How to distinguish between yeast vs bacterial balanitis in 3 yo - 2 times in 2 months

[LCBMAX]

Hi happy no circ folks -

Well, at least I'm less panicked this time, but I've got that worried furrow in my brow for sure. How do I tell between fungal and bacterial symptoms? 

My son will be 3 in Feb, and first had a severe severe balanitis/ posthitis in November, which resolved pretty quickly. We treated it with topical antifungal cream for 10 days total, though it was mostly gone in 3 - 4 days. That time, he first had redness around 3 pm, and by bedtime was insanely swollen, purplish, and then drained a good few ccs of smelly pus after we applied some antibiotic ointment. We started the antifungal cream the next day, and it slowly got better from there, and it's unclear if the antifungal really did the trick or whether it was self healing.

This time: he started with redness yesterday morning, and although it got worse during the day it hasn't (yet) progressed to the wildly awful state of last time. We've been applying the antifungal cream after every pee, and did a long hottish bath before bed. I notice a small amount of the same smelling pus dried in his underwear this am. Now, like last time, there's pain at the meatus with peeing (the peeing in water trick doesn't seem to help him.)

Both times: no inguinal involvement, no lymph nodes to speak of, no extension of redness to scrotum or torso, cheerful and mischievous when not peeing.

So, to distinguish between bacterial and fungal, I then think about likely causes - I can't think of any.

Fungal risks: We have an extremely low sugar diet (he thinks ak-maks are cookies, and diluted juice is a huge treat). He's been dry day and night and fully out of diapers since 18 months old (thanks, ec.) He's often naked at home, or just in underwear. I would think there'd be a risk for fungal if you sit around in a damp towel after bath, but in all weather, he throws off the towel before he's even dry and tears around the house for a while. He enjoys eating yogurt (plain) and chewing probiotic capsules straight.

Bacterial risks: Ummm. Well, he is more interested in his anus lately, and as he gets older he's more often out of sight so there could easily be some transference of bacteria that I don't catch. But I read that bacterial balanitis is usually staph/ strep and that's not usually found back there, I don't think. It doesn't seem like enterococcus could survive all that acidic pee, but I don't know. No sore throats in the past month at least.

Generally, and I don't know if this is pro- or con- 

he hasn't had a lot of baths or showers in the past week, but we have been twice to the local public and highly chlorinated pool. This is a usual weekly event for us. Because he drained so thoroughly after the bath and bacitracin last time, I wonder if that's a better approach. But he only got that once, so presumably that didn't really do the trick...

I'd really appreciate any thoughts on how to distinguish between the two possible causes, or redirect me to a different forum...

I'm bummed and worried that... worried that I'll never learn to quit worrying. Anyway.

Thanks in advance.

[eepster]

The only way to really know is to get a culture.  Getting a culture of course means going to the Dr, which brings up the whole risk of the Dr hurting him (forcible retraction and such.)  A minor infection down there from too much playing with it isn't really an emergency though,so as long as you watch it closely, I wouldn't rush off to the Dr.

If you start to suspect UTI (it doesn't really sound like it, but you did mention the pain while peeing) you can get his urine tested with out taking him to the Dr to be seen.  All you need to do is get a sterile sample container from your Dr or the lab and have him pee in it then drop it off at the lab.  

If you feel it warrants treatment, you can just start without a full dx.  Normally, I tell people to treat for yeast first, then if it doesn't work try bacterial treatments second.  This is b/c treating for bacteria will make a yeast infection worse if he has one, but yeast treatment will have no effect on a bacterial infection.  If you need to try an antibiotic cream, do not use neosporine (polysporine.) It has a high rate of causing reactions on genitals, you can use bacitracin.

It may just clear up on its own though.  It might just be a bit of separation going on, and the "puss" might just have been extra smell smegma (possibly bacteria was growing in the smegma.)  

[LCBMAX]

Thanks eepster!

Luckily we have a pro-intact doc, gentlest man in the world, so nothing to fear in being seen. And I'm not at all concerned about a UTI (as you guessed) - because my son is so clear about it only hurting at the meatus.

Having started the otc antifungal, yeast cultures will be obscured, and are often tricky and long to culture anyway, but certainly a bacterial culture could still be done.

It's just so hard to believe that separation is really this dramatic - 

And I wish there was some other way to distinguish between the two symptomatically...

How long does a usual fungal balanitis/ posthitis go for?

[LCBMAX]

And, anything concerning about having 2 rounds so close to each other?

[LCBMAX]

One more question - for the moment, anyway -

does anyone use gentian violet on little boys? Seems like if it's ok for infants' mouths and mamas' nipples...

[eepster]

Originally Posted by LCBMAX 

And, anything concerning about having 2 rounds so close to each other?

The main thing there, is that it may mean that the treatment you using isn't strong enough.  Since you feel your Dr is unlikely to do something damaging, you might want to go in for a culture.

Separation can be quite dramatic, but a couple of things you say don't quite fit perfectly.  The smell of the puss?/smegma? If it was just separation,  then the smegma should only have a slight odor, this is something hard to evaluate over the internet, so I don't know if you are overly sensitive to normal smegma smell or if there is that truly foul odor that indicates infection.  Also, smegma and puss look very similar, one can not tell the difference solely by appearance.  The peeing in water not relieving the pain while peeing also doesn't quite fit separation.

Of course, even if it is smegma and not puss and he is going through separation, that doesn't mean there is no infection.  Since separation can leave open areas it could be an opportunity for an infection to start.

[eepster]

Originally Posted by LCBMAX 

One more question - for the moment, anyway -

does anyone use gentian violet on little boys? Seems like if it's ok for infants' mouths and mamas' nipples...

I have no idea if it might be too harsh for genitals (seems unlikely if you can use it on a babies mouth,) but it will definitely turn his penis purple.

[Galatea]

It could be a combo of bacteria, fungus, and skin irritation.  I don't know if you could or should do this for a penis, but I know that every time I have a new baby, my nipples crack open and bleed terribly.  I used Dr. Newman's all-purpose nipple ointment this time and they healed in a day!  He combines a steroid for inflammation, an antibiotic for any bacteria, an antifungal for fungus, and it moisturizes.  The theory being, whatever is destroying your nipple, this will fix it.  This happens to some diaper rashes, too - yeast and bacteria at the same time.  Perhaps you could ask for a culture and also ask the doctor to treat all possible causes.  If it is yeast, you need to treat it for at least a week, and for longer afterward to make sure it is gone.

Also, wash his hands often - most kids like to touch their anuses and they can definitely transfer some yuck!