Tropical Medicine 10: Urogenital Manifestations
Hematuria
Bilharziasis
One species of schistosomiasis, Schistosoma haematobium, causes disease of the
bladder. (Note that schistosomiasis is
discussed in greater detail in TM4 Gastrointestinal And Abdominal Manifestations.
See Vol III—TM4 Gastrointestinal and Abdominal Manifestations). Eggs erode
their way through the
bladder wall and into the urine. The resulting chronic
tissue damage causes
hematuria. In endemic regions, gross hematuria becomes
apparent in early adolescence and is often referred to in local dialects as male
menarche. Hematuria generally abates with chronic infections, recurring only
with coexistent urinary tract or
other infections. There is a clear association
between schistosomiasis and bladder cancer. Diagnosis is identification of the
eggs in the urine, and treatment with praziquantel is quite efficacious.
Tuberculosis
Mycobactria can affect any portion of the reproductive tract, and has an insidious
onset. Involvement of the kidneys causes
hematuria and pyuria, but no bacterial
growth is seen on routine urine culture and there is no response to common
antibiotics.
Diagnosis is via acid--fast stain or specific mycobacterial
culture.
Miscellaneous
All of the
diseases that cause hematuria in temperate zones also apply, including
urolithiasis, glomerulonephritis, trauma, urinary tract infections,
hemaglobinopathies (eg, sickle cell anemia), and malignancies.
Genital lesions
Syphilis
Primary syphilis presents as an ulcer known as a chancre. The chancre is not
painful, only slightly weepy, and is located on the genitals. Secondary
syphilis shows up later (1 to 6 months) with the appearance of papules, which coalesce to
form lesions known as
condylomata lata. These are found on the palms, soles, and trunk. Large
numbers of the organism are found in both lesions, and contact
with them is highly contagious. Diagnosis is
by identification of the organism via dark field microscopy of the
lesion’s exudates; serology is also valuable. Treat
with benzathine penicillin G 2.4 million U IM
once (if infected for <1 year) or
weekly for 3 weeks (if infected for >1 year).
Nonvenereal syphilis (beljel) is discussed in TM5 Dermatological Manifestations. (Vol III—TM5 Dermatological Manifestations)
Chanroid
Chanroid is a venereal
Haemophilus infection that presents with a painful
ulceration and bubo formation. Initial vesicles ulcerate and become
hemorrhagic ulcers with irregular, undermined margins. Resolution is slow, and
relapse is common. Treat with erythromycin 500 mg 3 times daily for 7 days; single dose
regimens with quinolones or other agents have a high failure rate.
Granuloma inguinale
Chronic ulcers due to Calymmatobacterium begin as an indurated
papule, which progresses to the granulomatous ulcer. Subcutaneous granulomas may develop
(pseudobubos), and genital elephantoid enlargement may occur. Healing
without treatment is uncommon. Diagnosis is identification of mononuclear cells
containing the gram-negative
organisms (Donovan bodies). Doxycycline 100 mg
twice daily for 7 days is effective therapy.
Elephantiasis
Chronic, non--pitting edema follows infection with the lymphatic filariae, Wuchereria and
Brugia. This may involve the
genitals (primarily the scrotum) and
extremities (unilaterally or bilaterally, and lower extremities more
commonly than the upper extremities). Originally believed to be mechanical
obstruction by the worms, it is now clear that elephantiasis is due to functional
rather than anatomical effects. Transmitted by several species of mosquitoes, the
larvae mature to adults and reside in the lymphatic
vasculature. The microfilariae shed
circulate in the blood only at night, thus sampling time is a factor
critical in attempting to make the diagnosis by identification of the microfilariae
in blood smears. Acute infections may present with fever, adenitis, and tropical
eosinophilia. Chronic manifestations are unheard of in travelers and
expatriates; only those who spend a lifetime in endemic areas suffer them.
Diagnosis is via blood smear (remembering timing of draw); serology is also available. Treatment is ivermectin or diethylcarbamazine. The latter is not available in the United States, except directly from the CDC.