Author:

Herbert NeilWigder

Signs and Symptoms

Essential Workup

• Treat empirically if high enough clinical suspicion
• Females: Wet mount (“Hanging-drop”):
  • 60-70% sensitive in symptomatic patients
  • Saline wet mount from cervical/vaginal vault smear:
    • Requires immediate evaluation of slide
    • Many polymorphonuclear leukocytes (PMNs)
    • Motile, pear-shaped, flagellated trichomonads (slightly larger than leukocytes; seen in 60%)
    • Specimen from spun urine less sensitive
  • Absence of trichomonads does not rule out T. vaginalis infection (only present in 60-70%)
  • Many EDs not equipped to perform wet mount
• Elevated vaginal pH (>4.5) common:
  • Not specific
• Males: Wet mount insensitive
  • PCR reliable but not widely available

Diagnostic Tests & Interpretation

Differential Diagnosis

• UTI
• Gonorrhea
• Chlamydia
• Bacterial vaginosis
• Cand idal vaginitis
• Nonspecific vaginitis

ED Treatment/Procedures

• Female:
  • Metronidazole 2 g PO once:
    • 90-95% cure rate
  • Metronidazole 250 mg PO t.i.d for 7 d (urethritis)
  • Tinidazole 2 g PO once:
    • 86-100% cure rate
  • Metronidazole gel, less effective:
    • Not recommended
• Pregnant:
  • Symptomatic:
    • Metronidazole (FDA category B)
  • Asymptomatic:
    • Treatment is controversial as it does not reduce incidence of premature rupture of membranes or preterm delivery
    • Metronidazole
• Males (urethritis):
  • Metronidazole 2 g PO once
  • Tinidazole 2 g PO once
  • Metronidazole 250 mg PO t.i.d for 7 d
• HIV positive
  • Consider 7-d course of treatment because of evidence of increased single dose treatment failure
• Treat sex partners to prevent reinfection
  • No sexual intercourse until both partners are asymptomatic and until after at least 1 wk after treatment completed
• Advise using latex condoms
• Avoid concomitant alcohol use with metronidazole:
  • No alcohol for 24 hr after last metronidazole as it precipitates Antabuse reaction

Disposition

• Centers for Disease Control and Prevention. 2011 Sexually transmitted diseases surveillance . Available at http://www.cdc.gov/std/stats11/other.htm#trich
• GreerL, WendelGD Jr. Rapid diagnostic methods in sexually transmitted infections . Infect Dis Clin North Am. 2008;22:601-617.
• KissingerP. Epidemiology and treatment of trichomonas . Curr Infect Dis Rep. 2015;17:484.
• SuttonM, SternbergM, KoumansEH, et al. The prevalence of Trichomonas vaginalis infection among reproductive-age women in the United States, 2001-2004 . Clin Infect Dis. 2007;45:1319-1326.
• WendelKA, WorkowskiKA. Trichomoniasis: Challenges to appropriate management . Clin Infect Dis. 2007;44:S123-S129.
• WorkowskiKA, BermanS; Center for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010 . MMWR Recomm Rep. 2010;59(RR-12):1-110.
• WorkowskiKA, BolanGA; Centers for Disease Control and Prevention. Sexually transmitted disease treatment guidelines, 2015 . MMWR Recomm Rep. 2015;64:1-137.

See Also (Topic, Algorithm, Electronic Media Element)

• Gonococcal Disease
• Pelvic Inflammatory Disease
• Urethritis
• Vaginal Discharge/Vaginitis

ICD9

• 131.01 Trichomonal vulvovaginitis

• 131.02Trichomonal urethritis

• 131.9Trichomoniasis, unspecified

• 131.00 Urogenital trichomoniasis, unspecified

• 131.03 Trichomonal prostatitis

• 131.09 Other urogenital trichomoniasis

• 131.0 Urogenital trichomoniasis

• 131.8 Trichomoniasis of other specified sites

• 131 Trichomoniasis

ICD10

• A59.01 Trichomonal vulvovaginitis

• A59.03 Trichomonal cystitis and urethritis

• A59.9 Trichomoniasis, unspecified

• A59.00 Urogenital trichomoniasis, unspecified

• A59.09 Other urogenital trichomoniasis

• A59.0 Urogenital trichomoniasis

• A59.8 Trichomoniasis of other sites

• A59 Trichomoniasis

SNOMED

• 56335008 Infection by Trichomonas (disorder)

• 81598001 Trichomonal vulvovaginitis (disorder)

• 30116001 Trichomonal urethritis

• 35089004 Urogenital infection by Trichomonas vaginalis (disorder)

• 276877003Trichomonal vaginitis

• 71590000 Trichomonal prostatitis