Vaginal Candidiasis (Vulvovaginal Candidiasis)


Article Author:
Rebecca Jeanmonod


Article Editor:
Donald Jeanmonod


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
2/24/2019 1:50:30 PM

Introduction

Vaginal complaints are common. Vulvovaginitis, or inflammation of the vulva and vagina, is most commonly secondary to infectious agents in reproductive-aged women. Candidal vulvovaginitis is responsible for about one-third of cases.[1][2][3][4]

Etiology

Candidal vulvovaginitis is caused by inflammatory changes in the vaginal and vulvar epithelium secondary to infection with Candida species, most commonly Candida albicans. Candida is part of the normal flora in many women and is often asymptomatic. Therefore, candidal vulvovaginitis requires both the presence of candida in the vagina/vulva as well as the symptoms of irritation, itching, dysuria, or inflammation.[5]

Epidemiology

Candidal vulvovaginitis is common. It is responsible for a third of all cases of vulvovaginitis in reproductive-aged women, and 70% of women report having had candidal vulvovaginitis at some point in their lifetimes. About 8% of women suffer recurrent candidal vulvovaginitis. The most common responsible pathogen is C. albicans (in about 90% of cases), with most of the remaining cases caused by Candida glabrata. It is important to recognize that detailed epidemiological data is not available for this disease process. Because of the wide availability of over-the-counter treatments, many patients with candidal vulvovaginitis likely do not present for care. Furthermore, diagnosis is based on both clinical and ancillary evaluation, and therefore, epidemiologic reports based on culture alone overestimate disease, as 10% of women are asymptomatic with positive candidal cultures. Finally, studies demonstrate that self-diagnosis is not accurate, so data derived from a patient query are likely somewhat inaccurate.

Recognized risk factors for acute candidal vulvovaginitis include estrogen use, elevated endogenous estrogens (from pregnancy or obesity), diabetes mellitus, immunosuppression (i.e., patients with chemotherapy or antimetabolite medications, HIV infection, or transplant patients), and broad-spectrum antibiotic use. Although candidal vulvovaginitis is more common in women who are sexually active, there is no evidence that candidal infection is sexually transmitted. Patients with recurrent candidal vulvovaginitis (defined as four or more episodes of culture-proven candidal vulvovaginitis) have predisposing genetic factors that cause them to be susceptible to recurrent fungal infections. These factors may also predispose to a hypersensitivity to Candida.

Pathophysiology

Candidal vulvovaginitis occurs when Candida species superficially penetrate the mucosal lining of the vagina and cause an inflammatory response. The dominant inflammatory cells are typically polymorphonuclear cells and macrophages. Patients may present with discharge, which is typically thick and adherent, or with excoriations, "external" dysuria, vaginal itching, vaginal burning, dyspareunia, or swelling.

History and Physical

Patients typically complain of irritation, itching, and burning. Symptoms are often prominent just before the patient's menstrual period. Many patients will have a history of similar symptoms, and some will have attempted over the counter treatment with topical agents or alternative therapies. On exam, the clinician will often encounter vulvar and vaginal erythema, excoriations, thick white adherent discharge, and swelling. Some patients will have little to no discharge. The provider should not encounter ulcers, asymmetric swelling/masses, or foreign bodies. The degree of irritation is typically severe in patients with acute vulvovaginal candidiasis. Patients with infection with Candida glabrata usually have less severe symptoms. There is much overlap in the presentation of patients with vulvovaginal candidiasis versus other forms of vaginitis or cervicitis, and therefore ancillary testing, including wet mount, whiff testing, and pH testing, should be performed to make this diagnosis.

Evaluation

To diagnose this condition, the provider should perform a pelvic exam, a vaginal wet prep, pH testing, and testing to exclude other etiologies of vaginal discharge and infection (specifically gonococcal and chlamydial disease). In patients with candidal vulvovaginitis, inflammation is evident during a pelvic exam. However, the cervix is typically normal and not inflamed. The patient should not have cervical motion tenderness, and there should be no abnormal discharge from the cervical os. In patients with vulvovaginal candidiasis, the vaginal pH is typically less than 5. On wet prep, the provider should see lactobacillus as the prominent bacteria present, and will also likely see inflammatory cells. The patient should have a negative Whiff test (a fishy odor when potassium hydroxide is applied to the discharge on a slide). After potassium hydroxide application, the provider may see budding yeast, hyphae, or pseudohyphae on microscopy.[6][7][8][9][10]

Vaginitis may be secondary to more than one etiology, and therefore the provider should be vigilant to the presence of clue cells (representative of bacterial vaginosis) or trichomonads (representative of trichomoniasis) on wet prep.

Most infections are secondary to Candida albicans, and if the provider sees budding yeast in the clinical setting of a reproductive age woman presenting with vulvovaginitis, there is no need to perform confirmatory cultures for Candida (although a DNA probe for sexually transmitted infections is often still appropriate). Since Candida species are part of normal vaginal flora in many women, routine cultures in asymptomatic women are also discouraged. In women with repeated episodes of candidal vulvovaginitis, culture should be obtained to identify the fungal species that may be resistant to typical empiric therapy or to identify alternative causes of vaginitis.

Treatment / Management

Acute candidal vulvovaginitis is treated with antifungal agents. Since most cases of candidal vulvovaginitis are secondary to C. albicans species, and since C. albicans does not have significant resistance to azole antifungals, these are the agents of choice for this disease. Antifungals may be taken orally as a single dose (fluconazole 150 mg) or can be applied intravaginally in a single day or 3-day regimens that are available over the counter. In patients with uncomplicated disease (those without immunosuppression or pregnancy who do not have recurrent candidal vulvovaginitis) either therapy is equally efficacious. Therefore, treatment decision may be made based on cost, patient preference, and drug interactions. If patients do not respond to standard therapy, cultures may be warranted to look for other species of candida, which are often resistant to azoles.

Patients with complicated candidal vulvovaginitis, for example those patients who are .immunosuppressed, require longer therapy. Typically, therapy includes intravaginal azole therapy for at least 1 week, or oral treatment with fluconazole 150 mg (renally adjusted for CrCl <50 ml/min) once every 3 days for three doses. Patients with recurrent candidal vulvovaginitis may benefit from suppressive therapy with weekly oral fluconazole for 6 months. Pregnant patients should not be given oral antifungals. In these patients, a 7-day course of intravaginal therapy is appropriate. Fluconazole is considered safe in breastfeeding women.

There is inadequate evidence to recommend intravaginal or oral yogurt therapy, intravaginal garlic, or douching.

Pearls and Other Issues

Although vaginitis is not a dangerous disease, it can be disabling and upsetting to patients. It is important to address social issues and sexual dysfunction in addition to the infection itself.

It is also important to maintain a broad differential diagnosis. Trauma, abuse, foreign body, malignancy, immune diseases, inflammatory bowel disease, and sexually transmitted infections can all present with vaginal discomfort. The provider should always perform a careful and complete physical exam, appropriate ancillary testing as described above, and further testing if treatment failure occurs.

Enhancing Healthcare Team Outcomes

Candida vulvovaginitis is usually managed by the gynecologist, nurse practitioner, primary care provider or an internist. The condition is clinically diagnosed and management is with antifungal medications. Most simple cases resolve within days. Patients with complicated candidal vulvovaginitis require longer therapy. Pregnant patients should not be given oral antifungals. In these patients, a 7-day course of intravaginal therapy is appropriate. Fluconazole is considered safe in breastfeeding women. There is inadequate evidence to recommend intravaginal or oral yogurt therapy, intravaginal garlic, or douching.[11]

At the same time patient education is important. The condition is not life threatening but can be associated with embarrassment and withdrawal from sexual activities. It is also important to maintain a broad differential diagnosis. Trauma, abuse, foreign body, malignancy, immune diseases, inflammatory bowel disease, and sexually transmitted infections can all present with vaginal discomfort. The provider should always perform a careful and complete physical exam, appropriate ancillary testing as described above, and further testing if treatment failure occurs.


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Vaginal Candidiasis (Vulvovaginal Candidiasis) - Questions

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A patient has vulvovaginal candidiasis and is about to receive the medication tioconazole. Which comment by the patient indicates she understands how to administer this medication?



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A patient with diabetes has been diagnosed with a vaginal infection for which she is to use nystatin vaginal suppositories. Which of the following should be included in the instructions to this patient?



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In a patient with vaginal candidiasis, what is the oral antimicrobial agent of choice?



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Which of the following is most likely to help in the treatment of a woman with recurrent vaginal candidiasis that is in a monogamous sexual relationship with a man?



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Which patients are at a lower risk for developing vulvovaginal candidiasis?



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A patient complains of a vaginal discharge and itching. Pseudohyphae are present on microscopic exam. What is the most appropriate treatment?



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What is not a characteristic of candidiasis?



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What is not true regarding vaginal candidiasis?



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What is the treatment in the first trimester for a pruritic, thick, white vaginal discharge diagnosed as vulvovaginal candidiasis?



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In which of the following populations is vaginal candidiasis more common?



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A patient is most likely to develop a vaginal yeast infection after taking which one of the following drugs?



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Vaginal Candidiasis (Vulvovaginal Candidiasis) - References

References

Buggio L,Somigliana E,Borghi A,Vercellini P, Probiotics and vaginal microecology: fact or fancy? BMC women's health. 2019 Jan 31;     [PubMed]
Aguirre-Quiñonero A,Castillo-Sedano IS,Calvo-Muro F,Canut-Blasco A, Accuracy of the BD MAX™ vaginal panel in the diagnosis of infectious vaginitis. European journal of clinical microbiology     [PubMed]
Ahangari F,Farshbaf-Khalili A,Javadzadeh Y,Adibpour M,Sadeghzadeh Oskouei B, Comparing the effectiveness of Salvia officinalis, clotrimazole and their combination on vulvovaginal candidiasis: A randomized, controlled clinical trial. The journal of obstetrics and gynaecology research. 2019 Jan 20;     [PubMed]
Swidsinski A,Guschin A,Tang Q,Dörffel Y,Verstraelen H,Tertychnyy A,Khayrullina G,Luo X,Sobel JD,Jiang X, Vulvovaginal candidiasis: histologic lesions are primarily polymicrobial and invasive and do not contain biofilms. American journal of obstetrics and gynecology. 2019 Jan;     [PubMed]
Farhan MA,Moharram AM,Salah T,Shaaban OM, Types of yeasts that cause vulvovaginal candidiasis in chronic users of corticosteroids. Medical mycology. 2018 Dec 12;     [PubMed]
Barnes P,Vieira R,Harwood J,Chauhan M, Self-taken vaginal swabs versus clinician-taken for detection of candida and bacterial vaginosis: a case-control study in primary care. The British journal of general practice : the journal of the Royal College of General Practitioners. 2017 Dec;     [PubMed]
Donders GGG,Ravel J,Vitali B,Netea MG,Salumets A,Unemo M, Role of Molecular Biology in Diagnosis and Characterization of Vulvo-Vaginitis in Clinical Practice. Gynecologic and obstetric investigation. 2017;     [PubMed]
van der Meijden WI,Boffa MJ,Ter Harmsel WA,Kirtschig G,Lewis FM,Moyal-Barracco M,Tiplica GS,Sherrard J, 2016 European guideline for the management of vulval conditions. Journal of the European Academy of Dermatology and Venereology : JEADV. 2017 Jun;     [PubMed]
van Schalkwyk J,Yudin MH, Vulvovaginitis: screening for and management of trichomoniasis, vulvovaginal candidiasis, and bacterial vaginosis. Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC. 2015 Mar;     [PubMed]
Mendling W,Brasch J,Cornely OA,Effendy I,Friese K,Ginter-Hanselmayer G,Hof H,Mayser P,Mylonas I,Ruhnke M,Schaller M,Weissenbacher ER, Guideline: vulvovaginal candidosis (AWMF 015/072), S2k (excluding chronic mucocutaneous candidosis). Mycoses. 2015 Mar;     [PubMed]
Crouss T,Sobel JD,Smith K,Nyirjesy P, Long-Term Outcomes of Women With Recurrent Vulvovaginal Candidiasis After a Course of Maintenance Antifungal Therapy. Journal of lower genital tract disease. 2018 Oct;     [PubMed]

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