TRICHOMONIASIS

by Major M. P. Vora, M.B.B.S., D.V.D., I.M.S. (Rtd.)

Ex. Hon. Sr. Venereologist.

St. George’s Hospital, Bombay.

Indian Medical Record

Oldest monthly journal of Public Health, Tropical Medicine & Surgery etc. Devoted to the interest of the medical profession in the East.

Volume No- LXXXVIII, Number. 7 of July 1968, Calcutta.

Page no. 107 to 109.

Trichomonas vaginalis was first demonstrated by Donne (1836) in vaginal discharges. A protozoa with a oval or pear-shape has the size of about two times the size of a polymorphonueclear leucocyte. It measures from 12 to 24 µ in length and from 6 to 18 µ in width. It has a nuecleus situated anteriorly and between the nuecleus and the surface of the broader end of the organism lie one or more rounded structures, “blapharoplasts”, from which arise four flagella and an undulating membrane to extend down for about ¾ of its margin of one side of the body. These flagellae help the organism in its typical movements. A large narrow axostyle extends posteriorly from the nuecleus to project beyond the margin of the cytoplasma. The organism can be identified by direct microscopic examination with either 1/6 or 1/12 objective in a freshly obtained sample of the secretion. It can be seen under the dark-field microscopy. It can be cultured on artificial medium composed of Loeffer’s dehydrated blood serum. The combination of tests by smear and culture is more reliable than a single test in the diagnosis of trichomoniasis.

Infestation in the male is usually acquired by sexual contacts. Incubation period varies from 10 to 20 days. It causes acute, subacute or chronic low-grade urethritis. When symptoms are present, they may be acute or mild and consist of burning, profuse or scanty urethral discharge, itching, balanitis and balano-posthitis. The infestation may be associated with gonorrhoea or non-gonococcal urethritis. The organism is found to affect the preputial sac, the anterior and the posterior urethra, the prostate, seminal vesicles and the epididymis. Complications are known to occur as in gonorrhoea but they are usually of mild nature. Recurrent attacks of prostato-vesiculitis are common. The diagnosis is confirmed by finding the organism in the secretion from either the urethra, the preputial sac or the prostate.

Infestation in the female with T. vaginalis is quite common especially during the times of her active sexual life. The infection is often acquired by sexual intercourse or by accidental contamination. By the time the patient seeks medical advice, the condition is already of long-standing. It often co-exists with gonorrhoea and other vulval or vaginal infection either due to bacteria or fungus or both. If one is not very alert, the presence of gonorrhoea in the female is very likely to escape one’s attention. Signs and symptoms may be totally absent, mild or severe. A profuse, frothy, purulent and offensive vaginal discharge in the female is not uncommon. This causes excoriation of the surface epithelium and leads to vulvitis, vulvo-vaginitis and intertrigo of the inner and proximal aspects of thighs. There is intense itching and burning of the external genitalia. Dysparunia may be the only presenting symptom. The inspection of the vaginal wall and the vaginal portion of the cervix reveals the typical redness or raw-beef appearance, punctate spots, flea-bitten appearance, and strawberry patches. The inflammatory changes stop at the external os of the cervix and do not affect the endo-cervix. The pH of the vaginal secretion varies from 6.8 to 8, raised above the normal level. The infection may give rise to urethritis, Skenitis, Bartholinitis, cystitis etc in the female.

Diagnosis- It is made by detecting and identifying the live organism in the secretion or by culture or by both. In a wet preparation, an organism with oval or pear shape, its jerky movements, flagellae and undulating membrane can rarely be missed. Some authorities recommend an addition of a drop of 0.1% saframine to the specimen before the examination. This gives the pink background but the organism is not stained. For a smear made, staining with 1% Pinocynol dye in methyl alcohol is recommended. S.T.S or Kupferberg’s serum medium is highly reliable for the culture of T. vaginalis. Redness like raw beef, strawberry patches, frothy purulent and offensive discharge, involvement of the thighs, exclusion of the endo-cervix etc are very useful clinical points to bear in mind.

Differential diagnosis- It is a complex problem in view of great possibilities of mixed infection that often exists.

• Non-specific genital infection due to streptococcus associated with staphylococcus aureus is often difficult to diagnose; it becomes evident only after trichomoniasis has been successfully treated. It causes an acute inflammatory reaction and involves endo cervix. Thighs are usually not affected and itching is not present.
• Gonorrhoea- This is diagnosed by detection of gonococcus in smears and culture. Co-existance of gonorrhoea and trichomoniasis is quite common especially in the female. In view of this fact, it is necessary to emphasise the importance of complete clinical and bacteriological investigations in these cases. When the discharge is profuse due to T. vaginalis, it is often difficult to find or culture gonococcus; however it becomes apparent only after T. vaginalis is controlled by treatment. Hence the imperative need to adopt as a routine the testing of the patient for the presence of gonococcus both at the beginning and at the end of the treatment for T. vaginalis.
• Candida albicans or moniliasis- This is common in diabetics and persons who have undergone a course of broad-spectrum antibiotics. It causes pruritis vulvae, vulvo-vaginitis and intertrigenous dermatitis. Vaginal discharge is scanty caseus and inspissated, curdy and yellowish-white patches can be seen on the vaginal surface and on the vulva. Acidity of the vagina is marked, the pH value being 4 to 5. Microscopic examination of the specimen will show oval spores and long hyphal filaments. Doderlein’s bacilli are present in large number. Local irritation is a predominant symptom. Persistence of signs and symptoms in spite of treatment should make one look for an additional element of infection.

Treatment- In the past, the treatment for T. vaginalis was very unsatisfactory and frequent recurrences was the rule. Various remedies were used; they helped only to relieve local symptoms but failed to eradicate the infection.

For the female vaginal douches either of lactic acid 30 min to a pint or copper Sulphate 1-2 gm to a litre of water, antiseptic powder insufflations into the vagina (acetarsone 12 parts, salicylic acid 2 parts, sodi bicarb 43 parts and kaolin 43 parts), painting the vaginal canal with 1% aqueous gentian violet solution, and vaginal pessaries such as floraquin, S.V.C., devegan, viozol and acetorsol were in use.

For the male, urethral instillations of 5% argyrol, acriflavin 1 in 100, or Tr. merthiolate 1 in 10,000 were given. For recurrent attacks of prostatovesiculitis, Mapharside 0.4 gm I.V. every fifth day, three injections or Atebrin 0.2 gm Q D S orally for seven days was prescribed.

Trichorad (W.B) 100 mg T.D.S. orally for 10 to 14 days yielded good results.

With the introduction of Flagyl (M.B), metronidazol 1-B-hydroxyethyl-2-methyl-5-nitroimidazole in the treatment of T. vaginalis, the concept of local treatment has become of minor importance. Metronidazole is potent trichomonacidal agent and is very effective both in the female and the male, when given by month. It has no antibacterial or antifungal activity. It is specific and effective in eradicating the infection. For adults, one tablet (200 mg) orally three times a day after meals should be given for 7 days. In some cases, an additional course may have to be given. Sexual partners must be examined and treated at the same time. An attempt must be made to exclude the possibility of venereal infection. At least three monthly examinations both clinical and cultural are necessary to confirm permanancy of cure. Contraindications for the use of metronidazole- The drug must not be given to a pregnant woman in the first trimester. It has an adverse effect on the development of the foetus.

Fig.

TRICHOMONAS VAGINALIS

by Courtesy of M. & B. Ltd.

Untoward reactions are few and generally mild. They consist of gastric irritation, skin rash and metallic taste in the mouth.

If the trichomonal infection is associated with candidiasis or bacterial infection, additional treatment with an appropriate remedy such as antifungal or antibacterial agent may be necessary. Without such a measure complete recovery will be impossible. In elderly patients, use of hormones may be indicated in addition to specific treatment.