An approach to venerophobia in males.

Venerophobia is a lesser recognized entity in clinical practice though the prevalence is on the rise. Our observations of current trends in the Sexually Transmitted Diseases (STI) clinic indicate that venerophobia is not an uncommon presentation among youngsters following an isolated or multiple episodes of sexual contact. This has a major bearing on the mental as well as sexual health. So far, there is no published data available in literature on the prevalence and extent of the problem. In this paper, we have made an attempt to cover the various modes of presentation, laboratory investigations and have outlined an approach towards the management of venerophobia in males.

INTRODUCTION

Venereophobia is defined as an exaggerated or irrational fear of contracting venereal disease following an isolated or multiple episodes of sexual intercourse. Being a lesser known entity in dermatology, very less cases are recognized and reported. It is a condition that is observed exclusively in males. This may be due to the signs and symptoms of venereal disease being more apparent in the male, and not necessarily because the male worries more over the consequences of illicit sexual intercourse. Besides, the external genitalia of a male can be easily viewed and frequently manipulated. The paucity of female patients that admit to having had a history of sexual contact is another reason why venereophobia is limited to males.

A considerable number of patients present to the dermatology clinic, or more specifically the sexually transmitted infections (STI) clinic with doubts and fears arising from sexual contact, or from lesions on genitalia, that are prima facie benign but lead to a heightened state of anxiousness to the sufferer who believes them to be as a result of an STI.

VENEREOPHOBIA: THE EXTENT OF THE PROBLEM

While estimates and data on the prevalence and the extent of STIs are plenty, no published material exists on the incidence of venereophobia. There is no denying, however, that an increasing number of apprehensive individuals, particularly in the premarital age group, come to the STI clinic for a voluntary check up to seek multiple consultations and undergo varied tests in a hunt for a cause and treatment that would lead to its “cure.” No explanation or demonstration satisfies them. It is a tricky and underestimated condition that is difficult to manage. The reason for it being a thought content disorder, where there is no actual infection unlike an actual infection, where there are more obvious signs and symptoms as well as therapeutic cure on instituting treatment.

Subsequently, it plays a major impact on the mental and reproductive health.

EVALUATION OF THE PATIENT

History

A thorough and detailed history is extremely important to arrive at a diagnosis of venereophobia. The male patient typically presents to the outpatient clinic for a voluntary check-up.

A history of sexual intercourse, whether consensual or not, such as a visit to a commercial sex worker or sexual abuse is often the inciting event. A guilty conscience soon ensues a cascade of fear and doubt falls on him. Thoughts of having contracted a venereal infection consume him, and he begins watching out for signs and symptoms of an infection.

The presenting complaint is usually that of asymptomatic papules in the external genitalia, discharge of semen in the urine, or involuntary discharge of semen also known as spermatorrhea.[1] Visible anxiety is written on the face of the patient. He presents with irrational fears of having contracted an STI. Repeated queries are made to the attending physician regarding the presenting complaint and efforts to reassure the patient are seldom helpful. Very often the patient gets investigations done before the presentation. Negative tests such as a negative serology for HIV or nonreactive venereal disease research laboratory (VDRL) fail to convince him of the absence of infection. Rather, he has repeated doubts playing on his mind, and he may undergo multiple tests in the hope of convincing the physician of having contracted an infection spread by sexual contact. This behavior stems from having had a history of sexual contact in the past, irrespective of the number of times or partners. The patient starts examining the external genitalia, watching out for signs and symptoms related to the genital organs. It is here that lesions previously unapparent come to his notice and thence starts the cycle of fear.

MODES OF PRESENTATION

Spermatorrhea: This is defined as an involuntary discharge of semen, frequently following the act of defecation. Perhaps an indication of recent sexual activity and/or the presence of constipation, this symptom of occasional spermal losses causes great concern to the young male[1]

Pearly penile papules (PPP): Clinically, PPP appear as asymptomatic, multiple, smooth, dome-shaped flesh colored papules localized circumferentially around the sulcus or corona of glans penis. The incidence is up to 48% and is more common in uncircumcised males in the second and third decades. Its presence is not associated with sexual activity. They are known to persist throughout life with less chances of spontaneous regression[2]

Sticky meatus: In the phobic patient, this sign is found to be the result of vigorous “milking” of the penis. Urethritis (gonococcal or nongonococcal) must be ruled out. A history of burning micturition, dysuria, fever, and signs of inflammation with or without inguinal adenopathy on the examination will indicate further work up for sexually transmitted urethritis. Sample from the sticky “discharge” is to be collected and urethral massage performed for collection if necessary. Smear for Gram staining and culture should be sent. In the case of venereophobia, pus cells will be absent and other serological tests negative

Threads in the urine: The phobic patient will examine anything that comes out of his urethra, leading to a close and careful examination of urine. He then discovers threads, particularly if he has had previous urethritis, gonococcal or nongonococcal. While these fine threads are cloudy mucous fibers, it is to be explained that these were due to a change in the character of the lining of the penis brought about by the previous infection. This will help reassure the patient that their presence did not indicate present infection

Phosphaturia: This is usually reported by the patient as a milky discharge in the urinary stream, toward the end of the act of micturition, as opposed to a discharge of spermatorrhea after defecation. An increased consumption of milk and milk products can lead to temporary phosphaturia due to the presence of calcium phosphate in the urine. Metabolic and hormonal causes such as parathyroid gland abnormality must be borne in mind. When accompanied by dysuria, oliguria or anuria, referral to a urologist is warranted. A useful bedside test is the acetic acid test wherein adding a few drops of acetic acid to the urine sample leads to the disappearance of cloudiness

Hyperpigmentation of median raphe penis and scrotum: In a study of normal variants in lesions of the male external genitalia, hyperpigmentation of the median raphe of the penis and scrotum was observed to be the most common variation, among the study population.[2]

Other modes of presentation include Fox-Fordyce spots, normal sebaceous glands and hair follicles, sebaceous hyperplasia, smegma, prominent veins, Bier's spots, skin tags, congenital and acquired melanocytic nevi, angiomas, and angiokeratomas, all of which do not produce any symptoms.[3]

One or more symptoms of phobia especially during a heightened state of anxiety such as palpitation, dry mouth, hurried breathing, dizziness, sweating, and trembling may accompany the other presenting features.

LABORATORY EVALUATION

The plain act of reassuring the distressed patient is inadequate. A phobic patient is eager to undergo a detailed workup, which includes laboratory investigations. They also help in establishing a diagnosis in the presence of an STI. A detailed history will help direct which laboratory tests to order.

The following are the investigations recommended in a case of venereophobia:

Urine analysis

VDRL

HIV serology

Urethral and rectal swabs for Gram-staining and culture

Semen analysis.

Additional investigations:

Rectal swab, when history is indicative of MSM

Serology for Chlamydia trachomatis

Thyroid function tests (anxiety, sweating)

Electrocardiogram (palpitation)

Ultrasound scrotum for varicocele

Computed tomography/magnetic resonance imaging brain imaging for organic lesions (spermatorrhea)

Dermoscopic examination of PPP, atypical naevi (sebaceous hyperplasia shows yellow or white nodules with small craters and arborizing vessels under dermoscopy)

Skin biopsy (Fox-Fordyce, warts)

HPV typing for atypical skin tags.

TREATMENT

As stated earlier, it is challenging to treat a patient of venereophobia. At the initial visit, he is often in no mood for reassurance, but after a few attendances, he will probably become transformed into a more receptive person. It is important that blood be taken at each attendance, for the patient places great importance on blood tests. Any attempt to get rid of him prematurely will result in failure of the treatment.

The physician must not be impatient at hearing out the patient's complaints and queries. Repeated reassurances are necessary. One must not dismiss his doubts, irrespective of how immaterial it is, and a diagnostic workup akin to an actual sexually transmitted disease is often required.

In the presence of benign physiological lesions of the male external genitalia such as PPP, ablation using cryotherapy, carbon dioxide laser, Nd:YAG laser, electrodessication with curettage, and excisional surgery has led to successful outcomes.

Psychiatric consultation is essential, and a joint approach forms the cornerstone of management. Behavior therapy, anti-anxiety medications, selective serotonin reuptake inhibitors, tricyclic antidepressants, psychotherapy, and cognitive behavioral therapy are the preferred modalities if conservative measures of counseling and repeated reassurances do not lead to improvement. In the more severe forms, antipsychotics are to be administered.

In summary, having questioned the patient and arriving at a diagnosis of venereophobia after ruling out an STI, the next step is to consider the frequency of follow-ups and the duration required for counseling. While this is highly variable and depends on the progress of the patient at each follow-up, it can be assessed in two ways. One, following procedural intervention wherein the patient sees no evidence of his disease as in the case of PPP, or two, when he attains a gradual sense of relief at subsequent follow-ups with a willingness to listen to the physician. This is taken as a positive sign toward recovery and decreased need for subsequent follow-ups. It may be safe to presume that the majority of venereophobias do not have an underlying pathological cause or an organic lesion with no personal history of psychiatric illness. It is a benign fear arising out of a poor understanding of venereal diseases that assumes much bigger proportion. Expectedly, it is the vulnerable and adventurous population of adolescents that have a high risk of developing venereophobia. We cannot overemphasize enough, the importance of timely and adequate sex education as a part of school curriculum. Patience is key toward an approach to venereophobia in the male.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.