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"We have read for you":Are ureaplasma and mycoplasma responsible for Bladder pain syndrome?

I have read an article entitled "A Systematic Review of Mycoplasma and Ureaplasma in Urogynaecology" written by doctors Nina Combaz-Söhnchen and Annette Kuhn of the maternal and child hospital in Bern, Switzerland.

The initial question that led me to read this article was: why don’t we look for mycoplasma and ureaplasma with normal tests (blood, urine, sampling) before going to specific diagnostic tests that are expensive and invasive?

Let's see what these two doctors say step by step.

Species of relevant mycoplasmas in the urogenital tract include hominid mycoplasma, genital mycoplasma and reaplasma urealyticum, which may occur as commensals or potential pathogens.

Its presence, in the context of urogynecological pathologies, has been shown in urethritis, cystitis and upper renal tract infections. Its role in overactive bladder and in interstitial cystitis/bladder pain syndrome is still under discussion.

Mycoplasma and ureaplasma are the smallest intracellular and extracellular bacteria without cell walls that belong to the Mollicutes class and are parasites in humans.

The need to find an organism that receives them is given by the lack of a cell wall, by an extremely small genome, by the limited capacity of biosynthesis, by its sensitivity to environmental factors, by resistance to antibiotics and by high demands in terms of living conditions.

These organisms can cause numerous "conditions" often chronic in humans. Sixteen of the more than 200 known species of mycoplasma in the animal and plant kingdoms can attack the human body, but only six of them seems to be pathogenic in immunocompetent humans: Mycoplasma pneumoniae, Mycoplasma hominis, Mycoplasma genitalium, Mycoplasma fermentans, Ureaplasma parvum and Ureaplasma urealyticum.

But how do these pathogens reach the genitals? Numerous investigations have shown that the number of partners in the previous months affects the prevalence of bacterial colonization in the urogenital tract.

Due to the anatomical proximity of the female urethra and the vagina, it can be assumed that vaginal bacterial colonization can also affect the urinary tract. There is already a lot of information about genital tract infections associated with mycoplasma, but there is still a lack of clarity about the influence and potential of mycoplasma pathogens and ureaplasma species in the context of urinary tract infections and other urogynecological symptoms such as the urethral syndrome, interstitial cystitis/bladder pain syndrome and overactive bladder.

We know that most uropathogenic organisms, especially those in the faeces, can be detected in the standard urine culture test. Although Mycoplasma and Ureaplasma species should be specifically investigated, they can be found in both asymptomatic and symptomatic patients. The count of bacteria in the urine is not necessarily related to the amount of bacteria that actually exist in the bladder wall. In fact, a significant number of these intracellular organisms can be found in the wall of the bladder in the absence of bacteriuria.

It has been shown that Mycoplasma hominis and Ureaplasma urealyticum may also be responsible for pyelonephritis. Potts together with the team observed that persistent symptoms of lower urinary tract infection or pyelonephritis with standard negative cultures and lack of response to routine antibiotics, should require an active search for mycoplasma and ureaplasma, with in line treatment with the antibiogram if the results are positive. The detection of pathogens must be carried out before more expensive or invasive diagnostic measures are taken.

Mycoplasma and ureaplasma can cause overactive bladder or interstitial cystitis?

Numerous recent studies have shown that ureaplasma and mycoplasma species can be detected in the urine of women with overactive bladder or interstitial cystitis. Potts and the team showed that symptoms improved in patients with interstitial cystitis after targeted antibiotics treatment.

In the presence of chronic urethral symptoms with negative routine cultures and in all patients with "unexplained" urinary tract symptoms, tests of mollicutes (mycoplasma and ureaplasma) should be run using urethral exudates with PCR analysis before resorting to invasive diagnostic measures and long-term treatments.

What are the best detection methods for mycoplasma and ureaplasma? Mycoplasma genitalium is not detected in routine culture due to its extremely slow growth. The real-time polymerase chain reaction (PCR) is the selected diagnostic method. On the contrary, Ureaplasma urealyticum and Mycoplasma hominis can be identified in urine culture test or PCR.

Doctor has the most difficult decision to take because must decide whether a certain bacterium, found in laboratory tests, is pathogenic or not.

The treatment should begin when the results of the tests are available. This in order to avoid resistance to antibiotics.

The study reports the use of specific doses and antibiotics for treatment.

In general, it is recommended to extend the treatment to the patient's partner with the same antibiotic that has been shown to be effective in the affected patient. The use of condoms or abstinence from sexual relations is recommended until the symptoms are resolved.

In light of the current situation, these pathogens, which, as we have seen, are difficult to culture, should be specifically investigated with urethral examinations by PCR analysis in patients with recurrent infections or when cultures and standard microbiological swabs are negative.

The treatment of symptomatic women should be always guided by the antibiogram. It can be presumed that these pathogens play a role in women with chronic cystitis, but are often underestimated because they are difficult to detect and their intracellular nature makes conventional antibiotics ineffective.

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