Overview

At some point in their lives, many people might have suffered from a fungal infection, or at least you might have heard about it happening to someone you know. A yeast infection is a type of fungal infection commonly caused by the fungus Candida. Although yeast infections are commonly associated with people assigned female at birth (AFAB), the male gender is not left out either. 

Penile yeast infection is a type of infection in people assigned male at birth (AMAB) caused by an overgrowth of the fungus Candida albicans. This infection, also called male candidiasis, can cause itching and inflammation of the head of the penis, called the glans, and has a higher recurrence rate in uncircumcised males. Thus, this article elucidates the association between an uncircumcised penis and susceptibility to yeast infection.

Understanding yeast infection in men 

Penile yeast infection, also called balanitis, occurs due to inflammation of the head of the penis (i.e., the glans). Inflammation of the foreskin is called posthitis. Balanitis and posthitis commonly occur concurrently in uncircumcised people AMAB as balanoposthitis.¹ Balanitis is a condition that occurs mostly in uncircumcised people AMAB. According to the British Association of Urological Surgeons, circumcision is a procedure that involves the removal of the entire foreskin from the glans, leaving the head of the penis exposed. Hence, people AMAB with a foreskin (i.e., uncircumcised) are at increased risk of developing balanitis.¹ Although yeast is the most common cause of balanitis, it can also be caused by a bacterial or viral infection. 

Penile yeast infection affects approximately 1 in every 25 boys and 1 in 30 uncircumcised people. Boys between the ages of 1 and 4 years and uncircumcised people AMAB are at the highest risk.² Globally, balanitis affects about 3% of uncircumcised males.² Oftentimes, a condition in which a tight foreskin cannot be retracted from the head of the penis can occur and is referred to as phimosis. This condition greatly increases the risk of balanitis. However, the most common health condition that predisposes to balanitis is diabetes.^3,4 

What causes yeast infections in men?

Penile yeast infections are commonly contracted through sexual activity. However, other risk factors that can lead to yeast infection include:

• Poor hygiene
• Diabetes mellitus, which causes high skin glucose levels and encourages the growth of yeast and bacteria^4,5
• Constant use of antibiotics
• Having a foreskin (i.e., uncircumcised)
• Wearing tight and wet clothes
• Having a compromised immunity 
• Use of spermicides and condoms with lubricants 
• Untreated sexually transmitted infections
• Use of glycosuric agents, like dapagliflozin and empagliflozin

Apart from Candida, other potential causes of balanitis are categorised into infectious and non-infectious agents.⁶ These include:

Anatomy of an uncircumcised penis 

The human penis consists of the glans, urethra, corpora cavernosa, corpus spongiosum, and foreskin (also known as the prepuce). These various parts represent different microenvironments with varying properties. These properties include: availability of oxygen, wetness, and keratinization, which provide convenient niches for bacterial growth.⁸ 

Symptoms of yeast infections in men 

Symptoms include:

• Sores or whitish discharge (called smegma) under the foreskin
• Burning sensation during urination
• Foul-smelling discharge 
• Intense itching around the foreskin¹²
• Red spots on the penis
• Small pus-filled bumps 
• Tenderness and sensitivity of the head of the penis (the glans)
• Symptoms worsen after sexual intercourse 

Notably, yeast infections can affect other regions of the skin apart from the penis. In such cases, they can cause red, itchy, or painful rashes that exude white or yellowish discharge.¹² For instance, a type of balanitis called circinate balanitis is associated with the onset of reactive arthritis. Circinate balanitis is characterised by small, shallow but painless ulcers on the glans penis.¹³

Association between an uncircumcised penis and susceptibility to yeast infections 

Uncircumcised people are more prone to Candida infection and proliferation compared to those with circumcised penises. This increased susceptibility in uncircumcised people could be due to the following:

Microenvironment

The prepuce or foreskin contains ectopic sebaceous glands that produce smegma. Smegma is a substance consisting of skin cells, oils, and moisture that can accumulate under the foreskin, especially under poor hygiene. This buildup can create a conducive ground for the growth and replication of yeast and bacteria.⁵

Protective role of circumcision

Circumcision removes the fold of the skin (which is called the foreskin). It gets rid of the warm, moist space between the skin and the tip, which can sometimes lead to infection. Consequently, removal of this space reduces the growth of pathogenic organisms and reduces the risk of multiplication of opportunistic ones.⁹

Change in penile microbiota

The composition and diversity of penile microbiota are significantly impacted by circumcision. This is because circumcision drastically reduces the predominance of anaerobic bacteria, and this includes those that are proinflammatory and target cells for HIV.¹¹ Consequently, this lowers the risk of developing sexually transmitted infections, particularly HIV.¹¹ Thus, the shift from anaerobic to predominantly aerobic bacterial communities decreases microbial interactions that could otherwise support Candida persistence and growth.

Increased surface area

The foreskin has a larger surface area, which can increase the risk of viral and bacterial infections in males. This is because the anoxic (oxygen-poor) environment that supports the colonisation of the penile region predominantly with anaerobes. Under certain conditions, such as a compromised (weakened) immunity, abrasion, or trauma, these penial anaerobes can cause local inflammation, creating conditions that facilitate HIV contraction and transmission.¹⁰ Therefore, compared to the circumcised penis, the foreskin provides a larger surface area for pathogens to colonise.¹⁰

How to treat and manage yeast infection in uncircumcised men

The treatment and prevention of penile yeast infection aims to improve urinary dysfunction, treat the underlying disease, reduce symptoms, and prevent recurrence. Hence, the following strategies can be adopted:

• Use of antifungal creams, ointments, and over-the-counter drugs (azoles) includes clotrimazole and micronazole cream twice a day for 14 days, during which the symptoms subside.² Also, imidazole (usually topical) with 1% hydrocortisone can be used if inflammation is present.² This is for balanitis caused by Candida species
• For anaerobic infections caused by Bacteroides, the recommended regimen is metronidazole (400-500mg) twice daily for a week. An alternative therapy is Amoxicillin/clavulanic acid (205/125mg) three times daily for 1 week.¹⁴ The patient should also be advised on how to improve genital hygiene, and in severe cases, circumcision may be required if phimosis is present¹⁴ 
• For aerobic infections caused by Streptococcus (Group A Streptococcus) and Staphylococcus aureus, treatment entails the use of oral or topical antibiotics or broad-spectrum antibiotics in severe cases. ¹⁴ Alternatively, the use of clobetasone butyrate with nystatin and oxytetracycline cream could be recommended twice daily for 7–10 days¹⁴ 
• For the general management of penile yeast infection, soaps should be avoided when chronic inflammation occurs. The patient should also be advised about the health risks involved in condom failure and given a detailed insight into their condition and implications¹⁴ 
• For non-infectious agents such as penile intraepithelial neoplasia, individualized treatment can include topical agents such as imiquimod and fluorouracil. Also, photodynamic therapy followed by red light exposure, laser ablation, surgical excision, curettage and cautery, and cryotherapy could be included¹⁵

FAQs 

What are the complications of a yeast infection in men?

Male yeast infections, if left untreated, can lead to serious complications, especially if the patient is prone to recurrence. Some of these complications include prostatitis, lichen planus, leukoplakia, phimosis, and urethral stricture. In immunocompromised individuals, such as HIV patients, there could be multisystem involvement and damage to critical organs in the body. 

How is a penile yeast infection diagnosed?

For diagnosis of penile yeast infections, a combination of physical examination, laboratory tests, and subpreputial culture may be required to confirm the diagnosis and for the accurate identification of the type of yeast or organism involved. Urinalysis could also be done to test for glucose. 

Can a penile yeast infection or balanitis be prevented? 

Yes, penile yeast infection can be prevented. Some preventive measures include adopting good hygiene practices, especially when it comes to clothing and keeping the genital area clean and dry. Also, safe sex practices, consuming probiotic-rich foods, and addressing underlying health conditions such as diabetes can reduce the risk of this infection. 

Summary 

Penile yeast infection or balanitis is a condition commonly caused by Candida albicans. Other anaerobic and aerobic bacteria are also implicated in this infection. Poor hygiene, diabetes mellitus, and continuous use of antibiotics are some of the risk factors associated with the onset of penile yeast infection. 

The symptoms of this infection range from pain to white or yellowish discharge and painful urination. The increased susceptibility of yeast infection in males is primarily due to the presence of the foreskin (i.e., uncircumcised). This is because circumcision has been shown to remove the conducive environment for the growth and proliferation of Candida and other anaerobic or opportunistic organisms. 

Treatment of yeast infections involves the use of antifungals and antibiotics (topical or oral), depending on the causative organism and severity. Additionally, it is essential to incorporate good hygiene and practice safe sex to reduce the recurrence and improve the management of this disease.