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Trichomoniasis: Clinical Manifestations, Diagnosis and Management

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Trichomoniasis: Clinical Manifestations, Diagnosis and Management 91 Sex Transm Infect: first published as 10.1136/sti.2003.005124 on 30 March 2004. Downloaded from TROPICAL MEDICINE SERIES Trichomoniasis: clinical manifestations, diagnosis and management H Swygard, A C Sen˜a, M M Hobbs, M S Cohen ............................................................................................................................... Sex Transm Infect 2004;80:91–95. doi: 10.1136/sti.2003.005124 Trichomonas vaginalis was originally considered a either sex, concomitant infection with other sexually transmitted organisms occurs com- commensal organism until the 1950s when the monly.78 Because of the public health impor- understanding of its role as a sexually transmitted infection tance of this common STI, we review here the (STI) began to evolve. Trichomoniasis has been associated clinical aspects of trichomoniasis. with vaginitis, cervicitis, urethritis, pelvic inflammatory METHODS disease (PID), and adverse birth outcomes. Infection with T Using combinations of the keyword ‘‘trichomo- vaginalis could have an important role in transmission and niasis’’ with ‘‘epidemiology,’’ ‘‘diagnosis,’’ ‘‘man- ifestations,’’ and ‘‘therapy,’’ a Medline search acquisition of HIV. T vaginalis is site specific for the was performed. The search was limited to genitourinary tract and has been isolated from virtually all English language articles published in the pre- genitourinary structures. Asymptomatic disease is common vious 10 years. Editorials, letters to the editor, case reports, and case series were excluded. The in both men and women, thus screening for disease is resulting titles were searched for and limited to important. Various sociodemographic factors have been ‘‘trichomoniasis’’ or ‘‘Trichomonas vaginalis.’’ correlated with presence of T vaginalis, and may be used Resulting abstracts were reviewed and articles were excluded if the focus was not clinically to predict infection. Diagnosis is usually made from wet relevant. Articles representing a developing body mount microscopy and direct visualisation, which are of literature were limited to the most recent insensitive. DNA amplification techniques perform with publication date. good sensitivity, but are not yet approved for diagnostic RESULTS purposes. In areas where diagnostic methods are limited, A total of 396 articles were retrieved through the management of trichomoniasis is usually as part of a Medline search. Subsequent review by the clinical syndrome; vaginal discharge for women and authors resulted in 195 articles with ‘‘trichomo- niasis’’ or ‘‘T vaginalis’’ in the title. Abstracts urethral discharge for men. A single dose of metronidazole (n = 94) were reviewed; 52 of these were selected http://sti.bmj.com/ is effective in the majority of cases. Outside of the United and reviewed here. States, other nitroimidazoles may be used and are as Epidemiology effective as metronidazole. Metronidazole resistance is an Among US women, race has been identified in emerging problem, but its clinical importance is not yet several studies as predictive of infection with T 9 clear. Concomitant treatment of sexual partners is vaginalis. This association is probably multi- factorial, including access to care, personal on September 26, 2021 by guest. Protected copyright. recommended. health practices, and socioeconomic factors.1 ........................................................................... Older age, histories of previous STI, prostitution, pregnancy, and drug use have also been asso- ciated with trichomoniasis.10 11 The association richomoniasis is a sexually transmitted dis- with older age is in contrast with the association Series editor: David Lewis ease (STI) with important public health between age and other STIs, especially chlamy- Tramifications; it has been associated with dia. Reproductive hormone levels may be partly vaginitis, cervicitis, urethritis, and pelvic inflam- responsible for higher prevalence of trichomo- See end of article for matory disease (PID). Trichomoniasis also niasis in older women.12 Among African women, authors’ affiliations impacts upon birth outcomes and is a co-factor vaginitis including trichomonal vaginitis was ....................... in human immunodeficiency virus (HIV) trans- significantly associated with sexual debut at less 1 Correspondence to: mission and acquisition. than 20 years, a partner who travelled fre- Heidi Swygard, CB # Approximately 180 million women worldwide quently, history of STI, and presence of abnormal 7030, 130 Mason Farm may be infected with T vaginalis. Prevalence discharge.13 Concomitant STI diagnosis is com- Road, The University of estimates vary between populations studied, mon (15–28% chlamydial co-infection and 10% North Carolina at Chapel Hill, Chapel Hill, NC but range from 5–74% in women and 5–29% in gonorrhoeal co-infection rates) in women with 27599-7030, USA; men, with the highest rates reported in either sex trichomoniasis, indicating the importance of Heidi_Swygard@ from STI clinics and in other high risk popula- screening for other STIs.14 15 med.unc.edu tions.2–5 In men, the prevalence is less well Among US men attending STI clinics, the Accepted for publication described because many men are asymptomatic combination of age >30 years, discharge, and 1 September 2003 and may not seek evaluation. Furthermore, the diagnosis of non-gonococcal urethritis (NGU) ....................... diagnosis is less commonly sought in men.6 In was predictive of infection with T vaginalis, www.stijournal.com 92 Swygard, Sen˜a,Hobbs,etal Sex Transm Infect: first published as 10.1136/sti.2003.005124 on 30 March 2004. Downloaded from although this finding was not supported in a separate finding of colpitis macularis. Cervical mucopurulence, study.16 17 Sexual exposure to a woman with trichomoniasis erythema, and friability have been observed.723 T vaginalis and history of trichomoniasis were also associated with may be associated with cervical cancer; however, confound- trichomoniasis in multivariate analyses.16 As in women, ing factors, such as co-infection with HPV, have not been well concomitant infection with other urethral pathogens is controlled for in some of these studies.25 Among HIV infected common in trichomoniasis. Mixed infections with T vaginalis women, T vaginalis infection was associated with PID.21 and Neisseria gonorrhoeae and/or Chlamydia trachomatis occurred Trichomonal infections are neither restricted to nor in seven of 980 rural Tanzanian men, while 61.5% of 91 men exclusive for the vagina, and urinary tract infection may be with trichomoniasis in west Africa also had a gonococcal common. Dysuria was observed in 29% of South African infection.81819 women diagnosed with T vaginalis infection.23 Thus, con- Finally, trichomoniasis facilitates spread of the HIV sideration should be given to the presence of trichomoniasis epidemic. One theoretical calculation concludes that if for women with dysuria as a sole complaint. infection with T vaginalis increased the risk of HIV transmis- Finally, there is some suggestion that women may harbour sion by 90% in a population with 25% prevalence of T vaginalis for 3–5 years.26 The reasons for this are unclear, but trichomoniasis, approximately 20% of cases of HIV would may include imperfect screening tools, genitourinary anat- be attributable to trichomoniasis.1 This relation could explain omy, or type of infecting strain. some of the differences in rates of HIV infection in different regions of Africa where rates of trichomoniasis and HIV seem Men to be directly proportional.20 Less is known about T vaginalis infection in men. Current estimates of asymptomatic infection in men vary. In one US Clinical presentation study, 23 of 50 patients with trichomoniasis were asympto- 27 Women matic. Among 23 east African men with trichomoniasis, 19 28 T vaginalis is site specific for the genitourinary tract and has were asymptomatic. Finally, among 100 men presenting for been isolated from virtually all genitourinary structures. non-genitourinary complaints in the Central African 8 However, many women diagnosed with trichomoniasis are Republic, seven were diagnosed with trichomoniasis. When asymptomatic; in Zimbabwe 75% of women denied symp- symptoms of trichomoniasis become manifest, discharge may toms on direct questioning and 16% of these women had be less profuse and purulent than that seen with gonococcal 27 trichomoniasis.13 When symptoms arise, the most common infection. Men may also complain of dysuria. Of 103 presenting complaint among women diagnosed with T Tanzanian men with trichomoniasis, dysuria occurred in 19 vaginalis is vaginal discharge, seen in more than 50% of 42%; only five men complained of urethral discharge. cases, followed by pruritus or dysuria. One study of 200 Finally, trichomoniasis was diagnosed in 66 of 410 men 8 Nigerian women demonstrated 74% with vaginal discharge from the Central African Republic with urethral discharge. were infected with T vaginalis.2 On speculum examination, In men, urethral discharge and dysuria are the most common the vaginal discharge may be of any colour or characteristic, symptoms; however, some men diagnosed with trichomo- 29 and although a frothy green discharge has classically been niasis are asymptomatic. Many men clear T vaginalis from 30 associated with trichomoniasis, this was not observed in any the genitourinary tract within 2 weeks. Involvement of of 149 Nigerian women with discharge caused by trichomo- other male genitourinary structures has been described, but niasis.2 The
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