A 55-year-old man finds himself single after being in a mutually monogamous relationship for 20 years. In order to prepare himself for future sexual relationships, he goes to the local drugstore to purchase condoms. Once in the store, however, he becomes alarmed at the number and types of condoms available. He sees four shelves in front of him, all containing condoms. There are lubricated and nonlubricated condoms. There are spermicidal and nonspermicidal condoms. There are colored, flavored, studded, ribbed, latex, natural skin, and polyurethane condoms. Also within view are boxes of female condoms. Now totally perplexed, he leaves the drugstore and makes an appointment with his primary care practitioner, a physician assistant. As the PA enters the examination room, the man exclaims, “Please help me choose a condom. I'm so confused!”
His response is understandable, of course. The variety of condoms available today can be bewildering, even for primary care practitioners. To help clarify matters, this article describes the important differences among male condoms, female condoms, microbicides, spermicides, and lubricants.
Male latex condoms
Male condoms are currently made from three materials: latex, polyurethane, and natural animal skin. Latex condoms are made from natural rubber that is extremely elastic and can stretch to fit almost any size (see Figure 1).
The most reliable way for patients to avoid transmitting or contracting a sexually transmitted infection (STI) is to abstain from sex (oral, vaginal, and anal sex) or to be in a long-term, mutually monogamous relationship with an uninfected partner. For patients who choose not to abstain, who continue to have sex with multiple partners, or who have an infected partner, condom use is the most effective way to reduce the risk of STIs.
Several cross-sectional and case-control studies have shown that when used consistently and correctly, male 
latex condoms are effective in preventing the sexual transmission of HIV infection and can reduce the risk for other STIs.1 A recent review indicated that consistent use of male latex condoms resulted in an 80% reduction in the incidence of HIV infection.2 Additionally, prospective studies published since June 2000 show that condom use is associated with statistically significant protection of men and women against several other types of STIs, including chlamydia, gonorrhea, herpes simplex virus type 2 infection, and syphilis.3
Failure to use a condom correctly and consistently, rather than potential defects of the condom itself, is considered to be the major barrier to condom effectiveness. Many incidents of condom breakage and leakage are associated with improper handling or inappropriate use of lubricants.4 For instance, patients frequently ask if “doubling up” (using two condoms) confers additional protection against disease. This practice is not recommended, however, as the friction between the two condoms can lead to an increase in breakage. If lubricant is used between the two layers to reduce friction, an increase in slippage occurs.
Since 1976, condoms have been regulated under the Medical Device Amendments to the Federal Food, Drug, and Cosmetic Act. In 1987, the FDA sent a letter to all US condom manufacturers, importers, and repackagers recommending proper labeling of male latex condoms to include adequate instructions for usage.
Male latex condoms come in various types, including extra thin, extra sensitive, extra large, extra strength, form-fitting, extra head room, ribbed, studded, and spiraled. In addition, male latex condoms may have additives such as lubricants, spermicidal agents, flavors, and dyes. Patients should know that they need to be cautious about additives, not just because they may weaken the condom, but also because they may cause a contact dermatitis. While the variety of condoms available is confusing, the important point to remember about those just discussed is that all are made of latex and thus are regulated by the FDA.
Educating patients about how to use a condom is essential. Note the following important points:
- A condom should be used before the expiration date.
- The condom should be opened in a manner that will not tear it and placed on an erect penis before any genital contact with the partner occurs.
- Enough room should be left at the tip of the condom to allow for ejaculate collection; this can be ensured by pinching the tip and then rolling the condom down the shaft of the penis.
- If the condom is inadvertently put on upside down, that condom should not be turned over and reapplied. Instead, it should be thrown away to avoid exposing the partner to fluid from the penis that might have gotten on the condom when it was put on incorrectly.
- To remove a condom, the patient should hold it firmly against the base of the penis, withdrawing the penis while it is still erect in order to prevent slippage. The condom should then be removed from the penis and disposed of wrapped in tissue in a trash can (so that children, animals, and others do not come into contact with the condom or its fluid content). It may be helpful to educate patients that flushing condoms down the toilet adversely affects municipal sewage treatment facilities and is potentially harmful to septic systems.
- Condoms should be stored in a cool, dry place. Keeping condoms in a vehicle may subject them to temperatures high enough to accelerate their decomposition.