. In moist areas, bacteria such as Staphylococcus spp and Corynebacterium spp can be seen. In dry areas of the skin, Staphylococcus spp can also commonly be seen.
Interestingly our skin microbiomes change from birth to puberty/adulthood. Newborns that are delivered through C-section tend to have skin microbiomes of normal skin while newborn that are delivered vaginally tend to have skin microbiomes that are also found in the vaginal lining. The prepubertal skin microbiomes have a greater population of Staphylococcus spp and Streptococcus spp. The population of microbiomes shifts and remodels during pubertal period as the skin becomes oilier following hormonal stimulation of the sebaceous glands. With that, in pubertal and adult skin, there are more thriving Propionibacterium spp, Corynebacterium spp, Malassezia spp etc.
What factors change the normal skin microbiome?
The skin microenvironment is kept in equilibrium by multiple factors such as temperature and humidity, pH, UV exposure, sebaceous oil production, etc. The accessorial tissues around the skin such as the sweat glands, sebaceous glands and hair follicles ensures the microenvironment is being maintained.
Unfortunately, over time with the process of ageing, immunity changes, external insults such as strong contactant, allergies and etc, disruption of the skin microbiomes equilibrium can happen, with more ‘bad’ bacteria and less ‘good’ bacteria colonising the skin, resulting in various skin diseases.
Acne vulgaris is the most common chronic skin inflammatory disease after atopic dermatitis in the world. Acne occurs when there is inflammation of the skin resulting from blockage and excessive sebum production on the skin follicles. While the actual mechanism remains much elucidated, it is documented that one with acne has more colonisation of bacteria Propionibacterium acne (also known as cutibacterium acne). It is believed that Propionibacterium acne plays a role in comedone formation and the inflammatory process in acne.
Decreasing the amount of Propionibacterium acne has been shown to be beneficial in many acne patients and the idea is used as a target mechanism in the treatment of acne. Treatment options such as benzoyl peroxide, azelaic acid, antibiotics such as doxycycline, clindamycin and erythromycin can reduce the colonisation and inflammation caused by Propionibacterium acne.
Rosacea is a chronic adult skin condition presented with recurring facial flushing, redness, pimple-like bumps. While the actual cause of rosacea remains unknown, microbiome mite- Demodex folliculorum is implicated in rosacea. Studies have shown that skin biopsy samples of rosacea patients have a high load of Demodex on inflamed affected skin, suggesting the link of the mite and the skin condition. Permetrin cream or oral ivermectin are offered as part of management of rosacea to reduce the colonisation of demodex mites on rosacea skin.
Atopic dermatitis- presenting with chronic relapsing itchy, dry, red rashes is the most common skin condition worldwide which has a major negative impact on a person’s quality of life. The condition can be associated with other atopic conditions such as allergic rhinitis and asthma. While there is genetic predisposition and family history in atopic dermatitis, the distribution of skin microbiomes in atopic dermatitis may have its effect on a person’s clinical outcome.
Staphylococcus aureus has been well documented as a colonizer in atopic dermatitis. There is a correlation between the amount of the bacteria and the severity of the disease. The higher the density of the colonization of Staphylococcus aureus, the graver the inflammation. There is disruption of the normal microbiome skin environment in atopic dermatitis due to excessive colonization of Staphylococcus aureus. This results in impairment of skin barrier and susceptibility to other infections.
In order to reduce colonization of Staphylococcus aureus, antibiotics (in the form of oral or topical) and bleach baths are used to manage eczema. Such treatment regimens can synergize the treatment outcome with conventional treatment of emollient, topical anti-inflammatory and systemic oral medications.
Seborrheic dermatitis is a skin relapsing inflammatory condition affecting areas that are rich in sebaceous glands such as the face, scalp and body. One may notice the common exacerbating triggers such as hot weather, increase humidity, emotional heighten- which may all increase further production of sebaceous oil.
Fungi such as Malassezia spp are found in oily skin surfaces, and play a role in inflammatory response in seborrheic dermatitis. Antifungal treatment is used in combination with anti-inflammatory medication to effectively manage seborrheic dermatitis.
Probiotics are live microorganisms that when being introduced into the body sufficiently, produce a positive health outcome to the person. Prebiotics on the other hand are non-digestible food substances that can encourage the person to produce selectively certain ‘good’ bacteria in the body. Over the past decades, both probiotics and prebiotics are being marketed for their potential benefits in a person’s health for a wide range of diseases including gut symptoms such as irritable bowel syndrome, diarrhoea, to even treating vaginal infections.
For the context of skin, there is medical literature looking into the role of probiotics and prebiotics in atopic dermatitis, focusing more on children rather than adults. Studies for the role of these potentially beneficial supplements are still lacking for other common skin conditions such as psoriasis, acne, rosacea, etc.
At this stage, probiotics and prebiotics are not considered a medical intervention for skin conditions. As a consumer or patient, one should be prudent in considering probiotics and prebiotics to avoid spending unnecessarily for non-clinically proven treatment due to marketing gimmicks.
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Douching is the physical act of washing the internal vagina with water or ‘mixed liquid’. Feminine douche is commonly available over the counter. They are usually made up of mixed water and iodine, baking soda, vinegar, fragrant or other chemicals etc. Feminine douche are administered by squirting the douche mixture upwards through a bottle nozzle into the vagina to ‘clean’ the vagina.
Some ladies may have the habit of douching, in order to feel ‘cleaner and fresher’. One may douche in hope to take away unpleasant vaginal smell, leftover menstrual blood, or even hoping to prevent STDs and pregnancies after intercourse.
In this articles, we discuss about the cons of douching, and many reasons why you should avoid douching.
The healthy vaginal microenvironment is slightly acidic with abundant hydrogen peroxide (H202) producing lactobacilli. By constantly producing lactic acid to keep the vaginal pH less than 4.5, these ‘good’ lactobacilli bacteria avoid the growth of ‘bad’ bacteria and fungi. The lactobacilli also attached themselves to the surface lining of the vagina, competing with the ‘bad’ organism from adhering onto the vaginal wall, and secrete protective mucus and discharge for the vagina.
Douching can alter the microenvironment of the vagina which is made up good vaginal bacteria under an acidic environment. Healthy good vaginal bacteria protect the vagina from external insults such as infections. The act of douche can wipe out the good bacteria leading to overgrowth of bad bacteria and fungus leading to recurring vaginal infections.
Aside from removing the normal vaginal flora and causing overgrowth of ‘bad’ bacteria, douching can act as a ‘pressurised fluid transporter’, allowing external bacteria/viruses (pathogens) to ascend from the vagina to the cervix, uterus, fallopian tube, ovaries or even the abdominal cavity. This can eventually lead to pelvic inflammatory disease.
It is clinically documented that frequent douching is associated with bacteria vaginosis, recurring vaginal yeast infection, HIV and STDs infection, pelvic inflammatory disease, ectopic pregnancy, pre-termed labour and infertility.
Strangely but rightfully, the vagina cleans itself automatically. The vagina produces mucous accordingly to flush out the unwanted ‘bacteria’, menstrual blood, semen, or discharge and ensure the vaginal microenvironment and pH are maintained.
The external of the vagina can be rinsed with water and mild soap. If you have sensitive skin, chemical soap/bath may cause external vagina (vulva) irritation and dryness. Scented pads, tampons, sprays or powder should be avoided as these can cause vaginal irritation or even infection, in more severe cases.
No, douching before and after intercourse does not prevent STDs. On the contrary, douching can increase risk of contracting STDs including HIV as it washes away the ‘good’ bacteria in the vagina, leading to the vagina susceptible to external bacterial STDs and virus STDs.
Regular douching is associated with female related vaginal infection such as bacterial vaginosis and vaginal candidiasis (fungal infection). Those who douche weekly has a 5 times increase risk of developing bacterial vaginosis. Due to a significant reduction of H202 lactobacilli, the vagina environment is tempered with a hostile overgrowth of ‘bad’ bacteria such as Gardnerella spp, Mycoplasma hominis and etc.
Bacterial vaginosis though is not a STD, increases the risk of a women acquiring STDs, and frequently is associated with womb lining infection, pelvic inflammatory disease, pre-termed labour and low birth weight in babies.
It is a ‘chicken-and-egg’ situation whether women with abnormal vaginal symptoms engage in douching in hope to ease the symptoms, or women who engage in douching subsequently develop abnormal vaginal symptoms. Regardless of the chronological causative link, there is a strong association of douching and female-related vaginitis.
Douching is unlikely to resolve vaginitis and may exacerbate the symptoms further by ‘over-cleansing’ and causing greater susceptibility of contracting other infections. If you have abnormal vaginal symptoms, you are advised to see your female health care professional for further treatment and management of your condition.
With the act of douching, reducing the amount of ‘good’ vaginal bacteria, the vagina is even more susceptible to STDs such as Chlamydia trachomatis, Neisseria gonorrhea, Trichomoniasis and other bacterial STDs.
As mentioned above, as the act of douching provides a vacuum-transport-pathway for the untreated STD bacteria, one can be predisposed to ascending infection of the womb, fallopian tube, ovaries, leading to pelvic inflammatory disease, chronic pelvic scarring and infertility.
It is understandable that some women douche following experiencing abnormal vaginal symptoms such as itching, abnormal discharge, pain or irritation, discomfort down below. Unfortunately douching does not resolve the symptoms, in fact it may even exacerbate the underlying problem. You should see your medical professional staff whom you are comfortable with to further evaluate your symptoms. STD tests may be offered accordingly to one’s exposure risk and symptoms. Only via testing, the right medication can be offered to treat and resolve the symptoms.
Interestingly the healthy acidic vaginal environment is able to partially inactivate viruses including HIV (human immunodeficiency virus). The vaginal flora changes when a personal douche the vagina, with an obliteration of acidic lactobacilli and vaginal protection layer, a rise of vaginal pH and production of inflammatory cells. These inevitably encourages the ‘bad’ bacteria such as bacterial vaginosis or external pathogens (STDs), HIV to thrive more easily.
No, douching does not prevent pregnancy. It is not medically proven to control and avoid unwanted pregnancies. While douching can wash away the semen in the vagina, the sperm inside the semen can travel quickly into the cervix, uterus, fallopian tube to fertilise the ‘egg’. Douching is unable to halt the progressive journey of the sperm.
If you are concerned of pregnancy after unprotected sex, you can consider emergency contraception to prevent becoming pregnant. You can consider long term contraception methods if you have recurring risk of unwanted pregnancy. You can understand more on various contraceptive options by consulting your health care provider.
One may consider douching out of ‘hygiene’ purpose, amelioration of vaginal odor, resolution of vaginal discomfort, avoidance of STDs or even pregnancy. Nonetheless, there is no clinical proof to support the use of douche for the above roles.
If there are abnormal vaginal symptoms and concerns of vaginal infections including STDs, douching will not help the underlying condition. One will need appropriate medical attention and treatment. In some cases, vaginal swab testing, urine test, blood tests, STD tests may be required to evaluate for the underlying vaginal infection.
Using douching as a mode of preventing pregnancy is ineffective and medical contraception is advised.
There is no sufficient medical data to prove the benefits of douching and good evidence to show that douching can be detrimental to health. It is hence, advisable to avoid douching.
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Women who are with a child, or are breastfeeding are not protected against acquiring sexually transmitted diseases (STDs). While most STDs are treatable, some of the STDs can be transmitted vertically from the pregnant mother to the unborn child or during breastfeeding. If a baby has STD, it can harm the baby’s health and long term development.
Most STDs are without any tell-tale signs or symptoms. Both yourself or your partner can have STDs without knowing. The only way to determine a person’s status is through STD testing.
Majority of antenatal follow up do involve sexual health checkup. Nonetheless, it is still paramount to consider STD screening before pregnant or during pregnancy/ breastfeeding if you are concerned of possible exposure to STD infections.
Both women who are not pregnant and women who are pregnant can develop similar health complications from untreated STDs. However, in one who is pregnant, persistent STDs can be detrimental to the unborn child’s wellbeing.
STDs in pregnancy can be associated with:
Mother who is pregnant or lactating can acquire STDs through vaginal, oral or anal intercourse. In some STDs, the infections can also be passed on via skin-to-skin contact of the genital region.
STDs that can be passed on to babies during pregnancy include:
STDs that can be passed on to babies during breastfeeding include:
The unborn child can be infected with STDs when he is in the placenta of the pregnant mother. Infections such as HIV and syphilis can pass through the placenta during pregnancy and infect the baby.
STDs such as chlamydia, gonorrhea, genital herpes or genital warts, can be transmitted to the baby during delivery when the baby passed through the birth canal. HIV is also able to infect a baby during delivery.
Babies who acquired STDs via vertical transmission from pregnant mother can be associated with serious long term health complications such as:
In some of the STD conditions, breastfeeding may be possible. You are advised to speak to your healthcare professionals if you are lactating and you are having STDs.
| STDs | Should I still breastfeed? |
| HIV | You should not breastfeed as the virus can be passed on through breastmilk to your infant. |
| Syphilis | Breastfeeding is okay as long as there is no active syphilis lesions on the breasts/nipple/areola and the infant or breast pump equipment is not in contact with the affected area. |
| Chlamydia | Can breastfeed |
| Gonorrhea | Can breastfeed |
| Trichomoniasis | Can breastfeed. You may discuss with your doctor on timing of breastfeeding when you are on antibiotics treatment |
| HPV | Can breastfeed as long as there is no warts on the breasts/nipple/areola |
| Herpes | Breastfeeding is okay as long as there is no active herpes lesions on the breasts/nipple/areola and the infant or breast pump equipment is not in contact with the affected area. |
| Hepatitis B | Breastfeeding is possible, as long as the infant born from known Hep B positive mothers receive immunoglobulin/vaccine at birth ( this is within current hospital guidelines) |
| Hepatitis C | Can breastfeed. Based on CDC guidelines, as HSV is a blood-borne disease, no clinical evidence to prove breastfeeding can spread HCV |
Some of the STDs medication can be excreted into the breastmilk, though most of them are safe. It is important to discuss with your physician as well when you are on any medication treatment to ensure it is safe during breastfeeding.
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Ejaculation that is painful can be debilitating and distressing. This is the unbearable sensation that happens during orgasm. Painful ejaculation, also medically termed dysorgasmia, dysejaculation, odynorgasmia, is quite a common medical condition that can affect up to 25% of male. The pain that is experienced during ejaculation can last for seconds to minutes, or in some cases last up to days. The pain intensity can vary from mild dull pain to severe excruciating sharp pain.
This is a medical symptom that are under-diagnosed as patients may not openly discuss such embarrassing symptom and also due to the sensitive nature of the clinical presentation (present during orgasm). Despite the fact that most cases of painful ejaculation are not life- threatening, it can significantly affect a man's quality of life, leading to low self-esteem and sexual dysfunction.
This article strives to increase awareness of this medical condition that can affect men, and encourages patients with such symptom to reach out for medical evaluation and treatment.
There are 2 phases for a man to ejaculate:
Painful ejaculatory disorders may arise when pain occurs anywhere along this pathway of ejaculation.
The pain during ejaculation is being described as pain that occurs in the urethra that may extend to the scrotum, abdomen or the lower perineum. It can range from being a dull ache to an intense great pain that potentially last a few seconds to a few days long. Some men may also notice the presence of blood in the semen while experiencing painful ejaculation.
You should see your health care providers if you have above symptoms for further checkup and treatment.
While a painful ejaculation is usually not a dangerous symptom, it can have a negative impact in a person’s sexual wellbeing and esteem. Hence, understanding the cause of a person’s painful ejaculation symptoms can be the first step in regaining a man’s quality of life.
Possible causes include:
Although painful ejaculation is not a life-threatening condition, leaving the symptoms unattended can greatly impair a man's quality of life, sexual wellbeing and self-esteem. In some cases, it can also lead to infertility eventually.
You should consider consulting your doctor if you have:
Your doctor will obtain a history of your symptoms and physically examine your genital and perineum region. Sometimes your doctor may also offer a rectal physical examination to palpate the prostate. Depending on individual circumstances, your doctor may offer further tests including:
The treatment of painful ejaculation is dependent on the underlying cause of the symptom.
In some cases, the underlying cause of painful ejaculation may not be determined. Psychological counselling and cognitive behavioural therapy may be offered in managing the pain.
Pruritus is a medical term for ‘itch’. Itch is an uncomfortable sensation that provokes a person to scratch. When the itching lasts more than six weeks, it is termed chronic pruritus [1].
Although itching is not a life-threatening symptom, it can have a profound negative effect on a person’s social life. It can cause difficulty sleeping and an inability to concentrate on work/studies or daily routine. Chronic pruritus can cause emotional distress and is associated with mental health conditions such as anxiety and depression [2]. To make things worse, frequent scratching or rubbing of the affected skin area can lead to injury or impairment of skin tissues, resulting in infections and other health complications.
In this article, we explore these itchy symptoms and explain the possible underlying causes in simple layman's terms. The article strives to educate and empower patients to better understand these common symptoms and seek medical attention when symptoms persist.
Chronic pruritus is a common symptom that can affect anyone at any age or in any walk of life. Approximately 22% of people may experience chronic pruritus throughout their lifetime [3]. The condition is commonly seen in elderly people who are above the age of 65 [4]. In Singapore, nearly half of the elderly may experience chronic pruritus [5].
Though the sensation of ‘itch’ is a nuisance, it functions as a body’s self-protective mechanism. It is supposed to warn us against harmful external agents and protect our bodies. The itch sensation is comparable to other skin sensations such as touch, pain, etc.
Itch occurs when the itch-sensing nerve endings known as ‘pruriceptors’ on the skin are stimulated by heat, chemical, mechanical causes, infection, or even inflammation. Once the pruriceptors are activated, the ‘nerve signals’ will be delivered via the C-fibres that are present on the skin to the spinal cord and the brain. When we scratch or rub the affected area, the pain and touch receptors on the skin can also be activated. The concurrent pain and touch sensation can interfere with the itch sensation, resulting in temporary relief. However, the skin can be irritated or injured via scratching, eventually leading to a never-ending vicious itch-scratch cycle [6].
You should consider seeing a doctor for further checkups and treatment if your itch:
There are a few key questions that you may want to consider preparing yourself before seeing your doctor to evaluate chronic pruritus further; these are:
Chronic pruritus is a medical condition that can be tricky for patients and physicians to diagnose and manage.
We can split the causes of a persistent itch into broad categories, such as:
In a real-world circumstance, a person may have multiple factors that contribute to experiencing a persistent itch. Unfortunately, sometimes, it may be impossible to pinpoint a single cause of chronic pruritus.
Prolonged, unattended itch can lead to a vicious itch-scratch cycle. Out of itch desperation, one may even resort to repeated rubbing and washing to achieve temporary relief of the symptoms. Nonetheless, all these actions can lead to injury of the normal skin barrier, resulting in skin infection or even scarring of the affected area.
Chronic pruritus can be uncomfortable, affecting the quality of social life. It is known that a person with chronic pruritus is predisposed towards mental health disorders such as anxiety and depression.
Furthermore, chronic pruritus can be more than a skin-deep issue. It may suggest underlying medical conditions that, if left unattended, may result in potential long-term systemic complications.
It is useful to discuss your symptoms with your healthcare providers. Depending on individual circumstances, your doctor may offer tests such as the ones below to identify the possible trigger of your persistent itch symptoms.
Tests offered may include:
If there is an underlying condition that causes the recurring of itch, the underlying medical condition needs to be addressed.
Chronic pruritus can be relieved with:
You can discuss with your doctor to understand more about the management of chronic itch symptoms.
Erectile dysfunction (ED) is a medical condition when a man is unable to achieve or sustain an erection that is satisfactory for sexual intercourse. It is an alarming health condition that affects up to half of the men aged 30 and above in Singapore. It is slightly common in those with concurrent cardiovascular health risk factors.
Conventional treatment for erectile dysfunction involves lifestyle changes to improve underlying medical conditions and oral medication treatment with phosphodiesterase-5 inhibitors (PDE5i) such as sildenafil or tadalafil. In those who are unable to consume oral treatment or have poor improvement with oral treatment, more drastic and invasive options such as vacuum devices, injections, and penile prostheses may be considered. Patients with erectile dysfunction may also be susceptible to the exploitation of non-clinically proven medication or treatment options that are available in the market, leading to further waste of money with unsatisfactory outcomes.
Over the years, low-intensity shockwave therapy has slowly gained popularity among both patients and clinicians as one of the treatment options for ED. In this article, we want to understand and explore the efficacy and sustainability of this option in erectile dysfunction.
The effect of shockwave therapy relies on incorporating the theory of basic physics onto biologically targeted human tissue to achieve the desired outcome.
In physics, a shockwave is produced when:
As the name ‘shockwave’ suggests, the shock allows forward propagation of disturbance that moves faster than the speed of sound in the medium. The sudden delivery and discontinuity of the ‘disturbances’ in the medium allow shockwave to achieve an abrupt high-pressure level onto the targeted region. When the shockwave forces are applied to a localised area of the body, it leads to repeated and sudden sheer pressure, compression and expansion of the tissues.
In erectile dysfunction, the repetitive sheer pressure delivered by shockwave therapy stimulates the regrowth of blood vessels (neo-angiogenesis), improves micro-blood circulation, regenerates localised nerve (neurogenesis), activates progenitor cells to remodel, and restores erectile tissue from local inflammation and stress.
We now know that in most patients with erectile dysfunction, there is abnormal or reduced blood circulation through the erectile tissues. The idea of tissue regeneration with shockwave therapy changes the conventional treatment paradigm of erectile dysfunction.
Over the years, there have been increasingly promising clinical studies showing that shockwave therapy can be used beneficially and safely in ED. Shockwave therapy is also seen to work as an adjunct to improve patients' responses to oral medications such as PDE5i.
Currently, the EAU (European Association of Urology) recommends shockwave therapy as a first-line alternative treatment for patients who are unable to tolerate oral medications such as PDE5i. The Asia-Pacific Society for Sexual Medicine (APSSM) also recommends shockwave therapy to patients with mild or moderate vasculogenic (blood-circulatory related) ED who do not respond to oral medications.
Shockwave therapy is a convenient and relatively quick treatment therapy that can be offered in an outpatient setting. You are not required to fast for preparation prior to the procedure.
Your doctor will place a hand-held shockwave device onto your penis. The device will release gentle shock pulses to trigger the regeneration of the erectile tissues. There will be no needle involvement, and no anaesthesia is required. The entire procedure takes about 30 minutes. As there is generally no downtime, you are expected to be able to drive home, go to work, continue sports activities, and go about your usual everyday routine.
Patients with erectile dysfunction who:
If you are taking blood thinner medications such as anticoagulants or antiplatelets, you should inform your healthcare providers before treatment. Depending on your circumstances and health risks, your doctor can advise you further on the suitability of shockwave therapy.
Shockwave therapy is not a completely new medical technology and treatment option. In fact, this therapy has been available for over 40 years in the medical field. It is used to manage health conditions, including kidney stones, pelvic pain, and musculoskeletal injuries such as frozen shoulder and plantar fasciitis.
Sexually transmitted diseases (STDs) are an umbrella term for infections that can be acquired through sexual intercourse. Based on the local epidemiological studies in Singapore, STDs affected 201.6 per 100,000 of the population in 2017.
This leads us to the following questions:
We will explore the above points in this article.
STDs can have a detrimental effect on male hormones and can result in prostatitis and sexual dysfunction.
Testosterone is an essential male sex hormone that regulates the male libido, sperm production, general energy level, fat and muscle mass distribution, and red blood cell production. Testosterone hormone is produced mainly in the testicles, and the level can fluctuate. Common causes of reduction of testosterone hormone include ageing, diabetes, trauma, thyroid disease, hormonal disorders, tumour, and infection.
STD Infections can cause inflammation of the testicles (this is known as epididymitis), leading to impairment of the production of testosterone. Common STDs that are associated with low testosterone include HIV, chlamydia, gonorrhoea, and syphilis.
The prostate gland is a small chestnut organ located at the neck of the bladder, just in front of the rectum, and at the base of the urethra (the urinary tube that delivers urine). It is an important organ in the male reproductive system and aids in the production of semen to ensure the sperm is viable and able to move. Due to its location, the prostate gland can easily become infected by pathogens such as STDs.
Untreated STDs, such as HIV, gonorrhoea, and chlamydia, can infect the prostate, leading to prostatitis – inflammation of the prostate. When the prostate is inflamed, the surrounding blood circulation to the genitals can be compromised; there will be lesser blood flow to the penis which can result in difficulty in sustaining an erection.
Urethritis is a type of urinary tract infection that affects the urethra. The urethra is the opening tube that allows urine to flow from the bladder to the external body. Due to the proximity to the external environment, it is easily infected by STDs. Chlamydia and gonorrhoea remain two of the most common STDs associated with urethritis. However, there are other bacteria, such as syphilis, trichomonas, mycoplasma spp, ureaplasma spp, candida, etc that may contribute to urethritis symptoms.
Abnormal urinary symptoms such as painful urination, itching or burning sensation, and discharge over the urethral can occur in untreated urethritis. Untreated STD-related urethritis can be associated with the further spread of the disease to the surrounding reproductive organ, resulting in peri-pelvic infection or abscess, urinary tract scarring, inflammation of the testicles and prostate, etc. These can all lead to penile discomfort, pelvic pain, and inflammation and again affect a person’s sexual function.
Thankfully, most STDs that affect male sexual function are treatable with the correct diagnosis and medications.
STDs have been known to have a negative role in menstrual cycle and PMS.
Although STD infections do not affect the female hormonal axis, they can be associated with abnormal vaginal discharge and spotting symptoms. One may notice spotting from light to dark brown/red discharge when they are not having their usual period or after intercourse. Less commonly, STDs can be associated with irregular periods or missed periods, though other causes such as pregnancy, PCOS (polycystic ovarian syndrome), or thyroid disorder should be considered as possible differentials as well.
In chronic untreated STD infections, one may develop more severe complications such as inflammation and scarring of the pelvis and reproductive organs, including the uterus, fallopian tubes, and ovaries. In such instances, the ovulation or menstrual cycle can cease to function, leading to clinical presentation of irregular or missed periods.
Common bacterial STDs can be associated with abnormal menstrual cycle or vaginal symptoms. STDs bacteria including chlamydia, HPV, gonorrhoea, trichomonas, and mycoplasma genetalium, are common culprits. Unfortunately, as most symptoms of abnormal vaginal discharge or abnormal menstrual spotting tend to be mild, one may delay seeking medical treatment. If it is a case of an untreated STD, delaying treatment increases the risk of long-term complications such as pelvic inflammatory disease and can affect future fertility.
Studies have shown that there may be a link between untreated STDs and worsening premenstrual symptoms (PMS). Premenstrual symptoms such as headache, sadness, and longer period of cramps are exacerbated by untreated STDs (such as chlamydia, herpes, HPV) based on a clinical study in Oxford using a period-tracker app for smartphones.
The hypothesis suggests that with the associated inflammatory phase and falling of progesterone level prior to menses, STDs can worsen further this inflammation, hence, exacerbating PMS symptoms.
Aside from the physical complications from STDs, these infections are also associated with negative psychological impacts. The way general society stigmatizes STDs, a person’s upbringing and cultural background may affect a person’s mental outlook against STDs.
Emotional responses such as anger, depression, guilt, shame, and isolation can occur. This can be followed closely with reduced self-worth, low self-esteem, anxiety, and depression when one is dealing with STD conditions. Over time, constant mental stress against STDs can be associated with restlessness and reduced sexual desire or satisfaction.
One may be scared of contracting STDs to the extent of being unable to be aroused sexually. In males, psychogenic erectile dysfunction can occur out of fear of STDs. In females, one can experience sexual dysfunction symptoms such as vaginismus, reduced libido, painful intercourse, etc.
This will depend on the underlying cause of sexual dysfunction. If the root of the medical condition is due to underlying STD infections, treating or managing the underlying culprit STD infections is likely to improve a person’s overall sexual function. However, bear in mind that most cases of sexual dysfunction can be multi-factorial, and it may benefit to discuss your concerns with your doctor to address any other causes.
Based on the WHO diagnostic criteria, diabetes mellitus is defined as a fasting serum glucose level equal to or more than 7 mmol/L or 126 mg/dl. In diabetes, a person has chronically high sugar levels in the bloodstream due to a defect or reduced insulin production.
Diabetes is infamously associated with long-term health complications such as increased risk of heart attack, stroke, kidney disease, nerve complications, blindness, poor wound healing, various disabilities, and even death. According to the International Diabetes Federation, 1 in 10 people lives with diabetes worldwide. Based on the National Population Health Survey 2022 Singapore, the prevalence of diabetes (between the age group 18 to 75) in Singaporean is 8.5%.
In this article, we aim to discuss the correlation and overlapping symptoms of both medical conditions.
A person with diabetes tends to have a weaker general immune system, and this predisposes the person towards various forms of infections, including sexually transmitted diseases (STDs).
Interestingly, an untreated STD, just like any form of infection, may increase the blood sugar level in a diabetic person. This can create a vicious cycle for a diabetic patient with STDs- predisposition to high risks of infection and is more complicated to treat.
There is no direct causative effect between diabetes and STDs. Diabetes does not cause STDs, and vice versa. Both conditions are due to completely different underlying physiology. STDs are due to sex and infection. Diabetes is due to the ineffective breakdown of sugar by insulin in the body, leading to a long-term hyperglycaemic state in the circulation.
It is imperative to note that STDs, as the name has suggested, sexually transmitted diseases, are transmitted through sexual encounters. STDs occur due to exposure to unsafe unprotected oral, vaginal, or anal intercourse. A person with diabetes without a history of sexual encounters is, hence, unlikely to acquire an STD.
Nonetheless, people tend to be confused by both medical conditions, as their presentations are similar, and we strive to iron them out in simpler terms.
In both diabetes and STDs, a patient (both men and women) can present with itching over the genital region.
In diabetes, chronic high blood sugar and a low immune system cause a person to have a poorer skin barrier, which increases the risk of fungal and bacterial infection. Itching can be a symptom of a skin infection.
On the other hand, STDs such as Chlamydia, Gonorrhoea, Trichomoniasis, Mycoplasma Genitalium, HPV/warts, and Herpes Simplex Virus infection can present with itching over the genital region.
A rash over the genital region is always a concern of a possible STD. STDs such as herpes infection and HPV infection can present with a rash and are commonly mistaken as eczema or sensitive skin.
A rash over the lower pelvic, groin, or even anal region can also be non-STD related. In the case of diabetes, a combination of a weakened immune system and environmental factors such as increased sweating/ hygiene/ humidity of surroundings, one can present with a bacterial or fungal-related skin infection over the moist area below.
Furthermore, patients with diabetes may be more commonly seen with skin tags. Skin tags are small appendages, stalk-like skin bumps that can be confused with STD skin bumps such as HPV viral warts.
Abnormal vaginal discharge is characterised by unusual excessive volume (compared to baseline), colours such as yellow to green or greyish in appearance, and foul-smelling vaginal discharge. There can be occasional associated painful urinary symptoms, lower pelvic pain or, in more severe cases, even fever.
This abnormal symptom invariably always rings a red flag alarm on a possible underlying STD (as long as there is a sexual history involved). Bacterial STDs such as Chlamydia, Gonorrhoea, Trichomoniasis, Ureaplasma spp, Mycoplasma spp, etc, are common culprits that are involved in the abnormal symptoms.
Nonetheless, abnormal vaginal discharge can be seen more frequently in diabetic patients due to recurring fungal/yeast infections.
Urinary tract infection is frequently seen in a person with diabetes due to high blood sugar levels in the body. Confusingly, in bacterial STDs, one can present with similar symptoms such as urinary tract infection- painful urination, discharge from the urethral, burning sensation upon peeing, urinary urgency, etc.
In a person with a urinary tract infection that is not caused by an STD, the urinary tract is infected due to migration or contamination of the bacteria from the surrounding genital region. In the case of diabetes- it is due to an underlying poor immune system, poor skin integrity, and a higher risk of general infection.
In STDs, the causative bacteria, such as chlamydia and gonorrhoea, come from an external source- such as an infected sexual partner.
Pain during intercourse should not be ignored. Reversible and manageable causes such as STDs or diabetes should be addressed to avoid irrevocable complications such as chronic discomfort and infertility.
As diabetes can affect the blood vessels and nerve supplies of the body, in females, it can be associated with vaginal dryness due to reduced lubrication as a result of diabetic neuropathy. In diabetic males, the blood flow to the penis can be impaired, leading to sexual dysfunction. In both circumstances, sex can be painful and uncomfortable.
Painful sex can be an indicator of an untreated STD. Over time, an undiagnosed STD can cause chronic inflammation and scarring of the reproductive organs and chronic pain during intercourse. STDs are important to treat, not just to address sexual discomfort but, more importantly, to prevent the infection from causing scarring and eventual infertility.
High-risk pregnancies are commonly seen in a person with diabetes or untreated STDs.
In diabetes, the pregnant mother is at higher risk of miscarriage, pre-term labour, stillbirth, and serious birth defects in babies (congenital heart, brain, and spine defects).
Vertical transmission of STDs from mother to unborn foetus is possible. Infections such as HIV, hepatitis, syphilis, chlamydia and gonorrhoea can be passed on to the foetus during pregnancy. STDs in newborns can be associated with neurological defects, meningitis, blindness, deafness, chronic infection in the babies, failure to thrive, or even death. STDs are one of the preventable causes in newborns if screening and early treatment are offered to pregnant mothers.
1. Diabetes and STDs are two medical conditions of different entities and underlying causes.
2. A person can have both diabetes and STDs.
3. A person with underlying diabetes can be more susceptible to STDs.
4. Diabetes clinical presentation can be similar to STD symptoms, though the treatment for both are completely different.
5. As diabetes and STD presentations can be confusing, a review with your healthcare professional can be beneficial to diagnose the symptoms correctly.
6. Both diabetes and STDs can be screened accurately, and there are effective treatment options in managing both conditions to minimise long-term complications.
With the recent hype over skin food for luscious hair and longer, stronger nails, biotin is becoming a common supplement in our multivitamin drug cupboard. Have you ever wondered how safe biotin is and whether it has any long-term implications for our health?
In this article, we explore the role of biotin in the human body and the benefits and potential drawbacks of this supplement.
Biotin, also known as Vitamin B7, Vitamin H, and Coenzyme R, is a water-soluble protein that facilitates the production of energy for the body by acting as a catalyst in the metabolism of protein, carbohydrates, and fats.
It can be found in meat, salmon, eggs, innards such as liver, dairy products, cereal and grains, soy flour, fruits and vegetables such as bananas, carrots, cauliflower, etc. Biotin, when consumed, is absorbed in the small intestine and stored predominantly in the liver.
Currently, there are no blood tests that enable us to monitor the level of biotin in our body.
Biotin plays an essential role in the growth of skin, hair, and nails. Biotin deficiency is known to be associated with brittle nails, skin rash, or hair loss. Furthermore, low biotin can be associated with cardiovascular consequences such as high cholesterol and heart disease.
There are ongoing medical studies and research on the role and benefits of biotin in skin conditions such as seborrhoeic dermatitis, acne, or eczema and neurological conditions such as multiple sclerosis. However, there is insufficient clinical evidence to prove its efficacy in these conditions.
Patients who are on anti-convulsants (epilepsy medication) can be associated with lower biotin levels in their bodies.
Biotin deficiency is uncommon in healthy people with a regular, varied diet.
Biotin can be lower in chronic alcohol drinkers or pregnant or lactating mothers. Rarely, one can be genetically predisposed to biotin deficiency due to biotinidase enzyme deficiency (an enzyme that allows the release of free biotin in the body).
Biotin deficiency can be associated with hair loss, brittle nails, and skin rash, particularly over the mouth, eyes, nasal hole, and perianal region). In more severe cases, one can develop neurological symptoms such as seizures, numbness in the limbs, and psychiatric symptoms such as depression and hallucination.
Thankfully, no major side effects have been reported for overdosing on biotin. However, informing your healthcare provider before starting the supplement is still good practice.
As high biotin intake can lead to falsely high or low biochemistry laboratory test results, which can lead to misdiagnosis and mismanagement of a person’s health condition, it is always prudent to check with your doctor about your biotin dose.
There is slowly emerging medical evidence of biotin interference with laboratory test results. Most laboratory immunoassays (tests) use the biotin-streptavidin system to run samples, as this system allows high affinity and sensitivity (the ability of chemical proteins to bind together and pick up abnormalities). It is found that a high amount of biotin (>1mg/day) can cause false test readings.
Abnormal thyroid hormone blood tests and Vitamin D serum levels are found in patients who consume high biotin levels. There have been reports of false hyperthyroidism or inappropriate diagnosis and treatment of Grave’s disease in patients who are taking high-dose biotin (30-100 mg biotin/day). Aside from this, some reports reveal biotin can interfere with blood markers for heart failure (such as pro-BNP {brain natriuretic protein}), both female and male hormones, cortisol, parathyroid hormone readings, folate, vitamin B12, iron readings, etc.
The concern and danger here:
You are encouraged to inform your doctor on the supplement(s) that you are taking prior medical tests to ensure the tests is run and interpreted appropriately.
Thought for the day…
The interference of biotin with our daily biomarkers raises a few new questions to ponder:
A more pragmatic approach is to educate ourselves as both patients and consumers on the supplement that we are delving into. On the other hand, physicians have a role in screening patients' drug and supplement lists. Those who are on biotin should be counselled on the potential interference with laboratory results before blood testing.
1. Gifford JL, Sadrzadeh SMH, Naugler C. Biotin interference: Underrecognized patient safety risk in laboratory testing. Can Fam Physician. 2018 May;64(5):370.
2. Elston MS, Sehgal S, Du Toit S, Yarndley T, Conaglen JV. Factitious Graves’ disease due to biotin immunoassay interference—a case and review of the literature. J Clin Endocrinol Metab. 2016;101(9):3251–5.
3. Piketty ML, Polak M, Flechtner I, Gonzales-Briceño L, Souberbielle JC. False biochemical diagnosis of hyperthyroidism in streptavidin-biotin-based immunoassays: the problem of biotin intake and related interferences. Clin Chem Lab Med. 2017;55(6):780–8.
4. https://ods.od.nih.gov/factsheets/Biotin-HealthProfessional/#ref
There are two schools of thought on the management of molluscum contagiosum. Some physicians prefer conservative treatment, allowing the immune system to run its course and clear off the virus over time. On the other hand, one may opt for a more proactive approach to medically treating the infection.
In this article, we explore the reasons for considering treating molluscum contagiosum.
Molluscum contagiosum is a benign viral skin infection caused by the poxvirus [1]. The infection causes small, discrete, firm, white skin bumps known as Mollusca, with a classical characteristic of a dimple or pit in the centre. Molluscum lesions can occur on any part of the body, including the face, neck, body, arms, legs, or even the genital region.
Medical literature shows that 70% of molluscum contagiosum infections take months (up to 6-18 months) to resolve spontaneously [2]. However, in some patients, new molluscum lesions can continue to appear intermittently for 3-4 years. Less commonly, medical reports suggest the infection can even last up to 5 years.
One can acquire the viral infection through skin-to-skin contact, sexual contact, and fomite transfer through wet towels, pools, bathtubs, spa rooms, gym floor surfaces, etc [3]. Practising good hand hygiene is imperative in reducing the transfer of infection to self and others.
While molluscum contagiosum can be acquired through skin contact with contaminated surfaces/fomites, it is considered an STD when one contracts it from sexual partners. Typically, an STD-related molluscum contagiosum infection involves the genital areas or the oral region due to skin-to-skin transmission during physical intercourse [4].
If you are unsure whether your symptoms are due to molluscum contagiosum, you can contact your trusted physician for further evaluation. The lesions are characterised by round, discrete, waxy, pale dots with a central umbilication (indentation).
In cases where the diagnosis is unclear, your doctor may further evaluate the lesion with a dermatoscope or surgically remove a small skin sample (biopsy) to confirm the diagnosis.
The Mollusca that remains on the skin has a high risk of being passed on via skin-to-skin contact to people around us and self-inoculate to other parts of our body such as the hands, eyes, face, neck, and genital region.
As sexual activities involve physical intimacy and friction, the viral infection can easily be passed on between sexual couples. Untreated molluscum over the genital region increases a person’s risk of acquiring other types of STDs.
Incessant scratching can be a nuisance and an embarrassment in our daily life. The itch can even affect sleep and daily productivity. Although not life-threatening, molluscum can be uncomfortable and significantly reduce our well-being.
One of the common complications from persisting molluscum lesions is secondary bacterial infection. This is particularly important in patients with a compromised immune system [5], such as HIV patients. Concurrent bacterial and molluscum infections can further complicate health and hamper recovery. In these situations, it is imperative to get molluscum (the primary problem) treated.
This is particularly true in the case of inflammatory skin conditions such as eczema, where molluscum can cause a flare-up of existing eczema [6]. Persistent molluscum infection also makes the treatment of eczema more recalcitrant.
Although uncommon, when molluscum infection occurs in a pregnant woman, there is a possibility of vertical transmission of the disease from the mother via the uterus/birth canal to the baby.
Molluscum lesions covering the skin surface, particularly exposed areas such as the face, arms, legs, and hands, can be disfiguring and cause social embarrassment. Even having them over the genital regions can be socially awkward and embarrassing between couples.
Scratching, picking, and inappropriate scooping of the molluscum lesions can lead to scarring of the skin. Spontaneous scarring from molluscum infection is also possible due to chronic inflammation of the skin infection [7]. Skin scarring is irreversible.
It is medically indicated to consider treating molluscum contagiosum if:
Medical treatment of molluscum infection involves the following:
Effective physical removal treatments are offered safely in outpatient settings.
As molluscum contagiosum infection may continue to resurface due to underlying immune system inadequacy to combat the virus, physical removal treatment may be required in repeated sessions to eradicate the infection.
It is not advised to self-attempt to pick or remove the skin lesions as this can increase the risk of scarring and further self-inoculation of the virus to the surrounding skin.
When a person has genital molluscum contagiosum, this is an indication of an increased risk of other sexually transmissible infections. Other STD testing, including HIV testing, should be offered to prevent further complications develop from STDs and to protect loved ones from contracting STDs.
A person who has had molluscum contagiosum and has been treated before is not immunised or protected against future infections. Even with successful clearance of molluscum infection, you are still at risk of developing a new molluscum infection if exposed to a new source of the virus. There is currently no vaccination against molluscum contagiosum.
As long as you have the molluscum bumps, you can spread them to others.
If you are concerned about acquiring molluscum contagiosum infection or exposure to other forms of STDs, you are encouraged to reach out to your trusted physician and take proactive steps to protect yourself and the people around you.