Infections of the Urinary & Reproductive Systems

1. Uniwersytet Mikołaja Kopernika w Toruniu Collegium Medicum w Bydgoszczy Infections of the Urinary & Reproductive Systems dr hab. n. med. Marek Szymański KATEDRA i KLINIKA POŁOŻNICTWA,CHORÓB KOBIECYCH i GINEKOLOGII ONKOLOGICZNEJ

2. Structures of Reproductive System • Females • Urinary and reproductive systems are distinct

3. 23.2 Normal Biota of the Urinary Tract • Outer region of the urethra harbors some normal biota • Nonhemolytic streptococci, staphylocci, corynebacteria, and some lactobacilli • Normal Biota of the Male Genital Tract • Same as described for urethra, since the urethra is the terminal “tube” • Normal Biota of the Female Genital Tract • The vagina harbors a normal population of microbes • Lactobacillusi species • Candida albicans at low levels

4. Cystitis • Cystitis: sudden onset of symptoms • Pain in the pubic area • Frequent urges to urinate even when the bladder is empty • Burning pain accompanying urination (dysuria) • Cloudy urine • Orange tinge to the urine (hematuria) • Fever and nausea • Back pain indicates kidneys may also be involved

5. 23.4 Reproductive Tract Diseases Caused by Microorganisms • Many are transmitted through sexual contact, but not all are • Three broad categories of sexually transmitted diseases • Discharge diseases • Ulcer diseases • Wart diseases

6. Vaginitis and Vaginosis • Inflammation of the vagina • Vaginal itching to some degree • Burning and sometimes a discharge occurs • Symptoms depend on the etiologic agent

7. Candida albicans • Normal biota living in low numbers • If grows rapidly and causes a yeast infection, white vaginal discharge occurs

8. Gardnerella species • Infection called vaginosis rather than vaginitis because inflammation in the vagina does not occur • Vaginal discharge with a very fishy odor, especially fater sex • Itching is common

9. Trichomonas vaginalis • Asymptomatic infections in approximately 50% of females and males • Some people experience long-term negative effects

10. Discharge Diseases with Major Manifestation in the Genitourinary Tract • Increase in fluid discharge in male and female reproductive tracts • Includes trichomoniasis, HIV, gonorrhea, and Chlamydia infection

11. Gonorrhea • N. gonorrhoeae is the etiologic agent- also known as the gonococcus • Symptoms in the male • Urethritis, painful urination and a yellowish discharge • Can occasionally spread from the urethra to the prostate gland and epididymis • Scar tissue in the spermatic ducts during healing can render a man infertile (rare)

12. Symptoms in the Female • Likely that both urinary and genital tracts will be infected • Mucopurulent or bloody vaginal discharge • Painful urination if urethra is affected • Major complications occur when the infection ascends from the vagina and cervix to higher reproductive structures • Salpingitis • Pelvic inflammatory disease

13. Chlamydia • Most common reportable infectious disease in the U.S. • Majority of cases are asymptomatic • Symptoms in males • Inflammation of the urethra • Symptoms mimicking gonorrhea • Untreated infections may lead to epididymitis • Symptoms in females • Cervicitis • Discharge • Salpingitis • May lead to PID

14. Genital Ulcer Diseases • Three common infectious conditions resulting in lesions on a person’s genitals • Syphilis, chancroid, and genital herpes • Having one of these diseases increases the chances of infection with HIV because of the open lesions

15. Syphilis • Three distinct clinical stages: primary, secondary, and tertiary • Latent periods of varying duration also occur • Transmissible during the primary and secondary stages, and the early latency period between secondary and tertiary • Largely nontransmissible during late latent and tertiary stages

16. Primary Syphilis • Appearance of a hard chancre at the site of entry of the pathogen (after an incubation period of 9 days to 3 months) • Lymph nodes draining the affected region become enlarged and firm • Chancre filled with spirochetes • Chancre heals spontaneously in 3 to 6 weeks but by then the spirochete has moved into the circulation

17. Secondary Syphilis • 3 weeks to 6 months after the chancre heals • Many systems have been invaded • Fever, headache, sore throat, followed by lymphadenopathy and a red or brown rash that breaks out on all skin surfaces • Hair often falls out • Lesions contain viable spirochetes and disappear spontaneously in a few weeks • Major complications occur in bones, hair follicles, joints, liver, eyes, and brain

18. Latency and Tertiary Syphilis • Highly varied latent period, can last for 20 years or longer • Tertiary syphilis is rare because of the use of antibiotics • Major complications occur by this stage • Cardiovascular syphilis- weakens the arteries in the aortic wall • Gummas develop in tissues such as the liver, skin, bone, and cartilage

19. Congenital Syphilis • From a pregnant woman’s circulation into the placenta and fetal tissues • Inhibits fetal growth • Disrupts critical periods of development

20. Chancroid • No systemwide effects • Infection usually begins as a soft papule at the point of contact • Develops into a soft chancre (painful in men, but may be unnoticed in women) • Inguinal lymph nodes can become swollen and tender

21. Wart Diseases • Human papillomavirus (HPV) • Causative agents of genital warts • An individual can be infected with HPV without having warts, however • MolluscumContagiosum • Unclassified virus in the pox family • Can take the form of skin lesions • Wartlike growths on the mucous membranes or skin of the genital area

22. Group B Streptococcus “Colonization”- Neonatal Disease • 10% to 40% of women in the U.S. are colonized asymptomatically by group B Streptococcus • When these women become pregnant, about half of their infants become colonized by the bacterium during passage through the birth canal • Small percentage of infected infants experience life-threatening bloodstream infections, meningitis, or pneumonia

23. Normally urine and urinary tract above bladder are sterile • Urethra contains normal resident flora • Lactobacillus, Staphylococcus, Corynebacterium and Streptococcus • Normal flora varies in female genital tract • Depends on hormones • Lactobacillus

24. Urinary Tract Infections May include any or all of the organs • Urethritis – inflammation of urethra • Cystits – inflammation of the urinary bladder • Ureteritis –inflammation of the ureters • Pyelonephritis – inflammation of the kidneys

25. Causative agents: • Usually intestinal flora • E. coli – most common • Proteus and Klebsiella • Psudomonas • Typically nosocomial • Non-enteric bacteria • Non-invasive and opportunistic

26. Signs and Symptoms Dysuria – frequent, painful urination cloudy urine with foul odor; may have pale red color 9due to blood in urine) Tenderness of pelvic area May have slight fever

27. Prevention • Adequate fluid intake (2-4 liters daily) • Cranberry juice may help prevent attachment of bacteria • Void urine immediately after sex • Proper personal hygiene • Treatment • Sulfonamides or cephalosporins

28. Bacterial Vaginosis • Causative agent: • May be caused by multiple anaerobic bacteria • Gardnerella vaginalis • Change in vaginal flora • pH increases and allows overgrowth of pathogen

29. Signs & Symptoms • Thin, grayish-white vaginal discharge • Can be slightly bubbly • Pungent ‘fishy’ odor • Some itching and irritation • 50% asymptomatic

30. Prevention • No proven prevention • Associated with multiple sexual partners, vaginal douching, anti-microbial therapy • Treatment • Metronidazole • Vinegar douche • Reestablishment of lactobacilli

31. Vaginal Candidiasis • Causative agent • Candida albicans • Normal flora for up to 80% of women • Opportunistic pathogen • Dimorphic

32. Signs & Symptoms • White mucoid colonies on vaginal mucus membranes and labia • Severe itching and burning • White curd-like discharge

34. Vaginal Cancer

35. Vaginal Cancer • Rare tumor representing only 1-2% of all gynecologic malignancies • 80-90% are metastatic • Mean age of patients with primary vaginal cancer is 60-65 years • Most primary tumors are squamous cell in origin • HPV DNA identified in VAIN

36. Vaginal Cancer precursors • VAIN – avg age of VAIN 3 is 53 • Ratio of VAIN to CIN is 1:23 • 5% progress to Vaginal Ca • Hallmark of VAIN • cytologic atypia-Pleomorphisim, irreg nuclear contours and chromatin clumping • Abnormal maturation • nuclear enlargement

37. Vaginal Cancer precursors • VAIN 3 • usually occurs in upper third of vagina and is multifocal and diffuse in half the cases. • 1/3 of patients have a hx/o CIN • CIN coexists w/ VAIN in 10-20% of pts • Colposcopic findings are similar to those of CIN (aceto white epithelium with punctations and mosaic patterns)

38. Vaginal Cancer precursors VAIN 1- Proliferation of basal layer Koilocytotic atypia Enlarged pleomorphic nuclei vacuolated cytoplasm

39. Vaginal Cancer precursors VAIN 2- Proliferation of basal layer,crowding and loss of polarity Koilocytotic atypia Enlarged pleomorphic nuclei vacuolated cytoplasm

40. Vaginal Cancer precursors VAIN 3 Increased proliferation of abnormal basal and parabasal cells replacing full thickness of epithelium

41. Vaginal Cancer precursors • Treatment Options for VAIN • Excisional Bx for small lesions • Partial Vaginectomy • Laser Vaporization • Intravaginal 5FU cream

42. Vaginal Cancer: Predisposing Factors • Low socioeconomic status • History of genital warts • Vaginal discharge or irritation • Previously abnormal Pap smear • Early hysterectomy • Previous pelvic radiation (?) • In-utero exposure to DES

43. Anatomy of the Vagina • Muscular dilatable tube averaging 7.5 cm in length • Vaginal wall composed of three layers: mucosa, muscularis, adventitia. • Epithelium normally contains no glands and changes little during reproductive cycle • Lymphatic drainage of upper vagina via pelvic nodes while lower vagina drains via femoral and inguinal nodes.

44. Natural History and Patterns of Spread • Lesions usually found in the upper vagina on the posterior wall • Vaginal primary tumors may spread along mucosa to cervix or vulva (changes diagnosis) • Direct extension to bladder, parametria, paracolpos, rectum, cardinal ligaments, uterosacral ligaments

45. Gross and microscopic Findings • 50% of Vag Ca ulcerative • 30% are exophytic • 20%are annular and constricting

46. Natural History and Patterns of Spread • Any of the nodal groups may be involved regardless of the location of the tumor • Inguinal nodes most often involved if lesion is in the lower 1/3 of the vagina • Clinically apparent inguinal node mets seen in 5-20% of patients • Incidence of pelvic nodes varies with stage and location of the tumor

47. Lymphatic Drainage of Vagina

48. Clinical Presentation • Abnormal vaginal bleeding • 50-75% of patients with primary tumors • Dysuria • Pain

49. Diagnostic Work-up • Complete history and physical • Speculum examination and palpation of the vagina • Bimanual pelvic and rectovaginal examination • Pap smear, colposcopy, directed biopsies

50. Diagnostic Work-up • Cystoscopy • Proctosigmoidoscopy • Chest X-ray • IVP • Barium enema • Computed Tomography • MRI (84% PPV, 97% NPV)