Penile beading in a Nepalese man with latent syphilis: A case study on cultural sensitivity in venereology

Abstract

Genital beading or pearling, the practice of implanting small beads under the penile skin for sexual enhancement, is a cultural tradition in certain regions of Nepal, East Asia, Southeast Asia, the Pacific islands, some parts of Africa, and Eastern Europe. This case report discusses the presentation of a couple in Nepal who migrated to India and was diagnosed with latent syphilis of unknown duration, highlighting the clinical and cultural implications of genital modifications.

Introduction

Pearling, also known as genital beading or penile implants, is a practice where small beads or implants are inserted beneath the skin of the penis. This procedure is primarily performed for sexual enhancement, believed to increase pleasure for both the individuals and their partner.[1] The practice varies widely in terms of materials used, implantation methods, cultural significance, and prevalence across different regions. The practice of pearling has historical roots in various cultures around the world. It is often shrouded in secrecy and may not be widely discussed even within communities where it is practiced. Understanding these cultural contexts is crucial for healthcare providers when encountering patients with such modifications. In some Filipino communities, pearling is known as “tuli beads” or “bolitas”. The practice is believed to have originated from ancient tribal traditions and is sometimes performed during adolescence. Materials such as plastic beads or pearls are commonly used. Similar practices are observed in certain Indonesian regions, where men implant small beads under the penile skin for sexual enhancement. Bamboo, metal, and plastic beads are among the materials used. Historical records indicate that pearl divers in the Micronesian and Polynesian regions practiced genital beading, using shells or pearls. In Japan, known as “hōmotsu” (treasures), the practice was reportedly popular among yakuza (Japanese organized crime members).[2] Pearls or metal beads are implanted as a symbol of status and virility. As highlighted in this case report, pearling is relatively common in certain Nepalese communities. Plastic ball bearings are frequently used, and the practice is considered a cultural norm and is believed to result in lasting marriage. While not as prevalent, some reports indicate the presence of genital beading in specific Indian subcultures, often influenced by neighboring practices in Nepal and Southeast Asia.[3] In modern contexts in the USA and Canada, pearling has been adopted by some individuals within the body modification communities. Unlike traditional practices, these procedures are often performed in professional body modification studios using surgical-grade materials.

Case Report

A 35-year-old Nepalese male and his 30-year-old wife presented to the Apex Regional STI center after routine screening by their employer revealed positive Venereal Disease Research Laboratory (VDRL) tests with titers of 1:8 and positive Treponema pallidum Hemagglutination Assay (TPHA) tests for both individuals. Upon further examination and history taking, the male patient revealed that he had a plastic ball bearing implanted in his penis before marriage, a practice he described as common in Nepal. Physical examination of both patients showed no overt symptoms of syphilis or other abnormalities, apart from the five genital beading in the male patient [Figure 1]. There were subcutaneous scars present on the penis [Figure 2]. Both patients were asymptomatic, and their general health was otherwise unremarkable, leading to a diagnosis of latent syphilis. Other tests for sexually transmitted infections (STIs) were negative. Both patients were prescribed and administered a regimen of intramuscular benzathine penicillin-G for the treatment of syphilis. They were also counseled about safe sexual practices and the potential risks associated with genital modifications. The patients were scheduled for follow-up appointments to monitor their response to the treatment and ensure the resolution of the infection.

Figure 1.

Five plastic ball bearings embedded in a flaccid penis

Figure 2.

Subcutaneous scars are seen over the penile skin

Discussion

Syphilis is an STI caused by the bacterium Treponema pallidum. It progresses through distinct stages: primary, secondary, latent, and tertiary. Latent syphilis, the stage diagnosed in the Nepali couple in this case, is characterized by serological evidence of infection without clinical symptoms. This stage can be further divided into early latent (within one year of infection) and late latent (more than one year after infection or of unknown duration). Without treatment, latent syphilis can progress to tertiary syphilis, which can result in severe complications such as neurosyphilis, cardiovascular syphilis, and gummatous lesions.[4]

The incidental finding of latent syphilis in both individuals during routine employer-mandated screening underscores the silent and often unnoticed nature of this stage. The positive VDRL tests with titers of 1:8 and positive TPHA tests confirmed the diagnosis. Despite the absence of symptoms, latent syphilis requires prompt treatment to prevent progression to more severe stages and to interrupt transmission.

A significant aspect of this case is the male patient’s disclosure of having five plastic ball bearing implanted in his penis, a practice known as genital beading or pearling. This cultural practice, intended for sexual enhancement, is common in certain regions of Nepal, but is considered unusual and rare in India. Genital beading involves the insertion of small beads or implants under the penile skin, which can increase the risk of infections, including STIs, if performed under nonsterile conditions or without proper medical guidance.

The cultural practice of genital beading presents unique challenges for healthcare providers. While the practice is rooted in cultural traditions and personal choice, it poses potential health risks. Nonsterile procedures can lead to local infections, and the presence of foreign bodies can complicate the clinical presentation of STIs. In this case, the male patient’s genital beading was not associated with any immediate complications, but it underscores the importance of discussing the potential risks with patients engaging in such practices.

The relevance of recognizing genital beading practices is paramount for venereologists and other healthcare providers. Awareness of this cultural practice is crucial to avoid misdiagnosis of these implants as pathological nodules or lumps. The taboo nature of genital modifications in many societies, coupled with patients’ potential hesitation to disclose such practices, can lead to diagnostic confusion. Venereologists must be familiar with various cultural body modifications to conduct accurate examinations and avoid unnecessary procedures or misdiagnoses.

In this case, the relationship between genital beading and syphilis was purely incidental. However, this coincidental finding underscores the importance of conducting thorough physical examinations and maintaining cultural sensitivity in venereology. It serves as a reminder that cultural practices can coexist with, and sometimes complicate, the diagnosis and management of sexually transmitted infections. The discovery of both genital beading and latent syphilis in this patient highlights the need for comprehensive, culturally informed healthcare that considers both traditional practices and modern medical diagnoses.

The management of latent syphilis in this couple involved treatment with intramuscular benzathine penicillin-G, the recommended therapy for latent syphilis.[5] This treatment aims to eliminate the infection, prevent progression to tertiary syphilis, and reduce the risk of transmission. The couple was also counseled on safe sexual practices and the importance of regular STI screening, particularly given the male patient’s history of genital modification.

Culturally sensitive health care is crucial in effectively managing cases involving unique cultural practices. Healthcare providers must approach such cases with respect and understanding, recognizing the cultural significance of practices like genital beading while providing comprehensive education on the associated health risks. In this case, the couple was educated on the potential complications of genital beading and the importance of maintaining sexual health.

Conclusion

This case report highlights the need for cultural sensitivity in health care. The diagnosis of latent syphilis in a Nepalese couple, coupled with the male’s practice of genital beading, underscores the importance of understanding cultural practices in medical care. The relevance of recognizing genital beading is crucial for venereologists to avoid misdiagnosis and provide appropriate care. While the relationship between genital beading and syphilis in this case was incidental, it emphasizes the need for comprehensive physical examinations and cultural awareness in clinical practice. Successful treatment and counseling emphasize the value of routine STI screening and culturally informed patient education. By integrating cultural awareness with medical expertise, healthcare providers can more effectively address the unique health challenges of diverse populations.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.