What evaluation and treatment are recommended for a patient with suspected Acute Viral (AV) and Escherichia coli (E. coli) infections, high semen viscosity, and concerns about reinfection and fertility while trying to conceive?

Evaluation and Treatment for Suspected Urogenital Infections and High Semen Viscosity in a Male Partner Attempting Conception

Treat the patient empirically with doxycycline 100 mg orally twice daily for 7 days to cover both Ureaplasma and potential Chlamydia/Mycoplasma genitalium, and simultaneously treat his partner to prevent reinfection. 1

Immediate Diagnostic Evaluation

Before or concurrent with treatment, obtain:

• Urethral swab or first-void urine for nucleic acid amplification testing (NAAT) for Chlamydia trachomatis and Neisseria gonorrhoeae 2
• Gram stain of urethral secretions if urethritis symptoms present (>5 WBCs per oil immersion field confirms urethritis) 2
• First-void urine microscopy for leukocytes (>10 WBCs per high power field suggests urethritis) 2
• Semen analysis to document baseline parameters including viscosity, and screen for leukocytospermia 3
• Syphilis serology and HIV testing as part of comprehensive STI screening 2

The key distinction here: Do NOT wait for culture results before treating if the patient is at high risk for STI exposure (partner being treated) or unlikely to return for follow-up 2.

First-Line Treatment Regimen

Doxycycline 100 mg orally twice daily for 7 days is the CDC-recommended first-line treatment for both Mycoplasma genitalium and Ureaplasma infections 1. This regimen also effectively covers Chlamydia trachomatis, which is the most common sexually transmitted urethral pathogen 2.

Alternative Regimens (if doxycycline contraindicated):

• Azithromycin 1 g orally as single dose (preferred when compliance is questionable, allows directly observed therapy) 1
• Erythromycin base 500 mg orally four times daily for 7 days 2, 1
• Levofloxacin 500 mg orally once daily for 7 days 2, 1

Critical caveat: While azithromycin offers single-dose convenience, doxycycline is generally preferred for Mycoplasma genitalium due to emerging azithromycin resistance, though both are acceptable first-line options 1.

Partner Management: Absolutely Essential

Both partners must be treated simultaneously with the same regimen to prevent reinfection 1. This is non-negotiable:

• Treat all sexual partners with contact within 60 days of diagnosis 1
• Both partners must abstain from sexual intercourse for 7 days after completing therapy (or 7 days after single-dose azithromycin) 1
• Failure to treat partners is the most common cause of persistent or recurrent infection 2

The partner currently being treated for "AV and E. coli infections" should have her treatment regimen reviewed to ensure appropriate STI coverage, as E. coli urinary infections do not typically require partner treatment unless there is concurrent STI 2.

Addressing High Semen Viscosity

High semen viscosity alone does not require specific antibiotic treatment unless documented infection is present 3. However:

• Repeat semen analysis 4-6 weeks after completing antibiotic therapy to assess if viscosity normalizes with infection resolution 3
• Document sperm parameters including count, motility, and morphology 3
• Do NOT treat leukocytospermia alone without documented infection, as this does not improve conception rates 3

High viscosity can be associated with accessory gland infections (prostatitis, seminal vesiculitis), but treating empirically without documented bacterial infection is not evidence-based 3.

Follow-Up Protocol

• Return for evaluation only if symptoms persist or recur after completing therapy 1
• If symptoms persist: re-evaluate for treatment non-compliance, partner re-exposure, or alternative diagnoses 2, 1
• Re-treatment with the initial regimen is appropriate if non-compliant or re-exposed to untreated partner 1
• Repeat semen analysis in 4-6 weeks to assess fertility parameters post-treatment 3

Critical Pitfalls to Avoid

Do NOT treat with antibiotics targeting E. coli (such as ciprofloxacin or trimethoprim-sulfamethoxazole) for presumed urogenital infection in this fertility context 2, 3. E. coli causes urinary tract infections and epididymitis in specific populations (men >35 years, those with urinary instrumentation), but is not a sexually transmitted pathogen requiring partner treatment 2. The patient's concern about "E. coli infection" likely represents confusion about his partner's separate urinary tract infection.

Do NOT prescribe testosterone to this patient if fertility is desired, as it suppresses spermatogenesis 3.

Do NOT continue empiric antibiotics beyond the initial 7-day course without documented persistent infection, as this does not improve fertility outcomes 3.

Special Considerations for Fertility

• Encourage weight loss, smoking cessation, and regular exercise, as these improve sperm parameters 3
• Screen for cardiovascular risk factors, as infertile men have higher cardiovascular and overall mortality risk 3
• If documented chronic bacterial prostatitis (NIH Type II) is found, antibiotic therapy may improve sperm quality but does not necessarily improve natural conception rates—assisted reproductive technology may still be needed 3
• Asymptomatic Chlamydia infection may improve sperm parameters with treatment, though impact on conception rates is unclear 3

When to Consider Further Evaluation

If symptoms persist after appropriate treatment and partner management:

• Consider evaluation for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), though antibiotics are NOT indicated for CP/CPPS 3
• Refer to urology if structural abnormalities suspected 2
• Consider assisted reproductive technology consultation if natural conception does not occur after 6-12 months of attempting conception with treated infections 3