Essentials of Pathology Lesson Eight Todd Caldecott LESSON EIGHT: Genitourinary and reproductive disease I. Female reproductive tract Vaginal inflammation Vaginitis refers to a non-specific irritation and inflammation of the vagina with burning and irritation, sometimes with discharge, in which no specific pathogenic agent can be identified. The underlying mechanism is often a deficiency of the bacteria that act upon the vaginal secretions to make the vagina slightly acidic. The intensity of the vaginal secretions typically reach their height during ovulation, but gradually decrease during the luteal phase and during menopause. Thus, the susceptibility to vaginitis increases late in the luteal phase just before menstruation, and also during menopause when vaginal secretions naturally diminish. Other factors however can negatively affect the pH of the vagina, including antibiotics, diabetes, pregnancy, frequent douching, and a diet high in refined carbohydrates. Factors that promote the irritation of the vagina include sensitivities or allergies to sexual lubricants, topical contraceptives and scented hygiene products, as well as frequent or unlubricated sexual intercourse. Hygiene is an important issue, Synthetic fibers, tight clothing around vagina and sitting for long periods on vinyl seats (as in a long car trip) all can facilitate the growth of micro-organisms such as Candida, leading to yeast infections and vaginitis. Poor toilet habits (i.e. wiping back to front after a BM) can also lead to vaginal infection. Sexually transmitted diseases (STDs) All healthy women experience some kind of vaginal discharge, which ranges from simple, clear mucosal secretions, the egg-white cervical secretions that indicate fertility, to menstrual blood. Any change in the quality and quantity of the vaginal secretions may be indicative of pathological changes. Beyond that of abnormal menstruation, which will be covered later, these changes are usually indicative of some kind of inflammatory or infective process. A watery, bloody discharge however suggests malignancy, so care must be taken in the diagnosis. ©2003 by Todd Caldecott and the 1 Wild Rose College of Natural Healing Essentials of Pathology Lesson Eight Todd Caldecott The term commonly used to describe an abnormal discharge is leucorrhea, and could include a number of infectious causes including trichomoniasis, yeast infections, gardnerella, gonorrhea, or chlamydia. Trichomoniasis Trichomoniasis is caused by Trichomonas vaginalis is a protozoa found in roughly 65% of women, and is responsible for up to 30% of all cases of vaginitis. Characteristic symptoms include itching, burning and a thin pale yellow to greenish malodorous discharge. With acute inflammation there may be “strawberry” colored spots in the mucosa. Symptoms often appear after menses. As many women are asymptomatic carriers for this protozoa, the manifestation of symptoms are often related to other causes, such as a secondary vaginal infection, emotional stress, and lowered resistance and immunity. Sexual partners may also be affected and thus treatment should be to both the woman and her partner to avoid a cycle of reinfection. (Berkow 1992, 1786-88) Vaginal candidiasis Vaginal candidiasis, or a yeast infection, is an overgrowth of the fungus Candida albicans, a naturally occurring microbe in the vagina. The infection may be localized in the vagina, but is commonly a reflection of a systemic yeast infection. Both within the vagina and in the gut Candida is kept in check by the Lactobacillus bacteria, and in the vagina specifically by the relatively low pH. The symptoms of a yeast infection can range from mild chronic irritation to a thick white (cottage cheese) discharge with a strong smell, with intense itching, inflammation, and burning upon urination. Candidal infection is more common among women who have diabetes, who use IUDs, who have recently used an antibiotic (e.g. tetracycline for acne), who use corticosteroids regularly, or who are immunodeficient. (Berkow 1992, 1786-88) Gardnerella Gardnerella is caused by the Gardnerella vaginalis is a gram- negative bacterium and a frequent cause of vaginal infection. Although it is classified as a sexually transmitted disease, it is a normal constituent of the vaginal flora, and its manifestation is linked with recurrent vaginal irritation, alterations in vaginal pH, emotional stress, and lowered resistance and immunity. The primary symptom of gardnerella is a thin, greyish discharge with a ‘fishy’ odour. (Berkow 1992, 1786-88) ©2003 by Todd Caldecott and the 2 Wild Rose College of Natural Healing Essentials of Pathology Lesson Eight Todd Caldecott Chlamydia Chlamydia is caused by the bacteria of the genus Chlamydia, a unique bacteria that acts like virus in that it invades a host cell in order to reproduce. Chlamydia trachomatis is found in humans, and lives in the conjunctiva of the eye, and in the urethra and cervix. In poor countries such as Nepal, chlamydia is the primary cause of blindness. Chlamydia is thought to affect up to half of all sexually active women, although as many as 60% of these women are not bothered by symptoms. As a result, chlamydia often goes untreated and can result in a low grade chronic inflammation that negatively affects fertility. When symptoms do manifest they may include a yellowish or greenish discharge from the cervix, bleeding of the cervix from a Pap smear, irregular vaginal bleeding, lower abdominal pain, and pain upon urination. It is difficult to diagnose chlamydia as it is hard to culture it from vaginal swabs and urine samples, and as a result there is probably a high false negative rate in diagnosis. Women who are at risk for chlamydia are under the age of 24, have multiple sexual partners, and are not using barrier methods of contraception (i.e. condoms). The use of oral contraceptives enhances the likelihood chlamydia infection, as do many surgical procedures that artificially dilate the uterus such as a fitting for an intrauterine devices (IUDs), abortion, dilatation and curettage (D&C), and fetal monitoring. (Berkow 1992, 1786-88) Genital herpes While herpes simplex virus (HSV) is not a cause of leucorrhea, it does promote genital ulcers. Any ulceration however should be carefully assessed, to rule out syphilis. Most HSV genital infections are due to HSV type 2, and infection typically occurs during intimate contact with someone shedding the virus. After an incubation period of 5 to 7 days small vesicles appear, releasing the virus over a 4-5 day period until the lesions completely crust over. During the initial infection, the virus ascends via the peripheral nerves into the sacral plexus, where it resides permanently, and thus serves as a reservoir for recurrent infection. The initial infection is usually associated with malaise, regional lymphadenopathy, and fever, which usually resolves in about one week. The herpetic lesions are very tender and heal over a 10-21 day period. Recurrent infections, which tend to be milder and localized, are typically preceded by a prodrome of numbness or tingling at the site. Reactivation of the virus during late term pregnancy can result infection of the infant during birth, which can be fatal. (Berkow 1992, 270; Rubin 2001, 508-9) Genital warts Genital warts are caused by the human papillomavirus (HPV), of which there are several types (1, 2, 6, 11, 16, 18), and is ©2003 by Todd Caldecott and the 3 Wild Rose College of Natural Healing Essentials of Pathology Lesson Eight Todd Caldecott typically transmitted through intimate contact with an infected individual. It is the most common viral STD, with a reported incidence of 6% in women aged 20 to 34 years. Pathologists have identified several different some of which are involved in cervical dysplasia and invasive cervical cancer. Condyloma acuminatum is a benign lesion of the external genitalia and rectum that can result from HPV infection, appearing first as a papule, plaque or nodule, eventually growing as a spiked or cauliflower-like growth. In many cases these patients will have other infections as well, suggesting the virus replicates and grows with lowered immunity. (Berkow 1992, 271; Rubin 2001, 508) Urethritis, cystitis and pyelonephritis The urinary tract is typically sterile and highly resistant to bacterial colonization through the secretion of protective antibodies and by mechanical washing during urination. Women of reproductive age have a much greater incidence of infection, up to 50 times greater than men of the same age, due to the proximity of the urethral opening to the vagina and the relatively short length of the urethra. Gram-negative aerobic bacteria cause most bacterial UTIs, the vast majority occurring when colonizing bacteria ascend from the vagina into the urethra (causing urethritis) to the bladder (causing cystitis), and in some cases, up the ureter to the kidney causing pyelonephritis. Escherichia coli is the most common bacterium isolated, accounting for upwards of 80% of infections, Staphylococcus saprophyticus accounting for about 10%, the remaining organisms typically Klebsiella or Proteus. In most cases the urine will be acidic, having a pH less than 7. In some cases, such as in Klebsiella or Proteus the urine pH will be elevated. (Berkow 1992, 1714) Bacteruria is more frequent among sexually active women, especially with the concurrent use of spermicides that induce changes in the vaginal flora, promoting an overgrowth of E. coli. Although the relationship between frequent bacterial infection and diet isn’t entirely clear, many women who consume a diet rich in carbohydrates are particularly prone to recurrent cystitis, suggesting a complex disruption of the vaginal flora, beginning with the overgrowth of Candida followed by secondary bacterial infection. Pregnant women are frequently affected by cystitis due to a functional and anatomic obstruction of ureters and bladder, which leads to urinary stasis and an increase in the risk of infection. ©2003 by Todd Caldecott and the 4 Wild Rose College of Natural Healing Essentials of Pathology Lesson Eight Todd Caldecott The onset of cystitis is typically sudden, with frequency, urgency, and burning pain upon urination, with small volumes of urine voided.