Mycoplasma genitalium is associated with symptomatic urethritis

Updates on Sexually Transmitted Urethro-cystitis

Purpose of Review

We performed recent literature review with the aim to address the updates in diagnosis and management of sexually transmitted urethro-cystitis.

Recent Findings

There are multiple, recently published studies that collectively lead to an organized stepwise plan for diagnosis and management of sexually transmitted urethro-cystitis.

Summary

Sexually transmitted urethro-cystitis is a common health condition that can be managed efficiently if the appropriate steps are taken in diagnosis and management.

UAA-AAUS guideline for M. genitalium and non-chlamydial non-gonococcal urethritis

Non-chlamydial non-gonococcal urethritis (NCNGU) is defined as urethritis with neither Neisseria gonorrhoeae nor Chlamydia trachomatis. Possible causative agents of NCNGU include Mycoplasma genitalium, Ureaplasma urealyticum, Ureaplasma parvum, Mycoplasma hominis, Trichomonas vaginalis, and so on. Among these microorganisms, the pathogenicity of M. genitalium and T. vaginalis to the male urethra has been confirmed so far. The Asian Association of Urinary Tract Infection and Sexually Transmitted Infection (AAUS) belonging to the Urological Association of Asia (UAA) had developed the guidelines regarding NCNGU and the present guidelines were updated from previous edition. Relevant references were meticulously reviewed again and latest studies were collected. In addition to the levels of evidence, the recommendation grades were defined using the modified GRADE methodology. Herein, we present the new edition of the UAA-AAUS guidelines for M. genitalium and non-chlamydial non-gonococcal urethritis.

Mycoplasma genitalium in Symptomatic Male Urethritis: Macrolide Use Is Associated With Increased Resistance

BACKGROUND

Mycoplasma genitalium (MG) causes symptomatic urethritis in men, and can infect alone or together with other sexually transmitted infection (STI) agents.

METHODS

The prevalence of MG and other STIs was determined in 1816 men with symptomatic urethritis. Resistance of MG to macrolides and fluoroquinolones was determined by sequencing; the impact of recent antimicrobial usage on the distribution of MG single or mixed infections was determined.

RESULTS

Overall, prevalence of MG infection was 19.7% (358/1816). Fifty-four percent (166/307) of MG infections occurred alone in the absence of other STI agents. Men with single MG infection self-administered or were prescribed antibiotics more often in the 30 days prior to enrollment than subjects with urethritis caused by MG coinfection (P < .0001). Higher rates (96.7%) of infection with macrolide resistance in MG were identified in men who had taken macrolides prior to enrollment (P < .03). Overall, 88.9% (303/341) of 23S ribosomal RNA (rRNA) genes contained mutations responsible for macrolide resistance; 89.5% (308/344) of parC and 12.4% (42/339) of gyrA genes had mutations responsible for fluoroquinolone resistance. Approximately 88% (270/308) of MG had combined mutations in 23S rRNA and parC genes; 10.4% (32/308) had mutations in all 3 genes.

CONCLUSIONS

MG was the single pathogen identified in 11% of men with symptomatic urethritis. Overall, nearly 90% of MG infections were resistant to macrolides and fluoroquinolones. Men who took macrolides in the 30 days prior to enrollment had higher rates (97%) of macrolide-resistant MG. Resistance was associated with numerous mutations in 23SrRNA, parC, and gyrA genes.

Mycoplasma genitalium in the Far North Queensland backpacker population: An observational study of prevalence and azithromycin resistance

Background

Mycoplasma genitalium is a sexually transmitted infection (STI), and a common cause of non-gonococcal urethritis (NGU). There is concern regarding the rise in prevalence of M. genitalium and rates of resistance to macrolide antibiotics. International backpackers represent a unique population that may be at an increased risk of STIs. The purpose of this study was to determine the prevalence of M. genitalium and antibiotic resistance in international backpackers.

Methods

First void urine samples were obtained utilising opportunistic sampling from 294 non-treatment-seeking international backpackers at a variety of hostels in Cairns, Queensland Australia. Participants also answered a fixed-answer survey regarding sociodemographic characteristics and sexual risk behaviours. Samples were tested for M. genitalium, Chlamydia trachomatis and Neisseria gonorrhoeae using polymerase chain reaction (PCR). Samples positive for M. genitalium were investigated for macrolide resistance-associated mutations in the 23S rRNA genome at positions A2058G, A2058C, A2058T, A2059G and A2059C (Escherichia coli numbering).

Results

Of the 294 samples, 23 failed the internal control. The prevalence of M. genitalium was 1.8% (5/271, 95% confidence interval [CI] ± 1.58), C. trachomatis was 4.1% (11/271, 95% CI ± 2.36) and N. gonorrhoeae was not detected. Macrolide resistance-associated mutations were identified in 40% (2/5) of M. genitalium-positive samples. M. genitalium infection was associated with reporting symptoms (odds ratio [OR] 14.36, 95% CI 2.17–94.94, p < 0.05).

Conclusions

M. genitalium and C. trachomatis are relatively common amongst non-treatment seeking international backpackers, but may not differ from Australian population prevalence. This article provides evidence to further support the increased utilisation of M. genitalium PCR in the diagnosis of NGU, and for macrolide resistance testing for all identified M. genitalium infections.

Prevalence of Mycoplasma genitalium in different population groups: systematic review andmeta-analysis

BACKGROUND

Mycoplasma genitalium is a common cause of non-gonococcal non-chlamydial urethritis and cervicitis. Testing of asymptomatic populations has been proposed, but prevalence in asymptomatic populations is not well established. We aimed to estimate the prevalence of M. genitalium in the general population, pregnant women, men who have sex with men (MSM), commercial sex workers (CSWs) and clinic-based samples, METHODS: We searched Embase, Medline, IndMED, African Index Medicus and LILACS from 1 January 1991 to 12 July 2016 without language restrictions. We included studies with 500 participants or more. Two reviewers independently screened and selected studies and extracted data. We examined forest plots and conducted random-effects meta-analysis to estimate prevalence, if appropriate. Between-study heterogeneity was examined using the I2 statistic and meta-regression.

RESULTS

Of 3316 screened records, 63 were included. In randomly selected samples from the general population, the summary prevalence was 1.3% (95% CI 1.0% to 1.8%, I2 41.5%, three studies, 9091 people) in countries with higher levels of development and 3.9% (95% CI 2.2 to 6.7, I2 89.2%, three studies, 3809 people) in countries with lower levels. Prevalence was similar in women and men (P=0.47). In clinic based samples, prevalence estimates were higher, except in asymptomatic patients (0.8%, 95% CI 0.4 to 1.4, I2 0.0%, three studies, 2889 people). Summary prevalence estimates were, in the following groups: pregnant women 0.9% (95% CI 0.6% to 1.4%, I2 0%, four studies, 3472 people), MSM in the community 3.2% (95% CI 2.1 to 5.1, I2 78.3%, five studies, 3012 people) and female CSWs in the community 15.9% (95% CI 13.5 to 18.9, I2 79.9%, four studies, 4006 people).

DISCUSSION

This systematic review can inform testing guidelines for M. genitalium. The low estimated prevalence of M. genitalium in the general population, pregnant women and asymptomatic attenders at clinics does not support expansion of testing to these groups.

REGISTRATION NUMBERS

PROSPERO: CRD42015020420.

Mycoplasma genitalium Infection in Men

Mycoplasmagenitalium is one of the major causes of nongonococcal urethritis (NGU) worldwide but an uncommon sexually transmitted infection (STI) in the general population. The risk of sexual transmission is probably lower than for Chlamydia trachomatis. Infection in men is usually asymptomatic and it is likely that most men resolve infection without developing disease. The incubation period for NGU caused by Mycoplasma genitalium is probably longer than for NGU caused by C. trachomatis. The clinical characteristics of symptomatic NGU have not been shown to identify the pathogen specific etiology. Effective treatment of men and their sexual partner(s) is complicated as macrolide antimicrobial resistance is now common in many countries, conceivably due to the widespread use of azithromycin 1 g to treat STIs and the limited availability of diagnostic tests for M. genitalium. Improved outcomes in men with NGU and better antimicrobial stewardship are likely to arise from the introduction of diagnostic M. genitalium nucleic acid amplification testing including antimicrobial resistance testing in men with symptoms of NGU as well as in their current sexual partner(s). The cost effectiveness of these approaches needs further evaluation. The evidence that M. genitalium causes epididymo-orchitis, proctitis, and reactive arthritis and facilitates human immunodeficiency virus transmission in men is weak, although biologically plausible. In the absence of randomized controlled trials demonstrating cost effectiveness, screening of asymptomatic men cannot be recommended.

Detection of markers predictive of macrolide and fluoroquinolone resistance in Mycoplasma genitalium from patients attending sexual health services in England

Objectives

Resistance to both macrolides and fluoroquinolones has been reported in Mycoplasma genitalium; however, due to limited diagnostics, studies are often small and confined to specific geographical areas. This study sought to determine the rate of predicted resistance in M. genitalium-positive specimens referred for diagnostic testing.

Methods

Seventy-four M. genitalium-positive specimens, referred to the national reference laboratory (2010-2013) from 19 centres across England, were blinded and anonymised. Specimens were examined for markers predictive of resistance to macrolides and fluoroquinolones using PCR followed by sequence analysis of 23S rRNA gene, or gyrA and parC, respectively.

Results

23S rRNA gene PCR sequencing revealed that 82.4% (61/74) of specimens harboured a single nucleotide polymorphism (SNP) associated with macrolide resistance. Differences were observed between the rates of predicted macrolide resistance in male (95.1% (58/61)) and female (23.1% (3/13)) patients (P = <0.001). By contrast, all specimens for which sequencing data were available (73/74) yielded wild-type gyrA sequences; and 58/61 (95.1%) had wild-type parC genes. Three specimens (3/61 4.9%) had SNPs in the parC gene associated with fluoroquinolone treatment failure, and all three also had predicted resistance to macrolides.

Conclusions

Eighty-two per cent and 4.9% of M. genitalium specimens had SNPs associated with macrolide and fluoroquinolone resistance, respectively. Due to lack of widespread availability of testing for M. genitalium in the UK, this study sample was likely to be sourced from patients who may have already failed first-line macrolide therapy. Nevertheless, this study highlights the need for both greater access to M. genitalium diagnostics and genetic antimicrobial resistance testing.

The Ballseye programme: a mixed-methods programme of research in traditional sexual health and alternative community settings to improve the sexual health of men in the UK

Background

Sexually transmitted infection (STI) diagnoses are increasing and efforts to reduce transmission have failed. There are major uncertainties in the evidence base surrounding the delivery of STI care for men.

Aim

To improve the sexual health of young men in the UK by determining optimal strategies for STI testing and care

Objectives

To develop an evidence-based clinical algorithm for STI testing in asymptomatic men; model mathematically the epidemiological and economic impact of removing microscopy from routine STI testing in asymptomatic men; conduct a pilot randomised controlled trial (RCT) of accelerated partner therapy (APT; new models of partner notification to rapidly treat male sex partners of people with STIs) in primary care; explore the acceptability of diverse venues for STI screening in men; and determine optimal models for the delivery of screening.

Design

Systematic review of the clinical consequences of asymptomatic non-chlamydial, non-gonococcal urethritis (NCNGU); case–control study of factors associated with NCNGU; mathematical modelling of the epidemiological and economic impact of removing microscopy from asymptomatic screening and cost-effectiveness analysis; pilot RCT of APT for male sex partners of women diagnosed withChlamydia trachomatisinfection in primary care; stratified random probability sample survey of UK young men; qualitative study of men’s views on accessing STI testing; SPORTSMART pilot cluster RCT of two STI screening interventions in amateur football clubs; and anonymous questionnaire survey of STI risk and previous testing behaviour in men in football clubs.

Settings

General population, genitourinary medicine clinic attenders, general practice and community contraception and sexual health clinic attenders and amateur football clubs.

Participants

Men and women.

Interventions

Partner notification interventions: APTHotline [telephone assessment of partner(s)] and APTPharmacy [community pharmacist assessment of partner(s)]. SPORTSMART interventions: football captain-led and health adviser-led promotion of urine-based STI screening.

Main outcome measures

For the APT pilot RCT, the primary outcome, determined for each contactable partner, was whether or not they were considered to have been treated within 6 weeks of index diagnosis. For the SPORTSMART pilot RCT, the primary outcome was the proportion of eligible men accepting screening.

Results

Non-chlamydial, non-gonococcal urethritis is not associated with significant clinical consequences for men or their sexual partners but study quality is poor (systematic review). Men with symptomatic and asymptomatic NCNGU and healthy men share similar demographic, behavioural and clinical variables (case–control study). Removal of urethral microscopy from routine asymptomatic screening is likely to lead to a small rise in pelvic inflammatory disease (PID) but could save > £5M over 20 years (mathematical modelling and health economics analysis). In the APT pilot RCT the proportion of partners treated by the APTHotline [39/111 (35%)], APTPharmacy [46/100 (46%)] and standard patient referral [46/102 (45%)] did not meet national standards but exceeded previously reported outcomes in community settings. Men’s reported willingness to access self-sampling kits for STIs and human immunodeficiency virus infection was high. Traditional health-care settings were preferred but sports venues were acceptable to half of men who played sport (random probability sample survey). Men appear to prefer a ‘straightforward’ approach to STI screening, accessible as part of their daily activities (qualitative study). Uptake of STI screening in the SPORTSMART RCT was high, irrespective of arm [captain led 28/56 (50%); health-care professional led 31/46 (67%); poster only 31/51 (61%)], and costs were similar. Men were at risk of STIs but previous testing was common.

Conclusions

Men find traditional health-care settings the most acceptable places to access STI screening. Self-sampling kits in football clubs could widen access to screening and offer a public health impact for men with limited local sexual health services. Available evidence does not support an association between asymptomatic NCNGU and significant adverse clinical outcomes for men or their sexual partners but the literature is of poor quality. Similarities in characteristics of men with and without NCNGU precluded development of a meaningful clinical algorithm to guide STI testing in asymptomatic men. The mathematical modelling and cost-effectiveness analysis of removing all asymptomatic urethral microscopy screening suggests that this would result in a small rise in adverse outcomes such as PID but that it would be highly cost-effective. APT appears to improve outcomes of partner notification in community settings but outcomes still fail to meet national standards. Priorities for future work include improving understanding of men’s collective behaviours and how these can be harnessed to improve health outcomes; exploring barriers to and facilitators of opportunistic STI screening for men attending general practice, with development of evidence-based interventions to increase the offer and uptake of screening; further development of APT for community settings; and studies to improve knowledge of factors specific to screening men who have sex with men (MSM) and, in particular, how, with the different epidemiology of STIs in MSM and the current narrow focus on chlamydia, this could negatively impact MSM’s sexual health.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

2016 European guideline on the management of non-gonococcal urethritis

We present the updated International Union against Sexually Transmitted Infections (IUSTI) guideline for the management of non-gonococcal urethritis in men. This guideline recommends confirmation of urethritis in symptomatic men before starting treatment. It does not recommend testing asymptomatic men for the presence of urethritis. All men with urethritis should be tested for Chlamydia trachomatis and Neisseria gonorrhoeae and ideally Mycoplasma genitalium using a nucleic acid amplification test (NAAT) as this is highly likely to improve clinical outcomes. If a NAAT is positive for gonorrhoea, a culture should be performed before treatment. In view of the increasing evidence that azithromycin 1 g may result in the development of antimicrobial resistance in M. genitalium, azithromycin 1 g is no longer recommended as first line therapy, which should be doxycycline 100 mg bd for seven days. If azithromycin is to be prescribed an extended course of 500 mg stat, then 250 mg daily for four days is to be preferred over 1 g stat. In men with persistent NGU, M. genitalium NAAT testing is recommended if not previously undertaken, as is Trichomonas vaginalis NAAT testing in populations where T. vaginalis is detectable in >2% of symptomatic women.

Prevalence of Mycoplasma genitalium in men with urethritis and in high risk asymptomatic males in Tel Aviv: a prospective study

We sought to investigate the prevalence of Mycoplasma genitalium, Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis in men presenting to a sexually transmitted infection (STI) clinic, with special attention to M. genitalium, its occurrence in Israeli patients, coinfections, and risk factors. In a cross-sectional study, 259 men were successively enrolled in the Tel Aviv Levinsky Clinic for STIs between November 2008 and November 2010. There were 118 men with urethritis and 141 high-risk men without symptoms. M. genitalium, C. trachomatis, N. gonorrhoeae, and T. vaginalis were detected using nucleic acid amplification tests. Demographic characteristics and risk factors were documented. The overall prevalence of infection with M. genitalium, C. trachomatis, N. gonorrhoeae, and T. vaginalis, were 6.6%, 12.7%, 23.1%, and 0%, respectively. Prevalences in men with urethritis were 11.9%, 22%, and 49%, for M. genitalium, C. trachomatis, and N. gonorrhoeae, respectively. Prevalences in men without symptoms were 2.1%, 5.0%, and 1.4%, for M. genitalium, C. trachomatis, and N. gonorrhoeae, respectively. Co-infections were found only in symptomatic individuals, in whom 5.9% were infected concomitantly with C. trachomatis and N. gonorrhoeae, and 2.5% had dual infection with M. genitalium and N. gonorrhoeae. N. gonorrhoeae, C. trachomatis, and M. genitalium were significantly more prevalent in patients with urethritis. M. genitalium was significantly more prevalent in the heterosexual population than in homosexual males. To conclude, we have found that M. genitalium infection is associated with urethritis in Israeli men, and more so in the heterosexual population. Testing men for M. genitalium as a cause of non-gonococcal urethritis is warranted, particularly because of its poor response to doxycycline and possible failure of azithromycin.

Management of non-gonococcal urethritis

Non-gonococcal urethritis (NGU), or inflammation of the urethra, is the most common treatable sexually transmitted syndrome in men, with approximately 20-50 % of cases being due to infection with Chlamydia trachomatis and 10-30 % Mycoplasma genitalium. Other causes are Ureaplasma urealyticum, Trichomonas vaginalis, anaerobes, Herpes simplex virus (HSV) and adenovirus. Up to half of the cases are non-specific. Urethritis is characterized by discharge, dysuria and/or urethral discomfort but may be asymptomatic. The diagnosis of urethritis is confirmed by demonstrating an excess of polymorpho-nuclear leucocytes (PMNLs) in a stained smear. An excess of mononuclear leucocytes in the smear indicates a viral etiology. In patients presenting with symptoms of urethritis, the diagnosis should be confirmed by microscopy of a stained smear, ruling out gonorrhea. Nucleid acid amplifications tests (NAAT) for Neisseria gonorrhoeae, C. trachomatis and for M. genitalium. If viral or protozoan aetiology is suspected, NAAT for HSV, adenovirus and T. vaginalis, if available. If marked symptoms and urethritis is confirmed, syndromic treatment should be given at the first appointment without waiting for the laboratory results. Treatment options are doxycycline 100 mg x 2 for one week or azithromycin 1 gram single dose or 1,5 gram distributed in five days. However, azithromycin as first line treatment without test of cure for M. genitalium and subsequent Moxifloxacin treatment of macrolide resistant strains will select and increase the macrolide resistant strains in the population. If positive for M. genitalium, test of cure samples should be collected no earlier than three weeks after start of treatment. If positive in test of cure, moxifloxacin 400 mg 7-14 days is indicated. Current partner(s) should be tested and treated with the same regimen. They should abstain from intercourse until both have completed treatment. Persistent or recurrent NGU must be confirmed with microscopy. Reinfection and compliance must be considered. Evidence for the following recommendations is limited, and is based on clinical experience and guidelines. If doxycycline was given as first therapy, azithromycin five days plus metronidazole 4-500 mg twice daily for 5-7 days should be given. If azithromycin was prescribed as first therapy, doxycycline 100 mg x 2 for one week plus metronidazole, or moxifloxacin 400 mg orally once daily for 7-14 days should be given.

2015 UK National Guideline on the management of non-gonococcal urethritis

We present the updated British Association for Sexual Health and HIV guideline for the management of non-gonococcal urethritis in men. This document includes a review of the current literature on its aetiology, diagnosis and management. In particular it highlights the emerging evidence that azithromycin 1 g may result in the development of antimicrobial resistance in Mycoplasma genitalium and that neither azithromycin 1 g nor doxycycline 100 mg twice daily for seven days achieves a cure rate of >90% for this micro-organism. Evidence-based diagnostic and management strategies for men presenting with symptoms suggestive of urethritis, those confirmed to have non-gonococcal urethritis and those with persistent symptoms following first-line treatment are detailed.

Performance evaluation of automated urine microscopy as a rapid, non-invasive approach for the diagnosis of non-gonococcal urethritis

Objectives

Gram-stained urethral smear (GSUS), the standard point-of-care test for non-gonococcal urethritis (NGU) is operator dependent and poorly specific. The performance of rapid automated urine flow cytometry (AUFC) of first void urine (FVU) white cell counts (UWCC) for predicting Mycoplasma genitalium and Chlamydia trachomatis urethral infections was assessed and its application to asymptomatic infection was evaluated.

Methods

Receiver operating characteristic curve analysis, determining FVU-UWCC threshold for predicting M. genitalium or C. trachomatis infection was performed on 208 ‘training’ samples from symptomatic patients and subsequently validated using 228 additional FVUs obtained from prospective unselected patients.

Results

An optimal diagnostic threshold of >29 UWC/µL gave sensitivities and specificities for either infection of 81.5% (95% CI 65.1% to 91.6%) and 85.8% (79.5% to 90.4%), respectively, compared with 86.8% (71.1% to 95%) and 64.7% (56.9% to 71.7%), respectively, for GSUS, using the training set samples. FVU-UWCC demonstrated sensitivities and specificities of 69.2% (95% CI 48.1% to 84.9%) and 92% (87.2% to 95.2%), respectively, when using validation samples. In asymptomatic patients where GSUS was not used, AUFC would have enabled more infections to be detected compared with clinical considerations only (71.4% vs 28.6%; p=0.03). The correlation between UWCC and bacterial load was stronger for M. genitalium compared with C. trachomatis (τ=0.426, p≤0.001 vs τ=0.295, p=0.022, respectively).

Conclusions

AUFC offers improved specificity over microscopy for predicting C. trachomatis or M. genitalium infection. Universal AUFC may enable non-invasive diagnosis of asymptomatic NGU at the PoC. The degree of urethral inflammation exhibits a stronger association with pathogen load for M. genitalium compared with C. trachomatis.

Time to manage Mycoplasma genitalium as an STI: but not with azithromycin 1 g!

PURPOSE OF REVIEW

Mycoplasma genitalium is a sexually transmitted infection that causes significant morbidity in men and women and is a co-factor in HIV transmission. However, commercial diagnostic tests are not generally available for M. genitalium and sub-optimal treatment is often given. We review the literature on the burden of infection, how it may present in clinical practice and the effectiveness of current treatment regimens.

RECENT FINDINGS

In-vivo and in-vitro data strongly suggest that M. genitalium is an important cause of urethritis, cervicitis, pelvic inflammatory disease and potentially asymptomatic proctitis. Studies now consistently demonstrate suboptimal eradication rates with the current treatment regimens recommended first line for the treatment of nongonococcal urethritis. Concurrently, there has been a rapid emergence of antibiotic resistance in M. genitalium, with macrolide resistance now appearing to be endemic in some centres, and quinolone resistance is beginning to emerge.

SUMMARY

In the absence of specific M. genitalium diagnostic and antimicrobial resistance testing, azithromycin 1 g should not be used for the management of patients with symptomatic disease potentially caused by M. genitalium. This review offers an alternative evidence-based approach to managing such patients that should, theoretically, reduce the risk of the development of antimicrobial resistance.

Prevalence of Trichomonas vaginalis, Mycoplasma genitalium and Ureaplasma urealyticum in men with urethritis attending an urban sexual health clinic

We conducted a study to determine the prevalence of Trichomonas vaginalis (TV), Mycoplasma genitalium (MG) and Ureaplasma urealyticum (UU) in men with urethritis, attending an urban sexual health clinic, in order to inform screening and treatment policies. Men attending an urban sexual health clinic between June 2011 and January 2012 were evaluated. Urine samples were collected from men with urethritis and tested for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (GC) and TV using transcription-mediated amplification and for MG and UU using polymerase chain reaction. Eighty-three samples were analysed. The prevalence of CT was 33.7% (28/83), GC was 16.8% (14/83), TV was 3.6% (3/83), MG was 12.0% (10/83) and UU was 4.8% (4/83). Fifteen men had recurrent urethritis. Of these, three were found to have had TV, five to have had MG and none to have had UU, at initial presentation. Given the prevalence of MG in this study, there is an urgent need for further larger studies looking at optimal treatment regimens and screening strategies in urethritis.

Mycoplasma genitalium: An emergent sexually transmitted disease?

This article summarizes the epidemiologic evidence linking Mycoplasma genitalium to sexually transmitted disease syndromes, including male urethritis, and female cervicitis, pelvic inflammatory disease, infertility, and adverse birth outcomes. It discusses the relationship of this bacterium to human immunodeficiency virus infection and reviews the available literature on the efficacy of standard antimicrobial therapies against M genitalium.

Asymptomatic urethritis is common and is associated with characteristics that suggest sexually transmitted etiology

We evaluated 236 asymptomatic men for urethritis, assessed sexual behaviors, and tested urine for pathogens. Asymptomatic urethritis was present in 38 (16.1%). Of these, nearly half (42.1%) had a previously unrecognized discharge on examination; only 18.4% had a known pathogen. Correlates included black race, anal intercourse, and number of sex partners.

Factors associated with asymptomatic non-chlamydial non-gonococcal urethritis in heterosexual men: findings from a case-control study

Summary

The significance of asymptomatic non-chlamydial non-gonococcal urethritis (NCNGU) is unclear. Organisms associated with NCNGU, e.g. Mycoplasma genitalium, for which there is no widely available test, are linked to reproductive sequelae in women but UK guidance no longer recommends urethral smear microscopy to screen for asymptomatic NCNGU. This case-control study of heterosexual male genitourinary (GU) medicine clinic attenders aimed to identify clinical, demographic and sexual behaviour factors associated with asymptomatic NCNGU so that we could determine whether the presence or absence of symptoms provides a rational basis for deciding to whom we should offer microscopy and whom we should treat. Men with asymptomatic NCNGU were very similar to men with symptomatic NCNGU, except for more consistent condom use. Asymptomatic and symptomatic NCNGU could be different ends of the same clinical syndrome. Until the microbiological basis of NCNGU is understood, we recommend treatment of men with NCNGU irrespective of symptoms.

Mycoplasma genitalium: should we treat and how?

Mycoplasma genitalium is associated with acute and chronic urethritis in men. Existing data on infection in women are limited and inconsistent but suggest that M. genitalium is associated with urethritis, cervicitis, pelvic inflammatory disease, and possibly female infertility. Data are inconclusive regarding the role of M. genitalium in adverse pregnancy outcomes and ectopic pregnancy. Available data suggest that azithromycin is superior to doxycycline in treating M. genitalium infection. However, azithromycin-resistant infections have been reported in 3 continents, and the proportion of azithromycin-resistant M. genitalium infection is unknown. Moxifloxacin is the only drug that currently seems to uniformly eradicate M. genitalium. Detection of M. genitalium is hampered by the absence of a commercially available diagnostic test. Persons with persistent pelvic inflammatory disease or clinically significant persistent urethritis or cervicitis should be tested for M. genitalium, if possible. Infected persons who have not previously received azithromycin should receive that drug. Persons in whom azithromycin therapy fails should be treated with moxifloxicin.

Mycoplasma genitalium: from Chrysalis to multicolored butterfly

The history, replication, genetics, characteristics (both biological and physical), and factors involved in the pathogenesis of Mycoplasma genitalium are presented. The latter factors include adhesion, the influence of hormones, motility, possible toxin production, and immunological responses. The preferred site of colonization, together with current detection procedures, mainly by PCR technology, is discussed. The relationships between M. genitalium and various diseases are highlighted. These diseases include acute and chronic nongonococcal urethritis, balanoposthitis, chronic prostatitis, and acute epididymitis in men and urethritis, bacterial vaginosis, vaginitis, cervicitis, pelvic inflammatory disease, and reproductive disease in women. A causative relationship, or otherwise strong association, between several of these diseases and M. genitalium is apparent, and the extent of this, on a subjective basis, is presented; also provided is a comparison between M. genitalium and two other genital tract-orientated mollicutes, namely, Mycoplasma hominis, the first mycoplasma of human origin to be discovered, and Ureaplasma species. Also discussed is the relationship between M. genitalium and infertility and also arthritis in both men and women, as is infection in homosexual and immunodeficient patients. Decreased immunity, as in HIV infections, may enhance mycoplasmal detection and increase disease severity. Finally, aspects of the antimicrobial susceptibility and resistance of M. genitalium, together with the treatment and possible prevention of mycoplasmal disease, are discussed.

A review of the epidemiology, diagnosis and evidence-based management of Mycoplasma genitalium

Mycoplasma genitalium is attracting increasing recognition as an important sexually transmitted pathogen. Presented is a review of the epidemiology, detection, presentation and management of M. genitalium infection. Accumulating evidence suggests that M. genitalium is an important cause of non-gonococcal, non-chlamydial urethritis and cervicitis, and is linked with pelvic inflammatory disease and, possibly, obstetric complications. Although there is no standard detection assay, several nucleic acid amplification tests have >95% sensitivity and specificity for M. genitalium. To date, there is a general lack of established protocols for screening in public health clinics. Patients with urethritis or cervicitis should be screened for M. genitalium and some asymptomatic sub-groups should be screened depending on individual factors and local prevalence. Investigations estimating M. genitalium geographic prevalence document generally low incidence, but some communities exhibit infection frequencies comparable to that of Chlamydia trachomatis. Accumulating evidence supports an extended regimen of azithromycin for treatment of M. genitalium infection, as data suggest that stat 1 g azithromycin may be less effective. Although data are limited, azithromycin-resistant cases documented to date respond to an appropriate fluoroquinolone (e.g. moxifloxacin). Inconsistent clinical recognition of M. genitalium may result in treatment failure and subsequent persistence due to ineffective antibiotics. The contrasting nature of existing literature regarding risks of M. genitalium infection emphasises the need for further carefully controlled studies of this emerging pathogen.

Mycoplasma genitalium symptoms, concordance and treatment in high-risk sexual dyads

The objective of this study was to determine the prevalence and concordance of Mycoplasma genitalium (MG) among Mexican American and African American women and their male sexual partners. Secondary objectives were to determine symptoms of MG infection and persistence of MG after antibiotic therapy. Heterosexual couples were tested for MG and interviewed separately regarding symptoms and behavioural/epidemiologic variables at baseline, six and 12 months. The overall prevalence of MG among women and men was 9.5% and 10.6%, respectively. Subjects were five times more likely to be infected with MG if their sexual partner was MG positive. Among men and women, MG prevalence and mean bacterial loads were similar after receiving single-dose azithromycin, doxycycline or no antibiotics. MG was associated with current urethral discharge in men. No clinical symptoms were specifically diagnostic of MG infection in women.

A case-control study of men with non-gonococcal urethritis at Auckland Sexual Health Service: rates of detection of Mycoplasma genitalium

BACKGROUND

Previous studies have identified Mycoplasma genitalium as a cause of urethritis in men. As there is no New Zealand data, a case-control study was conducted to determine whether this organism is a significant cause of urethritis in men presenting to Auckland Sexual Health Service.

METHODS

Enrollment for the study commenced in March 2006 and finished in February 2008. Inclusion criteria for cases of non-gonococcal urethritis were onset of urethritis symptoms within one month confirmed by urethral Gram staining showing >or=10 polymorphonuclear leucocytes per high-powered field. Controls were men presenting during the same time period for asymptomatic sexual health screening. All participants were tested for Neisseria gonorrhoeae, M. genitalium, and Chlamydia trachomatis. Information regarding symptoms, sexual behaviour and treatment was collected using a standard questionnaire.

RESULTS

We recruited 209 cases and 199 controls with a participation rate of 96%. The prevalence of C. trachomatis and M. genitalium in non-gonococcal urethritis cases was 33.5% and 10% respectively. Co-infection with these organisms was uncommon (1.9%). C. trachomatis and M. genitalium were diagnosed in 4% and 2% of controls, respectively, and both infections were detected significantly less often than in the cases (P < 0.0001, P < 0.005). Cases were more likely to report inconsistent condom use, multiple sexual contacts and not having sexual intercourse in the last week (P = 0.03, P = 0.02, P = 0.03). A past history of non-gonococcal urethritis was a significant predictor of current symptoms (P < 0.0001).

CONCLUSIONS

This is the first study to investigate M. genitalium infection in New Zealand men. Our results confirm that M. genitalium is a cause of non-gonococcal urethritis in men presenting to our service.

Idiopathic urethritis in young men in the United States: prevalence and comparison to infections with known sexually transmitted pathogens

PURPOSE

Urethritis is the most common male reproductive tract disease syndrome; yet 20-50% of diagnosed cases have no defined etiology, and few population-level data exist on the prevalence or etiology of the syndrome. We estimated the prevalence of urethritis among young men in the United States and compared correlates of idiopathic cases to correlates of detected infections with sexually transmitted pathogens.

METHODS

Questionnaire data and urine specimens from 5,447 men aged 18-27 years participating in Wave III of the National Longitudinal Study of Adolescent Health were analyzed. Symptomatic urethritis was defined as self-reported dysuria or urethral discharge in the past 24hours. Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and Mycoplasma genitalium were identified using nucleic acid amplification tests. Idiopathic urethritis (IU) was defined as urethral symptoms in the absence of these four pathogens. Stratified weighted analyses generated population-based estimates.

RESULTS

Urethritis was reported by 1.2% (95% CI=.8-1.6%) of men, of whom 82.4% (61.1-93.3%) had IU. Men with previous STD diagnoses (aOR=9.3 [95% CI=3.0-28.7]), or fewer (1-4) or no lifetime vaginal sex partners (aOR=7.5 [2.9-19.3] and aOR=7.2 [1.9-27.4]), were more likely to have IU compared with men without urethral symptoms or identified pathogens, whereas men of Native American or Asian/Pacific Islander descent (aOR=.04 [.01-.2]) and heavy drinkers (aOR=.08 [.03-.2]) were less likely to have IU. Unlike infection with known pathogens, IU was not associated with black race, Hispanic ethnicity, or age at sexual debut.

CONCLUSIONS

Urethral symptoms were rarely associated with known pathogens. IU and known pathogens were associated with distinct characteristics.

Population-based assessment of Mycoplasma genitalium in Vietnam--low prevalence among married women of reproductive age in a rural area

OBJECTIVE

To analyse the prevalence of Mycoplasma genitalium infection in a population-based study among married women from a demographic surveillance site in a rural geographical area of Vietnam.

MATERIALS AND METHODS

Women, aged 18-49 years, were randomly selected to participate. DNA was isolated from endocervical swabs sampled from 990 participating women. The M. genitalium MgPa adhesion gene was detected using a real-time polymerase chain reaction with TaqMan probe.

RESULTS

Eight (0.8%; 95% confidence interval, 0.25-1.35%) of the included women were infected with M. genitalium. Two of these positive women reported clinical symptoms. One additional M. genitalium-positive but symptom-free woman, however, showed clinical signs of vaginitis. None of the M. genitalium-positive women was concomitantly infected with Chlamydia trachomatis, Neisseria gonorrhoeae, syphilis or human immunodeficiency virus (HIV). Furthermore, there was no obvious association between M. genitalium infection and vaginal douching, use of intrauterine device, or occurrence of bacterial vaginosis, candidiasis, or Trichomonas vaginalis.

CONCLUSIONS

The prevalence of M. genitalium among married women in Vietnam was relatively low. However, more large, well-designed and appropriately performed studies in other population groups including unmarried women and men, and in other geographical areas, rural as well as urban, are crucial in order to extract any evidence-based conclusions regarding the overall prevalence of sexually transmitted infections (STIs), including M. genitalium infections, in the Vietnamese society. The present study compiled with such future studies may form the basis for a national sexual health strategy for prevention, diagnosis, and surveillance of STIs, including M. genitalium infections, in Vietnam.

Diagnostic utility of urethral smears in predicting urethral chlamydia in HIV-infected men

We collected data from 218 HIV-infected men to assess the usefulness of the urethral smear and symptoms in predicting Chlamydia trachomatis infection. Prevalence of urethral chlamydia was 9%. A polymorphonuclear leucocyte (PMNL) count ≥5 was 73% sensitive and 71% specific for C. trachomatis infection. Adjusted odds ratio for risk of chlamydial infection was significant for urethral irritation (7.48; 1.54–36.4), a PMNL count of 20 or more (9.83; 2.52–8.4) and a PMNL count of 5–19 (4.10; 1.34–12.5). We had to perform 50 urethral smears in HIV-positive men without symptoms to treat one case of C. trachomatis at the time of visit. Findings suggest that the presence of symptoms, in particular urethral irritation may be associated with chlamydial urethritis and that the higher the urethral PMNL count, the more likely it is for C. trachomatis to be detected. The findings in this study also lend further support to recent guidelines that urethral microscopy is not useful in asymptomatic men and hence should be abandoned.

Is the urethral smear necessary in asymptomatic men attending a genitourinary medicine clinic?

Available evidence does not support the performance of urethral smears in asymptomatic men