A familiar pattern turns up in men’s health clinics. A man has burning with urination and perhaps a small amount of discharge. He is tested for chlamydia and gonorrhea, both come back negative, and he is treated with a standard antibiotic anyway. The symptoms improve for a while and then return. He is tested again, negative again, and by the third visit he has begun to wonder whether the problem is in his head.
It usually is not. A common explanation for that sequence is an organism called Mycoplasma genitalium, a sexually transmitted bacterium that has only been widely recognised in the last couple of decades and that most standard testing panels still do not include.
What It Is and Why It Is Missed
Mycoplasma genitalium is a small bacterium transmitted through sexual contact. In men it most often causes urethritis — inflammation of the urethra producing burning with urination, discomfort at the tip of the penis, and sometimes a thin discharge that is easy to overlook. It can also contribute to inflammation of the prostate and, less commonly, of the epididymis.
It goes undetected for two connected reasons. The first is that it is not part of the standard STI panel in most settings; a routine screen tests for chlamydia and gonorrhea, and a negative result on both is often read as ruling out an infectious cause. The second is that the organism lacks a cell wall, which makes it invisible on conventional bacterial cultures and also means several common antibiotics have no effect on it whatsoever. A man can be treated with something that would have cleared chlamydia and see no benefit at all, which reinforces the impression that no infection is present.
Like chlamydia and gonorrhea, it frequently causes no symptoms. Many people carry it without knowing, and it can be passed on regardless.
Testing and Treatment
Testing requires a specific nucleic acid amplification test that is ordered separately from the standard panel. In men this is usually done on a urine sample, the same way chlamydia and gonorrhea testing is done. The practical obstacle is simply that someone has to think to request it, which is why persistent or recurrent urethral symptoms after negative routine testing are worth returning about rather than tolerating.
Treatment is more involved than for chlamydia. Mycoplasma genitalium has developed considerable resistance to the antibiotics that were first used against it, and treatment failure is common enough that a specific approach is required. Current practice generally involves a sequence of two antibiotics rather than a single course, and where laboratory capability allows, testing the sample for resistance markers guides which agents to use. A test of cure some weeks after treatment is standard, because assuming success is not safe with this organism.
Partners need treatment as well. Reinfection between untreated partners is a frequent cause of what looks like recurrent failure, and treating one person while the other remains positive achieves very little.
When to Raise It
The situation that should prompt the question is persistent urethral symptoms in the absence of a positive standard test — burning, irritation, intermittent discharge, or vague discomfort that comes and goes over weeks or months, particularly if a previous antibiotic course helped only briefly. It is also worth considering when a partner has unexplained pelvic inflammation or cervicitis.
None of this means every man with urinary discomfort has Mycoplasma genitalium. Non-infectious causes of urethral irritation exist, as do prostatitis and other conditions that produce similar symptoms. The value in knowing the organism exists is that it gives you something concrete to ask about, and it counters the far more damaging conclusion that unexplained symptoms mean nothing is really wrong.
Dr. Raymond Nash assesses urinary and sexual health symptoms, including persistent urethritis, at Grande Prairie Men’s Medical Clinic. Appointments are available through gpmm.clinic or at (587) 416-8296. This article provides general information and cannot substitute for a proper clinical assessment of your own symptoms.