STI and Vaginitis Case Analysis: Trichomoniasis Diagnosis, CDC Treatment, Partner Management and Follow-Up (A.B., 28)
6 min read STI and Vaginitis Case Analysis: A.B., 28-year-old female
A.B. is a 28-year-old G0P0 African American woman with 7 days of vaginal itching, dysuria, dyspareunia and thin, yellow-green, foul-smelling discharge. She has had two male partners in the past 3 months with inconsistent condom use, her last STI screening was over a year ago, and OTC miconazole did not help. History: LMP 2 weeks ago, combined oral contraceptive, chlamydia treated at age 22, no chronic conditions or allergies. Exam: afebrile, mild vulvar erythema, thin frothy yellow-green discharge, mildly erythematous friable cervix and mild cervical motion tenderness. Diagnostics: vaginal pH 6.0; wet mount with motile trichomonads and increased WBCs; NAAT positive for Trichomonas vaginalis; negative urinalysis and pregnancy test.
- Identify the most likely diagnosis and two differential diagnoses.
- Explain which clinical findings support the primary diagnosis.
- Outline evidence-based treatment according to current CDC guidelines.
- Describe appropriate patient education and partner management.
- Identify recommended follow-up and rescreening.
2 to 3 pages with at least two current scholarly sources, five sentences per paragraph and current APA format with DOIs.
NAAT positive, motile trichomonads, pH above 4.5
Metronidazole 500 mg orally twice daily for 7 days
Treat partners; abstain until all are treated
Retest within 3 months; test for other STIs
Model case analysis
Original example for study purposes (about 620 words). Each paragraph has five sentences, as the assignment requires. Write your submission in your own words.
Primary and Differential Diagnoses
The most likely diagnosis for A.B. is trichomoniasis caused by Trichomonas vaginalis, with associated cervicitis. Trichomoniasis is the most common nonviral sexually transmitted infection in the United States, and it often presents with malodorous discharge and genital irritation in women (Workowski et al., 2021). The first differential diagnosis is bacterial vaginosis, which also causes thin, malodorous discharge and an elevated vaginal pH. The second differential diagnosis is cervicitis or early pelvic inflammatory disease caused by Chlamydia trachomatis or Neisseria gonorrhoeae, given her friable cervix, mild cervical motion tenderness, multiple partners and history of chlamydia. Vulvovaginal candidiasis is less likely because her discharge is not thick and white, her pH is elevated and OTC miconazole provided no relief.
Findings Supporting the Primary Diagnosis
Several subjective and objective findings support trichomoniasis. A.B. reports thin, yellow-green, foul-smelling discharge along with itching, dysuria and dyspareunia, which are classic symptoms. On examination, she has frothy yellow-green discharge, and her cervix is erythematous and friable, which can reflect the punctate hemorrhages sometimes called “strawberry cervix.” Her vaginal pH of 6.0 is above the normal range of 3.8 to 4.5, which is typical of trichomoniasis and bacterial vaginosis but not candidiasis. Most importantly, the wet mount shows motile trichomonads with increased white blood cells, and the NAAT, the most sensitive and specific test, is positive for T. vaginalis (Workowski et al., 2021).
Evidence-Based Treatment
According to the CDC’s 2021 STI treatment guidelines, the recommended regimen for women is metronidazole 500 mg orally twice daily for 7 days (Workowski et al., 2021). This multidose regimen replaced the former 2 g single dose for women after a randomized trial found that the 7-day course produced significantly fewer treatment failures than the single dose (Kissinger et al., 2018). The alternative regimen is tinidazole 2 g orally in a single dose, while men are treated with metronidazole 2 g orally as a single dose. Because A.B. has cervical motion tenderness and a friable cervix, the provider should await her gonorrhea and chlamydia NAAT results and consider presumptive treatment for cervicitis or PID if clinical criteria are met. Her combined oral contraceptive can be continued, and the 2021 guidelines no longer recommend abstaining from alcohol during metronidazole treatment.
Patient Education and Partner Management
Patient education should explain that trichomoniasis is a common, curable STI and that taking every dose for the full 7 days is essential even if symptoms improve. A.B. should abstain from sexual intercourse until she and her partners have completed treatment and their symptoms have resolved, which helps prevent reinfection. Both of her recent sexual partners should be notified, evaluated and treated, and expedited partner therapy may be used where state law permits (Workowski et al., 2021). She should be counseled on consistent condom use, the increased risk of HIV acquisition associated with trichomoniasis and the importance of regular STI screening. Education should be nonjudgmental, culturally respectful and delivered in plain language, with written instructions and time for her questions.
Follow-Up and Rescreening
Because reinfection rates are high, the CDC recommends retesting all sexually active women treated for trichomoniasis within 3 months after treatment (Workowski et al., 2021). NAAT can be used for retesting, but testing too soon after treatment may detect residual nucleic acid rather than active infection, so it should not be performed earlier than 2 weeks after treatment. A.B. should also be tested for other STIs, including gonorrhea, chlamydia, syphilis and HIV, because a trichomoniasis diagnosis indicates exposure risk. If her symptoms persist after treatment and reinfection is excluded, the provider should evaluate for possible metronidazole resistance and follow CDC guidance for persistent infection. Finally, she should continue routine STI screening at least annually, or more often based on new partners and risk behaviors.
References
Kissinger, P., Muzny, C. A., Mena, L. A., Lillis, R. A., Schwebke, J. R., Beauchamps, L., Taylor, S. N., Schmidt, N., Myers, L., Augostini, P., Secor, W. E., Bradic, M., Carlton, J. M., & Martin, D. H. (2018). Single-dose versus 7-day-dose metronidazole for the treatment of trichomoniasis in women: An open-label, randomised controlled trial. The Lancet Infectious Diseases, 18(11), 1251–1259. https://doi.org/10.1016/S1473-3099(18)30423-7
Workowski, K. A., Bachmann, L. H., Chan, P. A., Johnston, C. M., Muzny, C. A., Park, I., Reno, H., Zenilman, J. M., & Bolan, G. A. (2021). Sexually transmitted infections treatment guidelines, 2021. MMWR Recommendations and Reports, 70(4), 1–187. https://doi.org/10.15585/mmwr.rr7004a1
[Your advanced health assessment or women’s health textbook, in APA format.]
Before you submit: paraphrase in your own words, add a title page and check the CDC website for any updates to the STI treatment guidelines published after 2021.
Frequently asked questions
Why did the CDC change trichomoniasis treatment for women?
A randomized trial found that a 7-day metronidazole course led to fewer treatment failures than a single 2 g dose in women, so the 2021 guidelines recommend the 7-day regimen.
Why retest within 3 months?
Reinfection is common, often from untreated partners, so the CDC recommends retesting sexually active women within 3 months of treatment.
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