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*Corresponding author: Email: forman.siagian@uki.ac.id;
Cite as: Siagian , F. E. (2024). Vaginal or Fecal Contamination Which Contributes to Parasite Existence in Urine Sediment.
International Journal of Pathogen Research, 13(3), 76–89. https://doi.org/10.9734/ijpr/2024/v13i3288
International Journal of Pathogen Research
Volume 13, Issue 3, Page 76-89, 2024; Article no.IJPR.117870
ISSN: 2582-3876
Vaginal or Fecal Contamination
Which Contributes to Parasite
Existence in Urine Sediment
Forman Erwin Siagian a*
a Department of Parasitology, Faculty of Medicine, Universitas Kristen Indonesia, Jakarta, Indonesia.
Author’s contribution
The sole author designed, analyzed, interpreted and prepared the manuscript.
Article Information
DOI: https://doi.org/10.9734/ijpr/2024/v13i3288
Open Peer Review History:
This journal follows the Advanced Open Peer Review policy. Identity of the Reviewers, Editor(s) and additional Reviewers,
peer review comments, different versions of the manuscript, comments of the editors, etc are available here:
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Received: 20/03/2024
Accepted: 23/05/2024
Published: 25/05/2024
ABSTRACT
Aims: intended to deepen our knowledge to date regarding parasites that might found in urine
sediment as consequences of vaginal or fecal contamination during voiding
Discussion: Urine in the bladder is a sterile waste product composed of water soluble nitrogen
products. But during voiding, the passage of the urine through lower/outer portion of the urinary
tract might come across normal microbiota which function in maintaining the urothelial integrity and
preventing urinary tract infection (UTI), as well as promoting local immune function. Parasites and
parasitic ova may be seen in urinary sediments as a result of fecal or vaginal contamination.
Identification of parasites in centrifuged deposits of urine sediment is a relatively rare occurrence in
clinical practice but still must be considered carefully, whether as a consequence of contamination
or definite causes of infection. Two of the common parasite found in urine sediment are
Trichomonas vaginalis and Enterobius vermicularis. Urine collection procedure must be explained
briefly to the patient along with appropriate informed consent prior obtaining the sample.
Conclusion: The possibility of parasites being found in urine sediment remain to happen. An in-
depth analysis needs to be carried out to determine whether this occurs due to vaginal or rectal
contamination or whether it is due to a definitive infection occurring in the urinary tract.
Minireview Article
Siagian; Int. J. Path. Res., vol. 13, no. 3, pp. 76-89, 2024; Article no.IJPR.117870
77
Keywords: Trichomonas vaginalis; enterobius vermicularis; centrifugation; contact; urinalysis; non-
pathognomonic.
1. INTRODUCTION
Parasitic diseases with its characteristics of
tissue tropism [1] may develop slow and causing
chronic ailment that facilitate other infection to
happen [2,3]. In most cases, it exhibits unclear,
non-specific symptoms [4] along with non-
pathognomonic physical signs [5] and make it
difficult to withdraw and conclude a parasite
based diagnosis [6]. Through brief medical
history and physical examination, doctor can
choose what lab or radiology test appropriate for
the patient’s subjective complaint [7]. The definite
diagnosis is primarily based on the result of
laboratory tests result or radiographic findings
[8,9]. The commonly applied method for making
correct diagnosis of a parasitic diseases include
anamnesis, physical examination and
laboratory/supporting examination [10], including
urinalysis [11,12], that confirmed diagnosis.
“Urinalysis is the examination of urine for certain
pattern of physical properties, solutes, cells,
casts, crystals, organisms, metabolomes or
certain particulate matter” [13-15]. “Because the
procedure and steps of urinalysis is easy to
conduct, economically affordable, and productive
in terms of the result, it is recommended as part
of the initial examination of all adult hospitalized
patients” [16] and should always be
recommended to be reiterated as clinically
needed [17]. The rationale and technique of
urinalysis are always straightforward [18].
Nevertheless, “various circumstances, whether
patient based (excessive exercise. Excessive
food consumption etc.) or transportation based
(time from collection to analysis or handling the
specimen), may alter the final information
obtained after analysis conducted [19].
Sometime, urinalysis can reveal parasite during
microscopic examination” [11,12,16]. This mini
review intended to deepen our knowledge to date
regarding parasites that might found in urine
sediment as consequences of vaginal or fecal
contamination during voiding.
2. CHARACTERISTIC OF URINE
As study conducted by Rotter et al [20] revealed
the instability of urine’s composition based on
time (e.g., delay in processing) [20,21],
temperature [20,22] and on the addition of
preservatives [22,23]. “Urine contrasts
substantially in ion and other solute constituent
from plasma and destined to accommodates
harmful and filthy substances” [24] that must be
initially stored for some time prior to voiding- the
bladder then acts as the storage site for this
waste product until higher-order centers within
the central nervous system initiate the voiding
process, which then in order to do so is quickly
removed the urine into the urethra, located on
the inferior aspect of the bladder [25]- an activity
conducted when it is socially suitable to do so.
As soon as it leaves the body by urination, its
makeup is altered [20–25]. Following the right
procedures for sample collection, handling, and
storage is essential to preserving the sample's
integrity and, by extension, the analysis's
outcome [26]. Urine collected from the first void,
also known as "morning urine," is thought to be
the most representative sample for analysis
purposes when compared to spot urine, such as
when assessing microalbuminuria [27]. This is
because urine that has accumulated in the
bladder over night is more concentrated [28],
which gives insight into the kidneys' ability to
concentrate [29,30], and makes it possible to
detect traces of substances in concentrated
rather than diluted samples [31]. There are
consistent correlations between gender and/or
diet and urinary element concentrations [31].
Other urine specimen kinds, such as random
collection, 2-hour postprandial collection, or 24-
hour collection—each with a distinct purpose—
can be arranged in accordance with
predetermined guidelines. It helps doctors
interpret and identify the source of bloody urine,
abdominal pains, burning sensations, or any
other problems related to micturition [35] by
screening and monitoring medication metabolites
[32], diagnosing metabolic diseases [33], and
treating urinary tract infections [34].
Urine should be ideally examined as soon as
possible [34,35], or at least within the first hour
after the collection (unless preservative
agent/condition added) [36] due to the instability
of some urinary components (cells, casts, and
crystals) [31]. If not possible, the sample should
be refrigerated at 40 C for up to 24 hours [37],
which will slow down the decomposition process
without the application of additional preservatives
[38]. Any specimen older than 24 hours without
any treatment at all should not be used for
urinalysis [35-38].
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78
There are two methods to obtain a urine
specimen: non-invasive (for example, urine bags,
pads, or clean catch) [43] and invasive (for
example, catheter or SPA) techniques [44].
Spontaneous voiding is the main non-invasive
technique, such as commonly used in cases of
dysfunctional voiding [45] although other
strategies may be used in children who cannot
yet control their voiding, such as the use of bag
urine [46]. In contrast, urethral catheterization
[47] and suprapubic bladder puncture [48] are
the two invasive procedures commonly applied
nowadays. Urine collection preference order are
as follows: cystocentesis [39], followed by sterile
urinary catheterization [40], followed by mid-
stream void [41] and last but no least
contaminated first void [42].
The fundamental principle of either approach is
to obtain the best specimen without any external
contamination.
3. PARASITOLOGY URINALYSIS
Urine tests can surely make a definite diagnosis
of parasitic infections [11-13]. In the era of
automated machine-based analysis [13-16],
these parasitic organisms are easily overlooked
[14] because it is not available in the system or
possible overlapping between parasite
morphology [15], and though doing things
manually becomes inconvenient, subjectively
and clinically [16], but applying microscopic
examination of urinary sediments is very
important for the diagnosis of these parasitic
organisms [11]. Several actively motile
organisms that can be seen morphologically in
urine are Trichomonas vaginalis with its
distinctive pyriform appearance, undulating
membrane and actively moving flagellae [49],
Microfilaria of Wuchereria spp or Brugia spp [50]
which usually found in urinary sample with
specific appearance of achylous hematuria [51],
Schistosoma hematobium eggs in urine which
usually increased number of eggs is shed in the
urine around midday, so an optimum urine
specimen for diagnosis should be collected at
noon [52], and other rare organisms such as
Balantidium coli [53] and even Paramecium [54].
In the context of urinary parasites, the incidence
is clinically rare compared to GI tract parasites
[10-12,55,56]. The rarity perhaps due to mild or
transient or even non-specific symptom which
sometime make it unnoticed/neglected [57] even
overlooked [58] by clinician or lab tech. Incidental
finding in routine urine examination is seldom
reported [12,59,60] ; even though from the
laboratory work perspective, urine is consistently
appraised as a flawless material for making
correct diagnostic out of clinical sample due to its
simpleness to collect, directly applicable and
conveniences to the patience because of its non-
invasiveness [11].
Parasites that may be found in urinary sediments
include Trichomonas vaginalis [11,61],
Enterobius vermicularis [11,62], and
Schistosoma haematobium (Chronically infected
adults pass few eggs in the urine, which are
often missed when current diagnostic methods
are used) [11,63]. Except for S. haematobium,
parasites and parasitic ova are usually present in
urine sediment as a result of vaginal or fecal
contamination [64,65]. The next section will
briefly focus on the parasitic contamination which
can be detected in urinalysis.
3.1 Trichomonas vaginalis and how it
Contaminated Urine
Trichomoniasis is the commonest non-viral
sexually transmitted disease [66], and it is
caused exclusively by the protozoan flagellate T.
vaginalis [49,61,66]. Although highly prevalent in
specific sub population namely reproductive age
of sexually active women [67], but unfortunately it
was often leave unnoticed in other sub groups of
potentially infected population such as male [68].
These findings raise concerns about a surge in
transmission to and between sexual partners,
especially if those concerned engage in
promiscuous practices [69,70]. Trichomoniasis
increases both transmission and acquisition of
HIV among women [71]. Anderson et al [72]
studied African women suffer from co-infection of
trichomoniasis and HIV and they revealed that
successful treatment for T. vaginalis can
decrease the potency of HIV genital shedding.
Trichomoniasis also reported to give rise to
horrifying adverse birth outcomes of pregnancy
[73], which has raised wide spread concern
regarding T. vaginalis detection [74] and
increased the need for highly sensitive diagnostic
tests [75,76].
As an obligate extracellular parasite [77], this
flagellate invaded and then occupied right on the
facet of the epithelium of the urogenital tract,
especially the cervical epithelium [78]. They
acquire its energy via anaerobic pathways where
they obtain glucose or maltose and used it as
their own primary carbon and energy
commencement [79]; its existence in this specific
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79
milieu maintained via contact dependent
cytolysis of epithelial cell [80].
Trichomoniasis is a gender-related parasitic
infection mainly exert influence on women with
roughly calculated to have a global ratio
prevalence of 8.1% among women compared to
only one percent among men [81]. Surprisingly,
most men are capable of briskly remove the
infection, because infection only lasts transiently
and self-limiting [82] a condition which made
male with trichomoniasis often referred as
Trichomonads asymptomatic carrier [83]. This
discrepancy perhaps facilitated by the
differences in the specific urogenital micro-
environments which directly affecting
trichomonad ability to exists and conduct its
pathogenesis [77]. “T. vaginalis benefited from
an iron-rich environment in the vagina, especially
during menstruation because iron, an essential
nutritional and metabolic element for T. vaginalis
parasitism available in higher concentrations
during menses and seems to be entangled in the
resistance to complement lysis and contributes to
the immune evasion” [82]. On the other hand,
this parasite confronted with a belligerent and
dangerous milieu of zinc-rich surrounding in the
prostatic glands [84]. Zinc is a known antioxidant,
anti-inflammatory and also antimicrobial chemical
substance which act as first line of defense in
humans [85]. A preliminary report conducted by
Krieger and rein [86] revealed that men with
lower amount of zinc in their prostatic secretions
(<1.6 mM) are more tolerate to T. vaginalis, a
condition which facilitate them to agonize chronic
trichomonads prostatitis.
Trichomonas vaginalis replicates by binary
longitudinal fission, with mitotic division of the
nucleus [87]; even though study conducted by
Yusof and Kumar [88] confirms that multiple
modes of nuclear division do exist in T. vaginalis
and are a precursor to progeny formation. The
life cycle of this parasite possesses a trophozoite
form without a cystic stage. However, the
presence of non-proliferative and non-motile, yet
viable and reversible spherical forms with
internalized flagella, denominated pseudocysts,
has been commonly observed for this parasite
[89]. There is no evidence regarding existence of
this parasite in the external environment outside
its host; it seems that the parasite’s survivability
outside the host is questionable [90].
This parasite stays in the female lower genital
tract [67,68,71,72] while for the male patient, it
occupies the epithelial urethra and prostate
[68,76]. It is responsible of causing
trichomoniasis in women that is usually
characterized by vaginitis with a thin purulent
discharge accompanied by vulvar and cervical
lesions, abdominal pain, or dysuria [91,92]. The
incubation period is 5–28 days. In men, the
infection can be asymptomatic or have
characteristics of urethritis, epididymitis, and
prostatitis [68,76,92]. Trichomoniasis is usually
diagnosed by direct wet mount microscopy
analysis of vaginal swab sample [93,94], which
has an average sensitivity of 60 to 80 percent for
detection of the motile T. vaginalis organisms.
In urine specimens which actually come from
female patient, it is believed that the presence of
T. vaginalis represents vaginal contamination
[92], specifically is contaminated by organisms
from the vaginal discharge [64,65]. Despite the
fact that the midstream clean-catch technique is
commonly used for urine collection [42,64],
contaminated urine cultures are commonly
happening with distressing regularity [64,65].
Practically in the hospital/clinic, the midstream
clean-catch procedure is tedious to describe and
because of that it is commonly not performed
correctly by patients, costly for supplies, often
embarrassing for patients, staff and or lab
technician, and sometime also of unproven
benefit [95]. However, all these risks must be
minimized by the hospital good clinical practice
[96] so that the urine collected is free of
contamination and the results of the urinalysis
examination are not biased. Sufficient
explanation in a brief informed consent is a
mandatory prior to specimen collection [97].
A clean catch urine sample or specimen [46] is
one of the least invasive procedures for a urine
culture or urinalysis. The clean catch method
aims to intercept any microorganisms from the
skin of the penis or vagina and also from vaginal
discharge from contaminating the urine specimen
[98]. It is mandatory for the patient to follow the
clean catch process to have accurate results
from an uncontaminated sample.
Some clinics provide a clean catch kit consisting
of a plastic container with a lid, a label for the
patient to write their name on, and an individually
clean and wrapped moist towel. Others ask that
the patient to use soapy water to clean their
perineal and genital region instead of providing a
moist towel. Note that for best urinalysis result, it
is important to collect a urine sample midstream
[34]. This means that the patient should start
urinating, then stop the flow, followed by put the
Siagian; Int. J. Path. Res., vol. 13, no. 3, pp. 76-89, 2024; Article no.IJPR.117870
80
collection container underneath their genital
area and then release the urine flow again and
collect it in sufficient amount (not too much or too
little). The patient can usually see
similar instructions to those below listed on a
laminated instruction sheet posted in the clinic
bathroom.
Female patients should use a packaged, moist
towel to clean the vulva and perianal areas
starting from front to back. Repeat with a second
moist towel. On the other hand, male patients
should retract the foreskin from the penis if
necessary and use the packaged towel to clean
the penis from the tip to the base. Repeat with
second towel.
Female patients should then spread their labia
with one hand and start urinating into the toilet.
With the other free hand, put the urine container
under the genital area to catch the stream of
urine without touching any skin. Male patients
should retract the foreskin if necessary with
one hand and start urinating into the toilet.
Then, position the urine container with the other
hand to catch the stream without touching any
skin.
Patients must be instructed not to fill urine to the
top of the sterile container. No more than half a
container is necessary. Place the lid on the
container and set it on the sink or someplace
stable while the patient finish urinating into the
toilet. Screw the lid securely on the container
and wipe it off. The patient must wash their
hands and drop off the container to the
laboratory as instructed.
3.2 Enterobius vermicularis and how it
Contaminated Urine
Enterobius vermicularis, also called pinworm, is
one of the most common nematode infections in
the world. Originally, E. vermicularis was named
Oxyuris vermicularis [99]. Humans are the only
known natural host for this pinworm; as the result
of study conducted by Paknazhad et al [100] in
Iran regarding paleoparasitological evidence
active enterobiasis in a female adolescent
residing in ancient Tehran over 7000 years ago.
Transmission highly facilitated in area where
individuals living in overcrowded urban slum
areas [101] and spread more easily within
families where closed contact is imaginable
[102].
Enterobiasis or Oxyuriasis commonly occurs in
children [103]. Transmission is via fecal-oral
route, either directly by hand, e.g., in children
with finger sucking habit [104] (this route of
infection named auto infestation) or indirectly
through contaminated toys, clothing, toilette seat,
bedding, eating utensil, food, or other articles, or
even during sexual contact, especially oral sex
with an infected person, including men having
sex with men and women having sex with
women [105]. Most infections are asymptomatic
[99,103,105]. The cure rate is actually high (up to
>90%) [106], but unfortunately recurrences are
quotidian [107].
Fig. 1 A. Trichomonas vaginalis, 1 B. the egg of Enterobius vermicularis (courtesy dept. of
Parasitology, Faculty of Medicine, Universitas Kristen Indonesia, Jakarta-Indonesia)
Siagian; Int. J. Path. Res., vol. 13, no. 3, pp. 76-89, 2024; Article no.IJPR.117870
81
Asymptomatic Enterobiasis or Oxyuriasis
occurred, approximately 30 to 40% of infested
patients do not show any clinical symptoms of
the disease [108]. For symptomatic patients, the
most common presenting symptom is nocturnal
pruritus ani and with addition of possible perineal
pruritus [109]. The worms emerge from the anal
canal at night till dawn in order to lay down their
eggs in the perianal region; thus, pruritus is worst
at those times. It is precisely under these
conditions that contamination of urine can occur.
for example, children who have previously
experienced enterobiasis, then for other reasons
(for example, suspected urinary tract infections)
need to have their urine checked; If urine
sampling is not done carefully and does not
follow good clinical practice and correct sampling
protocols, urine being collected can pass through
the perineal area and become contaminated with
Enterobius eggs [110].
Because urinary tract infection is particularly
common in young girls and Enterobius
vermicularis (pinworm) is one of the most
prevalent worms found in children worldwide
encourages Ok et al [111] to search and explore
a possible relationship between urinary tract
infection among young girls, with or without
urinary tract infection, with Enterobiasis, they
reported that urinary tract infections may be
related to pinworms. When a urinary tract
infection is diagnosed in young girls, cellulose
tape should also be applied to both the perianal
and the perineal regions on at least three
consecutive occasions in order to find the
primary source. The diagnosis of enterobiasis is
best established by using the cellophane tape
test [103,106]. The sensitivity of one single test is
around 50%; however, the sensitivity increases
to approximately 90% with tests performed on
three different consecutive mornings [112].
Whenever a pinworm is envisaged in the perianal
area or the stool, a morpho-parasiological
analysis of the worm will relinquish a definitive
diagnosis of enterobiasis. Because mature
pinworms and eggs are not normally excreted in
the stool, copro-parasitological examination is
not suggested.
The urinary tract is actually rarely affected by this
worm and only few cases have been scarcely
reported. Sammour et al [113] report a case of
bladder infestation by mature female worms of E.
vermicularis in a woman presenting with irritative
voiding symptoms. While Zahariou et al [114]
reported an extremely rare manifestation of
enterobius vermicularis infection since an
intestinal-breeding worm is rarely found in the
male genital tract of a patient complaint with mild
voiding difficulties such as urgency, frequency,
nocturia, dysuria, mild low back pain or perineal
discomfort. The patient's prostatic secretions
showed a large number of inflammatory cells and
several eggs. These reports showed us that,
urinary tract involvement in enterobiasis can also
be an active ectopic infection, rather than
contamination and this is become the main
reason to look carefully and determined whether
it is caused by an active ectopic infection or just
contamination [115-117].
4. CONCLUSION
The possibility of parasites being found in urine
sediment remain to happen. Both T. vaginalis
and E. vermicularis are remain as the public
health problem, especially in specific population
of poor urban areas, and transmission among
member of those sub population remain ensue
which facilitated by closed contact and poor
hygiene practice. An in-depth and careful
analysis needs to be accomplish to determine
whether this occurs due to vaginal or rectal
contamination or whether it is due to a definitive
infection occurring in the urinary tract.
ACKNOWLEDGEMENTS
The author would like to thank Mr Urip
Susiantoro, a well trained lab tech in the dept. of
Parasitology, faculty of Medicine, Universitas
Kristen Indonesia, Jakarta-Indonesia for his
microscopy photography on E. vermicularis egg
and T. vaginalis (courtesy dept. of Parasitology,
faculty of Medicine, Universitas Kristen
Indonesia, Jakarta-Indonesia)
COMPETING INTERESTS
Author has declared that no competing interests
exist.
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