Do You Always Treat Ureaplasma Species?
No, you do not always treat Ureaplasma species—treatment is indicated only when patients have documented urethritis symptoms (mucopurulent discharge, dysuria, urethral pruritis) or objective signs of inflammation (>5 WBCs per oil immersion field on Gram stain, positive leukocyte esterase, or >10 WBCs per high-power field on first-void urine). 1
Critical Decision Algorithm: When to Treat vs. Not Treat
DO NOT TREAT in These Situations:
Asymptomatic colonization detected on routine screening - There is no evidence that treating genital tract infections without symptoms improves conception rates, even when organisms are detected 1
Positive Ureaplasma testing alone without documented urethritis symptoms or objective signs of inflammation 1, 2
Detection of U. parvum specifically - U. parvum's pathogenic role is questionable and should generally NOT be treated 3
Asymptomatic Ureaplasma colonization during infertility workups - Randomized controlled trials with live birth as primary outcomes are needed to establish treatment benefit 1
DO TREAT in These Situations:
Symptomatic urethritis with documented Ureaplasma - Patients presenting with mucopurulent discharge, dysuria, or urethral pruritis AND positive testing 1, 2
Objective signs of inflammation - >5 WBCs per oil immersion field on Gram stain, positive leukocyte esterase, or >10 WBCs per high-power field on first-void urine 1
U. urealyticum specifically (not U. parvum) - Only U. urealyticum is considered a true urethritis pathogen and is associated with male infertility based on meta-analysis evidence 1, 3
Species-Specific Pathogenicity Matters
U. urealyticum is the pathogenic species that warrants treatment when symptomatic, as it is associated with male infertility and confirmed as a true urethritis pathogen 1, 3
U. parvum should generally not be treated as its pathogenic role remains questionable 3
Always exclude Chlamydia trachomatis, Neisseria gonorrhoeae, and M. genitalium before attributing urethritis to Ureaplasma 3
First-Line Treatment When Indicated
Doxycycline 100 mg orally twice daily for 7 days is the first-line treatment, achieving 91% susceptibility rates 1, 2, 3
Azithromycin 1 g orally as single dose is the alternative when compliance with 7-day therapy is questionable, with 71% susceptibility 1, 2, 3
Erythromycin base 500 mg orally four times daily for 7 days serves as a second alternative 1, 2, 3
Partner Management Requirements
All sexual partners require evaluation and treatment to prevent reinfection 2, 3
Treat partners with last sexual contact within 30 days of symptom onset for symptomatic patients 1, 2
Treat partners with last sexual contact within 60 days of diagnosis for asymptomatic patients 2, 3
Both patients and partners must abstain from sexual intercourse for 7 days after single-dose therapy or until completion of 7-day regimen 1, 3
Common Pitfalls to Avoid
Do not routinely screen asymptomatic individuals - Ureaplasma frequently colonizes healthy individuals without causing symptoms and is not classified as a traditional STD like gonorrhea or chlamydia 1
Do not confuse U. urealyticum with U. parvum - Only U. urealyticum has stronger pathogenic evidence and association with infertility 1, 3
Do not retreat based on persistent symptoms alone without documented urethritis on re-evaluation 2
Test-of-cure is NOT routinely recommended after doxycycline or azithromycin unless symptoms persist or reinfection is suspected 3
Do not use fluoroquinolones empirically if the patient has used them in the last 6 months or comes from a urology department where resistance rates are higher 3