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Urologic Clinics of North America
1 November 1999, Vol.26(4):701-718, doi:10.1016/S0094-0143(05)70212-3
FUNGAL INFECTIONS OF THE GENITOURINARY SYSTEM: MANIFESTATIONS, DIAGNOSIS, AND TREATMENT
Gilbert J. Wise MDGiridhar S. Talluri MDVenkata K. Marella MD
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Despite the more than 100 species of fungi that have pathogenic potential for humans, only a few species caused the 27,200 nosocomial infections (7.9%) that were reported to the National Nosocomial Infections Surveillance System (NNIS) during the decade
of 1980 to 1990.29 and 59 In 1994 the journal Science published an article entitled "The Emerging Fungal Threat," which commented on an increasing number of fungi that are pathogenic for humans and the few drugs that are effective antifungal agents.101 A
comparison of the NNIS data obtained between 1980 and 1990 indicates that the rate of fungal infections increased from 2.0 to 3.8 per 1000 hospital discharges. During the same period, the nosocomial fungal infection rate for the urinary tract increased
from 9.0 to 20.5 per 10,000 hospital patients (surgical wound fungal infections increased from 1.0 to 3.1 and fungemia from 1.0 to 4.9).9 The increased prevalence of fungal infections is caused by multiple factors, including the changing patterns of
patient demographics (older patients, increased environmental exposure) and the higher incidence of chronic illness, debilitation, and immunocompromised patients.120 European studies indicate that fungi are responsible for 17% of nosocomial infections in
intensive care units patients.112 An analysis of intensive care unit surveillance data in the United States indicated that Candida spp accounted for 10.1% of infections, Pseudomonas aeruginosa, 12.4%, Staphylococcus aureus, 12.3%; and coagulase-negative
staphylococci, 10.2%.44

Fungal pathogens can be placed into three groups, which in the current "era" of immunocompromised patients is an arbitrary classification. The first group or so-called "opportunistic" pathogens consist of fungi that are indigenous to the patient's normal
flora or environment. These fungi include candidal species that can exist as saprophytes of the skin, gastrointestinal tract, and genital region. Other opportunistic fungi include aspergilli and cryptococcus, which can be found in soil, dirt, debris, and
bird excreta. These fungi become pathogenic for patients who are immunocompromised by chronic disease or prolonged antibiotic or chemotherapy. The second group of fungi consists of blastomyces, Coccidoides, and Histoplasma, which are found in the
environment in soil or bird guano.

Exposure to fungal spores may cause a self-limiting pulmonary infection that may disseminate and cause genitourinary disease in susceptible patients. A third group of fungi have been designated as rare and unusual because their occurrence in clinical
practice has been an isolated finding.

In recent years, these rare fungi have been more virulent and more frequently encountered. One species, Mucor, has become more prevalent and may be considered part of the opportunistic group.

This article reviews the diverse group of fungi that can cause infections of the genitourinary system. Emphasis is placed on clinical manifestations of fungal infection and newer concepts of antifungal therapy.


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Address reprint requests to Gilbert J. Wise, MD, Director, Division of Urology, Maimonides Medical Center, 48-02 Tenth Avenue, Brooklyn, NY 11219, e-mail: gjw@mail.idt.net

This work was supported by The Maimonides Research and Development Foundation. Copyright (c) 1999 W. B. Saunders Company. Published by Elsevier Inc. All rights reserved.
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