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Ureaplasma spp is a type of bacteria under the bacteria family of mycoplasma species. There are over 100 types of mycoplasma bacteria species; though about 17 types of mycoplasma can be found in human beings, most of the bacteria are harmless. Mycoplasma bacteria tend to thrive around mucosal regions such as the respiratory or the urogenital tracts. In the case of ureaplasma spp, the bacteria can be found in the urogenital system.
Ureaplasma urealyticum and ureaplasma parvum are two subtypes of ureaplasma spp that one may notice on their medical checkup test results. Occasionally, the presence of the bacteria can cause anxiety and strains in relationships. In this article, we explore further the bacteria, the implications of having this bacteria in our body, and the role of testing and treating this bacteria.
Bacterial colonisation is the establishment and physical growth of bacteria as a local community [1]. In the context of genitalia, ureaplasma spp can behave as a colony, making their constant presence over the mucosal linings over the vagina of a female or the urethra linings of a male. As a colony, ureaplasma spp co-exists with other background mucosal bacteria and does not cause harm or symptoms.
In some circumstances, ureaplasma spp can become infectious and more harmful—they become pathogens. When pathogenic, ureaplasma spp can invade the mucosal lining of the urogenital system, causing inflammation and abnormal localised inflammatory symptoms. Although Ureaplasma spp generally has low pathogenicity and virulence, in a host (human) with a weakened immune system, one can present with infective symptoms [2].
It is imperative to note that a healthy, sexually active person (both female and male) can have ureaplasma bacteria colonisation in the urogenital region, and this is unlikely to be eradicated through repeated courses of antimicrobials [3]. Probiotics may be beneficial in encouraging the growth of good bacteria in the urogenital region, competing and inhibiting the growth of bacteria such as Ureaplasma spp. Abstinence from sexual partners may prevent recurrence once the bacteria has been eradicated.
Ureaplasma spp can be passed on during sexual intercourse in both males and females. It can be passed on through the body fluid- be it- vaginal fluid, semen, saliva, or anal fluid. Less commonly, one can also transmit ureaplasma spp to the offspring during pregnancy and childbirth if the pregnant mother is having infective symptoms.
The term 'STD' or sexually transmitted disease, as its name has suggested, denotes any medical infectious disease that can be passed through sexual contact. Hence, if ureaplasma spp infection is passed between partners, the bacteria can also be considered a type of STD. The caveat is that ureaplasma spp can be a long-term colony bacteria in a person, so just 'having ureaplasma bacteria' may not necessarily mean being positive for STD. In simple layman's language, having ureaplasma spp bacteria in a person's body does not equate to being promiscuous.
When ureaplasma spp bacteria become pathogenic, it can be associated with urogenital infections.
In men, ureaplasma spp can be associated with a condition known as non-gonococcal urethritis (NGU) [4]. Due to chronic invasion and inflammation of the ureaplasma spp bacteria, one can present with a burning or stinging sensation or even an itch over the urethral region. NGU is important to treat to reduce the risk of further infection of the urogenital region, with possible inflammation of the testicles. Medical literature has shown that ureaplasma spp can be associated with poorer sperm quality and lower sperm count [5].
In women, those with ureaplasma spp infection have a higher risk of acquiring other vaginal infections; this includes infections such as bacterial vaginosis [6]. A person with ureaplasma spp infection can experience persistent excessive vaginal discharge with associated unpleasant itch and odour. In more severe presentations, one can even have vaginal pain leading to reduced quality of life. In more severe circumstances, ureaplasma spp bacterial infection can be associated with cervicitis (inflammation of the cervix) or even pelvic inflammatory disease (PID), leading to chronic lower abdomen/pelvic pain and infertility disorders.
In pregnant women, ureaplasma spp active infection increases the risk of miscarriage, early pre-term labour, or serious conditions such as chorioamnionitis (infection of the amniotic fluid- the fluid and membrane enveloping the embryo) [7].
Abnormal urogenital symptoms include:
Seek medical attention if you have any of the above abnormal symptoms to evaluate and screen for any urogenital infection and receive appropriate treatment without further delay.
When one is experiencing abnormal genito-urine abnormal symptoms or if there is a concern of exposure to ureaplasma spp, your doctor may offer you testing in the form of a urine test or vaginal swab (in females) to screen for the bacteria.
As ureaplasma spp can behave as a commensal or bacteria colony that 'do-no-harm' to the body, you do not need to regularly screen for the bacteria if you are well and asymptomatic. Screening for ureaplasma spp is advisable when a person has abnormal genito-urine symptoms or if a person has a persistent urogenital infection that is not recovering with treatment and time. This is a clinical decision and judgement that requires a careful discussion with your doctor on your clinical history and symptoms; your doctor will advise you further on whether you need to screen for this bacteria.
Antimicrobials are usually used to treat ureaplasma spp infection. Antibiotics are often used to treat ureaplasma spp infection. Following worldwide progressive antibiotic resistance, there are increasing cases of treatment failure, requiring repeated cycles of antibiotics/different groups of antibiotics. It is advisable to abstain from sexual activities until you have completed your treatment to reduce chances of re-infection to yourself and other sexual partners.
If a person is well, with no abnormal symptoms, yet with test results showing ureaplasma spp present, your doctor may discuss with you the possibility of the bacteria being a colony rather than an infectious pathogen. In those instances, antibiotics may not be required.
Urogenital probiotics may be beneficial in boosting the amount of good microbes in the uro-genitalia areas, competing and preventing the growth and development of ureaplasma spp/mycoplasma spp on the mucosal linings.
Human Papillomavirus (HPV) remains one of the most common sexually transmitted infections in the world. Based on statistics from the World Health Organization (WHO), 1 in 3 men are infected with HPV [1].
HPV screening and vaccination programmes are commonly health-highlighted among women. On the other hand, HPV checkups and vaccination in men are much less heard of. Having said that, men can be susceptible to HPV-related infections and HPV-related long-term health complications.
In this article, we attempt to shed further light on HPV infection in men and ways to protect and prevent men from HPV comorbidities.
HPV are viruses from the Papillomaviridae family. HPV viruses can affect the skin epithelial and membrane linings of the body – particularly the skin, genitals, and upper respiratory tract system. Hitherto, there are over 150 types of HPV, with around 15 types that are classified as higher risk and can be associated with cancers, including cervical cancers, vaginal cancers, and anal cancers [2].
Unlike women, following HPV infection, men may not develop immunity or antibodies against HPV. In other words, even if men have been exposed to HPV in the past, they may not be protected against future HPV infection. This makes men susceptible to reinfection of HPV if they are re-exposed to HPV throughout their lives, making them a reservoir of HPV infection to others.
Yes, just like women, men can get HPV infection. HPV can be passed on via direct skin-to-skin contact with infected skin or mucosal linings.
In the context of sexual health, HPV infection can be passed on in the following ways:
HPV infection can be without any symptoms, but this may be temporary. Persistent HPV infection in men can lead to the presentation of genital warts or even mucosal-lining-related cancers such as anal cancers.
HPV types 6 and 11 are known to be associated with over 90% of genital and anal warts [3]. These lesions are highly infectious to one’s sexual partner(s). Genital warts can persist for months or even years, even if left alone. With treatment, 30% of genital warts may still recur within four months [4].
High-risk HPV types 16 and 18 can cause chronic inflammation and, over time, abnormal skin changes, leading to the formation of cancer. We now know about 80% of anal cancers can be associated with HPV types 16 and 18 infections [5].
Signs and symptoms of genital warts in men include:
Unfortunately, there is currently no HPV test that is approved and validated to be used to screen for HPV in men. Diagnosis of active/persistent HPV infection in the form of genital warts can be detected by clinical visual review with your health care professional.
As such, men can even be asymptomatic when they are having HPV infections.
If you were exposed to the HPV virus and are asymptomatic, there is no treatment (as there is no validated test to screen for to begin with). There are no antibiotics, antivirals, or oral medications that have shown efficacy in getting rid of the virus. Thankfully, in most men (and women), the HPV virus can disappear spontaneously over time if one takes care of one’s immune system.
If you are experiencing active HPV symptoms such as genital warts – this is treatable.
If you are experiencing chronic HPV symptoms with associated genitalia HPV-related skin dysplasia/cancer, medical treatment is possible to manage the disease.
9-valent HPV vaccination is approved for men aged 9 to 45 years old in Singapore to prevent HPV infection and HPV-related cancers. Although HPV vaccination has yet to be part of the National Immunisation Schedule, the clinical benefits of the vaccine are telling over the years. In a recent Straits Times news article [6], doctors from the Society for Men’s Health Singapore urged the public to consider HPV vaccination in men due to the known positive benefits of the vaccine for public health [7].
We now know that the HPV vaccination is clinically proven to:
As smoking reduces a person’s immune system, a person who has an HPV infection generally has a slower recovery period to clear off HPV infection. A smoker with HPV infection also has a higher risk of developing HPV-related cancers [8].
Eczema, also known as atopic dermatitis, is a common chronic relapsing inflammatory skin condition that can affect any part of the body. This skin-itching disease is caused by a complex interaction between genetics and environmental factors. Patients with eczema tend to develop symptoms during early childhood.
Eczema symptoms predominantly relapse and recur; in some, the symptoms may continue into adulthood. Patients with eczema are associated with an inherent genetically impaired skin barrier, leading to increased susceptibility to environmental insults such as stress, allergies, soap and detergent, and infectious pathogens.
In this article, we want to understand the correlation between skin, the presence of eczema, and skin infections; in particular, are patients with eczema more prone to acquiring STDs?
The skin is the biggest organ in our body. Its primary function is to provide a physical barrier to protect the internal organs and body against the external environment. Unfortunately, in eczema, inborn cracks and defects in the skin’s epidermis layer result in weaker or ineffective skin protection against noxious environmental agents. Additionally, clinical studies have shown that patients with eczema have a significantly higher risk of contracting skin infections from bacteria, viruses, and fungi [1].
Staphylococcus aureus is one of the most common bacterial infections associated with eczema [2]. This bacteria can be found even on a normal skin surface and is usually harmless. However, in the case of eczema, the bacteria invade the fragile and defective epidermis of the skin, triggering an immune response and leading to a vicious cycle of eczema flare-ups and skin infections.
Fungus and mould are other common microbes that can be detected on healthy skin. They are generally environmental colonies that' do no harm’ to the human body. When a person has an eczema flare-up, the affected skin can be inflamed, broken, weepy, red, and raw. This can be a thriving ground for fungus and mould. The fungus has the potential to invade the eczematous skin, leading to skin infection.
You might be at risk of:
In severe eczema with generalised involvement, the skin surface appears dry, chappy, cracking, excoriated, oozing, and possibly bleeding. At this stage, the skin cannot fully function as a physical barrier against external bacteria and viruses.
HSV is an STD known to be associated with localised cold sores affecting the mouth or the genital region. In generalised eczema, one can develop a condition known as eczema herpeticum [3]. It is a medically serious condition, as one can be gravely ill with generalised extensive sores and blistering and flaring of eczema; some may even warrant hospitalisation to stabilise the condition. See your doctor to diagnose this condition early and receive antiviral medication and proper eczema care.
Viruses and mites, such as HPV, pox virus, and scabies mites, can inoculate the impaired skin layer in patients with eczema. This leads to the clinical presentation of warts and molluscum bumps. Although these skin infections are not generally life-threatening, they can be annoying. They can cause chronic itch and discomfort and are easily spread throughout the body and to other sexual partners if not treated.
You can be at risk of:
It is imperative to note that the skin and mucous membrane around the vulva in females and the scrotal/penile region in males are generally thinner and less robust than the skin over our soles or hands. Hence, with the chronic breakdown and inflammation of the skin over the genitals secondary to eczema, one is invariably predisposed to infections, including STDs.
Symptoms of STDs acquired via skin-to-skin contact tend to be more localised to the genitalia region. Nonetheless, as the viruses and the mites can spread, it is possible that the sores, warts, bumps, and scabies rash can be transmissible to other parts of the body. There is a theoretical risk (low risk) of syphilis if there is an open eczematous wound over the genital, though this is less common.
There are two main domains here in reducing the risk of contracting STDs.
Firstly, it is important to ensure the skin can function effectively as a barrier layer against external noxious agents, including STDs. This will help ensure good, effective, and consistent long-term management of underlying eczema. Manage your eczema in the following ways:
Secondly, to reduce the risk of contracting STDs, you should:
Lymphogranuloma Venereum (LGV) is a difficult medical condition for both patients and physicians to spot. First, it is less commonly heard of, and second, it is less commonly seen in clinical practice. Diagnosing Lymphogranuloma Venereum tends to be late, leading to the development of irreversible health complications.
This article aims to create awareness, leading to a higher degree of suspicion if there is an unusual presentation in the genital region.
Lymphogranuloma Venereum is an infectious medical condition that can present with ulcers over the genital region. It is a sexually transmitted disease that is caused by a bacteria known as Chlamydia trachomatis, serovars L1, L2, and L3. As its name suggests, it is transmitted through sexual contact, be it- vaginal, oral, or anal sexual intercourse.
Chlamydia trachomatis tends to present mild genital symptoms in an affected person. Common symptoms include mild to vague urinary pain and discomfort, genital itch, or abnormal vaginal discharge. In the case of Lymphogranuloma Venereum, the bacteria invades the mucosal skin tissues and regional lymph nodes, leading to the ulceration and inflammation of the affected lymph nodes.
Lymphogranuloma Venereum is caused by the bacteria Chlamydia trachomatis. Contrary to common variants of STD-chlamydia that affect and infect local mucosal surfaces such as the mouth or genital region, causing milder symptoms in the infected host, Lymphogranuloma Venereum is due to an invasive strain of chlamydia serovars L1,L2, and L3 that invades the lymphatic vessels, causing more detrimental effects in an infected person.
Lymphgoranuloma Venereum can appear as painless pimple-like lesions that, over time, turn into ulcer patches. It can be hard and sometimes mistaken for genital herpes or warts, as it can present with pus discharge or appear patchy/warty-like.
Over time,, as the infection spreads deeper from the skin to the lymph nodes, one will experience painful swelling of the lymph nodes over the genital area. Eventually, due to the chronic inflammation of the lymph nodes, the glands can rupture, leading to a swelling that bursts with pus flowing out. By then, one can develop systemic symptoms such as fever, chills, muscle aches, or feeling generally unwell.
Lymphogranuloma Venereum was first reported in 1833. It was considered rare before the year 2003. In 2004, following an outbreak of the disease in the Netherlands, the condition slowly started resurfacing. It has been reported more in industrialised countries such as the UK, Germany, France, Belgium, Italy, Switzerland, Sweden, the US, and Canada. There have also been reports in Asia.
It is a condition that can affect both females and males, though reports are more on male patients due to a more clear-cut presentation in men. As the clinical presentation is less distinct in females, female patients tend to present at a later stage of the disease with significant disease complications. There is a major association between Lymphogranuloma Venereum and HIV infection.
There are three stages of lymphogranuloma venereum. Unfortunately, infected people tend to seek medical aid during the later stages of the disease.
During the first phase of the disease, the infected person can present with a short-lived painless pimple, rash, or ulcer following 3-30 days of exposure to the bacteria. Under untrained eyes, this tends to be mistaken as genital herpes or even warts. The rash disappears spontaneously, so the infected person tends not to seek medical aid, with the wrong impression that the disease has recovered on its own.
The secondary phase of the infection tends to occur 2 to 6 weeks following the first stage. One will present with painful swelling over the groin area. This is due to the invasion of the bacteria to the regional lymph nodes around the groin. Eventually, the inflamed and swollen lymph nodes can burst or rupture, draining out pus and blood. There can be associated vague symptoms such as fever, chills, lower back pain, lower pelvic pain, abnormal discharge (vaginal or urethral), anal pain, change of bowel habits, having the unusual urge to pass motion, or even vomiting.
Over time, chronic untreated Lymphogranuloma Venereum infection can lead to complications of the affected anatomy due to chronic inflammation and scarring. One can develop an abscess, obstruction and rupturing lymph nodes, fistulae (abnormal connection or opening that connects organ or vessels), scarring and narrowing (strictures) of the anal and genital anatomy, elephantiasis of the genital region with genital irreversible deformities and infertility.
Lymphogranuloma Venereum is a difficult diagnosis, and unfortunately, it is commonly missed. Laboratory tests can detect it.
In cases where Lymphogranuloma Venereum is suspected, a full sexual health screening should be offered. This is due to the increased risk of multiple concurrent STD infections in the presence of Lymphogranuloma Venereum. Full STD testing should include anti-retroviral (HIV) testing, syphilis, gonorrhoea, Herpes, Hepatitis B, and Hepatitis C screening.
Lymhogranuloma Venereum is an important medical condition that needs to be picked up. If you have concerns about this condition or unusual symptoms in the genital area, you are encouraged to seek medical assistance with your doctor.
The goal of treatment is to eradicate the bacteria and prevent further tissue damage to the genital region.
As the medical condition is rare and uncommon to both patients and physicians, Lymphogranuloma Venereum can be mistaken for common STD, such as genital warts or herpes. If there is involvement of the infection over the anus or rectal region, one may even have confused the condition with gastroenteritis or inflammatory bowel disease such as ulcerative colitis.
If the medical condition is not treated, irreversible complications can set in. This includes the distortion of the affected anatomy. The lymph nodes affected can get obstructed, ruptured, or even die off (necrosis), leading to eventual scarring of the area with fibrous tissues, stricturing, fistulae, and elephantiasis of the genital region. The medical condition left untreated can also result in infertility.
You are advised to seek medical aid early if you have abnormal symptoms over the genitals or are concerned about exposure to STDs. In the case of Lymphogranuloma Venereum, early detection and early proper treatment are keys to avoiding irreversible complications.
Testosterone is an essential sex hormone in men. It is regulated by the brain and produced in the testes. Men start producing testosterone during their pubertal period, and the level tends to decline in their 30s and 40s. Testosterone is vital in the development and maintenance of a male's characteristics.
Testosterone deficiency affects 7% of males 50 years old and above, with cases increasing as they age. It occurs when the body is no longer able to produce a sufficient amount of testosterone hormone. Low testosterone can have a deleterious impact on a man's sexual well-being and general health, leading to a poor quality of life.
The incidence of low testosterone increases with age. Based on health screening studies conducted between 2007 and 2009, it is estimated that about 26% of men after the age of 45 in Singapore suffer from testosterone deficiency. The average lifespan of men in Singapore as of 2021 is 83 years old. This means that about 1 in 4 men may experience some degree of health co-morbidities from low testosterone throughout half of their remaining time on earth.
Testosterone is a vital hormone that regulates a person's metabolism. It utilises and produces lipids (fats), protein, and carbohydrates.
Most of us are aware that low testosterone can be associated with low sex drive and erectile dysfunction. We may not know that testosterone deficiency may affect other facets of a person’s physical well-being. A persistent low testosterone state can predispose the body to a constant ‘inflammatory’ state, leading to an increased risk of cardiovascular diseases.
Health issues such as high cholesterol, heart disease, stroke, insulin resistance, diabetes, hypertension, and obesity are more common in people with testosterone deficiency. There is also medical literature that reveals an increased incidence of sudden death in patients with low testosterone.
The various associated health implications with low testosterone suggest the intricate, essential, and complex role of this male sex hormone in all organs of our body.
Symptoms that can be associated with testosterone deficiency include:
If you have any of the above symptoms, you might be experiencing testosterone deficiency. You are encouraged to discuss your concerns with your doctor.
To understand the causes of low testosterone, we must know how this hormone is produced.
The brain, specifically the hypothalamus and pituitary gland, regulates the testes, which control the amount of testosterone released in the bloodstream. The hypothalamus produces a hormone known as gonadotropin-releasing hormone (GnRH) to encourage the pituitary gland to produce luteinising hormone (LH), which in turn regulates the testicles to produce testosterone.
Low testosterone can be secondary to any disruption of the hypothalamus-pituitary gland-testicles axis.
Testosterone generally declines as we age, and this is a physiological progression in health. However, there are other causes associated with low testosterone.
Causes of low testosterone include:
Your healthcare provider can guide you through the possible causes of low testosterone and recommend targeted tests based on your symptoms and past medical history.
Testosterone levels can be evaluated through a blood test. This is commonly done together with other sexual hormone levels, such as brain and testicular hormones, as well for underlying endocrine abnormalities. Depending on individual symptoms and concerns, your doctor may also advise further testing to evaluate the function and structure of the respective organs.
Low testosterone levels are usually replaced with hormonal medication in various forms. Currently, in the market, testosterone medications are available in the form of oral, injections, and a gel etc.
Speak to your doctor about which form of testosterone replacement option is more suitable for you and your lifestyle.
Common side effects of testosterone replacement include:
Testosterone replacement may not be suitable for all patients, in particular in those with a history of cancers such as prostate and breast cancers, a history of blood clotting disease, heart failure, or severe untreated obstructive sleep apnoea.
Testosterone replacement is generally safe under the strict titration and follow-up guidance of your doctor, though you should always consult your doctor before starting testosterone replacement. The risks and benefits of the treatment should be discussed prior to beginning the hormonal replacement. Regular follow-up and blood tests are encouraged during testosterone replacement.
Low testosterone with long-term testosterone replacement therapy…
Gonorrhoea is a common type of Sexually Transmitted Infections (STI) that can infect the genitals, rectum, and pharynx (throat) of both females and males. Gonorrhoea remains Singapore's top three main bacterial STIs, affecting 33.4 per 100,000 populations in 2016. It is caused by a bacteria known as Neisseria gonorrhoea. As the name suggests, gonorrhoea is spread through intercourse- vaginal, oral, or anal penetration. Less commonly, gonorrhoea infection can be passed on from mother to child from an infected pregnant mother to the baby.
Common symptoms of gonorrhoea in women include abnormal vaginal discharge, abnormal bleeding in between periods, and painful urination. In men, gonorrhoea may present with abnormal whitish to yellow/green urethral discharge, painful urination, or even painful testicles. In those with infections over the anus or the throat, one can experience anal itch or pain, discharge and bleeding from the anus, sore throat or neck, and painful lymph nodes.
Occasionally, one may have no symptoms when they are contracted with gonorrhoea. That does not mean they are safe from long-term health complications. In fact, in an asymptomatic person, there can be a delay in diagnosis and seeking of treatment, leading to irreversible complications from the infection, such as infertility, chronic pelvic inflammation, and pain.
Over the recent years, there have been increasing sporadic cases of treatment failure with current antibiotics. (The Current CDC health guideline suggests dual antibiotic treatment for gonorrhoea infection.) In 2018, in the UK, there were reports of repeated failures in the treatment of Neisseria gonorrhoea, requiring up to four antibiotics to eradicate the infection. Treatment failure of gonorrhoea tends to be seen in infections associated with the pharynx. This reflects the progressive emergence of multi-drug-resistant Neisseria gonorrhoea infection.
The term super gonorrhoea came about during the last few years when multiple antibiotic-resistant cases of gonorrhoea were reported in several countries, including the United Kingdom, the United States, France, Spain, Japan, and others.
The treatment of bacterial STIs such as gonorrhoea has changed over the decades due to progressive resistance to various strong antibiotics, including penicillin, sulphonamides, macrolides (such as azithromycin), fluoroquinolones (such as ciprofloxacin), and tetracycline. The current recommended treatment for gonorrhoea is a dual antibiotic regimen with ceftriaxone and azithromycin.
In super gonorrhoea, the bacteria 'outsmart' the currently recommended antibiotics, remain thriving, and tend to continue transmitting to others, hence being coined the 'superbug' of STI.
Gonorrhoea can become resistant to treatment due to:
Antibiotics are often repeatedly prescribed and offered by clinicians or requested by patients without proper testing. Medications are frequently provided due to the patient’s demand and anxiety or solely based on the clinician’s discretion, leading to unnecessary and inappropriate repeated use of antibiotics. In such circumstances, the bacteria may, over time, ‘adapt’ and ‘evade’ from being ‘killed’ by the antibiotics.
Physicians and patients may not be familiar with the dosage of antibiotics. Patients may also have poor compliance with medication, not completing the full dose due to various reasons such as ‘subjectively feeling better’, concern about side effects of antibiotics, forgetfulness in taking medications, etc. These potentially can lead to sub-therapeutic treatment of gonorrhoea infection, allowing the bacteria to thrive and mutate or adaptively evade the antibiotic effect over time.
Bacteria such as Neisseria gonorrhoea tend to adapt to medicine, time, and environment. When similar antibiotics target them, the bacteria tend to adapt and mutate their internal genes to survive the antibiotics, leading to the development of resistance of bacteria when treated repeatedly with the same antibiotics.
The presence of gonorrhoea infection in other sites, such as anal and pharyngeal (throat) sites, allows the bacteria to ‘adapt’ and ‘mutate’ with the local anatomical sites and resist the effect of antibiotics. Over time, this leads to treatment failure with the usage of conventional antibiotics when gonorrhoea is present in anatomical regions such as anal and throat.
Untreated gonorrhoea infection can lead to pelvic inflammatory disease and, in the long run, can lead to infertility in both males and females due to chronic inflammation and scarring from the bacteria. In females, there is a risk of ectopic pregnancy if gonorrhoea is unattended when one is trying to conceive. In pregnant women with untreated gonorrhoea, there might be complications such as miscarriage, neonatal blindness, and neurological defects. Less commonly, it can also cause infection of the bloodstream (sepsis) and joint infection.
In addition, evidence has shown the presence of untreated gonorrhoea increases the risk of a person acquiring other STIs. This is particularly imperative in incurable STIs such as HIV infection, as the risk of acquiring HIV is five times higher in a person with untreated gonorrhoea.
Gonorrhoea can be passed on easily through intercourse with sexual partners. Even if asymptomatic, there might still be transmission risks unless the bacteria is being eradicated medically.
The emergence of multi-drug resistant gonorrhoea and untreated gonorrhoea can put a high financial strain on both the individual affected and the government as a whole for public health. Prolonged infection and health complications from chronic gonorrhoea can potentially place a burden on the health system and health resources to contain and treat the infection.
There is currently no immunisation vaccine against gonorrhoea infection. However, ongoing trials of a meningitis B vaccine for this condition exist. These options remain under research and have not been approved for clinical use.
Promising antibiotics, such as gepotidacin and zoliflodacin, are currently in clinical phase 3 drug trials with comparable results to ceftriaxone-azithromycin combination treatment for gonorrhoea. These medications raise the hope of future management of super gonorrhoea, though they are not clinically available yet.
The efficacy of consuming high-dose doxycycline antibiotics 72 hours after unprotected intercourse may only reduce the risk of acquiring gonorrhoea by 50-55%, suggesting it is not an effective option in preventing gonorrhoea.
To avoid and stop the development of super gonorrhoea, we must:
Together, we can mitigate the risk of development of multi-drug resistant gonorrhoea with practical steps, such as:
1. Landhuis EW. Multidrug-Resistant “Super Gonorrhea” Rallies Multipronged Effort. JAMA. Published online May 03, 2024. doi:10.1001/jama.2023.15355
2. Ministry of Health Singapore. Blood-borne and Sexually transmitted Diseases Chapter 5. https://www.moh.gov.sg/docs/librariesprovider5/resources-statistics/reports/blood-borne-and-sexually-transmitted-diseases.pdf
3. https://www.cdc.gov/gonorrhea/about/index.html
4. Cannon CA, Celum CL. Doxycycline postexposure prophylaxis for prevention of sexually transmitted infections. Top Antivir Med. 2023 Dec 5;31(5):566-575.
5. Angelo Roberto Raccagni et al. Neisseria gonorrhoea Antimicrobial Resistance: The Future of Antibiotic Therapy. J Clin Med 2023 Dec 18;12(24):7767.
Age is not an amulet against STDs. STDs are not just a young person’s problem. STDs can affect anyone regardless of age, gender, and socioeconomic background.
According to the epidemiology data from the Centers for Disease Control (CDC), STDs such as chlamydia affect 0.03% of young adults between ages 20-24 and affect 0.0002% of adults 55 and above. Even though the numbers are lesser in comparison to the younger generation, the incidence of STDs in older people is not completely negligible. Just like the younger population, the elderly can be infected with STDs.
This article strives to increase sexual health awareness in mature adults and highlight the importance of taking proactive measures by considering screening and early treatment in those who may have contracted STDs.
According to a retrospective epidemiological study between 1996 and 2000, it is noted that 7.6% of the notified STD cases in Singapore involve patients aged 50 and older. The common STD infections that affect the elderly group include STDs such as gonorrhoea, syphilis, non-gonococcal urethritis, genital warts, and genital herpes.
Older adults may be becoming more sexually active with other partners following divorce and widowhood. They may resume sexual relationships after decades of sexual inactivity without being equipped with safe sex information. This group will be ready to mingle and forge new relationships via friends, social outings, social media platforms, and various dating apps.
With medical advancements, life expectancy has improved, and people tend to live longer. Furthermore, effective treatment for erectile dysfunction and beneficial hormonal replacement for both men and women allow the older generation to continue enjoying sexual experience into their ripe years.
Unfortunately, there remains a poor understanding of sexually transmitted diseases (STDs) as STDs topics are usually taboo back in those days. Furthermore, sexual education was incomplete or an embarrassing topic in society back then. Older adults may also no longer be in that stage of life where they need to be worried about unwanted pregnancy in a sexual relationship; hence, they may engage more frequently in unprotected sex, underestimating the risk of STDs that may be involved.
Although STD complications such as infertility are not a concern in older adults, chronic untreated STDs can be associated with persistent inflammation and scarring, leading to chronic pelvic pain in females or chronic testicular pain/urinary discomfort in males. STDs such as HIV, syphilis, or hepatitis B or C can have severe implications for various vital organs of the body – one can even succumb to the complications of STDs.
Not to forget, being responsible for ourselves, screening and treating STDs is another way of ensuring our loved ones are safe from the spread of STDs.
You can be at risk if you:
If you are unsure of your risk of exposure to STDs, you are encouraged to reach out to your physician for further discussion and evaluation of your risk.
If you have had a recent unprotected sexual encounter or you are experiencing abnormal symptoms such as:
You are encouraged to see your trusted doctor for further evaluation and consider STD screening. It is important to note that STD infection will require the correct medication and the correct dose of medication for treatment. Delay in seeking treatment of STDs may result in further health complications and spreading of the disease to your loved ones.
STD tests should include screening for infections such as HIV, syphilis, chlamydia, gonorrhoea, herpes, hepatitis infection, HPV warts, trichomonas, etc.
STD screening tests usually begin with your doctor obtaining a concise and relevant medical and sexual history, followed closely by a physical examination of your genital/pelvic region. Depending on individual risk of exposure, your doctor may offer screening tests such as finger prick tests, blood tests, genital swabs, oral swabs, and urine tests to evaluate for any STD infections.
1. Tan HH, Chan RK, Goh CL. Sexually transmitted diseases in the older population in Singapore. Ann Acad Med Singap. 2002 Jul;31(4):493-6
2. Smith ML, Bergeron CD, Goltz HH, Coffey T, Boolani A. Sexually Transmitted Infection Knowledge among Older Adults: Psychometrics and Test-Retest Reliability. Int J Environ Res Public Health. 2020 Apr 3;17(7):2462.
3. Relhan V, Bansal A, Hegde P, Sahoo B. Sexually transmitted infections in the elderly: A 6-year retrospective study in a tertiary care hospital in New Delhi. Indian J Sex Transm Dis AIDS. 2021 Jul-Dec;42(2):144-149.
4. Bourchier L, Malta S, Temple-Smith M, Hocking J. Do we need to worry about sexually transmissible infections (STIs) in older women in Australia? An investigation of STI trends between 2000 and 2018. Sex Health. 2020 Dec;17(6):517-524.
5. Camacho C, Camacho EM, Lee DM. Trends and projections in sexually transmitted infections in people aged 45 years and older in England: analysis of national surveillance data. Perspect Public Health. 2023 Sep;143(5):263-271.
Oral allergy syndrome is a unique and uncommon phenomenon, also known as pollen-food allergy syndrome. It can affect one out of three people who have seasonal allergies. Due to the rarity and unawareness of this medical condition, the actual incidence is likely under-reported.
Oral allergy syndrome occurs in a person with a history of hay fever who is allergic to airborne allergens such as pollen and grass. In oral allergy syndrome, the affected person has a concurrent allergic reaction to raw fruits, vegetables, or nuts. One can develop oral allergy syndrome despite being able to tolerate certain fruits or vegetables over the years. The allergy symptoms tend to be seasonal and exacerbated during the pollen season.
Oral Allergy Syndrome seldom occurs in children. This condition is more frequently seen in older children and adults.
Oral allergy syndrome is an IgE-mediated form of allergy. Immunoglobulin E (IgE) is a type of antibody that the body produces when the body’s immune system reacts exaggeratingly against an allergen/protein. IgE can trigger a cascade of chemicals and inflammatory cells in the body, leading to an allergic clinical presentation. In oral allergy syndrome, the IgE effect is localised to the mouth and throat region, leading to itching and swelling in the affected area.
The actual cause of oral allergy syndrome remains unknown. It is stipulated that airborne allergens such as grass, common weed, and pollen may have similar proteins as certain fruits and vegetables, leading to a cross-reactivity of the proteins between the two groups of substances. One typically has background asthma or allergic rhinitis (hay fever), airborne allergies against grass, pollen, and common weed, and further immune sensitisation when consuming raw fruits, vegetables, or nuts.
Interestingly, for the allergic reaction to occur, the person must be exposed to pollen or grass first so that the immune system can recognise the pollen-related allergens. Upon later exposure to raw fruits or vegetables, the immune system recognises the cross-reactive protein between pollen and fruits/vegetables, thus mounting an allergic immune response. In other words, if a person has never been exposed to pollen allergens, the person will not develop fruit-vegetable allergies.
Allergy symptoms associated with oral allergy syndrome tend to be mild, though symptoms can be worsened during the pollen season.
Common symptoms of oral allergy syndrome include localised symptoms such as:
Occasionally one may also develop itching, rashes, or mild swelling over their fingers and hands when handling or peeling raw fruits and vegetables. Less commonly, there may be other gastrointestinal symptoms such as nausea, vomiting, or diarrhoea following swallowing the culprit food into their alimentary system.
In rare cases, oral allergy syndrome can be associated with anaphylaxis. In anaphylaxis, catastrophic and life-threatening systemic allergic symptoms can occur, such as acute shortness of breath, airway tightening, facial/lip/eye swelling, generalized rash, feeling of impending doom, and fainting. One can succumb to anaphylaxis and should seek medical attention immediately to reverse the allergy.
Curiously, as oral allergy syndrome is a seasonal condition, one may be able to tolerate a particular fruit, vegetable, or nut on normal occasions but develop allergy symptoms during pollen season.
| Season | Pollen | Food that has similar protein cross-reactivity with pollen | ||
| Spring | Birch tree | Nuts and legumes: • Almond • Hazelnut • Peanut • Soya bean | Fruits: • Peach • Pear • Plum • Apple • Apricot • Cherry • Kiwi • Carrot | Vegetables/Seeds: • Potato • Pumpkin seed • Celery • Parsley |
| Summer | Grass | Fruits: • Melon • Orange • Tomato • Peach • Kiwi | ||
| Fall | Ragweed | Fruits/Seeds: • Melon • Banana • Cantaloupe • Cucumber • Zucchini • Sunflower seed | ||
Interestingly, if the food is cooked, you are likely to be able to tolerate it, as the protein (cross-reactive protein between pollen and fruits) is broken down following high temperature, and the body will not mount a response to cooked fruits/vegetables.
If you have allergy symptoms, you are advised to seek medical attention. In a dire situation of anaphylaxis, you should seek medical aid immediately. In stable allergy symptoms, your doctor will obtain further medical and social history of your symptoms. It would be useful if you could identify any possible triggers for your allergy symptoms. If there is concern of airborne or food allergies, your doctor may advise you to undergo further allergy testing.
If there is suspicion of oral allergy syndrome, your doctor may recommend allergy tests, such as a skin prick or blood test (RAST test), to confirm your allergy to pollen and food. You can discuss your allergy symptoms with your doctor, and your doctor can guide you and narrow down the possible triggering allergens for testing.
Identifying the food allergens and avoiding the food that causes allergy is key.
Your doctor or allergist can help you identify the culprit allergens.
In mild allergy symptoms, antihistamines and steroids can alleviate your symptoms.
In life-threatening allergy symptoms such as anaphylaxis, adrenaline may be required to reverse the allergy.
Genital sores are punched-out erosions and ulcers that can be found over the external genital region, affecting the vulva in females and the penis and scrotum in males. These sores may occasionally extend to the surrounding pubis and anal region.
Often, due to the acute extensive clinical presentation of ulcers and associated pain, patients do seek medical assistance. The first shiver that runs down most of our spines is whether this is a case of STD. Is it possible genital ulcers are not due to an STD?
In this article, we delve into both the non-STD causes and STD causes of genital ulcers.
Commonly, genital ulcers are associated with infectious causes, particularly an underlying STD. According to the Centers for Disease Control and Prevention (CDC), Herpes Simplex Virus (HSV) remains the most common cause of genital ulcers.
| STDs that can present with genital ulcers(most common to least common) | How do they present? |
| 1. Herpes Simplex Virus (HSV) | The ulcers present as small blisters that progress over time into ulcers, open wounds, or erosions. |
| 2. Syphilis | The ulcer is usually solitary and painless (chancre). |
| 3. Chlamydia trachomatis(Lymphgranuloma venereum) | The ulcer is a painless individual ulcer. One can have associated abnormal urinary symptoms such as painful urination, itching, or urethral discharge. |
| 4. Haemophilus ducreyi | The ulcers (chancroid) can be extremely painful and associated with painful pustular surrounding lymph nodes. |
| 5. Klebsiella Granulomatis(Donovanosis) | Painless beefy-red genital ulcers that are slow to progress and associated with surrounding lymph nodes. |
| 6. Monkeypox | Ulcers are painful, firmed, and deep-seated, with a ‘dot’ on top of the lesion. They can be individual or multiple in appearance. Ulcers can occur in the mouth. There can be an associated body rash and systemic symptoms such as fever and flu-like symptoms. |
STD-related genital ulcers, if left untreated, run a risk of transmitting further to other sexual partners. Furthermore, untreated open sores increase the risk of a person getting infected with subsequent STDs, including the risk of acquiring HIV infection. It is worth noting that there are beneficial evidence-based treatments for most STDs. STDs are not able to resolve on their own with a person’s immune system, and treatment will be required to manage the disease.
If you are concerned that you may be exposed to STDs, reach out to your healthcare provider for screening and early treatment of STDs.
Less commonly, genital ulcers can occur without being sexually acquired. This can happen in both females and males, though with a slight predisposition in females. The underlying mechanism of non-STD-related genital ulcers remains poorly understood. There are suggestions that an exaggerated immune response may trigger the formation of genital ulcers following a recent infection or inflammation in the body.
In non-STD-related genital ulcers, one may commonly present with recent viral-like symptoms such as fever, chills, lethargy, sore throat, respiratory symptoms, or gastrointestinal (diarrhoea) symptoms.
Common infectious viruses that can be associated with non-STD-related genital ulcers include:
Occasionally, genital ulcers can be associated with shingles, a case usually mistaken for a herpes (HSV) outbreak.
Shingles occur when an old virus (Varicella Zoster Virus) that has been dormant in the nerve root of the body reactivates. It is important to promptly pick up shingles rather than manage them as a case of herpes genital ulcer, as the treatment dose of shingles differs. The delay in treatment of shingles can be associated with complications such as chronic pain (post-herpetic neuralgia), brain inflammation (encephalitis), respiratory infection (pneumonia), etc.
Non-infectious genital ulcers
A careful history of the progression of the ulcers, together with a sexual history (if any), can be instrumental in differentiating the cause of the genital ulcers. A physical examination by your doctor, with whom you are comfortable, is important. If it is not possible to tease out the underlying cause, laboratory testing with swabs for viruses/bacteria can be beneficial. Depending on the risk of suspicions, your doctor may offer appropriate STD testing to reach the correct diagnosis.
Genital ulcers due to untreated underlying STDs pose a risk of spreading the undiagnosed and untreated STDs to other partner(s). Furthermore, untreated STD-related genital ulcers increase a person’s risk of acquiring different forms of STDs due to impaired skin barrier, low immune system, etc. It is important to note that untreated STDs cannot be resolved by one's immune system unless one receives the correct treatment.
Symptomatic relievers are usually offered for non-STD-related genital ulcers. Management of non-STD-related genital ulcers revolves around good wound care. Medications such as anti-inflammatories, pain relievers, and topical numbing cream may be offered to aid recovery.
Delivering the right medication for the STD that causes the genital ulcer is critical in managing the infection and symptoms. To do so, arriving at the correct diagnosis with an appropriate screening test is vital.
The prognosis of non-STD-related genital ulcers is generally favourable if the underlying cause resolves over time. Non-STD-related genital ulcers usually resolve spontaneously without scarring and seldom recur.
With the correct diagnosis and course of treatment, and if the underlying STD is addressed, the genital ulcers resolve with treatment.
Brain aneurysms, also known as cerebral aneurysms, have been surfacing as new headlines following a recent young Malaysian artiste, Queenzy Cheng, who collapsed and succumbed at a work site due to a ruptured brain aneurysm.
Slightly closer to home and heart, within the same month, one of our blog authors' friends (also a young adult) collapsed from a similar medical condition and had a haemorrhagic stroke. The friend survived but with significant neurological complications and is currently undergoing intense rehabilitation in the hospital.
A brain aneurysm is a medical condition that, in its wake, causes a catastrophic event to patients and their surrounding family and friends. Brain aneurysms tend to have a high mortality rate (approximately 50%), and even if an individual survives a rupture, they may have to live with profound long-term neurological disability. This is a condition that nobody wishes to happen to themselves or their loved ones.
This article is written to serve as a general information guide to patients and families on brain aneurysms to promote awareness of this serious medical condition.
Aneurysm is a medical condition where there is a 'weakened point' [1] on the wall of a blood vessel. Over time, this weakened area may herniate or ‘bulge’ externally. An aneurysm can occur in any blood vessel – it can occur in the abdomen (abdominal aneurysm) and in the brain (brain aneurysm).
The thinning of the blood vessel wall can be due to a disease, trauma, injury, or a malformation at birth. If the aneurysm/thinning becomes significant, it runs a risk [2] of rupturing and bursting. If this occurs in the brain, the blood will spill over to the surrounding brain tissue, leading to brain inflammation, swelling, and irreversible brain tissue damage. A ruptured brain aneurysm can potentially lead to a disastrous event of a stroke, irreversible nerve paralysis, or even death.
A brain aneurysm that has ruptured can cause catastrophic symptoms [3] or even death. Patients with brain aneurysms are usually asymptomatic; however, when the aneurysm gets bigger, it may compress onto surrounding brain tissues or nerve cells, leading to neurological abnormal symptoms, such as:
At the onset of a ruptured aneurysm, one may present with:
In the event of suspicion of a ruptured brain aneurysm, time is of the essence. Seek medical attention and go to the hospital immediately, as early neuro-surgical intervention can be life-saving. Delaying seeking medical assistance can result in death.
In most patients, the cause of brain aneurysm remains unknown.
However, one may be predisposed to brain aneurysm if there are hereditary [4] conditions such as connective tissue disease, blood vessel malformations, or polycystic kidney disease.
Environmental factors such as head injury, uncontrolled high blood pressure, smoking, recreational drug usage, infection, or even high cholesterol leading to atherosclerosis can also put a person at risk of developing a brain aneurysm.
As the brain aneurysm extends over time, the arterial wall of the aneurysm can ‘thin out’ and may eventually rupture. Once the aneurysm is ruptured, the blood will spill into the brain space known as the subarachnoid region. This is an area that is usually filled with cerebrospinal fluid that cushions the brain. The bleeding blood causes inflammation and swelling over the surrounding brain tissue. Simultaneously, the brain region that is supposed to receive blood supply from the aneurysm is deprived of blood supply, leading to a stroke.
To make things worse, the massive outpour of blood from the aneurysm, brain inflammation and swelling will lead to fluid and pressure build-ups in the enclosed brain area. This can crush the brain tissue against the solid skull or force the brain to shift or herniate.
One can become terminally ill very quickly with confusion, coma, paralysis, stroke symptoms, or even death.
A Brain Magnetic Resonance Imaging (MRI) is safe, pain-free, and reliable to screen for brain aneurysm(s). It allows one to understand the brain structures, including the arteries and the veins in the brain. An MRI can visualise succinctly the size, location, character of the aneurysm (if any), and potential progression or effect from the aneurysm.
Sometimes, your doctor may recommend a brain MRI with contrast dye to facilitate the structure of the blood vessels in the brain.
A brain MRI can serve as a way of detecting aneurysms in high-risk asymptomatic individuals or symptomatic patients. This may be beneficial in facilitating the physician (usually a neurologist or neurosurgical specialist) to decide the patient's future management. This includes monitoring the progression of the aneurysm closely or taking a proactive approach to surgically repairing the aneurysm.
In the case of an acute rupture of a brain aneurysm, a computed tomography (CT) scan and brain MRI serves as a diagnostic life-saving imaging option to confirm the diagnosis, assess the extent and severity of the effect, thereafter allowing the physician to plan the immediate next best course of action for the patient.
You are advised to follow up with your neurologist or neurosurgical specialist regularly to monitor the progression of the brain aneurysm.
In terms of lifestyle:
If you have any modifiable risk factors above, you should speak to your doctor about lifestyle alternatives to lower your risk of developing a brain aneurysm. If you have concerns about family history and personal history of potential undiagnosed brain aneurysms, discuss with your doctor for appropriate medical screening tests and follow-up.
Aches and pains remain one of the common reasons people visit the clinic. Both patients and doctors sometimes tend to brush the issues away and treat these symptoms with simple pain relievers before issuing medical certificates. But are we doing enough to address any possible underlying issues?
Arthritis is a broad term for inflammation in and around a joint. There are more than 100 different types of arthritis [1]. Generally, arthritis manifests with joint pain as the primary symptom, and you also experience the occasional joint stiffness and swelling.
The point is that sometimes, we overlook or dismiss persistent aches and pains as mere inconveniences. However, it is important to recognise that these symptoms may indicate underlying conditions such as arthritis, which may require more comprehensive evaluation and management.
Symptoms of arthritis include:
These symptoms can vary in how they appear. They may show up intermittently, meaning they come and go. Alternatively, they could be consistently present and remain the same over time. Sometimes, the symptoms may be progressive, meaning they worsen with time.
In Singapore, common musculoskeletal diseases affecting patients include rheumatoid arthritis, gout, and osteoarthritis.
According to the Global Burden of Diseases (GBD) 2019 study [2], musculoskeletal diseases rank among the top 5 broad causes of medical conditions leading to disability and overall health burden [3]. This means that these conditions significantly impact a person’s ability to function and contribute to the overall burden of healthcare.
When it comes to arthritis risk factors, we can categorise them into two main groups: modifiable and non-modifiable factors.
Modifiable risk factors include:
Non-modifiable risk factors include:
While there are over 100 types of arthritis, we can broadly classify them into the following:
| Rheumatoid arthritis | Gout | Osteoarthritis | |
| Cause/type of arthritis | Autoimmune disorder – the body’s immune cells attack their own body | Inflammatory – high purine diet and lifestyle | Mechanical – progressive wear and tear of joints |
| Joint location | Small joints such as hands/feet are usually symmetrical in nature (though larger joints can be affected) | Single joints such as big toe/feet/ankle/knee | Large weight-bearing joints such as hip and knee |
| Pain onset | Progressive, though symptoms can be acute during a flare-up | Acute, which intensifies progressively | Insidious and progressive |
| Associated symptoms | - Affected joints can be warm, tender to touch, and swollen-Lethargy-Weight loss-Fever | -Affected joint is likely warm, tender to touch and swollen-Fever | -Cracking of the joints-Worsening pain upon repeated use of the joint/end of the day |
| Other systemic symptoms | -Chest pain-Shortness of breath-Reduced exercise tolerance-Red eyes-Rash-Hair loss | -Blood in urine-Painful urination-Lower back pain associated with kidney stones-Possible associated chronic conditions such as hypertension/ hyperlipidaemia/ diabetes | -Spine/back pain due to ageing/degenerative process-Associated raised BMI/obesity |
If you notice symptoms of arthritis, such as joint pain, swelling, and stiffness, you should speak to your primary care doctor. They will evaluate your symptoms based on your medical history and physical examinations of the joints. Your doctor may also recommend blood tests and X-rays to confirm the nature of your condition.
Determining the specific type of arthritis you have is crucial as it guides the choice of the most appropriate treatment plan. Early diagnosis and proper management can help you effectively address arthritis and improve your overall joint health and quality of life.
The primary goal of seeking prompt medical attention when you experience symptoms of arthritis is to ensure you receive an accurate diagnosis and early treatment without further delay. This approach aims to effectively manage and alleviate your symptoms and prevent the condition from progressing.
The key objectives for arthritis treatment are to:
In cases of autoimmune arthritis, such as rheumatoid arthritis, your doctor may refer you to a rheumatologist or orthopaedic specialist for specialised care and management.
When arthritis is left untreated, it has the potential to cause permanent and irreversible damage to your joints [15]. This can result in a loss of joint function, ultimately leading to difficulties in carrying out your daily activities and routines.
In certain forms of arthritis, particularly rheumatoid arthritis, the impact can extend beyond the joints, affecting other vital organs, including the heart, eyes, kidneys and lungs [16]. This highlights the importance of managing joint symptoms and addressing the underlying causes and potential complications associated with arthritis.
There is no cure for arthritis; however, as previously mentioned, the primary goal in treating arthritis is to manage symptoms; this includes:
The specific treatment for arthritis depends on the type and underlying causes of the condition. While a primary care doctor can diagnose arthritis, there may be situations where collaborative care with specialists from various disciplines is necessary.
You may be offered medication based on the type of arthritis to control the symptoms. Additionally, your doctor will guide you on suitable regular physical exercises to keep your affected joints active and ensure your overall functionality is not compromised. In more severe cases, surgical options may be considered to manage the affected joint.
Listening to your body and recognising the symptoms it is signalling is the crucial initial step in addressing a potential arthritis condition. Taking the proactive step of getting checked and evaluated by your general practitioner is essential to addressing a brewing arthritis condition. So, don’t delay further; seek medical attention to start the journey toward diagnosis and appropriate treatment!
Pruritus ani, also known as anal itching, is a medical condition where a person experiences itchiness around the anal region. You may notice that the itchiness worsens at night or when you are having a bowel movement [1].
There are two types of pruritus ani, these are:
While this condition does not threaten your internal health and body, it can affect you psychologically. This includes disrupting your sleep quality, affecting your mood, and even leading to embarrassment when symptoms occur in public.
As previously mentioned, most cases of pruritus ani have no apparent cause. However, sometimes, it can be seen as an early warning sign of an underlying medical condition. Some possible causes of pruritus ani include:
| Skin conditions | Infections | Structural causes | Systemic medical conditions | Miscellaneous (food and medication) |
| -Eczema-Contact dermatitis-Psoriasis-Seborrhoeic dermatitis | -Fungal infection-Threadworms-STDS (herpes, scabies, warts, chlamydia) | -Piles/haemorrhoids-Cyst-Fissure-Abscess-Tumour/growth | -Thyroid disease-Diabetes-Iron deficiency anaemia-Liver disease | -Colchicine-Peppermint oil-Antibiotics-Food such as milk, spices, chilli peppers |
The symptoms of an itchy bottom can be exacerbated by:
While there can be various reasons for experiencing anal itching, it is essential to be aware that an untreated STD may potentially be a cause [2]. If the itch persists or becomes more severe and frequent, it is advisable to consult your doctor, especially if you have had a concerning exposure in the past.
It is important to know that STD-related pruritus ani is typically treatable, but diagnosis and prompt treatment by a healthcare professional is necessary.
If you are worried about contracting an STD and experiencing anal itching, you can discuss it with your doctor. Common STDs linked to anal itching are outlined below:
| Bacterial STDs | Chlamydia, Gonorrhoea |
| Viral STDs | Warts (HPV), Herpes Simplex Virus (HSV) |
| Mites STDs | Scabies, Pubic lice/crab |
You should speak to your doctor if you notice persistent or worsening peri-anal itch. Consider undergoing STD screening and seek early medical treatment if you test positive.
If you find that the itching in your anal area persists or worsens in terms of frequency and intensity, it is recommended that you seek medical advice. Since there can be multiple underlying causes for pruritus ani, it is crucial to have a thorough examination by a healthcare professional. This will help identify potential causes and ensure you receive appropriate treatment for your symptoms.
When you consult your doctor regarding anal itching, they will begin by taking your medical history and conducting a physical examination. During this examination, your doctor will carefully inspect the external skin around the anal area, checking for any lumps, bumps, or rashes. In some cases, your doctor may suggest an anoscopy procedure, which involves using a proctoscope to examine the anal canal for any abnormalities visually.
Depending on your specific concerns and medical history, you may be recommended additional tests, such as swabs or blood tests. These tests help further assess the situation and determine any underlying causes for your symptoms.
Interestingly, while poor hygiene practices can contribute to skin problems and make you more susceptible to skin inflammation and itching, it is essential to note that perianal itching is typically not a result of inadequate cleanliness. In fact, individuals with pruritus ani often tend to be very concerned about hygiene and, as a result, may excessively and vigorously clean the affected area with soap and water. Paradoxically, this excessive cleaning can damage the skin’s protective barrier and lead to irritation, worsening the itching symptoms.
If there is a specific underlying medical condition, your doctor may prescribe targeted treatments such as topical steroids, antifungal creams, deworming medications, or antibiotics to address the root problem. In cases involving structural issues such as haemorrhoids or anal fissures, your doctor will offer guidance on further treatments, which may include surgery.
However, pruritus ani may not have a clear cause in many instances. In such situations, you are advised to:
If the root medical problem is treated successfully, the itching symptoms can resolve independently. However, in cases where the cause of pruritus ani remains unknown, the itching can persist and become a chronic issue, which can be quite frustrating for you. In more chronic cases, your doctor may recommend consulting a dermatologist or a colorectal surgeon for further evaluation and management [3].
Symptoms or red flags that warrant you to seek medical attention immediately include:
Pruritus ani can be frustrating for you and your physician because identifying the root cause can be challenging. Discussing this with your physician may feel embarrassing and daunting, but it is crucial to do so, especially if there is a chance of treatable or reversible causes such as STDs. You can receive the most appropriate and effective treatment through a thorough examination and screening for potential infections and other factors. It is essential not to let embarrassment deter you from seeking the help you need.
Steroid medication is often labelled as a ‘bad’ medication with numerous side effects. Then why do doctors still prescribe this medication to patients?
In this article, we will clarify some pressing questions that the public may have regarding topical steroids. We also hope to encourage patients to consider the appropriate use of topical steroids in order to achieve treatment control of dermatological conditions.
Topical steroids are steroid medications applied to the skin surfaces and are usually prescribed as a treatment for skin disorders.
There are 3 main functions of topical steroid creams:
Upon usage of the right type and amount of topical steroid, one may notice alleviation of skin symptoms such as itch or burning sensation.
You may notice that your doctor prescribes you various tubes of medication with various colour coding. In general, topical steroids are categorised based on their strength or potency and formulation. The higher the potency or strength of the topical steroid, the more effective it is to reduce inflammation.
| Steroid potency |
| Mild |
| Moderate |
| Potent |
| Superpotent |
Topical steroids can be further subdivided depending on their formulation, this is also known as the ‘vehicle’ of the topical steroids. Different areas of the skin have different levels of thickness, as such, it is important to use the appropriate formulation to ensure sufficient penetration and absorption of the medication into the skin.
| Vehicle/formulation of the steroid | Where is it suitable for |
| Lotion | Areas with more hair follicles – face, scalp |
| Cream | Moist and weepy areas |
| Ointment | Dry and thick skin |
Your doctor will guide you on which type of topical steroid is advisable based on your individual skin condition. Do speak to your doctor if you are unsure which type of topical steroids is suitable for you.
There are potential side effects to topical steroid application known as local or systemic side effects of steroids. Local side effects are defined as side effects that are localised on the affected skin area that was exposed to steroids. Systemic side effects, on the other hand, are side effects that affect a person’s overall body and internal organs.
| Local side effects | Systemic side effects |
| Initial stinging/burning sensationSkin thinning/atrophyStretch marksBruisingThin blood vessels (telangiectasia)Hair growthWorsening of acne/rosacea/perioral dermatitis | Fluid retentionElevated blood pressureOsteoporosisCushing’s syndrome |
There are also multiple discussions on topical steroid withdrawal (TSW) [3], also known as red skin syndrome. These are a sub-section of patients who face extreme side effects when discontinuing the use of topical steroids. Some have even documented their journey of withdrawing from steroid treatment and their remorse for using them in the first place. So how can something so “bad” be a good idea to begin with?
TSW is a cluster of symptoms that occur when an individual develops a physical dependence on the topical steroid. This tends to occur in situations when a person has been using topical steroids for prolonged periods inappropriately, using moderate to high potency steroids, or excessive frequency usage of topical steroids.
Rebounding or ‘withdrawal’ symptoms with worsening skin conditions such as itch and burning/stinging of the skin may occur upon discontinuation of topical steroids. TSW is a combination of topical steroid addiction, steroid eczema, and red skin syndrome. TSW commonly affects the face and genital region.
TSW remains a challenge for both physicians and patients to diagnose and manage. Currently, there is insufficient data to conclude the definitive cause of this condition. However recent research [4] has indicated that TSW is more commonly seen in adult women who apply mid- or high-potency topical corticosteroids to the face or genital region. Additionally, risks of side effects also occur with inappropriate use of topical steroids such as prolonged periods of topical steroid usage or exposure without tapering or periodic breaks [5].
You are advised to discuss with your doctor on the frequency and quantity of application of topical steroids that you are prescribed. We also suggest discussing plans on safely tapering off from topical steroid usage to avoid extreme TSW outcomes.
As a rule of thumb, topical steroids are applied once or twice a day (maximum) in small amounts on the affected skin area or inflamed region. The quantity of topical steroids is measured by fingertip units (FTUs). One FTU of topical steroids is the amount squeezed out of a standard tube covering an adult’s fingertip (just like expressing toothpaste out of a tube). One FTU of medication is adequate to cover 2 flat surface areas of an adult’s palm.
As with any medication prescribed, if a medication is administered for the right condition at the right dose, right method, and right frequency, the symptoms will resolve or improve. Every medication has potential side effects. It is pertinent that patients and practitioners take accountability and be proactive in dealing with the prescribed medication. If topical steroids are used judiciously, they are safe and effective in managing certain dermatological conditions
Should I use topical steroids and moisturiser together?
Yes. Using both topical steroids and moisturiser allows for better absorption of the steroid medication and at the same time provides a good seal to the skin barrier with moisturiser to reduce further inflammation. Although there is no hard and fast rule, you can consider applying topical steroids to the affected area. After 15-30min, you can then apply a layer of moisturiser to the skin.
Is there a maximum duration to use topical steroids?
Generally, we suggest following your doctor’s guidance on the duration of topical steroid treatment as every patient’s condition may differ. Every case is subjective to the patient’s condition.
Typically you are advised for a short course (3 days to a week) of a suitable strength or strong topical steroid to manage your skin condition. Once the skin condition is under control, the topical steroid can be tapered to a weaker steroid. This approach involves the use of short bursts of high-strength topical steroids which is clinically proven to be an effective way of managing skin conditions.
In some patients who have recurring flare-ups of skin conditions upon withdrawal of topical steroids, short use of topical steroids (weekend therapy) to prevent flare-ups can be considered. In such a situation, your doctor may advise you to use the steroid cream over the frequent flare-up sites of the skin twice a week to prevent flares.
Your doctor may want to understand the triggers of your skin condition and tailor your topical treatment regimen based on your triggers and symptoms. Speak to your doctor without further hesitation.
Recently a patient walked into the clinic with a concern of acne on the shoulder that has remained unresolved over the course of several months.
What comes to mind?
He has a previous diagnosis of hypertriglyceridemia– elevated triglyceride levels in the flood. The rash that this patient mistook as acne is, in fact, eruptive xanthomas. Not all rashes are merely a skin condition. Rashes may be more than skin deep and suggestive of an underlying medical condition that has yet to be addressed.
The objective of this article is to promote awareness on the possibility of a warning sign of systemic cardiovascular health issues. This is when a person is plagued with a seemingly benign dermatological rash.
Eruptive xanthomas are small (less than 1cm) yellow-hued papules with a reddish rim that can be seen over the shoulders, upper back, neck, abdomen, face, knees, and the buttock region. They can be slightly tender and/or itchy.
While uncommon, eruptive xanthoma can be noticeable if a person has it. Eruptive xanthomas can be seen in 8.5% of patients with severe hypertriglyceridaemia. The lesions are benign and can resolve over time with treatment and management of the triglyceride level.
As mentioned, it is associated with severe hypertriglyceridaemia which is a condition where a person’s blood has abnormally elevated or high concentrations of triglycerides (a type of fat). If this is left unattended, you can be at risk of cardiovascular complications such as a stroke, coronary heart disease, heart attack, or even pancreatitis.
If you have an unexplained rash that is yellowish with a red rim and you are concerned that it could be a sign of eruptive xanthomas, do see a doctor to get yourself checked.
Triglycerides are lipids (fats) that can be found in your bloodstream. Triglycerides are made up of fatty acids (both saturated and unsaturated) and glycerol (a form of sugar).
They are produced from extra carbohydrate, alcohol, and glucose that we consume and are stored in the fat cells of our body. Our liver also naturally produces triglycerides. Triglycerides are used as a source of energy when required or when you are in between your meals.
Triglycerides are stored unused fat cells or calories. These provide your body with energy when required. Cholesterols, on the other hand, are proteins that help to synthesise cells and hormones.
Hypertriglyceridaemia is a common medical condition that is often encountered when a person performs a blood test for lipid screening as part of a cardiovascular risk workup. It is defined as an abnormal concentration of triglycerides in the blood. A normal triglyceride level is less than 150 mg/dl.
According to the Ministry of Health (MOH), Singapore, Clinical Practice Guidelines for lipid, the definition of hypertriglyceridaemia is as below:
There are several factors that may increase your risk of developing hypertriglyceridaemia, these are:
Patients with elevated triglyceride are usually asymptomatic. However, they may have non-specific symptoms when the triglyceride level is greater than 1000 to 2000 mg/dl.
Clinical symptoms include:
You are advised to seek medical attention if you develop any of the above symptoms to evaluate further any underlying medical conditions.
Hypertriglyceridaemia can be subcategorised into primary and secondary causes:
You are advised to discuss with your doctor with regards to your family history and general lifestyle patterns. Your doctor will be able to identify any modifiable causes of hypertriglyceridaemia and work out a feasible health care plan to improve and monitor your triglyceride level, simply make an appointment with us.
When triglyceride levels are elevated, a person can be at risk of pancreatitis. The risk for pancreatitis is elevated when the triglyceride level is more than 1000 mg/dl.
As elevated triglyceride is often associated with other abnormal lipid readings such as low high-density lipoprotein (HDL), high low-density lipoprotein (LDL) hypertension, diabetes, obesity, and metabolic syndrome, it can hence also be associated with a higher risk of cardiovascular issues such as coronary heart disease and stroke accidents.
If you are in adulthood, you may consider screening your cholesterol (including triglyceride levels) at least once every 2-3 years, as cholesterol levels tend to increase as we age. You are advised to speak to your health care provider, as you may be offered the tests more frequently depending on your previous results and underlying medical risk factors.
Your doctor will obtain a medical and social history to understand your general health status and background lifestyle. Your doctor may also obtain a family history for cardiovascular risk factor assessment. A physical examination covering the cardiovascular system will be offered. Depending on your individual risk factors, your doctor may advise for blood tests to screen for cholesterol profile, diabetes screening, and other vital organs screening.
The aim of treating hypertriglyceridaemia is to prevent and reduce risk of pancreatitis and cardiovascular disease.
Your doctor will advise you on lifestyle modifications, such as:
If lifestyle changes are inadequate to control the triglyceride level, your doctor may prescribe you with oral medications to manage the levels. The risks and benefits of individual pharmacological options will be discussed prior to prescribing. Medication options include omega-3 fatty acids, fibrate, niacin, or statin.
While hypertriglyceridaemia is a medical condition that is generally asymptomatic, our body may signal us with vague symptoms such as rash or gastrointestinal symptoms to warn us of an underlying brewing medical condition. Take care of your cholesterol and triglyceride level with early screening and testing with us!
When the opening of the urinary system— the urethra, becomes inflamed, it is medically known as urethritis or an infection of the lower urinary tract [1]. This medical condition can be due to an infection, or other non-infectious related causes such as excessive physical pressure, exposure to irritants, and catheter insertion.
Hence, it is worth paying attention to your symptoms and addressing the underlying condition rather than fobbing the symptoms off as a general discomfort or aches and pains.
While some patients may have no symptoms, some patients exhibit the following:
If you develop any unusual symptoms to suggest urethritis, speak to your doctor for further screening.
Common infectious causes of urethritis include [1]:
Unfortunately, up to 35% of urethritis has no reason found [4].
Your physician will obtain a medical history and assess your symptoms to discuss with you further on the possible causes and triggers of your urethritis symptoms.
Infectious urethritis related to STIs is on a resurging trend over the years. Interestingly, in 2021, the CDC STD epidemiology report showed a significant rise in syphilis, gonorrhea, and chlamydia cases [5]. The reduction of chlamydial infection reports may be secondary to limited access to medical services during the COVID-19 pandemic and due to asymptomatic/minimal symptoms presentation.
Urethritis can occur in any person who is sexually active, though it is most common in the younger cohort between the ages of 20-24 [4].
Although some patients may have no symptoms in urethritis, others may experience symptoms such as painful urination, increased urinary frequency, lower pelvic pain, lymph node swelling, or abnormal vaginal discharge/smell (in females). Please seek medical attention for further evaluation if you are experiencing any of these symptoms.
Your doctor will take a medical history including your social/sexual history and examine you physically. Physical examination includes examination of the genital region for abnormal skin changes, discharge, and swelling (this includes your lymph nodes).
Most patients with urethritis may not have any signs of infection. Depending on your individual risk factors and presentation, your doctor may offer you urine tests or swab tests to screen further for possible infectious causes of urethritis.
As every patient may have a different cause of urethritis, it is worth discussing your symptoms and letting your doctor examine you further to determine the next course of testing for further evaluation of your condition.
Treatment of urethritis is dependent on the underlying cause. Commonly, if urethritis is associated with an underlying infection, your doctor may offer you antibiotics for further treatment of the condition. If there are concerns of an STI, your doctor may advise your sexual partners to be treated as well to avoid recurrence or reinfection.
Thankfully, most patients recover well following antibiotics treatment for urethritis. While some may take time to recover, most patients’ symptoms resolve spontaneously over time after treatment.
Approximately 10-20% of patients may have persistent symptoms or recurring infection after treatment.
It is important for patients to be followed-up if their symptoms are non-resolving or persistent. Adherence to antibiotic treatment therapy is also important and a reassessment of reinfection by an untreated partner or new partners are important to anaylse treatment options.
In recurring urethritis patients, after ruling out infectious causes/treatment failure, one should consider non-infectious causes including trauma or anatomical abnormalities that have been discussed previously. You will have to work with your doctor for further evaluation of your symptoms.
To avoid recurrence of urethritis, you should:
Ever wondered why there are days we vigorously scratch our rashes or our friends drop comments stating our skin rash resembles a map? Sometimes the mere action of picking up a pen can induce an itch, which then leads to swelling and redness.
This is known as hives. And it’s more common than you would think. Read on to find out more about this itchy situation.
Hives, medically known as Urticaria, comes from the term Urtica Dioica, the stinging nettle plant abundantly found in Europe. Hives are your body’s response to irritation and come in the form of little marks on your skin similar to mosquito bites.
Hives are typically represented by an itchy wheal (swelling of the skin) surrounded by the occasional redness. The wheal tends to be slightly paler than your surrounding skin colour, is swollen, very itchy, and with lesions. Thankfully, these will usually resolve within or after 24 hours.
If you notice wheals or have any persistent itchy redness on your skin, consult your doctor for proper treatment and ways to reduce or manage possible symptoms of hives and rashes.
Hives occur when there is a sudden release of a chemical agent (such as histamine) into your skin.
Histamine is a substance that causes blood vessels to dilate and leak, leading to extra fluid accumulation in the tissue. If this has occurred, you may experience swelling, warmness and a slight itch on the affected region.
There are a risk factors that trigger histamine to be released, these are:
The cause of your hives may be different from someone else. Determining this will require a medical history and/or physical examination.
Visiting your doctor can help to determine what your skin is reacting to and if you have hives.
In some cases, patients with hives may have no known direct or obvious trigger for their condition but can be easily identified for others.
Below is a table with common stimuli that can induce hives, and depending on the type of stimuli, the condition can be further sub categorised.
| Stimuli | Name of the hives / urticaria |
| Cold temperature (cold air or water) | Cold urticaria |
| Hot temperature (hot air or water) | Heat urticaria |
| Sweat from to exercising/heightened emotions | Cholinergic urticaria |
| Pressure on the skin surface from heavy bags, seat belts, bra straps, or belt lines | Delayed pressure urticaria |
| Tight clothing or scratching of the skin | Dermographism |
| Towel drying after a hot shower | Vibratory urticaria |
| Contact with water | Aquagenic urticaria |
| Substance absorbed through the skin from contact with latex, saliva, flour, meat, fish, vegetables, caterpillar, or stinging nettle | Contact urticaria |
It is important to note that these symptoms can sometimes be an early sign of an allergic reaction, which can potentially be dangerous. Always seek medical attention if you suspect you are having an allergic reaction.
You can discuss any concerns with your doctor regarding symptoms of hives for further evaluation and treatment.
Hives can be categorised according to the duration of each symptom:
Chronic urticaria can be further sub categorised into:
Hives are a very common condition in Singapore, affecting 1 in every 5 Singaporeans (42%) at some point in their lives. Although hives are not a life-threatening condition, its wax and wane periods are enough to cause some discomfort and disruption in their daily lives.
Consider discussing any concerns with your doctor if you are experiencing any symptoms of hives.
Hives are not a self-limiting condition but avoiding proper treatment can lead to anaphylaxis — a life-threatening allergic reaction.
You are advised to monitor your symptoms and resolve them if they do not show any signs of improvement and progresses to spread all over your body and face. This could then lead to a slew of other reactions such as shortness of breath, wheezing, and feeling faint.
If you experience any of the above, please seek medical attention immediately.
Luckily, hives are not infectious, and you will not contract it from someone with hives — be it airborne or through direct contact.
While hives are a subset of allergy, it can occur without the presence of an allergen. Triggers such as dust mites, mould, pet dander, pollen, chemicals, drugs, latex, and food allergens can trigger hives-like symptoms. This can be confusing for both patients and physicians to deduce underlying medical conditions.
You are advised to speak to your doctor for further evaluation of any hives or allergy symptoms.
The short answer is there is a low chance of you succumbing to hives.
However, hives can be an early sign of anaphylaxis, which is a severe allergic reaction that can be fatal.
Signs of anaphylaxis include:
Anaphylaxis is a treatable medical condition. If you show any signs of anaphylaxis, you should seek immediate medical attention.
Hives can be a sign of an underlying medical condition, these include:
It is advisable to speak to your doctor if you notice any signs of hives or if symptoms of hives persist and worsen over a long period of time for further evaluation and treatment.
In most cases, hives symptoms are temporary and can be resolved on their own.
However, it is always recommended to see your doctor if symptoms:
Hives are usually clinically diagnosed by your doctor by viewing your medical history for a better understanding of what could be triggering your hives. Depending on your individual conditions or if your doctor suspects an allergic reaction, you may be offered to do an allergy test followed by allergy treatment. Occasionally, your doctor may also require blood tests to be done to evaluate and rule out any underlying medical condition you may have that could trigger hives.
Mild or transient hives may resolve their own without any medical treatment. However, if
the itchiness is troubling you on a daily basis – be it pain or other symptoms – that leads to feeling unwell or a fever, you are advised to seek medical attention for hives treatment.
If you show any signs or symptoms of hives, your doctor will usually prescribe you with antihistamines to reduce symptoms. For severe cases, steroid medication, H2-antagonist Montelukast, or newer injectables such as biologics omalizumab may be prescribed instead.
During your consultation, your doctor will go through some triggers that could possibly be causing hives and ways to reduce the chances of a recurrence.
Although hives are not a life-threatening condition on its own, one fourth of patients with hives can have coexisting angioedema.
Angioedema is a medical condition that causes swelling and fluid build-up in the deeper part of the skin. It mainly occurs over the softer, gravitational-dependent regions of the body such as the eyes, lips, genitals, hands, and feet.
More importantly, hives can also be an early sign of an allergic response known as anaphylaxis. If you ever experience lightheadedness, narrowing of your airways, wheezing, swelling of your eyes and lips, feeling unwell or abdominal pain, please call an emergency hotline and seek immediate medical attention as a severe allergic reaction can lead to death.