1. Female
   • Ovaries
   • Fallopian tubes
   • Uterus
   • Cervix
   • Vagina
   • Accessory glands
   • Labia
   • Clitoris
2. Male
   • Testes
   • Epididymis
   • Vas deferens
   • Prostate
   • Accessory glands
   • Urethra
   • Penis

• Overview
  • Most UTI move upward from urethra
  • Microbes usually enter from the outside
  • Intestinal bacteria predominate
  • Many are of nosocomial origin
    • Many of these are associated with urinary catheters
    • Many are caused by E. coli
    • Others are due to Proteus, Klebsiella, Enterococcus, Pseudomonas
  • Some originate in kidneys
    • Due to systemic infections

• Symptoms
  • Dysuria
  • Pyuria
• Number one cause is E. coli
• Number two cause is Staphylococcus saprophyticus

• Symptoms
  • Fever
  • Flank/back pain
• 75% of cases due to E. coli
• Potentially life-threatening
  • IV antimicrobials often initiated
• Leptospira interrogans

• Sequelae to Streptococcus pyogenes infection
  • Unlike rheumatic fever, which follows strep throat infections, this may follow either strep throat or streptococcal skin infection
• Immune complexes present
  • Streptococcal antigens and high levels of anti-streptococcal antibodies that also cross-react with host’s kidney tissue cells
  • Complement is activated
    • Deposition of the immune complexes along small blood vessels/capillaries of kidney basement membrane (glomerular capillaries) is responsible for activation
    • Phagocytes are mobilized
    • Macrophages release cytokines, causing inflammation and further kidney damage
  • Recall, this is a Type III autoimmune disorder
• Symptoms include blood and protein in urine, generalized edema, and hypertension

• Most are STDs
  • 30+ bacterial, viral, protist etiologic agents identified
  • 15 million new cases/year in the U.S.
  • Bacterial and protist infections are curable
  • Viral infections are treatable, but not curable
• A few are not sexually transmitted

1. Gonorrhea (GC)
2. Nongonococcal Urethritis (NGU)
3. Pelvic Inflammatory Disease (PID)
4. Syphilis
5. Lymphogranuloma Venereum (LGV)
6. Chancroid (Soft Chancre)
7. Bacterial Vaginosis

• Neisseria gonorrhoeae
  • Gram negative diplococcus
  • Oxidase positive
• Symptoms
  • In men, PAINFUL urination and discharge of pus
  • In women, often none; abdominal pain late in disease

• Can infect throat (pharyngeal gonorrhea) and anus (anal gonorrhea)
• Can be passed from mother to infant (ophthalmia neonatorum)
• Untreated, GC may disseminate
  • Systemic infection can involve the joints, heart, meninges, eyes, pharynx
  • Gonorrheal endocarditis
  • Gonorrheal meningitis
  • Gonorrheal arthritis

• Sometimes called arthritis dermatitis syndrome
• Primarily a disorder of females
• Dissemination occurs as a result of septic infection following gonococcus infection, often following a menstrual period
• Skin lesions are characteristic, and joints are frequently affected
• Although WBC infiltration is often observed in joint fluid, positive cultures occur only 30% of the time

• AKA nonspecific urethritis (NSU)
• Any inflammation of urethra not due to GC
• Most commonly due to Chlamydia trachomatis
  • Most common STD in the US
  • Often co-infection with GC
  • Other causes include Ureaplasma urealyticum and Mycoplasma hominis
• Symptoms, when present:
  • Painful urination and watery discharge in men
  • Most women, some men have no symptoms

• Males
  • Inflammation of epididymis
• Females
  • Inflammation/scarring of fallopian tubes
  • Pelvic inflammatory disease
• Newborns (born to infected mothers)
  • Eye infections
  • Pneumonia
• To diagnose: rapid DNA tests are way to go (urine/cervical/urethral discharge samples OK)

• A clinical syndrome that is due to the ascending spread of microbes from the vagina and cervix to the endometrium, fallopian tubes, or other associated structures
• Very common
  • 10% of women suffer from this
  • Of these, 25% will develop serious complications such as infertility
  • May include endometritis, salpingitis, tuba-ovarian abscess, and pelvic peritonitis.
  • Salpingitis may lead to ectopic pregnancy or sterility
• Caused by N. gonorrhoeae and C. trachomatis

• Prior infections of the fallopian tubes (usually of N. gonorrhoeae or C. trachomatis) take place resulting in damage to the ciliary cells lining the fallopian tubes
• Another infection ensues and the organisms are able to ascend the fallopian tubes and cause infections in contiguous structures
• The morbidity produced by PID is greater than that of any other serious infection. In the U.S. about 850,000 women, requiring more than 212,000 hospital admissions and 115,000 surgical procedures are reported each year
• Risk factors include:
  1. Multiple sex partners
  2. History of previous PID
  3. Menstruation
  4. IUD use (oral contraceptives however decrease the risk)
  5. Marital status (single women are at higher risk)
  6. Asymptomatic gonococcal infection in either sexual partner

• Treponema pallidum
  • Very weak staining Gram negative spirochete
  • Cannot be cultured on media; darkfield exam allows visualization of spirochete
• STD mainly, BUT also transmitted by
  • Direct inoculation
  • Blood transfusion
  • Placental transmission
  • Most contagious within first four years following primary infection
• Occurs usually as a result of exposure to a moist lesion

• Serological tests used to diagnose
  1. RPR/VDRL: screening test (nontreponemal)
     • 93% of primary syphilis patients will have positive RPR
       • High false positive rate, however
       • Easiest and most economical screening method
     • All positives should be confirmed
     • VDRL used more to follow treatment and for neurosyphilis
  2. FTA-ABS; MHA-TP are confirmatory tests
     • Remains positive for life; cannot be used to follow treatment response
     • False positives may be observed with lupus, mono, and leprosy; also positive with other treponemal infections (yaws, pinta)
     • FTA-ABS is more sensitive with primary syphilis; is the most specific and sensitive test, BUT requires good technique

1. Primary syphilis
   • Chancre at site of infection (about 10 days-3 months after infection; generally 2-6 weeks)
     • Small, hard-based, painless chancre; highly infectious serum in center that is TEEMING with spirochetes (use darkfield to view)
     • Heals within 2-8 weeks
   • Direct test is positive as soon as chancre is evident
   • RPR will usually be positive, once antibody is present
   • Confirmatory tests are positive, once antibody is present
2. Secondary Syphilis
   • Spirochete is disseminated
   • Skin rash
     • Also found in mouth, throat, cervix
     • Lesions of rash TEEMING with spirochetes and very infectious (greatest concentration)
   • This stage appears about 3-6 weeks after the chancre (primary stage), BUT may show up while chancre is still present
   • Rash heals within several weeks-months
   • This rash may come and go over the next two years
   • All tests for syphilis should be positive here
3. Latent Syphilis
   • Untreated secondary syphilis goes latent
     • No clinical manifestations
     • No longer contagious
     • Syphilis tests are positive
     • Relapses into secondary syphilis may occur during first four years; less likely after first four years
4. Tertiary Syphilis
   • Progressive process that may or may not be apparent
     • Aortitis, neurosyphilis, gumma formation
   • Darkfield test is not useful at this point, but serological tests will come up positive
5. Congenital Syphilis
   • About 25% of infected pregnant women will have a stillbirth
   • 40-70% will give birth to a baby with congenital syphilis
     • Symptoms include skin sores, rashes, fever, jaundice, anemia, various deformities
     • Baby’s sores are infectious
     • If undetected or untreated, baby will develop tertiary syphilis
   • Laboratory diagnosis is difficult because of maternal antibodies
6. Penicillin is Drug of Choice
   • Snuffles: persistent, bloody rhinitis
   • Multi-organ failure
   • Characteristic bone and teeth changes
   • Syphilitic rash
   • Bloody fissures around lips, nose, and anus
   • CNS involvement
   • Hair loss
   • Gumma in viscera

• Chlamydia trachomatis
  • Strain that is invasive
  • This strain infects lymphoid tissue, leading to obstruction of lymph vessels
    • Causes massive enlargement of external genitals in males and rectal narrowing in females
• To diagnose:
  • Stain aspirated lymph node pus with iodine and look for clumped, intracellular Chlamydias
  • Rarely, grow Chlamydia in cell culture/embryonated eggs
• Mainly a tropical disease

• Hemophilus ducreyi
  • Small, Gram negative rod
• Symptoms
  • Soft chancre
    • Swollen, painful ulcer with lymph node involvement
      • Lymph nodes may break through skin, discharging pus
  • Lesions occur on genital and other regions (e.g., lips, tongue)
• Mainly a tropical disease

• Inflammation of the vagina is most often due to:
  1. Candida albicans (a fungus)
  2. Trichomonas vaginalis (a protist)
  3. Gardnerella vaginalis (most common)
     • Often presents as a vaginosis, rather than a vaginitis (no inflammation evident)
     • These women will have a decrease in Lactobacillus, with an overgrowth of both G. vaginalis and Bacteroides
     • Vaginal pH rises
     • May not be an STD
     • May be a factor in premature births
     • Symptoms
       • Fishy odor
       • Frothy vaginal discharge
       • Clue cells (epithelial cells covered with bacteria)

• Candidiasis
• Cause a vaginitis and NGU in men
• Not usually an STD
• Often opportunistic in origin
  • Antimicrobial therapy
  • Diabetes
• Symptoms: itching, cheesy discharge, yeasty or no odor

• Trichomoniasis
• Causes a vaginitis
• Often accompanied by GC coinfection
• Symptoms: profuse, foul smelling, green discharge; itching
• Usually an STD

1. Genital herpes
2. Genital warts
3. AIDS
4. Hepatitis B
5. Hepatitis C, less efficiently

• Herpes simplex
  • Exists as two distinct antigenic forms, HSV-1 and 2
    1. HSV-1
       • 5-30% of herpes infections are type 1
       • Type 1 has fewer clinical recurrences
       • It is primarily transmitted by nonveneral routes following contact with infected saliva and causes common cold sores and gingivostomatitis
    2. HSV-2
       • Usually transmitted venereally or maternally to newborn infants
       • Primarily responsible for genital herpes and neonatal infections
       • Linked epidemiologically to cervical cancer
• However, the often quoted rule of "above the waist, HSV-1; below the waist, HSV-2" is not true
  • 20% of genital herpes is due to HSV-1
  • HSV-2 can cause oropharyngeal infections

• Viruses may go latent and then recur
• Disease may be transmitted in absence of lesions
• There is no cure, although treatment manages outbreaks

• Virus crosses placental barrier
• Result can be abortion or serious fetal damage
  • Herpes is especially deadly to developing fetus, if mother acquires her first infection during pregnancy
  • Women whose latent herpes resurfaces during pregnancy can avoid infecting their babies by having a Cesarean section rather than a vaginal delivery

• Papillomaviruses
• Association with cervical and penile cancer

• Any lesion from any other STD will dramatically increase the likelihood of transmission of the HIV
  • Because organism requires blood/body fluid for transmission
• Frequently diagnosed after decrease in T lymphocytes causes opportunistic types of infections

• Type A, B, and C are all sexually transmitted diseases caused by different viruses that are also transmitted through non-STD routes as well
• Type B is the most easily sexually transmittable disease and both hepatitis A and B are preventable
• Transmission: Type A is fecal-oral; Type B is body fluid contact; Type C is body fluid contact
• Symptoms: Malaise, jaundice; liver failure with B and C
• Treatment: A generally runs its course; there is no cure, and outcome varies by individual for Type B and C

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