Trichomonal Vaginitis

1. See also
   1. Vaginitis
2. Epidemiology
   1. Accounts for 10% of Vaginitis
   2. Prevalence
      1. General gynecology clinics: 13-23%
      2. Prostitutes: 75%
   3. Transmission
      1. Sexually Transmitted Disease
      2. Men are asymptomatic in 90% of cases
      3. Often transmitted with Gonorrhea and Chlamydia
      4. Rarely transmitted by moist cloths
3. Etiology
   1. Protozoan infection
4. Symptoms
   1. Asymptomatic in 25-44% of women
   2. Copious, grayish-green Vaginal Discharge
      1. Fishy odor to discharge
      2. Frothy discharge (Carbon dioxide bubbles)
         1. Sensitivity: 10%
         2. Specificity: 70%
   3. Vulvar and vaginal Pruritus with irritation and edema
   4. Dysuria (20%)
5. Signs
   1. Vulvar edema and erythema
   2. Strawberry Cervix (2-3% of cases)
      1. Punctate Hemorrhages or Petechiae
      2. Telangiectasia
6. Lab
   1. Vaginal pH > 5.0
   2. KOH Preparation
      1. Sniff Test positive
         1. Fishy odor to discharge when KOH added
   3. Wet preparation (from vaginal vault, not endocervix)
      1. Motile pear shaped Trichomonads with flagella (70%)
         1. Twice the size of White Blood Cells (WBC)
         2. 
      2. Efficacy
         1. Test Sensitivity: 60-70%
   4. Specific diagnostic tests (available as point-of-care clinic based tests)
      1. Osom Trichomonas Rapid Test
      2. BD Affirm VPIII Microbial Identification Test
      3. Efficacy
         1. Test Sensitivity: 83%
         2. Test Specificity: >97% (false positives are a concern in regions of low Prevalence)
   5. Other testing
      1. Gram Stain
         1. White Blood Cells over 10 per high powered field
      2. Culture of Trichomonas vaginalis
         1. Grown on modified Diamond media
7. Associated Conditions
   1. Preterm Labor
   2. Test for other Sexually Transmitted Disease
      1. NeisseriaGonorrhea
      2. Chlamydia trachomatis
8. Management
   1. General
      1. Treat Sexual Partner also
      2. Avoid treatment in first trimester of pregnancy
      3. Avoid intravaginal preparations of Metronidazole or Tinidazole due to low cure rates
   2. Non-Pregnant, Non-Lactating Patient
      1. Metronidazole (Flagyl) 2 g orally for 1 dose (preferred) or
      2. Metronidazole (Flagyl) 250 mg PO three times daily for 7 days or
      3. Metronidazole (Flagyl) 500 mg PO twice daily for 7 days or
      4. Tinidazole (Tindamax) 2 grams orally for 1 dose
   3. Pregnant (after first trimester, and preferred after 37 weeks)
      1. Metronidazole (Flagyl) 2 g PO for 1 dose ($5) or
      2. Metronidazole (Flagyl) 500 mg PO bid for 7 days
   4. Lactation
      1. Metronidazole (Flagyl) 2 grams PO for 1 dose
      2. Discontinue Lactation for 24 hours after dose
   5. Persistent or Recurrent Cases
      1. Metronidazole 500 mg PO bid for 14 days
      2. Metronidazole 2g PO qd for 3 days
      3. Metronidazole gel 5g PV bid for 5 days ($30)
      4. Povidone-Iodine Suppository PV bid for 14 days ($60)
      5. Clotrimazole 100 mg vag tab PV qhs for 7 days ($14)
      6. Tinidazole
      7. Paromomycin (Humatin) 5g intravaginally qd x14 days
         1. Higher rate of Vulvitis and local Ulceration
9. References
   1. Mandell (2000) Infectious Disease, Churchill, p. 2894-7
   2. (1998) MMWR Morb Mortal Wkly Rep 47:1-115
   3. Epling (2001) Am Fam Physician 64(7):1241-4
   4. Workowski (2006) MMWR Recomm Rep 55:1-94