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DESCRIPTION
Trichomoniasis is a sexually transmitted disease (STD). It is sometimes called Trichomonas infection or trich (pronounced "trick"). Trich should be treated to prevent transmitting this STD to others and to prevent complications if you are pregnant. Trichomoniasis is the most common curable STD in young, sexually active women. An estimated 5 to 8 million new cases occur each year in women and men, with an estimated rate of asymptomatic cases as high as 50 percent. The WHO has estimated that 180 million infections are acquired annually worldwide.
Infection or inflammation of the vagina caused by a single-celled anaerobic protozoan trichomoniasis vaginalis parasite that lives in the lower genitourinary tract. It is very contagious between sexual partners. The disorder involves the vagina, urethra and bladder in women. The vagina is the most common site of infection in women. In men, it affects the prostate gland and urethra. The urethra (urine canal) is the most common site of infection in men.
Trichomonas infection is transmitted by having unprotected sex with an infected partner. The parasite is sexually transmitted through penis-to-vagina intercourse or vulva-to-vulva (the genital area outside the vagina) contact with an infected partner. Women can acquire the disease from infected men or women, but men usually contract it only from infected women. Many women and most men do not have any symptoms of trich. If symptoms develop, they usually appear within 1 week of being infected, but can develop from 1 to 6 months after being infected. Trich should be treated to prevent transmitting this STD to others and to prevent complications if you are pregnant.
In rare cases, it may be possible to get trich by coming in contact with an object (such as a wet towel) that a person who has trich has just used. The Trichomonas organism cannot live on objects for long, so trich is not usually spread this way.
Trichomoniasis may be transmitted from a mother to her baby during a vaginal delivery, but this is rare.
There is no cyst in the life cycle, so transmission is via the trophozoite stage only. Most people infected with trichomoniasis are asymptomatic. It is one of the most frequent sexually transmitted diseases in man. 30 to 50 % of all women in western countries may be infected. In males the infection normally does not lead to any symptoms, while in females this may lead to an increased secretion, characterized by a white discharge from the genital tract and itching. Diagnosis depends on finding trophozoites in secretions of the genital tract from men or women. In cases where the numbers of organisms are very low, the trophozoites can be cultured to increase their numbers.
Trichomonas vaginalis is a facultative anaerobic protozoan parasite that has no mitochondria or peroxisomes. Trichomoniasis is treated with metronidazole (Flagyl). The drug is reduced inside the parasite by the enzyme hydrogenase located in typical organelles called hydrogenosomes. When the drug reacts with traces of oxygen present in the organism it forms oxygen radicals that rapidly kill the parasite. Metronidazole is also used for the treatment of Giardia and Entamoeba infections and for infections by some anaerobic bacteria.
A trophozite of Trichomonas vaginalis from culture. The four flagella and single nucleus are visible. The dark median rod is the axostyle which is characteristic of the trichomonads; approximate size = 26 µm.
FREQUENT SIGNS & SYMPTOMS
About 50% of women infected with trichomoniasis and 90% of infected men do not have symptoms. If symptoms develop, they usually appear within 1 week of being infected. Symptoms can develop from 1 to 6 months after being infected. The severity of discomfort varies greatly from woman to woman and from time to time in the same woman. Symptoms can be worse during pregnancy or right before or after a menstrual period.
Symptoms in women include:
- Large amounts of pale yellow or gray-green, strongly foul-smelling (musty odor), sometimes frothy or foamy vaginal discharge that is most noticeable several days after a menstrual period.
- Vaginal itching, irritation, and pain.
- Patchy redness of the genitals, including vaginal lips (labia) and vagina.
- Frequent, painful urination (dysuria), if urine touches inflamed tissue.
- Red, inflamed cervix (strawberry cervix).
- Pain with sexual intercourse even if you use a lubricant such as K-Y Jelly or Astroglide.
- Discomfort in the lower abdomen. This is not a common symptom of trichomoniasis and may mean another problem is present.
- Symptoms usually appear in women within 5 to 28 days of exposure.
Infected men may have no symptoms. However, if they do, symptoms in men include:
- Abnormal discharge from the penis.
- Irritation and redness of the tip of the penis and inside the penis (the urethra).
- Burning feeling with and after urination or ejaculation.
Trichomonas and other sexually transmitted diseases can have similar symptoms.
CAUSES
Infection from a tiny one-cell protozoan parasite, Trichomoniasis vaginalis. The parasite passes from person to person during sexual intercourse. It may live in its host for years without producing symptoms. Then, perhaps from altered resistance, it will suddenly multiply rapidly and cause distressing symptoms. Since it thrives in both the male and female, both sexual partners must receive treatment.
In women, trich organisms usually infect the vagina, urethra, cervix, bladder, and other glands in the genital area, such as Bartholin's and Skene's glands. In men, infections develop in the urethra or under the foreskin of an uncircumcised penis.
PROTEIN FUNCTION
T. vaginalis also has many enzymes that catalyze a number of reactions making the organism relevant to the study of protein function. T. vaginalis lacks mitochondria and other necessary enzymes and cytochromes to conduct oxidative phosphorylation. T. vaginalis obtains nutrients by transport through the cell membrane and by phagocytosis. The organism is able to maintain energy requirements by the use of a small amount of enzymes to provide energy via glycolysis of glucose to glycerol and succinate in the cytoplasm, followed by further conversion of pyruvate and malate to hydrogen and acetate in an organelle called the hydrogenosome.
MORPHOLOGY
The T. vaginalis trophozoite is oval as well as flagellated. Five flagella arise near the cytosome; four of these immediately extend outside the cell together, while the fifth flagellum wraps backwards along the surface of the organism. The functionality of the fifth flagellum is not known. In addition, a conspicuous barb-like axostyle projects opposite the four-flagella bundle; the axostyle may be used for attachment to surfaces and may also cause the tissue damage noted in trichomoniasis infections.
While T. vaginalis does not have a cyst form, organisms can survive for up to 24 hours in urine, semen, or even water samples. Combined with an ability to persist on fomites with a moist surface for 1 to 2 hours, T. vaginalis is among the most durable protozoan trophozites.
RISK INCREASES WITH
Behaviors that will increase your risk of getting trich include:
- Not using condoms when having sex with a new partner or a partner who may have been exposed to an STD. It is possible for a partner to transmit the trich organism without having any symptoms of the infection.
- Having many sex partners, which increases your risk of being exposed to someone who has trich.
- Teenagers and young adults are at higher risk for getting trich and other STDs because their sex partners often have had other recent partners who may carry an STD. Sexually active women from ages 16 to 35 are most affected by trichomoniasis. It is thought that 1 in 5 women in this age group will become infected at some time.
- People can get other STDs at the same time they get a Trichomonas infection. If one STD is diagnosed, testing for other STDs should be done so that all infections can be treated at the same time.
- 30% to 50% of women with trich also have gonorrhea.
- 15% of women with trich also have chlamydia.
- Some STDs, such as the human immunodeficiency virus (HIV) infection, are life-threatening. Studies show that Trichomonas infection may increase the risk of HIV transmission by 2 to 4 times. Health professionals around the world are concerned about the increased risk of trichomoniasis and HIV.
- Women with trich may also be at risk for other vaginal infections. About 20% of women with trich also have a yeast infection.
PREVENTIVE MEASURES
The surest way to avoid transmission of sexually transmitted diseases is to abstain from sexual contact, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.
Latex male condoms, when used consistently and correctly, can reduce the risk of transmission of trichomoniasis.
Any genital symptom such as discharge or burning during urination or an unusual sore or rash should be a signal to stop having sex and to consult a health care provider immediately. If you are told you have trichomoniasis (or any other STD) and receive treatment, you should notify all of your recent sex partners so that they can see a health care provider and be treated. Sex partners need treatment even if they have no symptoms. This will reduce the risk that your partners will develop complications from trichomoniasis and will reduce your risk of becoming re-infected. Do not have sex until both you and your sex partners complete your treatment for trichomoniasis and have no symptoms.
EXPECTED OUTCOME
Usually curable with treatment.
POSSIBLE COMPLICATIONS
Secondary bacterial infections.
The genital inflammation caused by trichomoniasis can increase a woman's susceptibility to HIV infection if she is exposed to the virus. Having trichomoniasis also increases the chances that an HIV-infected woman can pass HIV to her sex partners.
Pregnant women with trichomoniasis may have babies who are born early (premature) or with low birth weight (less than five pounds).
TREATMENT
GENERAL MEASURES
MEDICAL HISTORY & EXAMINATION
Your medical history, which will include questions about your sexual history and practices. Diagnostic tests may include laboratory blood studies, examination of vagina and culture of the vaginal discharge. Pap smear and pelvic examination. The parasite is harder to detect in men than in women.
External Exam
Internal Exam: Note the "Frothy" Discharge seen around the cervix.
The physical exam:
- For women, this will include a visual exam of the genitals, vagina, or cervix to detect patchy red spots (small red ulcerations) that are caused by trichomoniasis. These sores (ulcerations) can be seen on the vaginal wall, cervix and/or on the inner folds of the labia. Any vaginal discharge will be assessed for color, odor, and texture. A sample of discharge is taken for a wet mount test.
- For men, this will include a visual exam of the penis and a sample of discharge from the urethra.
DIAGNOSTIC TESTS
Tests to identify the trich organism include:
- The most common test is a wet mount. The microscopic exam using the Wet mount identifies trich 60% to 70% of the time.
Other tests available but less commonly used include:
- Culture. A culture has greater sensitivity than microscopic examination. It identifies trich over 95% of the time but is not often needed because a physical exam and wet mount adequately identify trich.
- Molecular Assay - DNA probe test, which detects genetic material (DNA) of the Trichomonas organism. This test is rarely needed to identify trich and is usually available only in research studies.
People can get other sexually transmitted diseases (STDs) at the same time they get a Trichomonas infection. If one STD is diagnosed, testing for other STDs should be done so that all infections can be treated at the same time.
The Trichomonas organism may also be identified on a routine Pap test that is being done as part of a regular gynecologic (pelvic) exam.
CLINICAL ASPECTS OF TRICH
Trichomoniasis can occur in females (males rarely exhibit any symptoms of a T. vaginalis infection) if the normal acidity of the vagina is shifted from a healthy, semi-acidic pH (3.8 - 4.2) to a much more basic one (5 - 6) that is conducive to T. vaginalis growth. Some of the symptoms of T. vaginalis include: preterm delivery, low birth weight, and increased mortality as well as predisposing to HIV infection, AIDS, and cervical cancer. T. vaginalis has also been reported in the urinary tract, fallopian tubes, and pelvis and can cause pneumonia, bronchitis, and oral lesions. Other symptoms include inflammation with increasing number of organisms, greenish-yellow frothy vaginal secretions and itching.
T. vaginalis can be detected by studying discharge or with a pap smear and culturing. With a pap smear, infected individuals would have a transparent "halo" around their superficial cell nucleus. T. vaginalis is diagnosed via a wet mount, in which "corkscrew" motility can be observed. Condoms are effective at preventing infection.
Metronidazole or tinidazole can treat an infection in progress, and should be prescribed to sexual partners as well.
TREATMENT
Trichomoniasis (trich) is treated with an oral medication called metronidazole in a single dose or multiple doses. See Medication below for more information.
Other treatment recommendations include:
- Both sexual partners require simultaneous treatment. The symptoms of trichomoniasis in infected men may disappear within a few weeks without treatment. However, an infected man, even a man who has never had symptoms or whose symptoms have stopped, can continue to infect a female partner until he has been treated. Therefore, both partners should be treated at the same time to eliminate the parasite. Persons being treated for trichomoniasis should avoid sex until they and their sex partners complete treatment and have no symptoms.
- Don't douche unless prescribed for you. Douching should be avoided because it does not help relieve symptoms.
- Wear cotton underpants or pantyhose with a cotton crotch.
- Take showers instead of tub baths.
- If urinating causes burning: Urinate through a tubular device, such as a toilet paper roll or plastic cup with the bottom cut out or pour a cup of warm water over the genital area while you urinate.
- Don't sit around in wet clothing, especially in a wet bathing suit.
- Trich is not usually transmitted by contact with objects but it is important to avoid sharing objects (such as a washcloth or wet towel) that another person with trich may have used.
- It is safe for a woman to use tampons while she has a trich infection, but it may be uncomfortable.
- There is no home treatment recommended for treating trichomoniasis infection. Surgery is not done to treat trichomoniasis.
MEDICATION
Metronidazole (Flagyl) is usually prescribed for you and your sexual partner or partners in pill, tablet or capsule form. Follow directions carefully. Oral (by mouth) metronidazole is taken either as a single dose (2 grams) or as multiple doses (500 mg) 2 times a day for 7 days. The cure rate in treating trich using oral metronidazole is 90% to 95%. Metronidazole vaginal suppositories or creams are not recommended because oral metronidazole is much more effective. Vaginal medications cure trichomoniasis in about 50% of cases. Vaginal medications are not effective in treating trichomoniasis in areas other than the vagina and cervix. Metronidazole vaginal gel, which is used to treat bacterial vaginosis, is not recommended by the CDC for treatment of trichomoniasis.
Treatment of sex partners increases the cure rate and reduces the possibility of further transmission or reinfection. Sexual intercourse should be avoided during treatment until symptoms have gone away.
People who are infected with HIV receive the same treatment for trich as those who are HIV-negative.
Don't drink alcohol or use vinegar when you take metronidazole. Alcohol or vinegar and metronidazole interact to cause a violent reaction with nausea, vomiting, sweating, weakness and other symptoms.
TRICHOMIASIS & PREGNANCY
Trichomoniasis during pregnancy increases the risk of premature rupture of membranes (PROM) and premature delivery. Treating the infection does not appear to reduce this risk.
The United States Centers for Disease Control and Prevention (CDC) has recommended that a single oral dose of 2 grams metronidazole can be taken by a pregnant woman with symptoms of trich at any time in the pregnancy. Vaginal suppositories and creams are not as effective in curing trich, but they will reduce the discomfort and swelling in the genital area.
FOLLOW-UP & RE-TREATMENT
No follow-up is needed if symptoms go away. It is possible to get trich again so it is important to take measures to reduce your risk for trich and other STDs.
If symptoms persist, re-treatment with metronidazole 500 mg twice a day for 7 days is recommended.
If treatment fails again, metronidazole 2 grams once a day for 3 to 5 days is recommended.
If treatment fails after this and you have not been reinfected, further testing may be done to determine the cause of your symptoms. It is possible to have a strain of trich that is resistant to the antibiotic metronidazole. High-dose tinidazole has been used for these metronidazole-resistant trich organisms and is as effective as metronidazole in curing trich, though it is not currently available in the United States.
Having trichomoniasis once does not protect a person from getting it again. Following successful treatment, people can still be susceptible to re-infection.
OTHER TREATMENT OPTIONS
Metronidazole vaginal suppositories or creams are not recommended because oral metronidazole is much more effective. Vaginal medications cure trich in about 50% of cases. Vaginal medications are not effective in treating trich in areas other than the vagina and cervix.
Metronidazole vaginal gel, which is used to treat bacterial vaginosis, is not recommended by the CDC for treatment of trich.
There are many reasons to treat trich. Trich can be treated to:
- Reduce symptoms.
- Prevent spreading it to others. Some people can carry the organism but not have symptoms, so it is important to practice safe sex and have sex partners treated.
- Reduce the risk of pelvic infections, which may lead to the inability to become pregnant (infertility).
- Reduce the risk of infection after any pelvic surgery.
Paromomycin May Cure Treatment-Resistant Vaginal Trichomoniasis PHILADELPHIA, PA -- May 1, 1998 --
As reported in this month's issue of Clinical Infectious Diseases, a study led by Dr. Paul Nyirjesy, director of Temple University Vaginitis Referral Center, has resulted in a second line of defence for the treatment of vaginal trichomoniasis. This study has confirmed the effectiveness of the antibiotic paromomycin in curing difficult-to-treat cases.
Vaginal trichomoniasis is a common infection, affecting an estimated three million women annually. Flagyl (metronidazole) has been the only approved treatment in the United States for years. It continues to be very effective in treating more than 95 percent of cases. However, there are these challenging medical situations where women don't respond to the treatment, even at higher doses.
This study is the largest to date and the only one to find a cure for treatment-resistant vaginal trichomoniasis. Nine patients -- four who were allergic to metronidazole and five whose infections were resistant to it -- took part in the study. The paromomycin cream was applied topically for two weeks. The result: six women were cured with the paromomycin cream alone and a seventh was cured with a combination of the cream and an antibiotic which had previously failed.
"The major impact of paromomycin cream is that it presents an effective, alternative treatment option for women with hard-to-treat vaginal trichomoniasis," Nyirjesy said.
http://content.nejm.org/cgi/content/short/345/7/487
NEJM: Failure of Metronidazole to Prevent Preterm Delivery among Pregnant Women with Asymptomatic Trichomoniasis
ACTIVITY
Avoid overexertion, heat and excessive sweating. Delay sexual relations until you are well. Allow about 10 days for recovery.
DIET
No special diet instructions except those involving alcohol and vinegar (see medications).
In addition to your daily supplements, take:
- Vitamin C: 1,000 mg daily.
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- Vitamin E: 400 IU daily.
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Vitamin E Skin Cream, NOW Foods, 28,000 IU, 4 oz.
- Beta carotene: 10,000 IU daily.
Vitamin A, 10,000 IU, 100% Natural, Nature's Way, 100 Softgels
Beta Carotene, (Natural Dunaliella salina), Nature's Way, 100% Natural, 25,000 IU, 100 Softgels
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NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...
You or a family member has symptoms of trichomonal vaginitis. Trichomonas infection is transmitted by having unprotected sex with an infected partner. Many women and most men do not have any symptoms of trich. If symptoms develop, they usually appear within 1 week of being infected, but can develop from 1 to 6 months after being infected. Trichomonas should be treated to prevent transmitting this STD to others and to prevent complications if you are pregnant.
In rare cases, it may be possible to get trich by coming in contact with an object (such as a wet towel) that a person who has trich has just used. The Trichomonas organism cannot live on objects for long, so trich is not usually spread this way.
Trichomoniasis may be transmitted from a mother to her baby during a vaginal delivery, but this is rare.
Symptoms persist longer than 1 week or worsen, despite treatment.
Unusual vaginal bleeding or swelling develops.
After treatment, symptoms recur.
FOR MORE INFORMATION
Parasitic Disease Information
Centers for Disease Control and Prevention, Division of Parasitic Diseases
Web Address: http://www.cdc.gov/ncidod/dpd/parasites/trichomonas
The CDC Web site provides a fact sheet on Trichomonas infection.
American Social Health Association
Web Address: http://www.ashastd.org/stdfaqs/vaginitis.html
The American Social Health Association provides accurate, medically reliable information about STDs to the public, patients, providers, and policy makers. Its Web site offers resources to answer your questions, find referrals, join HELP groups, and get access to in-depth information about sexually transmitted diseases.
Planned Parenthood Federation of America
810 Seventh Avenue
New York, NY 10019
Phone: 1-800-669-0156
Phone: (212) 541-7800
Fax: (212) 245-1845
Web Address: http://www.plannedparenthood.org
This organization provides comprehensive reproductive health care and consumer information about family planning, sexual health, and sexually transmitted diseases (STDs).
Centers for Disease Control and Prevention (CDC) STD National Hotline
1600 Clifton Road, N.E.
Atlanta, GA 30333
Phone: 1-800-227-8922
Web Address: http://www.cdc.gov/nchstp/dstd/hotlines.htm
The hot line is available Monday through Friday, 8 a.m. to 11 p.m., Eastern standard time. The hot line can provide education and referrals on sexually transmitted diseases.
The Web address is the home page for Centers for Disease Control; links to information on sexually transmitted diseases (STDs) can be found by searching specific STDs in the health topics.
MoonDragon's Obgyn Information: Sexually Transmitted Diseases (STDs)
