How do you diagnose bacterial vaginosis (BV) in a male?

Diagnosing Bacterial Vaginosis in Males

There is no standardized diagnostic method for bacterial vaginosis (BV) in males as BV is primarily defined as a condition affecting the vaginal microbiome. 1, 2

Understanding BV in Males

Bacterial vaginosis is defined as a clinical syndrome resulting from the replacement of normal hydrogen peroxide-producing Lactobacillus species in the vagina with high concentrations of anaerobic bacteria. While BV is well-characterized in females, the concept of "male BV" is not clinically established for several reasons:

• BV is specifically defined by changes in vaginal flora and pH
• Diagnostic criteria (Amsel criteria) are designed for vaginal assessment
• Males lack the vaginal environment where BV develops

Why Males Cannot Be Tested Using Standard BV Criteria

The standard diagnostic criteria for BV in females include:

1. Homogeneous, white, non-inflammatory discharge that coats vaginal walls
2. Presence of clue cells on microscopic examination
3. Vaginal fluid pH >4.5
4. Fishy odor of vaginal discharge before or after addition of 10% KOH (whiff test) 1, 2

These criteria cannot be directly applied to males because:

• Males lack vaginal flora and the vaginal environment
• The pH measurement is specific to vaginal secretions
• Clue cells are vaginal epithelial cells with adherent bacteria

Clinical Relevance for Male Partners

While males cannot be diagnosed with BV per se, there are important clinical considerations:

• BV is associated with having multiple sex partners and sexual activity 1
• However, treatment of male sex partners has not been beneficial in preventing the recurrence of BV in females 1
• The CDC does not recommend routine treatment of male partners of women with BV 2

Potential Testing Approaches for Research Purposes

In research settings, some approaches have been used to detect BV-associated bacteria in males:

• Urethral swabs for PCR testing of BV-associated bacteria
• Penile skin or coronal sulcus swabs for bacterial culture or molecular testing
• Semen analysis for presence of BV-associated organisms

However, these are not standardized clinical tests and are primarily used in research contexts.

Key Points for Clinicians

• BV is defined as a condition of the vaginal microbiome and cannot be formally diagnosed in males
• Treatment of male partners is not recommended in current guidelines 1, 2
• If a male patient presents with urethritis or other genital symptoms, standard STI testing should be performed rather than attempting to diagnose "male BV"
• The focus should remain on diagnosing and treating BV in female patients according to established guidelines

Common Pitfalls to Avoid

• Attempting to apply female BV diagnostic criteria to male patients
• Treating asymptomatic male partners of women with BV (not supported by evidence) 1
• Confusing BV-associated bacteria colonization in males with actual BV diagnosis
• Overlooking other potential causes of genital symptoms in males that may require different diagnostic approaches