Genital Candidiasis in Men

Genital candidiasis in men is inflammation of the glans and foreskin (candidal balanitis or balanoposthitis) caused by Candida albicans overgrowth. It is common in uncircumcised men, and often follows sex with a partner who has vulvovaginal candidiasis.

• Risk factors: diabetes (including SGLT2 inhibitor use), obesity, poor hygiene, uncircumcised foreskin, antibiotics, corticosteroids, immunosuppression, HIV, urinary incontinence.
• Not strictly a sexually transmitted infection but can be transmitted.

Itching, burning, soreness of the glans, erythema with white curd like plaques, satellite pustules, subpreputial discharge and pain on retracting the foreskin; sometimes asymptomatic.

• Differential diagnosis: lichen sclerosus, psoriasis, circinate balanitis (reactive arthritis), irritant or allergic contact dermatitis, herpes simplex, syphilis, trichomoniasis, bacterial balanitis (anaerobes, streptococci), Zoon balanitis, erythroplasia of Queyrat and squamous cell carcinoma.
• Complications: phimosis, paraphimosis, urethral meatal stenosis, recurrent balanoposthitis, secondary bacterial infection, systemic candidiasis in immunosuppression.

Clinical, with swab or scraping for KOH microscopy and culture.

• Fasting glucose or HbA1c, HIV test; swab for bacterial culture if purulent; STI screen (HIV, syphilis, gonorrhoea, chlamydia) where indicated.
• Biopsy for persistent, indurated or atypical lesions.

Topical antifungals with hygiene and control of predisposing disease.

• Supportive: wash gently with water alone or emollient soap substitute, retract and dry the foreskin carefully, avoid irritants (perfumed soaps), loose cotton underwear, glycaemic control, weight loss, treat the partner simultaneously, avoid sexual contact until healed.
• Pharmacological: clotrimazole 1 percent cream or miconazole 2 percent cream twice daily for 7 to 14 days; hydrocortisone 1 percent cream combined with an antifungal for 5 to 7 days when inflammation is marked; nystatin cream 100,000 units/g twice daily. Oral fluconazole 150 mg single dose (repeat after 7 days if needed) for extensive or recurrent disease, or itraconazole 200 mg twice daily for 1 day. Bacterial co infection: flucloxacillin 500 mg four times daily for 7 days.
• Procedures: circumcision for recurrent balanoposthitis, phimosis or lichen sclerosus; biopsy for non resolution.
• Special groups: diabetes, optimise glucose and check SGLT2 inhibitor use; HIV, treat and screen for other opportunistic infections; infants and children, topical clotrimazole and nappy care; liver disease, topical therapy.
• Red flags: ulceration, induration, bleeding, white sclerotic changes, persistent lesion over 4 weeks, phimosis, systemic illness.
• Follow-up: review at 2 weeks; investigate recurrent cases (glucose, HIV, partner treatment); circumcision discussion.