35-12: Trichomoniasis

ESSENTIALS OF DIAGNOSIS

GENERAL CONSIDERATIONS

Trichomoniasis is caused by the protozoan Trichomonas vaginalis and is among the most common sexually transmitted diseases, causing vaginitis in women and nongonococcal urethritis in men. It can also occasionally be acquired by other means, since it can survive in moist environments for several hours.

CLINICAL FINDINGS

A. Symptoms and Signs

T vaginalis is often harbored asymptomatically. For women with symptomatic disease, after an incubation period of 5 days to 4 weeks, a vaginal discharge develops, often with vulvovaginal discomfort, pruritus, dysuria, dyspareunia, or abdominal pain. Examination shows a copious discharge, which is usually not foul smelling but is often frothy and yellow or green in color. Inflammation of the vaginal walls and cervix with punctate hemorrhages are common. Most men infected with T vaginalis are asymptomatic, but it can be isolated from about 10% of men with nongonococcal urethritis. In men with trichomonal urethritis, the urethral discharge is generally scantier than with other causes of urethritis.

B. Diagnostic Testing

Diagnosis is traditionally made by identifying the organism in vaginal or urethral secretions. Examination of wet mounts will show motile organisms. Tests for bacterial vaginosis (pH > 4.5, fishy odor after addition of potassium hydroxide) are often positive with trichomoniasis. Newer point-of-care antigen detection and nucleic acid probe hybridization tests and nucleic acid amplification assays offer improved sensitivity compared with wet mount microscopy and excellent specificity.

TREATMENT

The treatment of choice is tinidazole or metronidazole, each as a 2 g single oral dose. Tinidazole may be better tolerated and active against some resistant parasites. Toxicities of these drugs are discussed in the section on amebiasis. If the large single dose cannot be tolerated, an alternative metronidazole dosage is 500 mg orally twice daily for 1 week. A meta-analysis suggested that a 7-day course of metronidazole (500 mg twice daily) is more effective than a single dose; this regimen is recommended for women living with HIV and may become standard for other groups. All persons with infection should be treated, even if asymptomatic, to prevent subsequent symptomatic disease and limit spread. Treatment failure suggests reinfection, but metronidazole-resistant organisms have been reported. These may be treated with tinidazole, longer courses of metronidazole, intravaginal paromomycin, or other experimental therapies (see Chapter 18).