CHAPTER

Sexually Transmitted and Urinary Tract Infections 15

INTRODUCTION
The urinary system is composed of organs that regulate the chemical composi on
and volume of the blood and as a result excrete mostly nitrogenous waste products and
water. Because it provides an opening to the outside environment. the urinary system is
prone to infec ons from external contacts. The mucosal membranes that line the urinary
system are moist and, compared to skin, more suppor ve of bacterial growth.
The reproduc ve system shares several of the organs of the urinary system. Its
func on is to produce gametes to propagate the species and, in the female, to support and
nourish the developing embryo and fetus. In the same fashion as the urinary system, it
provides openings to the external environment and is therefore prone to infec ons. This is
especially true because in mate sexual contact can promote exchange of microbial
pathogens between individuals. It is not surprising, therefore, that certain pathogens have
adapted to this environment and a sexual mode of transmission. O en they have done this
at the cost of an inability to survive in more rigorous environments.

LEARNING OUTCOMES
At the end of the chapter, students must have:
1. Recognized common sexually transmi ed and urinary tract infec ons based on
clinical manifesta ons;
2. Described the characteris cs of the causa ve organisms of each sexually transmi ed
and urinary tract infec on;
3. Iden ed the individuals at risk of sexually transmi ed infec ons;
4. Determined the appropriate laboratory diagnosis and treatment of each infec on;
and
5. Discussed the global strategy for the preven on and control of sexually transmi ed
infec ons.

WARM-UP ACTIVITY
Am I Hydrated?
A quick way to test how well you are hydrated is to check the
color of your urine.
Be Aware!
If you are taking single vitamin supplements or a mul vitamin
supplement, some of the vitamins in the supplements can
change the color of your urine for a few hours making it
bright yellow or discolored. If you are taking a vitamin
supplement, you may need to check your hydra on status
using another method.
Your Nose Knows! While some foods can cause urine to
smell di erent, a strong smelling odor can also be a sign of
dehydra on.

Angelica May DC. Mendoza, RPh, MS Page 1 of 8

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 CENTRAL ACTIVITIES
Learning Input 1 (Lecture)
Sexually Transmi ed Infec ons
The WHO has come up with a Global strategy for the preven on and control of sexually
transmi ed infec ons.
1. The technical which involves methods on the use of protec ve barriers, promo on of
sexual behavior, accessibility to e ec ve care system, and improved monitoring and
evalua ons of control strategy.
2. The advocacy which addresses the need for an e ec ve STI advocacy campaign to
raise awareness and mobilize resources at the na onal and interna onal level.

Clinical Manifesta on of STIs

1. Skin Lesions
b. Ulcera ve lesions
iii. Chancre - primary lesion of syphilis; painless and well-delineated. clibshella
iv. Chancroid - ulcer with ragged edges; painful granumolatis??
v. Genital herpes - start as a vesicle that becomes an ulcer a er rapture
b. Granuloma reac ons - typical of granuloma inguinale
c. Rashes - commonly seen in secondary syphilis, gonorrhea, and candidiasis
d. Warty lesions - characteris c of condyloma, gororrhea, and candidiasis
2. Discharge
a. Vaginal - usually accompanied by dysuria, dyspareunia, and vulvar irrita on
ii. Trichomonas vaginalis - thin, foamy, foul-smelling
iii. Neisseria gonorrhea - greenish, purulent
iv. Candida albicans - thick, cheesy exudates (milk curd-like appearance)
b. Urethral - in males, any urethral discharge other than ejacula on is abnormal

Common STIs
1. Syphilis - ranks third among the most common sexually transmi ed diseases
worldwide.
• E ologic Agent: Treponema pallidum - a spirochete with ne regular coils witn
tapered ends. The organism cannot be grown in the cell-free culture medium.
• Modes of Transmission:
a. direct sexual contact
b. congenitally
c. blood transfusion
• Clinical Findings:
a. Adult syphilis
ii. Primary syphilis - a highly infec ous stage with abundant organisms
that can be isolated from the ulcer. The primary lesion is called
chancre. Within 2 months, the ulcer heals spontaneously even
wothout treatment but will con nue to disseminate through the
blood and lympha cs and eventually progress to secondary syphilis.
iii. Secondary syphilis - a skin rash (especially on the palms and soles)
about 4–6 weeks later, with fever and mucous membrane lesions.

Angelica May DC. Mendoza, RPh, MS Page 2 of 8

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 The symptoms of secondary syphilis usually subside a er a few
weeks, and the disease enters a latent period.
iv. Latent syphilis - during this period, there are no symptoms. A er 2
cant transmit through
to 4 years of latency, the disease is not normally infec ous, except
sexual inter but
for transmission from mother to fetus. The majority of cases do not
through mother to
progress beyond the latent stage, even without treatment.
baby
v. Ter ary syphilis - with damage to the CNS, car- diovascular system,
visceral organs, bones, sense organs, and other sites. Damage to the
CNS or heart is usually not reversible.
b. Congenital syphilis
i. Early Congenital syphilis - right a er birth, the infected newborn
may not present with any clinical manifesta on. Later the newborn
may manifest with runny nose (snu es), rash, and condylomata as
well as hepatosplenomegaly.
ii. Late Congenital syphilis - manifested at 8th nerve deafness with
bone and teeth deformi es (saddle nose, saber shins, Hutchinson’s
teeth, and Mulberry or Moon’s molars)
• Laboratory Diagnosis:
a. Dark eld microscopy
b. Serology
• Treatment and Preven on:
c. Penicillin - DOC
d. Tetracycline or Doxycycline - alterna ve
2. Gonorrhea - second most common STI worldwide. Females are asymptoma c carriers
1st- of the infec on. In men, a single unprotected exposure results in infec on with
chlamydia gonorrhea 20% of the me. Women become infected 50% of the me from a single
trachomatis exposure.
• E ologic Agent: Neisseria gonorrheae (also known as gonococcus or GC), a
Gram-nega ve diplococcus. It is kidney bean-shaped when it is single and co ee
bean-shaped when in pairs. It has pili which are used for a achment to host
cell, mo lity, transfer of gene c materials and plays an important role in the
pathogenesis.
• Clinical Findings:
a. Gonorrhea infec on in males - Men become aware of a gonorrheal
infec on by painful uri- na on and a discharge of pus-containing material
from the urethra. About 80% of infected men show these obvious
symptoms a er an incuba on period of only a few days; most others
show symptoms in less than a week.
b. Gonorrhea infec on in females - In females, the disease is more insidious.
Only the cervix, which contains columnar epithelial cells, is infected. The
vaginal walls are composed of stra ed squamous epithelial cells, which
are not colonized. Very few women are aware of the infec on. Later in the
course of the disease, there might be abdominal pain from complica ons
such as pelvic in ammatory disease
c. Disseminated infec ons - this occurs in 1%-3% of cases and present as
fever, migratory arthralgia, suppura ve arthri s of the wrists, knees, and

Angelica May DC. Mendoza, RPh, MS Page 3 of 8

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 ankles, and pustules with erythematous base over the extremi es. Other
diseases associated are perhepa s (Fitz-Hugh-Cur s Syndrome) and
purulent conjunc vi s in adults. If the mother is infected with gonorrhea,
the eyes of the infant can become infected as it passes through the birth
canal. This condi on, ophthalmia neonatorum, can result in blindness.
• Laboratory Diagnosis:
a. Microscopy
b. Culture using modi ed Thayer-Mar n medium
• Treatment and Preven on:
a. Ce riaxone, cipro oxacin, ce pime or o oxacin - for uncomplicated
gonorrhea
b. A combina on of the aforemen oned drugs with doxycycline or
azithromycin - for mixed infec on with
c. 1% Silver nitrate or 0.5% eyrthomycin or tetracycline eye ointment -
preven on of ophthalmia neonatorum
3. Lymphogranuloma Venereum (LGV)
• E ologic Agent: Chlamydia trachoma s, obligate intracellular bacteria that do
not have cell walls. Serotypes D to K are associated with non-gonococcal
urethri s, cervici s, and PID while serotypes L1, L2, and L3 are associated with
lymphogranuloma venereum.
• Clinical Findings:
bubos- lesions on a. Urogenital tract infec ons - most are aymptoma c. If symptoma c, it may
the skin that are manifest as cervici s, endometri s, urethri s, salpingi s, bartholini s,
black perihepa s, and mucopurulent discharge.
b. Lymphogranuloma Venereum - a primary lesion appears at the site of
infec on, either a papule or ulcer, which is small, painless, and heals
rapidly. The second stage is manifested by enlarged lymph nodes that are
painful (buboes) and ruptures to form draining stulas.
• Laboratory Diagnosis:
a. Visualiza on using Giemsa-stained specimen from scrapings from the
lesion.
b. Cullture is the most speci c diagnos c method
• Treatment and Preven on: Azithromycin, doxycycline, or erythromycin.
4. Chancroid (So Chancre)
• E ologic Agent: Haemophilus ducreyi, a gram-nega ve coccobacillus. It is a
blood-loving organism and must be grown in culture medium containing blood.
It only requires hemin (X factor) for growth which is derived from the blood in
the culture medium.
• Clinical Findings: swollen, painful ulcer that forms on the gen- itals involves an
infec on of the adjacent lym ph nodes. Infected lymph nodes in the groin area
some mes even break through and discharge pus to the surface.
• Laboratory Diagnosis: culture on at least two kinds of enriched media
containing vancomycin.
• Treatment and Preven on: Azithromycin, cephalosporins, erythromycin or
cipro oxacin.

Angelica May DC. Mendoza, RPh, MS Page 4 of 8

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 5. Genital Herpes
• E ologic Agent: Herpes Simplex Virus (HSV), a DNA virus under the family of
Human Herpesviridae. The virus is capable of latency in the neurons hence the
occurence of recurrent infec ons. There are two types (1) Type 1 and (2) Type
2. oral(1) genital(2)
• Mode of Transmission: oral secre ons or sexual contact
• Clinical Findings: In general, herpes simplex infec ons are characterized by a
localized primary lesion, latency, and a tendency to localized recurrence.
a. In women, the principal sites of primary anogenital herpes virus infec on
are the cervix and vulva, with recurrent disease a ec ng the vulva,
perineal skin, legs, and bu ocks.
b. In men, lesions appear on the penis, and in the anus and rectum of those
engaging in anal sex.
c. Neonatal Herpes - a serious considera on for women of child- bearing
age. The virus can cross the placental barrier and a ect the fetus. The
result can be spontaneous abor on or serious fetal damage, such as
mental retarda on and defec ve vision and hearing.
• Laboratory Diagnosis:
a. Tzanck smear and histopathologic examina on are done to demonstrate
the characteris c cytopathologic e cts that includes Cowdry type A
inclusions, syncy a forma on, and ballooning of infected cells.
b. PCR or immuno uorescence - a more speci c
• Treatment and Preven on: Acyclovir - DOC
6. Condyloma acuminata (Genital warts)
• E ologic Agent: Human Papilloma Virus (HPV) serotypes 6 and 11
• Clinical Findings: Genital warts start as ny, so , moist, pink or red swellings,
which grow rapidly and may develop stalks. Their rough surfaces give them the
appearance of small cauli owers. Mul ple warts o en grow in the same area,
most o en on the penis in men and the vulva, vaginal wall, cervix, and skin
surrounding the vaginal area in women. Genital warts also develop around the
anus and in the rectum in men or women who engage in anal sex. These warts
can become malignant.
• Laboratory Diagnosis: histologic examina on and Papanicolaou smear
• Treatment and Preven on:
a. Injec on of interferon - most bene cial treatment
b. HPV vaccine - for 11 years and above; sexually ac ve males and females.
i. Tetravalent vaccine - contains serotypes 6,11,16, and 18
ii. Bivalent vaccine - contains serotypes 16 and 18
7. Acquired Immunode ency Syndrome (AIDS)
• E ologic Agent: Human Immunode ciency Virus (HIV) - an RNA virus under the
family of Retroviruses. The virus possesses the enzyme reverse transcriptase
that allows it to integrate its genome into the host cell’s DNA. It possesses a
glycoprotein known as gp120 on its envelope that binds to the CD4+ receptor
on helper T cells and macrophages. Another envelope glycoprotein, gp41,
facilitates absorp on of the virus to the CD4+ T cells.

1-10 years of incubation.

people die because of
Angelica May DC. Mendoza, RPh, MS Page 5 of 8
pnenomnia
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 •
Modes of Transmission:
a. Transmission occurs via direct sexual contact (homosexual or
heterosexual)
b. Sharing of contaminated needles and syringes by intravenous drug
abusers
c. Transfusion of contaminated blood and blood products
d. Transplacental transfer from mother to child
e. Breast-feeding by HIV-infected mothers
f. Transplanta on of HIV-infected ssues or organs
g. Needles ck, scalpel, and broken glass injuries.
• Clinical Findings:
a. Acute HIV Infec on - The signs and symptoms of acute HIV infec on
usually occur within several weeks to several months a er infec on with
HIV. Ini al symptoms include an acute, self-limited mononucleosis-like
illness las ng 1 or 2 weeks. Unfortunately, acute HIV infec on is o en
undiagnosed or misdiagnosed, because an -HIV an bodies are usually not
present in a high enough concentra on to be detected during this early
phase of infec on. Without appropriate an -HIV treatment,
approximately 90% of HIV-infected individuals ul mately develop AIDS.
b. AIDS - a severe, life-threatening syndrome that represents the late clinical
stage of infec on with HIV. Invasion and destruc on of helper T cells leads
to suppression of the pa ent’s immune system. Secondary infec ons
caused by viruses (e.g., cytomegalovirus, herpes simplex), protozoa (e.g.,
Cryptosporidium, Toxoplasma), bacteria (e.g., mycobacteria), and/or fungi
(e.g., Candida, Cryptococcus, Pneumocys s) become systemic and cause
death. Persons with AIDS die as a result of overwhelming infec ons
caused by a variety of pathogens, o en opportunis c pathogens.
• Laboratory Diagnosis:
a. ELISA (Enzyme-linked immunosorbent assay)
b. Western Blot assay
c. p24 an gen determina on
d. Polymerase chain reac on (PCR)
• Treatment and Preven on: HAART (Highly ac ve an -retroviral treatment)
8. Pediculosis Pubis (Pubic lice or crabs)
• E ologic Agent: Phthirus pubis - the organism is ny, about 2 mm long, and
visible to the naked eye. It is a parasi c insect that feeds on the blood of the
host. The lice are primarily seen a ached to the pubic hair and in coarse hairs
found in other parts of the body like the chest, beard, moustache, and armpits.
• Mode of Transmission: sexual contact and fomites
• Clinical Findings: They readily a ach to human hair and cause intense pruritus
and red spots. Secondary bacterial infec on may occur and eczematous lesions
may develop.
• Laboratory Diagnosis: iden ca on of the parasite a ached to hair.
• Treatment and Preven on: insec cidal creams, lo ons, and shampoos that
contain 1% malathion or permethrin.

Angelica May DC. Mendoza, RPh, MS Page 6 of 8

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 Urinary Tract Infec ons

• Predisposing Factors:
1. Gender - UTI is more common in females especially school-aged girls and those
above 60 years of age.
2. Mechanical factors - catheriza on, sexual intercourse, kidney stones, and
improper use of tampons and douches.
3. Metabolic disorders - increased sugar content of urine, due to diabetes for
instance, is conducive for bacterial growth.
4. Anatomic abnormali es of the urinary tract - can lead to obstruc on or
incomplete voiding of urine or re ux of urine.
• E ological Agents:
1. Escherichia coli - a gram-nega ve bacillus that is part of the normal microbial
ora of the human body, speci cally the colon hence, infce ons are
endogenous. Improper washing a er defeca on is a factor that promoted entry
of the organism into the urinary tract, most especially in women because of the
proximity of the urethral ori ce to the anal opening. It is the most common
cause of community-acquired UTIs.
2. Proteus mirabilis - gram-nega ve bacilli that produces urease which causes
alkaliniza on of urine, making the pa ent more prone to development of
urinary stones. It is the second most common cause of community-acquired UTI
and is a major cause of nosocomial infec ons.
3. Serra a spp. - are also gram-nega ve bacilli which are major en es in
nosocomial infec ons. Almost all infec ons caused by these organisms are
associated with underlying disease, changing physiological pa erns,
immunosuppresive therapy, or mechanical manipula ons of the pa ent. The
most frequent isolated species is Serra a marcescens. The organism produces a
bright red pigment called prodigiosin, which imparts a red color to the colonies.
4. Enterococcus faecalis - part of the normal enteric ora. They grow in 6.5% NaCl
and are more resistant to Pen G. It is the most common among the Enterococci.
These are also frequent causes of nosocomial infec ons, par cularly in intensive
care units.
5. Staphylococcus saprophy cus - a gram-posi ve coccus and a common cause of
UTI in sexually ac ve young women. It is a common colonizer of the urinary
tract.
• Clinical Manifesta ons:
1. Cys s - in amma on of the urinary bladder. It is the most common type of UTI
and it is most commonly caused by E. coli. Symptoms are suprapubic pain and
tenderness, frequency of urina on and occassional hematuria.
2. Urethri s - in amma on of the urethra. Symptoms are dysuria, frequency and
urgency of urina on.
3. Pyelonephri s - in amma on of the kidneys, par cularly the tubules.
4. Urethrocys s - may be asymptoma c; usually malodorous urine, especially in
women, incon nence.
• Laboratory Diagnosis:
1. Urinalysis colony count- 100000
midstream specimen
2. Urine culture
less than 1000 colonies
per ml-normal
Angelica May DC. Mendoza, RPh, MS Page 7 of 8
1000-100000ml
infection
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 • Treatment and Preven on:

1. Trimethoprim + Sulfamethoxazole - for uncomplicated infec on with E. coli
2. Fluoroquinolone - for infec ons with Proteus and Pseudomonas
3. Fluoroquinolone or 3rd genera on cephalosporins - in acute pyelonephri s
4. Increased water intake is o en advised to avoid dehydra on

Ac vity 1
You are expected to par cipate in the online lecture on December 29, 2020
(Tuesday; 8am-8:30am for Level IIA and 9am-9:30am for Level IIB).

Learning Input 2 (Laboratory)

The incidence of secually transmi ed diseases has increased tremendously through
the years. The age incidence has also increased not only in the adult popula on but more so
among adolescents. Sexually transmi ed infec ons (STI) are most caused by mixed
infec ons and not just single organisms. STIs are worldwide in distribu on and can a ect all
age groups but sexually ac ve individuals are the most vulnerable.

Ac vity 2
You are expected to par cipate in the online lecture on December 29, 2020
(Tuesday; 8:30am-9:00am for Level IIA and 9:30am-10:00am for Level IIB).

WRAP-UP ACTIVITY
Summarize what you have learned or how your new learnings has changed your
thoughts on the topic.

POST-ASSESSMENT

Worksheet 15 (Lecture)
You are required to accomplish the Worksheet 15. The ac vity will be posted on
December 28, 2020 (Monday) in the mVLE course page. Make sure to complete and submit
your output on or before 11:59 pm January 3, 2021 (Sunday).

Worksheet 15 (Laboratory)
You are required to accomplish the Worksheet 15. The ac vity will be posted on
December 28, 2020 (Monday) in the mVLE course page. Make sure to complete and submit
your output on or before 11:59 pm January 3, 2021 (Sunday).

Quiz 15
You are required to take the Quiz 15. The quiz will be posted on December 29, 2020
(Tuesday) a er the online lecture in the mVLE course page. Make sure to complete and
submit your output on or before 11:59 pm December 29, 2020 (Tuesday).

Angelica May DC. Mendoza, RPh, MS Page 8 of 8

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