Management of Male with Yeast in Urine
Initial Assessment: Determine if Treatment is Needed
Most asymptomatic males with yeast in urine require only observation and removal of predisposing factors—not antifungal therapy. 1
Observation Only (No Treatment)
- Remove indwelling urinary catheter if present—this alone clears candiduria in approximately 50% of asymptomatic patients 1, 2
- Stop broad-spectrum antibiotics if clinically feasible 3
- Monitor for symptom development 1
Mandatory Treatment Scenarios
Treat asymptomatic males with yeast in urine ONLY if they meet these high-risk criteria:
- Neutropenic patients (treat as candidemia) 1, 4
- Planned urologic procedure/manipulation within days 1, 4
- Severely immunocompromised with fever (consider disseminated candidiasis) 1, 4
- Urinary tract obstruction present 1
Treatment Algorithm for Symptomatic Cystitis
First-Line Therapy
Fluconazole 200 mg (3 mg/kg) orally daily for 2 weeks is the treatment of choice for symptomatic Candida cystitis in males 1, 5
- Fluconazole achieves high urinary concentrations in active form, making it superior to all other antifungals for lower urinary tract infections 1
- This recommendation is based on the only randomized, double-blind, placebo-controlled trial in candiduria 1
- Available as oral formulation, eliminating need for IV access 1
Alternative Therapy for Resistant Species
For fluconazole-resistant C. glabrata:
- Amphotericin B deoxycholate 0.3–0.6 mg/kg IV daily for 1–7 days 1, 5
- OR oral flucytosine 25 mg/kg four times daily for 7–10 days 1, 5
- Consider amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) for refractory cystitis 1
For C. krusei:
- Amphotericin B deoxycholate 0.3–0.6 mg/kg IV daily for 1–7 days 1
Treatment for Pyelonephritis
Fluconazole 200–400 mg (3–6 mg/kg) orally daily for 2 weeks for fluconazole-susceptible organisms 1, 4
- For fluconazole-resistant C. glabrata: Amphotericin B deoxycholate 0.3–0.6 mg/kg daily for 1–7 days with or without flucytosine 25 mg/kg four times daily 1
- Do NOT use lipid formulations of amphotericin B—they fail to achieve adequate urine concentrations 1
Pre-Procedure Prophylaxis
For males undergoing urologic procedures with candiduria:
- Fluconazole 400 mg (6 mg/kg) daily OR amphotericin B deoxycholate 0.3–0.6 mg/kg daily for several days before and after the procedure 1
Special Considerations for Males
Candida Prostatitis/Epididymo-orchitis
- Fluconazole is the agent of choice (dose and duration extrapolated from cystitis recommendations) 1
- Most patients require surgical drainage of abscesses in addition to antifungal therapy 1
- These infections are rare but require aggressive management 1
Fungus Balls
- Surgical or endoscopic removal is mandatory—antifungal therapy alone will fail 1
- Add systemic fluconazole or amphotericin B deoxycholate as adjunctive therapy 1
- If nephrostomy tube present, consider amphotericin B irrigation (25–50 mg in 200–500 mL sterile water) 1
Critical Pitfalls to Avoid
Do NOT use echinocandins (caspofungin, micafungin, anidulafungin) or other azoles (voriconazole, posaconazole, isavuconazole) for Candida UTI—they achieve minimal urinary concentrations and are ineffective for lower tract infections 1, 2
Do NOT treat asymptomatic candiduria in otherwise healthy males—this represents colonization and treatment does not prevent complications 1, 6
Do NOT overlook disseminated candidiasis in high-risk patients—candiduria may be the first sign of hematogenous spread, particularly in neutropenic or severely immunocompromised patients 1, 4, 6
Do NOT rely on colony counts or pyuria to differentiate infection from colonization—clinical symptoms and risk factors guide treatment decisions 1