Trichomoniasis

Trichomoniasis is one of the most common diseases of the genito-urinary tract and occupies one of the first places among STDs.

Causes of Trichomoniasis

Trichomoniasis is caused by the simplest Trichomonas vaginalis. Most men infected with T. Vaginalis have no symptoms, although a small amount shows non-nasal urethritis. In women, most of whom have symptoms, T. Vaginalis causes characteristic diffuse yellow-green discharge with an unpleasant odor and vulvar irritation, although many women have minor symptoms. Recently, evidence has been obtained of a possible association between vaginal trichomoniasis and adverse pregnancy outcomes, especially early bladder rupture and premature births.

Trichomonas vaginalis - flagellated protozoa. It is an infection that is transmitted exclusively to adults through sexual intercourse. Trichomonas is a unicellular parasite, the signs of which are:

• ability to repeat the relief of the epithelial cell, penetrate into the intercellular spaces and invaginate into the host cell;
• fix on its surface a large amount of antitrypsin, which provides protection;
• dependence of virulence on their hemolytic activity;
• infection develops only after intravaginal or intraaural inoculation of the microorganism;
• presence on the surface of Trichomonas proteolytic enzymes, which contribute to a significant loosening of tissues and a more free penetration into the intercellular spaces of toxic metabolic products of the accompanying flora;
• pronounced chemotaxis of polymorphonuclear leukocytes.

[1], [2], [3], [4], [5]

Symptoms of Trichomoniasis

Clinical manifestations in women are characterized by discharge from the vagina liquid, greenish-yellow - up to 70%, from 10-30% of cases - frothy. Patients report itching and burning in the vulva, dysuric phenomena that increase during menopause. In 30-50% of patients there are no complaints. The main lesion is the vagina, urethra, the vaginal part of the cervix. Skin and mucous of the labia majora, vestibule and vagina are edematic, hyperemic, covered with secretions. Characteristic liquid, purulent, foamy greenish-yellow discharge. When viewed in mirrors: the cervix is edematic, there are punctate hemorrhagic areas with signs of erosion. This characteristic is typical for trichomoniasis and is found in 40% of women with colposcopy.

Complications of trichomoniasis in women are observed in the form of vulvitis, bartholinitis, endocervicitis, rupture of the bladder, premature birth and infertility.

Indications for laboratory testing for trichomoniasis in women

Change in the nature of vaginal discharge compared with the norm, detection of trichomoniasis in the sexual partner, absence of positive changes in the nature of vaginal discharge after empirical treatment, remaining pruritus of the vulva after the empirical treatment with antifungal drugs.

Clinical manifestations of trichomoniasis in men proceed according to the type of transient and asymptomatic carriage, which is observed in 10-36%. Symptomatic complaints - a burning sensation in the urethra, there are scanty gray or whitish-watery discharge. Also observed are dysuric phenomena.

Complications of trichomoniasis in men are diagnosed as epididymitis, prostatitis, vesiculitis, urethral stricture, erectile dysfunction and infertility.

Indications for laboratory testing for trichomoniasis in men

Discharge from the urethra, dysuria, burning and itching in the urethra, irritation in the penis, reproductive disorders, erectile dysfunction, orhoepididymitis, prostatitis.

Classification of Trichomoniasis

Depending on the duration of the disease and the intensity of the body's reaction to the introduction of the causative agent, the following forms of trichomoniasis are distinguished:

1. fresh, acute, subacute, torpid (malosymptomatic);
2. chronic (torpid current and prescription of the disease over 2 months);
3. trichomonadonositelstvo (in the presence of trichomonads, there are no objective and subjective symptoms of the disease).

[6], [7], [8], [9],

Laboratory diagnosis of trichomoniasis

Conduct a microscopy of the native and colored preparation. In native preparations, the vaginal trichomonas is determined by the pear-shaped or oval shape of the body, which is a little bit larger than the leukocyte, with a characteristic jerky movement and flagellum. The advantage of studying trichomonads in colored preparations is the possibility of their study after a long time after taking the material. In colored preparations (methylene blue, according to Gram), they have an oval, round or pear-shaped form with well-defined contours and a gently cellular structure of the cytoplasm.

To detect a more delicate structure of trichomonads, more complex methods of staining (Romanovsky-Giemsa, Heidenhain, Leishman) are used. These methods allow to identify the causative agent of the disease from 40 to 80% of cases.

Cultural studies using special media can detect up to 95% of cases.

Treating Trichomoniasis

Effective is metronidazole (trichopolum, flagel). Metronidazole is applied to 0.25 g 2 times a day for 10 days; on the course - 0.5 g or the first 4 days for 0.25 g 3 times a day, the remaining 4 days - 0.25 g 2 times a day; for a course of 5.5 g. Tipidazole (fazijin) is administered once in a dose of 2.0 g (four tablets). With resistance of trichomoniasis to metronidazole, oripizol (orpidazole) is effective. In uncomplicated trichomoniasis, it is used 1.5-2.0 g once, in case of complicated trichomoniasis, 500 mg twice a day for 5-10 days.

The recommended scheme of treatment of trichomoniasis

Metronidazole 2 g orally once.

Alternative scheme

Metronidazole 500 mg twice twice a day for 7 days.

In the United States, only oral metronidazole is used to treat trichomoniasis. Randomized trials have shown that the probability of cure with recommended metronidazole regimens is approximately 90% -95%, treatment of sexual partners can increase this level of cure. Treatment of patients and sexual partners leads to the disappearance of symptoms, microbiological cure and a reduction in the likelihood of transmission of infection. Metronidazole gel has been approved for the treatment of bacterial vaginosis, but like other local antibacterial drugs whose concentration does not reach the therapeutic level in the urethra or in the bartholin glands, it is significantly less effective in treating trichomoniasis than oral metronidazole preparations and therefore not recommended for use . Some other local antibacterial drugs are used to treat trichomoniasis, but probably their efficacy is not higher than that of metronidazole gel.

Follow-up

Follow-up is not necessary for men and women who have had symptoms after treatment, or who initially did not have symptoms.

Infections caused by strains of T. Vaginalis with reduced sensitivity to metronidazole may occur. However, most of these microorganisms were eliminated after using higher doses of the drug. If the treatment regimen is broken, the patient should be treated repeatedly according to the scheme: metronidazole 500 mg 2 times a day for 7 days. If the treatment is again ineffective, it is necessary to appoint the patient metronidazole 2 g once a day for 3-5 days.

Patients in whom the infection is confirmed by culture isolation, and treatment performed according to the regimens recommended in this manual proved ineffective, and who have been excluded from reinfection, should be consulted by the expert; consultations are available from the CDC. When evaluating such cases, it is necessary to determine the sensitivity of T. Vaginalis to metronidazole.

NB! The FDA approved the use of Flagyl 375 ™ - twice daily for 7 days - for the treatment of trichomoniasis, based on pharmacokinetic similarities with metronidazole 250 mg three times daily for 7 days. However, there is no clinical evidence to support the clinical similarity between the two regimens.

[10], [11], [12], [13], [14],

Management of sexual partners

Sexual partners should be treated. Patients should be warned about the need to avoid sexual intercourse before recovery. If there is no microbiological confirmation of the cure, this means - until the treatment is completed and the patient and his partners have no symptoms of the disease.

Special Remarks

Allergy, intolerance and side effects

There are no effective alternative to metronidazole treatment regimens. Patients with an allergy to metronidazole may be given a desensitization.

Pregnancy

Patients can be treated with metronidazole at a dose of 2 g per single dose.

HIV infection

Persons with HIV infection and trichomoniasis should receive the same treatment as patients without HIV infection.