What should be done for a 45-year-old with mild itching at the meatus, otherwise asymptomatic with a normal physical exam, who reports recent unprotected sex with a partner tested positive for Ureaplasma?

Management of Ureaplasma Exposure in Asymptomatic 45-Year-Old

For a 45-year-old with mild meatal itching who is otherwise asymptomatic with normal physical exam and reports recent unprotected sex with a Ureaplasma-positive partner, empiric treatment with doxycycline 100 mg orally twice daily for 7 days is recommended.

Diagnostic Considerations

When evaluating a patient with minimal symptoms (mild meatal itching) and exposure to a Ureaplasma-positive partner, the following approach is recommended:

1. Testing vs. Empiric Treatment:

   • Although testing can confirm diagnosis, empiric treatment is appropriate in this case due to:
     • Known exposure to Ureaplasma-positive partner
     • Presence of mild symptoms (meatal itching)
     • Risk of transmission to future partners

2. Testing Considerations (if pursued):

   • Nucleic acid amplification test (NAAT) on first-void urine or urethral smear is the preferred diagnostic method 1
   • Testing should rule out other STIs including Neisseria gonorrhoeae, Chlamydia trachomatis, and Mycoplasma genitalium 2, 1

Treatment Recommendations

First-Line Treatment:

• Doxycycline 100 mg orally twice daily for 7 days 1
  • Highest efficacy against Ureaplasma urealyticum
  • Recommended by CDC and European guidelines
  • Effective against potential co-infections

Alternative Regimens (if doxycycline contraindicated):

• Azithromycin 1-1.5 g orally as a single dose 1

  • Offers better compliance due to single-dose regimen
  • Similar effectiveness to doxycycline in clinical trials

• Other alternatives:

  • Erythromycin 500 mg orally four times daily for 7 days 2, 1
  • Levofloxacin 500 mg orally once daily for 7 days 2, 1
  • Ofloxacin 300 mg orally twice daily for 7 days 2

Partner Management

Partner management is critical to prevent reinfection:

• All sexual partners within 60 days should be evaluated and treated 2, 1
• Empiric treatment of partners is recommended even without testing 1
• Abstinence from sexual activity is recommended until:
  • 7 days after treatment initiation
  • Complete resolution of symptoms 2, 1

Follow-Up Recommendations

• No routine follow-up is needed if symptoms resolve 1
• Patient should return for evaluation if:
  • Symptoms persist after treatment completion
  • Symptoms recur after initial resolution 2, 1

Important Clinical Considerations

1. Ureaplasma as a Pathogen:

   • There is ongoing debate about the pathogenic role of Ureaplasma in urethritis 3, 4
   • Asymptomatic colonization is common (found in 40-80% of sexually active adults) 3, 5
   • However, with known exposure and symptoms, treatment is warranted

2. Urethral Inflammatory Response:

   • Urethral inflammatory response to Ureaplasma is typically less severe than to Chlamydia trachomatis and Mycoplasma genitalium 6
   • This explains the minimal symptoms in many cases

3. Antimicrobial Resistance:

   • Increasing resistance has been reported worldwide 1
   • Doxycycline maintains the highest susceptibility rates
   • Treatment failure often results from reinfection rather than resistance

By following these recommendations, the risk of complications and transmission can be minimized while providing effective treatment for the patient's condition.