External (formerly male) condoms

INTRODUCTION — External (formerly male) condoms are a coital-dependent barrier contraceptive that do not interfere with fertility. When used consistently and correctly, external condoms can reduce the risk of pregnancy and transmission of many sexually transmitted infections, including HIV. Appropriate counseling encourages correct condom use and minimizes difficulties.

This topic will discuss the types, patient counseling, and use of external condoms. Discussions related to internal (formerly female) condoms and contraceptive selection in general are presented separately.

●(See "Internal (formerly female) condoms".)

●(See "Contraception: Counseling and selection".)

In this topic, when discussing study results, we will use the terms "woman/en", "man/en", or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

TYPES OF EXTERNAL CONDOMS — External condoms are available in a variety of shapes, sizes, colors, and thicknesses; with or without lubricants or spermicides; and with or without reservoir tips or nipple ends [1]. They can be straight-sided or tapered toward the closed end; textured (ribbed) or smooth; solid-colored or nearly transparent; and odorless, scented, or flavored. Most are approximately 7 inches (180 mm) long, 2 inches (52 mm) wide, and up to 0.003 inches (0.08 mm) thick.

Material — Condoms are made of latex rubber, natural membranes, or synthetic material.

●Rubber (latex) – Approximately 80 percent of external condoms available in the United States are manufactured from natural rubber latex [2]. They are generally less expensive than condoms made from other materials. The dual protection provided by latex condoms against unintended pregnancy, as well as many sexually transmitted infections (STIs; particularly HIV), is well documented. However, latex condoms cannot be used by persons with latex sensitivity or allergy and are not compatible with oil-based lubricants or medications.

●Natural membrane – A small proportion (<5 percent) of condoms are made from the intestinal cecum of lambs ("natural skin," "natural membrane," or "lambskin" condoms). While any type of lubricant can be used with these condoms, natural membrane condoms contain small pores that may permit the passage of viruses, including hepatitis B virus, herpes simplex virus, and HIV [3,4]. There are no available effectiveness data on contraceptive or STI prevention. Because these materials are porous, these condoms may not provide the same level of protection against STIs as latex condoms and should not be recommended for this purpose [5].

●Synthetic – Polyurethane and other synthetic materials such as polyisoprene are also used to manufacture condoms and account for the remaining 15 percent of condoms. Compared with latex condoms, synthetic condoms are generally nonallergenic, compatible with both oil-based and water-based lubricants, and have a longer shelf-life [6]. The effectiveness of synthetic condoms to prevent STIs has not been well studied; however, synthetic condoms are believed to provide STI protection similar to latex condoms. For pregnancy prevention, synthetic condoms have rates of contraceptive failure comparable to latex condoms [7-9].

Spermicide coating — External condoms are produced with and without additional spermicidal lubricant. Condoms prelubricated with a small amount of the spermicide nonoxynol-9 (N-9) are no more effective than other lubricated condoms, have a higher cost and shorter shelf life [10], and may cause adverse effects in users. In one study, spermicidal condom use was associated with increased risk of urinary tract infections in young female participants [11]. Given these disadvantages and the absence of any advantages of spermicidal condoms, we do not advise their use.

Quality control — Every condom is tested electronically for holes and weak spots before it is packaged and released for sale. Samples of condoms also undergo a series of additional laboratory tests for leakage, strength, dimensional requirements, and package integrity [12]. If the sample condoms fail any of these tests, the entire lot is rejected and destroyed. A 2009 Consumer Reports Survey showed that all condoms tested met industry standards [13], and previous surveys reported that test performance did not vary with price, thickness, or country of manufacture [14].

MECHANISM OF ACTION — The condom acts as a barrier by preventing direct contact with semen (and thus sperm), genital lesions, and subclinical viral shedding on the glans and shaft of the penis. It also prevents contact with penile, vaginal, or anal discharges. Condom contraceptive efficacy depends on the skill level and experience of the user [1].

COUNSELING POINTS

General — All patients should understand why condoms are recommended (protection from sexually transmitted infections [STIs] and/or pregnancy), when to use them, how to use them most effectively, how to discuss condom use with their partner(s), and how to integrate condom use into sexual activity (vaginal, anal, oral). Counseling should be adapted to each patient's needs since they may have formed their own attitudes about condom use and may have had varying experiences with condoms. Similarly, the counseling session should be tailored to each patient's risk factors and abilities [1]. As with all contraceptive counseling, patients should understand the risks and benefits of the range of contraceptive methods available. (See "Contraception: Counseling and selection".)

Pregnant individuals at high risk of acquiring STIs should be counseled to use condoms to protect their fetus, their partner(s), and themselves. Patients who would be at high medical risk if they became pregnant should be counseled to use a highly effective contraceptive method and should understand the risk of using a less effective method, such as condoms (figure 1).

Contraceptive efficacy — An estimated 2 percent of users will become pregnant during the first year of perfect use (ie, consistent and correct) of the condom, and approximately 13 of every 100 users will become pregnant during the first year of typical use, which places condoms in the moderate effectiveness category (figure 1) [15]. The marked difference in contraceptive failure rates between perfect and typical use is attributable to failure to use condoms during every act of sexual intercourse and failure to use condoms correctly throughout intercourse. Individuals vary widely in their ability to use external condoms consistently and correctly. The typical-use and perfect-use effectiveness of a variety of contraceptive methods, including condoms, is shown in the table (table 1).

Device failure (slippage and breakage) — Condom breakage rates vary by material, product, and route of use.

•Vaginal intercourse – The majority of studies report that condoms break approximately 2 percent of the time during vaginal intercourse; a similar proportion slip off completely [16-21].

•Anal intercourse – While condom breakage and slippage during anal intercourse may be slightly more likely compared with vaginal intercourse [16,22-25], one study that defined condom failure as slippage, breakage, or both reported a 0.68 percent failure rate with anal intercourse compared with 1.89 percent for vaginal intercourse [16].

Latex sensitivity or allergy — When exposed to latex-containing products, persons sensitive or allergic to natural rubber latex may experience irritation, allergic contact dermatitis, or systemic anaphylactic symptoms [26,27]. It is estimated that 1 to 6 percent of the United States population is allergic to latex [27], but the prevalence can be much higher in certain groups, such as health care workers and patients who have repeated exposure to latex-containing medical devices (eg, surgical and examination gloves, catheters, intubation tubes, anesthesia masks, and dental dams) [26-28]. (See "Latex allergy: Epidemiology, clinical manifestations, and diagnosis".)

All patients should be questioned for potential latex allergy. As an example, does the patient experience itching, rash, or wheezing after wearing latex gloves or inflating a balloon [27,28]? If latex sensitivity is suspected, the patient can be referred for allergy skin testing or offered nonlatex condoms [29]. (See "Latex allergy: Management" and "Latex allergy: Epidemiology, clinical manifestations, and diagnosis".)

Allergic reactions that occur only after exposure to latex condoms and not after exposure to other latex-containing products may be due to brand-specific condom attributes, such as spermicides, lubricants, perfumes, local anesthetics, or other chemical agents added during the manufacturing process [30]. In these cases, we advise patients to try a different brand.

Strategies for promoting effective external condom use — The most effective approaches for improving condom use are unclear. A 2013 systematic review of behavioral interventions with an educational or counseling component to encourage or improve condom use was unable to find strong evidence of the efficacy of this approach compared with another behavioral intervention, usual care, or no intervention [31]. Educational and/or counseling programs were associated with reductions in HSV-2 incidence, syphilis incidence, and gonorrhea prevalence but no differences in pregnancy or HIV infection rates.

Although the optimal method(s) for improving condom use are not known, we discuss the following issues with our patients:

●Counsel regarding correct and consistent use – Effective use of external condoms depends heavily on the skill level and experience of the user. Appropriate counseling can minimize problems with condom use [32]. Interventions promoting condom use should address user-related behaviors that result in inconsistent use, incorrect use, or nonuse.

●Emphasize that external condoms should be used with every coital act – Make sure patients understand that condoms are most effective when used correctly during every act of anal, vaginal, and oral intercourse [33]. Strategies that emphasize condom use for contraception in addition to disease prevention may help decrease nonuse [34]. Recommend that patients use a new condom for each act of intercourse [1,35].

●Instruct the patient on use – Encourage inexperienced patients to practice using external condoms on a model of a penis or a banana. Many problems that occur during condom use can be attributed to inexperience and can be overcome with practice [36]. Users who have had negative experiences with external condoms may be at risk of discontinuing condom use altogether [37]. (See 'Information for use' below.)

●Inform the patient to use the external condom during the entire sexual act – Some users put condoms on after starting intercourse or remove condoms prior to ejaculation [24,25,38-43]. These behaviors could expose partners to risk of pregnancy or STI. Patients should be counseled to use condoms throughout intercourse, from beginning of genital contact to after ejaculation.

●Provide external condoms at low or no cost to encourage use – In some settings, providing patients with a large number of condoms at low or no cost increases convenience and thus may increase consistent use. Providing patients with only a few condoms is only a short-term solution for patients who find the health care system inaccessible or who find it embarrassing to return repeatedly for condoms. Selling condoms, even at a low cost, dramatically reduces the number of condoms a patient will obtain from a clinic compared with the number of free condoms the patient will take.

Impact of external condom use on sexual risk taking — Although widespread support exists for targeted interventions to encourage condom use, concerns have been raised about the potential negative consequences of condom promotion. Some interventions promoting condom use may result in risk compensation [44,45], thus facilitating the onset or frequency of high-risk sexual activity [46,47]. Few randomized controlled trials have evaluated whether such a compensation effect exists or whether it outweighs the protective effects of condom use. However, a systematic review of 174 sexual risk reduction intervention studies concluded condom-related interventions do not undermine sexual risk reduction efforts by increasing the frequency of sexual behavior [48].

Prevention of STIs through condom use and other methods is discussed in detail separately. (See "Prevention of sexually transmitted infections".)

Inaccurate beliefs — Many misunderstandings exist about condom use. We ask patients what concerns they may have and attempt to address them all. We discuss the following points about external condoms [15]:

●Do not make users sterile, impotent, or weak.

●Do not decrease a male user's sex drive.

●Cannot get lost in the partner's body.

●Do not have holes that HIV can pass through and are not laced with HIV.

●Do not cause illness in a female partner. Exposure to semen or sperm is not needed for a female partner's good health.

●Do not cause illness in users by making sperm "back up."

●Not only for use outside of committed relationships. Condoms are also used by established couples.

●Do not cause cancer and do not contain cancer-causing chemicals.

WHY CHOOSE EXTERNAL CONDOMS?

Advantages — External condoms offer several contraceptive and noncontraceptive benefits to users:

●Condoms are a coital-dependent, reversible method of contraception that do not disrupt fertility.

●Condoms provide protection against STIs during both vaginal and anal sex. (See 'Protection from STIs' below.)

●Condoms are readily accessible without a medical examination, prescription, or special fitting, and can be obtained from many sources, including drug stores, grocery stores, clinics, vending machines, gas stations, bars, and mail-order services.

●Condoms are among the most inexpensive and cost-effective coital-dependent contraceptives. Some programs offer them at no cost.

●Condoms can be easily and discretely carried.

●Condoms have minimal side effects since they are relatively inert and the body is exposed to them only with coitus, not at other times.

●For some users, condom use may help prevent premature ejaculation.

Disadvantages — External condoms also have disadvantages that may result in inconsistent use, incorrect use, or nonuse. Allergy to latex is the only contraindication to latex condom use. (See 'Latex sensitivity or allergy' above.)

●Using an external condom requires partner cooperation. In some instances, male partners will not accept wearing a condom, thus making external condom use impossible.

●Many users and their partners complain of reduced sensitivity when condoms are used during intercourse.

●Foreplay is interrupted to put the external condom on, although placing the condom can be incorporated into foreplay activity.

●Some users cannot consistently maintain an erection when wearing a condom.

●Some users and their partners feel embarrassed or uncomfortable when obtaining condoms or suggesting use of condoms.

●Some users have difficulty finding a condom with a proper fit, which may decrease satisfaction and increase problems such as breakage and slippage [49-51].

Protection from STIs — The primary noncontraceptive benefit of condom use is the protection offered against STI acquisition. Patients (male and female) benefit from external condom use (latex or synthetic), even if another contraceptive method is being used. A general consensus exists that external condoms should play a central role in any STI/HIV prevention program [16,52].

A condom placed on the penis before any genital contact and used throughout intercourse reduces the risk of partner-to-partner transmission of infectious pathogens associated with semen; penile, vaginal, cervical, and anal epithelium; and penile, vaginal, or anal discharges. Laboratory studies indicate that latex condoms provide an effective physical barrier against passage of even the smallest sexually transmitted pathogen (hepatitis B) [53-57]. The level of protection observed during actual use varies because STIs differ in their routes of transmission, infectivity, and prevalence [58-60].

External condoms greatly reduce the risk of STIs transmitted primarily to or from the penile urethra, including gonorrhea, chlamydia, trichomoniasis, hepatitis B infection, and HIV. Condoms should also reduce the risk of STIs transmitted primarily through skin or mucosal surfaces (eg, herpes simplex virus [HSV], syphilis, chancroid, and both human papillomavirus [HPV] and HPV-associated diseases) when these areas are covered by the condom. However, the protection may be less when condoms do not completely cover the entire infected area [3,4,32,35,61,62].

●HIV – Well-designed clinical studies of HIV-discordant couples (where one partner is HIV-infected and the other is not) have reported that consistent use of latex condoms is highly effective against sexually acquired HIV infection [63,64]. One meta-analysis reported that consistent condom use reduced the risk of acquiring HIV by approximately 80 percent [65]. Across 13 cohort studies reviewed, only 11 seroconversions occurred among 587 HIV-discordant heterosexual couples reporting consistent use [65]. (See "HIV infection: Risk factors and prevention strategies", section on 'Condom use'.)

●Other STIs – Clinical studies of effectiveness of condoms against most other STIs also suggest protection, though the level of protection observed has been inconsistent [60-62,66-69]. Much of this inconsistency can be attributed to limitations in study design [38,60-62,69-79] since the overall quality of clinical studies for these STIs is considerably weaker than for the HIV studies. Despite these limitations, studies and systematic reviews have found condom use to be associated with a reduced risk of gonorrhea, chlamydia, trichomoniasis, syphilis, genital herpes, and HPV infection [60,66-69,80-98]. By preventing STIs and their long-term sequelae, condoms also protect female fertility. (See "Prevention of sexually transmitted infections", section on 'Male condom use'.)

INFORMATION FOR USE

Instructions — In 2005, the World Health Organization Experts Meeting developed a Global Handbook for Family Planning Providers that provided consensus statements on five key instructions. These five messages, with minor modifications and additional explanation, follow [1,15,32,99]. In addition, sites such as the Centers for Disease Control and Prevention provide fact sheets on external condom use with drawings to help explain the text.

●First – Use a new external condom for each act of intercourse if any risk of pregnancy or sexually transmitted infections (STIs) exists.

Patients should discuss condom use with their partner before intercourse and should have an adequate supply of condoms readily available. Extra condoms will be needed if the first is damaged, torn before use, or put on incorrectly.

The condom package should be opened carefully to avoid damaging it with fingernails, teeth, or other sharp objects. Condoms in damaged packages or that show obvious signs of deterioration (brittleness, stickiness, or discoloration) should not be used.

●Second – Before any genital contact, place the external condom on the tip of the erect penis with the rolled side out.

Unrolling the condom a short distance helps to make sure the condom is being unrolled in the right direction. If the condom does not unroll easily, it is probably inside-out and should be discarded because flipping it over and using it could expose the partner to infectious organisms contained in the pre-ejaculate.

●Third – Unroll the external condom all the way to the base of the erect penis.

•The condom should cover the penile glans and shaft.

•Adequate, appropriate lubrication (natural or synthetic) is important before intercourse to prevent irritation of the sexual partner. (See 'Strategies for promoting effective external condom use' above.)

●Fourth – Immediately after ejaculation, hold the rim at the base of the external condom and withdraw the penis while it is still erect.

The condom is held firmly against the base of the penis to prevent slippage and leakage of semen while the penis is withdrawn. The condom is then inspected for evidence of breakage or leakage. We educate patients who are using external condoms as their contraceptive method about the availability of emergency contraception should leakage occur, if pregnancy is of concern. (See 'Complications or failure' below.)

●Fifth – Throw away the used external condom safely. Condoms should not be flushed down a toilet.

•Properly discard – After removing the condom, it should be checked for visible damage, and then wrapped in tissue and discarded.

•Do not reuse condoms – A new condom should be used from "beginning to end" with each act of intercourse. If the condom breaks or falls off during intercourse but before ejaculation, it should be replaced with a new condom.

•Change the condom with change in type of sex – New condoms should also be used for prolonged intercourse and for different types of intercourse within a single session (eg, change the condom after anal sex if vaginal sex also is planned).

If the condom breaks, falls off, leaks, is damaged, or is not used, then pregnancy and infection are possible. (See 'Complications or failure' below.)

Concomitant use of lubricants and/or medications — Water-based lubricants (eg, K-Y, Astroglide, saliva, glycerine) and most silicone-based lubricants can be used with latex condoms, but oil-based lubricants reduce latex condom integrity and may facilitate breakage [100]. Common oil-based products that should not come into contact with latex condoms include baby oil, cold creams, edible oils (olive, peanut, corn, sunflower, canola, coconut), butter, cocoa butter, margarine, whipped cream, hand and body lotions, massage oil, petroleum jelly, rubbing alcohol, suntan oil and lotions, and mineral oil [15].

Patients should be aware of whether the products they use (eg, lubricants, medications) that come into contact with their condoms contain oil. This cannot be determined reliably by the look, feel, or characteristics (eg, water soluble) of the product. Spermicides are water-based. Other vaginal medications, however, often contain oil-based ingredients that can damage latex condoms (eg, butoconazole contains mineral oil); therefore, patients using these medications should remain abstinent or use synthetic condoms until intravaginal medical therapy is fully completed. Oil-based products may be safely used with polyurethane and polyisoprene condoms.

Complications or failure — Although users often fear that the condom will break or fall off during use, these events are relatively uncommon. (See 'Device failure (slippage and breakage)' above.)

We advise users to have several condoms available in case a condom is torn, put on incorrectly, falls off, or repeated intercourse is desired. We also discuss treatment options the patient should be aware of in case a condom breaks, falls off, or is discovered to have a hole following intercourse, including [15]:

●Emergency contraception – Emergency contraception can be used as a backup method against pregnancy. We discuss availability and use of emergency contraception with all of our patients who desire to avoid pregnancy. (See "Emergency contraception".)

●HIV and STI prevention – Patients who may have been exposed to HIV or STI are evaluated for possible postexposure prophylaxis against HIV and possible presumptive treatment against other STIs. (See "Prevention of sexually transmitted infections", section on 'Antimicrobial-based prevention strategies'.)

In addition, immediately gently washing the penis, vulva, anus, and adjacent areas with soap and water may help to reduce the risk of acquiring an STI, although the effectiveness of this practice has not been well studied. Inserting an applicator full of spermicide into the vagina as soon as possible may also help to prevent pregnancy. Female partners should not douche.

Storage and expiration — External condoms should be stored in a cool and dry place, out of direct sunlight, as excessive heat will weaken latex. However, latex condoms can probably be carried, for convenience, in a wallet for up to one month [101].

Patients should check the expiration or manufacturing date on the box or individual package. Latex condoms should not be used beyond their expiration date or more than five years after the manufacturing date.

MANAGING PROBLEMS — Routine follow-up is not required to monitor external condom use. However, we encourage patients to return any time they experience difficulties with condom use or if they desire further education. The World Health Organization also advises clinicians to ask patients about their experiences and satisfaction with condom use at any visit [15]. Possible questions include:

●Is the patient satisfied with the method? Is there anything the patient would like to discuss?

●Is the patient having difficulty using condoms correctly every time they have sex?

●Have any medical (eg, diabetes) or life changes (eg, desire for pregnancy) occurred that may impact condom use?

RESOURCES FOR PATIENTS AND CLINICIANS — Additional information about external condoms and other contraceptive options can be found at the following sites:

●World Health Organization Family Planning Global Handbook for Providers, 2018

●Bedsider.org – A free website developed by the National Campaign to Prevent Teen and Unplanned Pregnancy, a private nonprofit group.

●Planned Parenthood – A nonprofit organization dedicated to reproductive health with resources for patients and clinicians.

●CHOICE Project – A free website sponsored by the Washington University School of Medicine in St. Louis that provides resources on contraceptive options and training resources for clinicians.

●Center for Young Women's Health – A free website run by Boston Children's Hospital that addresses reproductive health needs of teens and young adults.

●Beyond the Pill – A free website run by the University of California San Francisco.

●SexandU.ca – An educational site run by the Society of Obstetricians and Gynaecologists of Canada that includes descriptions of various methods and a tool to help with selection of birth control.

●Association of Reproductive Health Professionals – A nonprofit organization that provides resources for patients including an interactive tool to compare birth control methods.

●US Centers for Disease Control and Prevention (CDC)

●ACOG Contraceptive FAQs – American College of Obstetricians and Gynecologists addresses frequently asked questions (FAQs) about contraception.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Contraception".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Barrier methods of birth control (The Basics)")

●Beyond the Basics topics (see "Patient education: Barrier and pericoital methods of birth control (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Condom materials and types – Condoms are made of latex rubber, natural membranes, or synthetic material. (See 'Material' above.)

•Latex (rubber) – Latex accounts for approximately 80 percent of external (formerly male) condoms and has the advantages of low cost and protection from sexually transmitted infections (STIs; including HIV), as well as pregnancy, but can be damaged by oil-based lubricants.

We advise latex condoms for all patients who may be at risk for or are concerned about STI (including HIV) acquisition/transmission or pregnancy prevention.

•Natural membrane – Natural membrane condoms are made from the intestinal cecum of lambs and contain small pores that may permit the passage of viruses; therefore, they are not recommended for STI prevention.

•Synthetic – Synthetic condoms provide an option for people who are allergic or sensitive to latex and should provide similar protection against pregnancy and STIs as latex condoms.

•Spermicide-coated condoms – We do not advise use of spermicide-coated condoms because they are no more effective than other lubricated condoms, have a higher cost and shorter shelf-life, and may cause adverse effects in users. (See 'Spermicide coating' above.)

●Indications – Condoms provide protection from STIs, including HIV, and/or pregnancy. Counseling of patients includes when to use condoms, how to use them most effectively, how to discuss condom use with their partner(s), and how to integrate condom use into intercourse. (See 'General' above.)

●Mechanism and efficacy – The condom acts as a barrier by preventing direct contact with semen (and thus sperm), genital lesions, and subclinical viral shedding on the glans and shaft of the penis. It also prevents contact with penile, vaginal, or anal discharges. Condom effectiveness depends on the motivation, skill level, and experience of the user.

•Unintended pregnancy – It is estimated that 2 percent of female partners will become pregnant during the first year of perfect (ie, consistent and correct) use of the condom, and approximately 13 percent of female partners will become pregnant during the first year of typical use. (See 'Mechanism of action' above.)

•Condom slippage and/or breakage – Condom slippage and breakage rates vary by material, product, route of use, and experience of the user. While reported rates vary, condom failure occurs with approximately 2 percent of vaginal intercourse events and with <1 percent of anal intercourse events. (See 'Device failure (slippage and breakage)' above.)

●Advantages, disadvantages, and contraindication – Benefits of external condoms include protection against pregnancy and STIs as well as noncontraceptive benefits. The main disadvantage is that external condom use requires partner cooperation. The only contraindication to external condom use is latex allergy.

•(See 'Why choose external condoms?' above.)

•(See 'Latex sensitivity or allergy' above.)

●Instructions for use – Appropriate counseling and instruction can minimize problems with condom use. The most critical factors for protection from unintended pregnancy and STIs are that a new condom is placed on the penis before any genital contact, remains intact until the penis is withdrawn, and is used with every act of intercourse.

•(See 'Strategies for promoting effective external condom use' above.)

•(See 'Information for use' above.)

●Role of lubricants – Water-based lubricants (eg, K-Y, Astroglide, saliva, glycerine) and most silicone-based lubricants can be used with latex condoms, but oil-based lubricants reduce latex condom integrity and may facilitate breakage. (See 'Concomitant use of lubricants and/or medications' above.)

●Role of emergency contraception – Although users often fear that the external condom will break or fall off during use, these events are relatively uncommon. In the event of condom slippage or breakage, patients should be offered emergency contraception and/or postexposure prophylaxis for STIs. (See 'Complications or failure' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Willard Cates, Jr, MD, MPH, who contributed to an earlier version of this topic review.

The findings and conclusions in this topic review are those of the authors and do not necessarily represent the views of the United States Agency for International Development, National Institutes of Health, or Centers for Disease Control and Prevention.