Urinary Tract Infection ( UTI )

or
Genitourinary Infection

EFRIDA
WARGANEGARA

GENITOURINARY INFECTION
I.

Urogenital Infection
1. Infeksi Saluran Kemih
a. Bacterial Cystitis
b. Leptospirosis
2. Infeksi Saluran Genital
a. Bacterial Vaginosis
b. Staphylococcal Toxic Shock Syndrome

II.

Sexually Transmitted Infections

1. Bactaerial Sexually Transmitted Infections
a. Gonorrhea
b. Chlamydial Infection
c. Syphilis
d. Chancroid
2. Viral Sexually Transmitted Infections
a. Genital Herpes
b. Papillomavirus
c. HIV/AIDS
3. Fungal Sexually Transmitted Infections
a. Vulvovaginal Candiidiasis

I. Urogenital
Infection
1. Urinary Tract Infection
a. Bacterial Cystitis
b. Leptospirosis
2. Genital System Disease
a. Bacterial Vaginosis
b. Staphylococcal Toxic Shock
Syndrome

Anatomy of the Urinary System

Introduction

Urinary Tract : Urethra to calyces, is

lined with a sheet of epithelium that is
continuous with that of the skin is
potential pathway for entry of m.o. from
the outside.

UTIs can involve the urethra, bladder, or

kidneys, alone or in combination

Introduction

UTI is arise by :
- the ascent of bacteria following colonization of
periurethral area by fecal organism
- hematogenous infection of the kidney much
rarer
- Anaesthesia and mayor surgery (for example)
temporarely stop the reflex ability to urinate,
and urine accumulation in the bladder.
- Even being too busy to empty the bladder
may predispose a person to infection
- Most cases of UTIs occur in otherwise healthy
young women with normal urinary flow

Introduction

The main defences against UTIs are :

- the flow of urine
- the sloughing of epithelial cell to with
bacteria may be attach
- immune defences (humoral and
cellular) play little role here,

Introduction
The Urinary Tract is one of the most common sites
of bacterial infection, particularly in females (the
mayority of patients are women)
10-20% of women have UTI at some time in their
life by the age of 30 years and have
recurrent
infection
Majority of infection are acute and short lived
contributed to a significant amount of morbidity in
population.
Severe infection result in loss of renal function
and serious longterm sequele

Introduction

In female : a distinction is made between

cystitis, urethritis, vaginitis but GU tract is
continum and the symptom often overlap

All portions of the urinery tract may be

affected, but the most common UTIs are
infection of the bladder (cyctitis) and the
kidney (pyelonephritis).

Infection of the urethra alone or urethritis, is

discussed with the STD

Introduction

Prostatic infection is usually considered

as separated from UTI, although chronic
bacterial prostatitis may lead to recurrent
UTI

Renal abscesses mau occur as a result of

ascending UTI or of bacteremia, and
pyelonephritis may also result from
bacteremia, without other involvement of
the urinary trac

Classification of UTI, according

location :
1.Upper

UTI pyelum to ureter

UTI vesica urinaria,

prostat and urethra
2.Lower

Other Classification :
1. according symptom
- Symptomatic UTI
- Asymptomatic UTI
2. According structure
- Complicated UTI

Normal Flora
The

Renal, Ureter to Bladder

are normally steril

Commonly

in women and
man, there is m.o. in distal
urehtra (1/3 distal)

M.o.

in distal urethra are

same with flora normal in
skin and perineum or vulva

ENTRY

Access of infectious agents into the urinary tract

is nearly always by accent from the urethra
(blood-borne infections relatively infrequent
source and may be result in renal abscesses

Most ascending UTIs are caused by enteric or

skin bacteria most frequent are fecal bacteria,
frequent chlamydiae and candida albicans, and
rarely by virus, protozoa or worm.

Acquition and Aetiology

A. Bacteial Infection

Usually acquired by ascending

route from urtethra to bladder and
may proceed to kidney with the renal
tissue to be infected

Less commonly infection may result

from hematogenous spread of an
organism to the kidney

Occasionaly : bacteria infecting UT

Acquition and Aetiology

A. Bacteial Infection cont.

Ascending infection of UTI : most commonlly

caused by:
1. Gram negative rod : E. coli
2. Other members of Enterobacteriaceae :
a) Proteus mirabilis associated with urinay
stone
(produce urease act to urea, produce
ammonia
causes urine alkaline);
b) Klebsiella, Enterobacter, Serratia species
and

Acquition and Aetiology

A. Bacterial Infection cont.
3. Gram positive species :
a) Staphylococcus saprophyticus
causing
infection in young, sexually active
women
b) Staphylococcus epidermidis UTI
in
hospitalized patient
c) Others, capnophilic (m.o. which

Acquition and Aetiology

B. Viral Infection
Viral causes of UTI is rare, although
certain virus may be recovered from
urine in the absence of UTI

E.g. a) Human polyoma virus JC and BK

from
respiratory syst. to epithelial cell in
kidney
tubulus and ureter;
b) cytomegalo-virus;
c) adenovirus causes of

Pathogenesis of UTI
Factors predisposing to infection
A. Mechanical Factors
- anything that disrups normal urine flow or
complete emptying of the bladder or facilitates
acces of m.o. to the bladder will predispose
to infection
- the shorter female urethra is risk for fecal
contamination
- sexual intercouse facilitates the movement of
m.o. up the
urethra, particularly women
- in women preceeding bacterial colonization of

Pathogenesis of UTI
B. Obstruction to complete bladder
emptying
- Pregnancy, prostatic hypertrophy, renal
calculi,
tumors and strictures of any sort causes
obstruction UTI when residual urine
more
than 2-3 ml, infection is more likely
- Loss of neurological control of the bladder
and
sphincter resultant large residual volume
urine in the bladder functional obstruction

Pathogenesis of UTI
D. Diabetic
- may suffer more severe UTI and when
diabetic neuropathy interference with
normal
bladder function persistent UTI
commonly
occur

E. Catheterization
- is another major predisposing factor for
UTI
- During insertion of catheter m.o.

Pathogenesis of UTI
Bacterial Virulence Factors

Most Urinary tract pathogens originate in the fecal flora

but only the aerobic and facultative species such as E. coli
posses the attributed required to colonize and infect the
UT - Ability to colonized the periurethral area:
1. Fimbrie (pili) adhere to urethral and bladder
epithelium
2. Capsular acid polysacharide (K) antigen resist
host
defences by inhibiting phagocytosis - pyelonephritis
3. Hemolysin act as membrane damaging toxin
4. Produce Urease (Proteus spp) ability causes
pyelonephritis

Pathogenesis of UTI

Host Defence mechanism Host

Factor

pH, chemical content and flushing

mechanism normal urethral flora do not
multiply readily in urine, although urine is
good cultur medium for bacteria

The role of humoral immunity is poorly

understood

After infection of the kidney, IgG and

secretory IgA antibodies can be detected

Host Defence mechanism Host factor

1. Complicated UTI - structure
abnormalities :
a. stones - caused by Proteus sp.
urea-splitting m.o. raise the pH
urine b. obstructions prostatic
hypertrophy
c. catheters caused by Gram neg
(Klebsiella, Enterobacter,
Acinetobacter, Serratia sp. or
Pseudomonas aeruginosa, relative

Defence Mechanism of
Urinary Tract

1. Faktor Urine :

- Urea conc. Tinggi dan osmolaritas

- pH urine yg rendah membunuh
bakt.

2. Faktor Hidrokinetik
- Eksresi urine secara periodik
- Pengenceran sisa urin krn aliran
dari ginjal
- Pengosongan sempurna urine

Defence Mechanism of
Urinary Tract
3. Faktor Mukosa
- Mukosa vesika urinaria t.d sel epitel
lebih dari satu lapisan
- Mukosa sal. Kemih dan vesika urinaria
ditutupi oleh mukus mencegah
penempelan
- Efek antribakteri dari sekret prostat
- Sekresi lokal IgA mencegah
penempelan m.o. pada uroepithelium
dan mencegah toksin penetralisir dari

Clinical Features and Complication

1. Lower urinary Tract
Acute infection of lower UT are characterized by a rapid
onset of dysuria (burning pain on passing urine);
urgency (the urgent need to pass urine) and frequency
of micturition
Urine is cloudy, due to the presence of pus cell (pyuria) and
bacteria (bacteriuria), and many contain blood
(haematuria). Patient with genital tract infection
(vaginal thrush or chlamydia urethritis) may present
with similar symptom
Pyuria in the absence of positive urine culture can be due to
chlamydia, tuberculosis or patient receiving
antibacterial therapy for UTI

Clinical Features and Complication

2. Upper Urinary Tract

Patient with pyelonephritis, complain of lower
tract symptom and usually have a fever
Staphylococcus are a common cause and
renal abscesses are generally present
Recurrent episode of pyelonephritis result in
loss of function of renal tissues which may,
in turn, cause hypertension, itself a cause
of renal damage.
Infection associated with stone formation can
result in obstrction of the renal tract and

Laboratory Diagnosis of UTI

1. Sampel Urine :

- Urine midstream

- Aspirasi supra pubik

- Kateterisasi

2. Kultur
- Umumnya ISK ditandai dengan adanya bakteriuri
- Bakteriuri Infectif :
a. jumlah m.o. > 100.000 per ml urine
b. jumlah m.o. < 100.000 per ml urine dengan
lekosituri
c. jumlah m.o. < 100.000 per ml urine, pada kultur
kedua
didapatkan jenis m.o. yang sama
d. jumlah m.o. < 100.000 per ml urine, t.d. satu

Prevention of UTI

Infection in catheterized patients is very common but

can be reduced by good catheter care procedure.
Whenever possible catheterization should be avoid or
kept to a minimum duration
Use intermittent, rather than continous,
catheterization when feasible
Insert catheter with good aseptic technique, use a
closed sterile drainage system
Use topical antiseptic around the meatus in women
Wash hands before and after inserting catheters and
collecting specimens, and after emptying drainage
bags

Pengobatan ISK, perlu

difikirkan :

1. Penyebab ISK : Bakteri Gram (-)

batang usus dan Enterokokus
2. Kegagalan terapi disebabkan oleh :
- Hipertropi prostat
- Disfungsi o.k. batu vesikaurinaria
- Gangguan neurologi
- Cateterisasi

Pengobatan ISK, perlu

:
3.difikirkan
Gangguan Respon
Imun, karena :

a. Persistent m.o. tetap dlm urine dengan atau

tanpa gejala,
diperkirakan : abses perinefrik, infeksi
prostat, corpus alinum
b. Relaps infeksi berulang sesudah terapi
berakhir
c. Reinfeksi umumnya infeksi disebabkan oleh
spesies yg
berbeda
d. Infeksi rekurent berfluktuasi

4. Sisi Infeksi :

Dalam Pengobatan ISK

1.

Antibiotika harus sesuai

dengan uji kepekaan

2.

Stop kateterisasi atau ganti

dgn balon kateter atau
drainase supra pubik

3.

Atasi dulu gangguan struktur

Bacterial Cystitis
Cystitis (inflamation of the bladder) most
common type of UTI
Bacterial Cystitis (BC) common among
otherwise healthy women and is also a frequent
healthcare-associated infection
Sign and Symptom
BC sometime asymptomatic, especially among
children and the elderly
Symptom (if occur) : typically start suddenly and
include a burning pain during urination, urgent
need to urinate, and frequent release of small
amount of urine

Bacterial Cystitis
Sign and Symptom (continued)
The urine is cloudy due to accumulation of WBC and
may be a pale red color to blood.
It also often has a bad smell
The area above the pubic bonr may be painful
because of the underlying inflamed bladder
Sometime a more serious condition occurs
(Pyelonephritis), the symptom include fever, chills,
vomiting, back pain and tenderness overlying the
kidneys
Repeated episode of pyelonephritis lead to scarring
and shrinkage of the kidneys and can cause kidney
failure

Bacterial Cystitis
Causative Agents
Ussually from the normal intestinal microbiota
More than 80% : caused by spesific uropathogenic strain
of Escherichia coli.
The remaining infections (young women) caused by other
Enterobacteriaceae members Gram (-) Klebsiella and
Proteus species, or Gram (+) Staph. saprophyticus).
Hospitalized patient and people with long standing
bladder catheter, often chronically infected with multiple
species of bacteria Gram (-) Serratia marcencens and
Pseudomonas aeruginosa and Gram (+) Enterococcus
faecalis.
Many of these species are resistance to antibiotics and
are difficult to treat.

Bacterial Cystitis
Pathogenesis
Ussually agent reach the bladder by moving up the urethra,
helped by motility of m.o.
Uropathoegenic E.coli (UPEC) strain have fimbriae that attach
specifically to receptor on bladder epithelial cell
Bacterial attachment followed by the death and sloughing of
this superficial layer of cells
Bacteria enter the epithelium by endocytosis and multiply to
create intracellular bacterial communities (IBCs) biofilm-like in
nature
Bacteria later detach from the outer surface of IBC and move into
the bladder lumen to attach to surrounding epithelium new
IBCs
UPEC may eventually establish a dormant intracellular reservoir
that resists antibiotics and is undetected by immune system,
often leading to chronic or recurrent infections

Bacterial Cystitis
Epidemiology

About 30% of women develop cystitis at some time during their life.
Factors that predispose women to UTIs include :
* Short urethra risk for fecal contamination
* Sexual intercourse 1/3 UTI associated with sexintercourse
* Birth control devices diaphragma compress urethra
and slow the flow of urine increasing the risk UTIs
Other factors involved in development of UTIs include :
* Enlargeed prostate age 50 , enlargement prostate gland
compresses uretgra difficult to completely empty the
bladder
* Catheterization - bacteria to reach to bladder UTIs
* Paraplegia paralysis of the lower half of body - cannot urinate
normally require catheter

Bacterial Cystitis
Treatment and Prevention
Cystitis easily to treat with a few days of an antibiotic
effective against to causative bacterium
Pyelonephritis more serious condition, usually
requires hospitalization and intravenous antibiotic
treatment
To prevent UTIs :
* drinking enough to ensure urinating at least four or
five
times daily
* urinating immediately after sexual intercourse
* wiping from front to back after defecation to minimize
fecal contamination of the urethra

M.O. Penyebab ISK

1. Escherichia coli
A. Sifat Umum :
* Penyebab plg umum dari ISK
* terjadi setelah kontak daerah genital dengan
feces
* Sering pd wanita o.k. urethra yg pendek dan
dekatnya area
anus

B. Faktor patogenisitas
1. M.o. segera menempel pd mukosa via villi
shg menimbulkan
kerusakan

M.O. Penyebab ISK

(lanjutan)

1. Escherichia coli (lanjutan)

C. Gejala Klinik
1. Sistitis : sering b.a.k. dan nyeri,
hematuri dan
urgency
2. Piolonefritis (infeksi ginjal) o.k. ISK
yang asenderens.
Khas : demam,
nyeri dan panas pd pinggang, dan
mungkin menyebabkan shock
endotoksin
3. Prostatitis dpt terjadi pada laki-laki
tua

M.O. Penyebab ISK

(lanjutan)

2. Staphylococcus saphrophyticus
A. Sifat Umum :
- Termasuk Staphylococcus, seluruhnya
catalase (+), gram (+),
biasanya tersusun dlm sel tunggal,
diplokokus, rantai pendek
dlm jaringan
- Non hemolitik, coagulase (+), resisten
novobiosin,
kultur
pada agar darah
- Tidak mempunyai protein A
B. Faktor Patogenitas : m.o. menempel pada sel
uroepithelial

M.O. Penyebab ISK

(lanjutan)

3. Proteus mirabilis
A. Sifat Umum :
- Bakteri gram (-), batang pendek, bergerak
- Menghasilkan pertumbuhan swarming yg
khas pada
kultur pada agar darah
- bersifat opportunistik, transmisi mel.
kateter
B. Faktor Patogenisitas :
- menghasilkan protease yg kuat yg dpt
menghidrolisis urea
jadi amonia dan CO2
- Hasil dari batu & calculus menyebabkan
obstruksi sal. kemih
C. Gejala Klinik : ISK terjadi baik pada

M.O. Penyebab ISK

(lanjutan)

4. Enterococcus faecalis
A. Sifat Umum :
- Dulu diklasifikasi sbg Group D
Streptococcus
- Merupakan flora normal pada usus dan oral
pada manusia
dan hewan
- bersifat B-hemolitik, paling sering adalah a
atau Y hemolitik
- Dapat dibedakan mel. reaksi thdp
antiserum, resistensi
bacitracin, tumbuh dlm 40% bile, pH 9.0 /
sol. 6.5 % garam
B. Faktor Patogenisitas : belum diidentifikasi
- M.o. umumnya noninvasif, menyebabkan
infeksi nosokomial

2. Genital System Disease

a. Bacterial Vaginosis (BV)

The genital tract is the portal of entery for many

infectious disease both non-sexuallly and sexually
transmitted.
This section discusses some genital system
disease that are not generally transmitted sexually
BV is the most common vaginal disease of women
in their childbearing years.
Term vaginosis raher than vaginitis, because there
are no inflammatory changes.
BV in pregnant women and puts them at risk for
premature delivery

2. Genital System Disease

a. Bacterial Vaginosis (BV)
Sign and Symptoms

BV is characterized by a thin, grayish-white,

slightly bubbly vaginal discharge that has a
characteristic strong fishlike smell
The bacteria associated with BV may spread
to the uterus or fallopian tubes, causing pelvic
inflammatory disease (PID), which can lead to
sterility.
About half of BV cases are a symptomatic

2. Genital System Disease

a. Bacterial Vaginosis (BV)
Causative Agent

Causes of BV are unknown

Because cases show a significant decrease in vaginal
lactobacilli
Condition that suppress lactobacilli or promote the growth of
other m.o. are though to play a causative role
The discharge that characterizes BV contain large number
of bacteria, including :
* aerotolerant Gardnerella vaginalis
* anaerobic species of Mobiluncus sp. and Provetella sp.
* Mycoplasma sp.
* Aerobic streptococci
these m.o. generally present in women with BV

2. Genital System Disease

a. Bacterial Vaginosis (BV)

Pathogenesis

Women with BV
* characteristik changes in the vagina, including a loss of
acidity of the vaginal secretion (N : pH 3,8-4,2)
* disruption of the normal microbiota
* substantial increase in the number of clue cells (epithelial
cells that have sloughed off the vaginal wall and are
coverred with bacteria)
* There is no inflammation unless another, concurrent
vaginal infection is present
* The strong fishy odor is caused by metabolic product of
the anaerobic bacteria and is used for diagnosis in the
whiff test

2. Genital System Disease

a. Bacterial Vaginosis (BV)

Clue Cells

2. Genital System Disease

a. Bacterial Vaginosis (BV)

Diagnosis
Three of the four criteria should be
positive :
thin homogeneous discharge.
pH of discharge >4.5.
Clue cells in saline wet mount or
Gram stain of vaginal discharge.
Mixture of vaginal discharge and 10%
KOH liberates an "amine-like" or "fishy"
odor.

2. Genital System Disease

a. Bacterial Vaginosis (BV)
Epidemiology

The disease is most common among sexually active women

and sometimes occurs in children who have been sexually
abused
Pregnant women are at increased risk of BV
Women who wear thongs, douche, have multiple sex partner,
have sex with orher women, have a new sex partner, or use
an intrauterine devise (IUD) also have an increased risk
There is no proof that BV is sexually transmitted
However, women with BV are at higher risk of getting other
STIs such as gonorrhea, HIV, or chlamydia.
Virgin seldom get BV

2. Genital System Disease

a. Bacterial Vaginosis (BV)
Treatment and Prevention

Respond quickly to treatment with antibiotics e.g.

metronidazole or clinadamycin orally or vaginally
The disease can recur
Treatment of BV is important in pregnant women
because BV may cause premature birth
BV can prevent by abstinence, limiting the number
of sex partner, and avoiding douching and the use
of thongs.
Treatment of the male sex partner of patient with BV
does not prevent recurrences

2. Genital System Disease

b. Vulvovaginal Candidiasis (VVC)
Vulvovaginal Candidiasis (CCV)
VVC is fungal infection, is the second most common cause of
vaginal symptom after BV
Like BV, it seems to occur after a disruption of the normal
microbiota.
Often involved not only the vagina, but the vulva as well as.
Symptom and Sign
The most common - constant, intense itching and burning of
the vagina or vulva
Typically large amount of thick, clumpy whitish or whitishgray vaginal discharge
Vaginal mucosa usually red &somewhat swollen, and may
have patches of cottage cheese appearing clumps attached to it

2. Genital System Disease

b. Vulvovaginal Candidiasis (VVC)
Causative Agent
VVC is caused by Candida albicans a yeast (eucaryotic) that
is part of the normal microbiota of the vagina in about a third of
all women
Pathogenesis
Normally, vaginal colonization by C. albicans causes no symptoms.
The growth of the m.o. is usually limited by the immun system and
the normal vaginal lactobacilli that occupy the same niche and
compete for nutritients
When the normal microbiota balance is disturbed as occurs during
menstruation or pregnancy, or when using oral contraceptives or
antibiotics C. albicans can multiply freely, causing an inflammatory
respons.
The sign and symptom of VVC occur within about 10 days.

2. Genital System Disease

b. Vulvovaginal Candidiasis (VVC)

Epidemiology
Factor predispose to C.albicans late pregnancy, poorly
controlled diabetes, and use of oral contraceptive or antibotic..
Hormon replacement therapy, may also increase the risk of
VVC
The disease does not spread from person to person
Treatment and Prevention
Intravaginal treatment with antifungal e.g. nystatin,
clotrimazole, or fluconazole is usually efective
Fluconazole taken by mouth is generally safe and effective,
although it may cause side effects e.g. headache, and nausea..
Self diagnosis and treatment with over the counter medication
development drug resistant
Prevention minimizing use and duration antibacterial, and
effective treatment of underlying disease e.g. diabetes.

2. Genital System Disease

c. Staphylococcal Toxic Shock Syndrome
Toxic Shock Sydrome

Late 1970s children with Staphylococcal infection

In 1980 became epidemic in young, healthy, menstruation women
who were using a brand og high-absorbency tampon that has since
been removed from the market
Term Toxic Shock Syndrome describe the sign and symptom of the
illness. Now, it is called Staphylococcus toxic shock syndrome

Sign and Symptom

Is characteristic by the suddent development of high temperatur,

headache, muscle aches, bloodshot eyes, vomiting, diarrhea, a
sunburnlike rash, and confusion
Typically, the skin peels about a week after the development of the
disease.
Without treatment, the blood pressure can drop, leading to
multiorgan failure, coma, and sometimes death

2. Genital System Disease

c. Staphylococcal Toxic Shock Syndrome
Causative Agent

Is caused by strain of Staphylococcus aureus that produce toxic

shock syndrome toxin-1 (TSST-1) or other related exotoxin

Pathogenesis

Tampon-associated toxic shock syndrome begin 2-3 days after the

start of menstruation when tampon are used.
The staphylococci grow in the blood-soaked tampon.
The bacteria rarely spread throughout the body, but as they multiply
they produce TSST-1 or other exotoxin
Staphylococcal toxic shock syndrome results from absorption of
these toxin into the blood stream
Toxin (superantigen) activation of large number of helper Tcell leading a massive release of cytokines drop in blood pressure and
multiorgan failure the most dangerous of the potentially a fatal
illness

2. Genital System Disease

c. Staphylococcal Toxic Shock Syndrome
Epidemiology

Syndrome can occur : after infection of surgical wound,

infection childbirth, and others. Not spread from person to
person

Increase the risk using tampon; higher-absorbency

tampon may pose a greater risk; intravaginal contraceptive
sponges

Treatment and Prevention

Staphylococcus TS Syndrome is a severe disease and

requires hospitalization
Effectively treated with antibacterial, IV fluid, and other
measures to prevent shock and kidney damage
Source of the infection should be removed if possible

2. Genital System Disease

c. Staphylococcal Toxic Shock Syndrome
Treatment and Prevention (continued)

Most people recover fully in 2-3 weeks, the disease can be

fatal within a few hours.
Prevented by appropriate use of tampon, washing hand
before/ after inserting tampon, tampon with the lowest
practical absorbency, changing tampons about every 6
hours, using a pad instead of tampon while sleeping
It is also important to avoid trauma to the vagina when
inserting tampons, to recoqnize the sign and symptom of
Staph. TSS , and remove any tampon immediately if
symptom occur
Women who have had Staph. TSS previously should not
use tampon