Tric Overview
Trichomoniasis is a common sexually transmitted infection caused by a parasite. In women, testing for Trich is helpful as it can cause a foul-smelling vaginal discharge, genital itching and painful urination. Men who have it typically have no symptoms and need an STD Lab test. Learn More.
CASE ONE
The 58-year-old woman with symptomatic vaginitis had a positive diamond media culture for Trichomonas vaginalis infection. She and her partner both received a single 2 g oral dose of metronidazole, but her infection persisted. See STD 10-in-1 Test Kit.
Severe urticaria and acute respiratory failure. A patient had developed an allergy to metronidazole. Subsequently, her doctors tried several other treatments. These included saline solutions, iodine (Betadine) sprays, and vaginal clotrimazole. And were with and without vaginal conjugated equine estrogen cream. However, despite these treatments, the infection persisted.
After topical paromycin cream treatment, she developed a severe vestibular rash, prompting discontinuation of the treatment. Following this, healthcare providers referred her to the colposcopy unit. Despite her lack of sexual activity, she remained severely symptomatic with positive wet preparation and cultures for Trichomonas vaginalis. Treatment starts using vaginal conjugated equine estrogen cream 1g nightly alternating with vaginal clotrimazole cream. Two weeks later, Trichomonas vaginalis was still present.
They applied a 4% acetic acid vaginal douche/debridement, followed by a routine of alternating vaginal clotrimazole nightly with vaginal boric acid 600 mg in gelatin capsules to acidify the vagina.
After six weeks, healthcare providers stopped this regimen, and vaginal symptoms with culture-positive Trichomonas vaginalis returned within two weeks. The previous routine using boric acid alternating with clotrimazole was reintroduced and continued for five months.
She has remained asymptomatic and culture-negative for more than five years.
CASE TWO
A 40-year-old woman with symptomatic vaginitis screened positive for Trichomonas vaginalis infection in diamond media culture and wet preparation. Despite not being sexually active, she received initial treatment with a single 2 g dose of oral metronidazole, which proved ineffective in clearing the infection. Subsequent treatments with metronidazole, including doses of 250 mg three times daily for seven days, 2 g daily for five days, and 2 g daily for seven days, all failed to resolve the infection.
They referred the patient to the colposcopy unit, where she remained severely symptomatic with positive wet preparation and cultures for Trichomonas the vaginalis. Boric acid intravaginal use may lead to an increase in vaginal discharge, a symptom of Trichomoniasis, a common concern. However, compared to the severe reactions associated with high-dose metronidazole, an increase in vaginal discharge seems insignificant. Women with persistent Trichomonas vaginalis infection may require metronidazole STD sensitivity testing to develop a curative regimen that does not rely on metronidazole, thereby reducing additional expenses.
Based on these cases, we recommend the use of boric acid for vaginal acidification in cases of persistent Trichomonas vaginalis infection.
CASE THREE
In 2019, a midwifery clinic in Bandar Abbas received a referral for a 32-year-old Iranian woman with signs of vaginitis infection. They found vaginal problems. She received 150 mg clindamycin capsule, 1% clotrimazole cream, and triple sulfa vaginal to treat her infection. However, her husband did not do so, and all the clinical signs reappeared after a short time.
She had a spontaneous miscarriage six months ago. Among her clinical symptoms were genital warts in the lower end of the uterus (cervix), yellowish-green foamy secretion, uterine bleeding, dyspareunia, and vigorous redness in the lower end of the uterus.
An STD Laboratory reported the disease by sampling from the posterior fornix of the vagina and performing a direct smear and Diamond medium examination to detect the presence of T. vaginalis in the specimen.
The vaginal pH was > 5.5. The wet mount and Giemsa-stained direct STD smear results were positive for yeast and bacteria and negative for T. vaginalis.
Therefore, regular screening helps fight the infection of the human genitourinary tract and exert mechanical stress on host cells. Because T. vaginalis infection has a significant impact on HIV transmission in men and women, patients with chronic Trichomoniasis have recently received much attention as a major public health problem. The relationship between these two infections is bidirectional. T. vaginalis infection increases the risk of HIV transmission and vice versa. The prevalence rate of T. vaginalis differs in other geographical regions of Iran, depending on the type of communities, cultures, and religions. It varies from 0.4 to 42%.
CURRENT RESEARCH
A recent study of STI screening reported a rate of 2.6% for Trich among women in Bandar Abbas. The patient under investigation in this study had a history of miscarriage, consistent with findings from studies by Ghobahi et al. (2019) in Bandar Abbas and Habibi.
Due to these STDs, the patient, co-infected with candidiasis, bacteria, Trichomoniasis, and herpes virus, likely experienced altered vaginal flora and potentially elevated the risk of miscarriage.
However, further studies are necessary to confirm the effect of Trichomoniasis Swab result on the increased risk of miscarriage.
Since the signs and symptoms of different types of vaginitis are similar, clinical symptoms alone cannot reliably establish a correct diagnosis. The researchers treated the patient in this study solely based on clinical symptoms with drugs suitable for treating other causes of vaginitis for two years, but these treatments proved ineffective. Despite being the most sensitive and specific, molecular methods are uncommon in laboratory settings. Therefore, simultaneous use of both wet preparation methods served as the most cost-effective and fastest approach. This is true, especially with the assistance of Soheila Morad in sampling. The authors also express gratitude to the patient for her efficient cooperation. Ethical clearances: The authors have said that they have no ethical clearance.
EFFECTIVE TREATMENT
The Food and Drug Administration (FDA) approves 5’-nitroimidazole as the only efficient drug commonly used for therapy. Men often carry asymptomatic infections and serve as carriers for women. Therefore, simultaneous treatment of both sexual partners (female and male) is recommended and necessary. In this study, we treated the patient under study and her husband simultaneously after correctly diagnosing the disease. This eased the symptoms. The World Health Organization (WHO) estimates that accurate and timely diagnosis with a Trichomoniasis Accurate Home Test could treat half of all sexually transmitted infections.
Trich causes a rise in the pH of the vagina from 4 to as high as 7. This pH change is associated with the loss of acid-producing Lactobacillus, a normal part of vaginal flora. The increased pH creates a better environment for the growth of the Trichomonas parasite. An acidic environment also inactivates factors contributing to Trichomonas pathogenicity, such as CDF. The need for an alkaline environment has been shown in a trichomonas vaginalis exam, and the proliferation explains why this disease often worsens during menstruation.
FINAL MESSAGE
By using a process of vaginal acidification, we were able to resolve recalcitrant Trichomonas vaginalis infection in two patients.
One patient underwent treatment with a combination of gentian violet, vaginal acidification using boric acid, and clotrimazole. The other patient underwent acidification and clotrimazole treatment. Clotrimazole was included in these regimens due to evidence suggesting reduced symptoms in patients needing a Trichomoniasis lab Test.
Still, the process of vaginal acidification appears to have been fixed, as proven that STD Swab Tests are the final cure. Boric acid (applied in a gelatin capsule containing 600 mg of boric acid) is cheap and has minimal side effects. The most common concern in Trich is when a patient is using boric acid intravaginally is an increase in vaginal discharge. Compared with the severe reactions patients may have with high-dose metronidazole, having an increase in vaginal discharge seems trivial.
Ref: 6