Survey of Obstetrician-gynecologists in the United States About Trichomoniasis, 2016.

PURPOSE: Trichomoniasis is the most prevalent nonviral sexually transmitted infection (STI) in the United States. It can present with vaginitis in women and urethritis in men, but is most often asymptomatic or occurs with minimal symptoms. It is associated with other STIs, adverse pregnancy outcomes and pelvic inflammatory disease. For these reasons, health care provider awareness of trichomoniasis is of public health importance. METHODS: To assess practitioner knowledge, attitudes, and practices concerning trichomoniasis management, the American College of Obstetricians and Gynecologists conducted an online survey in 2016 of its members, and we analyzed results from 230 respondents. RESULTS: We note discrepancies between practice and recommendations among surveyed providers: a minority of respondents routinely screen human immunodeficiency virus (HIV)-positive patients for trichomoniasis (10.7%, "most of the time"; 95% confidence interval [CI], 6.7-15.8; 33.0%, "always"; 95% CI, 26.5%-40.0%), treat trichomoniasis in HIV-positive patients with the recommended dose of metronidazole 500 mg twice a day for 7 days (25.8%; 95% CI, 20.0%-32.3%), or retest patients diagnosed with trichomoniasis 3 months after treatment (9.6%; 95% CI, 6.1%-14.3%). Only 29.0% (95% CI, 23.0%-35.5%) retreat with metronidazole 500 mg twice a day for 7 days in patients who have failed prior treatment. CONCLUSIONS: Screening for and treatment of trichomoniasis in HIV-positive patients, and retesting and retreatment for trichomoniasis in the general population appear to be suboptimal. Continuing education for providers is needed for this common but "neglected" STI.

Diagnosis of Trichomoniasis in Male Patients on Performing Nested Polymerase Chain Reaction.

OBJECTIVE: Trichomoniasis is a parasitic infection that occurs with the settlement of Trichomonas vaginalis in female and male urinary and reproductive tracts. This infection is generally asymptomatic in males, and males are thought to be a carrier for the transmission of infection. In this study, our aim was to detect trichomoniasis using nested polymerase chain reaction among males who were referred to a hospital with suspected urinary tract infection. METHODS: Urine samples were collected from 138 male patients between 18 and 50 years of age who were referred with suspected urinary system infection to the Urology Outpatient Clinic at Malatya University Medical Center Malatya between December 2013 and May 2014. Direct microscopy, two different culture methods, and nested Polymerase chain reaction (PCR) were performed for the investigation of T. vaginalis in urine samples. RESULTS: Urinary tract infection was diagnosed in 47 of the 138 patients according to white and red blood cell counts in the urine samples. T. vaginalis infection was detected in 6.5% (9/138) of the suspected patients by nested PCR, while none of the samples tested positive by direct microscopy and culture examinations. Statistical significance was found between infection of the urinary tract and nested PCR positivity for T. vaginalis. CONCLUSIONS: According to our results, nested PCR is the most sensitive method for the detection of trichomoniasis in male patients. We strongly recommend using nested PCR for the differential diagnosis of urinary infections in males.

Trichomonas vaginalis infection: How significant is it in men presenting with recurrent or persistent symptoms of urethritis?

Persistent or recurrent non-gonococcal urethritis has been reported to affect up to 10-20% of men attending sexual health clinics. An audit was undertaken to review the management of persistent or recurrent non-gonococcal urethritis in men presenting at Whittall Street Clinic, Birmingham, UK. Detection of Trichomonas vaginalis infection was with the newly-introduced nucleic acid amplification test. A total of 43 (8%) of 533 men treated for urethritis re-attended within three months with persistent or recurrent symptoms. Chlamydia trachomatis infection was identified in 13/40 (33%), T. vaginalis in 1/27 (4%) and Mycoplasma genitalium in 6/12 (50%). These findings suggest that the prevalence of T. vaginalis infection remains low in our clinic population and may not contribute significantly to persistent or recurrent non-gonococcal urethritis.

Detection of Mycoplasma genitalium from male primary urine specimens: an epidemiologic dichotomy with Trichomonas vaginalis.

A total of 2750 male urines subjected to a transcription-mediated amplification (TMA)-based Mycoplasma genitalium assay yielded 188 positive results (6.84%). This rate was similar to Chlamydia trachomatis (6.87%; P = 0.96) and greater than Neisseria gonorrhoeae (4.0%) and Trichomonas vaginalis (2.3%; P < 0.0002). Mean age of M. genitalium-infected males (30.8) was similar to N. gonorrhoeae (P = 0.78) but less than T. vaginalis (mean, 41.6; P < 0.0001). A total of 266 STI clinic encounters had at least 1 sexually transmitted infection (STI); 36.5% of these encounters had sole detection of M. genitalium (P ≤ 0.009 versus sole detection of other STI agents). In 209 community encounters with at least 1 STI, 22.0% exhibited sole detection of M. genitalium (P = 0.0007 versus sole M. genitalium detection in STI clinic males), while 18.7% had sole detection of T. vaginalis (P < 0.0002 versus detection in STI clinic males). TMA-based M. genitalium screening identifies additional cases of nongonococcal urethritis.

The clinical spectrum of Trichomonas vaginalis infection and challenges to management.

Trichomonas vaginalis is the most common curable sexually transmitted infection worldwide. T vaginalis infections in women can range from asymptomatic to acute inflammatory vaginitis. In men, this infection is typically asymptomatic but is increasingly being recognised as a cause of non-gonococcal urethritis. Diagnosis of T vaginalis has traditionally been made by direct microscopic examination of a wet mount of vaginal fluid or through the use of culture. The recent commercial availability of nucleic acid amplification tests for the detection of T vaginalis has seen these replace culture as the gold standard for diagnosis. Nitroimidazoles (ie, metronidazole and tinidazole) are the mainstay of therapy. In the case of treatment failure due to drug resistance or in the case of a severe nitroimidazole allergy, alternative intravaginal therapies exist, although their effectiveness has not been evaluated systematically. Novel systemic agents other than nitroimidazoles for the treatment of T vaginalis are needed, and efforts to promote and support antimicrobial drug development in this setting are necessary.

Prevalence and morbidity of urethral Trichomonas vaginalis in Japanese men with or without urethritis.

OBJECTIVES: Trichomonas vaginalis is one of the pathogens causing sexually transmitted infections. This microorganism is a common pathogen among women, but its significance as a cause of morbidity among men remains uncertain. We sought to determine the prevalence and morbidity of T. vaginalis infection in Japanese men with and without urethritis. METHODS: We examined urine specimens from 215 men with urethritis and 98 men without urethritis for the presence of urethral T. vaginalis by PCR assay. RESULTS: Only four patients-one with gonococcal urethritis, one with non-gonococcal chlamydial urethritis, one with non-gonococcal non-chlamydial urethritis and one without urethritis-were positive for T. vaginalis. The prevalence of T. vaginalis was 1.4% in men with urethritis and 1.0% in men without urethritis. A possible relation between the appearance of T. vaginalis and clinical symptoms was not confirmed. CONCLUSIONS: In the present study, the incidence of urethral T. vaginalis infection appears to be rare in Japanese men with or without urethritis, and T. vaginalis may be an uncommon pathogen in male urethritis in Japan.

Standard treatment regimens for nongonococcal urethritis have similar but declining cure rates: a randomized controlled trial.

BACKGROUND: Azithromycin or doxycycline is recommended for nongonococcal urethritis (NGU); recent evidence suggests their efficacy has declined. We compared azithromycin and doxycycline in men with NGU, hypothesizing that azithromycin was more effective than doxycycline. METHODS: From January 2007 to July 2011, English-speaking males ≥16 years, attending a sexually transmitted diseases clinic in Seattle, Washington, with NGU (visible urethral discharge or ≥5 polymorphonuclear leukocytes per high-power field [PMNs/HPF]) were eligible for this double-blind, parallel-group superiority trial. Participants received active azithromycin (1 g) + placebo doxycycline or active doxycycline (100 mg twice daily for 7 days) + placebo azithromycin. Urine was tested for Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), Ureaplasma urealyticum biovar 2 (UU-2), and Trichomonas vaginalis (TV) using nucleic acid amplification tests. Clinical cure (<5 PMNs/HPF with or without urethral symptoms and absence of discharge) and microbiologic cure (negative tests for CT, MG, and/or UU-2) were determined after 3 weeks. RESULTS: Of 606 men, 304 were randomized to azithromycin and 302 to doxycycline; CT, MG, TV, and UU-2 were detected in 24%, 13%, 2%, and 23%, respectively. In modified intent-to-treat analyses, 172 of 216 (80%; 95% confidence interval [CI], 74%-85%) receiving azithromycin and 157 of 206 (76%; 95% CI, 70%-82%) receiving doxycycline experienced clinical cure (P = .40). In pathogen-specific analyses, clinical cure did not differ by arm, nor did microbiologic cure differ for CT (86% vs 90%, P = .56), MG (40% vs 30%, P = .41), or UU-2 (75% vs 70%, P = .50). No unexpected adverse events occurred. CONCLUSIONS: Clinical and microbiologic cure rates for NGU were somewhat low and there was no significant difference between azithromycin and doxycycline. Mycoplasma genitalium treatment failure was extremely common. Clinical Trials Registration.NCT00358462.

PCR for diagnosis of male Trichomonas vaginalis infection with chronic prostatitis and urethritis.

The aim of this study was to assess the usefulness of PCR for diagnosis of Trichomonas vaginalis infection among male patients with chronic recurrent prostatitis and urethritis. Between June 2001 and December 2003, a total of 33 patients visited the Department of Urology, Hanyang University Guri Hospital and were examined for T. vaginalis infection by PCR and culture in TYM medium. For the PCR, we used primers based on a repetitive sequence cloned from T. vaginalis (TV-E650). Voided bladder urine (VB1 and VB3) was sampled from 33 men with symptoms of lower urinary tract infection (urethral charge, residual urine sensation, and frequency). Culture failed to detect any T. vaginalis infection whereas PCR identified 7 cases of trichomoniasis (21.2%). Five of the 7 cases had been diagnosed with prostatitis and 2 with urethritis. PCR for the 5 prostatitis cases yielded a positive 330 bp band from bothVB1 and VB3, whereas positive results were only obtained from VB1 for the 2 urethritis patients. We showed that the PCR method could detect T. vaginalis when there was only 1 T. vaginalis cell per PCR mixture. Our results strongly support the usefulness of PCR on urine samples for detecting T. vaginalis in chronic prostatitis and urethritis patients.

[Current approaches to the treatment of non-gonococcal urethritis in men].

The study was made of 50 men suffering from non-gonococcal urethritis caused by mixed pathogenic and opportunistic urogenital infection. Clinical characteristics of urethritis in relation to infection pathogen are shown. The results of clinical and laboratory examinations were considered in choice of antibacterial therapy. Safocid, a combined antibacterial medicine, demonstrated its clinical and microbiological efficacy in the treatment of patients with non-gonococcal urethritis of mixed etiology.

Chlamydia trachomatis ompA genotypes in male patients with urethritis in Greece: conservation of the serovar distribution and evidence for mixed infections with Chlamydophila abortus.

PCR amplification and nucleotide sequencing of the ompA gene of Chlamydia trachomatis were used to determine the prevalence and distribution of genotypes in 51 urine and urethral specimens from Greek male patients with urethritis, that were positive by the COBAS Amplicor test. A single C. trachomatis serovar was identified in 43 of the 51 amplified samples. Serovars F and E were the most prevalent (both 12, 28%), followed by D (9, 21%), G (4, 9%), B and K (both 2, 5%) and H and J (both 1, 2%). Over one third of the samples bared a variant ompA genotype that had been previously identified in other areas worldwide. Two results in this study, both observed for the first time, were of particular interest. First, the emergence of the unique variant genotype D/Ep6 (X77364.2) identified in 3 urethral samples. Second, the ompA genotype OCLH196 of the animal pathogen Chlamydophila abortus as well as a 23S rRNA gene fragment of this species detected by the assay ArrayTube™ was found in 7 urethral samples. The implications resulting from this observation for the health of the general population are discussed.

Re-evaluating the treatment of nongonococcal urethritis: emphasizing emerging pathogens--a randomized clinical trial.

BACKGROUND: Nongonococcal urethritis (NGU) is a common chlamydia-associated syndrome in men; however, Trichomonas vaginalis and Mycoplasma genitalium are associated with its etiology and should be considered in approaches to therapy. We sought to determine whether the addition of tinidazole, an anti-trichomonal agent, to the treatment regimen would result in higher cure rates than those achieved with treatment with doxycycline or azithromycin alone. A secondary aim was to compare the efficacy of doxycycline therapy and with that of azithromycin therapy. METHODS: Randomized, controlled, double-blinded phase IIB trial of men with NGU. Participants were randomized to receive doxycycline plus or minus tinidazole or azithromycin plus or minus tinidazole and were observed for up to 45 days. RESULTS: The prevalences of Chlamydia trachomatis, M. genitalium, and T. vaginalis were 43%, 31%, and 13%, respectively. No pathogens were identified in 29% of participants. Clinical cure rates at the first follow-up visit were 74.5% (111 of 149 patients) for doxycycline-containing regimens and 68.6% (107 of 156 patients) for azithromycin-containing regimens. By the final visit, cure rates were 49% (73 of 149 patients) for doxycycline-containing regimens and 43.6% (68 of 156 patients) for azithromycin-containing regimens. There were no significant differences in clinical response rates among the treatment arms. However, the chlamydia clearance rate was 94.8% (55 of 58 patients) for the doxycycline arm and 77.4% (41 of 53 patients) for the azithromycin arm (P = .011), and the M. genitalium clearance rate was 30.8% (12 of 39 patients) for the doxycycline arm and 66.7% (30 of 45 patients) for the azithromycin arm (P = .002). CONCLUSIONS: Addition of tinidazole to the treatment regimen did not result in higher cure rates but effectively eradicated trichomonas. Clinical cure rates were not significantly different between patients treated with doxycycline and those treated with azithromycin; however, doxycycline had significantly better efficacy against Chlamydia, whereas azithromycin was superior to doxycycline for the treatment of M. genitalium.

Aetiological agents of urethritis in symptomatic South African men attending a family practice.

The objective was to determine the occurrence of four urethral pathogens in urine specimens from symptomatic men using transcription mediated amplification (TMA) assay. Urethral swab and urine specimens from 300 men presenting to a family practitioner were Gram stained and tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis and Mycoplasma genitalium using three TMA assays respectively. Except for T. vaginalis, the other recognized pathogens viz. N. gonorrhoeae, C. trachomatis and M. genitalium were detected in significantly larger numbers of patients with urethral discharge than in those with burning on micturition (BOM). The overall prevalences were 16.7% for N. gonorrhoeae, 12.3% C. trachomatis, 8.0% T. vaginalis and 17.3% M. genitalium. With regard to microscopic evidence of urethritis, significant associations were found for N. gonorrhoeae and C. trachomatis, but not for M. genitalium and T. vaginalis. This study demonstrated that in symptomatic men attending family practice, M. genitalium and T. vaginalis are also important aetiological agents of urethritis and hence treatment strategies be they syndromic management or laboratory directed should cover for these causative agents. The microscopic diagnosis of urethritis may not be important for treatment strategies. The current syndromic treatment guidelines for developing countries including South Africa need modification.

An unusual and unsettling place for a worm.

A 56-year-old man presented complaining of urinary frequency, passing urine eight times per day, urethral irritation and dysuria. Investigations showed no evidence of urinary tract infection or sexually transmitted infections. Three months later he presented, again complaining of increased urinary frequency and urethral irritation. He brought with him a urine specimen containing a small 'worm', 2 mm in length, identified as a drain fly (or moth fly) larva, of the genus Psychoda (dipterous flies). Psychoda lay eggs in organically polluted water such as sewage plants, sink drains or on decaying vegetables and fruits. Urogenital myiasis may arise from hatching of larvae near the urethral opening and ascending migration along the urethra with consequent urethritis. Following larval identification, ivermectin was prescribed and the man's symptoms improved after six weeks.

Simultaneous identification of 14 genital microorganisms in urine by use of a multiplex PCR-based reverse line blot assay.

The aim of this study was to develop and evaluate a sensitive method for the simultaneous identification of 14 urogenital potential pathogens. A multiplex PCR-based reverse line blot (mPCR/RLB) assay was developed to detect 14 urogenital pathogens or putative pathogens, namely Trichomonas vaginalis, Streptococcus pneumoniae, Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma parvum, U. urealyticum, Gardnerella vaginalis, Haemophilus influenzae, herpes simplex virus type 1 (HSV1) and HSV2, N. meningitidis, Mycoplasma hominis, M. genitalium, and adenovirus, using two species-specific primer pairs and probes for each. The method was validated using a reference strain or a well-characterized clinical isolate of each target organism and was found to be both sensitive and specific. The limits of detection for the mPCR/RLB assay varied among the 14 target organisms from 4.2 x 10(-1) to 7.0 x 10(-11) ng/microl of genomic DNA. There were no cross-reactions among any of the probes. This method was used to test 529 first-voided urine specimens from male patients with and without urethritis attending two Sydney sexual health clinics. One or more target species were detected in 193 (36%) subjects. Of 233 positive results, overall 216 (93%) were concordant between mPCR/RLB and a comparator method (culture and/or species-specific PCR), 9 were positive only by mPCR/RLB, and 8 were positive only by the comparator method. The mPCR/RLB method was an accurate, convenient, and inexpensive method for the detection of multiple potential pathogens in first-voided urine specimens from men.

How men with non-chlamydial, non-gonococcal urethritis are managed in Australasia.

The aim of this study was to ascertain how sexual health physicians in Australia and New Zealand manage men with chlamydia-negative non-gonococcal urethritis (NGU), particularly in relation to the notification of their female sexual partners. In July 2006, a cross-section survey was sent out to all the members of the Australasian Chapter of Sexual Health Medicine. Seventy-three percent of sexual health physicians believed that female partners of men who present with chlamydia-negative NGU were at risk of adverse reproductive health outcomes. At least 62% usually initiated some form of partner notification of female partners of men with chlamydia-negative NGU. However, only 19% (21/111) of sexual health physicians routinely tested for, and only 65% sometimes tested for, pathogens other than Neisseria gonorrhoeae and Chlamydia trachomatis in men presenting with NGU. These included Mycoplasma genitalium, herpes simplex virus, ureaplasma species, Trichomonas vaginalis and adenoviruses.

[Nongonococcal urethritis treatment in men with avelox (moxifloxacin)].

The role of urogenical infection in males in present-day urology is demonstrated with a focus on fluoroquinolones efficacy in combined treatment of urogenital infection. The mechanism of action, pharmacokinetics, the spectrum of antimicrobial activity of a novel fluoroquinolone drug avelox are detailed. Avelox use in combined therapy of mono- and mixed infections caused by ureaplasmas, chlamidias, mycoplasms is illustrated by original experience of the authors. Avelox is well tolerated and safe.

Failure to detect urethral Trichomonas vaginalis in Japanese men with or without urethritis.

AIM: Trichomonas vaginalis may cause symptomatic or asymptomatic urethritis in men. There are few recent studies on the prevalence of T. vaginalis infection in Japanese men, and quantification of the number of cases of urethritis attributable to this pathogen has not been performed in Japan. The aim of this study was to determine the prevalence and morbidity of T. vaginalis infection in Japanese men. METHODS: One hundred subjects with or without urethritis were examined for the presence of urethral T. vaginalis using culture swabs. RESULTS: Urethral swabs from all subjects were negative for T. vaginalis. CONCLUSION: These results indicate Japanese men, including those with urethritis, have a low incidence of urethral T. vaginalis infection or colonization. T. vaginalis appears to be an uncommon pathogen for male urethritis in Japan.

Trichomoniasis and its treatment.

Trichomonas vaginalis has long been recognized as a cause of infectious vaginitis in women. More recently, studies have demonstrated a significant burden of disease in men with urethritis or men at high risk for sexually transmitted diseases. There is increasing interest in this pathogen as more data accumulates linking it to HIV transmission and perinatal morbidity. New diagnostic methods have emerged that may increase sensitivity of diagnosis or improve point-of-care access to testing. Nitroimidazoles remain the mainstay of therapy. Metronidazole and tinidazole are highly effective as single-dose therapy. Unfortunately, despite the link between T. vaginalis infection and perinatal morbidity, nitroimidazole therapy during pregnancy remains controversial. Although metronidazole resistance is currently uncommon, pharmacological features and nitroimidazole resistance patterns suggest that tinidazole may be more effective in treating patients with metronidazole treatment failure. Alternatives to nitroimidazole therapy are few, and most have limited efficacy and significant toxicity.