Trichomonal Vaginitis

Aka: Trichomonal Vaginitis, Trichomonas, Trichomoniasis

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II. Epidemiology

  1. Accounts for 10% of Vaginitis
  2. Prevalence
    1. General gynecology clinics: 13-23%
    2. Prostitutes: 75%
    3. Increasing Prevalence in asymptomatic women over age 45 years old
    4. More common in women with HIV Infection
      1. Screen women with HIV yearly
  3. Transmission
    1. Sexually Transmitted Disease
      1. Trichomonas is the most common non-viral Sexually Transmitted Infection
    2. Men are asymptomatic in 90% of cases
    3. Often transmitted with Gonorrhea and Chlamydia
    4. Rarely transmitted by moist cloths

III. Etiology

  1. Protozoan infection

IV. Risk Factors

  1. Multiple sexual partners
  2. Sexually Transmitted Infections
  3. Unprotected Intercourse
  4. Illicit Drug use
  5. Tobacco Abuse

V. Symptoms

  1. Asymptomatic in 25-44% of women
  2. Copious, yellow-green or grayish-green Vaginal Discharge (variably present)
    1. Fishy odor to discharge (variably present)
    2. Frothy discharge (Carbon dioxide bubbles)
      1. Sensitivity: 10%
      2. Specificity: 70%
  3. Vulvar and vaginal Pruritus with irritation and edema
  4. Dysuria (20%)

VI. Signs

  1. Vulvar edema and erythema
  2. Tender vaginal or vulvar ulcerations
  3. Strawberry Cervix (2-3% of cases)
    1. Punctate Hemorrhages or Petechiae
    2. Telangiectasia

VII. Lab

  1. Vaginal pH > 5.0
  2. KOH Preparation
    1. Sniff Test positive
      1. Fishy odor to discharge when KOH added (often negative)
  3. Wet Preparation (from vaginal vault, not endocervix)
    1. Read slide immediately
      1. Motility wanes quickly, over minutes
      2. Trichomonad shape morphs from pear-shaped to round with slide drying
    2. Motile pear shaped Trichomonads with flagella exiting from tapering end (70%)
      1. Twice the size of White Blood Cells (WBC)
      2. GynVaginitisTrichomonas.jpg
    3. Efficacy
      1. Test Sensitivity: 60-70%
  4. Specific diagnostic tests
    1. DNA Testing is preferred for Trichomonas diagnosis, and can be added to DNA probe and liquid pap
      1. Preferred over microscopy in symptomatic or high risk women
      2. Nucleic Acid Amplification Test (NAAT) Sensitivity: >95%
        1. May be added to GC/Ch DNA probe or liquid pap
      3. Rapid swabs are also available, with Test Sensitivity 80-90%
        1. Available as point-of-care clinic based tests
        2. Test Sensitivity: 83%
        3. Test Specificity: >97% (False Positives are a concern in regions of low Prevalence)
    2. BD Affirm VPIII Microbial Identification Test (Nucleic Acid probe)
    3. Osom Trichomonas Rapid Test (immunochromatographic)
  5. Other testing
    1. Gram Stain
      1. White Blood Cells over 10 per high powered field
    2. Culture of Trichomonas vaginalis (replaced with DNA probes)
      1. Grown on modified Diamond media

VIII. Associated Conditions

  1. Preterm Labor
  2. Test for other Sexually Transmitted Disease
    1. NeisseriaGonorrhea
    2. Chlamydia Trachomatis

IX. Management

  1. General
    1. Treat Sexual Partner also
      1. Metronidazole 500 mg orally twice daily for 7 days is most effective for male partners
      2. However, Metronidazole 2 g orally for one dose is recommended in guideline for male partners
      3. Abstain from intercourse until they and their sexual partners are treated
    2. Avoid treatment in first trimester of pregnancy
    3. Avoid intravaginal preparations of Metronidazole or Tinidazole due to low cure rates
    4. Re-test in 3 months (high risk of reinfection)
  2. Non-Pregnant, Non-Lactating Patient
    1. Metronidazole (Flagyl) 500 mg orally twice daily for 7 days (preferred) OR
      1. Avoid single Metronidazole (Flagyl) 2 g oral dose (less effective)
    2. Tinidazole (Tindamax) 2 grams orally for 1 dose
      1. Teratogenic, Category D (do not use if any risk of pregnancy)
      2. More expensive than Metronidazole options
  3. Pregnant (after first trimester, and preferred after 37 weeks)
    1. Metronidazole (Flagyl) 2 g orally for 1 dose OR
    2. Metronidazole (Flagyl) 500 mg orally twice daily for 7 days
  4. Lactation
    1. Metronidazole (Flagyl) 2 grams orally for 1 dose
    2. Discontinue Lactation for 24 hours after dose
  5. Persistent or Recurrent Cases
    1. Retreat both the sexual partner and the patient
    2. Metronidazole 500 mg orally twice daily for 7-14 days
    3. Metronidazole 2g orally daily for 3 days (for up to 7 days)
    4. Metronidazole gel 5g PV bid for 5 days
    5. Povidone-Iodine Suppository PV bid for 14 days
    6. Clotrimazole 100 mg vag tab PV qhs for 7 days
    7. Tinidazole 2 g orally daily for 5 days
      1. Teratogenic, Category D (do not use if any risk of pregnancy)
    8. Paromomycin (Humatin) 5g intravaginally qd x14 days
      1. Higher rate of Vulvitis and local ulceration
    9. Secnidazole (Solosec) 2 g orally for 1 dose
      1. Expensive in 2021 ($270 for one dose)
      2. (2021) Presc Lett 28(9): 49-50

X. Complications

  1. HIV Infection and transmission risk
  2. Preterm Labor
  3. Associated with concurrent other Sexually Transmitted Infections

XI. References

  1. Mandell (2000) Infectious Disease, Churchill, p. 2894-7
  2. (1998) MMWR Morb Mortal Wkly Rep 47:1-115 [PubMed]
  3. Epling (2001) Am Fam Physician 64(7):1241-4 [PubMed]
  4. Workowski (2006) MMWR Recomm Rep 55:1-94 [PubMed]

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Related Studies

Ontology: Trichomonas Infections (C0040921)

Definition (MEDLINEPLUS)

Trichomoniasis is a sexually transmitted disease caused by a parasite. You get it through sexual intercourse with an infected partner. Many people do not have any symptoms. If you do get symptoms, they usually happen within 5 to 28 days after being infected.

Symptoms in women include

  • Yellow-green or gray discharge from the vagina
  • Discomfort during sex
  • Vaginal odor
  • Painful urination
  • Itching in or near the vagina

Most men do not have symptoms. If they do, they may have a whitish discharge from the penis and painful or difficult urination and ejaculation.

Lab tests can tell if you have the infection. Treatment is with antibiotics. If you are infected, you and your partner must be treated. Correct usage of latex condoms greatly reduces, but does not eliminate, the risk of catching or spreading trichomoniasis.

NIH: National Institute of Allergy and Infectious Diseases
Definition (MSHCZE) Infekční onemocnění způsobené prvokem Trichomonas vaginalis (bičíkovec poševní). Přenáší se zejm. pohlavním stykem a způsobuje u ženy zánět s výtokem. U mužů probíhá buď bez příznaků, nebo jako zánět močové trubice. Léčí se některými chemoterapeutiky (např. metronidazolem), nutná je léčba sexuálních partnerů. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (MSH) Infections in birds and mammals produced by various species of Trichomonas.
Concepts Disease or Syndrome (T047)
MSH D014245
ICD9 131.9, 131
ICD10 A59 , A59.9
SnomedCT 187206001, 187364002, 56335008, 105648001
English Infections, Trichomonas, Infection, Trichomonas, Trichomonas NOS, Trichomoniasis, unspecified, [X]Trichomoniasis, unspecified, INFECT TRICHOMONAS, TRICHOMONAS INFECT, Trichomonas Infections, trichomoniasis (diagnosis), trichomoniasis, Trichomonas infections, Trichomoniasis NOS, Trichomonas Infections [Disease/Finding], trichomonosis, trichomona, trichomonas infection, trichomonas, Trichomonas NOS (disorder), [X]Trichomoniasis, unspecified (disorder), Trich, Trichomoniasis, Trichomonosis, Disease due to Trichomonadidae (disorder), Disease due to Trichomonadidae, Infection by Trichomonas (disorder), Infection by Trichomonas, Trichomonas; infection, infection; Trichomonas, Infection by Trichomonas, NOS, Trichomonas Infection
Italian Infezioni da trichomonas, Tricomoniasi, Tricomoniasi NAS, Infezioni da Trichomonas
Dutch trichomoniasis, niet-gespecificeerd, Trichomonas; infectie, infectie; Trichomonas, Trichomoniasis, niet gespecificeerd, Trichomonasinfecties, trichomoniasis, Trichomoniasis
French Trichomonase, non précisée, Infections à Trichomonas, Trichomonase, Trichomoniase
German Trichomoniasis, unspezifisch, Trichomoniasis, nicht naeher bezeichnet, Trichomonen-Infektionen, Trichomonadeninfektionen, Trichomoniasis
Portuguese Tricomoníase NE, Infecções por Tricomonas, Infecções a tricomonas, Tricomoníase
Spanish Tricomoniasis no especificada, [X]tricomoniasis, no especificada, Trichomonas, SAI, [X]tricomoniasis, no especificada (trastorno), Trichomonas, SAI (trastorno), Infecciones por Tricomonas, enfermedad por Trichomonadidae (trastorno), enfermedad por Trichomonadidae, infección por Trichomonas (trastorno), infección por Trichomonas, tricomoniasis, tricomonosis, Infecciones por tricomonas, Tricomoniasis
Japanese トリコモナス感染, トリコモナス症、詳細不明, ﾄﾘｺﾓﾅｽｶﾝｾﾝ, ﾄﾘｺﾓﾅｽｼｮｳ, ﾄﾘｺﾓﾅｽｼｮｳｼｮｳｻｲﾌﾒｲ, トリコモナス感染症, トリコモナス症
Swedish Trichomonasinfektioner
Finnish Trikomoniaasit
Russian TRIKHOMONADNYE INFEKTSII, ТРИХОМОНАДНЫЕ ИНФЕКЦИИ
Czech Trichomonádové infekce, Trichomoniáza, Trichomoniáza, blíže neurčená, Trichomonas - infekce, trichomoniáza, trichomonóza
Korean 편모충증, 상세불명의 편모충증
Polish Trichomoniaza, Rzęsistkowica, Trychomonadoza
Hungarian Trichomonas fertőzések, trichomoniasis, trichomoniasis, nem meghatározott
Croatian Trihomonas, infekcije
Norwegian Trichomonasinfeksjoner, Trikomonasinfeksjoner
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Trichomonas Vaginitis (C0040923)

Definition (NCI) A sexually transmitted parasitic infection caused by Trichomonas vaginalis. Symptoms include vaginal discharge, vaginal odor, vaginal itching, and discomfort during intercourse.
Definition (MSH) Inflammation of the vagina, marked by a purulent discharge. This disease is caused by the protozoan TRICHOMONAS VAGINALIS.
Concepts Disease or Syndrome (T047)
MSH D014247
SnomedCT 187202004, 266165009, 187201006, 500000, 276877003
English Trichomonas Vaginitides, Vaginitides, Trichomonas, Vaginitis, Trichomonas, Trichomonal vulvovaginitis, Leukorrhea - vag.-trichomonal, Leukorrhea vaginalis - trichomonal, Leukorrhoea vaginalis - trichomonal, Trichomonal leukorrhea, Trichomonal leukorrhoea, trichomonas vaginalis vaginitis, Trichomonal vaginitis (diagnosis), Vaginitis trichomonal, Trichomonas Vaginitis [Disease/Finding], Trichomonas Vaginitis, trichomoniasis vaginal, vaginitis trichomonas, Vaginitis;trichomonal, trichomonas vaginitis, vaginal trichomoniasis, Trichomonal fluor vaginalis, Trichomonal leukorrhea vaginalis, Trichomonal vaginitis, Vaginal trichomoniasis, Trichomonal leukorrhoea vaginalis, Trichomonal vaginitis (disorder), Vaginal trichomoniasis (disorder), trichomonal vaginitis
French Vaginite trichomonale, Vaginite à Trichomonas
German Vaginitis durch Trichomonen, Trichomonaden-Vaginitis, Trichomonadenvaginitis, Trichomonas-Vaginitis, Trichomonas-Kolpitis, Trichomonadenkolpitis, Trichomonaden-Kolpitis, Vaginitis, Trichomonas-
Italian Vaginite da trichomonas, Vaginite da Trichomonas
Portuguese Vaginite a tricomonas, Vaginite por Trichomonas
Spanish Vaginitis por tricomonas, Tricomoniasis Vaginal, leucorrea vaginal por tricomonas, tricomoniasis vaginal (trastorno), tricomoniasis vaginal, vaginitis por tricomonas, vaginitis tricomoniásica (trastorno), vaginitis tricomoniásica, Vaginitis por Trichomonas
Japanese トリコモナス性腟炎, ﾄﾘｺﾓﾅｽｾｲﾁﾂｴﾝ
Swedish Trichomonas-vaginit
Czech trichomonádová vaginitida, Trichomonádová vaginitida, vaginální trichomonóza
Finnish Trikomonasvaginiitti
Russian TRIKHOMONADNYI VAGINIT, ТРИХОМОНАДНЫЙ ВАГИНИТ
Polish Rzęsistkowica pochwy
Hungarian Vaginitis, trichomonas okozta, Trichomonas vaginitis
Norwegian Trichomonas-vaginitt, Trikomonas-vaginitt
Dutch Trichomonas-vaginitis, Vaginitis, trichomonas-
Derived from the NIH UMLS (Unified Medical Language System)

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