What is the most likely diagnosis for a patient presenting with itching and burning during urination, white, thick, curd-like penile discharge, and swelling of the foreskin, with laboratory results indicating glycosuria and microscopic hematuria, but no evidence of bacterial infection or other systemic symptoms?

Candidal Balanitis with Underlying Diabetes Mellitus

This patient has candidal balanitis (yeast infection of the glans penis and foreskin), and the presence of 3+ glucosuria strongly suggests undiagnosed or poorly controlled diabetes mellitus as the underlying predisposing factor. 1

Clinical Diagnosis

The clinical presentation is pathognomonic for candidal balanitis:

• White, thick, curd-like penile discharge is the hallmark finding that distinguishes candidal infection from bacterial urethritis 1
• Swelling of the foreskin with dry, cracked skin represents the inflammatory response and fissuring characteristic of Candida infection 1
• Itching and burning (rather than purulent discharge) are typical symptoms of fungal rather than bacterial infection 1
• Absence of fever, systemic symptoms, and negative bacterial markers (negative WBC esterase, negative nitrites, no bacteria on microscopy) effectively rules out bacterial urethritis 1, 2

Critical Underlying Condition

The 3+ glucosuria is a red flag that demands immediate attention - this patient almost certainly has diabetes mellitus, which is the most important predisposing factor for candidal balanitis 3, 4. The microscopic hematuria (11-30 RBCs) may represent diabetic nephropathy or unrelated pathology requiring follow-up, but does not change acute management 4.

Treatment Regimen

For uncomplicated candidal balanitis, topical antifungal therapy is first-line treatment: 1

• Topical azole cream (clotrimazole 1% or miconazole 2%) applied twice daily for 7-14 days is the preferred initial therapy 1
• Alternative: Fluconazole 150 mg oral single dose can be used, though this is more commonly recommended for vulvovaginal candidiasis, it is effective for candidal balanitis 1
• Advise improved hygiene - gentle cleansing and thorough drying of the glans and foreskin after washing 3

Mandatory Concurrent Actions

Three critical steps must occur simultaneously with antifungal treatment:

1. Screen for diabetes immediately - obtain fasting glucose, HbA1c, and comprehensive metabolic panel 3, 4
2. Evaluate and treat sexual partner - the patient's partner should be examined for vulvovaginal candidiasis and treated if symptomatic, as reinfection can occur 1
3. Consider circumcision consultation if recurrent episodes occur - circumcised males have 68% lower prevalence of balanitis, and circumcision may be definitive treatment for recurrent candidal balanitis 3

Common Pitfalls to Avoid

Do not empirically treat for bacterial STIs - the clinical presentation (curd-like discharge, absence of purulent discharge, negative bacterial markers) does not support gonorrhea or chlamydia, and unnecessary antibiotics promote resistance 1, 2, 5. The CDC specifically recommends against empiric antibiotic treatment without documented urethritis 1, 5.

Do not ignore the glucosuria - failing to diagnose and manage underlying diabetes will result in recurrent infections and progression of diabetic complications 3, 4.

Do not confuse this with lichen sclerosus - while lichen sclerosus can cause foreskin tightening and fissuring, it presents with porcelain-white plaques and does not produce curd-like discharge 1.

Follow-Up Strategy

• Re-evaluate in 7-14 days to confirm resolution of symptoms 1
• If symptoms persist despite adequate treatment, consider non-albicans Candida species (particularly C. glabrata) and treat with boric acid 600 mg intravaginally daily for 14 days (compounded for topical penile application) or nystatin 1
• If recurrent episodes occur (≥2 episodes), refer to urology for consideration of circumcision as definitive management 3