Mycoplasma Genitalium
A discussion about Mycoplasma Genitalium, Mycoplasma Hominus and Ureaplasma
Mycoplasma genitalium is emerging as a relatively new cause of urethritis and cervicitis. Few clinicians are aware of its role in causing pelvic inflammatory disease. Current assays performed by Public Health Ontario utilize a culture method of detection, which is insufficient to detect the presence of Mycoplasma genitalium as it is difficult to culture. This page was written for individuals strugging with understanding the differences between mycoplasma genitalium, ureaplasma and mycoplasma hominum (large colony mycoplasma).
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Definitions
What is urethritis?
Urethritis is an inflammation of the urethra. The urethra is the tube that carries urine from the bladder out of the body. When it becomes inflamed, it can cause discomfort and a few other symptoms.
People with urethritis might experience a burning sensation when urinating, an increased urge to urinate, and sometimes a discharge. The causes of urethritis can vary. Often, it's the result of a bacterial or viral infection. Some common causes include the bacteria responsible for gonorrhea and chlamydia, but there are also non-infectious causes.
What is cervicitis?
Cervicitis is an inflammation of the cervix, which is the lower, narrow end of the uterus that opens into the vagina. When the cervix becomes inflamed, it can lead to various symptoms.
People with cervicitis might experience vaginal discharge, pain during intercourse, spotting or bleeding between menstrual cycles, or a feeling of pressure in the pelvis. Sometimes, there might be a burning sensation during urination or an increased urge to urinate.
Cervicitis can be caused by a number of factors. Often, it's the result of an infection. Some sexually transmitted infections, like gonorrhea and chlamydia, can lead to cervicitis. But other things, like allergies to products used in the vaginal area, can also cause inflammation. In many cases, the exact cause of cervicitis might not be identified.
What is Pelvic Inflammatory Disease (PID)?
PID stands for Pelvic Inflammatory Disease. It's an infection of a woman's reproductive organs, typically involving the uterus, fallopian tubes, and ovaries. PID is usually the result of an untreated sexually transmitted infection (STI), most commonly chlamydia or gonorrhea, spreading from the vagina to the upper reproductive organs.
Symptoms of PID can vary, but they often include pain in the lower abdomen, fever, unusual vaginal discharge with an unpleasant odor, painful intercourse, painful urination, and irregular menstrual bleeding. However, some women might have mild symptoms or even none at all, which can make PID tricky to diagnose.
If not treated promptly, PID can lead to serious complications, including chronic pelvic pain, ectopic pregnancy (a pregnancy that occurs outside the uterus, typically in a fallopian tube), and infertility (difficulty getting pregnant).
Understanding Mycoplasma Genitalium ('MGEN')
What is Mycoplasma genitalium (M. genitalium)?
Mycoplasma genitalium, often abbreviated as M. genitalium, is a type of bacteria. Just like other bacteria can cause infections in different parts of your body, M. genitalium specifically tends to infect the reproductive parts, like the vagina or the urethra (the tube that helps us pee). While many people who have this infection might not show any clear symptoms, others can experience discomfort or other signs of an infection.
Why is M. genitalium unique?
Most bacteria have a protective layer around them called a cell wall. Think of it as a sort of armor or shield that the bacteria use to defend themselves. What's special about M. genitalium is that it doesn't have this cell wall. Instead, it has a different kind of outer layer. This might sound like a minor detail, but it's actually really important when it comes to treating infections caused by this bacteria, because a lot of common antibiotics target that cell wall. Since M. genitalium doesn't have one, these antibiotics don't work against it.
Are there common antibiotics that are ineffective against M. genitalium? Why?
Yes, there are. Antibiotics like penicillins, which include familiar names like amoxicillin, are designed to target and break down the cell wall of bacteria. But as mentioned earlier, M. genitalium is unique because it doesn't have a cell wall. So, when you try to treat it with these antibiotics, they don't really have the effect you'd want them to. They can't break down the protective shield of the bacteria because, well, that particular shield doesn't exist. It's like using a key on a door that has no lock - it just doesn't work.
What symptoms might suggest I have an M. genitalium infection?
M. genitalium can be a bit sneaky because sometimes, people who have it might not feel any different. But in other cases, it can cause symptoms. For men, it might cause urethritis, which is an inflammation of the urethra. This can lead to symptoms like a burning feeling when urinating or a discharge from the penis. For women, it can lead to inflammation in the cervix, which might cause symptoms like abnormal vaginal discharge or discomfort during intimate activities.
Large Colony Mycoplasma, Mycoplasma Genitalium and Ureaplasma
What is mycoplasma?
Mycoplasma refers to a group of bacteria that lack a cell wall around their cell membrane. This absence of a cell wall is significant because it makes them resistant to many common antibiotics that target cell wall synthesis. Without a rigid cell wall, these bacteria can change shape and are often described as having a "fried egg" appearance under a microscope. They are among the smallest bacteria capable of independent replication and survival, and they can inhabit various parts of the human body.
What the difference between 'Mycoplasma Hominus' and 'Mycoplasma Genitalium'?
They're both related organsism within the same 'genus'. Think about 'Homo Sapiens' (Humans today) and 'Homo neanderthalensis' (Neanderthal). They're different species within the same family. Mycoplasma is also referred to as 'Large Colony Mycoplasma'.
Mycoplasma hominis:
Location and Infection: This bacterium is often found in the genital tract. While many individuals carry it without symptoms, it can cause infections in some cases. For instance, it might lead to pelvic inflammatory disease (PID) in women or certain types of joint infections.
Significance: It's important to note that its presence in the body doesn't always indicate disease. The relationship between its presence and specific diseases is complex and not fully understood. It can be part of the normal flora in some people.
Mycoplasma genitalium:
Location and Infection: Like M. hominis, M. genitalium is found in the genital tract but is more specifically associated with genital and urinary infections. It has been identified as a cause of non-gonococcal urethritis in men (an inflammation of the urethra not caused by gonorrhea) and has associations with cervicitis and pelvic inflammatory disease in women.
Significance: The recognition of M. genitalium as a sexually transmitted infection (STI) is relatively recent, and its overall significance in genital infections is still a topic of research. It's worth noting that treatment can be tricky, as it has shown resistance to some common antibiotics.
What is ureaplasma?
Ureaplasma are also distinct because they lack a cell wall, which makes them different from many other types of bacteria and also renders them resistant to certain antibiotics that target bacterial cell walls. Ureaplasma species are primarily found in the urogenital tract of humans and can be part of the normal microbial flora. However, in certain situations, they can be associated with infections.
What are the types of ureaplasma?
There are several species within the Ureaplasma genus, but the two primary species that are important to note are:
Ureaplasma urealyticum: This species has been associated with various urogenital infections. It's been linked to non-gonococcal urethritis in men, which is an inflammation of the urethra. It's also been associated with infections in women, which can lead to complications like pelvic inflammatory disease (PID) in some cases.
Ureaplasma parvum: Like U. urealyticum, U. parvum is also found in the urogenital tract of many individuals. Its isn't commonly associated with urogenital infections like ureaplasma urealyticum.
In most instances, these organisms are found and not assocated with infection. Having had multiple sexual partners increases the likelihood that are you are colonized with ureaplasma.
What does the term 'colonization' mean in the context of genital infections?
A colonizing organism is one we find on the body that isn't causing symptoms. Ureaplasma and Large Colony Mycoplasma (Mycoplasma Hominus) are considered a normal part of genital flora (the normal mix of organisms we find in the genital area). Between 20- 80% of women have Ureaplasma (depending on the study referenced) and 5-50% of women have Mycoplasma in their genital tract. The greater the number of lifetime partners you have, the more likely you are to be colonized with mycoplasma hominus and ureaplasma.
This means if we took a 100 men and women who had no symptoms, and swabbed their genital tracts, approximately 20-80 might test positive for ureaplasma and another 5-50 might test positive for mycoplasma hominus.
Does everyone who tests positive for Mycoplasma Homonis or Ureaplasma need treatment?
Treatment is dependent on if you have urogenital symptoms (i.e. symptoms of cervicitis or urethritis). In individuals who do not have symptoms, treatment is not recommended as these are thought to represent a colonizing organism.
An example of where colonization in combination with symptoms affects whether doctors prescribe treatment is the case of Group A Strep (i.e. the bacteria that causes Strep Throat). According to the CDC, 1 in 4 school-aged children are 'colonized with Group A Strep'. This means if we swabbed every child in school, 25% would have a swab indicating a strep infection. Treating based on a positive test result would lead to over-treatment (i.e. treat more people than have an infection) with antibiotics. Most of these school-aged children are only 'colonized' and do not require antibiotics. Therefore, symptoms are important in the context of deciding treatment when we are dealing with colonizing organisms. Both mycoplasma and ureaplasma are colonizing organisms.
Are there harms from being prescribed antibiotics?
Beyond the general side effects from antibiotics, including nausea, vomiting, diarrhea, abdominal pain and allergic reactions, there are other potential side effects from specific antibiotics.
For example
Azithromycin can affect the electrical rhythm of the heart leading to an irregular heart rhythm in suspceptible individuals called a 'prolonged QT' which can can be dangerous, and in some cases fatal. One large study found that for every 1 million people given a 5-day course of Azithromycin, 50 people would die due to cardiac effects attributable to the antibiotic.
Moxifloxacin is part of a family of antibiotics called floroquinolones, that these can cause tendon rupture, and potentially permanent damage to your nervous system. Some studies estimate your risk of tendon rupture following use of moxifloxacin at 0.14-0.4%. For every 1000 people treated with moxifloxacin, between 1 and 4 patients will rupture their tendon.
Clostridium Difficile Diarrhea
C. difficile infections often occur in people who have recently taken antibiotics including those used to treat mycoplasma and ureaplasma. While antibiotics are designed to kill harmful bacteria, they can also disrupt the balance of beneficial bacteria in the gut. When this happens, it can provide an opportunity for C. difficile bacteria in your gut, which might have been previously kept in check, to grow and multiply. In addition to diarrhea, which might be bloody, symptoms of C. difficile colitis can include abdominal pain, fever, loss of appetite, and nausea. Severe cases can lead to dehydration, kidney failure, and in some cases can require the removal of your large intestine if the infection cannot be controlled.
Why is colonization important when discussing symptoms?
When someone has symptoms of urethritis and cervicitis, due to the high colonization rates, these specific organisms are less likely to be the ultimate cause for your symptoms, though it remains a possibility that they are the cause.
In the presence of symptoms that fail to respond to 1st line treatments for gonorrhea and chlamydia (even with negative test results), it's reasonable to consider treating these organisms as a potential cause of your symptoms.
Testing Recommendations
When should I get tested?
You work in the adult film industry and require a test before being active
You had a partner test positive for Mycoplasma Genitalium
If you are a biological male, you have symptoms of urethritis (burning when urinating, discharge, etc)
AND have tested negative for gonorrhea, chlamydia, trichomonas
AND you have been treated with Ceftriaxone (injection) and Azithromycin (pills)
AND you have had a test after treatment for gonorrhea, chlamydia which was normal
If you are a biological female, you have symptoms of urethritis (burning when urinating, discharge, etc)
AND have tested negative for gonorrhea, chlamydia, trichomonas
AND you have been treated with Ceftriaxone (injection) and Azithromycin (pills)
AND you have had a test after treatment for gonorrhea, chlamydia which was normal
When should I not get tested?
You have no symptoms or known exposures to Mycoplasma Genitalium, Ureaplasma or Mycoplasma Hominus
You have symptoms of abdominal and pelvic pain following a new sexual contact. Abdominal and pelvic pain may indicate a diagnosis of PID (Pelvic Inflammatory Disease) that warrants immediate antibiotic treatment
PID treatment consists of
Ceftriaxone 0.5g (Intramuscular injection)
AND Metronidazole 500mg (Twice daily for 14 days)
AND Doxycycline 100mg (Twice daily for 14 days)
What do Canadian Guidelines recommend?
Canadian guidelines recommend individuals who have symptoms of urethritis (burning when urinating) and cervicitis (discharge) test if they have already been treated for chlamydia and gonorrhea and go on to have a negative 'Test of Cure' result. A test of cure is a test completed a minimum of 21 days after treatment.
Does Public Health Ontario test for Mycoplasma Genitalium?
Lab testing completed by Public Health Ontario does NOT identify Mycoplasma Genitalium. Mycoplasma genitalium is hard to culture in a lab environment, so Public Health Ontario testing only identifies Mycoplasma Hominus and Ureaplasma.
Should I complete mycoplasma and ureaplasma testing?
We do not recommend routine testing for mycoplasma and ureaplasma, unless:
You have symptoms of urethritis or cervicitis
AND have already been treated for chlamydia and gonorrhea
AND have had a negative 'Test of Cure' result after treatment (a test of cure is a test completed a minimum of 21 days after treatment).
How can I get tested for Mycoplasma Genitalium?
Life Labs currently offers Mycoplasma Genitalium testing within the province of Ontario. This test is not covered, even if you have OHIP insurance. The test costs $80 as of 2023.
Treatment Medications
What is resistance-guided therapy and why is it preferred?
Resistance-guided therapy is a treatment approach that's tailored based on the specific type of M. genitalium you have. Instead of giving everyone the same medicine, doctors first test to see if the M. genitalium bacteria in your body resist certain antibiotics. This approach avoids using antibiotics that won't work and reduces the chance of the bacteria developing further resistance.
Does Ontario offer resistance testing for Mycoplasma Genitalium?
We do not have access to resistance testing of mycoplasma genitalium within Ontario.
Mycoplasma Genitalium
What antibiotics are to be used to treat Mycoplasma Genitalium infections?
The CDC has issued treatment recommendations for Mycoplasma Genitalium.
If antibiotic sensitivity is known based on testing, we use the recommendations suggested below. If sensitivities are not known based on lab testing, then we use a macrolide-resistant regimen as there is a higher rate of treatment failure with the 'macrolide-sensitive' regimen.
Macrolide sensitive
Doxycycline 100 mg orally 2 times/day for 7 days
Followed by azithromycin 1 g orally initial dose, followed by 500 mg orally once daily for 3 additional days (2.5 g total)
Macrolide resistant (preferred if no sensitivity information)
Doxycycline 100 mg orally 2 times/day for 7 days
Followed by moxifloxacin 400 mg orally once daily for 7 days
Does TeleTest provide treatment without test results?
Due to the significant side effect profile of the antibiotics used for Mycoplasma genitalium, TeleTest physicians will only offer treatment if you have positive test results.
Does TeleTest provide treatment with negative test results?
Due to the significant side effect profile of the antibiotics used, TeleTest physicians do not offer treatment if you have normal (i.e. negative) test results.
I tested positive. Should I repeat testing to ensure the infection is gone?
No, according to the CDC for individuals who do not have symptoms, a test of cure should not be completed following treatment.
I failed treatment for Mycoplasma Geniltaium. What should I do?
If you have failed the macrolide-resistant regimen for Mycoplasma Genitalium, you should seek out a referral to a local infectious disease specialist through a local walk-in clinic.
References
[2] https://www.cdc.gov/std/treatment-guidelines/mycoplasmagenitalium.htm
General Questions
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