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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Cow’s milk allergy can occur in anyone, including adults. However, it is a condition that more commonly affects the paediatric population. Diagnosis for cow’s milk allergy can be difficult and can often be confused with cow’s milk/ lactose intolerance.
In this article, we’ll highlight the differences and similarities between milk allergies and milk intolerance, the underlying causes of a cow’s milk allergy, common questions that one may encounter, and practical ways to deal with cow’s milk allergy.
No, a milk allergy and milk/lactose intolerance are different.
Milk allergy is an immune response to milk proteins. The body mistakenly identifies these proteins as harmful, producing specific antibodies against it. Upon repeated exposure to these proteins, the immune system triggers an exaggerated antibody response, leading to a cascade of chemical immune reactions, which manifest as signs and symptoms of milk allergy.
A lactose intolerance occurs due to the lack of the enzyme lactase, which is needed to digest lactose — a sugar found in milk. A milk protein intolerance is a non-allergic sensitivity to milk proteins, such as casein or whey.
In milk/lactose intolerance, one develops unpleasant gastrointestinal symptoms when they are unable to digest lactose effectively due to reduced amount of lactase.
The poorly digested lactose in the gut is subsequently being fermented by gut bacteria causing uncomfortable irritable-bowel-syndrome-like symptoms such as:
Contrary to milk or lactose intolerance, an individual with a true milk allergy will not be able to tolerate any amount of milk, while in the case of lactose intolerance, one may still be able to tolerate a small amount of milk.
This type of allergy can occur very fast within seconds to minutes upon consumption of cow's milk. In IgE related allergy response, once the body is exposed to the 'allergen' protein, there will be an immediate trigger of a cascade of inflammatory allergic response and release of IgE antibodies, leading to an acute allergic reaction.
This type of allergy tends to occur slower over a period of hours up to 3 days after consumption of cow’s milk. The immune response tends to develop progressively over time, and usually this is non-IgE related, immune response can often drag on with symptoms for days to even weeks. One commonly confused the symptoms of delayed response with milk/lactose intolerance.
Milk allergy symptoms can occur within the first few months of human life (within the first 6 months of life), though less commonly symptoms can occur in adulthood. There is a spectrum of severity of milk allergy symptoms, making nailing the diagnosis difficult.
Within hours after consumption of milk. Symptoms include:
From hours to days after consumption of milk. Symptoms include:
An immediate, dangerous fulminant allergic response within seconds to minutes after consumption of milk. Symptoms include:
Cow’s milk is a rich source of nutrients for the body, with over 20 beneficial proteins.
In milk allergy, the body's immune system reacts to protein that is found in the milk, particularly in 2 types of proteins — casein and whey.
Casein protein is the main emulsifier in milk and it makes up 80% of the protein in cow’s milk and 20-60% of proteins in human milk. Casein is also found in high quantities in cheese, and can be used as a food additive/ emulsifier to stabilise processed food.
Whey protein is the left over from milk when it is coagulated during the formation of cheese. Whey protein makes up 20% of cow’s milk, and about 60% of human milk. Whey protein is made up of 2 major proteins known as alpha-lactalbumin, beta-lactoglobulin.
Whey protein is commonly seen in yoghurt and protein supplement (in building muscle mass). Whey protein can also be used as a food thickener.
Common foods with milk protein include:
Reading food labels is important to pick up any cow’s milk protein content. If you are eating out, beware of possible milk in the food content.
Extra caution should be taken if eating out in coffee shops, pizza shops and ice cream places. If in doubt, it is worth highlighting any history of food allergy or food restrictions to the restaurant staff.
A good history with a clear timeline of exposure to milk allergens and presentation of the allergic symptoms is suggestive of cow’s milk allergy. Nonetheless, in the practical world, this can be much more difficult as one may be exposed to other food substances or environmental allergens or symptoms can be confounded with underlying intolerance.
Allergy tests may not be foolproof either, but may facilitate the history of presenting complaints:
You are advised to discuss any concerning symptoms with your doctor so that they can provide guidance on which tests can be offered to you to evaluate your condition further.
As there are no antidotes for cow’s milk or food allergies, the treatment is by eliminating the culprit allergen — milk from the diet.
In situations when one has inadvertently consumed milk, medication such as antihistamine and steroid can reduce or abort allergic symptoms. In severe allergic response or anaphylaxis, one will require adrenaline injection or medical emergency to reverse the allergy.
As cow’s milk allergy is commonly seen in children, it is imperative to ensure the child still receives a healthy balanced diet and is taking supplements to replace the common nutrients that are found in milk.
Breastfeeding is encouraged especially if the infant has cow’s milk allergy.
As cow’s milk protein can be passed from mother who consumed it to the child through breast feeding, the mother should avoid food that contains cow’s milk protein if the infant has cow’s milk allergy.
Alternative options such as soy formula milk may not be useful as some children may also have soy protein allergy. Due to high protein allergy cross-reactivity, those with cow’s milk protein are usually not suitable to take goat’s milk as well.
Understanding and determining the allergic components in milk proteins can aid prudent food selections to avoid allergy.
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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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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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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.
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.
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.
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.
Genital itch symptoms can be broadly categorised into dermatological versus infectious/sexually transmitted disease STD-related causes.
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.
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:
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.
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.
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.
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.
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.
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 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:
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:
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 (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:
Patients with urinary tract infection can present with abnormal penile discharge and developing symptoms such as:
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.
Abnormal penile discharge can be due to underlying sexually transmitted infections (STIs) .
Common STIs that can be associated with penile discharge include:
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.
You are advised to seek advice from your doctor if you notice penile discharge when you are not:
OR if you are experiencing:
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.
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 4th or 5th decades of life. There are some men who start to undergo this change much earlier, such as in their 3rd decade of life.
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.
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.
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:
As mentioned, treatment of Andropause largely revolves on testosterone replacement in the form of
Common side effects of testosterone replacement
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.