Vaginitis: Differential Diagnosis and Management - BPA Pathology

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10% 77 , 78 . Interestingly, in males diagnosed with urethritis but failingto respond to several courses of antibiotics not active against T.vaginalis, 85% were subsequently found to be infected with theprotozoan 79 , 80 . However, one difficulty with these studies was thatthe patients were not evaluated for the presence of N. gonorrhoeae,C.trachomatis, Mycoplasma hominis, Ureaplasma urealyticum, or HSV.It may be that infection in the male tends to be asymptomatic and itis often difficult to document the presence of a protozoan. Severalstudies have demonstrated the presence of T. vaginalis inasymptomatic husbands and the sexual partners of infectedwomen 35 , 81 , 82 . In one investigation, 30 husbands of infected womenwere cultured; 60% of the husbands were found to be positive for T.vaginalis and 61% of the males were asymptomatic 83 . The percentageof male sexual contacts of infected women who subsequently developsymptomatic urethritis and are found to be positive for T. vaginalisranges from 16 to 83% 84 .Sexual partners treated simultaneously may not respond in asimilar manner. The trichomonads present in all infected tissue maynot all be killed, and adequate levels of metronidazole may not beachieved in sufficient concentration in all infected tissues. The maleinfected with T. vaginalis possesses significant problems, for example,treating the infected prostate gland is often difficult and requiresprolonged administration of metronidazole. Infection in the male mayinvolve various sites, like the epididymis, posthitis (infection of theforeskin), balanitis (infection of the glans penis), and may result indraining sinus of the median raphe 37 , 42 , 85 – 89 . Infection in males alsoappears to occur easily. In 1963 Weston and Nicol 90 examined malesexual partners 2 days after being exposed to infected females andrecovered T. vaginalis from 70% of the males. Interestingly, increasingthe time between sampling of the male and exposure correlated witha decrease in recovery rate of the protozoan. Only 30% of theexposed males had positive T. vaginalis cultures when sampled 14 daysafter exposure to an infected female. Thirty days following exposure,only 23% of the males remained positive and subsequent examinationfailed to recover trichomonads. T. vaginalis in males can besummarized thus:(1)symptomatic infection is common;TRICHOMONIASIS 71
72 VAGINITIS: DIFFERENTIAL DIAGNOSIS AND MANAGEMENT(2)males exposed to infected females should be consideredcolonized, whether symptomatic or asymptomatic;(3)symptomatic male infection is typically diagnosed as urethritisand these individuals typically have a purulent discharge; and(4)prostatitis is uncommon.Thus, a physician responsible for the health of women shouldremember that all women with documented vaginal trichomoniasisshould be considered a vector for the transmission of T. vaginalis.Finally, when treating a woman for vaginal trichomoniasis it isimperative that her sexual partners be treated, whether they aresymptomatic or not.The only anti-trichomonal agent approved for use in the UnitedStates is metronidazole, which was approved for use in 1963. Anazomycin, a nitroimidazole drug, isolated from a species ofStreptomyces lead to the discovery of synthetic agents that have activityagainst T. vaginalis. Metronidazole was one of these agents and it wassubsequently found to have activity against Giardia lamblia, and canalso be used in the treatment of amebiasis 90−92 . Theanaerobic activityof metronidazole was discovered accidentally: a woman was treatedwith metronidazole for vaginal trichomoniasis and she was also knownto have acute ulcerative gingivitis that simultaneously responded tothe treatment for vaginal trichomoniasis 93 . Davis and co-workers 94confirmed that metronidazole was effective in the treatment ofVincent’s stomatitis and the drug inhibited Fusobacteriumnecrophorum 94 , 95 .Nitroimidazole available in countries other than the United Statesare: nimorazole (Nagogin ® ), tinidazole (Fasigyn ® ), ornidazole,secnidazole, carnidazole, and misonidazole 96 , 97 . Tinidazole is similarto metronidazole in its spectrum of activity against parasites andobligate anaerobic bacteria. The minimum trichomonicidalconcentration is lower than that for metronidazole 98 , 99 . T. vaginalisresistant to metronidazole are usually resistant to tinidazole, but therehave been reports of strains resistant to the former agent but sensitiveto tinidazole 100 , 101 .Metronidazole, when taken orally, is almost completely absorbedby the gastrointestinal tract and approximately 95% of thisantimicrobial agent is bioavailable. The serum half-life is
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VAGINITISDifferential Diagnosis and
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CONTENTSColor illustrations v1. Hea
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viFigure 4 Gram stain of vaginal fl
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viiiFigure 8 Cytolytic vaginosis. N
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xrelative absence of white blood ce
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xiiFigure 16 Cytolytic vaginosis. W
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2 VAGINITIS: DIFFERENTIAL DIAGNOSIS
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2.VULVITISOften, conditions that af
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12 VAGINITIS: DIFFERENTIAL DIAGNOSI
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3.BACTERIAL VAGINOSISINTRODUCTIONIn
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Vaginitis: Differential Diagnosis and Management - BPA Pathology

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