1. 1 Dr. Adi.Khssawneh Dr. Adi Khassawneh M.D Family medicine consultant Assistant professor Public health and family medicine Department Faculty of Medicine JUST

2. Risk factors and determinants of health and disease in genital – urinary system 1.Sexually transmitted infections (STIs) 2.Pelvic inflammatory diseases (PID) 3.Urinary tract infections (UTI) 2

3. What are sexually transmitted diseases (STDs)? STDs are diseases that are passed from one person to another through sexual contact. These include chlamydia, gonorrhea, genital herpes, human papillomavirus (HPV), syphilis, and HIV. Many of these STDs do not show symptoms for a long time, but they can still be harmful and passed on during sexHIV 3

4. Anyone who is sexually active can get an STD. They don’t even have to “go all the way” to get an STD, since some STDs, like herpes and HPV, are spread by skin-to- skin contact 4

5. 5  Risk Factor: Anything which is known to affect, or is perceived as likely to affect, the frequency of occurrence of a disease other than its direct cause (s).

6. 6 Dr. A.Khassawneh  Determinants: Anything which causes disease (etiology) or predispose to disease, protects against disease, prevents disease from occurring, or anything which affects the frequency of occurrence of disease.

7. 7 Dr. A.khassawneh 1. Risk of STIs transmission: I. Increased susceptibility to STIs infections among women. In this aspect, women bear much more risk compared to men. This is because of two factors: A. Biological susceptibility factors: Increased susceptibility in younger women Increased proportion of columnar epithelium lining the cervix in young women.

8. 8 Biological susceptibility factors: This kind of epithelia is particularly susceptible to STIs infection especially gonorrhea and Chlamydia. With maturity, the columnar epithelium is replaced by squamous epithelium that is less penetrable to infection. The vaginal ecology, the concomitant pH, and the presence of resident flora.

9. 9 As female progress through adolescence to adulthood, developmental changes involve replacement of endogenous vaginal flora, predominantly characterized by enteric organisms and a basic pH, to an environment predominated by lactobacilli and an acidic environment that is hostile to many STI pathogens.

10. 10  In post-adolescence and adulthood, changes include increased thickening of cervical mucus that is less permeable to STD pathogens, and harbors immunological defenses such as white blood cells and antibodies.  In adult women, presence of bacterial vaginosis (e.g. Candida) alter a healthy vaginal ecosystem and cause reduction in the bacilli that produce hydrogen peroxide, increasing pH, resulting in favorable environment to STDs associated pathogens.

11. 11  Gender differences in anatomy. During intercourse, the exposure time of semen in the vaginal cavity is risky to women more than the exposure of female secretions to male genitalia.  Menstruation represents a risky period for transmission. The cervix become open, the mucus is with less thickness, and may account for high rates of upper genital tract infection.  During pregnancy, women are more susceptible to STD infection, especially HPV, and genital herpes. Risk factors and determinants of health and disease in genital – urinary system

12. 12 Risk factors and determinants of health and disease in genital – urinary system B. Behavioral susceptibility factors:  The susceptibility to infection may be increased or decreased according to one ’ s behavior or decision.  Gender imbalance: men make more decisions about sexual activity, and use of protection (condoms).  Socio-economic factors increase the risk (crowded populated areas, poverty,..).

13. 13 – –Cultural and religious factors: some cultures encourage the pre-marital sex, legal or illegal prostitution. The religion commitment is the most protective factor among all, especially that all religions prohibits the pre-marital or extra-marital sexual relationships. – – Health care seeking behavior is less frequently among women when it comes to STI infection. Women are more asymptomatic, which may delay seeking care, which is a risk for PID.

14. 14 Risk of Chlamydia, Gonorrhea, and Syphilis Infections: Chlamydia caused by infection with Chlamydia trachomatis and it is the most common reported bacterial sexually transmitted infections in the U.S.A. Most cases are among women, male / female ratio is 1 : 2 ( women are more likely to have symptoms). Biological risk: Adolescents are very susceptible to recurrent infection due to their cognitive immaturity and peer pressure. Chlamydia Trachomatis infect columnar not the squamous cells. Older women previously infected and treated acquire protective immunity. Behavioral risk: Associate with early sexual relationship, especially multiple partners. Risky population are low socioeconomic and crowded areas.

15. Chlamydial infections in women are usually asymptomatic. However, untreated infection can result in pelvic inflammatory disease (PID), which is a major cause of infertility, ectopic pregnancy, and chronic pelvic pain. Data from randomized controlled trials of chlamydia screening suggested that screening programs can lead to a reduction in the incidence of PID 15

16. As with other inflammatory STDs, chlamydial infection might facilitate the transmission of human immunodeficiency virus (HIV) infection. 5 In addition, pregnant women infected with chlamydia can pass the infection to their infants during delivery, potentially resulting in neonatal ophthalmia and pneumonia 5 16

17. Because of the large burden of disease and risks associated with infection, CDC recommends that all sexually active women younger than age 25 years receive annual chlamydia screening 17

18. 18 Risk of Gonorrhea infection:. N. gonorrhoeae Gonorrhea is the second most commonly reported communicable disease (118). Urethral infections caused by N. gonorrhoeae among men can produce symptoms that cause them to seek curative treatment soon enough to prevent sequelae, but often not soon enough to prevent transmission to others. 118 (age group of 15-19 in U.S.A. M/ F ratio is equal between genders )

19. Among women, gonococcal infections are commonly asymptomatic or might not produce recognizable symptoms until complications (e.g., PID) have occurred. PID can result in tubal scarring that can lead to infertility and ectopic pregnancy. 19

20. (age group of 15-19 in U.S.A. M/ F ratio is equal between genders ) (age group of 15-19 in U.S.A. M/ F ratio is equal between genders ) Annual screening for N. gonorrhoeae infection is recommended for all sexually active women aged <25 years and for older women at increased risk for infection (e.g., those who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has an STI 20

21. Risk of Syphilis infection Syphilis is a systemic disease caused by Treponema pallidum. The disease has been divided into stages based on clinical findings, helping to guide treatment and follow-up. Persons who have syphilis might seek treatment for signs or symptoms of primary syphilis infection (i.e., ulcers or chancre at the infection site) 21

22. secondary syphilis (i.e., manifestations that include, but are not limited to, skin rash, mucocutaneous lesions, and lymphadenopathy), or tertiary syphilis (i.e., cardiac, gummatous lesions, tabes dorsalis, and general paresis). Latent infections (i.e., those lacking clinical manifestations) are detected by serologic testing. Latent syphilis acquired within the preceding year is referred to as early latent syphilis 22

23. Peaks age 20-24 Common in men as women 23

24. 24 Risk of PID infection: This the inflammation of the upper reproductive tract including the tubes, the ovaries, and the endometrium as a result of ascention of microorganisms (mostly Chlamydia and Gonorrhea) from the lower genital tract. Risk factors: 1. Age: 70% are 25 years old or younger. 2. Highest among sexually active teenage, crowded areas, lower socioeconomic status, single or divorced compared to married. 3. Young age at first intercourse. 4. Multiple lifetime sex partners and in the last six months prior infections of PID. 5. Using contraceptive intrauterine device. 6. Cigarette smoking

25. 25 Risk of UTI infection: Risk factors: 1. Age: increase with age. Higher among women than men. 2. Any factors that enhance bacterial movement peri- urethral facilitate ascendance to the bladder. 3. Frequent intercourse. 4. Younger age at first intercourse. 5. Abnormal or unusual sexual behaviors (anal-vaginal transmission of microorganisms). 6. Prior UTI episodes. 7. Oral contraceptive use. 8. Premarital or extramarital sexual relationships. 9. Frequent antibiotic use. 10. Exposure of genitalia to non-hygienic environment. 11. Exposure to cold.

26. Screening recommendations by CDC All adults and adolescents from ages 13 to 64 should be tested at least once for HIV. Annual chlamydia screening of all sexually active women younger than 25 years, as well as older women with risk factors such as new or multiple sex partners, or a sex partner who has a sexually transmitted infection 26

27. Annual gonorrhea screening for all sexually active women younger than 25 years, as well as older women with risk factors such as new or multiple sex partners, or a sex partner who has a sexually transmitted infection. Syphilis, HIV, chlamydia, and hepatitis B screening for all pregnant women, and gonorrhea screening for at-risk pregnant women starting early pregnancy, with repeat testing as needed, to protect the health of mothers and their infants. 27

28. Screening at least once a year for syphilis, chlamydia, and gonorrhea for all sexually active gay, bisexual, and other men who have sex with men (MSM). MSM who have multiple or anonymous partners should be screened more frequently for STDs (i.e., at 3-to-6 month intervals). Anyone who has unsafe sex or shares injection drug equipment should get tested for HIV at least once a year. Sexually active gay and bisexual men may benefit from more frequent testing (e.g., every 3 to 6 months ). 28

29. THANK YOU 29