S5: Medical Pathology

Key Unit Competencies

pathologies of urogenital system.

Introductory activity 4.0

Observe the image below and answer the questions that follow.

Figure 4.1 Urinary tract infection

3. How do you think the microorganisms can enter in the urinary system?

4.1 URINARY TRACT INFECTION (UTI)

Learning Activity 4.1

pain management, IV fluids and admitted A.K for further management.

nitrogenous waste products of protein metabolism, assisting in maintenance of acid

transport (ureters), storage (bladder), and excretion (urethra) of urine.

mechanisms.

the risk for a UTI.

a foreign body such as stone acting as a harbor for bacteria, and papillary necrosis.

Signs and Symptoms

Lower urinary tract symptoms are experienced in patients who have UTI of the

upper urinary tract, as well as those confined to the lower tract. Symptoms are

related to either bladder storage or bladder emptying. These symptoms include

dysuria, frequent urination (more than every 2 hours), urgency, and suprapubic

discomfort or pressure. The urine may contain grossly visible blood (hematuria) or

sediment, giving it a cloudy appearance. Flank pain, chills, and fever indicate an

infection involving the upper urinary tract (pyelonephritis). People with significant

bacteriuria may have no symptoms or may have nonspecific symptoms such as

fatigue or anorexia.

The UTI symptoms are often absent in older adults as they tend to experience

non localized abdominal discomfort rather than dysuria and suprapubic pain. In

addition, they may have cognitive impairment or generalized clinical deterioration.

The older adults are less likely to experience a fever with a UTI, the value of body

temperature as an indicator of a UTI is unreliable.

Investigations

In a patient suspected of having a UTI:

• Initially obtain a dipstick urinalysis to identify the presence of nitrites

(indicating bacteriuria), white blood cells (WBCs), and leukocyte esterase (an

enzyme present in WBCs indicating pyuria). These findings can be confirmed

by microscopic urinalysis.

• After confirmation of bacteriuria and pyuria, a urine culture may be obtained.

A urine culture is indicated in complicated UTI, persistent bacteriuria, or

frequently recurring UTI (more than two or three episodes per year). Urine

may also be cultured when the infection is unresponsive to empiric therapy

or the diagnosis is questionable. A urine culture is accompanied by sensitivity

testing to determine the bacteria’s susceptibility to a variety of antibiotic drugs.

• Imaging studies of the urinary tract like intravenous pyelogram (IVP),

cystoscopy, ultrasound can be performed. A computed tomography (CT)

urogram or ultrasound may be obtained when obstruction of the urinary

system is suspected or UTI occurs.

Adequate medical diagnosis

Most patients with urinary tract infection (UTI) can be managed as outpatients.

Indications for hospitalization include clinical uro-sepsis, immunocompromised

patient, vomiting or inability to tolerate oral medication, lack of outpatient followup,

and failure to respond to outpatient therapy. Empiric antimicrobial therapy

immediately after appropriate urine collection is warranted from patients with a high

probability of UTI based on the clinical and laboratory data available. Definitive

therapy is based upon the results of urine culture and sensitivities. There are other

investigations that must be performed like imaging.

Treatment plan

The goals of treatment of UTI include:

• Elimination of infection and prevention of uro-sepsis

• Relief of acute symptoms (eg, fever, dysuria, frequency)

• Prevention of recurrence and long-term complications including hypertension,

renal scarring, and impaired renal growth and function.

• Treatment to be effective should be oriented to both people if it is a couple

Interventions that must be carried out to meet those goals are:

• Ensuring adequate fluid intake if it is not contraindicated. Maintaining

adequate fluid intake may be difficult because of the patient’s perception that

fluid intake will worsen the discomfort and urinary frequency associated with

a UTI. Tell patients that fluids will increase frequency of urination at first but

will also dilute the urine, making the bladder less irritable. Fluids will help flush

out bacteria before they have a chance to colonize in the bladder. Caffeine,

alcohol, citrus juices, chocolate, and highly spiced foods or beverages should

be avoided because they are potential bladder irritants.

• Application of local heat to the suprapubic area or lower back may relieve the

discomfort associated with a UTI. Advise the patient to apply a heating pad

(turned to its lowest setting) against the back or suprapubic area. A warm

shower or sitting in a tub of warm water filled above the waist can also provide

temporary relief.

• Instruct the patient about the prescribed drug therapy, including side effects.

Emphasize the importance of taking the full course of antibiotics. Often

patients stop antibiotic therapy once symptoms disappear. This can lead to

inadequate treatment and recurrence of infection or bacterial resistance to

antibiotics.

• Instruct the patient to monitor for signs of improvement (e.g., cloudy urine

becomes clear) and a decrease in or cessation of symptoms. Teach patients

to promptly report any of the following to their health care provider: (1)

persistence of bothersome UTI beyond the antibiotic treatment course, (2)

onset of flank pain, or (3) fever.

• Antibiotic medications are necessary for the UTI. For treatment of uncomplicated

UTI, oral (by mouth) antibiotics are usually adequate. However, for major

complications such as sepsis or pyelonephritis, intravenous (IV) antibiotics

may be typically necessary. The antibiotics usually used are Nitrofurantoin

(Macrobid), Fosfomycin (Monurol), Trimethoprim-Sulfamethoxazole (Bactrim

and others), Cefixime, Cefuroxime, Cefotaxime or Ceftriaxone, Gentamicin,

Ciprofloxacin (Cipro) or Levofloxacin (Levaquin). Doxycicline or Erythromycin

can also be provided. Metronidazole will be needed in case of Trichomonas

infection or Nystatine in case of candida infection. The choice of regimen

depends on Antimicrobial spectrum and susceptibility, where the ultimate

choice of antimicrobial therapy is based upon the susceptibilities of the

organism isolated. Cephalosporins are the first-line oral agent in the treatment

of UTI among patients without genitourinary abnormalities. Amoxicillin and

ampicillin are not routinely recommended for empiric therapy because of the

high rate of resistance of E. coli.

• Inpatient parenteral therapy: this will require hospitalisation and the parenteral

therapy generally is indicated for the following cases: <2 months, clinical

urosepsis (eg, toxic appearance, hypotension, poor capillary refill), immune

compromise, vomiting or inability to tolerate oral medication, lack of adequate

outpatient follow-up (eg, no telephone, live far from hospital, etc), failure to

respond to outpatient therapy.

• Adjunctive therapies might be used to reduce the renal parenchymal

inflammation which if not treated leads to renal scarring. The therapies used

are anti-inflammatory drugs like Dexamethasone, Prednisolone, etc.

Evolution and complications

If all prescribed regimen are respected, the outcome is very good. Without treatment,

UTI can cause major health problems. Severe effects of a UTI that can develop

include:

• Pyelonephritis (acute or chronic): An infection involving the kidneys

• Sepsis: A dangerous, systemic, whole-body infection

• Renal scarring: due to chronic inflammation of renal parenchyma

• Hypertension: related to ineffective Angiotensin-Renin-Aldosteron

Self-assessment 4.1

1. What are all possible causes or risk factors to develop the urinary tract

infections?

2. What are the signs and symptoms of urinary tract infections?

3. What are the investigations that should be requested to make the diagnosis

of urinary tract infections?

4. What are their rationales?

5. What must be included into the management plan of that medical condition?

6. If not treated, what are the complications of UTIs?

4.1.1 URETHRITIS

Learning Activity 4.1.1

Carefully read the case below and answer the following questions:

A male patient aged around 25 years came to our hospital with the complaints

of discharge per urethra since 2 days. He also had burning micturition since

10 days which was followed 12 hours later by foul smelling white discharge

from urethra which continued to be present till the day he visited the hospital.

He also gave history of unprotected sexual intercourse with a commercial sex

worker 2 days prior to the onset of all symptoms. On examination, there was

mucopurulent discharge from urethra.

The meatus was cleaned using gauze soaked in saline. The discharge was

collected using a sterile swab under aseptic precautions. It was processed

for Gram staining and showed many pus cells and intracellular gram negative

diplococci, with adjacent sides concave (Kidney shaped). On chocholate agar

colonies were small, round, slightly raised and greyish white. Gram staining was

done from the colonies which showed gram negative diplococci. He was treated

with ciprofloxacin 500mg two times a day for 10 days, metronidazole 2gr single

dose and doxycycline 100mg two times a day and ibuprofen 400mg three times

a day for 3 days.

1. What are the possible medical conditions of this patient?

2. What are the signs and symptoms of this medical condition?

3. What are the causes of this above medical condition?

4. What are the investigations that should be used to diagnose that medical

condition?

5. Propose the treatment plan regarding this medical condition

6. If the patient is not well treated what are possible complications?

Urethritis is an inflammation of urethra that is the tube that carries urine from the

bladder to outside the body.

Causes and risk factors

Urethritis is an inflammatory condition that can be infectious or posttraumatic

in nature. Infectious causes of urethritis are typically sexually transmitted and

categorized as either gonorrhoea urethritis (ie, due to infections with Neisseria

gonorrhoeae) or non-gonorrhoea urethritis (eg, due to infections with Chlamydia

trachomatis, Ureaplasma urealyticum, Mycoplasma hominis, Mycoplasma

genitalium, or Trichomonas vaginalis). Bacteria that normally are present cause

no difficulty unless these tissues are traumatized, usually after instrumentation

such as catheterization or cystoscopic examination. Other causes of nonspecific

urethritis in men include irritation during vigorous intercourse, rectal intercourse, or

intercourse with a woman who has a vaginal infection.

Urethritis is seen more commonly in men than in women. In women, urethritis may

accompany cystitis but also may be secondary to vaginal infections. Soaps, bubble

baths, sanitary napkins, or scented toilet paper also may cause urethritis. In men, a

common cause of urethritis is infection with Chlamydia trachomatis or Ureaplasma

urealyticum, which causes an STI. The distal portion of the normal male urethra is

not totally sterile.

Pathophysiology

The pathogenesis of urethritis depends on the causative pathogen. N.

gonorrhea is usually transmitted via the genital tract to the human host. Following

attachment to host cell, which is mediated by pili, gonococci become engulfed

in a process known as parasite-directed endocytosis. This organism will survive

inside the vacuoles and replicate. Among non-gonorrheal causes, Chlamydia

trachomatis is the most common. The infectious process begins with cell surface

attachment and phagocytosis by the host cell. The pathogen survives inside

the cell by debilitating the cellular lysosomes and replicating as elementary bodies

which is considered as the infective form of the pathogen.

Signs and symptoms

Infection of the urethra results in discomfort on urination varying from a slight

tickling sensation to burning or severe discomfort and urinary frequency. Fever is

not common, but fever in the male client may be due to further extension of the

infection to areas such as the prostate, testes, and epididymis.

Urethritis can cause itching, pain, or discomfort when a person is not urinating, pain

during sexual intercourse, discharge from the urethral opening or vagina, in men

there can be blood in the semen or urine.

Investigations

The diagnosis of urethritis relies on:

• Physical examination that includes the genitals, abdomen, and rectum.

• Urine tests and culture for gonorrhea, chlamydia, or other bacteria.

• Examination of any discharge under a microscope

• Blood tests may be done in certain situations.

Adequate medical diagnosis

The client’s history and symptoms often provide a tentative diagnosis. In men,

a urethral smear is obtained for culture and sensitivity to identify the causative

microorganism. In women, a urinalysis (clean-catch midstream specimen) may

identify the causative microorganism.

Treatment plan

Treatment includes appropriate antibiotic therapy (doxycycline, azithromycin,

ceftriaxone, etc), liberal fluid intake, analgesics, warm sitz baths, and improvement

of the client’s resistance to infection by a good diet and plenty of rest. If urethritis is

due to an STI, it is treated with appropriate antibiotic therapy. Oral Antibiotic treatment

for 1-2 weeks (Men 2 weeks recommended). Urethritis due to trichomonas infection

(called trichomoniasis) is usually treated with an antibiotic called metronidazole

(Flagyl). Tinidazole (Tindamax) is another antibiotic that can treat trichomoniasis.

The nurse reinforces the need to complete antibiotic therapy, drink plenty of fluids,

and take warm sitz baths and analgesics for pain. Urethritis may be seen in clients

with indwelling urethral catheters. To prevent or decrease urethritis, the nurse needs

to be vigilant with sterile technique, as well as to exercise gentleness when changing

catheters. It also is essential to provide frequent perineal care, especially if the

client is incontinent of faeces. In addition to washing around the anus and buttocks,

the nurse also cleans the meatus and labia of the female client. When cleaning the

anal area, wiping away from the urethra ensures that there is no contamination. If

cotton pledgets are used, the nurse wipes from the urethral meatus to the anus in a

single stroke and discards the pledget. Client teaching information about prevention

include: avoid having intercourse with multiple partners, use condoms every time

you have unsafe sex, get tested regularly, protect others if you find out you have an

STI, inform others who are also at risk of an infection.

Evolution and complications

Failure to seek treatment for gonococcal urethritis may result in a urethral stricture

in men. Medication can often treat urethritis quickly. If the infection goes untreated,

however, the effects can be lasting and quite serious. For example, the infection

may spread to other parts of the urinary tract, including the ureters, kidneys, and

bladder. These infections can be painful on their own. While they can be treated

with more intensive rounds of antibiotics, they can cause damage to the organs if

left untreated for too long. These untreated infections can also spread to the blood

and result in sepsis, which can be deadly.

In addition, the STIs that frequently cause urethritis can damage the reproductive

system. Women may develop pelvic inflammatory disease (PID), which is painful

and can result in infertility, ongoing pelvic pain, or pain during sex. Women with

untreated STIs are also at a higher risk for ectopic pregnancies, which can be lifethreatening.

Men may develop painful inflammation or infection of the prostate

gland, or the narrowing of a section of the urethra due to scarring, leading to painful

urination. Major complications of urethritis are: pyelonephritis, pre-term delivery,

urinary retention, recurrent UTI, prostatitis, sepsis, renal abscess.

Self-assessment 4.1.1

1. What are all possible causes or risk factors to develop the urethritis?

2. What are the signs and symptoms of urethritis?

3. What are the investigations that should be requested to make the diagnosis

of urethritis?

4. What are their rationales?

5. What must be included into the management plan of the urethritis?

6. If not treated, what are the complications of urethritis?

4.1.2 CYSTITIS

Learning Activity 4.1.2

Carefully read the case below and answer the following questions:

6. What are possible complications if the patient is not well treated?

Cystitis is an inflammation of the urinary bladder usually caused by the bladder

infection. Although it is usually able to be treated on an outpatient basis, it is

common type of UTIs that are potential source of ore complex problems requiring

invasive treatment.

Causes of cystitis

Cystitis can be either acute or interstitial:

Bacterial cystitis:

UTIs typically occur when bacteria outside the body enter the urinary tract through

the urethra and begin to multiply. Most cases of cystitis are caused by a type of

Escherichia coli (E. coli) bacteria. Bacterial bladder infections may occur in women

as a result of sexual intercourse. But even sexually inactive girls and women are

susceptible to lower urinary tract infections because the female genital area often

harbors bacteria that can cause cystitis.

Non-infectious cystitis:

Although bacterial infections are the most common cause of cystitis, a number

of noninfectious factors also may cause the bladder to become inflamed. The

causes include urologic instrumentation (e.g., cystoscopy, catheterization), faecal

contamination, prostatitis, or benign prostatic hyperplasia, indwelling catheters,

pregnancy, and sexual intercourse. Some examples include:

• Interstitial cystitis: The cause of this chronic bladder inflammation, also

called painful bladder syndrome, is unclear. Most cases are diagnosed in

women. The condition can be difficult to diagnose and treat.

• Drug-induced cystitis: Certain medications, particularly the chemotherapy

drugs cyclophosphamide and ifosfamide, can cause inflammation of your

bladder as the broken-down components of the drugs exit your body.

• Radiation cystitis: Radiation treatment of the pelvic area can cause

inflammatory changes in bladder tissue.

• Foreign-body cystitis: Long-term use of a catheter can predispose you

to bacterial infections and to tissue damage, both of which can cause

inflammation.

• Chemical cystitis: Some people may be hypersensitive to chemicals

contained in certain products, such as bubble bath, feminine hygiene sprays

or spermicidal jellies, and may develop an allergic-type reaction within the

bladder, causing inflammation.

• Cystitis associated with other conditions: Cystitis may sometimes occur

as a complication of other disorders, such as diabetes, pregnancy, kidney

stones, an enlarged prostate or spinal cord injuries.

Pathophysiology

The inflammation usually is caused by a bacterial infection. Bacteria can invade

the bladder from an infection in the kidneys, lymphatics, and urethra. Because the

urethra is short in women, ascending infections, or microorganisms from the vagina

or rectum are more common.

The lining of the bladder provides a natural resistance to most bacterial invasions

by preventing an inflammatory reaction from occurring. If bacteria do survive in the

bladder, however, they adhere to the mucosal lining of the bladder and multiply. The

surface of the bladder becomes edematous and reddened, and ulcerations may

develop. When urine contacts these irritated areas, the client experiences pain and

urgency, which is magnified in the presence of even slight bladder distention.

Signs and Symptoms

The symptoms of cystitis include urgency (feeling a pressing need to void although

the bladder is not full), frequency, low back pain, dysuria, perineal and suprapubic

pain, and hematuria, especially at the termination of the stream (terminal hematuria).

If bacteremia is present, the client also may have chills, fever, dark urine, cloudy

or strong smelling. When the disease/infection becomes severe, the patient will

experience some systemic signs and symptoms: nausea, vomiting, loss appetite,

weakness, etc. Chronic cystitis causes similar symptoms, but usually they are less

severe.

Investigations

Microscopic examination of the urine reveals an increase in the number of red

and white blood cells.

Culture and sensitivity studies are used to identify the causative microorganism

and appropriate antimicrobial therapy.

If repeated episodes occur, intravenous pyelogram (IVP) or cystoscopy with or

without retrograde pyelograms may be needed to identify the possible cause, such

as chronic prostatitis or a bladder diverticulum (weakening and outpouching of the

bladder wall), which encourages urinary stasis and infection.

Adequate medical diagnosis

The client’s history and symptoms often provide a tentative diagnosis. Culture and

sensitivity studies are used to identify the causative microorganism. Intravenous

pyelogram or cystoscopy may identify the possible cause of cystitis.

Treatment Plan

Medical management includes antimicrobial therapy and correction of contributing

factors. Examples of drugs that may be used include trimethoprim-sulfamethoxazole

(Bactrim) and nitrofurantoin macrocrystals (Macrodantin). Antibiotics like

sulfonamides are drugs commonly used to treat urinary tract infections (UTIs).

Other drugs used are nitrofurantoin macrocrystals (Macrodantin) and nitrofurantoin

(Furadantin), and the acids methenamine mandelate (Mandelamine) and nalidixic

acid (NegGram). An azo dye, phenazopyridine (Pyridium), may be ordered for its

soothing effect on bladder mucosa and often is used in conjunction with urinary

antimicrobial drugs.

Cranberry juice or vitamin C may be recommended to keep the bacteria from

adhering to the wall of the bladder and thus promoting their excretion and enhancing

the effectiveness of drug therapy.

When there is a partial urethral obstruction, no treatment of cystitis is fully effective

until adequate drainage of urine is restored by the removal of the obstruction (see

discussion of urethral strictures).

In some instances, treatment may be prolonged and may need to be repeated.

Advise clients to follow their physicians’ instructions about the medication, such as

drinking extra fluids.

Evolution and complications

When treated promptly and properly, bladder infections rarely lead to complications.

But left untreated, they can become something more serious. Complications may

include:

• Kidney infection: an untreated bladder infection can lead to kidney infection,

also called pyelonephritis. Kidney infections may permanently damage the

kidneys.

• Young children and older adults are at the greatest risk of kidney damage

from bladder infections because their symptoms are often overlooked or

mistaken for other conditions.

• Blood in the urine: with cystitis, the patient may have blood cells in the

urine that can be seen only with a microscope (microscopic hematuria) and

that usually resolves with treatment. If blood cells remain after treatment, the

doctor may recommend a specialist to determine the cause.

• Blood in the urine that the patient can see (gross hematuria) is rare with

typical, bacterial cystitis, but this sign is more common with chemotherapy- or

radiation-induced cystitis

Self-assessment 4.1.2

1. What are all possible causes or risk factors to develop the cystitis?

2. What are the signs and symptoms of cystitis?

3. What are the investigations that should be requested to make the diagnosis

of cystitis?

4. What are their rationales?

5. What must be included into the management plan of the cystitis?

6. If not treated, what are the complications of cystitis?

4.1.3 ACUTE AND CHRONIC PYELONEPHRITIS

Learning Activity 4.1.3

Carefully read the case below and answer the following questions:

S.U. a 38-yr-old woman came at the accident and emergency of Kibungo DH

for a history of painful, frequent urination with passage of small volumes of urine

for 3 days. Had intermittent fever, chills, and back pain during 3 days. She was

frightened when she saw blood in her urine and reports this is her third attack of

painful urination and back pain in 4 months. She is anxious because her father

died of kidney cancer and remembers having many UTIs as a child. She has

had four pregnancies with difficult vaginal deliveries. She complains of bilateral

flank pain and abdominal tenderness to palpation, and severe pain (pain score

of 9/10) while palpating the costovertebral area. Her vital signs are BP: 134/67

mmHg, Pulse: 78 beats/min, respiratory rate of 24 cycles/min, temperature of

38° C. The urinalysis revealed pyuria, hematuria and the presence of white blood

cells in the urine. Urine and blood cultures were still pending and treating team

decided to hospitalize her, gave her the IV fluids (Normal saline 2liters/24hours),

ciprofloxacin tablets 500mg BID for 7 days, and IV paracetamol 100mg as

needed.

1. What are the abnormal signs and symptoms the patient was presenting?

2. What are the risk factors that predispose S.U to develop her medical

condition?

3. What is the medical condition that S.U is presenting?

4. List all investigations that have been ordered to the patient, and all other

helpful investigations based on her medical condition.

5. What was included into her treatment plan?

6. What do you think could be the complications if her medical condition is

poorly managed?

The most common urologic disorders are infectious and inflammatory conditions.

Those that affect the kidneys are extremely dangerous because damage to the

nephrons can result in permanent renal dysfunction and the consequences can

lead to acute or chronic renal failure.

Pyelonephritis is an acute or chronic bacterial infection of the kidney (which

involves one or both kidneys) and the lining of the collecting system (kidney pelvis).

Acute pyelonephritis presents with moderate to severe symptoms that usually

last 1 to 2 weeks. If the treatment of acute pyelonephritis is unsuccessful and the

infection recurs, the chronic pyelonephritis occurs.

A. ACUTE PYELONEPHRITIS

In acute pyelonephritis, the inflammation causes the kidneys to grossly enlarge.

The cortex and medulla develop multiple abscesses. The renal calyces and pelves

also can become involved. Resolution of the inflammation results in fibrosis and

scarring.

Causes and Risk Factors

Pyelonephritis usually begins with colonization and infection of the lower urinary

tract via the ascending urethral route. Acute pyelonephritis commonly starts in the

renal medulla and spreads to the adjacent cortex. The common causes are:

• Bacteria normally found in the intestinal tract, such as E. coli or Proteus,

Klebsiella, or Enterobacter species, frequently cause pyelonephritis.

• A preexisting condition like vesicoureteral reflux (retrograde, or backward,

movement of urine from lower to upper urinary tract)

• Dysfunction of the lower urinary tract causing the urinary stasis or urinary

obstruction (e.g., obstruction from benign prostatic hyperplasia, tumors, a

stricture, a urinary calculi or stone).

• Instrumentation of urethra and bladder (Urinary tract catheterization,

cystoscopy, urologic surgery) is also a common cause of pyelonephritis and

urosepsis.

• Another important risk factor for acute pyelonephritis is pregnancy-induced

physiologic changes in the urinary system.

• Women with increased sexual activity, who use the diaphragm or spermicide,

who fails to void after intercourse, history of recent urinary infection.

• Men who perform anal intercourse, who has infection with HIV

• Inability to empty the bladder

• Other existing conditions/comorbidities like diabetes mellitus, other renal

disease (polycystic kidney disease), neurogenic bladder (post stroke, multiple

sclerosis, or spinal cord injury)

Pathophysiology

Infection spread by ascending microorganisms along the ureters, and may be also by

bloodstream. The infection causes the inflammation, and the inflammatory process

affects the pelvis, calyces, medulla and tubules. There is medullary infiltration of

white blood cells with renal inflammation, renal edema and purulent urine. In severe

infection, the abscess may be formed in the medulla and extend into the cortex.

The necrosis of renal papillae may develop.

Signs and Symptoms

The clinical manifestations of acute pyelonephritis are acute onset and vary from

mild fatigue to the sudden onset of chills, fever, vomiting, malaise, flank or groin pain,

and the lower UTIs characteristics that include dysuria, urgency, and frequency.

The patient might also have the cloudy or purulent urine.

Costovertebral tenderness to percussion (costovertebral angle pain) is typically

present on the affected side. Although the clinical manifestations may subside within

a few days, even without specific therapy, bacteriuria and pyuria usually persist.

Investigations

For investigating the pyelonephritis, the complete history taking and comprehensive

physical examination must be performed first. The most useful investigations are:

• Urinalysis that will indicate pyuria, bacteriuria, and varying degrees of

hematuria. White blood cells casts may be found in the urine indicating

involvement of the renal parenchyma.

• A full blood count ( FBC) shows leucocytosis (increased levels of leukocytes

in the blood)

• Urine cultures must be obtained when pyelonephritis is suspected to detect

the causative agents.

• In patients with more severe illness who are hospitalized, blood cultures

are usually obtained as well.

• Ultrasonography of the urinary system may be performed to identify anatomic

abnormalities, hydronephrosis, renal abscesses, or an obstructing stone.

• Other Imaging investigations include CT scan alone or combined with

Intravenous pyelography, VCUG (a voiding cystourethrogram is a study

used to look at bladder and urethral abnormalities and to determine if you

have ureteral reflux), CT urograms are also used to assess for signs of

infection in the kidney and complications of pyelonephritis such as impaired

renal function, scarring, chronic pyelonephritis, or abscesses.

Adequate Medical diagnosis

The client’s history and symptoms often provide a tentative diagnosis. The physical

examination and most useful investigations such as urinalysis, a full blood count ,

urine culture may contribute to confirm the diagnosis

Treatment Plan

The treatment plan is made basing of severity of signs and symptoms that the

patient is presenting.

Mild Symptoms (Uncomplicated Infection):

• Outpatient management or short hospitalization

• Antibiotics therapy should be for 2 – 3 weeks

• Empirically selected broad-spectrum antibiotics: ampicillin, vancomycin

combined with an aminoglycoside (e.g., tobramycin, gentamicin)

• Switch to sensitivity-guided therapy: trimethoprim/sulfamethoxazole (Bactrim)

when results of urine and blood culture are available

• Fluoroquinolones are helpful too like ciprofloxacin, ofloxacin, norfloxacin,

gatifloxacin

• Adequate fluid intake (oral preferably)

• Nonsteroidal antiinflammatory drugs (NSAIDs) or antipyretic drugs

• Follow-up urine, blood cultures and imaging studies

Severe Symptoms:

• Require Hospitalization

• Antibiotics therapy should be for 2 – 3 weeks

• Parenteral (Intravenous) Antibiotics

• Oral antibiotics (broad spectrum antibiotics, fluoroquinolones, etc) when

patient tolerates oral intake

• Adequate fluid intake (parenteral initially and switch to oral fluids as nausea,

vomiting, and dehydration subside)

• NSAIDs as antipyretic or analgesic drugs to reverse fever and relieve

discomfort

• Follow-up urine, blood culture and imaging studies

Evolution and complications

After the acute phase, healing occurs with deposition of scar tissue and

atrophy of affected tubules. Acute pyelonephritis rarely causes renal failure.

The most common complications of acute pyelonephritis are:

1. Transformation to Chronic pyelonephritis

2. Papillary necrosis due to inflammatory thrombosis of the blood vessels

supplying the renal papilla.

3. Pyonephrosis (filling of the dilated calyces and pelvis by pus due to obstruction

at pelviureteric junction.

4. Perinephric abscess due to spread of the inflammation to the perinephric fat

B. CHRONIC PYELONEPHRITIS

This is a persistent or recurrent infection of the kidney, leading to scarring of the

kidney. One or both kidneys may be involved. In chronic pyelonephritis, the kidneys

become small, atrophic, and shrunken and lose function due to fibrosis (scarring).

Chronic pyelonephritis is usually the result of recurring infections involving the upper

urinary tract. However, it may also occur in the absence of an existing infection,

recent infection, or history of UTIs.

Causes and Risk factors

The most common causes of chronic pyelonephritis are:

• Recurrent episodes of acute pyelonephritis

• Chronic obstruction (e.g., strictures and stones)

• Reflux disorders that allow urine to flow backward up the ureters

Pathophysiology

There is a process of progressive inflammation, altered renal pelvis and calyces,

destruction of the tubules, atrophy or dilation, and diffuse scarring; and finally

impaired urine- concentrating ability, leading to chronic renal failure.

Signs and Symptoms

Repeated acute pyelonephritis leads to chronic pyelonephritis. In exacerbation,

the symptoms are similar to acute pyelonephritis. The general clinical signs and

symptoms are:

– General body weakness, fatigability, headache

– Anorexia/poor appetite

– Polyuria and frequency urine

– Excessive thirst

– Weight loss

– Pain and/or unpleasant sensation at costovertebral region

– Flank pain

– Cloudy urine

– Progressive scarring leads to Renal failure

– Systemic signs: elevated BP (Hypertension), vomiting, diarrhea.

Investigations

Investigations of chronic pyelonephritis are similar to the ones of acute pyelonephritis.

The complete history taking and comprehensive physical examination must be

performed first. Radiologic imaging and a biopsy, rather than clinical features are

used to confirm the diagnosis of chronic pyelonephritis.

The level of renal function in chronic pyelonephritis depends on whether one or

both kidneys are affected, the extent of scarring, and the presence of coexisting

infection.

The most useful investigations are:

• Urinalysis that will indicate pyuria, bacteriuria, and varying degrees of

hematuria. White blood cells casts may be found in the urine indicating

involvement of the renal parenchyma.

• A full blood count ( FBC) shows leucocytosis (increased levels of leukocytes

in the blood)

• Urine cultures must be obtained when pyelonephritis is suspected to detect

the causative agents.

• In patients with more severe illness who are hospitalized, blood cultures

are usually obtained as well.

• Ultrasonography of the urinary system may be performed to identify anatomic

abnormalities, hydronephrosis, renal abscesses, or an obstructing stone.

• Other Imaging investigations include CT scan alone or combined with

Intravenous pyelography, VCUG (a voiding cystourethrogram is a study

used to look at bladder and urethral abnormalities and to determine if you

have ureteral reflux), CT urograms are also used to assess for signs of

infection in the kidney and complications of pyelonephritis such as impaired

renal function, scarring, chronic pyelonephritis, or abscesses.

• Imaging studies reveal a small, fibrotic kidney. The collecting system may be

small or hydronephrotic.

• Renal Biopsy results indicate the loss of functioning nephrons, infiltration of

the parenchyma with inflammatory cells, and fibrosis.

Adequate medical diagnosis

The client` history and symptoms often provide a tentative diagnosis. A comprehensive

physical examination must be performed . The most useful investigations such as

urinalysis, a full blood count, urine culture and ultrasonography may contribute to

confirm the diagnosis.

Treatment plan

The treatment should focus on treating the causes (Obstruction must be relieved)

and treat all risk factors (vesicoureteral reflux, neurogenic bladder dysfunction,

arterial hypertension) and should also include the prolonged Antibiotics for 4-6

weeks.

The patient will require hospitalization, Parenteral (Intravenous) Antibiotics but Oral

antibiotics (broad spectrum antibiotics, fluoroquinolones, etc.) can be preferred

when patient tolerates oral intake. Patient must also receive the adequate fluid intake

(parenteral initially and switch to oral fluids as nausea, vomiting, and dehydration

subside) and NSAIDs as antipyretic or analgesic drugs to reverse fever and relieve

discomfort.

Surgical management (Nephrectomy) is indicated when there is unilateral

manifestation of chronic pyelonephritis with organ dysfunction to control current

UTI or arterial hypertension.

Evolution and Complications

Chronic pyelonephritis often progresses to end-stage kidney (renal) disease

(ESRD) even if the underlying infection is successfully treated.

The most common complications of chronic pyelonephritis are:

• Anemia

• Fluid overload

• Bacteremia

• Hypertension

• Renal stones

• End stage renal disease

Self-assessment 4.1.3

1. What is the most common cause of acute pyelonephritis resulting from an

ascending infection from the lower urinary tract?

a) The kidney is scarred and fibrotic.

b) The organism is resistant to antibiotics.

c) There is a preexisting abnormality of the urinary tract.

d) The patient does not take all of the antibiotics for treatment of a UTI.

2. Which characteristic is more likely with acute pyelonephritis than with a

lower UTI?

a) Fever

b) Dysuria

c) Urgency

d) Frequency

3. Which test is required for a diagnosis of pyelonephritis?

a) Renal biopsy

b) Blood culture

c) Intravenous pyelogram (IVP)

d) Urine for culture and sensitivity

4. Referring to their causes, differentiate the acute and chronic pyelonephritis

5. What are the investigations and their rationale requested for pyelonephritis?

6. What are the treatment modalities are available for severe form of acute

pyelonephritis?

7. What are the most clinical signs and symptoms that determine the

pyelonephritis?

8. What are the treatment options for chronic pyelonephritis?

9. Referring to RAA system, describe how the pyelonephritis can cause the

hypertension

10. What are the complications of chronic pyelonephritis?

11. Describe how the pyelonephritis can lead to renal failure.

4.1.4 ACUTE AND CHRONIC PROSTATITIS

Learning Activity 4.1.4

symptoms like the ones he has been experiencing over the past few days.

He was advised to drink plenty of much water, prescribed ciprofloxacine 500mg

BID for 7 days, paracetamol 500mg TDS for 5 days, requested the abdominal

ultrasound and the urine culture that results were still pending.

1. What are abnormal signs and symptoms was the patient having?

2. What is the medical diagnosis is the patient presenting?

3. What are different risk factors to the development of that medical condition?

4. What are all relevant investigations are helpful in confirming that diagnosis?

5. What is the treatment plan of that medical condition?

6. What might be the complications if poorly treated?

The term prostatitis has been used for various inflammatory conditions affecting

the prostate, including acute and chronic infections with specific bacteria and, more

commonly, instances in which signs and symptoms of prostatic inflammation are

present but no specific organisms can be detected.

Classification of prostatitis

Prostatitis is classified as:

– Acute bacterial prostatitis

– Chronic bacterial prostatitis

– Nonbacterial prostatitis (Chronic pelvic pain syndrome).

A. ACUTE PROSTATITIS

Acute prostatitis is a sudden inflammation of the prostate gland. It is a rare type of

prostatitis, which is a common prostate problem. When the prostate gland becomes

inflamed, symptoms may be similar to those of an acute UTI. Acute prostatitis

is often caused by a type of bacteria that causes UTIs and sexually transmitted

infections.

Causes and Risk factors

Inflammation can result from bacteria entering the prostate via the blood or an

infection in the area. It can also be caused by urethral stricture and prostatic

hyperplasia. A medical procedure may also lead to bacteria entering the prostate.

Underlying causes of acute prostatitis might also be a blocked urethra or suppressed

immune system. The most common causes of prostatitis are bacteria, fungi or

mycoplasma:

– Escherichia coli

– Enterobacter

– Klebsiella

– Pseudomonas

– Chlamydia trachomatis

The risk factors for acute bacterial prostatitis (all allow bacterial colonization) are

intra-prostatic ductal reflux, phimosis and redundant foreskin, unprotected anal

intercourse, urinary tract infections, acute epididymitis, indwelling foley catheter,

transurethral surgery, altered prostatic secretions, recent transrectal ultrasoundguided

prostate needle biopsy, immunosuppression (patients with underlying

immunosuppression, may be more likely to have prostatic involvement with

organisms other than the usual bacteria that tend to cause urinary tract infection),

etc.

Pathophysiology

The infection stimulates an inflammatory response in which the prostate becomes

enlarged, tender, firm, or boggy (too wet). Acute inflammatory prostatic edema may

cause urinary obstruction with dysuria. The onset of the illness may be acute, or

follow catheterization or cystoscopy.

An inflammation of the prostate gland and surrounding tissue due to an infection

can be acute or chronic. Some physiological factors that contribute to development

of prostatitis are altered prostate secretory functions, decreased zinc, decreased

prostatic antibacterial factor and altered prostatic PH. The prostatitis can also be

due to catheters, urethral instrumentation and transurethral prostatectomy.

Signs and symptoms

Patient with acute prostatitis present with low back pain, perineal pain, high fever

up to 40o C, chills, dysuria, inability to empty the bladder, nocturia, urinary retention,

systemic signs and symptoms of infection (myalgia, arthralgia, fatigue/malaise),

prostatic pain especially when an individual is in upright position, symptoms can

include pain (in the perineum, lower abdomen, testicles, penis, and with ejaculation),

bladder irritation, bladder outlet obstruction, and sometimes blood in the semen,

sexual dysfunction may accompany chronic bacterial prostatitis.

Investigations

The ways of diagnosing the acute prostatitis include:

• Complete history taking

• Complete physical exam that include the Digital rectal examination: there

may be prostatic hypertrophy, tenderness, edema, and nodularity. However,

the prostate exam is frequently normal.

• FBC, Urea and creatinine, PSA (prostatic specific antigen): Laboratory

findings that suggest inflammation or infection like elevated serum

leukocytes or inflammatory markers may be absent. Usually there is an

elevated prostatic specific antigen (>4 ng/mL).

• Urinalysis: Gram stain, culture, bacteriuria (WBC >105 )

• The diagnostic standard for bacterial prostatitis is the finding of bacteria at

higher levels in prostatic fluid compared with urethral and bladder specimens.

It is better to obtaining prostatic specimens for analysis and culture to

confirm the prostate as the site of infection.

• Abdominal ultrasound can also be helpful (demonstrated the prostate

increased in size).

Adequate medical diagnosis

Treatment plan

The treatment plan for acute prostatitis includes:

Antibiotics: prolonged antibiotic therapy (for at least six weeks) with an agent that

has good penetration into the prostatic tissue is generally necessary for treatment

of bacterial prostatitis. A fluoroquinolone is generally the drug of choice for both

initial and recurrent episodes. Trimethoprim-sulfamethoxazole is an adequate

alternative regimen. Other agents with good penetration into prostatic fluid and

tissue include tetracyclines and macrolides. In mild case: Oral antibiotics up to 6

weeks, in severe cases: IV Ampicilline+ Gentamycine for 7 days, then 4-6 weeks

oral antibiotics.

Analgesics and Antipyretics

Bed rest and adequate hydration

Addressing urinary obstruction — Symptoms of difficulty urination, a sensation of

incomplete emptying, or post-void dribbling should trigger further investigations.

Alpha-blockers (prazocin, terazocin, etc) may be used to relax the bladder muscles

and reduce discomfort

Most cases of acute prostatitis will clear up with antibiotic treatment. Some

severe cases of infection may require a hospitalisation, and mainly due to failed

outpatients management, inability to tolerate oral intake, evidence of resistance risk

factors (recent fluoroquinolones use, recent transurethral or transrectal prostatic

manipulation), systemically ill patient or septicaemia, urinary retention, etc

In addition to medical interventions, a patient may try to alleviate symptoms with

home remedies like taking warm showers or baths, avoiding activities that put

pressure on the prostate such as bicycling, sitting on a cushion, avoiding alcohol,

reducing or avoiding consumption of spicy foods, drinking plenty of fluids that do

not contain caffeine. There are a variety of lifestyle changes that may reduce the

risks of developing chronic or recurring prostatitis: reducing stress, using protection

during sexual activity, ejaculating at least once a week, avoiding processed foods,

eating a healthful diet, protecting against pelvic trauma, maintaining a healthy

weight.

Evolution and Complications

Most cases of acute prostatitis will clear up with antibiotic treatment. Acute prostatitis

may cause a blockage of the urethra. When this occurs, a person will experience

pain and discomfort in the bladder. If left untreated, a blocked bladder can lead

to permanent kidney damage. Other complications may include residual chronic

prostatitis, inflammation of the epididymis or epididymoorchitis (a coiled tube at

the back of the testicles), bacteremia (a bacterial infection of the blood), prostatic

abscess (a pus-filled pocket in the prostate), semen abnormalities, seminal

vesiculitis, infertility.

B. CHRONIC BACTERIAL PROSTATITIS

The chronic bacterial Prostatitis is characterized by recurrent urinary tract symptoms

and persistence of pathologic bacteria (usually Gram negative) in urine or prostatic

fluid. It is similar to chronic pelvic pain syndrome (CPPS). Chronic prostatitis is the

inflammation or infection of the prostate that lasts at least 3 months.

Causes and risk factors

Chronic bacterial prostatitis is caused by bacteria getting to the prostate through the

urethra. This infection can be caused by an infection originating from the bladder or

contaminated urinary catheter. Some bacterial infections contribute to the formation

of prostate stones that are not expelled during urination. Prostate stones are about

the size of a poppy seed and are not always detectable during physical exam.

Infected prostate stones are a common cause of recurring UTIs and make curing

chronic bacterial prostatitis very difficult.

Pathophysiology

The infection stimulates an inflammatory response in which the prostate becomes

enlarged, tender, firm, or boggy (too wet). Acute inflammatory prostatic edema may

cause urinary obstruction with dysuria.

Signs and symptoms

The signs and symptoms of chronic prostatitis and CPPS are very similar. They

usually start out mild and build in intensity over time. Those signs and symptoms

include: a constant urge to urinate, burning pain when urinating, difficulty starting

urination followed by uneven flow, blood in urine, feeling as if the bladder isn’t fully

emptied after urination, painful ejaculation, pain in following locations: lower back,

lower abdomen, above pubic area, between the testicles and anus, etc. It may also

be accompanied by fever and chills.

Symptoms may be similar to those of prostatic cancer, urinary retention, bladder

stones and those from an acute bladder infection: urgency, frequency, dysuria,

perineal discomfort, low back pain, myalgia, arthralgia and sexual dysfunction.

The prostate may only slightly enlarged or wet, but yet fibrosis because with

repeated infections can cause it to be rigid and irregular in shape.

Investigations

– Complete history taking

– Complete physical exam that include the Digital rectal examination: there

may be prostatic hypertrophy, tenderness, edema, and nodularity. However,

the prostate exam is frequently normal.

– FBC, Urea and creatinine, PSA (prostatic specific antigen): Laboratory

findings that suggest inflammation or infection like elevated serum leukocytes

or inflammatory markers may be absent. Usually there is an elevated prostatic

specific antigen (>4 ng/mL).

– Urinalysis: Gram stain, culture, bacteriuria (WBC >10⁵ )

– The diagnostic standard for bacterial prostatitis is the finding of bacteria at

higher levels in prostatic fluid compared with urethral and bladder specimens.

It is better to obtaining prostatic specimens for analysis and culture to confirm

the prostate as the site of infection.

– Abdominal/pelvic imaging (CT scan, MRI, ultrasound)

– Prostatic massage to express secretions: culture, Gram-stain

– Pelvic X-ray may show prostatic calculi

– Biopsy guided by transurethral or transrectal ultrasonography

Adequate medical diagnosis

Chronic prostatitis is a pelvic condition that needs to be distinguished from other

forms of prostatitis, such as acute and chronic bacterial prostatitis. It is characterized

by pelvic or perineal pain lasting longer than 3 months without evidence of urinary

tract infection. Symptoms include pain that may radiate to the back and perineum

causing discomfort while sitting, dysuria, frequency, urgency, arthralgia, myalgia,

unexplained fatigue, abdominal pain, and burning sensation in the penis may be

present. Post-ejaculatory pain mediated by nerves and muscles is a hallmark of

the condition. Some patients report low libido, sexual dysfunction, and erectile

difficulties. The symptoms of chronic prostatitis appear to result from interplay

between psychological factors and dysfunction in the immune, neurological,

and endocrine systems. The prognosis is good with use of multimodal treatment

including antibiotics use, psychotherapy, pelvic nerve trigger point release, anxiety

control, and chronic pain therapy

Treatment plan

Antibiotics: prolonged antibiotic therapy (for 12 weeks) with an agent that has good

penetration into the prostatic tissue is generally necessary for treatment of bacterial

prostatitis. A fluoroquinolone is generally the drug of choice for both initial and

recurrent episodes. Trimethoprim-sulfamethoxazole is an adequate alternative

regimen. Other agents with good penetration into prostatic fluid and tissue include

tetracyclines and macrolides. In mild case: Oral antibiotics, In severe cases: IV

antibiotics.

Analgesics and Antipyretics (Nonsteroidal anti-inflammatory drugs or corticosteroids)

Bed rest, adequate hydration.

Addressing urinary obstruction — Symptoms of difficulty urination, a sensation of

incomplete emptying, or post-void dribbling should trigger further investigations.

Alpha-blockers may be used to relax the bladder muscles and reduce discomfort

Patients may require the hospitalisation

Treat the underlying cause (e.g.: surgical removal of prostatic stone through

transurethral prostatectomy, surgery to remove scar tissue in the urethra, which

can help urination difficulties)

Muscle relaxants to relieve spasm of the pelvic muscles

Therapy to help with psychological stress and anxiety

Evolution and complications

The prongosis is good with use of multimodal treatment including antibiotics use,

psychotherapy, pelvic nerve trigger point release, anxiety control, and chronic pain

therapy. When chronic prostatitis is caused by a bacterial infection, it can be treated

with antibiotics. When the cause is unknown, treatment of the symptoms may be

the best course of action. If left untreated, a blocked bladder can lead to permanent

kidney damage, inflammation of the epididymis or epididymoorchitis, bacteremia,

prostatic abscess, semen abnormalities, seminal vesiculitis, infertility.

Self-assessment 4.1.4

1. Differentiate the acute and chronic prostatitis

2. Describe briefly the pathogenesis of bacterial prostatitis.

3. What are the signs and symptoms of acute prostatitis?

4. What are the causes of prostatitis?

5. List the risk factors of acute prostatitis

6. Enumerate all investigations needed to diagnose prostatitis and their

rationale.

7. What are the treatment modalities of acute prostatitis?

8. Explain when is surgical interventions needed during the management of

chronic prostatitis.

9. List some complications of acute prostatitis.

10. What is the standard investigation of prostatitis?

11. What are the indications of hospitalisation to a patient with acute prostatitis?

4.2. SEXUAL TRANSMISSIBLE DISEASES (STDs)

Introductory activity 4.2

Observe the picture below and answer the questions that follow.

Figure 4.2.1Relationship between girl and boy

1. What do you see on the picture?

2. What do you think could be the consequences of their act?

Sexually transmitted infections (STIs), also known as Sexually Transmitted Diseases

(STDs), are caused by bacteria, viruses or parasites that are transmitted through

unprotected sex (vaginal, anal, or oral) and skin to skin genital contact. The most

common bacterial infections include chlamydia, gonorrhoea, and syphilis. The viral

infections include genital herpes, Hepatitis B, Human Papillomavirus (HPV) and

Human Immunodeficiency Virus (HIV). Parasites are responsible for trichomoniasis.

4.2.1 CHLAMYDIA

Learning Activity 4.2.1

Ms A.E, a 20 year old female was worried because she had vaginal discharge

and irritation for three days. The discharge was slight, clear, watery, and nonoffensive,

and she had no abnormal vaginal bleeding. Ms A.E had changed

her sexual partner two months previously. Soon after this she had contracted

genital thrush, which responded to topical clotrimazole. She uses a combined

contraceptive pill and does not use condoms. Ms A.E has no other sexual

partners, and thinks it unlikely her partner has. During the physical examination,

the abnormal finding at vaginal examination was that Ms A.E’s cervix bled

easily when swabbed. A vaginal swab was taken for laboratory examination.

Ms A.E was prescribed doxycycline 200 mg two times a day for seven days and

metronidazole 400 mg three times daily for seven days and sent back home and

waited for results.

A few days later the laboratory reported that chlamydia had been detected. Ms

A.E was called to come back at health facility to be communicated the results.

She was upset to be told that she might have had a sexually transmitted disease

and was unpleasant to go together with her partner.

1. What were the abnormal signs and symptoms was the patient presenting?

2. Basing on those signs and symptoms, what do you think was the medical

diagnosis?

3. What were the risk factors that predisposed her to develop that condition?

4. What were the investigations requested to guide in the confirmation of that

diagnosis?

5. What were the treatment options were available towards that diagnosis?

6. If not well managed, what will be the complications?

Chlamydia is a sexually transmitted disease caused by a bacterium named

Chlamydia trachomatis.

Risk factors

A person is at risk of getting infected of STIs if he/she drinks alcohol (it may be difficult

to convince a drunken partner to use a condom or use one condom correctly). If the

partner uses drugs, it may also make it easier for them to pressure a person into

engaging in unsafe sexual behaviours. Having one STI frequently is a risk to getting

more infections. If the skin is swollen, or scorched, it is easy for another pathogen

to cause infection.

Pathophysiology

Disease pathogenesis due to Chlamydia trachomatis is a complicated process that

involves: (1) exposure to the organism and infectivity; (2) survival within the host

cell; (3) virulence associated with specific strain types; (4) innate and acquired

immunity, and (5) host genetic susceptibility to infection and disease.

Most female and male infections are asymptomatic, which provides an ongoing

opportunity for silent transmission and the development of disease. In addition,

repeat and persistent infections are common among at risk adolescent and young

adult populations. Even with appropriate detection, there is increasing evidence

for antibiotic resistance to the common drugs used to treat Chlamydia trachomatis.

Consequently, the inability to adequately prevent, diagnose, treat, and eradicate

infection provides the opportunity for pathogenicity and disease.

functionally and morphologically distinct forms.

recruitment of actin with subsequent engulfment of the bacterium.

intercept sphingomyelin-containing vesicles.

The mechanism by which the host cell protein is trafficked to the inclusion through

the exocytic pathway is not fully understood. As the RBs replicate, the inclusion

grows as well to accommodate the increasing numbers of organisms. Through

unknown mechanisms, RBs begin a differentiation program back to the infectious

EBs, which are released from the host cell to initiate a new round of infection.

Because of their obligate intracellular nature, Chlamydiae have no tractable genetic

system, unlike E. coli, which makes Chlamydiae and related organisms difficult to

investigate.

Signs and symptoms

Chlamydia is the most common curable bacterial STD. The symptoms may not be

noticed, or they may be vague and nonspecific. Some people experience no health

effects at all. Chlamydia Symptoms are burning or itching of the genitals, discharge

from the penis or vagina, and pain during sex or urination. Those symptoms can

appear within days or weeks. It infects the cervix in women which is the opening to

the uterus or womb and the penile urethra in men. Chlamydia infections can also

develop in the rectum and throat.

Investigations

Screening and diagnosis of chlamydia is relatively simple. Tests include:

A urine tests: a sample of the urine is analyzed in the laboratory for presence of

this infection.

A swab: for women, your doctor takes a swab of the discharge from your cervix

for culture or antigen testing for chlamydia. This can be done during a routine Pap

test/smear. Some women prefer to swab their vaginas themselves, which has been

shown to be as diagnostic as doctor-obtained swabs. For men, the doctor inserts a

slim swab into the end of the penis to get a sample from the urethra. In some cases,

the doctor will swab the anus

Adequate medical diagnosis

In females, Chlamydia trachomatis most commonly affects the cervix. The majority

of infected females are asymptomatic, although some may present with the typical

findings of cervicitis, including vaginal discharge, abnormal vaginal bleeding, and

purulent endocervical discharge on exam.

The most concerning complication of untreated cervical chlamydial infection is

pelvic inflammatory disease, which in turn can lead to infertility, ectopic pregnancy,

or chronic pelvic pain.

In males, C. trachomatis is a common cause of nongonococcal urethritis. The

majority of infected males are asymptomatic. When present, symptoms include

a mucoid or watery urethral discharge and dysuria. C. trachomatis is a frequent

cause of acute epididymitis in males younger than 35 years of age and may be an

etiology in some cases of chronic prostatitis.

The diagnostic test of choice for chlamydial infection of the genitourinary tract is

nucleic acid amplification testing (NAAT) of vaginal swabs for females or urine for

males. NAAT should also be used on rectal swabs to diagnose chlamydial infection.

If non-NAAT-based testing is used for diagnosis or if adequate follow-up cannot be

insured, patients with signs and symptoms consistent with chlamydia should be

treated empirically before diagnostic test results return.

Treatment plan

Chlamydia can be easily cured with antibiotics. HIV-positive persons with chlamydia

should receive the same treatment as those who are HIV-negative.

Persons with chlamydia should abstain from sexual activity for 7 days after single

dose antibiotics (metronidazole, doxycycline, etc) or until completion of a 7-day

course of antibiotics, to prevent spreading the infection to partners. It is important

to take all the medications prescribed to cure chlamydia. Chlamydial infection in

infants can be treated with antibiotics.

Preventive strategies

It is important to practice proper self-hygiene, for instance, shower regularly, clean

the toilet and bathroom with disinfectants, detergent, and clean water, because one

can easily get an infection from a dirty toilet.

To ensure protection during sexual intercourse, when the client thinks he/she is at

risk of STIs, he/she should go for instant check-up and seek treatment when the

infection is suspected. However, both partners should be treated.

Also, it is urgent to see a doctor immediately if the person is sexually active and may

have been exposed to an STI, or when signs and symptoms of an STI are present.

Evolution and complications

If left untreated, chlamydia can cause permanent damage to the reproductive system

in both males and females. It can cause infertility by blocking the reproductive tract

in men and women. Chlamydia can do a lot of damage to the body in the long run.

Repeated infection with chlamydia is common. Women whose sex partners have

not been appropriately treated are at high risk for re-infection. Having multiple

chlamydial infections increases a woman’s risk of serious reproductive health

complications, including pelvic inflammatory disease and ectopic pregnancy.

Women and men with chlamydia should be retested about three months after

treatment of an initial infection, regardless of whether they believe that their sex

partners were successfully treated. In addition, the infants infected with chlamydia

may develop ophthalmia neonatorum (conjunctivitis) and/or pneumonia.

Self-assessment 4.2.1

1. Name the bacteria that is responsible of chlamydia.

2. What are the signs and symptoms of chlamydia?

3. What are the necessary tests performed to diagnose the infection of

chlamydia?

4. Explain the treatment plan of chlamydia

5. What are the preventive measures?

6. What are the complications of chlamydia in women and men?

4.2.2 SYPHILIS

Learning Activity 4.2.2

Carefully read the case below and answer the following questions:

A 39-year-old woman presented to the emergency department reporting several

weeks of generalized weakness, headache, nausea, and arthralgia. The patient

had unprotected sexual intercourse with a man whom the past 6 months physical

examination revealed a painful ulcerated plaque on the upper lip, a macular rash

with painless lesions (considered to be healing chancres) on the glans, a nonpruritic

hyperkeratotic palmar rash and bilateral submandibular lymphadenopathy.

Results of laboratory testing included a positive reactive syphilis immunoglobulin

G (IgG) enzyme immunoassay and a positive rapid plasma reagin (RPR) test.

The human immunodeficiency virus (HIV) testing was negative, and serologic

testing demonstrated prior immunization to hepatitis B virus. Given the clinical

presentation and laboratory findings, she was treated with benzathine penicillin

G 2.4 million units intramuscularly.

1. Basing on the scenario above, what are the signs and symptoms the

patient was presenting.

2. What is the medical diagnosis is the patient presenting?

3. What are different risk factors and causes of that medical condition?

4. What are different investigations used to diagnose that medical condition?

5. What are different treatment modalities for that medical condition?

6. If not properly treated, what might be some complications?

Syphilis is a chronic bacterial disease that is contracted mainly by infection during

sexual intercourse, but also congenitally by infection of a developing foetus.

Causes and Risk Factors

Syphilis is mainly caused by the bacteria called Treponema pallidum. It is a common

and dangerous infection that is spread from person to person through sexual contact.

It is an infection that is transmitted by direct contact with a syphilitic sore via skin

and mucous membranes such as the vagina, anus, rectum, lips and mouth, most

commonly during oral, anal or vaginal sexual activity. In rare occasions syphilis

spread during kissing.

Treponema pallidum also crosses the placenta, thereby resulting in fetal infection

(Congenital syphilis). This congenital syphilis is generally acquired through

transplacental transmission of spirochetes in the maternal bloodstream or,

occasionally, through direct contact with an infectious lesion during birth

The acquisition of syphilis through transfused blood is very rare because all donors

are screened and T. pallidum cannot survive longer than 24 to 48 hours under blood

bank storage conditions.

While syphilis can affect anyone, there are a number of risk factors (related to

sexual behaviors, while others are associated with characteristics that can place an

entire population at risk) that can increase your likelihood of infection: inconsistent

condom use is the main cause of transmission in all groups, and Men who have sex

with men (due to physiological vulnerabilities such as the fragility of rectal tissues),

multiple sex partners place you at risk simply by providing you a greater opportunity

for exposure, injecting drug use that can impair judgment and increase the risk of

sexual violence or the exchange of sex for drugs, risk attitude and behaviors of

avoidance of STIs screening mainly among those people who have multiple sex

partners.

Pathophysiology

The pathogenesis of Syphilis is explained through different following stages:

• Early local infection: T. pallidum initiates infection when it gains access to

subcutaneous tissues via microscopic abrasions. The spirochete evades

early host immune responses and establishes the initial ulcerative lesion, the

chancre. During the period of early local replication, some organisms establish

infection in regional draining lymph nodes, with subsequent dissemination.

Early syphilis comprises primary and secondary syphilis, which typically occur

within weeks to months after initial infection, as well as early latent syphilis

(asymptomatic infection that was acquired within the previous 12 months).

• Late infection: The prolonged latent period that is characteristic of most

types of late syphilis suggests that immune mechanisms may be involved in

one of two ways. Waning immunity with aging may facilitate recrudescence

of a small number of treponemes that had survived in sequestered sites.

Alternatively, a partially immune hypersensitive host may react to the

presence of treponemes, engendering a chronic inflammatory response. Late

benign syphilis often involving the skin, viscera, or other tissues (eg, bone,

brain, abdominal viscera), are characterized pathologically by the presence

of granulomas, a finding that is consistent with a cellular hypersensitivity

reaction.

If left untreated, syphilis will go through five stages of infection: primary, secondary,

early latent, late latent, and tertiary. The risk and mode of transmission can vary by

the stage:

• During primary syphilis, the disease is passed by coming into contact with

a chancre.

• During secondary syphilis, the disease can be passed by coming into

contact with the secondary rash.

• During early latent syphilis, secondary symptoms can sometimes relapse

and increase the risk of transmission.

• During late latent or tertiary syphilis, the disease is considered noncontagious.

Syphilis cannot be passed via toilet seats, casual contact, or the shared use of

utensils or personal care items. This is because T. pallidum has a fragile shell that

lacks the lipoproteins needed to sustain life outside of the body for very long.

Signs and Symptoms

Patients with syphilis can present with a wide range of symptoms depending on

the stage of disease. Others will have serologic evidence of syphilis based upon

laboratory testing, but will not have symptoms (mainly in latent syphilis).

The clinical manifestations depend upon the stage of disease. The signs and

symptoms of syphilis are related to the stage of the infection. The first involves a

painless sore on the genitals, rectum, or mouth. After that heals, the second stage

will begin and usually produce a rash. After a long period with no symptoms (stage

three), the fourth stage can suddenly develop, causing extensive damage to the

brain, nerves, eyes, or heart.

Primary syphilis (Stage 1): is the first stage of infection. It will typically start with

the appearance of an ulcer called a chancre between 10 to 90 days after the initial

exposure; the average is 21 days. The sore will develop at the point of contact,

most commonly on the cervix, vagina, penis, anus, rectum, or mouth. There may

be one or more lesions. Because the sores are painless, they can be missed if they

are located internally.

Sometimes swollen lymph nodes can develop near the site of the infection. These

are small glands that, among other things, contain white blood cells that help fight

infection called lymphocytes. Without treatment, a chancre will heal in three to six

weeks.

Secondary Syphilis (Stage 2): If left untreated, a primary infection will progress

to secondary syphilis. Symptoms typically appear within two to eight weeks of the

appearance of the chancre. During this stage, a person may experience general

symptoms of illness such as fever, sore throat, fatigue, weight loss, headache,

muscle ache. They may also experience symptoms that may be a bit more telling:

unexplained hair loss (syphilitic alopecia), cracked lesions on the corner of the

mouth (fissure cheilitis), generalized swelling of the lymph nodes, widespread, nonitchy

rash on the palms and soles of the feet, the trunk, or the limbs.

Rarely, secondary syphilis affects the liver, kidneys, bones, and central nervous

system and may produce associated symptoms and complications. The symptoms

of secondary syphilis typically resolve without treatment within weeks or months.

Latent Syphilis (Stage 3): Latent syphilis is the third, so-called “hidden” stage of

infection. It is marked by the relative absence of symptoms and positive blood tests.

This stage is further divided into two stages:

• Early latent syphilis is the period within a year of the initial infection.

Secondary symptoms can sometimes relapse during the early latent phase.

• Late latent syphilis is the period a year after the initial infection. It can last

for years and even decades with no signs of disease.

Tertiary Syphilis (Stage 4): Tertiary syphilis is the most serious stage of this

infection and it is characterized by three major complications:

• Gummatous syphilis causes the formation of soft, tumor-like lesions called

gummas. These noncancerous lesions can cause large ulcerative sores on

the skin and mouth, and erode tissues of the heart, liver, muscles, bones, and

other vital organs. Symptoms typically develop between 3 and 10 years after

a person is first infected.

• Cardiovascular syphilis can cause severe inflammation of the aorta and

swelling and weakening of the aortic wall (aortic aneurysm). It generally

occurs 10 to 30 years after the initial infection.

• Neurosyphilis affects the central nervous system and usually develops

within four to 25 years after the initial infection. While some people will

not develop symptoms, others may experience severe issues such as

General signs and Symptoms of Syphilis include: fever, general ill feeling, joint

pain, loss of appetite, moist warty patches (called condylomata lata) in the genitals

or skin folds, muscle aches, skin rash usually on the palms of the hands and soles

of the feet, sores called mucous patches in or around the mouth, vagina or penis.

Investigations

The diagnosis of syphilis relies on:

Physical examination and clinical manifestations– a doctor or nurse will

ask to examine your genitals (and inside the vagina for women) or other parts

of your body to look for growths or rashes that may be caused by syphilis.

Blood test (Rapid plasma regain: RPR, Venereal Disease Research Laboratory:

VDRL, T. pallidum particle agglutination assay: TPPA, T. pallidum enzyme

immunoassay: TP-EIA, Polymerase chain reaction: PCR): can show whether you

have syphilis or have had it in the past; repeating the test a few weeks later may

be recommended if it’s negative, in case it was too early to give an accurate result.

Swab test – a swab is used to take a small sample of fluid from any sores, so it can

be checked for syphilis.

CSF (cerebro-spinal fluid) testing to detect neurosyphilis is strongly recommended

in patients with tertiary syphilis or with neurological signs or symptoms consistent

with neurosyphilis and in patients without symptoms whose serologic titers do not

decline appropriately after being treated with recommended therapy.

Adequate medical diagnosis

Syphilis is a sexually transmitted infection (STI) caused by a spiral-shaped

bacterium called Treponema pallidum. The infection is typically transmitted through

contact with a sore during a sexual encounter with an infected person, although a

mother can pass to her child during pregnancy. During the initial phase of infection,

the organism disseminates widely, setting the stage for subsequent manifestations.

If untreated, syphilis can have a number of significant late manifestations, including

cardiovascular, gummatous, and neurologic complications. The investigations

should be obtained just before initiating therapy (ideally, on the first day of treatment).

Penicillin is the treatment of choice for all stages of syphilis. Patients should be

monitored clinically and with serologic testing after treatment to ensure they are

responding appropriately to therapy.

Treatment plan

While syphilis infection can still be treated during the tertiary stage, any damage

caused to the heart, kidneys, and other organs may be permanent and can lead

to end-stage organ failure. Treatment is determined by the type and extent of the

damage.

A single intramuscular injection of long acting Benzathine penicillin G (2.4 million

units administered intramuscularly) will cure a person who has primary, secondary

or early latent syphilis.

Three doses of long acting Benzathine penicillin G (2.4 million units administered

intramuscularly) at weekly intervals is recommended for individuals with late

latent syphilis or latent syphilis of unknown duration. Treatment will kill the syphilis

bacterium and prevent further damage, but it will not repair damage already done.

In the treatment of late syphilis by weekly injections, missing a dose of penicillin for

a period of 10-14 days does not require restarting the entire course of injections.

The exception to this is in the case of pregnant women in whom there is no latitude

for missing a dose of penicillin.

Doxycycline is the best alternative for treating early and late latent syphilis. Syphilis

associated with HIV infection does not require any enhanced antimicrobial therapy.

For patients who are allergic to penicillin, alternative agents include tetracyclines,

cephalosporins (ceftriaxone, etc) and macrolides (azithromycin, etc). However, we

only use azithromycin if no other options are available due to concerns of treatment

failure associated with macrolide resistance

Prevention of syphilis: avoid having sex with multiple partners, avoid sharing

sex toys, get screened for sexually transmitted infections and talk to your partners

about their results, syphilis can also be transmitted through shared needles. Avoid

sharing needles if you’re going to use drugs.

Evolution and complications

Early diagnosis and initiation of treatment provides good outcome to patients with

syphilis. At its beginning stage, syphilis will cause sores called chancre in the body.

Chancres are seen mostly in genital areas of the body. Syphilis can also cause rash,

mild fever, fatigue, headache, sore throat, patchy hair loss, and swollen glands

through the body. If left untreated, syphilis can spread to all areas of the body.

If it is untreated, syphilis can cause serious long-term health

problems such as arthritis, brain damage, and blindness.

During the tertiary stage of syphilis, small, rubbery lesions may develop on the

bones, skin, nervous system tissue, and/or arteries of the heart or the brain. Due to

these lesions and other health complications, these individuals are susceptible to

heart attack, paralysis, blindness, stroke, numbness, dementia.

Complications in new-borns if the syphilis is left untreated, the symptoms may

include:

• Liver and spleen enlargement

• Purplish skin spots caused by ruptured capillaries (petechiae)

• Profuse nasal drip with highly infectious mucus discharge (known as syphilitic

“snuffles”)

• Neurosyphilis

• Lung inflammation

• Yellowing of the skin and eyes (jaundice)

• Seizures

By age 2, the child may have characteristic facial or physical deformities and

significant sensory impairment, including:

• Blunted upper front teeth (known as Hutchinson’s teeth)

• A collapse of the bony part of the nose (saddle nose)

• A protruding jawbone and foreshortened upper jaw

• A protruding frontal bone of the skull (frontal bossing)

• Swollen knees

• Bowing of the shin bones (saber shins)

• Inflammation and scarring of the cornea, the clear cover over the front of the

eye (interstitial keratitis)

• Glaucoma, a disease that damage’s the optic nerve and can cause bliness

• Deafness

• Developmental delays

Self-assessment 4.2.2

1. What is the cause of syphilis?

2. Can you list some risk factors to syphilis development?

3. Differentiate different phases/stages of syphilis.

4. Describe briefly the pathogenesis of congenital syphilis.

5. What are different investigations used to diagnose syphilis and their

rationale?

6. What are the preventive strategies for syphilis?

7. What are the treatment options are for a patient with syphilis?

8. What are the complications of syphilis?

4.2.3 GONORRHEA

Learning Activity 4.2.3

Read carefully this below situation and answer the following questions:

Mr. B.E is a 54-year-old male patient who visited RUHENGERI Hospital with

complaints of a purulent white discharge from the penis accompanied by

itching and burning sensation when urinating, painful and the physical examination

(palpation and inspection) revealed swollen testicles on palpation. The history

taking revealed that he is performed unprotected sexual intercourse with a sex

worker met in a hotel two days ago after missing condom. Body temperature

was 36.5 degree Celicius, blood pressure was 110/70 mmHg, pulse rate was

74beats per minute, respiratory rate was 19 breaths per minutes. Mr. B.E was

treated with Doxycycline tablet 100mg two times a day for 7 days associated

with a single dose of Ciprofloxacin 500mg and ibuprofen 400mg two times per

day for 3 days. After taking medication given from health center, the signs and

symptoms persisted despite the adherence of health care provider’s provided

instructions and decided to re-visit the hospital where the pus culture was

done and revealed Neisseria Gonorrhea bacterium, antibiogram showed that

the bacteria can respond to Azithromycin only among others. Other laboratory

investigations were performed and revealed white blood cells (WBC) of 150000.

1. What are abnormal signs and symptoms that patient was presenting?

2. Basing on those signs and symptoms, what could be the medical problem

of this patient?

3. What are the investigations that have been ordered to guide the confirmation

of the medical problem?

4. What was included in the management of this case at different levels of

health care settings he visited?

5. If not treated, what will be the consequences?

Gonorrhea is an infection caused by a sexually transmitted bacterium that

infects both males and females. It can cause infections in the genitals (the urethra,

rectum and throat). In females, gonorrhea can also infect the cervix. This sexually

transmitted disease (STD) or sexual transmission infection (STI) is a very common

infection, especially among young people ages 15-24 years.

Causes and risk factors

Gonorrhea is caused by Neisseria Gonorrhea, any sexually active person can get

gonorrhea through unprotected vaginal, anal, or oral sex. If a patient is sexually

active, must have an honest and open talk with the health care provider and ask

whether he/she should be tested for gonorrhea or other STDs. A sexually active

man who is gay, bisexual, or who has sex with men, should be tested for gonorrhea

every year. A sexually active woman younger than 25 years or an older woman

with risk factors such as new or multiple sex partners, or a sex partner, who has a

sexually transmitted infection, should be tested for gonorrhea every year.

A pregnant woman, who has gonorrhea, can give the infection to the baby during

delivery. This can cause serious health problems for the baby. If the patient is

pregnant, it is important that she talks to the health care provider so that she get

the correct examination, testing, and treatment, as necessary. Treating gonorrhea

as soon as possible will make health complications for your baby less likely.

Pathophysiology

The infection is caused by a bacterium, Neisseria gonorrhoea, which can be

transmitted heterosexually or homosexually. The microorganism invades the

urethra, vagina, rectum, or pharynx, depending on the nature of sexual contact;

it can spread throughout the body. In untreated men, the localized infection may

spread to the prostate, seminal vesicles, and epididymis. Urethral strictures may

develop, requiring periodic dilation of the urethra or, possibly, reconstructive urethral

surgery. In women, the infection may progress upward to the cervix, endometrium,

and fallopian tubes, and symptoms of pelvic inflammatory disease (PID) may

develop. Gonorrhoea also can be transmitted to an infant’s eyes at the time of birth.

Signs and symptoms of gonorrhea

In men, symptoms usually appear 2 to 6 days after infection. Urethritis with a purulent

discharge and pain on urination are the most common signs and symptoms. A small

proportion of men are asymptomatic.

More than half of infected women experience no symptoms. When symptoms do

occur, women have a white or yellow vaginal discharge, intermenstrual bleeding due

to cervicitis, and painful urination. Other symptoms may include burning or frequent

urination, yellowish vaginal discharge, redness and swelling of the genitals, and a

burning or itching of the vaginal area. If untreated, gonorrhea can lead to severe

pelvic infections and even sterility. Even when a woman has symptoms, they are

often mild and can be mistaken for a bladder or vaginal infection. Women with

gonorrhea are at risk of developing serious complications from the infection, even if

they don’t have any symptoms. Symptoms in women can include painful or burning

sensation when urinating; increased vaginal discharge; vaginal bleeding between

periods.

An anal infection is accompanied by painful bowel elimination and a purulent rectal

discharge; the throat is sore when the pharynx is infected. If the microorganism

disseminates (scatters) throughout the body, the client may manifest a skin rash,

fever, and painful joints. Men with gonorrhea may have a yellowish discharge from

the penis accompanied by itching and burning.

Complications in later life can include inflammation of the heart valves, arthritis, and

eye infections. Gonorrhea can also cause eye infections in babies born of infected

mothers.

Some men with gonorrhea may have no symptoms at all. However, men who do

have symptoms may have a burning sensation when urinating; a white, yellow, or

green discharge from the penis; painful or swollen testicles (although this is less

common).

Rectal infections may either cause no symptoms or cause symptoms in both men

and women that may include discharge; anal itching; soreness; bleeding; painful

bowel movements.

The client should be examined by the doctor if he/she notices any of these symptoms

or if his/her partner has an STD or symptoms of an STD, such as an unusual sore,

a smelly discharge, burning when urinating, or bleeding between periods.

Investigations

Swabs from pus or discharge must be sent for analysis and identify the germ

Specimens of drainage from infected tissue are examined microscopically

immediately after they are collected or are inoculated on a culture medium and

incubated to reveal the causative organism.

Other laboratory blood tests (FBC, electrolytes, Renal and liver function tests,

etc) might be helpful to look for other existing conditions.

Medical diagnosis

The medical diagnosis of gonorrhea is based on the clinical manifestation of the

clients as well as the history taking and laboratory findings where possible.

Most of the time, urine can be used to test for gonorrhea. However, if the client has

had oral and/or anal sex, swabs may be used to collect samples from the throat

and/or rectum. In some cases, a swab may be used to collect a sample from a

man’s urethra (urine canal) or a woman’s cervix (opening to the womb).

Treatment plan

The microorganism N. gonorrhoea has become increasingly resistant to penicillin,

tetracycline, and fluoroquinolones.

Therefore, currently CDC (2006) recommendation for treating gonorrhoea is a

single intramuscular dose of a broad-spectrum cephalosporin such as ceftriaxone

(rocephin) or oral dosing with cefixime (suprax). Coinfection with chlamydia

is common; therefore, clients also are given a single dose of oral azithromycin

(zithromax) or oral doxycycline (vibramycin) for 7 to 10 days. Clients with complicated

gonococcal infections, as in PID or disseminated infection, are hospitalized and

treated with IV multiple-drug therapy.

The nursing management and client teaching are similar for those clients other

STDs. However, when a culture is collected from a woman, the vaginal speculum

is moistened with water rather than lubricated, because lubricant may destroy the

gonococci and cause inaccurate test results.

Evolution and complications

Untreated gonorrhoea can cause serious and permanent health problems in both

men and women.

In women, untreated gonorrhoea can cause pelvic inflammatory disease (PID).

Some of the complications of PID are formation of scar tissue that blocks fallopian

tubes external icon, ectopic pregnancy (pregnancy outside the womb external

icon), infertility (inability to get pregnant); long-term pelvic/abdominal pain,

untreated gonorrhea may also increase your chance of getting HIV, the virus that

causes AIDS.

In men, gonorrhoea can cause a painful condition in the tubes attached to the

testicles. In rare cases, this may cause a man to be sterile. Rarely, untreated

gonorrhoea can also spread to your blood or joints. This condition can be life-threatening.

Self-assessment 4.2.3

1. What is gonorrhoea?

2. Describe the causes and triggering factors contributing to the gonorrhoea

development.

3. What are different treatment options for a patient with gonorrhoea?

4. State the preventive measures to be taken to prevent gonorrhoea

5. What are possible investigations to be performed to confirm gonorrhoea?

6. If acute gonorrhoea is not well treated effetely, what could be the

complications?

4.2.4 HIV Infection (Human Immunodeficiency Virus Infection)

Learning Activity 4.2.4

Carefully read the case study below and answer the following questions:

The patient M.V a 24-year-old female who had spent 6 months in Matimba/

Biryogo consulted Muhima hospital for repetitive flu like syndrome, episode

of fevers and generalized body weakness with fatigue. A few weeks ago she

became ill with general body weakness, lymphadenopathy and fever of 39.2 o

C. All laboratory investigations requested (blood smear negative, FBC normal)

were normal and was given paracetamol 1g TDS for 5 days. During the current

visit she was further examined and denied recent sexual contacts, her marital

status is single and lives alone in a house. She reported to be unemployed

and stated that it is very difficult to find living means. Laboratory tests as FBC,

Urea and creatinine, ASAT and ALAT, HIV test and blood culture were ordered

and the health care professionals decided to hospitalise her and put her on IV

paracetamol 100mg TDS for 3 days and IV ceftriaxone 1gr BID for 7 days while

waiting for all results. The results became as normal FBC and a positive ELISA

test for HIV.

As the counselling was not done for HIV prior testing, they proceeded on

counselling and retested for HIV using rapid test to be able to communicate

results. The HIV rapid test became positive too and counselling for possible

initiation of antiretroviral drugs started. During this counselling, she reported

that she get living means from selling her sex and this was also known by her

neighbours. As she was unstable, they waited until to be stable for CD4 control

to decide on initiation of ARV drugs.

1. What was the medical diagnosis the patient was presenting?

2. What were the risks factors that exposed her to develop that medical

condition?

3. What must be considered before initiating the treatment to that condition?

4. What are different investigations are useful to decide on the management

of that medical condition?

5. What are different drugs you know that are used to treat that medical

condition?

6. What are the possible complications related to that medical condition?

HIV (human immunodeficiency virus) is a virus that attacks the immune system,

the body’s natural defence system. Without a strong immune system, the body

has trouble fighting off disease. Both the virus and the infection are called HIV.

White blood cells are an important part of the immune system. HIV infects and

destroys certain white blood cells called CD4+ cells. If too many CD4+ cells are

destroyed, the body can no longer defend itself against infection. The last stage of

HIV infection is AIDS (Acquired Immunodeficiency Syndrome). People with AIDS

have a low number of CD4+ cells and get infections or cancers that rarely occur in

healthy people. These can be deadly. But having HIV doesn’t mean you have AIDS.

Causes and Risk Factors

HIV infection is caused by the human immunodeficiency virus. HIV doesn’t

survive well outside the body, therefore it can’t be spread by casual contact like

kissing or sharing drinking glasses with an infected person. The patient can’t

catch HIV or AIDS by hugging, kissing, dancing or shaking hands with someone

who has the infection. HIV isn’t spread through the air, water or insect bites.

The HIV can be contaminated/transmitted from contact with infected blood, semen,

or vaginal fluids. This can happen in several ways:

By having sex: Infection comes if there is unprotected sexual intercourse being

vaginal, anal or oral with an infected partner whose blood, semen or vaginal

secretions enter your body. The virus can enter the body through mouth sores or

small tears that sometimes develop in the rectum or vagina during sexual activity.

By sharing needles: Sharing contaminated used IV drug materials (needles and

syringes) puts a person at high risk of HIV and other infectious diseases, such

as hepatitis. Health care professionals can get the HIV infections when not being

careful while giving injections or through blood sample collection due to needle

stick injuries while caring for HIV patients.

From blood transfusions: In some cases, the virus may be transmitted through

blood transfusions.

During pregnancy or delivery or through breast-feeding: Infected mothers can

pass the virus on to their babies. Mothers who are HIV-positive and get treatment

for the infection during pregnancy can significantly lower the risk to their babies.

The virus can also be passed from a mother to her baby during pregnancy, birth, or

breastfeeding.

The other greatest risk of HIV/AIDS are:

Have unprotected sex: Anal sex is more risky than is vaginal sex; and the risk

of HIV increases if there are multiple sexual partners.

Have an STI: Many STIs produce open sores on the genitals, and those sores act

as doorways for HIV to enter your body.

Pathophysiology

HIV destroys CD4+ cells in 3 ways: Viral replication leaves the holes in the cell

membranes, Infected cells fuse with other cells, Antibodies against HIV bind to the

infected cells and activate the complement system, which destroy the infected cells.

Figure4.2.4 Signs and symptoms of HIV infection

The symptoms of HIV and AIDS vary depending on the phase of infection:

Primary infection (Acute HIV): Some people infected by HIV develop a flu-like

illness within two to four weeks after the virus enters the body. This illness, known

as primary (acute) HIV infection, may last for a few weeks. Possible signs and

symptoms include fever, headache, muscle aches and joint pain, rash, sore throat

and painful mouth sores, swollen lymph glands, mainly on the neck, diarrhea,

weight loss, cough, night sweats.

These symptoms can be mild that the patient might not even notice them. However,

the amount of virus in your bloodstream (viral load) is quite high at this time. As a

result, the infection spreads more easily during primary infection than during the

next stage.

Clinical latent infection (Chronic HIV): In this stage of infection, HIV is still

present in the body and in white blood cells. However, many people may not have

any symptoms or infections during this time. This stage can last for many years if

the patient is not receiving antiretroviral therapy (ART). Some people develop more

severe disease much sooner.

Symptomatic HIV infection: As the virus continues to multiply and destroy the

immune cells (the cells in your body that help fight off germs) may develop mild

infections or chronic signs and symptoms such as fever, fatigue, swollen lymph

nodes often one of the first signs of HIV infection, diarrhea, weight loss, oral yeast

infection (thrush), shingles (herpes zoster), pneumonia.

Progression to AIDS: Untreated, HIV typically turns into AIDS. When AIDS occurs,

the immune system has been severely damaged. The patient is more likely to

develop opportunistic infections or opportunistic cancers or diseases that wouldn’t

usually cause illness in a person with a healthy immune system. The signs and

symptoms of some of these infections may include sweats, chills, recurring fever,

chronic diarrhea, swollen lymph glands, persistent white spots or unusual lesions

on your tongue or in your mouth, persistent or unexplained fatigue, weakness,

weight loss, skin rashes or bumps.

Investigations

Diagnosing HIV should be done basing on:

Clinical suspicion: due to the wide range of symptoms associated with acute

HIV infection, the possibility of HIV infection should be considered in patients who

present with the more typical signs and symptoms, including an ill-defined febrile

illness, heterophile-negative mononucleosis-like syndrome, heterophile positive

mononucleosis in an unusual host (for example, an older adult patient), and/or

aseptic meningitis. Certain clinical features, such as a rash, mucocutaneous ulcers,

diarrhea, or lymphadenopathy, should heighten the suspicion for HIV infection

HIV can be diagnosed through blood or saliva testing. During the use of blood

test to diagnose HIV infection, If the test is positive (meaning that HIV antibodies or

antigens are found), a test to detect HIV DNA or RNA will be done to be sure. HIV

antibodies may show up in the blood as early as 2 to 4 weeks after contact but can

also take as long as 3 to 6 months to show up in the blood.

When the possibility of acute or early HIV infection is being considered, we perform

the most sensitive screening immunoassay available (ideally, a combination

antigen/antibody immunoassay) in addition to an HIV virologic (viral load) test. We

favor using an RT-PCR based viral load test, if available. A positive HIV virologic

test is generally indicative of HIV infection

Available tests include:

• Antigen/antibody tests: These tests usually involve drawing blood from a

vein. Antigens are substances on the HIV virus itself and are usually detectable

— a positive test — in the blood within a few weeks after exposure to HIV.

• Antibodies are produced by the immune system when it’s exposed to HIV.

It can take weeks to months for antibodies to become detectable. The

combination antigen/antibody tests can take two to six weeks after exposure

to become positive.

• Antibody tests: These tests look for antibodies to HIV in blood or saliva.

Most rapid HIV tests, including self-tests done at home, are antibody tests.

Antibody tests can take three to 12 weeks after the patient is exposed to

become positive.

• Nucleic acid tests (NATs): These tests look for the actual virus in your

blood (viral load). They also involve blood drawn from a vein. If you might

have been exposed to HIV within the past few weeks, the doctor may

recommend NAT. NAT will be the first test to become positive after exposure

to HIV

• In addition to these tests, there is need of general screening to look for

hemodynamic and physiological status of a person suspected (FBC, Urea,

Creatinine, electrolytes, ASAT and ALAT and any other helpful investigation

depending on patient condition).

Once the patient thinks that he/she has been exposed to HIV but the test is negative,

should get tested again. A repeat test can be done after a few weeks to be sure he/

she is not infected.

After the confirmation of diagnosis of HIV/AIDS, several tests can help the clinician

to determine the stage of the disease and the best treatment:

CD4 T cell count: CD4 T cells are white blood cells that are specifically targeted

and destroyed by HIV. Even if the patient doesn’t have symptoms, HIV infection

progresses to AIDS when the CD4 T cells count below 200.

Viral load (HIV RNA): This test measures the amount of virus in your blood.

After starting HIV treatment the goal is to have an undetectable viral load. This

significantly reduces your chances of opportunistic infection and other HIV-related

complications.

Drug resistance: Some strains of HIV are resistant to medications. This test helps

the clinician to determine if the specific form of the virus has resistance and guides

treatment decisions.

Treatment plan

The standard treatment for HIV is a combination of medicines called antiretroviral

therapy or ART or ARV drugs. Antiretroviral medicines slow the rate at which the

virus multiplies. Taking these medicines can reduce the amount of virus in the body

and help to stay healthy.

Preventive strategies

There’s no vaccine to prevent HIV infection and no cure for AIDS. But you can

protect yourself and others from infection.

To help to prevent the spread of HIV:

Use treatment as prevention: If living with HIV, taking HIV medication can keep

the partner from becoming infected with the virus. If the viral load stays undetectable

(a blood test doesn’t show any virus) the patient will not transmit the virus to anyone

else. This requires taking the medication exactly as prescribed and getting regular

check-ups.

Use post-exposure prophylaxis (PEP) after being exposed to HIV: If exposed

through sex, needles or in the workplace, contact the doctor or go to the emergency

department or HIV clinic. Taking PEP as soon as possible within the first 72 hours

can greatly reduce the risk of becoming infected with HIV. Patient will need to take

medication for 28 days.

Use a new condom every time having sex: Use a new condom every time client

has anal or vaginal sex. Women can use a female condom. If using a lubricant,

make sure it’s water based. Oil based lubricants can weaken condoms and cause

them to break.

Consider Pre-exposure prophylaxis (PrEP): The combination drugs emtricitabine

plus tenofovir (Truvada) and emtricitabine plus tenofovir alafenamide (Descovy)

can reduce the risk of sexually transmitted HIV infection in people at very high

risk. PrEP can reduce the risk of getting HIV from sex by more than 90% and from

injection drug use by more than 70%, according to the Centers for Disease Control

and Prevention. Client will need an HIV test before start taking PrEP and then every

three months as long as he/she is taking it. The doctor will also test the kidney

function before prescribing Truvada and continue to test it every six months. These

PrEP drugs don’t prevent other STIs, so patient still need to practice safe sex. If

client has hepatitis B or C, he/she should be evaluated for any infectious disease or

liver disease before beginning therapy.

Tell the sexual partners if client has HIV: It›s important to tell all the current and

past sexual partners that client is HIV-positive. They›ll need to be tested.

Use a clean needle: If using a needle to inject drugs, make sure it›s sterile and

don›t share it. Take advantage of needle-exchange programs in the community.

Consider seeking help for the drug use.

If client is pregnant, get medical care right away: If client is HIV-positive, she

may pass the infection to the baby. But if she receives treatment during pregnancy,

she can significantly cut the baby›s risk.

Consider male circumcision: There›s evidence that male circumcision can help

reduce the risk of getting HIV infection.

Adequate medical diagnosis

A variety of symptoms and signs may be seen in association with acute HIV

infection, known as the acute retroviral syndrome. The most common findings are

fever, lymphadenopathy, sore throat, rash, myalgia/arthralgia, and headache.

The diagnosis of acute HIV infection requires a high level of clinical suspicion and

should be considered in patients who present with consistent signs and symptoms,

including an ill-defined febrile illness, heterophile-negative mononucleosis-like

syndrome, and/or aseptic meningitis. Early HIV infection should also be considered

in patients who have had a recent high-risk exposure or those who have had a

recent sexually transmitted infection regardless of the presence of symptoms or

signs. When the possibility of acute or early HIV infection is being considered, we

perform the most sensitive immunoassay available (ideally, a combination antigen/

antibody immunoassay) in addition to an HIV virologic (viral load) test. A positive

virologic test indicates HIV infection.

All patients with suspected or confirmed acute or early HIV infection should be

counseled to adopt behaviors that guard against HIV transmission, including

consistent and correct condom use and avoidance of sharing injection drug use

equipment and develop other positive behaviors towards other people.

There is no cure of HIV but the standard treatment for HIV is a combination of

medicines called antiretroviral therapy or ART or ARV drugs. Antiretroviral medicines

slow the rate at which the virus multiplies. Taking these medicines can reduce the

amount of virus in your body and help you stay healthy.

Evolution and Complications

There’s no vaccine to prevent HIV infection and no cure for it. Taking the ART

medicines can reduce the amount of virus in the body and help to stay healthy.

There is also need of protecting yourself and others from infection.

HIV infection weakens the immune system, making the person much more likely to

develop many infections and certain types of cancers:

Infections common to HIV/AIDS:

Pneumocystis pneumonia (PCP): This fungal infection can cause severe illness.

Although it›s declined significantly with current treatments for HIV/AIDS, the PCP is

still the most common cause of pneumonia in people infected with HIV.

Candidiasis (thrush): Candidiasis is a common HIV-related infection. It causes

inflammation and a thick, white coating on the mouth, tongue, esophagus or vagina.

Tuberculosis (TB): In resource-limited nations, TB is the most common

opportunistic infection associated with HIV. It›s a leading cause of death among

people with AIDS.

Cytomegalovirus: This common herpes virus is transmitted in body fluids such as

saliva, blood, urine, semen and breast milk. A healthy immune system inactivates

the virus, and it remains dormant in the body. If the immune system weakens, the

virus resurfaces causing damage to the eyes, digestive tract, lungs or other organs.

Cryptococcal meningitis: Meningitis is an inflammation of the membranes and

fluid surrounding the brain and spinal cord (meninges). Cryptococcal meningitis is a

common central nervous system infection associated with HIV, caused by a fungus

found in soil.

Toxoplasmosis: This potentially deadly infection is caused by Toxoplasma gondii,

a parasite spread primarily by cats. Infected cats pass the parasites in their stools,

which may then spread to other animals and humans. Toxoplasmosis can cause

heart disease, and seizures occur when it spreads to the brain.

Cancers common to HIV/AIDS:

Lymphoma: This cancer starts in the white blood cells. The most common early

sign is painless swelling of the lymph nodes in the neck, armpit or groin.

Kaposi›s sarcoma: A tumor of the blood vessel walls, Kaposi›s sarcoma usually

appears as pink, red or purple lesions on the skin and mouth. In people with darker

skin, the lesions may look dark brown or black. Kaposi›s sarcoma can also affect

the internal organs, including the digestive tract and lungs.

Other complications related to HIV infection:

Wasting syndrome: Untreated HIV/AIDS can cause significant weight loss, often

accompanied by diarrhea, chronic weakness and fever.

Neurological complications: HIV can cause neurological symptoms such as

confusion, forgetfulness, depression, anxiety and difficulty walking. HIV-associated

neurocognitive disorders can range from mild symptoms of behavioral changes and

reduced mental functioning to severe dementia causing weakness and inability to

function.

Kidney disease: HIV associated nephropathy is an inflammation of the tiny filters

in the kidneys that remove excess fluid and wastes from the blood and pass them

to the urine.

Liver disease: Liver disease is also a major complication, especially in people who

also have hepatitis B or hepatitis C.

Self-assessment 4.2.4

1. Describe briefly the steps of HIV infection pathogenesis

2. What are different classes of ART drugs and their site of actions?

3. Describe different coping skills needed towards HIV preventive strategies

4. Differentiate signs and symptoms depending on the different phases of

HIV

5. Discuss different complications of HIV

4.2.5 Human Papilloma Virus (HPV)

Learning Activity 4.2.5

Read carefully this below situation and answer the following questions:

Mrs. N, V is a 39-year-old female patient who visited MUHIMA Hospital with

complaints of itching, burning, and discomfort of the genital area and the physical

examination (palpation and inspection) revealed large, pink, flat shaped wart

on the vulva. The history taking revealed that she is HIV Positive and treated

on Highly Antiretroviral therapy (HAAT) initiated 2 years ago as she delayed to

get tested for HIV/AIDs. Her vital signs were body temperature of 36.5 degree

Celsius, blood pressure of 100/70 mmHg, pulse rate was 68 beats per minute,

respiratory rate was 19 breaths per minute. The pap smear and DNA tests were

performed from vulva and cervical tissues and revealed abnormal cell growth,

the physician encouraged her to adhere to the ARVs treatment and salicylic

acid was prescribed to be applied on the affected area.

1. What are abnormal signs and symptoms that patient was presenting?

2. Basing on those signs and symptoms, what could be the medical problem

of this patient?

3. What are the investigations that have been ordered to guide the confirmation

of the medical problem?

4. What was included in the management of this case at different levels of

health care settings he visited?

5. If not treated, what will be the consequences?

Human papillomavirus is an infection caused by human papillomavirus (HPV), a

DNA virus from the papillomaviridae family.

Causes and risk factors

HPV infection occurs when the virus (human papillomavirus: HPV, a DNA virus

from the papillomaviridae family) enters the human body, usually through a cut,

abrasion or small tear in the skin. The virus is transferred primarily by skin-to-skin

contact.

Genital HPV infections are contracted through sexual intercourse, anal sex and

other skin-to-skin contact in the genital region. Some HPV infections that result in
oral or upper respiratory lesions are contracted through oral sex.

If a client is pregnant and has an HPV infection with genital warts, it’s possible her

baby may get the infection. Rarely, the infection may cause a noncancerous growth

in the baby’s voice box (larynx).

Warts are contagious. They can spread through direct contact with a wart. Warts

can also spread when someone touches something that already touched a wart.

The Risk factors for HPV infection include number of sexual partners (The

more sexual partners that the client has, the more likely he/she is to contract a

genital HPV infection. Having sex with a partner who has had multiple sex partners

also increases the risk), Age (Common warts occur mostly in children. Genital warts

occur most often in adolescents and young adults), Weakened immune systems

(People who have weakened immune systems are at greater risk of HPV infections.

Immune systems can be weakened by HIV/AIDS or by immune system-suppressing

drugs used after organ transplants).

Other risks are damaged skin (Areas of skin that have been punctured or

opened are more prone to develop common warts), Personal contact (Touching

someone’s warts or not wearing protection before contacting surfaces that have

been exposed to HPV such as public showers or swimming pool might increase the

risk of HPV infection unprotected intercourse, numerous sexual partners and age at

first intercourse), Teens that are sexually active and young adult females are at

a higher risk of contracting the virus, than women and men over 25, the people who

are immunocompromised, such as young adults with HIV, Smokers have higher

rates of HPV infection, Contracting herpes or chlamydia increases the risk of

HPV infection “due to inflammation of the epithelial cells and breaks in the epithelial

layer that allows a pathway for HPV introduction”.

HPV can pass from person to person regardless of whether symptoms are present.

The strains of HPV that cause warts are different from those that increase the risk

of cancer.

In children, HPV can transmit to an infant during birth. However, research suggests

that this risk is relatively low, as the immune system usually takes care of the

infection in this situation. Signs of an HPV infection in an infant include genital warts

or lesions in the mouth. If a young child develops HPV symptoms, it may indicate

child abuse.

Pathophysiology overview

The HPV virus is a small, non-enveloped, double stranded DNA virus that infects

the mucosal or cutaneous epithelium. Since HPV affects epithelial cells and does

not enter the bloodstream, having an HPV infection in one part of the body should

not cause infection in another part. Once HPV gets into the epithelial cell, the virus

begins to make proteins that can interfere with normal functions in the cell, enabling

the cell to grow in an uncontrolled manner and to avoid apoptosis. HPV modifies

the DNA damage response (DDR) pathways by interacting with many proteins,

including ATM, ATR, MRN, y-H2AX, Chk1, Chk2, p53, BRCA1, BRCA2, RAD51,

etc. The HPV virus can activate and dysregulate DDR pathways throughout various

stages of their life cycles to replicate itself in host cells. Cell biology during a different

periods of a woman’s life can make her more susceptible to contracting the virus.

Signs and symptoms

Once infected, many patients remain asymptomatic and most cases resolve on

their own. The virus can remain dormant for years and then appear untriggered.

Appearance of ano-genital warts or abnormal pap smears are signs of likely HPV

infection.

In most cases, the body’s immune system defeats an HPV infection before it creates

warts. Symptoms of HPV may appear years after the initial infection. Some types of

the virus cause warts to form, while others can increase the risk of cancer. A person

may have one small skin bump, a cluster of bumps, or stem-like protrusions. These

warts can range in size and appearance, and they may be large or small, flat or

cauliflower-shaped, white, pink, red, purplish-brown, or skin-colored. The warts can

be formed on the vulva, cervix, penis or scrotum, anus, groin area, face or at any

part of the musculoskeletal system. These warts can cause itching, burning, and

other discomfort. When warts do appear, they vary in appearance depending on

which kind of HPV is involved:

Genital warts: These appear as flat lesions, small cauliflower-like bumps or tiny

stem like protrusions. In women, genital warts appear mostly on the vulva but can

also occur near the anus, on the cervix or in the vagina. In men, genital warts

appear on the penis and scrotum or around the anus. Genital warts rarely cause

discomfort or pain, though they may itch or feel tender.

Common warts: Common warts appear as rough, raised bumps and usually occur

on the hands and fingers. In most cases, common warts are simply unsightly, but

they can also be painful or susceptible to injury or bleeding

Plantar warts: Plantar warts are hard, grainy growths that usually appear on the

heels or balls of the feet. These warts might cause discomfort.

Flat warts: Flat warts are flat-topped, slightly raised lesions. They can appear

anywhere, but children usually get them on the face and men tend to get them in

the beard area. Women tend to get them on the legs. Flat warts are smaller and

smoother than other warts. They generally occur on the face or legs and are more

common in children and teens than in adults.

Female genital warts: Genital warts are a common sexually transmitted infection.

They can appear on the genitals, in the pubic area or in the anal canal. In women,

genital warts can also grow inside the vagina.

Male genital warts: Genital warts are a common sexually transmitted infection.

They can appear on the genitals, in the pubic area or in the anal canal.

HPV and cervical cancer: nearly all cervical cancers are caused by HPV infections,

but cervical cancer may take 20 years or longer to develop after an HPV infection.

The HPV infection and early cervical cancer typically do not cause noticeable

symptoms. Being vaccinated against HPV infection is the best protection from

cervical cancer.

Because early cervical cancer does not cause symptoms, it is vital that women have

regular screening tests to detect any precancerous changes in the cervix that might

lead to cancer. Current guidelines recommend that women ages 21 to 29 have a

Pap test every three years. Women ages 30 to 65 are advised to continue having a

Pap test every three years, or every five years if they also get the HPV DNA test at

the same time. Women over 65 can stop testing if they have had three normal Pap

tests in a row, or two HPV DNA and Pap tests with no abnormal results.

Investigations

Specimens from cervical tissue are examined microscopically immediately after

they are collected to reveal the abnormal cells growth, vinegar (acetic acid) solution

test. A vinegar solution applied to HPV-infected genital areas turns them white. This

may help in identifying difficult-to-see flat lesions.

Pap test: the doctor collects a sample of cells from your cervix or vagina to send

for laboratory analysis. Pap tests can reveal abnormalities that can lead to cancer.

DNA test: This test, conducted on cells from the suspect’s cervix, can recognize the

DNA of the high-risk varieties of HPV that have been linked to genital cancers. It›s

recommended for women 30 and older in addition to the Pap test.

The WHO recommends 3 different types of screening tests: HPV DNA testing for

high-risk HPV types, Visual inspection with Acetic Acid (VIA), conventional (Pap)

test and liquid-based cytology (LBC).

Adequate medical diagnosis

Human papillomavirus (HPV) is the most common sexually transmitted infection

(STI).

Many people with HPV don’t develop any symptoms but can still infect others

through sexual contact. HPV infection is a viral infection that commonly causes skin

or mucous membrane growths (warts). Symptoms may include warts on the genitals

or surrounding skin. An infection that causes warts in various parts of the body,

depending on the strain. If the warts are not visible, several tests/investigations can

be done to diagnose the HPV infection.

There is no cure for the virus and warts may go away on their own. Treatment

focuses on removing the warts. HPV vaccines work best if administered prior to

exposure to HPV. Therefore, WHO recommends to vaccinate girls, aged between

9 and 14 years, when most have not started sexual activity. A vaccine prevents the

HPV strains most likely to cause genital warts and cervical cancer is recommended

for boys and girls.

The vaccines cannot treat HPV infection or HPV-associated disease, such as

cancer. Because pre-cancerous lesions take many years to develop, screening

is recommended for every woman from aged 30 and regularly afterwards

(frequency depends on the screening test used). For women living with HIV who

are sexually active, screening should be done earlier, as soon as they know their

HIV status. Screening has to be linked to treatment and management of positive

screening tests.

Treatment plan

Medications to eliminate warts are typically applied directly to the lesion and

usually take many applications before they’re successful. Examples include:

Salicylic acid: Over-the-counter treatments that contain salicylic acid work by

removing layers of a wart a little at a time. For use on common warts, salicylic acid

can cause skin irritation and isn’t for use on the face.

Imiquimod: This prescription cream might enhance the immune system›s ability

to fight HPV. Common side effects include redness and swelling at the application

site.

Podofilox: Another topical prescription, podofilox works by destroying genital wart

tissue. Podofilox may cause burning and itching where it›s applied.

Trichloroacetic acid: This chemical treatment burns off warts on the palms, soles

and genitals. It might cause local irritation.

If medications don’t work, surgical management for treatment of pre-cancer

lesions will be used. WHO recommends the use of cryotherapy or thermal ablation/

Burning with an electrical current, Laser susrgery and Loop Electrosurgical Excision

Procedure (LEEP)/surgical removal when available. For advanced lesions,

women should be referred to gynaecologist for further investigations and adequate

management

For abnormal HPV or Pap test, the gynaecologist will perform a procedure called

a colposcopy. Using an instrument that provides a magnified view of the cervix

(colposcope), he/she will look closely at the cervix and take samples (biopsy) of any

areas that look abnormal.

Preventive measures

It’s difficult to prevent HPV infections that cause common warts. If there is a common

wart, prevent the spread of the infection and formation of new warts by not picking

at a wart and not biting your nails.

To reduce the risk of contracting HPV infections that cause plantar warts, wear

shoes or sandals in public pools and locker rooms.

To reduce the risk of developing genital warts and other HPV-related genital lesions,

there is need of being in a mutually monogamous sexual relationship, reducing

the number of sex partners, using a latex condom, which can reduce the risk

of HPV transmission.

HPV vaccine: Gardasil-9 is an HPV vaccine approved and can be used for males

and females to protect against cervical cancer and genital warts. CDC recommends

routine HPV vaccination for girls and boys ages from 9 to 14. It’s ideal for girls

and boys to receive the vaccine before they have sexual contact and are exposed

to HPV. Once someone is infected with HPV, the vaccine might not be as effective

or might not work at all.

Nurses play a key role in education and advocacy for receiving the vaccine. Nurses

must focus their care and health education on STI screenings, reproductive health

needs, lifestyle modifications, and primary prevention, and risk reduction education.

Evolution and complications

The human papilloma virus may cause oral and upper respiratory

lesions. Some HPV infections cause lesions on the tongue, tonsils, soft palate, or

within the larynx and nose.

Genital warts that go untreated may eventually cause abnormal urine flow in men (if

warts are present in the urethra); bleeding from the urethra, vagina, or anus; or

vaginal discharge.

The Pap test and HPV tests can detect cervical changes at an early stage, so that

cervical cancer can be avoided, in most cases. The HPV types that cause genital

warts are not linked to cancer, but some other types of HPV that also infect the

mucous membranes are linked to cancers. While most of those HPV infections

never cause any symptoms, some cause changes in the cells that eventually can

lead to cancer. High-risk types of HPV can cause these different types of cancers:

cervical cancer, vulvar cancer, vaginal cancer, penile cancer, anal cancer, cancer

of the back of the throat. There are no screening tests for the other types of

cancer caused by HPV, so it’s important to notice any changes in appearance,

lumps, skin changes, pain, abnormal bleeding, or any other abnormalities in the

areas potentially infected with HPV

Self-assessment 4.2.5

1. What is Human Papilloma virus?

2. Describe the causes and triggering factors contributing to the human

Papilloma Virus development

3. What are different treatment options for a patient with Human Papilloma

virus infection?

4. State the preventive measures to be taken to prevent Human Papilloma

Virus

5. What are possible investigations to be performed to diagnose HPV?

6. If HPV is not well treated effetely, what could be the complications?

4.2.6 HEPATITIS B

Learning Activity 4.2.6

Carefully read the case scenario below and answer the following

questions

A 28-year-old female presents to the clinic with a 10-day history of flu-like

symptoms, including anorexia and malaise. She does not report any pertinent

prior medical history or surgeries. She takes no medications. Her family history

is non-contributory, and she reports no sick contacts. She is sexually active with

multiple partners and has used oral contraceptives regularly for the past 12

years.

On physical examination, she is alert and oriented, in no acute distress. Her vital

signs are temperature of 38 degree celsius, pulse 78 beats/minute, respirations of

18 cycles/minute, and blood pressure of 121/78 mmHg. Her extraocular muscles

are intact; however, mild scleral icterus is noted. Heart sounds are regular rate

and rhythm without murmurs, and lungs are clear to auscultation bilaterally. The

abdomen is soft and not tender, except the liver that is tender when palpated and

extends 8 cm below the costal margin, with a smooth edge.

Initial laboratory testing is performed and shown Complete blood count

(CBC) that is within normal limits. Liver function tests are performed, and the

significant findings are Alanine aminotransferase (ALT) 3817 U/L (Normal 7-55

U/L), Aspartate aminotransferase (AST) 2152 U/L (Normal 8-48 U/L), Alkaline

phosphatase (ALP) 176 U/L (Normal 45-115 U/L), Albumin 3.4 g/dL (Normal 3.5-

5 g/dL), Total protein 6.7 g/dL (Normal 6.3-7.9 g/dL), Total bilirubin 8.5 mg/dL

(Normal 0.1-1.2 g/dL). Viral Serology for Hepatitis B revealed HBsAg Positive

(hepatitis B surface antigen), HBeAg (hepatitis B envelope antigen) Positive,

IgM Anti-HB core Positive, Ig (immunoglobulin) G Anti-HBe Negative, IgG Anti-

HBs Negative, Hepatitis B Virus-DNA Positive

1. Given the clinical case, what were the abnormal signs and symptoms the

patient was presenting?

2. What is mostly the medical diagnosis?

3. What are the causes and risk factors of developing the medical condition

described above?

4. What are different possible treatments of that medical condition?

5. What are the complications related to that medical condition?

Hepatitis B is a potentially life-threatening liver infection caused by the hepatitis

B virus (HBV). It can cause chronic infection and puts people at high risk of death

from cirrhosis and liver cancer. Hepatitis B is a serious liver infection caused by the

hepatitis B virus (HBV). For some people, hepatitis B infection becomes chronic,

meaning it lasts more than six months. Having chronic hepatitis B increases your

risk of developing liver failure, liver cancer or cirrhosis a condition that permanently

scars of the liver.

Hepatitis B infection may be either short-lived (acute) or long lasting (chronic).

Acute hepatitis B infection lasts less than six months. The immune system likely

can clear acute hepatitis B from the body, and patient should recover completely

within a few months. Most people who get hepatitis B as adults have an acute

infection, but it can lead to chronic infection.

Chronic hepatitis B infection lasts six months or longer. It lingers because the

immune system can›t fight off the infection. Chronic hepatitis B infection may last

a lifetime, possibly leading to serious illnesses such as cirrhosis and liver cancer.

Causes and risk factors

Hepatitis B infection is caused by the hepatitis B virus (HBV). The virus is passed

from person to person through blood, semen, or other body fluids. It does not spread

by sneezing or coughing.

Common ways that HBV can spread are:

Sexual contact: when having unprotected sex with someone who is infected. The

virus can be transmitted if the person’s blood, saliva, semen, or vaginal secretions

enter someone’s body.

Sharing of needles or Accidental needle sticks: HBV easily spreads through

needles and syringes contaminated with infected blood. Hepatitis B is a concern for

health care workers and anyone else who meets human blood.

Mother to child: Pregnant women infected with HBV can pass the virus to their

babies during childbirth. However, the newborn can be vaccinated to avoid getting

infected in almost all cases.

The hepatitis B virus can survive outside the body for at least 7 days. During this

time, the virus can still cause infection if it enters the body of a person who is not

protected by the vaccine. The incubation period of the hepatitis B virus ranges from

30 to 180 days. The virus may be detected within 30 to 60 days after infection and

can persist and develop into chronic hepatitis B, especially when transmitted in

infancy or childhood.

Pathophysiology

The hepatitis B virus is constructed of an outer capsule containing HBsAg (hepatitis

B surface antigen), an inner core containing HBcAg (HBV core antigen), and

the HBeAg (hepatitis Be antigen). As the blood becomes exposed to HBV, the

body mounts a cell-mediated immune response by sending cytotoxic T cells and

natural killer cells to the virus and release inflammatory cytokines. The greater the

immune response, the greater the chance of fighting the virus. As the hepatocytes

are attacked and infiltrated by the HBV, they appear to have a ground glass look

under histological exam due to the HBsAg infiltrating the cell’s cytoplasm – this is

a differentiator for HBV versus other forms of hepatitis. Because hepatocytes are

continually proliferating, the virus is constantly being shed into the blood which

contributes to chronic infection.

The liver cell injury during HBV infection occurs per these 3 mechanisms: first,

due to a restricted cytotoxic T cell response directed at HBcAg/HBeAg on HBV

infected hepatocytes (immune mediated cells injury); second, possible mechanisms

is direct cytopathic effect of HBcAg expression in infected hepatocytes (cytopathic);

thirdly, possible mechanism is high level expression and inefficient secretion of

HBsAg.

The process by which the HBV virus replicates occurs in six (simplified) steps:

Attachment: The virus enters the cell using endocytosis by binding to a receptor

on the surface of the cell.

Penetration: The viral membrane merges with the host cell membrane then sends

its DNA and several proteins into the host cell’s cytoplasm.

Uncoating: Unlike other viruses, HBV uses RNA to replicate. HBV has partially

double stranded DNA that must be made into fully double stranded DNA first. Core

proteins separate from the partially double stranded viral DNA and make covalently

closed circular DNA (cccDNA). The cccDNA becomes the transcription template for

four mRNAs.

Replication: The largest of the four mRNA is used to make new copies of the

genetic material.

Assembly: The four mRNA are reprocessed, forming progeny virions that are

returned to the nucleus where they are recycled and make additional virions.

Release: DNA is synthesized via reverse transcriptase and new virus is sent into

the cytoplasm, then towards the cell membrane where it is released.

Signs and Symptoms

Most people do not experience any symptoms when newly infected with HBV.

However, some people have acute illness with symptoms that last several weeks,

including yellowing of the skin and eyes (jaundice), dark urine, extreme fatigue,

nausea, vomiting and abdominal pain. People with acute hepatitis can develop

acute liver failure, which can lead to death. Other Hepatitis B signs and symptoms

may include fever, joint pain, loss of appetite, nausea and vomiting, weakness and

fatigue, yellowing of your skin and the whites of your eyes (jaundice). The signs and

symptoms of hepatitis B range from mild to severe. They usually appear about one

to four months after you’ve been infected, although you could see them as early as

two weeks post-infection. Some people, usually young children, may not have any

symptoms.

Investigations

It is not possible on clinical grounds to differentiate hepatitis B from hepatitis caused

by other viral agents; hence laboratory confirmation of the diagnosis is essential.

Several blood tests are available to diagnose and monitor people with hepatitis B.

They can be used to distinguish acute and chronic infections.

The initial evaluation of patients with chronic HBV infection should include:

• A history and physical examination, emphasizing risk factors for coinfection

with hepatitis C virus (HCV), hepatitis delta virus (HDV), and/or HIV; use of

alcohol; family history of HBV infection and hepatocellular carcinoma (HCC);

and signs and symptoms of cirrhosis.

• Laboratory tests, including: a complete blood count with focus on

platelets, liver chemistry tests like aspartate aminotransferase [AST], alanine

aminotransferase [ALT], total bilirubin, alkaline phosphatase, albumin,

international normalized ratio (INR), and tests for HBV replication (HBeAg,

antibody to HBeAg [anti-HBe], HBV DNA). Testing for immunity to hepatitis A

virus (HAV) with HAV immunoglobulin G (IgG) antibody should be performed

in patients who are not known to be immune.

• Evaluation for other causes of liver disease (eg, hemochromatosis, HCV,

HDV) by testing for iron, total iron binding capacity, ferritin, and HCV antibody

in all patients. Other experts suggest one-time screening for HDV in all

patients with chronic hepatitis B.

• Screening for HIV infection in those who have not undergone routine screening,

and in those persons with ongoing risk factors for HIV (eg, injection drug use,

multiple sexual exposures, men who have sex with men).

• Screening for HCC if indicated.

• Screening for fibrosis using noninvasive tests (eg, vibration-controlled

transient elastography, serum fibrosis panel) or liver biopsy. Noninvasive

assessments of liver fibrosis, notably measurements of liver stiffness, are

increasingly used instead of liver biopsies; however, liver stiffness can be

influenced by inflammation as well as fibrosis, and therefore, liver stiffness

measurements may overestimate liver fibrosis in patients with a high ALT

(more than 100 units/L)

• Liver biopsy: Most patients will not need a liver biopsy.

Adequate medical diagnosis

Hepatitis B is a vaccine-preventable liver infection caused by the hepatitis B virus

(HBV).

Hepatitis B is spread when blood, semen, or other body fluids from a person

infected with the virus enters the body of someone who is not infected. This can

happen through sexual contact; sharing needles, syringes, or other drug-injection

equipment; or from mother to baby at birth. Not all people newly infected with HBV

have symptoms, but for those that do, symptoms can include fatigue, poor appetite,

stomach pain, nausea, and jaundice. For many people, hepatitis B is a short-term

illness. For others, it can become a long-term, chronic infection that can lead to

serious, even life-threatening health issues like cirrhosis or liver cancer. The best

way to prevent hepatitis B is to get vaccinated.

Treatment Plan

There is no specific treatment for acute hepatitis B. Therefore, care is aimed at

maintaining comfort and adequate nutritional balance, including replacement

of fluids lost from vomiting and diarrhea. Most important is the avoidance of

unnecessary medications. Acetaminophen, paracetamol, and medication against

vomiting should be avoided.

Chronic hepatitis B infection can be treated with medicines, including oral antiviral

agents. Treatment can slow the progression of cirrhosis, reduce incidence of liver

cancer, and improve long term survival.

In low-income settings, most people with liver cancer die within months of diagnosis.

In high-income countries, patient present to hospital earlier in the course of the

disease and have access to surgery and chemotherapy which can prolong life for

several months to a few years. Liver transplantation is sometimes used in people

with cirrhosis or liver cancer in high-income countries, with varying success.

The goals of antiviral therapy are suppression of HBV DNA, loss of HBeAg (in

patients who were initially HBeAg-positive), and loss of HBsAg. Antiviral agents for

chronic HBV include pegylated interferon (PegIFN) or nucleos(t)ide analogs (eg,

entecavir and tenofovir). WHO recommends the use of oral treatments (tenofovir

or entecavir) as the most potent drugs to suppress hepatitis B virus. Most people

who start hepatitis B treatment must continue it for life. Antiviral agents that are

treatment strategies for chronic HBV typically include interferons or nucleoside

analogs (entecavir and tenofovir):

1. Interferon: the main role of interferon is primarily treatment of young patients

with well compensated liver disease who do not wish to be on long-term

treatment. The advantages of interferon compared to nucleoside analogs are

its finite duration of treatment. Furthermore, interferon should not be used in

pregnant women and patients with decompensated disease or compensated

cirrhosis and portal hypertension.

2. Nucleoside analogs: Several nucleoside analog agents are available. The

available agents include: Entecavir, Tenofovir, Lamivudine, Adefovir and

Telbivudine.

Prevention

A safe and effective vaccine that offers 98% to 100% protection against hepatitis B is

available. Preventing hepatitis B infection averts the development of complications

including chronic disease and liver cancer. The hepatitis B vaccine is typically given

as three or four injections over six months. The hepatitis B vaccine is recommended

for newborns, children and adolescents not vaccinated at birth, those who work or

live in a center for people who are developmentally disabled, people who live with

someone who has hepatitis B, health care workers, emergency workers and other

people who come into contact with blood, anyone who has a sexually transmitted

infection including HIV, Men who have sex with men, people who have multiple

sexual partners, sexual partners of someone who has hepatitis B, people who

inject illegal drugs or share needles and syringes and the health care professionals,

people with chronic liver disease, people with end-stage kidney disease, travelers

planning to go to an area of the world with a high hepatitis B infection rate.

Evolution and Complications

Most patients with hepatitis B recover fully, even if their signs and symptoms are

severe. Infants and children are more likely to develop a chronic (long-lasting)

hepatitis B infection. A vaccine can prevent hepatitis B, but there’s no cure if

you have the condition. If infected, taking certain precautions can help prevent

spreading the virus to others. The diagnosis of acute HBV infection is based upon

the detection of hepatitis B surface antigen (HBsAg) and IgM antibody to hepatitis B

core antigen (anti-HBc). For most patients, treatment is mainly supportive. Having

a chronic HBV infection can lead to serious complications such as:

Self-assessment 4.2.6

1. What are different modes of HBV transmission?

2. Briefly described the pathogenesis of HBV infection.

3. What are different investigations used to the diagnosis of HBV?

4. What are the complications resulting from HBV infection?

4.2.7 GENITAL HERPES

Learning Activity 4.2.7

Carefulyl read the case study below and answer the following questions

Mrs B.A is 28 year old female patient who was presented at Rubona Health

Center with complaints fever, headache, pain during sex intercourse, itching and

sores in the vagina and anus area. The vital signs were the body temperature

of 38.5 degree Celius, blood pressure of 120/70 mm Hg, PR was 88bpm. Mrs

B.A was immediately referred to Rwamagana Hospital where she received an

antiviral drugs tha she doesn’t remember. After six months the same symptoms

reappeared and she revisited the Rwamagana Hospital for further management.

Arriving at hospital, the medical doctor did complete physical eamination and

found that she had sores at external genitalia and inside the vagina.

He decided to hospitalise her, gave her IV fluids 1.5 liters/24 hours, brufen 400mg

three times a day for 3 days, IV ceftriaxone 500mg TDS for 5 days, Acyclovir

200mg TDS for 7 days and local care of sores. He also requested the complete

blood count, vaginal and cervical swabs that the results were pending.

1. What are the abnormal signs and symptoms that the patient was presenting?

2. Basing on those signs and symptoms, what could be the medical problem

of this patient?

3. What are the investigations that have been requetsed to confirm the

medical condition of Mrs B.A?

4. What was included in the treatment plan of this case?

5. If not well treated, what will be the complications?

Genital herpes is a common sexually transmitted infection caused by the herpes

simplex virus type 1 or type 2 and manifests as either a primary or recurrent

infection, Sexual contact is the primary way that the virus spreads. After the initial

infection, the virus lies dormant in the body and can reactivate several times a year.

Two types of herpes simplex virus infections can cause genital herpes:

HSV-1: This is the type that usually causes cold sores or fever blisters around the

mouth. HSV-1 is often spread through skin-to-skin contact, though it can be spread

to the genital area during oral sex. Recurrences are much less frequent than they

are with HSV-2 infection.

HSV-2: This is the type that commonly causes genital herpes. The virus spreads

through sexual contact and skin-to-skin contact. HSV-2 is very common and highly

contagious, whether or not there is an open sore.

Because the virus dies quickly outside of the body, it’s nearly impossible to get the

infection through contact with toilets, towels or other objects used by an infected

person.

Risk factors for acquiring HSV-2 infection revolve around direct exposure to fluids

(i.e., semen, blood, saliva, etc.) from a seropositive individual containing viral

products most often during sexual intercourse. HSV-2 is mainly transmitted through

sexual intercourse, attributing to its predominant rise starting at puberty. Due to its

low stability outside the body, HSV can only remain infectious for days on moist

surfaces. Therefore, modes of transmission other than sexual intercourse are often

insignificant. Both primary and recurrent HSV infections in pregnant women can

lead to intrauterine transmission and resultant congenital HSV infection.

Pathophysiology

HSV-2 is transmitted through direct contact of sections in a seropositive individual

who is actively shedding the virus. The virus preferentially affects the skin and

mucous membranes with the virus invading epithelial cells on initial exposure

and ultimately replicating intracellularly at that site. After the initial exposure and

symptoms resolve, in 10 to 14 days, on average, the virus then lays dormant in

the periaxonal sheath of the sensory nerves of either the trigeminal, cervical,

lumbosacral, or autonomic ganglia. In these locations, the viral replication is often

controlled by the patient’s immune system and remains in a dormant state only to

later reactive later in life. When reactivation does occur, the virus travels through

the sensory nerves until it reaches the muco-cutaneous sites where replication then

takes place and leads to vesicular clusters at the dermatological site of that sensory

neuron.

Signs and Symptoms

Most people infected with HSV do not know they have it because they don’t have

any specific signs or symptoms or because their signs and symptoms are so mild.

When present, symptoms may begin about two to 12 days after exposure to the

virus.

The signs and symptoms of genital herpes include:

Pain or itching: client may experience pain and tenderness in your genital area

until the infection clears.

Small red bumps or tiny white blisters or sores: These may appear a few days

to a few weeks after infection. Sores appear where the infection entered the body.

The infection can be spread by touching a sore and then rubbing or scratching

another area of the body, including the eyes.

Men and women can develop sores on the buttocks and thighs, anus, mouth and

urethra. Women can also develop sores in or on the vaginal area, external genitals,

and cervix. Men can also develop sores in or on the penis, and scrotum.

Ulcers: These may form when blisters rupture and ooze or bleed. Ulcers may make

very painful when urinating.

Scabs: Skin will crust over and form scabs as ulcers heal.

Genital herpes is different for each person. The signs and symptoms may recur,

off and on, for years. Some people experience numerous episodes each year. For

many people, however, the outbreaks are less frequent as time passes. During a

recurrence, shortly before sores appear, the client may feel burning, tingling and

itching where the infection first entered your body, pain in your lower back, buttocks

and legs. However, recurrences are generally less painful than the original outbreak,

and sores generally heal more quickly.

Investigations

Sometimes people mistake a pimple or ingrown hair for herpes. The doctor can

take a small sample from sores by using a swab test for laboratory examination.

If a client doesn’t have symptoms but think he/she might have herpes, the doctor

can order other test:

Viral culture: This test involves taking a tissue sample or scraping of the sores for

examination in the laboratory.

Polymerase chain reaction (PCR) test: PCR is used to copy the DNA from a

sample of the blood, tissue from a sore or spinal fluid. The DNA can then be tested

to establish the presence of HSV and determine which type of HSV the client has.

Blood test: This test analyzes a sample of the blood for the presence

of HSV antibodies to detect a past herpes infection.

Adequate medical diagnosis

Genital herpes is a common sexually transmitted infection marked by genital pain

and sores. It is caused by the herpes simplex virus, and this disease can affect

both men and women. Pain, itching and small sores appear first. They form ulcers

and scabs. After initial infection, genital herpes lies dormant in the body. Symptoms

can recur for years. Medication (mainly painkillers, antiviral drugs) can be used to

manage the condition.

Treatment plan

There’s no cure for genital herpes, but the treatment with antiviral medications may

help sores heal sooner during an initial outbreak, lessen the severity and duration

of symptoms in recurrent outbreaks, reduce the frequency of recurrence, minimize

the chance of transmitting the herpes virus to another. There are three major drugs

commonly used to treat genital herpes symptoms: acyclovir (zovirax), famciclovir

(famvir), and valacyclovir (valtrex). Moderate and minor cases are treated with

oral medications and severe cases may be treated with the intravenous (IV) drugs

seven to 10 days. Therapy should be initiated as early as possible following onset

of signs and symptoms.

Prevention

If the client is sexually active, there’s a chance to get herpes. He or she will make

it a lot less likely if he/she use a latex or polyurethane condom or dental dam every

time, for every activity. The dam or condom only protects the area it covers. If client

has herpes, he/she and his or her partner should get tested for STDs before sex.

To feel better during an outbreak, the client should wear loose-fitting clothes and

cotton underwear, avoid sun or heat that could cause more blisters, take a warm,

soothing bath, not use perfumed soaps or douches near the blisters.

Evolution and Complications

During vaginal birth, the herpes virus could spread to the baby, especially if the first

outbreak happens around the delivery time. The virus could give the baby rashes,

eye problems, or more serious issues. A caesarean section makes that less likely.

The doctor may also prescribe an anti-viral medicine starting at about 34 weeks to

avoid an outbreak around the due date.

Complications associated with genital herpes may include:

AIDS.

the newborn.

requiring the insertion of a catheter to drain the bladder.

and cerebrospinal fluid surrounding the brain and spinal cord.

lining of the rectum, particularly in men who have sex with men.

will suggest a cesarean section to reduce the risk of passing the virus to the baby.

Self-assessment 4.2.7

6. What are the complications of Genital Herpes?

4.2.8 TRICHOMONIASIS

Learning Activity 4.2.8

month for evaluation and possible biopsy of the wart lesions.

5. If poorly treated, what will be the complications?

are infected.

Causes and risk factors

sex without a condom.

Physiopathology

to others.

treatment, the infection can last for months or even years.

Investigations

the following to diagnose trichomoniasis:

Complete physical exam (For women, this exam includes a pelvic exam)

Lab test: The healthcare provider examines a sample of the genital discharge

under a microscope to check for the cause of infection. The vaginal swab collected

may be sent to the lab for further testing if trichomonas are not seen under the

microscope. Trichomoniasis can be diagnosed by looking at a sample of vaginal

fluid for women or urine for men under a microscope. If the parasite can be

seen under the microscope, no further tests are needed. If this test isn’t conclusive,

tests called rapid antigen tests and nucleic acid amplification may be used.

can give the STD to his or her sexual partners.

Treatment plan

all sex partners should get treated with antibiotics at the same time.

following points in mind while undergoing treatment:

(new-borns who weigh less than 2kg500), limit your number of sexual partners.

6. What are the complications of trichomoniasis?

23. What are different preventive measures of STDs?