1. 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

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

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

4. Female Reproductive Organs Figure 26.2a

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

6. Male Reproductive and Urinary Organs Figure 26.3

7. 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

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

9. 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

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

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

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

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

14. Sexually Transmitted Disease Surveillance 2010 Division of STD Prevention

15. 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 0 125 250 375 500 625 750 20102008200620042002200019981996199419921990

16. Chlamydia—Rates by Age and Sex, United States, 2010 15–19 20–24 25–29 30–34 35–39 40–44 45–54 55–64 65+ Total MenWomenRate (per 100,000 population) Age 3,7002,9602,2201,48074000 1,4802,2202,9603,700 774.3 1,187.0 598.0 309.0 153.2 91.3 39.3 233.7 2.8 10.9 3,378.2 3,407.9 1,236.1 530.9 220.1 94.7 32.8 610.6 2.1 9.3

17. 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 0 300 600 900 1200 1500 2010200920082007200620052004200320022001

19. 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

20. 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

21. Neisseria gonorrhoeae Figure 26.7

22. Gonorrhea—Rates, United States, 1941–2010

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

24. Gonorrhea—Rates by Age and Sex, United States, 2010 15–19 20–24 25–29 30–34 35–39 40–44 45–54 55–64 65+ Total MenWomenRate (per 100,000 population) Age 75060045030015000 300450600750 253.4 421.0 241.3 146.5 85.1 64.2 34.1 94.1 2.4 11.0 570.9 560.7 226.3 107.5 48.2 23.8 9.0 106.5 0.5 1.9

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

26. 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 1990. 0 5 10 15 20 20092008200720062005200420032002200120001999199819971996199519941993199219911990 Intermediate Resistance Resistance Percentage Year 2010

27. 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%

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

29. 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

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

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

32. 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

33. Lesions of Primary Stage Syphilis Figure 26.11a

34. Lesions of Secondary Stage Syphilis Figure 26.11b

35. Lesions of Tertiary Stage Syphilis Figure 26.11c

36. 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

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

38. Primary and Secondary Syphilis—Rates by Age and Sex, United States, 2010 15–19 20–24 25–29 30–34 35–39 40–44 45–54 55–64 65+ Total MenWomenRate (per 100,000 population) Age 252015105005 152025 5.6 21.9 19.2 15.8 12.7 13.8 8.5 7.9 0.6 2.7 4.5 3.0 2.0 1.4 1.0 0.8 1.1 0.0 0.2

39. 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) 0 5 10 15 20 25 Year 2010200920082007200620052004200320022001

40. 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

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

42. Chancroid—Reported Cases, United States, 1981–2010 0 1 2 3 4 5 Cases (in thousands) Year 200920072005200320011999199719951993199119891987198519831981

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

44. How common is genital herpes? Nationwide, 16.2%, or about one out of six, people 14-49 years of age have genital HSV-2 infection. Genital HSV-2 infection is more common in women (approximately one out of five women 14-49 years of age) than in men (about one out of nine men 14-49 years of age). Transmission from an infected male to his female partner is more likely than from an infected female to her male partner.

45. 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

46. 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.

48. 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

49. 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):566-73 50–5940–4930–3925–2920–2414–19 Low-risk HPV* Prevalence, % High-risk HPV* Age 0 10 20 30 40 50 60

50. 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.

51. 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.

52. 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

53. 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

54. Figure 26.16 Trichomonas vaginalis

55. 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.

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

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

58. 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 2,5002,0001,5001,00050000 1,0001,5002,0002,500 59.7 761.8 184.4 69.9 233.7 276.4 167.2 1,536.5 567.6 205.1 610.6 898.7

59. Gonorrhea—Rates by Race/Ethnicity and Sex, United States, 2010 * AI/AN = American Indians/Alaska Natives; A/PI = Asians/Pacific Islanders. 75060045030015000 300450600750 Men Rate (per 100,000 population) Race/ Ethnicity Total Women AI/AN* A/PI* Blacks Hispanics Whites 17.1 433.6 48.7 19.5 94.1 77.0 14.0 430.8 51.1 26.6 106.5 133.5

60. 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 352821147007 212835 2.6 28.2 8.5 4.0 7.9 4.3 0.1 6.4 0.5 0.3 1.1 0.7