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Candidiasis, Vulvovaginal

Basics

Description

- Contraceptive devices - Diaphragm - Intrauterine device

- DNA probe - Commercially available probe that simultaneously detects the presence of Candida species, Gardnerella vaginalis, and Trichomonas vaginalis from a single vaginal swab - Results within 45 minutes - Performed in laboratory - Sensitivity 82%, specificity 98.5%

- Gram stain - Less convenient for making diagnosis in outpatient setting

- Screening for sexually transmitted infections should occur, if clinically indicated including: - Chlamydia - Gonorrhea - Trichomoniasis - Syphilis - Hepatitis B and C - HIV

- For complicated infections (RVVC, severe symptoms, pregnancy, poorly controlled diabetes, immunosuppression, organisms other than C. albicans), identify possible precipitating factors (see "Risk Factors"). Treatment options include (1)[A]: - RVVC - Fluconazole 150 mg PO q3d until asymptomatic then qweek 6 months - Topical antifungal daily 10-14 days then b.i.w. 6 months

  • Vulvovaginal candidiasis is the second most common cause of vaginal discharge, after bacterial vaginosis (BV).
  • Candida albicans is the most common organism and is responsible for 90% of cases.
  • Recurrent vulvovaginal candidiasis (RVVC):Can occur in 5-8% of healthy womenDefined as >4 episodes in 1 year

Epidemiology

Prevalence

  • Up to 75% of women will have 1 episode of vulvovaginal candidiasis during their lifetime.
  • 5-8% will have recurrent episodes.

Risk Factors

  • Recent antibiotic use
  • ImmunosuppressionDiabetes mellitusHIVSteroid use
  • Increased estrogen levelsPregnancyOral contraceptive pillsEstrogen therapy
  • Contraceptive devicesDiaphragmIntrauterine device
  • Douching
  • Receptive anal and oral sex practices

General Prevention

  • Avoid douching
  • Optimal control of blood sugar in diabetic patients
  • Patients with RVVC should avoid use of panty liners, pantyhose, sexual lubricants, and consumption of cranberry juice or acidophilus-containing products.

Pathophysiology

  • Not sexually transmitted
  • Changes in the vaginal milieu, such as increase in glycogen production from pregnancy or oral contraceptive pills use, lead to increased adherence of C. albicans to vaginal epithelium and germination of yeast.
  • In RVVCSome women may remain colonized with small numbers of yeast even after treatment.When yeast increase in number, a recurrence of the symptoms occurs.

Etiology

  • In the general population, 15-20% colonized with yeast.Routine cultures will identify asymptomatic women.
  • Organisms may access vagina via migration across perianal area from rectum.Decreasing GI carriage does not prevent recurrent vaginal infection.
  • Most common organismsC. albicans: Cause in 90% of casesC. glabrataC. tropicalisC. parapsilosisSaccharomyces cerevisiae
  • RVVCC. glabrata, C. parapsilosis, and S. cerevisiae are responsible for up to 33% of the cases.

Associated Conditions

Other causes of vaginal discharge:

Diagnosis

History

  • Recent antibiotic use
  • Contraceptive use
  • Diabetes
  • Pregnancy
  • Self-diagnosis by patients is only accurate in 10-35% of the cases.
  • Symptoms:Vulvar pruritusThick, white, clumpy vaginal dischargeVaginal irritationDysuriaDyspareuniaVulvovaginal swelling

Physical Exam

  • Thick, white, "cottage cheese"-like discharge
  • Vulvar and vaginal erythema and/or ulcerations

Tests

Lab

  • Vaginal pHNormal in vulvovaginal candidiasis (<4.5)
  • Light microscopy (see below)Negative in up to 50% of confirmed cases but can be performed while patient in office
  • DNA probeCommercially available probe that simultaneously detects the presence of Candida species, Gardnerella vaginalis, and Trichomonas vaginalis from a single vaginal swabResults within 45 minutesPerformed in laboratorySensitivity 82%, specificity 98.5%
  • CultureFungal cultureIndicated in RVVC as can identify causative organism and help in guiding treatmentViral cultureIn patients with ulcerations, culture for herpes simplex virus should be performed.Gram stainLess convenient for making diagnosis in outpatient setting
  • Screening for sexually transmitted infections should occur, if clinically indicated including:ChlamydiaGonorrheaTrichomoniasisSyphilisHepatitis B and CHIV
  • Samples for pH, microscopy, DNA probe, and culture should be obtained from the posterior fornix or vaginal wall.
  • Obtaining a sample from the cervical os may reveal normal cervical mucous.

Surgery

  • Light microscopyNormal saline or potassium hydroxide (KOH) preparation slide can be used.Place thin layer of discharge on slide.Add 1 drop of normal saline or 10% KOH.KOH causes lysis of epithelial cells, increasing ability to identify yeast forms.KOH slides associated with 50% sensitivity.Presence of hyphae, pseudohyphae, and budding yeast cells (see image)Lactobacilli should be present.Lack of lactobacilli is suggestive of concomitant BV.Few or no white blood cells (WBCs)Ratio of WBCs to epithelial cells of >1:1 is suggestive of underlying infection such as trichomoniasis or gonorrhea/chlamydia.
  • BiopsyIf ulcerations or chronic skin changes exist, consider vulvar biopsy to rule out lichen sclerosus, other vulvar dermatoses, or malignancy.

Differential Diagnosis

  • Allergic reaction
  • Contact dermatitis
  • BV
  • T. vaginalis
  • Atrophic vaginitis

Treatment

Medication

  • For uncomplicated infections (sporadic episodes in healthy, nonpregnant women), oral and topical therapies achieve comparable cure rates, which are >90% (1)[A].
  • Topical therapy may offer faster symptom relief than oral therapy.
  • Cure rates of short-course topical regimens comparable to that of longer courses
  • Treatment options include:Clotrimazole1% cream 5 g intravaginally daily 7-14 days100 mg tablet intravaginally daily 7 days200 mg intravaginally 3 daysMiconazole2% cream 5 g intravaginally daily 7 days100 mg vaginal suppository daily 7 days200 mg vaginal suppository daily 3 days1,200 mg vaginal suppository 1 doseFluconazole: 150 mg PO 1 dose
  • For complicated infections (RVVC, severe symptoms, pregnancy, poorly controlled diabetes, immunosuppression, organisms other than C. albicans), identify possible precipitating factors (see "Risk Factors"). Treatment options include (1)[A]:RVVCFluconazole 150 mg PO q3d until asymptomatic then qweek 6 monthsTopical antifungal daily 10-14 days then b.i.w. 6 monthsSevere symptomsAvoid short-course therapyTopical antifungal daily 7 daysFluconazole 150 mg PO q3d 2-3 dosesNon-albicans candidal infection: Resistance to azoles rare in infections with albicans species. For non-albicans species, resistance to azoles more common.C. glabrata: Intravaginal boric acid 600 mg daily 14 days; if no effect, 17% flucytosine cream 5 g nightly 14 daysC. krusei: Intravaginal boric acid 600 mg daily 14 days or clotrimazole 2% cream daily 7-14 daysAll other species: Fluconazole 150 mg PO 1
  • For patients with severe discomfort, a low-potency steroid cream can be added.
  • Topical azole cream daily 7 days is first line as oral azoles not recommended in pregnancy (1)[A].
  • Breastfeeding womenNystatin does not enter breast milk.Fluconazole excreted in breast milk but is compatible with breastfeeding as no adverse effects reported.

Additional Treatment

Issues for Referral

  • To obstetrician/gynecologist if symptoms do not resolve after treatment
  • To endocrinologist if poorly controlled diabetes is cause of recurrent infections

Complementary and Alternative Medicine

A systematic review concluded that the following options are not effective for treatment or prevention of vulvovaginal candidiasis, although small trials have demonstrated some efficacy (2)[B], (3)[C].

  • Lactobacillus acidophilus containing yogurt
  • Boric acid
  • Tea tree oil
  • Garlic
  • Douching

In-Patient Considerations

Admission Criteria

Treatment is primarily in outpatient setting.

Ongoing Care

Follow-Up Recommendations

Generally good response to topical or oral therapy but up to 5% will have RVVC.

Patient Monitoring

  • Routine glucose monitoring for patients with diabetes
  • Patients receiving weekly fluconazole suppressive therapy should have periodic liver function tests.
  • For RVVC, a repeat fungal culture is helpful to confirm treatment success.Positive culture with negative culture on follow-up associated with resolution of symptoms in 90% cases

Diet

Dietary changes, such as yeast-free diets, have been frequently recommended for RVVC, but there is no evidence to support this approach.

Patient Education

  • Cotton underwear
  • Avoid tight-fitting pants

Complications

  • Severe complications are very rare.Chorioamnionitis in pregnancy and vulvar vestibulitis syndrome have been reported.

References

1Workowski KA, Berman S Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59.2Spence D. Candidiasis (vulvovaginal). Clin Evid (Online). 2007;pii: 0815. [View Abstract]3Van Kessel K, Assefi N, Marrazzo J. Common complementary and alternative therapies for yeast vaginitis and bacterial vaginosis: A systematic review. Obstet Gynecol Survey. 2003;58:351-358. [View Abstract]

Additional Reading

1Ferris DG, Nyirjesy P, Sobel JD. Over-the-counter antifungal drug misuse associated with patient-diagnosed vulvovaginal candidiasis. Obstet Gynecol. 2002;99:419-425. [View Abstract]2Hale TW. Drug therapy and breastfeeding: Antibiotics, analgesics, and other medications. NeoReviews. 2005;6(5):e233.

Additional Reading see also

Blastospores, hyphae, and pseudohyphae

Codes

ICD9

112.1 Candidiasis of vulva and vagina

ICD10

B37.3 Candidiasis of vulva and vagina

SNOMED

72605008 candidal vulvovaginitis (disorder)

Clinical Pearls

  • Self-diagnosis of vulvovaginal candidiasis by patients is accurate in only 34% of cases.
  • Patients who self-diagnose often have more than one type of vaginitis.
  • Patients who have symptoms of vaginal discharge should be encouraged to be seen by a health care provider.