Continuing Education Activity

This continuing education activity provides clinicians with a comprehensive review of Trichomonas vaginalis infection, including its epidemiology, pathophysiology, clinical presentation, diagnostic evaluation, and evidence-based treatment strategies. Trichomoniasis is the most common nonviral sexually transmitted infection worldwide, yet it remains underdiagnosed due to its high rate of asymptomatic presentation and inconsistent screening practices. This activity addresses the gap between current clinical practice and established diagnostic and management standards by reviewing nucleic acid amplification testing as the preferred diagnostic method, updated treatment regimens, screening recommendations, and the importance of partner treatment and retesting. Participants are expected to achieve improved diagnostic accuracy, updated management strategies, enhanced risk-assessment skills, and a strengthened approach to interprofessional collaboration, with the ultimate goal of reducing transmission, preventing complications, and improving patient-centered outcomes.

Objectives:

• Identify the epidemiology, pathophysiology, and risk factors associated with Trichomonas vaginalis infection in symptomatic and asymptomatic individuals.
• Differentiate the clinical presentations of Trichomonas vaginalis infection in women and men, including common and atypical findings on history and physical examination.
• Evaluate the clinical consequences of untreated or inadequately managed Trichomonas vaginalis infection and apply strategies to improve patient adherence, partner notification, and follow-up care.
• Collaborate with interdisciplinary team members, including infectious disease specialists, gynecologists, and nursing staff, to coordinate comprehensive, patient-centered care for individuals diagnosed with trichomoniasis.

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Introduction

Trichomonas vaginalis is the most common nonviral sexually transmitted infection (STI) globally and is among the most common protozoal infections both in the United States and globally. This organism is also one of the leading infectious causes of symptomatic vaginitis in women. T vaginalis is a unicellular motile protozoan parasite that lives in the lower genitourinary tract of women and in the prostate and urethra of men. Both men and women infected with T vaginalis are commonly asymptomatic.

Infection with T vaginalis, termed trichomoniasis, increases the risk of both transmission and acquisition of human immunodeficiency virus as well as other STIs in both women and men. In addition, the infection is associated with adverse birth outcomes during pregnancy, including low birth weight, preterm labor, and early rupture of membranes.[1] Trichomoniasis is underdiagnosed, and when diagnosed, clinicians often do not test the sexual partner, allowing continued transmission. The drug of choice is oral metronidazole, although clinicians may use other 5-nitroimidazoles, such as tinidazole.

Etiology

Trichomoniasis is an infection caused by the protozoan T vaginalis. The infection is sexually transmitted and almost exclusively acquired through direct sexual contact. Humans are the only known host for T vaginalis. While the average incubation period is between 4 and 28 days, infection can persist asymptomatically for long periods. T vaginalis does not exist in cyst form, so, unlike many other protozoans, the organism can only live for a few hours in moist locations outside the human body.[2]

T vaginalis primarily infects the squamous epithelium of the urogenital tract, using adhesion proteins to bind to squamous epithelial cells. Adherence often triggers the parasite to change from a flagellated form to an amoeboid form, which increases its ability to attach to the lining of the urogenital tract and cause damage and resulting inflammation. Infection often raises vaginal pH above 4.5, creating an environment that favors the parasite while disrupting the normal lactobacilli-dominated flora, which can lead to co-infections such as bacterial vaginosis.[1] Risk factors for T vaginalis infection include a lack of barrier contraception during sex, multiple sex partners, and a history of sexually transmitted infections. Other risk factors include increased age, concomitant sexually transmitted infections, incarceration, injection drug use, and commercial sex work.[3] 

Epidemiology

Trichomoniasis is the most common nonviral STI globally, with an estimated 156 million cases.[4] Because trichomoniasis is not nationally reportable in the United States, the prevalence can only be estimated. Prevalence ranges from 8.7% to 20% in women overall, with higher rates in certain populations.[5][6][7] In men, prevalence ranges from around 4% to 10%.[6][7][8] The prevalence is higher in certain populations, with a prevalence of up to 22% in incarcerated women. Other risk factors include older age, multiple sex partners, and a concomitant sexually transmitted infection.[5][9][10]

T vaginalis is highly transmissible through sexual contact, and symptoms are often absent, leading to high rates of silent transmission. Results from studies have shown that 14% to 60% of male partners of infected women become infected, and 67% to 100% of female partners of infected men become infected. Data on the transmissibility of T vaginalis between sex partners of the same sex are limited.[11] Trichomoniasis is more commonly diagnosed in people who identify as Black individuals.[3] Reasons for this include disparities in social determinants of health,[12] disparities in health care access and access to STI testing,[13] and ongoing discrimination and racism.[14] 

Pathophysiology

Trichomonas vaginalis is a motile, single-cell protozoan comparable in size to a white blood cell, that is pear- or round-shaped, with at least 4 flagella that provide undulating motility. The organism typically resides in the lumen of the urogenital tract. Infection occurs after the protozoan attaches membrane-surface glycolipids and glycoproteins to the epithelial surface of the urogenital tract. The organism releases cytotoxic proteins that destroy the epithelial lining. During an infection, the vaginal pH usually exceeds 4.5.

Trichomonas vaginalis can live in the female urogenital tract for months to years without causing symptoms, often persisting asymptomatically for 6 months or longer. In men, the protozoan generally persists for shorter periods but can live asymptomatically in the male urogenital tract for months.[3][15] The majority of both men and women are asymptomatic.[16]

In women, T vaginalis has an incubation period of 4 to 28 days.[15] Women with trichomoniasis often present with concerns of a foul-smelling, yellow or green vaginal discharge, dyspareunia, increased urinary frequency, dysuria, and vulvar pruritus or erythema. In men, T vaginalis infection often causes no symptoms, but when symptoms occur, the most common presentation is urethritis. Less commonly, men may also develop prostatitis and epididymitis.

Histopathology

On microscopy, the presence of motile trichomonads is diagnostic of T vaginalis infection. The organism's motion is jerky and spinning. Trichomonads remain motile for only about 15 minutes after sample collection; consequently, sensitivity decreases over time.

History and Physical

Infection with T vaginalis can vary from an asymptomatic carrier state to a severe, acute infection. Women may present with vaginal discharge, which is often thin, frothy, and malodorous. Other symptoms may include pain with intercourse, urinary tract infection symptoms (eg, dysuria, increased urinary frequency), or pelvic pain.

Postcoital bleeding may occur. On physical examination, there may be vulvar erythema and a yellow-green, frothy, malodorous vaginal discharge. A classic but uncommon physical examination finding is punctate hemorrhages on the vaginal mucosa or cervix, termed a strawberry cervix, which only occurs in about 2% of women.[17] The majority of women are asymptomatic, with only around 15% presenting with symptoms.[17][18]

Men are often asymptomatic, or they may present with symptoms including urethral discharge, dysuria, or mild urethral discomfort after sex. Occasionally, T vaginalis infection may cause testicular pain, epididymitis, or prostatitis. In men, around 20% present with symptoms of infection.[19] On examination, distinguishing T vaginalis infection from other causes of urethritis is challenging.

Evaluation

Diagnostic testing for T vaginalis infection should be performed for women seeking care for vaginal discharge and men with urethral discharge. T vaginalis can be diagnosed by microscopy, a rapid antigen test, or a nucleic acid amplification test (NAAT). In the clinic, vaginal discharge can be evaluated for T vaginalis using pH testing and microscopy. On microscopy, the presence of motile trichomonads on a wet mount is diagnostic for infection. Trichomonads typically exhibit a jerky or spinning motion, but they remain motile for only about 15 minutes, so sensitivity decreases over time after collection. In pH testing, T vaginalis infection typically raises vaginal pH above 4.5. Under optimal conditions, wet mount has a sensitivity of around 60% but is highly specific, with greater than 99% specificity when trichomonads are visualized.[20]

When available, NAAT is the preferred diagnostic test for trichomoniasis in both men and women, given its high sensitivity and specificity. Results from a recent meta-analysis showed NAAT had a sensitivity of 99% and a specificity of 100%.[21] Potential limitations of NAAT include a longer turnaround time and higher cost than microscopy. NAAT can be performed from vaginal swabs, endocervical swabs, or urine, although the sensitivity from urine is lower than from vaginal swabs.

Findings from one meta-analysis showed that sensitivity from vaginal swabs was 98%, compared with 95% from urine.[22] Rapid antigen tests are used as point-of-care tests on clinician-obtained vaginal specimens. Results from a recent meta-analysis showed sensitivity and specificity of around 87% and 98%, respectively. NAAT remains preferred given its higher sensitivity.[23]

One diagnostic strategy is to perform microscopy for T vaginalis and, if the results are negative, to refer to NAAT testing. This approach can help evaluate for other pathogens (eg, Chlamydia trachomatis and Neisseria gonorrhoeae), because multiplex assays are available to test for multiple pathogens. Other causes of vaginal discharge (eg, bacterial vaginosis and vaginal candidiasis) can also be evaluated using wet mount or NAAT.

In the United States, trichomoniasis is not a reportable disease, so there are no general screening recommendations. The Centers for Disease Control and Prevention (CDC) recommends that annual screening can be considered for persons receiving care in high-prevalence settings (eg, sexually transmitted infection clinics and correctional facilities) and for women considered to be at increased risk for infection (eg, multiple sex partners, transactional sex, drug use, a history of STIs, or a history of incarceration). Routine annual screening is recommended for asymptomatic women living with HIV.[24] No screening recommendations exist for T vaginalis in men. Given the high prevalence of asymptomatic T vaginalis infection, further research on optimal screening strategies is needed. 

Treatment / Management

Treatment is indicated for both asymptomatic and symptomatic persons with T vaginalis infection, because treatment is highly curative, reduces transmission of T vaginalis between sex partners, and reduces the risk of long-term sequelae. The 5-nitroimidazoles are the only class of drugs recommended for the treatment of trichomoniasis. Metronidazole 500 mg given orally twice daily for 7 days is recommended for women because it is typically less costly and more widely available than other 5-nitroimidazoles, such as tinidazole and secnidazole.

Oral metronidazole is preferable over topical intravaginal metronidazole, given improved cure rates. Metronidazole 2 g, given orally once, is recommended for treating men with trichomoniasis. Alternatively, a single oral dose of 2 g of tinidazole can be used to treat trichomoniasis in both men and women. Compared with metronidazole, tinidazole tends to cause fewer gastrointestinal adverse effects, but it may be more expensive and less widely available. Secnidazole has a longer half-life than metronidazole or tinidazole and can be given as a single oral dose of 2 g.

Sexual activity should be avoided until treatment is completed, symptoms have resolved, and all sex partners have completed treatment and are asymptomatic. The CDC recommends that women be retested for T vaginalis within 12 weeks of treatment, given the high rates of persistent infection and reinfection. NAAT can be completed as soon as 2 weeks following treatment.

Many states allow expedited partner therapy. Expedited partner therapy laws typically enable clinicians to prescribe treatment to a third-party sexual partner without performing a medical examination or establishing a clinician-patient relationship with the third-party sexual partner of a patient diagnosed with trichomoniasis or other STIs. A list of participating states and the laws surrounding expedited partner therapy can be found on the CDC website.

Differential Diagnosis

The differential diagnoses for trichomoniasis include the following:

Women

• Chlamydia trachomatis infection
• Neisseria gonorrhoeae infection 
• Bacterial vaginosis
• Vulvovaginal candidiasis
• Vaginal atrophy/atrophic vaginitis
• Retained foreign body
• Dermatitis
• Allergic reaction
• Desquamative inflammatory vaginitis 

Men

• Chlamydia trachomatis infection
• Neisseria gonorrhoeae infection 
• Mycoplasma genitalium

Pertinent Studies and Ongoing Trials

As of March 2026, the following studies are ongoing:

• NCT06261840 is a phase 4, multicenter, randomized, open-label clinical trial comparing the effectiveness and cost-effectiveness of oral metronidazole twice daily for 7 days versus oral secnidazole given in a single dose for the treatment of T vaginalis in both women and men. 
• NCT05383521 is a multicenter, randomized, open-label clinical trial comparing oral tinidazole 1 g 3 times daily for 14 days plus metronidazole once daily by vaginal administration for 14 days versus oral tinidazole 2 g twice daily for 14 days plus metronidazole once daily by vaginal administration for the treatment of refractory trichomoniasis infection.
• NCT07082127 is a retrospective cohort study investigating the molecular epidemiology of T vaginalis and its endosymbionts (Mycoplasma hominis and Trichomonas vaginalis virus) and their impact on T vaginalis virulence.

Prognosis

Persons treated with oral metronidazole, tinidazole, and secnidazole have a 90% to 95% cure rate.[25] Topical metronidazole has a lower cure rate of around 50% compared to oral metronidazole, so oral treatment is preferred over topical.[26] An estimated 4% to 10% of T vaginalis isolates in the United States are resistant to metronidazole; resistance to tinidazole is thought to be much lower, at around 1%.[27][28] Globally, T vaginalis resistance to metronidazole is estimated at around 15%.[29] In cases of drug-resistant infections, high-dose tinidazole is an option. Recurrent infections are common due to persistent or recurrent infection.

Trichomoniasis is strongly associated with other STIs, including HIV, Chlamydia trachomatis, Neisseria gonorrhoeae, human papillomavirus, and herpes simplex virus. Pregnant women are at risk for preterm delivery, low-birth-weight infants, and premature rupture of membranes. Trichomoniasis also raises concern for pelvic inflammatory disease.

Complications

T vaginalis can cause morbidity if infections are not treated during pregnancy, including preterm delivery, low-birth-weight infants, and premature rupture of membranes. In men, complications may include epididymitis, prostatitis, and reduced fertility. T vaginalis can also increase the risk for other STIs, including HIV infection.

Consultations

When a person has a known allergy to the 5-nitroimidazoles, a desensitization protocol may be used. However, consultation with a specialist is recommended before proceeding. Specialists should also be consulted when resistance to T vaginalis is suspected. In the United States, T vaginalis susceptibility testing and consultation are available through the CDC.[CDC. Trichomonas vaginalis Susceptibility Testing]

Deterrence and Patient Education

If a clinician diagnoses a person with trichomoniasis, the clinician should educate the patient on safe sexual practices and encourage notification of their partner or partners about the diagnosis so the partners may pursue testing and treatment. Sex should also be avoided until both the patient and their partner or partners have completed treatment and any symptoms have resolved.

Pearls and Other Issues

Pearls regarding T vaginalis infection include the following:

• Although most women with trichomoniasis are asymptomatic, around 50% will develop clinical symptoms within 6 months, making screening critical to prevent symptomatic infection.[15]
• Findings from a systematic review and meta-analysis showed that T vaginalis was significantly associated with preterm delivery (odds ratio [OR], 1.27), prelabor rupture of membranes (OR, 1.87), and delivery of low-birth-weight infants (OR, 2.12).[30]
• T vaginalis infection can increase the risk of HIV acquisition. In populations with a high T vaginalis prevalence of 25%, as many as 20% of HIV infections could be attributed to T vaginalis infection. Additionally, as many as 6% of all HIV infections among women in the United States may be attributed to T vaginalis infection.[3]

Enhancing Healthcare Team Outcomes

Patients with trichomoniasis are best treated by an interdisciplinary team. While most individuals are initially seen by the primary clinician, consultation with an infectious disease expert or gynecologist can be helpful. If a diagnosis of trichomoniasis is made in urgent care or the emergency department, the individual's primary care clinician or gynecologist should be notified.

Timely communication supports care coordination and helps ensure that retesting within 12 weeks is completed. Persons diagnosed with trichomoniasis will also need to be tested for other STIs, including HIV. The patient's primary care clinician may complete this testing, or the patient may seek testing at an STI clinic.

When performing a pelvic examination to collect vaginal swabs or a bimanual examination to determine if pelvic inflammatory disease is suspected, the recommendation is to have a chaperone, preferably a woman. Often, in the emergency department, this will be a female nurse or technician. Clinicians should document the chaperone in the patient's health record.

Patient education is vital. The infectious disease nurse can educate the patient about barrier contraception and ensure adherence to treatment. Additionally, the sexual partner must be identified and treated to prevent continued transmission. Clinicians should rescreen sexually active women after 12 weeks to ensure a complete cure. Open communication between team members is vital to ensure the patient receives standard-of-care treatment and a complete cure.

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Disclosure: Jeffrey Jenks declares no relevant financial relationships with ineligible companies.

Disclosure: Scott Plasner declares no relevant financial relationships with ineligible companies.