1. health and fitness
2. disease
3. aids and hiv

Republic of Iraq
Ministry of Higher Education
And Scientific Research
University of Baghdad
College of Science
The usage of In-Pouch TV culture system as a
method for Trichomonas vaginalis detection in
Baghdad /AL-Karkh
A Thesis
Submitted to the College of Science, University of Baghdad
in Partial Fulfillment of the Requirements for
M.Sc. Degree in Biology/ Zoology/ Parasitology
By
Ayat Mohammad Saba
B.Sc. in Biology / College of Science /
University of Baghdad
(2009)
Supervised by
Asst. Prof. Dr .Ban Noori AL-Qadhi
2012 A.D.
1433 A.H
‫ﺇﻥَ ﺍﻟَﺬﻳﻦ ءَﺍﻣِﻨﻮَﺍْ ﻭَﻋَﻤِﻠُﻮﺍْ ﺍﻟﺼﺎﻟِﺤﺎﺕِ ﻛَﺎﻧَﺖ ﻟَﻬُﻢ ﺟَﻨﺎﺕُ ﺍﻟﻔِﺮﺩَﻭﺱِ ﻧُﺰُ ًﻻ‬
‫)‪ (107‬ﺧَﺎﻟِﺪﻳﻦَ ﻓِﻴﻬَﺎ ﻻَ ﻳَﺒﻐُﻮﻥَ ﻋَﻨﻬَﺎ ﺣِﻮَﻻً )‪ (108‬ﻗٌﻞ ﻟﻮ ﻛﺎﻥَ ﺍﻟﺒَﺤﺮُ‬
‫ﻣﺪَﺍﺩﺍً ﻟِﻜﻠَﻤﺎﺕ ﺭَﺑِﻲ ﻟَﻨﻔِﺪ ﺍﻟﺒَﺤﺮُ ﻗَﺒﻞَ ﺃﻥ ﺗَﻨَﻔﺪ ﻛﻠِﻤﺎﺕُ ﺭَﺑِﻲ ﻭَﻟَﻮ ﺟِﺌﻨﺎ‬
‫ﺑِﻤِﺜﻠِﻪ ﻣﺪَﺩَﺍً )‪(109‬‬
‫ﺍﻟﻌﻈﻴﻢ‬
‫ﺻﺪﻕ ﺍﷲ‬
‫ﺳﻮﺭﺓ ﺍﻟﻜﻬﻒ)‪(109-107‬‬
Supervisor Certification
We certify that this Thesis was prepared under my supervision at the
Department of Biology / College of Science / University of Baghdad, as a
partial fulfillment of the requirements for the degree of Master of Science in
Biology/Zoology/Parasitology
Supervisor
Assist. Professor
Dr. Ban Noori AL-Qadhi
Biology Department
College of Science
University of Baghdad
/
/ 2012
In view of the available recommendations, I forward this thesis for
debate by the examining committee.
Prof. Dr. Hayfa H. Hassani
Head of Biology Department
College of Science
University of Baghdad
/ /
2012
Committee Certification
We, the examining committee, certify that we have read this thesis and examined
the student in contents and that in our opinion; it is adequate for awarding the
Degree of Master of Science in Zoology/ Parasitology.
Dr. Ban A. Abdul Rahman
Dr. Khawla H. Zghair
Member(Assist. Prof.)
/ /2012
Dr. Ban N. AL-Qadhi
Member(Assist. Prof.)
/ /2012
Prof. Fawzia A. AL-Shinawy
Chair man (Prof.)
Supervisor (Assist. Prof.)
/ /2012
/ /2012
Approved by The Council of The College of Science, University of Baghdad.
Prof. Dr. Saleh M. Ali
Dean of College of Science
University of Baghdad
/
/2012
Dedication
To the prophet Mohammed, whom his words
were the guide of my steps in life
To my parents who have given me the support
throughout my life.
To my brothers who have always stood by me
To my supervisor who taught me the meaning
of patience and perseverance
Ayat
Acknowledgments
In the beginning my thanks and my compliment for my God (Glory to
God and to be all rise above everything); without his mercy and his
assistance this research would never been finished.
I would like to thank Prof. Dr. Saleh M. Ali the Deanery of the College
of Science / University of Baghdad and Prof. Dr. Hayfa H. Hassani the
head of Biology Department, for their support to complete M.Sc.degree.
I am indebted to my parents, without their support for me I couldn't
complete my study.
I am heartily thankful to my supervisor, Dr .Ban AL-Qadhi, whose
encouragement, guidance and support from the initial to the final level,
My deepest gratitude goes to both Dr. Hala AL-Rawi and Dr. Wafa
Ahmed who helped me a lot, despite the large number of visitors and
patients.
I would like to acknowledge the help and support of the staff of
Laboratory of viruses in the blood bank in the city of Rahmaniya for their
help and cooperation.
My thanks also extend to, Dr. Khawla AL-Rawi, Dr.Ahlam AL-Musawi
,my brothers and sisters Doaa, Ali, Zainab, Hussain , Rokaia and my
friends Suhar Dakhal , Donia salman , Noha Nagem,Melad Majed
,Mervet Basim ,Khitam Sabar,Ilaf Adnan ,Israa Hassan and Zainab ALMusawi.
Lastly, I offer my regards and blessings to whoever helped me and whose
name is not mentioned here, Thank you to all.
Index
Index
Index-1 The incidence of T. vaginalis according to different identification
methods.
Methods
Trichomonas +ve
Percentage
Urine Examination
10
5%
Wet mount
14
7%
OLM culture
21
10.50%
Whiff test
23
11.50%
CPLM culture
30
15%
In-Pouch TV system
42
21%
Index-2 The sensitivity and accurate rate among different detection
methods
Methods
Sensitivity
Accurate rate
In-Pouch TV system
100%
100%
CPLM culture
71%
94%
OLM culture
50%
89%
Whiff test
54%
90%
wet mount
33%
86%
Urine Examination
23%
84%
Index
Index -3 Distribution of T.vaginalis infection according to age groups.
Age
Group
Number
positive
(%)
Number
negative
(%)
Total
16-25
15
29.5%
36
70.5%
51
26-35
18
20.5%
70
79.5%
88
36-45
7
14.3%
42
85.7%
49
46-55
1
9.1%
10
90.9%
11
Total
42
21%
158
79%
200
X²=4.41, df=3, P>0.05
Index -4 The distribution of T. vaginalis infection according to the marital
status.
Maritial status
Number
positive
(%)
Number
negative
(%)
Total
Married
39
25.8%
112
74.7%
151
Widow
2
6.1%
31
93.9%
33
Divorced
1
6.2%
15
93.8%
16
Total
42
21%
158
79%
200
X²=9.1, df=2 , p<0.05
Index
Index-5 The distribution of T. vaginalis infection according to the parity.
Parity
Number
positive
(%)
Number
negative
(%)
Total
primipara
7
17.9%
32
82.1%
39
Multipara
33
21.8%
118
78.2%
151
Infertile
3
15.0%
17
85.0%
20
Total
42
200
158
X²=0.78, df=2 , p>0.05
Index -6 The distribution of T. vaginalis infection according to the education
level.
(%)
(%)
Number
Number
Total
Level of
positive
negative
education
Uneducated
12
11.1%
96
88.9%
108
Educated
30
32.6%
62
67.4%
92
Total
42
21%
158
79%
200
X²=13.6, df=1 , p<0.05
Index
Index -7 The distribution of T. vaginalis infection according to the pH level
Ph
Number
positive
(%)
Number
negative
(%)
4
4.5
5
5.5
6
Total
2
6
12
10
12
42
2.9%
11.7%
44.4%
32.1%
63.1%
66
49
15
21
7
158
97.1%
88.3%
55.6%
60.8%
30.9%
Total
68
51
27
31
19
200
X²=51.26, df=4 , p<0.05
Index -8 The distribution of T. vaginalis infection according to the use of
contraception.
The use of
contraceptive pills and
intrauterine device
Used
Number of positive
trichomoniasis women
(%)
23
54.7%
Not use
19
45.3%
Total
42
100%
X²=0.09, df=1 , p>0.05).
Index
Index -9 The distribution of T. vaginalis infection according to the clinical signs
in trichomoniasis patients group
Signs
Number positive
(%)
Vaginal erthrema
5
11.9%
Vulval erthema
3
7.1%
No signs
34
80.9%
Total
42
X²=0.081, df=2 , p>0.05
Index -10 The distribution of T. vaginalis infection according to the odor of
vaginal discharge .
Odor
Number positive
(%)
Bad Odor
32
76.2%
No Odor
10
23.8%
Total
42
X²=5.87, df=1, P<0.05
Index
Index -11 The distribution of T. vaginalis infection according to the color of
vaginal discharge.
Color of discharge
Number positive
(%)
Yellowish color
24
57.1%
White color
13
30.9%
colorless
5
11.9%
Total
42
X²=6.12, df=2, P<0.05
Index -12 The distribution of T. vaginalis infection according to clinical
symptoms.
Symptoms
Number positive
(%)
Discharge only
10
23.8%
Discharge and itching
14
33.3%
Discharge and dysuria
8
19.0%
Discharge ,itching and dysuria
10
23.8%
Total
42
df =3, P<0.05, X²=11.2
Summary
Summary
Trichomonas vaginalis Donne,1836, accounts for almost half of all curable
sexually transmitted infections and has also been associated with adverse
outcomes of pregnancy and increased risk of HIV. Therefore , accurate diagnosis
important and cost-effective .
This study was carried out during the period from October ,2010 to April, 2011
to compare the use of a newer diagnostic culture system , In-Pouch (Biomed
Diagnostics, USA)to different classical detection methods used in Iraq , and to
evaluated the recent prevalence of trichomoniasis accordance with studying
different factors that affect on vaginal trichomoniasis in females complaining of
vaginal discharge .
Vaginal swabs and urine samples were collected from 200 women complaining
vaginal discharge attending the Obstetrics and Gynecology out -patient
department of AL-Yarmok Hospital, AL-Noor training Health Center and Privet
Clinic in AL Shoulla city in Baghdad –AL-Khark . Their age was ranging from
16-55 years. The vaginal swabs examined by wet mount and cultivated in
different culture media (In-Pouch TV system, OLM culture and Trichomonas
Modified CPLM) to detect the presence of T. vaginalis .
The pH strips and whiff test were used to detect the vaginal acidity and odor
respectively. Urine
samples
were ,examined as well by General Urine
Examination to detect the presence of T. vaginalis. Of the 200 women,42 were
positive by In-Pouch TV culture giving the prevelance rate of (21%) with
sensitivity and specifiaty 100% . In-Pouch TV system was found to be a good
tool to detect T. vaginalis with more sensitivity and accurate rate than other
detection methods used .
Women aged 16-25 years had significantly higher prevalence of trichomoniasis
(29.5%) than other age groups.
I
Summary
Married women had the highest percentage of trichomoniasis (25.8%), comparing
with widowed women (6.1%). Statistical significant difference was detected
between these groups.
Multipara women revealed the highest rate of trichomoniasis (21.8%) followed by
primipara group (17.9%)
and finally infertile group
(15.0%). No statistical
significant difference was detected between infection and parity.
Educated women had significantly higher rate of T.vagnalis infection (32.6%) than
Illiterate women (11.1%).
Women with vaginal pH 6 , 5.5 and 5 had significantly higher rate of infection
(63.1% , 32.1% and 44.4% respectively).
Women who used (pills and device) contraception had the highest
rate of
infection(54.7%) than those not using any contraception(45.3%). No statistical
significant differences were detected between these two groups.
Women with no clinical signs had the higher percentage of infection 34(80.9%)
than women with vaginal erthrema and vulval erthema 5(11.9%), 3(7.1%)
respectively. No statistical significant differences were detected between these
groups.
Women with yellowish discharge color showed higher significantly percentage of
infection 24(57.1%) than other with white color and colorless discharge 13(30.9%),
5(11.9%) respectively.However women complaining of both discharge and itching
had significantly higher percentage 14 (33.3%)
than other clinical symptoms
studies (discharge with itching and dysuria , discharge only , discharge and dysuria).
II
List of Contents
No.
Subject
Page
Summary
I
List of contents
III
List of Figures
V
List of table
VII
Abbreviations
VIII
Chapter One: Introduction and Literatures Review
Introduction
1
Literatures Review
5
1-1
Historical background of Trichomonas vaginalis
5
1-2
Classification
6
1-3
Morphology and structure of T. vginalis
7
1-4
Life cycle
9
1-5
Transmission of Trichomoniasis
12
1-6
Epidemiological study
13
1 -7
Host-Parasite interaction (Pathogenesis)
15
1-8
18
1-9
Immune system evasion
Interaction with the Vaginal Flora
1-10
Trichomoniasis clinical manifestation
20
1-11
19
22
Trichomoniasis Complications
1-12
Diagnosis
25
1-12-1
Wet Mount
25
1-12-2
Whiff test
26
1-12-3
Staining method
27
1-12-4
Culture media
27
1-12-5
Polymerase chain reaction (PCR)
30
III
1-12-6
Antibody-Based Techniques
30
1-13
Treatment
31
Chapter Two: Materials and Methods
2-
Materials and methods
34
2-1
Instruments
34
2-2
Equipments
34
2-3
Chemicals material
35
2-4
Laboratory Kits
35
2-5
Subjects Selection
35
2-6
Specimen collection
36
2-6-1
Urine
36
2-6-2
Vaginal examinations
37
2-7
Cultivation of T.vaginalis
40
2-7-1
Trichomonas modified CPLM culture
41
2-7-2
Orange leaves medium (OLM)
41
2-7-3
42
In-Pouch TV Culture System
2-7-3-1
Reagents in In-Pouch TV system
43
2-8
Statistical analysis
43
Chapter Three : Results and Discussion
3-
Results and Discussion
45
3-1
Incidence of Trichomonas vaginalis infection
45
3-2
Sensitivity and accurate rate
47
3-3
The relationship of T. vaginalis infection and Age groups
55
distribution
3-4
The relationship of T. vaginalis infection and marital status
56
3-5
The relationship of T. vaginalis infection and parity
58
3-6
The relationship of T. vaginalis infection and education levels
59
IV
3-7
The relationship of T. vaginalis infection and pH level
60
3-8
The relationship of T. vaginalis infection and the contraception
61
3-9
The relationship of T. vaginalis infection and the clinical signs
63
3-10
The relationship of T.vaginalis infection and the vaginal discharge
64
characters (Odor and color)
3-11
The relationship of T.vaginalis infection and clinical symptoms
66
Conclusions
68
Recommendations
70
References
71
List of Figures
Figures
Subject
Page
1-1
Showing an electron micrograph depicts the T. vaginalis parasite
adhering to vaginal epithelial cells collected from vaginal swabs.
A non-adhered parasite (right) is pear-shaped, whereas the
attached parasite is flat and amoeboid (Pereira -Neves and
Benchimol, 2007)
8
1-2
showing T,vaginalis trophozoite(Campbell, 2001)
9
1-3
Showing life cycle of T. vaginalis(Strous,2008)
Showing T. vaginalis cohesion on the surface of epithelial cells of
the vagina (Petrin et al .,1998)
11
1-5
Showing "strawberry cervix" due to a Trichomonas vaginalis
infection (Strous, 2008)
21
1-6
Showing collection of lateral vaginal swab for wet mount
examination (Vorvick, 2009).
26
1-4
V
18
1-7
Showing In-pouch TV system culture (Sood et al.,
2007)
29
2-1
questionnaire sheet for the study conducted on female with
36
trichomoniasis.
2-2
Left Transport cotton swab. Right Bivalve speculum
37
2-3
38
2-4
Showing A: epithelial cell B: T.vaginalis under microscope 40 x
by wet mount preparation
Orange Leaves Medium, which used in culturing of T. vaginalis. .
2-5
Showing the steps of In-Pouch TV System media inoculation
40
2-6
Showing In-Pouch TV culture kit
43
3-1
The incidence rate of T.vaginalis according to different
identification methods
The sensitivity and accurate rate between different identification
methods
47
3-3
Percentage of T. vaginalis Infection according to the age groups
56
3-4
Percentage of T. vaginalis infection according to the marital
status.
57
3-5
Percentage of T. vaginalis infection according to the parity.
59
3-6
The relationship between T.vaginalis infection and education
level .
60
3-7
The relationship between T .vaginalis infection and pH level.
61
3-8
The percentage of T. vaginalis infection rate according to use of
contraceptives.
62
3-9
The percentage of T. vaginalis infection according to the clinical
signs .
63
3-10
The percentage of T. vaginalis infection according to the odor of
65
3-2
discharge.
VI
39
48
3-11
3-12
The percentage of T. vaginalis infection according to the color of
discharge.
The percentage of T. vaginalis infection according to the clinical
65
67
symptoms.
List of Tables
Tables
Subject
Page
2-1
Showing instruments used in this study.
34
2-2
Showing equipment used in this study
34
2-3
showing chemicals material used in this study
35
2-4
showing contents of CPLM culture
41
2-5
3-1
contents of OLM culture
42
The incidence of T.vaginalis according to different identification 46
methods used for 42 women positive by In-Pouch TV system.
3-2
Showing the sensitivity and accurate rate of G.U.E
48
3-3
Showing the sensitivity and accurate rate of wet mount.
49
3-4
Showing the sensitivity and accurate rate of OLM culture
49
3-5
Showing the sensitivity and accurate rate of whiff test
50
3-6
Showing the sensitivity and accurate rate of CPLM culture.
50
3-7
Showing the sensitivity and accurate rate of In-Pouch TV system
51
VII
Abbreviation
ABBREVIATIONS
ATP
CDF
CPLM
DNA
HCV
HIV
HPV
Adenosine Tri-Phosphate
Cell-detaching factors
Cysteine/Peptone/Liverinfusion /Maltose
Deoxyribonucleic acid
Hepatitis C Virus
Human Immuno deficiency Virus
HSV-2
LBW
NGU
OLM
Herpes simplex virus-2
Low Birth Weight
Nongonococcal urethritis
Orange leaves medium
Pap
Papanicolaou
PCR
Polymerase chain reaction
PID
Pelvic inflammatory disease
PROM
Premature rupture of membrane
STDs
Sexually Transmitted Diseases
STI
Sexual transmitted infection
TAB
Trichomonas Agar Base
TYM
Complex trypticase-yeast extract-maltose medium
Human papillomavirus
VIII
Chapter One
Introduction
&
Literatures Review
Chapter one
Introduction
Introduction:
Trichomoniasis is commonly known as a sexually transmitted disease(STD) of
humans (Petrin et al., 1998; Swinnerton, 2001; Jay and Berman,2008
;Saksisampant, et al.,2009).It is an ubiquitous protozoal infestation of the lower
genitourinary tract in both men and women .It is usually encountered during the
reproductive years, and its transmission is almost exclusively through sexual
intercourse (Graves and Gardener,1993),This disease is caused by flagellated
parasite named Trichomonas vaginalis (Swaygard et al.,2004).
According to the World Health Organization’s(WHO) estimation, there are 7.4
million trichomoniasis cases annually in the U.S.A., and over 180 million cases
worldwide (Soper, 2004). The actual number of people infected with
trichomoniasis may be much higher than this according to the Center for Disease
Control and prevention (CDC,2006), T. vaginalis, with prevalence rates of 15%
or higher in developing countries particularly where access to health care is
limited. Consequently, it is likely that up to 25 million pregnant women globally
are infected with trichomoniasis (Jay and Berman, 2008; WHO ,2010).
Infection rates between men and women are the same with women showing
symptoms while infections in men are usually asymptomatic (Hook,1999).T.
vaginalis accounts for almost half of all curable sexually transmitted infections.
In Iraq,this disease has become more prevalent among women . The prevalence
rate has varied from relatively high rate of 19.5%, 19.6% , 18.2% and 20.11%,
(Al-Shabandar,1979;AL-Kaisi,1994;AL-Sheik
,1995;
AL-Zaiadi,2004)
to
moderatr rate of 10% ,9.7% and 6% (Kadir,1986;AL-Mudhaffar ,1995;
Edan,2007),to as low as 4.8% ,3.9% and 2.4% (Khider, 1985;AL-Rawi,1993,
;Al-A'ani,2005) .
The symptoms of trichomoniasis in women range from none at all to a severe
acute inflammatory state. Classic signs and symptoms include a purulent,
1
Chapter one
Introduction
malodorous vaginal discharge with associated pruritus, burning, dysuria and
dyspareunia. Physical examination in affected women shows vaginitis and
vulvitis, with a frothy, yellow-green mucupurulent discharge. Colpitis
macularis(“strawberry cervix”) may be seen colposcopically (El-Shazly et
al.,2001 ; Cudmore et al., 2004;Workowski and Berman, 2006). T.vaginalis
associated with other organisms like Nisseria gonorrhoeae, Chlamydia
trachomatis, Candida Spp., Pediculosis pubis, Treponema pallidium and
Haemophilus ducreyi (Khan et al., 1991; Agrawal et al., 1997 ) . T.vaginalis may
damage the cervical mucus plug, which eases the passage of anaerobic bacteria
and other pathogens linked to pelvic inflammatory disease (PID) from the lower
to the upper genital tract (Moodley et al., 2002 ).
T.vaginalis
infections are not self-limited and produce non-ulcerative
inflammation of genital epithelium that can progress to necrosis and hemorrhage,
this inflammatory response has been associated with an increased risk of HIV
transmission and aquisition (Sorvillo and kerndt ,1998; Sorvillo et al.,2001; CuUvin, et al.,2002 ).Incident trichomoniasis was an independent predictor of
Herpes simplex virus-2(HSV-2) ;women with trichomoniasis were almost four
times as likely to acquire HSV-2 infection (Gottlieb et al., 2004), infection
with T. vaginalis has been associated with a 2-fold increased risk of cervical
neoplasia, even after controlling for human papillomavirus (HPV) infection
(Gram et al., 1992).Trichomonads may serve as vectors for spread of other
organisms by arrying these pathogens up the fallopian tubes (Keith et al., 1986).
Several studies have shown T. vaginalis to be a risk factor for tubal infertility
(Grodstein et al., 1993), as well as low birth weight infants have been associated
with T. vaginalis infection (Cotch et al.,1997). Therefore, the magnitude of T.
vaginalis infections and their associated morbidity make accurate diagnosis
important and cost effective.
2
Chapter one
Introduction
Accurate diagnosis is necessary for specific treatment and control of this disease.
Diagnosis of trichomoniasis in women is usually accomplished via direct
microscopic examination of the vaginal fluid by wet mount preparation;
however, the sensitivity of this test is low (overall 60%) and may be lower in
asymptomatic women(Lawing et al., 2000).. Culture is clearly the most sensitive
diagnostic method
and
various culture
media
have been described for
cultivation of T.vaginalis(Madico et al.,1998 ; Lawing et al., 2000).Due to the
expense and culture techniques have not been readily available ,this will lead the
clinicians to remote from the routinely clinical laboratory cultivation to another
standard culture system ,In-Pouch system and similar culture systems have been
developed whereby the specimen was directly put into a plastic bag culture
system that provides upper chamber for an immediate exam of the specimen plus
the a lower chamber for a trichomonas culture( Beal et al.,1992; Levi et al.
,1997).
Nowadays, isolation and identification of T. vaginalis are still an issue in many
clinics and laboratories in Iraq. This is usually because the available facilities
and the experience of workers are limited and not up-to-date.Also unstable
electricity may lead to the culture media to be contaminated or give false results.
This will made most physicians now depending on clinical symptoms only of
patients to diagnose trichomoniasis, with no accurate laboratory detection of the
causative agent, T. vaginalis, which mainly lead to confusion or bogus diagnosis
with other causative agents. So, patients with trichomoniasis being left with no
well treatment will lead for this parasite to be transmitted, especially when
having sexual intercourse with partners. due to these reasons this study was
done.
3
Chapter one
Introduction
The aims of the present study:
1-Application of newly culture system techniques (In-pouch TV system) that
have not be used previously in Iraqi laboratories and evaluate its effectiveness.
2- Compare the sensitivity , specificity and even the cost of In –Pouch TV
system with other routinely culture media used in Iraqi laboratories.
3-Evaluate the present prevalence of trichomoniasis in Iraq accordance with
studying different factors that affect vaginal trichomoniasis in females
complaining of vaginal discharge.
4
Chapter one
Literatures Review
1-Literature review
1-1 Historical background of Trichomonas vaginalis
T. vaginalis is a flagellated eukaryote responsible for trichomoniasis which is
consider as one of the important venereal diseases (Garcia et al., 2003; Zaino et
al., 2011). It's a protozoan parasite transmitted principally through vaginal
intercourse ( Cates , 1999 ; Sorvillo et al., 2001; Alfonso and Monzote , 2011 ),
T. vaginalis inhabits the vagina and urethra of women and the urethra, seminal
vesicles, and prostate of men (Meyer ,1996; Cox , 2010).This species was first
found by Alfred Donne in 1836 in purulent vaginal secretions and in secretions
from the male urogenital tract .Donne described it as being twice the size of an
erythrocyte and least as large as a pus cell. Its body described as usually being
rounded although it was capable of assuming various shapes. The organism was
compaired to a Monas by reason of its trumpet and to Trichade because of its
cilia. So that in 1837 he named it Trichomonas because of its similarities to two
other protozoa, Trichade and Monas (Powell, 1936; Robert and Janovy, 2000;
Jamali et al., 2006; Diamantis et al.,2009). In 1838, Ehrenberg added the species
vaginalis (Hare, 1988; Diamantis et al.,2009).In 1841,Dujardin published the
generic name as Trichomonas ,with two species T.vaginalis and T.limacis
(Kirby,1947).
Many attempts have been made to grow T.vaginalis in a variety of media.
In 1915, Lynch make the first simple liquid media were used for cultivation of
T.vaginalis (Asami et al.,1955), T. vaginalis pathogenicity was initially thought
to be non-pathogenic because a majority of infected patients were asymptomatic.
The development of culture medium in the 1940 allowed more detailed study of
the organism and its pathogenicity (Spence, 1992). T. vaginalis infection was
first described as a venereal disease in the mid of the 20th century(Van Der Pol,
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2006). T. vaginalis genome was published in 2007, it is one of the largest parasite
genomes known (Carlton et al., 2007).
1-2 Classification
T. vaginalis is an eukaryotic protozoan (Morada et al., 2011).It has some
characteristics make it similar to bacteria so that it's consider a link between
eukaryotic and Prokaryotic organisms ( Koonin, 2009).
T. vaginalis
an early-diverging parabasalid protozoan that appears to have
branched before protozoan genera, some of the earliest protozoa with
mitochondria(Viscogliosi et al., 1999; Schwebke and Burgess, 2004).Here the
taxonomic position is that based on the classification scheme by Dyer (Dyer,
1990).
Kingdom:
Animalia
Sub Kingdom:
Protozoa
Phylum:
Zoomastigina
Class:
Parabasalia
Order:
Trichomonadid
Family:
Genus:
Species:
Trichomonadidae
Trichomonas
Trichomonas vaginalis
There are three species of trichomonads was generally recognized as pathogens:
Trichomonas gallinae, T. vaginalis, and Tritrichomonas foetus. T. gallinae is a
parasite of the upper alimentary tracts of birds species and can cause severe
necrotic ingluvitis. The remaining two species are sexually transmitted parasites
that reside in the urogenital tracts of humans and cattle, respectively (Conrad et
al., 2011).
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1-3 Morphology and structure of T. vginalis
T. vaginalis it is known to exist only as a trophozoite and lacks a cystic stage and
there are many forms of the trophozoites giant and dwarf forms (Hare.1988;
Sood and Kapil, 2008). In general the trophozoite is an oval as well as flagellated
Fig.(1-1),(1-2). It is slightly larger than a white blood cell, measuring 9 X 7 μm
(Ryan, 2004). But an amoeboid shape is evident in parasites adhering to
mammalian cells (Noel et al., 2010). T. vaginalis has five flagella are near the
cytosome, four of which extend outside the cell together (Schwebke and
Burgess, 2004). The fifth flagellum is the least understood; it wraps along the
surface of the organism. Opposite the four flagella that extend outward, lies the
barb-like axostyle. The axostyle forms a complex of cross-linked microtubules.
The axostyle may be used for attachment to host and can cause the tissue damage
noted in trichomoniasis infections.The flagella and axostyle are distinguishing
features of T. vaginalis (Ryan, 2004). The nucleus in T. vaginalis is located at its
anterior portion, and, as in other eukaryotes, it is surrounded by a porous nuclear
envelope. And axostyle, commences at the nucleus and bisects the protozoan
longitudinally. It protrudes through the posterior end of the parasite, terminating
in a sharp point (Petrin et al., 1998).The trichomonads, like many other protozoa,
exhibit an anerobic metabolism and lack mitochondria. Part of energy
metabolism of trichomonads involves a unique organelle called the
hydrogenosome. The hydrogenosome has a double membrane and is distantly
related to the mitochondrion. However, cytochromes and many typical
mitochnondrial functions such as enzymes of the tricarboxylic acid cycle and
oxidative phosphorylation. The primary function of the hydrogenosome is the
metabolism of pyruvate, produced during glycolysis within the cytosol, to acetate
and carbon dioxide with the concomitant production of ATP. The electrons
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release from the oxidation of pyruvate are transferred to hydrogen ions to
produce molecular hydrogen, hence the name hydrogenosome (Yarlett and
Hackstein, 2005), so that their granules are catalase negative, indicating that they
are not peroxisomes because they produce molecular hydrogen (Petrin et al.,
1998; Dacks et al., 2005). There are two sets of these granules: paracostal and
paraxostylar. The latter set is arranged along the axostyle in three parallel rows,
which is a distinguishing feature of T. vaginalis. Glycogen granules are also
present in T. vaginalis and can be observed by transmission electron microscopy
(Benchimol, 2010). T. vaginalis demonstrates hydrolase activity , and contains
lysosome-like structures such as phagosomes(Petrin et al., 1998; Clark et al.,
2007).
Figure(1-1): Showing an electron micrograph depicts the T. vaginalis parasite
adhering to vaginal epithelial cells collected from vaginal swabs. A non-adhered
parasite (right) is pear-shaped, whereas the attached parasite is flat and amoeboid
(Pereira -Neves and Benchimol, 2007)
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Figure(1-2): showing T,vaginalis trophozoite(Campbell, 2001)
AF: anterior flagella; AX: axostyle; CO: costa; HY: hydrogenosomes; N: nucleus; PB: parabasal body;
PG: parabasal body and Golgi apparatus; RF: recurrent flagellum.
1-4 Life cycle
T. vaginalis, an asexual flagellated protist (Kleina et al., 2004), it is an
extracellular obligate human parasite of the urogenital tract (Vanacova et al.,
2003) .The life cycle of T. vaginalis is simple in that, the trophozoite is
9
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transmitted through sexual intercourse
and no cyst form is known. While,
trophozoite consider diagnostic stage and infective stage too(Strous, 2008).The
trophozoite divides by longitudinal binary fission with mitotic division of the
nucleus (Carlton et al., 2007).In natural infections, gives rise to a population in
the lumen and on the mucosal surfaces of the urogenital tracts of humans.
(Schwebke and Burgess, 2004).But the frequency of produced individuals can be
vary (Prugnolle and Meeus, 2010). The normal vaginal pH is 3.8 to 4.5,
trichomoniasis and atrophic vaginitis often cause a vaginal pH higher than 4.5.
(Pagana and Pagana, 2010), their activity different between seasons.
Trichomoniasis in the winter time is almost fixed, and only when hot, before
moving too obvious, it was found more in the summer a little more. If
trichomoniasis is excreted in the natural environment, they can still live for some
time. Trichomonas strong resistance to the outside world, in dry conditions, they
can survive for nearly 20 hours, even in conditions of - 10 °C, they live seven
hours. At room temperature, Trichomonas can survive in the semen of six hours,
in the urine to survive 24 hours. In the river, Trichomonas can live about five
days, and also be able to reproduce in the river. In the tub bath, bath towels,
footbath, foot rubbing cloth and sitting on the toilet, they survive 12 hours. Thus,
even outside the human body, trichomoniasis can still spread, should be cause for
vigilance (Pagana and Pagana, 2010)
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Figure(1-3): Showing life cycle of T. vaginalis(Strous,2008)
T. vaginalis resides in the female lower genital tract and the male urethra and prostate , where it
replicates by binary fission . The parasite does not appear to have a cyst form, and does not
survive well in the external environment. T. vaginalis is transmitted among humans, its only
known host, primarily by sexual intercourse
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1-5 Transmission of Trichomoniasis
Trichomoniasis is one of a sexually transmitted diseases (Schwebke and
Burgess, 2004; Van Der Pol et al., 2007; Fichorova, 2009 ;Zaino et al.,2011).
Four points support the belief that T. vaginalis is transmitted sexually. The most
important evidence is isolated of T. vaginalis from Urethra, prostate gland,
Epididymis and seminal fluid in men, while in women that parasite was isolated
from vagina ,urethra ,cervix and bartholin gland ,and the high rate of infection in
women who had many sexual partner(prostitutes).Also, the high rate of infection
in men who were partners to infected women (Martinez-Garcia et al.,1996;
Mgone et al.,2002; Schwebke and Burgess ,2004 ; Reynolds et al.,2008;
Fichorova, 2009). But Nonsexual transmission of trichomoniasis is extremely
rare (Thomason and Gelbart 1989). Asymptomatically infected individuals are an
important vector and act as a stealth factor in trichomoniasis transmission. More
than 70% of male partners of infected females are also infected (Hobbs et al.,
2006).T. vaginalis trophozoite is among the most durable protozoan organisms
that can survive for up to 24 hours in urine, semen or even in water samples and
has the ability to persist on formites with a moist surface for up to one or two
hours (Swygard et al.,2004,). Although organisms are able to survive for hours
on damp towels and clothes of infected women (Lossick ,1989),always the
transmission happen by sexual intercourse but seldom transmission happen by
moist washcloths, contaminated douche nozzles, specula ,or toilet seats through
which trichomonads may find their way into the vagina.(Faro and Soper ,2001).It
can also be transmitted to neonates during passage through an infected birth
canal, ( Danesh et al.,1995; Temasvari et al., 2002), which was isolated T.
vaginalis of tracheal secretions (Tracheal disharge) of two neonates with
respiratory problems in Hncaraa (Szarka-temesvari et al.,2002).Trichomoniasis
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has an incubation period of from four days after exposure to one month, but
symptoms may not appear for up to six months. During that period of time the
organism can be spread and the person may not know he is infected (Anderson et
al., 2004; Evans, 2009).
1-6 Epidemiological study
T. vaginalis has long been recognized as one of the most prevalent sexually
transmitted infections (Shafir et al., 2009). More than double the number of
Chlamydia trachomatis cases and treble the cases of gonorrhea (Josephine et al.,
2010).The incidence of trichomoniasis depends on the population examined.
Also, certain factors such as poor personal hygiene, multiple sex partners, low
socio-economic status and underdevelopment (Crosby et al., 2002; Jatau et al.,
2006).In the United States of America, five million women and one million men
are infected annually (WHO,2004). Trichomoniasis accounts for 4% to 35% of
vaginitis diagnosed in symptomatic women in a primary care setting in the
United States (Anderson et al., 2004),T. vaginalis is more prevalent in women
and race has been identified in several as predictive of infection with this
parasite. Moreover, with very high prevalence estimates reported among black
women (Sorvillo et al., 2001).While, in Latin America, trichomonal prevalence
has varied from 2.9% to 16.5%, where the highest prevalence was found in
population samples in the jungle and the highlands of Perú, and the lower
prevalence were found in clinical settings such as family planning clinics,
pharmacies and obstetrics services (Alvis et al.,2007 ; García et al.,2007 ).
In Africa, the prevalence of trichomoniasis is reported to be much higher
(WHO,2004) in several African countries the incidence was documented as the
following ; 7.3% of patients suffered multiple infections included trichomoniasis
in Khartoum, Sudan( Ortashi et al.,2004) 17.7% in Uyo, Nigeria (Okpara et
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al.,2009) 18.7% in Zaria, Nigeria(Jatau et al.,2006), 18.75% in Egypt ( El-Ahl et
al., 2002 ) ,24.7% in Tanzania (Klouman et al.,1997), 34.0% in Nairobi, Kenya
(Mirza et al.,1983), 49.2% in South Africa(O’Farrell et al.,1989) and 69.8% in
Entebbe, Uganda ( Tann et al.,2006). The prevalence of T. vaginalis in African
populations is higher than prevalence in United State and Latin America. That
difference due to different in access to care, personal health practices and lower
level of education (Swygard et al.,2004). In Australia, exactly urban area
T.vaginalis prevalence is reportedly low, based upon routine wet preparation
diagnostic methods. Australian rates of trichomoniasis peaked in the 1950 at 20–
30% and rapidly declined through the 1960 and 1970 to below 1% in 1990.
(Josephine et al., 2010).
In Europe, in Swansea, United Kingdom , 401 consecutive patients attending for
termination of pregnancy. The proportion of the incident of T. vaginalis between
those patients was 0.75% ( Blackwell et al., 1993).In Greece , the prevalence
rate of infection with T. vaginalis was found to be 6.7% in symptomatic women
and 2.4% in asymptomatic (Piperaki et al.,2010 ),another study included 1,050
women: 530 in Western Europe and 520 in Ukraine ,the prevalence rate of
infection with T.vaginalis was found to be 12.1%( Landes et al.,2007 ).In
Poland , 218 women-workers of a cement plant was examination 18.7% of them
were infected with T. vaginalis ( Dudkiewicz et al.,1983 ) and in Lisbon,
Portugal, examined 211 female with vaginal discharge T. vaginalis was detected
alone in 23.8%, while 76.2% of them had multiple infections with Trichomonas
and other STDs(Garcia et al.,2004 )
In Asia, Trichomoniasis incidence was less than Africa , 9.4% in Goa
India(Shahmanesh et al.,2006), 13.1% in Manisa, Turkey( Yereli et al,1997) ,
15.1% in Indonesia ( Tanudyaya et al,2010), 18.1% in Hamedan City, Iran (
Shobeiri and Nazari, 2006). In Iraq , AL- Kaisi (1994) revealed that out of 480
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women with vaginal discharge only 92 of them were infected with T. vaginalis
giving an incidence of 19.16%.Another study by Mahdi (1996) showed that
vaginal swabs were collected from 300 females and examined by the wet
preparation and culture methods. T. vaginalis parasite was identified in 34
female
subjects
(11.3%)
with
vaginal
discharge.
While,
AL-
Ani
(1998)examined 559 vaginal swab of women attended the gynecological
antenatal out patients clinic and the family planning clinic at the maternity and
pediatrics hospital in Ramadi city .She was found that the infection rate of T.
vaginalis among women complaining of vaginal discharge in Ramadi city was
24.5% and the infection rate in asymptomatic women was 13.6%.
Mahdi et
al.(2001) investigated Trichomonas vaginalis infection among 352 women with
vaginal discharge, 46 were found to be infected, an infection rate of
13%.Another study by AL-Zayadi (2004) showed that females with vaginal
discharge in AL-Najaf general hospital maternity and children only 72 cases to
be infected ,going an incidence of 20.11%.While, AL- Lihaibi (2005)examined
vaginal swabs of 65 women attending the out –patients clinic at AL-kadmyia
teaching hospital in Baghdad, the prevalence rate of infection with T.vaginalis
was found to be (38.5%).Al-A'ani (2005) investigated the epidemiology of
vaginal infections during one season of ayear in Baghdad city, and showed the
prevalence rate of infection with T. vaginalis was (1.6%).While, Edan (2007)
examined 250 females with abnormal vaginal discharge in AL-yarmouk teaching
hospital during 2004 and 2005 ,15 patients (6%) were infected with T. vaginalis .
1-7 Host-Parasite interaction (Pathogenesis)
Although T. vaginalis is the most common cause of nonviral STD (Gavgani et
al., 2008), the exact mechanism of its pathogenesis has not been clearly
elucidated. The host-parasite relationship is very complex, and the broad range
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of clinical symptoms cannot likely be attributed to a single pathogenic
mechanism. Many mechanisms are thought to be involved and all the pathogenic
mechanisms (contact-dependent, contact-independent, and immune response) are
probably important in the virulence of this disease (Sood and Kapil, 2008).The
adhesion of the parasite to the epithelial cells seems to be mediated by four
adhesion proteins: AP65, AP51, AP33, and AP23 (Harp and Chowdhury, 2011),
which act in a specific receptor-ligand fashion, dependent on time, temperature,
and pH. Gene expression of the four adhesion proteins is coordinately
upregulated at the transcriptional level by iron (Sood and Kapil, 2008). That
explained the enhances the ability of the T. vaginalis to attach to the vaginal
epithelium at menstrual, because of the menstrual blood makes available
increased amounts of iron (Cudmore et al., 2004). Little is known about the host
cell receptors to which the parasite adhesion molecules bind, although there is
some evidence that laminin may be a target for trichomonad adhesion (Garcia et
al., 2003). Adherence, does not correlate directly with virulence, since virulent
strains isolated from symptomatic patients exhibited wide differences in their
ability to adhere to host cells (Midlej and Benchimol, 2010). The hemolytic
activity of the parasite appears to be correlated with virulence (Krieger et al.,
1983a).The ability to synthesize lipids is lacking in T. vaginalis, erythrocytes
may be a prime source of the fatty acids that are needed by the parasite. In
addition, iron, which is an important nutrient for the parasite, may also be
acquired by lysis of RBCs. Also, a variety of hydrolases have been described in
T. vaginalis, with cysteine proteinases being particularly prevalent (Schwebke
and Burgess, 2004; Sood and Kapil, 2008).The contact-dependent mechanisms
described above play an important role in the pathogenesis of the disease.
Besides these, there are contact-independent mechanisms. There are reports of
other parasite products, described as cell-detaching factors (CDF), which are
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released by the parasite and are known to have trypsin-like activity. CDF, a
glycoprotein, is heat and acid labile and its activity is pH dependent, this is of
clinical relevance since the normal pH of the vagina is 3.8-4.2 but is greater than
5.0 in the presence of trichomoniasis. The rise of vaginal pH during
trichomoniasis may therefore be crucial in the pathogenesis of the disease.
Further, the production of CDF has been shown to decrease in the presence of
estrogen. This finding may explain some of the etiology of the disease, the
worsening of symptoms around the time of menses, when estrogen levels are at
their lowest (Sood and Kapil, 2008).
Some studies have indicated that cytophagocytosis may constitute one of
pathogenic mechanism (Honigberg, 1990; Mirhagani and Warton, 1996;
Rendón-Maldonado et al., 1998). It is understood that T. vaginalis is a
phagocytic cell, since it is able to efficiently ingest inert particles and cells by a
mechanism similar to that observed in other phagocytic cells (Benchimol et al.,
1990; Rendón-Maldonado et al., 1998). Also, ingestion of several types of
bacteria (Juliano et al., 1991), as well as different mammalian cells (GonzálezRobles et al., 1995; Rendón-Maldonado et al., 1998).
T. vaginalis infection in males is generally mild or asymptomatic. The oxidative
nature of the male genital tract is hypothesized to be inhibitory to certain
pathogenic factors of the protozoan (Sood and Kapil, 2008). Zinc, in prostatic
fluid, is also cytotoxic to the parasite (Gehrig and Efferth , 2009). In contrast, the
vagina is a reducing environment, which may contribute to the activation of
some pathogenic mechanisms of T. vaginalis(Sansom et al.,2008).
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Figure(1-4): Showing T. vaginalis cohesion on the surface of epithelial cells of
the vagina (Petrin et al .,1998).
1-8 Immune system evasion
The T. vaginalis virulence factors responsible for the remarkable evasion of the
host immunity and the severity of the pathologic inflammatory reaction in
trichomoniasis remain elusive. Although, women may develop specific
antibodies to T. vaginalis antigens, the infections do not provide lasting
immunity, and reinfection is common (Singh et al.,2009). Its ability to evade the
host immune system is an important aspect of pathogenesis. Avoidance of
complement is a strategic tactic which is used by T. vaginalis to overcome the
human immune system ( Petrin et al., 1998). It has long been known that T.
vaginalis activates the alternative pathway of complement
(Weart and
Yang,2006). T. vaginalis has taken advantage of a niche in which little
complement is present. Cervical mucus is surprisingly deficient in complement
(Petrin et al., 1998).Menstrual blood represents the only source of complement
available to the vagina. Interestingly, its complement activity is about half that of
18
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venous blood, and about one-third of menstrual blood samples have no
complement activity at all (Petrin et al., 1998). Menstrual blood has appreciable
complement-mediated cytotoxicity toward T. vaginalis, and although a reduction
in parasite concentration is seen during menses, trichomonal infection persists
even after menses (Demes et al., 1988; Sood and Kapil, 2008). While the number
of organisms in the vagina actually decreases during menses, many of which are
mediated by iron, which contribute to the exacerbation of symptoms at this time.
(Shiraishi et al., 2011). Like many other protozoan parasites, T. vaginalis
displays phenotypic variation as a mechanism of immune evasion (Cudmore et
al., 2004). Thus, the phenotypes are described as A+ B− (P270 positive) and A−
B+ (P270 negative) (Forgetta et al., 2011). The positive-phenotype organisms
lack adhesions and cannot cytoadhere or parasitize host cells (Alderete et al.,
1995). Only the organisms of the negative phenotype, which express the
adhesions, have the ability to cytoadhere (Alderete et al., 1995). T.vaginalis
parasite also secretes copious amounts of highly immunogenic soluble antigens
(Alderete and Garza,1985). A continuous release of these antigens may
neutralize antibody or cytotoxic T lymphocytes, thus short-circuiting specific
anti-T. vaginalis defense mechanisms. As well, T. vaginalis can coat itself with
host plasma proteins. This coating does not allow the hosts immune system to
recognize the parasite as foreign. Thus, immune system mechanisms such as
antigen presentation and complement-mediated lysis will not occur(Adegbaju
and Morenikeji, 2008).
1-9 Interaction with the Vaginal Flora
The establishment of T. vaginalis in the vagina is puzzling since the normal pH
of the vagina is very acidic 4.5, while the organism thrives in less acidic pH > 5
(Adegbaju and Morenikeji , 2008). The relationship between protective
19
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lactobacilli and T. vaginalis is not completely understood (Valandkhani,
2004),demonstrated that Lactobaccillus acidophilus has enhancing effect on the
adhesive ability of T. vaginalis to vaginal epithelial cells which is probably due
to the reduction in vagina pH (4.5), peaking only during the initial phase of the
attachment. T. vaginalis was unable to grow well when a higher concentration of
L. acidiphillus is present (Abraham et al., 1996). There was increase in the
number of T. vaginalis after the reduction of
L. acidophilus, at the end of
menstrual cycle and during menopause ,thus increasing symptoms of
trichomoniasis. The parasite also seems to have a deleterious effect on
L.
acidophilus ( Singh et al., 2011).Several mechanisms have been proposed; T.
vaginalis has been observed to phagocytize bacteria and this may occur with
lactobacillus as well (Adegbaju and Morenikeji , 2008). Another hypothesis is
that products such as proteinases secreted by T. vaginalis, may destroy the
lactobacilli (Petrin et al., 1998; Adegbaju and Morenikeji , 2008).
1-10 Trichomoniasis clinical manifestation
The vagina was kept clean and in a healthy state by production secretion of
normal vaginal discharge .Furthermore, all women had some amount of vaginal
discharge. Glands in vagina and cervix produce small amounts of fluid that flow
out of the vagina take with it old cells that line the vagina. And the normal
vaginal discharge helps to clean the vagina, as well as kept the vagina lubricated
and free from infection and other germs. A normal vaginal discharge did not
have a foul odor and no odor at all. Normal vaginal discharge was appear clear or
milky when it was dried on clothing; occasionally might notice white spots or a
normal vaginal discharge that was thin and stringy looking (Jomegarry,
2010).But when that discharge become purulent ,called abnormal vaginal
discharge ,and that change of vaginal discharge can be clinical manifestation of
20
Chapter one
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vaginitis , T. vaginalis infection is one of the major three causes of vaginitis
(Cudmore et al.,2004) . The Symptoms of trichomoniasis typically occur after an
incubation period of 4-28 days in about 50% infected individual (Smith and
Ramos, 2010). According to severity of infection, T. vaginalis causes
asymptomatic, acute or chronic urogenital infection (Oud, 2009; Escario et al.,
2010).The clinical picture in the acute infection reveals diffuse vulvitis due to
copious leukorrhea. The discharge is typically frothy, yellowish-green, and
mucopurulent (Jamali et al,2006; Loo et al.,2009) Small punctate hemorrhagic
spots may be found on the vaginal and cervical mucosa. This speckled
appearance has been referred to as a “strawberry appearance” (Cudmore et al.,
2004; Workowski and Beraman, 2006).
Figure(1-5): Showing "strawberry cervix" due to a Trichomonas vaginalis
infection (Strous, 2008).
In chronic infection, the predominant symptoms are mild, with pruritus, cause
vulvovaginal itching, soreness, dyspareunia (pain during sexual intercourse) and
dysuria (pain during urination), while the vaginal secretion may be very scanty
21
Chapter one
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and mixed with mucus. However, Cervicitis due to trichomoniasis is
characterized by two major signs purulent discharge in the endocervical canal
and easily induced endocervical bleeding. Moreover, the chronic stage of
trichomoniasis infection considered important stage of infection because of the
patients (with chronic trichomoniasis) are the major source of transmission of
T.vaginalis (Workowski and Berman, 2006).In females, 50% of cases are
asymptomatic. Infection can persist for long periods of time in the urogenital
tract of women, 25 - 50% are asymptomatic for the first six months of infection,
and organisms can survive indefinitely in the lower urogenital tract if left
untreated (Swygard et al.,2004).T. vaginalis acquired during birth may cause
vaginal discharge during the first week of life of newborn females. Furthermore,
the prepubertal child with trichomoniasis may present with symptoms similar to
the adolescent and adult patient (Ahrens et al., 2010). A recent studies have
found that T.vaginalis is associated with asymptomatic infections in 50%–75%
of infected males(Stark et al.,2009) When symptoms are present, the Symptoms
typically include urethral discharge, pain during urination, mild local itching, and
burning after sexual intercourse ( Kreiger,1995; Guenthner et al.,2005).
1-11 Trichomoniasis Complications
Trichomoniasis had long been regarded as a sexually transmitted infection of
minor importance, evidences recently accumulated implicates T. vaginalis as a
contributor to a variety of adverse outcomes in both women and men (Soper,
2004; Brown et al., 2010). Trichomonas may play a critical role in amplifying
human immunodeficiency virus (HIV) transmission. Given the evidence that T.
vaginalis likely promotes HIV infection (Laga et al., 1993; Petrin et al., 1998;
Sorvillo and Kerndt, 1998; Sorvillo et al., 2001; Shafir et al., 2009; Alfonso and
Monzote, 2011). Furthermore, persons with trichomoniasis are twice as likely to
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Chapter one
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develop HIV infection as the general population (Laga et al., 1993; Aberg et al.,
2009), this is explained by the fact that an association exists between acquisition
of T. vaginalis and HIV: disruption of the epithelial monolayer cells leading to
microulcerations of inhabited tissues and increased passage of the HIV virus
(Workowski and Berman, 2006). Studies reveal that T. vaginalis induces
immune activation, specifically lymphocyte activation, replication and cytokine
production, leading to increased viral replication in HIV-infected cells (Smith
and Ramos, 2010). And T. vaginalis has also been shown to be associated with
increased viral load in the seminal and the cervicovaginal compartments.
Because viral load is the largest risk factor for transmission of HIV within
couples with discordant infection status, this suggests that control of T. vaginalis
infection in men may help reduce the infectivity of HIV-infected persons (Van
Der Pol, 2007). Trichomoniasis has been associated with an increased risk of
pelvic inflammatory disease (PID) in women infected with HIV-1 (Huppert,
2009).Also, T. vaginalis may damage the cervical mucus plug, which eases the
passage of anaerobic bacteria and other pathogens linked to PID from the lower
to the upper genital tract (Laga et al., 1993; Moodley et al., 2001; Becher et al.,
2009).Trichomoniasis may be an important cause of nongonococcal urethritis
NGU. A recent study found that in men with NGU, 19.9% were infected with
Trichomonas ( Schwebke and Hook ,2003).The Centers for Disease Control
CDC treatment guidelines recommend inclusion of Trichomonas therapy for men
with recurrent NGU (CDC ,2006) .In 2004, a study demonstrated both
trichomoniasis and bacterial vaginosis to be independent predictors of incidence
of Herpes simples virus type 2 (HSV-2) among women. In a multi center study
of 1,766 patients attending STD clinics who were enrolled in a study to
determine the incidence and predictors of HSV-2 infection, women with newly
diagnosed trichomoniasis were 3.7 times as likely to acquire HSV-2 infection;
23
Chapter one
Literatures Review
those with bacterial vaginosis were 1.9 times as likely to acquire HSV-2(Gottlieb
et al, 2004).
T. vaginalis infection during pregnancy can cross into the amniotic fluid and
result in preterm labor. Preterm birth is associated with poor infant health and
early death, admission of the newborn to neonatal intensive care in the first few
weeks of life, prolonged hospital stay and long-term neurologic disability
including cerebral palsy. Pregnant women with T.vaginalis are at increased risk
for premature rupture of membranes (PROM), preterm delivery and low birth
weight infants (LBW). Trichomoniasis has been shown to be associated with
increased risk of preterm birth( Saurina and
McCormack, 1997;Cotch et
al.,1997; Rasti, et al.,2011),and treatment of asymptomatic trichomoniasis in
pregnancy is controversial.( Klebanoff et al.,2001; Kigozi et al.,2003).
The association between T. vaginalis and cervical neoplasia has been reported in
many studies since the early 1950. It has been suggested that this organism is
responsible for the induction of changes in the human cervical mucosa, resulting
in dysplasia or carcinoma (Bechtold and Reicher, 1952; Zhang, 1994; Johnston
and Mabey, 2008; Becher et al., 2009). Other results from the analysis indicated
that T. vaginalis is associated with increased risk of cervical neoplasia (Zhang
and Begg, 1994).Also, T. vaginalis is associated with urethritis, prostatitis,
epididymitis, reduced sperm function, and infertility in men (Singh et al., 2011).
Proper diagnosis and appropriate treatment of asymptomatic trichomoniasis is
necessary to control and prevent complications of the disease (Johnston and
Mabey, 2008).
24
Chapter one
Literatures Review
1-12 Diagnosis
The classic symptoms associated with the clinical diagnosis of T. vaginalis
include a yellowish –green frothy discharge, pruritus, dysuria, dyspareunia, and
the “strawberry” cervix, which is characterized by punctate hemorrhagic lesions
(Farage et al., 2008). However, diagnosis cannot be readily made solely on the
basis of clinical presentation for several reasons: (i) The clinical symptoms may
be synonymous with those of other STDs (Passos et al., 2010), (ii) The classic
“strawberry” cervix is seen in approximately only 2% of patients (Strous, 2008),
and (iii) The frothy discharge is seen in only 12% of women with T. vaginalis
(Fouts and Kraus, 1980 ; Lewis, 2010). Fouts and Kraus (1980) demonstrated
that if these classic features are used alone in the diagnosis of trichomoniasis,
88% of infected women will not be diagnosed and 29% of uninfected women
will be falsely indicated as having infection. The data suggest that clinical
manifestations are not reliable diagnostic parameters and that laboratory
investigations are necessary for the accurate diagnosis of trichomoniasis.
Accurate diagnosis is essential, since it will lead to appropriate treatment and
will facilitate the control of the spread of T. vaginalis infection.
1-12-1 Wet Mount
Diagnosis of trichomoniasis by microscopic examination considers most
traditionally method (Radonjic et al., 2006). Wet mount preparations are useful
for giving clear images of fresh specimens under the microscope (Fankhauser,
2005).Wet-mount microscopy is assumed to have perfect specificity and its Wet
mount examination is the most frequently used method for diagnosis of
trichomoniasis in women (Kaydos et al., 2002).Diagnosis by wet-mount requires
visualization of viable, motile protozoa; therefore, specimens must be examined
25
Chapter one
Literatures Review
immediately. Vaginal secretions are obtained from the lateral walls and fornices
using a swab; in men, any urethral discharge, prostate secretions, or urethral
scrapings may be used (Swygard et al., 2004). The sensitivity of wet-mount
microscopy can be further reduced as a result of delays between specimen
collection and examination (Kingston et al., 2003).
Figure (1-6): Showing collection of lateral vaginal swab for wet mount
examination (Vorvick, 2009).
1-12-2 Whiff test
In this test the amine odor test was performed by mixing several drops of 10%
potassium hydroxide (KOH) to a sample of vaginal discharge. A strong fishy
odor is indicative of a positive test result (Briselden and Hillier, 1994; Wilkerson
and Sinert, 2010) .This test may be positive for either trichomoniasis or bacterial
vaginosis. This test should not be considered an accurate means of diagnosis for
trichomoniasis (Wilkerson and Sinert, 2010).
26
Chapter one
Literatures Review
1-12-3 Staining method
Stain method was one of methods which used for T. vaginalis detection .Besides
these, a number of staining techniques using Fontana (Nagesha et al., 1970)
,acridine orange (Fripp et al., 1975) periodic acid-Schiff (Rodriguez-Martinez et
al., 1973), Leishman (Levett , 1980), Modified Field's stain(Afzan et al., 2010) ,
Gram stain(Afzan et al., 2010), Giemsa stain (Özdemir et al., 2011), have been
used to improve the sensitivity of direct microscopy. The Papanicolaou test is a
microscopic examination of a stained specimen. It is mainly used as a diagnostic
test for the screening of various cervical abnormalities and genital infections,
while it may occasionally detect trichomonads(Wright et al., 2007).Moreover,
Papanicolaou (Pap) staining may be the most practical approach for the detection
of asymptomatic infections as a large number of asymptomatic women undergo
routine cytologic screening (Aslan et al.,2005). But its sensitivity 57% or more
than that (Yazar et al., 2002 ). While Wiese et al. (2000) showed that detection
using the Papanicolaou test has reported sensitivity of 60% and specificity of 95–
97%.
1-12-4 Culture media
Culture using a variety of liquid and semi-solid media remains the gold standard
for diagnosis of trichomoniasis in women (Clark, 2002). Culture is more
sensitive than both wet mount and Papanicolaou test, and it has a high specificity
(Wendel et al.,2002; Lobo et al.,2003).The disadvantages of the culture method
include the cost, contamination with bacteria is a major problem, even with broth
cultures spiked with antibiotics to eliminate vaginal flora (Garber, 2005) .
Incubation periods ranging from two to seven days are required to identify T
vaginalis in culture (Garber, 2005), and the need to delay treatment until the
results are available. Patients will continue to be infectious to others during this
time (Thomason and Gelbart, 1989).
27
Chapter one
Literatures Review
There are many cultures used for T. vaginalis isolation and detection such as:
· Kupferberg's medium (Gelbart et al., 1990).
· Diamond medium (Borchardt et al., 1997).
· Orange leaves medium (OLM)( Khalaf and AL-Akeede, 1997;AlDabbagh and Kharofa, 2007).
· Trichomonas modified CPLM culture (Garcia and Bruckner, 1995; AlDabbagh and Kharofa, 2007).
· Feinberg’s medium (Loo et al., 2009).
· Cysteine/Peptone/Liverinfusion /Maltose (CPLM) (Saksirisampant et al.,
2009).
· Complex trypticase-yeast extract-maltose (TYM) medium (Song et al.,
2010).
T.vaginalis cultivation in these cultures with optimum temperature between
37-35°C and PH was between 6.5-5.5 (Vandyke et al., 1999). But culture
techniques have not been readily available but would be the most effective
way of establishing the true epidemiology of T vaginalis, particularly where
Sexual transmitted infection(STI) clinics are remote from the clinical
laboratory (Garber, 2005).
The In_pouch TV system culture
The In_pouch TV system was disposable culture system for the maintenance,
transport and detection of T. vaginalis in clinical specimens Figure(1-7). It is
constructed of clear plastic film which eliminates medium loss and maintains a
reduced (Pillay et al., 2004; Domeika et al., 2010). The InPouch TV culture
system combines a two-chambered bag that allows one to perform a wet mount
28
Chapter one
Literatures Review
using the upper chamber and a culture using the lower chamber, in one selfcontained system (Barenfanger et al., 2002). In-Pouch offers some distinct
advantages, microscopic observation can be made directly through the bag as the
bag can be used as a slide on the stage of the microscope. This obviates the need
for sampling to examine the culture for growth thereby preventing
contamination. In-Pouch has selective media that inhibitory for both yeast and
bacteria. It may take three to four days to determine culture results , the In-Pouch
TV system has demonstrated a greater sensitivity than either the saline wet
mount or modified Diamonds media (Borchardt et al., 1995; Sood et al., 2007).
Figure (1-7): Showing In-pouch TV system culture (Sood et
al.,2007).
In-Pouch TV culture specific for cultivation of T. vaginalis only, other
trichomonas species not survive and replicate at the PH and medium composition
found in the In-Pouch TV culture test kit (Borchardt and Smith, 1991).
29
Chapter one
Literatures Review
1-12-5 Polymerase chain reaction (PCR)
PCR is based on DNA amplification and detection using known primers to
T.vaginalis specific genes (Madico et al., 1998; Prokopi et al., 2011). The
sensitivity and specificity of these primers in clinical studies with vaginal swab
specimens have varied, with sensitivities of 85 to 100% being reported (Jeremias
et al., 1994; Heine et al., 1997; Madico et al., 1998; Sobel et al., 2001; Schirm et
al., 2007).Unlike PCR for infections such as Neisseria gonorrhea and
Chlamydia, which appears to have greater sensitivity than culture methods, PCR
for trichomoniasis in women does not appear to offer a diagnostic advantage.
This may be because T. vaginalis is much less fastidious to culture than N.
gonorrhoeae or Chlamydia trachomatis. Successful culture of T. vaginalis
requires only the multiplication of a single organism (Habib et al., 2009), the
same as that needed for PCR. PCR of vaginal swabs may be advantageous in
settings where incubation of cultures is not possible and shipping of specimens to
a reference laboratory is required. Self-obtained vaginal swab specimens may
also be useful for the PCR technique. In addition, PCR may be superior to culture
for the diagnosis of T. vaginalis in males.Of note is the many different primers
which have been used for the detection of T. vaginalis by PCR. Direct
comparisons of these primers, and perhaps the development of new primers,
could prove useful with regard to refining the technique and improving its
sensitivity (Krieger et al., 1993; Kurth et al., 2004).
30
Chapter one
Literatures Review
1-12-6 Antibody-Based Techniques
There are an estimated eight serotypes observed in T. vaginalis . However, by
immunoblot analysis, a wide variety of antigenic markers are seen (Garber,
2005). Various techniques including agglutination, complement fixation, indirect
hemagglutination, gel diffusion, fluorescent antibody, and enzyme-linked
immunosorbent assay have been used to demonstrate the presence of
antitrichomonal antibodies (Yadav et al., 2007; Garber, 2005;Kaur et al.,2008;
Domeika et al.,2008 ). However, the serum or local antibody response to a
pathogen depends on several factors, such as the nature of the antigen or
pathogen, its live or inactivated form, its local concentration, and the frequency
and length of immune system stimulation. It has several inherent disadvantages.
In some instances, an antibody response is not observed either because the
system is too insensitive to detect low levels of specific antibodies or because the
serum humoral response has not yet been elicited. Since trichomonal antibodies
may persist for a long time after treatment, current and past infections cannot be
distinguished.(Krieger et al., 1983b).
1-13 Treatment
The mainstay of treatment for infection with T. vaginalis is oral metronidazole.
Metronidazole is a 5-nitroimidazole derived from the Streptomyces antibiotic
azomycin. It was developed in 1959 and approved for the treatment of
trichomoniasis in the early 1960s.Metronidazole was the first drug to have a cure
rate in trichomoniasis that approached 100% with systemic treatment (Cosar and
Julou, 1959). At present, metronidazole is prescribed either as a single 2 g oral
dose or as a seven-day course of 500 mg twice daily for the treatment of
trichomoniasis(Workowski and Berman, 2006). A strain of metronidazole31
Chapter one
Literatures Review
resistant Trichomonas vaginalis was first isolated in 1978, (Thurner
and
Meingassner, 1978) although there were prior reports of treatment failures(
Kanne and Sobel , 2003; Dunna et al.,2003 ;Waters et al., 2005) .Data published
by the Centers for Disease Control (CDC) indicate that 5% of trichomoniasis
showed some resistance to metronidazole, although 80% of cases responded to
an increase in dose or duration(Lossick,1991). The current CDC guidelines for
the treatment of refractory cases recommend the use of tinidazole or an increased
dose of metronidazole (2 g daily for five days) (CDC,2006) Most cases of
refractory trichomoniasis are treated with metronidazole given in an increased
doses, increased duration of treatment, or multiple courses of treatment.
Resistance appears to be relative, so an increased dose of metronidazole can
overcome resistance but will also lead to an increase in the occurrence of side
effects. Several alternatives to the standard dosing of metronidazole have been
reported. A combination of oral and vaginal courses of treatment or an increase
in dose and duration have been shown to be effective (Sobel et al.,2001)
Tinidazole, has been shown to achieve cure in cases of metronidazole failure;
one study reported cure rates as high as 92% (Hager , 2004) Topical treatments
have also been studied, both in combination with oral metronidazole and alone,
but they have shown much lower efficacy.Paromycin cream was the first to be
used with any success,but it was associated with side-effects ranging from mild
to severe, including vaginal and vulvar ulceration(Poppe , 2001) Normal saline
douching and pessaries containing acetarsol, clotrimazole, and provodine-iodine
have all been used in cases of recalcitrant trichomoniasis with differing results (
Waters et al., 2005) . Zinc sulphate douching has also been used in combination
with metronidazole; one study found that lower doses of metronidazole were
required in patients who also douched with zinc sulphate (Houang et al.,1997).
Trichomoniasis occur in females if the normal acidity of the vagina is shifted
32
Chapter one
Literatures Review
from a semi acidic pH (3.8 - 4.2) to a much more basic one (5.0 - 6.0) that is
conducive to T. vaginalis growth (Swygard et al., 2004).That mean the vaginal
environment became alkaline that explains why this disease often worsens with
menstruation .According to that change in pH the resolved to trichomoniasis
infection was found to be by acidification , and used of boric acid for vaginal
acidification in cases of recalcitrant T.vaginalis (Aggarwal and Shier, 2008).And
there are some things helps to treat trichomoniasis like patient should eat some
acidic foods, such as strawberries, oranges, pineapple, grapes. This allows urine
to become acidic, help kill trichomoniasis. Patients should be forbidden to drink,
have strict control on the sex life. Because of trichomoniasis was an STD, both
partners should be treated at the same time, even if one does not have symptoms
or if symptoms have cleared up. Although men infected with trichomoniasis are
often asymptomatic, evidence shows that in order to prevent re-infection and to
improve cure rates in females, partners should be treated(Hobbs et al.;2006).
Moreover ,it is possible that treatment of women with T vaginalis in pregnancy
will reduce the incidence of premature rupture of membranes and premature
labour(Bowden and Garnet , 2000).
33
Chapter Two
Materials
&
Methods
Chapter two
Materials and Methods
2- Materials and methods
2-1 Instruments
Many types of Instruments were used; they were listed in the following table:
Table (2-1) :Showing instruments used in this study.
Equipments
Origin
Burner
England
Centrifuge
Japan
Electric oven
Germany
Incubator
Germany
Microscope
Japan
Oven
England
Refrigerator
France
Sensitive electric balance
China
Autoclave
Company
Portable
England
Spencer
Kokusan
Kottermann
Memmert
Olympus
Gallen Kamp
Concord
MAX
2-2 Equipments
The equipments were used ,they were listed in Table (2-2)
Table (2-2): Showing equipments used in this study.
Tools names
Beaker
Cover clips
Disposable syringes
Filter paper
Flask
Graduated glass cylinder
PH indicator paper universal
indicator PH
Plain tube
Slides
Speculum
Swabs
Universal tube
Origin
France
Germany
Germany
China
England
England
China
Company
Pyrex
Objekttrager
Medeco
Zelpa
Pyrex
Volac
Xinxing
AFMA
Shan Ghai
MAX
Citoswab
Pyrex
Jordan
China
China
China
England
34
Chapter two
Materials and Methods
2-3 Chemicals material
The chemical material were used,they were listed in Table (2-3)
Table(2-3):showing chemicals material used in this study.
Chemicals
Symbol
Origin
UK
Company
Dextrose
C6H12O6.H2O
England
BDH
Hydrochloric acid
HCL
Iraq
AL-Rrahma
Maltose
(C6H10O5)n
Iraq
AL-Rrahma
Potassium chloride
KCl2
England
BDH
Sodium hydroxide
NaOH
Iraq
AL-Rrahma
Sodium chloride
NaCl
England
BDH
Agar
-
Lancashine
2-4 Laboratory Kits
In-Pouch TV System culture media was used in this study its Origin USA and
related to Biomed Company.
2-5 Subjects Selection
Two hundred females suffered vaginal discharge attending the Obstetrics and
Gynecology out -patient department of AL-Yarmok Hospital, AL-Noor Health
Center and Privet Clinic in AL shoulla city in Baghdad –AL-Khark were
included in this study.The vaginal swabs and urine samples were collected from
each female during the period from October 2010 to April 2011.These females
were ranging from 16-55 years old.
A questionnaire sheet; show in Figure (2-1) was filled out for each female
studied.
35
Chapter two
Materials and Methods
Questionnaire
No.
Name:Age:Marital status:Level of education:Parity or infertility:Symptoms:
· Discharge only
· Discharge and itching
· Discharge and dysuria
· Discharge, itching and dysuria
-Color:
-Odor:
Figure (2-1):A questionnaire sheet for the study conducted on female with
trichomoniasis.
2-6 Specimen collection
2-6-1 Urine
Urine was collected from each woman suffering from vaginal discharge in a
sterile container then the urine was centrifuged for 10 min at 1,500 rpm at room
temperature. The supernatant was discarded, and then the deposit was placed on
36
Chapter two
Materials and Methods
a clean glass slide and covered by cover slide to examine under 40X
magnification, (Blake et al., 1999).The positive result characterized by the
presence of motile parasites with some pus cells and epithelial cells, while vice
versa shown according to the negative result (Blake et al., 1999).
2-6-2 Vaginal examinations
Two vaginal examinations were done during this study.
A-External examination:
This exam included inspection the external genitalia for redness or congestion.
B-Internal examination:
This exam included five vaginal swab collections from symptomatic patients
with vaginal discharge, these vaginal swabs were collected from woman placed
in a lithotomy position ,and then by the insertion of sterile metal speculum into
vagina without any lubricate or solution ,swabs were taken from the posterior
fornix by sterile cotton swab(Fouts and Kraus , 1980),Figure(2-2).
Figure (2-2): Left Transport cotton swab. Right Bivalve speculum
37
Chapter two
Materials and Methods
These five swabs were managed as follow:
1-The first one was obtained from the lateral wall of vagina and placed in tube
containing 0.5 ml physiological saline solution (0.9% NaCl)for wet mount
examination .The tube was carried to the laboratory ,then gently shaken and a
slide was prepared to examination immediately under light microscope using
10X and 40X
objectives
to detect the motile organism (Fouts and Kraus,
1980).At last 20 fields were examined to recognize the motile trichomonads
(Thomason and Gelbart, 1989) Figure(2-3).The slide was considered negative
when the parasite could not be found during a three minute scan of the slide
(Fouts and Kraus, 1980).
Figure (2-3):Showing A: epithelial cell B: T.vaginalis under microscope 40X by
saline wet mount preparation
2-The second swab was divided for two tests, one of them was done by mixing a
few drops of vaginal discharge with an equal volume of 10% potassium
hydroxide solution (KOH).The two liquids mixed immediately under the noise.
If ammonia (fishy) smell present the result considers positive but if absent the
38
Chapter two
Materials and Methods
test consider negative ,this test called whiff test and it was used in case of
Gardinilla vaginalis and T. vaginalis (Pagana and Pagana, 2010). While the
second test was used for vaginal pH measurement, this done by dipping a piece
of the pH strip in to the vaginal discharge ,and then read according to the change
in colour of strip (Thomason et al., 1990).
3-The third swab inoculated in to culture tubes containing Trichomonas modified
medium
CPLM and incubated at 37 °C for seven days. The culture was
examined every day for one week before being consider negative (Collee et al.,
1996).
4-The fourth swab inoculated in culture tubes containing Orange Leaves Media
(OLM) and then incubated at 37 °C for four days. The culture was examined
every day for half week before being consider negative (AL-Dabbagh and
Karofa , 2007), Figure (2-4).
Figure (2-4): Orange Leaves Medium, which used in culturing of T. vaginalis.
39
Chapter two
Materials and Methods
5- The fifth swab was pressed between the In-Pouch TV System media walls,
then the swab discarded and the top edge of In-Pouch media chamber was
folded down and rolled three times, after that a wire tape was folded the endtabs behind the pouch Figure (2-5), then In-Pouch medium incubated at 37 °C
for three days. The culture was examined every day for three days before being
considered negative (Kreiger, 1995).The positive result characterized by the
observation of a white sediment along the side and along the bottom of the
chamber then the media were changed to a darker.
Figure(2-5): Showing the steps of In-Pouch TV System media inoculation.
2-7 Cultivation of T.vaginalis
Three kinds of culture media were used for Trichomonas cultivation in this
study. The Trichomonas modified media CPLM (Saksirisampant et al., 2009),
Orange leaves medium (OLM)(Al-Dabbagh and Kharofa, 2007) and In-Pouch
TV System media (Biomed Diagnostics, USA).
These media were prepared as follow:
40
Chapter two
Materials and Methods
2-7-1 Trichomonas modified CPLM culture medium
Table(2-4) :showing the contents of CPLM culture
Ingredients
Weight
Peptic digest of animal tissue
32(gm/l)
Liver digest
20(gm/l)
Maltose
1.6(gm/l)
L- cysteine hydrochloride
2.4(gm/l)
Ringers solution 1/4 th strength
Qs
The ingredients were mixed with 900 ml of distilled water,then the mixture was
heated then media sterilized using autoclave at 121 ºC for 15 minutes. The
medium cooled down to 50ºC ,then 10 ml of human serum and 1 ml of antibiotic
solution were added,
prior medium dispensed
into glass containers.The
prepared medium was incubated overnight at 37 ºC for sterility testing .Only
positive vaginal swabs and swabs with pH higher than 4.5 were inoculated in this
medium and incubated at 37 ºC for 7 days.
2-7-2 Orange leaves medium (OLM)
Orange leaves have been chosen for the preparation of this medium , 50 g. of
orange leaves were kept at 50 ºC for 24 hours to get them dry ,then leaves were
crushed until the dry weight achieved 1.72 g. .To this weight 500 ml of tap
water was added then , the mixture was boiled for 5 minutes , filtered and the
volume brought to 1000 ml of distal water (Al-Dabbagh and Kharofa, 2007).The
following ingredients were added ,Table(2-5).
41
Chapter two
Materials and Methods
Table (2-5): showing the contents of OLM culture medium
Ingredients
Weight (gm)
Sodium chloride
6.5
Agar
1.0
Dextrose
5.0
The volume sterilized using autoclave at 121 ºC for 15 minutes. The pH was
adjusted to 6.4 (Al-Dabbagh and Kharofa, 2007). The media cooled down to
56ºC and, chloramphenicol 0.125 gm was added to inhibit bacterial growth ,
then the medium dispensed into glass containers.
2-7-3 In-Pouch TV Culture System
The In-Pouch TV is a self-contained system for the detection of T. vaginalis
from female vaginal samples or male urethra/urine samples (Biomed
Diagnostics, USA). The proprietary medium is selective for the transport and
growth of T. vaginalis, while inhibiting the growth of contaminating
microorganisms which might interfere with a reliable diagnosis. The In-Pouch
consists of a high barrier, oxygen resistant, plastic pouch with two V-shapedchambers connected by a narrow passage. The two chamber system permits
direct observation (wet mount) of a newly collected specimen in the upper
chamber before expressing the inoculum into the lower chamber for culture. The
sample can be concentrated by letting the cellular material settle to the bottom of
the chamber before microscopic observation. Microscopic observation of the
chamber was done with or without using the plastic microscope viewing clip. An
inoculum containing 1 to 10 trichomonads was sufficient to cause a positive test.
42
Chapter two
Materials and Methods
Transport and off-site testing can be performed easily due to the flexible
packaging and integral design of the In-Pouch. Figure (2-6)
2-7-3-1 Reagents in In-Pouch TV system
The In-Pouch medium contains the following: trypticase, proteose peptone, yeast
extract, maltose and other sugars, amino acids, salts, antifungal and antimicrobial
agents in normal saline phosphate buffer. An unopened In-Pouch should contain
a clear, liquid chamber.
Figure (2-6): Showing In-Pouch TV culture kit
(BioMed Diagnostics,USA)
2-8 Calculation and Statistical analysis
Any culture reported positive for T. vaginalis considered a true positive ;no
cultures were considered false positive,False negative were defined as T.
vaginalis cultures negative in one culture medium which were positive in the
other (Levi et al.,1997) . Comparison of all culture methods was done by using
Fisher's exact tests(Shimano et al.,2004).
43
Chapter two
Materials and Methods
True+Ve
Sensitivity= ‫ ـــــــــــــــــــــــــــــــــــــــــــــــ‬x 100
False-Ve + True+Ve
False-Ve + True+Ve
Accurate rate= ‫ ــــــــــــــــــــــــــــــــــــــ ـــــــــ‬x 100
Total
Other parameters were also calculated to check for any significance of
differences between patients according to Chi square test(Shimano et al.,2004).
Results were considered statistically significant if the p value was <0.05.
44
Chapter Three
Results
&
Discussion
Chapter three
Results and discussion
3-Results and Discussion
3-1 Incidence of Trichomonas vaginalis infection
This study showed that out of 200 women complaining of vaginal discharge, 42
women revealed the presence of T. vaginalis by In-Pouch TV system culture
giving an incidental rate of (21%). Ten (23.8%) of these 42 women were
positive for urine exam,14(33.33%) of them positive for direct exam(wet
mount),21 (50%)were positive for OLM medium ,23(54.76%) of them were
positive for Whiff test, and 30(71.42%) were positive for CPLM media Table(31).While the incidence rate of trichomoniasis according different identification
methods used for 200 women was showed in Figure(3-1), index-1 . The higher
frequency rate of T.vaginalis obtained in this study was much high than the other
previous studies reported in Baghdad by many researchers. AL-Kaisi(1994) and
AL-Mokdady(1999) were found that the incidence rate of trichomoniasis was
(19.16%) and (19.13%) respectively , while AL-Sheikh (1995) and ALMudhaffar(1995) found that the incidence rate was (18.2%) and (15.6%)
respectively. Much lower incidence of trichomoniasis were reported in Baghdad
by Al-Rawi (1993) and Edan (2007) they were (3.9%) and (6%) respectively.
This increase of trichomoniasis incidence showed in the current study may be
attributed to many reasons, first of all the detection of T.vaginalis in Iraq remains
suboptimal along the years. Moreover, the difficult social and economic
conditions faced by Iraqi women present significant obstacles that could prevent
their seeking for private medical care, which is surely expensive. As a result,
many women in our society may prefer to stay at home in spite of their
symptoms, so there is no periodical examination (Early diagnosis) of such
disease, also there are no awareness campaigns of sexually transmitted diseases
(STD) like trichomoniasis in our country. Another important reason worth
45
Chapter three
Results and discussion
mentioning is the low cultural levels of the patients enrolled in the present study.
All these reasons may help in maximizing the incidence of
T.vaginalis
infections .Therefor ,novel strategies are needed for the detection for T. vaginalis
infection in Iraq , including cheep culture media with high sensitivity and
specificity application .
Table(3-1) :The incidence of T.vaginalis according to different identification
methods used for 42 women positive by In-Pouch TV system.
Methods
Percentage
Urine Examination
23.80%
Wet mount
33.33%
OLM culture
50.00%
Whiff test
54.76%
CPLM culture
71.42%
In-Pouch TV system
100%
46
Chapter three
Results and discussion
25%
21%
percentage of infection
20%
15%
15%
10.50%
11.50%
10%
7%
5%
5%
0%
Urine
Examination
Figure(3-1):The
Wet mount
incidence
OLM culture
rate
Whiff test
of
CPLM culture In-Pouch TV
system
T.vaginalis
according
to
different
identification methods used for 200 women.
3-2 Sensitivity and accurate rate
The sensitivity and accurate rate between different T. vaginalis identification
methods were done according to (Levi et al.,1997; Shimano et al., 2004).The
calculation of both parameters was shown in Tables(3-2),(3-3),(3-4),(3-5),(3-6) ,
(3-7) and the overall results were shown in Figure (3-2),Index 2.
The lowest percentage of sensitivity (23%) was showed for urine exam followed
by Wet mount (33%), OLM culture (50%), Whiff test (54%), CPLM culture
(71%) and (100%) for In-Pouch TV system, while the accurate rate was, (84%),
(86%), (89%) ,(90%) ,(94%) and In-Pouch TV system (100%) respectively.
47
Chapter three
Results and discussion
Figure (3-2): The sensitivity and accurate rate between different identification
methods.
Table(3-2):Showing the sensitivity and accurate rate of urine examination
True+Ve False+Ve Total
+ Ve
10
0
10
False-Ve
True -Ve
Total
- Ve
32
158
190
Total
42
158
200
10
Sensitivity= ‫ ــــــــــــــ‬x 100 = 23 %
42
10+158
Accurate rate= ‫ ــــــــــــــــــــ‬x 100 = 84%
200
48
Chapter three
Results and discussion
Table (3-3):Showing the sensitivity and accurate rate of wet mount .
True+Ve False+Ve Total
+ Ve
14
0
14
False-Ve
True -Ve
Total
- Ve
28
158
186
Total
42
158
200
14
Sensitivity= ‫ ــــــــــــــ‬x 100 = 33 %
42
14+158
Accurate rate= ‫ ــــــــــــــــــــ‬x 100 = 86%
200
Table(3-4):Showing the sensitivity and accurate rate of OLM culture
True+Ve False+Ve Total
+ Ve
21
False-Ve
0
True -Ve
21
Sensitivity= ‫ ــــــــــــــ‬x 100 = 50 %
42
21
Total
- Ve
21
158
179
Total
42
158
200
21+158
Accurate rate= ‫ ــــــــــــــــــــ‬x 100 =89%
200
49
Chapter three
Results and discussion
Table (3-5): Showing the sensitivity and accurate rate of whiff test .
True+Ve False+Ve Total
+ Ve
23
0
23
False-Ve
True -Ve
Total
- Ve
19
158
177
Total
42
158
200
23
Sensitivity= ‫ ــــــــــــــ‬x 100 =54 %
42
23+158
Accurate rate= ‫ ــــــــــــــــــــ‬x 100 = 90%
200
Table (3-6): Showing the sensitivity and accurate rate of CPLM culture.
True+Ve
False+Ve Total
+ Ve
30
0
30
False-Ve
True -Ve
Total
- Ve
12
158
170
Total
42
158
200
30
Sensitivity= ‫ ــــــــــــــ‬x 100 = 71 %
42
30+158
Accurate rate= ‫ ــــــــــــــــــــ‬x 100 =94%
200
50
Chapter three
Results and discussion
Table(3-7):Showing the sensitivity and accurate rate of In-Pouch TV system
True+Ve False+Ve Total
+ Ve
42
0
42
False-Ve
True -Ve
Total
- Ve
0
158
158
Total
42
158
200
42
Sensitivity= ‫ ــــــــــــــ‬x 100 = 100%
42
42+158
Accurate rate= ‫ ــــــــــــــــــــ‬x 100 =100%
200
This result was agreement with many previous studies that revealed differences
in the sensitivity and the accurate rate of many different identification methods
used in the diagnosis of T. vaginalis(Borchardt et al., 1997; Peruzzi,et al., 2010).
In the present study urine examination showed sensitivity and accurate rate less
than other diagnostic methods used
characterized by only (23%) positive
samples in comparison to In-Pouch test
previous study by
, this result was agreement with the
AL-Zaiadi (2004)who showed that the sensitivity and
accurate rate of urine examination was less than both of culture and wet mount.
While, Mohamed et al. (2001) were showed that culture of centrifuged urine
poor sensitive for identification of trichomonads in women. Since only 5–10
organisms in a sample are necessary for a positive culture, this mean the load of
T. vaginalis was very low. And Contamination of the external genitalia with
vaginal fluid, a first void urine specimen might have proved a better sample(
Mohamed et al., 2001). Or most of women studied , washed their genitalia that
will lead
to less load of organisms so less sensitivity and
concurrent with this test .
51
accurate rate
Chapter three
Results and discussion
The diagnosis of trichomoniasis has traditionally depended on the microscopic
observation of motile protozoa from vaginal or cervical samples and from
urethral or prostatic secretions (wet- mount)(Garber, 2005). T vaginalis can be
differentiated on the basis of its characteristic jerky movements. On occasion,
flagellar movement can also be noted. Wet mount preparation has been the most
commonly used method for diagnosis in women. Although this method has
imperfect sensitivity (Wendel et al., 2002), the sensitivity of wet mount varies
from 38% to 82% ( Preethi et al., 2011), but the sensitivity of wet mount in this
study was less than these percentages 33% resulted from only 14 positive
samples in comparison to In-Pouch test , such result may be explained due to the
following reasons:
· The sensitivity of the wet-mount method is highly dependent on the experience
of the microscopist as well as the time of specimen transport to the laboratory
(Wendel et al., 2002 ; Kingston et al., 2003).
· As well, the need for the specimen to remain moist and the experience of the
observer are important variables. The size of the trichomonad is approximately
the same as that of a lymphocyte (10 µm to 20 µm) or a small neutrophil; when
not motile, a trichomonad can be difficult to differentiate from the nucleus of a
vaginal epithelial cell(Garber, 2005).
· The high organism load necessary for vaginal sampling to capture organisms. So
wet preparations with positive results are obtained from women with high
organisms loads ,while women with low organism load give negative result (Van
Der Pol, 2011) .
Whiff test sensitivity and accurate rate were found to be 54%, 90% respectively,
this result disagreement with previous study by Thompson et al. (2000) who they
found that the sensitivity of whiff test was 84%, this percentage was more than
the current result and this may be happened due to several reasons may account
52
Chapter three
Results and discussion
such as, delay in performance of this test,the use of insufficient quantity of
discharge, or interference with the test by use of absorbent material (such as a
cotton swab),another explanation may be the degree of skill in performing the
test and the ability to smell. The degree of ventilation and distance from the
sample during performing this test may be another reason. OLM culture had poor
sensitivity and accurate rate than other cultures media in this study ,
characterized by only 21 positive culture for trichomoniasis in comparison to InPouch test .This finding was disagreement with that reported by Al-Dabbagh
and Kharofa(2007) in Mosul who showed that OLM medium was good media
for T. vaginalis detection, This difference may be due to the parasites load was
very low to give positive result in this test, or perhaps because of the different
laboratory conditions and preperation.
CPLM culture was more sensitive than other diagnostic methods(71%) but less
sensitive than In-Pouch TV culture, this finding was in agreement with that
reported by Borchardt and Smith (1991) who were reported that CPLM culture
was more sensitive than wet mount
. Moreover, Edan(2007) in Baghdad
reported that the sensitivity of CPLM culture was higher than direct examination
,staining method , Trichomonas Agar Base (TAB) medium and serological
methods.
In this study 42/200 (21%) patients were found to be infected with T. vaginalis
by In-Pouch TV system ,and In-Pouch TV test characterized by a greater
sensitivity and accurate rates in comparison to all other studies tests(100%).
This result was agreement with the previous studies by Draper et al. (1993)
showed that InPouch TV system detected T. vaginalis isolates in 30 of 34
(88.25%) patients and the wet mount examinations were able to detect T.
vaginalis isolates in 29 of 34 (85.3%) patients. While Borchardt et al.(1995)
53
Chapter three
Results and discussion
were showed that InPouch TV culture system was as reliable as Diamond's
medium in detecting T. vaginalis and may be useful and effective in a pregnancy
clinic setting. In another study by Farys (2003) showed that the InPouch TV
system with sensitivity of 86.7% and specificity of 100% which is higher than
that of 38.5% and 98.7% respectively by using wet mounts preparation. Sood et
al. (2007) showed that the In-Pouch TV culture detected 45 % more positives
than the traditional wet mount.
The sensitivity of this test may be increased either by a reduction in initial
growth generation time or the greater volume of media examined (Borchardt and
Smith, 1991; Borchardt et al., 1997). Although the combination of culture and
wet mount examination remains the standard approach for detecting T. vaginalis
in patient samples (Levi et al.,1997), In-Pouch offers some distinct advantages.
Once the specimen is placed by a clinician into the In-Pouch chamber, an
inoculum containing 1 to 10 trichomonads is sufficient to cause a positive test,
This suggests that a positive culture would be found sooner with lower organism
counts with the In-Pouch TV system. Microscopic observation can be made
directly through the bag as the bag can be used as a slide on the stage of the
microscope which alleviates the need to enter the broth culture. This decreases
contamination problems and speeds up the examination time,and This obviates
the need for sampling to examine the culture for growth thereby preventing
contamination. These can be conveniently transported from the site of collection
to the laboratory and can be stored at room temperature, other media, once
prepared, require refrigeration. Further, its cost is comparable to the ordinary
culture tube. InPouch system can be stored at room temperature up to one year
whereas other media has a shorter expiration date.
The standard method of culturing and the required microscopic examination of
the culture fluid is considered time-consuming and laborious. Commonly, in Iraq
54
Chapter three
Results and discussion
samples for culture are sent to centralized laboratories for processing, and
frequently, results are not available for a week or more. In some large clinic
settings where the prevalence rate of trichomoniasis is low, culturing of samples
from all patients would not be considered cost-effective. Thus, an improved
method of culturing which is sensitive, cost-effective, and efficient would be
useful. Therefore, the In-Pouch culture system may be used as a routine method
of diagnosing trichomoniasis.
In fact this medium proved to be superior to other techniques used in the current
study.
3-3 The relationship of T. vaginalis infection and Age groups distribution
Figure(3-3), Index -3 showed the distribution of T.vaginalis infection according
to age groups ,women at the age group of 16-25 years had a higher
significant(P<0.05)prevalence rate of infection 15/51(29.5%)than other groups
, followed by 26-35 years 18/88(20.5%). Women at the age group 36-45 years
had infection rate of 7/44(14.3%), while those in the age group of 46-55 years
reaching the lowest percentage of 1/11(9.1%),Figure(3-3).
The highest rate of infection in young age (16-25 years) could be correlated with
the marriage status. In our society this is the age of marriage, so the high
incidence of infection occurs of the ages of greatest sexual activity (Omer et al.,
1980). At this ages (reproductive age) the estrogen hormone level is higher than
other ages so that vaginal environment more suitable for the growth of T.
vaginalis ( Westhoff et al.,1996).Whereas the lowest infection rate showed at
old ages of (46-55) years ,this may be related to the menopause, during this time,
there are fluctuations in the amount of estrogen production in the body. Also, the
pH begins to fluctuate back and forth causing an imbalance (Vliet , 2002).
Glycogen and lactic acid production also begins to dwindle, all that changes in
vaginal environment lead to lack the suitable condition for T. vaginalis growth.
55
Chapter three
Results and discussion
The results of present study is in agreement with Al-Mallah and Al-Janabi(1983)
were showed that
women at the age group of 14-40 years had a highest
prevalence rate of infection than other ages.
Figure (3-3) Percentage of T. vaginalis Infection according to the age groups
3-4 The relationship of T. vaginalis infection and marital status
The relationships of T.vagnalis infection and marital status was demonstrated in
Figure (3-4) and Index -4, married women revealed the highest percentage of
trichomoniasis (25.8%) followed by divorced women (6.2%) then widowed
women (6.1%) Statistical significant difference (p<0.05) was detected between
these groups. Two points could explain such result:
56
Chapter three
Results and discussion
· It is generally believed that the vast majority of women in our society do not
have sexual relationships before marriage, so the most of infected women were
those with direct sexual contact and probably didn’t clean the genitalia well after
the sexual intercourse .
· Widowed and divorced women may had got infection by extra-sexul route like
the use of common toilets (contaminated toilets sites) or may be by using
contaminated instruments (speculum , gloves) during gynecological examination
or even the using contaminated under wear of infected females .
The results of the present study were in agreement with the previoes studies by
AL-Kaisi(1994) in Baghdad ,AL-Ani(1998)in AL-Romadi who both referred
that married women had the highest percentage of infection.
Figure (3-4) :Percentage of T. vaginalis infection according to the marital status.
57
Chapter three
Results and discussion
3-5 The relationship of T. vaginalis infection and parity
Index -5, Figure (3-5) showed the distribution of
T.vaginalis infection
according to the parity. The highest percentage of T.vagnalis infection
33/151(21.8%) was showed in multipara women group followed by primipara
women group 7/39(17.9%) and finally infertile women group 3/20(15.0%).No
significant difference was detected among these various groups.( p>0.05).
This high rate observed in multipara women group in comparison to other groups
may be related to the one of the following explanation;
· Multi-delivery meaning high chance to get infection by use contaminated
equipment or may be contaminated physician cloves during gynaecological
examination, or certain factors other than parity status may play a role such as
poor personal hygiene, low socio-economic status and under development are
also associated with high incidence of infection in those women.
The results of the present study were in agreement with previous studies by ALKaisi (1994) and AL-Zaiadi (2004) who showed that multipara women had
higher infection rate than primipara or nullipara. While , Naguib et al.(1966)and
Omer et al.(1985) demonstrated that no association was detected between the
infection and parity.
58
Chapter three
Results and discussion
90.00%
85.00%
82.10%
80.00%
78.20%
positive
negative
persentage of infection
70.00%
60.00%
50.00%
40.00%
30.00%
21.80%
17.90%
20.00%
15.00%
10.00%
0.00%
Multipara
primipara
Infertile
Figure (3-5): Percentage of T. vaginalis infection according to the parity.
3-6 The relationship of T. vaginalis infection and education levels
The relationship between T.vaginalis infection and education level was
demonstrated in Figure(3-6) ,Index -6, the results showed that educated women
had the highest significant difference (P<0.05)of infection (32.6%) in
comparison to uneducated women(11.1%).
The normal expected result is educated women have the lower percentage of
infection in comparison to uneducated one because they were knowledgeable
about the risk effect of STDs ,and they were not deterred in engaging with risky
behaviors ,but the current result showed adverse expect. The explanation of such
result may by related to one or more of the following reasons:
· This group of women may used vaginal therapy rather than oral therapy as
studies have shown that antibiotics taken by mouth are preferred to vaginal
59
Chapter three
Results and discussion
treatment. And the cure rates for vaginal therapy are 50 percent, which is
significantly lower than with treatment taken by mouth ( Bell et al.,1993)
· The infection may recurrent because their couples did not submitted to treatment,
so the women get infection again.
· Perhaps educated women work busy so there was no time to visit the women's
clinics, or the using of common toilet during job offices.
100.00%
positive
Persentage of infection
90.00%
negative
88.90%
80.00%
70.00%
67.40%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
32.60%
11.10%
0.00%
Uneducated
Educated
Figure(3-6)The relationship between T.vaginalis infection and education level
.
3-7 The relationship of T. vaginalis infection and pH level
Figure (3-7), Index -7 showed the distribution of T.vaginalis infection according
to the pH level ,women with vaginal pH 5, 5.5 and 6 had the higher percentages
of T.vaginalis infection rate (44.4% , 32.1% and 63.1%) respectively than other
pH values .The lower rate of T. vaginalis infection was found in women with pH
60
Chapter three
Results and discussion
4 (2.9%).High statistical significant difference was detected among these
groups.(p<0.05).This finding could be explained that ,the normal pH of the
vagina is shifted from a healthy semi-acidic (3.8 - 4.2) to a much more basic or
alkaline one of (5 - 6) that is conducive to T. vaginalis growth.The rise in the pH
of the vagina may be due to, a concomitant reduction (or complete loss) of
Lactobacillus acidophilus and an increase in the proportion of anaerobic bacteria
(McGrory et al., 1994).Or may be T. vaginalis has been observed to phagocytize
bacteria , and this may occur with lactobacilli as well. Another hypothesis is that
products, such as proteinases secreted by T. vaginalis, may destroy the
lactobacilli (McGrory and Garber ,1992).The results of the present study were
in agreement with previous study by AL-Ani (1998)who reported that women
with vaginal pH 6 had higher rate of T. vaginalis infection than other pH values .
Figure(3-7):The relationship between the percentage of T .vaginalis infection
and pH level.
61
Chapter three
Results and discussion
3-8 The relationship of T. vaginalis infection and the contraception
Figure(3-8),Index -8 Showed the relationship between T. vaginalis infection and
contraceptive use .Infected women (using oral contraceptive pills and
intrauterine
device) had higher non significant percentage of T. vaginalis
infection 23(54.7%)than those didn’t use such contraceptive 19(45.3%).
The present result could be happened due to the usage of contraceptive itself ,
such contraceptive (pills and
device)
contains estrogen horrmone may
providing the necessary glycogen for nourishment which is considered to be a
good medium for T. vaginalis growth (Rodgerson,1972),or change the vaginal
pH toward the optimum condition for T. vaginalis growth (Komor, 2009).
The current result was agreed with AL-Ani(1998)showed that women who used
companied oral contraceptive pills and intra uterine contraceptive devices had
higher percentages of vaginal trichomoniasis than those not used any
contraception .
percentage of infection
60.00%
50.00%
40.00%
30.00%
54.70%
45.30%
20.00%
10.00%
0.00%
contraception
No contraception
Figure(3-8): The percentage of T. vaginalis infection according to the use of
contraceptives.
62
Chapter three
Results and discussion
3-9 The relationship of T. vaginalis infection and the clinical signs
Figure(3-8),Index -9 showed the relationship between T. vaginalis infection and
clinical signs ,women with no signs had higher non-significant percentage of
infection 34(80.9%) than women with vaginal erthrema and vulval erthema
5(11.9%)and 3(7.1%) respectively.
The present result noted that the largest proportion of trichomoniasis patients
were hadn’t signs this may be due to the infection was repeated during the
treatment or perhaps the patients under treatment weakened the parasite activity
and thus reduced the influence of it, or did not completely eliminate the parasite
so that no signs appears.
This result
was disagreement with pervious study by AL-Ani (1998)who
showed that women with signs had higher trichomoniasis than women without
signs, such difference may be due to the different types of women studied in the
current study in comparison to previous studied women especially in their
persentage of infection
immunological responses toward the parasite.
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
80.90%
11.90%
7.10%
Vaginal erthrema
Vulval erthema
No signs
Figure(3-9):The percentage of T. vaginalis infection according to the clinical
signs .
63
Chapter three
Results and discussion
3-10 The relationship of T.vaginalis infection and the vaginal discharge
characters (Odor and color)
Index -10 and Index -11 showed the distribution of T.vaginalis infection according
to the odor and color of vaginal discharge. 32(76.2%) of 42 samples appeared with
bad odor and the other 10(23.8%) without any odor ,whereas the color of discharge
showed that high percentage of samples with yellowish color 24(57.1%) fallowed
by white color 13(30.9%) and the colorless discharge percentage was 5(11.9%) .
Figure (3-10) and Figure (3-11). Statistical significant difference was detected
between these groups (p<0.05).
The precence of bad odor in most patients discharges in the current study may be
according to the fact that vaginitis caused by trichmonial infection is the main
cause of bad odor in discharge, or may be the bad odor caused by monilial
infection which sometimes companied with Trichomonas infection (Linda and
Eckert, 2006) . Bad odor also was commonly observed in patients suffering from
diabetics, or women taking antibiotics for a longer time, women taking
contraceptive pills were also prone to monilial infection.Inflammation and
infection of the cervix can also cause abnormal discharge and bad
odor(Hui Wang and Tai Chao , 2006).
The different colors of discharge resulted in this study may be happened due to
the presence of other infected organisms
associated with trichomoniasis
infection .
The results of the present study were agreed with previous study by Edan
(2007)who showed that yellow to green discharge was most color accompanied
with trichomoniasis.
64
Chapter three
Results and discussion
Figure (3-10):The percentage of T. vaginalis infection according to the odor of
discharge.
Figure (3-11):The percentage of T. vaginalis infection according to the color of
discharge.
65
Chapter three
Results and discussion
3-11 The relationship of T.vaginalis infection and clinical symptoms
Index -12 showed the relationship between T. vaginalis infection and clinical
symptoms . out of 42 women infected with trichomonisis ,14 (33.3%) had both
discharge and itching, this percentage was significantly higher(P<0.05) than the
percentages of other clinical symptoms studied .While 10(23.8%)
of them
showed discharge with itching and dysuria and similar percentage was showed in
females suffered from discharge only ,but the lowest percentage 8(19%) was
showed in females with discharge and dysuria.Figure(3-12).
The results of the present study showed that T.vaginalis infection may be
companied
with different
clinical symptoms
, discharge
with itching,
discharge with itching and dysuria , discharge only and discharge with dysuria.
This symptoms actually resulted due to the parasites invasion to genital and
urinary system.
The results of the present study was agreed with previous studies by AL-Ani
(1998) who showed that women complaining of vaginal discharge and itching
had a higher percentage than other symptoms acompained with this disease
.While, Bassiouni and Raid (2005) showed that women with discharge only had
percentage of (50%)but other complained with
dysuria, whereas Edan
(2007)showed that women with discharge and itching
had percentage of
(46.7%),while those of discharge with itching and dysuria showed (20%).
66
Chapter three
Results and discussion
33.30%
35.00%
30.00%
25.00%
23.80%
23.80%
19.00%
20.00%
15.00%
10.00%
5.00%
0.00%
Discharge only
Discharge and itching
Discharge and
dysuria
Discharge ,itching
and dysuria
Figure (3-12):The percentage of T. vaginalis infection according to the clinical
symptoms.
However, The diagnosis of trichomoniasis based solely on clinical signs and
symptoms is unreliable, as the spectrum of infection is broad and other sexually
transmitted pathogens can cause similar signs and symptoms(Krieger and
Alderete,2000). Fouts and Kraus(1980) demonstrated that if these classic
features are used alone in the diagnosis of trichomoniasis, 88% of infected
women will not be diagnosed and 29% of uninfected women will be falsely
indicated as having infection. The data suggest that clinical symptoms are not
reliable diagnostic parameters and that laboratory investigations are necessary
for the accurate diagnosis of trichomoniasis. Accurate diagnosis is essential,
since it will lead to appropriate treatment and will facilitate the control of the
spread of T. vaginalis infection.
67
Conclusions
&
Recommendations
Conclusions
Conclusions
1- In–Pouch TV system culture used for the first time in Iraq offered some
distinct advantages when compared to other identification methods used in
the current study .Once convenience of sampling ,ease of transport ,
relative low cost , storage at room temperature and along shelf life ,as well
as characterized by a higher sensitivity and accurate rate in T. vaginalis
detection makes it an ideal tool for the diagnosis .
2- The prevalence of T.vaginalis infection in Baghdad –AL-Karkh was 21%.
3- The culture techniques were more sensitive and accurate in diagnosis of
T. vaginalis than the wet-mount, Urine examination , whiff test and acidly
.
4- Women aged 16-25 years had a higher significantly prevalence rate
,whereas the lowest rate was at 46-55 years age group.
5- Married women had significantly higher infection rate than other women.
6- Multipara women had the higher rate of infection than primipara and
Infertile women .
7- Educated women had the highest prevalence of infection than uneducated
women,
8- Women who were used contraceptive had the higher rate of infection
than women who didn’t used.
9- Women with vaginal pH ranged (5-6) had significantly higher rate of
infection than other pH values.
10- Women with no clinical signs had the higher percentage of infection
than women who had vaginal erthrema and vulval erthema
11- Discharge with bad odor had significantly higher infection rate than
discharge with no odor, also yellowish discharge was high percentage
68
Conclusions
than white discharge and colorless .
12- Women complaining of vaginal discharge and itching had high rate of
infection than other symptoms.
69
Recommendations
Recommendation
1. The simple, cost-effective and sensitive In-Pouch TV culture system is recommended as a method of diagnosing trichomoniasis in routine work.
2. Infected women should be treated to eradicate the organism and prevent
trichomoniasis to partner.
3. Repeat testing for trichomoniasis if symptoms persist after treatment or
recur after treatment is completed.
70
References
References
A
· Aberg, J.A.; Kaplan, J.; Libman, H.; Emmanue,P.; Anderson, J.; Stone,V.; Oleske,J.;
Currier,J. and Gallant,J.( 2009). Primary care guidelines for the management of
persons infected with human immunodeficiency virus: update by the HIV Medicine
Association of the Infectious Diseases Society of America, Clin. Infect. Dis.; 49 (5):
651-681.
· Abraham, M.C.; Desjardins, M.; Filion, L.G. and Garber, G.E.( 1996). Inducible immunity to
Trichomonas vaginalis in a mouse model of vaginal infection, Infect. Immun.;
64:3571– 3575.
· Adegbaju, A. and Morenikeji, O. (2008). Cytoadherence and pathogenesis of Trichomonas
vaginalis , S. R. E.; 3 (4): 132-138.
· Afzan, M. Y. ; Sivanandam, S. and Kumar,G.S.(2010). Modified Field's staining a rapid stain
for Trichomonas vaginalis, Diagn. Microbiol. J.; 68(2):159-162.
· Aggarwal, A.and Shier, M. R. (2008). Recalci tran Trichomonas vaginalis infections
successfully treated with vaginal acidification,JOGC; 30(1):55-58.
· Agrawal, S.; Agrawal, B.M.; Rizvi, G. and Ansari, K.H.(1997). Changing scenario of
microbial flora in pregnancy " Present and Past", Ind. J. Obstet. & Gynaec.; 3: 37-44.
· Ahrens, K.R.; Richardson, L.P.; Courtney, M.E.; McCarty ,C.; Simoni, J. and
Katon,W.(2010). Laboratory-Diagnosed sexually transmitted infections in former
foster youth compared with Peers, Pediatrics.;126(1): 97-103.
71
References
· AL-Ani(1998)Isolation and identification of Trichomonas vaginalis from women
complaining of vaginal discharge in AL-Ramadi. M.Sc. Thesis, AL-Anbar
University, Iraq.
· Al-A'ani,Z.S.(2005). Epidemeological seasonal study of vaginal infections in Baghdad.
M.Sc. Thesis, Baghdad University, Iraq.
· AL-Dabbagh, N.Y. and Karofa, A.(2007).Prepration and evaluation of local medium for
culture and growth of Trichomonas vaginalis isolated from patients in Mosaul ,Iraq.
J. Biotech. ; 6(2):111-119.
· Alderete ,J. F. Garza, C.E. (1985) Specific nature of Tricomonas vaginalis parasitism of host
cell surfaces, Infact. Immun.;50:701-708.
· Alderete, J. F.;O’Brien, J. L.;Arroyo, R. ;Engbring, J. A.; Musatovova, O.; Lopez, O.;
Lauriano, C. and Nguyen, J. (1995). Cloning and molecular characterization of two
genes encoding adhesion proteins involved in Trichomonas vaginalis cytoadherence,
Mol. Microbiol.; 17:69–83.
· Alfonso,Y. and Monzote,L.(2011). HIV protease inhibitors: Effect on the opportunistic
protozoan parasites, Open. Med. Chem. J.; 5: 40–50.
· AL-Kaisi,A.A.R. (1994). The incidence of Trichomonas vaginlis
among females with
vaginal discharge , M.Sc.Thesis, Coll.Med., Baghdad University
.
· AL-Lihaibi,R.K.(2005)An immunological study on women infected with Trichomonas
vaginalis . M.Sc. thesis, AL-Nahrain University.
72
References
· AL-Mallah O, Al-Janabi BM. (1983).The incidence of Trichomonas vaginalis among
selected groups of women in Mosul, Iraqi med. J.; 31:29-33.
· AL-Mokdady, S.(1999). Prevalance of Trichomonas vaginalis infection and other
microorganisms in AL-Sader city in Baghdad. M.Sc. thesis, Baghdad University.
· AL-Mudhaffar, Z.M.J. (1995). Trichomonas vaginalis infection: Clinical, immunological
and biochemical studies among Iraq women complaining of vaginal discharge. M.Sc.
thesis, Coll. Med., AL-Nahrain University.
· AL-Rawi,
M.A.M.
(1993).Epidemiological
study
of
trichomoniasis
and
other
microorganisms among Iraqi women complaining of vaginal discharges . M.Sc.thesis,
Coll.Med., AL-Nahrain University.
· AL-Shabandar N. (1979). Histopathological studies on Trichomonas. M.Sc. Thesis,
Coll.Med., Baghdad University, Iraq.
· AL-Sheikh,S. A. A. (1995). Study of pathogencity and associated microorganisms of vaginal
trichomoniasis in Baghdad .M. Sc. thesis, Coll .Med.,AL-Nahrain University.
· AL-Zaiadi,S.(2004).Isolation and detection of Trichomonas vaginalis from trichomoniasis
patients in AL-Nagaf city, M.Sc.Thesis ,Alkofa University.
· Alvis, N.; Mattar, S.; García, P.J.; Conde, E. and Diaz, A. (2007).Infecciones de transmisión
sexual en UN grupo de alto riesgo de la ciudad de Montería, Colombia, Revista de
Salud Pública; 9(1):86–96.
· Anderson, M.R.;Klink,K.and Cohrssen,A.(2004). Evaluation of vaginal complaints, JAMA.;
291(11):1368-1379.
73
References
· Asami,K.; Nodake,Y. and Ueno,T.(1955). Cultivation of Trichomonas vaginalis on solid
medium, Experimental Paras. J.; 4(1): 34-39.
· Aslan, D.L.; McKeon, D.M.; Stelow, E.B.; Gulbahce, H.E.; Kjeldahl, K.and Pambuccian, S.
E. (2005). The diagnosis of Trichomonas vaginalis in liquid-based Pap tests:
Morphological characteristics, Diagn. Cytopathol . ; 32(5):253-259.
B
· Barenfanger, J.; Drake, C. and Hanson, C.( 2002). Timing of inoculation of the pouch makes
no difference in increased detection of Trichomonas vaginalis by the InPouch TV
method, J. Clin. Microbiol.; 40:1387-1389.
· Bassiouni ,S.O.and Riad, R.M.(2005). Nonoxynol 9 as an additive therapy in metronidazoleresistant cases of vaginal trichomoniasis, J. Egypt Soc. Paras.; 35(2):551–562.
· Beal, C.; Goldsmith, R. ;Kotby, M.; Sherif M.; EL-Tagi A,; Farid A.; Zakaria S. and Eapen
J.(1992). The plastic envelope method, a simplified technique for culture diagnosis of
trichomoniasis, J. Clin. Microbiol .;30:2265-2268.
· Becher, N.; Waldorf,K.; Hein,M. and Uldbrg,N.(2009). The cervical mucus plug, Acta Obst.
et Gynecol. Scandinavica; 88(5): 502–513.
· Bechtold, E. and Reicher, N.B.(1952). The relationship of Trichomonas infestations to false
diagnoses of squamous carcinoma of the cervix, Cancer.; 5(3):442-57.
74
References
· Bell, G.D.; Powell, K.U.;Burridige, S.M.; Bowen, A.N.;Rameh, B.;Bolton, G.;Purser, K.;
Harrison, G.;Brown, C.; Gant, P. W.;Jones, P. H. and Trowell, J. E.(1993).
Helicobacter pylori eradication: efficacy and side effect profile of a combination of
omeprazole, amoxycillin and metronidazole compared with four alternative regimens.
Q. J. Med.; 86:743-750.
· Benchimol, M.; Batista, C. and De Souza, W. (1990). Fibronectin- and lamin-mediated
endocytic
activity
in
the
parasitic
protozoa
Trichomonas
vaginalis
and
Tritrichomonas foetus, J. Submicrosc. Cytol. Pathol. ;22: 39–45.
· Benchimol, M.(2010). The mastigont system in Trichomonads, Micro. Monographs.; 17(10):
1-26.
· Blackwell, A. L.; Thomas, P .D.; Wareham, K . and Emery, S J.(1993). Health gains from
screening for infection of the lower genital tract in women attending for termination
of pregnancy, Lancet.; 342 (8865):206-210 .
· Blake, D. R.; Duggan, A. and Joffe, A. (1999).Use of spun urine to enhance detection of
Trichomonas vaginalis in adolescent women, ARCh. Pediatr .Adolesc. Med.;
153:1222-1225.
· Borchardt, K.A. and Smith, R.F. (1991).An evaluations of an inpouch TV culture method for
diagnosis Trichomonas vaginalis infection, Gentourin.Med.;67:49-52.
· Borchardt,K. A. ;AL-Haraci, S. and Maida,N.(1995). Prevalence of Trichomonas vaginalis in
amal sexually transmitted disease clinic by interview, wet mount microscopy and InPouch TV culture ,Genitrourin. Med.;11:405-406.
75
References
· Borchardt,K.A.; Zhang,M.Z.; Shing,H. and Flink,k.(1997). A comparison of the sensitivity
of the In-Pouch TV, Diamond's, and Trichosel media for detection of Trichomonas
vaginalis, Genitourin Med.; 73:297-298.
· Bowden , F. J. and Garnet , G.P.(2000). Trichomonas vaginalis epidemiology:
parameterising and analysing a model of treatment interventions, Sex. Transm. Infect
.;76(10):248-256 .
· Briselden, A. M., and Hillier, S. H. (1994). Evaluation of Affirm VP microbialidentification
test for Gardnerella vaginalis and Trichomonas vaginalis, J. Clin. Microbiol.;
32:148–152.
· Brown,L.; Pate,S.; Ives,N.J.; McDermott, C. and Ross,J.D.C.(2010). Is non-invasive testing
for sexually transmitted infections an efficient and acceptable alternative for patients?
A randomised controlled trial, Sex. Transm. Infect.; 86:525-531.
C
· Campbell, W. C. (2001). A historic photomicrograph of parasite
(Trichomonas
vaginalis),Trends in Parasitol.;17: 499-500.
· Carlton, J.M.; Hirt, R.P.; Silva, J.C.; Delcher, A.L.; Schatz, M.; Zhao, Q.; Wortman ,J.R.
;Bidwell ,S.L.; Alsmark, U.C.; Besteiro ,S. ;Mottram ,J.C.; Tachezy, J. ;FraserLiggett ,C.M. and Johnson, P.J. (2007). Draft genome sequence of the sexually
transmitted pathogen Trichomonas vaginalis, Science ;315: 207–212.
· Cates, W. (1999).Estimates of the incidence and prevalence of sexually transmitted diseases
in the United States. American Social Health Association Panel,Sex.Transm.
Dis.;26:2-7.
76
References
· Centers for Disease Control and Prevention(CDC).(2006). Sexually transmitted diseases
treatment guidelines;55:1-94.
· Clark, C.G.(2002). Methods for cultivation of luminal parasitic protists of clinical
importance, Clin. Microbiol. Rev.;15:329–341.
· Clark, C.G.; Alsmark ,U.C.M.; Tazreiter, M.; Saito-Nakano, Y.; Ali, V.; Marion, S.; Weber,
C. and Hall, N.(2007). Structure and content of the Entamoeba histolytica genome,
Advances in Parasitol. ; 65: 51-190.
· Collee, G.J.; Frasen, A.C.; Marmion, B.P. and Simmons,A.(1996).Macke and McCartney
practical medical microbiology.14th ed .Churchill Livingstone. Philadelphia.
· Conrad, M.; Sullivan, S.A.and Carlton,J.M.(2011). Trichomonas infections of humans and
animals. Ann. of the New York Acad. of Sci.; 1230: 74–107.
· Cosar,C,
and
Julou,
L.(1959).
Activity
of
1-(2-hydroxylethyl)-2-methyl-5-
nitroimidazole(8823 RP) against experimental Trichomonas vaginalis infection, Ann.
Inst . Pasteur;96:238–241.
· Cotch ,M.F.; Pastorek, J.G. ;Nugent, R.P.; Hillier, S.L.; Gibbs, R.S.;Martin ,D.H.;
Eschenbach ,D.A.; Edelman, R.; Carey, J.C.; Regan ,J.A.; Krohn, M.A.; Klebanoff
,M.A.; Rao, A.V.avd Rhoads ,G.G.(1997). Trichomonas vaginalis associated with
low birth weight and preterm delivery. The vaginal infections and prematurity study
group, Sex Transm. Dis. ;24(6):353-60.
· Cox, F.(2010). Classification and Introduction to the Parasitic Protozoa. Topley and Wilson's
Microbiology and Microbial Infections,London.
77
References
· Crosby, R.; DiClemente, R. J. and Wingwood, G.M. (2002). Predictions of infection with
Trichomonas vaginalis: a prospective study of low-income African-American
adolescent females, Sex. Tran. Infect.; 78: 360-364.
· Cudmore, S.L .; Delgaty, K. L. ; Hayward, S. F. ; Petrin, D. P. and Garber , G. E.(2004).
Treatment of infections caused by Metronidazole-resistant Trichomonas vaginalis,
Clin Microbiol. Rev. ;17(4): 783–793.
· Cu-Uvin, S.; Ko, H. ; Jamieson,D. J.; Hogan, J. W.; Schuman, P.; Anderson, J. and Klein, R.
S. (2002). Prevalence, incidence, and persistence or recurrence of trichomoniasis
among human immunodeficiency virus (HIV)-positive women and among HIVnegative women at high risk for HIV infection, Clin. Infect. Dis. ;34:1406-1411.
D
· Dacks, J. B.; Carlton, J.; Hirt, R. P. and
Embley, T. M. (2005). Massive differential
expansion of the Trichomonas vaginalis adaptin genomic complement. Eukaryotic
Microbiol. J.; 52: 7–27.
· Danesh ,I.S.; Stephen, J.M.and Gorbach, J.(1995) . Neonatal Trichomonas vaginalis
infection, J . Emerg.Med.;13:51– 54.
· Demes,
P.; Gombosova, A.; Valent, M.; Fabusova, H. and Janoska, A.(1988). Fewer
Trichomonas vaginalis organisms in vaginas of infected women during menstruation,
Genitourin Med.;64 :22–24.
· Diamantis ,A.; Magiorkinis ,E. and Androutsos ,G.(2009). Alfred François Donné (1801–78):
a pioneer of microscopy, microbiology and haematology, J. Med .Biogr. ;17(2):81-87.
78
References
· Domeika, M.; Litvinenko, I.; Smirnova, T.;Gaivaronskaya, O.; Savicheva, A.;Sokolovskiy,
E.; Ballard, R. and Unemo, M.(2008).Laboratory diagnostics for non-viral sexually
transmitted infections in St. Petersburg, Russia: current situation and hallmarks for
improvements, the Europ. Acade. of Dermatol. and Venereol. J. ; 22(10): 1094–
1100.
· Domeika, M.; Zhurauskaya, L.;Savicheva, A.; Frigo, N.; Sokolovskiy, E.; Hallén, A.;
Unemo, M.
and
Ballard, R.(2010).Guidelines for the laboratory diagnosis of
trichomoniasis in East European countries ,Europ. Acad. Dermatol. Venereol. J.;
24(10): 1125–1134.
· Draper, D. ; Parker, R. and Patterson, E. (1993). Detection of Trichomonas vaginalis in
pregnant women with the In-Pouch TV culture system,Clin. Micr.,31(4): 1016-1018.
· Dudkiewicz,J.;
Kamiński,K.
and
Rybczyńska,A.(1983).
Preventive
gynecological
examinations of women employed in the cement industry, Med Pr.; 34 (1):89-94 .
· Dunne, R.L.; Dunn, L.A.; Upcrott, P.; O'Donoghue, P.J.; Upcroft, J.A.( 2003). Drug
resistance in the sexually transmitted protozoan Trichomonas vaginalis, Cell Res.; 13:
239-249.
· Dyer, B. (1990). Phylum Zoomastigina Class Parabasalia, p. 252-258. In :L. Margulis, J. O.
Corliss, M. Melkonian, and D. J. Chapman (ed.), Handbook of Protoctista. Jones and
Bartlett, Boston, Mass.
E
· Edan, E.M.(2007). The Role of specific and non specific immunological stimulators in
protection of albino mice against infection with Trichomonas vaginalis, ph.D thesis
Biology College of Science for Women, Baghdad University.(in Arabic).
79
References
· El-Ahl,S.A.; El-Wakil,H.S.; Kamel, N.M. and Mahmoud ,M.S.(2002). A preliminary
study on the relationship between Trichomonas vaginalis and cervical cancer in
Egyptian women , Egypt Soc Parasitol. ; 32 (1):167-178.
· El-Shazly, A.M. ; El-Naggar, H.M. ;Soliman, M.; El-Negeri, M. ; El-Nemr, H.E.; Handousa
,A.E. and Morsy, T.A.(2001). A study on Trichomoniasis vaginalis and female
infertility, J. Egypt. Soc. Parasitol. ; 31(2):545-553.
· Escario,
A.;
Gómez
Barrio,
A.;
Simons
Diez,
B.
and
Escario,
J.A.(2010).
Immunohistochemical study of the vaginal inflammatory response in experimental
trichomoniasis, Acta Tropica.; 114(1):22-30.
· Evans,A.S.(2009).Epidemiological Concepts ,department of epidemiology and public health
,Yale University School of Medicine , New Haven .
F
· Fankhauser, D. B. (2005). Preparation of wet mount slide , M.Sc. Thesis, University of
Cincinnati Clermont College.
· Farage, M. A.; Miller, K. W.; Ledger, W. J. (2008). Determining the cause of vulvovaginal
symptoms. Obstetrical & Gynecological Survey.;63(7):445-464.
· Faro, S. and Soper, D.E.(2001).Infection diseases in women , Sander company J. ;240-247.
· Farys,A. (2003).Diagnosis study of Trichomonas vaginalis, M.Sc. Thesis, Abd AL-Aziz
University, Saudi Arabia.
· Fichorova, R.N.(2009). Impact of T. vaginalis infection on innate immune responses and
reproductive outcome, Rep. Immunol.; 83(1):185-189.
80
References
· Forgetta,V,; Oughton, M.; Marquis,P.; Brukner,I,; Blanchette,R.; Kevin Haub, K.;Vince
Magrini,V. ; Mardis,E. ; Gerding,D.; Loo,V.; Miller, M.; Mulvey, M.; Rupnik,M.;
Dascal,A. and Dewar,k.(2011) . A Fourteen genome comparison identifies DNA
markers for severe disease-a ssociated strains of Clostridium difficile, J. Clin.
Microbiol; 10:1-25.
· Fouts, A. C. and Kraus, S. J.(1980). Trichomonas vaginalis: reevaluation of its clinical
presentation and laboratory diagnosis, J. Infect. Dis.;141:137–143.
· Fripp, P.J.; Mason, P.R.; Super, H.(1975). A method for the diagnosis of Trichomonas
vaginalis using acridine orange, J. Parasitol. ;61:966-7.
G
· Garber,G.(2005). The laboratory diagnosis of Trichomonas vaginalis, J. Infect. Dis. Med.
Microbiol. ; 16(1): 35–38.
· Garcia, L.S. and Bruckner, A.D. (1995) .Trichomonas vaginalis In:Diagnostic Medical
Parasitology, American society for microbiology.
· Garcia, A. F.; Chang, T.-H.; Benchimol, M.; Klumpp, D. J.; Lehker, M. W. and Alderete, J.
F. (2003). Iron and contact with host cells induce expression of adhesins on surface of
Trichomonas vaginalis, Molecular Micro.; 47: 1207–1224.
· Garcia,A.;
Exposto,F.; Prieto,E.; Lopes,M.; Duarte,A.and Correia da Silva ,D.(2004).
Association of Trichomonas vaginalis with sociodemographic factors and other STDs
among female inmates in Lisbon, J. STD AIDS. ; 15 (9):615-618 .
81
References
· García, P. J.; Cárcamo, C. P.; Chiappe, M. and Holmes, K. K. (2007). Sexually transmitted
and reproductive tract infections in symptomatic clients of pharmacies in Lima, Peru,
Sex. Tran. Inf.; 83(2):142–146.
· Gavgani,A.; Namazi,A.; Ghazanchaei,A.; Alizadeh,S.; Sehhati,F.; Rostamzadeh,S. and
Dolatkhah,A.(2008). Prevalence and risk factors of trichomoniasis among women in
Tabriz, Iranian J. Clin. Inf. Dis.;3( 2) :67-71.
· Gehrig, S.and Efferth, T. (2009). Development of drug resistance in Trichomonas vaginalis
and its overcoming with natural products. The Open Bioactive Compounds J.; 2:2128.
· Gelbart,
S.M.;
Thomason,J.L.;
Osypowski,P.J.;
Kellett,A.V.;
James,J.A.
and
Broekhuizen,F.F.(1990). Growth of Trichomonas vaginalis in commercial culture
media, J. Clin. Microbiol.; 28(5): 962–964.
· González-Robles, A.; Lázaro-Haller, A.; Espinosa-Cantellano, M.; Anaya-Velázquez, F. and
Martínez-Palomo, A. (1995). Trichomonas vaginalis: ultrastructural bases of
cytopathic effect, J. Eukaryot. Microbiol.; 42: 641–651.
· Gottlieb, S.L.; Douglas, J.M.; Foster, M.; Schmid, D.S. ; Newman ,D.R.; Baron ,A.E. ;
Bolan, G. ; Iatesta, M. ; Malotte, C.K. ; Zenilman, J ; Fishbein, M. ; Peterman, T.A.
and Kamb, M.L.(2004). Project respect study group. Incidence of Herpes simplex
virus type 2 infection in 5 sexually transmitted disease (STD) clinics and the effect of
HIV/STD risk-reduction counseling, J. Infect. Dis. ;190(6):1059-1067.
· Gram ,I.T.; Macaluso, M.; Churchill, J. and Stalsberg,H. (1992).Trichomonas vaginalis (TV)
and human papillomavirus (HPV) infection and the incidence of cervical
intraepithelial neoplasia (CIN) grade III, Cancer Causes Control ;(3):231-236.
82
References
· Graves, A. and Gardener, W. A.(1993).Pathogenicity of Trichomonas vaginalis,Clin Obstet
gynecol.; 36: 137 – 143.
· Grodstein, F.; Goldman, M.B. and Cramer, .D.W.(1993). Relation of tubal infertility to
history of sexually transmitted diseases, Am. J. Epidemiol. ; 137(5):577-584.
· Guenthner, P.C.; Secor, W.E. and Dezzutti CS.(2005). Trichomonas vaginalis-induced
epithelial monolayer disruption and human immunodeficiency virus type 1 (HIV-1)
replication: implications for the sexual transmission of HIV-1, Infect. Immun.;
73(7):4155-4160.
H
· Habib, F.A.; El-Aal,A.A.; Yamany ,N.S.; mohamadein,A.M.; Hamed,O.; Bahashwan,A.;
Shehata ,N. and El-Hosseiny,L.A.(2009). Feasibility of a nested PCR for the
diagnosis of vaginal trichomoniasis Saudi Arabia,
Int. J. Med. and Med. Sci.; 1 (5): 206-210.
· Hager ,W.D.(2004). Treatment of metronidazole-resistant Trichomonas vaginalis with
tinidazole. Sex. Transm. Dis.; 31(6):343–45.
· Hare, M.J.(1988).Trichomoniasis, in: genital tract infection in woman. florida; 190-198.
· Harp,D.F.and Chowdhury,I.(2011). Trichomoniasis: evaluation to execution, Eur.J.of
Obstetrics & Gynecology and Reproductive Biology; 157(1):3-9.
· Heine, R. P.; Wiensfeld, H. C.; Sweet, R. L. and Witkin, S. S. (1997). Polymerase chain
reaction analysis of distal vaginal specimens: a less invasive strategy for detection of
Trichomonas vaginalis, Clin. Infect. Dis.; 24:985-987.
83
References
· Hobbs, M.M. ; Lapple, D.M. ; Lawing, L.F.; Schwebke ,J.R.; Cohen, M.S. ; Swygard, H.;
Atashili, J.; Leone, P.A. ; Miller, W.C.and Seña A.C.(2006). Methods for detection of
Trichomonas vaginalis in the male partners of infected women: implications for
control of trichomoniasis. J. Clin. Microbiol. ; 44(11):3994-3999.
· Honigberg, B.M.(1990). Host cell–trichomonad interactions and virulence assays in vitro
systems. 155–212, In: Trichomonads Parasitic in Humans (Honigberg, B.M., ed.),
Springer–Verlag, New York
· Hook, E.W. (1999). "Trichomonas vaginalis--no longer a minor STD". Sexu. Transm.
Dis.;26 (7): 388–389 .
· Houang, E.T.; Ahmet, Z.and Lawrence, A.G.(1997). Successful treatment of four patients
with recalcitrant vaginal trichomoniasis with a combination of zinc sulphate douche
and metronida-zole therapy. Sex. Transm. Dis.;24(2):116–119.
· Hui Wang,P. and Tai Chao,H.(2006). Single-dose sertaconazole vaginal tablet treatment of
vulvovaginal candidiasis. Chinese Med. Association;69(6): 259-263.
· Huppert, J.S.(2009). Trichomoniasis in teens, Curr. Opin. Obstet. Gynecol.; 21 (5): 371-378.
J
· Jamali,R.;Zareikar,R.;Kazemi,A.;Yousefee,S.;Ghazanchaei,A.;Estakhri,R.
and
Asghar-
zadeh,M.(2006). Diagnosis of Trichomonas Vaginalis infection using PCR method
compared to culture and wet mount microscopy, Int. Med J ; 5 ( 1):11.
84
References
· Jatau, E. D.; Olonitola, O. S. and Olayinka, A. T.(2006). Prevalence of Trichomonas
infection among women attending antenatal clinics in Zaria , Nigeria, Annals of
African Medicine; 5(4):178-181.
· Jay, M. and Berman, M.D.(2008). Trichomonas Infection, Genitourine Med . ;71:405-406.
· Jeremias, J.; Draper, D. and Ziegert, M. (1994). Detection of Trichomonas vaginalis using
the polymerase chain reaction in pregnant and non-pregnant women, Infect. Dis.
Obstet. Gynecol.; 2:16-19.
· Johnston, V.J. and Mabey, D.C.(2008). Global epidemiology and control of Trichomonas
vaginalis, Curr Opin Infect Dis.; 21(1): 56-64.
· Jomegarry,B.(2010).Primary care procedures in women's health .University of Medicine and
Dentistry of New Jeresy .USA .
· Josephine Lusk, M.;
Naing ,Z.; Rayner,B.; Rismanto,N.; McIver,C.J.; Cumming,R.G.;
McGeechan,K.; Rawlinson,W.D. and Konecny,p.(2010). Trichomonas vaginalis:
underdiagnosis in urban Australia could facilitate re-emergence, Sex Transm Infect
.;86:227-230.
· Juliano, C.; Cappuccinelli, P. and Mattana, A.(1991). In vitro phagocytic interaction between
Trichomonas vaginalis isolates and bacteria, Eur. J. Clin. Microbiol. Infect. Dis. ;10:
497–502.
K
· Kadir,M.A.;Salahy,A.M.S. and Hammad,E.F.(1986).Diagnosis of vaginal discharge in Erbil
women ,Eribil, Northern Iraq,Tant.Med.J.;14(1):85-93.
85
References
· Kanna, M. and Sobel, J. D. (2003). Late recurrence of resistant Trichomonas vaginalis
vaginitis: relapse or re-infection? ,Sex. Transm. Infect. ;79:260–261.
· Kaur,S.; Khurana,S,; Bagga,R.; Wanchu,A. and Malla,N.(2008). Antitrich- omonas IgG,
IgM, IgA, and IgG subclass responses in human intravaginal trichomoniasis.
Biomedical and Life Sciences;103(2): 305-312.
· Kaydos ,S.C.;Swygard, H.;Wise, S.L.; Sena,A.C.; Leone,P.A.; Miller,W.C.; Cohen,M.S. and
Hobbs, M.M.(2002). Development and validation of a PCR-based enzyme-linked
immunosorbent assay with urine for use in clinical research settings to detect
Trichomonas vaginalis in women, J. Clin. Microbiol .; 40:89-95.
· Keith, L.G. ; Friberg, J. ; Fullan, N. ; Bailey, R. and Berger, .G.S.(1986). The possible role of
Trichomonas vaginalis as a "vector" for the spread of other pathogens, Int. J. Fertil.;
,31(4):272-277.
· Khalaf, S.H. and AL-Akeede,M.A.(1997).The use of orange leaves as basal medium in
preparation of culture media for various microorganisms ,Rafd.J.Sci.;8(2);2-6.
· Khan, S.M.; Rao, S.and Smith, N.(1991). Screening of the prostitutes of Mehandi red light
area of Hyderabad, Indian J Med Microbiol. ; 9: 68-71.
· Khider, M. S. (1985) Candida species and other microorganism isolated from female genital
tract infection. M.Sc. thesis of microbiology , College of medicine , Baghdad
university .
· Kigozi, G.G.; Brahmbhatt, H.; Wabwire-Mangen, F.; Wawer, M.J.; Serwadda, D.;
Sewankambo, N. and Gray, R.H.( 2003).Treatment of Trichomonas in pregnancy and
86
References
adverse outcomes of pregnancy: a subanalysis of a randomized trial in Rakai,
Uganda, Am. J. Obstet .Gynecol.;189(5):1398-1400.
· Kingston, M.A.; Bansal, D. and Carlin, E.M.(2003). ‘Shelf life’ of Trichomonas vaginalis,
Int .J. AIDS;14:28–29.
· Kirby, H.(1947).Flagellated and host relationships of Trichomonas flagellated,J.of
parasitol.;33(3):214-220.
· Klebanoff, M.A.; Carey, J.C.; Hauth, J.C.; Hillier, S.L.; Nugent, R.P.; Thom, E.A.; Ernest,
J.M.; Heine, R.P.; Wapner, R.J.; Trout ,W.; Moawad, A.; Leveno, K.J.; Miodovnik,
M.; Sibai, B.M.; Van Dorsten, J.P.; Dombrowski MP, O'Sullivan MJ, Varner M,
Langer, O.; McNellis, D.and Roberts, J.M.(2001). Failure of metronidazole to prevent
preterm delivery among pregnant women with asymptomatic Trichomonas vaginalis
infection, National Institute of Child Health and Human Development Network of
Maternal-Fetal Medicine Units, N. Engl. J. Med.;345(7):487-93.
· Kleina ,P.; Bettim-Bandinelli, J.; Bonatto, S.L.; Benchimol, M. and Bogo, M.R.(2004) .
Molecular phylogeny of Trichomonadidae family inferred from ITS-1, 5.8S rRNA
and ITS-2 sequences, Int. J. Parasitol. ; 34:963-970.
· Klouman, E., Masenga, E. J. and Klepp, A. B. (1997). HIV and reproductive tract infections
in a total village population in rural Kilimanjaro, Tanzania: women at increased risk.
J. Acqu. Imm. Def. Synd. Hum.Retrovirol.; 14: 163-168.
· Koonin,E.V.(2009). Darwinian evolution in the light of genomics, Nucl. Acids Res.; 37 (4):
1011-1034.
· Komor,A.J.(2009). Perspectives on the History of Oral Contraceptives:Popular, Progesterone
and Personal, Bachelor of Arts thesis, Wesleyan University.
87
References
· Krieger, J.N.; Poisson, M.A. and Rein, M.F.(1983a). Beta-hemolytic activity of Trichomonas
vaginalis correlates with virulence, Infect Immun. ;41:1291-1295.
· Krieger J.N.; Holmes, K.K.; Spence, M.R.; Rein, M.F.; McCormack, W.M. and Tam ,
M.R.(1983b). Geographic variation among isolates of Trichomonas vaginalis:
demonstration of antigenic heterogeneity by using monoclonal antibodies and the
indirect immunofluorescence technique, J. Infect. Dis. ; 152(5):979-984.
· Krieger, J. N.; Verdon, M. ; Siegel, N. ; and Holmes, K. K. (1993). Natural history of
urogenital trichomoniasis in men, J. Urol.; 149:1455-1458.
· Kreiger, J.N.(1995). Trichomoniasis in Men: Old Issues and New Data, Sex. Trans
.Dis.;22:83-96.
· Krieger, J.N. and Alderete, J.F.(2000). Trichomonas vaginalis and trichomoniasis, Sex.
Trans. Dis.; 587–604.
· Kurth, A.; Whittington, W. L. H. ; Golden,M. R.; Thomas, K. K. ; Holmes, K. K. and
Schwebke, J. (2004). Performance of a new, rapid assay for detection of Trichomonas
vaginalis, J. Clin. Microbiol. ;42:2940-2943.
L
· Laga, M.; Manoka, A.; Kivuvu, M.; Malele, B.; Tuliza, M.; Nzila, N.; Goeman ,J.; Behets,
F.; Batter, V.and Alary, M.(1993). Non-ulcerative sexually transmitted diseases as
risk factors for HIV-1 transmission in women: results from a cohort study,
AIDS.;7(1):95-102.
88
References
· Landes,M.; Thorne,C.;
Barlow,P.; Fiore,S.;
Malyuta,R.; Martinelli,P.;
Posokhova,S.;
Savasi,V.; Semenenko, I.; Stelmah,A.; Tibaldi,C. and Newell ,M.(2007). Prevalence
of sexually transmitted infections in HIV-1 infected pregnant women in Europe, Eur.
J .Epidemiol.; 22(1): 9-14.
· Lawing, L.; Hedges, S. and Schwebke, J.(2000). Detection of trichomoniasis in vaginal and
urine specimens from women by culture and PCR, J. Clin. Microbiol.; 38 : 3585-3588
.
· Levett, P.N.(1980). A comparison of five methods for the detection of Trichomonas
vaginalis in clinical specimens, Med Lab Sci;37:85-88.
· Levi, M.H.; Torres, J.; Pina, C. and Klein, R.S.(1997). Comparison of the In-Pouch TV
culture system and Diamond's modified medium for detection of Trichomonas
vaginalis, J Clin Microbiol.;35(12):3308-3310.
· Lewis, D.A.(2010). Vaginal infections Trichomoniasis , Am. J. of Med.; 38(6):291-293.
· Linda, O. and Eckert, M.D.(2006). Acute vulvovaginitis, N. Engl. J .Med .; 355:1244-1252.
· Lobo ,T.T.; Feijó ,G.; Carvalho, S.E.; Costa PL, Chagas, C.; Xavier, J. and Simoes-Barbosa
,A. (2003).A comparative evaluation of the Papanicolaou test for the diagnosis of
trichomoniasis, Sex Transm Dis.;30(9):694-699.
89
References
· Loo, S. K.; Tang, W. Y. and Lo, K.(2009). Clinical significance of Trichomonas vaginalis
detected in Papanicolaou smear: a survey in female Social Hygiene Clinic, Hong
Kong Med. J.; 15(2):90-93.
· Lossick, J. G. (1982). Treatment of Trichomonas vaginalis infections, Rev. Infect. Dis.;
4:801-818.
· Lossick, J.G.(1989). Therapy of urogenital trichomoniasis. In: Honigberg, B.M. (ed.)
Trichomonads parasitic in man. New York: Springer-Verlag, 324-341.
· Lossick J.G.(1991). Chemotherapy of nitro-imidazole resistant vaginal trichomoniasis, Acta.
Univ. Carol. Biol.;30:533–545.
M
· Madico, G. ; Quinn ,T.C. ;Rampalo, A. ; McKee, .K.T . and Gaydos, C.A.(1998). Diagnosis
of Trichomonas vaginalis infection by PCR using vaginal swab samples, J. Clin.
Microbiol .;36 : 3205-3210.
· Mahdi, N.K.(1996) Urogenital trichomoniasis in Iraqi population . East Mediterrinean.
Health. J. ; 2(3) : 501 - 505.
· Mahdi, N. K.; Gany Z .H. and Sharief, M.(2001). Risk factors for vaginal trichomoniasis
among women in Basra, Iraq, East Mediterranean Health J.; 7 (6):918-924.
90
References
· Martinez-Garcia, F.; Regadera, J.; Mayer, R.; Sanchez, S. and Nistal M.(1996). Protozoan
Infections in the male genital tract, J. Urol.; 156 (2): 340-349.
· McGrory, T.and Garber, G. E.(1992). Mouse intravaginal infection with Trichomonas
vaginalis and role of Lactobacillus acidophilus in sustaining infection, Infect.
Immun.; 60:2375–2379.
· McGrory, T.; Meysick, K. C.; Lemchuk-Favel, L. T.and Garbe,r G. E. (1994). The
interaction of Lactobacillus acidophilus and Trichomonas vaginalis in vitro, J.
Parasitol; 80:50–54.
· Meyer, E. A. (1996). Other Intestinal Protozoa and Trichomonas vaginalis In: Baron ,S.( ed).
Medical Microbiology. University of Texas Medical Branch Galveston.
· Mgone, S.; Passey, M. ;Mbbs, M.; Anang, J.; Peter, W.; Lupiwa, T.; Russell, D.; Babona, D.
and
Alpers, M.(2002). Human immunodeficiency virus and other sexually
transmitted infections among female sex workers in two major cities in Papua New
Guinea, Sex. Tran. Dise.; 29(5):165-172.
· Midlej, V. and Benchimo,M.(2010). Trichomonas vaginalis kills and eats – evidence for
phagocytic activity as a cytopathic effect, Parasitol.; 137: 65-76.
· Mirhagani, A. and Warton, A.(1996). An electron microscope study of the interaction
between Trichomonas vaginalis and epithelial cells of the human amnion membrane,
Parasitol. Res.; 82: 43–47.
· Mirza, N. B.; Nzanze, H.; Li, D. C. and Piot, P.(1983) . Microbiology of vaginal discharge
in Nairobi, Kenya, British J. of Vener. Dis.; 59: 186-188.
91
References
· Mohamed, O.A.; Cohen,C.R.; Kungu, D.; Kuyoh, M.A.; Onyango, A.O.; Bwayo, J.J.;
Welsh,M. and
Feldblum,P.J. (2001).Urine proves a poor specimen for culture of
Trichomonas vaginalis in women, Sex Transm. Infect. ;77:(10)78-79 .
· Moodley, P.; Connolly, C. and Sturm, A.W. (2001). Interrelationships among human
immunodeficiency virus type 1 infection, bacterial vaginosis, trichomoniasis, and the
presence of yeasts, J. Infect. Dis.; 185(1):69-73.
· Moodley, P.; Connolly, C. and Sturm, A.W.(2002). Trichomonas vaginalis is associated
with pelvic inflammatory disease in women infected with human immunodeficiency
virus, Clin. Infect. Dis.;34:519-22.
· Morada,M.; Smid,O.J.; Hampl,V.; Sutak,R.; Lam,B.; Rappelli,P.; Dessì,D.; Fiori,P.L.;
Tachezy,J.and Yarlett,N.(2011). Hydrogenosome-localization of arginine deiminase
in Trichomonas vaginalis, Mole. and Bioch. Parasitol.;176(1):51-54.
N
· Nagesha, C.N.; Ananthakrishna, N.C.and Sulochana, P.(1970). Clinical and laboratory
studies on vaginal trichomoniasis, Am. J. Obstet. Gynecol. ;106:933-935.
· Naguib ,S.M. ; Comstock , G.W. and Davis , H.J. (1966).Epidemioloy study of
trichomoniasis in normal women. Obstet. Gynoacol. ;27(5):607-616.
· Noel ,J.C. ;Diaz,N. ; Sicheritz-Ponten,T.; Safarikova L.; Tachezy ,J.; Tang,P.; Fiori ,P.and
Hirt ,R.P.(2010). Trichomonas vaginalis vast BspA-like gene family: evidence for
functional diversity from structural organisation and transcriptomics, BMC Genomics
J.; 11(10):99.
92
References
O
· O’Farrell, N.; Hoosen, A.A and Kharsarry, A. H. (1989). Sexually transmitted pathogens in
pregnant women in a rural South African community, Genitour. Med.; 65: 276-280.
· Okpara, K., Udoidung, N., Ating, I., Bassey, E., Okon, O and Nwabueze, A. (2009). Risk
factors for vaginal trichomoniasis among women in Uyo, Nigeria. Int. J. of Health.;9
(2): 1528-8315.
· Omer ,E.E.; Ali ,M.H. and Erwa ,H.H.(1980).Study of sexual transmited diseases in
Sudanese women ,Trop.Doct.;10:99-102.
· Omer ,E.E.; Ali ,M.H : Caterall ,R.D. ; EL-Naeem ,H.A. and Erwa ,H.H.(1985).Vaginal
trichomoniasis,Trop.Doct.;15:170-172.
· Ortashi, O M.; Khidir, I .E.l.and Herieka. E.(2004). Prevalence of HIV, syphilis, Chlamydia
trachomatis, Neisseria gonorrhoea, Trichomonas vaginalis and candidiasis among
pregnant women attending an antenatal clinic in Khartoum, Sudan.
J. Obstet.
Gynaecol. ;24 (5):513-515.
· Oud, L. (2009). Trichomonal Sinusitis in an adolescent patient with multiple trauma,
Southern Med. J.; 102 (3): 330-332.
93
References
· Özdemir, E.; Keleştemur, N. and Kaplan, M.( 2011). Trichomonas vaginalis as a rare cause
of male factor infertility at a hospital in East Anatolia, Androl.; 43(4): 283–285.
P
· Pagana ,K.D. and Pagana, T.J. (2010). Mosby’s manual of diagnostic and laboratory tests,
4th ed.: Mosby Elsevier, St. Louis.
· Passos , M.; Camposarze ,W.; Mauricio,C.; Barrto ,N.; Varella ,R.; Cavalcanti,S.;
Giraldo,P.(2010).Is there an increase in STDs during carnival?Time series of
diagnoses in a STD clinic,Rev. Assoc. Med. Bras.; 56(4): 420-427.
· Pereira-Neves, A. and Benchimol, M.(2007).Phagocytosis by Trichomonas vaginalis: new
insights, Biol. Cell.;99(2):87-101.
· Petrin, D.; Delgaty, K.; Bhatt, R. and Garber, G.(1998). “Clinical and microbiological
aspects of Trichomonas vaginalis,” Clin.Microbiol. Rev.; 11(2): 300–317.
· Peruzzi, S.; Calderaro, A.; Gorrini, C.; Montecchini, S.; Piccolo, G.; Rossi, S.; Gargiulo,
F.and Chezzi ,C.(2010) .Evaluation of a real-time polymerase chain reaction assay for
the detection of Dientamoeba fragilis , Diagn.Microbiol. Infect. Dis.; 67 (3): 239-245.
· Pillay,A.; Lewis,J. and Ballard,R.C.(2004). Evaluation of xenostrip-Tv, a rapid diagnostic
test for Trichomonas vaginalis infection, J. Clin. Microbiol.; 42(8): 3853-3856.
· Piperaki,E.; Theodora, M.;Mendris,M.;
Barbitsa,L.;
Pitiriga,V,
Antsaklis,A. and
Tsakris,A.(2010). Prevalence of Trichomonas vaginalis infection in women attending
94
References
a major gynaecological hospital in Greece: a cross-sectional study, J. Clin. Pathol. ;63
(3):249-253.
· Poppe, W.A.(2001).Nitro-imidazole resistant vaginal trichomoniasis treated with paromycin,
Eur. J. Obstet. Gynaecol. Reprod Biol .;96:119–120.
· Powell, W.N.(1936).Trichomonas vaginalis Donne 1836: its morphologic characteristic,
mitosis and specific identity , Am. J. of Epid.;24(1):145-169.
· Preethi, V.; Mandal, J.; Halder, A. and Parija, S.(2011). Trichomoniasis: An update,rev.
articles;1(2): 73-75.
· Prokopi,M.; Chatzitheodorou,T.; Ackers,J.P. and Clark,C.G.(2011).
A preliminary
investigation of microsatellite-based genotyping in Trichomonas vaginalis, Trans.
Roy. Soci. of Trop. Med. and Hyg.; 105(8):479-481.
· Prugnolle,F. and Meeus,T.D.(2010). Apparent high recombination rates in clonal parasitic
organisms due to inappropriate sampling design, Heredity J.; 104: 135–140.
R
· Radonjic, I.V.; Dzamic, A.M.; Mitrovic, S.M.; Arsic Arsenijevic, V.S.; Popadic, D.M. and
Kranjcic Zec, I.F.(2006). Diagnosis of Trichomonas vaginalis infection: The
sensitivities and specificities of microscopy, culture and PCR assay, Eur. J. Obstet.
Gynecol. Reprod. Biol.; 126(1):116-120.
· Rasti, S.; Behrashi, M. ; Mousavi ,G.H. and
Moniri, R. (2011) .Complications of
trichomoniasis on the pregnant women, Jundishapur J. Microbiol.; 4(1): 61-63.
95
References
· Rendón-Maldonado, J.G.; Espinosa-Cantellano, M.; González-Robles, A. and MartínezPalomo, A.(1998). Trichomonas vaginalis: in vitro phagocytosis of lactobacilli,
vaginal epithelial cells, leukocytes and erythrocyte., Exp. Parasitol.; 89: 241–250.
· Reynolds, S.; Bollinger, R. and Quinn,T.C.(2008). Parasitic diseases during pregnancy ,Glob.
libr. Women's med.J.; 1756-2228.
· Roberts,S.L.and Janovy,J.J. (2000). Foundation of parasitelogy ,McGrow Hill.; 49 -83.
· Rodgerson,
E.(1972).Vulvo-vaginal
papillomas
and
Trichomonas
vaginalis
,
Obstet.Gynaecol.;40(3):327-333.
· Rodriguez-Martinez, H.A.; De la Luz Rosales, M.; Gallaso de Bello, L. and Ruiz-Moreno
JA.(1973). Adequate staining of Trichomonas vaginalis by McManus' periodic acidSchiff stain, Am .J. Clin. Pathol.;59:741-6.
· Ryan, K.J (ed.) .(2004). Sherris Medical Microbiology(4th ed.). McGraw Hill. Canada .
S
· Saksirisampant, W.; Prownebon, J. and Wiwanitkit, V.(2009). Cost identification analysis
of culture methods for trichomoniasis, Arch Hellen Med.; 26(4): 517-519.
· Sansom,F.M.; Robson,S.C. and Hartland,E.L.(2008). Possible effects of microbial ectonucleoside
triphosphate
diphosphohydrolases
on
host-pathogen
interactions,
Microbiol. Mol. Biol. Rev.; 72(4):765-781.
· Saurina, G.R.and McCormack, W.M.(1997). Trichomoniasis in pregnancy, Sex Trans. Dis.;
24:361-362.
96
References
· Schirm, J.; Bos, P.A.; Roozeboom-Roelfsema, I.K.; Luijt, D.S.and Möller, L.V. (2007) .
Trichomonas vaginalis detection using real-time TaqMan PCR, J. Microbiol.
Methods. ;68(2):243-237.
· Schwebke, J.R.and Hook, E.W.(2003). High rates of Trichomonas vaginalis among men
attending a sexually transmitted diseases clinic: implications for screening and
urethritis management, J. Infect. Dis.;188(3):465-468.
· Schwebke, J. and Burgess, D.(2004).Trichomoniasis, Clin. Microbiol. Rev.; 17(4): 794-803.
· Shafir,S.C.; Smith,L. and Sorvillo,F.J.(2009).Current Issues and considerations regarding
trichomoniasis and human immunodeficiency virus in African-Americans, Clin.
Microbiol. Rev.; 22(1): 37-45.
· Shahmanesh, M.; Cowan, F.M.; Wayal, S.S.; Copas, A.; Patel, V. and Mabey, D.(2006). The
burden and determinants of HIV and sexually transmitted infections in a population
based sample of female sex workers in Goa, India, Sex. Transm. Infect.; 85(1):50–59.
· Shimano, S.; Nishikawa, A.;Sonoda, T. and Kudo, R. (2004). Analysis of the prevalence of
bacterial vaginosis and Chlamydia trachomatis infection in 6083 pregnant women at
a hospital in Otaru, Japan. J. Obstet. Gynaecol. Res.; 30: 230–236.
· Shiraishi, T. ;Fukuda, K. ;Morotomi, N. ;Imamura ,Y. ;Mishima, J. ;Imai, S. ;Miyazawaw,K.
and Taniguchi,H.(2011).Infection of menstruation on microbiota of health women's
labia minora as analyzed using a 163 r RNA gene-based clone library method, Jpn. J.
infect. Dis.; 64:76-80.
· Shobeiri, F. and Nazari, M. (2006). A prospective study of genital infections in Hamedan,
Iran , Southeast Asian J. Trop. Med. Public Health. ; ( 37):174-177.
97
References
· Singh,B.N.; Hayes,G.R.; John J. L. ;Viseux,N.; Ekaterina, M. ;Radiana, T. T.; Rosaria , S.
;Catherine, E. C. and
Raina, N. F.(2009) Structural details and composition of
Trichomonas vaginalis lipophosphoglycan in relevance to the epithelial immune
function , Glycoconj J .;26:3–17.
· Singh,V.; Amdekar,S.; Yadav,H.; Mishra,N. and Jain,S.(2011). Future Application of
Probiotics: A Boon from Dairy Biology, Micr. Microb. Technol.; 10: 87-100.
· Smith, D. A. and Ramos, N. (2010). Trichomoniasis. eMedicine Specialties. Website:
emedicine. Mediscape.com
· Sobel ,J.D.; Nyirjesy, P. and
Brown, W.(2001). Tinidazole therapy for metronidazole-
resistant vaginal trichomoniasis, Clin.Infect. Dis.; 33(8):1341–1346.
· Sood,S.; Mohanty,S.; Kapil,A.; Tolosa,J.and Mittal,S.(2007). In-Pouch TV culture for
detection of Trichomonas vaginalis, The Indian J. Med. Res.; 125(4): 567-571.
· Sood, S. and Kapil, A. (2008). An update on Trichomonas vaginalis, Indian J. sex transm.
dis.; 29(1):7-14.
· Song, H.; Lim,Y.; Moon, S.; Ahn,M.and Ryu,J.(2010). Delayed human neutrophil apoptosis
by Trichomonas vaginalis lysate, Korean J. Parasitol.; 48(1): 3-7.
· Soper, D. (2004). Trichomoniasis: under control or undercontrolled? Am. J. Obstet.
Gynecol.; 190(1):281-290.
98
References
· Sorvillo, F. and Kerndt, P. (1998) . Trichomonas vaginalis and amplification of HIV-1
transmission. Lancet. , 351(9097):213-214.
· Sorvillo, F; Smith, L; Kerndt, P.and Ash,
L. (2001). Trichomonas vaginalis and HIV,
African- Am. Emerg. Infect. Dis.;7:927-932.
· Spence, M.(1992). Trichomoniasis. Contemp OB/GYN.; 132-141.
· Stark,J.R. ; Judson,G. ; Alderete,F. ; Mundodi,V.;Kucknoor,A.S.; Giovannucci, E.;
Platz,E.A.;
Sutcliffe,S.;
Fall,K.;
Kurth,T.;
Ma,J.;
Stampfer,M.J.
and
Mucci,L.A.(2009). Prospective study of Trichomonas vaginalis infection and prostate
cancer incidence and mortality: Physicians' Health Study, NCI J. Natl. Cancer Inst.;
101 (20): 1406-1411.
· Strous, M. M.(2008). Trichomonas vaginalis, Int. J. STD AIDS.; 16(7):488-490.
· Swaygard, H.; Seña, A.C.; Hobbs, M.M. and Cohen, M.S.(2004). Trichomoniasis: clinical
manifestations, diagnosis and management. Sex. Transm. Infect.; 80(2): 91-95.
· Swinnerton, K.J.(2001). The ecology and conservation of pik pigeon Columba mayeri in
Mauritius,Ph.D.thesis .University of Kent,Canterbury ,United Kingdom.
· Szarka-temesvari,P. ;Kerekes,A.;Tege,A.and Repkeny,A.(2002). Neonatal pneu -monia
caused by Trichmoanas vaginalis , Acta. Microbiol. Immunol . Hung., 49(1):15-9.
99
References
T
· Tann, C .J.; Mpairwe, H.; Morison, L.; Nassimu, K .; Hughes, P.; Omara, M.; Mabey, D .;
Muwanga, M.; Grosskurth, H. and Elliott, A. M. (.2006). Lack of effectiveness of
syndromic management in targeting vaginal infections in pregnancy in Entebbe,
Uganda. Sex Transm. Infect.; 82 (4):285-289.
· Tanudyaya, F. K .; Rahardjo, E.; Bollen, L. J. M.; Madjid, N.; Daili,F. S.; Priohutomo, S.;
Morineau, G.;Nurjannah, Roselinda, A.; Anartati, S.; Purnamawati, E. and Mamahit,
R. S.(2010). Prevalence of sexually transmitted infections and sexual risk behavior
among female sex workers in nine provinces in Indonesia, Southeast Asian J. Trop.
Med. Public Health. ; 41 (2):463-473.
· Temasvari,P.;A.;Tege,A. and szarka,,K.(2002).Demonstratin of Trichomonus vaginalis in
tracheal aspirates in infants with early Reapirtory failure, J.Matern. Fetal Neonatal.
Med.;11(5):347-349.
· Thompson, D. A.; Tsai, Y.; Gilman, R. H.; Vivar, A. and Calderon, M. (2000). Sexually
transmitted diseases in a family planning and an antenatal clinic in Peru: Limitations
of current practices and analysis of the use of potential markers, pH Testing, and
Whiff Testing, Sex. Trans.Dis.; 27 ( 7) : 386–392.
· Thomason, J.L. and Gelbart, S.M.(1989). Trichomonas vaginalis, Obstet. Gynecol.;74(3
2):536-541.
· Thomason, J.L. ;Monagle, L.M. ; James, J.A.; Brocknulzen, F.F. and Gelbart, S.M. (1990).Is
pH test as accurate as electronic measurement of the pH of vaginal secretions , Am. J.
Obstst. Gynaecol. ; 162(5):1213-1214.
100
References
· Thurner, J. and Meingassner, J.G. (1978). Isolation of Trichomonas vaginalis resistant to
metronidazole,Lancet;2:738.
V
· Valandkhani, Z .(2004). Role of pH on adhesion of Trichomonas vaginalis isolated from
symptomatic and asymptomatic women to vaginal epithelial cells in vitro, IJMS.;
(29): 134-138.
· Vanacova, S.; Liston, D.R.; Tachezy, J. and Johnson, P.J.(2003). Molecular biology of the
amitochondriates parasites , Giardia intestinalis, Entamoeba hystolitica and
Trichomonas vaginalis, Int. J. Parasitol ; 33:235-255.
· Van Der Pol, B.(2006). Use of an adaptation of a commercially available PCR assay aimed at
diagnosis of Chlamydia and gonorrhea to detect Trichomonas vaginalis in urogenital
specimens, J. Clin. Microbiol.; 44:366-373.
· Van Der Pol, B.(2007). Trichomonas vaginalis Infection: The Most Prevalent Nonviral
Sexually Transmitted Infection Receives the Least Public Health Attention, Clin.
Infect. Dis.; 44:23–25.
· Van Der Pol, B. (2011). Changing sexually transmitted infection screening protocol will
result in improved case finding for Trichomonas vaginalis among high-risk female
populations, Sex. Transm. Dis. ; 38(5):398-400.
101
References
· Vandyck , E.; Mehens , A .Z. and Plot ,P .(1999).Trichomoniasis , In:laboratory diagnosis of
sexual transmitted disease. WHO, Genever.
· Viscogliosi, E.; Edgcomb, V. P.; Gerbod, D.; Noel, C. and Delgado-Viscogliosi, P.(1999).
Molecular evolution inferred from small subunit rRNA sequences: what does it tell us
about phylogenetic relationships and taxonomy of the parabasalids, Parasite ;6:279291.
· Vliet E.L. (2002).Menopause and perimenopause: The role of ovarian hormones in common
neuroendocrine syndromes in primary care , Primary Care - Clinics in Office
Practice.;29 (1): 43-67.
· Vorvick, L.J.(2009). Medical director, MEDEX Northwest Division of Physician Assistant
Studies, University of Washington, School of Medicine.
W
· Waters, L.J,; Dave, S.S.; Deayton, J.R.and French, P.D.(2005). Recalcitrant Trichomonas
vaginalis infection a case series, Int. J. STD. AIDS;16:505–509.
· Weart, I. F. and Yang, S. (2006) Detection of Trichomonas
,United States Kimberly-
Clark Worldwide, US.
· Wendel, K.A.; Erbelding, E.J.; Gaydos, C.A. and Rompalo, A.M.(2002). Trichomonas
vaginalis polymerase chain reaction compared with standard diagnostic and
102
References
therapeutic protocols for detection and treatment of vaginal trichomoniasis, Clin.
Infect. Dis.;35(5):576-580.
· Westhoff, C.; Gentile,G.; Lee,J.; Helbig ,D.and Zacur,H.(1996). Predictors of ovarian
steroid secretion in reproductive-age women ,Am. J. Epidemiol. ; 144 (4): 381-388.
· Wiese, W.; Patel, S.R.; Patel, S.C.; Ohl, C.A. and Estrada, C.A.(2000). A meta-analysis of
the Papanicolaou smear and wet-mount for the diagnosis of vaginal trichomoniasis,
Am . J. Med.; 108:301–308.
· Wilkerson, R.G. and Sinert, R. H.(2010). Trichomoniasis in Emergency Medicine:
Differential Diagnoses & Workup, Contributor.
· Workowski, K.A.and Berman, S.M.(2006). Sexually transmitted diseases treatment
guidelines, MMWR Recomm Rep. ;55:2-94.
· World Health Organization (WHO). (2004). Integrating care for reproductive health,
sexually transmitted and other reproductive tract infections; A guide to essential
practice, Morbidity Mortality Weekly Recommendation Report; 51 (RR-2): 1-118.
· World Health Organization.(2010).Global prevalence and incidence of selected curable
sexually transmitted infections.
· Wright, T.C. ; Massad, L.S. ; Dunton, C.J. ; Spitzer, M.; Wilkinson, E.J. and Solomon, D.
(2007).American Society for Colposcopy and Cervical Pathology-sponsored
Consensus Conference. 2006 consensus guidelines for the management of women
with abnormal cervical cancer screening tests, Am. J. Obstet. Gynecol.;197(4):34655.
103
References
Y
· Yadav, M.; Dubey, M. L.; Gupta, I. and Malla, N. (2007).Cysteine proteinase 30 (CP30) and
antibody response to CP30 in serum and vaginal washes of symptomatic and
asymptomatic
Trichomonas
vaginalis-infected
women,
Parasite
Immun.;
29(10): 359–365.
· Yarlett,N. and Hackstein,J. H. P.(2005). Hydrogenosomes: One organelle, multiple origins,
BioScience; 55(8):657-668.
· Yazar,S.;Dagel,H.;Aksoy,U.;Ustun,S.;Aklsu,C.;Ak,M. and Daladal, N.(2002). Frequency of
Trichomonas
vaginalis
among
women
having
vaginal
discharge,In
Izmir
,Turkey.Inonu University Tip fakultesi Dergisi.;9(3):159-161.
· Yereli, K.;Balcioglu,I.C.;Degerli,K.; Ozbilgin,A.and Daldal ,N.(1997) .Incid -ence of
Trichomonas vaginalis among women having vaginal discharge, J .Egypt Soc.
Parasitol. ;27 (3):905-911.
Z
· Zaino, R. J.; Nucci, M. and Kurman, R. J. (2011). Diseases of the vagina ,Trichomonas
vaginalis; In Blausteins pathology of female genital tract ,6 th ed.,springer science
Business media LLC; 116-118.
· Zhang, Z.F.and Begg, C.B.(1994). Is Trichomonas vaginalis a cause of cervical neoplasia?
Results from a combined analysis of 24 studies, Int. J. Epidemiol.; 23(4):682-90.
104
‫ﺍﻟﺨﻼﺻﺔ‬
‫ﺍﻟﺨﻼﺻﺔ‬
‫ﻳﻌﺪ ﻃﻔﻴﻠﻲ ‪ Trichomonas vaginalis Donne,1836‬ﺍﻟﻤﺴﺒﺐ ﺍﻟﻤﺮﺿﻲ ﻟﺪﺍء ﺍﻟﻤﺸﻌﺮﺍﺕ ﺍﻟﻤﻬﺒﻠﻴﺔ‬
‫ﻭﺍﻟﺬﻱ ﻳﻌﺪ ﻣﻦ ﺍﻛﺜﺮ ﺍﻻﻣﺮﺍﺽ ﺍﻟﺠﻨﺴﻴﺔ ﺍﻟﻤﻨﺘﺸﺮﺓ ﻓﻲ ﺍﻟﻌﺎﻟﻢ ‪.‬ﻭﻫﺬﺍ ﺍﻟﻤﺮﺽ ﻳﺴﺒﺐ ﺧﻄﺮ ﺍﻻﺻﺎﺑﺔ ﺑﺎﻟﺘﻬﺎﺏ ﻋﻨﻖ‬
‫ﺍﻟﺮﺣﻢ ﻭﺍﻟﻤﻬﺒﻞ ﻭﻳﺆﺧﺮ ﻋﻤﻠﻴﺔ ﺍﻟﺤﻤﻞ‪ ،‬ﻭﻣﻦ ﻣﻀﺎﻋﻔﺎﺗﻪ ﺍﻧﺨﻔﺎﺽ ﻭﺯﻥ ﺍﻷﺟﻨﺔ ﻋﻨﺪ ﺍﻟﻮﻻﺩﺓ‪ ،‬ﻭ ﺣﺪﻭﺙ ﺇﺟﻬﺎﺽ‬
‫ﻣﺴﺘﻤﺮﻭﻗﺪ ﺗﺆﺩﻱ ﺍﻻﺻﺎﺑﻪ ﺑﻪ ﺍﻟﻰ ﺍﺳﺘﺌﺼﺎﻝ ﻟﻠﺮﺣﻢ ‪.‬ﻳﻌﺘﺒﺮ ﻫﺬﺍ ﺍﻟﻄﻔﻴﻞﻱ ﻋﺎﻣﻞ ﻣﺴﺎﻋﺪ ﻓﻲ ﺇﻧﺘﺸﺎﺭ ﻓﻴﺮﻭﺱ‬
‫ﻱ‪.‬‬
‫ﻣﺮﺽ ﻧﻘﺺ ﺍﻟﻤﻨﺎﻋﺔ)‪ ،(HIV‬ﻟﺬﻟﻚ ﺍﻟﺘﺸﺨﻴﺺ ﺍﻟﺪﻗﻴﻖ ﻭﺍﻟﻔﻌﺎﻝ ﻓﻲ ﻏﺎﻳﺔ ‪.‬ﺍﻻﻫﻢ ﺓ‬
‫ﻭﻗﺪ ﺃﺟﺮﻳﺖ ﻫﺬﻩ ﺍﻟﺪﺭﺍﺳﺔ ﺧﻼﻝ ﺍﻟﻔﺘﺮﺓ ﻣﻦ ﺗﺸﺮﻳﻦ ﺍﻟﺜﺎﻧﻲ ‪ 2010‬ﻭﻟﻐﺎﻳﺔ ﻧﻴﺴﺎﻥ ‪ 2011‬ﻟﻤﻘﺎﺭﻧﺔ ﺍﺳﺘﺨﺪﺍﻡ ﺍﻝﻧﻈﺎﻡ‬
‫ﺍﻟﺘﺸﺨﻴﺼﻲ ﺍﻟﺠﺪﻳﺪ‪،‬‬
‫‪ In_pouch TV system‬ﻋﻦ ﺍﺳﺘﺨﺪﺍﻡ ﻃﺮﻕ ﺍﻟﺘﺸﺨﻴﺺ ﺍﻟﻜﻼﺳﻴﻜﻴﺔ ﺍﻟﻤﺨﺘﻠﻔﺔ‬
‫ﺍﻟﻤﺴﺘﺨﺪﻣﺔ ﻓﻲ ﺍﻟﻌﺮﺍﻕ ‪ ،‬ﻭﻗﻴﻤﺖ ﺍﻷﺧﻴﺮﺓ ﺍﻧﺘﺸﺎﺭ ﺩﺍء ﺍﻟﻤﺸﻌﺮﺍﺕ ﻭﻓﻘﺎ ﻟﺪﺭﺍﺳﺔ ﺍﻟﻌﻮﺍﻣﻞ ﺍﻟﻤﺨﺘﻠﻔﺔ ﺍﻟﺘﻲ ﺗﺆﺛﺮ‬
‫ﻋﻠﻰ ﺩﺍء ﺍﻟﻤﺸﻌﺮﺍﺕ ﺍﻟﻤﻬﺒﻠﻴﺔ ﻓﻲ ﺍﻹﻧﺎﺙ ﺍﻻﺗﻲ ﻋﺎﻧﻴﻦ ﻣﻦ ﺍﻹﻓﺮﺍﺯﺍﺕ ﺍﻟﻤﻬﺒﻠﻴﺔ‬
‫‪.‬ﻭﻗﺪ ﺟﻤﻌﺖ ﻣﺴﺤﺎﺕ ﻣﻬﺒﻠﻴﺔ‬
‫ﻭﻋﻴﻨﺎﺕ ﺍﻻﺩﺭﺍﺭ ﻣﻦ ‪ 200‬ﺍﻣﺮﺃﺓ ﻋﺎﻧﺖ ﺍﻹﻓﺮﺍﺯﺍﺕ ﺍﻟﻤﻬﺒﻠﻴﺔ ﻓﻲ ﻣﺴﺘﺸﻔﻰ ﺍﻟﻴﺮﻣﻮﻙ ﻭﺍﻟﻤﺮﻛﺰ ﺍﻟﺘﺪﺭﻳﺒﻲ ﺍﻟﺘﺎﺑﻊ‬
‫ﻟﻤﺴﺘﺸﻔﻰ ﺍﻟﻨﻮﺭ ﻭﻋﻴﺎﺩﺓ ﻧﺴﺎﺋﻴﺔ ﺧﺎﺻﺔ ﻓﻲ ﻣﺪﻳﻨﻪ ﺍﻟﺸﻌﻠﺔ ‪ ،‬ﺗﺮﺍﻭﺣﺖ ﺃﻋﻤﺎﺭﻫﻦ ﻣﺎﺑﻴﻦ ‪ 55-16‬ﻋﺎﻣﺎ ‪ .‬ﺍﻟﻤﺴﺤﺎﺕ‬
‫ﺍﻟﻤﻬﺒﻠﻴﺔ ﺗﻢ ﻓﺤﺼﻬﺎ ﺑﻮﺍﺳﻄﻪ ) ‪(wet mount‬ﻭﺗﻢ ﺯﺭﻋﻬﺎ ﻓﻲ ﻋﺪﻩ ﺍﻭﺳﺎﻁ‪In-Pouch TVsystem‬‬
‫‪ OLM culture‬ﻭ‪ Modified CPLM‬ﻟﻠﻜﺸﻒ ﻋﻦ ﻭﺟﻮﺩ ﺍﻟﻄﻔﻴﻠﻲ ‪ Trichomonas vaginalis‬ﺑﻴﻨﻤﺎ‬
‫ﺗﻢ ﺍﺳﺘﺨﺪﺍﻡ ﺍﺧﺘﺒﺎﺭ ﺍﻷﺱ ﺍﻟﻬﻴﺪﺭﻭﺟﻴﻨﻲ ﻭ‪whiff test‬ﻛﺸﻒ ﻋﻦ ﺍﻱ ﺗﻐﻴﺮﻓﻲ ﺍﻻﺱ ﺍﻟﻬﻴﺪﺭﻭﺟﻴﻨﻲ ﻭ ﺭﺍﺋﺤﻪ‬
‫ﺍﻟﻤﻬﺒﻞ ﺍﻣﺎ ﺍﻻﺩﺭﺍﺭ ﻓﻘﺪ ﺗﻢ ﻓﺤﺼﻪ ﺑﺎﺳﺘﺨﺪﺍﻡ ‪ Urine Exam‬ﻟﻠﻜﺸﻒ ﻋﻦ ﻭﺟﻮﺩ ﺍﻟﻄﻔﻴﻠﻲ ‪.‬‬
‫ﻭﻛﺎﻧﺖ ﺍﻟﻨﺘﺎﺋﺞ ﻛﻤﺎ ﻳﻠﻲ ‪:‬‬
‫· ﺷﻜﻠﺖ ﻧﺴﺒﺔ ﺍﻟﻨﺴﺎء ﺍﻟﻤﺼﺎﺑﺎﺕ ﺑﻄﻔﻴﻠﻲ ﺍﻟﻤﺸﻌﺮﺍﺕ ﺍﻟﻤﻬﺒﻠﻴﺔ‬
‫‪ 42 ) ٪21‬ﻣﺮﻳﻀﺔ( ﻣﻦ ﺍﺻﻞ ‪200‬‬
‫ﺍﻣﺮﺃﺓ ﻋﺎﻧﻴﻦ ﻣﻦ ﺃﻓﺮﺍﺯﺍﺕ ﻣﻬﺒﻠﻴﺔ ﻏﻴﺮ ﻃﺒﻴﻌﻴﺔ‪.‬‬
‫· ﻭﺟﺪ ﺍﻥ‬
‫‪ In-pouch TV system‬ﺫﻭ ﻛﻔﺎءﻩ ﻋﺎﻟﻴﺔ ﻓﻲ ﺍﻟﻜﺸﻒ ﻋﻦ ﺍﻟﻄﻔﻴﻠﻲ ﻣﻘﺎﺭﻧﻪ ﺑﺎﻟﻄﺮﻕ‬
‫ﺍﻻﺧﺮﻯ ﺍﻟﻤﺴﺘﺨﺪﻣﻪ ﻓﻲ ﻫﺬﻩ ﺍﻟﺪﺭﺍﺳﺔ ﻓﻘﺪ ﻭﺟﺪ ﺍﻧﻪ ﻳﻤﻠﻚ ﺍﻋﻠﻰ ﻗﻴﻤﻪ ﻟﻠﺤﺴﺎﺳﻴﺔ ﻭﺩﻗﻪ ﺍﻟﺘﺸﺨﻴﺺ‬
‫‪.٪100‬‬
‫· ﻛﺎﻧﺖ ﻧﺴﺒﺔ ﺍﻧﺘﺸﺎﺭ ﺍﻟﻤﺸﻌﺮﺍﺕ ﺍﻟﻤﻬﺒﻠﻴﺔ ﻓﻲ ﺍﻟﻔﺌﺔ ﺍﻟﻌﻤﺮﻳﺔ‬
‫‪25-16‬ﺳﻨﻪ )‪ (٪ 29.5‬ﺍﻋﻠﻰ ﺑﻜﺜﻴﺮ ﻣﻦ‬
‫ﻣﻌﺪﻝ ﺍﻧﺘﺸﺎﺭﻩ ﻓﻲ ﺍﻟﻔﺌﺎﺕ ﺍﻟﻌﻤﺮﻳﺔ ﺍﻻﺧﺮﻯ‪.‬‬
‫· ﻟﻘﺪ ﻭﺟﺪ ﺍﻥ ﻧﺴﺒﺔ ﺍﻧﺘﺸﺎﺭ ﺍﻟﻄﻔﻴﻠﻲ ﺿﻤﻦ ﺍﻟﻨﺴﺎء ﺍﻟﻤﺘﺰﻭﺟﺎﺕ )‪(٪ 25.8‬ﺍﻋﻠﻰ ﻧﺴﺒﺔ ﺍﻣﺎ ﺍﻻﺭﺍﻣﻞ ﻓﻘﺪ‬
‫ﺍﻣﺘﻠﻜﻦ ﺍﻗﻞ ﻧﺴﺒﺔ )‪.(٪ 6.1‬‬
‫ﺍﻟﺨﻼﺻﺔ‬
‫· ﻭﺟﺪ ﺍﻥ ﻟﻠﻨﺴﺎء ﺍﻟﻤﺘﻌﻠﻤﺎﺕ ﺃﻋﻠﻰ ﻣﻌﺪﻝ ﻣﻦ ﺍﻻﺻﺎﺑﺔ ) ‪ (٪ 32.6‬ﺍﻣﺎ ﺍﻟﻨﺴﺎء ﻏﻴﺮ ﺍﻝﻣﺘﻌﻠﻤﺎﺕ ﻓﻘﺪ ﻛﺎﻧﺖ‬
‫ﻧﺴﺒﺔ ﺍﻻﺻﺎﺑﺔ)‪.(٪ 11.1‬‬
‫· ﻛﺎﻧﺖ ﺍﻟﻨﺴﺎءﺫﺍﺕ ﺍﻟﻮﻻﺩﻩ ﺍﻟﻤﺘﻜﺮﺭﺓ ﺫﺍﺕ ﺍﻋﻠﻰ ﻧﺴﺒﺔ ﻣﻦ ﺍﻻﺻﺎﺑﺔ ) ‪ (٪ 21.8‬ﻳﻠﻴﻬﺎ ﺍﻟﻔﺌﺔ ﺑﻜﺮﻳﺔ ) ‪17.9‬‬
‫‪ (٪‬ﻭﺃﺧﻴﺮﺍ ﻣﺠﻤﻮﻋﺔ ﺍﻟﻤﺼﺎﺑﺔ ﺑﺎﻟﻌﻘﻢ )‪. (٪ 15‬‬
‫· ﻭﺟﺪ ﺍﻥ ﺍﻟﻨﺴﺎء ﺫﺍﺕ ﺍﻻﺱ ﺍﻟﻬﺪﺭﻭﺟﻴﻨﻲ ‪ 6‬ﻭ ‪ 5.5‬ﻭ ‪ 5‬ﺍﻣﺘﻠﻜﻦ ﺍﻋﻠﻰ ﻧﺴﺒﺔ ﻣﻦ ﺍﻻﺻﺎﺑﺔ ) ‪ ٪63.1‬ﻭ‬
‫‪٪ 32.1‬ﻭ ‪ (٪44.4‬ﻋﻠﻰ ﺍﻟﺘﻮﺍﻟﻲ‪.‬‬
‫· ﻭﻭﺟﺪ ﺍﻥ ﺍﻟﻨﺴﺎء ﺍ ﻝﻻﺗﻲ ﺍﺳﺘﺨﺪﻣﻦ ﻭﺳﺎﺋﻞ ﻣﻨﻊ ﺍﻟﺤﻤﻞ ﺍﻣﺘﻠﻜﻦ ﺃﻋﻠﻰ ﻣﻌﺪﻝ ﻟﻺﺻﺎﺑﺔ ) ‪ (٪ 54.7‬ﻣﻦ‬
‫ﺍﻟﻨﺴﺎء ﺍﻻﺗﻲ ﻻ ﻳﺴﺘﺨﺪﻣﻦ ﺍﻱ ﻭﺳﻴﻠﺔ ﻟﻤﻨﻊ ﺍﻟﺤﻤﻞ‪.‬‬
‫· ﺍﻟﻨﺴﺎء ﺍ ﻝﻻﺗﻲ ﻟﻢ ﻳﻌﺎﻧﻴﻦ ﻣﻦ ﺍﻱ ﻋﻼﻣﺎﺕ ﺳﺮﻳﺮﻳﺔ ﺍﻣﺘﻠﻜﻦ ﺍﻋﻠﻰ ﻧﺴﺒﺔ ﻟﻼﺻﺎﺑﺔ ‪ (٪ 80.9)34‬ﺍﻣﺎ‬
‫ﺍﻟﻨﺴﺎء ﻣﻊ ﻭﺟﻮﺩ ﻋﻼﻣﺎﺕ ﺳﺮﻳﺮﻳﺔ) ‪ (vaginal erthrema and vulval erthema‬ﻓﻘﺪ ﻛﺎﻧﺖ‬
‫ﻧﺴﺒﺔ ﺍﻻﺻﺎﺑﺔ‪( ٪11.9) 5‬ﻭ‪. (٪ 7.1)3‬‬
‫· ﻭﺟﺪ ﺍﻥ ﺍﻟﻨﺴﺎء ﺍﻻﺗﻲ ﻋﺎﻧﻴﻦ ﻣﻦ ﺍﻓﺮﺍﺯﺍﺕ ﺻﻔﺮﺍء ﺍﻣﺘﻠﻜﻦ ﺍﻋﻠﻰ ﻧﺴﺒﺔ ﻣﻦ ﺍﻻﺻﺎﺑﺔ ‪(57.1%)24‬‬
‫ﻣﻦ ﺍﻟﻨﺴﺎء ﻣﻊ ﺍﻓﺮﺍﺯﺍﺕ ﺫﺍﺕ ﻟﻮﻥ ﺍﺑﻴﺾ ﻭﺍﻓﺮﺍﺯﺍﺕ ﻋﺪﻳﻤﺔ ﺍﻟﻠﻮﻥ‪.‬‬
‫· ﺍﻟﻨﺴﺎء ﻣﻊ ﻭﺟﻮﺩ ﺍﻓﺮﺍﺯﺍﺕ ﻭﺣﻜﻪ ﻛﺎﻧﺖ ﺫﺍﺕ ﺍﻋﻠﻰ ﻧﺴﺒﺔ ﻣﻦ ﺍﻻﺻﺎﺑﺔ ‪ (33.3%) 14‬ﻣﻦ ﻏﻴﺮﻫﺎ ﻣﻦ‬
‫ﺍﻹﻋﺮﺍﺽ ﺍﻟﺴﺮﻳﺮﻳﺔ‪.‬‬
‫· ﺇﻥ ﻧﺴﺒﺔ ﺍﻟﻨﺴﺎء ﻣﻊ ﺍﻓﺮﺍﺯﺍﺕ ﺫﺍﺕ ﺭﺍﺋﺤﺔ ﻛﺮﻳﻬﺔ ﻛﺎﻧﺖ ﺃﻋﻠﻰ ) ‪ (76.2%‬ﻣﻦ ﺍﻟﻨﺴﺎء ﻣﻊ ﺍﻓﺮﺍﺯﺍﺕ‬
‫ﻋﺪﻳﻤﺔ ﺍﻟﺮﺍﺋﺤﺔ ‪.‬‬