Trichomoniasis

Trichomoniasis is caused by a motile protozoan and affects 120 million women worldwide every year. It is usually sexually transmitted and is associated with transmission of other

STIs (Forna, 2009). Risk factors for acquisition include multiple sexual partners and possibly a decrease in the normal vaginal acidity. Men are usually asymptomatic carriers, but 10% of nongonococcal urethritis in men is caused by Trichomonas (French et al., 2004).

Up to 50% of women with trichomoniasis are asymptomatic. Symptomatic women may complain of a yellow-green, malodorous discharge, vaginal burning, and dysuria. On physical examination, hemorrhagic, punctate cervical lesions are pathognomonic but are only present in 2% of cases (French et al., 2004). More common signs are foul-smelling purulent discharge, vaginal tenderness, vulvar erythema and edema. The vaginal pH is usually basic. Office microscopy is first line for diagnosis of trichomoniasis (ACOG, 2006). The sample should be taken from the posterior vault, diluted in 2 drops of saline, and assessed quickly because motility of the protozoa diminishes rapidly (Fig. 25-3). Although microscopy has good specificity (99%), motile trichomonads are seen in only 50% to 80% of culture-proven cases. Thus, culture is the gold standard. Trichomonads can be reported on a Pap smear, but it is not recommended as a diagnostic test because of the low sensitivity (58%) (French et al., 2004). In men the wet prep has poor sensitivity, so culture of both a urethral sample and a first-voided urine sample is necessary to increase the diagnostic rate.

Metronidazole or tinidazole single-dose therapy is effective for treatment of trichomoniasis. An alternative effective regimen is metronidazole, 500 mg orally twice daily for 7 days. Metronidazole gel is less effective (<50% cure rate) as compared to oral metronidazole (CDC, 2006). Desensitization is recommended for patients allergic to metronidazole. Avoidance of alcohol is important with all nitroimidazoles. Met-ronidazole is not teratogenic in the first trimester (BASHH, 2007). Because most male sexual partners have asymptomatic trichomoniasis, simultaneous treatment is recommended.

If treatment fails with a 2-g single dose of metronidazole, a trial of metronidazole, 500 mg twice daily for 7 days, or a single 2-g dose of tinidazole is recommended (CDC, 2006). If this fails, a trial of tinidazole or metronidazole, 2 g orally once daily for 5 days, is recommended. Referral is advised for persistent failure. A test of cure is unnecessary if symptoms resolve (BASHH, 2007).

KEY TREATMENT

Women with trichomoniasis should abstain from intercourse until both she and her partner have been treated and are asymptomatic (ACOG, 2006) (SOR: A).

A single dose of a nitroimidazole can achieve parasitologic cure; tinidazole as a single 2-g dose may be most efficacious (CDC, 2006; Forna, 2009) (SOR: A).

If treatment fails with a single 2-g dose of metronidazole, a trial of metronidazole, 500 mg twice daily for 7 days, or a single 2-g dose of tinidazole is recommended (CDC, 2006) (SOR: B).

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