Ch 26 & 27- Alterations of the male reproductive system & STIs

• Epididymitis generally affects sexually active young men (under 35) and rarely occurs before puberty
• The most common cause of epididymitis is a sexually transmitted microorganism such as N. gonorrheoeae or C. trachomatis
• Men who engage in unprotected anal intercourse are at risk of developing sexually transmitted epididymitis due to organisms such as Escherichia coli, Haemophilus influenza, TB, Cryptococcus, or Brucella
• In men over 35, epididymitis may be caused by enterobacteriaceae and Pseudomonas aeruginosa, often associated with UTI and prostatitis

Other Causes of Epididymitis

• Chemical inflammation from sterile urine reflux into the ejaculatory ducts is a potential cause
• Urethral strictures, congenital posterior valves, and excessive physical straining can contribute to epididymitis

Complications of Epididymitis

• Possible complications include abscess formation, testicular infarction, recurrent infection, and infertility
• Testicular infarction is likely caused by thrombosis (blood clot obstruction) of prostatic vessels due to severe inflammation
• Recurrent epididymitis can result from inadequate initial treatment or failure to address predisposing factors
• Chronic epididymitis leads to scarring of the epididymal endothelium; once scarring occurs, treatment is necessary

Four Stages of Syphilis

Primary Syphilis

• Local bacterial invasion occurs, with the organism multiplying in the epithelium and producing a granulomatous tissue (chancre)
• Consider syphilis in the presence of any open lesion
• A chancre presents as an eroded, painless, firm, and indurated ulcer less than 2cm in diameter
• Some microorganisms drain with lymph into adjacent lymph nodes
• Cell-mediated and humoral immune responses are stimulated within the nodes and at the chancre site
• Untreated chancres typically heal in 2-8 weeks, disappearing without a scar

Secondary Syphilis

• Systemic spread occurs as bloodborne bacteria reach all major organ systems
• The immune system can suppress the infection during a period following systemic spread
• Even without treatment, spontaneous resolution of skin lesions can occur, leading to a latent stage (relapses possible for years)
• Presents with symptoms like low-grade fever, malaise, sore throat, hoarseness, anorexia, generalized adenopathy, headache, joint pain, pruritus, and skin or mucous membrane lesions/rashes (e.g., condylomata lata)
• In women, lesions appear in the perineum, vulva, inner thigh, anal area, and groin
• In men, lesions appear in the inner thigh and anal area

Latent Syphilis

• Divided into early and late stages, but difficult to delineate between them
• Characterized as a silent infection, where medical history and serologic studies indicate syphilis without clinical manifestations
• Transmission of infection is possible during both late and early latent stages

Tertiary Syphilis

• The most severe stage, associated with significant morbidity and mortality (non-infectious disease)

• Destructive skin, bone, and soft tissue lesions called gummas may develop due to a severe hypersensitivity reaction to the microorganism

• Cardiovascular complications include aneurysms, heart valve insufficiencies, and heart failure

• CNS manifestations of neurosyphilis may develop, potentially occurring at any stage of syphilis infection

Evaluation of Syphilis

• Early diagnosis relies on darkfield microscopy of specimens from the infected site; repeat the test for 2 successive days if the initial result is negative

• Two categories of serologic testing:

  • Nontreponemal antigen tests detect the presence of reagin (antibodies present in syphilis) in serum, providing indirect evidence of infection
  • VDRL antigen/RPR tests yield positive results in >50% of individuals with primary and 100% with secondary syphilis, making them useful for screening and assessing treatment response, but they have high rates of false positives
    • Treponemal antibody tests are performed if the VDRL antigen (RPR test) is positive to assess for antibody response to T. Pallidum
    • Includes enzyme immunoassays (EIAs), FTA-ABS test, and TP-PA assay

• During the latent phase, patients may have positive serologic evidence; confirmation requires the presence of treponemata in cerebrospinal fluid

Treatment for Syphilis

• Preferred treatment for all stages is parenteral injection of benzathine PCN G

• No other types of penicillin are effective

• If infected for less than 1 year, a single IM dose is appropriate

• If infected for over 1 year, asymptomatic, and presumed to be in the late stage, treatment involves 3 weekly injections

• Penicillin is safe for pregnant women to prevent vertical transmission to the baby

• Non-pregnant women with PCN allergies receive Doxycycline 100mg BID for 14 days

• Pregnant women with PCN allergies should be desensitized and treated with PCN G because tetracycline causes permanent discoloration of the fetus's teeth

• Repeated assessment of VDRL and RPR titers determines treatment effectiveness; titers should decrease 4-fold

• Sexual partners are examined and treated, and condoms are recommended until treatment is complete

• If infants require treatment, PCN is the drug of choice

• Infants receive serologic tests for syphilis every 2-3 months until the test becomes nonreactive, or the titer has decreased 4-fold

• Typical symptoms found on assessment during the secondary stage: low-grade fever, malaise, and sore throat

• Secondary stage presents with variable systemic symptoms, including low-grade fever, malaise, sore throat, hoarseness, anorexia, generalized adenopathy, headache, joint pain, and skin or mucous membrane lesions/rashes

• Each year in the US, 19 million individuals contract a sexually transmitted infection; half of those infected are younger than 25

• Adolescents have the greatest risk for STI exposure and infection due to risk-taking behavior, unprotected intercourse, or selection of high-risk partners.

• Adolescent women may also have an increased susceptibility to infections due to cervical immaturity

• STI is prevalent in all socioeconomic and racial or ethnic groups

• CDC does not require that all STIs be reported, so most private MD's don't but Health Departments do

• Etiology may be bacterial, viral, protozoal, parasitic, or fungal

Cervical Cancer

• Persistent infection with high-risk HPV serotypes increases the risk to developing cervical or anal cancer
• More than 120 different types of HPV have been identified.
• Over 40 serotypes are unique to the stratified squamous epithelium of the genital area
• Divided into serotypes with high risk and low risk
• High risk = cervical cancer
• Low risk = benign lesions
• High risk 16 and 18 = 70% of anogenital cacners
• Low risk subtypes can coexist with high-risk types, but do not cause cancer
• Most cases occur in post-menopausal women ages 50-60
• Mortality of black women twice as high
• Fortunately, transient and resolve on time

Teenage Girls and STIs

• Teenage girls are more susceptible to STIs due to:
  • Risk taking Behavior
  • Incrased infection susceptibility
  • HPV increased infection suscepitbility
• In older women, the transformation zone/cancer is highly susceptible to HPV's oncogenic effects