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Trichomoniasis is a common cause of vaginitis. The causative organism is Trichomonas vaginalis, a flagellated protozoan. Sexual intercourse is the principal method of transmission. Transmission may occur through contaminated fomitcs.

In females, the condition may present as an offensive vaginal discharge which is commonly frothy, light yellow in colour and profuse. Pruritis is the presenting symptom in some patients. Symptoms may appear from 4 days to 4 weeks after sexual contact. Many patients are asymptomatic; in about 10%, no evidence of cervicovaginal inflammation can be seen. Trichomonads are occasionally detected in cervical smears.

In males, trichomoniasis is usually asymptomatic. It may cause a mild urethritis, prostatitis or epididymitis.

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In females, herpetic infection may be complicated by urinary retention due either to local pain or to neurogenic bladder due to radiculitis. Herpes may cause an extensive necrotising lesion of the cervix which causes a sanguineous vaginal discharge and may resemble cervical carcinoma.

HSV infection may produce no symptoms and asymptomatic viral shedding from the cervix or other sites may occur.

Relapse may be attributed to emotional or physical stress, fever, trauma, hormonal changes, menstruation, sunlight, alcohol etc. Relapses are characterised by a milder prodromal period, lesions of 4 to 5 days average duration healing in 1 to 2 weeks and a milder degree of lymphadenopathy.

HSV has a high morbidity and mortality in neonates. The infection can be transmitted from mother to infant during parturition if the mother is actively shedding the virus. A higher rate of neonatal infection occurs if primary infection occurs late in the pregnancy and there is insufficient time for maternal antibody to develop and be transferred to the foetus.

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Primary syphilis

The primary lesion or chancre usually develops at the point of inoculation after an incubation period averaging 21 days (ranging from 10 to 90 days). The chancre is typically firm, painless, punched out and clean. The adjacent lymph nodes are discretely enlarged, firm and non-suppurating. Anorectal chancres may occur in homosexual men.

Untreated, early clinical syphilis usually resolves spontaneously leading to latent disease which may proceed to late destructive lesions.

Secondary stage

The interval between the appearance of the primary chancre and the onset of secondary manifestations varies from 6 to 8 weeks. Constitutional symptoms including fever, headache, malaise and general aches and pains may precede or accompany the signs of secondary syphilis.

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Patients with acute PID usually present with mild to severe lower abdominal pain or discomfort. Other common symptoms are vaginal discharge, dysuria, deep dyspareunia, pain on defaecation, fever with or without chills and menstrual irregularities.

A patient with chronic PID may have symptoms such as chronic lower abdominal pain, dyspareunia, menstrual irregularities or infertility.

Some patients with pelvic inflammatory disease may have no significant symptoms or signs. Practitioners must be alert to the possibility of PID in patients at risk even in the absence of clinical signs and laboratory evidence of infection.

Examination may reveal lower abdominal tenderness, unilateral or bilateral adnexal tenderness with or without a mass, cervical motion tenderness (elicited by gentle movement of the cervix), purulent vaginal discharge and fever. In some cases clinical examination is negative.

Complications include pyosalpinx, tubo-ovarian abscess and peri-hepatitis (Fitz-Hugh-Curtis syndrome). PID is a major cause of tubal damage leading to ectopic pregnancy and infertility.

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Distribution in the population

Follow-up

At least one post-treatment visit is essential to assess the response to treatment, to perform appropriate follow-up investigations and to confirm that sexual contacts have been investigated. At this visit the practitioner should reinforce counselling.