.jpg)
Win an iPod
Trichomoniasis: An update for clinicians
| Author: Jill Huppert, M.D., M.P.H. |
| Article Date: 10/1/2007 |
What is Trichomoniais?:
Trichomonas vaginalis (TV) is the infectious agent responsible for the condition often referred to as trichomoniasis. The organism is a flagellated, motile protozoan whose ecologic niche is human vaginal and urethral epithelial cells. TV is now recognized as an important, but often undetected, sexually transmitted infection (STI).
How many people have TV?
In the past, it has been difficult to accurately measure true TV prevalence. Unlike other STIs such as Chlamydia, gonorrhea and HIV, TV infection is not a reportable condition. In addition the most commonly used test to detect TV is the wet mount, an in-office test that only detects about 35-60% of infections in women. 1 There are no good tests for TV in men. Despite these difficulties, several authors have estimated that TV is the most widely prevalent non-viral STI in the US and in the world. 2, 3
Recently published national prevalence data using sensitive nucleic acid amplification tests now provides compelling evidence that the burden of infection is as high as was estimated in the past, and that asymptomatic infections are common. A longitudinal study of young men and women (age 18-26) demonstrated that TV was nearly as common as Chlamydia and more common than gonorrhea. In addition, 95% of those with documented TV reported no symptoms in the week prior to testing4. More recent data from NHANES confirmed these findings. One ominous finding is that higher TV prevalence is found among populations known to be at high risk for HIV: women, African Americans, and the Southeastern area of the US.
So what:
TV can cause symptoms such as vaginitis and cervicitis in women and urethritis in women and men.5 However, in most cases the infection is asymptomatic. Like other STIs, asymptomatic infection is not innocuous, and can lead to other more serious consequences. For example, TV has been linked to higher rates of pelvic inflammatory disease, and there are some reports of poor obstetric outcomes such as miscarriage and preterm births.6, 7 However, new studies report alarming associations between TV and serious viral infections such as herpes simplex (HSV), human papillomavirus (HPV), and human immunodeficiency virus (HIV). Women with TV are at higher risk of acquiring herpes.8 Women with TV are unable to clear HPV as quickly as those unaffected with TV 9, and thus may be at higher risk of progressing to cervical cancer. Women and men infected with HIV and TV shed more HIV in their secretions than those without TV, making them more dangerous to their sex partners.5, 10 Women with TV have a 50% increased risk of acquiring HIV 11.
Well, thatÕs discouraging. Now what:
Several new tests for TV have been developed that can assist clinicians in accurately detecting TV in women. Culture has been available for years, but the InPouch TV¨ culture provides a convenient stable media for inoculation, transport and growth of TV.12 Pouches are inexpensive, but require a microbiology laboratory and personnel, and results are available in 1-5 days. The OSOM TV rapid antigen test employs an enzyme linked detection of antibodies on a ÒdipstickÓ, much like a rapid strep test, with results available in under 10 minutes.13 Both culture and rapid test increase the proportion of infections detected over wet mount (up to 90%) with no false positives.14 Nucleic acid amplification tests demonstrate great sensitivity and high specificity in research settings, but are not yet commercially available. Of the presently available methods, culture of urethral swabs, semen or urine sediment is the best approach to TV detection in men, but is less sensitive than culture in women. Unfortunately, few public health laboratories even offer new TV tests.15
For clinicians who work in settings where a pelvic exam is not feasible, self-obtained vaginal swabs can be used for TV tests such as wet mount, culture and rapid tests.16 As test development continues, in the future, a single swab or urine sample may be enough to detect multiple STIs.
What if I detect more TV?
TV is easily treated with a single 2 gram dose of metronidazole or tinidizole.17 Both the infected patient and all sex partners should be treated, and should abstain from sex for the next week. Detection of any STI should spur the provider to offer testing for all other STIs including HIV, and to offer prevention and counseling messages.
Summary:
TV is a widespread STI that is often neglected. New TV tests are now available, making TV one of the easiest STIs to detect and treat. Better detection of TV will pave the way for HIV prevention, and should be a goal of all physicians in the US.
Jill Huppert, M.D., M.P.H. Assistant Professor of ÊPediatrics and OB/GYN Cincinnati Children's Hospital Medical Center Division of Adolescent Medicine 3333 Burnet Avenue, ML 4000 Cincinnati, OH 45229-3039 Phone: Ê513-636-7042 FAX: Ê513-636-8844 Email: Êjill.huppert@cchmc.org
1. Wiese W, Patel SR, Patel SC, Ohl CA, Estrada CA: A meta-analysis of the Papanicolaou smear and wet mount for the diagnosis of vaginal trichomoniasis. Am J Med 2000, 108:301-308.
2. Cates W, Jr.: Estimates of the incidence and prevalence of sexually transmitted diseases in the United States. American Social Health Association Panel. Sex Transm Dis 1999, 26:S2-7.
3. Weinstock H, Berman S, Cates W, Jr.: Sexually transmitted diseases among american youth: incidence and prevalence estimates,2000. Perspect Sex Reprod Health 2004, 36:6-10.
4. Miller WC, Swygard H, Hobbs MM, Ford CA, Handcock MS, Morris M, Schmitz JL, Cohen MS, Harris KM, Udry JR: The prevalence of trichomoniasis in young adults in the United States. Sex Transm Dis 2005, 32:593-598.
5. Hobbs MM, Kazembe P, Reed AW, Miller WC, Nkata E, Zimba D, Daly CC, Chakraborty H, Cohen MS, Hoffman I: Trichomonas vaginalis as a cause of urethritis in Malawian men. Sex Transm Dis 1999, 26:381-387.
6. Paisarntantiwong R, Brockmann S, Clarke L, Landesman S, Feldman J, Minkoff H: The relationship of vaginal trichomoniasis and pelvic inflammatory disease among women colonized with Chlamydia trachomatis. Sex Transm Dis 1995, 22:344-347.
7. Kienstra AJ, Ward MA: Third place winner. Three-year-old female with intermittent ovarian torsion. J Emerg Med 2002, 23:375-377.
8. Gottlieb SL, Douglas JM, Jr., Foster M, Schmid DS, Newman DR, Baron AE, Bolan G, Iatesta M, Malotte CK, Zenilman J, et al: Incidence of herpes simplex virus type 2 infection in 5 sexually transmitted disease (STD) clinics and the effect of HIV/STD risk-reduction counseling. J Infect Dis 2004, 190:1059-1067.
9. Shew ML, Fortenberry JD, Tu W, Juliar BE, Batteiger BE, Qadadri B, Brown DR: Association of condom use, sexual behaviors, and sexually transmitted infections with the duration of genital human papillomavirus infection among adolescent women. Arch Pediatr Adolesc Med 2006, 160:151-156.
10. Wang CC, McClelland RS, Reilly M, Overbaugh J, Emery SR, Mandaliya K, Chohan B, Ndinya-Achola J, Bwayo J, Kreiss JK: The effect of treatment of vaginal infections on shedding of human immunodeficiency virus type 1. J Infect Dis 2001, 183:1017-1022.
11. McClelland RS, Sangare L, Hassan WM, Lavreys L, Mandaliya K, Kiarie J, Ndinya-Achola J, Jaoko W, Baeten JM: Infection with Trichomonas vaginalis increases the risk of HIV-1 acquisition. J Infect Dis 2007, 195:698-702.
12. Borchardt KA, Zhang MZ, Shing H, Flink K: A comparison of the sensitivity of the InPouch TV, Diamond's and Trichosel media for detection of Trichomonas vaginalis. Genitourin Med 1997, 73:297-298.
13. Huppert JS, Batteiger BE, Braslins P, Feldman JA, Hobbs MM, Sankey HZ, Sena AC, Wendel KA: Use of an immunochromatographic assay for rapid detection of Trichomonas vaginalis in vaginal specimens. J Clin Microbiol 2005, 43:684-687.
14. Huppert JS, Mortensen JE, Reed JL, Kahn JA, Rich KD, Miller WC, Hobbs MM: Rapid antigen testing compares favorably with transcription-mediated amplification assay for the detection of Trichomonas vaginalis in young women. Clin Infect Dis 2007, 45:194-198.
15. Dicker LW, Mosure DJ, Steece R, Stone KM: Testing for sexually transmitted diseases in U.S. Public health laboratories in 2004. Sex Transm Dis 2007, 34:41-46.
16. Crucitti T, Van Dyck E, Tehe A, Abdellati S, Vuylsteke B, Buve A, Laga M: Comparison of culture and different PCR assays for detection of Trichomonas vaginalis in self collected vaginal swab specimens. Sex Transm Infect 2003, 79:393-398.
17. Forna F, Gulmezoglu AM: Interventions for treating trichomoniasis in women. Cochrane Database Syst Rev 2003:CD000218.
Trichomonas vaginalis (TV) is the infectious agent responsible for the condition often referred to as trichomoniasis. The organism is a flagellated, motile protozoan whose ecologic niche is human vaginal and urethral epithelial cells. TV is now recognized as an important, but often undetected, sexually transmitted infection (STI).
How many people have TV?
In the past, it has been difficult to accurately measure true TV prevalence. Unlike other STIs such as Chlamydia, gonorrhea and HIV, TV infection is not a reportable condition. In addition the most commonly used test to detect TV is the wet mount, an in-office test that only detects about 35-60% of infections in women. 1 There are no good tests for TV in men. Despite these difficulties, several authors have estimated that TV is the most widely prevalent non-viral STI in the US and in the world. 2, 3
Recently published national prevalence data using sensitive nucleic acid amplification tests now provides compelling evidence that the burden of infection is as high as was estimated in the past, and that asymptomatic infections are common. A longitudinal study of young men and women (age 18-26) demonstrated that TV was nearly as common as Chlamydia and more common than gonorrhea. In addition, 95% of those with documented TV reported no symptoms in the week prior to testing4. More recent data from NHANES confirmed these findings. One ominous finding is that higher TV prevalence is found among populations known to be at high risk for HIV: women, African Americans, and the Southeastern area of the US.
So what:
TV can cause symptoms such as vaginitis and cervicitis in women and urethritis in women and men.5 However, in most cases the infection is asymptomatic. Like other STIs, asymptomatic infection is not innocuous, and can lead to other more serious consequences. For example, TV has been linked to higher rates of pelvic inflammatory disease, and there are some reports of poor obstetric outcomes such as miscarriage and preterm births.6, 7 However, new studies report alarming associations between TV and serious viral infections such as herpes simplex (HSV), human papillomavirus (HPV), and human immunodeficiency virus (HIV). Women with TV are at higher risk of acquiring herpes.8 Women with TV are unable to clear HPV as quickly as those unaffected with TV 9, and thus may be at higher risk of progressing to cervical cancer. Women and men infected with HIV and TV shed more HIV in their secretions than those without TV, making them more dangerous to their sex partners.5, 10 Women with TV have a 50% increased risk of acquiring HIV 11.
Well, thatÕs discouraging. Now what:
Several new tests for TV have been developed that can assist clinicians in accurately detecting TV in women. Culture has been available for years, but the InPouch TV¨ culture provides a convenient stable media for inoculation, transport and growth of TV.12 Pouches are inexpensive, but require a microbiology laboratory and personnel, and results are available in 1-5 days. The OSOM TV rapid antigen test employs an enzyme linked detection of antibodies on a ÒdipstickÓ, much like a rapid strep test, with results available in under 10 minutes.13 Both culture and rapid test increase the proportion of infections detected over wet mount (up to 90%) with no false positives.14 Nucleic acid amplification tests demonstrate great sensitivity and high specificity in research settings, but are not yet commercially available. Of the presently available methods, culture of urethral swabs, semen or urine sediment is the best approach to TV detection in men, but is less sensitive than culture in women. Unfortunately, few public health laboratories even offer new TV tests.15
For clinicians who work in settings where a pelvic exam is not feasible, self-obtained vaginal swabs can be used for TV tests such as wet mount, culture and rapid tests.16 As test development continues, in the future, a single swab or urine sample may be enough to detect multiple STIs.
What if I detect more TV?
TV is easily treated with a single 2 gram dose of metronidazole or tinidizole.17 Both the infected patient and all sex partners should be treated, and should abstain from sex for the next week. Detection of any STI should spur the provider to offer testing for all other STIs including HIV, and to offer prevention and counseling messages.
Summary:
TV is a widespread STI that is often neglected. New TV tests are now available, making TV one of the easiest STIs to detect and treat. Better detection of TV will pave the way for HIV prevention, and should be a goal of all physicians in the US.
Jill Huppert, M.D., M.P.H. Assistant Professor of ÊPediatrics and OB/GYN Cincinnati Children's Hospital Medical Center Division of Adolescent Medicine 3333 Burnet Avenue, ML 4000 Cincinnati, OH 45229-3039 Phone: Ê513-636-7042 FAX: Ê513-636-8844 Email: Êjill.huppert@cchmc.org
1. Wiese W, Patel SR, Patel SC, Ohl CA, Estrada CA: A meta-analysis of the Papanicolaou smear and wet mount for the diagnosis of vaginal trichomoniasis. Am J Med 2000, 108:301-308.
2. Cates W, Jr.: Estimates of the incidence and prevalence of sexually transmitted diseases in the United States. American Social Health Association Panel. Sex Transm Dis 1999, 26:S2-7.
3. Weinstock H, Berman S, Cates W, Jr.: Sexually transmitted diseases among american youth: incidence and prevalence estimates,2000. Perspect Sex Reprod Health 2004, 36:6-10.
4. Miller WC, Swygard H, Hobbs MM, Ford CA, Handcock MS, Morris M, Schmitz JL, Cohen MS, Harris KM, Udry JR: The prevalence of trichomoniasis in young adults in the United States. Sex Transm Dis 2005, 32:593-598.
5. Hobbs MM, Kazembe P, Reed AW, Miller WC, Nkata E, Zimba D, Daly CC, Chakraborty H, Cohen MS, Hoffman I: Trichomonas vaginalis as a cause of urethritis in Malawian men. Sex Transm Dis 1999, 26:381-387.
6. Paisarntantiwong R, Brockmann S, Clarke L, Landesman S, Feldman J, Minkoff H: The relationship of vaginal trichomoniasis and pelvic inflammatory disease among women colonized with Chlamydia trachomatis. Sex Transm Dis 1995, 22:344-347.
7. Kienstra AJ, Ward MA: Third place winner. Three-year-old female with intermittent ovarian torsion. J Emerg Med 2002, 23:375-377.
8. Gottlieb SL, Douglas JM, Jr., Foster M, Schmid DS, Newman DR, Baron AE, Bolan G, Iatesta M, Malotte CK, Zenilman J, et al: Incidence of herpes simplex virus type 2 infection in 5 sexually transmitted disease (STD) clinics and the effect of HIV/STD risk-reduction counseling. J Infect Dis 2004, 190:1059-1067.
9. Shew ML, Fortenberry JD, Tu W, Juliar BE, Batteiger BE, Qadadri B, Brown DR: Association of condom use, sexual behaviors, and sexually transmitted infections with the duration of genital human papillomavirus infection among adolescent women. Arch Pediatr Adolesc Med 2006, 160:151-156.
10. Wang CC, McClelland RS, Reilly M, Overbaugh J, Emery SR, Mandaliya K, Chohan B, Ndinya-Achola J, Bwayo J, Kreiss JK: The effect of treatment of vaginal infections on shedding of human immunodeficiency virus type 1. J Infect Dis 2001, 183:1017-1022.
11. McClelland RS, Sangare L, Hassan WM, Lavreys L, Mandaliya K, Kiarie J, Ndinya-Achola J, Jaoko W, Baeten JM: Infection with Trichomonas vaginalis increases the risk of HIV-1 acquisition. J Infect Dis 2007, 195:698-702.
12. Borchardt KA, Zhang MZ, Shing H, Flink K: A comparison of the sensitivity of the InPouch TV, Diamond's and Trichosel media for detection of Trichomonas vaginalis. Genitourin Med 1997, 73:297-298.
13. Huppert JS, Batteiger BE, Braslins P, Feldman JA, Hobbs MM, Sankey HZ, Sena AC, Wendel KA: Use of an immunochromatographic assay for rapid detection of Trichomonas vaginalis in vaginal specimens. J Clin Microbiol 2005, 43:684-687.
14. Huppert JS, Mortensen JE, Reed JL, Kahn JA, Rich KD, Miller WC, Hobbs MM: Rapid antigen testing compares favorably with transcription-mediated amplification assay for the detection of Trichomonas vaginalis in young women. Clin Infect Dis 2007, 45:194-198.
15. Dicker LW, Mosure DJ, Steece R, Stone KM: Testing for sexually transmitted diseases in U.S. Public health laboratories in 2004. Sex Transm Dis 2007, 34:41-46.
16. Crucitti T, Van Dyck E, Tehe A, Abdellati S, Vuylsteke B, Buve A, Laga M: Comparison of culture and different PCR assays for detection of Trichomonas vaginalis in self collected vaginal swab specimens. Sex Transm Infect 2003, 79:393-398.
17. Forna F, Gulmezoglu AM: Interventions for treating trichomoniasis in women. Cochrane Database Syst Rev 2003:CD000218.