A more detailed laboratory work-up might include the following:
• Serum glucose test (as part of a diabetes screening; in older men, this inflammatory condition can be a presenting sign of diabetes mellitus6)
• Culture of discharge, if any is present
• Serology test for STDs
• Wet mount with potassium hydroxide (for Candida albicans infection)
• Ultrasound, in severe cases or when urinary obstruction is suspected.
Additionally, in chronic cases, the patient should be referred to dermatology or urology for biopsy.5,9 Testing for anaerobes should also be considered for the patient and his sexual partner; if results are positive, treatment with oral metronidazole (400 mg tid for 10 days) is advised.6
In this patient’s case, the test that would best support an in-office diagnosis of candidiasis balanitis is a wet mount with potassium hydroxide. This was not performed at the time of the case patient’s visit, however; the diagnosis was empirically determined.
Management, Including Patient Education
Treatment of candidiasis balanitis involves routinely cleaning the penis and foreskin, as the case patient was instructed; use of soap, an irritant, should be avoided until the condition is resolved.7,10 Appropriate topical antifungal creams include nystatin, ketoconazole, miconazole, clotrimazole, econazole, and terbinafine, applied two to three times daily for at least 10 days; a cream combining an imidazole with 1% hydrocortisone may be effective for patients with significant inflammation.5,6,8,10,13
The patient should be instructed to:
• Keep the area clean and dry
• Wash twice daily with weak saline solution after removing residual medication and before applying fresh medication
• Wear loose cotton underwear
• Avoid sharing towels or cleaning cloths
• Wash personal items and surfaces, if possible, with disinfectant
• Notify sexual partner(s) that they may need treatment
• Discontinue sexual intercourse until infection is resolved
• Continue treatment for 10 to 14 days, even though relief may occur early
• Follow up with the clinician if no improvement is seen within one week
• Consider circumcision, in case of chronic infection.1,2,8,12
Conclusion
It is important to diagnose balanitis correctly, as this condition can affect sexual and urinary function, and its effects should not be underestimated in older men. Differentiating between infectious, noninfectious, premalignant, and malignant lesions will lead to appropriate care and allow early diagnosis or prevention of curable malignancies.