IF YOU MUST GO TO BANGKOK, TAKE YOUR SPOUSE ALONG!

The heading of this article must sound strange but I have been pushed to write this article after another of my patients came back from Thailand, all stressed out and looking depressed. This young man had gone to Thailand with a few of his friends and had had a “regrettable” encounter with a commercial sex worker! During the course of my 25 yrs as a doctor, I have seen many a good man being remorseful after coming to his senses and (out of his alcohol or drug induced fugue) filled with guilt and fear on returning to his wife and life in Chennai. I write this article for the benefit of someone planning on being naughty on a holiday and hopefully, to give you enough information to help you stay safe during your trip.

What are the common sexually transmitted infections?

Syphilis, Gonorrhoea, Chancroid (Bacterial infections), Lymphoma granuloma venereum (Chlamydial infection), HIV, Genital herpes (HSV), Genital warts (HPV) (viral infections) and Trichomonas vaginalis (protozoal). Hepatitis A, B, C and pubic lice can also be transmitted during sex. HIV chlamydia and gonorrhoea are transmitted by sexual (body) fluid, HIV and Hepatitis B are transmitted via blood and Genital herpes, papilloma viruses and Syphilis are transmitted by skin to skin contact. Except for HIV, all STIs are curable if detected.

What are the risks of transmission of STD after a single heterosexual encounter?

The risks for women are much higher than it is for men. Syphilis has a 50-65% risk per sexual act, Gonorrhoea has a 20% risk for men and 60-90% risk for women to catch an STI after a single unprotected sexual act. Chlamydia has a 4.5% risk per sexual act and Mycoplasma has a 20-65% risk. HPV and genital warts are transmitted 4% for men and 3.5% for women after a single sexual act. The risks for HIV transmission is 0.05-0.1% for men and 0.08-0.19% for women after a single act. Receptive anal and vaginal intercourse has a 10 fold increased risk of infection transmission compared to Insertive anal and vaginal intercourse. Luckily the risk of catching HIV is a lot lower than for other infections. You should consider all sexual encounters with people not known to you in a foreign country as a high risk (for infection) encounter. Receptive Anal/Vaginal sex is more dangerous for catching an STI compared to Insertive sex and oral sex!

How soon will you see the effects if you catch any of the common infections?

Different infections have different incubation periods ( the time taken for the first symptom after entry of the pathogen into the body i.e., infection).

So what symptoms should you look for in case you have had an unprotected sexual encounter?

Common symptoms to look out for are Genital ulcers, enlarged lymph nodes in the groin, urethral discharge with burning on urination, vaginal discharge and fever, body aches, joint aches, headaches and rash etc. Most symptoms would show up a few days to upto a month after unprotected intercourse.

What tests are useful in the diagnosis of STIs?

Swabs from ulcers, from mucous membranes of the penis, vagina and mouth. Serological tests (to check for antibodies to certain infections) can be done for Chlamydia, syphilis and for HIV.

For syphilis, TPHA and FTA-ABS can be done. Nuclear antigen amplification tests or PCR can be done for HIV, Chlamydia, Chancroid, Gonorrhoea, Herpes, Trichomonas, Candida and bacterial vaginosis can be done. Biopsy can be done for genital warts.

What antibiotics are useful after unprotected sexual intercourse?

Azithromycin 1gm stat will treat Chlamydial infections and Chancroid.

Doxycycline 100mg twice daily for 14 days for Syphilis and Donovanosis.

Valacyclovir 1gm twice daily for 10 days for Genital Herpes.

Fluconazole 200mg at night for 3 days for Candidal infections.

Metronidazole 500mg twice daily for 7 days for Trichomoniasis.

Inj. Ceftrioxone 500mg IM stat for Gonococcal infection.

Inj. Benzathine penicillin 2.4 MU IM stat for primary syphilis.

Taffic (Bictegravir 50/Emtricitabine 200/Tenofovir Alafenamide 25) once daily or Viropil (Dolutegravir 50/Lamivudine 300/Tenofovir Disoproxil fumarate 300) once daily for 28 days, to be started as soon as you suspect that you may have caught HIV infection.

How do you protect yourself from catching a STI/STD?

1. Avoid going to places of temptation in the first place. If you must, take your spouse along with you!

2. Avoid mixing alcohol and drugs with sex. These substance will reduce your inhibitions and fear and make you do things that you wouldn’t do if you were in your senses.

3. Limit the number of sexual partners.

4. Use barrier methods of contraception. Use condoms, oral dams etc and avoid skin on skin contact and exchange of body fluids. Oral sex isn’t safe!

5. Get to know your partner before hand and if possible have an honest talk about previous sexual contacts, sexual habits and preferences and history of previous STIs.

6. Get yourself vaccinated against all possible sexually transmitted infections such as Hepatitis A and B, Human Papilloma virus etc.

7. Test yourself regularly especially if you have had numerous sexual contacts with multiple partners.

To sex or not to sex, that is the question you need to ask yourself! (All pun intended) If you choose to have sex, take all necessary precautions. If you have had unsafe sex or if you can’t remember, see your doctor as soon as you return and start relevant prophylactic medicines (as no test will be positive in early infection especially when you are asymptomatic).

So plan now and don’t regret later.

Male Sexual Dysfunction

Male sexual dysfunction includes the following: decreased Libido, Erectile dysfunction (ED), ejaculatory disorders and disorders of orgasm. All types of sexual dysfunction increase with age.

Libido is the medical term for sexual drive or the desire for sex and decreased libido can occur in 5-15% of adult males. Libido is influenced by biological, psychological and social factors. Sex hormonal levels, stress and depression, endocrine conditions such as hypothyroidism, drugs such as antidepressants,antipsychotic, opioids, beta blockers, substances such as smoking and alcohol can affect libido.

Erectile dysfunction refers to the inability to attain and maintain a sufficiently rigid penis to permit penetrative sexual intercourse. It is very common and is estimated to affect 50% of all men between the ages of 40-70 yrs sometime during their lifetime. Common causes for ED are Vascular (arterial and venous), neurogenic, hormonal and psychogenic. Erections are Neuro vascular events provoked by thoughts, visual images or dreams.

Erections start when the mind is stimulated by erotic thoughts, visual stimuli or sounds. These electric discharges from the brain stimulate the erection centre in the lower spinal cord (segments T11-L2). Impulses generating from this area, stimulate vasodilation of the blood vessels flowing into the penile muscles. Rapid filling of the penis leads to compression of the penile veins until it leads to the attainment of an erection. When nitric oxide (vasodilatory mediator) is metabolised and also in stimulation of the Noradrenaline system, vasoconstriction occurs and the blood flow into the penis is reduced with subsequent drainage of blood out of the penis and loss of erection (detumescence). Therefore attaining an erection requires appropriate Mental and psychological function, intact neurological pathways, open blood vessels and hormonal activities. Erections can also happen to penile stimulation and spontaneously during sleep (normally 3-4times per night)

Ejaculatory disorders could be premature ejaculation, retrograde ejaculation, delayed ejaculation, anejaculation and anorgasmia. Premature ejaculation refers to when the man ejaculates within a minute of vaginal penetration or sooner than desired. It can occur in upto 30% of men. Retrograde ejaculation refers to backwards discharge of semen during intercourse into the bladder which then comes out during urination. This is one of the causes for infertility and may not require treatment unless fertility is desired. Ejaculation occurring after a reasonable period of sexual activity is called delayed ejaculation. Anejaculation is when there is no ejaculation after sexual stimulation and may be associated with anorgasmia.

What is required to find the cause for male sexual dysfunction?

1. A thorough medical history including a history of diabetes, hypertension, prostate disease, obesity, dyslipidaemia, depression, chronic kidney disease, sleep apnoea, substance abuse and medications (including off label medications) used. A detailed sexual history of the patient, including that of sexual preference, frequency of dysfunction and the circumstances associated with dysfunction needs to be elicited. History of injury to hip or genitals or pelvic surgery may be causative. A history of spontaneous erections occurring at night would make a vascular or neurological disease unlikely and a psychological cause more likely.

2. A thorough medical examination including examination of the genitals and a rectal examination to examine the prostate gland would be needed.

3. A thorough psychological assessment by an experienced counsellor.

4. To do appropriate tests such as general screening tests (CBC, ESR, RFT-E, LFT, Lipid profile, Hba1c, urine complete, stools complete and an ECG. More specific tests might include Thyroid function tests, Testosterone and LH assays, Penile Doppler and Ultrasound whole abdomen and Rectal ultrasound in select cases.

There are 5 broad categories that cause male sexual dysfunction. They include 1.Systemic diseases such as Diabetes, hypertension, heart disease, chronic kidney disease, 2.Psychological causes, 3.medicines (25% of all causes) 4.endocrine disease such as thyroid dysfunction and androgen deficiencies and 5.Neurological causes such as spinal cord diseases, multiple sclerosis and dementia.

Commonly prescribed medicines that can cause sexual dysfunction in men are:

1. Antidepressants – SSRIs

2. Antihypertensives medications: Betablockers, Amlodepine, Chlorthalidone, Enalapril and Doxazosin.

3. Antiandrogens – Androgen deprivation therapy

4. Others- Clonidine, methyldopa, ketoconazole and Spironolactone.

Treatment of Male sexual dysfunction

1. Lifestyle changes – advice patient to stop using recreational drugs including alcohol and cigarettes and help him with Deaddiction. Weight loss and physical activity will also help improve the situation.

2. Professional counselling – counselling patient with partner by a sex therapist may be helpful.

3. To stop medicines that can cause sexual dysfunction.

4. To correct androgen deficiencies and other endocrine disorders ( Thyroid, Prolactin and Estradiol). To stop antiandrogens including Finasteride and Dutasteride if possible.

5. To provide a prescription for a phosphodiesterase 5 inhibitor – Sildenafil, Tadalafil etc.

6. To consider surgery – penile prosthesis

7. Other therapies – use of a vaccine device, intraurethral alprostadil suppository etc. Premature ejaculation can be treated with counselling and use of Lignocaine/Prilocainegel on penis before intercourse.

Patient stories: One gentleman who was 70 yrs old and was on treatment for benign prostatic hypertrophy on Urimax F (Tamsulosin and Finasteride) came to me with a history of erectile dysfunction. I suggested that he change his Tamsulosin to Alfuzocin, stopped the Finasteride and also gave him a prescription for Tadalafil.

Patient 2 was a 50 year old who was on SSRI antidepressant and who reported loss of libido. I asked him to change his Escitolopram to Mirtazapine with good effect.

Patient 3 was a retired banker who had had presented with dullness, slurred speech and memory deficits. Investigations had shown low sodium, hypopituitarism, hypogonadism and atypical tuberculosis.1 yr after recovery he was started on Testosterone injections for lack of libido and ED and reported good improvement in his complaints.

Male sexual dysfunction has many effective therapies but often needs a multidisciplinary approach to providing the best care.