Is testing for Ureaplasma urealyticum recommended for an asymptomatic male spouse of a positive case?

Testing for Ureaplasma urealyticum in Asymptomatic Male Partners

Routine testing for Ureaplasma urealyticum in asymptomatic male partners is not recommended, even when the spouse tests positive. 1

Key Rationale Against Testing Asymptomatic Partners

Asymptomatic carriage of U. urealyticum is extremely common (40-80% of detected cases represent colonization rather than infection) and does not require treatment. 1 The European STI Guidelines Editorial Board explicitly states that routine testing and treatment of asymptomatic men for U. urealyticum is not recommended because we lack evidence that detection and treatment provide more benefit than harm. 1

Why Testing Is Not Indicated

• U. urealyticum is only pathogenic at high bacterial loads (≥5 × 10³ cells/ml in first-void urine), which correlates with symptomatic urethritis. 2 Without symptoms or objective signs of urethritis, the organism is likely a commensal colonizer rather than a pathogen. 1

• The majority of individuals colonized with U. urealyticum never develop disease. 1 Testing asymptomatic individuals leads to unnecessary antibiotic exposure, which promotes antimicrobial resistance in both these organisms and other bacteria in the normal microbiota. 1

• CDC guidelines from 1993-2002 consistently state that specific diagnostic tests for U. urealyticum are not indicated because detection is difficult and would not alter therapy in the absence of clinical urethritis. 3

When Testing Would Be Appropriate

Testing should only be considered if the male partner develops:

• Documented urethritis symptoms (mucopurulent/purulent urethral discharge, dysuria, or urethral pruritis). 4

• Objective signs of inflammation (≥5 polymorphonuclear leukocytes per oil immersion field on urethral Gram stain, or ≥10 WBCs per high-power field in first-void urine). 3, 4

Testing Algorithm If Symptoms Develop

If urethritis symptoms appear, the following sequence must be followed:

1. First exclude traditional STI pathogens (Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis) before considering U. urealyticum testing. 1

2. Use quantitative species-specific molecular diagnostic tests to distinguish U. urealyticum from U. parvum (only U. urealyticum is a true aetiological agent of urethritis). 5, 4, 1

3. Only treat if high bacterial load is detected, though appropriate evidence for effective treatment regimens in this context is lacking. 1

Partner Management Recommendations

If the female partner requires treatment for symptomatic U. urealyticum infection, the male partner should be evaluated and treated only if he has symptoms or signs of urethritis. 4 The European Association of Urology guidelines recommend that sexual partners with last contact within 60 days of diagnosis be evaluated and treated, but this applies to symptomatic index cases where treatment is clinically indicated. 5, 4

Important Caveats

• Treatment of asymptomatic partners does not prevent reinfection because U. urealyticum colonization is so prevalent and often represents normal genital flora rather than pathogenic infection. 1

• Antibiotic treatment of asymptomatic colonization may cause more harm than benefit through unnecessary drug exposure, cost, and promotion of antimicrobial resistance. 1

• There is no clear evidence that asymptomatic U. urealyticum colonization impairs male fertility or causes adverse reproductive outcomes. 6