BV: treat male sexual partner?

BV: SHOULD MALE SEXUAL PARTNERS BE TREATED?

Clinical Scenario: 31 y/o F with BV asks if male partner with genital pruritis should be tested or treated.

REVIEW:
BV caused by change in vaginal flora, namely Lactobacillus --> Anaerobes. Not 1 organism but many (G. Vaginalis main one, but many other anaerobes). Lose Lactobacilli --> pH rises --> more vaginal anaerobes --> lyse vaginal peptides causing odor, squamous cell exfoliation --> G.Vaginalis sticks to these squamous cells causing clue cells.

Cause of change in vaginal flora unclear. Though BV is associated with several sexual risk factors (see below), whether it results through sexual transmission is unclear. Of note, cases have been reported in women who have never had sex, though this is rare.

RF:
--new sex partners, multiple sex partners (however can occur in absense of sex!)
--douching
--smoking.

Sx: fishy, thin-white discharge, but 50% asx!

Dx:
3/4 clinical criteria for dx:
--vag pH >4.5
--+whiff test
--clue cells
--thin-white discharge

OR Gram Stain

BV is a RF for:
Other STD’s: HIV, HSV-2, G/C
Pregnancy related: PID, preterm birth, PROM, postpartum endometritis (CDC recs treat all pregnant women with BV and consider screening high-risk pregnant pts)

Tx:
1) to tx sx 2) to decrease risk of post-abortion or post-hysterectomy infectious complications
*Resolves spontaneously in 1/3.
--Flagyl 500 po bid x 7 days
--topical Flagyl (0.75 % gel daily x 5 days), topical Clinda (2% cream daily x 7 days)

Alternative:
--Clinda 300 po bid x 7 days

Relapse: Tx with longer course and different abx. Some studies suggest decreased
recurrence with condoms, abstinence, and flagyl gel maintenance.

NOW REGARDING SEXUAL PARTNERS:
No current evidence to support treating sexual partners. Will not alter woman’s response to treatment or risk of relapse. This is a 1B recommendation by CDC and STD 2006 guidelines.

6 RCTs, 5 show no benefit to treating partners.
--All dx BV by accepted criteria above. All excluded pregnant pts and those with
coexistant vaginal infxns.

The 2 RCTs with the longest follow-up period (12 wks) showed no benefit in treating male partners with flagyl or clindamycin.
--Moi et al study, Genitourinary medicine 1989: RCT, double-blind, international,
multicenter. 241 women total with BV. All got Flagyl 2 g x 2 doses 2 days apart. 123
women whose male partner got same dose. 118 control whose male partner got
placebo. In intention to treat analysis at 1, 4, 12 weeks no difference in recurrence of
BV.
Critique: Strange dosing of Flagyl?
--Colli et al study, Genitourinary medicine 1997: RCT, double-blind trial. 139 women total with BV. Women all received Clinda 2% Vaginal cream daily x 7 days. 69 women whose partner got Clinda 150 mg po 4x/day x 7 days, 70 women whose partner got placebo. In intention to treat analysis at 1, 4, 12 weeks no difference in recurrence rate of BV.

Briefly 3 shorter RCT also showed no benefit:
--Vejtorp and Vutyavanich, and Swedberg studies with no difference at 5, 4, and 3 weeks, respectively. Studied Flagyl or Tinidazole.

The 1 RCT that showed different results was fishy (excuse the pun):
--Mengel study, J Fam Practice 1989. RCT, double-blind, 8 weeks. Studied if single-dose Flagyl tx for partners improved cure rate and decreased recurrence rate. 98 women with BV, improvement in cure rate at 2 weeks by Gram stain criteria (but not by wet mount criteria!) and improvement in symptoms at 8 weeks. No significant improvement in recurrence rate at 5 and 8 weeks by gram stain criteria.
Critique: Gram stain criteria not routinely used to dx BV—clinically relevant? The 5 and 8 wk f/u was actually a telephone interview for sx and gram stain of self-collected vaginal fluid.

BOTTOM LINE:
No evidence currently to support routine treatment of male sexual partners for BV (1B recommendation). Will not help response to therapy or prevention of recurrence. Of note, all trials are relatively small studies of short duration.

References:
1) Moi H, Erkkola R, Jerve F, et al. Should male consorts of women with bacterial vaginosis be treated? Genitourin Med. 1989;65:263-268.
2) Colli E, Landoni M, Parazzini F. Treatment of male partners and recurrence of bacterial vaginosis: a randomised trial. Genitourin Med. 1997;73:267-270.
3) Vejtorp M, Bollerup AC, Vejtorp L, et al. Bacterial vaginosis: a double-blind randomized trial of the effect of treatment of the sexual partner. Br J Obstet Gynaecol. 1988;95:920-926.
4) Vutyavanich T, Pongsuthirak P, Vannareumol P, Ruangsri R, Luangsook P. A randomized double-blind trial of tinidazole treatment of the sexual partners of females with bacterial vaginosis. Obstet Gynecol. 1993;82:550-554.
5) Swedberg J, Steiner JF, Deiss F, Steiner S, Driggers DA. Comparison of single-dose vs one-week course of metronidazole for symptomatic bacterial vaginosis. JAMA. 1985;254:1046-1049.
6) Mengel M, Berg AO, Weaver CH, et al. The effectiveness of single-dose metronidazole therapy for patients and their partners with bacterial vaginosis. J Fam Pract. 1989;28:163-171.
7) CDC guidelines 2006
8) STD guidelines 2006
9) UpToDate online