Introduction
Male genital schistosomiasis (MGS) is a specific manifestation of schistosomal disease, associated with the presence of schistosome eggs and pathologies in various genital organs and reproductive fluids. MGS was originally reported by Professor Frank Cole Madden, Professor of Surgery at Kasr-el-Ainy Hospital in Cairo, Egypt, in 1911. He described a 14-year-old Egyptian boy with an enlarged scrotum showing epididymal schistosomiasis and an English soldier complaining of haemospermia (blood in semen) concurrently with urinary schistosomiasis. Other symptoms of MGS described in literature include pelvic pain appearing spontaneously, during coitus or on ejaculation, ejaculate changes, erection discomfort or dysfunction, and infertility (Squire and Stothard, Reference Squire, Stothard, Beeching and Gill2014; Kayuni et al. Reference Kayuni, Lampiao, Makaula, Juziwelo, Lacourse, Reinhard-Rupp, Leutscher and Stothard2019a). Although observations indicate that genital organs are frequently infested with schistosome eggs along with the urinary bladder (Schistosoma haematobium) or intestines (Schistosoma mansoni), the current extent of morbidity associated with MGS in endemic areas remains under-researched and is most clearly evidenced by post-mortem studies and case reports. Schistosomiasis is one of the parasitic diseases prominently featured in the 2012 London Declaration on Neglected Tropical Diseases (NTDs) and requires significant global attention alongside multisectoral investment in its long-term control (Olorunlana, Reference Olorunlana, Morales-Montor, Del Río-Araiza and Hernandéz-Bello2022).
In sub-Saharan Africa (SSA), two manifestations of schistosomiasis exist, intestinal and urogenital. The former is broadly caused by infection with S. mansoni, while the latter is typically caused by infection with S. haematobium, although other schistosome species within the S. haematobium group have been incriminated (Stothard et al. Reference Stothard, Juhász and Musaya2025). Another key difference between disease manifestations is that sex-related pathology in urogenital schistosomiasis is much more pronounced than in intestinal schistosomiasis; so much so that a sex- and gender-specific terminology has been introduced with the World Health Organization (WHO) widely publicising female genital schistosomiasis (FGS) and MGS (Buonfrate et al. Reference Buonfrate, Ferrari, Adegnika, Stothard and Gobbi2025).
Common to both forms of schistosomiasis in SSA, however, are exposure and transmission routes, which both typically take place in various freshwater habitats, and each has an intricate interplay between human behaviour and environmental determinants, as well as sex and gender (Li et al. Reference Li, Zheng, Midzi, Mutsaka-Makuvaza, Lv, Xia, Qian, Xiao, Berguist and Zhou2024). Some 15 years ago, Aagaard-Hansen et al. (Reference Aagaard-Hansen, Mwanga and Bruun2009) outlined an influential forward-looking social science general agenda for sustainable schistosomiasis control. Their recommendations included ways of ensuring equitable access to health services and access to preventive chemotherapy like praziquantel (Salari et al. Reference Salari, Furst, Knopp, Utzinger and Tediosi2020; Choko et al. Reference Choko, Dovel, Kayuni, Conserve, Buttterworth, Bustinduy, Stothard, Kamchedzera, Mukoka-Thindwa, Jafali, MacPherson, Fielding, Desmond and Corbett2024). They further recommended the involvement of endemic communities and local health care systems based on equitable partnerships (Aagaard-Hansen et al. Reference Aagaard-Hansen, Mwanga and Bruun2009). Whilst FGS was mentioned specifically, MGS was overlooked. Nevertheless, their framework remains relevant today when the broader dimensions of MGS are considered. These include diagnosis and screening, praziquantel treatment, water and sanitation, health communication, community involvement, and health systems strengthening (Aagaard-Hansen et al. Reference Aagaard-Hansen, Mwanga and Bruun2009). Since then, social science research on FGS has progressed significantly. However, MGS remains understudied, with the role of men considered as a determinant of the health-seeking behaviour of women (partners) and girls (children) within their FGS-afflicted households (Lambert et al. Reference Lambert, Samson, Matungwa, Kosia, Ndubani, Hussein, Kalua, Bustinduy, Webster, Bond and Mazigo2024). Diagnosis of MGS involves microscopic examination of semen for the presence of schistosome eggs, Figure 1, and of note here, eggs may or may not be present within the associated urine specimen (Kayuni et al. Reference Kayuni, Lampiao, Makaula, Juziwelo, Lacourse, Reinhard-Rupp, Leutscher and Stothard2019a).
Figure 1. A photomicrograpy at x400 of a viable atypical S. haematobium egg most likely Schistosoma mattheei within a semen. Detection of eggs in semen by light microscopy is pathnognomic for MGS, which can vary in number up to several hundred within a single sample. Semen microscopy is a low cost method within primary care yet nearly all primary care health outputs off this service and only a small minority of men seek diagnosis and treatment for MGS.
In our short scoping review presented here, we aim to better set out the social science research agenda for the MGS across SSA, highlighting its impacts, to suggest more informed and tailored MGS interventions.
A foundational rationale for social science research
Across SSA, MGS continues to be neglected and has not received adequate attention in awareness and diagnostics, as well as in the index of suspicion of health care personnel (Bustinduy et al. Reference Bustinduy, Randriansolo, Sturt, Kayuni, Leustcher, Webster, Van Lieshout, Stothard, Feldmeier and Gyapong2022). Despite being the responsibility of technically competent healthcare professionals, diagnosis, screening, and treatment are often mediated by different socio-cultural factors, including cultural and gender norms, which may result in misdiagnosis and inadequate treatment (Aagaard-Hansen et al. Reference Aagaard-Hansen, Mwanga and Bruun2009). MGS symptoms have previously been mistaken for sexually transmitted infections (STIs), with patients wrongly admitted to syndromic management of STIs (Kayuni et al. Reference Kayuni, Corstjens, LaCourse, Bartlett, Fawcett, Shaw, Makaula, Lampiao, Juziwelo, de Dood, Hoekstra, Verweij, Leutscher, van Dam, van Lieshout and Stothard2019b), a common diagnostic misunderstanding in parallel with FGS, percolating throughout many levels within the health system and causing unnecessary stigmatization (Bustinduy et al. Reference Bustinduy, Randriansolo, Sturt, Kayuni, Leustcher, Webster, Van Lieshout, Stothard, Feldmeier and Gyapong2022).
Whilst there is a growing body of research on FGS, including social science research and references therein (Kukula et al. Reference Kukula, MacPherson, Tsey, Stothard, Theobald and Gyapong2019; Masong et al. Reference Masong, Mengue, Marlene, Dean, Thomson, Stothard and Theobald2024), there is a clear need for accompanying research on MGS. For instance, the true burden of MGS and its psychosocial dimensions across SSA is unknown, not overlooking any travel-related infections that are detected elsewhere (Bustinduy et al. Reference Bustinduy, Randriansolo, Sturt, Kayuni, Leustcher, Webster, Van Lieshout, Stothard, Feldmeier and Gyapong2022). Central to this dilemma is, arguably, the lack of tailored responses that are firmly grounded in the social and cultural realities of the affected demographics and communities. For example, an important requirement for scale-up in parasitological surveillance of MGS is the appropriate collection and microscopic inspection of semen necessary to visualize schistosome eggs directly therein (Kayuni et al. Reference Kayuni, Alharbi, Makaula, Lampiao, Juziwelo, LaCourse and Stothard2021).
Even with sufficient prior community sensitization and adequate confidential explanation, many men still refuse or are unable to submit a semen sample, or to a lesser extent, a urine sample, requiring additional motivation or further instructions to do so. Even after such empowerment, not all will submit a sample for diagnosis for such culturally awkward testing (Kayuni et al. Reference Kayuni, Alharbi, Makaula, Lampiao, Juziwelo, LaCourse and Stothard2021). Developing an appropriate community entry point still needs optimization, as evidenced by a systematic review of MGS in SSA, which yielded few qualitative and quantitative studies in this area (Kayuni et al. Reference Kayuni, Lampiao, Makaula, Juziwelo, Lacourse, Reinhard-Rupp, Leutscher and Stothard2019a, Reference Kayuni, Corstjens, LaCourse, Bartlett, Fawcett, Shaw, Makaula, Lampiao, Juziwelo, de Dood, Hoekstra, Verweij, Leutscher, van Dam, van Lieshout and Stothard2019b), clearly pointing to a paucity in social science research around MGS even at such a foundational level.
Masculinity and health-seeking behaviour
In Africa, hegemonic masculine norms are prevalent and significantly influence men’s poor health-seeking behaviours (Beia et al. Reference Beia, Kilemann and Diaconu2021). Hegemonic masculine norms not only negatively influence men’s health, but also the broader household’s health, including women and children who may also suffer from either of the two main forms of schistosomiasis. However, the focus on how masculinities influence men’s behaviours and experiences risks over-emphasising individual determinants of health, thereby overlooking other systems of power that intersect with masculinities (Phillips and Pirkle, Reference Phillips and Pirkle2011; Affleck et al. Reference Affleck, Carmichael and Whitley2018). Scholarship on masculinities acknowledges that although men and masculinities are explicitly gendered, multiple systems of power (economic, political, and social) intersect to create simultaneous privileges and disadvantages for individuals based on their position within axes of social inequality. These are also shaped by broader power relationships (Hankivsky, Reference Hankivsky2012; Fast et al. Reference Fast, Bukusi and Moyer2020). These intersecting axes of inequity need to be acknowledged, understood, engaged, and explored, especially from a social science perspective (Bardosh, Reference Bardosh2014). Intersectionality theory offers a valuable framework for understanding these complexities.
Masculinity and sexual and reproductive health
MGS has implications for a range of SRHR issues affecting men and their partners. Schistosome infections, specifically FGS and MGS, have been noted to increase the risk of HIV infection and transmission (Jourdan et al. Reference Jourdan, Roald, Poggensee, Gunderson and Kjetland2011; Wall et al. Reference Wall, Kilembe, Vwalika, Dinh, Livingston, Lee, Lakhi, Boeras, Naw, Brill, Chomba, Sharkey, Parker, Shutes, Tichacek, Secor and Allen2018; Sturt et al. Reference Sturt, Webb, Francis, Hayes and Bustinduy2020; Kayuni et al. Reference Kayuni, Abdullahi, Alharbi, Makaula, Lampiao, Juziwelo, LaCourse, Kumwenda, Leutscher, Geretti and Stothard2023). Other risks include co-infection with STIs, putative risk of prostate cancer development, as well as the possibility of subfertility or infertility (Wall et al. Reference Wall, Kilembe, Vwalika, Dinh, Livingston, Lee, Lakhi, Boeras, Naw, Brill, Chomba, Sharkey, Parker, Shutes, Tichacek, Secor and Allen2018; Choto et al. Reference Choto, Mduluza, Mutapi and Chimbari2020; Kayuni et al. Reference Kayuni, Abdullahi, Alharbi, Makaula, Lampiao, Juziwelo, LaCourse, Kumwenda, Leutscher, Geretti and Stothard2023). The mere location of the condition is a threat to masculinity. In a study by Gyapong et al. (Reference Gyapong, Gyapong, Weiss and Tanner2000) on the burden of hydrocele on men in Ghana, the authors note that the disease threatens the integrity of a body organ (penis) that is associated with self-esteem, sexuality, fertility, and masculinity, issues of importance to ill and healthy men alike (Gyapong et al. Reference Gyapong, Gyapong, Weiss and Tanner2000).
It is important to not only consider the link between MGS and SRHR from a biomedical perspective but also to integrate a social science lens that incorporates gender and equity to better understand the nature, context, and implications of the contemporary linkages. For instance, there are underlying power dynamics that influence sexual relationships and men’s (and women’s) decisions to test for, and/or prevent the spread of HIV (Kayuni et al. Reference Kayuni, Abdullahi, Alharbi, Makaula, Lampiao, Juziwelo, LaCourse, Kumwenda, Leutscher, Geretti and Stothard2023; Choko et al. Reference Choko, Dovel, Kayuni, Conserve, Buttterworth, Bustinduy, Stothard, Kamchedzera, Mukoka-Thindwa, Jafali, MacPherson, Fielding, Desmond and Corbett2024). If explored, such power dynamics could shed light on how men perceive MGS and its attendant complexities, including misdiagnosis, infertility, and stigma.
MGS and the invisible socioeconomic impacts
There is a well-established link between NTDs and poverty in many low-to-medium income countries, including in SSA, entrenching vulnerability among the ‘bottom billion’ of the world’s poorest (Hotez et al. Reference Hotez, Fenwick, Savioli and Molyneux2009). MGS and other NTDs are ‘diseases of poverty’ as they arise from and contribute to poverty, causing a cycle of poor health and economic hardship (King Reference King2010; Onasanya et al. Reference Onasanya, Bengtson, Oladepo, Van Engelen and Diehl2021). Due to MGS, men’s productivity across different occupations in endemic areas is likely reduced, and livelihoods are potentially threatened, which could further exacerbate poverty. In Burkina Faso, for example, Rinaldo et al. (Reference Rinaldo, Perez-Saez, Vounatsou, Utzinger and Arcand2021) noted ‘…infected individuals, households and populations who have poorly managed schistosomiasis experience detrimental health, social and financial burdens.’ In terms of increasing general economic security, large-scale irrigation schemes are an important policy response designed to reduce poverty, particularly in SSA, however, they often further propagate schistosomiasis, especially where occupational exposure is raised (Ayabina et al. Reference Ayabina, Clark, Bayley, Lamberton, Toor and Deidre Hollingsworth2021). An exploration of the extent of the socioeconomic impacts of MGS is essential for the identification of more meaningful responses.
Leveraging on aligned social science activities
Instead of premising our understanding of MGS in purely biomedical/parasitological terms, the application of a social science lens should be adopted. This will help us understand how cultural and social nuances influence perceptions towards and responses to it. Dean et al. (Reference Dean, Ozano and Thomson2023) emphasize the importance of moving away from ‘medicalized perspectives’ to ‘people-centred’ approaches to NTDs, highlighting the importance of taking forward a social science research agenda to understand MGS in the broadest sense. Parker et al. (Reference Parker, Polman and Allen2016) also call for the adoption of a biosocial approach which emphasizes the integration of biological and social lenses to the control of NTDs.
Taking a bottom-up perspective within the provision of primary care, healthcare workers’ understanding of urogenital schistosomiasis (FGS and MGS) remains generally low, with most mis-profiling it as an STI (Mazigo et al. Reference Mazigo, Samson, Lambert, Kosia, Ngoma, Murphy, Kabole and Matungwa2022). While there is insufficient informative literature assessing, or even promoting, healthcare workers’ knowledge of the epidemiology of MGS (Makene et al. Reference Makene, Zacharia, Haule, Lukumay and Ngasala2024), it is essential to identify people-centred and context-embedded approaches that will increase the index of suspicion for MGS among healthcare personnel. Similarly, international disease control programming in MGS, unlike that for FGS, provides little information to guide national policies on its surveillance and control (WHO, 2022).
Understanding lived experiences of MGS
For men with frequent and prolonged contact with infested water in susceptible occupations, including farming and fishing, the disease is near-inevitable, especially in the absence of adequate access to praziquantel treatment (Kayuni et al. Reference Kayuni, Alharbi, Makaula, Lampiao, Juziwelo, LaCourse and Stothard2021; Makene et al. Reference Makene, Zacharia, Haule, Lukumay and Ngasala2024). Just like its diagnosis and management, which is not well-pronounced, awareness around MGS by afflicted men is also negligible. In Malawi, men with genital symptoms of MGS attributed them to STIs or were not sure of the cause, while others speculated about social/cultural causes such as witchcraft (Kayuni et al. Reference Kayuni, Alharbi, Makaula, Lampiao, Juziwelo, LaCourse and Stothard2021). Education status is also critical in men’s perception of the causes and consequences of MGS. Most respondents in the Malawi study reported not having attended school or having attained only primary school education (Kayuni et al. Reference Kayuni, Alharbi, Makaula, Lampiao, Juziwelo, LaCourse and Stothard2021). This, coupled with other axes of inequity, shaped men’s understanding and awareness of MGS. Unlike women who have generally better health-seeking behaviour and tend to report FGS symptoms, men often underreport or ignore MGS symptoms (Mashilo et al. Reference Mashilo, Oladimeji, Gumede and Lalla-Edward2025; Kayuni et al. 2019). A social science lens is therefore essential to understand the workings of MGS and how diverse axes of inequity intersect to influence it.
Though not yet fully explored, the impact of MGS on men’s relationships could potentially include increased incidence of gender-based or intimate partner violence if its symptoms continue to be confounded with STIs (Sabri et al. Reference Sabri, Wirtz, Ssekasanvu, Nonyane, Nalugoda, Kagaayi, Ssekubugu and Wagman2019). Similarly, where women are (erroneously) suspected to be transmitters of MGS, relationships may be strained. Moreso, the likely occurrence of subfertility and infertility among sufferers of MGS and FGS may also result in adverse mental health and social consequences for affected couples (Masong et al. Reference Masong, Mengue, Marlene, Dean, Thomson, Stothard and Theobald2024). Subfertility brings a heavy psychosocial toll from external blame and rejection, exacerbated by internalized stigma and the challenge of not being able to fulfil cultural and gendered social norms. Previous research shows how gendered power dynamics in decision making, gendered experiences around men’s health and structural gaps in service provision combine and lead to poor mental well-being (Masong et al. Reference Masong, Mengue, Marlene, Dean, Thomson, Stothard and Theobald2024). Sensitization of both men and women on the epidemiology of MGS is therefore an important aspect of the social science agenda. As earlier noted, schistosome infection heightens the likelihood of HIV transmission in both sexes and acquisition in women (Wall et al. Reference Wall, Kilembe, Vwalika, Dinh, Livingston, Lee, Lakhi, Boeras, Naw, Brill, Chomba, Sharkey, Parker, Shutes, Tichacek, Secor and Allen2018). This therefore increases vulnerability to HIV and related health challenges among men with MGS and calls for an integrated response strategy targeting both MGS and HIV (Choko et al. Reference Choko, Dovel, Kayuni, Conserve, Buttterworth, Bustinduy, Stothard, Kamchedzera, Mukoka-Thindwa, Jafali, MacPherson, Fielding, Desmond and Corbett2024).
Posing questions to frame an agenda
To further unpack the social science research agenda for MGS, the following six principal questions can be posed.
1. What are the socio-cultural perceptions around MGS in endemic areas?
2. What is the typical burden of MGS within an endemic area of urogenital schistosomiasis?
3. What are the barriers and facilitators to screening, diagnosis, treatment, and destigmatization of MGS?
4. How acceptable, convenient, and effective are current strategies for identifying men with short- or long-term MGS and linking them to appropriate care?
5. How can existing treatment routes or therapeutic itineraries be used by men with MGS?
6. How can a local health system co-develop and pilot male-friendly MGS services as part of gender-responsive genital schistosomiasis programming in general?
Additional questions are included in Table 1.
Table 1. Additional domains for exploration of social science agenda in MGS
An overarching methodological note
It is sensible to develop a methodology that is inclusive and speaks to the realities of men and how their experiences of masculinities intersect with other axes of inequity to influence diagnosis, screening, and treatment of MGS. It is also plausible to integrate MGS into standard clinical guidelines and training, especially in endemic areas. Intervention co-development and theory of change are important in this regard as they encourage buy-in from men, most of whom are not keen to discuss (their) health issues. Other immersive methods that have been successfully used with groups of men elsewhere, such as photovoice and drama skits, also offer good opportunities for MGS studies (Oliffe and Bottorff, Reference Oliffe and Bottorff2022). Participatory and peer-led methods of information dissemination to promote interventions like mass drug administration with praziquantel are also ideal as they afford men the chance to learn about MGS (and receive treatment in situ at their workstations) as well as other associated high-risk infections such as HIV (Choko et al. Reference Choko, Dovel, Kayuni, Conserve, Buttterworth, Bustinduy, Stothard, Kamchedzera, Mukoka-Thindwa, Jafali, MacPherson, Fielding, Desmond and Corbett2024). Such methods may be important in encouraging men’s health-seeking practices as they traditionally put their livelihoods ahead of their health (Mavhu et al. Reference Mavhu, Neuman, Hatzold, Buzuzi, Maringwa, Chabata, Mangenah, Taruberekera, Madidi, Munjoma, Ncube, Xaba, Mugurungi, Johnson, Corbett, Weiss, Fielding and Cowan2021; Majam et al. Reference Majam, Hatzold, Mavhu, Tembo, Zishiri, Phiri, Conserve, Haile, Chidarikire, Johnson, Moyo, Meyer-Rath and Venter2025). Illness narratives are also important in documenting men’s lived experiences with MGS. The confidential exploratory focus of illness narratives is likely to work well to explore men’s SRHR experiences and concerns (Lucius-Hoene et al. Reference Lucius-Hoene, Breuning, Helfferich, Lucius-Hoene, Holmberg, Meyer, Lucius-Hoene, Holmberg, Meyer, Lucius-Hoene, Breuning, Helfferich, Lucius-Hoene, Holmberg, Meyer, Lucius-Hoene, Holmberg and Meyer2018).
A research agenda in outline
There are many unanswered questions in relation to how the social sciences can contribute to an improved understanding of the diagnosis, screening, and treatment of MGS in SSA. It is not yet clear how healthcare personnel can improve their understanding of the epidemiology of MGS as well as their index of suspicion. Beyond the parasitological conception of the epidemiology of MGS, it is essential to consider sociocultural mediators of the disease, hence the need for social science perspectives. An understanding of how culture and context influence men's and women’s perception of the disease is also required. Similarly, access to affordable praziquantel treatment outside of the governmental infrastructure, such as private pharmacies that can provide over-the-counter praziquantel treatment by retail, is needed. As such, treatment delivery could have fewer bottlenecks such that all men who seek treatment can access it and are better empowered. Of essence, also, is the introduction of an integrated approach to understanding men’s experiences with MGS and other critical sexual and reproductive health (SRH) issues, including infertility, associations with prostate cancer, voluntary male medical circumcision, and HIV.
Future studies on MGS are needed, not only to raise its awareness but also encourage wide policy-led discussions across many health system stakeholders that seek to better address its public health importance and improve its future control. On the 16-17th September 2025, WHO convened a two-day discussion meeting in Geneva entitled “Informal consultation on genital schistosomiasis “attended by two of our authors. The meeting’s aim was to review progress to date on interventions against urogenital schistosomiasis, to make public health recommendations for accelerating implementation of interventions and, identify global priorities to address genital schistosomiasis. We hope our scoping review on MGS will help to add a better appreciated social science dimension within these deliberations
Conclusions
To address MGS across SSA in future, there is need for better mobilization of traditional stakeholders in schistosomiasis control, including funders, policymakers, researchers, community members, and leaders. There is also need to establish new cross-sectoral links and those in SRH as well as other health system agencies, such as private pharmacies that can provide over-the-counter praziquantel treatment. Mass drug administration is also needed such that all men who are sufficiently motivated to seek treatment can access it and are therefore better empowered along a route towards better health. It is further recommended that MGS should be integrated into standard clinical guidelines and training especially with MDA campaigns targeting the wider population and not just school-aged children, as is currently obtaining in many endemic communities.
Author’s contribution
O.N., W.M., J.R.S., M.G., S.T. conceived of the review, the first draft was written by O.N. with all authors approving and contributing to the final draft.
Financial support
There was no specific funding for this scoping review.
Competing interests
The authors declare there are no conflicts of interest.
Ethical standards
Not applicable.
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