TV

Question 1

Describe the organism of TV

Answer 1

Flagellated protozoon

Question 2

where is TV found most commonly in ;-

a) women
b) men

Answer 2

a) urethra, vagina, paraurethral glands

b) urethra

Question 3

what percentage of women and men can be asymptomatic with TV infection

Answer 3

up to 50% can be asymptomatic

most men present as contacts of women with confirmed TV

Question 4

what are the most common symptoms of TV in men and women

Answer 4

Women: change and an increase to vaginal discharge, can be thin or scanty or yellow and thick, often with an odour, a/s with dysuria or itching
rarely women have lower abdominal pain or vaginal ulceration

men: often asymptomatic, or urethral discharge +/- dysuria

Question 5

in what percentage of women with confirmed TV will you observe a ‘strawberry cervix’

Answer 5

up to 2% of patients

Question 6

list the complications that can result from TV during pregnancy or at the time of vaginal delivery

Answer 6

pre-term birth
low birth weight
if TV present at the time of delivery can increase the risk of maternal postpartum sepsis

Question 7

We screen for TV in asymptomatic men and women: true or false

Answer 7

false we do not screen for TV

• we only test women who are symptomatic for TV
• it is recommended on BASHH guidance that men who are contacts of TV should be tested and men presenting with persistent urethritis but this does not routinely happen due to a lack of TV testing availability within the UK

Question 8

When is it recommend to test for TV in;

a) women
b) men

Answer 8

A) women presenting with change to vaginal discharge i.e. symptomatic or evidence of vulvitis or vaginitis on examination
b) men - who are contacts of TV or with persistent urethritis

Question 9

what is the first line treatment option for TV in men and women

Answer 9

metronidazole 2g stat or metronidazole 400-500mg BD for 5-7 days or tinidazole 2 gram stat

Question 10

what is an alternative option first line if metronidazole is not suitable for treatment of TV?

Answer 10

tinidazole 2 gram stat

Question 11

Marie was treated 3 weeks ago with metronidazole 500mg BD for 7 days by her GP for confirmed TV. Her partner was treated and they abstained from sex. She does not feel her symptoms have improved. What treatment would you offer her now?

Answer 11

Repeat treatment with metronidazole 500mg BD for 7 days, abstain from sex for 1 week once Rx completed and partner also Rx and symptoms resolve

Question 12

When treating patients with metronidazole or tinidazole what do you need to warn them about?

Answer 12

advised them to avoid alcohol for the duration of treatment and for metronidazole 48 hours after completion and tinidazole 72 hours after completion of treatment in case of a disulfiram-like reaction.

Question 13

Maria was treated initially for TV with 2 gram stat dose of metronidazole, she returned 3 weeks later with persistent symptoms and so you re-treated with metronidazole 500mg BD for 7 days and also re-treated her partner. She has not had any sex since the TV was first diagnosed. She has now returned 3 weeks after the repeat treatment with persistent symptoms. Microscopy done on the day demonstrates TV.
What treatment would you offer her now?

Answer 13

third line treatment: higher dose of a nitroimidazole
Metronidzaole or tinidazole 2 grams OD for 7 days or metronidazole 800mg TDS for 7 days

(note for those that fail to respond to second course of treatment, 70% responded to a higher course of metronidazole)

Question 14

at what point in treatment failure should you consider doing resistance testing to metronidazole?

Answer 14

If patients fail second line treatment (high dose nitroimidazole)

Note if resistance testing not available treat with high dose tinidazole as a study suggested that of those who fail second line treatment 65% of those did not have tinidazole resistance and 83% of those receiving the recommended high dose treatment were cured compared to 57% of women receiving a lower than recommended dose.

Question 15

Marie returns after now completing metronidazole 2g OD for 7 days with persistence symptoms and repeat microscopy shows TV. She is very fed up. We don’t have resistance testing available in the clinic. What treatment should you offer her?

Answer 15

Very high dose course of tinidazole -

tinidazole 1g BD or TDS or 2G BD for 14 days (PO) +/- intravagainl tinidazole 500mg BD for 14 days

Question 16

what percentage of patients who have failed other treatments does high dose tinidazole cure TV?

Answer 16

90-92% responded to a very high dose course of tinidazole

Question 17

what would you recommend if a patient fails high dose tinidazole? (i.e. 1g tds or 1 gram bd or 2gram bd for 14 days +/- intravaginal tinidazole 500mg BD)

Answer 17

it is hard to recommend one specific further trreatment as evidence supporting them is limited and they can cause vulvar irritation. the largest published case reports are on intravaginal furazolidone and intravaginal paromomycin. 
options include: 
1. Intravaginal paromomycin 
2. intravaginal furazolidone 
3. Acetarsol pessaries 
4. 6% nonoxynol-9 pessaries

Question 18

is TOC recommended for TV

Answer 18

no - TOC is not recommended for TV, TOC is only recommended if patients remain symptomatic or symptoms recrur.

Question 19

what is the look back period for PN in TV management

Answer 19

4 weeks look back period