Structure and Function of Urinary System  Urinary system:  Two kidneys  Two ureters  One urinary bladder  One urethra  Infection prevented by:  Valves prevent backflow to kidneys  Acidity of urine  Mechanical flushing

Figure 26.1 Female Urinary System  Predisposition to infection  Short urethra  Proximity to anus

The Female Reproductive System  Female:  Two ovaries  Two uterine (fallopian) tubes  The uterus, including the cervix; the vagina  External genitals

Female Reproductive Organs Figure 26.2a

The Male Reproductive System  Male:  Two testes  Accessory glands  Penis  Epididymis  Ductus (vas) deferens  Ejaculatory duct  Urethra

Male Reproductive and Urinary Organs Figure 26.3

Normal Microbiota  Urinary bladder and upper urinary tract are sterile  Lactobacilli are predominant in the vagina  Produce H 2 O 2  Grow on glycogen secretions  Infection is indicated by:  >10,000 bacteria/ml  100 coliforms/ml  Positive urine leukocyte esterase (LE) test

Urinary System Infections  Cystitis  An inflammation of the urinary bladder  Urethritis  An inflammation of the urethra  Pyelonephritis  An inflammation of one or both kidneys

Cystitis  Usual causative agents:  E. coli  S. saprophyticus  Symptoms:  Dysuria (difficult or painful urination)  Pyuria (pus in urine)  Diagnosis: >100 CFU/ml potential pathogens and + LE test  Treatment: Trimethoprim-sulfamethexazole

Pyelonephritis  Causative agent: Usually E. coli  Symptoms: Fever; back or flank pain  Diagnosis: 10 4 CFUs/ml and + LE test  Treatment: Cephalosporin

Leptospirosis  Causative agent: Leptospira interrogans  Reservoir: Dogs and rats  Transmission: Skin/mucosal contact from urine-contaminated water Figure 26.4

 Symptoms: Headaches, muscular aches, fever, kidney failure a possible complication  Diagnosis: Serological test  Treatment: Doxycycline Leptospirosis

Sexually Transmitted Infections (STIs)  Prevented by condoms  Bacterial infections are treated with antibiotics

Sexually Transmitted Disease Surveillance 2010 Division of STD Prevention

Chlamydia—Rates by Sex, United States, 1990–2010 NOTE: As of January 2000, all 50 states and the District of Columbia have regulations that require the reporting of chlamydia cases. Total Women Men Rate (per 100,000 population) Year

Chlamydia—Rates by Age and Sex, United States, –19 20–24 25–29 30–34 35–39 40–44 45–54 55– Total MenWomenRate (per 100,000 population) Age 3,7002,9602,2201, ,4802,2202,9603, , , , ,

Chlamydia—Rates by Race/Ethnicity, United States, 2001–2010 Whites Hispanics Blacks Asians/Pacific Islanders American Indians/Alaska Natives Rate (per 100,000 population) Year

Gonorrhea  Caused by Neisseria gonorrhoeae  Attaches to oral or urogenital mucosa by fimbriae  Opa proteins prevent CD4 + T-cell proliferation  Anal gonorrhea, pharyngeal gonorrhea  If left untreated, may result in  Endocarditis  Meningitis  Arthritis  Ophthalmia neonatorum

Gonorrhea  Symptoms:  Men: Painful urination and discharge of pus  Women: Few symptoms but possible complications, such as PID  Diagnosis: Gram stain, ELISA, PCR  Treatment: Fluoroquinolones

Neisseria gonorrhoeae Figure 26.7

Gonorrhea—Rates, United States, 1941–2010

Gonorrhea—Rates by Sex, United States, 1990–2010

Gonorrhea—Rates by Age and Sex, United States, –19 20–24 25–29 30–34 35–39 40–44 45–54 55– Total MenWomenRate (per 100,000 population) Age

Gonorrhea—Rates by Race/Ethnicity, United States, 2001–2010

Gonococcal Isolate Surveillance Project (GISP)— Percentage of Neisseria gonorrhoeae Isolates with Resistance or Intermediate Resistance to Ciprofloxacin, 1990–2010 NOTE: Resistant isolates have ciprofloxacin minimum inhibitory concentrations (MICs) >1 µg/ml. Isolates with intermediate resistance have ciprofloxacin MICs of 0.125–0.5 µg/ml. Susceptibility to ciprofloxacin was first measured in GISP in Intermediate Resistance Resistance Percentage Year 2010

Gonococcal Isolate Surveillance Project (GISP)— Penicillin, Tetracycline, and Ciprofloxacin Resistance Among GISP Isolates, 2010 NOTE: PenR = penicillinase producing Neisseria gonorrhoeae and chromosomally mediated penicillin- resistant N. gonorrhoeae; TetR = chromosomally and plasmid mediated tetracycline-resistant N. gonorrhoeae; and QRNG = quinolone-resistant N. gonorrhoeae. PenR/QRNG PenR TetR/QRNG PenR/TetR QRNG PenR/TetR/QRNG TetR Susceptible 72.8% 1.8% 6.9% 2.0% 2.9% 9.4% 3.5% 0.6%

Antibiotic Resistance in N. gonorrhoeae Clinical Focus, p. 751

Nongonococcal Urethritis (NGU)  Nonspecific urethritis  Chlamydia trachomatis  Mycoplasma hominis  Ureaplasma urealyticum  Symptoms: Painful urination and watery discharge; in women, possible complications, such as PID  Diagnosis: Culturing, PCR  Treatment: Doxycycline, azithromycin

Pelvic Inflammatory Disease (PID)  Polymicrobic, usually  N. gonorrhoeae  C. trachomatis  Salpingitis (infection of uterine tubes)  Symptoms: Chronic abdominal pain  Treatment: Doxycycline and cefoxitin

Syphilis  Caused by Treponema pallidum  Invades mucosa or through skin breaks Figure 26.9

Syphilis  Primary stage: Chancre at site of infection  Secondary stage: Skin and mucosal rashes  Latent period: No symptoms  Tertiary stage: Gummas on many organs  Treatment: Benzathine penicillin  Congenital: Neurological damage

Lesions of Primary Stage Syphilis Figure 26.11a

Lesions of Secondary Stage Syphilis Figure 26.11b

Lesions of Tertiary Stage Syphilis Figure 26.11c

Diagnosis of Syphilis  Direct diagnosis  Staining with fluorescent-labeled monoclonal antibodies  Indirect, rapid screening  VDRL, RPR, EIA  Confirming  FTA-ABS tests for anti-treponemal antibodies

Syphilis—Reported Cases by Stage of Infection, United States, 1941–2010

Primary and Secondary Syphilis—Rates by Age and Sex, United States, –19 20–24 25–29 30–34 35–39 40–44 45–54 55– Total MenWomenRate (per 100,000 population) Age

Primary and Secondary Syphilis—Rates by Race/Ethnicity, United States, 2001–2010 Whites Hispanics Blacks Asians/Pacific Islanders American Indians/Alaska Natives Rate (per 100,000 population) Year

Lymphogranuloma Venereum (LGV)  Causative agent: Chlamydia trachomatis  Initial lesion on genitals heals  Bacteria spread through lymph  Symptoms: Swelling in lymph nodes in groin  Diagnosis: Microscopic and culture  Treatment: Doxycycline

Chancroid (Soft Chancre)  Causative agent: Haemophilus ducreyi  Symptoms: Painful ulcers of genitals swollen lymph nodes in groin  Diagnosis: Culture  Treatment: Erythromycin; cetriaxone

Chancroid—Reported Cases, United States, 1981– Cases (in thousands) Year

Bacterial Vaginosis  Causative agent: Gardnerella vaginalis  Symptoms: Copious fishy, gray-white, thin, frothy discharge  pH: >4.5  Diagnosis: Clue cells  Treatment: Metronidazole

How common is genital herpes? Nationwide, 16.2%, or about one out of six, people years of age have genital HSV-2 infection. Genital HSV-2 infection is more common in women (approximately one out of five women years of age) than in men (about one out of nine men years of age). Transmission from an infected male to his female partner is more likely than from an infected female to her male partner.

Genital Herpes  Caused by herpes simplex virus 2 (human herpesvirus 2, or HSV–2)  Painful vesicles on genitals  Neonatal herpes transmitted to fetus or newborns  Recurrences from viruses latent in nerves  Suppression: Acyclovir

Herpes Simplex Virus Type 2—Seroprevalence in Non-Hispanic Whites and Non-Hispanic Blacks by Age Group, National Health and Nutrition Examination Survey, 1976–1980, 1988–1994, 1999–2004, 2005–2008 * Age-adjusted by using the 2000 U.S. Census civilian, non-institutionalized population aged 14–49 years as the standard. NOTE: Error bars indicate 95% confidence intervals.

Genital Warts  Human papillomaviruses  Warts in genital area  HPV 16 causes cervical cancer and cancer of the penis  Treatment: Podofilox; imiquimod  Prevention: Vaccination against HPV strains

Human Papillomavirus—Prevalence of High-risk and Low-risk Types Among Females Aged 14–59 Years, National Health and Nutrition Examination Survey, 2003–2006 * HPV = human papillomavirus. NOTE: Error bars indicate 95% confidence intervals. Both high-risk and low-risk HPV types were detected in some females. SOURCE: Hariri S, Unger ER, Sternberg M, Dunne EF, Swan D, Patel S, et al. Prevalence of genital HPV among females in the United States, the National Health and Nutrition Examination Survey, 2003–2006. J Infect Dis. 2011;204(4): –5940–4930–3925–2920–2414–19 Low-risk HPV* Prevalence, % High-risk HPV* Age

Genital Warts—Initial Visits to Physicians’ Offices, United States, 1966–2010 NOTE: The relative standard errors for genital warts estimates of more than 100,000 range from 18% to 30%. SOURCE: IMS Health, Integrated Promotional Services™. IMS Health Report, 1966–2010.

Genital Herpes—Initial Visits to Physicians’ Offices, United States, 1966–2010 NOTE: The relative standard errors for genital herpes estimates of more than 100,000 range from 18% to 30%. SOURCE: IMS Health, Integrated Promotional Services™. IMS Health Report, 1966–2010.

Candidiasis  Causative agent: Candida albicans  Grows on mucosa of mouth, intestinal tract, and genitourinary tract  NGU in males  Vulvovaginal candidiasis, yeasty discharge  pH: <4  Diagnosis: microscopic and culture  Treatment: Clotrimazole; fluconazole

Trichomoniasis  Causative agent: Trichomonas vaginalis  Found in semen or urine of male carriers  Vaginal infection causes irritation and profuse foul, greenish yellow frothy discharge  pH: 5–8  Diagnosis: Microscopic identification, DNA probe  Treatment: Metronidazole

Figure Trichomonas vaginalis

Trichomoniasis and Other Vaginal Infections—Women— Initial Visits to Physicians’ Offices, United States, 1966– 2010 NOTE: The relative standard errors for trichomoniasis estimates range from 16% to 27% and for other vaginitis estimates range from 8% to 13%. SOURCE: IMS Health, Integrated Promotional Services™, IMS Health Report, 1966–2010.

The TORCH Panel of Tests  Toxoplasmosis  Other (such as syphilis, hepatitis B, enterovirus, Epstein-Barr virus, varicella-zoster virus)  Rubella  Cytomegalovirus  Herpes simplex virus

STDs in Racial and Ethnic Minorities Sexually Transmitted Disease Surveillance 2010 Division of STD Prevention

Chlamydia—Rates by Race/Ethnicity and Sex, United States, 2010 * AI/AN = American Indians/Alaska Natives; A/PI = Asians/Pacific Islanders. AI/AN* A/PI* Blacks Hispanics Whites Total Men Women Rate (per 100,000 population) Race/ Ethnicity 2,5002,0001,5001, ,0001,5002,0002, ,

Gonorrhea—Rates by Race/Ethnicity and Sex, United States, 2010 * AI/AN = American Indians/Alaska Natives; A/PI = Asians/Pacific Islanders Men Rate (per 100,000 population) Race/ Ethnicity Total Women AI/AN* A/PI* Blacks Hispanics Whites

Primary and Secondary Syphilis—Rates by Race/Ethnicity and Sex, United States, 2010 * AI/AN = American Indians/Alaska Natives; A/PI = Asians/Pacific Islanders. Men Rate (per 100,000 population) Race/ Ethnicity Total Women AI/AN* A/PI* Blacks Hispanics Whites