Introduction
As medical science is growing daily with newer treatment regimes, the survival rate after HIV infection has increased in the coming years. This article will focus on urological complications associated with HIV infection.
What Do We Know About HIV and AIDS?
AIDS (acquired human immunodeficiency syndrome) was described in 1981 and caused by HIV (human immunodeficiency virus), which was described in 1986. It is a lentivirus that causes failure in the immune system leading to life-threatening opportunistic infections. Life expectancy after the infection is around nine to eleven years. HIV particles are transmitted through saliva, breast milk, blood, plasma tears, and urine. It is also transmitted through pre-ejaculate fluid, seminal fluid, and vaginal secretions. The replication of the virus in the blood depends on its concentration, and replication is faster when the concentration is higher and slower when the concentration is low. Most cases of HIV infections are reported through sexual contact (around 75 % to 85 %). There is data about male circumcision that suggests that an uncircumcised male is at 1.5 to 8.4 times more risk than a circumscribed male.
What Are the Complications Caused by Infections?
Urinary Tract Infections:
It is one of the most common infections an individual suffers after contracting HIV. The symptoms involve increased frequency and urgency of urinating, dysuria, and hematuria. Escherichia coli and Pseudomembranous aeruginosa are the main causative agents, and Pseudomembranous aeruginosa accounts for up to 33 % of urinary tract infections in HIV patients. HIV patients with CD4 counts less than 200 are prone to bacterial infections as well as neurological symptoms such as bladder areflexia and hyporeflexia, which causes complications of urinary stasis and infection. Individuals with low CD4 counts also suffer from non-bacterial urinary tract infections such as yeast, viral and fungal. In addition, asymptomatic HIV patients show hematuria after urine analysis.
Prostatitis:
The obstructed or dysfunctional urinary system leads to urinary stasis, causing prostatitis. In an HIV-infected person, the defense mechanism of the prostate glands, such as spermine, spermidine, and prostatic antibacterial factor, fails to resist bacterial infection, leading to bacterial invasion. Escherichia coli is one of the causative agents in 3 % of HIV-infected individuals and 14 % of individuals with AIDS. Other bacterial organisms which may be involved are Klebsiella pneumonia, Staphylococcus aureus, P. aeruginosa, Serratia marcescens, and Salmonella typhi. Mycobacterium tuberculosis and Mycobacterium avium intracellulare are also responsible for causing prostatitis, although they primarily affect the lungs. Fungal organisms such as Cryptococcus neoformans and Histoplasma capsulatum can cause prostatitis. The poor penetration of antimicrobials into the prostate tissue causes relapse and persistent subclinical foci of prostatitis.
Prostatic Abscess:
In the general population, a prostatic abscess is found in individuals with urinary obstruction, diabetes mellitus, and a history of bladder catheterizations. The prostatic abscess in HIV-positive individuals is an emerging problem. The symptoms include fever, dysuria, urinary retention, and perineal pain. Enlarged prostate, prostatic tenderness, and fluctuant mass are the clinical signs. Enterobacteriaceae and gram-negative bacteria are the main causative agents. Secondary manifestations involve fungal abscesses of H. capsulatum and Aspergillus.
Voiding Dysfunction in HIV and AIDS Patients:
AIDS patients suffer from neurological bladder function in the later stages of HIV infection. Bladder hyperreflexia is caused by upper motor neuron injury, which is caused by encephalopathy or AIDS dementia which leads to urgency and urinary incontinence. Anticholinergic drugs treat hyperreflexia. Malignancy or infection causes areflexia resulting from lower motor neuron injury. Areflexia causes urinary tract infection, stasis, and urinary retention. It is treated by foley catheterization or suprapubic cystostomy and clean intermittent catheterization.
Testicular Atrophy:
AIDS patients having testicular atrophy have a chronic illness, cachexia, prolonged fever, and malnutrition. In addition, vascular changes such as intravascular thrombosis and smaller vessel lumen size lead to atrophy and ischemia. HIV has a cytotoxic effect on Sertoli cells and germinal tissue. Cytomegalovirus is the common causative agent along with Toxoplasma and Mycobacterium.
Erectile Dysfunction:
Psychogenic and neurogenic factors cause erectile dysfunction. Individuals suffering from fatigue and depression have decreased libido. The difficulties in maintaining erections and achieving ejaculation were seen in individuals in the studies conducted by Tindall. Low testosterone levels and hypogonadism may cause erectile dysfunction and decreased libido.
What Are the Neoplasms Seen in HIV and AIDS Patients?
Kaposi’s Sarcoma:
It is one of the most common malignancies associated with AIDS. Studies have suggested that 20 % of the individual's affected show genital lesions. The causative agents include cytomegalovirus and herpes virus. Clinical features include purple papular, plaque-like, or ulcerated lesions found on the scrotum or penis. Symptoms include pain and edema and irritating and obstructive voiding symptoms. In addition, urinary retention is seen, and Kaposi's sarcoma may turn into gangrene. Treatment involves the excision of smaller lesions by radiation therapy or laser, whereas larger lesions are treated only by radiation therapy. Chemotherapy is used in cases of dissemination, and the drugs used are Bleomycin, Vincristine, and Doxorubicin.
Testicular Malignancy:
It is the third most common AIDS-associated malignancy after Kaposi's sarcoma and Non-Hodgkin's lymphoma. The incidence rate is higher in black and Hispanic patients. The non-seminomatous type of testicular malignancy is common in HIV patients, and the seminomatous type is seen in the general population. The seminomatous type is treated by radiation therapy, and the non-seminomatous type is treated by chemotherapy. Studies have shown that there may be tumor relapse in immunocompromised individuals.
Lymphoma :
Seen in individuals above 50 years and accounts for 5 % of testicular malignancies. Common symptoms involve bilateral testicular masses and testicular enlargement. It is widely metastatic and shows histopathological features such as diffuse histiocytic lymphoma. Lymphomas are treated with chemotherapy and radiation therapy.
Nephropathy in HIV and AIDS Patients:
Nephropathy in HIV patients was first reported in 1984. Mild to moderate proteinuria and fluid and electrolyte changes, including hyponatremia and hypokalemia. Renal failure and tubular necrosis can be avoided if electrolyte imbalance is maintained. There is a higher incidence seen in black males and intravenous drug abusers. Treatment involves using drugs such as Zidovudine, a Thymidine analog that helps decrease HIV replication.
Conclusion:
The genitourinary system is affected both primarily and secondarily by HIV and AIDS. It involves infectious complications, malignancy, and systemic malignancies. Several treatment modalities involve radiotherapy, chemotherapy, and surgery to reduce mortality and morbidity.
