Mycoplasma genitalium (M. genitalium) is a tiny bacterium that causes sexually transmitted infections. It's similar to chlamydia but smaller and harder to detect. It lives in the urinary and genital tracts.

Signs and symptoms

M. genitalium can cause a range of symptoms, though some people have none. Common symptoms by sex:

In Men:

1. Urethritis: Inflammation of the urethra, causing pain during urination.
2. Discharge: A clear or white discharge from the penis.
3. Dysuria: Pain or burning sensation during urination.
4. Testicular Pain: Sometimes associated with discomfort or pain in the testicles.

In Women:

1. Cervicitis: Inflammation of the cervix, causing abnormal vaginal discharge.
2. Pelvic Pain: Pain in the lower abdomen or pelvic area.
3. Dysuria: Pain or burning sensation during urination.
4. Intermenstrual Bleeding: Bleeding between menstrual periods or after sexual intercourse.
5. Vaginal Discharge: Abnormal vaginal discharge that may be clear, white, or yellowish.

Potential complications:

• Pelvic inflammatory disease (PID): in women, M. genitalium can cause PID, which can lead to infertility.
• Epididymitis: in men, it can cause inflammation of the epididymis, causing scrotal pain and swelling.
• Preterm birth: infection during pregnancy is linked to preterm birth and other complications.
• Higher HIV risk: raises the risk of getting and transmitting HIV for both men and women.

Why screening for M. genitalium matters

When screening is recommended

Screening isn't routine. It's recommended in specific situations:

1. Persistent symptoms: persistent or recurrent urethritis, cervicitis, or PID after treatment for chlamydia or gonorrhea.
2. High-risk groups: multiple sexual partners or people attending sexual health clinics.
3. Test of cure (TOC) after treatment, especially where antibiotic resistance is high.

Routine screening vs. targeted testing

• Routine screening: regular checks for common STIs like chlamydia and gonorrhea, done regardless of symptoms.
• Targeted testing: focused on people with specific symptoms or risks. For M. genitalium, that means testing when other infections are ruled out but symptoms persist.

How screening helps

Benefits at the public and individual level:

• Public health: reduces the spread of the infection and antibiotic-resistant strains. Early detection prevents complications and transmission.
• Individual health: avoids complications like PID, infertility, and chronic pain. Gets you proper treatment and follow-up.

Challenges to wider screening:

1. Limited awareness: providers and the public often aren't familiar with M. genitalium and its risks.
2. Testing availability: tests like NAAT aren't always available or affordable.
3. Antibiotic resistance: rising resistance complicates treatment, which makes targeted testing crucial.

Public health significance

M. genitalium is a common cause of non-gonococcal urethritis (NGU) in men, and causes cervicitis and PID in women. Antibiotic resistance is rising, which makes it harder to treat.

Prevalence in Canada varies by region and population:

• General population: 1-3%.
• High-risk populations (sexual health clinic attendees): up to 4-5%.
• Antibiotic resistance: about 58% of detected cases are macrolide-resistant.

A Toronto study found 4.5% of men and 3.2% of women tested positive. The data points to a real need for awareness and testing.

How is M. genitalium diagnosed in Canada?

Diagnostic tests and NAAT

Diagnosis in Canada relies on Nucleic Acid Amplification Tests (NAAT). NAAT detects the bacteria's genetic material and is highly accurate. It's the gold standard for M. genitalium because of its sensitivity and specificity. Culture tests aren't practical because M. genitalium grows slowly and needs special media.

Sample types:

• Urine: used for men and women. Non-invasive and easy to collect.
• Cervical: swabs from the cervix, mostly for women.
• Vaginal: swabs from the vaginal wall.
• Urethral: swabs from the urethra, used in both men and women.
• Endometrial: samples from the uterine lining, used when PID is suspected.

Rule out other STIs first

Before diagnosing M. genitalium, rule out chlamydia and gonorrhea. The symptoms overlap.

1. Persistent symptoms: if symptoms continue after treating chlamydia or gonorrhea, test for M. genitalium.
2. Accurate diagnosis: makes sure treatment is targeted, which prevents misuse of antibiotics and resistance.

Follow-up testing

Test of cure (TOC) confirms the infection is gone:

• Timing: do TOC at least three weeks after finishing treatment. Earlier may pick up residual bacterial DNA and give false positives.
• Symptomatic patients: always do TOC if symptoms persist.
• High-resistance regions: TOC is crucial to confirm treatment worked.

How to treat M. genitalium

Antibiotic regimens: azithromycin and moxifloxacin

Treatment in Canada uses specific antibiotics:

• Azithromycin: for first-time treatment, start with 500 mg on day 1, then 250 mg daily for four more days. The multi-day approach is preferred over a single large dose because it reduces the risk of resistance.
• Moxifloxacin: used when azithromycin fails or the strain is known to be resistant. Standard dose is 400 mg once daily for seven days. Reserve it for confirmed or suspected resistance to keep it effective.

Treating macrolide-resistant strains

If azithromycin doesn't work, moxifloxacin is next: 400 mg daily for seven days.

Treating PID

PID from M. genitalium needs more aggressive treatment:

• PID: 400 mg moxifloxacin once daily for 14 days. The longer course is needed to clear the infection from the reproductive organs.
• Combination therapy: moxifloxacin is often combined with other antibiotics to cover the range of possible pathogens.

Why following treatment guidelines matters

To prevent antibiotic resistance:

• Finish the full course, even if symptoms improve.
• Don't self-prescribe antibiotics or use leftover medication.
• Schedule follow-up appointments to confirm the infection is cleared, especially in high-resistance regions.

Why follow-up matters after treatment

Test of cure (TOC) at least three weeks post-treatment

• Why three weeks? This gives time for any remaining bacterial DNA to clear. Earlier testing can show false positives from leftover DNA fragments.
• Confirming success: TOC confirms the antibiotic regimen worked.

Patients in high-resistance regions

• Use local resistance data to pick the right antibiotic. In regions with high macrolide resistance, moxifloxacin may be first-line.
• Closer follow-ups catch treatment failures early.

Handling persistent symptoms

• If symptoms continue, reassess and possibly retest for M. genitalium and other STIs like chlamydia or gonorrhea.
• If first-line treatment fails, alternative antibiotics or combination therapy may be needed.

How to notify and manage partners to prevent reinfection

Partner notification and treatment

Treating partners is critical to stopping the spread:

1. Identify current and recent partners: ask patients for contact info for all sexual partners in the past six months.
2. Confidential notification: use anonymous notification services or have patients inform partners directly.
3. Encourage testing and treatment: partners should test and treat even without symptoms.

Preventing reinfection of the index case

• Simultaneous treatment: all identified partners should be treated alongside the index case to prevent ping-pong reinfection.
• Abstain from sex during treatment until both partners complete the course and TOC confirms the infection is cleared.

Treat current partners regardless of symptoms

• Asymptomatic carriers spread the infection unknowingly.
• Treating all partners eradicates the bacteria and reduces recurrent infections.

At TeleTest, we offer testing and treatment. You can test for M. genitalium alone with NAAT, or do a full STI panel to rule out chlamydia and gonorrhea.

Disclaimer: This blog post is intended for educational purposes only and should not be taken as medical advice. Always consult your healthcare provider for personal health concerns.