Skip to main content

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 — an evolving area supported mainly by observational studies; (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 are unsuitable for routine ascending Candida UTI. Hematogenous renal candidiasis is different: tissue-active therapy, including an echinocandin, may be appropriate as part of candidemia treatment.[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; systemic treatment is IV and nephrotoxic; local irrigation is a separate specialist use[1]
Lipid AmB formulations (L-AmB, ABLC)Do NOT achieve adequate urinary concentrationsAvoid for isolated ascending Candida UTI[1]
Echinocandins (caspofungin, micafungin, anidulafungin)Minimal urinary excretionPoor choice for ascending urinary infection; a role remains in hematogenous renal candidiasis[1]
Voriconazole, posaconazole, itraconazole, isavuconazolePoor urinary concentrationsPoor choice for ascending Candida UTI; tissue-targeted use (e.g., renal parenchymal aspergillosis)[1][11]

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 or replace an unnecessary catheter, 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, but evidence is low quality and relapse is common; it treats the bladder only, not pyelonephritis or candidemia.[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 200–400 mg (3–6 mg/kg) PO daily × 2 weeks (strong recommendation; low-quality evidence)
Fluconazole-resistant C. glabrataAmB deoxycholate 0.3–0.6 mg/kg IV daily × 1–7 days with or without flucytosine 25 mg/kg QID; flucytosine alone × 2 weeks is a weaker alternative
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
  • Consider removing or replacing nephrostomy tubes and stents, when feasible
  • 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
  • Duration differs between guidelines: AUA uses single-dose prophylaxis for asymptomatic funguria with urinary-tract surgery; IDSA recommends fluconazole 400 mg (6 mg/kg) daily or AmB deoxycholate 0.3–0.6 mg/kg daily for several days before and after urologic manipulation. Apply the chosen local protocol explicitly rather than attributing the IDSA schedule to AUA.[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 — observational prevention evidence​

Fungal infection is a relevant part of the IPP infection spectrum, often in patients with diabetes or excess weight. In the Gross 2019 retrospective series, 26 of 217 infected implants involved fungi (12%); this is a proportion of infected devices, not the risk among all implants.[14] The broader literature is reviewed by Natsos 2024.[6]

Abou Chawareb 2025 studied 5,261 primary or revision IPP procedures at 16 centers. IV antifungal use was associated with lower adjusted infection odds (OR 0.22, p < 0.001; 78% lower odds, not 92% lower risk). Prolonged IV prophylaxis and perioperative oral antibiotics did not show a protective association. This retrospective study cannot establish a causal benefit or an optimal drug/dose for every patient.[7]

Antifungal prophylaxis may be considered within a local implant protocol informed by patient risk, cultures, susceptibility, interactions and antimicrobial stewardship. Routine fluconazole for every implant, or amphotericin substitution for all non-albicans species, is not established by these data. Systemic prophylaxis and experimental device dipping are separate interventions.

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 testing found preserved antibacterial activity with selected antifungal-containing dips; this does not establish clinical infection prevention or compatibility of every mixture.[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] This before/after study changed several agents simultaneously and cannot isolate a fluconazole effect. It supports reviewing local microbiology, not routine antifungal prophylaxis after every cystectomy; prior azole exposure can increase resistance concerns.

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 is a specialist means of achieving high local concentrations; 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​

QuestionEvidence and limitation
Candida UTI and fungus ballsIDSA guidance; most urinary recommendations rely on low-quality evidence, with moderate-quality evidence for susceptible Candida cystitis.[1]
Funguria before urinary surgeryAUA BPS and IDSA differ in procedure scope and duration; see above.[1][5]
IPP antifungal prophylaxisLarge retrospective PUMP cohort; association rather than randomized treatment effect.[7]
Radical cystectomySingle-center before/after multicomponent prophylaxis change.[10]
Renal aspergillosisIDSA weak recommendation based on low-quality evidence.[11]

Clinical Positioning​

  • Confirm infection and site before treating candiduria. Catheter management and relief of obstruction often matter more than an antifungal prescription.[1][3]
  • Use the separate cystitis and pyelonephritis tables above; flucytosine is not an option for C. krusei. Resistant organisms and fungus balls merit infectious-disease input.[1]
  • Choose tissue-active therapy for candidemia with renal involvement or renal aspergillosis rather than relying on urine penetration alone.[1][11]
  • Review renal dosing, QT/CYP interactions and liver toxicity before fluconazole. For repeated dosing, the US label reduces maintenance dosing to 50% at CrCl ≤50 mL/min in patients not receiving dialysis, after the initial dose; dialysis requires its own schedule.[15] Flucytosine requires renal adjustment and close blood-count/liver monitoring; amphotericin requires renal/electrolyte monitoring.[1]
  • Keep implant prophylaxis distinct from treatment of an established fungal device infection. Observational prophylaxis findings do not replace source control or culture-directed treatment.

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

14. Gross MS, Reinstatler L, Henry GD, et al. "Multicenter investigation of fungal infections of inflatable penile prostheses." J Sex Med. 2019;16:1100–1105. doi:10.1016/j.jsxm.2019.05.003

15. Pfizer. DIFLUCAN US prescribing information. Renal dosing, warnings and interactions; accessed September 12, 2026.