What is the appropriate treatment for Candida urethritis in a male?

Treatment of Candida Urethritis in Males

Fluconazole is the antifungal agent of choice for treating symptomatic Candida urethritis in males, as it achieves high urinary concentrations and demonstrates superior efficacy for genitourinary Candida infections. 1

Initial Assessment and Treatment Decision

Before initiating antifungal therapy, determine whether treatment is actually indicated:

• Asymptomatic candiduria does not require treatment in most cases, as it typically represents colonization rather than true infection 1, 2
• Treatment is mandatory for symptomatic urethritis with confirmed Candida (urethral discharge, dysuria, penile discomfort) 1, 3
• Remove predisposing factors first (indwelling catheters, discontinue unnecessary antibiotics), which clears candiduria in approximately 50% of asymptomatic patients without antifungal therapy 2, 3

First-Line Treatment Regimen

Fluconazole is the definitive first-line agent:

• Fluconazole achieves high urine concentrations with oral formulation and is highly water-soluble, primarily excreted in active form in urine, easily exceeding MIC for most Candida strains 1, 2
• No other azole antifungal is useful for urinary tract Candida infections due to minimal excretion of active drug into urine 1
• Newer azoles (voriconazole) and echinocandins are not recommended because they fail to achieve adequate urinary concentrations 1, 2

Alternative Agents for Fluconazole Failure or Resistance

When fluconazole cannot be used due to allergy, resistance (particularly C. glabrata or C. krusei), or treatment failure:

• Amphotericin B deoxycholate (AmB-d) at 0.5-0.7 mg/kg daily is the alternative systemic agent 1, 3
• Oral flucytosine demonstrates good activity and concentrates in urine, but is limited by toxicity and rapid resistance development when used alone; not recommended as monotherapy 1
• Bladder irrigation with AmB-d (50 mg/L sterile water) resolves candiduria in >90% but has high relapse rates; reserved for refractory cystitis from azole-resistant organisms 1

Treatment Duration

• Continue treatment until symptoms resolve and urine cultures no longer yield Candida species 1
• Monitor for treatment failure, which may indicate azole-resistant species requiring AmB-d 1, 3

Special Considerations for Male Genitourinary Candida Infections

Candida prostatitis and epididymo-orchitis:

• These are rare complications requiring surgical drainage of abscesses plus antifungal therapy 1
• Fluconazole remains the agent of choice, though recommendations are based on limited anecdotal data 1

Critical Pitfalls to Avoid

• Do not use lipid formulations of amphotericin B (LFAmB) as first choice for renal/urinary Candida infections due to presumed low concentrations in renal tissue and documented treatment failures 1
• Do not treat asymptomatic candiduria unless the patient is neutropenic, a very low-birth-weight infant, or undergoing urologic procedures 3
• Recognize that C. glabrata accounts for ~20% of adult urine isolates and frequently requires AmB-d rather than fluconazole 1, 3
• Ensure adequate diagnostic confirmation before treating, as candiduria may represent contamination or colonization rather than true infection 2, 3