F UNGAL G ENITOURINARY S YSTEM I NFECTIONS

Bladder and kidneys infections Valvovaginal infections

F UNGAL U RINARY T RACT I NFECTIONS Primarily affect the bladder and kidneys Candida species ( the most common cause) Candida species is part of the micro flora of the lower genitourinary tracts Candida colonization differs from infection

K IDNEYS F UNGAL I NFECTION All invasive fungi may infect kidneys as part of systemic or disseminated mycotic infection: Candida sp (yeast) Aspergillus sp (filamentous, septate) Zygomycetes ( filamentous, aseptate) Primary systemic fungi (dimorphic) Histplasma capsulatum Blastomyces dermatitidis Coccidioides immitis

R ENAL CANDIDIASIS Acquired hematogenously Commonly originates from the GI tract Ascending infection is possible and occurs mainly in patients with: Nephrostomy tubes Other permanent indwelling devices and stents Immunocompromised patients at high risk: Cancer AIDS Chemotherapy

C ANDIDA CYSTITIS Mainly Candida Urinary catheters After bacteriuria Antibiotic therapy C. albicans prostatitis occurs infrequently in patients with diabetes, usually after instrumentation

Candida albicans in urine

V AGINITIS Vaginitis (infection of the vagina) The most common gynecologic condition Diagnosis based on the presence of symptoms of: abnormal discharge vulvovaginal discomfort Cervicitis may also cause a discharge and sometimes occurs with vaginitis

V AGINITIS Normal vaginal discharge maintain a normal healthy environment. Normal discharge is usually clear or milky with no malodour A change in the amount, color or smell Irritation, itching or burning Could be due to an imbalance of healthy bacteria in the vagina, leading to vaginitis

C AUSES OF VAGINITIS The most common causes of vaginitis in symptomatic women are: Bacterial vaginosis (40-45%) Vaginal candidiasis (20-25%) Trichomoniasis (15-20%)

P ATHOPHYSIOLOGY A complex balance of microorganisms is maintaining the normal vaginal flora Important organisms include: Lactobacilli Corynebacteria Yeast Aerobic and anaerobic bacteria can be cultured from the vagina from all age groups

P ATHOPHYSIOLOGY A number of factors can change the composition of the vaginal flora, including the following: Age Sexual activity (or abuse) Hormonal status Hygiene Immunologic status Underlying skin diseases

P ATHOPHYSIOLOGY The normal vaginal pH is At this pH, growth of pathogenic organisms usually inhibited Disturbance of the normal vaginal pH can alter the vaginal flora, leading to overgrowth of pathogens

P ATHOPHYSIOLOGY OF VAGINITIS The overgrowth of normally present bacteria, infecting bacteria, or viruses can cause symptoms of vaginitis

V ULVOVAGINAL CANDIDIASIS C. albicans, C. tropicalis, and C. glabrata are found as normal flora in 50% of women Vaginal candidiasis is the second most common cause of vaginitis Caused by C albicans in 85-90% of cases 5-10% caused by C. glabrata or C. parapsilosis

R ISK FACTORS OF FUNGAL VAGINAL INFECTION Oral contraceptive use Intrauterine device use Diabetes HIV or other immunocompromised states Long-term antibiotic use Pregnancy

ConditionDescriptionpH Candida vaginitis watery, white, cottage cheese-like vaginal discharges. The discharge is irritating to the vagina and the surrounding skin. low (4.0–4.5) Bacterial vaginitis discharge thin and milky with a strong fishy odour. It is associated with itching and irritation, but not pain during intercourse. elevated Trichomonas vaginalis Yellow-green, foamy, and bad-smelling discharge. There is pain upon urination, painful intercourse, and inflammation of the external genitals. elevated

V AGINAL WET MOUNT Normally, there are no yeast, bacteria, trichomons, or clue cells are found on the slide White blood cells are normally absent or very low in number (presence of white blood cells is a general sign of infection)

Candida in vaginal smear

V ALIDATION OF A SIMPLIFIED GRADING OF G RAM STAINED VAGINAL SMEARS Smears made of vaginal fluid and Gram stained and then assessed qualitatively as normal (grade I), intermediate (grade II), or consistent with BV (grade III)

a, b: grade Ia, i.e. mainly Lactobacillus crispatus cell types, plump quite homogeneous lactobacilli. c, d: grade Ib, i.e. non- L. crispatus cell types, long or short, thin lactobacilli.

i, j: grade II, i.e. mixture of Lactobacillus cell types and bacterial vaginosis-associated bacteria ( Gardnerella, Bacteroides- Prevotella and Mobiluncus cell types). k, l: grade III, i.e. bacterial vaginosis.

Clue cells of Gardnerella vaginalis infection

Gardnerella Vaginalis Clue Cells

T REATMENT Numerous topical treatments: Almost all azoles such as clotrimazole Azole drugs do not work for C. glabrata Oral therapies (not to be used in pregnancy) include fluconazole and itraconazole