Urethral Discharge: Is it Urethritis?

Urethritis is typically a sexually transmitted infection, but not always. It can be divided into gonococcal urethritis (GU) and non-gonococcal urethritis (NGU).

Gonoccal urethritis is caused by the bacteria Neiserria gonorrhea, while NGU can be caused by other bacterias include Chlamydia, Ureaplasma, Mycoplasma and even syphilis etc.

Both GU and NGU usually produce similar symptoms, though some infected people does not have any complains. The most common symptoms are:

• urethral /vaginal discharge
• urethral/ vaginal itchiness / pain
• dysuria (pain when passing urine)

Due to certain sexual practice, patients may also have symptoms (pain and discharge) at the pharynx, anus or rectum.

Sometimes the infection may spread to the adjacent organs such as bladder (cystitis), testis (orchitis), epididymis (epididymitis), cervix (cervicitis), ovary (oophroritis) etc.

     Urethral discharge from tip of penis

Useful investigation:

• urethral discharge swab
• gram stain (GU - intracellular gram negative diplococci)
• culture & sensitivity (modified Thayer Martin culture)
• nucleic acid amplification test (NAAT)
• urine
• FEME/culture (not very useful)

Treatment (CDC 2010 guidelines):

Since GU and NGU commonly co-exist. It is preferable to cover both condition when treatment for urethritis is give.

Uncomplicated GU

• IM ceftriaxone 250mg single dose OR
• T cefixime 400mg single dose OR
• T cefuroxime 1g single dose

Plus (for NGU)

• T azithromycin 1g single dose OR
• T doxycycline 100mg bd for 7 days

Contact tracing should be done. Those who has recent sexual contact with patients should be treated, even if they are asymptomatic.

Various Types of Hair Loss

Normal human hair grows in a cycle consists of 2 phases: growth phase and rest phase.

In growth phase (anagen) which lasts for 2-3 years, the hair grow about 1cm a month. After that, it enters rest phase (telogen) which lasts for 3-4 months. During rest phase, hairs stop to grow. At the end of rest phase, the hairs will fall and a new cycle of growth phase will begin. A person normally shed 50-100 hairs a day.

Causes of hair loss:

• aging
• 40% of men by 35 years old and 65% of men by 60 years old have noticeable hair loss
• 50% of women by 50 years old have noticeable hair loss

• genetic 
• more prone to develop hair loss if one of your immediate family has it

• poor nutrition
• iron, zinc or protein deficiency

• medication
• warfarin, fibrates, anti-acne, ACE-inhibitor, calcium-channels blockers, allopurinol, anti-thyroid drugs, epilepsy drugs, birth control pills etc

• male-pattern baldness (androgenic alopecia)
• hair loss at both temporal areas & the top
• treated with oral finasteride / topical minoxidil

• female-pattern baldness (androgenetic)
• hair thinning at the mid-line top
• treated with oral anti-androgen / topical minoxidil

• telogen effluvium 
• hair growth enters into telogen phase prematurely, triggered by body insult / stress such as: emotional/physical stress, surgery, starvation, high fever, serious illness, extreme diets, childbirth etc
• hair loss starts 3-4 months after the stress event
• reversible after the stress factors subside

• anagen effluvium
• caused by chemotherapy drugs where actively growing hairs at anagen phase are most affected

• tinea capitis (scalp fungal infection / ringworm)
• itchy red scaly scalp with patchy hair loss
• treated with topical anti-fungal 

• alopecia areata
• autoimmune disorder with exact cause unknown
• non-scarring patchy hair loss
• may regress (hair grow back), recur or progress to total baldness
• treated with topical steroids/minoxidil or monthly steroid injection

• cicatricial alopecia (scarring)
• caused by inflammation and damage to hair follicles
• patchy and permanent hair loss
• associated with SLE and lichen planus

• traction alopecia
• caused by regular use of hairstyles that tightly pulling the hair
• patchy hair loss and non-permanent hair loss

• hormonal changes
• hyper- or hypothyroid
• diabetes
• childbirth / menopause

• excessive hair styling
• chemicals used & over-styling

• trichotillomania
• a mental disorder with irresistible hair-pulling
• patchy bald areas

Abnormal Menstrual Bleeding

An ideal menstrual cycle lasts for 28 days, with the first day calculated from the onset of menstrual bleeding and ovulation is at day-14 of the cycle. Normal menstrual cycle has a mean interval of 21-35 days, with a duration of 2-7 days and 30-80ml menstrual bleeding. 

Anything outside these range may be viewed as abnormal. These can be:

• menorrhagia: excessive (>80ml/day) or prolonged (>7 days) bleeding
• polymenorrhea: menstrual bleeding interval <21 days
• oligomenorrhea: menstrual bleeding interval >35 days
• metrorrhagia: irregular and more frequent menstrual bleeding
• metromenorrhagia: irregular, more frequent and excessive bleeding
• dysmenorrhea: excessive menses pain
• amenorrhea: absent of menstrual bleeding for >6 months
• intermenstrual bleeding: bleeding/spotting in between regular menstrual cycles
• postmenopausal bleeding: bleeding after >6 months menopause

Important causes of abnormal menstrual bleeding that need to be ruled out:

• Pregnancy and its related complication

• Gynecological pathology

• Benign lesion
• uterine fibroid/polyp
• cervical polyp
• adenomyosis
• polycystic ovary syndrome

• Non-benign lesion
• uterine cancer
• ovarian cancer
• cervical cancer
• vaginal cancer
• endometrial cancer
• endometrial hyperplasia

• Pelvic inflammatory disease
• cervicitis
• salpingitis
• endometritis

• Trauma
• cervix
• vagina
• vulva

• Endocrine disorders
• Hyperthyroidism
• Hypothyroidism
• Hyperprolactin

• Blood clotting disorders
• Thrombocytopenia
• Von-Willebrand's disease
• Coagulopathy

• Iatrogenic
• Oral contraceptive pills
• Intrauterine contraceptive devices
• Medication
• anti-coagulants

• Dysfunctional uterine bleeding (diagnosis of exclusion in the absence of organic disease)
• Stress / Excessive exercise etc.

Dysfunctional uterine bleeding is more common in the extremes of reproductive age, which are the first 2 years after the onset of menses (menarche) and a few years before the termination of menses (menopause). About 90% of the abnormal bleeding is anovulatory, in which there is no ovulation within the cycle because of certain disruption in the hypothalamus-pituitary-ovary axis.

Important investigations for abnormal uterine bleeding

• pregnancy test
• pelvis ultrasound scan
• blood test: platelet, coagulation, thyroid function, prolactin
• hysteroscopy
• endometrial sampling/biopsy

     Endometrial biopsy

The treatment depends on the underlying cause of abnormal bleeding. If no organic disease can be found (dysfunctional uterine bleeding), treatment available includes:

• Tranexemic acid
• NSAIDs
• Danazol (ethisterone)
• GnRH agonists
• Combined oral contraceptive pills
• Progesterone only pills
• Intrauterine devices with progesterone
• Endometrial ablation (if future pregnancy not wanted)
• Hysterectomy (if future pregnancy not wanted)

Why is My Platelet Count Low?

Sometimes you just go for a routine blood test and you are told that your platelet count is abnormally low. The doctor may ask you whether you have easy bruising, red dots on your skin (petechiae), delayed blood clotting or spontaneous bleeding. You may or may not have these problems. What actually cause your platelet to be low?

Platelet is one of the 3 major types of blood cells produced in the bone marrow, besides red blood cells and white blood cells. Platelet is important in the process of blood clotting. If your platelet count is too low or not functioning, then you may have easy bleeding problem. The medical term of low platelet is thrombocytopenia.

      red cell, platelet, white cell

Normal range of platelet count is between 150,000-450,000/mcL. If you find that your platelet count is low for the first time and you do not have any symptoms, you can repeat the test as sometimes during blood taking and processing, the platelets may clump. If 10 platelets clump together, the machine may read it as only one platelet.

Though platelet count <150,000/mcL is considered low, it usually will not cause bleeding problem as long as their function is not affected. Spontaneous bleeding may be a concern if the count is <20,000/mcL.

There are many possible causes of thrombocytopenia. They can be classified into 3 large groups.

1. Reduced production in bone marrow
2. Increased destruction (by immune system or not)
3. Splenic sequestration (due to enlarged spleen)

The list below are not comprehensive, only the important and common ones listed.

• Reduced production in bone marrow

• some viral infection (HIV, EBV, parvovirus, mumps, rubella, varicella, dengue)
• some medication (thiazides, phenytoin, valproate)
• alcohol
• chemotherapy
• radiation to the marrow
• leukemia
• lymphoma
• cancer infiltrating the bone marrow 
• vitamin B12/Folic acid deficiency

• Increased destruction

• Idiopathic Thrombocytopenic Purpura (ITP)
• Autoimmune diseases (Systemic Lupus Erythemathosus)
• Drugs-induced (heparin, sulfonamides antibiotics, quinine, quinidine, carbamazepines, digoxin, paracetamol / acetaminophen)
• Sepsis (severe systemic infection)
• Disseminated Intravascular Coagulation (DIVC)

• Platelet sequestration

• chronic liver disease (cirrhosis)
• leukemia
• lymphoma

If you have thrombocytopenia, you should check the numbers of your red and white blood cells. If they are normal, then it is less likely that the whole bone marrow is affected. The doctor will ask you some questions to find out any relation to the causes listed above, such as the medication you take, whether you have recent infection, your alcohol consumption, hepatitis status and other associated symptoms etc. 

      petechiae can be a sign of low platelet

A peripheral blood film / full blood picture should be done to see the size, shape and characteristic of all 3 types of blood cells. Sometimes a bone marrow aspiration may be done to rule out abnormality in the marrow. If no cause can be found after extensive investigation, and the platelet count is persistently low, steroid treatment may be given as a trial. If the platelet count increase significantly after steroid treatment, then it is likely to be idiopathic thrombocytopenic purpura, where the low platelet count is caused by immune system mediated platelet destruction.

Urticaria: A Common Problem

Urticaria, hives or wheals are raised, pink or red skin lesion that are usually associated with allergy. The lesion can be generalized or localized at certain body parts. It is a fairly common problem that everyone will experience in their lifetime. Some are mild, but some can be serious.

When the mast cells are stimulated by allergens, they release certain chemical mediators such as histamine etc. These mediators result in the dilation of the small blood vessels in which fluid will leak out from the vessels into the tissues under the skin, causing the swelling in urticaria and the itchiness.

       Urticaria rash

Urticaria can be classified into a few types depends on its clinical manifestation

• acute (last<6 weeks)
• chronic (last>6 weeks)
• episodic (acute & intermittent)

Common causes of acute urticaria are allergy to certain foods or medication, insects bite and viral infection esp in children. The urticaria emerges within few minutes to few hours after the contact with allergens and typically goes away within a day.

If the urticaria does not really goes away and persist for more than 6 weeks, then it is called chronic urticaria. The causes for chronic urticaria are more complex and may overlap with causes of acute urticaria. 

Causes of chronic urticaria include:

• Physical
• dermatographism
• pressure
• cold
• heat, exercise, stress (cholinergic)
• sunlight
• water (aquagenic)
• vibration

• Food consumption (milk, nuts, eggs, seafood etc)

• Insects bite/sting (scabies, bedbugs, fleas etc)

• Contact urticaria (latex, animals, foods etc)

• Medication and drugs
• aspirin
• NSAIDs
• ACE-inhibitors
• opioids
• alcohol

• Autoimmune conditions 
• urticarial vasculitis
• systemic lupus erythematosus (SLE)
• autoimmune thyroid disorders
• rheumatoid arthritis

•  Infection
• hepatitis B
• mycoplasma
• streptococcus
• herpes simplex virus
• helicobacter pylori
• mycobacterium tuberculosis

• Chronic idiopathic urticaria (no cause can be found)

The actual cause for chronic urticaria is not easy to determine accurately. History from the patients is important and it can suggest physical, medication and food related urticaria. For example if the urticaria rash appears after a hot bath, then it is likely a cholinergic urticaria. Physical challenge can be done if physical cause is suspected.

       Papular urticaria

Laboratory tests are mainly done to rule out the presence of autoimmune disorders in chronic urticaria. Acute episode usually does not need any test. Tests that can be done include complete blood and differential count, ESR, CRP, IgE, ANA, RF, complement, thyroid function and its autoantibodies. Skin biopsy is beneficial only if urticarial vasculitis is suspected. 

The type of tests to be done depends on clinical evaluation by the doctor. If no cause can be found after thorough examination and investigation, the urticaria is referred to as chronic idiopathic urticaria.

Most common and useful treatment for urticaria is oral non-sedating anti-histamine (2nd or 3rd generation). If anti-histamines do not work well, other types of medication can be tried. If you know what is the most likely precipitating cause, then try your best to avoid it. Sometimes chronic urticaria may improve after a few years.