eMedicine Specialties > Pediatrics: General Medicine > Parasitology

Trichomoniasis

Author: Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Coauthor(s): Renee Wilson, MD, Clinical Assistant Instructor, Department of Emergency Medicine, SUNY-Downstate and Kings County Hospital; Binita R Shah, MD, FAAP, Professor of Clinical Pediatrics and Emergency Medicine, SUNY Health Science Center at Brooklyn, Director of Pediatric Emergency Medicine, Depts of Emergency Medicine and Pediatrics, Kings County Hospital Center
Contributor Information and Disclosures

Updated: Jan 27, 2009

Introduction

Background

Trichomoniasis, a type of vaginitis, is predominantly a sexually transmitted disease (STD). Because of both the common practice of self-diagnosis and treatment and diagnosis by practitioners without adequate testing, a number of individuals with trichomoniasis are misdiagnosed. Self-diagnosis is fostered by the ease with which over-the-counter treatment agents are obtained. The symptoms and signs of trichomoniasis are nonspecific, and diagnosis requires basic testing, such as a wet mount.

Trichomoniasis results in missed days from school or work because of the discomfort that it causes, so this infection should not be trivialized. Incidence of coinfection with other STDs is important and needs to be considered when making the diagnosis of trichomoniasis. Trichomoniasis is problematic for the adolescent who contracts it because of the myriad of possible presenting symptoms and because of the complications associated with this disease.

Pathophysiology

In prepubertal girls, the healthy vaginal wall is thin and hypoestrogenic, the healthy vaginal pH is greater than 4.7, and culture of the vagina demonstrates a number of organisms. As the girl enters adolescence, the vagina thickens, and lactobacilli become the predominant species. The pH of the vagina decreases to less than 4.5.

Lactobacilli are important in protecting the vagina from infection and they remain the dominant, but not the only, flora of the vagina. The range of the incubation period, before symptoms of trichomoniasis develop, is 3-28 days. During infection with the protozoan Trichomonas vaginalis, jerky motile trichomonads may be observed on wet mount. The vaginal pH increases, as does the number of polymorphonuclear (PMN) leukocytes.

PMN leukocytes are the predominant host defense mechanisms and respond to chemotactic substances released by trichomonads. T vaginalis destroys epithelial cells by direct cell contact and by release of cytotoxic substances. It also binds to host plasma proteins, thus preventing recognition by the alternative complement pathway and by host proteinases.

Frequency

United States

Trichomoniasis is one of the most common STDs, with approximately 2-3 million infections annually.

International

Worldwide, approximately 180 million infections occur yearly. Prevalence of trichomoniasis was found to range from 5% in patients at family planning clinics to 75% in prostitutes.

Mortality/Morbidity

Trichomoniasis has a high coinfection rate with other STDs. In a study by Wolner-Hanssen et al, gonorrhea was especially noted to be significantly associated with trichomonal infection.1 Trichomoniasis is also believed to facilitate the transmission of human immunodeficiency virus (HIV).

Trichomoniasis infection in women can range from asymptomatic to an inflammatory state associated with vaginal itching and discharge.

In pregnancy, untreated trichomoniasis may be associated with premature rupture of membranes, low birth weight babies, and posthysterectomy cellulitis.

Sex

Trichomoniasis is observed in both males and females but is more common in women. In males, trichomoniasis may range from asymptomatic infection or carriage to urethritis, prostatitis, or epididymo-orchitis. Women also can be asymptomatic carriers; however, the disease tends to be an acute inflammatory process associated with the features listed below.

Age

Trichomoniasis is more common in adolescent and adult sexually active males and females.

Clinical

History

  • Females
    • Patients with trichomoniasis may complain of vaginal itching and/or burning. Patients may also have an abnormal vaginal odor, which is described as musty.
    • Dyspareunia may be the major complaint in individuals with trichomoniasis.
    • An abnormal vaginal discharge may also be present. The discharge may be purulent, frothy, or bloody. Frothy vaginal discharge, which is thought to be the classic presentation of trichomoniasis, is observed in only 12% of patients with this infection.
    • Patients with trichomoniasis may also complain of postcoital bleeding and lower abdominal pain.
  • Males
    • Most males with trichomoniasis are asymptomatic.
    • Male patients may complain of dysuria, pain in the urethra, testicular pain, or lower abdominal pain.

Physical

  • Females
    • Upon pelvic examination, signs suggestive of trichomoniasis include colpitis macularis (ie, strawberry cervix); purulent vaginal discharge that can be creamy white, yellow, green, or grey; frothy vaginal discharge; vaginal erythema; and vulvar erythema.
    • Colpitis macularis and frothy vaginal discharge together have a specificity of 99% and individually have a positive predictive value of 90% and 62%, respectively. Interestingly, in the study performed by Wolner-Hanssen et al, colpitis macularis was observed by the unaided eye in only 1.7% of patients with trichomoniasis; however, with the aid of colposcopy, colpitis macularis is observed in 70% of patients with trichomoniasis with a positive wet mount.1
    • Most of the symptoms described above are not specific for trichomoniasis and can occur in other vaginal or cervical infections. Therefore, relying on physical examination findings alone misses the diagnosis of most patients with trichomoniasis. Definitive diagnosis requires demonstration of the flagellated protozoan on wet mount, Papanicolaou (Pap) smear, or culture media.
  • Males
    • Most males with trichomoniasis have no physical findings.
    • Infrequently, some males with this infection may have abnormal penile discharge.
    • Others may have signs of prostatitis or epididymitis.
  • Newborn females: T vaginalis acquired during birth may cause vaginal discharge during the first week of life.
  • Prepubertal child
    • The prepubertal child with trichomoniasis may present with symptoms similar to the adolescent and adult patient.
    • Suspect sexual abuse with the presence of T vaginalis in prepubertal children.

Causes

  • T vaginalis is a flagellated protozoan.
  • Incubation period averages 1 week but can have a range of 3-28 days.
  • Trichomoniasis is predominantly an STD.
  • The risk of acquiring this infection is based on the patient's level of sexual activity.
  • Risk factors for T vaginalis include the following:
    • Number of lifetime sexual partners
    • Recent sexual partners
    • Not using barrier contraception
    • Using oral contraception

More on Trichomoniasis

Overview: Trichomoniasis
Differential Diagnoses & Workup: Trichomoniasis
Treatment & Medication: Trichomoniasis
Follow-up: Trichomoniasis
References
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Further Reading

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Keywords

trichomoniasis, abnormal vaginal discharge, abnormal vaginal odor, cellulitis, colpitis macularis, dyspareunia, dysuria, epididymo-orchitis, frothy vaginal discharge, prostatitis, sexually transmitted disease, STD, strawberry cervix, trich, Trichomonas vaginalis, T vaginalis, urethritis, vaginal burning, vaginal erythema, vaginal itching, vaginitis, venereal disease, VD, vulvar erythema

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Contributor Information and Disclosures

Author

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Coauthor(s)

Renee Wilson, MD, Clinical Assistant Instructor, Department of Emergency Medicine, SUNY-Downstate and Kings County Hospital
Renee Wilson, MD is a member of the following medical societies: Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Binita R Shah, MD, FAAP, Professor of Clinical Pediatrics and Emergency Medicine, SUNY Health Science Center at Brooklyn, Director of Pediatric Emergency Medicine, Depts of Emergency Medicine and Pediatrics, Kings County Hospital Center
Binita R Shah, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Ashir Kumar, MBBS, MD, FAAP, Professor, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University; Consulting Staff, Department of Pediatrics, EW Sparrow Hospital
Ashir Kumar, MBBS, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association of Physicians of Indian Origin, American Federation for Clinical Research, American Society for Microbiology, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Martin Weisse, MD, Program Director, Associate Professor, Department of Pediatrics, West Virginia University
Martin Weisse, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting; Pfizer Honoraria Consulting

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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