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Antifungals

Antifungals play a focused but critical role in urology across six domains: (1) symptomatic Candida cystitis and pyelonephritis (the most common fungal urologic infection); (2) fungus balls / mycetoma in the bladder or renal pelvis; (3) perioperative antifungal prophylaxis for urologic procedures in patients with funguria; (4) penile prosthesis infection prevention — currently the strongest modifiable signal in IPP infection literature; (5) renal aspergillosis; and (6) rare fungal infections of the prostate, epididymis, and testes.[1][2]

The cornerstone principle that shapes every one of these decisions is pharmacokinetic: fluconazole is the drug of choice for most urinary Candida infections because it is essentially the only azole excreted in active form into the urine at concentrations exceeding the MIC for most Candida isolates. Lipid amphotericin B formulations and echinocandins do not achieve therapeutic urinary concentrations and should not be used for Candida UTI.[1][2]

For related classes, see UTI treatment antibiotics, Perioperative antibiotic prophylaxis, and Prosthetic infection & biofilm protocols.

Agents — which antifungals reach the urine?​

AgentUrinary excretionUrinary role
FluconazoleExcreted as active drug at high urinary levelsDrug of choice for most Candida UTI[1][2]
FlucytosineExcreted as active drug; broad Candida activity (except C. krusei)Alternative; limited by toxicity (marrow suppression, hepatitis) and rapid resistance when used alone[1]
AmB deoxycholateAchieves adequate urinary concentrations even at low dosesFluconazole-resistant species, fungus-ball local irrigation; IV only, nephrotoxic[1]
Lipid AmB formulations (L-AmB, ABLC)Do NOT achieve adequate urinary concentrationsShould not be used for Candida UTI[1]
Echinocandins (caspofungin, micafungin, anidulafungin)Minimal urinary excretionGenerally ineffective for Candida UTI; mixed case reports only[1]
Voriconazole, posaconazole, itraconazole, isavuconazolePoor urinary concentrationsNot effective for urinary tract infection; tissue-targeted use (e.g., renal parenchymal aspergillosis)[1][3]

Asymptomatic candiduria — when NOT to treat​

The most important clinical decision regarding antifungals in urology is recognizing that most candiduria represents colonization rather than infection and does not require antifungal therapy.[1]

IDSA 2016 Candidiasis guideline:

  • Antifungal treatment is not recommended for asymptomatic candiduria unless the patient is at high risk for dissemination
  • High-risk groups requiring treatment: neutropenic patients, very low-birth-weight infants (<1,500 g), and patients undergoing urologic manipulation
  • First-line interventions: remove the catheter (up to 40% clearance), eliminate broad-spectrum antibacterials where feasible, address diabetes and obstruction[1]

Overtreatment is endemic. Jacobs 2018 multi-institutional study found 43% of asymptomatic candiduria cases were overtreated, driven primarily by unnecessary fluconazole use.[3] Antifungal stewardship in candiduria is low-hanging fruit in most institutions.

Symptomatic Candida cystitis​

Per IDSA 2016:[1]

SpeciesRegimen
Fluconazole-susceptibleFluconazole 200 mg (3 mg/kg) PO daily × 2 weeks (strong recommendation)
Fluconazole-resistant C. glabrataAmB deoxycholate 0.3–0.6 mg/kg IV daily × 1–7 days OR oral flucytosine 25 mg/kg QID × 7–10 days
C. kruseiAmB deoxycholate 0.3–0.6 mg/kg IV daily × 1–7 days

AmB deoxycholate bladder irrigation (50 mg/L sterile water daily × 5 days) may be useful for cystitis due to fluconazole-resistant species, though bladder irrigation has limited utility overall and should not be considered definitive therapy.[1][4]

Remove or replace the indwelling catheter whenever feasible before initiating antifungal therapy.[1]

Candida pyelonephritis​

Ascending Candida pyelonephritis requires systemic therapy; hematogenous renal candidiasis from candidemia is treated as candidemia, not as a primary UTI.[1]

SpeciesRegimen
Fluconazole-susceptibleFluconazole 200 mg PO daily × 2 weeks (strong recommendation; moderate-quality evidence)
Fluconazole-resistant C. glabrataAmB deoxycholate 0.3–0.6 mg/kg IV daily × 1–7 days OR flucytosine 25 mg/kg QID × 7–10 days
C. kruseiAmB deoxycholate 0.3–0.6 mg/kg IV daily × 1–7 days

Fungus balls (mycetoma)​

Fungus balls in the bladder or renal pelvis cause obstruction and preclude cure with antifungals alone. Management requires a combined medical and procedural approach.[1]

  • Fluconazole-susceptible: fluconazole 200–400 mg PO daily × 2 weeks
  • Fluconazole-resistant C. glabrata: AmB deoxycholate 0.3–0.6 mg/kg daily × 1–7 days ± flucytosine 25 mg/kg QID; flucytosine monotherapy × 2 weeks may also be considered
  • C. krusei: AmB deoxycholate 0.3–0.6 mg/kg daily × 1–7 days
  • Eliminate obstruction — percutaneous nephrostomy, ureteral stent, or endoscopic removal as anatomy allows
  • Remove or replace nephrostomy tubes and stents
  • Local irrigation via nephrostomy with AmB deoxycholate achieves high local concentrations and is a useful adjunct in refractory fungus-ball disease[1]

Perioperative antifungal prophylaxis for urologic procedures​

Per the AUA Best Practice Statement on Urologic Procedures and Antimicrobial Prophylaxis (2020):[5]

  • Asymptomatic funguria alone does not require antifungal prophylaxis for simple nephrostomy exchange or ureteral stenting (in the absence of neutropenia or other high-risk features)
  • Antifungal prophylaxis IS recommended for patients with asymptomatic funguria undergoing:
    • Resective / enucleative / ablative outlet procedures (TURP, HoLEP)
    • TURBT
    • Ureteroscopy
    • PCNL
    • All endoscopic procedures
    • Procedures using high-pressure irrigation
    • Procedures with planned surgical entry into the urinary tract
    • Patients with neutropenia and urinary tract obstruction
  • Periprocedural dosing: fluconazole 400 mg (6 mg/kg) PO/IV daily or AmB deoxycholate 0.3–0.6 mg/kg IV daily for several days before and after the procedure[1][5]
  • Symptomatic fungal UTI at the time of tube / stent exchange requires full treatment (not single-dose prophylaxis), with fungicidal levels established before the procedure[5]

See Perioperative antibiotic prophylaxis for the full BPS framework.

Penile prosthesis — the strongest modifiable signal​

Antifungal prophylaxis for inflatable penile prosthesis (IPP) surgery is the single largest modifiable signal in the contemporary IPP infection literature. In Gross 2017's multicenter cultures analysis, fungi — predominantly C. albicans and C. glabrata — now account for up to 11% of IPP infections, with 83% occurring in diabetic or obese patients.[6]

PUMP collaborative data:

  • Abou Chawareb 2025 (n = 5,261, 16 centers) — perioperative IV antifungal use was independently associated with lower infection risk (OR 0.22; p < 0.001) — a ~92% reduction. Postoperative oral antibiotics and prolonged IV antibiotic prophylaxis >24 h showed no protective effect[7]

Standard perioperative regimen in contemporary IPP practice: fluconazole 400 mg IV as a single preoperative dose, combined with vancomycin + a gram-negative agent tailored to local antibiogram. AmB may substitute where non-albicans Candida coverage is a concern.

Antifungal adoption varies — a 2025 multicenter SMSNA/SUPS/GURS survey found antifungal use in 25.9% of primary, 72.3% of diabetic, 65.2% of salvage, and 48.2% of revision cases.[8] Bench data confirm that adding antifungal to hydrophilic-dip solutions does not compromise antibacterial efficacy.[9]

For the full prosthetic-infection framework (dipping solutions, Irrisept device-specific effects, salvage protocols) see Prosthetic infection & biofilm protocols and Penile implants — infection.

Radical cystectomy​

Pariser 2016 (single-institution, n = 386 radical cystectomies with urinary diversion): switching from cefoxitin to a culture-directed regimen that added fluconazole 400 mg (alongside ampicillin-sulbactam and gentamicin) dropped the overall infection rate from 41% → 30% (p = 0.043), with significant reductions in wound infection (14% → 6%) and fungal infection (10% → 3%).[10] Not universal practice, but a defensible addition in high-risk cystectomy patients — particularly diabetics, those with recent antifungal exposure, or prior funguria.

Renal aspergillosis​

Rare and typically from hematogenous dissemination in immunocompromised patients. Per IDSA aspergillosis guidelines:[11]

  • Combined medical + urologic management is required
  • Parenchymal disease: voriconazole is first-line for invasive aspergillosis — tissue is the target, not urine, so voriconazole's poor urinary excretion is not limiting
  • Renal pelvis disease / aspergillus fungus balls: local instillation of AmB deoxycholate via nephrostomy achieves high local concentrations without systemic absorption or nephrotoxicity; no role in parenchymal disease
  • Ureteral obstruction: decompress with nephrostomy or stent
  • Larger abscesses may require surgical drainage; nephrectomy is a last resort for refractory parenchymal disease

Rare genitourinary fungal infections​

  • Candida prostatitis, epididymitis, orchitis — rare; occur in diabetic, immunosuppressed, or recently instrumented patients. Candida epididymo-orchitis may require drainage or orchiectomy for definitive diagnosis, though oral fluconazole alone has been effective in reported cases.[1][12]
  • Endemic mycoses (blastomycosis, histoplasmosis, coccidioidomycosis) — rare GU involvement of prostate, epididymis, testis. Communicate with microbiology early so specimens are processed correctly (extended incubation, dedicated fungal media).[13] Treatment follows endemic-mycosis guidelines: typically itraconazole for mild / moderate disease or amphotericin B for severe / disseminated disease.

Evidence Summary​

IndicationEvidence levelKey guideline / trialNotes
Asymptomatic candiduriaLevel 1IDSA 2016 candidiasis guideline[1]Do NOT treat outside high-risk groups
Symptomatic Candida cystitis / pyelonephritisLevel 1IDSA 2016[1]Fluconazole 200 mg × 2 wk first-line
Fungus ballsLevel 2IDSA 2016[1]Combined medical + procedural
Perioperative antifungal prophylaxisLevel 2AUA BPS 2020[5]Fluconazole 400 mg for funguria + GU mucosal-disrupting procedures
IPP antifungal prophylaxisLevel 1Abou Chawareb 2025 PUMP[7]OR 0.22 for IV antifungal — strongest modifiable signal
Radical cystectomy + fluconazoleLevel 3Pariser 2016[10]Fungal infection 10% → 3%
Renal aspergillosisLevel 1IDSA 2016 aspergillosis guideline[11]Voriconazole for parenchymal; AmB locally for pelvic

Clinical Positioning​

  • Most candiduria is colonization — do not treat. Remove catheters, address predisposing factors (diabetes, broad-spectrum antibacterials, obstruction), and observe.[1][3]
  • Fluconazole 200 mg × 2 weeks is first-line for symptomatic cystitis and pyelonephritis due to fluconazole-susceptible Candida.[1]
  • Lipid AmB formulations and echinocandins are not for Candida UTI. This is a critical, common prescribing error — these agents do not achieve therapeutic urinary concentrations.[1][2]
  • Fungus balls need both antifungal and drainage — antifungals alone fail without relief of obstruction and removal of colonized tubes / stents.[1]
  • AUA BPS supports antifungal prophylaxis for patients with funguria undergoing mucosal-disrupting urologic procedures — typically fluconazole 400 mg.[5]
  • For IPP surgery, add fluconazole 400 mg IV. PUMP OR 0.22 for IV antifungal use is the single largest modifiable signal in contemporary IPP infection data — particularly in diabetic, obese, and revision cases.[7][8]
  • Voriconazole is the first-line agent for renal-parenchymal aspergillosis despite poor urinary excretion — the target is tissue, not urine.[11]
  • For fluconazole-resistant Candida UTI (C. glabrata, C. krusei), AmB deoxycholate 0.3–0.6 mg/kg IV or oral flucytosine 25 mg/kg QID are the defensible options; consult ID for complex cases.[1]
  • Bladder irrigation with AmB has limited efficacy and should not substitute for systemic therapy in true infection — reserve for refractory fluconazole-resistant cystitis as an adjunct.[1][4]

See Also​

References​

1. Pappas PG, Kauffman CA, Andes DR, et al. "Clinical practice guideline for the management of candidiasis: 2016 update by the Infectious Diseases Society of America." Clin Infect Dis. 2016;62(4):e1–e50. doi:10.1093/cid/civ933

2. Odabasi Z, Mert A. "Candida urinary tract infections in adults." World J Urol. 2020;38(11):2699–2707. doi:10.1007/s00345-019-02991-5

3. Jacobs DM, Dilworth TJ, Beyda ND, Casapao AM, Bowers DR. "Overtreatment of asymptomatic candiduria among hospitalized patients: a multi-institutional study." Antimicrob Agents Chemother. 2018;62(1):e01464-17. doi:10.1128/AAC.01464-17

4. Fisher JF, Sobel JD, Kauffman CA, Newman CA. "Candida urinary tract infections — treatment." Clin Infect Dis. 2011;52(Suppl 6):S457–S466. doi:10.1093/cid/cir112

5. Lightner DJ, Wymer K, Sanchez J, Kavoussi L. "Best practice statement on urologic procedures and antimicrobial prophylaxis." J Urol. 2020;203(2):351–356. doi:10.1097/JU.0000000000000509

6. Natsos A, Tatanis V, Lekkou A, et al. "Unveiling the hidden perils: a comprehensive review of fungal infections in inflatable penile prosthesis surgery." J Pers Med. 2024;14(6):644. doi:10.3390/jpm14060644

7. Abou Chawareb E, Hammad MAM, Azad B, et al. "Perioperative antimicrobial strategies in inflatable penile prosthesis surgery: associations between antifungals, oral antibiotics, and intravenous antibiotic duration, and infection outcomes." J Urol. 2025;214(6):642–653. doi:10.1097/JU.0000000000004716

8. Abou Chawareb E, Barham DW, Hammad MAM, et al. "Multicenter examination of contemporary penile prosthesis surgery infection prophylaxis practices." J Sex Med. 2025;22(8):1531–1533. doi:10.1093/jsxmed/qdaf145

9. Im B, Giordano A, Winslow A, Hickok N, Chung P. "Addition of antifungal agents to antibiotic solutions does not diminish the antibacterial properties of penile prosthesis hydrophilic surface dips." J Sex Med. 2026;23(2). doi:10.1093/jsxmed/qdaf372

10. Pariser JJ, Anderson BB, Pearce SM, et al. "The effect of broader, directed antimicrobial prophylaxis including fungal coverage on perioperative infectious complications after radical cystectomy." Urol Oncol. 2016;34(3):121.e9–121.e14. doi:10.1016/j.urolonc.2015.10.007

11. Patterson TF, Thompson GR, Denning DW, et al. "Practice guidelines for the diagnosis and management of aspergillosis: 2016 update by the Infectious Diseases Society of America." Clin Infect Dis. 2016;63(4):e1–e60. doi:10.1093/cid/ciw326

12. Jenkin GA, Choo M, Hosking P, Johnson PD. "Candidal epididymo-orchitis: case report and review." Clin Infect Dis. 1998;26(4):942–945. doi:10.1086/513937

13. Miller JM, Binnicker MJ, Campbell S, et al. "Guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2024 update by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)." Clin Infect Dis. 2024;ciae104. doi:10.1093/cid/ciae104