and most men with T. vaginalis infections are

HPV may be associated with nonspecific symp-

asymptomatic. In women, the signs and symp-

toms, such as vulvodynia, pruritis, or a malodor-

toms of trichomoniasis include vaginal dis-

ous vaginal discharge. There is a high rate of

charge and itching, irritation, odor, edema,

coinfection with other STIs.

erythema, and dysuria. Frothy discharge

Over 100 types of HPV exist and over 30 types

occurs in about 10% of patients. Colpitis mac-

can infect the genital area. Types 6 and 11 HPV

ularis (strawberry cervix) is a specific clinical

most often account for visible external genital

sign but is rarely detected during routine

warts but patients may be infected with more

examination. Men may have short-lived symp-

than one type of HPV.24 Types 6 and 11 HPV are

toms of urethral discharge, dysuria, and uri-

low risk for conversion to invasive carcinoma of

nary urgency.

the external genitalia.

Wet mount of the vaginal fluid with normal

Over 99% of cervical cancers and 84% of anal

saline (performed within 20 min of sample col-

cancers are associated with HPV, most com-

lection) or microscopic examination of first void

monly HPV 16 and 18; however, other types have

urine sediment in men or women may show

been associated with cervical dysplasia and neo-

motile protozoa, which are one to four times the

plasm in women and squamous intraepithelial

size of polymorphonuclear cells. The gold stan-

neoplasia in men.25–27 Smoking may increase the

dard of diagnosis remains culture of vaginal or

risk of dysplastic progression and malignancy

urethral swab or urine sediment. The specimens

in both men and women.

may remain at room temperature for up to

The diagnosis is made by the visualization or

30 min before inoculation on the media and

palpation of nontender papillomatous genital

therefore may be performed if the wet prepara-

lesions. Aceto-whitening with 3–5% acetic acid

tion is negative. Enzyme immunoassay, nucleic

placed on a towel and wrapped around the geni-

acid amplification, and immunofluorescence

tals may show flat condylomas as whitish areas

techniques are also available for confirmatory

but is not routinely recommended because of

testing.

low specificity. The benefit of evaluating and

treating asymptomatic sexual partners of women

Treatment

with genital warts or abnormal PAP smears

remains unclear. Biopsies of genital warts are

Infected individuals and their sexual partners

not routinely needed, but should be undertaken

should be treated to prevent recurrence of infec-

in all instances of questionable, atypical, pig-

tion. A single 2 g oral dose of metronidazole is

mented, indurated, fixed, or ulcerated warts, if

effective in most cases and can be used in the

the lesions persist or worsen after treatment, and

second trimester of pregnancy. Tinidazole is a

in immunocompromised patients.

more expensive alternative but equally effective.

Repeat testing at 5–7 days and 30 days should be

Treatment

performed if symptoms fail to resolve and treat-

ment failure is suspected.For nonpregnant treat-

The choice of therapy for genital warts depends

ment failures, a longer course of metronidazole,

on several factors including wart size, number,

500 mg twice daily for 7 days, or 2 g once daily

and location and patient and physician prefer-

for 3–5 days may be tried. Metronidazole gel for

ence. Since genital warts spontaneously resolve

intravaginal application is available; however, it

with time, observation remains an option.

is less than 50% as effective as oral treatment.

Patient-applied therapies are less expensive and

may be more effective than provider-applied

Human Papilloma Virus

therapy.28,29

Recommended treatment choices for patient-

Diagnosis

applied therapy include podofilox 0.5% solu-

tion or gel, and imiquimod 5% cream.30

Genital warts (condylomata acuminata) are

Podofilox solution should be applied every 12 h

caused by human papilloma virus (HPV). HPV

for 3 days, then off for 4 days. The treatment

is spread by skin to skin contact usually at sites

cycle may be optionally repeated up to four

of microtrauma on the genitalia. Most infections

times. The total volume of solution used should

are subclinical and asymptomatic. In women,

not exceed 0.5 mL/day and the total wart area