Mycoplasma genitalium

Mycoplasma genitalium or Mgen is a emerging sexually transmitted disease (STD) that can cause infections in both men and women ¹, ², ³. You can get mycoplasma genitalium by having vaginal, anal, and oral sex with someone who has the infection ⁴, ⁵. Mycoplasma genitalium can infect the cervix (opening to the uterus), inside the penis (the urethra), or the rectum.

According to the 2021 Guidelines for the Sexually Transmitted Infections Treatment issued by the United States Centers for Disease Control and Prevention, Mycoplasma genitalium infection can cause cervicitis (inflammation of the cervix) and pelvic inflammatory disease (PID) and 20%–30% of male urethritis cases (inflammation of the urethra) ⁶, ⁷, ⁸. A meta-analysis showed that M. genitalium infection was significantly associated with an increased risk of cervicitis, pelvic inflammatory disease, female infertility, preterm birth and spontaneous abortion ⁹. A recent meta-analysis from China showed that the infection rate of M. genitalium infection in pregnant women was 4.86%, and the M. genitalium infection rates in women with ectopic pregnancy, spontaneous abortion, induced abortion, and premature rupture of membranes were 13.01, 11.81, 6.11, and 12.63%, respectively ¹⁰. This suggests that the incidence of Mycoplasma genitalium infection in pregnant women with ectopic pregnancy, spontaneous abortion, and premature rupture of membranes is higher than that in other pregnant women ³.

Rectal infection with Mycoplasma genitalium has been reported among 1%–26% of men who have sex with men ¹¹, ¹², ¹³, ¹⁴ and among 3% of women ¹⁵. Rectal infections often are asymptomatic, although higher prevalence of M. genitalium has been reported among men with rectal symptoms. Similarly, although asymptomatic M. genitalium has been detected in the pharynx, no evidence exists of it causing oropharyngeal symptoms or systemic disease ⁸.

The recommended treatment for all cases of Mycoplasma genitalium infections includes a two-stage approach with doxycycline, followed by an additional agent (either moxifloxacin or azithromycin), ideally using resistance-guided therapy ¹⁶.

Recommended antibiotic regimens if M. genitalium resistance testing is available ¹⁶, ⁸:

• If 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)
• If macrolide resistant: Doxycycline 100 mg orally 2 times/day for 7 days followed by moxifloxacin 400 mg orally once daily for 7 days

Recommended antibiotic regimens if M. genitalium resistance testing is Not Available ¹⁶, ⁸:

• If M. genitalium is detected by an FDA-cleared NAAT: Doxycycline 100 mg orally 2 times/day for 7 days, followed by moxifloxacin 400 mg orally once daily for 7 days

Although cure rates with doxycycline monotherapy are low, using doxycycline as the initial agent may lower Mycoplasma genitalium organism load and facilitate organism clearance, thereby increasing likelihood of moxifloxacin success ¹⁷. Higher doses of azithromycin have not been effective for M. genitalium after azithromycin treatment failures. Men with persistent or recurrent urethritis after treatment for M. genitalium should be referred to an infectious disease or urology specialist ⁸.

Mycoplasma genitalium treatment failures can occur when using doxycycline, azithromycin, and moxifloxacin ¹⁸. Microbiologic cure rates are poor with either doxycycline or azithromycin monotherapy (~50% or less). Microbiologic cure rates for moxifloxacin were initially high (close to 100%) but have declined to 89% in studies conducted from 2010-2017 ¹⁹.

For cases of suspected treatment failure, consult the STD Clinical Consultation Network here https://www.stdccn.org

Resistance to azithromycin, which has been recommended for treatment, is high across the globe ²⁰, ²¹. Pharmacokinetic data indicate that changing azithromycin dosing from a single-dose strategy to a multiday strategy might protect against inducing resistance in M. genitalium infections ²², ²³.

How do I know if I have Mycoplasma genitalium?

People with Mycoplasma genitalium often have no symptoms ¹⁸.

Someone with symptoms may notice:

• Vaginal discharge;
• A burning sensation when urinating;
• Discharge from the penis.

See your doctor if you notice any of these symptoms.

You should also see a doctor if your partner has an STD or symptoms of one. Symptoms of an STD can include an unusual sore, a smelly discharge, burning when peeing, pain/bleeding after sex, and bleeding between periods.

How common is Mycoplasma genitalium?

The 2017-2018 National Health and Nutrition Examination Survey (NHANES) estimates overall prevalence of urogenital Mycoplasma genitalium to be 1.7% among people aged 14-59 years in the United States. The survey reported similar prevalence between males at 1.8% and females at 1.7% ²⁴.

Reported estimates of Mycoplasma genitalium prevalence among STD clinic-based populations are higher. Among men presenting with urethritis in select STD clinics, 28.7% were positive for Mycoplasma genitalium ²⁵. Among women presenting in a STD clinic in Seattle, 26% had an Mycoplasma genitalium infection ²⁶. A large U.S. prospective multicenter study of a nucleic acid amplification diagnostic test for Mycoplasma genitalium including male and female patients seeking care in diverse geographic regions found overall prevalence to be 10.3%. In this study, Mycoplasma genitalium was more common among people ages 15 to 24 years than in people ages 35 to 39 years. The risk for Mycoplasma genitalium was higher in Black participants than White participants and higher in non-Hispanic than in Hispanic participants ²⁷. A meta-analysis of Mycoplasma genitalium prevalence among gay, bisexual, and other men who have sex with men (MSM) found that urethral (5.0%) and rectal (6.2%) Mycoplasma genitalium infections were more common than pharyngeal infections (1.0%) ²⁷.

Is there a cure for Mycoplasma genitalium?

Yes, the right treatment with antibiotics can cure Mycoplasma genitalium. It is important that you take all of the medicine your doctor gives you to treat Mycoplasma genitalium infection. Do not share medicine for Mycoplasma genitalium with anyone. Your sex partner(s) should also see a doctor who can test and treat them if needed. When taken properly, treatment will stop the infection and can decrease your chances of having problems later. Although medicine will stop the infection, it will not undo any permanent damage caused by the disease.

It is becoming harder to treat some Mycoplasma genitalium infections, as drug-resistant strains of Mycoplasma genitalium are increasing. Return to your doctor if your symptoms continue for more than a few days after completing treatment.

When can I have sex again after my Mycoplasma genitalium treatment?

Wait until you and your sex partner(s) complete Mycoplasma genitalium treatment and symptoms are gone before you have sex again.

If you were treated for Mycoplasma genitalium in the past, you can still get it again. This can happen if you have vaginal or anal sex without a condom with a person who has Mycoplasma genitalium.

What happens if I don’t get Mycoplasma genitalium treated?

Left untreated, Mycoplasma genitalium can cause serious and permanent health problems in women, including pelvic inflammatory disease (PID). Some of the complications of PID are:

• Formation of scar tissue that blocks fallopian tubes;
• Ectopic pregnancy (pregnancy outside the uterus);
• Infertility (not being able to get pregnant); and
• Long-term pelvic or abdominal pain.

For people who are already pregnant, Mycoplasma genitalium may be associated with preterm (early) delivery or pregnancy loss.

Currently experts do not know if men develop long-term health problems from Mycoplasma genitalium.

Mycoplasma genitalium transmission

You can get mycoplasma genitalium by having vaginal or anal sex without a condom with someone who has the infection. Researchers are still determining whether sex partners can spread Mgen through oral sex.

A person with mycoplasma genitalium can pass the infection to someone even when they have no signs or symptoms.

How can I reduce my risk of getting Mycoplasma genitalium?

The only way to completely avoid STDs such as Mycoplasma genitalium is to not have vaginal or anal sex.

If you are sexually active, the following things can help lower your chances of getting Mycoplasma genitalium:

• Being in a long-term mutually monogamous relationship with a partner who does not have Mycoplasma genitalium; and
• Using condoms the right way every time you have vaginal or anal sex.

Mycoplasma genitalium signs and symptoms

Mycoplasma genitalium causes symptomatic and asymptomatic urethritis among men.

When present, the typical symptoms of Mycoplasma genitalium urethritis include:

• painful urination (dysuria),
• urethral itch, and
• purulent or mucopurulent urethral discharge.

On examination, urethral discharge is often present. However, the discharge may not be grossly evident, and urethral milking (placing pressure along the length of the penis to express discharge) may be necessary for detection.

Among women, Mycoplasma genitalium may cause cervicitis and pelvic inflammatory disease (PID), though individuals with cervicitis due to Mycoplasma genitalium often are asymptomatic.

When present, symptoms associated with Mycoplasma genitalium cervicitis include:

• vaginal discharge,
• vaginal itching,
• painful urination (dysuria), and
• pelvic discomfort.

Clinical findings associated with cervicitis include purulent or mucopurulent cervical discharge and cervical friability. Vaginal wet smear or cervical fluid Gram stain may show elevated numbers of polymorphonuclear leukocyte cells.

Symptoms of pelvic inflammatory disease (PID) due to Mycoplasma genitalium may include:

• mild to severe pelvic pain,
• abdominal pain,
• abnormal vaginal discharge, and/or
• bleeding.

Research shows that 1%-26% of men who have sex with men and 3% of women have rectal infections of Mycoplasma genitalium ²⁸, ²⁹, ³⁰, ³¹, ³² Rectal infections often are asymptomatic, but not always.

Similarly, people may have asymptomatic Mycoplasma genitalium in the pharynx. However, no evidence exists of it causing oropharyngeal symptoms or systemic disease. At this time, more research is needed to determine whether oral sex can spread Mycoplasma genitalium.

Mycoplasma genitalium complications

Mycoplasma genitalium is consistently associated with urethritis in men. However, there is not enough data to implicate Mycoplasma genitalium infection with adverse reproductive consequences (e.g., epididymitis, prostatitis, or infertility). The consequences of asymptomatic infection with Mycoplasma genitalium among cisgender men are unknown.

While Mycoplasma genitalium is associated with cases of pelvic inflammatory disease (PID), there are conflicting data regarding the strength of the association ³¹, ⁹. There are no clinical trials examining treatment of Mycoplasma genitalium and prevention of PID. In vitro inoculation of Mycoplasma genitalium into fallopian tube tissue causes damage to cilia, and Mycoplasma genitalium is more common among cisgender women with infertility. However, data are conflicting regarding the association between Mycoplasma genitalium and tubal factor infertility. Data are also limited regarding the association of Mycoplasma genitalium with ectopic pregnancy or preterm delivery.

Mycoplasma genitalium diagnosis

Laboratory tests can diagnose Mycoplasma genitalium. Your doctor may ask you to provide a urine sample for testing. In some cases, they may use (or ask you to use) a swab to get a sample from the vagina or cervix.

Nucleic acid amplification testing (NAAT) also called polymerase chain reaction (PCR) is the preferred method of detection for Mycoplasma genitalium. To diagnose Mycoplasma genitalium in men using nucleic acid amplification testing (NAAT), urine samples are the optimal specimen. For females, urine or cervical or vaginal swab samples are acceptable, but the preferred specimen types are vaginal swabs ³³. Several commercial laboratories in the U.S. have laboratory-developed tests which also utilize nucleic acid amplification (NAAT). There are not published data on the sensitivity and specificity of these tests compared to FDA-approved NAATs.

Mycoplasma genitalium is an extremely slow growing organism. Culture can take up to six months and only a few research settings in the U.S. have the technical capability to culture Mycoplasma genitalium ³⁴.

Mycoplasma genitalium treatment

The recommended treatment for all cases of Mycoplasma genitalium infections includes a two-stage approach with doxycycline, followed by an additional agent (either moxifloxacin or azithromycin), ideally using resistance-guided therapy ¹⁶, ⁸.

Recommended antibiotic regimens if M. genitalium resistance testing is available ¹⁶, ⁸:

• If 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)
• If macrolide resistant: Doxycycline 100 mg orally 2 times/day for 7 days followed by moxifloxacin 400 mg orally once daily for 7 days

Recommended antibiotic regimens if M. genitalium resistance testing is Not Available ¹⁶, ⁸:

• If M. genitalium is detected by an FDA-cleared NAAT: Doxycycline 100 mg orally 2 times/day for 7 days, followed by moxifloxacin 400 mg orally once daily for 7 days

Although cure rates with doxycycline monotherapy are low, using doxycycline as the initial agent may lower Mycoplasma genitalium organism load and facilitate organism clearance, thereby increasing likelihood of moxifloxacin success ¹⁷. Higher doses of azithromycin have not been effective for M. genitalium after azithromycin treatment failures. Men with persistent or recurrent urethritis after treatment for M. genitalium should be referred to an infectious disease or urology specialist ⁸.

Mycoplasma genitalium treatment failures can occur when using doxycycline, azithromycin, and moxifloxacin ¹⁸. Microbiologic cure rates are poor with either doxycycline or azithromycin monotherapy (~50% or less). Microbiologic cure rates for moxifloxacin were initially high (close to 100%) but have declined to 89% in studies conducted from 2010-2017 ¹⁹.

For cases of suspected treatment failure, consult the STD Clinical Consultation Network here https://www.stdccn.org

Resistance to azithromycin, which has been recommended for treatment, is high across the globe ²⁰, ²¹. Pharmacokinetic data indicate that changing azithromycin dosing from a single-dose strategy to a multiday strategy might protect against inducing resistance in M. genitalium infections ²², ²³.

Recommended PID treatment regimens are not effective against M. genitalium. Initial empiric therapy for PID, which includes doxycycline 100 mg orally 2 times/day for 14 days, should be provided at the time of presentation for care ¹⁶. If M. genitalium is detected, a regimen of moxifloxacin 400 mg orally once daily for 14 days has been effective in eradicating the organism ¹⁶. Nevertheless, no data have been published that assess the benefits of testing women with PID for M. genitalium, and the importance of directing treatment against this organism is unknown ¹⁶.

HIV infection

Persons who have M. genitalium and HIV infection should receive the same treatment regimen as those persons without HIV ¹⁶.

Follow-Up

Test of cure is not recommended for asymptomatic persons who received treatment with a recommended regimen ¹⁶. In settings in which M. genitalium testing is available, persons with persistent urethritis, cervicitis, or PID accompanied by detection of M. genitalium should be treated with moxifloxacin.

Management of Sex Partners

Recent studies report a high concordance of M. genitalium among partners of males, females, and men who have sex with men; however, no studies have determined whether reinfection is reduced with partner treatment ¹⁴, ³⁵, ³⁶. Sex partners of patients with symptomatic M. genitalium infection can be tested, and those with a positive test can be treated to possibly reduce the risk for reinfection ¹⁶. If testing the partner is not possible, the antimicrobial regimen that was provided to the patient can be provided ¹⁶.

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