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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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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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A noticeable lump over the groin is usually a symptom that most people will be concerned of. The left and right groins are the area just above the top of the legs, with creases noted over the area that the legs join the rest of the body. The groins house numerous lymphatic nodes and they are generally not palpable. There are also inguinal canals on both groins to allow internal visceral tissues such as ligament to pass through the abdomen to the genital region.
The two most common causes of lumps in the groin are swollen lymph nodes and hernia. Other causes of groin lumps include underlying dermatological condition, cancer, blood vessels disorder such as aneurysm.
In this article we explore the common causes of palpable lumps over the groin, highlight the differentials of possible STD infections and common non-STD causes of groin lump and the importance of reaching out to your health care providers for evaluation.
Both our groins are full of lymphatic nodes and drainage. These are network vessels and circulations that collects lymph fluid (made up of white cells) to clear and fight against any external pathogens or infections. Occasionally, when the body or immune system is filtering and fighting against external pathogens, the lymph nodes nearby to the source of infection will be swollen and tender. The presentation of lumpy painful lymph nodes over the groin can be the first sign of the body trying to inform us that the body is having a brewing infection including STDs. STDs that can cause both local genital symptoms or general symptoms, such as:
STDs that can be associated with lymph node swelling include:
The important caveat here, although STDs can present with abnormal additional genito-urinary symptoms, having no symptoms does not rule out STDs. The only way to confirm or rule out presence or absence of STDs is via testings.
One can still have STDs, and remain indolent and asymptomatic or present with just a lymph node lump felt over the groin.
Do consider reaching out to your health care providers if you have palpable lymph nodes over the groin and have potential exposure to STDs. Once the underlying infection or STDs are managed, the groin lymph node will eventually subside.
Skin STDs are usually due to direct skin-to-skin contact from the affected external party (partners) leading to direct inoculation and acquisition of the pathogens. This can lead to clinical presentation of unusual ‘lumps’ or ‘bumps’ over the genital or groin area.
| Skin STDs | Presentations |
| Human Papillomavirus (HPV) | Warts |
| Pox Virus | Molluscum Contagiosum lesions |
| Herpes Simplex Virus | Painful punch-out blisters and erosions |
| Syphilis | Painless ulcer (Chancre) |
| Scabies/ Lice | Itchy red eczema-like patch/areas, Possible moving mites |
| Monkey Pox | Unusual, never seen-before: Painful, deep-seated ulcers with a ‘dot’ on the top of the lesions |
As STDs has potential to spread to other sexual partner(s) and can be associated with long term comorbidities such as infertility, one should seek medical assistance for further evaluation and early treatment of STD groin lumps.
Not all lumps in groin are sexually related and sexually transmissible. Lumps in groin can be due to common skin conditions such as a cyst or a boil or an inflamed hair follicle in the case of folliculitis. Medical treatment may be required if the lump(s) causes inconveniences, pain, irritation, is infected or purely treated for aesthetic reasons.
Lumps in the groin can also be a hernia. Hernia is the medical condition that occurs when the internal organs or body viscera are protruded through a weaken abdomen or groin. When hernia occurs, it can present as a lump seen over the groin. Hernias are usually painless and can be reduced/ tucked back into the body by lying down, changing body position. Nonetheless, it can get trapped and remained externally as a ‘lump’, causing pain, strangulation of the internal organs or even necrosis of the organs and may require surgery in severe cases.
Blood vessel structural causes such as aneurysm can present as a lump over the groin. When there is weakness on the blood vessel (artery) wall, the wall may bulge-out and present as a lump in the groin. The lump can be noticeable ‘pulsating’ when one place the finger over it. This can cause pain, bleeding or even can be dangerous.
Less commonly, yet imperative not to miss, lumps in groin can be due to underlying cancer, blood malignancies such as leukemia and lymphoma. One may have other constitutional symptoms such as weight loss, feeling poorly, fever and etc. You should always get your ‘lump’ checked with your healthcare providers.
Although some groin lump are benign and self-resolving, you are encouraged to seek medical attention to evaluate unusual lump when you first notice it.
Red-flags of requiring medical attention without further delay include:
Your doctor will obtain a relevant medical history. In the context of concern of possible STDs infection, your doctor may acquire personal sexual history. Your doctor will then perform a physical examination by palpating the lump over the groin.
Investigations will also be carried out, such as:
Treatment of lump on the groin depends on the underlying cause.
It is important to pick up common reversible causes such as infection including STDs as the infections are usually treatable or manageable with the right antibiotics or antiviral medication. Delaying or ignoring the signs and symptoms may lead to future health complications such as scarring and infertility.
Operation may be required if there is concern of cysts, hernia, aneurysm or other structural causes. Chemo or radiotherapy may be required if there is concern of underlying malignancy/ blood disorders.
With the advancement of medical care in Singapore, HIV (human immunodeficiency virus) infection is no longer seen as a ‘death sentence’. Clinically effective treatment has shown that one with a HIV infection is able to have a near normal life expectancy as someone without HIV infection. The outlook of HIV infection has transformed from being a terminal illness to a chronic medical condition that is controllable.
To achieve this, those who are found to be HIV infected are advised to start on anti-retroviral medication as soon as possible to decelerate, control the progression of disease, and improve long term quality of life of an infected person.
Dermatological manifestation of HIV infection is unique at various stages of HIV. Understanding possible association of certain dermatological conditions can facilitate picking up undiagnosed HIV, hence allowing commencement of anti-retroviral medication without further delay.
In this article, we want to highlight the common skin diseases that can be associated with people living with HIV. We want to encourage public social awareness and we encourage those who are at risk to consider HIV testing.
During acute HIV infection, when the body sero-converts HIV virus, one can present with a body eruption. It can be a red rash over the body that is generalised yet faint, subtle in appearance, and it is very easily missed. One may present concurrently with fever, flu symptoms or even unexplained lymph nodes on the body.
Picking up HIV infection at this stage is very beneficial as this allows early treatment of HIV and reduce the chance of progressive transmission of disease. One should consider HIV testing if there is concern of exposure to HIV infection.
As its name suggests, HIV is an infection associated with progressive deficit of the host’s immune system, hence predisposing the infected person with various skin conditions, such as infections and even cancer.
Furthermore, anti-retroviral medication used for HIV management is commonly known to be associated with skin allergy and reactions.
One living with HIV infection are predispose to fungal infection due to the constant immunocompromised state of the condition. Commonly, thrush (candidiasis), skin (tinea infections) or nail fungal infection can occur any part of the body areas. The fungal infection tends to be more aggressive and resistant to treatment in comparison with those without fungal infection.
When the HIV infection progresses with dwindling of the immune system of the infected person, one can develop fungal opportunistic infections that involve uncommon widespread skin appearance, mucosal (oral/ genital involvement) or in severe cases even disseminate and affect the blood stream, internal organs such as the lungs, liver etc.
Living with HIV increases a person’s risk of developing skin-related cancers due to impairment of the immune system. Skin cancers such as melanoma, basal cell carcinomas or squamous cells carcinoma can occur more rapidly in patients with HIV. Skin related lymphomas, Kaposi sarcoma can be seen associated with HIV patients.
Certain skin presentations tend to occur in advanced or severe compromised immune system state in HIV or AIDS. Picking up these conditions should warrant a screening for HIV.
These are some of the skin conditions that are associated with severe HIV infections/AIDS and will require a trained health care worker or further biopsy skin tests to confirm the diagnosis. Nonetheless, if there is any doubt or concern of a person’s skin condition, it is always advisable to seek medical advice and if need, consider HIV testing.
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.
References:
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.
In this article, we explore the difficulties encountered in delivering adequate cervical cancer screening and HPV preventive care to patients. The article also aims to debunk some of the common misconceptions about HPV, cervical cancer, and HPV vaccination. It is written to increase awareness of the importance of proactive measures in screening and preventing HPV infection and HPV-related cancers.
Cervical cancer is a preventable medical condition, yet hitherto remains the 10th most common cancer affecting females in Singapore. We now understand cervical cancer is due to a chronic infection of the cervical cells from human papillomavirus (HPV). While there are over 150 strains of HPV, high-risk HPV that can be associated with cancer includes HPV type 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68.
Through proper regular screening, early detection, and treatment of pre-cancerous stages of cervical cancer, this is a type of cancer that we can avoid. HPV vaccinations have proven effective by more than 90% in protecting against HPV infection and HPV-related cancers such as cervical cancer.
HPV vaccination is encouraged and offered to BOTH women and men from the age of 9 to 45 years old.
Following the introduction of the Cervical Screen Singapore programme in 2004, there had been a steady initial decline in the incidence of cervical cancer up until 2015, when the incidence of cervical cancer plateaued. Unfortunately, in recent years, there has been evidence of a possible rise in cervical cancer incidence.
In an attempt to eliminate cervical cancer by 2030, the World Health Organization (WHO) advocates a target goal of 90-70-90 where:
Currently, our local cervical cancer screening rate is only 48%, way below our national target rate of 70%.
Local awareness of cervical cancer screening and prevention in the younger adult group (age 25-29) is only 76.5%, while awareness is better at 91% in the older adult group (age 30-69).
The poor uptake of pap smear and HPV testing is multifactorial, involving the obstacles faced by patients, health care providers, and the health system as a whole. In this article, we focus mainly on issues faced by patients.
Three key points that will determine whether a patient will opt for the screening test:
Misinformation about HPV infection and cervical cancer is common. Although the majority of women have heard of a pap smear, the purpose of the test and the screening frequency of the tests remain uncertain to most patients. Patients also may deem screening against cervical cancer unnecessary as they ‘feel fine’, asymptomatic, or feel the test is not required due to ‘lack of sexual activity’.
Furthermore, the uptake of cervical cancer screening tests is correlated to a person’s educational background, personal beliefs, and cultural barriers. Patients tend to confuse HPV with other STDs (such as chlamydia, gonorrhoea, HIV, etc) and may view HPV testing as taboo. Additionally, one may have the wrong impression that HPV infection only occurs in a person who is promiscuous in their sexual habits. The stigma associated with HPV infection can dissuade a person from getting screened for cervical cancer.
Reluctance to get cervical cancer screening is often due to fear, embarrassment, and potential discomfort from the procedure. As cervical cancer screening is usually performed by health care providers involving examination of a female’s genital region, this can be a turn-off for females to undergo pap smear or HPV testing.
Other reasons for poor uptake of cervical cancer screening include the financial burden of regular medical screening, missed appointments, unable to find time for screening, and generally uninterested in screening.
The lack of HPV vaccination uptakes can be multifactorial. A few common reasons include:
The move towards better uptake of HPV vaccination and cervical cancer screening will require concerted effort from all parties, including the health care system, the government and legislation, the allocation and availability of resources, and the participation of patients and the community.
As a community and as a patient, we can each play our part as below:
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.
A sudden noticeable swelling over the vulva region is always a cause for concern. Furthermore, painful swelling in the vulva region is a particularly concerning symptom that warrants medical evaluation. Often the question arises “Doctor, is this an STD (Sexually Transmitted Disease)?”
Due to the acute presentation and discomfort of a Bartholin’s cyst, people tend to turn up in the consultation room with concerns of possible infection and seeking treatment. In this article, we explore this medical condition, the possible triggers, and how we can manage it.
Over the lining opening of the vulva (external vagina), there are small glands known as the Bartholin’s glands. These glands serve to produce healthy fluid to lubricate your vagina. However, the opening of the gland can develop blockages, leading to the accumulation of fluid in the gland and the formation of a cyst. Bartholin’s cysts are usually painless, but they can be palpable and swollen over the opening of the vagina.
Occasionally, Bartholin’s cysts can become infected with bacteria, leading to a painful abscess that requires medical attention.
Bartholin’s cyst or infection commonly affects women of reproductive age. The incidence decreases once a woman reaches menopausal age. Bartholin’s cyst cases make up approximately 2% of gynaecological cases seen annually.
Bartholin’s cysts generally do not cause symptoms as they tend to be small. However, when it gets infected, one may experience the following:
The actual cause of Bartholin’s gland becoming blocked is still unclear. Bartholin’s cysts tend to occur during reproductive years and become less common after menopause. A Bartholin’s gland can potentially get blocked due to:
It can be useful to evaluate the possible triggers with your trusted healthcare providers. Modifiable triggers, such as lifestyle that irritates the vulva, can be avoided, and infection can be treated to prevent the further occurrence of Bartholin’s cyst.
Risk factors for developing Bartholin’s cysts include:
Although the majority of the cause of Bartholin’s cysts or abscesses remains unknown, there is an association of Bartholin’s cysts/abscesses with sexually transmitted infections (STIs), particularly chlamydia and gonorrhoea. It may be worthwhile to consider screening for bacterial STIs if there is evidence of recurring Bartholin’s cyst infections and if you are sexually active.
Non-STI-related bacteria such as E coli (bacteria from the colon/anorectal region), Streptococcus pneumoniae, and Haemophilus influenza are pathogens that can potentially block the Bartholin’s glands and lead to infection and abscess formation.
If the STI-related bacteria are not treated, Bartholin’s infection may not recover. In the long run, one may risk developing chronic vaginitis, pelvic inflammatory disease (PID), and infertility, and one can spread the infection to one's partner(s). Thankfully, infectious Bartholin’s cysts are treatable with proper antibiotics.
If you are concerned about a Bartholin’s cyst, reach out to your healthcare provider. Your doctor will offer a physical examination involving the vaginal area to look for any abnormal lumps and infections over the area. In certain circumstances where there are concerns of infection, your doctor may offer swab tests to send off fluid discharge samples to the laboratory for further testing.
If the infected Bartholin’s cyst is left untreated, there is a possibility that the cyst may burst spontaneously over time, causing pain and discomfort. Sometimes, the infected cyst may progress and become an abscess (a pocket collection of pus); one can be unwell with fever and vulva pain. In such circumstances, oral treatment may be insufficient, and surgery may be required to manage the symptoms.
Small and painless Bartholin’s cysts do not require treatment. Nonetheless, if the cyst becomes painful and infected, medical treatment is advised.
Treatment for a Bartholin’s cyst usually involves:
Avoid possible triggers such as repeated friction or trauma to the vulva region. If this is a risk factor in your circumstances, consider a regular STI screen. In the case of a mild Bartholin’s cyst without evidence of infection, you can consider a regular Sitz bath method to allow spontaneous resolution of symptoms.
Genital itch is one of the most common symptoms we are likely to encounter at some point in our lives. It can be debilitating and significantly limit a person’s quality of life. Despite the inconvenience, we often choose to monitor the itch and silently wish it would resolve spontaneously over time. What if the issue keeps recurring? What if the itch may hint at an underlying condition, such as an STD?
In this article, we strive to guide readers to understand genital itch and delineate the differences between a vaginal yeast infection and herpes simplex viral infection.
Vaginal yeast infection (vulvovaginal candidiasis) is a common female-related vaginal infection due to an overgrowth of fungus (Candida spp) in the vaginal cavity. Candida is a common and healthy commensal microbe that can be found in the vagina.
Nonetheless, when the amount of candida is excessive, it can invade the vagina mucosal layer, causing uncomfortable vaginal symptoms such as vaginal itch and an abnormal whitish-yellow curdly vaginal discharge.
Herpes is a sexually transmitted disease caused by the herpes simplex virus (HSV). Symptoms usually include itchy and painful rashes or blisters on the affected skin.
There are two types of HSV virus – HSV-1 and HSV-2. Conventionally, HSV-1 is associated with oral cold sores, while HSV-2 is associated with genital cold sores. With the evolution of the human race and changes in sexual orientation, the viral strain of HSV no longer determines the location of a cold sore, i.e. HSV-1 can cause genital cold sore, and it no longer strictly causes oral cold sore. This applies to HSV-2 as well; HSV-2 can cause both oral and genital cold sores- depending on the area of exposure during sexual intercourse.
Herpes virus can be passed on through direct skin-to-skin contact or skin-to-secretion of an affected person. Due to the mode of transmission, sexual intercourse (including oral, vaginal, and anal intercourse) are possible ways of transmitting herpes virus infection. It is worth noting that many people can be asymptomatic of herpes (i.e. no rash or blisters). Yet, they are still shredding the virus unknowingly to their sexual partners, triggering a herpes viral infection on their partner.
Vaginal yeast infection is not an STD. Interestingly, vaginal yeast infection can be triggered during sexual physical activities due to the disturbances of the vaginal floral pH and microbes. Hence, vaginal yeast infection symptoms can occur following a sexual encounter, confusing most people that it may be an STD.
Unfortunately, you cannot tell by seeing or looking at partners whether they have herpes or STDs. The only safe and reliable way is through appropriate STD testings.
| Symptoms | Vaginal Yeast Infection | Herpes Simplex Viral Infection |
| Itching | Yes | Yes |
| Vulva/Genital swelling | Yes | Yes |
| Burning sensation | Yes | Yes |
| Pain and irritation Sensation | Yes | Yes |
| Abnormal urinary symptoms | Sometimes | Sometimes |
| Recurring symptoms | Yes | Yes, when the immune system is weak |
| Surrounding Skin Rash | Sometimes | Yes |
| Blisters and shallow ulcers over the genital skin | Usually no, though in severe yeast infection, the skin integrity can be broken and raw secondary from scratching and rubbing | Yes |
| Vaginal discharge | Yes, Curdly, Cottage-Cheese-like discharge | May have watery discharge or normal discharge |
| Vaginal Odour | Can smell of yeast/bread smell | None |
| Painful intercourse | Yes | Yes |
| Fever | No | Sometimes |
| Lymph nodes swelling | No | Sometimes |
As both conditions may have overlapped symptoms, you are encouraged to see your healthcare providers for testing to differentiate the two conditions, as treatment options are completely different for both conditions. Furthermore, herpes infection is a type of STD that can be easily spread to your partner if it is not managed appropriately.
Yes, you can test for both conditions.
If a herpes viral infection is suspected, your doctor may discuss with you the screening option of PCR swab tests of the rash/blisters or serum blood tests to screen for herpes antibodies.
For vaginal yeast infection, one can consider a fungal vaginal swab test and culture, which can confirm the suspected diagnosis.
Both screening tests for herpes and yeast infection are relatively noninvasive and can be done in an outpatient setting with your trusted health care providers. Testing will ensure the right diagnosis is clenched down and the right treatment delivered without delay.
Unfortunately, there is no ‘cure’ for herpes viral infection. Nonetheless, even though the disease is not curable, there are effective medications to manage and control the symptoms.
Antiviral medications such as acyclovir, valacyclovir, and famciclovir can lower the virus in the body, manage flare-ups, and reduce the risk of transmission to others.
You are advised to discuss your symptoms/ frequency with your doctor. Your doctor will then advise you accordingly on the dosage and duration of your antiviral medication.
Yeast infection can be treated with antifungal medications. Anti-fungal treatment options can range from vaginal suppositories, oral tablets, topical cream or even anti-fungal wash.
In those cases of recurring yeast infection, your doctor will discuss with you on possible lifestyle triggers to avoid triggers, if possible, in preventing further yeast infection. In more recalcitrant cases, your doctor may discuss antifungal suppressive therapy to minimise the frequency of yeast infection flare-ups.
No, it may not be a good idea to continue your bedroom activities when you are symptomatic. It can be uncomfortable, and you may experience pain during intercourse when your underlying infection has yet to recover.
In the case of yeast infection, although it is not an STD, occasionally, your partner may experience transient urinary abnormal symptoms such as itching or red rash over the genital region.
If you are actively having a herpes infection, this can be passed on to your partner through skin-to-skin transmission or body fluid transmission. You are advised to get checked. Once the diagnosis is confirmed, antiviral medication can be delivered without further delay to prevent the spreading of symptoms to your partner.
If you are concerned about your genital symptoms and have concerns of exposure to STDs, do reach out to your healthcare providers early for further health advice and testing.
Obesity has become a common global public health concern that affects both children and adults for the past few decades.
The incidence of obesity is also on the rise in Singapore. According to the National Population Health Survey 2021/2022, obesity affects 13.1% of males and 10.2% of females [1]. The causes of excessive weight gain tend to be multifactorial, a combination of genetic predisposition, physical activity levels, sleeping patterns, and eating habits.
In this article, we explore the effect of obesity on sexual health and discuss medical options that can be offered to address this rising concern.
Research has shown that the physiological state of an obese person can impact a person’s sexual function [2].
Females
In obese women, a normal menstrual-ovulation cycle can be affected due to a persistent hyperandrogenic state – a body physiological state where one has excessive male hormones [3]. The level of sex-hormone binding globulin (SHBG) is lesser, while male hormones, such as testosterone, dihydrotestosterone, and androstenediol, can be much higher. Obesity is also associated with clinical symptoms such as menstrual abnormalities, reduced libido, and urinary incontinence in females as an effect of hormonal dysregulation.
Males
Ironically, in men, obesity is associated with reduced testosterone due to the aromatisation of excessive fat (adipose) tissues into estradiol (a type of female hormone) [4]. The tilt of hormonal equilibrium causes men with obesity to have reduced libido and erectile dysfunction.
Both females and males
As the body of a person with obesity is always in a ‘physiological inflammatory state’, the oxidative stress can impair both sperm and ovum qualities [5], leading further to infertility issues [6].
A person with obesity has a higher risk of cardiovascular chronic disease [7], including diabetes [8].
In poorly controlled diabetes, blood vessels and nerve endings can be affected, leading to poor circulation of the genital region. This can present itself with sexual dysfunction symptoms such as physical disability such as the inability to erect in males and the inability to enjoy sexual experiences in both males and females.
Over time, excessive weight bearing can be associated with general physical limitation, chronic fatigue, and predisposition to arthritic symptoms such as joint aches and pain [9].
Obesity is also known to correlate with an increased risk of cardiovascular and metabolic disorders. Obesity increases the chance of developing heart disease, hypertension, high cholesterol, type-2 diabetes, and even cancers [10].
Side effects of medications from chronic conditions, such as anti-hypertensives [11] and diabetes medications [12], can lead to sexual dysfunction and reduced libido, hence indirectly affecting a person’s sexual well-being.
Clinical studies have shown the correlation between obesity and mental health disorders such as anxiety and depression [13]. These mood disorders can have a negative impact on a person’s sexual relationship with others. One can be disinterested in sexual activities, having poor libido and unable to enjoy their sexual life.
One might also have lower self-esteem and be embarrassed about their body image, hence having lower sexual confidence and dissatisfaction with their sexual life.
Weight management should be a holistic approach. Medical management of weight loss with prescription drugs should be followed by a targeted, realistic eating plan and consistent, achievable physical activities to achieve the target weight and maintain that ideal weight.
Healthy eating
Make clever decisions when choosing food options and quantity to ensure balanced nutrients are acquired yet not overeating.
Physical activities
Regular physical activity helps lower weight and achieve a healthy weight. Staying motivated and consistent with your physical regimen is key to achieving and maintaining your target weight in the long run.
Being creative and engaging in physical activities are useful to stay motivated and consistent with your exercise.
Most people struggle with long-term weight loss. Many may have tried to lose weight, only to regain it as time passed. Medical treatment of weight management can address this concern effectively and safely.
Weight Loss Injections
Under the guidance of your prescribing medical practitioner, these weight loss injections can be titrated safely and effectively to reduce a person’s weight. Clinical studies over three years in patients who are on the medication show that 56% of patients can lose significant weight at the 1-year mark of taking the medication [14].
What have I learnt today?
If you have concerns about your weight, you are encouraged to reach out to your trusted physician to learn more about the medical management of weight control.
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.