TRICHOMONIASIS

INTRODUCTION

Trichomonas vaginalis is the causative agent of trichomoniasis, a common cause of

vaginitis. Despite being a readily diagnosed and treatable sexually transmitted disease (STD),
trichomoniasis is not a reportable infection, and control of the infection has received relatively
little emphasis from public health STD control programs. More recently, however, appreciation
of the high rates of disease and of associations of trichomoniasis in women with adverse
outcomes of pregnancy and increased risk for human immunodeficiency virus HIV infection
suggest a need for increased control efforts. 

TRICHOMONAS VAGINALIS

The protozoan in question is Trichomonas vaginalis, which is a pear-shaped flagellate

parasite that only infects the human genitalia. Trichomoniasis, which is the disease caused
by Trichomonas, is relatively benign. In fact, Trichomoniasis has been given the title of most
common curable STD.

CLASSIFICATION
T. vaginalis is a parasitic protozoan, and the taxonomic position is based on the classification
scheme by Dyer , in which protozoa with the “9 + 2” flagellum fall into the phylum
Zoomastigina.

 Phylum: Zoomastigina—possess flagella.

 Class: Parabasalia—presence of a parabasal body: Golgi associated with kinetosomes;

axostyle (bundled microtubules); undulating membrane, an extension of the plasma
membrane, enveloping the recurrent flagellum; occur in association with animals.

 Order: Trichomonadida (Kirby, 1947 emend. Honigberg, 1974)—four to six flagella,

free or attached to an undulating membrane; no true cysts.

 Family: Trichomonadidae (Wenyon, 1926)—presence of a cytostome, three to five free

flagella (one flagellum on the margin of the undulating membrane); axostyle protruding
through the posterior of the cell.
  Genus: Trichomonas—four free flagella; one recurrent, along the outer margin of the
undulating membrane; a costa at the base of the undulating membrane, and an axostyle
extending through the cell.

 Species: Trichomonas vaginalis 

LIFECYCLE

The lifecycle of Trichomonas is very simple in comparison to some other protozoal

parasites. There is only one stage: trophozoite. The trophozoites are motile, infectious,
reproductive, and cause the symptoms of the disease. Trichomonas reproduces by simple binary
fission and it prefers the slightly acidic environment of the reproductive tracts of infected
individuals. Most protozoa have a cyst stage that is infectious and able to survive in the
environment. Trichomonas is noteworthy because it is unable to make any cysts. This means it
cannot persist for long in the environment and infection occurs by direct contact with viable
trophozoites.

 Resides in the female lower genital tract and the male urethra and prostate

 Replicates by binary fission
 Does not appear to have a cyst form, and does not survive well in the external
environment
 Transmission occur among humans, its only known host, primarily by sexual intercourse
TRANSMISSION AND PREVENTION

Viable trophozoites can be passed in one of two ways: person-to-person or through

contact with contaminated surfaces.

vast majority of infections are a result of direct sexual contact from person to person. As
a result, abstinence is obviously almost 100% effective as a preventative. Proper and consistent
condom usage is also effective, but uncovered areas can still transmit the parasite.

Without a cyst stage that can resist environmental conditions, getting Trichomonas from

contaminated surfaces is rare, but possible. The trophozoites can survive outside of the host for a
couple of hours as long as they stay moist. This makes toilet seats, sauna benches, and wet beach
towels potential sources of infection. Fortunately, common household cleaners like bleach are
very effective at eliminating the trophozoites from surfaces, additional aspect of transmission
needs to be addressed. If there is already damage to the genital area, like broken or raw skin, this
can make it easier for Trichomonas to attach to host cells and cause disease symptoms. Poor
hygiene, diabetes, concurrent infection by other pathogens, and certain drugs can lead to
irritation of the genital membranes. This creates a more favorable environment for not
only Trichomonas but other disease-causing organisms as well.

EPIDEMIOLOGY

Trichomoniasis is the most common curable STD in young, sexually active women. An

estimated 7.4 million new cases occur each year in the United States. In 2008, the incidence of
trichomoniasis was estimated to be 358 cases per 100,000 individuals in the United
States. Females are more commonly affected with trichomoniasis than males.

Demographic factors

The following demographic factors may affect incidence and prevalence of trichomoniasis:

 Age

Trichomoniasis occurs most commonly among women aged 20-45 years.

 Gender

Females are more commonly affected by trichomoniasis than males.

 Race

Trichomoniasis usually affects African American individuals. Caucasian individuals are

less likely to develop trichomoniasis. In the United States, the highest prevalence of trichomonas
infection in women is observed among African-Americans, with rates ranging from 13–51%

RISK FACTORS

 Multiple sexual partners

 Unprotected sexual activity
 Co-existing venereal diseases
  Intravenous drug use

CAUSES

A parasite called Trichomonas vaginalis causes this STD. Vaginal-penile or vaginal-vaginal

intercourse.

 Anal sex.
 Oral sex.
 Genital touching (skin-to-skin contact without ejaculation)

PATHOPHYSIOLOGY

Trichomonas is a motile organism with a size comparable to a white blood cell. It has at
least 4 flagella that provide undulating motility. The organism resides in the lumen of the
urogenital tract. The organism releases cytotoxic proteins that destroy the epithelial lining.
During an infection, the vaginal pH usually increases.

In women, T. vaginalis has an incubation period of five to twenty-eight days. Women

with trichomoniasis often complain of a foul-smelling yellow or green vaginal discharge,
dyspareunia, urinary frequency, dysuria, and/or vulvar pruritus or erythema. In men, it often does
not cause symptoms. If a male is symptomatic, the most common symptom is urethritis. Less
commonly, men may also develop prostatitis and epididymitis.

SYMPTOMS

The majority of women (85%) and men (77%) with trichomoniasis are asymptomatic. One-third
of asymptomatic women become symptomatic within 6 months. Common symptoms of
trichomoniasis in women include:

 Vaginal discharge (which is often diffuse, malodorous, and yellow-green or gray in color)

 Painful urination (dysuria)
 Vulvar irritation and itching
 Abdominal pain
 Discomfort during sexual intercourse
Symptoms of trichomoniasis in men include:

 Clear or mucopurulent urethral discharge

 Painful urination
 Pruritus or burning sensation following sexual intercourse

DIAGNOSIS

History

It is critical to collect a detailed and thorough sexual history from the patient. Specific areas
of focus when obtaining a history from the patient include:

 Number and type of sexual partners (new, casual, or regular)

 Contraception use
 Previous history of trichomoniasis or other sexually transmitted diseases

Physical Examination

Appearance

 Patients with trichomoniasis are usually appear well.

 Genitourinary
 Strawberry cervix: petechial haemorrhages on the ectocervix, specific to trichomoniasis
 Frothy, mucopurulent, yellow-green or gray vaginal discharge
 Foul smelling (fishy odor)
 In males, there may be scanty, mucopurulent urethral discharge

LABORATORY FINDINGS

Microscopy

Wet-mount microscopy: has been used as the preferred diagnostic test, however it has

low sensitivity (44%–68%) compared with culture. To improve detection, clinicians using wet
mounts should attempt to evaluate slides immediately after specimen collection
because sensitivity decreases quickly to 20% within 1 hour after collection.
 Trichomoniasis is diagnosed by visually observing the trichomonads via a microscope. In
women, the examiner collects the specimen during a pelvic examination by inserting
a speculum into the vagina and then using a cotton-tipped applicator to collect the sample. The
sample is then placed onto a microscopic slide and sent to a laboratory to be analyzed.
Trichomoniasis has been difficult to diagnose due to the poor sensitivity of the tests.

Findings on microscopy suggestive of trichomoniasis include:

Characteristic "tumbling" motility of protozoa

Leukocytes

Trichomonas vaginalis Pap smear

Culture

Historically, culture has been the gold standard for diagnosis of trichomoniasis.
However, sensitivity is somewhat low (70-89%).

Nucleic Acid Amplification Tests

Nucleic acid probe techniques, the most sensitive tests, are moderately priced and fast,
but they require instrumentation and thus are not considered point-of-care. The
APTIMA Trichomonas vaginalis Assay (Hologic Gen-Probe, San Diego, CA) was FDA-cleared
in 2011 for use with urine, endocervical, and vaginal swabs, and endocervical specimens
collected in the Hologic Preserve Cyt solution (ThinPrep) from females only. Sensitivity is 95–
100% and specificity is also 95–100%.

Other diagnostic tests

Another diagnostic test that may be helpful in the diagnosis of trichomoniasis is the whiff test.

Whiff test

Vaginal infection with trichomonas vaginalis alters the vaginal pH from acidic to basic.
The whiff test is based on the addition of 10% potassium
hydroxide to vaginal secretions. Vaginal pH >4.5 gives off a strong, fishy odor based on the
presence of amines.

The Solana trichomonas assay (Quidel)

Another rapid test for the qualitative detection of T. vaginalis DNA and can yield results
<40 minutes after specimen collection. This assay is FDA cleared for diagnosing T.
vaginalis from female vaginal and urine specimens from asymptomatic and symptomatic women
with sensitivity >98%, compared with NAAT for vaginal specimens, and >92%
for urine specimens

The Osom trichomonas rapid test (Sekisui Diagnostics)

An antigen-detection test that uses immunochromatographic capillary flow dipstick

technology by using clinician-obtained vaginal specimens. Results are available in
approximately 10–15 minutes, with sensitivities of 82%–95% and specificity of 97%–100%,
compared with wet mount, culture, and transcription-mediated amplification

The Amplivue trichomonas assay (Quidel)

Another rapid test providing qualitative detection of T. vaginalis that has been FDA
cleared for vaginal specimens from symptomatic and asymptomatic women, with sensitivity of
90.7% and specificity of 98.9%, compared with NAAT. 
MEDICAL THERAPY

Antimicrobial therapy is the standard of care for trichomoniasis in both genders once the
diagnosis has been confirmed. The symptoms of trichomoniasis in infected men may disappear
within a few weeks even without treatment, but asymptomatic men may continue to be infectious
and should therefore be treated.

Antimicrobial Regimen

T. vaginalis infection in women

 Preferred regimen: Metronidazole 500 mg PO bid for 7 days

 Alternative regimen: Tinidazole 2 g PO in a single dose
 Note: Patients should avoid sexual contact until they are fully cured of trichomoniasis
 Note: Testing for other STIs, including HIV, syphilis, gonorrhea, and chlamydia, should
be performed for persons with T. vaginalis.

T. vaginalis infection in men

 Preferred regimen: Metronidazole 2 g PO in a single dose

 Alternative regimen: Tinidazole 2 g PO in a single dose
 Note: Patients should avoid sexual contact until they are fully cured of trichomoniasis
 Note: Testing for other STIs, including HIV, syphilis, gonorrhea, and chlamydia, should
be performed for persons with T. vaginalis.

T. vaginalis infection in pregnant and lactating Women

 Pregnant women

 Preferred regimen: Metronidazole 2 g PO in a single dose

 Post-partum and Breastfeeding
 Preferred regimen (1): Metronidazole 500 mg PO bid for 7 days
 Preferred regimen (2): Tinidazole 2 g PO in a single dose
 Note (1): Do not breastfeed for 12-24 hrs following Metronidazole and 72 hrs
following Tinidazole
  Note (2): Symptomatic pregnant women, regardless of pregnancy stage, should be tested
and considered for treatment. Pregnant women should be advised of the risk and benefits
to treatment as infection (definitely) and treatment (possibly)
 Note (3): Pregnant women with HIV who are treated for T. vaginalis infection should be
retested 3 months after treatment.

T. vaginalis infection in patients with HIV

 Preferred regimen: Metronidazole 500 mg PO bid for 7 days

Persistent or recurrent trichomoniasis

 Treatment failure:

 In a woman after completing a regimen and has been re-exposed to an untreated partner
 Preferred regimen: Metronidazole 500 mg PO bid for 7 days
 In a woman after completing a regimen and no re-exposure has occurred:
 Preferred regimen (1): Metronidazole 2 g PO for 7 days
 Preferred regimen (2): Tinidazole 2 g PO for 7 days

In men after completing a regimen and has been re-exposed to an untreated partner

 Preferred regimen: Metronidazole single 2-g dose.

In men after completing a regimen and no re-exposure has occurred:

 Preferred regimen (1): Metronidazole 500 mg PO BID for 7 days.

 Nitroimidazole-resistant T. vaginalis
 Antibiotic susceptibility testing recommended
 Preferred regimen: Tinidazole or metronidazole 2 g daily for 7 days
 Alternative regimen (1): high-dose oral tinidazole 2 g daily plus tinidazole 500 mg BID
intravaginal for 14 days
 Alternative regimen (2): If the first failed, high-dose oral tinidazole 1 g TID
plus paromomycin 4 g of 6.25% intravaginal paromomycin cream nightly for 14 days.

Treatment of Sexual Partners

  Sexual partners of patients with trichomoniasis should be treated.
 Patients and their sexual partners should avoid sexual contact until they are fully cured of
trichomoniasis.

Follow-up

 Patients should be re-evaluated at the end of the antimicrobial therapy regimen to

determine whether therapy has been successful.
 Patients should be instructed that they are still susceptible to re-infection.
 Retesting is recommended for sexually active women within 3 months of treatment for
initial infection. If retesting at 3 months is not possible, clinicians should retest whenever
persons next seek medical care <12 months after initial treatment. 
 Data are insufficient to support retesting men after treatment.

ENHANCING HEALTHCARE TEAM OUTCOMES

 Patients with trichomoniasis are best managed by an interprofessional team. While most
patients are initially seen by the primary clinician, the role of the infectious disease expert
and gynecologist are invaluable.
 If a diagnosis of trichomoniasis is made in urgent care or emergency department, the
patient's primary care clinician or obstetrics and gynecology clinician should be notified.
This communication is helpful in care coordination and helps ensure a test of cure is
completed. Patients diagnosed with trichomoniasis will also need to be tested for other
STIs, including HIV. The patient's primary care provider may complete this testing, or
the patient may seek testing at an STI clinic.
 When completing a pelvic examination to collect vaginal swabs or completing a
bimanual examination to determine if pelvic inflammatory disease is a concern, the
recommendation is to have a chaperone, preferably a female. Often, in the emergency
department, this will be a female nurse or technician. Clinicians should document the
chaperone in the patient's health record.
 Patient education is vital. The infectious disease nurse should educate the patient on the
use of barrier contraception and be compliant with treatment. In addition, the sexual
partner must be sought and treated otherwise the cycle of transmission continues. Finally,
 clinicians should rescreen sexually active women after 12 weeks to ensure a complete
cure.
 Open communication between the team members is vital to ensure that the patient
receives the standard of care treatment and complete cure.

PREVENTION

 To prevent infection or reinfection, any sexual partners should also receive treatment.
 Ways of preventing the risk of infection or reinfection include:
 limiting the number of sexual partners
 avoiding sex for 7–10 days after treatment for trich
 not using a douche, as this can affect the healthy bacteria in the vagina
 limiting or avoiding the use of recreational drugs and alcohol, as these increase the risk of
unsafe sex
 using a condom for protection during sex
 A condom can prevent transmission to some extent, but it is not fully reliable because the
parasite can pass from person to person on areas of the body that it does not cover.
 Anyone who has symptoms or thinks that they have been exposed to trich should speak to
a doctor.

COMPLICATIONS

Problems during pregnancy

 preterm birth
 early rupture of the membrane
 low birth weight in newborns
 infertility

A woman can sometimes pass on the infection to the newborn during delivery, but this is rare.

It is safe to receive treatment with metronidazole during pregnancy.

Other problems
  Trich may increase the risk of reproductive tract infections.

DIFFERENTIAL DIAGNOSIS

Trichomoniasis must be differentiated from other causes of vaginitis such as 

 bacterial vaginosis,
 vulvovaginal candidiasis, and 
 atrophic vaginitis.

JOURNAL
1.STUDY THE EFFECT OF MATERIAL MICROSAFE FROZEN IN THE
TREATMENT OF TRICHOMONAS GALLINUM AGAINST THE PIGEONS
Trichomonas gallinae is a single-celled protozoan parasite inhabiting in the upper
digestive tract of many birds but mostly in pigeon squabs where it causes avian trichomoniasis.
It's a protozoan flagellate parasite causes avian disease usually in the back of the throat,
esophagus and disease in the bathroom usually called the scourge. For the treatment use
medications such as anti-protozoan metronidazole 2-amino-5-nitrothiazole and metronidazole,
also used the image currently being used on a large scale, and show case low efficiency and
resistance. In recent years, for the treatment of infected birds with the avian. If the bird is
shortness of breath or cannot swallow food until death. Micro safe: is safe in water, harmless to
humans, non-toxic, non-flammable, non-corrosive and does not contain any alcohol. It has
absolutely no side effects and is non-irritating to eye and skin, the main ingredient material is
purified super oxidized water (99.97%). In the result we found in the first and second day
weakness and the few number of parasite while in the third day we see the elimination of the
parasite and without any signs of infected birds , the proportion of treatment 80% of the total
compared with the control group under the level of significant different 0.05%, which was given
the new drug without easing and we did not show any apparent signs of harm to the infected
birds either the fourth group, which was given a drug metronidazole ,the significant difference
has been given 0.045 to eliminate the parasite within a period of four days, with the advent met
with signs of lethargy in some birds infected treatment while the third group was given a
significant difference 0.05 to eliminate the parasite doses microsafe frozen daily, morning and
night for four days without the emergence of any satisfactory only signs of a lack of appetite for
the birds. The aim of the study: the use of a new drug for the treatment of hairy T.galline parasite
that has been frozen microsafe in vivo and in vitro.

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WEBSITE

1. https://www.wikidoc.org/index.php/Trichomoniasis_medical_therapy

2. https://emedicine.medscape.com/article/230617-overview#a3

3. https://my.clevelandclinic.org/health/diseases/4696-trichomoniasis

4. https://www.nhs.uk/conditions/trichomoniasis/

JOURNAL REFERENCE

1. STUDY THE EFFECT OF MATERIAL MICROSAFE FROZEN IN THE

TREATMENT OF TRICHOMONAS GALLINUM AGAINST THE PIGEONS -
Scientific Figure on ResearchGate. Available from:
https://www.researchgate.net/figure/show-the-least-significant-difference-in-the-third-
fourth-fifth-sixth-and-seventh_tbl1_338253301 [accessed 25 Nov, 2021]