What is the recommended urine test and treatment for a male patient suspected of having a mycoplasma or ureaplasma (Ureaplasma) infection?

Testing and Treatment for Male Mycoplasma and Ureaplasma Infections

For male patients with suspected mycoplasma or ureaplasma infections, nucleic acid amplification testing (NAAT) of first-void urine or urethral swab specimens is recommended, with treatment using doxycycline 100 mg orally twice daily for 10 days as first-line therapy.

Diagnostic Testing Recommendations

When to Test

• Testing is primarily recommended in cases of:
  • Persistent or recurrent urethritis
  • Non-gonococcal urethritis (NGU) where other common causes have been ruled out
  • Before urological procedures that will breach the mucosa 1

Recommended Testing Methods

1. First-line specimen collection:

   • First-void urine sample for NAAT testing 1
   • Urethral swab (higher specificity and positive predictive value compared to urine) 1

2. Testing procedures for urethritis evaluation:

   • Gram-stained smear of urethral exudate or intraurethral swab specimen (>5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 2
   • NAAT for N. gonorrhoeae and C. trachomatis (on intraurethral swab or first-void urine) 2
   • Examination of first-void uncentrifuged urine for leukocytes if urethral Gram stain is negative 2
   • Species-specific molecular diagnostic tests for Ureaplasma and Mycoplasma 1

Important Testing Considerations

• Routine screening for asymptomatic individuals is not recommended due to high colonization rates 1, 3
• Traditional STI agents (N. gonorrhoeae, C. trachomatis, M. genitalium) should be excluded before testing for Ureaplasma 3
• Only quantitative species-specific molecular tests should be used for Ureaplasma 3

Treatment Recommendations

First-line Treatment

• For epididymitis or urethritis likely caused by chlamydial or gonococcal infection:
  • Ceftriaxone 250 mg IM in a single dose PLUS
  • Doxycycline 100 mg orally twice daily for 10 days 2

Alternative Treatments

• Azithromycin 1.0-1.5 g orally as a single dose (effective alternative) 1
• For patients allergic to cephalosporins and/or tetracyclines:
  • Ofloxacin 300 mg orally twice daily for 10 days OR
  • Levofloxacin 500 mg orally once daily for 10 days 2

For Persistent Symptoms

• If symptoms persist after doxycycline:
  • Switch to azithromycin 500 mg on day 1, then 250 mg for 4 days 1
• If symptoms persist after azithromycin:
  • Switch to moxifloxacin 400 mg daily for 7-14 days (for suspected macrolide resistance) 1

Management Considerations

Follow-up

• Failure to improve within 3 days requires reevaluation of both diagnosis and therapy 2
• Persistent swelling and tenderness after completing antimicrobial therapy warrants comprehensive evaluation 2
• Differential diagnosis for persistent symptoms includes tumor, abscess, infarction, testicular cancer, TB, and fungal epididymitis 2

Partner Management

• Sexual partners should be referred for evaluation and treatment if contact occurred within 60 days preceding symptom onset 2
• Concurrent treatment of sexual partners is essential to prevent reinfection 1

Precautions

• Patients should abstain from sexual intercourse until 7 days after initiating therapy or until resolution of symptoms 1
• Consider antimicrobial resistance patterns when selecting therapy, as resistance to macrolides, tetracyclines, and fluoroquinolones has been reported 1

Clinical Pearls

• High colonization rates of Ureaplasma species occur in healthy individuals, making interpretation of positive results challenging 3
• Only men with high U. urealyticum load should be considered for treatment, as asymptomatic carriage is common (40-80% of detected cases) 3
• The extensive testing and treatment of these bacteria may result in antimicrobial resistance selection and substantial economic costs 3