Chapter 24 Infectious Diseases Affecting the Genitourinary System

2 Genitourinary system Urinary system Reproductive system

3 Urinary system Removes substances from the blood Regulates body processes Forms urine to transport out of body

4 The major parts of the male reproductive system. Fig The male reproductive system.

5 Structures of the Urinary and Reproductive Systems Structures of the Male Reproductive System –Testes –Scrotum –System of ducts –Accessory glands –Penis Microorganisms enter through the urethra, skin of the penis © 2012 Pearson Education Inc.

6 The major parts of the female reproductive system. Fig The female reproductive system.

7 Structures of the Urinary and Reproductive Systems Structures of the Female Reproductive System –Ovaries –Uterine tubes –Uterus –Vagina –External genitalia Microorganisms enter through the vagina © 2012 Pearson Education Inc.

8 Protection Flushing action (desquamation) Urine contains antibacterial proteins (IgA), lysozyme and lactoferin Female vagina Mucous membrane (secretory IgA) Acidic pH (fermentation)

9 Normal flora Both male and female –Outer regions of the urethra –Non hemolytic streptococci, staphylococci, corynebacteria, some lactobacilli Female –Vagina –Bacterial and some fungi

10 Structures of the Urinary and Reproductive Systems Normal Microbiota of the Urinary and Reproductive Systems –Urinary system Urethra supports colonization by some microorganisms –Includes Lactobacillus and Staphylococcus Remainder of the urinary organs are sterile –Male reproductive system Regions above the prostate are sterile –Female reproductive system The vagina is colonized by various microorganisms depending on hormone levels © 2012 Pearson Education Inc.

11 Diseases Urinary tract Reproductive tract Genital ulcer Warts Group B streptococcus

12 Urinary tract Bacterial infection Cystitis Pyelonephritis Urethritis Leptospirosis Urinary schistosomiasis

13 Bacterial infection Escherichia coli Staphylococcus saprophyticus Proteus mirabilis Bacterial infection Acquired from GI tract More common in women Most common nosocomial infection

14 Urinary Tract Infection Many bacteria – E. coli, Klebsiella sp. Pseudomonas, S. saprophyticus Contaminants enter the urethra and travel upward. Symptoms – frequent urination, dysuria (painful urination), fever, flank pain, blood in urine. Prevention/treatment – Antibiotics, plenty of water. Symptoms are natural defense mechanisms Cranberry juice?

15 Features of urinary tract infections. Checkpoint 23.1 Urinary tract infections (cystitis, pyelonephritis)

16 Leptospirosis Bacterial infection Approximately 200 different serotypes Kidney infection Zoonotic –Present in animal urine

17 Leptospira interrogans, the causative agent of leptospirosis, is a spirochete bacteria. Fig Leptospira interogans, the agent of leptospirosis.

18 Features of leptospirosis. Checkpoint 23.2 Leptospirosis

19 Urinary schistosomiasis Helminth infection Lodges in the blood vessels of the bladder Obstruction of the bladder

20 Features of urinary schistosomiasis. Checkpoint 23.3 Urinary schistomiasis.

21 Nonvenereal Diseases of the Reproductive Systems Staphylococcal Toxic Shock Syndrome –Signs and Symptoms Sudden-onset fever, chills, vomiting, diarrhea, low blood pressure, confusion, and severe red rash Individuals go into shock if untreated –Pathogen and virulence factors Caused by some strains of S. aureus –These strains produce toxic shock syndrome toxin © 2012 Pearson Education Inc.

22 Nonvenereal Diseases of the Reproductive Systems Staphylococcal Toxic Shock Syndrome –Pathogenesis and epidemiology Absorption of toxin into blood triggers toxic shock syndrome Most cases occur in menstruating females –Diagnosis, treatment, and prevention Diagnosis based on signs and symptoms Considered medical emergency Requires removal of foreign material and antimicrobial drugs Avoiding tampons or using less absorbent tampons reduces risk © 2012 Pearson Education Inc.

23 Figure 24.3 The incidence of staphylococcal toxic shock syndrome in the U.S., Super-absorbent tampons withdrawn Food and Drug Administration requires tampon labeling Year Number of cases

24 Reproductive tract Vaginitis and vaginosis Discharge diseases Genital ulcer diseases Warts Group B Streptococcus

25 STD’s in general 12 million are diagnosed each year in the U.S. Most of these bacteria are fragile and don’t live long outside the body. We thought STD’s would go by the wayside with antibiotics, but not so, why? STD’s are more serious for women, more difficult to detect, easier to transmit, possible infertility, cancer, fetal death, birth defects and newborn blindness.

26 Vaginitis and vaginosis Fungi - vaginitis Mixed bacteria – vaginosis (noninflammatory) Bacterial - vaginitis

27 Bacterial vaginosis Overgrowth of normal bacterial flora, decrease in lactobacilli 16% of women may have BV, many with no symptoms Symptoms: Fishy/musty odor often after intercourse, pain, itching, burning, profuse white or gray discharge.

28 Can increase risk of PID (Pelvic Inflammatory Disease) after surgery, and increases risk of acquiring other STD’s Douching, multiple partners increase risk. Diagnoses: pelvic exam, sample of discharge. Rx – antibiotics orally, or vaginally

29 Gram stain of the fungi Candida albicans, the causative agent of vaginitis. Fig Gram stain of Canidida albicans in a vaginal smear.

30 For mixed infections, Gardnerella is the major bacteria involved, and can be identified by the formation of clue cells. Fig Clue cell in bacterial vaginosis.

31 Protozoan STDs Trichomoniasis –Signs and symptoms Females have vaginal discharge and vaginal irritation Males are typically asymptomatic –Pathogen and virulence factors Caused by Trichomonas vaginalis –Pathogenesis and epidemiology Transmission primarily via sexual intercourse Most common curable STD in women Trichomoniasis increases risk of infection by HIV © 2012 Pearson Education Inc.

32 Trichomonas vaginalis is a protozoan infection, and is considered a sexually transmitted disease (STD). Fig Trichomonas vaginalis adhering to humans cells.

33 Figure Trichomonas vaginalis Flagella Undulating membrane

34 Features of vaginitis and vaginosis. Checkpoint 23.4 Vaginitis/vaginosis

35 Discharge diseases Increase in fluid discharge for both male and female Gonorrhea Chlamydia

36 Gonorrhea

37 Gonorrhea Bacterial infection Strictly a human disease - STD Phase variation – fimbrial proteins IgA protease Male - urethritis Female –Salpingitis –Pelvic inflammatory disease (PID) Can affect other organs (skin, eye) Infant eye infections

38 Gonorrhea – Neisseria gonorrhoeae 700,000 new cases each year –Highest groups: –20-24 yr old men –15-19 yr old men –15-19 yr old women Most are asymptomatic Symptoms: men 3-6 days later, burning during urination, frequent urination, yellowish green pus discharge, Swollen testes.

39 Symptoms: women (if any at all) Increased discharge, itchy red vulva, PID if it reaches the uterus and fallopian tubes. Epididymitis in men Diagnose: culture on thayer martin media Rx – penicillin, not anymore! Larger doses of stronger antibiotics

40 N. gonorrhoeae, from a male patient with gonorrhea, are diplococcus inside neutrophils. Fig Gram stain of urethral pus from a male patient With gonorrhea.

41 Neisseria gonorrhoeae, the causative agent of gonorrhea, can cause peritonitis and PID, which can result in ectopic pregnancies. Fig Invasive gonorrhea in women.

42 N. gonorrhoeae can cause eye infections in new borns. Fig Gonococcal ophthalmia neonatorum in a Week-old infant.

43 Figure 24.5 Incidence of civilian gonorrhea in the U.S.-overview

44 Chlamydia Bacterial infection - Most common reportable STD in the U.S. Elementary body – infective form Reticulate body – reproductive form Intracellular Asymptomatic Male - nongonococcal urethritis Female - PID Infant conjunctivitis Rare - lymphogranuloma venereum

45 Chlamydia (Chlamydia trachomatis) Most frequently reported est. 2.8 million Americans each year. 72% are between ages Texas = #20 and Houston #30 of 63 cities. Can be asymptomatic –75% of women, 50% men –Enter body through scrapes or cuts –Infect conjunctival cells or cells lining mucous membranes –Infection in adolescence increases risk of cervical cancer Symptoms: 1-3 weeks after exposure Women: abnormal discharge, burning during urination, lower abdominal pain, back pain, nausea, fever. Men: discharge from penis, burning during urination,

46 If infection lingers 40% of women will develop PID, female infertility, infection of newborns Diagnosis: Women - Isolate sample for culturing Men – urine sample will suffice. Rx – Antibiotics 50% of babies born to infected mothers will get chlamydial conjunctivitis, 25% C. pneumonia

47 Chlamydia trachomatis, the causative agent of chlamydia, adheres to the mucosa of the fallopian tube. Fig Chlamydia trachomatis adhering to mucosa of fallopian tube.

48 Chlamydia is an intracellular pathogen, and the life cycle involves an infectious elementary body stage and a reticular body or multiplying stage. Fig The life cycle of Chlamydia.

49 Figure 24.9 The developmental forms and life cycle of Chlamydia-overview

weeks after exposure, sore appears, fever, then heals. Swelling of inguinal lymph nodes Leads to draining ulcers and secondary infection. Treated with antibiotics Lymphogranuloma Venereum complications of Chlamydia

51 Features of discharge diseases. Checkpoint 23.5 Genital “discharge” diseases

52 Genital ulcer diseases Lesions on the genitals Syphilis Chancroid Genital herpes

53 Syphilis Bacterial infection Stages –Primary - chancre –Secondary –Latency –Tertiary Congenital

54 Syphillis –Treponema pallidum Spirochete, causes a 3 stage disease. –Vaginal or orally transmitted. First stage appears a few weeks to 1 month after exposure, chancre – painless sore, can be small firm and round or large, and open. At this stage it is very infectious, but after 3-6 weeks it goes away. 6-8 weeks after chancre a rash develops. Can occur anywhere on the body but often it is a rough red to reddish brown rash on the palms and soles.

55 muscle aches, fever swollen glands, patchy hair loss, weight loss can accompany the rash, or not. Still infectious, but again goes away. After 5-40 years of latency 3rd stage develops. Internal damage can lead to heart damage, neurological damage; loss of coordination, paralysis, dementia. Gummas develop usually internally, and if on organs can cause damage Can be treated within stages 1 and 2, Penicillin very effective within 1 to 3 years of exposure. Darkfield microscopy must be used for detection, T. pallidum does not culture well.

56 Figure 24.7 The incidence of syphilis in the U.S.-overview

57 T. pallidum can be identified by dark-field microscopy, in which the characteristic spiral morphology can be observed. Fig Treponema pallidum from a syphilitic chancre, Viewed with dark-field illumination.

58 Treponema pallidum, the causative agent of syphilis, is a spirochete bacterium. Fig Electron micrograph of the syphilis spirochete Attached to cells.

59 Syphilis Chancre sores, first stage Syphilis rash, second stage

60 After the chancre has healed, secondary syphilis develops, in which a skin rash forms on the trunk, arms, palms, and soles. Fig Symptom of secondary syphylis.

61 After resolution of secondary syphilis, latency occurs which can last up to 20 years, and in time destruction of tissues (gummas) can result in cardiovasculer, hepatic, bone, cartilage, and nerve damage. Fig The pathology of late, or tertiary syphilis.

62 Syphilis Gummas, third stage

63 Congenital syphilis begins as an early profuse nasal discharge and later develops into a condition called Hutchinson’s teeth. Fig Congenital syphilis.

64 Incidence rates of gonorrhea and syphilis from 1964 to Fig Gonorrhea and syphilis-reported rates.

65 Chancroid Bacterial infection Pleomorphic Most prevalent in tropic and subtropic environments STD

66 Bacterial STDs Chancroid –Signs and symptoms Soft chancres, pain upon urination in women –Pathogens and virulence factors Caused by Haemophilus ducreyi Produces a toxin that kills epithelial cells –Pathogenesis and epidemiology Most cases in the U.S. are due to foreign travel –Diagnosis, treatment, and prevention Treated with antimicrobial drugs Prevented by abstinence or mutual monogamy © 2012 Pearson Education Inc.

67 Figure Soft chancres of chancroid

68 Genital herpes Virus infection Chronic – viral latency Asymptomatic Recurrent symptoms Serious in newborns

69 Genital herpes – herpes simplex virus HSV 2 usually causes genital herpes 1 in 4 Americans (45 million! Ages 12+) have it. HSV 1 can cause both oral or genital herpes. Though it is uncommon (receptor site specificity) Can be transmitted through oral sex. Can still be spread without an outbreak, virus shed through skin.

70 Within 2 weeks of exposure a primary outbreak can occur, only 50% know they are having the outbreak. Heals within 2-4 weeks. -Fever, headaches, muscle ache, 3 days later blisters develop, break and end up as open sores. After the primary infection approx. 4-5 recurrent infections in the next year, then outbreaks decline after that. Virus can become latent in nerve cells Physical exam/blood test, Rx- acyclovir Neonatal herpes causes whole body/brain infection. Death, blindness, retardation. *rare*

71 HSV-1 and –2 have an icosahedral capsid and envelope structure, as evident by the transmission electron micrograph. Fig Transmission electron micrograph of herpes simplex Virus.

72 Genital herpes Within the vagina, near the cervix

73 Herpes simplex virus -1 and –2 are responsible for genital herpes, and can be transmitted to the fetus, which then can infect the skin, mouth, eyes, and the CNS. Fig Prenatal herpes simplex.

74 HSV-1 is believed to be responsible for oral herpes or cold sores. Fig Oral herpes infection.

75 Reactivation of HSV-2 causes the virus to travel down the neuron to the body’s surface, forming visible lesions. Fig HSV-2 latent in lumbosacral ganglion.

76 Figure Herpes lesions of the eyes and skin-overview

77 Features of genital ulcer diseases. Checkpoint 23.6 Genital ulcer diseases

78 Warts Human papillomavirus (HPV) –Mild –Serious (cervical cancer- oncogenes) Molluscum contagiosum –Virus infection –Less severe than HPV

79 Genital Warts (Human Papilloma Virus) Viral infection of the skin that can cause painless cauliflower type tumors different strains, 30 are STD’s, 10 most likely to cause cancer. - most will not have symptoms, and self resolve. - high risk = abnormal pap and most likely to cause cervical, vulval, anal, vaginal or penile cancer. - low risk = slightly abnormal paps

80 Physical exam, biopsy and pap smears for detection or HPV DNA test. No test for men. No cure, 1/3 spontaneous resolution, freezing, laser burning, Imiquimod (Aldara) immune enhancer. HPV vaccine Gardasil protects against 4 HPV types that cause 70% of cervical cancer. FDA licensed for use for women aged 9-26 (suggested age 12 years) best if administered before becoming sexually active. 3 shots over 6 months, almost 100% effective.

81 Prevalence (CDC) Approximately 20 million people are currently infected with HPV. At least 50 percent of sexually active men and women acquire genital HPV infection at some point in their lives. By age 50, at least 80 percent of women will have acquired a genital HPV infection. About 6.2 million Americans get a new genital HPV infection each year.

82 Figure Genital warts

83 Genital warts Again in the vagina, on or near cervix

84 Features of wart diseases. Checkpoint 23.7 Wart diseases

85 Summary of diseases in the genitourinary tract. Taxonomic organization of microorganisms causing Disease in the genitourinary tract.

86 Fig. 23.p762 Infectious Diseases Affecting the Genitourinary System.

87

88 Because herpes can be shed without visible lesions, preventative methods include condom use by women. Fig The female condom.

89 Group B Streptococcus Bacterial infection Infants contract it from the mother during birth Pregnant women are routinely screened

90 Features of Group B streptococcus colonization. Checkpoint 23.8 Group B Streptococcus colonization

91