Trichomoniasis
Overview
- In Australia, trichomonas is more common in older women and women from regional and remote areas, especially Aboriginal & Torres Strait Islander women
- Uncommon cause of vaginal discharge or male urethritis in urban settings
- Long natural history (years) if not treated in women
- Without treatment, the infection is cleared more quickly in men than women.
Cause
Trichomonas vaginalis, a protozoan which infects the vagina, urethra and paraurethral glands.
Clinical presentation
| Male | Female |
| Symptoms | |
| Usually asymptomatic. See chlamydia for more information | Malodourous vaginal discharge - typically profuse and frothy |
| Urethral discharge (uncommon) | Vulval itch/soreness |
| Dysuria (uncommon) | Cervicitis |
| Complications | |
| Associated with prostatitis | Associated with premature rupture of membranes, pre-term delivery and low birth weight |
| Post-partum sepsis | |
Special considerations
- Up to 50% of infected women are asymptomatic, men are usually asymptomatic.
- May enhance HIV transmission.
Diagnosis
- Testing is not routinely recommended for men with urethritis
- Treat male contacts presumptively.
| Diagnosis in males | ||
|---|---|---|
| Test | Site/Specimen | Consideration |
| NAAT |
FPU | Available in major laboratories in each state |
| NAAT – Nucleic Acid Amplification Test FPU – First pass urine |
||
| Diagnosis in females | ||
|---|---|---|
| Test | Site/Specimen | Consideration |
| NAAT |
High vaginal swab or FPU |
High vaginal swab should ideally be clinician collected during pelvic examination but can be self-collected if client declines examination. |
| Other |
High vaginal swab (wet prep) |
TV can be found on a high vaginal swab (wet prep) by the laboratory if TV is requested. However this test has poor sensitivity compared to NAAT testing. |
|
NAAT – Nucleic Acid Amplification Test |
||
Specimen collection
Clinician collected | Self-collection
Investigations
- NAAT testing for Trichomonas vaginalis is currently available through some private pathology companies and the following laboratories:
- NSW: SydPath, St Vincent’s PathologyDarlinghurst & Pathology West – ICPMR, Westmead Hospital, Westmead
- QLD: QML Pathology, Brisbane & Queensland Pathology
- SA: SA Pathology, Adelaide
- VIC: Core Laboratory, The Royal Women’s Hospital, Melbourne
- WA: PathWest Laboratory, Queen Elizabeth II Medical Centre, Perth
- Cervical screening (Pap smear) and urine or high vaginal samples may report trichomonas but these results must be confirmed by NAAT before initiating treatment
- Cervical screening alone is not diagnostic of trichmonas
Management
| Principal Treatment Options | ||
|---|---|---|
| Situation | Recommended | Alternative |
| Uncomplicated infection |
Metronidazole 2g PO with food, stat. |
Metronidazole 400mg PO with food, BD for 5 days. |
Treatment advice
- Reinfection and poor adherence should be ruled out in persistent or recurrent infection
- Treatment failures with single-dose metronidazole should trial single dose tinidazole or extended metronidazole therapy
- High-level metronidazole resistance has been reported, although incidence is believed to be low. Reports indicate successful treatment with extended doses of oral or intra vagina tinidazole for these patients – discuss with local sexual health clinic
- Avoid alcohol with metronidazole and tinidazole treatment and for 24 hours thereafter.
Other immediate management
- Advise no sexual contact for 7 days after treatment is administered and their current sexual partner is treated
- Contact tracing
- Provide patient with factsheet
- Trichomoniasis is only a notifiable condition in the NT.
Special treatment situations
Special considerations
- Single-dose treatments are advised.
- Consider seeking specialist advice before treating any complicated presentation.
| Situation | Recommended |
|---|---|
Pregnant women  |
Due to conflicting outcomes of treating in pregnancy, seek specialist advice |
| Breastfeeding | Consider intravaginal treatment. Metronidazole may affect taste of breast milk; avoid high doses in breastfeeding. |
| Allergy to principal treatment choice | There is no effective alternative to 5 nitroimidazole compounds. Metronidazole desensitisation has been described |
| People who are HIV positive | Reports indicate single-dose metronidazole is less effective than extended metronidazole. |
Contact tracing
- For all sexual partners
- There is currently insufficient data to provide a definitive period for this, partner treatment encouraged presumptively.
See Australasian Contact Tracing Manual - Trichomoniasis for more information.
Follow up
Review in 1 week provides an opportunity to:
- Confirm patient adherence with treatment and assess for symptom resolution
- Confirm contact tracing procedures have been undertaken or offer more contact tracing support
- Provide further sexual health education and prevention counselling.
Test of Cure (TOC)
Not recommended.
Retesting
- For patients who remain symptomatic or where partner treatment remains uncertain, retesting should be performed after 4 weeks
- This also provides the opportunity to retest, post the window period, for other STIs.
Auditable outcomes
100% of women diagnosed are treated with recommended principle treatment option.
References
- Dize, Laura. Agreda, Patricia. Quinn, Nicole. Barnes, Mathilda R. Hsieh, Yu-Hsiang. Gaydos, Charlotte A. Comparison of self-obtained penile-meatal swabs to urine for the detection of C. trachomatis, N. gonorrhoeae and T. vaginalis. Sexually Transmitted Infections. 89(4):305-7, 2013 Jun.
- Lusk, Josephine. Naing, Zin. Rayner, Ben. Rismanto, Nikolas. McIver, Christopher. Cumming, Robert. McGeechan, Kevin. Rawlinson, William. Konecny, Pam. Trichomonas vaginalis: underdiagnosis in urban Australia could facilitate re-emergence. Sex Transm Infections. 86:227-230, 2010.
- https://www.bashh.org/guidelines
Last Updated: Thursday, 29 March 2018