Utigutimicro

1. 26 Microbial Diseases of the Urinary and Reproductive Systems

2. Microbial Diseases of the Urinary and Reproductive Systems Microbes usually enter the urinary system through the urethra. Microbes usually enter the reproductive system through the vagina (in females) or urethra (in males).

3. Female Urinary Organs Figure 26.1

4. Female Reproductive Organs Figure 26.2a

5. Male Reproductive & Urinary Organs Figure 26.3

7. Normal Microbiota Urinary bladder and upper urinary tract sterile Lactobacilli predominant in the vagina >1,000 bacteria/ml or 100 coliforms/ml of urine indicates infection

8. Cystitis Usually caused by E. coli S. saprophyticus May also be caused by Proteus Klebsiella Enterococcus Pseudomonas E. coli usually causes pyelonephritis. Antibiotic-sensitivity tests may be required before treatment.

9. UTI Ureteritis = inflammation of ureter (maybe caused by stone in the ureter) Cystitis = inflammation of bladder (caused by ascending bacterial infection usually E. coli) Urethritis= inflammation of urethra (may lead to prostatitis and epididymitis)

10. “Bad Stroke”

11. FACTORS THAT CONTRIBUTE TO UTI FEMALE (PROXIMITY TO THE ANUS, SHORTER URETHRA) POOR HYGIENE UNSAFE SEXUAL PRACTICES BACK TO FRONT STROKE HIGH pH URINARY STASIS KIDNEY STONES OBSTRUCTION OF URINE OUTFLOW

12. S/Sx: PAIN assessment Pain during and after urination = cystitis Pain after urination = urethritis Inguinal pain = ureteritis Flank pain = pyelonephritis Inflammatory manifestations fever and chills Cx: Ascending infection Obstruction (stones/calculi)

13. Management E. coli (most common C.A.) Increase fluids Warm sitz bath EMPTY the bladder Good hygiene Observe safe sexual practice Front to back stroke Acidify urine (cranberry juice, prune, plums) C/S test before giving antibiotics For urosepsis give aminoglycosides Observe complications

14. Leptospirosis Leptospira interrogans Reservoir: Dogs and rats Transmitted by skin/mucosal contact from urine-contaminated water Diagnosis: Isolating bacteria or serological tests Figure 26.4

17. (Anicteric leptospirosis) Systemic with aseptic meningitis

18. (Icteric leptospirosis) Overwhelming disease (Weil’s disease)

19. Vascular collapse

20. Thrombocytopenia

21. Hemorrhage

22. Hepatic and renal dysfunctionNOTE: Icteric refers to jaundice (yellowing of skin and mucus membranes by deposition of bile) and liver involvement

24. Direct invasion and replication in tissues

25. Characterized by an acute febrile jaundice & immune complex glomerulonephritis

28. Transmitted to humans from a variety of wild and domesticated animal hosts

29. In USA most common reservoirs rodents (rats), dogs, farm animals and wild animals

30. Transmitted through breaks in the skin or intact mucus membranes

31. Indirect contact (soil, water, feed) with infected urine from an animal with leptospiruria

33. Sexually Transmitted Diseases (STDs ) Prevented by condoms Treated with antibiotics

34. Gonorrhea Figure 26.5a

35. Gonorrhea Neisseria gonorrhoeae Attaches to oral or urogenital mucosa by fimbriae. Females may be asymptomatic; males have painful urination and pus discharge. Treatment is with antibiotics. If left untreated, may result in Endocarditis Meningitis Arthritis Ophthalmia neonatorum

36. Gonorrhea Figure 26.7

37. Gonorrhea UN 26.1

38. Nongonococcal Urethritis Chlamydia trachomatis May be transmitted to a newborn's eyes Painful urination and watery discharge Mycoplasma hominis Ureaplasma urealyticum

39. Pelvic Inflammatory Disease N. gonorrhoeae C. trachomatis Can block uterine tubes Chronic abdominal pain

40. GONORRHEA Neisseria gonorrhea, gram (+) IP: 3-7 days 28 Rex Karl S. Teoxon, R.N, M.D

41. SIGNS AND SYMPTOMS Females: usually asymptomatic or minimal urethral discharge w/ lower abdominal pain Male: Mucopurulent discharge, Painful urination 29 Rex Karl S. Teoxon, R.N, M.D

43. Epididymitis

44. Proctitis

46. 32

48. Endocervicitis

49. Proctitis

50. PID

52. Dermatitis

53. Pericarditis and endocarditis

54. Meningitis

56. 36 Rex Karl S. Teoxon, R.N, M.D

59. DIAGNOSIS GSCS of cervical secretions on Thayer Martin medium 39 Rex Karl S. Teoxon, R.N, M.D

60. GONORRHEAGRAM STAIN

62. Gram stain

63. Culture

66. Ectopic pregnancy

68. GONORRHEATREATMENT Patient and partner should be treated Drugs of choice Ceftriaxone Quinolone

69. CHLAMYDIA Chlamydia trachomatis, gram (-) IP: 2-10 days 46 Rex Karl S. Teoxon, R.N, M.D

70. SIGNS AND SYMPTOMS Maybe asymptomatic Gray white discharge, Burning and itchiness at the urethral opening DX: Gram stain Antigen detection test on cervical smear Urinalysis 47 Rex Karl S. Teoxon, R.N, M.D

71. Rex Karl S. Teoxon, R.N, M.D 48

73. CHLAMYDIADIAGNOSIS

75. Proctitis

77. Endocervicitis

78. Proctitis

79. PID

81. Syphilis Figure 26.9a

82. Syphilis Treponema pallidum Invades mucosa or through skin breaks. Figure 26.10

83. Syphilis Direct diagnosis Darkfield microscopic identification of bacteria Staining with fluorescent-labeled, monoclonal antibodies Indirect, serological diagnosis VDRL, RPR, ELISA test for reagin-type antibodies using cardiolipid (Ag) FTA-ABS tests for anti-treponemal antibodies

84. Syphilis Figure 3.6b

85. Syphilis Primary stage: Chancre at site of infection Secondary: Skin and mucosal rashes Latent period: No symptoms Tertiary: Gummas on many organs Congenital: Neurological damage Primary and secondary stages treated with penicillin

87. Hyaluronidase may facilitate perivascular infiltration

88. Antiphagocytic coating of fibronectin

93. Secondary

94. Latent

95. Early

96. Late

99. Occurs prior to development of the primary lesion

100. 10-90 days (usually 3-4 weeks) after initial contact the host mounts an inflammatory response at the site of inoculation resulting in the hallmark syphilitic lesion, called the chancre (usually painless)

101. Chancre changes from hard to ulcerative with profuse shedding of spirochetes

102. Swelling of capillary walls & regional lymph nodes w/ draining

107. Widely disseminated mucocutaneous rash

108. Secondary lesions of the skin and mucus membranes are highly contagious

110. Generalized Mucocutaneous Rash of Secondary Syphilis

113. SECONDARY SYPHILISPRINCIPAL CLINICAL FINDINGS

114. LATE STAGE SYPHILISPRINCIPAL CLINICAL MANIFESTATIONS Destructive gummas Aortic valve injury CNS manifestations Dementia Tabes dorsalis Pupillary abnormalities

116. First 4 years = early latent

117. Subsequent period = late latent

119. Granulomas reflect containment by the immunologic reaction of the host to chronic infection

120. Late neurosyphilis develops in about 1/6 untreated cases, usually more than 5 years after initial infection

121. Central nervous system and spinal cord involvement

122. Dementia, seizures, wasting, etc.

126. CONGENITAL SYPHILISCLINICAL MANIFESTATIONS Fetal death Growth restriction Multiple anomalies Immediately apparent at birth Delayed appearance

128. T. pallidumsepticemia in the developing fetus and widespread dissemination

130. SYPHILISDIAGNOSIS Clinical examination Darkfield microscopy Serology VDRL – screening test MHA or FTA – confirmatory test

131. DIAGNOSIS Dark-field examination of lesion- 1st and 2nd stage Non specific VDRL and RPR FTA-ABS Mgmt Primary and secondary - Pen G Tertiary - IV Pen G 85 Rex Karl S. Teoxon, R.N, M.D

132. Diagnostic Tests for Syphilis (Original Wasserman Test) NOTE: Treponemal antigen tests indicate experience with a treponemal infection, but cross-react with antigens other than T. pallidum ssp. pallidum. Since pinta and yaws are rare in USA, positive treponemal antigen tests are usually indicative of syphilitic infection.

133. SYPHILISTREATMENT Patient and sexual partner(s) should be treated Antibiotic therapy Penicillin – preferred in pregnancy Doxycycline Tetracycline

135. WHO monitors treatment recommendations

136. 7-10 days continuously for early stage

137. At least 21 days continuously beyond the early stage

138. Prevention with barrier methods (e.g., condoms)

140. LGVCLINICAL MANIFESTATIONS

141. CHLAMYDIALGV STD caused by serovars L1, L2, L3 Common in Asia, Africa, South America, and the Caribbean Incubation period 3 days to 3 weeks Painless vesicleregional lymphaticsinguinal and femoral adenitis and proctitis

142. Chancroid (Soft Chancre) Haemophilus ducreyi Ulcer on genitalia May break through surface Infection of lymph nodes Treatment: Erythromycin and ceftriaxone

143. Bacterial Vaginosis Gardnerella vaginalis Diagnosis by clue cells Treatment: Metronidazole Figure 26.12

144. DIAGNOSIS Viral culture Pap smear (shows cellular changes) Tzanck smear (scraping of ulcer for staining) 94 Rex Karl S. Teoxon, R.N, M.D

145. MANAGEMENT Anti viral – acyclovir (zovirax) CX: Meningitis – mild and self limiting Neonatal infection (vaginal birth) Disseminated with liver involvement Encephalitis Skin, eyes, mouth 95 Rex Karl S. Teoxon, R.N, M.D

146. Genital Herpes Herpes simplex virus 2 (Human herpesvirus 2 or HHV–2) Neonatal herpes transmitted to fetus or newborns Recurrences from viruses latent in nerves Suppression: Acyclovir or valacyclovir

147. HERPES GENITALIS HSV 2 Envelop, icosahedral, dsDNA Latent – sacral nerve ganglia 97 Rex Karl S. Teoxon, R.N, M.D

151. SIGNS AND SYMPTOMS Painful sexual intercourse Painful vesicular lesions (cervix, vagina, perineum, glans penis) 101 Rex Karl S. Teoxon, R.N, M.D

152. Genital Warts Human papillomaviruses Treatment: Imiquimod to stimulate interferon HPV 16 causes cervical cancer and cancer of the penis. DNA test is needed to detect cancer-causing strains. Vaccination against HPV strains

153. GENITAL WARTS Condyloma Acuminatum HPV type 6 & 11, papilloma virus 103 Rex Karl S. Teoxon, R.N, M.D

154. SIGNS AND SYMPTOMS Single or multiple soft, fleshy painless growth of the vulva, vagina, cervix, urethra, or anal area, Vaginal bleeding, discharge, odor and dyspareunia DX: Pap smear-shows cellular changes (koilocytosis) Acetic acid swabbing (will whiten lesion) 104 Rex Karl S. Teoxon, R.N, M.D

159. MANAGEMENT Laser treatment is more effective CX: Neoplasia Neonatal laryngeal papillomatosis (vaginal birth) Rex Karl S. Teoxon, R.N, M.D 109

160. Candidiasis Candida albicans Grows on mucosa of mouth, intestinal tract, and genitourinary tract. NGU in males Vulvovaginal candidiasis Diagnosis is by microscopic identification and culture of yeast. Treatment: Clotrimazole or miconazole.

161. CANDIDIASIS Moniliasis (oral candidiasis) Vulvovaginal candidiasis Candida albicans (Yeast or fungus) 111 Rex Karl S. Teoxon, R.N, M.D

162. SIGNS AND SYMPTOMS Cheesy white discharge Extreme itchiness DX: KOH (wet smear indicate positive result) 112 Rex Karl S. Teoxon, R.N, M.D

166. MANAGEMENT Imidazole, Monistat, Diflucan CX: Oral thrush to baby (vaginal birth) 116 Rex Karl S. Teoxon, R.N, M.D

167. Trichomoniasis Trichomonas vaginalis Found in semen or urine of male carriers Vaginal infection causes irritation and profuse discharge. Diagnosis is by microscopic identification of protozoan. Treatment: Metronidazole. Figure 26.15

168. TRICHOMONIASIS Trichomonas vaginalis parasite 118 Rex Karl S. Teoxon, R.N, M.D

169. SIGNS AND SYMPTOMS Females: itching, burning on urination, yellow gray frothy malodorous vaginal discharge, foul smelling Males: usually asymptomatic Dx: microscopic exam of vaginal discharge 119 Rex Karl S. Teoxon, R.N, M.D

170. MANAGEMENT Metronidazole (Flagyl) include partners CX: PROM 120 Rex Karl S. Teoxon, R.N, M.D

171. Vaginitis and Vaginosis Table UN 26.1

172. Know Normal! 1. Epithelial Cells 2. Lactobacilli - 5 to 15 µ 3. WBCs - Few = NL - Never > Epi’s - Many = Inflammation (Parabasilar Cell) >

173. Vaginosis - Know 3 Bacterial Vaginosis - FEW or NO LACTOBACILLI - MANY Coccobacillary Orgs. = “GARBAGE” - CLUE CELLS = CELL EDGE - FEW WBCs!!!!!!! - MOBILUNCUS = MOTILE Cytolytic Vaginosis = “Lactobacillus Overgrowth Syndrome” - MANY LACTOBACILLI - 5 to 15 µ

174. Vaginosis - Know 3 3. Lactobacillosis/Leptothrix - LONG LACTOBACILLI - 40 to 75 µ

175. Vaginitis - Know 2+ 1. Trichomonas 2. Candidiasis/Yeast - Candida albicans 1) Blastospores “CANDIDIASIS” 2) Budding Yeast 3) Pseudohyphae - Candida glabrata 1) Blastospores (Torulopsis g.) 2) Budding yeast “YEAST” Grow is clusters = CUMULI >

176. Additional Slides - Normals Normal Epithelial Cells with Sharp Borders Normal Lactobacilli - 5 to 15 µ (note size relative to cell nucleus) 1. Epithelial Cells 2. Lactobacilli - 5 to 15 µ 3. WBCs - Few = NL - Never > Epi’s - Many = Inflammation (Parabasilar Cell) >

177. Additional Slides - Clue CellsAND Inflammation of ? Cause 1. Epithelial Cells 2. Lactobacilli - 5 to 15 µ 3. WBCs - Few = NL - Never > Epi’s - Many = Inflammation (Parabasilar Cell) >

178. STD 128 Rex Karl S. Teoxon, R.N, M.D

179. HIV and AIDS Retrovirus (HIV1 & HIV2) Attacks and kills CD4+ lymphocytes (T-helper) Capable of replicating in the lymphocytes undetected by the immune system Immunity declines and opportunistic microbes set in No known cure Rex Karl S. Teoxon, R.N, M.D 129

181. MOT Sexual intercourse (oral, vaginal and anal) Exposure to contaminated blood, semen, breast milk and other body fluids Blood Transfusion IV drug use Transplacental Needle stick injuries 131 Rex Karl S. Teoxon, R.N, M.D

182. HIGH RISK GROUP Homosexual or bisexual Intravenous drug users BT recipients before 1985 Sexual contact with HIV+ Babies of mothers who are HIV+ Rex Karl S. Teoxon, R.N, M.D 132

184. SIGNS AND SYMPTOMS Acute viral illness (1 mo after initial exposure) – fever, malaise, lymphadenopathy Clinical latency – 8 yrs w/ no sx; towards end, bacterial and skin infections and constitutonal sx – AIDS related complex; CD4 counts 400-200 AIDS – 2 yrs; CD4 T lymphocyte < 200 w/ (+) ELISA or Western Blot and opportunistic infections 134 Rex Karl S. Teoxon, R.N, M.D

185. DIAGNOSIS HIV+ 2 consecutive positive ELISA and 1 positive Western Blot Test AIDS+ HIV+ CD4+ count below 200/ml 135 Rex Karl S. Teoxon, R.N, M.D

186. SIGNS AND SYMPTOMS Extreme fatigue Intermittent fever Night sweats Chills Lymphadenopathy Enlarged spleen Rex Karl S. Teoxon, R.N, M.D 136

187. SIGNS AND SYMPTOMS Anorexia Weight loss Severe diarrhea Apathy and depression PTB Kaposis sarcoma Pneumocystis carinii AIDS dementia 137 Rex Karl S. Teoxon, R.N, M.D

189. MANAGEMENT Nucleoside Reverse Transcriptase Inhibitors NRTI’s Zidovudine (AZT) – limit viral growth Non-nucleoside Reverse Transcriptase Inhibitors NNRTI’s Ritonavir (Norvir) Prevention of spread (safe sex) Universal precautions Symptomatic intervention and treatment of opportunistic infections Vaccines (influenza and hepa B) 139 Rex Karl S. Teoxon, R.N, M.D

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