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Antifungals

Antifungals play a focused role in urology across six domains: (1) symptomatic Candida cystitis and pyelonephritis (the most common fungal urologic infection), and (2) fungus balls / mycetoma in the bladder or renal pelvis.[1][2] Perioperative uses are (3) prophylaxis for urologic procedures in patients with funguria and (4) penile prosthesis infection prevention, an evolving area supported mainly by observational studies.[1][5][7] The remaining domains are (5) renal aspergillosis and (6) fungal infections described in the prostate, epididymis, and testes.[1][11][12]

For ascending Candida UTI caused by a susceptible isolate, fluconazole is favored 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
FluconazoleAbout 80% of a dose is recovered unchanged in urine (US label)Drug of choice for most Candida UTI[1][2][15]
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​

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
  • High-risk neutropenic patients and infants are treated as for candidemia; patients facing urologic manipulation receive a short peri-procedural course (see below)
  • First-line interventions: remove or replace an unnecessary catheter, eliminate broad-spectrum antibacterials where feasible, address diabetes and obstruction[1]
  • EAU Urological Infections 2026 agrees: asymptomatic funguria generally needs no antifungal, but treatment should be considered in neutropenic patients, infants under 1,500 g, and before urologic intervention that breaches the mucosa. Non-antimicrobial measures come first; catheter replacement alone can clear funguria, and an obstructed system needs prompt stent or nephrostomy drainage[17]
  • The 2026 urologist's manual (Bausch, written to supplement the EAU Urological Infections guideline) takes the same position: only 2–11% of funguria isolates are symptomatic, catheter replacement belongs in every treatment plan, fluconazole is first-line, and asymptomatic funguria is treated only in exceptional cases[16]

In the Jacobs 2018 four-center inpatient cohort, 105/243 (43%) asymptomatic candiduria cases were managed discordantly with IDSA guidance, and 98/243 (40%) received antifungal therapy without an indication, most often fluconazole.[3]

Symptomatic Candida cystitis​

Send urine for fungal culture, species identification, and susceptibility testing, particularly for non-albicans Candida, and adjust empirical therapy to the result .[17]

Per IDSA 2016:[1]

SpeciesRegimen
Fluconazole-susceptibleFluconazole 200 mg (3 mg/kg) PO daily × 2 weeks
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

EAU 2026 lists fluconazole, AmB deoxycholate and oral flucytosine as the agents, with species susceptibility deciding the choice. Empirical therapy is usually a two-week fluconazole course with a double first-day loading dose. C. krusei is intrinsically resistant to fluconazole, whereas C. glabrata susceptibility varies by isolate and testing method. Use fluconazole for C. glabrata UTI only when isolate susceptibility supports it, with MIC-guided and renal-adjusted dosing; EAU 2026 lists 800 mg/day for susceptible localized C. glabrata UTI rather than the generic 200 mg/day cystitis dose above.[17] Echinocandins have poor urinary excretion and are not standard treatment for ascending Candida pyelonephritis; their adequate renal-tissue exposure may justify use for hematogenous renal candidiasis during candidemia treatment.[1] EAU 2026 discusses micafungin for resistant cystitis only as an exceptional option supported by limited retrospective evidence without a cystitis-specific analysis.[17]

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] EAU 2026 describes continuous irrigation with 50 mg/L for five days as an option in localized fluconazole-resistant cases after upper-tract and systemic spread are excluded.[17] In a randomized trial of 109 hospitalized elderly patients with funguria, irrigation produced more culture clearance two days after treatment than fluconazole (96% versus 73%), but the proportions without funguria at one month were similar (84% versus 80%); one-month all-cause mortality was 41% versus 22%.[19]

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

EAU 2026 states that a course shorter than two weeks may be used for localized fungal cystitis without risk factors .[17] In a retrospective cohort of 103 hospitalized adults with symptomatic Candida UTI treated with fluconazole, clinical treatment success was 54/58 (93.1%) with courses shorter than 14 days (median 7 days) versus 42/45 (93.3%) with 14-day courses. In this mixed cystitis and pyelonephritis/febrile UTI cohort, success required symptom resolution or improvement, no treatment extension or antifungal switch, and no new antifungal prescription within 14 days after completion.[17][18]

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
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: oral fluconazole 200 mg daily × 2 weeks for cystitis or 200–400 mg daily × 2 weeks for ascending pyelonephritis[1]
  • Fluconazole-resistant C. glabrata: for cystitis, AmB deoxycholate 0.3–0.6 mg/kg IV daily × 1–7 days or oral flucytosine 25 mg/kg QID × 7–10 days; for ascending pyelonephritis, AmB deoxycholate 0.3–0.6 mg/kg IV daily × 1–7 days with or without oral flucytosine 25 mg/kg QID, or oral flucytosine 25 mg/kg QID alone × 2 weeks[1]
  • C. krusei: AmB deoxycholate 0.3–0.6 mg/kg IV daily × 1–7 days[1]
  • Relieve obstruction and remove the fungal mass in adults when feasible; use percutaneous nephrostomy or ureteral stenting for drainage, with surgical or endoscopic mass removal according to location and anatomy
  • Consider removing or replacing nephrostomy tubes and stents, when feasible
  • Local irrigation via nephrostomy with AmB deoxycholate (IDSA: 25–50 mg in 200–500 mL sterile water) achieves high local concentrations and is recommended by IDSA when a nephrostomy tube is in place [1]
  • Send fungal culture with susceptibilities. The AUA statement calls for antifungal therapy at the time of the procedure and afterward, with 5–7 days the majority opinion[5]

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 specific intermediate- and high-risk procedures, including:
    • Resective / enucleative / ablative outlet procedures (TURP, HoLEP)
    • TURBT
    • Ureteroscopy
    • PCNL
    • All endoscopic procedures, except ureteral stenting alone in patients without neutropenia or other high-risk features (as above)
    • Procedures using high-pressure irrigation
    • Procedures with planned surgical entry into the urinary tract
  • Drug and duration come from IDSA: the AUA statement names the procedures but gives no antifungal agent or prophylaxis duration for asymptomatic funguria. 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 .[1][5]
  • Neutropenic patients with funguria and urinary-tract obstruction are named separately in the AUA list as needing antifungal prophylaxis, and IDSA treats neutropenic candiduria as candidemia. Involve infectious disease early; the AUA statement sets no separate duration for this group[1][5]
  • Agent choice: IDSA offers oral fluconazole or AmB deoxycholate.[1] Fluconazole is usually chosen because it reaches the urine in active form; reserve AmB deoxycholate for fluconazole-resistant species or when fluconazole cannot be used (allergy, QT prolongation or interacting drugs, acute liver injury; see the label)[1][15]
  • 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.[14] In the Gross 2019 retrospective series of 217 patients who underwent salvage or explant for infected IPPs, 26 had fungal infection (12%).[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.[7]

Antifungal prophylaxis may be considered within a local implant protocol informed by patient risk, cultures, susceptibility, interactions and antimicrobial stewardship. Systemic prophylaxis and experimental device dipping are separate interventions.

Antifungal adoption varies; a 2025 voluntary survey of 112 implanters found that respondents reported perioperative antifungal use for primary (25.9%), diabetic primary (72.3%), salvage (65.2%), and revision (48.2%) IPP scenarios.[8] Selected antifungal-containing dips retained antibacterial activity in bench tests; clinical infection prevention and compatibility of other mixtures were not tested.[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 before/after study, n = 386 radical cystectomies with urinary diversion): the 30-day overall infection rate was 41% before versus 30% after a change from cefoxitin to a culture-directed regimen including fluconazole 400 mg, ampicillin-sulbactam, and gentamicin (p = 0.043); 30-day wound infection was 14% versus 6% (p = 0.025) and fungal infection 10% versus 3% (p = 0.021), respectively.[10] Prior azole exposure can increase resistance concerns.

Renal aspergillosis​

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

  • IDSA suggests combined medical and urologic management
  • Parenchymal disease: IDSA suggests voriconazole for renal parenchymal aspergillosis ; tissue is the target, not urine, so poor urinary excretion is not limiting[11]
  • 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 requires organism- and site-specific guidance.

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 defines the procedures that warrant prophylaxis (consensus statement); IDSA supplies drug and duration (low-quality evidence).[1][5]
IPP antifungal prophylaxisLarge retrospective PUMP cohort.[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.[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 pregnancy status, renal dosing, QT/CYP interactions and liver toxicity before systemic fluconazole; the US label advises avoiding use in pregnancy except for severe or potentially life-threatening fungal infection when anticipated benefit outweighs fetal risk.[15] For repeated dosing, the US label gives a loading dose of 50–400 mg, then reduces the daily dose to 50% at CrCl ≤50 mL/min without dialysis; patients on hemodialysis receive 100% of the recommended dose after each session and a reduced dose on nondialysis days according to creatinine clearance (a 3-hour session lowers plasma levels by about 50%).[15] The label contraindicates co-administration with QT-prolonging CYP3A4 substrates (erythromycin, pimozide, quinidine) and advises caution with hypokalemia or heart failure. Fluconazole also raises phenytoin, sulfonylurea and warfarin effect, so check the medication list first.[15] The label reports 50–200 mg daily for Candida UTI in small noncomparative studies; the 200 mg (3 mg/kg) IDSA dose sits at the top of that range.[1][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.

16. Bausch K, Smith EJ, Cai T, et al. "Fungal urinary tract infection: a brief manual for diagnosis and treatment for urologists." Eur Urol Open Sci. 2026;92:50-54. doi:10.1016/j.euros.2026.08.006

17. European Association of Urology. EAU Guidelines on Urological Infections. Limited update, March 2026. Section 3.17, fungal urinary tract infection. Full guideline.

18. Govel JC, Seabury RW, Asiago-Reddy EA, et al. "Evaluation of shorter versus longer antifungal treatment durations for Candida spp. urinary tract infections among hospitalized adults." Antimicrob Agents Chemother. 2025;69(6):e01920-24. doi:10.1128/aac.01920-24

19. Jacobs LG, Skidmore EA, Freeman K, Lipschultz D, Fox N. "Oral fluconazole compared with bladder irrigation with amphotericin B for treatment of fungal urinary tract infections in elderly patients." Clin Infect Dis. 1996;22(1):30–35. doi:10.1093/clinids/22.1.30