Guidelines 2016 – Trichomoniasis
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
Infection with trichomonas is usually sexually transmitted and found in the vagina and urethra of women and the urethra of males.
II. ETIOLOGY
The parasitic protozoan flagellate, T. vaginalis
III. HISTORY
A. What the patient may present with
1. Foul-smelling, diffuse vaginal discharge, often fishy
2. Burning and soreness of vulva, perineum, thighs
3. Vaginal and perineal itching
4. Dyspareunia, dysuria
5. Postcoital bleeding
6. Possibly no objective symptoms
B. Additional information to be considered
1. Previous vaginal infection, vaginosis; diagnosis, treatment; compliance with treatment
2. Sexual activity; partner preference (do not disregard possibility of women having sex with women)
3. History of STI or PID
4. LMP
5. Last intercourse, sexual contact
6. Method of birth control; other medications
7. History of chronic illness (especially seizure disorders)
8. Description of discharge
a. Color
b. Onset
c. Odor
d. Consistency
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e. Amount
f. Constant versus intermittent
g. Relationship to menses
h. Relationship to sexual contact
9. Whether or not partner has symptoms
IV. PHYSICAL EXAMINATION
A. External examination: observe perineum for excoriation, erythema, edema, ulceration, or lesions
B. Vaginal examination (speculum)
1. Inspection of vaginal walls; red papules may appear
2. Inspection of cervix: strawberry appearance of cervix and upper vagina because of petechiae
3. Discharge: greenish, yellow, malodorous, frothy with a pH greater than 4.5 (5.0–7.0)
C. Bimanual examination
V. LABORATORY EXAMINATION
A. Wet prep microscopic examination; should see highly motile cells, slightly larger than leukocytes, smaller than epithelial cells; more than 10 WBCs per high-power field
B. GC culture, Chlamydia test, serology testing for syphilis if history indicates; culture for T. vaginalis; DNA probe for T. vaginalis
C. CBC should be done if more than two courses of metronidazole taken within a 2-month period
D. KOH whiff test: sometimes fishy but not always
E. OSOM Trichomonas Rapid Test—dipstick of vaginal swab; 83% sensitivity
F. Affirm VPIII results available in 45 minutes (noting that with this test and OSOM, false positives can occur)
G. Modified Amplicor for T. vaginalis in vaginal or endocervical swabs and urine (sensitivity 88%–97%; specificity 98%–99%)
VI. DIFFERENTIAL DIAGNOSIS
A. Candidiasis
B. Bacterial vaginosis
C. Urinary tract infection
D. Gonorrhea
E. Chlamydia infection
VII. TREATMENT
A. Medications
1. Metronidazole (Flagyl, Metryl, Protostat, Satric) 2 g orally in single dose (review history for seizure disorder) or
2. Tinidazole (Tindamax) 2 g orally in a single dose with food (tablets come in 250 and 500 mg; pregnancy category C)
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3. Alternative regimen: metronidazole 500 mg orally twice a day for 7 days
4. In pregnancy at any stage: metronidazole 2 g orally in single dose
5. Note: Metronidazole gel: not recommended (< 50% efficacious as therapeutic levels are not achieved in the urethra or perivaginal glands)
6. Lactation: Tindamax single dose; interruption of breastfeeding for 72 hours following treatment
7. Refer sex partners for treatment
8. Treatment failure with metronidazole 2 g single dose: exclude reinfection and treat with metronidazole 500 mg orally twice daily for 7 days; for patients failing this regimen, treat with tinidazole or metronidazole 2 g orally for 5 days
9. Consult with specialist if the previous regimens are not effective
B. General measures
1. Stress the importance of not drinking alcohol during treatment or for 48 hours after treatment; with Tindamax 72 hours
2. Metronidazole can cause GI upset; also causes urine to darken
3. Stress avoidance of intercourse during treatment; if intercourse does occur, condoms should be used
4. Stress the importance of completing medication
5. Stress personal hygiene; cotton underpants, no underpants while sleeping, wipe front first and then back
6. Patient should be given informational handout to deliver to sexual partner advising need for partner’s treatment
7. Stress comfort measures for severe symptoms: sitz baths
8. Stress that if partner is not treated before next act of unprotected intercourse, reinfection can occur
VIII. COMPLICATIONS
A. Disease complications
1. Spread of the infection to the urethra or to prostate in the male
2. Untreated T. vaginalis may result in atypia on Pap smear; may also be associated with adverse pregnancy outcomes (premature rupture of membranes and premature delivery); increased susceptibility to HIV acquisition
3. Adverse pregnancy outcomes: premature rupture of membranes, preterm delivery, low birth weight
B. Treatment complications
1. Nausea
2. Neurologic symptoms: seizures
3. Vomiting (may be severe) if alcohol is consumed while on treatment or within 48 hours after treatment
4. Possibility of blood dyscrasia posttreatment
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IX. CONSULTATION/REFERRAL
A. Refer to physician if the woman has seizure disorder prior to initiating therapy
B. Refer if the woman is pregnant
C. Consult if treatment (see Trichomoniasis, Treatment, VII.A.1 and VII.A.2) fails
X. FOLLOW-UP
Consider rescreening at 3 months (because of high rate of reinfection) for sexually active women
See Appendix I and Bibliographies.
Website: www.cdc.gov/std/tg2015/tg-2015-Print.pdf
NOTES
1. Adapted from material developed by R. M. C. Secor (1997). Vaginal microscopy: Refining the nurse practitioner’s technique. Clinical Excellence for Nurse Practitioners, 1(1), 29–34; and from H. A. Carcio & R. M. C. Secor (Eds.). (2015). Vaginal microscopy. In Advanced health assessment of women (3rd ed.). New York, NY: Springer Publishing Company.
2. Note that KOH should be used with care because it is very damaging to the microscope.
3. Rewritten and updated by Thomas J. Loveless, PhD, CRNP, Clinical Assistant Professor, Rutgers University, Newark, New Jersey Adult Nurse Practitioner/HIV Specialist, Infectious Disease Associates, P. C., Philadelphia, Pennsylvania.