Urinary Tract

Infections and STD

 The Urinary Tract

Perineum: general area between the anus and genital organs

Anatomy of the Bladder
•Lower Urinary Tract Infections:
•Urethritis: infection of the urethra, usually
sexually transmitted
•Cystitis: infection of the bladder, commonly called
lower UTI
•Trigonitis: localized cystitis of the triangle
between the urethral and two ureteric orifices
•Urethral syndrome: dysuria and frequency
without cystitis
•Prostatitis: infection of the prostate
Upper Urinary Tract Infections
•Ureteritis: infection of the ureter,
rare usually caused by renal
tuberculosis
•Pyelitis: infection of the pelvis of
the kidney, usually occurs with a co-
infection of the kidney
•Acute pyelonephritis: infection of
the renal pelvis and some of the
renal tissue, most common upper
UTI
•Chronic pyelonephritis: diffuse
interstitial nephritis with
inflammatory changes, not easily
diagnosed
 Urinary Tract Infections (UTI)

•Usually acquired from external areas through the

urethra to the bladder
•Bacteriuria: presence of bacteria in urine
•Significant bacteriuria: 105 or more bacteria per ml of
voided mid-stream urine used as criterion for UTI
•Number below usually are from contamination except
with dysuria and pyuria where 103 can be significant
PYURIA
PYURIA is pus in the urine - or the
presence of inflammatory cells in
the urine sediment (neutrophils as
seen here).

HEMATURIA

HEMATURIA is the presence or red

blood cells in the urine.

The erythrocytes may have

originated from the kidney, ureter,
bladder or urethra. Remember
they may lyse if urine
concentration is dilute.
•Escherica coli is the most
common cause of ascending UTI
•Proteus mirabilis causes UT
stones due to the production of
urease which converts urea to
ammonia
•Klebsiella, Enterobacter, and
Serratia spp as well as
Psuedomonas aeruginosa are
more frequent in hospital-
acquired UTI
 Uropathogenic E. coli (UPEC)
•Facultative aerobic gram negative rods
•Ferment glucose producing acid and gas
•Oxidase-negative
•Some motile, produce peritrichous flagella.
•Urinary tract serotypes:
•O-serotypes O1, O2, O4, O6, O7, O75
•K serotypes (capsule) : K1,K2,K3,K5,K12, K13
•Adaptive pili for uroepithelium
•P fimbria or pyelonephritis-associated pili [PAP]
•K antigens
•are acidic polysaccharides prevent phagocytosis
•Hemolysin is associated with kidney damage
Infections with Viruses and Parasite are RARE
•Can isolate polyomaviruses and CMV from urine
(congenital) but usually not pathogenic
•Rarely, adenovirus shed from UT can cause hemorrhagic
cystitis and hantavirus can infect renal capillaries to cause
renal syndrome with proteinuria
•Candida spp and Histoplasma capsulatum can cause UTI
•Trichomonas vaginalis can cause urethritis in both males
and females but more commonly causes vaginitis
•Schistosoma haematobium causes inflammation of bladder
and hematuria due to egg penetration of bladder wall and
granuloma formation
•By unknown mechanisms, bladder cancer is associated with
chronic infections
Residual urine is a cause of infection

•Obstruction of complete emptying of bladder (2-

3 ml)
•Pregnancy, prostate hypertrophy, congenital tumors
•Foreign bodies like calculi, catheters
•Blockage can lead to movement to kidneys
•Loss of bladder and sphincters control (spina bifida,
paraplegia or multiple sclerosis) may lead to recurring
infections
•Vesicoureteral reflux (reflux up ureters to renal pelvis
or parenchyma)
 Pathogenesis of UTI
•Women are more prone
because of the shorter length
of urethra
•Sexually activity
•movement of organisms during
intercourse up the urethra
•Uncircumcised men have
slightly higher infections from
colonization of the prepuce
and urethra with E. coli
•Poor perianal hygiene
Catheterization
•Primary predisposing
factor for UTI
•Insertion of catheter
introduces pathogens into
bladder usually by
tracking up the side
Pyelonephritis
•Lower UTI symptoms
•Fever (If it is present around 103o)
•Books states Staphylococcal infections are the most
common cause it is an additional-mostly E. coli.
•Recurrent infections
•Loss of renal function leading to hypertension
•Hematuria
•Also a symptom seen with myocarditis as a result of
immune complex deposition (S. pyogenes)
•Note Hematuria may be seen as a result of renal trauma,
calculi, carcinomas, clotting disorders, thrombocytopenia,
and menstruation
 Acute Bacterial Prostatitis
•Fever
•Acute perineum pain
•Pyuria
•Similar symptoms to UTI
•Most common agent Enterobacteriacae and Pseudomonas
•Quinolones or cotrimoxazole
 Treatment UTI
•General
•Traditionally b-lactams but some species are resistant
•Cephalexin
•is a cephalosporin antibiotics which interfers with the cell wall formation,
causing it to rupture, and killing the bacteria.
•Nitrofurantoin
•no clinically significant bacterial resistance has been reported.
•Bacterial nitroreductases convert nitrofurantoin to highly reactive
electrophilic intermediates. These intermediates were shown to attack
bacterial ribosomal proteins non-specifically, causing complete inhibition
of protein synthesis.
• Quinolones in males (Cipro)
Sexually Transmitted Diseases
•STI (Sexually transmitted infections) can be
controlled by change of sexual behavior
•The use of condoms
•Number of sexual partners
•Host factors
•Immunosuppression
•Genital Ulcers or lesions
•Other STD
Sexually transmitted
diseases
chapter 21
“This section”
Gonorrhea
Nongonococcal urethritis
Chlamydia
Trichomonas vaginitis and urethritis
Bacterial vaginosis
 Urethritis
•Inflammation of the urethra
•Two major causes: gonorrhea and non-gonococcal
urethritis (NGU)
•Gonorrhea
•Neisseria gonorrhoeae
•NGU
•Commonly Chlamydia trachomatis
•Gender
•C. trachomatis in women causes cervicitis more commonly than
urethritis
•Sexual Orientation
•Gonorrhea predominates in homosexual men, C. trachomatis in
heterosexual men
Gonorrhea - Clinical Manifestations
•Urethritis - male
•Incubation: 1-14 d (usually 2-5 d)
•Symptoms: Dysuria and urethral discharge (5% asymptomatic)
•Discharge can be as extreme as copious yellow or yellow-green pus
•“Like urinating razorblades”

•Urogenital infection - female

•Endocervical canal primary site
•70-90% also colonize urethra
•Incubation: unclear; symptoms usually in l0 d
•Symptoms: majority asymptomatic; may have vaginal discharge,
dysuria, urination, labial pain/swelling, abdominal pain
•Complications

Extra-genital infection mostly asymptomatic!!

 Gonorrhea Infection in Infants
•Perinatal: infections of the conjunctiva, pharynx,
respiratory tract
•Prophylactic – erythromycin eye ointment for newborns
 Complications of Gonorrhea
•Local Spread
•Periurethral abscesses
•Urethral stricture
•Epididymitis or prostatitis
•Pelvic Inflammatory
Disease
•In women,
•Pelvic Inflammatory
Disease
•Infertility due to fallopian
tube damage
•Rectum and Throat
•Distant Spread
•Rare but gonococcaemia
with skin or joints
•1-3% of untreated
women
 Microbiology
•Etiologic agent: Neisseria gonorrhoeae
•Gram-negative intracellular diplococcus
•Infects mucus-secreting epithelial cells

Gram Stain of Urethral Discharge

Gonorrhea
•Neisseria gonorrhoeae
•Gram negative intercellular diplococci
•Oxidase positive
•Capsule: anti-phagocytic
•Pilus: Attach to epithelium of vagina or urethra,
but also throat or rectum (non-ciliated)
•IgA protease
•LPS : lack lipid A and O-side chains
•Controlled by serum factors (IgG, IgM, and
Complement:rarely disseminated to joints or
skin)
•Don’t develop specific immunity
 Gonorrhea Gram Stain

Source: Cincinnati STD/HIV Prevention Training Center

29
 Nongonococcal Urethritis
•Etiology:
•20-40% C. trachomatis
•20-30% genital mycoplasmas (Mycoplasma genitalium,
Ureaplasma urealyticum)
•Occasional Trichomonas vaginalis, HSV
•Unknown in ~50% cases
•Symptoms: Mild dysuria, mucoid discharge (clear to
mucopurulent)
•Diagnosis: Urethral smear  5 PMNs
• Urine microscopic  10 PMNs
•
Cervicitis

Normal Cervix

Source: Claire E. Stevens, Seattle STD/HIV Prevention Training Center

Chlamydia trachomatis
•Clinical Manifestations:
•Incubation period 7-21 days
•Mostly asymptomatic
•cervicitis, urethritis, proctitis, lymphogranuloma
venereum, and pelvic inflammatory disease

•Complications:
•Infertility due to Pelvic Inflammatory Disease
•Potential to transmit to newborn during delivery
•Conjunctivitis, pneumonia
Chlamydia

•Obligate intracellular parasites of animals

•Little metabolic capacity
•No peptidoglycan
•Infect columnar epithelial cells
•Survive by replication that results in the death of the cell
 Chlamydiaceae
•1999 Chlamydiaceae was divided into two genera: Chlamydia and
Chlamydophila
•Once considered viruses due to small size
•Intracellular pathogens which block phagosome-lysosome fusion
•Chlamydia trachomatis
•Serotypes A-C = eye infections
•Serotypes D-K = genital tract infections
•Serotypes L1-L3 = Lymphogranuloma venereum (LGV)
Chlamydiaceae Family
(species that cause disease in humans)
Species (genus) Disease
C. trachomatis Trachoma, NGU,
2 biovars, non-LGV MPC, PID,
LGV conjunctivitis,
Infant pneumonia,
LGV
C. pneumoniae Pharyngitis,
bronchitis,
pneumonia
C. psittaci Psittacosis
 Chlamydia Life Cycle
•Larger reticulate body
•Grows within cells
•Does not survive outside host
•Small elementary bodies
•Survives outside host
•Similar in function to
endospore
LAB
•Microscopy
•Culture
•Urethral, cervical, rectal and
pharyngeal swabs must be plated on a
warm Thayer-Martin medium and
Chocolate Agar
•Serology is useless
•DNA tests
•Treatment
•Penicillin G
•Beta-lactams
•Ceftraizone +doxycycline
Vaginitis
Vaginal Candidiasis
•Fungus Candida albicans
•Cheesy vaginal discharge
•May be accompanied by urethritis and dysuria
•Antifungals: fluconazole (oral) or topical Nystatin
Trichomonas vaginalis
•Protozoan infection of vagina
•Vaginitis with copious discharge
•Treat with metronidazole
Bacterial vaginosis
•Gardnerella vaginalis plus obligate anaerobe such as
Bacteroides
Bacterial Vaginosis
•50% asymptomatic
•Signs/symptoms when
present:
•malodorous (fishy
smelling) vaginal
discharge
•Diagnosis:
•vaginal Gram stain,
rapid tests