Mycoplasmal and non chlamydial non-gonococcal urethritis

Author

Koichiro Wada (Department of Urology, Okayama University Hospital, Japan)

Ryoichi Hamasuna^# (Department of Urology, Federation of National Public Services and Affiliated Personel Mutual Aid Associations, Shin-Kokura Hospital, Japan)

Takuya Sadahira (Department of Urology, Okayama University Hospital, Japan)

Motoo Araki (Department of Urology, Okayama University Hospital, Japan)

^#Corresponding author

Introduction (overview)

Urethritis is classified as either gonococcal urethritis or NGU according to the presence or absence of Neisseria gonorrhoeae. NGU where Chlamydia trachomatis is detected by any diagnostic methods is defined as "chlamydial urethritis", while the absence of C. trachomatis from NGU is defined as "NCNGU". Possible causative agents of NCNGU include Mycoplasma genitalium, Trichomonas vaginalis, Ureaplasma urealyticum, Ureaplasma parvum, Mycoplasma hominis, Neisseria meningitidis, Gardnerella vaginalis, Haemophilus species, herpes simplex virus, and adenovirus^[1–17]. Among these, the pathogenicity of M. genitalium and T. vaginalis to the male urethra has been confirmed^[16–19].While U. urealyticum can cause male urethritis, there is not sufficient evidence for it as a pathogen of male urethritis^[20]. In this guidelines, diagnosis and treatment recommendations for male urethritis caused by either M. genitalium, or T. vaginalis are described. In addition, the treatments for NGU are described since tests to detect NGU-related microorganisms are not available in many countries.
The levels of evidence levels (LE) of cited articles were determined according to the Outline for Preparation of Guidelines established by the Centre for Evidence-Based Medicine, Oxford^[21]. The modified GRADE methodology^[22] was used for grading the recommendations.

Level of evidence

1a: Systematic reviews (with homogeneity) of randomized controlled trials
1b: Randomized controlled trials
1c: All or none randomized controlled trials
2a: Systematic reviews of cohort studies
2b: Individual cohort study or low quality randomized controlled trials
2c: “Outcomes” Research; ecological studies
3a: Systematic review of case-control studies
3b: Individual case-control study
4: Case-series
5: Expert opinion without explicit critical appraisal, or based on physiology, bench research or “first principles”

Recommendation grade:

A: high
B: moderate
C: low
D: very low

Executive summary

Epidemiology and pathogenesis

1. Urethritis that occurs in the absence of Neisseria gonorrhoeae and Chlamydia trachomatis is called NCNGU.
2. Several microorganisms including bacteria, viruses, or protozoa are thought to be associated with NCNGU, but only Mycoplasma genitalium (LE-1b, RG-A) and Trichomonas vaginalis (LE-2a, RG-B) have been confirmed as pathogens for male urethritis.
3. Ureaplasma urealyticum can cause male urethritis, but there is not sufficient evidence to confirm it as a pathogen of male urethritis (LE-3a, RG-C). The associations of other microorganisms with male urethritis such as Ureaplasma parvum, Mycoplasma hominis, Neisseria meningitidis, and others remain unclear (LE-4, RG-C).

Diagnosis

1. M. genitalium is detected from urine specimens in 10–25% of male patients with symptomatic urethritis by NAATs (LE-1b, RG-A).
2. T. vaginalis can be detected by either microscopic examination or NAATs in the urine specimens of patients with urethral symptoms or whose sexual partners are infected with T. vaginalis (LE-2a, RGB).

Treatment

1. At the moment, either doxycycline regimen such as 100 mg twice a day for 7 days or azithromycin regimens, including a single 1 g oral dose of azithromycin or an extended azithromycin regimen such as 500 mg on day 1 followed by 250 mg once per day on days 2-5 are recommended as the first line treatment for M. genitalium urethritis (LE-3a, RG-C). Because macrolide-resistance in M. genitalium is spreading worldwide, in some countries where the detecting rates of MRM in M. genitalium are high, azithromycin regimen may not be appropriate for M. genitalium urethritis for much longer.
2. For macrolide-resistant M. genitalium strains, newer fluoroquinolone regimens such as moxifloxacin 400 mg per day for 10 days (LE-3a, RG-C) or sitafloxacin 100 mg twice a day for 7 days (LE-3a, RG-C) are recommended as the second line therapies.
3. For T. vaginalis urethritis, a single dose of either metronidazole 2 g orally or tinidazole 2 g is recommended (LE-1b, RG-A). If these regimens fail, metronidazole 500 mg twice a day for 7 days is recommended (LE-3, RG-B).

Pathogenicity of microorganisms for NCNGU and epidemiology

Several studies have investigated the frequency of microorganisms that are detected in NCNGU patients' urine^[1–17]. M. genitalium is detected in 10–25% of patients with symptomatic urethritis by NAATs, but only 1–7% of asymptomatic patients at sexually transmitted infection clinics or with other infections. To determine the pathogenicity of M. genitalium to the male urethra, Taylor-Robinson proposed a modification to the Henle-Koch postulates that focused on epidemiological studies, animal model studies, in vitro antimicrobial susceptibility testing, clinical responses to antimicrobials, and transmissibility to determine the pathogenicity of M. genitalium to the male urethra^[23]. Many studies supported the pathogenicity of M. genitalium to the male urethra, and it has been finally confirmed that M. genitalium is one of the pathogens that cause male urethritis^{[18,19,24–26]}. However, the relationship between M. genitalium and prostatitis, epididymitis, and other male disorders is still unclear.
T. vaginalis is detected in the urine of 1–20% of urethritis patients by either microscopic examination or NAATs^{[6,9–13,15,27–31]}. T. vaginalis is usually detected in patients whose sexual partners have trichomonal vaginitis, and most male patients are asymptomatic. However, T. vaginalis is also detected in patients with urethral symptoms such as urethral discomfort or dysuria, or who failed to respond to antimicrobial urethritis therapies^[30]. The pathogenicity of T. vaginalis to the male urethra is thought to be confirmed^[16,19].
U. urealyticum has been detected in 7–33% of urine specimens from symptomatic urethritis patients using NAATs^{[3,4,9,14,15,28,29,32–37]}. The possibility that U. urealyticum is a pathogen of the male urethritis has long been discussed. U. urealyticum alone can sometimes be detected from urine specimen of patients with strong urethritis symptoms and urethritis by U. urealyticum can be treated with antimicrobials which are sensitive to U. urealyticum in vitro. However, U. urealyticum is also detected in asymptomatic men at higher rates^[14,38]. U. urealyticum can be a pathogen for male urethritis, but there are still unresolved problems as described above^[20].
Other microorganisms such as herpes simplex virus, adenovirus, or N. meningitis are also possible NCNGU pathogens^[1,17]. However, comparative studies between patients with urethritis and controls have not been performed to determine the pathogenicity of these microorganisms. U. parvum and M. hominis have also been detected in the urine of urethritis patients, but are also detected in controls at high rates so the pathogenicity of these bacterial species has not been determined.

Diagnosis

M. genitalium can only be detected by NAATs. In some Asian countries and Australia, commercial-based tests using either multiplex-PCR or TMA on FVU are available for detection of N. gonorrhoeae, C. trachomatis, M. genitalium, U. urealyticum, T. vaginalis, and other bacteria^[26,39–42]. T. vaginalis can also be detected as actively motile organisms in the urinary sediments of FVU, urethral discharge, or prostate secretions with microscopy^[43]. Direct immunofluorescent antibody staining or culturing is also available. Recently, commercial-based NAATs for detecting M. genitalium and T. vaginalis have become available in some Asian countries^[40], but not in all countries^{[25,26,31,43]}.

Treatment

Treatment for M. genitalium urethritis

Antimicrobial susceptibility of M. genitalium in vitro

Since the isolation of M. genitalium from clinical specimens is difficult, there are not many strains available for testing antimicrobial susceptibilities^[44–47]. Macrolides, tetracyclines, or fluoroquinolones have been thought to have activities against M. genitalium. Among these antimicrobials, macrolides such as azithromycin, clarithromycin, and erythromycin have stronger antimicrobial activity against M. genitalium than either fluoroquinolones or tetracyclines^[44,46,47]. The activities of fluoroquinolones such as moxifloxacin and sitafloxacin are stronger than other fluoroquinolones such as norfloxacin, ciprofloxacin, and levofloxacin. However, antimicrobial-resistant M. genitalium strains have emerged; macrolide-resistant strains in particular are spreading worldwide^[29,45–58]. Macrolide-resistant strains have been isolated from M. genitalium urethritis patients in Australia^[45,49], Northern Europe^[45,46], and Japan ^[47]. The macrolide-resistance in M, genitalium is strongly associated with point mutations of 23S rRNA, and the detection of these mutations in M. genitalium DNA from urine specimens has been reported from many countries. The prevalence of these MRM among M. genitalium genomes from clinical specimens is high: 68–79% in Australia^[54–56,58], 72% in Japan^[53], 48% in the USA^[48,51], and 42% in Denmark^[52]. It is interesting that according to a European report, the prevalence of MRM in M. genitalium genomes is high in countries where macrolides are recommended as a first line treatment for NGU, but significantly lower in countries where tetracycline is recommended^[59]. Regarding fluoroquinolone-resistance, some studies demonstrated that treatment-failure cases by moxifloxacin^{[46,47,50,54,56,57,60,61]} or sitafloxacin are increasing^[47,62,63]. Additionally, mutations on the gyrA and parC genes, which are related to fluoroquinolone resistance in some bacteria, have been observed^{[47,50,53,57,62]}. Furthermore, multi-drug resistant (both macrolides and fluoroquinolones) M. genitalium clinical strains have been isolated^[46,47].

Clinical studies of M. genitalium urethritis

More than 30 clinical trials on M. genitalium urethritis, including double-blind, randomized, control studies, comparative studies, single arm studies, and retrospective observational studies, have been reported. Between macrolides and tetracyclines, the microbiological efficacy of macrolide-regimens such as a single 1 g oral dose of azithromycin or the extended-azithromycin regimen (500 mg on day 1 followed by 250 mg once per day on days 2-5 )^[55,64] was superior to that of tetracycline-regimens such as doxycycline 100 mg twice a day for 7 days^{[18,48,65,66]}. However, the efficacy of macrolides is decreasing due to the emergence of macrolide-resistant M. genitalium strains^{[29,48,50–52,54]}. Some macrolide-resistant strains with MRM have emerged following the single-dose, 1 g azithromycin treatment; it is possible that azithromycin itself can induce or select for macrolide resistance^[45]. The effect of azithromycin should be monitored. Thus, in some countries, tetracycline regimens such as doxycycline 200 mg/day for 7 days are recommended in place of macrolide regimens as the first line treatment for NGU, including M. genitalium urethritis^[59].
Among the fluoroquinolones, levofloxacin efficacy was low^[67,68]. However, both moxifloxacin 400 mg per day for 7-10 days and sitafloxacin 100 mg twice a day for 7 days had good efficacy against M. genitalium urethritis^[49,63,64]. Moxifloxacin was an especially effective therapy for cases where azithromycin-treatment failed^[45,49]. In Asia, sitafloxacin is available only in Japan and Thailand, but there is little evidence for its effectiveness in cases with azithromycin-treatment failure. Nevertheless, more attention should be paid to fluoroquinolone-resistant M. genitalium.
In some area where multi-drug resistant M. genitalium has emerged^[46,47], antimicrobial sequential therapy should be considered. A new clinical trial has been reported from Australia^[56,58], where a highprecision test was used to detect M. genitalium and MRM in NGU patients following treatment with doxycycline 100 mg twice daily for 7 days. MRM-negative M. genitalium cases were then treated with azithromycin (1 g followed by 500 mg daily for 3 days), while MRM positive M. genitalium cases were treated with sitafloxacin 100 mg twice daily for 7 days. The microbiological outcomes of MRM-positive and MRM-negative cases were 92.2% and 94.8%, respectively. Recent report showed that the efficacies of either sitafloxacin 100 mg twice daily for 7 days or of moxifloxacin 400 mg once a day for 7 days were similar for MRM-positive M. genitalium cases^[57].

Treatment for Trichomonal urethritis

Antimicrobial susceptibility of T. vaginalis in vitro

Nitroimidazoles (metronidazole and tinidazole) are the only drugs recommended for treating trichomoniasis. However, nitroimidazole-resistant strains have emerged from cases of persistent or recurrent trichomoniasis. Metronidazole resistance was found in 4–10% of cases of trichomoniasis vaginitis, and tinidazole resistance was found in 1% of cases in the USA^[69,70].

Clinical studies for T. vaginalis urethritis

Clinical studies for trichomoniasis were performed using metronidazole or tinidazole between the 1970s and the 1990s^[19,71–73]. A single 2 g oral dose of either metronidazole or tinidazole was effective with cure rates of 84–98% and 92–100%, respectively. For metroimidazole-resistant strains in single-dose metronidazole or tinidazole treatment-failure cases, an alternative regimen, such as metronidazole 500 mg orally twice a day for 7 days, is recommended^[19,74].

Treatment regimens for NGU

The main NGU pathogen is C. trachomatis, for which azithromycin (e.g., a single 1 g dose orally) or tetracycline regimens, such as doxycycline 100 mg twice a day for 7 days, are recommended. While the microbiological efficacy of the doxycycline regimen for M. genitalium is lower, the efficacy of azithromycin against M. genitalium has decreased^[29,48,75]. In this sense, the efficacies of azithromycin and doxycycline against M. genitalium are almost similar. Therefore, either an azithromycin regimen or a doxycycline regimen is also recommended for NGU as the first line therapy. If either M. genitalium or T. vaginalis is detected by any methods, the appropriate treatment regimen for each pathogen is recommended; however, if the first line therapy was ineffective, fluoroquinolone regimens such as moxifloxacin 400 mg a day for 7-10 days are recommended as the second line. If available, a sitafloxacin regimen, such as 100 mg twice a day for 7 days, is also recommended.

Recommendations for M. genitalium urethritis, T. vaginalis urethritis, or NGU treatment

M. genitalium urethritis

At the moment, either doxycycline regimen such as 100 mg twice a day for 7 days nor azithromycin regimens, including a single 1 g oral dose of azithromycin or an extended azithromycin regimen such as 500 mg on day 1 followed by 250 mg once per day on days 2–5 are recommended as the first line treatment for M. genitalium urethritis (LE-3a, RG-C). Because macrolide-resistance in M. genitalium is spreading worldwide, in some countries such as USA, Australia, Northern Europe, Japan and others, where the detecting rates of MRM in M. genitalium are high, azithromycin regimen may not be appropriate for M. genitalium urethritis for much longer. If these regimens were ineffective, a moxifloxacin regimen such as 400 mg orally once a day for 7–10 days is recommended. A sitafloxacin regimen, such as 100 mg twice a day for 7 days, is also recommended if available.
If the detecting tests of MRMs in M. genitalium are available, the sequential therapy such as doxycycline 100 mg twice a day for 7 days at the first visit for NGU and additional fluoroquinolone regimens such as moxifloxacin or sitafloxacin for MRM-positive cases or azithromycin regimens for MRM-negative cases is recommended.

T. vaginalis urethritis

If T. vaginalis is detected in urine specimens from patients with either symptomatic urethritis or asymptomatic patients whose partners have trichomoniasis vaginitis, metronidazole or tinidazole as a single 2 g dose orally is recommended. If the single-dose regimen fails, oral metronidazole at 500 mg twice a day for 7 days is recommended.

NGU

For NGU (or chlamydial urethritis), a tetracycline regimen such as doxycycline 100 mg twice a day for 7 days or an azithromycin regimen such as a single 1 g oral dose of azithromycin is recommended. If one of these fails, regimens for M. genitalium or T. vaginalis are recommended.

Conclusion

M. genitalium and T. vaginalis are confirmed to be pathogens for NCNGU. M. genitalium is detected from urine specimens in 10–25% of male patients with symptomatic urethritis by NAATs. Macrolide-resistance in M. genitalium is spreading worldwide. Clinical efficacies of either tetracycline or macrolide regimens are similar at the moment and these regimens are recommended as the first line treatment. If these regimens are failed, fluoroquinolone regimens as moxifloxacin or sitafloxacin are the second line treatment. T. vaginalis can be detected by either microscopic examination or NAATs in the urine specimens. For T. vaginalis urethritis, a single dose of either metronidazole or tinidazole regimens are recommended.

Abbreviations

NGU: non-gonococcal urethritis
NCNGU: non-chlamydial non-gonococcal urethritis
NAATs: nucleic acid amplification tests
FVU: first voided urine
PCR: polymerase chain reaction
TMA: transcription mediated amplification
MRM: macrolide-resistance mutation

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