Pemicu 4 Uro

Rifkie P 405120149

LO 1
Menjelaskan anatomi organ genitalia

Scrotum

cutaneous fibromuscular sac for the testes and associated

structures
Arterial supply
Anterior scrotal arteries; posterior scrotal arteries

Venous & lymphatic drainage

scrotal veins
superficial inguinal lymph nodes

Innervation
Anterior lumbar plexus: anterior scrotal nerves, derived from
the ilioinguinal nerve, and the genital branch of the
genitofemoral nerve
Posterior sacral plexus: posterior scrotal nerves, branches of
the superficial perineal branches of the pudendal nerve, and the
perineal branch of the posterior femoral cutaneous nerve

Penis
male copulatory organ and, by conveying the urethra,
provides the common outlet for urine and semen
consists of a root, body, and glans
Arterial supply
Dorsal arteries of the penis; Deep arteries of the penis; Arteries
of the bulb of the penis

Venous & lymphatic drainage

deep dorsal vein of the penis; superficial dorsal vein
Lymph from the skin of the penis drains initially to the superficial
inguinal lymph nodes; glans & spongy urethra drain to the deep
inguinal and external iliac nodes; from the cavernous bodies and
proximal spongy urethra drain to the internal iliac nodes

 Innervation
of penis

Female external genitalia

 Arterial supply (vulva)

internal pudendal artery supplies most of the skin, external
genitalia, and perineal muscles. The labial arteries are
branches of the internal pudendal artery, as are those of the
clitoris

Venous & lymphatic drainage (vulva)

labial veins are tributaries of the internal pudendal veins
superficial inguinal lymph nodes

 Innervation (vulva)
Anterior lumbar plexus: the anterior labial nerves, derived
from the ilioinguinal nerve, and the genital branch of the
genitofemoral nerve
Posterior derivatives of the sacral plexus: the perineal branch
of the posterior cutaneous nerve of the thigh laterally and the
pudendal nerve centrally
posterior labial nerves labia
deep and muscular branches of the perineal nerve supply the
orifice of the vagina and superficial perineal muscles
dorsal nerve of the clitoris supplies deep perineal muscles and
sensation to the clitoris
The bulb of the vestibule and erectile bodies of the clitoris
receive parasympathetic fibers via cavernous nerves from the
uterovaginal nerve plexus

LO 2
Menjelaskan histologi organ genitalia

Testes

Seminiferous Tubules

Spermatogenesis

Spermiogenesis

Tubuli recti & rete testes

Efferent ductules

Duct of epididimis & vas deferens

Seminal vesicle

Prostate glands

Penis

LO 3
Menjelaskan infeksi menular seksual

Sexually transmitted infections

Assestment

Urethritis in men
urethral discharge, dysuria, or both, usually without
frequency of urination
Etiologies

Neisseria gonorrhoeae,
C. trachomatis,
Mycoplasma genitalium,
Ureaplasma urealyticum,
Trichomonas vaginalis,
HSV,
perhaps adenovirus

 Approach to the patient

Establish the presence of urethritis
Milking purulent or mucopurulent discharge grams stained smear
>= 5 neutrophils per 1000x field
In gonococcal infections gram-negative intracellular diplococci

centrifuged sediment of the first 2030 mL of voided (morning specimen)

examined inflammatory cells >= 10 leukocytes per high-power field /
using leukocyte esterase test

Evaluate for complications or alternative diagnoses

Brief history & exam exclude epididymitis and systemic complications
men with dysuria who lack evidence of urethritis / sexually inactive men
with urethritis prostate palpation, urinalysis, and urine culture
exclude bacterial prostatitis and cystitis

 Evaluate for gonococcal and chlamydial infection

assessed for infection with N. Gonorrhoeae Culture or NAAT for N.
gonorrhoeae may be (+) when Gram's staining (-)
absence of typical gram-negative diplococci on Gram's + inflammatory
cells preliminary diagnosis of NGU urethral specimen test for C.
trachomatis

Treat urethritis promptly, while test results are pending

Abnormal vaginal discharge

 Strawberry cervix

Vaginal candidiasis

Ulcerative Genital or Perianal

Lesions
Etiology
HSV (62%)
Treponema pallidum (13%)
Haemophilus ducreyi (12
20%)

Other causes
candidiasis and traumatized
genital warts
lesions due to genital
involvement by more
widespread dermatoses
cutaneous manifestations of
systemic diseases (StevensJohnson syndrome or
Behet's disease)

 Clinical features

 Management

LO 2.1
Bacterial infection

Gonorrhea
a sexually transmitted infection (STI) of epithelium
and commonly manifests as cervicitis, urethritis,
proctitis, and conjunctivitis
Local complication
Female endometritis, salpingitis, tuboovarian abscess,
bartholinitis, peritonitis, and perihepatitis
Male periurethritis and epididymitis

Disseminated skin lesions, tenosynovitis, arthritis,

and (in rare cases) endocarditis or meningitis
Etiology Neisseria gonorrhoeae
Gram(-), nonmotile, non-spore-forming organism that grows
singly and in pairs

 Pathogenesis
Outer membrane proteins
Pili
mediating adherence

Opacity-Associated Protein
intergonococcal adhesion
Invasion of ephitelial bind
CEACAM antigen family
suppress CD4+

Porin
anion-transporting aqueous
channels

Other Outer-Membrane Proteins

H.8 excellent target for
antibody-based diagnostic
testing
Tbp1 and Tbp2 scavenging
iron from transferrin

Lipooligosaccharide
binding of organisms to
phagocytes and ephitelial

Host factors
terminal complement
components (C5 through C9)

Gonococcal resistance to
AB
Penicillinase
Tetracycline
Quinolone

 Clinical manifestations (male)

Acute urethritis (incubation 2-7d)
Urethral discharge and dysuria, without urinary frequency or
urgency major symptoms
Discharge scant and mucoid but becomes profuse and purulent
within a day or two

Gram stain PMNs and gram-negative intracellular

monococci and diplococci
Complications

edema of the penis

submucous inflammatory
periurethral abscess / fistule
Inflammation of Cowper's gland
Seminal vesiculitis

 Clinical manifestations (female)

Gonococcal cervicitis
Symptoms develop within 10d of infection
scant vaginal discharge issuing from the inflamed cervix & dysuria
Physical exam
mucopurulent discharge from cervical os cultured

Gonococcal vaginitis rare

can occur in anestrogenic women (e.g., prepubertal girls and
postmenopausal women)
Intense inflammation physical (speculum and bimanual) examination
painful
vaginal mucosa is red and edematous, and an abundant purulent
discharge is present
Infection in the urethra; Bartholin's glands; Inflamed cervical erosion /
abscesses in nabothian cysts

 Laboratory diagnosis
grams staining of urethral discharge gram-negative
intracellular monococci and diplococci
Nucleic acid probe tests
standardized culture of cervix / urethra
Blood culture

 Treatment

Syphilis
chronic systemic infection caused by Treponema
pallidum; sexually transmitted and is characterized by
episodes of active disease interrupted by periods of
latency
Epidemiology

 Clinical course
Incubation (2-6 weeks) primary lesion appears + regional
lymphadenopathy
Secondary stage: generalized mucocutaneous lesions +
generalized lymphadenopathy latent period of subclinical
infection lasting years or decades
tertiary stage (1/3 untreated): progressive destructive
mucocutaneous, musculoskeletal, or parenchymal lesions;
aortitis; or symptomatic central nervous system (CNS) disease

 Pathogenesis
T. pallidum rapidly penetrates intact mucous / microscopic
abrasions membranes lymphatic & blood systemic
incubation (21d) primary lesion at site of inoculation
(persist 4-6 weeks) heals spontaneously
secondary syphilis (generalized parenchymal,
constitutional, and mucocutaneous manifestations ) (6-8
weeks) subside 2-6 weeks latent stage
1/3 untreated tertiary stage gumma (benign
granulomatous lesion), cardiovascular syphilis, symptomatic
neurosyphilis (tabes dorsalis and paresis)

 Gumma

 Clinical manifestations
(primary)
single painless papule
eroded and usually
indurated
cartilaginous consistency
on palpation of the edge
and base of the ulcer
Predilexion
Male: penis (heterosex); anal
canal or rectum, mouth, ext
genitalia (homosex)
Female: cervix and labia

 Regional (usually inguinal)

lymphadenopathy
accompanies the primary
syphilitic lesion (1 week)
Nodes characters (firm,
nonsuppurative, and
painless)
Inguinal lymphadenopathy
(bilateral)
chancre generally heals
within 46 weeks
Lymphadenopathy persist
for months

DD

Primary genital herpes

Recurrent genital herpes
Chancroid
Donovanosis

 Clinical manifestations
(secondary)
Skin rash consists of
macular, papular,
papulosquamous, and
occasionally pustular
syphilides

 In warm, moist,
intertriginous areas
(commonly the perianal
region, vulva, and scrotum)
papules can enlarge
broad, moist, pink or graywhite, highly infectious
lesions (condylomata lata)
Superficial mucosal
erosions (mucous patches)
oral / genital mucosa

Other constitutional
symptoms

sore throat (1530%),

fever (58%),
weight loss (220%),
malaise (25%),
anorexia (210%),
headache (10%),
meningismus (5%)

 Clinical manifestation
(tertiary)
Symptomatic Neurosyphilis
Meningeal syphilis
headache, nausea, vomiting,
neck stiffness, cranial nerve
involvement, seizures, and
changes in mental status

Meningovascular syphilis
progressive vascular
syndrome headaches,
vertigo, insomnia, and
psychological abnormalities
stroke syndrome

Other manifestation

Cardiovascular Syphilis
1040 years after infection
uncomplicated aortitis, aortic
regurgitation, saccular
aneurysm (usually of the
ascending aorta), or coronary
ostial stenosis

Late Benign Syphilis (Gumma)

solitary lesions ranging from
microscopic to several
centimeters in diameter
Histologic exam
granulomatous inflammation,
with a central area of necrosis
due to endarteritis obliterans
indolent, painless, indurated
nodular or ulcerative lesions

 Laboratory examination
dark-field microscopy and immunofluorescence antibody
staining
Serologic test

 Treatment

Endemic Treponematoses

 Epidemiology

 Clinical features (yaws)

development of one or
several primary lesions
("mother yaw") multiple
disseminated skin lesions
Papule (extremity)
enlarges papillomatous or
"raspberry-like
secondarily infected with
other bacteria
Painful papillomatous lesions
on the soles painful
crablike gait ("crab yaws")
Periostitis nocturnal bone
pain

Late stage gumma,

hyperkeratoses of the
palms and soles, osteitis
and periostitis
Destruction of the nose,
maxilla, palate, and
pharynx (gangosa)

 Clinical features (endemic

syphilis)
The early lesions are
localized primarily to the
mucocutaneous and
mucosal surfaces
Initial lesions intraoral
papule mucous patches
on the oral mucosa and
mucocutaneous lesions

Late manifestations
osseous and cutaneous
gummas

 Clinical features (pinta)

initial papule located on
the extremities or face and
is pruritic
numerous disseminated
secondary lesions
(pintides) appear red but
become deeply pigmented,
ultimately turning a dark
slate blue

Secondary stage: infectious

and highly pruritic and may
persist for years;
pigmented lesions
(dyschromic macules)
Late stage: White achromic
lesions

 Diagnosis
based on clinical manifestations and, when available, darkfield microscopy and serologic testing

Treatment
benzathine penicillin (1.2 million units IM for adults; 600,000
units for children <10 years old)

Chancroid
Etiology Haemophilus ducreyi (gram-negative
bacterium whose growth requires X factor (hemin))
Histology the genital ulcers of chancroid
perivascular and interstitial infiltrates of macrophages and of
CD4+ and CD8+ T lymphocytes

Epidemiology & prevalence

transmission has been predominantly heterosexual
males have outnumbered females by ratios of 3:1 to 25:1
prostitutes have been important in transmission of the
infection
strongly associated with illicit drug use

 Clinical manifestation
Sexual contact
incubation period of 47
days initial lesiona
papule with surrounding
erythemaappears
2-3 days evolves into a
pustule ruptures
circumscribed ulcer that is
generally not indurated
painful and bleed easily;
little or no inflammation of
the surrounding skin is
evident

 Diagnosis
Gram's staining of a swab of the lesion characteristic gramnegative coccobacilli
Culture use of selective and supplemented media is
necessary
PCR

Treatment
a single 1-g oral dose of azithromycin
Alternative:
ceftriaxone (250 mg intramuscularly in a single dose),
ciprofloxacin (500 mg orally bid for 3 days),
erythromycin base (500 mg orally tid for 7 days)

Chlamydiasis (genital)
Etiology C. trachomatis
Produce fewer symptoms; often asymptomatic
Epidemiology
young men (3-5%)
>10% for asymptomatic soldiers undergoing routine physical
examination
1520% of heterosexual men seen in sexually transmitted
disease (STD)
~5% for asymptomatic women college students
>10% for women seen in family planning clinics
>20% for women seen in STD clinics

 Pathogenesis
infects the columnar epithelium of the eye and the respiratory
and genital tracts
induces an immune response but often persists for months or
years in the absence of antimicrobial therapy
inflammatory response tubal scarring and damage

 Clinical manifestation
Nongonococcal and Postgonococcal Urethritis
PGU NGU developing in men 23 weeks after treatment of
gonococcal urethritis
NGU diagnosis: leukocytic urethral exudate and by exclusion of
gonorrhea by Gram's staining or culture; NAATs on first-void urine
specimens
Symptoms: urethral discharge (often whitish and mucoid rather than
frankly purulent), dysuria, and urethral itching
Physical exam: meatal erythema and tenderness and a urethral
exudate

 Pelvic inflammatory disease

Symptoms
endometritis syndrome: vaginal bleeding, lower abdominal pain, and
uterine tenderness in the absence of adnexal tenderness
Salpingitis: milder symptoms than does gonococcal

Mucopurulent Cervicitis
no symptoms or signs
speculum examination: yellow mucopurulent endocervical discharge
and with >=20 neutrophils per 1000x microscopic field; edema of the
zone of cervical ectopy and a propensity of the mucosa to bleed on
minor trauma

Urethral Syndrome in Women

dysuria, frequency, and pyuria

 Evaluation

 Treatment
a 7-day course of doxycycline or tetracycline
For complicated infection a 2 / 3-week course of doxycycline
(100 mg orally bid) or erythromycin base (500 mg orally qid) for
LGV
C. trachomatis urethritis tetracycline hydrochloride (500 mg
qid for 7 days) or doxycycline (100 mg by mouth bid for 7 days)
C. trachomatis from the cervix tetracycline and doxycycline
pregnant women with C. trachomatis Azithromycin (a single
oral 1-g dose); amoxicillin (500 mg tid for 7 days)
Epididymis & PID infection Tetracycline hydrochloride (500
mg qid) or doxycycline (100 mg bid) for 14 days
ofloxacin (300 mg by mouth bid for 7 days) and levofloxacin
(500 mg/d by mouth for 7 days)

LO 2.2
Viral infection

Herpes genitalis
Etiology herpes
simplex viruses type 2

Both antibody-mediated and

cell-mediated reactions are
clinically important

Pathogenesis
Exposure to mucosal
surfaces or abraded skin
entry of the virus
initiation of its replication
in cells of the epidermis
and dermis
Virus then spreads to other
mucocutaneous surfaces
(via peripheral sensory
nerves)

Immunity

Some glycoproteins are target

for the antibody
natural killer cells, macrophages,
and a variety of T lymphocytes,
CD8+ T cell responses

Epidemiology

Antibodies to HSV-2 are not

detected routinely until
puberty; correlate with past
sexual activity and vary
greatly among different
population groups

 Clinical features
1st episode fever,
headache, malaise, and
myalgias; local symptoms
Pain, itching, dysuria,
vaginal and urethral
discharge, and tender
inguinal lymphadenopathy
Widely spaced bilateral
lesions of the external
genitalia are characteristic
vesicles, pustules, or
painful erythematous
ulcers

 Diagnosis
Staining (Wright's, Giemsa's (Tzanck preparation), or
Papanicolaou's) detect giant cells or intranuclear inclusions of
Herpesvirus infection
PCR

Treatment

Papilloma
Etiology human papilloma virus
These infections may be asymptomatic, produce warts,
or be associated with a variety of both benign and
malignant neoplasias
Epidemiology
Common warts (verruca vulgaris) are found in as many as 25%
of some groups and are most prevalent among young children
Plantar warts (verruca plantaris) are also widely prevalent;
they occur most often among adolescents and young adults
Anogenital warts (condyloma acuminatum) represent one of
the most common sexually transmitted diseases in the United
States

 Pathogenesis
incubation period of HPV disease is usually 34 months
All types of squamous epithelium can be infected
Replication / infection in basal cells DNA replicates and is
transcribed virions are assembled in the nucleus and
released when keratinocytes are shed
proliferation of all epidermal layers except the basal layer and
produces acanthosis, parakeratosis, and hyperkeratosis
Koilocyteslarge round cells with pyknotic nucleiappear in the
granular layer

 Clinical manifestation
Anogenital warts skin and
mucosal surfaces of external
genitalia and perianal areas
Circumcised man penile
shaft; occur at the urethral
meatus and may extend
proximally
Women posterior introitus
and adjacent labia; spread to
other parts of the vulva and
commonly involve the vagina
and cervix
internal lesions may be
present without external warts
(women)

 Diagnosis
history and physical examination alone
Application of 35% solutions of acetic acid may aid in the
visualization of lesions, although the sensitivity and specificity of
this procedure are unknown
Papanicolaou smears

Treatment

LO 2.3
Fungal infection

Vulvovaginal candidiasis
Etiology Candida albicans, C. guilliermondii, C.
krusei, C. parapsilosis, C. tropicalis, C. kefyr, C.
lusitaniae, C. dubliniensis, and C. glabrata
Clinical manifestations
pruritus, pain, and vaginal discharge that is usually thin but
may contain whitish "curds" in severe cases

 Diagnosis
visualization of pseudohyphae or hyphae on wet mount
(saline and 10% KOH),
tissue Gram's stain,
periodic acidSchiff stain,
methenamine silver stain in the presence of inflammation

Treatment
Oral fluconazole (150 mg) or azole cream or suppository
Alternative
Nystatin suppository

LO 2.4
Protozoal infection

Trichomoniasis
Etiology Trichomonas vaginalis
pear-shaped, actively motile organism that measures about
10 x 7 um; binary replication; inhabits the lower genital tract
of females and the urethra and prostate of males

Epidemiology
~3 million infections per year in women (US)

Life cycle
Can survive a few hours in moist environments direct
contact (person-to-person venereal transmission) infection

 Clinical manifestation
Men: asymptomatic; some develop urethritis; prostatitis ,
epididymitis (few)
Women: incubation (5-28d) malodorous vaginal discharge
(often yellow), vulvar erythema and itching, dysuria or urinary
frequency (in 3050% of patients)

Diagnosis
microscopic examination of wet mounts of vaginal or prostatic
secretions
Direct immunofluorescent antibody staining
Culture of the parasite

 Treatment
Metronidazole single 2-g dose or in 500-mg doses twice
daily for 7 days
Tinidazole (a single 2-g dose)
Pregnant women 100-mg clotrimazole vaginal suppositories
nightly for 2 weeks
Treatment to all sexual partners

References
Dalley, Arthur F. Keith L Moore. Clinically Oriented
Anatomy. 5th edition. Lippincott Williams & Wilcins; 2006
Fauci. Braunwald. Dkk. Harrisons Principles of Internal
Medicine. 17th edition. United State: The McGraw-Hills;
2008
Junqueira histology