Complex Case: Trans Woman w/ 15 year history of chronic genital dysbiosis, candidal balantis, MRSA colonization. New management protocol failed at 6 week mark. Physician stumped, feeling hopeless.
Hello friends. I'm posting here as a transgender penis-having individual struggling with a decade-plus of (presumably candidal) fungal balantis with increasing severity/complexity over time. I know this is not the intended subject of this subreddit, but I haven't had luck elsewhere and r/healthyhooha is famous for its depth of knowledge... I am hoping this post will be allowed and someone will have useful advice for my history. I'm sorry in advance for the length of this post.
The short version:
● penis-having trans woman (10 years estrogen) experiences a decade and a half of increasingly difficult to treat and recurrent genital candidiasis, dysbiosis, opportunistic bacterial colonization.
● After (physician-recommended) povidone-iodine sterilization to address MRSA colonization, maintenance routine includes topical lactobacillus probiotics, daily hygiene, black tea tannin rinses, nightly air drying of foreskin mucosa, attention to dryness after urination.
● Initial results extremely promising, all indicators of genital health very positive by week 5.
● 6 weeks after beginning treatment, novel presentation of balantis which responds to oral fluconazole but leaves patient feeling despirited and lost.
● Patient has multiple sexual partners, including a vagina-having spouse who has not undergone concurrent antifungal or antibacterial treatment during patient's treatment. Spouse has no history of recurrent yeast infection. Patient has not abstained from sexual contact with spouse or others since treatment reached "no symptoms, seems healthy" stage.
Why have I dealt with this my whole life? What am I doing wrong? Does anyone have suggestions for management? This is exhausting and miserable and in the context of my history of mrsa colonization (asymptomatic, see below) frankly pretty scary. I hope someone can help. My doctor, same as all my past physicians, is stumped. Thank you very much, everyone. If this is an inappropriate venue for my post please let me know.
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The long version: I'm a 29 year old mtf trans individual with a penis and a foreskin, on estrogen 10 years. Since gonadarche (~17 years?) I've dealt with recurrent balantis - minimum two events per year, every year since. Frequency and severity has increased since beginning a relationship with my husband (ftm transgender), suggesting he may be a carrier of a strain particularly disruptive to or capable of thriving within my microbiome. I have historically treated with increased attention to hygiene and, when necessary, topical vaginal-formulation miconazole cream. In the last couple of years I've had several long stints of very persistent infection which did not resolve for multiple weeks at a time, leading to a cycle of overtreatment and severe genital dysbiosis.
A bacterial culture taken two months back (at a time with minimal but still-present symptoms despite two weeks of topical miconazole) came back positive for a "heavy growth" of mixed-skin flora and MRSA. Since there was no suitable oral antibiotic available for my allergies and the strain's resistance profile, and since mupirocin resistant MRSA is such a problem in the US, after consulting with a couple clinicians I underwent a 5-day at home dilute povidone-iodine "scorched earth" regimen to clear genital colonization and biofilms, rigorous attention to tissue cleanliness and dryness, combined with aggressive topical probiotic supplementation (using oral l. reuteri rc-14 and l. rhamnosus gr-1 capsules hydrated, decanted, and applied directly to my genitalia). The goal was to clear bacterial colonization and then heavily seed with MRSA-suppressant lacto strains to minimize recolonization risk.
This worked exceptionally well for about 6 weeks. The iodine treatment was fairly harsh on my tissues, but after a brief recovery period I was completely free of infection symptoms, my genital odor was clean and yogurt-forward, and both visually and in terms of sensitivity the tissues seemed healthier and less reactive than I can ever remember. Then, about three days ago, I developed a rapidly-spreading infection starting from the interior of the preputial orifice (the very tip of the foreskin) and spreading as a kissing lesion across my glans. This is a unique presentation for candidiasis for me - I've never, ever, in all my years struggling with this had an infection start at the tip of the foreskin and then spread downward. It has responded very well to 150mg oral fluconazole so far (on day 2 since taking it), but I'm finding this episode extremely distressing and upsetting.
The microbiome (from what little you can really say without cultures) seemed as healthy as mine ever has, I'm paying more diligent care to my genital hygiene than at any other time in my life, and I STILL ended up with a fungal infection less than two months since starting this regimen. I have a few ideas for the weak link (my sexual partners, imperfect drying after urination, the topical use of oral probiotics which contain maltodextrin), but I'm despirited and don't know what to do next. If anyone has any suggestions, ideas, or questions, please feel free to comment or DM.