Fig. 18.18 Carcinomainsitu(CIS)withenlargedhyperchromaticnucleiandamitoticfigure(arrow).
Treatment of bladder cancer depends on tumor grade and stage and on whether the lesion is flat or papillary. For small, localized papillary tumors that are not high-grade, transurethral resection is both diagnostic and therapeutically sufficient. Patients with tumors that are at high risk for recurrence or progression typically receive topical immunotherapy consisting of intravesical instillation of an attenuated strain of the tuberculosis bacillus called Bacillus Calmette-Guérin (BCG), sometimes followed by intravesical chemotherapy. BCG elicits a granulomatous reaction that also triggers an effective local anti-tumor immune response. Patients are closely monitored for tumor recurrence with periodic cystoscopy and urine cytologic studies. Radical cystectomy is reserved for (1) tumor invading the muscularis propria; (2) CIS or high-grade papillary cancer refractory to BCG; and (3) CIS extending into the prostatic urethra and down the prostatic ducts, where BCG cannot come in contact the neoplastic cells. Advanced bladder cancer is treated using chemotherapy, which can palliate but is seldom curative.
Sexually transmitted diseases (STDs) have complicated human existence for centuries. Globally, approximately 15 million new cases of STD occur every year; of these, 4 million affect 15to 19-year-olds, and 6 million affect 20to 24-year-olds. Women are far more likely to become infected by an STD and to be asymptomatic. Of the 10 leading infectious diseases that require notification of the Centers for Disease Control and Prevention (CDC) in the United States, five—chlamydial infection, gonorrhea, acquired immunodeficiency syndrome (AIDS), syphilis, and hepatitis B—are STDs (
Table 18.3 ). In the United States, the two most common STDs are genital herpes and genital HPV infection, but these do not require CDC notification.
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HerpessimplexvirusPrimaryandrecurrentherpes,neonatalherpes
HumanpapillomavirusCancerofpenis(somecases)Condylomaacuminatum,analcancer,Cervicaldysplasiaandcancer,vulvarcanceroropharyngealcarcinoma
Chlamydia trachomatis Urethritis,epididymitis,LymphogranulomavenereumUrethralsyndrome,cervicitis,bartholinitis,proctitis salpingitis,andsequelae
Trichomonas vaginalis Urethritis,balanitis
Several of these entities, such as human immunodeficiency virus (HIV) infection, HPV infection, hepatitis B, and infection with E. histolytica, are discussed in other chapters.
Syphilis, or lues, is a chronic venereal infection caused by the spirochete Treponema pallidum. First recognized in epidemic form in 16th-century Europe as the Great Pox, syphilis is endemic in all parts of the world. In the United States, 20,000 cases of primary and secondary syphilis were reported to the CDC in 2014, representing almost a threefold increase since the year 2000. The increase for the most part can be attributed to the increased incidence in men who have sex with men. During 2013-2014, the incidence began to increase in women as well, raising the concern that there may be an impending increase in cases of congenital syphilis acquired from the mother. A strong racial disparity is evident; African Americans are affected six times more often than whites. Syphilis also is more common in HIV-infected patients, in whom syphilis is more likely to progress to organ involvement and neurosyphilis.