Trichomoniasis Clinical Presentation
- Author: Darvin Scott Smith, MD, MSc, DTM&H; Chief Editor: Michael Stuart Bronze, MD more...
Trichomoniasis is typically found in sexually active patients. Transmission occurs predominantly via sexual intercourse. The organism is most commonly isolated from vaginal secretions in women and urethral secretions in men. It has not been isolated from oral sites, and rectal prevalence appears to be low in men who have sex with men. While it is possible to contract trichomoniasis without engaging in sexual intercourse, it is less common. In the NHANES 2001-2004 study conducted among females aged 14-49 years, 1% of women with trichomoniasis had no history of sexual intercourse.
Trichomoniasis symptoms in women range from none to severe pelvic inflammatory disease (PID). Women with trichomoniasis frequently report an abnormal vaginal discharge, which may be purulent, frothy, or bloody. Frothy vaginal discharge, which is thought to be the classic presentation of trichomoniasis, may be observed in only 12% of patients with this infection.
Women with trichomoniasis also commonly report abnormal vaginal odor (often described as musty); vulvovaginal itching, burning, or soreness; dyspareunia (pain during sexual intercourse), which is often the major complaint; and dysuria (pain during urination).[11, 43] Patients may also complain of postcoital bleeding and lower abdominal pain.
Cervicitis due to trichomoniasis is characterized by 2 major signs: purulent discharge in the endocervical canal and easily induced endocervical bleeding. However, it may also be asymptomatic.
T vaginalis infection is one of the top 3 causes of vaginitis. Vaginitis is usually characterized by vaginal discharge, which may be accompanied by vulvar itching, irritation, and odor. The two other most common causes of vaginal discharge are anaerobic bacterial overgrowth of normal flora and candidiasis (infection with Candida albicans).
Men with trichomoniasis may be divided into the following 3 groups on the basis of their symptoms :
Asymptomatic carrier state (comprising the majority of patients)
Mild symptomatic disease
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 (purulent to mucoid in character), dysuria, and urethral pruritus. Some patients report pain in the urethra, testicular pain, or lower abdominal pain.
Most symptomatic infections are intermittent and self-limiting.
Vaginal discharge is found in 42% of infected women. The discharge is classically described as thin and frothy; however, this is only seen in about 10% of patients. The discharge is often yellow and sometimes is thick enough to be confused with that seen in candidiasis. Abnormal vaginal odor was found in 50% of infected women, and edema or erythema was found in 22-37%. Vaginal pH is often elevated (>4.5).
Colpitis macularis, or strawberry cervix, describes a diffuse or patchy macular erythematous lesion of the cervix. This is a specific sign for trichomoniasis but is visible in only 1-2% of cases without the aid of colposcopy; with colposcopy, colpitis macularis is detected in up to 45% of cases. Together, colpitis macularis and frothy vaginal discharge have a specificity of 99%; individually, they have positive predictive values of 90% and 62%, respectively.
Lower-abdominal tenderness may be present; however, this is described in fewer than 10% of patients. If this occurs, coexisting salpingitis or an intra-abdominal pathology is possible.
Coexisting Neisseria gonorrhoeae infection, candidiasis, and bacterial vaginosis are common and may produce a mixed clinical picture.
Most of the symptoms described above are not specific for trichomoniasis and can occur in other vaginal or cervical infections. In one study, the clinician’s ability to accurately diagnose Tvaginalis infection on the basis of physical findings alone had a positive predictive value of only 47%. Relying on physical examination findings alone misses the diagnosis of most patients with trichomoniasis. Definitive diagnosis requires appropriate laboratory testing.
Most men with trichomoniasis have no physical findings. Infrequently, infected men have abnormal penile discharge. However, the discharge usually is only scant and thin. Trichomoniasis in men may be associated with local inflammatory states, including balanitis and balanoposthitis. Physical findings of epididymitis and prostatitis may also occur.
In female newborns, T vaginalis acquired during birth may cause vaginal discharge during the first week of life. Respiratory infection of the newborn is also possible. An infected infant may present with fever.
Prepubertal children with trichomoniasis may present with symptoms similar to those seen in the adolescent and adult patient. T vaginalis infection in prepubertal children is suggestive of sexual abuse.
In women, vaginitis is the most common manifestation of infection. Other complications include infection of the adnexa, endometrium, and Skene and Bartholin glands. Pelvic inflammatory disease and tubo-ovarian abscess may also occur.
Research has shown that infection with T vaginalis increases the risk of HIV transmission in both men and women.[1, 3] It is estimated that in women alone, 747 new HIV cases per year are a result of the facilitative effects of T vaginalis on the transmission of HIV. Overall, persons with trichomoniasis are twice as likely to develop HIV infection as the general population. Treatment of trichomoniasis has been shown to decrease the rate of viral shedding in HIV patients.[3, 47]
In addition to HIV, T vaginalis infection also increases the susceptibility to other viruses, including herpes and human papillomavirus (HPV). T vaginalis may increase the rate of infection or reactivation of HPV, although it may shorten the duration of infection.
An association with cervical intraepithelial neoplasia has also been demonstrated. Trichomoniasis has also been associated with postoperative infections.
In pregnant women, T vaginalis infection has been associated with an increased risk of low birth weight, preterm delivery, and intrauterine infection.[1, 52] Systemic immune response has been demonstrated in pregnant women infected with T vaginalis; a significant increase in granulocyte-macrophage colony-stimulating factor (GM-CSF) and C-reactive protein (CRP) was noted.
In men, when symptoms occur, T vaginalis infection usually manifests as urethritis. As many as 11% of nongonococcal urethritis cases in men are caused by T vaginalis. Complications of untreated trichomoniasis in men include prostatitis, epididymitis, urethral stricture disease, and infertility, potentially resulting from decreased sperm motility and viability.[4, 55] Symptomatic men with comorbid T vaginalis and HIV infections have been found to have significantly higher numbers of HIV RNA particles in their seminal fluid.
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