Mycoplasma Genitalium (Mgen)#

Mycoplasma genitalium, often abbreviated as M. genitalium or Mgen, is a type of bacteria. Like other bacteria that cause infections in different parts of the body, Mgen specifically tends to infect the reproductive tract - the vagina, cervix, or urethra (the tube that carries urine out of the body). Many people with Mgen have no symptoms; others develop urethritis, cervicitis, or pelvic pain.

Most bacteria have a protective layer around them called a cell wall - a kind of shield. What's special about Mgen is that it doesn't have a cell wall. This sounds like a small detail, but it's clinically important: many common antibiotics work by attacking the cell wall, and those antibiotics are completely ineffective against Mgen.

Antibiotics that work by breaking down the bacterial cell wall - penicillin-class antibiotics and cephalosporins - are completely ineffective against Mgen because there is no cell wall to attack.

Treatment requires antibiotics that target different bacterial mechanisms (the medications used for Mgen come from specific classes selected for this organism). Detailed regimen information is discussed during your consultation rather than published here, in line with Health Canada Section C.01.044 restrictions on patient-facing drug information.

Mgen can be silent - many infected people have no symptoms at all. When symptoms do occur:

• In men: urethritis (burning when urinating, urethral discharge).
• In women: cervicitis (abnormal vaginal discharge, spotting, discomfort during sex) or pelvic pain.
• Pelvic inflammatory disease (PID) can occur if Mgen ascends into the upper reproductive tract in women.

Mycoplasma refers to a group of bacteria that lack a cell wall. This absence 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 survival and can inhabit various parts of the human body.

They are different bacteria within the same family.

Mycoplasma hominis:

• Where: found in the genital tract. Many people carry it without symptoms.
• Significance: its presence in the body doesn't always indicate disease. It can be part of the normal flora in some people. In some cases it may contribute to pelvic inflammatory disease or certain joint infections.

Mycoplasma genitalium (Mgen):

• Where: also found in the genital tract, but more specifically associated with genital and urinary infections.
• Significance: recognized as a sexually transmitted infection (STI). Mgen is a known cause of non-gonococcal urethritis in men (inflammation of the urethra not caused by gonorrhea) and is associated with cervicitis and pelvic inflammatory disease in women. Treatment can be challenging because Mgen has developed resistance to several common antibiotics.

Ureaplasma is another group of bacteria that lack a cell wall, making them different from many other bacteria and also 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. In certain situations they can be associated with infections.

Several species exist within the Ureaplasma genus; two are most relevant:

• Ureaplasma urealyticum - associated with various urogenital infections, including non-gonococcal urethritis in men. Also associated with infections in women that can sometimes lead to complications like pelvic inflammatory disease.
• Ureaplasma parvum - also found in the urogenital tract of many people, but less commonly associated with urogenital infections than U. urealyticum.

In most cases, these organisms are found without causing symptoms. Having had multiple sexual partners increases the likelihood that you are colonized with Ureaplasma.

A colonizing organism is one found on the body that isn't causing symptoms. Ureaplasma and Mycoplasma hominis are considered part of the normal genital flora (the normal mix of organisms in the genital area). Studies show that approximately 20-80% of women carry Ureaplasma (the range varies by study) and 5-50% of women carry Mycoplasma hominis in their genital tract. The greater the number of lifetime partners, the more likely you are to be colonized.

In practical terms: if we swabbed 100 women without symptoms, 20-80 might test positive for Ureaplasma and 5-50 might test positive for Mycoplasma hominis - without any of them being sick.

No. Treatment depends on whether you have urogenital symptoms (urethritis, cervicitis). In people without symptoms, treatment is not recommended - these organisms represent colonization rather than disease.

A useful analogy is Group A Strep (the bacteria that causes strep throat). About 1 in 4 school-aged children are colonized with Group A Strep at any time without being sick. Treating based on a positive swab alone would lead to substantial over-treatment with antibiotics. The same principle applies to mycoplasma and ureaplasma: symptoms drive treatment decisions, not colonization status alone.

Beyond common antibiotic side effects (nausea, diarrhea, abdominal pain, allergic reactions), there are more specific concerns:

• C. difficile diarrhea - antibiotics can disrupt the balance of beneficial bacteria in the gut, allowing C. difficile to grow. Symptoms can include severe diarrhea (sometimes bloody), abdominal pain, fever, and dehydration. Severe cases can require hospitalization.
• Resistance - exposing the body's normal flora and any low-level Mgen or other pathogens to antibiotics without a clear indication promotes resistance, which makes future infections harder to treat.

When someone has symptoms of urethritis or cervicitis, the high background colonization rates for Ureaplasma and Mycoplasma hominis mean that these organisms are less likely to be the actual cause of the symptoms - though it remains possible. The most likely causes are chlamydia, gonorrhea, and trichomoniasis; Mgen is also a candidate.

If you have symptoms that fail to respond to first-line treatment for chlamydia and gonorrhea - and those tests are negative on a test of cure - it's reasonable to consider Mgen and (less commonly) Ureaplasma/Mycoplasma hominis as possible causes.

Urethritis is inflammation of the urethra (the tube that carries urine from the bladder out of the body). Symptoms include a burning sensation when urinating, an increased urge to urinate, and sometimes a discharge. Causes vary - bacterial or viral infections are common (gonorrhea, chlamydia, Mgen, trichomoniasis), and non-infectious causes also exist (irritation, friction).

Cervicitis is inflammation of the cervix (the lower, narrow end of the uterus that opens into the vagina). Symptoms can include vaginal discharge, pain during sex, spotting between periods, and a feeling of pelvic pressure or burning during urination.

Cervicitis is most often caused by a sexually transmitted infection (gonorrhea, chlamydia, Mgen, trichomoniasis), but other things - including irritation from products used in the vaginal area - can also cause inflammation. Sometimes the exact cause isn't identified.

PID is an infection of the upper reproductive organs (typically the uterus, fallopian tubes, and ovaries) caused by bacteria ascending from the vagina or cervix. Most cases are caused by untreated STIs, most commonly chlamydia, gonorrhea, or Mgen.

Symptoms can include lower abdominal pain, fever, unusual vaginal discharge with an unpleasant odour, painful intercourse, painful urination, and irregular menstrual bleeding. Some women have mild or no symptoms, which can make PID difficult to diagnose.

If not treated promptly, PID can lead to chronic pelvic pain, ectopic pregnancy (a pregnancy outside the uterus, typically in a fallopian tube), and infertility.

Mgen is transmitted through sexual contact - vaginal, anal, or oral. Condoms reduce transmission risk but do not eliminate it. Asymptomatic transmission can occur from a partner who has Mgen but no visible symptoms.

Mgen NAAT becomes reliable approximately 1-2 weeks after exposure. Testing too early can produce a false-negative result because the bacterial load may not yet be detectable.

• Symptomatic patients can test right away.
• Asymptomatic exposures are best tested 1-2 weeks post-exposure for the most reliable result.

Mgen testing is generally indicated in these situations:

• You work in the adult film industry and require testing before working.
• Your partner tested positive for Mgen.
• You have persistent urethritis (burning urination, discharge) after treatment for chlamydia and gonorrhea, and your post-treatment chlamydia/gonorrhea testing has come back negative.
• You have persistent cervicitis (abnormal discharge, pelvic discomfort) after treatment for chlamydia and gonorrhea, with negative post-treatment testing.

Canadian guidelines recommend testing for Mgen when you have persistent symptoms of urethritis or cervicitis after appropriate first-line treatment for chlamydia and gonorrhea, and a negative post-treatment test of cure for those infections. A test of cure for chlamydia and gonorrhea is typically completed a minimum of 21 days after treatment.

Routine first-line Mgen testing in patients without symptoms is not recommended.

No. Mgen is difficult to culture, and provincial public-health laboratories do not currently offer Mgen NAAT testing as part of routine STI panels. Provincial labs can identify Mycoplasma hominis and Ureaplasma through other methods.

Dedicated Mgen NAAT testing is offered at certain commercial labs as an uninsured (out-of-pocket) test.

Routine testing for Ureaplasma and Mycoplasma hominis is not recommended because of the high background colonization rates (positive results often don't reflect active disease).

Testing may be considered if:

• You have symptoms of urethritis or cervicitis, AND
• You have already been treated for chlamydia and gonorrhea, AND
• You have had a negative test-of-cure for chlamydia and gonorrhea at least 21 days after treatment.

Yes - particularly in men who have sex with men, Mgen can be found at rectal and (less commonly) oral sites.

TeleTest does not currently offer site-specific (rectal or pharyngeal) Mgen testing. The Mgen NAAT we order through LifeLabs is a urine-based test only. If you have persistent rectal or pharyngeal urethritis-type symptoms after treatment for chlamydia and gonorrhea and Mgen at those sites is suspected, see a sexual-health clinic or infectious-disease specialist in person - some specialty centres can arrange site-specific Mgen testing through research or specialty lab pathways.

Nucleic acid amplification testing (NAAT) on a urine sample is the preferred method for detecting Mgen due to its high sensitivity and convenience. Accuracy depends on proper collection, handling, and the lab's testing platform.

In Ontario, LifeLabs currently offers Mgen NAAT as an uninsured test (not covered by your provincial health plan). The cost is approximately $80 (subject to change).

To request the test, choose the Mycoplasma Genitalium panel under the STI category on TeleTest. The intake helps the clinician confirm that testing is appropriate for your situation.

Resistance-guided therapy means choosing the antibiotic based on whether the Mgen strain you have is resistant to specific medications. Instead of giving everyone the same first-line antibiotic and hoping it works, the lab tests the sample for resistance markers, and the clinician picks a regimen the bacteria is likely to respond to. This approach avoids using antibiotics that won't work and reduces the chance of further resistance developing.

Not currently. Resistance testing for Mgen is not yet available in Ontario or most Canadian provinces. The clinician will choose a regimen based on guidelines and your history, rather than on a resistance test.

Health Canada Section C.01.044 restricts what we can publish about specific prescription drugs in patient-facing material. The clinician will discuss the specific antibiotic, dose, and duration during your consultation.

TeleTest clinicians have treated many patients with positive Mgen results, and we follow current Canadian and CDC guidance for first-line and second-line regimens. Mgen treatment uses antibiotic classes selected specifically for this organism - penicillins and cephalosporins do not work (see "Why is Mgen unique?" above). The clinician will choose your regimen based on your symptom pattern, prior antibiotic exposure, allergies, kidney function, and pregnancy status.

No. It is TeleTest's clinical policy to only prescribe Mgen-specific antibiotics when there is a confirmed positive NAAT result for Mgen.

This policy reflects three things:

• Mgen treatment uses antibiotics with a significant side-effect profile. Prescribing without a confirmed diagnosis exposes patients to those side effects unnecessarily.
• Antibiotic resistance is common with Mgen (macrolide-resistance rates approach 50% in some regions). Empiric treatment risks selecting a regimen the bacteria is already resistant to and contributes to further community resistance.
• First-line treatment of urethritis and cervicitis is for chlamydia and gonorrhea. Mgen is only considered when those infections have been treated and ruled out by a negative test of cure.

If you have persistent urethritis or cervicitis symptoms after first-line STI treatment, the clinician will discuss arranging Mgen testing before prescribing - that is the route through TeleTest.

If you would prefer a second opinion, you can be evaluated in person at a sexual-health clinic. Different clinics have different prescribing policies for Mgen, and a sexual-health clinic may take a different approach based on their own protocols.

Yes - test of cure IS recommended for Mgen due to the high rates of antibiotic resistance and treatment failure with this organism. This is a change from earlier guidance and from the approach used for most other STIs.

• Test of cure timing: the repeat NAAT is typically done 3-4 weeks (21-28 days) after completion of treatment to confirm the infection has cleared.
• Testing too soon after treatment can produce a false-positive result from residual bacterial DNA that doesn't reflect active infection.
• If the test of cure is negative, no further Mgen testing is needed.
• If the test of cure is positive, this represents treatment failure - the clinician will review options (see "What if I keep testing positive after treatment?" below).

Persistent positive testing after appropriate treatment usually indicates treatment failure due to antibiotic resistance. This is more common with Mgen than with most other STIs - some studies have found macrolide-resistance rates approaching 50% in many regions.

Next steps:

• The TeleTest clinician will review your treatment history and may recommend a second-line regimen that uses a different antibiotic class.
• If the second-line regimen also fails, referral to a sexual-health clinic or infectious-disease specialist is appropriate. Tertiary centres sometimes have access to additional regimens or more specialized testing.
• In some cases, persistent symptoms may not be from ongoing infection but from post-infectious inflammation that needs different management.

No - TeleTest does not contact partners directly. Partner notification is your responsibility, but it matters: an untreated partner is the most common cause of reinfection after successful treatment.

• Tell partners from the relevant exposure window so they can get tested and treated.
• TeleTest does not offer expedited partner therapy (EPT). Your partner needs to complete their own intake and consultation so the clinician can review their allergies, drug interactions, and pregnancy status before prescribing.
• Mgen is not currently a notifiable infection in most provinces - public health will not automatically follow up with partners.

Mgen in pregnancy has been associated with preterm birth, premature rupture of membranes, and postpartum infections in some studies, though the strength of these associations is still being clarified.

If you test positive for Mgen during pregnancy:

• Discuss treatment with your prenatal-care provider - some Mgen-active antibiotics are not recommended in pregnancy, and the regimen needs to be chosen carefully.
• Coordinate timing and follow-up with your prenatal team.
• TeleTest does not manage pregnancy directly - the prenatal team should lead the treatment decisions, with TeleTest as a possible adjunct for prescription support if appropriate.

Most Mgen care can be managed remotely through a TeleTest consultation, with the lab visit done at LifeLabs. Seek in-person care promptly if any of the following apply:

• Severe pelvic pain or lower-abdominal pain with fever - could indicate PID.
• Vomiting and inability to keep oral antibiotics down - may require IV antibiotics.
• Fever above 38.5°C combined with pelvic pain or urinary symptoms.
• Persistent symptoms despite second-line treatment - referral to a sexual-health clinic or infectious-disease specialist.
• Pregnancy with a new positive Mgen result - coordinate with prenatal-care provider.

No - Mgen NAAT testing through commercial labs (LifeLabs in Ontario) is currently not covered by provincial health plans. The test is paid out-of-pocket; the cost is approximately $80 (subject to change).

This is different from standard chlamydia/gonorrhea/trichomoniasis NAAT testing, which is covered through the provincial public-health lab.

Treatment prescriptions for Mgen are subject to your regular drug-coverage situation - the medications are covered the same way other prescriptions are (private insurance, provincial drug plan if eligible, or out-of-pocket). The TeleTest consultation fee is paid out-of-pocket.

Please select the Mycoplasma Genitalium panel under the STI category for a separate consultation. The clinician will review your symptoms, prior STI test results, and treatment history to confirm that Mgen testing is appropriate before issuing the requisition. We cannot modify an existing requisition once it has been issued.

Mgen is not part of the standard provincial STI panel because the provincial public-health lab doesn't test for it. It requires a separate requisition to a commercial lab (LifeLabs in Ontario) and is paid out-of-pocket. Specific clinical criteria help confirm that testing is the right next step - the dedicated Mgen panel intake collects the information the clinician needs.