1. Ch 26
Microbial Diseases of the Urinary and Reproductive Systems

2. Student Learning Outcomes
Describe the normal microbiota of the upper urinary tract, the male urethra, and the female urethra and vagina. Describe modes of transmission for urinary and reproductive system infections. List the microorganisms that cause cystitis and pyelonephritis. Name the predisposing factors for these diseases. List the causative agents, symptoms, methods of diagnosis, and treatments for gonorrhea, chlamydia, PID, and syphilis. List reproductive system diseases that can cause congenital and neonatal infections, and explain how these infections can be prevented. Discuss genital herpes, genital warts, candidiasis, and trichomoniasis.

3. Normal Microbiota Urinary bladder and upper urinary tract are sterile
Women: Flora influenced by estrogen. Lactobacilli dominate vaginal microbiota during reproductive years
Men: urethra normally sterile
>1,000 bacteria/ml or 100 coliforms/ml of urine indicates infection
Women – flora influenced by estrogen. Estrogen causes glycogen production  converted to lactic acid by Lactobacillus  Lower pH inhibits growth of potential pathogens (normal flora is acid tolerant)

4. Cystitis Common in females. Symptoms? Contributing factors:
Microorganisms at opening of the urethra and along lower parts of urethra
careless personal hygiene
sexual intercourse
Most common etiologies
E. coli
S. saprophyticus
May also be caused by Proteus, Klebsiella, Enterococcus, Pseudomonas, etc.
Antibiotic-sensitivity tests may be required before treatment.
Many nosocomial cases (how?)
Not uncommonly followed by yeast infection
Bacteria can ascend to the kidney  ureteritis  pyelonephritis. (75% caused by E. coli)

6. Sexually Transmitted Diseases / Infections (STDs / STIs)
Most diseases of reproductive system are STIs (15 million new cases each year)
8 billion dollars a year to control STIs
> 30 different types of STIs (bacterial, viral, parasitic)
Highly effective prevention (?)

7. Gonorrhea (“Clap”) N. gonorrhoeae (G, dipplococci), reportable
Attaches to mucosal cells of oral-pharyngeal area, genitals, eyes, and rectum by means of fimbriae.
Males usually symptomatic (painful urination and pus discharge). Blockage of the urethra and sterility are complications of untreated cases.
If left untreated, may result in endocarditis, meningitis, arthritis, ophthalmia neonatorum
Diagnosed by ELISA or PCR.
Antibiotic resistance increasing (R-plasmids)
~ 350’000 cases / year in US – only human reservoir
No immunity build up / no vaccination

8. Most males symptomatic
With pus containing discharge from urethra
Females often asymptomatic unless the infection spreads to uterus and uterine tubes leading to
PID = Pelvic Inflammatory Disease (polymicrobial; ~ 1 Mio women per year in US)
PID = extensive infection of female pelvic organs (uterus, cervix, uterine tubes, or ovaries) – Chlamydia most serious

9. PID  tubal infection, salpingitis, scar tissue, adhesions, ectopic pregancies and sterility, chronic abdominal pain.
50 % of females asymptomatic

10. Nongonococcal Urethritis (NGU) - Chlamydia
Chlamydia trachomatis, obligate intracellular bacterium
Most common reported STI in US, ~ 4 mio cases/year
“Silent disease”
50% of males asymptomatic
75% of females asymptomatic – PID possible!
Chlamydial ophthalmia and/or pneumonia in newborn
Diagnosis is based on the detection of chlamydial DNA in urine
Annual screening tests recommended for sexually active women < 25 y
To help prevent the serious consequences of chlamydia, screening at least annually for chlamydia is recommended for all sexually active women age 25 years and younger. An annual screening test also is recommended for older women with risk factors for chlamydia (a new sex partner or multiple sex partners). All pregnant women should have a screening test for chlamydia.
Chlamydia is the most frequently reported bacterial sexually transmitted disease in the United States. In 2008, 1,210,523 chlamydial infections were reported to CDC from 50 states and the District of Columbia. Under-reporting is substantial because most people with chlamydia are not aware of their infections and do not seek testing. Also, testing is not often done if patients are treated for their symptoms. An estimated 2,291,000 non-institutionalized U.S. civilians ages are infected with C. trachomatis  based on the U.S. National Health and Nutrition Examination Survey.  Women are frequently re-infected if their sex partners are not treated.

11. Syphilis Treponema pallidum (spirochete)
Cannot culture in vitro – grown in cell cultures
Transmitted by direct contact can invade intact mucous membranes or penetrate through breaks in the skin
No animal reservoir
“The Great Imitator”
Three stages
Hard chancre (painless) at site of infection
Flu-like symptoms, skin rash
Latent for years. May progress to
Gummas in skin and internal organs
Congenital: Neurological damage
Primary and secondary stages treated with penicillin

12. Secondary syphilis: + wide spread rash
Lesions can mimic almost anything. Often patient feels poorly and has flu like symptoms
+ wide spread rash
Lesion fluid still highly infectious!
Can last weeks to months.

13. Tertiary Syphilis Latent for up to 30 years, then Neurosyphilis
Cardiovascular syphilis
Aortic aneurysms
Gummatous syphilis
“Gumma”
becomes apparent after years of untreated infection (can appear anywhere)

14. Diagnosis: No culture  Darkfield microscopy and serological assays
Congenital syphilis – T. pallidum crosses placenta  Hutchinson's triad in 63% of cases: Hutchinson's teeth (notched incisors), keratitis and deafness
Diagnosis: No culture  Darkfield microscopy and serological assays
Treatment long acting antibiotics, but damage done is irreversible
Hutchinson's triad, which consists of Hutchinson's teeth (notched incisors), keratitis and deafness and occurs in 63% of cases

15. Genital Herpes – Herpes simplex virus
HSV-1 (HHV1) and HSV-2 (HHV2)
16.2%, or about one out of six, people 14 to 49 years of age have genital HSV-2 infection. More common in females
Symptoms: painful urination, genital irritation, and fluid-filled vesicles
Neonatal herpes: contracted during fetal development or birth. Can result in neurological damage or infant fatalities
Virus might enter latent stage in nerve cells (Life-long infection). Vesicle recurrences following trauma, stress, and hormonal changes
Highly transmittable – subclinical shedding can be as high as in symptomatic infection
Suppression: Acyclovir and others

16. original context on the page: www. hc-sc. gc. ca/
original context on the page: slides/hsv/pages/h990.html

17. Genital Warts Human papillomaviruses
~ 20 mio Americans currently infected. ~ 6 mio new infections each year.
Four types of HPV associated with cervical and penile cancer
DNA test detects cancer-causing strainsmportance of pap smear
Gardasil and Cervarix for boys and girls, 9 – 26 years old.
Dr. Papanicolaou
Exfoliative cytology of the vagina and cervix

18. Trichomoniasis Trichomonas vaginalis
Most common STI in young women. Not reportable. (~ 7.4 mio new cases per year)
Men usually asymptomatic carriers (reservoir).
Women frequently symptomatic: frothy, yellow-green vaginal discharge with strong odor.
Diagnosis based on observation of motile protozoa in purulent discharges (wet mounts) from infection site.
Treatment: Metronidazole.

19. TORCH Infections or TORCH Complex
Medical acronym for a set of congenital infections
Antibody screening tests for pregnant women
T__________________
Other infections: namely hepatitis B, syphilis, HHV-3 and 4 …
R __________________
CMV__________________
H __________________
the end