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Trichomoniasis

Trichomoniasis, sometimes referred to as "trich" or the ping pong disease, is a common sexually transmitted disease that affects 2 to 3 million Americans yearly. It is caused by a single-celled protozoan parasite called Trichomonas vaginalis. Trichomoniasis is primarily an infection of the genitourinary tract; the urethra is the most common site of infection in men, and the vagina is the most common site of infection in women. more...

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Symptoms

Trichomoniasis, like many other sexually transmitted diseases, often occurs without any symptoms. Men almost never have symptoms, while 20% of women are asymptomatic. When women have symptoms, they usually appear within 5 to 28 days of exposure. The symptoms in women include a heavy, yellow-green or gray vaginal discharge, discomfort during intercourse, vaginal odor, and painful urination. Irritation and itching of the female genital area, and on rare occasions, lower abdominal pain also can be present. In about two-thirds of infected females, there is edema, inflammation, cell hypertrophy and metaplasia. The symptoms in men, if present, include a thin, whitish discharge from the penis and painful or difficult urination.

Complications

Research has shown a link between trichomoniasis and two serious sequelæ. Data suggest that:

Trichomoniasis is associated with increased risk of transmission of HIV.
Trichomoniasis may cause a woman to deliver a low-birth-weight or premature infant.

Additional research is needed to fully explore these relationships.

Prevention

Use of male condoms may help prevent the spread of trichomoniasis, although careful studies have never been done that focus on how to prevent this infection.

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What Is the Best Way to Treat Trichomoniasis in Women?
From American Family Physician, 10/1/01 by John Epling

The Cochrane Abstract below is a summary of a review from the Cochrane Library. It is accompanied by an interpretation to help clinicians put the evidence into practice. John Epling, M.D., presents a clinical scenario and a clinical question based on the Cochrane Abstract, along with the evidence-based answer and a full critique of the abstract.

Clinical Scenario

A 26-year-old woman presents with a yellow vaginal discharge, vaginal itching and soreness, and mild dyspareunia. No cervicitis is found but, on wet mount, numerous motile protozoa consistent with Trichomonas vaginalis are seen.

Clinical Question

What is the most effective treatment strategy for women diagnosed with vaginal trichomoniasis?

Evidence-Based Answer

Nitroimidazoles (such as metronidazole [Flagyl]) are the most effective treatment for parasitological cure of trichomoniasis. Single-dose treatment is as effective as longer term treatment but increases side effects.

Cochrane Critique

Did the authors address focused clinical questions? Yes.

How precise were the results? Where a difference was shown, the confidence intervals were narrow enough to suggest reasonable precision of results.

Can the results be applied to patient care? Yes.

Do the conclusions make biologic and clinical sense? Yes.

Are the benefits worth the harms and costs? Yes.

Were the criteria used to select articles for inclusion appropriate? Yes. In review 1, the authors searched for "randomized or "quasi-randomized" trials. They categorized the trials based on whether the randomization scheme was hidden from the investigators ("allocation concealment").

Is it likely that important relevant articles were missed? Possibly. In review 2, the search does not appear to be as exhaustive as the search in review 1.

Was the validity of the individual articles appraised and were the appraisals reproducible? In review 2, the single author summarized a methodologic assessment similar to that used in the first study, but the assessment was performed by only one reviewer and without the quality assurance step. The lack of explicit detail regarding the methodologic assessment used in review 2 is concerning because it hinders the reader's ability to quickly determine the adequacy of the review.

Were the results similar from study to study? In review 1, the individual trials were generally very small, and the interventions and outcomes in each were sufficiently different that there was significant heterogeneity in the methods and results of the trials. Because of this, the authors could not meaningfully combine the results from these trials in a meta-analysis. In review 2, only one study met the inclusion criteria.

What are the overall results of the reviews? In review 1, the following significant results were found: treatment with nitroimidazoles was better than no treatment in achieving parasitological cure. Short-term treatment (usually as a single dose) was comparable to longer treatment in terms of parasitological cure. The most favorable mode of delivery of medication was oral plus intravaginal, followed by oral alone. Intravaginal nitroimidazoles alone were the least effective mode.

In review 1, a small trial of partner treatment showed that women were more likely to reacquire trichomonas infection if their partners were not also treated. The most powerful conclusion related by the reviewers in review 1 was that in most trials, a single dose of any nitroimidazole resulted in parasitological cure rates above 90 percent, but side effects were common and dose-related.

In review 2, only one study was found that satisfied the inclusion criteria. Low-risk symptomatic and asymptomatic pregnant women were randomized to receive benzoylmetronidazole (50 mL of benzoylmetronidazole equals 2 g of metronidazole) or placebo. The treatment group had a relative risk of 0.11 (95 percent CI, 0.05 to 0.24) of continued parasitological infection, but there was no effect on birth weight or gestational age at delivery.

Practice Pointers

In women with trichomoniasis, physicians can treat both the patient and her partner with a single dose of metronidazole (e.g., one 2-g oral dose) in return for a 90 percent chance of parasitological cure in one month. The use of single-dose therapy should improve compliance, but patients should be warned about the nausea and vomiting that can accompany this high dosage.

Physicians who treat patients with a longer course of lower dose metronidazole (e.g., 250 mg orally three times daily for seven days) should not feel pressured to change their regimen. The lack of more significant data on patient-oriented outcomes, such as symptom relief, infection recurrence and pregnancy outcomes, means that these reviews support single-dose therapy but not as a clearly better choice.

There has historically been concern about the use of metronidazole in the first trimester of pregnancy because of teratogenicity. Review 2 cites two narrative review articles that recommend withholding treatment during the first trimester. The Physicians' Desk Reference(3) lists a contraindication to metronidazole in the first trimester (because of carcinogenicity in rats and potentiation of teratogenicity related to alcohol intake) but notes that the risk and benefits of use at any point in pregnancy should be weighed carefully.

Two meta-analyses(4,5) of cohort, case-control and case series studies analyzing 150,000 and 200,000 patients, respectively, failed to find any evidence of teratogenicity with early pregnancy exposure to metronidazole. As with most pharmacologic therapy in pregnancy, the risks of the infection (including symptoms and risk of HIV transmission) and the risks of the treatment should be explained to the patient, and a decision should be reached with informed consent.

REFERENCES

(1.) Forna F, Gulmezoglu AM. Interventions for treating trichomoniasis in women. Cochrane Database Syst Rev 2000;(3):CD000218.

(2.) Gulmezoglu AM. Interventions for trichomoniasis in pregnancy. Cochrane Database Syst Rev 2000;(2):CD000220.

(3.) Physicians' desk reference, 2000. 54th ed. Montvale, N.J.: Medical Economics, 2000:2917-9.

(4.) Caro-Paton T, Carvajal A, Martin de Diego I, Martin-Arias LH, Alvarez Requejo A, Rodriguez Pinilla E. Is metronidazole teratogenic? A meta-analysis. Br J Clin Pharmacol 1997;44:179-82.

(5.) Burtin P, Taddio A, Ariburnu O, Einarson TR, Koren G. Safety of metronidazole in pregnancy: a meta-analysis. Am J Obstet Gynecol 1995;172(2 pt 1):525-9.

John Epling, M.D., is an assistant professor of family medicine in the Center for Evidence-Based Practice in the Department of Family Medicine at State University of New York-Upstate Medical University, Syracuse.

Address correspondence to John Epling, M.D., Department of Family Medicine, SUNY-Upstate Medical University, 475 Irving Ave., Suite 200, Syracuse, NY 13210 (e-mail: eplingj@upstate.edu). Reprints are not available from the author.