Genitourinary Tract

Genitourinary Tract

• The urinary tract removes substances from the blood, regulates body processes, forms urine, and transports urine
• The genital system functions in reproduction

Urinary Tract Defenses

• Flushing action of urine helps prevent infection
• Desquamation of epithelial cells lining the urinary tract is a defense mechanism
• Most bacteria adapted to adhere to cells of the GI tract cannot gain a foothold in the urinary tract
• Acidic pH of urine inhibits bacterial growth
• Lysozyme and lactoferrin are antimicrobial substances
• Secretory IgA provides immune protection

Female Reproductive Tract Defenses

• Vary over a woman's lifetime
• A protective covering of secreted mucus provides a physical barrier
• Secretory IgA offers immunological protection
• The vagina has a low pH beginning in adolescence
• Biota prevent establishment and invasion of microbes that might harm a developing fetus during childbearing years

Normal Biota of the Genitourinary Tract

• The exact microbial composition varies among men and women
• The short, 3.5 cm female urethra can act as a pipeline for microbes from the anus
• Circumcision changes the composition of the known normal biota of the penis and possibly in the urethra

Normal Biota of the Male Genital Tract

• Residents are similar to those on the external penis
• Lactobacillus and Streptococcus are present
• Microbiota shifts when sexual activity begins
• Microbes associated with STIs can take up residence in the genital tract
• Men engaging in intercourse can harbor bacteria that produce vaginosis in females

Normal Biota of the Female Genital Tract

• Once thought that the uterus and organs above it were sterile. This is false!
• The vaginal canal is colonized by a diverse array of microorganisms
• Lactobacillus lowers the pH of the vagina
• Microbial makeup can shift dramatically during the menstrual cycle and pregnancy
• Biota of postmenopausal women remains stable over time
• Candida albicans is present at low levels in the healthy female reproductive tract

Urinary Tract Infections

• Cystitis: infection of the bladder
  • Signs and symptoms: Pain in the pubic area, frequent urges to urinate, pain during urination, and cloudy urine or blood in the urine.
• Pyelonephritis: infection of the kidneys
  • Symptoms of cystitis accompanied by back pain and high fever
  • Can result in permanent damage to the kidneys
• Urethritis: infection of the urethra

Causative Agent of Urinary Tract Infections

• Escherichia coli causes 80% of UTIs
  • UPEC/ExPEC uses adhesins to attach to urinary epithelia and exhibits motility that allows them to travel along mucosal surfaces
• Transmitted from the GI tract to the urinary system
• Treatment: Nitrofurantoin and Phenazopyridine

Urinary Tract Infections Disease Table

• Escherichia coli

  • Opportunism: transfer from the GI tract or environment via catheter
  • Adhesins, motility
  • Culture-based; antimicrobial susceptibilities checked
  • Hygiene practices, limit catheter usage for CA-UTIs
  • Nitrofurantoin treatment
  • Causes 90% of community UTIs and 50-70% of CA-UTIs

• Staphylococcus saprophyticus

  • Opportunism: transfer from the GI tract or environment via catheter
  • N/A
  • Culture-based; antimicrobial susceptibilities checked
  • Hygiene practices, limit catheter usage for CA-UTIs
  • Nitrofurantoin treatment
  • Causes a small percentage of community UTIs and a lower percentage of CA-UTIs

• Enterococcus

  • Opportunism: transfer from the GI tract or environment via catheter
  • N/A
  • Culture-based; antimicrobial susceptibilities checked
  • Hygiene practices, limit catheter usage for CA-UTIs
  • Based on susceptibility testing; Vancomycin-resistant Enterococcus is in the Serious Threat category in the CDC Antibiotic Resistance Report
  • Frequent cause of CA-UTIs

Leptospirosis

• Zoonosis associated with wild and domesticated animals
  • Leptospiremic phase: pathogen appears in blood and cerebrospinal fluid
  • Symptoms: sudden high fever, chills, headache, muscle aches, conjunctivitis, and vomiting
  • Immune phase: mild fever, headache due to leptospiral meningitis
  • Weil's syndrome: kidney invasion, hepatic disease, jaundice, anemia, neurological disturbances
• Long-term disability and death can result

Leptospira Interrogans

• Spirochete with tight, regular, individual coils with a bend or hook
• Adhesins and invasion proteins enable rapid penetration of host cells and entry into the bloodstream
• Shed in urine of infected animals and can survive for months in neutral or alkaline soil and water
• Treat with doxycycline or Penicillin G or ceftriaxone in severe cases

Leptospirosis Disease Table

• Causative Organism: Leptospira interrogans
• Common Modes of Transmission: Vehicle-contaminated soil or water
• Virulence Factors: Adhesins, invasion proteins
• Culture/Diagnosis: Slide agglutination test for antibodies in-patient blood sample and the CDC culture specimens, in the US
• Prevention: Avoiding contaminated vehicles
• Treatment: Doxycycline, penicillin G, or ceftriaxone
• Epidemiology: 100-200 cases per year (half in Hawaii); 80% seropositivity in tropical areas

Urinary Schistosomiasis

• Schistosoma haematobium lodges in the blood vessels of the bladder
• Signs and Symptoms:
  • Itchiness where the helminth enters
  • Fever, chills, diarrhea, cough
  • Urinary tract symptoms (late)
  • Can cause chronic infection

Urinary Schistosomiasis Pathogenesis and Diagnosis

• Pathogenesis/Virulence:
  • Invades intact skin
  • Attaches to vascular endothelium
  • Antigenic cloaking
• Diagnosis: Identify eggs in urine
• Cycle of Infection: cannot be broken as long as people are exposed to untreated sewage
• Treatment: Praziquantel

Urinary Schistosomiasis Disease Table

• Schistosoma haematobium is the causative organism
• The vehicle of transmission is contaminated water
• Antigenic cloaking and induction of granulomatous response are virulence factors
• Diagnosis is through identification of eggs in urine, PCR methods
• Prevent by avoiding contaminated vehicles
• Praziquantel is the treatment
• Endemic in Africa, the Middle East, India, and Turkey; 120 million infected in sub-Saharan Africa

Vaginitis

• Inflammation of the vagina, characterized by vaginal itching, burning, and discharge
• Causative agents:
  • Candida albicans ("yeast infection")
  • Trichomonas

Candida Albicans

• Dimorphic fungus
• Normal biota in 50-100% of humans
  • Mouth, GI tract, vagina
• Easily detectable on wet prep or Gram stain
• Grows in thick, curd-like colonies on vaginal walls
• opportunistic infection (disruption of normal biota)
• Topical and oral azole drugs treat vaginal candidiasis

Trichomonas Vaginalis

• Small, pear-shaped protozoa
• Often asymptomatic, especially in men
• In females, causes white to green frothy discharge
• Women infected during pregnancy are predisposed to premature labor and low-birth-weight infants
• Most common nonviral STI
• Metronidazole is the drug of choice

Vaginitis Disease Table

• Candida albicans
  • Causative agent of vaginitis
  • Opportunism transmission
  • N/A virulence factors
  • Diagnosis via wet prep or Gram stain
  • N/A prevention
  • Use topical or oral azole drugs for treatment OTC
  • Distinctive feature is white, curd-like discharge
  • Causes 20% of vaginitis cases in the US -75% of all women report having had at least one candidiasis in their lifetime
• Trichomonas vaginalis
  • Causative agent of vaginitis
  • STI- direct contact for transmission
  • N/A virulence factors
  • Protozoa seen on Pap smear or Gram stain; culture is the gold standard for diagnosis
  • Use barrier for prevention during intercourse
  • Treatment Metronidazole, tinidazole
  • Discharge may be greenish -7 to 8 million women infected per year in the US

Vaginosis

• Common in women, childbearing years
• Does not induce inflammation in the vagina
• Discharge - fishy odor/itching in vagina
• Likely result of lactobacilli reduction
• Mixed infection involving Gardnerella vaginalis, Atopobium, and Mobiluncus organisms
• Untreated Vaginosis can lead to PID, infertility, ectopic pregnancies
• Not a Sexually transmitted infections but is still can be more common among sexually active women

Vaginosis Disease Table

• C.O: Mixed infection
• Transmission: Opportunism or STI
• VF: N/A
• CD: Visual exam of vagina, or clue cells seen in Pap smear or other smear
• Prevention: N/A
• Treatment: Metronidazole or clindamycin
• DF: Discharge may have a fishy smell
• EF: United States: estimated 7.4 million new cases per year; internationally: prevalence rates vary by country from 20% to 51%

Prostatitis

• Inflammation of the prostate gland
  • Acute: Generally, a bacterial infection from GI tract
  • Chronic: biofilms resistant to antibiotics Common Symptoms
  • Pain in the groin and lower back
  • Frequent urge to urinate
  • Difficulty urinatin
  • Blood in the urine
  • Painful Ejaculation

Prostatitis Disease Table

• The causative organisms are GI tract biota
• Most common mode of transmission is an endogenous transfer from the Gl tract; otherwise unknown
• Virulence Factors: Various
• Diagnosed with a digital rectal exam to examine the prostate; culture of urine or semen
• Prevention: None
• Treat with antibiotics, muscle relaxers, alpha-blockers
• Pain in the genital area and/or back, difficulty urinating are distinctive features
• 50% of men experience during their lifetime

Signs and Symptoms of Gonorrhea

• Males: urethritis, painful urination, yellowish discharges; many asymptomatic
• Females: mucopurulent/bloody vaginal discharge, painful urination
  • Salpingitis: inflammation of fallopian tubes
  • PID (pelvic inflammatory disease)
• Children born to carrier moms can get it passing thru birth canal
  • Gonococcal eye infections can result in blindness

Neisseria Gonorrhoeae

• Pyogenic, gram-negative diplococcus
• Fimbriae attach to mucosal epithelial cells and confuse the immune system (phase variation)
• Transmitted through all forms of sexual contact which increases one risky for HIV infection
• Antibiotic-resistant isolates exist

Chlamydia Disease

• The most common reportable infectious disease in the United States
• Symptom
  • Males: discharge and painful urination
  • Females: cervicitis, discharge, salpingitis, PID ( Up to 75% cases are asymptomatic )
  • Lymphogranuloma venereum: (Invasion of lymphatic tissues,Headache, fever, muscle aches)

Chlamydia Trachomatis

• Small, gram-negative
• Obligate intracellular parasite
• The cell wall prevents phagosome-lysosome fusion
• Broad distribution and steadily increase through population
• Drug Treatment ( azithromycin or ceftriaxone )
• Common coinfection with gonorrhea

Genital Discharge Diseases

• Gonorrhea
• Cause: Neisseria gonorrhoeae
• transmission: Direct contact (STI), also vertical
• virulence:Fimbrial adhesins, antigenic variation, IgA protease, membrane blebs/ endotoxin
• diagnostics: Gram stain in males, rapid tests (PCR, ELISA) for females, culture on Thayer- Martin agar
• prevention: Avoid contact; condom use treatment:Coinfection by gonorrhea and Chlamydia should be assumed; treat with ceftriaxone + azithromycin; antibiotic-resistant strains onUrgent Threat list from CDC distinctives: Rare complications include arthritis, meningitis, endocarditis
• effects: Eye infections, blindness
• epidemiology: United States: increased 67% between 2013 and 2017; internationally: 26 million cases -Chlamydia
• Cause: Chlamydia trachomatis
• transmission: Direct contact (STI), vertical
• virulence:Intracellular growth resulting in avoiding immune system and cytokine release, unusual cell wall preventing phagolysosome fusion
• diagnostics:PCR or ELISA, can be followed by cell culture
• prevention: Avoid contact; condom use
• treatment:Coinfection by Chlamydia and gonorrhea should be assumed; treat with ceftriaxone + azithromycin
• distinctives: More commonly asymptomatic than gonorrhea effects : Eye infections, pneumonia
• epidemiology: United States: 1.7 million cases in 2017, 22% higher than 2013; internationally: eye infection (trachoma) has 90% prevalence rate in developing world

Syphilis

• Recognized in 15th century Europe
• Scholars once thought was introduced from the New World
• Analysis found predecessor traveled to the New World from Old World
• Tuskegee Study (1932): scientists unethically studied subjects without treatment

Syphilis Signs and Symptoms

• Primary Syphilis: - Chancre:
• Appearance: Small, red, hard bump that appears at the site of the entry of the pathogen
• Location: Appear on internal and external genitalia, lips, oral cavity, nipples, fingers, or around the anus
• Secondary Syphilis: Fever, headache, sore throat Lymphadenopathy, red or brown rash on all skin surfaces, including palms of the hands and soles of the feet -Often accompanied by hair loss

Additional Signs and Symptoms of Syphilis

• Latent/Tertiary Syphilis:
• Damage to small arteries and aortic wall
• Gummas develop in the liver, skin, bone, cartilage
• Neurosyphilis: headaches, convulsions, atrophy of the optic nerve, blindness, dementia, Argyll-Robertson pupil
• Congenital Syphilis:
• Inhibits fetal growth and disrupts critical periods of development
• Causes fetal abnormalities to spontaneous miscarriage or stillbirth

Treponema Pallidum

• A thin, uniformly coiled cell with a gram-negative cell wall that attaches to epithelial cells
• Transmitted through sexual encounter
• Barrier condoms provide protection
• Penicillin G: drug of choice

Chancroid

• Haemophilus ducreyi is causative organism
• Pleomorphic gram-negative rod forms a soft chancre
• often painful, and sometimes unnoticed in women common in tropics and subtropics.
• Sex workers and people who have poor hygiene often contract the disease.
• more common to infect uncircumcised men
• Azithromycin and ceftriaxone are effective

Genital Herpes

• Herpes is caused by simplex viruses: HSV-1 and HSV-2
• You will experience single/multiple vesicles on the genitalia, perineum, thigh, and buttocks
• Filled with a clear fluid and intensely painful to the touch Recurrent episodes of lesions occur due to viral latency
• Rarely causes encephalitis

Neonatal Herpes Simplex:

• Occurs when infant comes in contact to it during birth

• Result: Infections of mouth, skin, and eyes: causes about 30% mortality rate If it infects the Infants CNS, 50% to 80% mortality rate If an expectant mom has evidence of an outbreak, the time of delivery necessitates a Cesarean section

HSV-1 and HSV-2

• DNA viruses with icosahedral capsids and envelopes with glycoprotein spikes
• Become latent in the ganglion of the lumbosacral spinal nerve trunk
• Reactivation occurs through stress, UV radiation, injury, menstruation, or other microbial infection Transmission occurs through direct exposure to secretions containing the virus The use of Acyclovir and its derivatives reduces viral shedding and occurrence of lesions but are not curative

Genital Ulcer Diseases

• Syphilis
  • Treponema pallidum Causes
  • transmitted: Direct contact and vertical
  • Risk Factors: Lipoproteins
  • diagnostics: Direct tests,immunofluorescence, dark-field microscopy, and blood tests, Treponemal and nontreponemal antibodies, PCR
  • Preventive measure: Abx and avoiding contact
  • Treatment: With Penicillin G
• Chancroid
  • transmitted: Direct contact (vertical transmission not documented)
  • Hemolysin (exotoxin) -Diagnostics: Rule out other ulcer diseases
  • Preventative measure: Avoiding contact
  • Treatment: Ceftriaxone or azithromycin-
• Herpes
  • transmitted: Direct contact; vertical
  • virulence: Latency
  • DX: Clinical presentation, PCR, Ab tests, growth of virus in cell culture
  • Preventive measure: Avoiding contact, antivirals can reduce recurrences Treatment: Acyclovir and derivatives

Genital Ulcer Diseases

• Syphillis:

• three stages, possibly fatal

• Congenital syphilis to fetus

  • US and Estimated are 30k cases annually.

• Chancroid: No systemic fetal exposure

  • US has little to none annually (estimated about 7 million)

• Herpes:

• Fetus can acquire Blindness disseminated herpes infection. Estimates a 25% pervasiveness.

Human Papillomaviruses

• Causative agents of genital warts
• Symptom:
  • Females: growths on the vulva/vagina; silent cervix infections
  • Both has warts on the anus, on the skin of the groin between the thigh and pelvis
  • Males: Penis/scrotum warts
  • Condyloma acuminata (branching cauliflower like masses)

Cancer and HPV

• HPV causes the majority of cervical cancers
• 4000 women die in the US yearly from cervical cancer
• There is a Link between HPV increased with oral sexual activity
• There is genitourinary tract cancer for males with HPV Infections

Other Human Papillomavirus Details

• Causative agent is nonenveloped DNA viruses in the Papovaviridae family
• Linked with cervical cancer
  • HPV -18
• Common in woman under 25

Prevention of Human Papillomaviruses

• Avoid direct, unprotected sexual contact Gardasil vaccine:
• It can be protect to all women: two strains and cause from wart related. Vaccine and Pap smear for a long cancer screen.

Molluscum Contagiosum

• Unclassified virus in Poxviridae family
• Warts, mucous membranes
• More serous people can effect the immune system
• Fomites and in Auto

Wart Diseases Disease Table

• HPV: H-PV

• The way it spread is direct contact, autoinoculation, and indirect Contact Oncogenes are malignant types of HPV Tests such as: PCR, Clinical diagnosis

• Molluscum disease is direct virus, clinical treatment, and also Histology PCR

Wart Diseases Disease Table

• HPV Infection can be a factor cause laryngeal infection Effects in United States has 6% factor 10% of children affect the united stats.
• *Helminths
• Bacteria Viruses
• *Molluscum Disease factor: Effect in United States Affect to 2-10% Children

Group B Streptococcus “Colonization” – Neonatal Disease

• 10 - 40% of Women with it
• Beta-streptococcus Lancefield group The infant will be effect from birth process (canal)
• Affect threat such as bloodstream infections, meningitis,

Group B Streptococcus Colonization Disease Table

Is streptococcus.

• The transmissions are more on Verticle Virulent with N\A.