Management of fungus balls as a result of Candida albicans
and Naoya Masumori
Department of Urology, and
Department of Infection
Control and Laboratory
Medicine, Sapporo Medical
University School of Medicine,
Sapporo, Hokkaido, Japan
One of the symptoms of fungal urinary tract infection is obstruction of the urinary tract, espe-
cially the ureter, as a result of fungus balls.
Here, we report a rare case with urinary retention
by urethral obstruction as a result of Candida albicans fungus balls.
A 69-year-old man had a fever >38°C, although there were no costovertebral tenderness and
pyuria. White blood cell count was 21 300/lL and C-reactive protein 25.41 mg/dL. Enterococ-
cus faecalis were isolated from his urine and blood. His illness was diagnosed as pyelonephritis,
and he was given intravenous tazobactam/piperacillin 4.5 g every 8 h for 7 days and intra-
venous meropenem 1 g every 12 h for 12 days. He had a past history of adult Still’s disease
treated with chronic oral prednisolone 10 mg daily since the age of 51 years. In addition, he
was diagnosed with type 2 diabetes mellitus at the age of 60 years, but did not have oral
sodium-glucose cotransporter 2 inhibitor. His glycated hemoglobin (National Glycohemoglobin
Standardization Program) was 10.6%. With the pyelonephritis, he felt difﬁculty in voiding.
Uroﬂowmetry (voided volume was 196 mL) showed a low maximum urinary ﬂow rate,
4.0 mL/s, and high post-void volume of 73 mL. His prostate volume determined by transrectal
ultrasounds was 41.0 cm
. We diagnosed benign prostatic hyperplasia and administered nafto-
pidil. After discharge of pyelonephritis, the patient continued to have pyuria, but felt only a little
difﬁculty in voiding. Thus, we did not suspect urinary tract infection.
Two months after the treatment, the patient had urinary retention. Although abdominal
ultrasound showed no hydronephrosis, spherical masses were found in his bladder (Fig. 1a).
Additionally, cystoscopy showed that spherical soft white masses ﬁlled the bladder (Fig. 1b).
A transurethral Foley catheter was then inserted. Urine microscopy ﬁndings revealed pyuria.
We frequently irrigated the bladder with saline and changed the catheter daily for 3 days due
to catheter blockage. When his catheter was removed at the last blockage, he could void. A
repeat cystoscopy carried out after catheter removal revealed a bladder with mild inﬂamma-
tory mucosa, but no spherical white mass. Only C. albicans was isolated from the culture of
his urine and spherical white masses collected by a ﬁrst transurethral Foley catheter. Thus, we
diagnosed urinary retention as a result of C. albicans fungus balls. There was not any clinical
evidence of disseminated Candida disease. His blood test showed that b-D-glucan was
<6.0 pg/mL. He was then given oral ﬂuconazole 300 mg per day for 7 days. His residual
urine volume gradually improved. It was 176 mL at the discharge and zero at 1 month after
the treatment. There has been no relapse of fungal urinary tract infection for 2 years.
A patient with acute renal failure as a result of bilateral ureteral obstruction by fungus balls
and another with emphysematous cystitis have been reported.
Therefore, we should deter-
mine whether the funguria is due to colonization, contamination or infection. Diabetes melli-
tus, indwelling catheter use, recent antimicrobial use, immunosuppression, neurogenic bladder
and urolithiasis have been reported to be strong risk factors for funguria.
In the present case,
he had chronic systemic steroid therapy, recent use of antibacterial agents and benign pro-
According to the review article by Fisher et al., the algorithm shows that the treatment for
fungus balls is oral administration of ﬂuconazole 400 mg daily for 4 weeks, ﬂucytosine four
times a day for 2–4 weeks or intravenous injection of amphotericin B (the duration has not
Additionally, the patient should have the indwelling urethral catheter
removed as soon as possible, because this results in clearance of the funguria.
dures, such as irrigation or transurethral resection of fungal balls, might need to be carried out
to relieve the obstruction.
In the present case, because urinary tract infection caused by fungi
was not diagnosed at the ﬁrst cystoscopy, transurethral resection was not carried out. The
attending physician decided the dose and duration of administration of the antifungal agent
according to the patient’s symptoms. Although the duration of administration was shorter and
the dose was smaller than the method described in the algorithm previously mentioned, there
was no recurrence.
Irrigation of the bladder might thus be effective for this condition.
Urinary tract infection caused by Candida is rare. Yeast was isolated from the urine of
approximately 5% of patients with complicated urinary tract infections.
A patient with ure-
thral obstruction followed by clot retention as a result of fungal balls was reported in the
Because he continued to feel difﬁculty in voiding after discharge of pyelonephritis, he
© 2018 The Japanese Urological Association