2 WHY IS THIS IMPORTANT?The genitourinary tract is the third of the body’s systems that are open to the outside world.Many pathogens use this portal of entry and as a health care professional you will see many infections here.
3 OVERVIEWMany infections occur in the urinary and reproductive systems.Some urinary system infections begin in the urethra.Travel up to the bladder, Can reach the kidneys &Outcome can be severe and even life-threateningVariety of reproductive system infectionsMany are sexually transmitted (STDs).
5 GENERAL INFORMATION ABOUT URINARY SYSTEM INFECTONS Urine is essentially sterile.Presence of pathogens or inflammatory cells indicates a urinary tract infection (UTI).UTIs are more common in women.Pathogen is usually bacterial or yeast.UTIs are serious problems in hospitals.Usually associated with indwelling cathetersBacteria or yeast ascend the outside of the catheter and reach the bladder.Antibiotics should be given following removal of the catheter.
9 BACTERIAL UTIs:Pathogenesis Males have some protection from a longer urethra.Shorter female urethra means a shorter route to bladder for bacteria.Female urethra ends in the vaginal area.Colonized by a variety of bacteria as part of normal floraMany can initiate a UTI.
10 …BACTERIAL UTIs: Pathogenesis Uropathogenic E. coli use adherent molecules to climb to the bladder.Also use them to stick to the walls of the bladderNormal flushing unable to remove themBladder infections cause an inflammatory response.This irritation causes the symptoms of bacterial UTIs:Increased frequency of urinationUrgency to urinateDysuria-refers to painful urination.
11 ..BACTERIAL UTIs: Pathogenesis Infection in males can reach the prostate.Causes prostatitis-inflammation of the prostate gland, a common condition in adult malesProstatitis can be either acute or chronic.Inflammation caused by prostatitis can lead to compression of the urethra lumen.Obstructs or retards flow of urine
12 …BACTERIAL UTIs: Pathogenesis E. coli is responsible for most bladder infections.Most potent of all the pathogens that cause UTIs.Pathogenicity is associated with virulence factors called α hemolysins & Specialized pili.Urethritis:Dysuria, frequency, and urgencyLow back pain, abdominal pain, and tenderness over bladder, Urine is cloudy.Cystitis: term that refers to urinary bladder inflammation & has more acute onset and more severe symptoms.Presence of bacteria and blood in urine
13 ..BACTERIAL UTIs: Pathogenesis Nephritis- Nephritis is inflammation of the kidneyFever above 38.3˚CSevere cases can cause septic shock (whole-body inflammatory state)Usually no damage to kidney function
14 … BACTERIAL UTIs: Pathogenesis ProstatitisPain in the lower back, perirectal area, and testiclesCan be high fever, chills, and symptoms similar to bacterial cystitisInflammatory swelling can lead to obstruction of the urethra.Acute prostatitis usually seen in young men.Chronic form in the elderly and usually with catheterizationSulfonamides and trimethoprim are commonly used as treatment.
15 BACTERIAL INFECTIONS OF THE REPRODUCTIVE SYSTEM:STD’s Major infections in the reproductive system are sexually transmitted- STDsSTDs can cause:UrethritisCervicitisProstatitisPharyngitisPelvic Inflammatory Disease (PID)
16 ..BACTERIAL INFECTIONS OF THE REPRODUCTIVE SYSTEM-STD’s Pelvic Inflammatory Disease (PID)PID can also result from gonococcal or chlamydial infection.Can lead to infertility and ectopic pregnancy (Ectopic means "out of place." ) e.g in fallopian tubeInfections can infect fetus and newborn.Expectant mothers routinely screened for STD.
17 ..BACTERIAL INFECTIONS OF THE REPRODUCTIVE SYSTEM:STD’s STDs have been around for hundreds of years.Affect all populations and social strataMost common pathogens:Chlamydia trachomatisNeisseria gonorrhoeaeAlso papilloma, herpes simplex, and HIV viruses
18 BACTERIAL INFECTIONS OF THE REPRODUCTIVE SYSTEM: STD’s
19 ..COMMON CLINICAL CONDITIONS ASSOCIATION WITH STDS Genital ulcersSexually transmitted urethritisEpididymisCervicitisVaginitisLymphadenitis
20 1. GENITAL ULCERSGenital Ulcers: Lesions on the genitalia & Pustules evolve into ulcers. Different infections cause different types of ulcer.
22 2. URETHRITISPresents as dysuria (painful urination) or urethral discharge or both.Caused by N. gonorrhoeae and Chlamydia trachomatisDiagnosis of gonococcal urethritis usually requires culture & can be done by direct microscopic examination & DNA analysis also used. Detection of C. trachomatis requires DNA amplification analysis.Successful treatment depends on:Agent causing infection & whether the infection has spread.
23 3. EPIDIDYMITIS Unilateral swelling of the epididymis Usually quite painfulPresents with fever and swelling of the testicles.Two bacteria implicated:N. gonorrhoeaeC. trachomatis
24 4. CERVICITIS Etiology can vary. Usually caused by N. gonorrhoeae and Chlamydia. trachomatisMay involve mucopurulent vaginal discharge.Inflammation of the cervixPhagocytic leukocytes found in discharge.
25 5. VAGINITIS Bacterial is the most common type of vaginitis. Associated with overgrowth of vaginal anaerobic floraCan be homogeneous yellowish dischargeStays adhered to vaginal wallDischarge can occur alone or in connection with salpingitis, endometritis, or cervicitis.
26 6. PELVIC INFLAMMATORY DISEASE (PID) Usually presents with abdominal pain.50% of cases caused by N. gonorrhoeae.Can be non-gonococcal and caused by a combination of bacteriaMore complex than gonococcal
27 7. LYMPHADENITIS Inflammation of lymph nodes. Seen in several sexually transmitted infectionsUsually begins as a small genital ulcer that is frequently unnoticed.First evidence is usually a tender swollen lymph node in groin.
28 COMMON SEXUALLY TRANSMITTED INFECTIONS Three of the most common bacterial sexually transmitted infections:SyphilisGonorrheaNon-gonococcal urethritis
29 SYPHILIS Earliest recorded sexually transmitted infection. First described in 1600sCaused by Treponema pallidumSlim spirochete; Slow rotating motility; Cannot be grown on bacterial media; Can be grown in mammalian cell cultures.Extremely susceptible to any changes in its environmentDies rapidly if dehydrated or heatedVery sensitive to detergents and disinfectantsTransmission restricted to direct contactExclusively a human pathogen
30 ..SYPHILIS Infection is acquired by sexual contact. Possibility of transmission through the sharing of contaminated needlesAlso transplacentallyStill a major health problemMore than 12 million cases each yearSpirochetes reach the subepithelial tissues by two means:Through breaks in skinPassing between epithelial cells of the mucous membranes
31 …SYPHILIS-Pathogenesis Several clinically defined stages:PrimarySecondaryLatentTertiaryCongenital
33 ..SYPHILIS Primary Syphilis Associated with appearance of primary syphilitic lesionStarts as a papule and becomes an ulcerUlcer usually located on external genitalia or cervix.Also found in the oral cavity or anusUlcer remains painless – a chancre ( is a painless ulceration formed during the primary stage of syphilis).
35 …Primary SyphilisIncubation time to appearance of the chancre is 3 weeks & Chancre will disappear in 4-6 weeks.Lymphadenopathy (Lymphadenopathy is a term meaning "disease of the lymph nodes“ occurs within 1 week of the initial lesion.Can persist for monthsPrimary syphilis can cause enlargement of lymph nodes of the groin.Also known as disseminated syphilisDevelops 2-8 weeks after the chancre disappears.Characterized by papular rash on the face, trunk, and extremities including the palms of the hands and soles of feet, fever, malaise.
37 ….Secondary SyphilisLesions of the rash are swarmimg with spirochetes & extremely infectiousLesions usually resolve in a few days & 1/3 of cases take many weeks.If lesions disappear in a few days, latent syphilis develops.
38 ….Latent syphilis Can last for years No clinical signs or symptoms but infection is continuing.Latency can be interrupted by less severe bouts of secondary syphilis.Sexual transmission only possible during relapses.Transmission from mother to fetus is possible throughout latent period.
39 ……Tertiary syphilis Occurs in about 1/3 of untreated patients. Takes years to develop; Can be 5 years after the initial infection ; Usually yearsCharacterized by appearance of GummasLocalized granulomatous lesions in skin, bones, joints, and internal organsClinical findings depend on where the infection spreads.Cardiovascular system – cardiovascular syphilisNervous system – neurosyphilis
41 Congenital syphillis Passed from mother to fetus Only after 4th month of gestationCan have devastating consequencesMiscarriageChanges to entire skeletal structureAnemia, thrombocytopenia, and liver failureMother must be treated before 4th month.
42 ..SYPHILIS: TreatmentTreponema pallidum is very sensitive to penicillin.Treatment of choicePatients allergic to penicillin are treated with tetracycline, azithromycin, or cephalosporin.Safe sex is effective for prevention.
43 GONORRHEA Caused by Neisseria gonorrhoeae Gram-negative diplococcus, Numerous piliGrows well on chocolate agar and requires CO2Can change antigens from generation to generationExtensive genetic changes that occur in N. gonorrhoeae:Allow pathogen to escape host defenses.Make it able to bind to variety of receptors.Maximize the potential for infection.
45 …GONORRHEAReported cases represent only 50% of the actual number & still a major public health problemHighest rates seen in young adults.Women aged & men aged 20-24Major reservoir is asymptomatic patients.50% are infectious & infection rate can be 20-50% for sexual intercourse with a carrier.
46 …GONORRHEA: Pathogenesis – Attachment and invasion Bacterium contains adherence proteins.Used to attach to urethral and vaginal epitheliumAlso attaches to sperm, neutrophils, parts of fallopian tubesPathogen invades host epithelial cells.
47 ..GonorrheaIn Males:In males who get infected, 95% have pus dripping from urethra from 14 daysSymptoms and signs include a burning sensation when urinating, or a white, yellow, or green discharge from the penis.Sometimes men with gonorrhea get painful or swollen testicles.
49 …GONORRHEA: Spread and Dissemination Pathogens tend to stay localized in the genital structures.Facilitates transmission & causes increased inflammation and localized tissue injuryInfection may spread to adjacent cells by progressive extension.Prostate, cervical glands, and fallopian tubesBacteria adhering to sperm can facilitate spread.Neisseria can reach the blood and cause systemic infection.
50 …..GONORRHEA: Clinical Manifestations CDC estimates that more than 700,000 persons in the U.S. get new gonorrheal infections each yearSeveral antibiotics can successfully cure gonorrhea in adolescents and adultsDrug-resistant strains of gonorrheaOther InfectionsGonococcal Eye InfectionsRespiratory Tract InfectionsPharyngeal infection
52 ..GONORRHEA: Pelvic inflammatory disease (PID) Seen in 10-20% of women infected with NeisseriaSymptoms are caused by pathogen spreading along the fallopian tubes and into the pelvic cavity.PID can have serious complications.Infertility and ectopic pregnancy
53 …..GONORRHEA: Treatment Patients who discontinue treatment early:Continue to transmit the disease.Increase development of antibiotic resistance.Resistance to penicillin has rendered this drug useless.Third-generation cephalosporins are the best option ; Fluoroquinolones, azithromycin, doxycycline are also effective.
54 NON-GONOCOCCAL URETHRITIS (CHLAMYDIA TRACHOMATIS) NGU is the most common sexually transmitted disease.Caused by Chlamydia – a unique form of bacteriaObligate intracellularRound cell surrounded by an envelopeDo not contain peptidoglycanOne of the smallest genomes of all the prokaryotesC. trachomatis most common species
55 ..NGU-Pathogenesis More than 700,000 cases each year in the US. Humans are the only reservoir.Many infected men show no symptoms of the disease.Re-infection is a common occurrence.
56 ..NGU- Pathogenesis Chlamydia has an affinity for: Epithelial cells of the cervix.Upper genital tract of women.Urethra and rectum of both men and women.If infection not treated or failure in the immune response; NGU can become chronic.Chlamydia are sensitive to doxycycline, azithromycin, and some fluoroquinolones.No vaccine against NGU.
57 VIRAL INFECTIONS OF THE GENITOURINARY SYSTEM Most important viral infection is HIV.Two other prominent viruses:Herpes simplex type 2Human papillomavirus
58 HERPES SIMPLEX VIRUSTwo distinct epidemiological and antigenic types of herpes simplex virus.Herpes simplex virus type 1 (HSV-1) -above-the-waist & causes cold soresHerpes simplex virus type 2 (HSV-2)- below-the-waist & causes genital herpesDNA viruses linear double-stranded DNA.Two types share many of the same antigens.50% homology in genomes.
59 ..HERPES SIMPLEX VIRUS- HSV-2 Transmission is through direct contact with infected secretions.Many patients infected with HSV-2:Are asymptomatic.Have small lesions that go unnoticed.Shedding of virus occurs in asymptomatic patients.They can transmit the infection.Estimated 1 million new cases each year in the US.
60 …HSV-2: PathogenesisAcute Infection: Virus in an acute infection can spread:Intraneuronally & interneuronally.By cell-to-cell transfer.Can result in death of neuronsLatent infectionInfection does not result in the death of neuron.Effects on host cell not understood.Most antiviral drugs do not eradicate latent infection
61 ..HSV-2: PathogenesisReactivation of latent virus accounts for most recurrent genital infections.Mechanisms not yet known, but there are several precipitating factors:Exposure to ultraviolet radiation, Fever, TraumaGenital herpes infections can be primary, recurrent, or neonatal.
62 .HSV-2: Primary Genital Herpes Relatively few people develop clinical symptoms.Incubation time from sexual contact to onset of lesions is about 5 days.Lesions begin as small papules.Develop into vesiclesThen pustules on mucosal tissue.Sensitive viewers close eyes for the next slide!!
64 ..HSV-2: Primary Genital Herpes Within 3-5 days, lesions break to form painful coalesced ulcers.Some crust over before healing.All lesions crust over eventually.Urethra and cervix can also be involved.First episodes last average of 12 days.Tender lymph nodes in groin persist for weeks or even months.Some cases of aseptic meningitis
65 ..HSV-2:Recurrent Genital Herpes Shorter duration than primary infectionUsually localized in genital regionUsual symptoms burning or prickly sensation in the pelvic areaOccur hours before appearance of grouped vesicular lesions.Last 4-5 daysLesions usually disappear in 2-5 days.80% patients develop recurrent episodesMedian number of recurrences 4-5 per yearRecurrent viral shedding may occur without evidence of disease
66 ..HSV-2:Neonatal herpes infection Infections in newborn infants results from transmission during delivery.Most cases associated with maternal primary infection at or near the time of delivery.Intense viral exposure to infant.Very serious infectionMortality rate of approximately 60%Those infants that survive have severe difficulties.Abnormal nervous system function , Disseminated vesicular lesions, Necrosis of the liver & adrenal glands, and seizures
67 ..HSV-2:TreatmentMost effective and most commonly used is the Nucleoside analog acyclovir.Decreases the duration of a primary infectionCan also suppress recurrent infectionsFoscarnet is effective for resistant virions.Can be prevented by avoiding contact with infected individuals expressing lesionsImportant to remember virus still being shed in asymptomatic individualsCan also be transmitted via saliva
68 HUMAN PAPILLOMAVIRUS (HPV) Papillomaviruses are small, non-enveloped, with double-stranded DNA and icosahedral symmetry.Cause papillomas (benign tumors) or wartsInfections are species specific.Tumors can be malignant.
69 ..HPV Wide genetic diversity among human papillomaviruses. Indicated by using numbers to identify different genotypes.More than 70 genotypes of HPV have been identified.Some are associated with specific lesions.HPVs cause cervical, vulvar, and penile wartsHPVs are also associated with cervical cancer.
70 …HPV 12 HPV genotypes identified in human genital lesions. Possible to be infected with more than one genotype of HPV.Incidence of HPV infection is rising:20-60% of women in the US are infected with one HPV genotype.Infections may lead to malignancy.Difficult to study because HPV is difficult to grow.
71 ..HPV: PathogenesisExternal genital HPV infection presents as genital warts.Lesions may grow to a cauliflower-like appearance during pregnancy or immunosuppression.HPV infections usually benign & leads carcinomaOnly treatments are surgical, cytotoxic drugs, and cryotherapy.Vaccine is being developed
72 ………. .HPV: wartsGenital warts usually appear as a small bump or groups of bumps in the genital areaThere is no treatment for the virus itself, but there are treatments for the diseases that HPV can causeVisible genital warts can be removed by the patient him or herself with medications.Cervical cancer (caused by HPV) is most treatable when it is diagnosed and treated early.
75 FUNGAL INFECTIONS OF THE GENITOURINARY SYSTEM Genitourinary system is exposed to many fungal organisms.Infections are usually opportunistic.Most prominent fungal infection is vaginal candidiasis.Caused by Candida albicans
76 VAGINAL CANDIDIASIS (CANDIDA ALBICANS) Candida albicans part of the normal microbial flora.Found in oropharyngeal gastrointestinal regions in males and femalesCan grow in multiple morphological forms & mainly seen as yeastInfection can be local or systemic.Main symptoms are itching and a thick white discharge.Indwelling catheters and over-use of antibiotics.
77 ..C. ALBICANS: Pathogenesis Candida infection of the vagina produces a thick discharge.Consistency of cottage cheeseAccompanyied by itchingSmall percentage of women become chronically infected.Experience recurrent symptoms.Candida can also infect urinary tract.Treatment : Amphotericin B, nystatin, and flucytosine
78 References http://en.wikipedia.org/wiki/Scientific_method Microbiology, A clinical Approach -Danielle Moszyk-Strelkauskas-Garland Science 2010Lecture PowerPoints Microbiology Principles and Exploration 7th edt. J G Black ; J Wiley Pub.