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Trichomoniasis of the Genito-Urinary System
Medical Clinics of North America January, 1937. Chicago Number
CLINIC OF DR. NORRIS
J. HECKEL
PRESBYTERIAN HOSPITAL
TRICHOMONIASIS OF THE GENITO-URINARY SYSTEM
vaginalis infestation of the male genital tract is now being recognized with greater frequency, and we observe that Trichomonas prostatitis is no more such a rare condition. Recently, it has also been observed that Trichomonas vaginitis in the female may cause associated pathologic changes in the bladder and urethra. To illustrate some of the more important findings in my studies on Trichomonas vaginalis, as found in the genitourinary system, I am presenting these patients. TRICHOMONAS
, Case I. Trichomonas Prostatitis.-Mr. B., age fifty-one and married, is referred to me in order to determine if the prostate gland may not be the cause of recurrent attacks of Trichomonas vaginitis in his wife. Except for a slight urethral discharge and occasional nocturia, this patient has no other urinary co'mplaints. The examination of the external genitalia reveals a very small external meatus from which a white mucoid discharge is obtained. The rectal examination shows the prostate to be slightly enlarged, especially in the left lobe with evidence of periprostatitis; the right lobe is normal. The microscopic examination of the urethral smear reveals no Trichomonas, however, in the prostatic fluid Trichomonas and 2+ pus are found. , The urine is normal with the exception of a few pus cells, no Trichomonas are present. Stained Smears from the urethra and prostatic fluid reveal no intracellular nor extr~ cellular diplococci. On exploring the urethra with diagnostic 31 9
3 20
NORRIS
J.
HECKEL
sounds, extensive multiple strictures are foound. Therefore, we can definitely say that this patient has Trichomonas prostatitis and strictures of the urethra. Our technic in searching for Trichomonas is very simple. The prostatic fluid or urethral discharge is collected directly on a glass slide and spread not too thick. An ordinary cover slip is placed over the material and an oil immersion lens is used for observation. For office routine this procedure takes little time and, in our opinion, has been just as accurate as the hanging drop, or other more elaborate methods. One examination is not sufficient to rule out the possibility of Trichomonas. Searches on several different occasions should be made before a negative diagnosis is given. In the treatment of this patient a ,meatotomy is first done. Then he is given prostatic massages and urethral sounds twice a week, and heat, either in the form of diathermy or an electrical heater, applied to the prostate. Urethral instillations of 20 per cent neosilvol, or irrigations of potassium permanganate, 1: 3000, are used. This procedure is carried out until the prostatic fluid is free of Trichomonas and pus cells. In the prostate and urethra the Trichomonas usually disappear early, that is one or two weeks after the treatment has begun. However, the pus cells and other bacteria, usually streptococci, may. be ,present for as long as three or four months, and it is important to continue treatment regularly until the prostate is entirely normal. In a problem such as this, an attempt should be made to establish the primary source of the infestation if possible and thereby recognize the factors which may predispose to recurrences. In this particular patient, it is apparent since he and his wife are both infested that one may be reinfecting the other. Unquestionably, in such cases, the reinfestation is by sexual intercourse, and if either the male or female is cured, and no attempt made to search for the possibility of infestation in the other, then recurrent attacks can and do occur. Therefore, in this instance, we will advise against sexual intercourse during '" sll'th time as the vaginitis, urethritis, or prostatitis is active.
TRICHOMONIASIS OF GENITO-URINARY SYSTEM
321
In my second case, the opposite picture is present-the wife is not infested with Trichomonas.
Case 11. Trichomonas Urethritis and Prostatitis.-
This patient is forty-nine years old, married, and presents himself complaining of urethral discharge and burning of five days' duration. He fears the return of an old gonorrheal uretliritis. Extramarital exposure is denied.
Fig. 23.-Prostatic fluid showing pus cells and Trichomonas .
.The examination, as you see, reveals a copious amount of frothy, milky urethral discharge. The meatus is red. A small . amount of the discharge is placed on a slide and examined-it is filled with Trichomonas. The ·rectal examination shows the prostate to be normal; however, the prostatic fluid contains many Trichomonas and pus cells (Fig. 23). Therefore, the diagnosis is an acute Trichomonas urethritis and prostatitis. The treatment of this patient will be very similar to the procedure followed for the first patient, except that during VOL. 21-2I
3 22
NORRIS
J.
HECKEL
the hyperacute stage, which is usually three to six days, he will be given only sitz baths and alkalis such as bicarbonate of soda, or potassium citrate. When the acuteness of the attack subsides, then urethral instillations and prostatic massages will be carried out. ~any times it is difficult to evaluate in what way the infection occurred. In an effort to determine the origin of the infestation, the patient's wife has been examined and repeatedly the smears show no evidence of Trichomonas. During the last few years, I have seen 5 cases of Trichomonas prostatitis. I have also had the opportunity to examine many husbands whose wives are infested with Trichomonas and it is surprising to find that a large number, although no Trichomonas can be found, do have an infected prostate, and in the culture from the prostatic fluid streptococci are usually found. According to some authors, these findings would be explained by the fact that the Trichomonas vaginalis itself is not pathogenic but occurs only as a secondary invader or in symbiosis. Those who hold this belief are of the opinion that the streptococcus is the pathogenic organism. The majority of these men presented no genito-urinary symptoms, and had not an examination been made, the infection would not have been recognized. Usually the symptoms of Trichomonas prostatitis are the same as those of a nonspecific prostatitis; that is, a persistent urethral discharge and morning drop, associated with other various genito-urinary complaints. The condition, however, may start as an acute urethritis in which the discharge has a frothy, bubbly appearance, burning and frequency of urination, and an itching or smarting of the urethra may be present. I have not as yet seen a patient with a Trichomonas urethritis, who did not also have an associated prostatitis. In the rectal examination, the prostate may be entirely normal in size, shape and consistency, or there may be areas of hardness and infiltration. It is never tender nor swollen as in acute gonorrheal prostatitis. In venereal infections those having nonspecific urethritis and . ,prostatitis are not a small number, and if more careful bacterio-
TRICHOMONIASIS OF GENITO-URINARY SYSTEM
323
logical examinations are made, I am sure that in a larger percentage of the cases Trichomonas infestation will be found. My third case is that of a woman with recurrent Trichomonas vaginitis in whom the urinary symptoms are pronounced.
Case Ill.
Recurrent Trichomonas Vaginitis.-Mrs.
H., aged forty, has been treated elsewhere during the past six months for recurrent attacks of Trichomonas vaginitis. These attacks have been accompanied by aggravating urinary symp. toms of frequency every two or three hours, nocturia four or five times, with burning and dysuria. Here I should like to stress the importance of obtaining a careful and accurate history. Because of the severe vaginal symptoms of leukorrhea, scalding, and dyspareunia which frequently occur in these patients, definite questions must be asked in order to elicit information concerning the urinary complaints. This patient has had a complete and thorough examination of the gastro-intestinal tract, teeth, tonsils, Bartholin and Shne glands as a possible focus for the recurrent vaginitis attacks, and all are negative. In the bacteriological study of the cultures taken from the vagina and cervix, streptococci have been found. I might also add that the same strain of streptococci has been cultured from the prostatic fluid of her husband, who, although no Trichomonas have been found, does have an infected prostate. Because of the patient's urinary symptoms a cysto-urethroscopic examination is done. The urine, as you see, is clear and sparkling and a specimen is collected for bacteriological study. Your attention is called to the normal capacity of the bladder. This is an important observation to be used in the differential diagnosis from elusive ulcer in which the bladder capacity is greatly diminished. The pathologic changes are seen on the base of the bladder in the region of, and anterior ,to the trigone. In some cases these changes may extend beyond the trigone and involve both the ureteral orifices; in others may be limited to the internal urethral sphincter. Observe the raised, granular, fluffy and
NORRIS
J.
HECKEL
crepelike appearance of the bladder mucosa. It is a dull, pearly gray, and resembles somewhat the appearance of leukoplakia. The borders of this area can be sharply outlined from the normal mucous membrane. Notice. the small petechial hemorrhages around this region which appear very similar to the surface of a strawberry. These changes look similar to those found in the vaginal vault of many patients with Trichomonas vaginitis. As the cysto-urethroscope is withdrawn into the urethra, note the marked edema around the internal urethral orifice, and the pronounced changes similar to those in the bladder. This cystoscopic picture is seen quite frequently in Trichomonas vaginitis and I feel that in patients who complain of lower urinary symptoms, if these findings are observed, a careful search of the vagina should be made for Trichomonas. In summarizing the condition of this patient, we find two possibilities for the recurrent attacks of the vaginitis. First, although Trichomonas were not found in the prostatic fluid of the husband, he did have an infected prostate and the same strain of streptococci was isolated from the prostate as was found in the vagina and cervix of the wife. He, therefore, may be the cause of his wife's recurrent attacks. Second, the cause may be found in the pathology of the urethra and the bladder. I have seen patients in whom, after the associated pathology in the urethra and bladder was cleared up, there have been no more recurrent attacks. In the treatment of this patient until the acute condition subsides, we will follow this procedure: she will be given sitz baths, 2 or 3 daily, and internal medication of oil of sandalwood 5 minims, t.i.d., and alkalis such as sodium acetate 20 grains, or bicarbonate of soda-, four times daily. Then the bladder is irrigated with an oxidizing agent such as 1: 3000 solution of potassium permanganate followed by instillation of 2 to 3 ounces of 15 per cent neosilvol, or 20 per cent argyrol, twice a week. At the same time, topical applications to the urethra of 2 per cent silver nitrate solution, or % of 1 per _Fent zinc sulphate are used. If urethral pockets or other per-
TRICHOMONIASIS OF GENITO-URINARY SYSTEM
325
sistent ducts in and about the urethra are present, it may be necessary to fulgurate them. The second part of the treatment will be directed to the husband and the prostatitis treated as previously outlined. CONCLUSIONS
1. Each of the three patients presented to you illustrates an interesting phase of the Trichomonas vaginalis infestation. 2. The first is an example of the infestation probably through sexual intercourse, since both the husband and wife are infested. 3. The second patient illustrates an infested prostate and urethra, but no infestation in the wife. Furthermore, the his. tory and. examination of husband and wife in this instance give no solution as to the source of the infestation. 4. In the third case, which is that of recurrent vaginitis with urinary symptoms, we "find first that while Trichomonas were not found in the prostate gland of the husband, a prostatitis was present, offering a possibility for the cause of the recurrent attacks of vaginitis. Second, the associated changes in the urethra and bladder indicate that the recurrences may be caused by these findings. 5. It cannot be too strongly emphasized that repeated examinations of the urethral discharge or the prostatic fluid must be made in many instances in order to find the Trichomonas. 6. In patients with so-called "nonspecific" urethritis and prostatitis a more careful examination will reveal a higher percentage of Trichomonas infestations.
CLINIC OF DR. NORRIS
J. HECKEL
PRESBYTERIAN HOSPITAL
TRICHOMONIASIS OF THE GENITO-URINARY SYSTEM
vaginalis infestation of the male genital tract is now being recognized with greater frequency, and we observe that Trichomonas prostatitis is no more such a rare condition. Recently, it has also been observed that Trichomonas vaginitis in the female may cause associated pathologic changes in the bladder and urethra. To illustrate some of the more important findings in my studies on Trichomonas vaginalis, as found in the genitourinary system, I am presenting these patients. TRICHOMONAS
, Case I. Trichomonas Prostatitis.-Mr. B., age fifty-one and married, is referred to me in order to determine if the prostate gland may not be the cause of recurrent attacks of Trichomonas vaginitis in his wife. Except for a slight urethral discharge and occasional nocturia, this patient has no other urinary co'mplaints. The examination of the external genitalia reveals a very small external meatus from which a white mucoid discharge is obtained. The rectal examination shows the prostate to be slightly enlarged, especially in the left lobe with evidence of periprostatitis; the right lobe is normal. The microscopic examination of the urethral smear reveals no Trichomonas, however, in the prostatic fluid Trichomonas and 2+ pus are found. , The urine is normal with the exception of a few pus cells, no Trichomonas are present. Stained Smears from the urethra and prostatic fluid reveal no intracellular nor extr~ cellular diplococci. On exploring the urethra with diagnostic 31 9
3 20
NORRIS
J.
HECKEL
sounds, extensive multiple strictures are foound. Therefore, we can definitely say that this patient has Trichomonas prostatitis and strictures of the urethra. Our technic in searching for Trichomonas is very simple. The prostatic fluid or urethral discharge is collected directly on a glass slide and spread not too thick. An ordinary cover slip is placed over the material and an oil immersion lens is used for observation. For office routine this procedure takes little time and, in our opinion, has been just as accurate as the hanging drop, or other more elaborate methods. One examination is not sufficient to rule out the possibility of Trichomonas. Searches on several different occasions should be made before a negative diagnosis is given. In the treatment of this patient a ,meatotomy is first done. Then he is given prostatic massages and urethral sounds twice a week, and heat, either in the form of diathermy or an electrical heater, applied to the prostate. Urethral instillations of 20 per cent neosilvol, or irrigations of potassium permanganate, 1: 3000, are used. This procedure is carried out until the prostatic fluid is free of Trichomonas and pus cells. In the prostate and urethra the Trichomonas usually disappear early, that is one or two weeks after the treatment has begun. However, the pus cells and other bacteria, usually streptococci, may. be ,present for as long as three or four months, and it is important to continue treatment regularly until the prostate is entirely normal. In a problem such as this, an attempt should be made to establish the primary source of the infestation if possible and thereby recognize the factors which may predispose to recurrences. In this particular patient, it is apparent since he and his wife are both infested that one may be reinfecting the other. Unquestionably, in such cases, the reinfestation is by sexual intercourse, and if either the male or female is cured, and no attempt made to search for the possibility of infestation in the other, then recurrent attacks can and do occur. Therefore, in this instance, we will advise against sexual intercourse during '" sll'th time as the vaginitis, urethritis, or prostatitis is active.
TRICHOMONIASIS OF GENITO-URINARY SYSTEM
321
In my second case, the opposite picture is present-the wife is not infested with Trichomonas.
Case 11. Trichomonas Urethritis and Prostatitis.-
This patient is forty-nine years old, married, and presents himself complaining of urethral discharge and burning of five days' duration. He fears the return of an old gonorrheal uretliritis. Extramarital exposure is denied.
Fig. 23.-Prostatic fluid showing pus cells and Trichomonas .
.The examination, as you see, reveals a copious amount of frothy, milky urethral discharge. The meatus is red. A small . amount of the discharge is placed on a slide and examined-it is filled with Trichomonas. The ·rectal examination shows the prostate to be normal; however, the prostatic fluid contains many Trichomonas and pus cells (Fig. 23). Therefore, the diagnosis is an acute Trichomonas urethritis and prostatitis. The treatment of this patient will be very similar to the procedure followed for the first patient, except that during VOL. 21-2I
3 22
NORRIS
J.
HECKEL
the hyperacute stage, which is usually three to six days, he will be given only sitz baths and alkalis such as bicarbonate of soda, or potassium citrate. When the acuteness of the attack subsides, then urethral instillations and prostatic massages will be carried out. ~any times it is difficult to evaluate in what way the infection occurred. In an effort to determine the origin of the infestation, the patient's wife has been examined and repeatedly the smears show no evidence of Trichomonas. During the last few years, I have seen 5 cases of Trichomonas prostatitis. I have also had the opportunity to examine many husbands whose wives are infested with Trichomonas and it is surprising to find that a large number, although no Trichomonas can be found, do have an infected prostate, and in the culture from the prostatic fluid streptococci are usually found. According to some authors, these findings would be explained by the fact that the Trichomonas vaginalis itself is not pathogenic but occurs only as a secondary invader or in symbiosis. Those who hold this belief are of the opinion that the streptococcus is the pathogenic organism. The majority of these men presented no genito-urinary symptoms, and had not an examination been made, the infection would not have been recognized. Usually the symptoms of Trichomonas prostatitis are the same as those of a nonspecific prostatitis; that is, a persistent urethral discharge and morning drop, associated with other various genito-urinary complaints. The condition, however, may start as an acute urethritis in which the discharge has a frothy, bubbly appearance, burning and frequency of urination, and an itching or smarting of the urethra may be present. I have not as yet seen a patient with a Trichomonas urethritis, who did not also have an associated prostatitis. In the rectal examination, the prostate may be entirely normal in size, shape and consistency, or there may be areas of hardness and infiltration. It is never tender nor swollen as in acute gonorrheal prostatitis. In venereal infections those having nonspecific urethritis and . ,prostatitis are not a small number, and if more careful bacterio-
TRICHOMONIASIS OF GENITO-URINARY SYSTEM
323
logical examinations are made, I am sure that in a larger percentage of the cases Trichomonas infestation will be found. My third case is that of a woman with recurrent Trichomonas vaginitis in whom the urinary symptoms are pronounced.
Case Ill.
Recurrent Trichomonas Vaginitis.-Mrs.
H., aged forty, has been treated elsewhere during the past six months for recurrent attacks of Trichomonas vaginitis. These attacks have been accompanied by aggravating urinary symp. toms of frequency every two or three hours, nocturia four or five times, with burning and dysuria. Here I should like to stress the importance of obtaining a careful and accurate history. Because of the severe vaginal symptoms of leukorrhea, scalding, and dyspareunia which frequently occur in these patients, definite questions must be asked in order to elicit information concerning the urinary complaints. This patient has had a complete and thorough examination of the gastro-intestinal tract, teeth, tonsils, Bartholin and Shne glands as a possible focus for the recurrent vaginitis attacks, and all are negative. In the bacteriological study of the cultures taken from the vagina and cervix, streptococci have been found. I might also add that the same strain of streptococci has been cultured from the prostatic fluid of her husband, who, although no Trichomonas have been found, does have an infected prostate. Because of the patient's urinary symptoms a cysto-urethroscopic examination is done. The urine, as you see, is clear and sparkling and a specimen is collected for bacteriological study. Your attention is called to the normal capacity of the bladder. This is an important observation to be used in the differential diagnosis from elusive ulcer in which the bladder capacity is greatly diminished. The pathologic changes are seen on the base of the bladder in the region of, and anterior ,to the trigone. In some cases these changes may extend beyond the trigone and involve both the ureteral orifices; in others may be limited to the internal urethral sphincter. Observe the raised, granular, fluffy and
NORRIS
J.
HECKEL
crepelike appearance of the bladder mucosa. It is a dull, pearly gray, and resembles somewhat the appearance of leukoplakia. The borders of this area can be sharply outlined from the normal mucous membrane. Notice. the small petechial hemorrhages around this region which appear very similar to the surface of a strawberry. These changes look similar to those found in the vaginal vault of many patients with Trichomonas vaginitis. As the cysto-urethroscope is withdrawn into the urethra, note the marked edema around the internal urethral orifice, and the pronounced changes similar to those in the bladder. This cystoscopic picture is seen quite frequently in Trichomonas vaginitis and I feel that in patients who complain of lower urinary symptoms, if these findings are observed, a careful search of the vagina should be made for Trichomonas. In summarizing the condition of this patient, we find two possibilities for the recurrent attacks of the vaginitis. First, although Trichomonas were not found in the prostatic fluid of the husband, he did have an infected prostate and the same strain of streptococci was isolated from the prostate as was found in the vagina and cervix of the wife. He, therefore, may be the cause of his wife's recurrent attacks. Second, the cause may be found in the pathology of the urethra and the bladder. I have seen patients in whom, after the associated pathology in the urethra and bladder was cleared up, there have been no more recurrent attacks. In the treatment of this patient until the acute condition subsides, we will follow this procedure: she will be given sitz baths, 2 or 3 daily, and internal medication of oil of sandalwood 5 minims, t.i.d., and alkalis such as sodium acetate 20 grains, or bicarbonate of soda-, four times daily. Then the bladder is irrigated with an oxidizing agent such as 1: 3000 solution of potassium permanganate followed by instillation of 2 to 3 ounces of 15 per cent neosilvol, or 20 per cent argyrol, twice a week. At the same time, topical applications to the urethra of 2 per cent silver nitrate solution, or % of 1 per _Fent zinc sulphate are used. If urethral pockets or other per-
TRICHOMONIASIS OF GENITO-URINARY SYSTEM
325
sistent ducts in and about the urethra are present, it may be necessary to fulgurate them. The second part of the treatment will be directed to the husband and the prostatitis treated as previously outlined. CONCLUSIONS
1. Each of the three patients presented to you illustrates an interesting phase of the Trichomonas vaginalis infestation. 2. The first is an example of the infestation probably through sexual intercourse, since both the husband and wife are infested. 3. The second patient illustrates an infested prostate and urethra, but no infestation in the wife. Furthermore, the his. tory and. examination of husband and wife in this instance give no solution as to the source of the infestation. 4. In the third case, which is that of recurrent vaginitis with urinary symptoms, we "find first that while Trichomonas were not found in the prostate gland of the husband, a prostatitis was present, offering a possibility for the cause of the recurrent attacks of vaginitis. Second, the associated changes in the urethra and bladder indicate that the recurrences may be caused by these findings. 5. It cannot be too strongly emphasized that repeated examinations of the urethral discharge or the prostatic fluid must be made in many instances in order to find the Trichomonas. 6. In patients with so-called "nonspecific" urethritis and prostatitis a more careful examination will reveal a higher percentage of Trichomonas infestations.