What is the diagnosis and treatment for a penile yeast infection with foreskin retraction issues?

Candidal Balanoposthitis: Diagnosis and Treatment

Candidal balanoposthitis is the appropriate diagnosis for penile yeast infection in males with foreskin retraction issues, and treatment should include topical antifungal therapy with clotrimazole or miconazole, along with proper hygiene and potentially oral fluconazole for severe or resistant cases.

Diagnosis

Candidal balanoposthitis refers to a yeast infection affecting the glans penis (balanitis) and foreskin (posthitis). This condition is particularly common in uncircumcised males and presents with:

• Erythematous (red) patches on the glans penis
• White, creamy, plaque-like lesions that can be scraped off
• Itching and burning sensation
• Pain during sexual intercourse (male dyspareunia)
• Difficulty retracting the foreskin (phimosis)
• Tenderness and swelling of the affected area

Diagnosis is primarily clinical but can be confirmed by:

• Microscopic examination of skin scrapings with potassium hydroxide (KOH) preparation showing characteristic yeast forms 1
• Culture of the lesions to identify Candida species (most commonly Candida albicans) 2

Treatment Algorithm

First-line Treatment:

1. Topical antifungal agents (7-14 days):

   • Clotrimazole cream/ointment applied 2-3 times daily
   • Miconazole cream/ointment applied 2-3 times daily
   • Nystatin cream applied 2-3 times daily

2. Proper hygiene measures:

   • Gentle cleansing with warm water (avoid soap)
   • Thorough drying after washing
   • Retraction of foreskin during urination and washing (if possible)

For Severe or Resistant Cases:

1. Oral antifungal therapy:

   • Fluconazole 150 mg single dose, may repeat after 3 days if needed 1
   • For fluconazole-resistant cases, itraconazole 200 mg daily for 7 days 3

2. For associated phimosis/foreskin retraction issues:

   • Gentle stretching exercises of the foreskin
   • Topical corticosteroids (0.05% betamethasone) may help reduce inflammation and facilitate retraction
   • Consider urological consultation if phimosis persists despite treatment

For Recurrent Infections:

1. Extended antifungal course:

   • Fluconazole 150 mg weekly for 2-3 weeks
   • Maintenance topical antifungals after showering

2. Address predisposing factors:

   • Diabetes control if applicable
   • Avoid irritants (soaps, spermicides)
   • Consider circumcision for definitive management 4

Special Considerations

• Circumcision: Studies show that circumcised males have a 68% lower prevalence of balanitis than uncircumcised males 4. For recurrent cases, circumcision may be considered as definitive treatment.

• Diabetic patients: More susceptible to candidal infections and may require longer treatment courses and closer monitoring.

• Sexual transmission: Partners may need treatment to prevent reinfection, particularly if female partner has vulvovaginal candidiasis 2.

• Differential diagnosis: Rule out other causes of balanitis such as bacterial infection, contact dermatitis, or lichen sclerosus (which can also cause phimosis) 1.

Common Pitfalls to Avoid

1. Inadequate treatment duration: Stopping treatment once symptoms improve often leads to recurrence.

2. Ignoring predisposing factors: Uncontrolled diabetes, poor hygiene, and tight foreskin contribute to recurrent infections.

3. Missing resistant strains: Some Candida strains may be resistant to fluconazole and require alternative antifungals 3.

4. Confusing with bacterial infection: Bacterial balanoposthitis requires antibiotics rather than antifungals. If in doubt, perform appropriate cultures 2.

5. Forceful retraction of foreskin: Can cause trauma and worsen inflammation. Gentle retraction only as tolerated during the healing process.

By following this treatment approach, most cases of candidal balanoposthitis resolve within 1-2 weeks, with improvement in both the infection and foreskin retraction issues.