How to check for HIV

Human Immunodeficiency Viruses (HIV) are two species of Lentivirus that can infect humans. If left untreated in the body, over time, they cause progressive failure of the immune system. As a result, life-threatening opportunistic infections and cancers can occur. This late stage of HIV infection is termed Acquired Immunodeficiency Syndrome (AIDS).

HIV is spread through contact of infected bodily fluids through mucous membranes, broken skin or wounds. Most people who get HIV get it through anal or vaginal sex, or sharing needles, syringes, or other drug injection equipment. HIV can also be transmitted from a mother to her baby during pregnancy, birth, or breastfeeding. However, because of advances in HIV prevention and treatment, it is possible for spread and infection to be mitigated.

There are a few ways that a person can test for HIV.

The most common test that is done is an antibody test. The antibody to HIV is only produced if you have been previously exposed to HIV before. Therefore, if you have the antibody to HIV, it is likely that you have been exposed to HIV at some point in time in your life. We can test for the HIV antibody from a blood sample, or from a sample of cells taken with a swab from inside your cheek. The HIV antibody test is commonly done together with a p24 antigen test. This combination testing is commonly termed a 4th generation HIV test. The p24 antigen is a distinctive HIV antigen; a structural viral protein makes up most of the HIV viral core, or ‘capsid’. Again, it will only be present in your blood if you have previously been exposed to HIV. If the doctor sends your blood to a laboratory, it is likely they use a technique known as ELISA/EIA (enzyme-linked immunosorbent assay/enzyme immunoassay). An antibody test or a 4th generation test can also be done as a rapid, point-of-care test, where all we need is a small amt of blood and 20 minutes wait time.

You might also have heard of a western blot test. A western blot is a different technique that laboratories use to test for HIV antibodies in a person. A western blot is usually used to confirm a positive ELISA/EIA result.

There are also tests which test for the HIV virus itself. This is termed a HIV PCR RNA or HIV viral load. This test can tell the doctor the concentration of HIV virus in a person’s blood. This test is also used to monitor how effective medications are in a HIV-positive patient undergoing treatment. This test is usually more expensive than the other investigations.

Window Period For HIV

The window period is time between HIV infection and the point when the test will give an accurate result. During the window period a person can have HIV and be very infectious but still test HIV negative. It is difficult to say exactly when the best time to test for HIV is, but in general, we can test for HIV as early as 10 days after exposure with a viral load test. For combination antibody testing, the result is usually deemed definitive 4-6 weeks after exposure.

If you feel that you might have been exposed to HIV, see your doctor early and the doctor can advise you on your risk, the best time to test and the type of test that is necessary. Also remember to practice safe sex to reduce your risk of contracting not just HIV, but other sexually transmitted infections as well.

 

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Risk of HIV Transmission Through Blowjob

A recent news report by Channel News Asia titled “HIV-positive man who donated blood during pandemic faces charge of lying about sexual history” may have caused some concern in the community with regards to the issue transmissibility of HIV through oral sex.

Based on the report, people may wonder just how transmissible is HIV via oral sex and how does it compare to other forms of sexual practices like vaginal sex.

Sexual Practice and HIV Transmission Risk

Based on the Department of STI Control Clinic in Singapore, the table below summarizes the risk of transmission of HIV based on the type of sexual practice.

Sexual PracticeEstimated risk of HIV transmission from a known HIV-positive individual not on effective HIV treatment

 

Receptive vaginal sex10 per 10,000 persons
Insertive vaginal sexAbout 8 per 10,0000 persons
Performing oral sex< 1 per 10,000 persons
Receiving oral sex< 1 per 10,000 persons

 

Can HIV be transmitted via oral sex yes, but the risk is roughly 10x less likely than vaginal sex.

 

So when is there no risk of HIV transmission?

  • Breathing the same air as someone.
  • Touching a toilet seat or door knob.
  • Drinking from a water fountain.
  • Hugging, kissing or shaking hands (although kissing may transfer fluids the level of virus in saliva is so low as to make the risk negligible).
  • Sharing food or utensils.
  • Sharing gym equipment.
  • Skin to skin contact with an HIV positive person even if they happen to have fluid of unknown origin on them (particularly applies to commercial sex workers).
  • Biting or scratching that does not break the skin or draw blood

 

How can we reduce risk of HIV transmission?

  • Monogomous relationship
  • Avoid casual sex or paid sex
  • Always use condoms
  • Regular testing if you are at risk – protect yourself and your loved ones

 

There are no way to know your HIV states unless you go for a HIV Test.

 


 

 

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Which STD Tests Should I Get In Singapore?

STD screening can be a confusing topic for many. For anyone who is sexually active, getting tested for STDs should be part of your regular health screening to protect yourself.

People often only get tested when they show symptoms, or if they have had recent new sexual partners whose health or infection status they are unsure about. However, individuals who are asymptomatic and with no specific sexual exposures of concern should still undergo routine STD screening.

Here are some of the screening recommendations suggested by the US Centers for Diseases Control and Prevention (CDC).

WhoRecommended testing Recommended interval
All adults between ages 13-64HIV screeningAt least once in lifetime
All sexually active women under 25Chlamydia and Gonorrhea testingAnnual
All sexually active women 25 and aboveChlamydia and Gonorrhea testingIf you have had new partners

If you have had multiple partners

 

If your partner has had an STD

All pregnant womenSyphilis, Hepatitis B and HIV testing

 

Chlamydia and Gonorrhea testing if you may be at risk of these

Early in pregnancy and repeated as required
All sexually active MSM (men who have sexual intercourse with men)Chlamydia, Gonorrhea and Syphilis testing

 

At least annually

 

More frequent testing (e..g 3-6 monthly intervals) is recommended for individuals with multiple partners or partners whose infection status’ they are unsure of

HIV testing3 to 6 monthly
Anyone who has had unsafe/unprotected intercourseHIV testingAt least annually

 

The above general recommendations detail the minimum sexual health testing that one should undertake as part of one’s routine screening. The types of tests recommended ultimately depend on your individual situation and symptoms.

If you have any reason to believe or be concerned about exposure to any STDs, or if you are having symptoms suggestive of an STD, a more thorough screen may be warranted. If you wish to find out more about STD screening, you can have an open conversation with your doctor about your sexual history and any possible concerns or symptoms you may have. Your doctor will then be able to best advise you on what relevant screening you can undergo.

 

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What Are Pubic Lice (Crabs) & How Do You Get Them?

Pediculosis Pubis is an infestation by the crab louse, Pthirus Pubis. Also known as “crabs”, pubic lice infestation is a relatively common but unreported sexually transmitted disease (STD) and it is estimated that 2% of the world population has had this infestation prior.

Pthirus Pubis

The crab louse is a small, translucent parasite around 1mm in length. It is one of the 3 species of lice that infects humankind and is differentiated by its almost round body. Crab Lice is exclusively found on human hosts and requires human blood to survive. As its name suggests, it is usually found in the hair at the pubic region but it can also be found in other coarse hair of the body, like eyebrows, armpits, beards for example.

Symptoms

The main symptom of a pubic lice infestation is intense scratching, typically at the pubis and the perineum. There can be also pale bluish discoloration of the skin following prolonged infestation as a result of injection of lice salivation during feeding.

When the eyelashes are involved, there can be crusting/matting of the eyelashes with eye irritation as well. Children might be seen continuously rubbing their eyes.

Thankfully, pubic lice are not known to be any vectors of any harmful diseases, unlike the body lice.

Diagnosis

Diagnosis is usually made by direct visualization of the lice or nits (lice eggs) by the patient or the doctor. No other blood tests or swabs are required.

Transmission

Transmission is usually during sexual contact with skin to skin contact.

Transmission via the environment, for example through clothing, towels or linen may also occur but are less common.

One is unlikely to catch pubic lice from a toilet seat as the organism gravitates towards a warm environment and is not adapted to crawl on smooth surfaces.

Treatment

Topical medication is available for treatment of pubic lice and a few applications might be required for complete eradication.

Shaving of the affected area is not required but the manual removal of nits with a nit comb or tweezers is recommended.

It is also important for close sexual contacts of the affected patient to be screened for pubic lice infestation as well. Abstinence is also recommended until re-examination to rule out persistent infection.

Bedding and clothing of the affected patient should also be machine washed in hot water and dried. There is no need for fumigation of the entire room.

 

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How to Test for Oral STDs

It is a common misconception amongst both men and women that oral sex (i.e. fellatio, cunnilingus, and analingus) is completely risk-free when it comes to infections. While oral intercourse is often thought to be a safer option compared to penetrative intercourse or conventional sex, the reality is that a variety of STDs can still be transmitted through direct contact with the mouth, lips, tongue or throat.

As such, it is important to monitor for symptoms of these infections as well as proactively test if there is a potential exposure risk, especially as a large proportion of these infections can be asymptomatic, or have symptoms that develop much later.

The most common infections transmissible through oral sex are Chlamydia, Gonorrhea, Herpes Simplex Virus (HSV), and Human Papillomavirus (HPV), and Syphilis. In this article, we will be outlining some of the common symptoms seen with these infections as well as how they can be tested.

Chlamydia and Gonorrhea

These are two of the most common STDs seen globally, and are caused by the bacteria Chlamydia Trachomatis and Neisseria Gonorrhea respectively. They will usually infect the genital region, urinary tract, anus, and oral cavity, although other sites of infection have been noted as well. While symptoms such as sore throat and throat discharge may be present in some individuals, up to 70-80% of throat infections with chlamydia and gonorrhea may be asymptomatic and a large portion will remain undiagnosed and untreated.

The most accurate method of testing for throat chlamydia and gonorrhea infections will be with Polymerase Chain Reaction, or PCR testing – this looks for specific genetic sequences from the DNA of these bacteria. Standard bacterial cultures are usually insufficient to pick up these infections.

Herpes Simplex Virus

There are two main types of HSV infection. Type 1 HSV is more commonly seen, and can be spread through both oral-to-oral transmission such as kissing, as well as oral-to-genital transmission. Type 2 HSV is more typically seen through genital-to-genital transmission, although it can also be spread to the mouth, tongue, and throat through oral sex. These viral infections can cause outbreaks of painful ulcers or cold sores at the site of transmission, and infection is carried lifelong. There is risk of transmission of these infections even without symptoms.

Testing for herpes infections can be performed either with blood serology testing or via PCR testing if there are symptomatic lesions. Serology or antibody testing will only be able to detect possible past exposure 1-3 months after transmission, and is not useful to detect new or acute infections.

Human Papillomavirus

HPV infections are one of the most common prevalent STDs worldwide. There are many subtypes of HPV, usually divided into low-risk and high-risk categories. Low-risk types include type 6 and 11, which are responsible for about 90% of genital warts or papillomas – these are benign, cauliflower-like growths on the skin and mucous membranes that can develop weeks to months after initial transmission. High-risk types include type 16, 18, 31, 33, 45 etc. and are more related to cancer risk, including cancers of the cervix, anus, penis, and mouth/throat. It is estimated that approximately 20,000 HPV-associated oral cancers are diagnosed per year in the US alone.

Warts from HPV are usually diagnosed clinically and do not require any specific testing; however, high-risk HPV infections are usually asymptomatic and would require PCR testing to be detected. Guidelines currently recommend women over the age of 30 to do regular HPV PCR testing together with their pap smears, and for men who have receptive anal sex to screen for rectal HPV if they are HIV positive. While oral HPV testing can be performed with the same type of test, there are no specific recommendations to do so, with the costs and benefits of the test to be determined by the individual and their doctor. HPV infections can be prevented with the HPV vaccine, which is now available for both males and females 9 years of age and older.

Syphilis

Syphilis infection is caused by the bacterium Treponema Pallidum. While incidence of syphilis had initially decreased with the availability of penicillin treatment in the 1940’s, rates of infection have been rising steadily for the past two decades, and it is commonly seen as a co-infection with Human Immunodeficiency Virus (HIV). Syphilis infection can be spread through direct contact to mucous membranes and compromised skin from an infected sore or chancre, usually at the genital region, anus, and mouth; it is estimated that around 20% of syphilis infections are transmitted through oral sex alone. Symptoms will depend on stage of infection at presentation, and can include sores or ulcers in primary syphilis, and a diffuse rash in secondary syphilis. Many cases are not detected when symptomatic and may be considered in the latent stage when screened on blood testing, or may even reach the tertiary stage many years after initial infection – this can cause complications with the heart and blood vessels (cardiovascular system), or with the central nervous system (neurosyphilis).

Syphilis testing is mostly performed with serological tests, which look for certain antibodies in the blood that can be detected 2-5 weeks after infection. Other forms of testing include dark-field microscopy, direct fluorescent antibody, and PCR testing; however, these are rarely performed in the clinical setting due to cost and availability of equipment and experienced lab personnel.

 

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Symptoms of Sexually Transmitted Diseases in Women

Sexually transmitted diseases (STD) are a major issue amongst women of any age. They may lead to a variety of complications as they can affect the reproductive health of women if left untreated. Therefore, it is important to recognize their symptoms and the need for early medical review and treatment cannot be emphasized strongly enough.

Some of the STDs are caused by:

1) Human papillomavirus
2) Chlamydia trachomatis
3) Neisseria gonorrhoea
4) Genital herpes
5) Trichomonas
6) Mycoplasma genitalium
7) Syphilis
8) HIV
9) Hepatitis B
10) Hepatitis C

It is important to note however, that many people with STDs do not know that they carry the infection. This is called asymptomatic infection. Therefore, even if you have no symptoms and are concerned about an exposure that may have been high risk (e.g. unprotected sex, a recent STD diagnosis in a partner, substance or alcohol use during sex or having multiple sexual partners), then STD tests should be performed to rule out asymptomatic infection.

Symptoms that may suggest that you have STD are as follows:

1) Abnormal vaginal discharge

Any discharge that is unusual for the woman such as a change in quantity, consistency, colour (yellow to greenish) and if there is blood mixed in may indicate an infection.

2) Vaginal itch

This is usually felt externally in the vulva area and may indicate an infection within the vagina.

3) Abnormal vaginal odour

A malodorous discharge or odour without discharge may be abnormal and can be caused by STDs.

4) Vaginal discomfort, pain or burning sensation

This can range from a mild discomfort to full-blown pain or a burning and stinging sensation down below.

5) Painful urination

Burning or a painful sensation during peeing or sometimes just a “hot” sensation during the process though may indicate a urinary tract infection (UTI) but do note that it could also point to an STD.

6) Painful sexual intercourse

This is also called dyspareunia and if it feels deeper inside, it may indicate an infection involving deeper areas such as the cervix.

7) Lower abdominal discomfort or pain

This again may mean infection of the deeper structures such as in pelvic inflammatory disease.

8) Bleeding outside of menses

This may again indicate pelvic inflammatory disease but may also be due to sinister conditions like cancer of the cervix.

9) Vulva blisters, sores, ulcers or wart-like lumps that can also involve other areas such as anal and oral areas

STDs can manifest as rashes or ulcers in the vulva areas or other places as stated above. A blister-like rash is typical for genital herpes whereas a single ulcer (painless or painful) may be early syphilis. Genital warts are due to an infection with human papillomavirus.

10) Non-specific flu-like symptoms such as sore throat, mild fever, headache, tiredness and fatigue

Though these symptoms may not seem to indicate anything serious (apart from suspicion of covid-19), a recent infection with viruses such as HIV and hepatitis B and C may manifest with any of these symptoms. These symptoms are due to the body’s antibody production against these viruses, also called ‘acute seroconversion syndrome’. It is important to think about these conditions particularly after a high-risk sexual exposure event.

11) Swollen (painful or painless) lymph nodes either widespread or limited to the groin area

An STD may cause regional lymph nodes to swell up and may cause pain or discomfort.

12) Widespread rash mainly in the trunk or back which can involve palms and/or soles

Generalised rash involving the body which can involve the palms or soles or both is one of the common symptoms of syphilis.

Though you may feel that you are unlikely to have an STD as you don’t feel any symptoms at all, as mentioned earlier, a large proportion of people who have STDs may not exhibit any symptoms. Thus one should exercise caution when it comes to engaging in high-risk activities (e.g. 100% protection including during oral sex, reduce number of sexual partners, avoid alcohol or substance use etc) and to always seek medical attention should a partner is diagnosed with an STD.

The importance of early diagnosis and treatment of STDs cannot be emphasized enough and this is so that the risk of transmission to others is eliminated and to also reduce the risk of development of complications from STDs.

Should you have any concerns regarding STDs or are experiencing any of the above symptoms, do consider making an appointment with us at DTAP clinic.

 

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HIV PrPEP & HIV PEP For HIV Prevention

Transcript from video:

Hi, I’m Dr. Jonathan Ti from Dr. Tan and Partners, and today I’d like to talk about HIV PrEP.

PrEP stands for Pre-Exposure Prophylaxis, and it has emerged in recent years as one of the most effective ways to prevent HIV infection. Individuals taking PrEP can reduce their risk of getting HIV by upwards of 95%. This type of medication must be taken before any risk exposure to be effective. It is different to Post-Exposure Prophylaxis, or PEP, which is taken immediately after a possible exposure and uses additional medications.

PrEP is usually taken as a once daily tablet, a combination of antiviral drugs tenofovir and emtricitabine. Other types of dosing regimens are available as well, depending on the unique lifestyle of the individual. Studies have shown that PrEP is generally safe for long term use, but some may experience side effects such as a reduction in kidney function and bone density, especially with the older version of medication called Truvada. The US FDA recently approved a newer drug called Descovy for use as PrEP, which has shown to be equally effective in preventing HIV infection whilst touting an improved safety profile for kidney and bone toxicity. The main difference between Descovy and Truvada is the form of tenofovir drug present – the newer Descovy uses TAF, which enters target cells more efficiently than Truvada’s TDF, and means that a much lower dose of tenofovir is needed. This means that other tissues such as kidney and bone are exposed to a much lower dose of the drug and there is less risk of drug toxicity and side effects.

HIV PrEP is recommended for individuals who belong to a high-risk group for HIV infection, and who do not have any current established HIV infection. HIV high-risk groups may include:

  • Someone who has an HIV-positive partner
  • Someone who has multiple sex partners, a partner with multiple partners, or a partner whose HIV status is unknown and does not practice safe sex; there is higher risk in men who have sex with men or transgender women
  • Someone who has sex with commercial sex workers
  • Someone who has recently had a sexually transmitted disease
  • Someone who injects drugs, or has unprotected sex with someone who injects drugs

Both Truvada and Descovy are available in our clinics. They are only available by prescription. Please speak to our Doctors if you think PrEP is right for you.

WORLD AIDS DAY 2020

On December 1st, the global community unites to commemorate World AIDS Day, showing support for those living with and affected by HIV, and to remember those who have lost their lives to AIDS. This year in particular, the COVID-19 pandemic has laid bare how critically interlinked our health is with issues such as social inequality, human rights, stigma and discrimination, economic security, and political will and stability.

The theme of World AIDS Day this year is “Global solidarity, shared responsibility”. The COVID-19 crisis has demonstrated that, during a pandemic, no one is safe until everyone is safe. We all have a part to play in addressing the dual pandemics of COVID-19 and HIV/AIDS, in order to successfully eliminate them both as a public health threat.

There were approximately 38 million people living with HIV/AIDS in 2019, with an estimated 1.7 million people acquiring HIV in the year, marking a 23% decrease in new HIV infections since 2010. In Singapore, latest figures released in June this year showed 323 new cases of HIV infection reported among residents in 2019, bringing the total number of HIV-infected residents to 8,618 as of end of 2019, of whom 2,097 had passed away. The annual incidence of new infections locally has decreased overall by about 25% when compared to 2007 to 2017.

This decrease of new HIV infections is a result of the concerted and coordinated efforts of both government and community-led initiatives, but there is still much that can be done. In 2014, UNAIDS set an ambitious goal of eradicating the HIV epidemic by 2030. This involved a set of targets called the “90-90-90” vision, which stated that by 2020:

  • 90% of people living with HIV would know their diagnosis
  • 90% of those diagnosed with HIV would be on antiretroviral therapy (ART)
  • 90% of those on treatment would have achieved viral suppression

Singapore has made significant improvements towards the last two goals, with approximately 89% of people diagnosed with HIV on treatment and 94% of those achieving viral suppression; however, we are still relatively lacking in our progress towards the first target, with only an estimated 72% of people living with HIV who have been diagnosed. 

We know that early diagnosis leads to early treatment and better outcomes. Knowing their HIV status early will also help to prevent the spread of infection to others. Providing access to better information and testing for HIV, increasing awareness and uptake of Pre-Exposure Prophylaxis (PrEP), and ensuring long term compliance to antiretroviral therapy (ART) by people living with HIV are some of the primary facets of eradicating the HIV epidemic.

As we approach the end of a tumultuous year, the impact of COVID-19 has forced us to view our global health responses, including the HIV/AIDS response, in a different way. We must now be more committed than ever to ensure no individual or community is left behind – healthcare must be funded and accessible to all, stigma must be eliminated and vulnerable populations offered social protections, and public health systems must be strengthened through investment and sound government policy.

As the WHO has so accurately and succinctly captured:

“Now is the moment for bold leadership for equal societies, the right to health for all and a robust and equitable global recovery. This World AIDS Day, join us in calling on countries to step up their efforts to achieve healthier societies. This World AIDS Day let us demand global solidarity and shared responsibility.”

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Mycoplasma Hominis

What is Mycoplasma hominis?

Mycoplasma hominis is a tiny bacterium which can be transmitted through sexual contact. It is a member of the Mycoplasma spp. family which also include Mycoplasma genitalium


How is Mycoplasma hominis transmitted?

Mycoplasma hominis is most commonly transmitted through sexual contact – genital-to-genital intercourse as well as oral-genital intercourse. It can also be transmitted from mother to neonate during vaginal delivery.

Most infections are acquired in sexually active adults and colonization, which is when one carries the bacterium but has no symptoms, can occur. 


What are the symptoms of Mycoplasma hominis?

Many individuals with Mycoplasma hominis may be asymptomatic, i.e. they have no symptoms whatsoever. 

In men who do experience symptoms, they may notice possible symptoms of urethritis (inflammation of the urine tube) – pain or discomfort in the urine tract/when passing urine or penile discharge. 

Women with Mycoplasma hominis infrequently have symptoms. However, Mycoplasma hominis can be associated with bacterial vaginosis, a vaginal infection with overgrowth of bacteria that are not normally part of the normal vaginal flora. 

Also read: Common Medical Conditions That Are Asymptomatic


What are possible complications of Mycoplasma hominis?

While there is some research that suggests Mycoplasma hominis infection may be possibly associated with complications in pregnancy and that it may have a correlation with developing pelvic inflammation and infertility, there is currently no consensus or conclusive data about this. 


How is Mycoplasma hominis diagnosed and treated?

Mycoplasma hominis can be diagnosed through a culture test, where the bacterium is grown from either a urine sample (if from a male) or a swab sample (if from a female), or a PCR test, which looks for the presence of the bacterial DNA in the aforementioned samples. 

Various types of antibiotic treatment can be used to clear a Mycoplasma hominis infection. However, the choice of antibiotics will depend on whether the specific strain of Mycoplasma hominis isolated has any antibiotic resistance or not. 


How can I prevent or avoid Mycoplasma hominis? 

As with all STDs, safe and responsible sexual practices are crucial in prevention of Mycoplasma hominis infection. These include using barrier protection if possible e.g. condoms, doing regular sexual health screening and also ensuring that you know your sexual partner’s infection status. 

Next read: 10 things you didn’t know about this STD: Mycoplasma Genitalium

Epididymitis

The epididymis is a ductal system behind the testis and serves as a conduit for sperm produced in the testicle to be transported into the Vas Derferens to eventually reach the urethra. Epididymitis is a condition where the epididymis becomes inflamed usually from an infection, though trauma and autoimmune disease is a possible cause.


Signs & Symptoms

Symptoms of epididymitis include localised testicular pain and swelling of the posterior aspect of the testicle. The area can sometimes be warm to touch with redness of the scrotal skin. The area will be  painful when being examined with relief of the pain achieved when the area is elevated. 

Severity and etiology of epididymitis varies with the age of the patient. For young children presenting with testicular pain, a diagnosis of Testicular Torsion needs to be considered first, after which a mumps infection affecting the testicle needs to be ruled out. For sexually active men under 35 years of age, Gonorrhea and Chlamydia are the 2 most common organisms responsible for epididymitis. In older patients, epididymitis can occur concurrently with prostatitis especially if there is an underlying prostatic obstruction such as Benign Prostatic Hyperplasia (BPH) or recent catheterization.

Rapid STD Test for Chlamydia and Gonorrhoea


Most cases of epididymitis can be treated outpatient with oral non-steroidal antiinflamatory drugs (NSAIDS), local application of ice and oral antibiotics. A urine test is sometimes done to determine the organism causing the infection. Patients with epididymitis generally improve within 48 – 72 hours. If the symptoms do not abate within that period, an alternative diagnosis needs to be considered and further imaging such as a scrotal ultrasound performed.