CC BY
55
UDC 616.62-002:616.65-002-036.22
EPIDEMIOLOGY OF UROGENITAL INFECTIONS IN PATIENTS WITH CHRONIC INFLAMMATORY DISEASES OF THE GENITOURINARY SYSTEM
Altai State Medical University, Barnaul Yu.S. Kondratyeva, A.I. Neimark
There was conducted clinical laboratory examination of 249 female patients with chronic recurrent cystitis and 509 male patients with chronic prostatitis in order to study the epidemiology of urogenital infections aggravating the course of genitourinary system chronic diseases. In the genitourinary tract of the patients were discovered pathogenic and/or potentially pathogenic causative agents in the form of single-agent infection - in 89 (35,7%) female patients by chronic cystitis and in 199 (39,1%) male patients by chronic prostatitis, in the other cases in 160 (64,3%) female patients and 310 (60,8%) male patients there was discovered mixed infection with the leading U. urealyticum.
Key words: urogenital infection, chronic cystitis, chronic prostatitis
Introduction. From year to year, the epidemiological consequences of cystitis caused by some species of chlamydiae and mycoplasms have been increasing [1]. These agents can cause acute and chronic forms of cystitis. Yearly cystitis is diagnosed in 15-20 ths. patients out of 1 mln. Moreover, every 4-5th woman bears the disease in one form or another, and 10% of patients suffer from recurrent cystitis with dysuric disorders of various degree of manifestation [2]. According to O.B. Loran and coauthors (2009), one of the causes is the growing number of sexually transmitted infections (STIs). In Russia and foreign countries, STIs are registered with constant high frequency and represent a serious problem for public health and a threat to reproductive health of population [37]. However, STI agents, as opposed to nonspecific pathogens, cause not an ordinary inflammatory damage to the urogenital tract tissues (UGT), but postinflammatory changes of urothelium, in the setting of which 50-68% of female patients with chronic cystitis show squamous metaplasia of transitional epithelium [8]. By a routine examination of female patients with dysuric events and chronic cystitis in past medical history an STD specialist refers a patient to the urologist or urogynecologist, who do not always pay attention to the diagnosis of urogenital infection (UGI) by examination. After the course of therapy, such patient is in the state of remission for a particular period of time. However, by the disease recurrence, the situation repeats, and the so-called "vicious circle" is formed, in which hidden persistent UGI fosters the chronic process in the urogenital tract [9-11].
Chronic prostatitis (CP) constitutes 35% of all diseases of the urogenital tract in male patients aged from 20 to 50, moreover, the frequency of CP occurrence increases and can reach 73% with aging [12]. Most frequently CP occurs as an urethritis complication, when the microorganisms from the posterior part of urethra reach the prostatic gland (PG) (ascending, canalicular infection) [13]. It is
assumed, that up to 56% of all chronic prostatitis cases have infectious etiology [14,15].
Consequently, the research objective was the study of the frequency of urogenital infections occurrence in female patients with chronic cystitis and male patients with chronic prostatitis.
Materials and methods. There was conducted clinical laboratory examination of 461 female patients with chronic recurrent cystitis (CC) and 737 male patients with chronic prostatitis. In 249 (54%) female patients and 509 (69%) out of them there were discovered urogenital pathogenic and potentially pathogenic infection, the mentioned patients were included into the following research. There were gathered the data of the complaints and past medical history of the examined persons. There was made microscopic and bacteriological urine examination for all patients, sampling and analysis of prostatic fluid, UGI analysis of the material from urethra and cervical canal by means of polymerase chain reaction (PCR) and bacteriological test. For 163 female patients and 167 male patients was made an additional analysis of microbial spectrum in biopsy specimen of the urinary bladder mucous membrane and biopsy specimen of the prostatic tissues.
Results: The average age of 249 examined female patients with chronic cystitis with underlying UGI constituted 40,5±3,7. More than the half of patients - 167 (67%) women were patients in the age from 21 to 30, the women of most active working, sexually active and childbearing age. As it is known, there is a correlation between the degree of woman's sexual activity and the occurrence of inflammatory urogenital diseases, and the frequency of sexual encounters is the risk factor of recurrent urogenital infections. The duration of illness in 83 patients (33,3%) constituted from 10 to 15 years, and in 24 female patients (9,7%) - over 15 years. In the remaining 142 patients (57%) the duration of illness
was less than 5 years in 69 (27,7%) women and less than 5-9 years in 73 (29,3%) women.
By the taking of obstetric-gynecologic medical history of female patients the attention was focused on the age of consent, the number of sexual partners, parity, number of pregnancies, abortions, spontaneous abortions, and also on keeping the rules of personal and sexual hygiene by patients. There were discovered the following risk factors concerning STIs: early consent (from 14 to 18 years) was took place in 57,4% of female patients, frequent change of sexual partners during the lifetime was marked in 39,4% of women. Every third patient had at least one abortion, and 12,9%
- more than 3 abortions. The breach of personal hygiene rules took place in 69,5% of cases. The past medical history showed that most women had various inflammatory diseases of pelvic organs, namely: 94 (37,8%) were treated by gynecologist for chronic adnexitis, colpitis, cervicitis; 31 (12,4%)
- were followed up for myoma of body of uterus, 18 (7,2%) - bore hysterectomy on account of quickly
Spectrum of bacteriological agents i
The data of medical history showed, that 75,1% of male patients had earlier had specialized STI tests, while nearly a half of them hade born one of STIs, and 23,8% had had cases of reinfection.
The clinical urine examination in female patients with CC showed, that the amount of leucocytes more than 10 per field of view was observed in 208 (83.5%) of patients; 163 (65,5%) had erythruria. The analyses of the remaining 41 (16,5%) of female patients did not show any changes in the urine.
The CC female patients showed bacteriuria in clinically significant concentrations in 97 (38,9%) cases and was represented by the following agents: : E. coli - in 16,5%, Enterobacterfaecalis - in 9,6%, in 6,8% - Klebsiellapneumonia, gram-positive flora was observed in 6% of cases. The lack of flora growth or clinically insignificant concentrations of agents are caused by constant intake of urinary antiseptics, uncontrolled intake of antibiotics, which lead to the slowdown in the growth of agent in the culture (Table 1).
According to the results of PCR-based
Table 1
patients with chronic cystitis (n=249)
Agents Number of examined female patients, abs.(%)
E. coli 41 (16,5)
Enterobacterfaecalis 24 (9,6)
Klebsiella pneumonia 17(6,8)
Staphylococcus aureus 15 (6,0)
No growth or agent concentration clinically insignificant 152 (61,1)
Total: 249 (100,0)
growing myoma. The medical history of 78 (31.3%) patients include cervical erosion, of 36 (14,5%) -cysts or polyps of uterine cervix and cervical canal.
Among the male patients the most numerous category was presented by patients in the age from 20 to 28 years (46,8%), in the period of maximum sexual, physical and working activity. The duration of illness in most patients - 232 (45,6%) - constituted from 2 to 4 years, and in 30 (5.9%) - over 4 years. In the remaining 222 patients (43,6%) the illness duration was smaller: up to 1 year - in 94 (18,5%) men and from 1 to 2 years - in 128 (25,1%) men.
The early consent (under 18) took place in 67,8% of patients, the part of persons, who had started sexual life under 16, constituted 27,3%. During recent 6 months nearly a half of men had weekly sexual encounters, 27,1% of patients had daily encounters, and 25,2% - no more than once a month. The existence of a permanent sexual partner was mentioned by 378 (74,3%) men. Moreover, married men had a partner in 89,6% of cases, unmarried - in 53,8% of cases, divorced - 72,3% of cases.
diagnostics obtained by the sampling of material from urethra and cervical canal, the presence of pathogenic and potentially pathogenic agents in the form of single-agent infection was registered in 89 (35,7%) female patients. The most frequently registered urogenital infection was U. urealyticum - in 15,3% of cases (38 women), M. hominis - in 7,2% of cases (18 women) and M. genitalium - in 6,4% of cases (16 women). As the urogenital tract is the most preferred place for the parasitism of these microorganisms, there was obtained a considerably high percent of positive results. Then, according to the frequency of occurrence, followed such pathogens, as C. trachomatis - in 3,6% of cases (9 patients) and T. vaginalis - in 3,2% of cases (8 patients). In the other cases of 160 (64,3%) female patients the mixed infection took place. Simultaneously the associations of urogenital infection agents C. trachomatis + U. urealyticum+ M. hominis n U. urealyticum+ T. vaginalis took place in 42,2% and 22,1% of cases respectively (Table 2). The results of PCR-
based diagnostics were confirmed by the cultural material showed the existence of pathogenic and
method. The cultural examination of the urethra potentially pathogenic microorganisms in all
Table 2
Agent types and diagnostic methods in female patients with chronic cystitis (n=249)
Agents Number of patients (n=249)
abs %±m
PCR results (n=249)
C. trachomatis 9 3,6±0,9
U. urealyticum 38 15,3±2,1
M. hominis 18 7,2±1,8
T. vaginalis 8 3,2±0,8
M. genitalium 16 6,4±1,1
C. trachomatis + U. urealyticum + M. hominis 105 42,2±2,3
U. urealyticum + T. vaginalis 55 22,1±1,9
Results of cultural examination of the material from cervical canal (n=249)
U. urealyticum 56 22,5±2,4
M. hominis 28 11,3±1,2
T. vaginalis 13 5,2±0,4
U. urealyticum + M. hominis 128 51,4±2,9
U. urealyticum + Klebsiella + Staphylococcus aureus 10 5,6±1,8
M. hominis + Escherichia coli + Enterobacter faecalis 14 4,0±1,9
Results of cultural examination of biopsy specimen of the urinary bladder mucous membrane (n=163)
U. urealyticum 25 15,4±2,4
M. hominis 11 6,7±1,7
T. vaginalis 6 3,7±1,5
U. urealyticum + M. hominis 69 42,3±3,3
U. urealyticum + Klebsiella + Staphylococcus aureus 14 23,311,7
M. hominis + Escherichia coli + Enterobacter faecalis 38 8,6±1,12
female patients. In most cases the infectious agents were in association with each other, in 61% of cases the combination of two or more infections was observed most frequently. The predominant agents oecizing the urethra were U. urealyticum and M. hominis. Upon that the mentioned agents in clinically significant concentrations in the form of single-agent infection were registered in 22,5% and 11,3% of cases respectively, in the form of mixed infection - in 57% and 55,4% of cases respectively.
T. vaginalis (5,2%) was much rarer observed in the form of single-agent infection. The bacteriological examination of scraping of female
Agent types and diagnostic methods in
patients with CC on plate and liquid cultures allowed to state the combination of pathogenic and potentially pathogenic microorganisms E. coli, Enterobacterfaecalis, Klebsiellapneumonia and Staphylococcusaureus. Such association were registered in 24 female patients (9,6%), in the remaining cases the microflora was not pathogenic (Table 2).
For 163 women there was carried cultural examination of biopsy specimen of the urinary bladder mucous membrane (Table 2). Out of the total number of examined female patients in 25 (15,4%) there was diagnosed U. urealyticum, in
Table 3
CP male patients with underlying UGI
Agents Number of patients
Abs. %±m
PCR results (n=509)
Ch. trachomatis 29 5,711,3
Ur. urealyticum 74 14,6±1,7
M. hominis 52 10,2±1,5
Tr. vaginalis 21 4,1±0,6
M. genitalium 23 4,5±0,9
Ur. urealyticum+ M. hominis + Ch. trachomatisUr. urealyticum + 201 39,5±2,7
Tr. vaginalis 109 21,4±2,1
Results of cultural examination of the material from urethra (n=509)
Ur. urealyticum 117 22,9±2,4
M. hominis 63 12.4±2,1
Tr. vaginalis 14 2,8±0,2
Ur. urealyticum +M. hominis 211 41,5±1,4
Ur. urealyticum + Tr. vaginalis 104 20,4±0,5
Results of cultural examination of biopsy specimen of the prostatic gland (n=167)
Ur. urealyticum 34 20,4±1,5
M. hominis 17 10,2±1,3
Tr. vaginalis 11 6,6±0,3
Ur. urealyticum+ M. hominis 62 37,1±2,1
Ur. urealyticum + Tr. vaginalis 43 25,7±1,8
11 (6,7%) - M. hominis, in 6 (3,7%) - T. vaginalis. In the biopsy specimen of the urinary bladder mucous membrane the associations of agents were observed in 74,2% of cases.
The microscopic examination of the PG fluid showed, that for most CP patients with underlying UGI the PG fluid is defined by leukocytosis (67,6%) and the decrease of lecithin granules level in 72,5% of cases.
According to the results of biomolecular analysis (PCR-based diagnostics) the occurrence of UGI in the form of single-agent infection was registered in 199 (39,1%) patients. The most frequently registered urogenital infections were Ur. urealyticum and M. hominis in 14,6% and 10,2% of cases respectively. M. genitalium was observed in 23 (4,5%) men, Ch. trachomatis - in 29 (5,7%) men and Tr. vaginalis - in 4,1% of cases (21 men).
In the other cases in 310 (60,9%) men the mixed infection took place. Simultaneously the associations of urogenital infection agents Ur. urealyticum + M. hominis + Ch. trachomatis and Ur. urealyticum+ Tr. vaginalis took place in 39,5% and 21,4% of cases respectively (Table 3).
By the cultural examination of the material from urethra the mixed infection was observed in most cases (61,5%), simultaneously the associations of Ur. urealyticum with M. hominis and Tr. vaginalis were registered in 41,5% and 20,4% of patients respectively. Ur. urealyticum in the form of singleagent infection was observed in 117 (22,9%) patients, M. hominis - in 63 (12,4%) patients, while Tr. vaginalis was registered only in 2,8% of men.
By the cultural examination of PG biopsy specimen the UGI agents in the form of singleagent infection were registered in 62 (37,1%) of patients, in the form of mixed infection - in 62,9% of cases. The most frequently occurred association was the combination of Ur. urealyticum +M. hominis (37,1% of cases), the association of Ur. urealyticum + Tr. vaginalis was registered in 25,7% of cases (Table 3).
Conclusions: Consequently, the results of complex bio-molecular and microbiological examination of the urogenital tract of 249 female patients with chronic recurrent cystitis and 509 male patients with chronic prostatitis associated with UGI showed pathogenic or potentially pathogenic agents in the form of single-agent infection in 89 (35,7%) female patients and 199 (39,1%) male patients, in the remaining cases in 160 (64,3%) women and 310 (60,9%) men was registered mixed infection with leading U. urealyticum.
The present research demonstrates the necessity of a more complete history taking in patients with chronic inflammatory urogenital diseases, of the compulsory exclusion of the urogenital infection, as one of the leading factors of inflammatory
chronization, especially, if the medical history contains confounding factors. The complete approach to the examination and early detection of UGI will allow to prevent complications of the urogenital system of women and men of the reproductive age.
Corresponding author - Kondratyeva Yuliya Sergeyevna, tel. (903)996 33 41,
E-mail: [email protected].
References:
1. Loran O.B., Sinyakova L.A., Kosova I.V. The role of urogenital infections in the etiology of cystitis and nonobstructive pyelonephritis in women (p.2). Urology. 2005; 3: 63-66.
2. Loran O.B., Sinyakova I.V., Kosova L.A. Treatment and prevention of chronic recurrent cystitis in women. Consilium medicum. 2004; 6 (7): 460-465.
3. Khryanin A.A. Urogenital chlamydial infection in women: tactics of case management according to modern foreign and Russian recommendations. Bulletin of dermatology and venerology. 2015; 2: 101110.
4. Canadian Guidelines on Sexually Transmitted Infections (with current updates and errata), January 2014. URL: http: // www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-5-10-eng.php.
5. Centers for Disease Control and Preventions Sexually Transmitted Disease Surveillance, 2015. Atlanta, GA: U.S. Department of Health and Human Services, 2011. URL: www.cdc.gov.
6. Sherrard J.G., Donders D. European (IUSTI/ WHO) Guideline on the Management of Vaginal Discharge, European (IUSTI/WHO) Guideline on the Management of Vaginal Discharge. White. 2011. URL: http://www. iusti.org/regions/europe/pdf/2011/Euro_ Guidelines_Vaginal_Discharge 2011.Intl_ Jrev.pdf.
7. Kubanova A.A., Melekhina L.Ye., Kubanov A.A., Bogdanova Ye.V. Resources and activity of dermatovenerological medical organizations of the Russian federation in 2013. Bulletin of dermatology and venerology. 2014; 3: 16-36.
8. Khmelnitsky O.K. Pathomorphological diagnostics of gynecological diseases. St. Petersburg: SOTS; 1994.
9. Rakovskaya I.V. Human mycoplasmas and mycoplasmal infections. Clinical laboratory diagnostics. 2005; 3: 25-32.
10. Baka S., Kouskouni E., Antonopoulou S. et al. Prevalence of Ureaplasma urealyticum and Mycoplasma hominis in Women with
chronic urinary symptoms. J. Urology. 2009; 28: 62-66.
11. Ekiel A.M. Friedek D.A., Romanik M.K. et al. Occurrence of Ureaplasma parvum and Ureaplasma urealyticum in women with cervical dysplasia in Katowice. Med. Sci. 2009; 24 (6): 1177-1181.
12. Kundelekov A.G., Shorsheva N.Yu., Dmitriyenko S.V., Ionov Ye.N. Lefokcin in treatment of chronic prostatitis. Fundamental research. 2013; 9-4: 674-677. URL: https://fundamental-research.ru/ru/ article/view?id=32493.
13. Mazo Ye.B., Popov S.V. Chronic bacterial prostatitis. Vrachebnoye sosloviye. 2004; 1: 18-28.
14. Frost S.D. Using sexual affiliation networks to describe the sexual structure of a population. Sex. Transm. Infect. 2007; 83(1): 137-142.
Contacts:
656038, Barnaul, Lenina Prospect, 40.
Altai State Medical University.
Tel.: (3852) 554578.
Email: [email protected]
