I'm a male patient with persistent penile symptoms, previously treated with oral and topical medications for a suspected fungal infection, but the treatment was unsuccessful, and my partner has been diagnosed with Bacterial Vaginosis (BV), what could be the cause of my symptoms?

Persistent Penile Symptoms After Failed Antifungal Treatment in Male Partner of Woman with Bacterial Vaginosis

You likely have non-gonococcal urethritis (NGU) or balanitis that requires antibiotic treatment, not antifungal therapy, and should be treated empirically with doxycycline 100 mg orally twice daily for 7 days or azithromycin 1 g orally as a single dose.

Understanding the Clinical Scenario

Your persistent symptoms despite antifungal treatment strongly suggest a misdiagnosis. While your partner's bacterial vaginosis (BV) is not typically sexually transmitted, the organisms associated with BV can occasionally cause urethritis or balanitis in male partners 1. More importantly, treatment of male sex partners for BV is not routinely recommended, but a minority of male partners may develop balanitis characterized by erythematous areas on the glans with pruritus or irritation 1.

The failure of both oral and topical antifungal medications indicates this is likely not a fungal infection, despite the initial clinical impression 1.

Most Likely Diagnoses to Consider

Non-Gonococcal Urethritis (NGU)

• NGU is characterized by mucoid or purulent urethral discharge and burning during urination, though asymptomatic infections are common 1.
• The most frequent causes include Chlamydia trachomatis (23-55% of cases), Ureaplasma urealyticum (20-40%), and Trichomonas vaginalis (2-5%) 1.
• Importantly, female sex partners of men with NGU are at risk for chlamydial infection and associated complications, making partner evaluation critical 1.

Bacterial Balanitis

• Men whose partners have BV may develop balanitis with erythematous areas on the glans, pruritus, or irritation, and these men benefit from treatment with topical antifungal agents to relieve symptoms 1.
• However, since antifungals failed in your case, bacterial causes should be strongly considered 2, 3.

Recommended Treatment Approach

First-Line Empiric Antibiotic Therapy

Treat immediately with one of the following regimens:

• Doxycycline 100 mg orally twice daily for 7 days (preferred for NGU) 1, 4
• Azithromycin 1 g orally as a single dose (alternative, better for compliance concerns) 1, 4

Both regimens achieve 97-98% cure rates for chlamydial and other bacterial causes of urethritis 4.

If Epididymitis is Suspected

If you have testicular pain, swelling, or tenderness, you require combination therapy:

• Ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 3

This covers both gonococcal and chlamydial infections, which are the primary causes of epididymitis in sexually active men 1.

Critical Diagnostic Considerations

Testing You Should Request

• Gram-stained smear of urethral exudate or intraurethral swab to diagnose urethritis (>5 polymorphonuclear leukocytes per oil immersion field) 1
• Nucleic acid amplification test (NAAT) for N. gonorrhoeae and C. trachomatis on first-void urine or urethral swab 1, 4
• Wet mount examination for Trichomonas vaginalis if initial treatment fails 1
• Syphilis serology and HIV testing should be offered 1

Why Antifungals Failed

Candidal balanitis in men is uncommon and typically responds well to topical azole therapy 1. Your treatment failure strongly suggests:

1. The initial diagnosis was incorrect
2. A bacterial pathogen is responsible
3. You may have been reinfected if your partner was not simultaneously treated 1

Partner Management is Essential

Your partner must be evaluated and treated, even if asymptomatic 1, 4. This is critical because:

• Patients should be instructed to refer sex partners for evaluation and treatment if their last sexual contact was within 60 days of symptom onset 1
• Failure to treat sex partners leads to reinfection in up to 20% of cases 4
• Both you and your partner must abstain from sexual intercourse for 7 days after initiating treatment and until both are cured 1, 4

Follow-Up and Persistent Symptoms

If Symptoms Persist After Treatment

Return for evaluation if symptoms persist or recur after completing therapy 1. At that point:

• Consider testing for Mycoplasma genitalium using NAAT, as this organism causes doxycycline-resistant urethritis 4
• Wet mount and culture for T. vaginalis should be performed 1
• If negative, retreat with an alternative regimen extended to 14 days (e.g., erythromycin base 500 mg orally four times daily for 14 days) 1

For Confirmed M. genitalium

Moxifloxacin 400 mg orally once daily for 7 days is highly effective, particularly for macrolide-resistant strains 4.

Common Pitfalls to Avoid

1. Do NOT assume this is a fungal infection just because your partner has BV - BV is not a fungal condition and does not typically cause fungal infections in male partners 5, 6, 7

2. Do NOT retreat with antifungals - the failure of initial antifungal therapy essentially rules out candidal infection 1, 2

3. Do NOT delay antibiotic treatment while waiting for test results if compliance with return visits is uncertain 4

4. Do NOT assume your partner was adequately treated - directly verify or ensure simultaneous treatment 4

5. Do NOT retreat based on symptoms alone without documenting objective signs of urethral inflammation or laboratory evidence of infection 4

When to Seek Urgent Care

Seek immediate medical attention if you develop:

• Fever, severe pain, or extensive swelling 2
• Testicular pain or swelling (possible epididymitis or torsion) 1
• Systemic symptoms suggesting spreading infection 2
• Signs of Fournier's gangrene (rare but serious) 2