[Question #620] trichomoniasis

90 months ago
Dr. Handsfield,

I was the person who asked question 571. Since that time, I have been reading about Trichomoniasis. I still believe I am having some of the symptoms I was experiencing before (slight pain/burn after urinating); however, the symptoms are not constant and I am unsure if they are mental or I am actually experiencing them. However, what I am perceiving appears to be what I have read are the symptoms of Trichomoniasis in males. As such my questions are:

1. When a male has trichomoniasis, what are the common symptoms?

2. Does trichomoniasis cure itself usually?

3. Why is trichomoniasis not routinely tested when undergoing an STD check?
Edward W. Hook M.D.
90 months ago

Welcome back to the Forum.  As you know, Dr. Handsfield and I share the Forum and answer questions interchangeably.  Today I happened to pick up your most recent question.  In preparing to answer, I reviewed your earlier interaction with Dr. Handsfield and agree with all that he said.  The symptoms you describe are compatible with NGU (non-gonococcal urethritis) which an be caused by a variety of pathogens but which most commonly has no pathogen associated with it.  In persons with NGU following receipt of oral sex, pathogen negative NGU is the most common form of NGU.  You had both vaginal and oral exposures so a variety of organisms could be causing your problem or there may not be a pathogen present.   For men with continuing NGU symptoms despite recommended therapy with azithromycin, the CDC now recommends re-treatment for NGU but this time adding a single 2.0 gram dose of metronidazole which would cure trichomonas.  Depending on your circumstance, you may also want to check locally for the availability of a urine NAAT test for trichomonas- they are available.

In answer to your specific questions:

1.  Most trichomonas infections in men are asymptomatic however, when symptoms are present, the most common symptoms are mild to moderate irritation on urination and/or a urethral (penile) discharge.  I might add that these are the same symptoms that we seen in pathogen-negative NGU.

2.  Yes, it appears that in most men with trichomoniasis that the infection cures itself in a few weeks.

3.  Good tests for trichomonas were not widely available until the past year or two.  As a result, as well as the fact that these infections do not cause a lot of symptoms in men (but do in women), tests were not widely available and when they were, they were not particularly good.  In the past couple of years however, test have become increasingly available and more sensitive.  As this has occurred, more trich in men has been diagnosis.  Currently there is a VERY sensitive urine NAAT test for trichomonas that is becoming increasingly available.  You (or your doctor) may need to call around to find it.

I hope these comments are helpful to you.  Take care.  EWH

90 months ago
Dr. Hook thank you for your quick reply. As with Dr. Handsfield, I have followed your publications for years and always respect your opinions. In follow-up, I have some concerns/questions. 

First I am not sure what to make of my symptoms. At first my symptoms (in January/early February) consisted of a slight pain/discomfort in the head of my penis but had no discharge nor pain when urinating. That pain/discomfort ceased until after I was told my ex-gf had tested positive for Chlamydia, at which time I started to notice "symptoms" again. These symptoms now consist of slight pain/burn either  when I start urinating or finish and then some discomfort after. I also do not experience these symptoms every time I urinate. 

Additionally, I have never noticed any discharge from the urethra nor experienced pain after ejaculation. Moreover, my Chlamydia test was negative and even if it was a false negative, I was treated for both Chlamydia and Gonorrhea. With this in mind, these are my questions:

1. Do my changing symptoms appear normal for NGU?

2. Despite my negative result, What is the likelihood I have Chlamydia that did not respond to the treatment I was given, which was  4 250 mg tablets of Azithromycin, which I took in one dose?

3. I am concerned about M. Genitalium and/or Trichonomonas. Do either cause health problems in men and women?

4. If I wanted to re-treat for Chlamydia and M.G and Trich, would the recommended treatment be taking 4 250 mg Azithromycin AND adding a single 2.0 gram dose of metronidazole? Or would I need to add something else for M.G.? As it may be difficult to finding adequate testing for M.G. and Trich I was wondering if would just be more cost effective to ask for a script of needed medicines rather than test.
Edward W. Hook M.D.
90 months ago

1.  Thanks for the additional information.  the treatment you received is the treatment recommended by the CDC for both gonorrhea and for NGU.  This was appropriate given your exposure to an infected sex partner (your GF).  On occasions "symptoms" of the sort you describe are not due to an infection but due to extra attention (scrutiny) paid in looking for symptoms. this not uncommonly causes persons to become aware of sensations which are otherwise normal but typically go unnoticed.  Changing symptoms or symptoms which come and go are rarely due to infections

2.  The treatment you received is the recommended treatment for chlamydia and can be expected to cure over 97% of chlamydial infections.  Treatment failure is so rare that repeat testing to assure cure is not recommended because of a person still had chlamydia, they would be symptomatic.

3.  M. genitalium and trichomonas can each cause NGU-like symptoms, urethral discharge or burning on urination.  They can both be tested for using a widely available urine test at commercial laboratories.  If you are tested and negative, you should not worry that you have these infections.

4.  We do not recommend or endorse treating "just in case" or without knowing infection is likely to be present.  Azithromycin treatment many M. genitalium infections.  As Dr. Handsfield implied, it is unlikely that you have and STI.  If you are concerned, my recommendation is to test but to also commit to believing the test result.  EWH