Mollicutes | Urological Pelvic Pain Synrome | Dr. Potts

Genital Mycoplasmas and Ureaplasma Urealyticum

Ureaplasma urealyticum, Mycoplasma hominis, and Mycoplasma genitalium are among the smallest known living organisms, known as Mollicutes. Mollicutes do not have a cell wall, which makes them hard to culture/identify and difficult to treat, that is, if they become clinically relevant. 

You see, mollicutes are considered commensal organisms of the genital tract in sexually active men and women, which means they are usually “innocent” colonizers. At least 60% of asymptomatic women have been shown to harbor Ureaplasma in their genital tract. However, these organisms have also been implicated in cases of chronic prostatitis in men, urgency/frequency syndromes in women, and up to 40% of nongonococcal urethritis cases. More recently, Ureaplasma has been implicated in infertility, as well as some complications of pregnancy, like preterm labor. 

They have been isolated as the sole pathogen in symptomatic patients, who respond to antimicrobial therapy targeting these mollicutes. Women, especially young sexually active women, with urgency frequency syndrome with or without dysuria who have repeatedly negative urine cultures may benefit from culture and subsequent treatment for Mycoplasma and Ureaplasma. Culturing for this organism should also be considered in men with symptoms previously attributed to prostatitis or in men with prior history of STI exposure.

In the past, because of their complex nutritional requirements, isolation and culturing of these organisms was challenging. Today, molecular testing has made it easier to test patients for this potential infection. Specimens are obtained from the cervix, vagina, urethra, semen, expressed prostatic secretions, or in urine. For urine, I usually recommend that patients avoid urinating for at least 3 hours prior to the appointment and to submit, the first 10 mL of urine, rather than the typical “mid void” urine sample. If cultures are positive, treatment is recommended with subsequent surveillance for improvement in symptoms. Sexual partners should be evaluated and treated as well as refrain from sexual activity for 2 weeks during treatment.

Historically, this group of organisms was highly sensitive to tetracycline. Today, however, up to 30% of strains may be resistant, which may explain persistent symptoms in those patients treated empirically for nongonococcal urethritis or presumed Chlamydia infection. Most tetracycline-resistant strains remain sensitive to erythromycin. Currently, the initial recommended therapy is doxycycline, 100 mg twice daily for 2 weeks,1 or a single 1-g dose of azithromycin, which can be repeated after 10 to 14 days. Other alternatives include erythromycin, 500 mg four times daily, or ofloxacin, 300 mg twice daily for 10 to 14 days. 

While Ureaplasma and Mycoplasma can play a role in genitourinary symptoms, such as urological pelvic pain syndromes, it is of utmost importance that patients be clinically evaluated for many other confusable diagnoses. These include, peripheral neuropathies, myofascial trigger points, orthopedic issues with referred pain to the GU system and central sensitization. Identifying these other causes are especially important as the prevalence of multi-drug resistance has been gradually increasing, and many patients who test positive may be able to avoid unnecessary antibiotic therapies. 

 1 Frenkl, Potts: Sexually transmitted and associated diseases in Campbells-Walsh Urology, 10th edition, Saunders Elsevier, 2011.

Frenkl, Tara L., Potts, Jeanette. Sexually Transmitted Diseases, in Practical Urology: Essential Principles and Practice, edited by Christopher C.R. Chapple and William D. Steers, Springer 2011.

Potts, Frenkl: Sexually Transmitted Infections; in Urologic Clinics of North America, Nickel and Resnick (Editors)Volume 35, Number 1, Elsevier, February, 2008

Potts, Ward, Rackley: Association of chronic urinary symptoms in women and ureaplasma urealyticum. Urol, 55(4): 486-89, 2000.

Potts, Sharma, Pasqualotto, Nelson, Hall, Agarwal: Association of ureaplasma urealyticum with abnormal reactive oxygen species levels and absence of leukocytospermia. J Urol, 163: 1775-78, June 2000.

Frenkl, Potts: Sexually transmitted infections, Part I and Part II. AUA Update STD’s. 2006

Potts, Rackley: Ureaplasma urealyticum in men: A commensal or pathogen? American Urologic Association, 1997