Download Fact Sheet: Trichomoniasis Brandi Barnhill, RN, BSN Juli Sublett

Fact Sheet: Trichomoniasis
Brandi Barnhill, RN, BSN
Juli Sublett, RN, BSN
Fact Sheet: Trichomoniasis
Incidence and Prevalence

Trichomoniasis is the most common curable STD in young sexually active
women. It is most commonly found in men and women of reproductive ages.
Trichomoniasis is not a reportable disease and its prevalence can only be
estimated. It is estimated that 7.4 million new cases occur each year in women
and men in the U.S., and more than 170 million cases worldwide. In a study by
the CDC in 2007 a large racial disparity was shown among infected women where
the prevalence among non-Hispanic black women was 10.3 times higher than that
of non-Hispanic white or Mexican American women (13.3% vs. 1.3% AND
1.8%, respectively). (Prevalence of Trichomonas)
Etiology and Pathophysiology

Trichomoniasis is caused by the protozoan Trichomonas vaginalis. (McPhee, S.J.
& Papadakis, 2011). The most common site of infection in women is the vagina
and the urethra (urine canal) in men; thus it causes vaginitis in women and
nongonococcal urethritis in men.
It is transmitted sexually through penis-to
vagina intercourse or vulva-to-vulva contact with an infected partner.
Trichomoniasis can live on moist environments for several hours, thus may be
transmitted by other means. While women can acquire the disease from infected
men or women, men usually contract it only from infected women. It is usually
found in both sexual partners and often coexists with gonorrhea.

T.vaginalis is an anaerobic, unicellular, flagellated, parasitic protozoan.
(McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. ,2010). The
protozoan selectively adheres to and damages squamous epithelial cells. Because
of this squamous cell selectivity vaginal and urethral tissues are most often
infected, as are Skene and Bartholin glands. The endocervical canal is lined with
columnar epithelium and is therefore not affected. The infection is most common
in the urethra in males, however the protozoa called tricomonads can infect the
epididymis and rarely the prostate. Because zinc is found in high concentrations
in the prostate and has potent antibacterial properties many trichomonads are
cleared from the male urethra during ejaculation. It is because of this action that
urethral trichomoniasis is a fairly self-limiting infection in men. Urethral
infections in men usually clear up within 2 weeks. Trichomoniasis primarily
infects the vagina and can induce a marked inflammatory response in the vagina,
causing a copious discharge that contains large numbers of polymorphonuclear
neutrophils.

Clinical manifestations of trichomoniasis range from none to severe, with some
women reporting an increase in distressing symptoms immediately after menses
(McCance et. al, 2010). The most common complaints are vaginal discharge and
internal pruritus. Dyspareunia and dysuria are also common. Secretions are
usually copious, frothy, malodorous, and yellow-green to gray-green. Vaginal
walls may be erythematous and sore, and rarely small punctate red makes referred
to, as strawberry spots or strawberry cervix are visible. Most men are
asymptomatic however possible symptoms include scant intermittent discharge,
slight pruritus, and mild dysuria.
Differential Diagnosis

Bacterial Vaginosis is the most common cause of vaginal discharge. Symptoms
include thin homogeneous white, gray, green, or brownish discharge that has a
foul odor. Pelvic tenderness or pain may be present, and vaginal pH is greater
than 4.5. Wet mount will show clue cells and a few lactobacilli; and the whiff test
is positive (Dains,J., Baumann,L., & Schiebel,P., 2007).

Candida Vulvovaginitis is another manifestation of vaginal discharge and
pruritus. Ninety percent of women with candida have vulvar pruritus present.
The discharge is usually thick, white, and curdy, and the labia are erythematous
and edematous. The vaginal pH is 4.0 to 4.7. The KOH wet mount shows
pseudohyphae and spores (Dains, J et. al, 2007).

Atrophic vaginitis is another cause of dyspareunia. However, unlike
trichomoniasis the vaginal wall is dry, pale and thin. The pH is alkaline and
ranges from 6.5 to 7.0 and the wet mount shows a few WBCs and is negative for
pathogens (Dains, J et. al, 2007).

Foreign Body is another diagnosis that may present with vaginal discharge. The
presenting symptoms are usually a very malodorous, white discharge, and the wet
mount will show many WBCs (Dains, J et. al, 2007).

Chlamydia is the most prevalent STI in the U.S., with about 30% of infected
women asymptomatic. Symptoms include increased vaginal discharge and
bleeding after intercourse. Wet mount shows greater than 10 WBCs/HPF and few
microscopic bacteria (Dains, J et. al, 2007).

Gonorrhea is a common reportable disease. Women are usually asymptomatic,
however, symptoms might include purulent discharge that originates from the
endocervical columnar and transitional cells. Inflammation of Skene’s glands,
Bartholin’s glands, or urethra, which causes pain and dysuria, may also be
present. Culture or DNA probe confirms the diagnosis (Dains, J et. al, 2007).

Pelvic Inflammatory Disease can also produce vaginal discharge. Other
symptoms include bleeding, abdominal pain, and fever. Some patients may have
a purulent discharge that originates from the endocervical columnar and
transitional cells. Abdominal tenderness, CMT, and adnexal tenderness are
present on examination, and some patients may have rebound tenderness.
Diagnosis can be assisted with cultures and gram stains, and WBCs and
erythrocyte sedimentation rate are usually elevated (Dains, J et. al, 2007).
Evaluation

History
o History and symptoms are not adequate in diagnosis of trichomoniasis
because it is often harbored asymptomatically (McCance et. al, 2010).
After a period of 5 days to 4 weeks a vaginal discharge develops, often
with vulvovaginal discomfort, pruritus, dysuria, dyspareunia, or
abdominal pain (McPhee et. al, 2011). Most infected men are
asymptomatic, however in men with trichomonal urethritis, the urethral
discharge is generally more scanty than with other causes of urethritis.
o 1. Question about the presence of discharge, characteristics of discharge
(odor, color, amount), and associated symptoms (vulvar irritation, dysuria,
dyspareunia (Uphold et.al, 2003)
o 2. Obtain menstrual history and ask if menstruation makes symptoms
worse (Uphold et.al, 2003)
o 3. In males, question about dysuria (Uphold et.al, 2003)
o 4. Obtain history of previous STDs; ask about condom use (Uphold et.al,
2003)

Physical Examination
o Copious, malodorous discharges, often frothy and yellow or green in color
are found on physical examination (McPhee et.al, 2011). Also commonly
seen are inflammation of the vaginal walls and cervix with punctate
hemorrhages also known as strawberry spots or strawberry cervix.
o 1. Examine external genitalia for signs of vulvar irritation, discharge
pooling at introitus or posterior fourchette (Uphold et.al, 2003)
o 2. Perform pelvic exam to determine if vagina has erythema, edema; note
type, color, and amount of discharge; examine cervix for erythema,
friability, discharge (Uphold et.al, 2003)
o 3. Obtain specimens for diagnostic testing (Uphold et.al, 2003)
Diagnostic Studies
 A definitive diagnosis is made by microscopic confirmation of the presence of the
trichomonads in vaginal secretions or urine (McCance et. al, 2010).

Laboratory Evaluation A fresh wet mount preparation that has been slightly
warmed will reveal the epithelial cells have relatively clean and sharp edges, the
ratio of polymorphonuclear leukocytes to epithelial cells excels 1:1, and the
trichomonads are visible (McCance et. al, 2010). The ovoid microorganism is
slightly larger than a polymorphonuclear leukocyte and has one rounded,
flagellated end and one slightly pointed, flagellated end. Their characteristic
twisting mobility is due to the flagella. In addition to the gyrating motile protozoa
the wet mount often shows WBCs/HPF greater than 10. The trichomonads
assume a ‘balled-up “or spherical shape and become less motile in an acidic
environment such as urine. The pH is greater than 5.
Treatment

Treatment of trichomoniasis is with nitromidazoles. The only medications cleared
by the FDA are metronidazoole and tinidazole (CDC, 2010).

A one time, oral dose of 2g Metronidazole (CDC, 2010).
or

A one time oral dose of 2g Tinidazole (CDC, 2010).

If the one time dose fails to treat trichomoniasis infection, an alternate regimien is
a 7-day course of metronidazole 500mg PO twice daily (CDC, 2010).

If failure with the 7-day regimen occurs metronidazole or tinidazole 2g oral for 5
days may be used. Metronidazole and tinidazole are treatments for bacteria and
protazoans (CDC, 2010).

If allergy exists to nitromidazoles a specialist should be consulted and
desensitization to metronidazole should occur (CDC, 2010).

Women can be treated at any point during pregnancy with a single dose of
metronidazole 2g PO. If pregnant woman is asymptomatic may wait until 37
weeks gestation (CDC, 2010).

Side Effects of these medications are nausea, vomiting, headache, and abdominal
cramping (Schuiling & Likis, 2006).

Low level 2-5% of resistance to metronidazole has occurred. High-level
resistance unlikely (CDC, 2010).
Expected Outcomes and Follow Up

Nitromidazole therapy is highly efficacious for curing trichomoniasis infection
(Sena et al., 2007).

Metronidazole regimen cure rate is 90-95% (CDC, 2010).

Tinidazole cure rate is 86 -100%. (CDC, 2010).

Reinfection rate is 17% within three months and is thought to be due to
intercourse with an untreated partner (CDC, 2010).

3-month follow up rescreening may be necessary for sexually active women
diagnosed with trichomoniasis (CDC, 2010).

Partner of the patient diagnosed with trichomoniasis needs to be evaluated and
treated as well to prevent reinfection (CDC, 2010). There is no current licensed
screening method for detection of infection in men (Schwebke & Desmond,
2010).

No data supporting rescreening in men with T. vaginalis (CDC, 2010).

If treatment failure occurs in women a higher dosing of metronidazole or
tinidazole should be initiated (CDC, 2010).
Patient Education

Transmission and Prevention
o
The spread of T. vaginalis is associated with sexual activity. The only way to
fully decrease risk of trichomoniasis is to abstain from sexual intercourse or be in
a sexually monogamous relationship where both parties have been tested (CDC,
2010).
o
Patients need to be educated to abstain from sexual intercourse until treatment
therapy is complete and patient is asymptomatic to prevent reinfection (CDC,
2010).
o
Consistent condom use as contraception is a preventative method for
transmission of sexually transmitted infection (Holmes, Levine, & Weaver,
2004).

Treatment of partners
o
Male partners are usually asymptomatic. Men can harbor infection in urethra or
prostate and could continue to infect female partner.
o
It is recommended that male partners be evaluated and treated especially if
associated with nitromidazole treatment failure in women. Treatment for men
should include a single dose of 2g tinidazole orally or metronidazole 500mg for 7
days (CDC, 2010).

Risk factors associated with trichomoniasis infection
o
Trichomoniasis infection is associated with an increased risk of acquiring HIV in
women due to increase in genital shedding (CDC, 2010).
o
In men trichomoniasis causes urethritis and can lead to epidymitis, prastitis, and
infertility if left untreated (Sena et al., 2007).
o
Trichomoniasis infection is associated with pelvic inflammatory disease and
adverse affects during pregnancy such as preterm labor and delivery, premature
rupture of membranes, and low birth weight infants (CDC, 2010).

Medication therapy considerations
o
If breastfeeding and on nitromidazole therapy, breastfeeding should be
interrupted for 24 hours after last dose of metronidazole or 3 days after last dose
of tinidazole.
o
Patients need to avoid alcohol while on metronidazole or tinidazole due to
abdominal discomfort associated with alcohol and medication therapy (Schuiling
& Likis, 2006),
References
Prevalence of Trichoniasis. Retrieved July 14, 2011 from
http://www.trichomoniasis.org/Prevalence/Index.aspx
Centers for Disease Control and Prevention. (2010). Sexually Transmitted Diseases
Treatment Guidelines, 2010. MMWR 2010;59, pp.1-109. Retrieved June 25, 2011
from http://www.cdc.gov/std/treatment/2010/toc.htm
Dains,J., Baumann,L., Schiebel,P., (2007) Advanced health assessment & clinical
diagnosis in primary care. 3nd ed. St. Louis: Mosby.
Garber, Gary (2005). The laboratory diagnosis of Trichomonas vaginalis. The Canadian
journal of Infectious Diseases & Medical Microbiology. 16 (1): 35-38. Retrieved
from PubMed July 14, 2011
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095007/
Holmes, K. K., Levine, R., & Weaver, M. (2004). Effectiveness of condoms in
preventing sexually transmitted infections. Bulletin of the World Health
Organization, 82 (6), 454-461. Retrieved from
http://www.ncbi.nlm.nih.gov.proxy.libraries.uc.edu/pmc/articles/PMC2622864/pd
f/15356939.pdf?tool=pmcentrez
McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2010). Pathophysiology:
The biologic basis for disease in adults and children (6th ed.). Maryland Heights,
MO: Mosby Elsevier.
McPhee, S.J. & Papadakis, M.A. (2011). Current medical diagnosis & treatment. (50th
ed.) Stamford, CT.
Schwebke, J.R., & Desmond, R. A. (2010). A randomized control trial of partner
notification methods for prevention of trichomoniasis in women. Sexually
Transmitted Disease, 37 (6), 392-396. doi: 10.1097/OLQ.0b013e3181dd1691
Sena, A.. C., Miller, W. C., Hobbs, M. M., Schwebke, J. R., Lwone, P. A. Swygard, H.,
…& Cohen, M. S. (2007). Trichomonas vaginalis infection in male sexual
partners: Implications for diagnosis, treatment, and prevention. Clinical Infectious
Disease, 44, 13-22. doi: 10.1086/511144
Uphold, C., & Graham, M. (2003). Clinical Guidelines in Family Practice (4th Ed.).
Barmarrae Books.