Dear Dr G,

I am a 48-year-old man who is slightly overweight.

Around four years ago, I started experiencing itchiness in my foreskin after making love with my wife. I initially thought it was thrush and the problem was temporary solved with anti-fungal medication.

But the itchiness became more frequent despite no sexual activity and meticulous hygiene.

I went to the doctor where I tested positive for diabetes and was told to start medication, but I would rather control it with lifestyle changes.

In recent months, the itchiness has become worse. Recurrent infections has caused scarring and tightness in my foreskin. The skin occasionally cracks and I need a prolonged course of antibiotics.

I went back to the doctor, who insisted I start diabetes medication and also suggested circumcision.

On the issues of diabetes and foreskin, do men really suffer from thrush because of diabetes?

Why does the foreskin become so tight and cracked?

Apart from circumcision, is there any other solution?

Itchy Ian

Thrush is a fungal infection caused by a type of yeast called candida albicans. Although the infection commonly affects women, the condition can also affect the external genitalia of men, leading to painful inflammation of the foreskin and the glans penis.

Candida is a normal pathogen that lives on the skin and mucous membranes of genitalia in both men and women. The risk factors for this excessive yeast growth in healthy individuals may include the use of antibiotics and steroids.

However, in patients who are diabetic or immune-compromised, genital candidiasis can occur insidiously, even with good hygiene.

The existence of candida in the genitalia of healthy individuals is often asymptomatic. Itchiness, irritation, soreness and blotchy rash can emerge on the penis and foreskin for men with poorly controlled diabetes.

In more serious cases, the inflammation can manifest as thick white lumpy discharge, accompanied by unpleasant odour. Painful sex or urination are often the reasons for seeking treatment.

Good hygiene such as washing the penis with warm running water and not using perfumed toiletries is often helpful to prevent infections. Anti-fungal topical creams or oral medication may help to relieve symptoms temporarily.

In men with foreskin – especially with poorly-controlled diabetes – the symptoms can often deteriorate to the extent of foreskin becoming non-retractable. This usually makes penetrative sex impossible.

Chronic inflammatory skin changes in the foreskin can be associated with whitish patches of scarring of the genitalia. This is known as Balanitis Xerotica Obliteran (BXO). Distress due to the discomfort and pain of BXO is normal as the condition can affect self-esteem and pleasure of sex.

Although the condition is non-contagious, progressive changes and inflammation is associated with the development of skin cancer. Often times the only solution is circumcision.

World Diabetes Day is the Global Awareness Campaign focusing on issues surrounding diabetes mellitus held on Nov 14 each year. Led by the International Diabetes Federation, each World Diabetes Day focuses on a theme related to this non-communicable disease, which is rapidly increasing in prevalence worldwide.

This year, the focus is on the family and diabetes concerns every family. Indeed, diabetes not only affects an individual, it also affects the family and sexual relationship.

The latest statistics from the Health Ministry highlighted that 3.6 million Malaysian are suffering from diabetes. Seven million Malaysian adults are likely to be diabetic by year 2025, and the worrying trend will see nearly one third of Malaysian adults affected by the disease.

The impact of diabetes is well documented, affecting the eyes, kidney function, heart disease and the nerves. Other areas of sexual adversity such as erectile dysfunction and penile candidiasis resulting in painful penetration are taboo subjects that are less publicised.

The Greek Philosopher and polymath, Aristotle once said: “The root of education are bitter, but the fruit is sweet”.

So Dr G’s response to diabetic Ian who is declining treatment, is “The root of the truth is bitter, as the only sweet ending is circumcision!”

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