If you have been treated for urethritis and the symptoms came back, Mycoplasma genitalium is the single most likely explanation. The CDC attributes about 40 percent of persistent or recurrent urethritis in men to it, and it does not appear on a chlamydia and gonorrhea panel. Ureaplasma is a different story: the CDC states that most men with Ureaplasma infections do not have overt disease unless the organism load is high, and there is no FDA-cleared test for it in the United States. TrufaMED tests for all of these in Surfside, seven days a week, and a physician reads the result with you.
Men usually arrive at this topic in one specific way. Burning or discharge appears, a clinic runs the standard panel, it comes back negative or shows nothing but a diagnosis of non-gonococcal urethritis, a week of doxycycline follows, and three weeks later it is back. This article is about that sequence.
What actually causes urethritis that returns
The CDC’s numbers on M. genitalium in men are worth stating plainly, because they reframe the problem:
- 15 to 20 percent of non-gonococcal urethritis
- 20 to 25 percent of nonchlamydial NGU
- 40 percent of persistent or recurrent urethritis
The guideline states it directly: “The most common cause of persistent or recurrent NGU is M. genitalium, especially after doxycycline therapy.”
So a returning case of urethritis is not usually a treatment that was taken wrong or a partner who was not honest. It is most often an organism that the first panel never looked for.
Who the CDC says should be tested
The recommendation for men is specific: “Men with recurrent NGU should be tested for M. genitalium using an FDA-cleared NAAT. If resistance testing is available, it should be performed and the results used to guide therapy.”
There is a sequencing detail in the guideline that matters. Trichomonas is checked first or ruled out by risk, and then M. genitalium testing follows: if trichomonas is unlikely, men with recurrent NGU should be tested for M. genitalium with an FDA-cleared NAAT. Trichomonas in men is easy to overlook and it produces the same picture, so skipping that step is how people end up chasing the wrong organism.
Screening men without symptoms is not recommended. The CDC is explicit: screening of asymptomatic M. genitalium infection among men and women, and extragenital testing for it, is not recommended. The consequences of asymptomatic infection in men are unknown. If you feel fine and want a general screen, the standard panel is the right test, and adding M. genitalium to it is not supported by the guidance.
What the test is
For men it is usually a first-catch urine sample, meaning the first part of the stream rather than a midstream clean catch. That is the opposite of how a urine sample is usually collected, so it is worth saying out loud. A urethral or penile meatal swab is the alternative.
There is an FDA-cleared molecular test for M. genitalium, cleared for urine and for urethral, penile meatal, endocervical and vaginal specimens. It is a standard, regulated NAAT.
Hold your urine for at least an hour before the sample if you can. A recently emptied bladder can weaken the specimen.
Treatment, and why the old single dose fails
This is the section to read if you have already been treated once.
Azithromycin resistance in M. genitalium is now widespread. The CDC states that molecular markers for macrolide resistance range from 44 to 90 percent across the United States, Canada, Western Europe and Australia, and that a single one-gram dose of azithromycin selects for resistant strains in 10 to 12 percent of cases. The guideline says it “should not be used.”
What replaced it is a two-stage course:
- Resistance testing available, macrolide-sensitive strain: doxycycline 100 mg twice daily for seven days, then azithromycin 1 g on day one followed by 500 mg daily for three more days.
- Resistance testing available, macrolide-resistant strain, or resistance testing unavailable: doxycycline 100 mg twice daily for seven days, then moxifloxacin 400 mg once daily for seven days.
The CDC notes that resistance-guided therapy achieves cure rates above 90 percent. It also notes that a test of cure is not recommended for people without symptoms who completed a recommended regimen.
One more point that explains a lot of failed treatment: M. genitalium has no cell wall. Penicillins and cephalosporins, including the ceftriaxone injection commonly given for suspected gonorrhea, have no effect on it whatsoever. If you were given a shot and a pill and the symptoms persisted, that is a predictable result rather than a mystery.
Ureaplasma in men
Men ask about this one more than women do, usually after finding a panel online that sells it.
The CDC’s position on urethritis is that “data are inconsistent regarding other Mycoplasma and Ureaplasma species as etiologic agents of urethritis,” and that “the majority of men with Ureaplasma infections do not have overt disease unless a high organism load is present.” That last clause is the whole issue. Ureaplasma is frequently present in men who are perfectly well, so detecting it does not establish that it is causing anything.
The European STI Guidelines Editorial Board reached the same conclusion in a 2018 position statement in the Journal of the European Academy of Dermatology and Venereology: routine testing and treatment for M. hominis, U. parvum and U. urealyticum are not recommended in symptomatic or asymptomatic men and women, asymptomatic carriage is common, and only men with a high Ureaplasma load should even be considered for treatment. They estimate that carriage rather than infection accounts for 40 to 80 percent of detected cases.
There is also no FDA-cleared Ureaplasma test in the United States. Every result comes from a laboratory-developed test. These are established methods and the result is real, but the interpretation belongs to a physician.
Where ureaplasma testing does earn its place in a man’s workup: symptoms that persist after a negative standard panel, a negative trichomonas test and a negative M. genitalium result. At that point it is a reasonable next step rather than a first move.
When it is not an infection at all
Worth naming, because a fair number of men end up here after three negative rounds of testing. Chronic urethral or pelvic discomfort in men is not always infectious. Chronic pelvic pain syndrome, sometimes labeled chronic prostatitis, produces burning, urgency and discomfort with no organism to find, and it does not respond to antibiotics. Irritant and dermatologic causes do the same.
If you have completed correct treatment for a correctly identified organism and symptoms persist, more antibiotics is usually the wrong next step. A physician should reassess rather than reorder.
Getting tested in Miami
Walk in at 9445 Harding Ave in Surfside, seven days a week, Monday to Friday 9 AM to 9 PM, Saturday 11 AM to 11 PM and Sunday 12 PM to 8 PM. Bring what you were treated with previously if you know it, because that history changes what gets ordered.
Mycoplasma genitalium testing is $350 self-pay, and the front desk checks your coverage first if you are using insurance. The genital mycoplasma profile covering Ureaplasma species and Mycoplasma hominis is priced separately. Our standard panel covering HIV, syphilis, herpes 1 and 2, gonorrhea, chlamydia and hepatitis B is $450 self-pay. Chlamydia and gonorrhea PCR alone, from urine or a swab, is $190. Rapid HIV read on site in about twenty minutes is $50. More of the menu is on our self-pay pricing page, and the front desk will quote anything not listed.
Collection can also happen at your home or hotel. See STD testing at your home or hotel in Miami. For the full comparison across all three organisms, read ureaplasma and mycoplasma testing in Miami, and for the female clinical picture, testing in women.
Call (305) 537-6396 or book through our sexual health testing page.
Frequently asked questions
Why does my urethritis keep coming back after antibiotics?
The most likely reason is Mycoplasma genitalium, which the CDC identifies as the most common cause of persistent or recurrent non-gonococcal urethritis, especially after doxycycline. It accounts for roughly 40 percent of those cases and does not appear on a chlamydia and gonorrhea panel. Other explanations include trichomonas missed on the first workup, reinfection from an untreated partner, or a non-infectious cause such as chronic pelvic pain syndrome.
Should men be tested for Mycoplasma genitalium?
The CDC recommends testing men with recurrent non-gonococcal urethritis using an FDA-cleared NAAT, and recommends resistance testing where it is available to guide therapy. Trichomonas should be ruled out first or considered unlikely. Screening men with no symptoms is specifically not recommended, because the consequences of asymptomatic infection in men are unknown.
How is Mycoplasma genitalium treated in men?
With a two-stage course. If resistance testing shows a macrolide-sensitive strain, doxycycline 100 mg twice daily for seven days followed by azithromycin 1 g on day one then 500 mg daily for three more days. If the strain is macrolide-resistant, or resistance testing is not available, doxycycline 100 mg twice daily for seven days followed by moxifloxacin 400 mg once daily for seven days. A single one-gram azithromycin dose is specifically advised against because macrolide resistance markers now run from 44 to 90 percent.
What kind of sample is needed?
For men it is usually a first-catch urine sample, meaning the first part of the stream rather than a midstream catch, or a urethral or penile meatal swab. Try to hold your urine for at least an hour before giving the sample. The FDA-cleared Mycoplasma genitalium test is cleared for urine and for urethral and penile meatal swabs.
Can ureaplasma cause urethritis in men?
The evidence is inconsistent. The CDC states that most men with Ureaplasma infections do not have overt disease unless a high organism load is present. The European STI Guidelines Editorial Board concluded that Ureaplasma urealyticum is probably not causal unless the load is high, and estimated that carriage rather than infection explains 40 to 80 percent of detected cases. Ureaplasma testing makes sense once the standard panel, trichomonas and Mycoplasma genitalium have all come back negative and symptoms persist.
Does a ceftriaxone shot treat mycoplasma?
No. Mycoplasma genitalium has no cell wall, so penicillins and cephalosporins, including ceftriaxone, have no effect on it. This is a common reason a course of treatment for suspected gonorrhea fails to resolve symptoms, and it is a predictable outcome rather than a sign anything was done incorrectly.
Do I need a test of cure?
The CDC does not recommend a test of cure for people without symptoms who completed a recommended regimen. If symptoms persist after treatment, that is a reason to be reassessed rather than automatically retested, because at that point the question may not be which organism but whether an organism is involved at all.
Does my partner need to be treated?
For Mycoplasma genitalium, yes, partner treatment is part of the plan, because reinfection is a frequent reason symptoms return after a correct course. For an isolated ureaplasma finding without symptoms, treating a partner is usually not indicated. The physician will tell you which of those applies.
What if every test comes back negative and I still have symptoms?
That happens, and more antibiotics is usually not the answer. Chronic pelvic pain syndrome, sometimes called chronic prostatitis, causes burning, urgency and discomfort with no organism to find and does not respond to antibiotics. Irritant and dermatologic causes do the same. At that point the right step is a physician reassessing the whole picture rather than ordering another panel.