Have you ever had an episode where you had to cross and uncross your legs in public due to the itchy sensation below? Or an episode of urgent need of the bathroom to scratch the itchy genitalia? The symptom may sound trivial, but it can profoundly impact our lives, affecting our daily routine and causing embarrassment when socialising with others.

How common is genital itch?

Genital itch is a common medical symptom that can occur in anybody. It is a non-discriminative symptom, regardless of your educational or socioeconomic background. 

What are the causes of genital itch?

Genital itch symptoms can be broadly categorised into dermatological versus infectious/sexually transmitted disease STD-related causes.

Dermatologically related genital itch:

• Fungal infection: this can occur due to a combination of factors of a hot and humid environment, moist genital region, and low self-immunity.
• Eczema: this is a common inflammatory skin condition secondary to impaired skin barrier compound further with environmental exacerbation.
• Psoriasis: this is an autoimmune skin condition associated with excessive and rapid building up of skin cells.
• Lichen planus/lichen sclerosus: lichen planus and lichen sclerosus are chronic inflammatory skin conditions that are not infectious and commonly affect the genital and mucosal surfaces of the bodies.
• Irritation/contact dermatitis: this can occur when the wrong usage of creams/topicals/wash to the groin region leads to skin irritation and inflammation.

STD-related genital itch:

• Genital warts: fleshy bumps and lumps due to HPV-related infection. Genital warts spread to people via contact/sexual contact. In females, HPV infection can be associated with cervical cancer. In males, certain high-risk strains of HPV infections can be associated with penile and anal cancer. 
• Herpes Simplex Virus infection: the affected area may have blisters and erosions. One can present with systemic symptoms of fever and swelling of lymph node glands. 
• Molluscum contagiosum: molluscum contagiosum manifests as small bumps commonly confused with genital warts. This is due to an infection from poxvirus. Typically, genital molluscum is a sexually transmitted condition, and it is imperative to treat it to prevent further spread of the condition to others.
• Scabies/lice or crabs: these are mite infections that are spread via sexual contact. Intense itch is one of the key symptoms. However, it is generally not life-threatening per se; the high spreading rate and the associated social stigmatisation of the condition warrant urgent treatment and termination of the mites.

Other causes of genital itch:

Some various bacteria or parasites can cause symptoms of itch over the genitalia when the infection is left unattended. This includes chlamydia trachomatis, Neisseria gonorrhoea, Mycoplasma Genetalium, Gardnerella bacteria, Trichomonas parasites, etc. These are commonly associated with sexually active people. If you are having trouble with genital itching and you are in a sexual relationship, do discuss it with your doctor and consider further screening for sexually related infections. These bacterial/parasitic-related sexually transmitted infections are treatable, and they do not resolve on their own unless treated with the correct medications.

A genital itch can be an embarrassing symptom to present to your doctor. Nonetheless, the condition is manageable if the right cause is determined and dealt with.

When should I see my doctor?

You are encouraged to see your doctor when your symptoms persist and cause impairment and nuisance to your daily routine. 

Further red flags to note and consider seeing your doctor if you have:

• Rash/growth/lumps and bumps
• Pain
• Blisters
• Unexplained discharge –both watery/serous or pus/yellow cloudy
• Sores/ulcers
• Noticeable crawling insects/mites
• Painful urination
• Vaginal discharge (in females), urethral discharge (in males)
• Painful testicles (in males)
• Fever
• Lower pelvic pain

Although 'itch' is a generally benign symptom, it may be a tell-tale sign of a more serious medical condition that requires treatment. Do see your doctor if the genital itch symptoms are not improving or if you develop any of the red flags discussed above.

What will my doctor do?

As genital discomfort or itch can be a private and embarrassing condition, you are encouraged to see a doctor that you are comfortable with.

Your doctor will obtain a relevant history of your symptoms and relevant social/sexual histories. Your doctor will then physically examine your genitalia region for skin integrity. In females, your doctor may request, with your consent, a vaginal examination. In males, your doctor may request, with your consent, to examine your scrotal and penis region. Depending on individual conditions, your doctor may examine the rest of the body for other relevant body signs associated with your symptoms. Your doctor may also offer various tests in the form of blood, swab, scrape, or even urine tests depending on the working differential diagnosis. 

How can I treat my itchy genitalia?

The treatment and management of itchy genital symptoms depend on the cause. In dermatological causes, your doctor may offer topical medicated cream as a steroid, antifungal, or antibacterial to manage the symptoms. In more severe cases of concern with fungal infections, your doctor may prescribe oral antifungals to manage the symptoms. Lifestyle advice to reduce triggers that irritate dermatological symptoms will be discussed.

If the underlying cause is an untreated infection, you may be offered targeted treatment through oral medication, cream, or even procedures such as cryotherapy or electrocautery. 

Discuss your symptoms with your doctor, allow your doctor to examine your condition, and discuss the treatment options available to manage your genital itch symptoms with your doctor.

What will happen if I do not treat my itchy genitalia?

Although itch can be a completely benign symptom that potentially resolves spontaneously, if the symptom is not addressed appropriately, one may miss or delay diagnosing an underlying medical condition. In the event of dermatological-related itchy genitalia, if the underlying skin condition is not addressed, one may have recurring symptoms in the near future. In the event of infectious-related itchy genitalia, one will have an untreated infection and be at risk of developing complications from the infection and spreading the disease to people around you. 

You don’t have to suffer genital itch alone…

There are effective treatments to manage the itch in the genital region. Understanding the possible differentials and having the courage to seek medical help are paramount steps to take to take control of your health and your overall quality of life.

References:

1. Raef HS, Elmariah SB. Vulvar Pruritus: A Review of Clinical Associations, Pathophysiology and Therapeutic Management. Front Med (Lausanne). 2021 Apr 7;8:649402. 
2. Krishnan A, Kar S. Scrotal Dermatitis - Can we Consider it as a Separate Entity? Oman Med J. 2013 Sep;28(5):302-5. 
3. Savas JA, Pichardo RO. Female genital itch. Dermatol Clin. (2018) 36:225–43. 
4. Fischer GO. The commonest causes of symptomatic vulvar disease: a dermatologist's perspective. Australas J Dermatol. (1996) 37:12–8. 
5. Connor CJ, Eppsteiner EE. Vulvar contact dermatitis. Proc Obstet Gynecol. (2014) 4:1–14. 
6. Gopinath H, Karthikeyan K. Genital scabies: Haven of an unwelcome guest. Indian J Sex Transm Dis AIDS. 2020 Jan-Jun;41(1):10-16. 
7. Thorstensen KA, Birenbaum DL. Recognition and management of vulvar dermatologic conditions: lichen sclerosus, lichen planus, and lichen simplex chronicus. J Midwifery Womens Health. 2012 May-Jun;57(3):260-75. 
8. Swamiappan M. Anogenital Pruritus - An Overview. J Clin Diagn Res. 2016 Apr;10(4):WE01-3. 
   

Penile discharge is the fluid that comes out of the urethra when you are not urinating.

The urethra is a tube over the urinary system that allows the flow of urine and semen from the bladder or ejaculatory ducts to the opening of the penis and thus the external body.

Urethral/penile discharge can sometimes be physiological and a normal part of the male body mechanism. However, when should we be alarmed about discharge from the penis? This article aims to educate readers on understanding the possible differentials and red flags that one should be looking out for in penile discharge.

Penile discharge can be perfectly normal

Penile discharge can be completely normal and acts as the body’s mechanism to lubricate the penis. It is normal for the penis to produce discharge when a person is sexually aroused or during intercourse. You may notice penile discharge just before ejaculation or during ejaculation. Occasionally you may notice a white coating overlying the tip of the penis after a long day out or on a hot day. 

Types of penile discharge include: 

• Pre-ejaculated penile discharge: a mucus-like liquid that is produced from the bulbourethral glands which are located just below the prostate. Pre-ejaculated discharge is produced when a person is sexually aroused. This fluid helps to lubricate the semen and the tip of the penis. It also creates an alkaline environment and reduces acidity due to urine thus allowing the sperm to survive longer.
• Ejaculated penile discharge: also known as the ejaculated semen. It is usually milky-cloudy in nature that is produced during orgasm. During sexual orgasm, the sperm that is produced by the testes will be mixed with the semen fluid. The ejaculated semen fluid is produced by the seminal vesicles which are situated next to the prostate glands. 
• Smegma: a white coating/substance that can be found over the head/glans of penis and the foreskin. It is made up of a combination of sebaceous oil, dead skin cells, and moisture, and it behaves as a natural lubricant to keep the genital moist and allows the foreskin to be retracted during sexual intercourse. Excessive smegma can predispose a person to bacteria or fungal infection and one may notice an odorous penis. If you have such symptoms, you can speak to your doctor for general lifestyle and hygiene advice.

Penile discharge can be abnormal

While some types of penile discharge are normal, there are others that are abnormal and may even be infectious.

Examples of abnormal penile discharge include:

Penile discharge that is non-infectious/non-sexually transmitted disease related

• Balanitis: benign medical condition associated with inflammation of the head of the penis. The cause of developing balanitis is multifactorial. The accumulation of dead skin, residual urine, sweat, oil beneath the foreskin, combined with a warm and moist environment is a conducive breeding ground for bacteria and fungus. Underlying skin conditions such as eczema, psoriasis can also worsen the situation. Chemicals from soap, condom, or lubricants can also irritate the skin. Underlying medical conditions such as diabetes can predispose a patient towards balanitis.
  

Patients with balanitis can present with penis discharge and also associated redness, inflammation or irritation over the head of penis. One may notice odour over the genital region, and in more severe cases, an itch or burning sensation upon urination. The symptoms of balanitis can come and go over time. You are advised to speak to your doctor if you have concerns of balanitis.

• Urinary tract infection: although males can develop urinary tract infection, it is less common in comparison to females due to a shorter urethra in women. This makes the urethra, bladder, and kidneys more accessible to bacteria.
  

Urinary tract infection (UTI) can affect any part of the urinary system including the urethra, bladder, or kidneys. Urinary tract infection occurs when bacteria from the surrounding area (skin or rectum) enters the urinary tract and causes inflammation and infection.

Risk factors for males developing urinary tract infection include:

• Unprotected sexual activity
• History of previous urinary tract infection
• History of abnormal urinary/renal anatomy
• History of kidney stones
• History of prostate issues
• Has used external instrumentation such as catheter
• Underlying medical condition affecting general immune system including diabetes, underlying anti-retroviral disease (HIV)

Patients with urinary tract infection can present with abnormal penile discharge and developing symptoms such as: 

• Painful or burning sensation during urination
• Increased urinary frequency
• Blood in the urine
• Smelly urine
• Fever
• Lower back pain, nausea vomiting

Urinary tract infection is not contagious but must be promptly treated so as to avoid complications such as kidney infections or blood infection. Do seek medical attention if you have penile discharge or urinary tract infection symptoms.

• Prostatitis: the prostate is a chestnut-sized gland that sits below the bladder of a male person. It functions to produce semen fluid. Prostatitis occurs when the prostate gland becomes inflamed or irritated, commonly due to bacterial infections. Patients with prostatitis may present with abnormal urinary symptoms including penile discharge, painful urination, increased urinary frequency, or even abnormal urine flow. Antibiotics are usually required to treat prostatitis, you are advised to seek medical attention if you develop any prostatitis symptoms.

Penile discharge that is infectious/related to sexually transmitted infections (STIs) 

Abnormal penile discharge can be due to underlying sexually transmitted infections (STIs) .

Common STIs that can be associated with penile discharge include:

• Chlamydia trachomatis 
• Neisseria gonorrhoeae 
• Mycoplasma genitalium
• Trichomonas vaginalis

Interestingly some patients with STIs can be completely asymptomatic but it is important to note that asymptomatic individuals can still spread STIs to their sexual partners. Not only is untreated STIs contagious, they are also associated with infertility in both men and women. 

If you are experiencing penile discharge with unusual colour and consistency, itchiness, burning sensation over the penis, inflammation,rashes over the penis, and testicular pain or swelling, seek further medical investigation to screen for underlying medical condition. 

When should I see a doctor if I have penis discharge?

You are advised to seek advice from your doctor if you notice penile discharge when you are not:

• Urinating
• Pre-ejaculating
• Ejaculating 

OR if you are experiencing:

• Unusual penis odour
• Unusual penile discharge colour
• Increased urinary frequency
• Abnormal urinary flow
• Itch, discomfort, or pain during urination
• Lower pelvic pain

Important note

While penile discharge can be a healthy physiological part of life, it can also signify underlying infection, inflammation, or medical condition. The silver lining– penile discharge that is abnormal is usually treatable. If you have concerns about penile discharge symptoms, avoid further hesitation, do see your trusted physician early.

References

1. Adler MW. Urethral Discharge: Diagnosis. British Medical Journal (Clinical Research Edition)Vol. 287, No. 6402 (Nov. 5, 1983), pp. 1360-1362 (3 pages)
2. Zenilman JM. Chapter 3. Urethral Discharge. In: Klausner JD, Hook EW, III. eds. CURRENT Diagnosis & Treatment of Sexually Transmitted Diseases. McGraw Hill; 2007. Accessed April 24, 2023. 
   https://accessmedicine.mhmedical.com/content.aspx?bookid=369&sectionid=39914779

Andropause, the Male Menopause

In females, this occurrence is known as menopause. The male counterpart to this is known as Andropause. Male levels of sexual hormones start to gradually decline when they enter their 4^th or 5^th decades of life. There are some men who start to undergo this change much earlier, such as in their 3^rd decade of life.

What is the Cause of Andropause?

Andropause occurs when a man’s testosterone level is low. Testosterone is a hormone produced by the testes. It Is the male hormone responsible for a male’s physical characteristics such as sexual drive (libido), facial and body hair, deep voice, muscle mass, and competitive personality.

The onset of Andropause can occur earlier. This can be attributed to multiple factors, including genetic cases, lifestyle and certain medical conditions. Common chronic medical conditions such as metabolic conditions (i.e. obesity, hypertension, diabetes, raised cholesterol) are associated with earlier Andropause. Andropause can also occur in patients with testicular cancer, or patients who are taking medication to lower their testosterone as part of treatment of prostate cancer.

What are the Symptoms of Andropause?

• Low libido (low sex drive)
• Low energy level, feeling perpetual lethargy
• Unexplained low mood and depression
• Unable to concentrate
• Mood swings, behavioral changes
• Erectile dysfunction and problems during ejaculation
• Reduction in muscle mass
• Reduction in bone density
• Developing breasts (gynecomastia)
• Loss of body and facial hair

What do I expect when I see my doctor?

Your doctor will take relevant medical histories, understanding your concerns and expectations, and perform general physical examination. Your doctor will offer you blood tests such as blood sugar counts, cholesterol levels, kidney, liver and cell count blood tests. This is to screen for chronic medical conditions. Hormonal blood tests will be offered as well.  Diagnosis will be based on physical examination and hormonal blood tests to determine if the patient has low testosterone levels.

What are the treatment options of Andropause?

While testosterone replacement is the backbone treatment for Andropause, this condition should be managed in a holistic manner, targeting different psychosocial and medical aspect of the associated condition.

Few important aspects to focus on:

• Managing any long term concurrent chronic metabolic conditions
• Encouraging a healthy lifestyle, moderating alcohol consumption, quitting smoking, exercising regularly to maintain a good body weight
• Addressing other sexual health problems such as erectile dysfunction, ejaculation problems, testosterone deficiency symptoms
• Considering mood management through seeing a psychologist

As mentioned, treatment of Andropause largely revolves on testosterone replacement in the form of

• Testosterone gel
• They are easy to use, and should be applied every morning over the shoulders or upper arms.
• You are advised not to shower or swim for at least 5 hours after application to ensure absorption of gel into the body.
• Importantly, avoid coming near a naked flame or smoking as testosterone gel is flammable.
• Ensure that you wash your hands after application and cover the application site with clothes.
• Avoid people around you from touching the gel, especially women and children. This may cause unwanted hair growth and more aggressive behaviors in those who has contact with the gel.
• Testosterone pills
• This is an oral medication to be taken 2-3 times a day. In general, only a short treatment cycle is recommended as prolonged use of oral testosterone can lead to heart diseases, raised cholesterol level or even stroke.
• Testosterone injections
• Effects are instantaneous and a patient will only need to repeat the injection every 3 months. However, the injection may be painful to some.

Is Testosterone Replacement Safe?

Common side effects of testosterone replacement

• Increase risks of heart disease, stroke, raised cholesterol and liver disease
• Increase stickiness of blood and red blood cell concentration, leading to  increased risk of blood clotting
• Causes enlarged prostate
• Acne

As testosterone replacement can promote and increase the growth of prostate tissue, the treatment may not be suitable in men with prostate cancer or if they have an enlarged prostate.

When you are on testosterone replacement, it is important to follow up regularly with your doctor. Your doctor will monitor your condition closely and conduct frequent blood tests to watch for side effects.