 

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

Female Urinary System

 Predisposition to infection   Short urethra Proximity to anus Figure 26.1

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

Leptospirosis

  

Symptoms

: Headaches, muscular aches, fever, kidney failure a possible complication

Diagnosis

: Serological test

Treatment

: Doxycycline

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 Rate (per 100,000 population)

750 625 Men Women Total 500 375 250 125 0 1990 1992 1994 1996 1998 2000

Year

2002 2004 2006 2008 2010

NOTE:

As of January 2000, all 50 states and the District of Columbia have regulations that require the reporting of chlamydia cases.

Chlamydia —Rates by Age and Sex, United States, 2010 Men

3,700 2,960 2,220 1,480

Rate (per 100,000 population)

774.3

740 0

Age

15 –19 0 740 1,187.0

598.0

20 –24 25 –29 309.0

153.2

91.3

30 –34 35 –39 40 –44 220.1

94.7

530.9

39.3

10.9

45 –54 55 –64 32.8

9.3

233.7

2.8

65+

Total

2.1

610.6

1,480 1,236.1

2,220 2,960

Women

3,700 3,378.2

3,407.9

Chlamydia —Rates by Race/Ethnicity, United States, 2001 –2010 Rate (per 100,000 population)

1500 1200 900 600 300 0 2001 American Indians/Alaska Natives Asians/Pacific Islanders Blacks Hispanics Whites 2002 2003 2004 2005

Year

2006 2007 2008 2009 2010

Gonorrhea

     Caused by

Neisseria gonorrhoeae

Attaches to oral or urogenital mucosa by fimbriae Opa proteins prevent CD4 +

Anal gonorrhea

, T-cell proliferation

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 Rate (per 100,000 population)

500 400 300 200 100 0 1941 1946 1951 1956 1961 1966 1971 1976

Year

1981 1986 1991 1996 2001 2006

Gonorrhea —Rates by Sex, United States, 1990–2010 Rate (per 100,000 population)

400 300 200 100 Men Women Total 0 1990 1992 1994 1996 1998 2000

Year

2002 2004 2006 2008 2010

Gonorrhea —Rates by Age and Sex, United States, 2010 Men

750 600 450 421.0

300 253.4

241.3

146.5

Rate (per 100,000 population)

150 0

Age

0 150 15 –19 20 –24 85.1

25 –29 30 –34 35 –39 48.2

107.5

64.2

23.8

34.1

11.0

40 –44 45 –54 55 –64 9.0

1.9

94.1

2.4

65+

Total

0.5

106.5

300 226.3

450 600

Women

750 570.9

560.7

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

300 200 100 0

Rate (per 100,000 population)

600 500 400 American Indians/Alaska Natives Asians/Pacific Islanders Blacks Hispanics Whites 2001 2002 2003 2004 2005

Year

2006 2007 2008 2009 2010

Gonococcal Isolate Surveillance Project (GISP) — Percentage of Neisseria gonorrhoeae Isolates with Resistance or Intermediate Resistance to Ciprofloxacin, 1990 –2010 Percentage

20 Resistance Intermediate Resistance 15 10 5 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Year

2001 2002 2003 2004 2005 2006 2007 2008 2009 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.

Gonococcal Isolate Surveillance Project (GISP) — Penicillin, Tetracycline, and Ciprofloxacin Resistance Among GISP Isolates, 2010 6.9% 0.6% 2.0% 1.8% 2.9% 9.4% 3.5% 72.8%

Susceptible PenR TetR QRNG PenR/TetR PenR/QRNG TetR/QRNG PenR/TetR/QRNG

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

.

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 Treatment

: Chronic abdominal pain : 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 Cases (in thousands)

600 500 400 300 200 100 Primary and Secondary Early Latent Total Syphilis 0 1941 1946 1951 1956 1961 1966 1971

Year

1976 1981 1986 1991 1996 2001 2006

Primary and Secondary Syphilis —Rates by Age and Sex, United States, 2010 Men

25 20 21.9

19.2

15 15.8

12.7

13.8

10 8.5

7.9

5.6

Rate (per 100,000 population)

5 0

Age

0 5 15 –19 3.0

20 –24 25 –29 3.0

4.5

2.0

2.7

30 –34 35 –39 40 –44 45 –54 55 –64 1.0

0.8

0.2

1.4

0.6

65+ 0.0

Total

1.1

10 15 20

Women

25

Primary and Secondary Syphilis —Rates by Race/Ethnicity, United States, 2001 –2010 Rate (per 100,000 population)

25 20 15 10 American Indians/Alaska Natives Asians/Pacific Islanders Blacks Hispanics Whites 5 0 2001 2002 2003 2004 2005

Year

2006 2007 2008 2009 2010

Lymphogranuloma Venereum (LGV)

     

Causative agent

:

Chlamydia trachomatis

Initial lesion on genitals heals Bacteria spread through lymph

Symptoms Diagnosis

: Swelling in lymph nodes in groin : Microscopic and culture

Treatment

: Doxycycline

Chancroid (Soft Chancre)

   

Causative agent

:

Haemophilus ducreyi

Symptoms

: Painful ulcers of genitals swollen lymph nodes in groin

Diagnosis Treatment

: Culture : Erythromycin; cetriaxone

Chancroid —Reported Cases, United States, 1981–2010 Cases (in thousands)

5 2 1 4 3 0 1981 1983 1985 1987 1989 1991 1993 1995

Year

1997 1999 2001 2003 2005 2007 2009

Bacterial Vaginosis

    

Causative agent

:

Gardnerella vaginalis

Symptoms

: Copious fishy, gray-white, thin, frothy discharge

pH

: >4.5

Diagnosis Treatment

: Clue cells : Metronidazole

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.

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 Percentage

100 80

Non-Hispanic Whites Percentage

100 80

Non-Hispanic Blacks

60 40 60 40 20 0 All Ages* 14 –19 20 –29

Age

30 –39 1976 –1980 20 40 –49 1988 –1994 0 All Ages* 1999 –2004 14 –19 2005 –2008 20 –29

Age

30 –39 40 –49 * 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 Prevalence, %

60 50 Low-risk HPV* High-risk HPV* 40 30 20 10 0 14 –19 20 –24 25 –29 30 –39 40 –49

Age

* 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 –59

Genital Warts —Initial Visits to Physicians’ Offices, United States, 1966 –2010 Visits (in thousands)

500 400 300 200 100 0 1966 1969 1972 1975 1978 1981 1984 1987

Year

1990 1993 1996 1999 2002 2005 2008

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 Visits (in thousands)

400 350 300 250 200 150 100 50 0 1966 1969 1972 1975 1978 1981 1984 1987

Year

1990 1993 1996 1999 2002 2005 2008

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 Treatment

: microscopic and culture : 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 Treatment

: Microscopic identification, DNA probe : Metronidazole

Trichomonas vaginalis

Figure 26.16

Trichomoniasis and Other Vaginal Infections —Women— Initial Visits to Physicians’ Offices, United States, 1966– 2010 Visits (in thousands)

4,500 3,600 2,700 1,800 900 Trichomoniasis Other Vaginitis 0 1966 1969 1972 1975 1978 1981 1984 1987

Year

1990 1993 1996 1999 2002 2005 2008

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

    

T

oxoplasmosis

O

ther (such as syphilis, hepatitis B, enterovirus, Epstein-Barr virus, varicella-zoster virus)

R

ubella

C

ytomegalovirus

H

erpes 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 Men

2,500 2,000 1,500 1,000

Rate (per 100,000 population)

500 0

Race/ Ethnicity

0 500 276.4

AI/AN* 1,000 898.7

1,500 2,000

Women

2,500 761.8

59.7

A/PI* Blacks 184.4

Hispanics 69.9

Whites 233.7

Total

167.2

205.1

567.6

610.6

1,536.5

* AI/AN = American Indians/Alaska Natives; A/PI = Asians/Pacific Islanders.

Gonorrhea —Rates by Race/Ethnicity and Sex, United States, 2010 Men

750 600 450 433.6

300

Rate (per 100,000 population)

150 0

Race/ Ethnicity

0 150 77.0

AI/AN* 133.5

300 17.1

A/PI* 14.0

Blacks 48.7

Hispanics 51.1

19.5

Whites 26.6

94.1

Total

106.5

450 600

Women

750 430.8

* AI/AN = American Indians/Alaska Natives; A/PI = Asians/Pacific Islanders.

Primary and Secondary Syphilis —Rates by Race/Ethnicity and Sex, United States, 2010 Men

35 28 28.2

21 14 7

Rate (per 100,000 population)

0

Race/ Ethnicity

0 7 4.3

AI/AN* 0.7

8.5

7.9

2.6

4.0

A/PI* 0.1

Blacks Hispanics 0.5

Whites 0.3

Total

1.1

6.4

14 21 28

Women

35 * AI/AN = American Indians/Alaska Natives; A/PI = Asians/Pacific Islanders.