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Ureaplasma & UTI

In our closed Facebook group we often discuss UTI-like symptoms in men and women who also have negative urine culture results (this is when no bacteria grows in their urine specimen).
While standard urine culture test could often be misleading, it is still an important piece of a puzzle in finding a cure. One of the issues with this test is that it can grow only a certain type of bacteria.
So when urine cultures are negative while symptoms seem to persist, physicians often screen for a range of other non-typical microbes, like mycoplasma and chlamydia.

Mycoplasma (Ureaplasma), Chlamydia & UTI-like symptoms

Cystitis or urinary tract infection could be caused by multiple microorganisms and their combination.
Typically, up to 90% of all UTIs are caused by bacteria that ascended from the lower gut (for example, E.coli bacteria) toward the urethra. While residing in your gut, these bacteria are helpful but could cause trouble if they reach your bladder.
Conversely, Chlamydia trachomatis, Mycoplasma genitalium, Ureaplasma species, Urealyticum, Gardnerella vaginalis, & Candida are among the few least popular ones that originate in female’s vagina.

  • Here is how to know if it’s a time to check for bacteria and yeast that could be originating in your vagina and causing UTI-like symptoms:
  • The are leukocyte (white blood cells) in your urinalysis but culture shows no bacterial growth.
  • Standard UTI antibiotics do not work. You took the complete course but symptoms remained the same.
  • You might have unusual vaginal discharge and pain during sex.
  • Swelling at the opening of the urethra and (especially for men) discharge from the urethra.

Are Mycoplasma & Ureaplasma an STD?

Ureaplasma is a part of Mycoplasma species family that is about 200 members large. While many of these species are a part of our body’s healthy microbiome, several types can cause a problem.

The ones you may have to worry about in relation to urinary tract symptoms are:

  • Ureaplasma urealyticum (in men & women),
  • Ureaplasma parvum (in women),
  • Mycoplasma hominis (in men & women),
  • Mycoplasma genitalia (in men & women).

These microorganisms live in cervix or vagina of many healthy women. Coincidentally, some men can have them in their urethras because they can spread through sex. They do not normally cause any harm to either of the partners. And since Mycoplasma bacteria are part of normal women’s vaginal flora they are not a sexually transmitted disease (STD).

Is Ureaplasma Causing My Symptoms?

While it is tempting to attribute all mysterious cases of UTI to a Ureaplasma overgrowth, it is more complicated than this. In fact, the more we know about bacteria and their types, the harder it is to put the blame on Ureaplasma alone.
Several studies looked at women with or without negative cultures and UTI-like symptoms and found no correlation between their symptoms and colonization with Ureaplasma.
While Ureaplasma is often present & could be detected in many women, it doesn’t seem to be solely responsible for cystitis-like symptoms.

In one study, 1,032 cases of women with bladder symptoms and there was no correlation found for UTI-like symptoms (while negative cultures) reviewed.
“No significant association between the detection of U. parvum or U. urealyticum and symptom status was found”, concludes another study.

However, an overgrowth of ureaplasma might signal that another pathogen is present.
For example, a positive result for Chlamydia trachomatis (C. trachomatis) & Ureaplasma is highly correlated “suggesting that mixed infection is an important factor in bacterial pathogenesis in the genital tract”, concluded a researcher.
It is even possible that the presence of U. parvum could provide some advantages for the survival of C. trachomatis in the genital tract. That’s why n most cases, a physician will test for Chlamydia and Ureaplasma at the same time.

We can speculate that ureaplasma could be contributing to the infection and symptoms when other bacteria are present as well.

Similar to ureaplasma, Chlamydia infections often go hand in hand with other infections and often wrongfully attributed as the main reason for UTI-like symptoms while a more extensive investigation could uncover even more pathogens.

Therefore, ask to also test for Trichomonas vaginalis, Gonorrhea, Mycoplasma genitalium, and Bacterial vaginosis, too.

If you do decide to run a test, PCR is the best option.

Specifics of Cystitis & Ureaplasma in Men

Ureaplasma urealyticum but not Ureaplasma parvum seem to be a culprit of symptoms for men. However, only high loads of Ureaplasma parvum might be associated with symptoms.
While some studies firmly attribute an overgrowth of Ureaplasma species to persistent and recurrent urethritis.
Others point out that men could be colonized with ureaplasma without symptoms and even without elevated leukocytes.

Similar to the points made earlier, it could be that U. parvum is only a surrogate marker for other bacterial infections that may cause urethritis in men.
And even more puzzling, in up to 35% of the cases, none of the known viral or bacterial causes are found.

Do Not Test for Ureaplasma!

Since it is still, for the most part, unclear when Mycoplasma species are responsible for UTI-like symptoms, some raise a question if treatment and even testing are necessary.
Here are parts of a position statement by European STI Guidelines Editorial board as of November 2018:
“At present, we have no evidence that we are doing more good than harm detecting and subsequently treating Mycoplasma hominis, Ureaplasma parvum, and Ureaplasma urealyticum colonization/infections. “ They continue to suggest that since these bacteria are so common, test for them only once other pathogens are ruled out and the patient still has symptoms.
First, rule out:

  • Neisseria gonorrhoeae
  • Chlamydia trachomatis
  • Mycoplasma genitalium
  • Trichomonas vaginalis
  • Bacterial vaginosis (BV).

Focusing on ureaplasma leads to overuse of antibiotics and creating antibiotic-resistant bacteria, argue the authors.

Current Treatment Protocols

Unfortunately, only certain types of antibiotics work on Ureaplasma microorganisms. Moreover, the antibiotics commonly prescribed for UTI are frequently not effective against this group of bacteria.

Should both partners be treated?

Since treatment for Ureaplasma (as mentioned above) recommended only when a patient is symptomatic, the traditional approach is to only treat one partner. This is because there is no correlation between symptoms in a couple. One partner might have symptoms, another might not while they could share a similar bacterial profile in regards to Ureaplasma.
But since rates of recurrence after standard treatment are high it could be beneficial to treat both partners especially if re-infection is not ruled out. This remains an area where further research is needed.

Which antibiotics for Ureaplasma?

Two top antibiotic options to treat UTI-like symptoms caused by Mycoplasma species are azithromycin and doxycycline.
There were no significant differences in efficacy between these two antibiotics.

Moxifloxacin should be used with caution and reserved for treatment failures which are thought secondary to macrolide-resistant M. genitalium, because of rare but serious adverse hepatic reactions.

It is also sometimes suggested that any treatment of persistent UTI-like symptoms should cover M.genitalium and T. vaginalis and/or bacterial vaginosis-associated bacteria. However, evidence for the following recommendations is limited and is based on clinical experience and guidelines.

Here is a review of two possible protocols
1) If doxycycline was prescribed as first-line therapy, switch to Azithromycin 500 mg or 1gram day one, then 250 mg once daily for 4 days plus metronidazole 4–500 mg twice daily for 5 days.
2) If azithromycin was prescribed as first-line therapy, doxycycline 100 mg twice daily for 7 days plus metronidazole 4–500 mg twice daily for 5–7 days should be prescribed.

To sum it all up:

  • The above-mentioned Mycoplasma microorganisms can occur as commensals or as potential pathogens.
  • In most cases their role in your symptoms cannot be proven, only assumed.
  • Ask for a wide range of STD testing prior to jumping to an antibiotic treatment protocol targeting only Mycoplasma.


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