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Fungal Infections

Disease name and synonyms

Candida balanitis (Candida balanoposthitis)

Fungi responsible links to these)

Candida spp., particularly C. albicans. Malassezia spp. and dermatophytic fungi are rare causes of penile infections. Several bacteria (Staphylococcus spp., Streptococcus spp., Pseudomonas spp., Gardnerella vaginalis, Treponema pallidum, Chlamydia trachomatis, anaerobes and Mycoplasma spp.) can also cause balanitis.

Disease description

Patients complain of soreness or irritation of the glans penis, and less commonly, they have subpreputial discharge.

Frequency and global burden

Common. C. albicans balanitis is the most frequent infection of the penis (~35%). In different patient populations the prevalence of balanitis has been reported to vary from 0% in uncircumcised Danish boys to 11-12.5% in uncircumcised men seen in urology clinics.  It has been estimated that globally, balanitis occurs in up to 3-4% of uncircumcised males.

Underlying problems and at risk patients

Uncircumcised males are at higher risk for balanitis than circumcised males.

Diabetes and age over 40 years increase the risk. Local genital risk factors include heavy Candida colonization, eczema, poor personal hygiene, water loss and dry skin, infections, chemical irritants, and obesity. Some factors are not associated with Candida balanitis such as a regular sexual partner with genital candidiasis, number of sexual partners, another sexual transmitted infection, immunosuppression, HIV status or an impaired glucose tolerance test result without diabetes.

Diagnostic testing

Culture is the usual definitive means of establishing the cause of balanitis; the cut-off being >10 colonies (OR = 9.6 for infection versus colonization). Clinical specimens for mycological investigation should be sampled from the coronal sulcus and the subpreputial sac. It is important to collect adequate amount of material. Asymptomatic candidal carriage of the preputial space is common (14–18%) whereby the mere positive laboratory finding of Candida spp. does not allow for the diagnosis of clinical disease.

Treatments

A single 150mg dose or oral fluconazole is generally adequate. Topical therapy with  clotrimazole, miconazole, or nystatin is effective but require 1–2 weeks of application for effective cure. If the glans penis is very inflamed a combined corticosteroid cream and antifungal agent (ie 1% clotrimazole) is better. Oral treatment is recommended when symptoms are more severe, in recalcitrant cases, or with concomitant diabetes. More severe inflammatory or erosive forms of balanitis initially require daily bathing of the penis or wet dressing with the prepuce retracted. In addition, sexual partners should be screened because they are likely to have a high rate of infection. It is important to identify and rectify predisposing factors such as diabetes, poor personal hygiene, eczema etc.

Outlook and prognosis

95%+ cure rate. Relapse likely if underlying factors not corrected.

 

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