Trichomonas Vaginitis or
Trichomoniasis is a sexually
transmitted infection caused by the
protozoa Trichomonas vaginalis
Trichomonas Vaginitis is an infection
caused by a one-celled protozoan called
trichomonas. This is an extremely
common cause of vaginal infections.
Trichomonas Vaginitis is also known as,
trichomoniasis, trichomonas vaginalis
Trichomoniasis in women may be
asymptomatic or may cause various
symptoms, including a frothy yellow-
green vaginal discharge and vulvar
irritation. Men with trichomoniasis are
frequently asymptomatic.
The high incidence of T vaginalis
infection worldwide and coinfection with
other sexually transmitted infections
make trichomoniasis a compelling public
health concern.
Notably, T vaginalis infection is believed
to increase the risk of HIV transmission.
Trichomoniasis is also associated with
adverse pregnancy outcomes, infertility,
postoperative infections, and cervical
neoplasia.
Pathophysiology
T vaginalis is approximately the size of a
white blood cell (about 10 μm in
diameter), although its size may vary
with physical conditions. Its flagellum
allows it to move around vaginal and
urethral tissues. T vaginalis directly
damages the epithelium, leading to
microulcerations of inhabited tissues,
increasing the risk of HIV transmission.
Symptoms of trichomoniasis typically
occur after an incubation period of 4-28
days. In women, T vaginalis is isolated
from the vagina, cervix, urethra, bladder,
and Bartholin and Skene glands. In men,
the organism is found in the anterior
urethra, external genitalia, prostate,
epididymis, and semen.
Frequency
International
Worldwide, the annual incidence of
trichomoniasis is about 170 million cases.
Mortality/Morbidity
T vaginalis infection is highly associated
with the presence of other sexually
transmitted infections, including
gonorrhea, chlamydia, and sexually
transmitted viruses. T vaginalis infection
increases the susceptibility to others
viruses, including herpes, human
papillomavirus (HPV), and HIV. Persons
with trichomoniasis are twice as likely to
develop HIV infection as the general
population.
Two explanations exist for the
association between T vaginalis and HIV:
(1) Disruption of the epithelial monolayer
leads to increased passage of the HIV
virus; (2) T vaginalis induces immune
activation, specifically lymphocyte
activation and replication and cytokine
production, leading to increased viral
replication in HIV-infected cells.
In men, complications of untreated
trichomoniasis include prostatitis,
epididymitis, urethral stricture disease,
and infertility. Infertility may result from
a decreased sperm motility and viability.
Race
Evidence suggests that T vaginalis
infection most likely increases HIV
transmission. Thus, the observed higher
prevalence of T vaginalis infection in
African Americans is cause for concern.
Although T vaginalis may increase the
risk of HIV transmission by only a small
to moderate amount, its high prevalence
in the African American community
makes it a cause of measurable increase
in rates of HIV transmission. Therefore,
control of T vaginalis may represent an
important means of slowing HIV
transmission, particularly among African
Americans.
Sex
Symptomatic trichomoniasis is more
common in women than in men.
Trichomoniasis infection in men is less
clinically apparent.
Age
Trichomoniasis is a sexually transmitted
infection. As such, it is typically found in
sexually active adolescents and adults.
In female adolescents, trichomoniasis is
more common than gonorrhea; this is
particularly disconcerting since it
increases the susceptibility to other
viruses.
Clinical
History
Women
Trichomoniasis symptoms in women
range from none to severe pelvic
inflammatory disease. Women with
trichomoniasis frequently report:
• a frothy yellowish-green vaginal
discharge
• abnormal vaginal odor
• vulvovaginal itching and soreness,
• dyspareunia (pain during sexual
intercourse)
• dysuria (pain during urination)
However, many infected women
experience no symptoms.
Men
Trichomoniasis symptoms in men range
from none to urethritis complicated by
prostatitis. Nongonococcal nonchlamydial
urethritis is the most common symptom
reported by men with trichomoniasis.
Symptoms of urethritis include:
• Discharge
• Dysuria
• Urethral pruritus
• The discharge may be purulent to
mucoid in character
Most symptomatic infections are
intermittent and self-limiting.
Complications of untreated
trichomoniasis:
• Prostatitis
• Epididymitis
• Urethral stricture disease
• Infertility
Physical
Women
• Purulent or homogenous vaginal
discharge and vulvar or vaginal
erythema are common.
• Colpitis macularis, or strawberry
cervix, describes a diffuse or
patchy macular erythematous
lesion of the cervix. is detected in
up to 45% of cases.
• Lower-abdominal tenderness may
be present; however, this is
 described in fewer than 10% of
patients
Men
• The findings of trichomoniasis in
men on physical examination are
generally unremarkable unless the
infection is complicated. It may be
associated with local inflammatory
states, including balanitis and
balanoposthitis.
• Physical findings of epididymitis
and prostatitis may also occur.
Laboratory Studies
Laboratory studies aid in demonstration
of the T vaginalis organism and are used
to differentiate trichomoniasis from
bacterial or fungal infection.
Saline microscopic examination
• Vaginal trichomoniasis is typically
diagnosed with microscopy. A
vaginal swab sample for saline wet
mount evaluation is an easy,
valuable, and economical tool, but
specificity is limited and the slide
should be evaluated immediately.
Trichomonas vaginalis on
a saline wet mount at 40X
on the microscope.
Several motile parasites
transit through the field,
surrounded by white
blood cells and squamous
epithelial cells.
pH testing
• In women with trichomoniasis, the
pH of vaginal secretions measured
on Nitrazine paper is often elevated
(>4.5). However, an elevation in
pH is not highly specific. Bacterial
vaginosis frequently also elevates
the pH.
• Upon application of 10% potassium
hydroxide to a vaginal swab
sample in the potassium hydroxide
(KOH) amine test, a fishy odor is
released, which can suggest
trichomoniasis or bacterial
vaginosis.
Standard culture
• Culture is more sensitive and
specific than microscopy. Culture
yields a sensitivity of about 95%.
• Disadvantages of culture method
include testing time and
availability.
• Swab is put in broth and incubated
anaerobically at 37°C. Growth is
usually detected within 48 hours,
and samples without growth after 7
days are considered negative for
trichomoniasis.
• Culture is especially important for
diagnosing trichomoniasis in men
since the wet preparation findings
are usually negative. Urethral
swab, urine, and semen cultures
are used to maximize sensitivity.
Papanicolaou (Pap) smear
• Trichomonads may be viewed on
Papanicolaou (Pap) smear, but this
test yields low sensitivity and
should not be relied on for
diagnosis (50%). False-positive
results are also common with this
technique.
Polymerase chain reaction (nucleic
acid amplification)
• Polymerase chain reaction (PCR)
methods yield a high sensitivity
(84%) and specificity (94%).
Although not yet widely available,
PCR has great diagnostic potential.
Histologic Findings
Trichomonads may be observed in a
saline wet mount of a vaginal swab or
secretion in approximately 60-70% of
women with trichomoniasis.
Trichomonads are ovoid in shape and
slightly larger than PMNs. They are
identifiable by to their ameboid mobility.
Because they cause an inflammatory
reaction, a large number of PMNs are
usually present, correlating with the
severity of the infection.
Medical Care
• Prompt trichomoniasis diagnosis is
important for eliminating infection
in the patient and sexual partners.
• Treatment of sexual partners is
thought to increase cure rates.
• Systemic treatment is important to
ensure a cure, as trichomoniasis is
an infection of multiple sites (eg,
vaginal epithelium, Skene glands,
Bartholin glands, urethra).
• Oral metronidazole is the
treatment of choice and has been
demonstrated in multiple studies to
offer efficacy that is superior to
that of intravaginal treatment.
• Treatment with oral metronidazole
is not associated with preterm birth
and is protective in women
diagnosed with trichomoniasis at
35 weeks’ gestation or later.
• Drug resistance is rare, despite the
prevalent use of nitroimidazole
drugs in the treatment of
trichomoniasis. Treatment failures
may require a higher dose
metronidazole regimen or the use
of a different nitroimidazole.
• In clinical practice, repeat testing is
rarely performed unless symptoms
do not improve with drug
treatment. Theoretically, repeat
testing at 5-7 and 30 days is
recommended.
• Routine screening for
trichomoniasis in asymptomatic
pregnant women is not currently
recommended.
Diet
Instruct the patient to avoid alcohol while
taking metronidazole, tinidazole, or other
nitroimidazole drugs. The interaction of
the drugs and alcohol may cause a
disulfiramlike reaction.
Activity
Patients should avoid sex until drug
therapy is completed and all symptoms
have disappeared. Treatment of the
patient’s partner is crucial to avoid
reinfection.
Medication
The 5-nitroimidazole group of drugs
includes antiprotozoal agents
(metronidazole, tinidazole, nimorazole,
carnidazole) used for the treatment of
trichomoniasis.
The mechanism of action is not well
understood; however, anaerobic
organisms preferentially reduce the 5-
nitro group, and active metabolites likely
interact with anaerobic bacterial and
protozoal DNA.
Resistance to these drugs is rare despite
their widespread use in the treatment of
trichomoniasis and is typically solved by
increasing the dose or switching to
another nitroimidazole.
When standard treatment regimens fail,
metronidazole or tinidazole at 2 g PO for
5 days should be considered.
Drugs may also be applied locally in the
vagina or rectum, although oral
treatment is usually preferred.
• Local intravaginal medications
include clotrimazole, povidone-iodine,
and nonoxynol-9 (N-9). Metronidazole
may also be applied vaginally or
rectally to reach therapeutic
concentrations in the blood. Topical
drugs other than nitroimidazoles yield
low cure rates (<50%).
Cause of Trichomoniasis
Trichomonis can be transmitted
through sexual intercourse.
Symptoms of Trichomoniasis
• a yellow or greenish
• frothy or bubbly discharge
• sometimes with a foul odor
• itching
• soreness and inflammation of the
vulva and inside the vagina.
couple is enough. However, if
infection recurs, the patient's sexual
partner(s) must also be treated.
Prevention of Trichomoniasis
All sexually active persons should
consider using latex condoms to prevent
STDs and HIV infection, even if they are
using another form of contraception.
Latex condoms used consistently and
correctly are an effective means for
preventing disease (and pregnancy). Talk
openly with your partner about STDs,
HIV, hepatitis B infection and the use of
contraception.

Diagnosis of Trichomoniasis
A complete medical history and
physical examination, including pelvic
examination, is performed. The
physician will prepare a wet smear by
mixing a sample of the vaginal
discharge with a drop of salt solution
(normal saline) and examining it
under a microscope.

Trichomonas organisms can be easily

identified because they swim quite
rapidly with their whip-like tails.
Trichomonas can also cause small,
dark red spots (petechiae) on the
cervix.

Treatment of Trichomoniasis
The most effective drug for treatment
of trichomonas is metronidazole. The
most common brand name is Flagyl.
The dosage is usually a single, 2,000
mg dose; or 500 mg twice daily every
day for seven days. Usually, treating
the female partner in a sexually active