Urethritis- It May Be More Than a Simple Urinary Tract Infection (UTI)

What is urethritis?

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.

Urethritis occurs when the urethra becomes inflamed.

What are the signs and symptoms of urethritis?

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.

What are the possible causes of urethritis?

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.

Urethritis is commonly caused by sexually transmitted infections (STIs).

How common is infectious urethritis?

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].

What are the red flags of urethritis and when should I see my doctor for urethritis?

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.

What should I expect when I see my doctor for urethritis?

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.

doctor appointment
Make an appointment to see your doctor if you suspect that you have urethritis.

What are the tests available for screening 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.

What are the treatment options for urethritis?

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.

Will I have recurring urethritis?

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.

urethritis treatment
Most patients recover after treatment of urethritis.

What should I do after treatment of urethritis to avoid recurrence?

To avoid recurrence of urethritis, you should:


  1. Young, A., Toncar, A., & Wray., A. A. (2022). Urethritis. Treasure Island (FL): StatPearls Publishing.
  2. Herchline, T. E. (n.d.). Urethritis. Infectious Disease and Antimicrobial Agents.
  3. Joseph U. Igietseme, Y. O. (2015). Molecular Medical Microbiology (Second Edition). Academic Press.
  4. Whitaker, D. L. (2022, October 3). Urethritis. Retrieved from Medscape: https://emedicine.medscape.com/article/438091-overview
  5.  CDC . (2023). U.S. STI Epidemic Showed No Signs of Slowing in 2021 – Cases Continued to Escalate. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/nchhstp/newsroom/2023/STD-Surveillance-Report-2021-media-statement.html

Hives / Urticaria — The Tic-Tac-Toe that we can create on our skin

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.

Reaction of hives on the skin

What is hives/urticaria?

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.

What causes hives/urticaria?

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:

An allergic reaction to food can cause hives.

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.

What triggers hives/urticaria?

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.

StimuliName 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 emotionsCholinergic urticaria
Pressure on the skin surface from heavy bags, seat belts, bra straps, or belt linesDelayed pressure urticaria
Tight clothing or scratching of the skinDermographism
Towel drying after a hot showerVibratory urticaria
Contact with waterAquagenic urticaria
Substance absorbed through the skin from contact with latex, saliva, flour, meat, fish, vegetables, caterpillar, or stinging nettleContact urticaria
Hives can cause the skin to become very itchy.

What are the signs and symptoms of hives/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.

Types of hives/urticaria

Hives can be categorised according to the duration of each symptom:

Chronic urticaria can be further sub categorised into:

How common are hives/urticaria in Singapore?

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.

Is hive/urticaria a serious condition?

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.

Seek immediate medical attention if you are having an allergic reaction

Are hives/urticaria contagious?

Luckily, hives are not infectious, and you will not contract it from someone with hives — be it airborne or through direct contact.

Are hives/urticaria an allergy?

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.

Can I die from hives/urticaria?

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.

Do hives/urticaria suggest underlying medical conditions?

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.

When should I see my doctor for hives/urticaria?

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:

What do I expect when I see my doctor for hives / urticaria?

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.

Find out the causes and triggers of your hives with a doctor

Is there any treatment for hives/urticaria?

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.

What are the possible complications of hives / urticaria?

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.

Rhabdomyolysis- See Your Doctor Before Your Body Spins Out of Control

A long-term patient of mine recently visited the clinic with an urgent presentation of coca-cola-coloured urine. She also complained of lower back and thigh muscle aches. In view of the unique presentation, the patient herself collected her urine in a bottle and showed it to me. 

Clinically, aside from mild lethargy and muscle aches and pain, she was feeling well. She was concerned about urinary tract infections and kidney stones. What do you think is wrong?

Rhabdomyolysis urine
Dark-coloured urine is one of the symptoms of rhabdomyolysis.

The reasonable thought process would be:
“Is there something wrong with my urinary filtration system’’

 “Is there an issue with my kidney or the bladder?’’

‘’ Do I have a urinary infection or a kidney stone, or even cancer?”’

Upon further history exploration, she stated that she had recently bought a new spin bike to work out at home and was immediately suspected of rhabdomyolysis after this revelation. In recent years, with an increase in spin class popularity and exercise bike workouts, a correlative trend of exercise-induced rhabdomyolysis has been observed– a condition less commonly heard of but can occur to anyone. 

The mention of “spin class” or “spin cycling” is sufficient to alert any experienced doctor about the possibility of rhabdomyolysis. I’m happy to report that the patient recovered uneventfully over time following the prompt diagnosis and treatment. 

What is rhabdomyolysis?

Simply put, rhabdomyolysis is a medical condition in which the breakdown of muscle tissues leads to a spike of protein in the bloodstream, subsequently clogging up the tubes in the kidney and leading to kidney injury or acute kidney failure. 

Clinical explanation of rhabdomyolysis

When the breakdown of the skeletal muscle occurs,  increased protein myoglobulin and creatinine kinase(CK) substances in the bloodstream cause kidney injury or kidney failure. A sudden rise of excessive myoglobulin and creatinine kinase proteins in the bloodstream clogs up the intricate tubing system of the kidneys, leading to kidney injury or acute kidney failure. 

These proteins are usually filtered and excreted through the kidney system. However, with an influx of these particles in the bloodstream, one can develop complications such as acute kidney injury/failure, electrolyte imbalance, heart rhythm abnormalities, disseminated intravascular coagulation (DIC) and other severe life-threatening medical risks.

What is exercise-induced (exertional) rhabdomyolysis?

Exercise-induced rhabdomyolysis in Singapore happens to be a recurring theme amongst spin class goers.

Exercised-induced rhabdomyolysis happens when a person undergoes intense physical exercise leading to a sudden or excessive muscle contraction and breakdown of skeletal muscles. This breakdown subsequently releases skeletal muscle proteins Into the bloodstream. 

How common is exercise-induced rhabdomyolysis in Singapore? 

Exercise-induced rhabdomyolysis
Increased reports of rhabdomyolysis in Singapore following spin class popularity.

Exercise-induced rhabdomyolysis has been more commonly reported in the medical literature since 2004. In Singapore, following the increased popularity of spin cycling classes, more cases of exercise-induced rhabdomyolysis have been seen in the local hospital in recent years.

In 2020, 4 cases were noted locally, while the number of cases of exercise-induced rhabdomyolysis has increased to 10 cases in 2022. Some cases may even be missed as patients may be misdiagnosed as having urinary tract infections following the presentation of blood in the urine. If you suspect that you have developed rhabdomyolysis, please seek medical attention.

What are the signs and symptoms of rhabdomyolysis?

Symptoms to suggest a person has rhabdomyolysis include:

rhabdomyolysis symptoms
Rhabdomyolysis can cause symptoms such as dizziness, lethargy, heart palpitations, and confusion.

What causes rhabdomyolysis?

Rhabdomyolysis can be categorised into exertional (exercise-induced) or non-exertional.

Non-exertional related rhabdomyolysis can be due to:

What are the common medications that can cause rhabdomyolysis?

Do speak to your doctor before considering taking medication to understand the possible side effects and suitable doses of the medications.

Some of the common drugs that can cause rhabdomyolysis include :

What do I expect when I see my doctor for rhabdomyolysis?

Diagnosing rhabdomyolysis would involve a number of steps:

  1. Your doctor will usually go through your medical history, and conduct a physical examination.
  2. A blood test to screen for your kidney function and creatinine kinase (CK) will be ordered. 
  3. A urine test would also be suggested to rule out other potential urinary system causes.
  4. In acute or severe cases, your doctor may refer you to the hospital for further management of the condition.
doctor patient
Always be honest when sharing your medical history with your doctor to ensure an accurate diagnosis and effective treatment.

What are the treatment options for rhabdomyolysis?

Thankfully, most patients with rhabdomyolysis recover uneventfully. The treatment goal involves early fluid resuscitation to maintain normal kidney function or to aid kidney function recovery over time. 

Treatment advice(s) include:

When should I go to the hospital if I have rhabdomyolysis?

If you develop acute symptoms such as feeling generally unwell, muscle aches, lethargy, or acute findings of dark, red, or brownish urine, please seek medical attention. Hitherto, there are no studies that evaluate the safety and any subsequent complication in the management of rhabdomyolysis as an outpatient. It is worthwhile seeing your doctor to get yourself checked and evaluated for further health advice.

You may be required to stay overnight at the hospital for observation due to rhabdomyolysis.

How can I prevent rhabdomyolysis?

There are ways to avoid exposure to the risks of rhabdomyolysis.

These include: 

Frequently asked questions

Can I treat and manage rhabdomyolysis at home?

In mild cases, one may be able to recover from symptoms with increased fluid hydration, though there is a lack of medical guidelines on the safety and possible complications following the management of rhabdomyolysis at home. 

Given the severity and dangers of the condition, self-diagnosis and attempts at self-management for recovery is advised against. If you ever suspect you may be dealing with rhabdomyolysis, please visit your doctor as soon as possible. 

Will I die from rhabdomyolysis?

In severe cases, mortality (death) from rhabdomyolysis is predicted to be at 59%.  However, these are not all exercise-induced rhabdomyolysis. Nevertheless, a risk of mortality does exist. 

Will I recover from rhabdomyolysis?

With prompt diagnosis and treatment, most patients with rhabdomyolysis recover without complication. Hence, you are advised to seek medical attention if you encounter any symptoms to give yourself the highest chance of recovery. 

How fast can I return back to physical activities after rhabdomyolysis?

Your doctor will usually evaluate your individual risk and medical possibilities of delayed recovery before advising you when you can return to your physical activities. Generally, you are advised to return to gradual sports 1-2 months after recovery with adequate rest, fluid hydration, and close monitoring of urine and blood tests.

Pubic Lice, Pubic Crab, Pediculosis and Pthiriasis

Do you have a persistent genital itch or discomfort that does not seem to be going away despite repeated visits to your doctor? Is your partner feeling itchy as well?

You may want to consider broadening your differentials to include parasites that may be thriving and crawling around your genital region. Pubic lice infestation affects between 2 to 10 percent of the human population with outbreaks from as far back as the 1970s.

In this article, we will dive into the unpleasantries of pubic lice. As scary as it sounds, pubic lice can be treated. Do read on.

pubic lice stage
Pubic lice can appear in 3 stages.

What are pubic lice?

Pubic lice, also known as “pubic crab”, are considered parasite infestations that can happen in your genital region.

Pubic lice can appear in 3 stages, these are:

How common is pubic lice in Singapore?

Regardless of your gender, ethnicity, race or socioeconomical standing, pubic lice infestation can affect anyone in Singapore.

Adult Singaporeans commonly infect one another with pubic lice through sexual contact, however, it can spread through close personal contact such as sharing clothing, towels, and linen from someone infected with pubic lice.
If there is pubic lice infestation on a child, especially if seen on their head or eye lashes, this can suggest the possibility of sexual abuse. Although, they could have simply contracted it by sharing clothing, bedding or towels with someone infected with pubic lice.

pubic crab
Pubic lice can be passed on by sharing clothing, bedding, and towels

Where can I find pubic lice?

Pubic lice can be found in your genital region. It is possible to pick out lice in areas of your body where coarse hair is present such as your armpit, beard, eyebrow, eye lashes, legs, or body. If you notice lice on your head, it is most likely due to head lice as opposed to pubic lice.

What are the risk factors of being infected by pubic lice?

Pubic lice are unable to fly or jump, but can climb from the hairs of one person to another. This increases the risk of being infected with pubic lice through the following factors:

What are the signs and symptoms of pubic lice?

Signs and symptoms to look out for if you suspect you have been infected by pubic lice include:

How are pubic lice diagnosed?

Pubic lice are diagnosed by physically pinpointing out louse or nits on the hair in the affected region — your pubic region or other parts of your body. Sometimes a magnifying glass or dermatoscope may be used for a better view of the lice or nits.

magnifying glass
A magnifying glass may be used for a better view of pubic lice.

What should I expect when visiting my doctor concerning pubic lice?

During your doctor’s visit, your doctor will inspect areas of your body with hair. These areas include your genital region, body, armpit, eye lashes, eyebrows, and even scalp to fully screen the possibility of nits and lice. A comb and magnifying glass may be used to facilitate the visualisation of the lice in these areas.

Are pubic lice a Sexually Transmitted Disease (STD)?

Although passed on in a similar manner (through close contact and sexual intercourse), pubic lice are not considered a Sexually Transmitted Disease, but rather, they are a Sexually Transmitted Infection (STI). 

When a visit to your doctor’s office concerns pubic lice, you will most likely be advised to get screened for other types of sexually transmitted diseases and/or genital infections depending on individual risk factors. Your sexual partner will most likely be advised to get the same screening to reduce these risks.

What is the treatment for pubic lice in Singapore?

Thankfully, there is a cure for pubic lice and you do not have to live with this infestation.

Medication in the form of lotions, creams, or shampoos containing malathion, permethrin, pyrethrins or piperonyl butoxide can be used to kill pubic lice. You will be advised to apply the medication on your whole body to fully treat the infestation. This will need to be left on for 24 hours before washing off. You are required to repeat this cycle for a whole week (7 days) to ensure all pubic lice and nits are killed.

For any lice or nits that have made it onto your eyebrows or eye lashes, you will be advised to apply petroleum ointment onto your eyelids for 10 days as an additional treatment.

It is important that your sexual partner(s) also receive treatment to reduce their risk of a cross-infection; even if they are asymptomatic.

All clothing, towels, and bedding should be washed if you have pubic lice infestation.

What should I do after pubic lice treatment?

  1. Wash all clothing, towels and bedding in hot water (> 50℃). These should then be dry cleaned and placed in plastic bags for at least 2 weeks to ensure all lice are dead.
  2. Mattresses should be vacuumed and cleaned to eliminate the presence of lice.
  3. Avoid sharing personal items including combs, razor blades, tweezers, clothing, bedding, or towels moving forward.
  4. If you had more than 1 sexual partner within the past month, they should be traced and informed for screening and treatment of pubic lice. Additionally, they can be screened for the possibility of other sexually transmitted infections.
  5. Avoid sexual contact with others until the end of your pubic lice treatment.
  6. Protect yourself against pubic lice by avoiding close or sexual contact with anyone you know that is infected with pubic lice until they have sought and completed the right treatment.

It is important to know that contraception methods such as barrier contraception are not effective at preventing pubic lice infections.

Can I contract pubic lice by sitting on dirty toilet seats or a couch?

Although it is possible for pubic lice to survive 1 to 2 days without human tissue cells, they generally do not fall off from their hosts unless the host themselves die.

Therefore, it is not possible to contract pubic lice from dirty toilet seats or a couch. This is because pubic lice rely on human tissue cells for survival and they will not be able to stay alive on other surfaces for long without live cells.

Pubic lice also do not posses the abilities to fly or jump, only climb from one person to another through close or sexual contact.