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Trichomoniasis

Definition

The spectrum of sexually transmitted diseases includes the classic venereal diseases – gonorrhea, syphilis, chancroid, lymphogranuloma venereum, and granuloma inguinale – as well as a variety of other pathogens known to be spread by sexual contact (Table Sexually Transmitted Diseases). Common clinical syndromes associated with sexually transmitted diseases are listed in Table Selected Syndromes Associated with Common Sexually Transmitted Pathogens. The most current information on epidemiology, diagnosis, and treatment of sexually transmitted diseases provided by the Centers for Disease Control and Prevention  can be found at http://www.cdc.gov.

TABLE. Sexually Transmitted Diseases
Disease Associated Pathogens
Bacterial
Gonorrhea Neisseria gonorrhoeae
Syphilis Treponema pallidum
Chancroid Hemophilus ducreyi
Granuloma inguinale Calymmatobacterium granulomatis
Enteric disease Salmonella spp., Shigella spp., Campylobacter fetus
Campylobacter infection Campylobacter jejuni
Bacterial vaginosis Gardnerella vaginalis, Mycoplasma hominis, Bacteroides spp., Mobiluncus spp.
Group B streptococcal infections Group B Streptococcus
Chlamydial
Nongonococcal urethritis Chlamydia trachomatis
Lymphogranuloma venereum Chlamydia trachomatis, type L
Viral
Acquired immune-deficiency syndrome (AIDS) Human immunodeficiency virus
Herpes genitalis Herpes simplex virus, types I and II
Viral hepatitis Hepatitis A, B, C, and D viruses
Condylomata acuminata Human papillomavirus
Molluscum contagiosum Poxvirus
Cytomegalovirus infection

Mycoplasmal

Cytomegalovirus
Nongonococcal urethritis

Protozoal

Ureaplasma urealyticum
Trichomoniasis Trichomonas vaginalis
Amebiasis Entamoeba histolytica
Giardiasis

Fungal

Giardia lamblia
Vaginal candidiasis

Parasitic

Candida albicans
Scabies Sarcoptes scabiei
Pediculosis pubis Phthirus pubis
Enterobiasis Enterobius vermicularis
TABLE. Selected Syndromes Associated with Common Sexually Transmitted Pathogens
Syndrome Commonly Implicated Pathogens Common Clinical Manifestationsa
Urethritis Chlamydia trachomatis, herpes simplex virus, Neisseria gonorrhoeae, Trichomonas vaginalis, Ureaplasma urealyticum Urethral discharge, dysuria
Epididymitis C. trachomatis, N. gonorrhoeae Scrotal pain, inguinal pain, flank pain, urethral discharge
Cervicitis/vulvovaginitis C. trachomatis, Gardnerella vaginalis, herpes simplex virus, human papillomavirus, N. gonorrhoeae, T. vaginalis Abnormal vaginal discharge, vulvar itching/irritation, dysuria, dyspareunia
Genital ulcers (painful) Hemophilus ducreyi, herpes simplex virus Usually multiple vesicular/pustular (herpes) or papular/pustular (H. ducreyi) lesions that may coalesce; painful, tender lymphadenopathyb
Genital ulcers (painless) Treponema pallidum Usually single papular lesion
Genital/anal warts Human papillomavirus Multiple lesions ranging in size from small papular warts to large exophytic condylomas
Pharyngitis C. trachomatis (?), herpes simplex virus, N. gonorrhoeae Symptoms of acute pharyngitis, cervical lymphadenopathy, feverc
Proctitis C. trachomatis, herpes simplex virus

N. gonorrhoeae, T. pallidum

Constipation, anorectal discomfort, tenesmus, mucopurulent rectal discharge
Salpingitis C. trachomatis, N. gonorrhoeae Lower abdominal pain, purulent cervical or vaginal discharge, adnexal swelling, feverd
aFor some syndromes, clinical manifestations may be minimal or absent.

bRecurrent herpes infection may manifest as a single lesion.

cMost cases of pharyngeal gonococcal infection are asymptomatic.

dSalpingitis increases the risk of subsequent ectopic pregnancy and infertility.

TABLE. Presentation of Gonorrhea Infections
Males Females
General Incubation period 1-14 days

Symptom onset in 2-8 days

Incubation period 1-14 days

Symptom onset in 10 days

Site of infection Most common – urethra

Others – rectum (usually due to rectal intercourse in MSM), oropharynx, eye

Most common – endocervical canal

Others – urethra, rectum (usually due to perineal contamination), oropharynx, eye

Symptoms May be asymptomatic or minimally symptomatic

Urethral infection – dysuria and urinary frequency

Anorectal infection – asymptomatic to severe rectal pain

Pharyngeal infection – asymptomatic to mild pharyngitis

May be asymptomatic or minimally symptomatic

Endocervical infection – usually asymptomatic or mildly symptomatic

Urethral infection – dysuria, urinary frequency

Anorectal and pharyngeal infection –  symptoms same as for men

Signs Purulent urethral or rectal discharge can be scant to profuse

Anorectal – pruritus, mucopurulent discharge, bleeding

Abnormal vaginal discharge or uterine bleeding; purulent urethral or rectal discharge can be scant to profuse
Complications Rare (epididymitis, prostatitis, inguinal lymphadenopathy, urethral stricture) Disseminated gonorrhea Pelvic inflammatory disease and associated complications (i.e., ectopic pregnancy, infertility)

Disseminated gonorrhea (3 times more common than in men)

Gonorrhea

Syphilis

Chlamydia

Genital herpes

Trichomoniasis

  • Trichomoniasis is caused by Trichomonas vaginalis, a flagellated, motile protozoan that is responsible for 3 to 5 million cases per year in the United States.
  • Coinfection with other sexually transmitted diseases (such as gonorrhea) is common in patients diagnosed with trichmoniasis.

Clinical presentation

The typical presentation of trichomoniasis in males and females is presented in Table Presentation of Trichomonas Infections.

Sexually Transmitted Diseases: Trichomoniasis
TABLE. Treatment of Genital Herpes
Type of Infection Recommended Regimens a,b Alternative Regimen
First clinical episode of genital herpesc Acyclovir 400 mg orally 3 times daily for 7-10 days, or

Acyclovir 200 mg orally 5 times daily for 7-10 days, or

Famciclovir 250 mg orally 3 times daily for 7-10 days, or

Valacyclovir 1 g orally 2 times daily for 7-10 days

Acyclovir 5-10 mg/kg intravenous every 8 h for 2-7 days until clinical improvement occurs, followed by oral therapy to complete at least 10 days of total therapyd
First clinical episode of herpes proctitis or oral infection including stomatitis or pharyngitis Acyclovir 400 mg orally 5 times daily for 7-10 dayse Acyclovir 5-10 mg/kg intravenous every 8 h for 2-7 days until clinical improvement occurs, followed by oral therapy to complete at least 10 days of total therapyd
Recurrent infection
Episodic therapy Acyclovir 400 mg orally 3 times daily for 5 days,f or
Acyclovir 800 mg orally 2 times daily for 5 days,f or
Famciclovir 125 mg orally 2 times daily for 5 days,f or
Valacyclovir 500 mg orally 2 times daily for 3-5 days,f or
Valacyclovir 1 g orally once daily for 5 daysf
Acyclovir 400 mg orally twice daily,g or
Suppressive therapy Famciclovir 250 mg orally 2 times daily, or
Valacyclovir 500 mg or 1000 mg orally once dailyh
aRecommendations are those of the Centers for Disease Control.

bHIV-infected patients may require more aggressive therapy.

cPrimary or nonprimary first episode.

dOnly for patients with severe symptoms or complications that necessitate hospitalization.

eRecommendations based on studies utilizing this dosage regimen rather than the lower dosage regimens recommended for first clinical episodes of genital herpes. It is not clear whether lower dosage regimens would have comparable efficacy. Famciclovir and valacyclovir are probably also effective for proctitis and oral infection, but clinical experience is limited.

fRequires initiation of therapy within 24 h of lesion onset or during the prodrome that precedes some outbreaks.

gIndicated only for patients with frequent and/or severe recurrences; although safety and efficacy are documented in patients receiving acyclovir daily therapy for as long as 6 yr and valacyclovir and famciclovir therapy for 1 yr, it is recommended that therapy be discontinued periodically (e.g., once a year) to reassess the need for continued suppressive therapy.

hValacyclovir 500 mg appears less effective than valacyclovir 1000 mg in patients with approximately 10 recurrences per year.

Diagnosis

  • T. vaginalis produces nonspecific symptoms also consistent with bacterial vaginosis, and thus laboratory diagnosis is required.
  • The simplest and most reliable means of diagnosis is a wet-mount examination of the vaginal discharge. Trichomoniasis is confirmed if characteristic pear-shaped, flagellating organisms are observed. Newer diagnostic tests such as monoclonal antibody or DNA probe techniques, as well as Polymerase chain reaction tests are highly sensitive and specific.
TABLE. Presentation of Trichomonas Infections
Males Females
General Incubation period 3-28 days Incubation period 3-28 days
Organism may be detectable within 48 hours after exposure to infected partner
Site of infection Most common – urethra Most common – endocervical canal
Others – rectum (usually due to rectal intercourse in MSM), oropharynx, eye Others – urethra, rectum (usually due to perineal contamination), oropharynx, eye
Symptoms May be asymptomatic (more common in males than females) or minimally symptomatic May be asymptomatic or minimally symptomatic
Urethral discharge (clear to mucopurulent) Scant to copious, typically malodorous vaginal discharge (50-75%) and pruritus (worsen during menses)
Dysuria, prurius Dysuria, dyspareunia
Signs Urethral discharge Vaginal discharge
Vaginal pH 4.5-6
Inflammation/erythema of vulva, vagina, and/or cervix
Urethritis
Complications Epididymitis and chronic prostatitis (uncommon) Pelvic inflammatory disease and associated complications (i.e., ectopic pregnancy, infertility)
Male infertility (decreased sperm motility and viability) Premature labor, premature rupture of membranes, and low-birth-weight infants (risk of neonatal infections is low)
Cervical neoplasia
TABLE. Treatment of Trichomoniasis
Type Recommended Regimena Alternative Regimen
Symptomatic and asymptomatic infections Metronidazole 2 g orally in a single doseb Metronidazole 500 mg orally 2 times daily for 7 daysc
Treatment in pregnancy Metronidazole 2 g orally in a single dosed
Neonatal infectionse Metronidazole 10-30 mg/kg daily for 5-8 days
Note: Tinidazole was approved by the FDA in 2004 for for the treatment of trichomonasis. The recommended dosage is 2 g orally in a single dose.

aRecommendations are those of the Centers for Disease Control.

bTreatment failures should be treated with metronidazole 500 mg orally 2 times daily for 7 days. Persistent failures should be managed in consultation with an expert. Metronidazole 2 g orally daily for 3-5 days has been effective in patients infected with T. vaginalis strains mildly resistant to metronidazole, but experience is limited; higher doses also have been used.

cMetronidazole labeling approved by the FDA does not include this regimen. Dosage regimens for treatment of trichomoniasis included in the product labeling are the single 2 g dose; 250 mg 3 times daily for 7 days; and 375 mg 2 times daily for 7 days. The 250 mg and 375 mg dosage regimens are currently not included in the Centers for Disease Control recommendations.

dMetronidazole is contraindicated in the first trimester of pregnancy. While the Centers for Disease Control recommends a single 2-g dose for treatment during pregnancy, a 7-day regimen is preferred by some since it produces lower peak serum drug concentrations.

eOnly infants with symptomatic trichomoniasis or with urogenital trichomonal colonization that persists beyond the fourth week of life.

TABLE. Treatment Regimens for Miscellaneous Sexually Transmitted Diseases
Infection Recommended Regimena Alternative Regimen
Chancroid (Haemophilus ducreyi) Azithromycin 1 g orally in a single dose, or

Ceftriaxone 250 mg intramuscularly in a single dose, or

Ciprofloxacin 500 mg orally 2 times daily for 3 days,b or

Erythromycin base 500 mg orally 4 times daily for 7 days

Lymphogranuloma venereum Doxycycline 100 mg orally 2 times daily for 21 days Erythromycin base 500 mg orally 4 times daily for 21 days
Human Papillomavirus Infection:
External genital warts Provider-Administered Therapies:

Cryotherapy (e.g., liquid nitrogen or cryoprobe), or

Podophyllin 10-25% in compound tincture of benzoin applied to lesions; repeat weekly if necessary,c, d or

Trichloroacetic acid (TCA) 80-90% or

bichloroacetic acid (BCA) 80-90% applied to warts; repeat weekly if necessary, or

Surgical removal (tangential scissor excision, tangential shave excision, curettage, or electrosurgery)

Patient-Applied Therapies:

Podofilox 0.5% solution or gel applied 2 times daily for 3 days, followed by 4 days of no therapy; cycle is repeated as necessary for a total of 4 cycles,d or

Imiquimod 5% cream applied at bedtime 3 times weekly for up to 16 wkd

Intralesional interferon or laser surgery
Human Papillomavirus Infection:
Vaginal, urethral meatus, and anal warts Cryotherapy with liquid nitrogen, or TCA or BCA 80-90% as for external HPV warts; repeat weekly as necessary (not for urethral meatus warts), or

Podophyllin 10-25% in compound tincture of benzoin applied at weekly intervals (not for vaginal or anal warts),d or

Surgical removal (not for vaginal or urethral meatus warts)

aRecommendations are those of the Centers for Disease Control.

cSome experts recommended washing podophyllin off after 1-4 h to minimize local irritation.

bCiprofloxacin is contraindicated for pregnant and lactating women and for persons aged <18 yr.

dSafety during pregnancy is not established.

Treatment

Sexually Transmitted Diseases: Trichomoniasis

  • Metronidazole is the only antimicrobial agent available in the United States that is consistently effective in T. vaginalis infections.
  • Gastrointestinal complaints (e.g., anorexia, nausea, vomiting, diarrhea) are the most common adverse effects, with the single 2-g dose of metronidazole, occurring in 5% to 10% of treated patients. Some patients complain of a bitter metallic taste in the mouth.
  • Patients intolerant of the single 2-g dose because of gastrointestinal adverse effects usually tolerate the multidose regimen.
  • To achieve maximal cure rates and prevent relapse with the single 2-g dose of metronidazole, simultaneous treatment of infected sexual partners is necessary.
  • Patients who fail to respond to an initial course usually respond to a second course of metronidazole therapy.
  • Patients taking metronidazole should be instructed to avoid alcohol ingestion during therapy and for 1 to 2 days after completion of therapy because of a possible disulfiram-like effect.
  • At present, no satisfactory treatment is available for pregnant women with Trichomonas infections.

Evaluation of therapeutic outcomes

  • Follow-up is considered unnecessary in patients who become asymptomatic after treatment with metronidazole.
  • When patients remain symptomatic, it is important to determine if reinfection has occurred. In these cases, a repeat course of therapy, as well as identification and treatment or retreatment of infected sexual partners, is recommended.

Other sexually transmitted diseases

Several sexually transmitted diseases other than those previously discussed occur with varying frequency in the United States and throughout the world.

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