Ureaplasma: An overlooked pathogen

Ureaplasma may be more prevalent and problematic than is currently appreciated by the medical community. It has been stated in a recent literature review that knowledge of the organism is incomplete and further research, particularly in women’s health care, is warranted [1]. Ureaplasma species are more difficult to culture and they are resistant to standard antimicrobial therapy for urinary tract infection [1]. Testing is warranted in cases of otherwise unexplained urethritis and hematuria [2]. Testing is best done by a urethral swab for polymerase chain reaction (PCR) analysis [1].

A 19-year-old college student was seen in our office in June 2018. She reported intermittent symptoms of painful urinary tract infection dating from March 2018. While at school she had received two courses of Macrobid antibiotic and one of Amoxicillin without complete relief. She had been seen urgently by her pediatrician on return from college in May 2018 for ongoing urethral and bladder pain. She was screened for bacterial urine infection; she was sexually active and was also screened for common sexually transmitted infections including chlamydia and gonorrhea. All results were negative; however, red blood cells had been noted on urinalysis.

She was seen in our practice and also sent to urologist for further evaluation. Following our suggestion ureaplasma urine culture was ordered by the urologist through the local hospital laboratory.

The patient went for testing but unfortunately the specimen was not processed properly and was canceled. She did not return to the laboratory for a repeat test.

She subsequently called in extreme pain in early July with worsening symptoms. She was advised to go to the laboratory immediately for the ureaplasma test. The laboratory was called as she was on her way and proper specimen processing for this less common test was assured. The result subsequently came back as positive for ureaplasma (Figure 1). She was treated with twice daily Doxycycline antibiotic for ten days and was cured of all symptoms.

A local gynecology specialist had a similar case of a patient (also a college student) with prolonged symptoms and months long delayed diagnosis for ureaplasma.

Since this case we have selectively screened more patients for the condition. Among the positive cases whose symptoms improved after diagnosis and treatment are the following:

• A young woman with irritable bladder symptoms who was first given anticholinergic by urologist.

• A pregnant patient with a stable relationship of about ten years duration who developed severe bladder spasms at the end of pregnancy. Azithromycin was used rather than Doxycycline due to pregnancy.

• Otherwise unexplained hematuria in menopausal patient.

Among the problems and issues are the following:

• Standard urine cultures are not diagnostic. The best and easiest screen is a viral/mycoplasma swab of the urethral meatus [1]. Many primary care offices may not carry this culture media. Urine ureaplasma culture by the lab (without office collection) is an option but without proper processing can lead to delay.

• Blood in the urine of girls and women should never be assumed to be “normal” or from menstrual flow, even when white blood cells are absent. And even if urine culture is normal the presence of blood should be evaluated [2],[3].

There is evidence that the organism is commonly present in the sexually active population, and in many cases may be asymptomatic [4]. Seemingly in the above individuals it caused painful symptoms and hematuria. The individuals’ susceptibility may be due to any of a variety of factors (new exposure, numbers of organism present, specific serotypes of ureaplasma present [2], and possibly changes in immunity). Attention should also be given to treatment of sexual partner [5].

There needs to be greater awareness and screening of ureaplasma in patients with resistant bladder symptoms. Undiagnosed cases may lead to chronic bladder inflammation, pain, and other unpleasant urinary tract symptoms. Hopefully, following this report that there will be increased awareness and diagnosis of this pathogen, and relief for patients who are impacted.