What is the recommended treatment for a 9-year-old male with testicular microlithiasis and a yeast infection on the penis?

Treatment for Testicular Microlithiasis and Penile Yeast Infection in a 9-Year-Old

Treat the penile yeast infection with topical antifungal therapy (clotrimazole or miconazole) for 7-14 days, and reassure the family that testicular microlithiasis requires no treatment or surveillance in the absence of risk factors for testicular cancer.

Management of Penile Yeast Infection

The penile yeast infection (candidal balanitis) should be treated with:

• Topical antifungal agents are the first-line treatment, with clotrimazole or miconazole applied to the affected area for 7-14 days 1
• For mild disease in this age group, topical therapy is preferred over systemic antifungals 1
• No oral fluconazole is needed unless the infection is severe or refractory to topical treatment 1
• Ensure proper hygiene and keep the area clean and dry during treatment 1

Important Considerations for Pediatric Candidal Infections

• The infection is typically uncomplicated in immunocompetent children and responds well to topical therapy 1
• Systemic antifungals (oral fluconazole 100-200 mg daily for 7-14 days) would only be considered for moderate to severe disease that fails topical treatment 1
• This is not a sexually transmitted infection in a 9-year-old, so the STI-focused recommendations for epididymitis do not apply 2, 3

Management of Testicular Microlithiasis

No treatment or surveillance is required for testicular microlithiasis in this child.

Evidence-Based Approach

• Testicular microlithiasis in the absence of solid mass and risk factors for developing germ cell tumor does not confer an increased risk of malignancy and does not require further evaluation 1
• The 2019 AUA guidelines explicitly state that incidentally detected microlithiasis should not undergo further evaluation unless other risk factors are present 1
• Risk factors that would warrant surveillance include: cryptorchidism, family history of testicular cancer, personal history of germ cell tumor, or Germ Cell Neoplasia In Situ 1

Why No Surveillance is Needed

• Testicular microlithiasis is present in 5.6% of the male population (14.1% in African Americans), far more common than testicular cancer (7:100,000) 4
• A prospective study showed no association between isolated testicular microlithiasis and development of germ cell tumors 1
• The majority of men with testicular microlithiasis will not develop testicular cancer 4
• Previously recommended surveillance regimens using ultrasound, tumor markers, or testicular biopsy are too costly and do not offer improved outcomes over testicular self-examination 4

What Parents Should Be Told

• Reassure the family that testicular microlithiasis is a benign finding that requires no treatment 1
• Teach testicular self-examination when the child reaches adolescence, as this is the recommended follow-up for men identified with testicular microlithiasis 4
• No repeat ultrasounds, tumor markers, or biopsies are indicated unless a solid mass develops or other risk factors emerge 1
• If a solid testicular mass is ever identified on physical exam or imaging in the future, it should be managed as a malignant neoplasm until proven otherwise 1

Common Pitfalls to Avoid

• Do not order surveillance ultrasounds or tumor markers for isolated testicular microlithiasis - this represents outdated practice that increases cost and anxiety without improving outcomes 1, 4
• Do not confuse testicular microlithiasis with a solid testicular mass - microlithiasis consists of >5 small echogenic non-shadowing foci, while a solid mass appears as a hypoechoic mass with vascular flow 1
• Do not use systemic antifungals as first-line therapy for uncomplicated penile yeast infection - topical therapy is sufficient and avoids unnecessary medication exposure 1
• Do not assume the penile infection is related to the testicular microlithiasis - these are separate, unrelated conditions 1