Persistent Urethritis Due to Ureaplasma Urealyticum in Conjugal Or Stable Partnerships
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Genitourin Med: first published as 10.1136/sti.62.5.329 on 1 October 1986. Downloaded from Genitourin Med 1986;62:329-332 Persistent urethritis due to Ureaplasma urealyticum in conjugal or stable partnerships 0 P ARYA* AND B C PRATTt From the *Department of Genitourinary Medicine, Royal Liverpool Hospital, and the tDepartment of Medical Microbiology, University ofLiverpool, Liverpool SUMMARY A study of four conjugal partnerships is described in which the male partners pre- sented with persistent or recurrent non-gonococcal, non-chlamydial, but ureaplasma positive urethritis. Resolution ofsymptoms and signs in the male partners was achieved only after treatmentto eliminate Ureaplasma urealyticum from both partners. Introduction Patients, materials, and methods Ofthe mycoplasmal flora, Mycoplasma hominis and Between July and December 1984, four men presented Ureaplasma urealyticum are the species most to the department of genitourinary medicine of the commonly isolated from the human genital tract in the Royal Liverpool Hospital because of persistent or presence or absence of disease. Though the aetiology recurrent urethral discharge or urinary symptoms, of non-gonococcal urethritis in men has not been despite treatment with various courses ofantibiotics by finally settled, M hominis has largely been dismissed their general practitioners or investigations and further as having no role in this disease. Uurealyticum, on the treatment by urologists, or both. They were all seen by other hand, may cause urethritis according to some the same clinician (OPA) after whose persuasion the http://sti.bmj.com/ workers,'2 but only in a small proportion of people female partners of the patients also attended. from whom the organism can be isolated.3 Attempts to History and clinical examination included explain this phenomenon by quantitative studies4 have demographic data, past history, relevant history of provided conflicting results. In a detailed review, exposure, details of treatment already received, and Taylor-Robinson and McCormack considered other symptoms and signs. explanations, including the possibility that only certain serotypes of Uurealyticum may be pathogenic or that SPECIMENS TAKEN on September 23, 2021 by guest. Protected copyright. the organism may be of low invasiveness, and hence Men clinically recognisable infection may result in only a Urethral specimens were collected with plastic loops small proportion of exposed men.' No single explana- for urethral smear for Gram staining and culture for tion has yet proved satisfactory, however, and until the Neisseria gonorrhoeae. Specimens for Chlamydia aetiological role of U urealyticum in an individual trachomatis, mycoplasmas, and herpes simplex virus patient is better defined, the indications for treatment were obtained with swabs made of sterile plain cotton will remain unclear, as will the optimum treatment and wool on a thin metal wire (Medical Wire Equipment the need for contact tracing. Co, Corsham, Wiltshire) inserted 3-5 cm into the Our recent experience prompted us to undertake an urethra and rotated several times. Non-gonococcal investigation of men with persistent or recurrent urethritis was diagnosed if five or more urethritis and their female partners to try to clarify the polymorphonuclear leucocytes were seen in a high situation concerning its cause and treatment power field (magnification x 1000), Gram negative diplococci were not seen, and culture for Neisseria gonorrhoeae gave negative results. Ifchronic prostatitis Address for reprints: Dr 0 P Arya, Departnent of Genitourinary was considered to be a possibility, prostate examina- Medicine, Royal Liverpool Hospital, Prescot Street, Liverpool L7 8XP tion and tests were carried out using the segmented culture technique described by Meares and Stamey5 Accepted for publication 29 January 1986 and Stamey.6 329 Genitourin Med: first published as 10.1136/sti.62.5.329 on 1 October 1986. Downloaded from 330 O P Arya and B C Pratt Women orally twice daily for 10 days. Details of the times of Specimens were collected with cotton wool swabs taking the tablets and their relation with food were from the urethra and cervix for smears for Gram stain- emphasised. ing and for culture for N gonorrhoeae and mycoplasmas, and from the cervix only for culture for Results C trachomatis. Swabs from the vaginal vault instead of the cervix were obtained from one patient who had Three ofthe men (a businessman, a doctor, and a fire- undergone hysterectomy. High vaginal swabs were man) were married and one (a health inspector) was also obtained for culture for Candida albicans and single but contemplating marriage. Their female Trichomonas vaginalis. partners included a teacher, a doctor, a sales assistant, Specimens of blood were taken from men and and a full time housewife. women for syphilis serology tests. All men at the time of first attendance were experiencing urethral discharge or dysuria, or both; the LABORATORY INVESTIGATIONS women, however, were asymptomatic. None of the Culture methods women had received an antibiotic during the preceding Specimens were inoculated directly on to modified six weeks. All men and women had negative cultures Thayer-Martin medium forculture forNgonorrhoeae. forNgonorrhoeae, C trachomatis, M hominis, and T Swabs for culture for C trachomatis, mycoplasmas, vaginalis, butpositive cultures for Uurealyticum. The and herpes simplex virus were placed in their respec- numbers of U urealyticum in the men ranged from 5 x tive transport media and either processed immediately 105 to 5 x 107 ccu/ml and in the women from 5 x 102 to or stored frozen at -70°C pending investigation. 5 x 105 ccu/ml. Cand albicans was isolated from one Material for C trachomatis isolation was inoculated female patient. None of the men showed evidence of on to cover slip cultures of cycloheximide treated chronic prostatitis. McCoy cells. Specimens in A3xB transport medium7 As the clinical features and laboratory findings ofall for culture of mycoplasmas or ureaplasmas were four couples were broadly similar, only one couple is inoculated into and then serially diluted in ten fold described in detail. A 28 year old man had been steps in Hayflick type broths. Broths for growth of U experiencing dysuria intermittently for one year. His urealyticum were adjusted to pH 6X0 and contained general practitioner, after unsuccessfully treating him 1% (w/v) urea, those for growth of M hominis were with several courses ofoxytetracycline, referred him to adjusted to pH 7X4 and contained 1% (w/v) arginine a urologist. The urologist found his prostate and intra- dihydrochloride. Both broths contained 0-002% (w/v) venous urogram to be normal, but urethroscopy phenol red indicator.8 After incubation at 37°C, broths showed a reddened urethra for which two further http://sti.bmj.com/ showing colour change were subcultured to A7 agar7 courses ofoxytetracycline were prescribed. The condi- and mycoplasma agar to confirm the presence of tion recurred yet again and the patient was then ureaplasmas or mycoplasmas, or both. Specimens for referred to one of us (OPA). A detailed interview herpes simplex isolation were inoculated into tubes of showed that this patient's symptoms usually recurred Vero tissue culture. about a week after sexual intercourse with his finacee, with whom he had had a stable relationship for seven Sensitivities to antibiotics years. The table shows the sequence ofevents and the on September 23, 2021 by guest. Protected copyright. Minimum inhibitory concentrations (MICs) of each management of the couple after that interview. ureaplasma isolate were measured against oxyte- As the man had already failed to respond to oxyte- tracycline, erythromycin, and doxycycline and were tracycline, he was treated with erythromycin 250 mg carried out in duplicate. The tests were performed in four times daily for one week, and the couple were microtitre well plates and used a standardised advised to abstain from sexual intercourse during the ureaplasma inoculum of 103 - 104 colour changing course of treatment. Whereas the man remained units (ccu)/ml. The antibiotics were diluted in two fold ureaplasma negative after completing the course of steps in urea broth. Plates were incubated at 37°C until erythromycin, the woman was persistently positive, colour changes in the wells were complete, the MIC despite receiving a total of two courses of oxyte- being recorded as the concentration of antibiotic just tracycline and one oferythromycin (see table). At this preventing a colour change. stage they were allowed and indeed encouraged to resume intercourse, which they did. Exactly seven TREATMENT days later the man's dysuria recurred, a Gram stained The following regimens were used: (1) oxytetracycline urethral smear showed excessive leucocytes, and a or erythromycin 250 mg orally four times daily for urethral swab was positive for ureaplasmas. Both seven days, (2) oxytetracycline or erythromycin 500 partners were then treated with doxycycline 200 mg mg orally four times daily for 10 days, or (3) initially followed by 100 mg twice daily for 10 days. doxycycline 200 mg initially, followed by 100 mg The man has remained asymptomatic ever since, and Genitourin Med: first published as 10.1136/sti.62.5.329 on 1 October 1986. Downloaded from Persistent urethritis due to Ureaplasma urealyticum in conjugal or stable partnerships 331 TABLE Sequence ofevents and management ofone couple Date Man Date Woman 1984 1984 23 July Dysuria 25 July No symptoms Urethritis absent