Should Mycoplasma urealyticum be checked routinely for STD evaluation?

Routine Testing for Mycoplasma urealyticum in STD Evaluation

Mycoplasma urealyticum (Ureaplasma urealyticum) should NOT be routinely checked during standard STD evaluation, as it is not recommended by CDC guidelines and lacks clear association with disease in most clinical contexts. 1

Guideline-Based Recommendations

Standard STD Screening Panel

The CDC explicitly recommends testing for the following organisms during STD evaluation:

• Chlamydia trachomatis (highest priority, especially in women <25 years and sexually active adolescents) 1
• Neisseria gonorrhoeae (second priority, with same risk-based screening criteria) 1
• Syphilis (all patients tested for gonorrhea/chlamydia should also be tested for syphilis) 1
• HIV (universal recommendation for all STD evaluations) 1
• Trichomonas vaginalis (when symptomatic or high-risk factors present) 1

Why Mycoplasma/Ureaplasma Are NOT Included

Lack of standardized diagnostic criteria: The CDC guidelines from 2002 and 2006 acknowledge that while Ureaplasma urealyticum and Mycoplasma genitalium are implicated in some cases of nongonococcal urethritis (NGU), "specific diagnostic tests for these organisms are not indicated" in routine practice 1. This reflects the fundamental problem that these organisms:

• Are frequently found in asymptomatic individuals (40-80% colonization rate for ureaplasmas in sexually mature women) 2
• Do not reliably predict disease even when present 1
• Lack FDA-cleared commercial testing with established clinical utility 1

Clinical context matters: The CDC recognizes M. genitalium and U. urealyticum may cause up to one-third of NGU cases, but reserves consideration of these organisms only for persistent/recurrent urethritis that has failed standard chlamydia and gonorrhea treatment 1. This is a fundamentally different clinical scenario than routine STD screening.

When Testing Might Be Considered (Non-Routine Scenarios)

Persistent Urethritis After Treatment

• Male patients with documented urethritis (≥5 WBCs per oil immersion field on Gram stain or ≥10 WBCs per high-power field on urine microscopy) who remain symptomatic after appropriate treatment for chlamydia and gonorrhea 1
• Reinfection and non-adherence must be excluded first 1

Persistent Cervicitis

• Women with mucopurulent cervicitis who have negative testing for C. trachomatis, N. gonorrhoeae, and T. vaginalis, and in whom bacterial vaginosis has been excluded 1
• The CDC notes that M. genitalium may be involved, but emphasizes that "in most cases of cervicitis, no organism is isolated" and additional antimicrobial therapy may be of minimal benefit 1

Infertility Evaluation (Controversial)

• While some research suggests associations between Ureaplasma/Mycoplasma and male infertility parameters 3, and one Chinese study found 18.8% prevalence in infertility clinic patients 4, this is NOT part of standard CDC STD screening guidelines 1
• The evidence remains insufficient to recommend routine screening in this population based on guideline-level recommendations

Critical Pitfalls to Avoid

Overinterpretation of multiplex PCR results: Modern multiplex PCR panels often include Mycoplasma/Ureaplasma detection, leading to incidental findings 5. The presence of these organisms does not automatically indicate pathology requiring treatment 6.

Treating asymptomatic colonization: Research demonstrates that M. hominis, U. urealyticum, and U. parvum are not associated with symptoms or signs in women without bacterial vaginosis 6. Treating asymptomatic detection disrupts normal vaginal flora without proven benefit 7.

Confusing association with causation: M. hominis increases dramatically in bacterial vaginosis (BV), but this reflects BV-associated dysbiosis rather than M. hominis causing BV 2, 6. The organism is associated with BV symptoms (abnormal discharge, malodor, elevated pH, clue cells) only in women who already have BV 6.

Ignoring the established pathogens: The temptation to test for Mycoplasma/Ureaplasma should never replace comprehensive testing for the CDC-recommended organisms (chlamydia, gonorrhea, syphilis, HIV) that have clear disease associations and treatment benefits 1.

Practical Algorithm for STD Evaluation

1. Screen all sexually active women <25 years for chlamydia and gonorrhea using NAAT (urine, vaginal, or endocervical specimens) 1

2. Screen all patients with STD risk factors (new/multiple partners, inconsistent condom use, prior STD, MSM) for chlamydia, gonorrhea, syphilis, and HIV 1

3. If urethritis or cervicitis is present: Test for chlamydia and gonorrhea first; treat appropriately 1

4. Only if symptoms persist after appropriate treatment and reinfection is excluded: Consider that non-chlamydial, non-gonococcal organisms might be involved, but recognize that additional antimicrobial therapy may provide minimal benefit 1

5. Do NOT routinely test for Mycoplasma/Ureaplasma in asymptomatic patients or as part of initial STD screening 1, 6