Table 2 lists studies for which HPV prevalence was measured for matched self-collected and clinician-collected samples.11,13,14 Overall, self-collected samples showed comparable detection of HPV types to clinician-collected samples. Two studies performed by Hernandez et al.11,14 showed similar estimates of detection of all HPV types for participants collecting genital swabs using self-collected and clinician-collected methods. A study by Lampinen et al.13 showed similar estimates of detection of high-risk HPV DNA types using matched rectal swab samples, with 67% of self-collected swabs and 62% of clinician-collected swabs found to be positive.
Two studies evaluated whether self-collected swabs submitted for anal cytology were of sufficient quality to be able to generate a cytology result. One study involving collection of swabs for anal cytology did not have a clinician-collected comparison group but did find that only 62.3% of self-collected anal swabs yielded samples of sufficient quality for interpretation of cytology results by a pathologist.20 In contrast, a study performed by Lampinen et al.15 in 2006 reported a higher overall proportion of self-collected swabs that were of sufficient quality to yield a cytology result, which was still less than that reported for paired clinician-collected swabs (83% vs. 92%, respectively; McNemar χ2 with P < 0.001). Unlike their ability to result in samples comparable with clinician-collected specimens for detecting HPV DNA, self-collected samples were less likely to meet the quality standards needed for interpretation of cytology to occur.
The study by Chin-Hong et al.16 was the only one identified that compared the sensitivity and specificity of anal cytology, assessed via self- and clinician-collected anal swabs, with biopsy-proven anal intraepithelial neoplasia (AIN) in MSM. Study results were reported separately for HIV-positive and HIV-negative MSM. Specificity of an abnormal anal cytology result did not significantly differ between self-collected and clinician-collected specimens for HIV-positive MSM (50% vs. 64%) or HIV-negative MSM (86% vs. 85%). However, self-collected samples were found to be less sensitive than clinician-collected samples for detection of AIN for both HIV-positive (75% vs. 90%) and HIV-negative (48% vs. 62%) MSM.16
Chlamydia and Gonorrhea Testing
Other sexually transmitted pathogens amenable to detection via the use of self-collected swabs in men include C. trachomatis and N. gonorrhoeae. The introduction of self-collected swab techniques into clinics has been particularly favorable for detection of chlamydia and gonorrhea at extragenital sites in particular subgroups of men (e.g., MSM).17,29 One study using a pretest posttest design found that combined rates of detection in MSM of extragenital chlamydia and gonorrhea increased by a factor of 4 after the introduction of self-collected swabs.29
A significant proportion of the literature related to self-collection for chlamydia and gonorrhea testing in men has focused on comparisons of self-collection techniques using different biological samples. Four studies compared self-collected swabs of the lower male genital tract (meatal, penile-meatal, or urethral swabs) with self-collected urine samples for detection of C. trachomatis and N. gonorrhoeae.19,23,24,30 Chernesky et al.23 found that detection of both chlamydia (35 vs. 33) and gonorrhea (14 vs. 11) infection was slightly greater using meatal swab samples compared with urine samples, respectively, in a supervised clinic setting. This finding was replicated in a subsequent study by Chernesky et al.30 in which the rate of detection of C. trachomatis was found to be statistically significantly higher with the use of meatal swabs compared with the use of urine samples.
A screening study conducted by Chai et al.19 in which men accessed test kits through the Internet and mailed back home-collected urethral swabs and urine samples showed that the sensitivity of detection of C. trachomatis was higher for the penile swab samples (93%) than for the urine samples (78%). Complementing these data was a study that showed greater sensitivity of home-based self-collection of penile-meatal swabs for detection of chlamydia (94.2% sensitivity) and gonorrhea (100% sensitivity), when compared with the use of urine samples (76.7% and 88.8% sensitivities, respectively).24
Trichomoniasis and M. genitalium Testing
Unlike chlamydia and gonorrhea, trichomoniasis has only recently emerged as a condition for which testing in men has become feasible with the use of nucleic acid amplification test assays. Five studies evaluated the use of self-collected samples for testing for T. vaginalis infection in men.19,24,25,28,30 A study conducted by Chai et al.19 showed sensitivity of detection of T. vaginalis to be 82% with urethral swab collection versus only 40% with urine collection. Two studies evaluated the use of swabs involving collection at the penile meatus compared with urine collection, and both of them demonstrated higher rates of detection of T. vaginalis via the use of meatal swabs.24,30 Of particular note was a study conducted by Dize et al.24 that showed a large difference in sensitivities for T. vaginalis detection between the use of self-collected penile-meatal swabs (80.4% sensitivity) and urine samples (39.3% sensitivity). A subsequent study performed by Dize et al.28 noted a similar rate of sensitivity of T. vaginalis detection (85%) when using clinician-collected urethral swabs as a criterion standard for collection. Finally, one study examining self-collected samples for evaluation of trichomoniasis in men did not include a comparative sample collection method for description in this context.25 Overall, quite large differences in sensitivity for detecting T. vaginalis emerged among studies where self-collected swabs were compared with self-collected urine samples.
M. genitalium has been linked to the development of urethritis in men, although diagnostic testing for this pathogen is limited to research-use-only nucleic acid amplification tests found in a few centers globally.31 Nevertheless, obtaining self-collected swabs for the detection of M. genitalium in men is a current area of exploration given the growing interest in the potential pathogenicity of this organism. One study using a transcription-mediated Amp-based research-use-only test noted greater detection of M. genitalium with the use of meatal swabs (15.3%) compared with first-catch urine samples (12.6%).30 Although that study looked favorable for the ability of meatal swabs to detect M. genitalium, a study performed by Dize et al.28 using penile-meatal swabs noted a detection sensitivity of only 79.3%. Of note, this sensitivity calculation used the assumption that clinician-collected urethral swabs were the criterion standard for detection of M. genitalium.
Feasibility and Acceptability of Swab Self-Collection
Four studies focused on the feasibility of performing self-collection in settings outside traditional clinics.19,20,27,28 One study evaluated the prevalence of HPV infection in MSM by recruiting men from venues that included bars, bathhouses, bookstores, community organizations, and community events that targeted gay and bisexual men. Two hundred sixty-eight individuals in this study self-collected rectal swabs; of the 498 who were approached and opted not to participate, 59.1% declined because of discomfort with the self-collection method, whereas 11.4% cited discomfort with engaging in self-collection at one of the aforementioned venues.20 In contrast, the study by Wood et al.27 found that 100% of the first 30 participants approached to participate in a nurse-delivered outreach screening service for self-collected STI testing at a sauna agreed to the use of self-collection for chlamydia and gonorrhea screening. Regarding ease of self-collection, most participants in all studies where this aspect of feasibility was measured rated self-collected swabs as “very easy” or “easy” to use.17,19,28
Several studies examined the acceptability of the self-collection process. One study evaluated acceptability in terms of participants' willingness to perform self-collection; it found that of a subset of HIV-positive MSM, 92% opted to perform self-collected rectal swabs as part of a sexual health screen.26 Acceptability was also measured in terms of participant satisfaction with the self-collection process. Using this definition, one study found that 76% of men self-collecting pharyngeal swabs and 82% of men self-collecting rectal swabs found the self-collection process to be acceptable.12 Another study found that more than 90% of surveyed participants who had undergone self-collection of rectal swabs would undergo self-collection again and would return to an STI clinic if self-collection were the standard method of testing for rectal STIs.17 Finally, a study involving the use of a nurse-led self-screening program for detection of C. trachomatis and N. gonorrhoeae found that all 21 MSM completing a patient satisfaction questionnaire about self-collected pharyngeal and rectal swabs after having obtained these samples noted self-collection to be an acceptable screening method.21
Two studies in the review examined participants' perceptions of the use of different types of swabs for self-collection.11,23 Chernesky et al.23 found that male participants thought first-catch urine sampling was easier and more comfortable than self-collection of swabs for chlamydia and gonorrhea screening. Hernandez et al.11 compared 2 different types of dry swabs and a wet swab method for detection of HPV from male penile-meatal samples. Swabs were rubbed over the entire surface of the penis from the tip of the glans to the base of the penile shaft using the wet swab method involving application of emery paper before application of a saline-moistened swab. The study found greater comfort, less pain, and less time required for swab collection among participants using the dry swab method compared with the wet swab method.
We identified 20 studies in which self-collected swab samples were obtained from adult men with the goal to submit these for STI testing. Our review demonstrates that most studies used a cross-sectional design with small sample sizes, indicative of the relatively new emergence of this collection method for use in men. Many studies that incorporated self-collection of samples into their methods but only briefly analyzed the self-collection process itself or evaluated it as a secondary outcome were identified. For example, 9 studies that would have met criteria for inclusion in the review were excluded because no STI outcome measures from self-collected samples were examined.
Self-collected samples were generally of sufficient quality for detection of specific HPV types in comparison with clinician-collected samples. However, the ability to yield swab samples that were of sufficient quality to generate a cytology result was less for self-collected samples compared with clinician-collected samples.15,18 Conducting larger studies comparing clinician collection with different self-collection practices and evaluating different methods of communicating the self-collection process to participants would be useful to further investigate whether self-collection is a reliable method for generating samples of sufficient quality to undergo cytology testing.
Self-collection of samples was found to perform as well as or better than clinician collection for STI detection in several studies detailed in this review.13,14,23,24,28 Given concerns about underdiagnosis of STIs, self-collection has the potential to complement and expand upon current screening efforts, in part, because of greater comfort and control of the collection process, patient privacy, and the ability to collect samples at home or in other nonclinical venues. A high level of willingness to undergo self-collection was seen among male participants in several studies, consistent with findings noted for performance of self-collection in prior studies involving women.12,17,21,26 However, conflicting perceptions about the use of swabs for self-collection was observed, as evident by men's preference for collecting urine samples over swab samples in one study and the preference for use of dry swabs over wet swabs in another.11,22 More studies are needed to determine which attributes of different self-collection methods are associated with increased feasibility and acceptability given the potential impact of self-collection on designing successful interventions to promote STI screening.
Our systematic review has several limitations. Our search strategy focused on English-language articles and articles featuring adults. Most of the studies evaluating self-collection methods consisted of cross-sectional studies with only 1 randomized trial identified. This limitation affects the sensitivity and specificity estimates of self-collection versus clinician collection. Confounding may also affect the validity of any comparisons, although the use of paired self- and clinician-collected swabs in some studies did help to partially counteract this. Cross-sectional studies that analyzed the acceptability of self-collection may be prone to bias because participants who entered these studies may have been more inclined to support or accept self-collection methods. However, high acceptability rates seen for self-collection methods across studies are consistent with literature showing similar findings for other groups and help to bolster the notion that self-collection methods are indeed acceptable for men.
Another important limitation of this review was the heterogeneity among studies that limited our ability to pool data across studies for a meta-analysis. Sources of heterogeneity included the type of swab used, the anatomic site at which self-collection was performed, and the pathogenic microorganism targeted for detection. This heterogeneity is likely a reflection of the continued novelty of performing self-collection for STI testing.
Despite these limitations, self-collection of swab samples in men has the potential to be a viable mode of STI detection given its comparable sensitivity for pathogen detection to clinician-collected samples and its high acceptability. Studies involving larger numbers of participants with robust randomization schemes, continued innovation in swab design, and communication of self-collection instructions would help to inform future protocols for health care and community organizations interested in improving STI detection and treatment rates. Innovative strategies to curb and reduce the growing burden of STIs in men remain important, and self-collection has the potential to play a significant role in achieving the desired improvements.
2. Odesanmi TY, Wasti SP, Odesanmi OS, et al. Comparative effectiveness and acceptability of home-based and clinic-based sampling methods for sexually transmissible infections screening in females aged 14–50 years: A systematic review and meta-analysis. Sex Health 2013; 10:559–569.
3. Holland-Hall CM, Wiesenfeld HC, Murray PJ. Self-collected vaginal swabs for the detection of multiple sexually transmitted infections in adolescent girls. J Pediatr Adolesc Gynecol 2002; 15:307–313.
4. Wiesenfeld HC, Lowry DL, Heine RP, et al. Self-collection of vaginal swabs for the detection of chlamydia, gonorrhea, and trichomoniasis: Opportunity to encourage sexually transmitted disease testing among adolescents. Sex Transm Dis 2001; 28:321–325.
5. Newman SB, Nelson MB, Gaydos CA, et al. Female prisoners' preferences of collection methods for testing for Chlamydia trachomatis
and Neisseria gonorrhoeae
infection. Sex Transm Dis 2003; 30:306–309.
6. Chernesky MA, Hook EW 3rd, Martin DH, et al. Women find it easy and prefer to collect their own vaginal swabs to diagnose Chlamydia trachomatis
or Neisseria gonorrhoeae
infections. Sex Transm Dis 2005; 32:729–733.
7. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Sexually Transmitted Disease Surveillance 2015 [Internet]. Atlanta, GA: Centers for Disease Control and Prevention; 2016. Available at: https://www.cdc.gov/std/stats15/default.htm
. Accessed February 27, 2017.
8. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. STDs in Men Who Have Sex with Men [Internet]. Atlanta, GA: Centers for Disease Control and Prevention; 2016. Available at: https://wwwcdcgov/std/stats15/msmhtm
. Accessed February 9, 2017.
9. Crum-Cianflone NF, Hullsiek KH, Marconi VC, et al. Anal cancers among HIV-infected persons: HAART is not slowing rising incidence. AIDS 2010; 24:535–543.
10. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration. J Clin Epidemiol 2009; 62:e1–e34.
11. Hernandez BY, Wilkens LR, Unger ER, et al. Evaluation of genital self-sampling methods for HPV detection in males. J Clin Virol 2013; 58:168–175.
12. Wayal S, Llewellyn C, Smith H, et al. Self-sampling for oropharyngeal and rectal specimens to screen for sexually transmitted infections: Acceptability among men who have sex with men. Sex Transm Infect 2009; 85:60–64.
13. Lampinen TM, Chan K, Anema A, et al. Self-screening for rectal sexually transmitted infections: human papillomavirus. Clin Infect Dis 2006; 42:308–309.
14. Hernandez BY, McDuffie K, Goodman MT, et al. Comparison of physician- and self-collected genital specimens for detection of human papillomavirus in men. J Clin Microbiol 2006; 44:513–517.
15. Lampinen TM, Latulippe L, Van Niekerk D, et al. Illustrated instructions for self-collection of anorectal swab specimens and their adequacy for cytological examination. Sex Transm Dis 2006; 33:386–388.
16. Chin-Hong PV, Berry M, Cheng S, et al. Comparison of patient- and clinician-collected anal cytology samples to screen for human papillomavirus–associated anal intraepithelial neoplasia in men who have sex with men. Ann Intern Med 2008; 149:300–306.
17. van der Helm JJ, Hoebe CJ, van Rooijen MS, et al. High performance and acceptability of self-collected rectal swabs for diagnosis of Chlamydia trachomatis
and Neisseria gonorrhoeae
in men who have sex with men and women. Sex Transm Dis 2009; 36:493–497.
18. Dodge B, van der Pol B, Rosenberger JG, et al. Field collection of rectal samples for sexually transmitted infection diagnostics among men who have sex with men. Int J STD AIDS 2010; 21:260–264.
19. Chai SJ, Aumakhan B, Barnes M, et al. Internet-based screening for sexually transmitted infections to reach nonclinic populations in the community: Risk factors for infection in men. Sex Transm Dis 2010; 37:756–763.
20. Gilbert M, Kwag M, Mei W, et al. Feasibility of incorporating self-collected rectal swabs into a community venue-based survey to measure the prevalence of HPV infection in men who have sex with men. Sex Transm Dis 2011; 38:964–969.
21. Soni S, White JA. Self-screening for Neisseria gonorrhoeae
and Chlamydia trachomatis
in the human immunodeficiency virus clinic—High yields and high acceptability. Sex Transm Dis 2011; 38:1107–1109.
22. Read TR, Hocking JS, Vodstrcil LA, et al. Oral human papillomavirus in men having sex with men: Risk-factors and sampling. PLoS One 2012; 7:e49324. Available at: http://journals.plos.org/plosone/
. Accessed April 20, 2016.
23. Chernesky MA, Jang D, Portillo E, et al. Self-collected swabs of the urinary meatus diagnose more Chlamydia trachomatis
and Neisseria gonorrhoeae
infections than first catch urine from men. Sex Transm Infect 2013; 89:102–104.
24. Dize L, Agreda P, Quinn N, et al. Comparison of self-obtained penile-meatal swabs to urine for the detection of C. trachomatis
, N. gonorrhoeae
and T. vaginalis
. Sex Transm Infect 2013; 89:305–307.
25. Gaydos CA, Barnes MR, Quinn N, et al. Trichomonas vaginalis
infection in men who submit self-collected penile swabs after Internet recruitment. Sex Transm Infect 2013; 89:504–508.
26. Keaveney S, Sadlier C, O'Dea S, et al. High prevalence of asymptomatic sexually transmitted infections in HIV-infected men who have sex with men: A stimulus to improve screening. Int J STD AIDS 2014; 25:758–761.
27. Wood M, Ellks R, Grobicki M. Outreach sexual infection screening and postal tests in men who have sex with men: Are they comparable to clinic screening? Int J STD AIDS 2015; 26:428–431.
28. Dize L, Barnes P, Barnes M, et al. Performance of self-collected penile-meatal swabs compared to clinician-collected urethral swabs for the detection of Chlamydia trachomatis
, Neisseria gonorrhoeae
, Trichomonas vaginalis
, and Mycoplasma genitalium
by nucleic acid amplification assays. Diagn Microbiol Infect Dis 2016; 86:131–135.
29. Nyatsanza F, Trivedy A, Brook G. The effect of introducing routine self-taken extra-genital swabs in a genitourinary medicine clinic cohort: A before and after study. Int J STD AIDS 2016; 27:1330–1333.
30. Chernesky M, Jang D, Smieja M, et al. Urinary meatal swabbing detects more men infected with Mycoplasma genitalium
and four other sexually transmitted infections than first catch urine. Sex Transm Dis 2017; 44:489–491.
© Copyright 2018 American Sexually Transmitted Diseases Association
32. Moher D, Liberati A, Tetzlaff J, et al. The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097.