Journal of Genital System & DisordersISSN: 2325-9728

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Research Article, J Genit Syst Disor Vol: 2 Issue: 3

Urogenital Schistosomiasis Presenting Genital and Urinary Tract Lesions and Abdominal Discomfort in a Sterile Angolan Woman

Jacinta Figueiredo1*, Joachim Richter2, Silvana Belo3 and Maria Amélia Grácio3
1Hospital Américo Boavida, Urology Service, Avenida Hoji Ya Henda, Luanda, Angola
2Tropical Medicine Unit, University Hospital for Gastroenterology, Hepatology and Infectious Diseases, Heinrich-University Düsseldorf University, Germany
3Medical Parasitology Unit/Medical Helminthology & Malacology Group, Instituto de Higiene e MedicinaTropical, Universidade Nova de Lisboa, Portugal
Corresponding author : Maria Amélia Grácio
Medical Parasitology Unit/Medical Helminthology & Malacology Group, Instituto de Higiene e MedicinaTropical, Universidade Nova de Lisboa, Portugal
Tel: +351 213652691
E-mail: [email protected]
Received: October 22, 2013 Accepted: December 15, 2013 Published: December 24, 2013
Citation:Figueiredo J, Richter J, Belo S, Grácio MA (2013) Urogenital Schistosomiasis Presenting Genital and Urinary Tract Lesions and Abdominal Discomfort in a Steril Angolan Woman. J Genit Syst Disor 2:3. doi:10.4172/2325-9728.1000115

Abstract

Urogenital Schistosomiasis Presenting Genital and Urinary Tract Lesions and Abdominal Discomfort in a Sterile Angolan Woman

Background: Schistosomiasis or bilharziasis is a parasitic disease caused by blood fluks of the genus Schistosoma. Schistosoma haematobium has been found in the Middle East, India, Portugal and Africa and it is responsible by urogenital schistosomiasis, pathology with strong economic and health repercussions in the endemic countries. The repercussions of schistosome infection in the health of an Angolan woman are presented and the effects of urogenital schistosomiasis in the human fertility are discussed.

Methods: A woman who came to the hospital for gynaecologic consultation because of primary sterility. She presented micturition problems, abdominal discomfort and back pain. Biopsies of the bladder and uterus epithelium showed Schistosoma haematobium ova. The patient was subdued to parasitological, ultrasonographical and cystoscopical examinations and treatment of the schistosomiasis associated to drug to prevent bacterial super-infection.

Results: Ultrasonography showed hypertrophy and irregularity of the bladder wall. Hystologic analysis showed S. haematobium eggs in the uterus epithelium and bladder. Cystocopy revealed sandy patches and ulceration at the ureteric meatus.

Conclusions: This was the first documented description of female genital schistosomiasis in Angola. Considering that S. haematobium is endemic in Angola, it is expected that a lot of similar cases of urogenital schistosomiasis are occurring in Angola. Then, preventive actions and early treatment of schistosomiasis should be implemented in endemic areas.

Keywords: Schistosomiasis; Urologic Complications; Genital Lesions; Cystocopy; Ultrasonography; Angola; Africa

Keywords

Schistosomiasis; Urologic Complications; Genital Lesions; Cystocopy; Ultrasonography; Angola; Africa

Introduction

Approximately 120 millions people in Africa alone are infected by S. haematobium with associated pathology in the urinary and genital tracts. Concerning urinary tract, fibrosis of the bladder and ureter, and kidney damage are common findings in advanced cases. In sub-Saharan Africa, the urinary tract lesions caused by S. haematobium are associated the urologic complications with an estimated 40 millions people are affected [1].
In the Urology Service of the Americo Boavida Hospital of Luanda – Angola, urinary tract lesions associated to S. haematobium represent 40% of the specific urinary infections [2]. Information on female urogenital schistosomiasis and associated complications in Angola is not available. We present a case of primary sterility and lesions in the urinary and reproductive tracts in a woman infected with S. haematobium.

Material and Methods

A 23-year-old woman living in Malanje (Angola) came to the Américo Boavida Hospital of Luanda (Angola) for gynaecologic consultation because of primary sterility for four years after her marriage. The hormonal profile of this woman was normal for luteinising hormone (LH) and follicle stimulating hormone (FSH), oestrogen, progesterone and prolactin, results of thyroid function tests were also normal, and the husband had children in extramarital relationship. At taking her history, she recalled taking baths in the river and having experienced macrohaematuria. Actually, she was complaining of abdominal discomfort, micturition problems and back pain. The initial suspicion was pelvic inflammatory disease associated to a bilateral dilatation of pyelocaliceal system of unknown etiology. Before the investigations, the patient was informed on the investigations planned and provided written informed content according protocol approved by Americo Boavida Hospital of Luanda and Health Minister from Angola. At vaginal speculum examination the vaginal wall and cervix of the uterus were hyperemic and very vulnerable. Biopsies were taken which at histological examination revealed cervicitis containing ova of S. haematobium (Figures 1-3). The patient was referred for further investigations to the Urology Service of the same Hospital. Parasitological, ultrasonographical and cystoscopical examinations were carried out. For detection of the S. haematobium eggs urine samples were collected, filtered through Nucleopore® polycarbonate microfilters, and the filters were examined with light microscopy. For ultrasonograhic examinations an Aloka, SSD-500 portable ultrasound device provided with a 3.5 MHz convex probe was used. During cystoscopy bladder biopsies were taken and stained with hematoxylin-eosin. The patient was treated with praziquantel at a single standard dose of 40 mg/kg body weight associated to ciprofloxacine (500 mg) to prevent bacterial super-infection and maxilase 3000 UI (owing to its anti-inflammatory action), with repetition after 15 days.
Figure 1: Endometrium with Schistosoma eggs colored with haematoxylin eosin stain (Objective 10x).
Figure 2: Endometrium with Schistosoma eggs colored with haematoxylin eosin stain (Objective 20x).
Figure 3: Endometrium with non-specific chronic exocervicitis colored with haematoxylin eosin stain (Objective 40x).

Results

The examination of the urine for S. haematobium eggs was negative. Ultrasonography showed bilateral upper urinary tract obstruction (Figures 4 and 5) and hypertrophy and irregularity of the bladder wall. Cystoscopy revealed friable granulata and an of ulcer of 1 cm of the right ureteric meatus (Figures 6 and 7). Biopsy of the bladder wall revealed calcified S. haematobium ova (Figure 8).
Figure 4: Ultrasonography of the hypertrophic urinary bladder wall, bladder masses and polyps (the circular intravesical structure is the ultrasound aspect of the balloon of the bladder catheter).
Figure 5: Ultrasonography of the kidneys. Bilateral Hydronephrosis.
Figure 6: Cystoscopy: sandy patches and ulceration at the right ureter meatus.
Figure 7: Cystoscopy: sandy patches scattered on the posterior bladder wall.
Figure 8: Biopsy of the bladder (objective 40x): chronic cystitis with Schistosomahaematobium ova.

Discussion

Schistosomiasis is a helminthic infection which is endemic in large parts of the tropical world with 700 million people at risk of infection and 207 million infected by all species of schistosomiasis, being 85% of this on the African continent [3]. S. haematobium infection is known to be endemic in Angola [4-6]. In this infection, the female parasite lays ova into the venules of the bladder wall. Most of them are liberated through the bladder wall into the lumen and they are excreted in the urine. However, some eggs are retained in the epithelium or in bladder tissues, principally in the subepithelial layer, cause the formation of pseudotubercules containing eggs in various stages of encapsulation, eroded areas of bladder lining (“sandy patches”), fibrosis of the bladder wall, with eventual distortion of the bladder, and calcification. The obstruction of the opening of the ureters into the bladder causes hydroureter and eventually hydronephrosis. Whereas the abnormalities of the urinary bladder and the distal ureter are characteristic, upper urinary tract obstruction is nonspecific and may be observed in other conditions [7-11]. The disease was known in Egypt since antiquity [12]. Diagnosis and its clinical consequences have again become a research focus in the nineties of the last century [13-19] and are being investigated further until today [14]. The infection of the lower female reproductive tract including ulcerations and sandy patches may make women susceptible to super-infection and sexually transmitted diseases, may cause contact bleeding, discharge and spontaneous bleedings and affect the sexual wellbeing. When lesions of the vulva occur, schistosomiasis may be
misinterpreted as a sexually transmitted disease, which may result in serious social consequences [20]. Whereas schistosomiasis is a wellknown risk factor for squameous bladder cancer, it is still not known whether or not schistosomiasis also constitutes a risk factor of cervical cancer [21,22]. It has been speculated that female genital mutilation was practiced to treat symptoms of female genital schistosomiasis [12]. Schistosomiasis may contribute to the development of vesicovaginal fistula [23]. The consequences of the infection of the upper female reproductive tract include primary and secondary sterility and ectopic pregnancy due to the occlusion of the fallopian tubes [24]. The impact of schistosomaisis on pregnancy is not known [25]. In a field context, urinary schistosomiasis may be investigated by use of questionnaires on haematuria, urine dipsticks, parasitological urine examination with microfiltration and ultrasonography. Male genital schistosomiasis may be investigated by parasitological examinations of the ejaculate [26]. Unfortunately, lesions of the lower female reproductive tract and abnormalities of the upper reproductive tract as seen by ultrasonography are, besides the inconstant finding of sandy patches, non-specific [22,27]. Furthermore, 20% of genital schistosomiasis cases are not recognized by urine microscopy, at least if 10 ml of urine are filtered, as it also occurred in the present case [28].
Reversibility of abnormalities after praziquantel therapy may be used as an indirect marker of genital schistosomiasis in an epidemiological context [29,30].
Rarely uterine squamous cell carcinoma develops over longstanding stricture associated with repeated bilharziasis infestation and microbial infection [31]. Since untreated or repeated urinary schistosomiasis has a major effect on the integrity of urinary tract and that the most serious effects are the predisposition to squamous cell of the bladder and development of obstructive myopathy that may lead to renal failure, then prevention and early treatment of schistosomiasis should be an important health care target in endemic areas [32].

Acknowledgment

The authors thank Dr. Mateus Guilherme of the Anatomopathology Service, Américo Boavida Hospital – Luanda, Angola for the biopsy samples preparation. This study was funded by the Portuguese Fundação para a Ciência e Tecnologia (FCT).

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