Dioecious species that reproduce by internal fertilization typically carry an associated risk of exposure to sexually transmitted parasites and pathogens. When hosts intermingle for procreation, certain protist and helminth parasites, for example, transfer successfully between individuals and then navigate across various life history traits of their hosts, often probing dimensions in both sex and gender, respectively. In humans, there are many sexually transmitted infections as well as sexually transmitted diseases. A well-known sexually transmitted infection is the flagellated protist Trichomonas vaginalis that causes trichomoniasis, with over 150 million new cases reported annually. By contrast, the schistosome blood fluke Schistosoma haematobium, though not a sexually transmitted infection, causes significant damage to the male and female genital tracts. Such overt damage raises risks of spreading and acquiring Human Immunodeficiency Virus and Human Papilloma Virus. In Africa, over 50 million women continue to suffer from female genital schistosomiasis, alongside a poorly quantified global burden of travel-related infections. In conjunction with male genital schistosomiasis, urogenital schistosomiasis causes much suffering, within and between afflicted households, inclusive of stigmatization. Both trichomoniasis and schistosomiasis expose several public health needs currently addressed inadequately by routine sexual and reproductive health services. This preface to the Parasitology Special Issue entitled ‘Parasites of the genital tract: short- and long-term consequences’, introduces 19 papers that explore the short – and long-term impacts of parasitic infections within the genital tract. While current parasitological research is weighted towards human medicine, we encourage future studies that explore veterinary contexts and analogous parasitic diseases within wildlife.

Both sex (biological) and gender (socio-cultural) are increasingly recognized as important factors in disease risks and outcomes, including parasitic infections and especially those of the genital tract. Many funding agencies now require these dimensions be incorporated into research proposals, though little guidance is given regarding how, leading to confusion among those who do not specialize in this area. In this commentary, I review instances of the use of the word ‘gender’ in the archives of Parasitology (174 articles) to assess how parasitologists are progressing in the incorporation of this dimension and identify what can be done to improve efforts. Use of the term has increased since 1990, reflecting an enthusiasm among parasitologists for including this dimension to their work. Examination of articles which use this term reveals that correct and thorough incorporation of the gender dimension has also increased, but that these articles only account for 8.0% of all articles using the term, demonstrating widespread persistent confusion around terminology regarding sex and gender and how to best account for gender in parasitological research. Parasitologists studying animals should only refer to sex and should incorporate sex into their research design and report whether there are differences in baseline or response between sexes. Parasitologists studying humans should incorporate sex, but then also consider whether any observed differences are due to biological factors like sex hormones and immunity or gendered social variables like behavioural norms and healthcare access. These considerations will further our understanding of host–parasite interactions and improve health outcomes.

Tritrichomonas foetus causes bovine trichomonosis, a venereal disease that reduces productivity in naturally mated cattle. Its high prevalence in Northern Australian herds underscores the need for a locally made strain-specific vaccine. This study developed and tested a whole-cell killed T. foetus vaccine using the Queensland isolate TfOz5 (vaccine strain) and TfOz-N36 (Northern Territory isolate) as the challenge strain. The heat-inactivated vaccine, adjuvanted with Montanide ISA 61 VG, was administered subcutaneously in 2 doses (5 × 10⁷ cells/dose) at a 1-month interval to mature bulls (n = 6) (4–7 years old), while controls (n = 6) (4–8 years old) received adjuvant with PBS. Bulls were experimentally challenged intrapreputially with live cultures of T. foetus at 2- and 6-months post first vaccination. A therapeutic trial with T. foetus-positive, persistently infected mature bulls (n = 10) (4–7 years old) used the same vaccine regime without the subsequent T. foetus challenges. The vaccine was found to be safe, causing only mild local reactions. The vaccine challenge experiment demonstrated similar duration of T. foetus positivity, confirmed by quantitative polymerase chain reaction (qPCR), compared to controls (94 vs. 106 days, P = 0.73). In the therapeutic experiment, 2/10 treated bulls tested negative for T. foetus at the end of the trial, while the remaining eight remained positive. Vaccinated bulls in both experiments showed significantly elevated serum anti-T. foetus IgG antibody levels, confirming the vaccine’s immunogenicity. These findings demonstrate that the experimental vaccine is safe and capable of eliciting a specific immune response in mature bulls.

Male genital schistosomiasis (MGS), a gender-specific manifestation of urogenital schistosomiasis and neglected tropical disease, typically results from the entrapment of Schistosoma haematobium eggs within the male genital tract. Across the world, there are no current and accurate estimates of the burden of MGS, due to disease underreporting primarily from diagnostic challenges and a lack of general awareness within the health system. Diagnostic methods for MGS are extremely limited. Conventionally, semen microscopy for Schistosoma ova is used though this technique suffers from low sensitivity and lacks protocol standardization. The introduction of molecular diagnostics, such as polymerase chain reaction (PCR), has partly helped overcome this challenge of low sensitivity, though may not be suitable for use in resource-constrained settings. To address these challenges, in this review, we propose a two-step diagnostic algorithm for MGS in accordance with recent WHO guidelines, consisting of a high sensitivity serological test followed by a high specificity test (microscopy or molecular assay, dependent on setting). Further investigation is required into standardization of sample collection, processing, storage, and analysis in order to identify an evidence-based optimal diagnostic pipeline. New diagnostic tools are needed such as isothermal molecular assays, alongside optimization for semen analysis, which may alleviate barriers to diagnosis and present opportunities for integration with other sexual and reproductive health screening. These areas of future investigation underpin the development of a suitable diagnostic pipeline, as the continued neglect of MGS and its underdiagnosis presents a threat to the goal of elimination of schistosomiasis as a public health problem.

We present four cases of male genital schistosomiasis (MGS) within children and adolescents opportunistically encountered as part of a wider screening programme for imported schistosomiasis in Germany and community outreach screening in Mali. Such genital manifestations in young children and adolescents are often overlooked but can include hydrocele, hypogonadism, varicocele, cutaneous granulomata on the penis and scrotum, echogenic spots in the prostate and the epididymis, alongside testicular masses. Though these cases appear sporadic, from our scoping literature review, they draw fresh attention on MGS in young children and highlight wider confusion with other congenital, neoplastic and infectious disease. These might include an insufficient closure of the tunica vaginalis, malignancies or lymphatic filariasis. Frequently haematuria is not present. One typical sign indicating MGS in adults, i.e. haematospermia is not present before puberty. Another reason of missing MGS cases may be that screening with scrotal or transabdominal ultrasonography are not easily accepted unless the reason for it is not extensively explained beforehand and that transabdominal ultrasonography is less sensitive for revealing prostatic lesions than transrectal ultrasonography.

In sub-Saharan Africa’s endemic areas for urogenital schistosomiasis, male genital schistosomiasis (MGS) can cause significant morbidity. As part of the Hybridization in UroGenital Schistosomiasis investigation, an MGS sub-study examined a cohort of adult men over a calendar year to better ascertain general infection dynamics and putative zoonotic schistosome transmission. During follow-up, demographic, health and socio-economic data were collected through individual questionnaire interviews. Collected urine and semen were analysed using urine filtration, urine and semen microscopy and molecular DNA analyses of semen. Ten participants with reported MGS-associated symptoms had Schistosoma eggs in their urine and semen at 6-month follow-up, with seven at 12 months. Ten out of 11 participants with Schistosoma haematobium eggs on semen microscopy at baseline had persistent infection at 6-month follow-up, together with 6 new participants, giving an MGS prevalence of 84·2% (n = 19). Two also had Schistosoma mattheei eggs co-infection. Four of the 13 participants at 12-month follow-up had S. haematobium eggs in their semen which were persistent at all the time points. Using semen PCR, 14 participants (73·7%) had Schistosoma infection at 6 months, with only 2 participants being infected for first time. Upon DNA analysis, three participants also had hybrid co-infection at this time point. At 12 months, only 6 participants had Schistosoma infection with no hybrids detected. In summary, like S. haematobium and despite praziquantel treatment, both zoonotic and hybrid schistosomes can continue to cause MGS, which pose a further tangible challenge in future management and control measures.

The prevalence of female genital schistosomiasis (FGS) and male genital schistosomiasis (MGS) remains high in many low-to-medium-income countries, and each has sex-specific disease sequelae with wider detrimental gender and health impacts. Social science research studies on the former outnumber those on the latter. Indeed, in many countries across sub-Saharan Africa (SSA), MGS (as with male reproductive and sexual health issues in general) is overlooked, underappreciated, and broadly orphaned within urogenital and intestinal schistosomiasis research and control. Similarly, in those countries where MGS has been reported formally, its psychosocial dimensions and effects remain poorly understood, especially in terms of context-specific cultural and societal factors. In this scoping review, we attempt to better contextualize MGS within men’s sexual and reproductive health and rights (SRHR) and general wellbeing, as it often draws parallels with social science research in FGS. We discuss common psychosocial determinants, highlighting why current surveillance of MGS is particularly poor and the primary health care response to mitigate it is bottlenecked and largely stalled within the wider health system, from both top-down and bottom-up perspectives. Our specific approach remains cognisant of the context of infected households where all members could be suffering from urogenital and/or intestinal schistosomiasis. Looking ahead, we develop and frame a pragmatic social science research agenda to encourage and better explore and assess the detrimental impact of MGS on infected men and boys, considering appropriate ameliorations more holistically within primary care.

Genital schistosomiasis, caused mainly by infection with Schistosoma haematobium flukes, causes a variety of symptoms and significant complications in men and women. With high levels of migration from sub-Saharan Africa to Europe and North America, genital schistosomiasis is likely to be encountered more frequently by clinicians in non-endemic areas. In this article, we review the current knowledge of genital schistosomiasis in non-endemic areas, available guidelines and barriers to clinical care of patients. Future work to address these barriers will likely improve care for patients with this neglected and stigmatized disease.

We analysed the early results of a screening and management protocol of imported female genital schistosomiasis (FGS) among migrant women from endemic countries. In total we screened 136 women, from which 39 had suspicion of FGS (serology-positive test and clinical signs and symptoms compatible). Median age was of 42.7 years [interquartile range (IQR 35–45)], median time living in the Europe (EU) was of 14 years (IQR 10–19) and all of them were coming from a West African country, mainly Senegal (17 out of 39; 43.6%). All of them had 1 or more clinical genitourinary findings [median 5 (IQR 2–6)], being the most prevalent pelvic pain, vaginal discharge and menstrual disorders. According to the protocol, colposcopy and cytology examination was performed in 11 participants, from whom 7 had findings compatible with FGS and 5 had low-grade cervical dysplasia with human papillomavirus (HPV)-negative results. After specific treatment with praziquantel (PZQ), we observed a high rate of resolution of clinical signs and symptoms, serology clearance at the 12th month of follow-up. Colposcopy lesions of 3 women assessed at the end of follow-up were fully resolved. Our findings and previous research support the implementation of management protocols of FGS in non-endemic countries, in spite of the knowledge gaps that still remain. Clinical trials need further assessment to determine the efficacy of PZQ, new diagnostic tools and the interaction between FGS, HPV and cervical cancer.

Schistosomiasis remains a significant public health concern in sub-Saharan Africa, particularly among women and children. In Cameroon, urogenital and intestinal schistosomiasis affect the lives of millions of impoverished populations, and female genital schistosomiasis (FGS) remains a serious threat which has not been quantified explicitly. The extent of stigmatization and discrimination related to FGS is currently unknown. This study explores the use of precision mapping to identify high-risk communities for urogenital schistosomiasis and guide targeted screening for FGS. Parasitological surveys were conducted between November 2020 and July 2021 in four health districts using urine filtration and Kato-Katz techniques, first in schools to identify areas of higher transmission, and secondly in selected high-risk communities. Geographic information system tools were employed to identify high transmission foci and households of targeted infected women. Results of surveys in schools showed no schistosomiasis transmission in Ayos (0%) and low prevalence in Akonolinga (8%), while Bertoua and Doume had high prevalence, up to 33% and 48% infection with Schistosoma haematobium, respectively. These results made the two health districts of Bertoua and Doume suitable for focused FGS investigations. Surveys in communities revealed higher schistosomiasis prevalence and infection intensity in Doume compared to Bertoua. Precision mapping effectively identified infected women and enabled targeted recruitment for further clinical studies, facilitating efficient resource allocation for gynaecological follow-up. This approach demonstrates the value of geospatial tools in enhancing targeted public health interventions, disease surveillance and control strategies.

In Africa, female genital schistosomiasis (FGS) damages women’s health. In Cameroon, diagnosis is rare and healthcare workers lack knowledge. Clinicians can be trained to identify FGS lesions, but the accuracy is uncertain. We assessed the acceptability and feasibility of FGS screening in Cameroon’s East Province by comparing static HIV clinics and mobile pop-up clinics through consultations and acceptance rates, guided by precise disease mapping. A clinician was remotely trained to diagnose FGS lesions, with success measured by expert comparison using cervix images. The proportion of FGS was compared between settings. A total of 1242 women were approached, 624 in the HIV clinics and 618 in the mobile clinics, respectively. Women at HIV clinics were significantly older [37.0 years (interquartile range, IQR: 31–43)] than those at mobile clinics [28.5 years (IQR: 23–36)]. Refusal of the screening procedures was significantly higher in the HIV clinics (50%) than in the mobile clinics (31%). FGS lesions were present in over half of women examined, 51% in the HIV clinic and 56% in the community. The diagnostic concordance between clinicians was more than 90%. It is both feasible and acceptable to identify and treat FGS lesions in areas without specialized care. Mobile pop-up clinics’ acceptability is better, with younger women participating which helps to better rectify age-inequities in FGS surveillance, and remote telemedicine training is effective. Prevalence of FGS suspect lesions was very high in both settings.

Liberia (West Africa) has an extensive (co)burden of urogenital and intestinal schistosomiasis; each largely restricted to more inland areas. Where urogenital schistosomiasis is endemic, as both disease surveillance and case management are nascent, many women may unknowingly be living with Female Genital Schistosomiasis (FGS). Using a recently developed FGS score card, we appraised FGS score card valuations with point-of-care gynaecological and molecular parasitological evaluations as undertaken within typical primary care settings of four Liberian counties. A total of 400 women, 100 participants from each of four endemic inland counties, underwent a cursory gynaecological examination using a speculum for visible FGS lesions, undertaken by a midwife, and provided a urine sample that was examined by centrifugation with microscopy for Schistosoma ova. Urine-sediments in ethanol were later analysed with a high-resolution melt (HRM) real-time (rt) PCR assay to screen for Schistosoma genetic markers. Using a combination of clinical and parasitological information, overall prevalence of UGS and FGS was <10% and a single case of putative FGS-associated co-infection with Schistosoma mansoni was observed. Participant interviews with the FGS score cards provided an insight into at-risk lifestyle and environmental factors, e.g. women who fished regularly were more likely to present with FGS whereas those who lived > 15 km from a local river were less likely to present with FGS. In this resource-poor setting of Liberia, active surveillance for FGS with either clinical or parasitological methods remains challenging such that sole future use of the FGS score card is most pragmatic for primary care.

Urogenital schistosomiasis (UGS) caused by zoonotic or hybrid schistosome infection(s) is an emerging public health concern in Malawi, and we describe a 1-year clinical sub-study with 3 inspection time points for female genital schistosomiasis (FGS) upon selecting 86 women with proven UGS. This sub-study was set within a broader 2-year longitudinal ‘Hybridization in UroGenital Schistosomiasis (HUGS)’ investigation. A detailed cervicovaginal examination with a portable colposcope was conducted, examining cervicovaginal lavage (CVL), cervical swab, cervical biopsy and urine with traditional parasitological and molecular diagnostic methods. At baseline, overt FGS by colposcopy was 72.1%, 64.3% by CVL real-time PCR and 51.2% by both colposcopy and CVL-PCR, noting urine-microscopy could often be negative. Human papillomavirus was detected in 31.0% of the cervical swabs, with 8.3% women also FGS positive by colposcopy and real-time PCR. Over the year, FGS prevalence by colposcopy increased by 32.7% during the study to 84.6%, homogenous yellow and grainy sandy patches being very common in the youngest 18–25 age group, where 51.9% were positive. FGS appears widespread locally and we discuss difficulties in its detection without invasive sampling. In addition to the presence of S. haematobium, S. mattheei was noted alongside key concurrent sexually transmitted infections. From our findings, we point out that improved prevention and management of FGS is required, foremost, better availability and regular accessibility to praziquantel treatment is needed. Furthermore, targeted health education, raised community awareness and dovetailing synergistic public health activities within Sexual and Reproductive Health services and local HIV/AIDS programmes could develop an appropriate holistic health intervention package.

Female genital schistosomiasis (FGS) is a chronically disabling gynaecological condition, impacting up to 56 million women and girls, mostly in sub-Saharan Africa. In lieu of a gold standard laboratory test, it is possible to diagnose FGS visually. Visual diagnosis is performed through inspection of the cervix and surrounding tissue to identify signs of Schistosoma egg deposition, associated inflammation and granuloma formation. The change related to egg deposition can be very subtle and heterogeneous and is often seen in the context of other altered cervical morphology. Visual diagnostics for FGS are therefore currently highly subjective and lack specificity, with low consistency of grading between trained expert reviewers. Computer vision, driven by artificial intelligence, is an enticing prospect to overcome these issues due to the potential to accurately detect and classify the subtle changes and patterns that are indiscernible to human graders. Computer vision also offers the opportunity to support resource-constrained regions with few staff trained on visual diagnostics. However, several challenges stand in the way of progressing and successfully implementing computer vision tools for FGS. These challenges are particularly related to the variation in the appearance of the cervix (with or without disease) and FGS lesions, as well as the difficulty with accurately labelling cervical images. Exploring alternative annotation methods and model architectures is likely to improve the performance of FGS computer vision tools. This paper will explore the challenges of FGS computer vision and provide suggestions on how to overcome these barriers to enhance visual diagnostics for FGS.

Women in sub-Saharan Africa face complex, multifaceted challenges to their health, including a high burden of infectious diseases aggravated by socioeconomic factors. Parasitic and sexually transmitted infections both cause significant morbidity and mortality. Co-infections compound these effects, leading to high rates of chronic illness and making diagnosis and treatment challenging. There are no integrated approaches for the detection of female genital schistosomiasis (FGS), a gynaecological condition caused by Schistosoma haematobium, and high-risk human papillomavirus (HR-HPV), responsible for over 90% of all cervical cancer cases worldwide. FGS is a chronic condition with health outcomes such as infertility and abortion and remains severely under-reported. HR-HPV infection is the main aetiological agent of cervical cancer, the leading cause of cancer death in women in sub-Saharan Africa. Both can be disabling and stigmatizing to the sufferer. A key to disease management at patient and community levels is accurate and available diagnostics. Due to both FGS and HPV diagnostics utilising cervicovaginal samples, they are ideal candidates for a multiplex molecular diagnostic. The standard molecular diagnostics (namely PCR), through the detection of pathogen DNA, are constrained in low resource settings by requirement of a highly reliable source of energy, reliance on a cold-chain, and prohibitive costs. Isothermal molecular diagnostics are an alternative method to PCR that are more suited to basic settings. This review explores current isothermal diagnostics, with a focus on RPA/RAA, a very simple isothermal technology, for FGS and HPV and proposes the development of a multiplex isothermal diagnostic test to enable integrated screening.

Urogenital schistosomiasis has 2 gender-specific manifestations, male genital schistosomiasis (MGS) and female genital schistosomiasis (FGS). The burdens of MGS and FGS are multifaceted, encompassing financial hardship, emotional and mental health problems and sometimes social stigmatization. Given the pernicious nature of sequelae in the genitalia, managing these chronic health conditions is expensive, difficult and problematic in resource poor settings. Key challenges include lack of epidemiological data on the burden of MGS and FGS, inadequate knowledge among primary and auxiliary health care workers, leading to misdiagnosis, incorrect treatment administration, e.g. overuse of antibiotics, and a lack of appropriate point-of-care diagnostic equipment. Prevention of MGS and FGS is therefore more preferable, however, current preventive programmes and chemotherapy campaigns offering praziquantel are becoming more resource constrained and in most endemic areas are not reaching at-risk adults (and adolescents), sufficiently. Furthermore, there are limited prospects for adequate access to treatment in pre-school children where infections can be first acquired. Therefore, we propose 3 key recommendations guiding movement towards elimination of schistosomiasis as a public health problem: scaling-up praziquantel treatment for other at-risk groups; developing a targeted One Health approach to reduce environmental transmission in both humans and animals; Multi-stakeholder collaboration and community engagement for effective implementation of Water Sanitation and Hygiene components of disease control. Whilst maintaining a school-based approach is still foundational, targeted and sustainable expansion of preventive chemotherapy to other at-risk groups within communities is needed to secure real prospects in elimination of genital schistosomiasis as a public health problem in Africa.

Female genital schistosomiasis (FGS) is a neglected manifestation of Schistosoma haematobium infection, affecting an estimated 56 million women in sub-Saharan Africa. It is characterized by lesions in the genital tract, leading to symptoms like pain, infertility and an increased risk of HIV transmission. Despite its prevalence, FGS remains underdiagnosed and underreported due to limited awareness and diagnostic capabilities. Current knowledge emphasizes the need for integrated approaches combining diagnosis, treatment with praziquantel and education. There are ongoing efforts to integrate FGS services into women’s sexual and reproductive services, yet to date many African countries lack programmatic guidance to achieve this. More comprehensive integration and mainstreaming of FGS prevention, control and treatment across various sectors is needed to ensure intersectoral collaboration and financing of programmes. This review examines the various intervention tools currently available to achieve FGS integration in health systems. These include water, sanitation and hygiene improvements, environmental management, health education and inclusion of preschool-aged children in national schistosomiasis control programmes. Highlighted are also the required diagnostic and therapeutic tools, preventive interventions, effective policy and sustainable funding, all integral to achieving comprehensive FGS mainstreaming.

Female genital schistosomiasis (FGS) remains a neglected sexual and reproductive health (SRH) condition, predominantly affecting women and girls in sub‐Saharan Africa. Infection with Schistosoma haematobium, resulting in trapped parasite eggs in the genital tract, causes lesions that mimic sexually transmitted infections and cervical neoplasia, often leading to misdiagnosis, stigma and delayed treatment. This review summarises current developments on FGS burden, prevention, diagnostics, integration, policy, community engagement and identifies critical threats to progress. Ongoing surveys show promise in ensuring robust burden estimates and age‐related risk data. Diagnostic advances include portable colposcopy, digital image analysis techniques and molecular assays, although limitations persist in resource‐limited settings. Praziquantel remains the cornerstone of treatment, yet single‐dose regimens inadequately reverse established lesions; repeated dosing shows improved parasite clearance but limited lesion regression, highlighting the necessity for early, life‐course preventive chemotherapy including access to paediatric praziquantel. Successful programmatic pilots have developed training curricula, minimum service packages, community engagement tools and have integrated FGS care into SRH platforms. Policy momentum is building through World Health Organization taskforces and national strategies, yet sustainable financing remains a challenge. Key threats include bilateral aid reductions, climate change, emerging infections, rising healthcare costs and persistent gender inequities. To address these challenges, we propose seven priority actions, encompassing all health system building blocks, for the global community. Nationally coordinated, multisectoral efforts are urgently required to embed FGS prevention, diagnosis and management within broader health systems, thereby improving outcomes for affected women and girls.

Female genital schistosomiasis (FGS) is a chronic disease manifestation of the waterborne parasitic infection Schistosoma haematobium that affects up to 56 million women and girls, predominantly in sub-Saharan Africa. Starting from early childhood, this stigmatizing gynaecological condition is caused by the presence of Schistosoma eggs and associated toxins within the genital tract. Schistosoma haematobium typically causes debilitating urogenital symptoms, mostly as a consequence of inflammation, which includes bleeding, discharge and lower abdominal pelvic pain. Chronic complications of FGS include adverse sexual and reproductive health and rights outcomes such as infertility, ectopic pregnancy and miscarriage. FGS is associated with prevalent human immunodeficiency virus and may increase the susceptibility of women to high-risk human papillomavirus infection. Across SSA, and even in clinics outside endemic areas, the lack of awareness and available resources among both healthcare professionals and the public means FGS is underreported, misdiagnosed and inadequately treated. Several studies have highlighted research needs and priorities in FGS, including better training, accessible and accurate diagnostic tools, and treatment guidelines. On 6 September, 2024, LifeArc, the Global Schistosomiasis Alliance and partners from the BILGENSA Research Network (Genital Bilharzia in Southern Africa) convened a consultative, collaborative and translational workshop: ‘Female Genital Schistosomiasis: Translational Challenges and Opportunities’. Its ambition was to identify practical solutions that could address these research needs and drive appropriate actions towards progress in tackling FGS. Here, we present the outcomes of that workshop – a series of discrete translational actions to better galvanize the community and research funders.