Today we will talk about the Infections of the Genitourinary Tract,

Let’s begin with the anatomy of the urinary tract, as you

all know the urinary tract is composed of the kidneys, the
ureters, the urinary bladder and the urethra.

And infections of the urinary tract can be divided into

two main categories
_ Infections that affect the upper part of the urinary tract;
infections that affect the kidneys and the ureters these are
known as the upper peritonitis.

_ Infections that affect the bladder and the urethra are

considered lower peritonitis.

Now let’s begin with a few definitions:

So terms relating to the infectious diseases of the urinary Tract first we have
nephritis and pyelonephritis these referred to inflammation or infection of the
kidneys, and pyelonephritis specifically inflammation or infection of the
parenchyma of the kidney, nephritis and pyelonephritis usually cause what we
call the ascending urinary tract infections; so first you have infections maybe of
the urinary bladder and then the pathogens or microbes come divert and
eventually they move on and cause infection of the kidneys so this is what we
referred to as the ascending urinary tract infections and most infections of the
kidneys happened through this method, less commonly infections of the kidney
can happened due to direct arrival of the pathogen in the blood so we referred
that as a hematogenous round of infection, so this is the minority of the
infections.
And next we have ureteritis which obviously means inflammation or infection
in the ureters, so one of the ureters or both can be infected, again most
infections happened through the ascending round and a few of them might
happened in the descending round, so first you have an infection of the kidneys
and then microbes will go down from the kidneys and then involve the
universe.
Next we have cystitis, which refers to an inflammation or infection of the
urinary bladder, and cystitis is the most common form of urinary bladder
infections. And remember this for the exam “the most common type or the
most common example of the urinary bladder infection is for cystitis”, now the
most common cause of cystitis is the bacteria known as E. coli.
Next we have urethritis which obviously means an inflammation or infection of
the urethra, and the most common cause of urethritis is a bacteria known as
Chlamydia trachomatis.

And finally prostatitis is inflammation of the male prostate gland and this might
happen with you due to a variant of pathogens.

As you all know the pathogens that cause the urinary tract infections need to
overcome a few local defences, first we have the constant flushing action of
urine, so it prevent flora to establish a disease, they have to resist the constant
flushing action of urine that keeps flushing them out of the urinary system,
second the urine is slightly acidic so they have to be able to survive in a slightly
acidic environment, most of them like neutral PH, also another point is that the
most common cause of nephritis and pyelonephritis is also
E. coli, so E. coli as the cause of the cystitis will eventually
or maybe can move on to the kidney and cause an infection.

Next we have the Genitoreproductive system _ and this is for

your own interest_.

A few terms related to infections of the genitourinary tract,

first we have bartholinitis which means inflammation or
infection of the bartholin’s glands in females and these
glands are found adjacent to the genital opening in the vulva,
next we have cervicitis obviously means an inflammation or
infection of the cervix, endometritis obviously means an inflammation or
infection of the lining of the uterus, epididymitis which means inflammation of
the epididymis in males, pelvic inflammatory disease or PID means
inflammation of the fallopian tubes in females, another name for PID is
salpingitis.
And the most important thing of all these is vaginitis which obviously means
inflammation or infection of the vagina, and vaginitis as you will see has three
main causes; it can be caused most commonly by Candida Albicans as a
profusely infection ( obviously Candida Albicans is a yeast infection and it is
the most common type of the yeast infection ), it can be caused by a protozoan
parasite called Trichomonas vaginalis, or it can be caused by a mixed bacterial
infection, so these are the three most common causes of vaginitis, and finally
we have vulvovaginitis which means inflammation of the external genital part
of the female in addition to the inflammation of the vagina.

An important thing when you are talking about infections of the genital tract
are the Sexually Transmitted Diseases , so sexually transmitted diseases as the
name implies are diseases that can transmit through the sexual activities, but
what people don’t hear about these diseases is that they don’t necessarily result
in symptoms in the genital organs, syphilis for example is associated with
genital ulcers and later on it will associate with destruction of various tissues in
the organism’s body, so this is an example of a disease transmitted through
sexual activities and has symptoms in the genital tract and other locations,
genital ulcers as we will talk about in the next few slides mainly is associated
with genital symptoms, others like HIV or AIDS even though it spread through
sexual activities the signs of the disease or the manifestations of the disease are
on the immune system not in the tissues of the genital tract, so sexual
transmitted disease does not always mean clinical genital disease.

Let’s talk about the causes of STDs, first let’s talk about the viral STDs, the
first one is Genital Herpes, which I mention briefly when we talked about oral
herpes another name or term for it is Anogenital Herpes Viral Infections ,
genital herpes is caused mainly by herpes simplex virus type 2 (90% of the
cases of genital herpes are caused by HSV-2 , and 10% of the cases are caused
by HSV-1) _ which is the reverse of the oral herpes, in oral herpes 90% of the
cases are caused by HSV-1, and 10% of the cases are caused by HSV-2_ ,
transmission occurs by infected humans by direct sexual contact, oral-genital,
oral-anal, anal-genital contact whenever the lesions are present on the skin, so
genital herpes is similar to oral herpes, it is associated with HSV so whenever
you experience the virus for the first time, that virus or deposit will experience
of a localized lesions, the lesions will last maybe for 7 to 10 days and
eventually will heal, and the virus is not treated forever it is only for now, it
enters a latent stage in your body and stays latent for many many years and
under cretin conditions such as stress it might be activate and you get a second
epson of genital herpes.

Next we have Genital Warts also known as Genital Papillomatosis or

Condyloma Acuminatum, genital warts are caused by special specific strains of
human papillomaviruses we have a large group of human papillomaviruses
some of them associated with genital warts _warts in Arabic means ‫ _ الثواليل‬so
whenever human papillomaviruses is deposited in the genital area the first
thing we see is small virus in the skin a small petrish life on the skin, this
rapidly increase in size and eventually form a collector looking lesion that has a
large surface _ it has the same texture as the Broccoli _ so these can happen
anywhere in the genital areas, obviously transmission from infected humans is
by direct contact which is usually sexual contact for the genital organs, the
most important cause of genital warts Santana Syntax specially HPV 16 and 18
are associated with a potential development of cervical carcinoma in females ,
so after experiencing the virus for the first time made by 10, 15, 30 years later
certain women developed cervical carcinoma due to HPV 16 and 18, they are
the main cause of cervical carcinoma , now in the USA they have the vaccine
for HPV 16 and 18 so before girls enter the 14 they can take the vaccine for the
HPV 16 and 18.
By the way the doctor mentioned that he does not know if we in Jordan have
that vaccine or not.

Next we have the Urinary Tract Infections, so for urinary tract infections the
most common cause is E. coli, and E. coli is the most common cause of
cystitis, so where does E. coli come from?
E. coli most commonly comes from the gastrointestinal mucosa.
And UTIs are more common in females than in males, because of the proximity
in the anal opening to the urethral opening , but in males obviously there is one
viscus so it is less common to have UTIs, or we can say that the infections do
not happen in males as often as in females, but also in addition to E. coli the
gastrointestinal normal flora has other organisms that can cause UTIs, so
Proteus and Klebsiella which are present in the gastro intestine tract are also
very common causes of UTIs, but the most common one for the exam will be
the E. coli.
In addition to these you still have other common causes of UTIs like
Staphylococcus spp. which can be present in the skin and can cause UTIs,
S. aureus is not that commonly present in the skin, it is found in lesser amounts
than the S. epidermidis and S. saprophyticus, but this spp. is not the only one
associated with UTIs, also we have Enterococcus spp. which is found in the
skin and also in the gastrointestinal tract which can cause UTIs and
Pseudomonas aeruginosa which is most commonly found in the environment
can cause UTIs.

The UTIs can be acquired outside the hospital setting and these are referred to
as community-acquired UTIs or in the case of hospital patients they can be
acquired in the hospital setting and these are referred to as healthcare-
associated UTIs.

And the most common reason why people developed healthcare-associated

UTIs is due to catheterization, so usually in mobile stations we will have a
urinary catheter and whenever you put a urinary catheter you increase the risk
of developing a urinary tract infection.

And we mention this in the Nosocomial Infections and Healthcare associated

infections lecture, we said that the most common type of healthcare associated
infection or the nosocomial infections are the UTIs, and I think it was one of
the questions in the exam.

So whenever you have a suspected urinary tract infection you will do the
colony count on the urine sample, so if you reach a threshold number ( more
than a 100,000 ) so that means that there is an UTI or there is probably a
contamination, but also you can stain down the urine and obtain the sediment
and do a direct gram stain on the sediment, usually
when you have a UTI you will find lots of viruses
and you will find lots of bacteria, and here is an
example of a gram stain done on a sediment taken
from urine, so you can see this gram negative
bacilli, these could be E. coli, could be Klebsiella,
or it could be Proteus, while Staphylococcus
aureus you find loops and clusters or gram positive
bacteria.
Now let’s talk about bacterial STDs, we have three common causes of bacterial
STDs, first we have Chlamydia, we have Neisseria gonorrhoeae, and we have
Treponema pallidum.

So we will begin with the Chlamydia, the disease is called Genital

Chlamydiasis or Genital Chlamydia Infections caused by a certain serotypes of
Chlamydia trachomatis, Chlamydia trachomatis has many serotypes and many
of them are associated with the eye infections and we will talk about them
when we talk about the eye infections, some of them may lead to blindness and
pulp trachoma, other serotypes are associated with genital infections and we
talked about genital cervicitis, so Chlamydia trachomatis is an obligate
intracellular gram negative bacteria, and the transmission via infected humans
through direct sexual contact or mother to neonate during delivery, the most
common presentation of the genital Chlamydial infections is a development of
a purulent discharge, vital discharge or neonatal discharge, the way to diagnose
this infections is to take purulent discharge and do a direct broth and look for
the organism or you can do a direct gram stain on the purulent discharge and
look for the intracellular organism in the case of Chlamydia.

Next we have Gonorrhea which is caused by bacteria known as Neisseria

gonorrhoeae another neck name for it is Gonococcus or GC, and as we have
said it is a gram negative streptococci, transmission via infected humans is
usually by sexual contact or direct mucous membrane to mucous membrane
contact, Neisseria gonorrhoeae is another organism that is not actually
constricted to the urinary tract, so it ends up in the throat it can lead to the
upper respiratory infection, if it ends up in the genital area it can lead to a
genital infections, the most common presentation of Neisseria Gonorrhoeae
infections is development of a urethral discharge or a vaginal discharge, but a
very common problem with Chlamydia infections and Gonorrhoeae infections
is that simple individuals may develop asymptomatic infections, so they have a
viridity activate systems but they don’t have any discharge on the urine or any
feeling of pee or any discomfort, so they can extent the infection without
knowing to other individuals and that is why these infections potentially distant
in the population, in addition to causing urinary discharge or the purulent
discharge these diseases might progress to other locations and might cause
damage to the genital tract, so specific treatment if we suspected we have it.
Next we have Syphilis, which is a disease caused by spirochete known as
Treponema pallidum _the spirochete looks like a snail, a spiral shaped
organism, like the spring_, so Treponema pallidum is a gram negative
spirochete that cause the disease Syphilis, and Treponema pallidum is
associated with four stages of the disease, so first when you apply the organism
through usually sexual contact, the organism will cause an ulcer, a pales ulcer
at the side of the infection this ulcer will last for a time and eventually will
heal, but the healing of the ulcer does not necessary mean that you have killed
the bacteria, in fact the bacteria will still be there and after healing maybe by 4
or 6 weeks you will developed a generalized rash on your skin, so the ulcer in
the genital area is called primary syphilis, whenever you developed the
generalized rash it is called secondary syphilis, the secondary syphilis or the
rash will last for a few days and eventually will heal and again that does not
mean that the bacteria is precipitate from your body, it is not gone from your
body and it enters a latent stage, this is called the latent syphilis and it is the
third stage of the disease, latency of the latent syphilis can last for 5 days up to
4 years or it can last up to the hole life of the individual, in a small percentage
of those who extend latent syphilis the disease will be activated leading to the
fourth stage of the disease which is known as tertiary syphilis, and tertiary
syphilis will result in a destruction of a various tissues and organs in the body
and it can be lethal, so it is best to treat the syphilis if you suspected that the
syphilis is there as early as possible, so transmission via infected humans is by
direct contact with lesions, body secretions, mucous membranes, blood, semen,
etc. containing organism, usually by sexual contact, with also blood
transfusions and has transplacentally from mother to fetus.

A keep knowing about these three bacterial diseases, Chlamydia trachomatis,

Neisseria gonorrhoeae, and Treponema pallidum, is that they are restricted to
humans, so restricted to humans mean that no animal present for them and all
of these or most of these required a close contact, for example Neisseria
gonorrhoeae is very fragile, so you cannot obtain it from an inanimate object,
so usually you have to have a close mucous membrane contact, also
Treponema pallidum is very fragile, it cannot survive in the environment, so we
have to have close physical contact in order to spread this organisms.
And here is an example of a gram-stained urethral
exudate from a male patient with gonorrhoeae, and
Neisseria Gonorrhoeae most of the time will seek
inside the cells due to the intracellular continent and
will be found outside the cells, and these are considered
a gram negative diplococcic, so as Klebsiella they are
gram negative streptococci, so these is highly
suggestive to Neisseria Gonorrhoeae in order to have a
defiantly identification of the patient we usually do a
culture and do a various chemical tests to establish the
identity of Neisseria.

In addition to Chlamydia, Gonorrhoeae and syphilis we have other causes of

bacterial STDs, one cause is called Haemophilus ducreyi it causes a lesion
centre to the primary lesions and it is known as chancroid, another example is a
certain serotypes of Chlamydia trachomatis can cause a more sever genital
disease called Lymphogranuloma venereum, so in addition to having discharge
at the genital area these certain serotypes will lead to an infection and sever
inflammation of the inguinal lymph nodes which are found around the genital
area, so that sever inflammation spread to it and eventually rupture to all the
lymph nodes around the genital area, with these certain serotypes of Chlamydia
trachomatis, so now we have Chlamydia trachomatis that cause eye infections
and causing urinogenital infections and causing Lymphogranuloma disease,
another thing about STDs is that usually you don’t get one at the same time,
usually when there are two diseases at the same time you don’t described both
of them at the same time, for example if a patient is diagnosed with a
Gonorrhoeae you should try to look for another causes of STDs, for example
Chlamydia is commonly found on patients of Neisseria, so basically multiple
STDs can be transmitted at the same time from infected individuals.

And vaginitis as we said can be caused by three types of organisms it can be

caused by a yeast most commonly Candida Albicans, it can be caused by a
protozoal parasite called Trichomonas vaginalis or it can be caused by a mixed
bacterial infection.
Let’s talk about the yeast vaginitis, most cases are caused by the yeast Candida
Albicans usually as an opportunistic infection, so the normal flora of the
vaginal tract try to protect that location from infection, so if you have hormonal
changes that eventually lead to changing on the PH of the vagina, which might
lead to sterility of the normal flora specially the lactobacillus and that will give
a chance to the opportunistic organisms to cause diseases, also if you take a
certain antimicrobial agents like certain antibiotics you can reduce the amount
of lactobacilli which increase the potential for Candida Albicans to over grow,
so proximately 85-90% of all yeast vaginitis is caused by Candida Albicans,
the minimal part can be caused by other spp. of Candida genus, and the key
thing here is that for the healthy females they have Candida spp. in their normal
flora, so the take of a wet mount of vaginal bacterial and doing a culture and
finding Candida this is not necessarily mean having vaginosis, you have to
have the clinical signs of vaginosis, Candida variations, abdominal pain and so
on or vaginal discharge, so the combination of the clinical symptoms plus
finding of Candida Albicans or Candida spp. is the way to diagnose, Candida
Albicans if you do a saline wet mount of vaginal discharge material you will
find budding yeast like that of the urinary infection yeast produced by budding,
so you will find budding yeast and Candida Albicans, Candida Albicans
specifically among all other yeasts can form highly tight structures called
pseudohyphae, so in the case of Candida Albicans infections you have to find
the budding yeasts and usually you find the pseudohyphae, so if you find
pseudohyphae you do not have to do any other test, it has the characteristic and
highly indicative of Candida Albicans.

Finally we have the protozoal infections, we will not talk about the bacterial
causes, so the protozoal infections to the genitourinary tract referred to as
Trichomoniasis caused by Trichomonas vaginalis which is a flagellate;
meaning it has flagella for moving, it is a sexually transmitted disease of men
and women, but a key thing here is that in females the disease is usually
symptomatic, maybe we have a purulent vaginal discharge, but in the case of
males it is an asymptomatic infection, so the protozoa will be found in the
prostate gland and in the urethra without any clinical symptoms of the disease,
so males can be spreading the infection to other females without knowing.
Trichomonas vaginalis causes about 1/3 of the cases of vaginitis in the U.S.A.,
the doctor mentioned that he don’t know about the other countries in the world.
The diagnosis is similar to that of the yeast vaginosis,
so we do a saline wet mount of vaginal discharge
material, and what we will see is actively moving
protozoa or actively moving Trichomonas vaginitis,
they have the pear shape, they have a strok in the
middle called axostyle, they have a nucleus, and they
have anterior flagella, and also they have an
undulating membrane, so this you can see in the
vaginitis bacteria and you see them actively moving or
jumping in the saline, so if you see these things it is
enough to diagnose Trichomonas vaginitis infections.

THE END

Done by Raja’ Amin haddad

I dedicate this work to my parents as they always support me to live and
survive in this crazy world.

And here are some words to you,

‫أيها الراجي عفو ربه‬...
‫ من أين أبدأ؟ طاعة هللا البداية‬: ‫ال تقل‬..
‫ أين طريقي؟ شرعة هللا الهداية‬: ‫ال تقل‬..
‫ كيف نجاتي؟ سنة الهادي وقاية‬: ‫ال تقل‬..
‫ أين نعيمي؟ جنة هللا كفاية‬: ‫ال تقل‬..
‫ في الغد أبدأ ربما تأتي النهاية‬:‫ال تقل‬.
Ten Words
The most selfish one-letter word … “I” … AVOID IT.
The most satisfying two-letter word … “WE” … USE IT.
The most poisonous three-letter word … “EGO” … OVERCOME IT.
The most used four-letter word … “LOVE” … VALUE IT.
The most pleasing five-letter word … “SMILE” … KEEP IT.
The fastest spreading six-letter word … “RUMOUR” … IGNORE IT.
The hardest working seven-letter word … “SUCCESS” … ACHIEVE IT.
The most enviable eight-letter word … “JEALOUSY” … DISTANCE
YOURSELF FROM IT.
The most powerful nine-letter word … “KNOWLEDGE” … ACQUIRE IT.
The most valued ten-letter word … “FRIENDSHIP” … MAINTAIN IT.