Dear Dr G,

I read with interest your argument that men are the weaker sex when it comes to immunity against HPV infection.

I am a woman in my late twenties, well protected against HPV through early vaccination.

However, as a woman, I cannot help but point out that HPV-related cancers affect more than half a million women globally every year.

Although you argue that men also suffer from HPV-induced cancers, the number of male-related cancers is significantly lower than in women.

I would imagine that women suffer more from HPV-related cancers largely because men constantly infect women with the disease.

Am I wrong to assume that transmission of HPV from men to women is higher?

I chose this opportunity to put Dr G on the spot for some clarification.

Is it true that HPV is a sexually transmitted disease?

Do men transmit HPV to women more than women transmit it to men?

Is it also true that men have a higher risk of promiscuity, which puts women at risk?

Lastly, am I also wrong in assuming that men have a higher disease burden of HPV and put more women at risk of cancers?

I look forward to your rebuttal.

Regards

Finger-pointing Florence

Human papillomavirus (HPV) is one of the most common sexually transmitted infections worldwide, and a complex interaction of biological, anatomical, and behavioural factors shapes its transmission dynamics. Although HPV spreads efficiently in both directions between sexual partners, research has explored whether transmission from female to male differs in likelihood compared to male to female transmission.

Transmission of HPV occurs primarily through direct skin-to-skin or mucosa-to-skin contact during sexual activity. In female-to-male transmission, the virus is typically shed from infected mucosal surfaces of the cervix and vaginal lining. These tissues are composed of non-keratinised epithelium, which supports viral replication and can release viral particles into genital secretions. During intercourse, the penile epithelium comes into contact with these secretions, allowing the virus to access susceptible cells, particularly through microscopic abrasions that occur naturally during sexual activity. This continuous shedding from a relatively large mucosal surface area may increase the likelihood that a male partner is exposed to an infectious dose of the virus.

In contrast, male-to-female transmission involves viral presence on the penile shaft, glans, foreskin, or surrounding genital skin. These areas are more keratinised, meaning the outer layer of cells is thicker and less conducive to viral shedding compared to mucosal tissue. However, transmission remains highly efficient because the virus can be transferred to the cervix, especially to the transformation zone, a region where two types of epithelial cells meet and which is particularly vulnerable to HPV infection. Even a relatively small viral inoculum can establish infection in this biologically susceptible area, which helps explain why male-to-female transmission is also clinically significant.

Differences in observed transmission rates between the two directions may partly reflect variations in viral load and shedding patterns. Women with active HPV infection can exhibit higher short-term viral loads in the cervix, leading to increased shedding and potentially a higher probability of transmitting the virus to male partners during that period. Men, on the other hand, often exhibit lower peak viral loads but may carry the virus for longer durations. This persistence may not always produce symptoms, allowing HPV to remain undetected and transmissible over extended periods. As a result, while men may not always transmit the virus as efficiently with a single exposure, their longer infectious period can sustain transmission within a population.

Immune response differences also contribute to these dynamics. Women tend to mount stronger localised immune responses in the cervix and are more likely to clear HPV infections within one to two years. In men, immune responses in penile tissue appear to be less robust or less durable, which may allow the virus to persist longer. This difference does not mean that men inevitably carry high viral loads throughout life, but it does suggest that persistent, low-level infection is more common in men than in women. The absence of routine screening programs for men, comparable to cervical screening in women, further contributes to the perception of prolonged infection, as many cases go undiagnosed.

Behavioural and environmental factors further influence transmission in both directions. Frequency of sexual contact, number of partners, and condom use all play significant roles in determining risk. Circumcision status has also been associated with differences in acquisition and persistence, with uncircumcised men showing higher rates in some studies, possibly due to the microenvironment under the foreskin. Additionally, the presence of microabrasions, coexisting infections, and individual immune status can modify susceptibility.

It is important to emphasise that HPV transmission is fundamentally bidirectional and highly efficient regardless of direction. While certain studies suggest that female-to-male transmission may occur more readily in some contexts due to higher viral shedding from mucosal surfaces, male-to-female transmission is equally important, particularly because of the higher likelihood of persistent infection and serious outcomes such as cervical cancer in women. Therefore, differences in transmission should not be interpreted as a simple imbalance but rather as variations influenced by timing, biology, and context.

Women exhibit higher viral shedding during active infection, increasing short-term transmission risk to men, while men may experience longer persistence of infection, sustaining transmission over time. Both directions of transmission are efficient, and both contribute significantly to the global burden of HPV. Preventive strategies such as vaccination, safe sexual practices, and appropriate screening remain essential for reducing transmission and its associated health consequences. Albert Einstein famously said, “You cannot blame gravity for falling in love!” Dr G is often put on the spot by finger-pointing spouses demanding to find out who should take the blame for the higher risk of HPV transmission. His view is: “It’s definitely not helpful to blame this virus of Love!”

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Dear Dr G,

I read with interest how you highlighted the possibility of men having of cancer following human papillomavirus (HPV) infection.

You did note HPV-related cancers are far more common in women and fully agree that raising public awareness is important.

However, I am concerned by the suggestion that men, as what some refer to as the “stronger” sex, may need less protection than women.

I read a study that found there was a higher HPV prevalence in men and lower rates of lasting immune response after natural infection.

If this is the case, is it true HPV infect men and women equally?

Do men carry the virus more than women as they age?

Lastly, is there evidence that men develop stronger natural immunity to HPV than women?

Yours truly,
Weaker William

HPV is one of the most common sexually transmitted infections worldwide, affecting both men and women across all age groups.

Despite this shared exposure, important differences exist in terms of immunological response.

While HPV has traditionally been framed as a major women’s health issue due to its association with cervical cancer, growing evidence shows that men have weaker natural immunity to HPV.

This reduced immune response contributes to persistent infection, repeated exposure and a significant burden of HPV-related disease throughout life.

The burden of HPV infection in men is substantial and remains relatively constant across the lifespan – unlike women, whose HPV prevalence typically peaks in early adulthood and declines with age.

Men continue to acquire new infections throughout life, indicating a lack of effective protective immunity. As a result, men serve as both reservoirs and transmitters of the virus.

Clinically, HPV infection in men can manifest as genital warts caused by low-risk HPV types, as well as more serious conditions such as penile, anal and oropharyngeal cancers linked to high-risk types. Notably, the incidence of HPV-related oropharyngeal cancers has been increasing in men and often presents later in life, reflecting the long-term consequences of persistent infection.

A key explanation for this sustained disease burden lies in the differences in immune response between men and women following natural HPV infection.

Women are more likely to undergo seroconversion, meaning they develop detectable antibodies against HPV, particularly high-risk types such as HPV16 and HPV18.

These antibodies can provide partial protection against reinfection, suggesting the development of some level of immune memory.

In contrast, men exhibit lower rates of seroconversion and produce lower levels of antibodies. Even when antibodies are present, they do not appear to offer significant protection against subsequent infections, indicating a weaker and less durable immune response.

The reasons for this disparity are both anatomical and biological. The female genital tract is primarily composed of mucosal epithelium, which allows for greater exposure of viral antigens to the immune system and promotes stronger immune activation.

In contrast, much of the male genital epithelium is keratinised, limiting antigen presentation and reducing the effectiveness of immune recognition.

Additionally, broader immunological differences between sexes play a role, as females generally mount stronger innate and adaptive immune responses. Hormonal influences such as estrogen enhance immune activity, while testosterone in males has been associated with relatively immunosuppressive effects, further contributing to weaker immunity in men.

As a consequence of these factors, men often clear individual HPV infections without developing lasting immune protection. This leads to a cycle of infection, clearance and reinfection rather than the development of durable immunity.

Over time, repeated exposure increases the likelihood of persistent infection with high-risk HPV types, which is a critical factor in carcinogenesis. The inability to effectively eliminate the virus or prevent reinfection places men at a higher cumulative risk of developing HPV-related cancers.

The implications for cancer are significant, particularly given the absence of routine screening programs for men. While women benefit from cervical screening that allows for early detection and intervention, men typically lack comparable preventive measures. This often results in HPV-related cancers being diagnosed at later stages, when treatment is more challenging and outcomes are poorer. The rising incidence of oropharyngeal cancers in men highlights the growing importance of addressing HPV as a men’s health issue.

In conclusion, men can be considered the weaker gender in terms of natural immunity to HPV infection due to their lower rates of seroconversion, weaker antibody responses and lack of effective immune memory.

These immunological disadvantages, combined with anatomical and hormonal factors, lead to persistent susceptibility, repeated infections and an increased lifetime burden of disease. Recognising this disparity is essential for informing public health strategies, particularly the promotion of vaccination and awareness, to reduce the impact of HPV-related diseases in men and the broader population.

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Dear Dr G,

I am a father of two boys who is keen to highlight the lack of awareness for cancers in men induced by HPV.

I have two teenage boys who are 13 and 14 years old. Both of them recently came home with HPV vaccination consent forms.

Initially, I found it amusing as I thought the boys had brought back the consent forms by mistake, since I assumed HPV only affects women.

As the boys explained to me that HPV-induced cancer is a serious condition that affects both boys and girls, I began to pay attention.

I realized HPV is so serious that it causes many types of cancers, including cancers that can affect men too.

I am not sure what I read is true and hope to put Dr G on the spot for clarification.

Can you tell me what HPV is and how it is transmitted?

What is the scale of HPV induced cancers affecting both men and women?

What sorts of cancers can HPV cause in men?

Can HPV affect different races differently?

Look forward to your valuable responses.

Yours truly,

Worried William

Human papillomavirus (HPV) is one of the most prevalent sexually transmitted infections globally and a well-established cause of multiple malignancies. It plays a significant role in the global cancer burden, contributing to approximately 690,000 cancer cases each year and accounting for about 4.5–5% of all cancers worldwide. HPV is unique among infectious carcinogens because of its widespread transmission and its ability to cause cancers in both women and men.

Cervical cancer represents the most significant manifestation of HPV-related disease and remains the cornerstone of its global impact. It is the fourth most common cancer among women worldwide, with an estimated 660,000 new cases and approximately 350,000 deaths annually.

More than 90% of cervical cancer cases are attributable to HPV infection, particularly high-risk types such as HPV 16 and HPV-18, which together account for about 70% of cases. The disease disproportionately affects women in low- and middle-income countries, where nearly 90% of deaths occur. The geographical distribution of cervical cancer reflects broader global health disparities. Regions such as sub-Saharan Africa, South Asia, and parts of Latin America bear the highest burden

This stark inequality is largely due to limited access to preventive measures such as HPV vaccination, regular screening through Pap smears or HPV testing, and treatment. In men, HPV-related cancers present a different epidemiological profile. Unlike women, men do not experience a single dominant cancer equivalent to cervical cancer. Instead, HPV contributes to cancers of the oropharynx, anus, and penis, with oropharyngeal cancer emerging as the most common HPV-related malignancy in men.

Although the overall number of HPV-related cancers in men is lower than in women, the incidence of certain cancers, particularly oropharyngeal cancer, has been increasing in many parts of the world. In some high-income countries, the incidence of HPV-related oropharyngeal cancer in men now surpasses that of cervical cancer in women.

The rising burden of HPV-related cancers in men can be attributed to several factors. Unlike cervical cancer, there are no widely implemented screening programs for HPV-related cancers in men, resulting in later detection and poorer outcomes. Additionally, HPV vaccination programs initially focused on girls, leading to lower vaccination coverage among males, particularly in older cohorts.

Behavioral factors, including changes in sexual practices, have also contributed to increased transmission of oral HPV infections. Studies indicate that approximately one in three men worldwide is infected with genital HPV, highlighting the widespread nature of the virus in the male population.

A comparison between HPV-related cancers in women and men reveals important differences in disease burden, prevention, and trends. Women bear a significantly higher overall burden due to the predominance of cervical cancer, but benefit from established screening programs that enable early detection and treatment. In contrast, men experience a lower overall burden but face increasing incidence rates of certain cancers, particularly oropharyngeal cancer, and lack comparable screening strategies.

As a result, while cervical cancer incidence is declining in many high-income settings, HPV-related cancers in men are rising, suggesting a potential convergence in disease burden between genders in the future.

Looking ahead, the global trajectory of HPV-related cancers will depend heavily on the implementation of effective prevention strategies. HPV vaccination has the potential to prevent more than 90% of HPV-related cancers caused by vaccine covered strains and represents a cornerstone of cancer prevention efforts. The World Health Organisation has set ambitious targets for the elimination of cervical cancer as a public health problem, emphasizing widespread vaccination, screening, and treatment.

However, achieving these goals will require addressing disparities in vaccine access and healthcare infrastructure, particularly in low and middle-income countries. Expanding vaccination programmes to include boys and improving awareness of HPV-related risks in men will also be critical in reducing the overall burden of disease.

HPV has a profound and multifaceted impact on global cancer epidemiology. Cervical cancer remains the dominant HPV-related malignancy, particularly affecting women in low-resource settings, while other HPV-related cancers, especially oropharyngeal cancers in men, are increasing in incidence. Without significant global efforts, the burden of HPV-related cancers is likely to rise, particularly in underserved populations.

Conversely, with comprehensive vaccination and screening strategies, there is a realistic opportunity to substantially reduce the most devastating consequences of HPV infection.

Malala Yousafzai famously said: “We cannot succeed when half of us are held back.”

Admittedly, this is in reference to discrimination against women. However, when HPV-induced malignancy indiscriminately affects both genders, awareness is crucial to ensure equity.

Men surprised by the fact HPV can cause cancer in them often put Dr G on the spot. His opinion is: “We cannot succeed in fighting cancer when anyone is held back by lack of knowledge!”

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Dear Dr G,

I am writing to you burdened by guilt over my past sexual encounters, hoping you can help me resolve this remorse.

I am a 30-year-old man with a troubling secret from my past.

A few years ago, I discovered a small, flower-like growth on my penis. The doctor diagnosed it as a genital wart.

I was shocked to learn that genital warts are linked to the Human Papillomavirus (HPV), a sexually transmitted infection (STI).

I was even more horrified to find out I could easily transmit the virus to my partner, potentially causing cervical cancer.

When I told my then-girlfriend that my past actions might have caused the warts, the relationship ended quickly. I haven’t dated since.

In fact, I have avoided sex for the past few years due to the risks.

I want to ask Dr G about the issue of my “flowers in the pants.”

What exactly is HPV? I thought it only affected women.

Is the virus contagious with every sexual encounter? How can I reduce the risk of transmission to my loved ones?

I feel I’m wasting the “golden years” of my sex life. I understand HPV is incurable, but should I remain sexless for the rest of my life?

Regards,

Flower Felix

Genital warts result from the transmission of the Human Papilloma Virus (HPV) during sexual contact. Of the 170 HPV subtypes, more than 40 spread through genital and anal contact, with HPV 6 and 11 commonly linked to genital warts. HPV transmission occurs in both men and women, with risk factors including early sexual activity, multiple partners, poor hygiene, and smoking.

HPV is often thought to affect women more, but it actually poses a greater risk to men. Firstly, HPV is 60% more transmissible from women to men than vice versa. Secondly, men are 26% less likely to develop natural immunity compared to women during sexual intercourse.

Lastly, while both genders can clear the virus naturally, women have more effective immunity as they age compared to men. This leads to a higher persistent disease burden in men, increasing their risk of recurrent disease. Nearly all sexually active people are infected by HPV at some point, making it the most common STI globally. Ninety percent of affected individuals show no symptoms, and the virus often resolves spontaneously within two years.

However, in those with lower immunity or persistent STI risks, HPV can persist in the genitalia, leading to recurrent warts and increased cancer risk. Diagnosing HPV in men is less accurate than a PAP smear in women. The visible “flower-like” lesion suggests an HPV infection. Normal skin tags can often be mistaken for genital warts. Scraping the lesion for DNA analysis of the virus subtype is the most accurate diagnosis method.

Most genital subtypes, including HPV 6 and 11, are low risk. While high-risk subtypes like HPV 16 and 18 are rare, close monitoring is crucial to prevent disease progression. Vaccination is the most effective protection against HPV. Although vaccines are recommended for boys and girls at age 13, protection is evident up to age 45.

The US’ Centers for Disease Control and Prevention indicate that male condoms may reduce HPV transmission risk, although less effectively than for other STIs. This is because HPV can transmit through genital skin not completely covered during sexual contact. Vaccination remains the best treatment for HPV infections.

Many believe vaccination is futile beyond the initial sexual debut, but data shows only 13% of men and 16% of women contract two or more HPV subtypes. Thus, protection against non-contracted viruses remains important.

Despite being incurable, HPV vaccination ensures 100% antibody seroconversion within seven months of inoculation. Enhanced antibodies play a vital role in preventing disease recurrence and progression.

Genital warts have been documented since ancient Greece, with viral causation only determined in 1907. Today, nearly 80 million Americans have HPV, with 14 million new cases annually, leaving 1% of sexually active adults with recurrent warts. HPV is highly contagious with each sexual contact, but its manifestations can vary from dormant to insidious.

Since nearly all sexually active adults encounter HPV, it’s fair to view the disease as mostly harmless, but enhancing immunity is key to reducing transmission risks. When individuals with HPV insist on abstinence as the only prevention, Dr G’s view is that vaccination and monogamy are crucial to not wasting future “golden years.”

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Dear Dr G,

I am a thirty-five-year-old man who has had a healthy sexual relationship with my wife for the last five years.

In reality, I am faced with a dark secret of my past that torments me regularly.

In my late twenties, I was curious about my sexuality and perhaps experimented a bit with my sexual orientation.

After confirming my true heterosexuality, I left that past dark secret behind me.

Unfortunately, I noticed a small flower-like growth arising from my anus recently and went to the doctors.

The doctor told me the growth was an anal wart, and I was shocked to find out it is related to the Human Papillomavirus (HPV), which is essentially a sexually transmitted infection (STI).

The doctor performed some cryotherapy treatment for the warts, which was successful for a while, but they recur regularly.

On the last occasion, the doctor decided to biopsy the wart.

Indeed, he found some precancerous cells he called AIN.

I am terrified and would like to put Dr G on the spot for the issues of my anal warts and the risk of cancer.

I thought HPV was a virus that only affects women. Why is it affecting my anus?

Is it true anal warts only affect men having sex with men? Can they be transmitted any other way?

Are the viruses oncogenic and always cause anal cancers?

What exactly is AIN and anal cancer?

Finally, I have heard about the vaccine. Do you think it is too late for me to have it?

Regards,

Aston

Almost 80 million Americans are infected with HPV, and about 14 million new cases are added each year. Around 1% of sexually active adults live with recurrent genital warts. Genital warts are an infection caused by the transmission of Human Papilloma Virus (HPV) during sexual contact.

Out of the 170 subtypes of HPV, more than 40 are spread through genital and anal contact, and HPV 6 and 11 are commonly linked to anal warts. HPV transmission occurs in both men and women, and the risk factors for cancer include an early age of sexual intercourse, multiple sexual partners, poor hygiene, and smoking.

Nearly all sexually active persons are infected by HPV at some point in their lives, making it the most common sexually transmitted infection globally. Ninety percent of affected individuals demonstrate no symptoms despite the infections, and the virus is thought to resolve spontaneously within two years.

HPV can persist, resulting in either warts or precancerous lesions. Low-risk HPV subtypes like HPV 6 and 11 can result in regular genital warts with low risks of cancer. On the other hand, oncogenic subtypes of the virus such as HPV 16 and 18 can typically affect the cervix, vulva, and vagina in women. The virus is also known to infect the oropharyngeal cavity and anus, risking oropharyngeal and anal cancers in both genders.

Anal warts appear as visible “flower-like” lesions in the anus. In many cases, normal skin tags can be mistakenly diagnosed as anal warts. Scraping the lesion for DNA analysis of the subtype of the virus is the most accurate way of diagnosis. Precancerous detection of AIN (Anal Intraepithelial Neoplasia) is typically associated with high-risk HPV subtypes.

Such precancerous lesions can be treated with minimally invasive modalities such as infrared photocoagulation and laser therapy. Regular follow-up and biopsies are required, as the progression of the lesions to anal cancer makes future treatments complicated.

About 8,300 people are diagnosed with anal cancers every year in the United States, representing about 0.5% of new cancers. Contrary to common belief, anal cancers do not just affect MSM (Men having Sex with Men). In fact, women are affected more often than men, with women above sixty having double the risk of such cancer.

The standard treatment of anal cancer may include radical surgery therapy and chemoradiation. The five-year survival rate of anal cancer in the United States is only 68%, due to late presentations. The most effective way to get protection against HPV is to get vaccinated.

Although the vaccine is supposed to be for both sexually naive boys and girls at the age of 13, protection is also demonstrable up to the age of 45. Other ways to diminish the transmission of HPV include reducing the number of sexual partners and avoiding sexual contact with a partner when the warts are present. HPV vaccines are also advocated for individuals diagnosed with anal warts to enhance immunity against HPV.

The French philosopher Albert Camus, who was the second youngest recipient of the Nobel Prize in Literature, once said: “Autumn is a second spring when every leaf is a flower.”

The existence of genital warts has been documented since ancient Greece, while causation by a virus was only determined in 1907. The curious nature of the transmission of HPV is that it is highly contagious with each sexual contact, but the manifestations may vary from being harmlessly dormant to precariously insidious.

When nearly all sexually active adults are infected with the HPV virus at some point in their sexual lives, it is indeed fair to assume “every visible leaf is a potential flower in the bum!”

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Dear Dr. G,

I am a fit and healthy man in my early forties.

I have just started a new sexual relationship, and that is going well, until I started noticing slight discomfort in my left scrotum a fortnight ago.

I don’t usually get so hung up about my balls, but the swelling has doubled in size over the last few days, and the pain is also worrying me a great deal.

I also don’t know whether I am just paranoid, but I have noticed that the painful urination has somewhat persisted, and I am struggling to empty my bladder.

Besides, I have also noticed a mild fever that has been recurring. I may have caught an infection somewhere, but I am really puzzled about how an infection could have got into my testicles.

I cannot help but wonder whether I have contracted some sort of sexually transmitted infection (STI).

I am too embarrassed to tell anyone about my lopsided, painful ball.

Therefore, I have decided to put Dr. G on the spot about my painful testicles.

Can you tell me what could possibly be wrong with my testicles?

Is it normal for the swelling of the testicles to progress so fast?

Can this be a sexually transmitted infection?

What are the possible causes of swelling in the scrotum?

The swelling of the testicle tends to increase in size and become more uncomfortable. Is it a bad sign?

I am worried and embarrassed about someone “fondling” my balls. Should I go and see the doctor? Regards

Sad Swollen Steven

Epididymal orchitis is an infection of the testicle and the surrounding structures responsible for testosterone production and spermatogenesis. Such infections can occur in men throughout their lives. Children and adolescent males are susceptible to the infection due to smegma from the foreskin. Sexually active younger men typically develop the infection after sexual intercourse, resulting in painful swelling of one testicle. Sexually induced infections are often associated with painful, frequent urination and urethral discharge. Common sexually transmitted infections, such as gonorrhea and chlamydia, trace back from the urethra into the testicles following unprotected sexual intercourse. Although sexually transmitted causes of epididymal orchitis are common, non-sexually induced infections of the testicles are also well recognised.

Infections of the testicles in older men are usually caused by enteric bacteria such as E. coli. Such infections arise from dehydration or bladder outflow obstruction due to prostate enlargement. Benign Prostatic Hyperplasia is common in older men, causing incomplete bladder emptying after urination. The residual urine tends to become infected in the bladder, and the backwards infection of the testicle occurs when cystitis is not treated early enough. Prostate-related infections of the testicles can recur frequently unless the issues of bladder outflow obstruction are treated accordingly. Besides bacterial infections, mumps is a viral illness caused by a paramyxovirus that is well-known to be associated with painful infections of the testicles. Although such viral infections are well recognised in pediatric populations, mumps orchitis is also rising in numbers due to unvaccinated individuals.

Symptoms of epididymal orchitis are typically sufficient for making a diagnosis. These include rapid, painful swelling of the testicle, accompanied by redness of the scrotum. Palpation of the testicle reveals a significant disparity in size, and the scrotal pain is relieved by the elevation of the affected testis. Rapid and painful testicular swelling is likely caused by an infection known as epididymal orchitis. On the other hand, gradual swelling of the testicles tends to be benign in nature. Benign swellings of the testicles, including varicoceles, hydrocele, epididymal cysts and hernia, develop slowly, and most of these swellings are painless. Even cancer of the testicles can mimic the symptoms of epididymal orchitis. Careful scrotal examinations and painless ultrasound imaging are definitive in determining the diagnosis.

Both acute and chronic forms of epididymal orchitis can be effectively treated with antibiotics. The preferred treatment for sexually transmitted bacteria is Ceftriaxone and Azithromycin. Enteric bacterial infections in older men are typically sensitive to antibiotics such as Ciprofloxacin and Augmentin. Complete resolution of the infection is possible with an adequate duration of antibiotics. Complications such as chronic epididymal orchitis and abscesses can also be detected through ultrasound scans. Delayed treatment of the infection may be associated with infertility or scrotal abscess, which could necessitate surgical removal of the testicle.

There is no doubt that the presence of scrotal swelling can be both embarrassing and worrying. The importance of simple examinations by doctors and ultrasound scans in determining the diagnosis and initiating treatment for epididymal orchitis is often reiterated. On the contrary, delayed diagnosis and late treatment often result in severe complications related to testicular malfunctions. Men who are embarrassed yet terrified about swellings of the testicles often turn to Dr. G for advice. His view is: “There comes a point in every man’s life with scrotal swellings to say enough is enough, and getting himself fondled in the sacs can potentially save his ball and even his life!”

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Dear Dr. G,

I know you usually answer questions for men.

However, I hope you can help resolve my sexual health issue related to a Sexually Transmitted Infection (STI) I contracted. Don’t get me wrong, I am not promiscuous, but I admit I had a previous sexual relationship that ended at least six months ago.

I have started a new relationship, and everything was fine until we began having sex. After we started having intercourse, my boyfriend began experiencing painful urination and continuous penile discharge.

We initially thought he might have contracted a UTI due to dehydration, but the symptoms persisted, and he went to the doctor. The doctor suspected chlamydia, and my boyfriend was tested for other STIs, including gonorrhoea and HIV. Thankfully, the other tests were normal.

My boyfriend was treated with antibiotics, and most of his symptoms resolved. He accused me of passing the infection to him and asked me to get tested. At first, I was furious because he suspected I was unfaithful.

As I am now getting tested, I started feeling guilty and doubting myself.

I want to ask Dr. G for clarification about STIs.

What exactly is chlamydia? Is it the same as gonorrhoea? Is it possible I was infected with chlamydia from my previous relationship and was completely unaware of the infection? What are the consequences of not getting treatment? As I get tested for STIs, I worry I might be a dormant carrier.

Regards,

Dormant Deborah

Chlamydia is a word derived from Greek, meaning “cloak”. As the name suggests, the infection often remains hidden. It is a sexually transmitted infection with an incubation period between exposure and the ability to infect others of two to six weeks.

Chlamydia is one of the most common STIs, affecting about 4.2% of women and 2.7% of men worldwide. The United States reported 1.4mil new cases in 2014, mostly among newly sexually active individuals aged 15 to 25. Globally, 61mil new cases of chlamydia are reported annually.

It is more common in women than men, as many women may harbour the infection without symptoms. Although most women are unaware of the infection, symptoms may include vaginal discharge and a burning sensation during urination. In severe cases, chlamydia may lead to pelvic inflammatory disease and future infertility.

Men are more likely to experience symptoms, including penile discharge, painful urination and testicular swelling. Men are more likely to seek treatment to eradicate the disease without dormant bacteria causing repeated transmissions. Similarly, gonorrhoea is another common STI transmitted with chlamydia.

Gonorrhoea is colloquially known as the clap and is caused by the bacteria Neisseria gonorrhoeae. The disease dates back to the Old Testament, and the term “gonorrhoea” was first coined by Greek physician Galen before 200CE, referring to it as “an unwanted discharge of semen”. Gonorrhoea affects about 0.8% of women and 0.6% of men.

An estimated 100mil new cases are reported yearly, mostly among newly sexually active young adults. Untreated gonorrhoea can spread to joints and heart valves, accounting for at least 700 related deaths annually.

Although some cases are asymptomatic, infected men often experience severe symptoms, including copious pus discharge from the penis and a burning sensation during urination. Women may also be asymptomatic with dormant infections in the genitalia. In severe cases, women can experience vaginal discharge, bleeding between periods and pelvic pain.

Sexually Transmitted Infections (STIs), also known as venereal diseases, spread through sexual contact, including vaginal intercourse, anal and oral sex. Common bacterial infections include gonorrhoea and chlamydia, and parasitic infections such as trichomoniasis. STIs do not always show symptoms, increasing the risk of transmission.

Fulminant symptoms may include vaginal or penile discharge, genital ulceration and pain during urination. Traditionally, gonorrhoea and chlamydia are diagnosed through gram staining, but modern PCR testing methods are increasingly common. Testing for screening and active infection is crucial to reduce the spread.

Individuals are often tested for other STIs, as co-infection with chlamydia, syphilis and HIV can be as high as 54%. Chlamydia and gonorrhoea can be prevented with abstinence, condom use and having sex with one uninfected partner.

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Dear Dr G,

My wife and I have been married since January, and the last few months have been a bit of a nightmare when it comes to sex. We are both in our late twenties and started courting at university. Although we had numerous opportunities, we did not engage in any sexual contact until we were finally married four months ago.

Don’t get me wrong, the erection and penetrative sex itself are all great as expected. However, my wife started having pain and bloody urine a few days after each intercourse. She has been to the doctors each time and was given antibiotics for the infections. The pain was so intense on several occasions she is simply too fearful to engage in sex. We were recommended to see a specialist to resolve this problem.

The urologist told us this is a common condition called Honeymoon Cystitis. Apparently, this can persist for several months before it finally resolves by itself.

Besides, my wife also started wondering whether this has anything to do with STIs (Sexually Transmitted Infections). I tried to assure her I have no other sexual partner and have never even had sex with anyone.

However, when she started getting such frequent infections, she began to lose trust and patience in our marriage. Hence, I am putting Dr G on the spot for some clarifications on Honeymoon Cystitis.

What exactly is Honeymoon Cystitis and how common is it? Is Honeymoon Cystitis a type of STI as it is induced by sex?

What bacteria can cause Honeymoon Cystitis? Can Honeymoon Cystitis be prevented at all and how long will it take to resolve? And why are Urinary Tract Infections more common in women than men?

Yours truly,

Honeymoon Herman

Urinary tract infections are bacterial infections affecting the bladder or the kidneys. When the bladder is affected, this is described as cystitis. On the other hand, when kidneys are affected, this tends to be a more serious condition known as pyelonephritis. Both cystitis and pyelonephritis are more common in women.

Urinary tract infections are known to affect more than half of women in their lifetime. The infection can also occur recurrently in one-third of women. The real pathogenesis of susceptibility of women to UTIs is not well understood, however, it is believed to be due to the short urethra in women that is more exposed to external pathogens.

Urinary tract infections are known to be common during high-risk periods of a woman’s life, especially childhood, sexual debut, pregnancy, and menopause. When the infections affect women during the initiation of sexual activities, this infection is also known as honeymoon cystitis. Honeymoon cystitis typically describes acute infection of the bladder occurring primarily during sexual debut.

Statistics suggest that about 60% of women experience at least one UTI during their lifetime, with a significant increase in incidence during the first year of marriage. Although there is no real data in medical literature on the true incidence of honeymoon cystitis, it is believed to affect up to 30% of newly-weds or women starting to engage in sexual intercourse. Generally, the symptoms of honeymoon cystitis are mild and self-limiting with adequate hydration.

However, the symptoms of painful urination, frequency, and urgency of urination can affect the quality of life for some women. In some cases, bleeding and constant fever requiring long-duration treatment can also be debilitating for the newlywed. Honeymoon cystitis almost exclusively occurs in women with the pathogenesis of infection intertwined with the close nature of penetrative intercourse.

During sexual activity, the short urethra in women can come into contact with bacteria from the genital area. This exchange can introduce unwelcome bacteria into the bladder. The warm, inviting environment of the urinary tract provides these bacteria with a perfect breeding ground, leading to infection and all the unpleasant symptoms that follow.

Up to 78% of bacteria that induce honeymoon cystitis are caused by E. Coli. Other common bacteria that induce such infections are Proteus Mirabilis and Klebsiella Pneumonia. As these pathogens are generally not related to Sexually Transmitted Infections and spontaneously occur without sex, honeymoon cystitis is not considered an STI.

Although some couples may start getting frustrated and losing faith in each other, assurance from healthcare professionals is generally adequate. The treatment of honeymoon cystitis is readily available and effective.

Short courses of antibiotics ranging from one, three, and five-day treatments are usually sufficient. The regular consumption of antibiotics may be frustrating and result in undesirable side effects. For some individuals, the infections may be prolonged or recurrent; under such circumstances, regular consumption or even long-term prophylactic antibiotics may be warranted.

Despite all the potential complications of regular antibiotics, very few individuals require more medications beyond six months of initiation of treatment. The key to avoiding Honeymoon Cystitis is prevention. Staying hydrated by drinking plenty of water assists in flushing out harmful bacteria from the urinary system, which is crucial. Urinating frequently and ensuring the bladder is emptied regularly can also help to eliminate any bacterial proliferation.

Good hygiene practices before and after sexual activity, ensuring a clean and healthy environment for you and your partner, are also important. Other measures such as cranberry juice or supplements may help to prevent bacterial adhesion and reduce the risk of UTIs.

Honeymoon cystitis can be a pesky little surprise that can put a damper on the honeymoon period. As frustrating as honeymoon cystitis may be, don’t let it steal the joy of newlywed bliss. By following good hygiene practices and staying hydrated, you can overcome such infections.

Dr G is often put on the spot by troubled couples facing this bumpy path of romance. His opinion is that honeymoon cystitis is just like the bittersweet taste of cranberry juice; the bitterness of early infection is just a small price to pay to ensure a long sweet journey of intimacy for many years to come.

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Dear Dr G,

I am a thirty-year-old man who is recently engaged and planning to marry before Christmas. The revelation of my recent diagnosis has left me devastated, and I hope you don’t mind my remaining anonymous.

A few months ago, I noticed some growths on the head of my penis when I retracted my foreskin. These growths are completely painless, yet raised my concerns. This prompted me to consult a doctor.

The specialist identified them as genital warts, explaining that they are a sexually transmitted infection. He emphasised the need to protect my fiancée.

The doctor offered freezing as a form of treatment, but overwhelmed, I left without undergoing the procedure.

I’m sorry to put Dr G on the spot, but can you shed more light on genital warts? How do you contract them? Are they always sexually transmitted? Besides freezing, what other treatments are available?

Are genital warts curable, or could they lead to cancer?

I’ve heard about a vaccine for genital warts. Would it benefit me? The doctor mentioned the need to protect my fiancée, but how can this be done? And finally, when do you think I contracted the infection? My past relationships are haunting me.

I eagerly await your response.

Regretfully yours, Ronald

Genital warts are either cauliflower-shaped or flat protrusions from the skin surface caused by the Human Papilloma Virus (HPV). They are highly contagious infections transmitted through sexual contact and are often asymptomatic, though some people may initially experience itchiness, discomfort, or redness.

The warts may appear individually or in clusters on the external genitalia, including the penile shaft, scrotum, anus, vagina, and labia. Understandably, their outbreak can lead to significant psychological distress, anxiety, and guilt among those affected.

HPV has various forms. Subtypes 6 and 11 typically result in genital warts, while HPV types 16, 18, 31, 33, and 35 are occasionally found. Virus transmission occurs through direct skin-to-skin contact during genitals penetrative, oral, or anal sex, usually manifesting one to eight months after exposure.

Notably, only 10% of those with HPV will develop visible genital warts, even though it is estimated that up to 20% of the US population carry genital HPV, with a clinical manifestation rate of 1% among the sexually active adult population. The majority of those affected fall within the 17-to-33-year-old age group.

Condom use for preventing HPV transmission has been debated in scientific circles. While recognised for reducing all forms of sexually transmitted infections, the genital areas not covered by condoms remain susceptible to the virus.

Genital warts treatment can be classified into ablative or topical interventions. Removal eliminates visible warts, but it does not guarantee a reduced risk of future recurrence. Physical ablative therapy options include simple excision, liquid nitrogen cryosurgery, electro-cauterisation, and laser ablation intervention, commonly used for patients with hardened (keratinised) warts that are smaller and fewer.

Conversely, topical agent treatments suit those with multiple larger warts, applying agents such as podophyllotoxin, imiquimod, and trichloroacetic acid to erode and destroy the lesions.

The HPV vaccine’s introduction to prevent cervical cancer is believed to impact the future prevalence of genital warts, especially in women. Recent clinical trials have also demonstrated a reduced risk of emergence and recurrence of genital warts in men and women already infected with the HPV virus. Thus, sufferers with repeated outbreaks of genital warts may benefit from vaccination.

The unsightly emergence and recurrence of lesions in private parts can induce feelings of regret and guilt. Although HPV infections are incurable, with genital warts’ recurrence rates as high as 50-75%, there are reports of spontaneous regression as the virus can be cleared by the host’s immunological responses.

Dr G is often put on the spot by remorseful men regretting past sexual experiences that caused their genital warts. His advice is to turn those regrets into lessons of prevention by reducing the number of sexual partners, embracing vaccines, and enhancing health and immunity to fend off future HPV infections or recurrences.

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Dear Dr G,

I am in my late 20s and have an active sexual life. My partner and I have sex regularly – sometimes even twice a day.

Three months ago, I noticed blood in my semen after a more-intense-than-normal bout of passion.

My partner and I were shocked and slowed down the frequency and intensity of sex, hoping the bleeding would disappear but the bleeding has continued. This has sadly dampened our sexual enthusiasm.

There is no pain associated with the bleeding. I went to a urologist, who gave me a thorough check including blood tests, MRI and even a camera up my penis.

He reckons I suffered from acute prostatitis which requires a long course of antibiotics.

To put Dr. G on the spot, why am I having blood in the semen? Is it because of too much or too vigorous sex?

Am I at greater risk of prostate cancer because of this?

Regards,

Red Richard

Blood in the semen is called hematospermia, which presents as a small drop of blood in the semen or copious amounts of blood in the ejaculate.

Its occurrence has been reported way back in history, back in ancient Greece around 400 BC and it is probably one of the most terrifying experiences for a man.

Its symptoms have little medical significance and are generally not related to serious illness.

The exact prevalence of this condition is largely unknown as it usually goes unnoticed.

A recent survey at a urological outpatient clinic shows hematospermia affects one in 5,000 patients and makes up around 1% of urological symptoms and can occur in sexually matured adults of any age.

It is mostly self-limiting and requires no investigation.

However, persistent fresh bleeding (more than 10 ejaculates or beyond two months) – especially if accompanied by pain – may warrant more extensive diagnostic work-up.

The most common cause of the bleeding is inflammatory conditions in the prostate and seminal vesicles, such as acute prostatitis, which constitutes around 40% of all causes.

Most of the infections are innocent in nature, although a STI (sexually transmitted infection) is probable for men with a history of sexual promiscuity. However, no specific cause of hematospermia is determined in around 15% of the cases.

Of course, the condition can cause cancer fears. In a recent Northwestern University study of 26,126 men, 14% had a history of hematospermia and 6.5% were detected with prostate cancer. This translates to 3-5% of men with bloody ejaculate may be associated with prostate cancer. Therefore, all men above 40 are investigated with blood tests, digital rectal examination and MRI scan.

The rupture of blood vessels in the prostate during vigorous sexual intercourse is another common reason for blood in the semen. This is particularly prevalent in men having sex after a long period of abstinence. The vast majority of such hematospermia are self-limiting, but this can take up to three months. Medication such as antibiotics and prostate-shrinking remedies may help. Occasionally, fulguration of the bleeding vessels in the prostate may be necessary to prevent haemorrhage.

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