What are the indications for a Mycoplasma (Mycoplasma) and Ureaplasma (Ureaplasma) Nucleic Acid Amplification Test (NAAT) urine test?

Indications for Mycoplasma and Ureaplasma Nucleic Acid Amplification Test (NAAT) Urine Testing

NAAT testing for Mycoplasma and Ureaplasma species is not recommended for routine screening in asymptomatic individuals due to high colonization rates in the general population, but should be performed in patients with persistent or recurrent urethritis after treatment for other STIs and in patients with non-gonococcal urethritis where other causes have been ruled out. 1

Primary Indications for Testing

Strongly Indicated:

• Persistent or recurrent urethritis after treatment for other sexually transmitted infections 2, 1
• Non-gonococcal urethritis (NGU) where other common pathogens (Chlamydia, Gonorrhea) have been ruled out 2, 1
• Symptomatic sterile leukocyturia (presence of white blood cells in urine without standard bacterial growth) 1
• Severe NGU (>30 polymorphonuclear leucocytes per high-powered field) 3

Consider Testing In:

• Patients with chronic urethritis unresponsive to standard therapy 1
• Patients with suspected hyperactive bladder or interstitial cystitis/painful bladder syndrome where other causes have been excluded 4
• Lower urinary tract symptoms (LUTS) in women under 50 years of age with normal filling cystometry 5

Not Indicated For:

• Routine screening in asymptomatic individuals 2, 1
• Asymptomatic colonization (Ureaplasma species are found in 14-15% of the general population) 3
• Recurrent UTI without ruling out other common uropathogens first 6

Specimen Collection Considerations

• First-void urine samples are appropriate for NAAT testing 2, 1
• Urethral swabs show higher specificity (98.7-99.9%) and positive predictive value (96.3-99.6%) compared to urine specimens for detection of both Mycoplasma hominis and Ureaplasma urealyticum 5
• Vaginal swabs (in women) can also be used but have lower specificity than urethral specimens 5

Clinical Pearls and Pitfalls

Important Considerations:

• The urethral inflammatory response to Ureaplasma is significantly lower than to Mycoplasma genitalium and Chlamydia trachomatis, which may lead to less obvious clinical presentations 3
• Ureaplasma parvum is often found in patients with no or mild signs of urethritis (0-9 PMNL/HPF) and may represent colonization rather than infection 3
• Prevalence of Mycoplasmas is significantly higher in women with LUTS (30.3%) compared to those without (14.5%) 5

Avoiding Common Pitfalls:

• Overdiagnosis and overtreatment can occur due to high colonization rates in asymptomatic individuals 1
• Misattribution of symptoms to Ureaplasma when other more common urogenital pathogens are present 1
• Failure to test for antimicrobial resistance, as resistance to macrolides, tetracyclines, and fluoroquinolones has been reported 1, 7

Testing Algorithm

1. First-line testing: Rule out common urinary pathogens and STIs (standard urine culture, NAAT for Chlamydia and Gonorrhea)
2. If negative but symptoms persist: Consider NAAT for Mycoplasma genitalium and Ureaplasma species
3. Specimen choice: Urethral swab preferred (highest specificity), first-void urine acceptable
4. Interpretation: Positive results in symptomatic patients after ruling out other causes should guide antimicrobial therapy based on local resistance patterns

By following these evidence-based indications, clinicians can appropriately utilize Mycoplasma and Ureaplasma NAAT testing to improve diagnosis and management of urogenital infections while avoiding unnecessary testing in colonized but asymptomatic individuals.