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Vaginal Candidiasis

Vaginal Candidosis

Vaginal or genital candidiasis, commonly described as a yeast infection, is a very common cause of vulvovaginitis in women. It is common in the setting of certain predisposing factors, including diabetes, pregnancy, use of oral contraceptives and immunosuppression.
Small amounts of Candida are routinely present in the human body. Any imbalance due to hormonal changes or vaginal changes may lead to the increased development of candida and its symptoms.


Presentation

Vaginal candidiasis presents typically with vaginal and vulvar pruritus and burning, which are the cardinal symptoms of the infection. It also presents with white, curdy, and odorless vaginal discharge which often sticks to the vaginal walls [10] [11] [12] [13]. The discharge bears the appearance of cottage cheese. Dyspareunia and dysuria are also common, as are vulvar erythema, swelling, and excoriation. The resulting vaginal sores may spread beyond the vulva to the inguinal and perineal regions. The lesions usually spare the cervix in vulvovaginal candidiasis.

Vaginal candidiasis may present in a cyclic pattern, typically a few days before each menstrual cycle. This is described as cyclic vaginitis.

Typical findings on physical examination include edema and erythema of the vestibule and both labial folds, which are more marked and presenting also with vulvar lichenification in chronic persistent vulvovaginal candidiasis. Chronic vaginal candidiasis occurs, more commonly, in older patients who are also obese and diabetic [14].

Genital candidiasis in men is rare and it usually presents with a pruritic rash on the penis.

A positive history of the predisposing factors of vaginal candidal overgrowth tilts the diagnosis to vaginal candidiasis because the symptoms are often similar to those of other genital infections.

Chancre
  • RESULTS: Of the 464 women examined, 177 (38.1%) had abnormal vaginal discharge, 68(14.7%) had genital ulcers, 272 (58.6%) had genital pruritus, 18 (3.9%) had genital warts and 58 (12.5%) had chancre.[ncbi.nlm.nih.gov]
Vaginal Discharge
  • RESULTS: The prevalence of abnormal vaginal discharge in pregnancy was 31.5%.[ncbi.nlm.nih.gov]
  • RESULTS: Candida species were detected in the test group in 60% (n 600/1000) cases of infective vaginal discharge while 12% (120/1000) in the control group. The isolation rate of Candida albicans was 69% more than the non- albicans.[ncbi.nlm.nih.gov]
  • Typical features of candidal vaginitis include vaginal pruritus, burning, and a thick, cottage-cheese-like vaginal discharge which is often odorless.[symptoma.com]
  • "Spores only" were identified in 65 (28%), "hyphae only" in 16 (7%), and both "spores and hyphae" in 101 (43%). 68% of culture positive women were symptomatic, the commonest symptoms being irritation alone (27%) or irritation plus vaginal discharge (25%[ncbi.nlm.nih.gov]
  • The studied variables included the demographic data information on parity, trimester of pregnancy, presence of vaginal discharge and the presence or absence of diabetes.[ncbi.nlm.nih.gov]
Pruritus Vulvae
  • Presentation [ 1 ] Symptoms Pruritus vulvae. Vulval soreness. White, 'cheesy' discharge. The discharge is non-offensive. Foul-smelling or purulent discharge suggests bacterial infection. Dyspareunia (superficial). Dysuria (external).[patient.info]
  • vulvae; 15 therefore, to have a definitive diagnosis of VVC, cultural isolation and identification of Candida spp. are crucial.[dovepress.com]

Workup

In vaginal candidiasis, vaginal PH remains normally at less than 4.5 [15] [16]. A diagnosis of vaginal candidiasis is made by the detection of candidal species on wet mount or KOH preparation of candidal smear on a microscopic analysis. Vaginal smears for microscopic analysis should be ordered to confirm suspected cases of vaginal candidiasis.

The wet mount involves microscopic examination of vaginal scrapings from the vulvar lesions or drops of the vaginal discharge after being mixed with a few drops of physiologic saline. Microscopic examination is done at low and high power magnifications and reveals pseudohyphae, budding yeast, or mycelia. In up to 50% of symptomatic patients with vaginal candidiasis, the pseudohyphae and yeast spores are detected on microscopy [17] [12].

In the absence of positive findings on microscopy, with symptoms suggestive of vaginal candidiasis, a fungal culture is done. Smears of the vaginal and vulvar are cultured. A fungal culture is also indicated in recurrent vaginal candidiasis to confirm the diagnosis and exclude Candidiasis caused by species other than Candida Albicans.

Skin Test Positive
  • We evaluated the efficacy of C. albicans allergen immunotherapy in women with immediate skin test positive for this fungus.[ncbi.nlm.nih.gov]

Treatment

Treatment of vaginal candidiasis consists typically of antifungal medications of the imidazole group. Topical or oral forms are effective. Topical clotrimazole, miconazole, tioconazole and butoconazole can be found over-the-counter, however, hypersensitivity to these topical agents is suggested with an exarcebation or persistence of symptoms. Furthermore, topical medications containing vegetable oil or mineral oil tend to weaken latex condoms. All the drugs are equally effective.

The azole component in these imidazole antifungal drugs inhibits the synthesis of ergosterol, which is the main component of candidal cell wall formation. Therefore, these antifungal agents have a cure rate of over 80%. The US Food and Drug Administration (FDA) currently approves only of fluconazole as the oral treatment of choice for vulvovaginal candidiasis. A single-dosage regimen of 150mg fluconazole proffers better treatment compliance. Single-dose itraconazole is an effective alternative. Therapeutic levels are attained after 72 hours of the single dosage of fluconazole [18]. Fluconazole is, however, contraindicated in pregnancy and before considering its use, pregnancy should be ruled out. Anti-pruritic medications may provide relief of the itch.

Recurrent cases of vaginal candidiasis are treated with a longer course of treatment and need to be investigated for non-Albicans vaginal candidiasis which is treated with boric acid. There is no recommendation for routine treatment of sexual partners. Screening for immunosuppressive diseases such as HIV is necessary in recurrent cases of vulvovaginal candidiasis.

Home remedies for vaginal candidiasis involve keeping the vulva clean and dry. Vulvar and vaginal moisture can be eliminated by wearing absorbent and loose clothing. Reducing genital moisture inhibits fungal growth.

Prognosis

Vaginal candidiasis responds well to treatment, however recurrences are frequent in more than half of the cases.

Etiology

Most cases of fungal vaginitis are caused by Candida Albicans. Candida species including C. albicans, C. tropicalis and C. glabrata are airborne microbes, which are part of the normal vaginal flora in up to 20% of non-pregnant women of reproductive age and 40% of pregnant women. Vaginal candidiasis is the most common cause of vaginitis.

Candidal vaginitis is a result of candidal overgrowth in the vagina. Conditions which, therefore, cause candidal vaginitis by causing candidal overgrowth include pregnancy, diabetes mellitus, prolonged use of broad-spectrum antibiotics, use of steroids, oral contraceptives, IUD, wearing tight-fitting undergarments, iron deficiency anemia, frequent sexual intercourse, and immunosuppressive diseases such as HIV. The infection, however, is not contracted via sexual intercourse. The infection is most frequently seen and more severe in immunosuppressed patients.

Estrogen causes proliferation of the endometrium and increased production of glycogen in the vagina. Glycogen, in turn, is a source of nutrition and growth for candida albicans. Therefore, women with low estrogen levels,such as prepubertal and postmenopausal women have a very low risk of developing vaginal candidiasis. However, cases are frequent in postmenopausal women on hormone replacement therapy.

Vaginal candidiasis may also cause superimposed infection on preexisting skin diseases including psoriasis and lichen planus.

Epidemiology

In the United States, approximately 10-50% of women in their reproductive age are asymptomatic carriers of vaginal candidiasis. Up to 75% of all women have had vaginal candidiasis at least once in their lifetime, a few of whom have recurrent episodes of the infection [3] [4] [5] [6] [7].

Recurrence of vaginal candidiasis occurs commonly in chronic immunosuppressive diseases such as diabetes, therefore, necessitating screening for diabetes mellitus. Most cases of vaginal candidiasis are seen in women of reproductive age, especially pregnant women [8]. Recurrent vaginal candidiasis is defined as at least 4 confirmed episodes of vaginal candidiasis within a 12-month period [9].

Sex distribution
Age distribution

Pathophysiology

Factors which alter the normal vaginal state or secretions predispose to candidal proliferation and development of vaginal candidiasis. The infection is not sexually transmitted.

Pregnancy is one of the commonest risk factors for vulvovaginal candidiasis. Pregnancy is characterized by increased levels of reproductive hormones and vaginal glycogen level, both of which promote growth, proliferation, and adherence of the Candida species. Additionally, the vaginal environment becomes acidic in pregnancy, suppressing other microbes found in the vagina, some of which serve to inhibit the growth of Candida, contributing to the susceptibility of pregnant women to vaginal candidiasis.

Antibiotics reduce the amount of healthy and protective resident bacteria in the vagina, therefore predisposing to the growth of Candida. Antibiotics commonly implicated include cephalosporins, penicillins, tetracycline, and other broad-spectrum antibiotics.

Wearing tight-fitting undergarments also plays a role in the pathogenesis of vaginal candidiasis. These promote heat and moisture which encourage candidal growth.

Prevention

Preventive measures include reduction of dietary sugar intake, as it has been shown that dietary sucrose and lactose promote fungal growth. Wearing nonocclusive, loose, and absorbent clothing prevents moisture and heat around the genitals, thereby preventing overgrowth of candidal species. Cotton undergarments also serve to reduce the moisture and heat in the genital area. Women with recurrent vaginal candidiasis may require prophylactic oral or intravaginal probiotics.

Summary

Vaginal candidiasis is also known as vaginal thrush, candidal vaginitis, vaginal candidosis and monilia. It is the commonest cause of vaginitis and as many as three out of every four women have been affected by it at some point in their life [1].

Vaginal candidiasis is caused by the overgrowth and predominance of candidal species, particularly Candida Albicans, due to certain predisposing conditions, including diabetes, prolonged antibiotic treatment, frequent sexual intercourse, steroid use, pregnancy, use of oral contraceptives and an immunodeficient state. However, it is not contracted via sexual intercourse.

It is also frequently seen in women of reproductive age, being very rare in children and postmenopausal women. Recurrence occurs in up to 10% of women [2].

Typical features of candidal vaginitis include vaginal pruritus, burning, and a thick, cottage-cheese-like vaginal discharge which is often odorless. It is very responsive to treatment with oral or topical antifungal agents, although resistant infection may be seen in some women.

Diagnosis is made by microscopic examination of vaginal smears which characteristically reveals candidal spores and pseudohyphae. However, cultures of vaginal lesions or the vaginal discharge, as well as screening for diabetes and immunosuppressive diseases, may be necessary in chronic and recurrent cases.

Patient Information

Vaginal candidiasis, also called vaginal thrush, is an infection of the vulva and vagina which is caused by a yeast called Candida, most commonly by a species called Candida Albicans. Yeast is found normally in the vagina along with other healthy microorganisms and the infection results from an overgrowth of yeast due to certain predisposing factors. This condition is the most common cause of inflammation of the vagina.

Factors which reduce the amount of healthy microorganisms in the vagina cause growth, development, and attachment of the yeast to the vaginal walls, leading to a yeast infection. These factors include diabetes, use of antibiotics, use of steroids, intrauterine contraceptive devices, oral contraceptives and factors which weaken the immune system, including immune diseases such as HIV. Yeast infections are very common in women of reproductive age and are particularly common in pregnant women. It is rare in children and women who are past the age of menopause. This is due to the fact that the female hormone, estrogen, which promotes the overgrowth of Candida, is low in these age groups.

Yeast infection commonly occurs within the days before the menstrual flow and is often worsened by sexual intercourse. The infection presents as vaginal and vulvar itching and burning with white, thick, and odorless vaginal discharge which resembles cottage cheese. In addition, the vulva may appear red and swollen. The symptoms are severer in patients with diseases which weaken the immune system. Occasionally, there may be pain during sexual intercourse and urination.

Yeast infection has affected 3 out of every 4 women at a point in their lifetime. More than 50% of all women who have had the infection have recurrent or persistent infection. A few of the women affected may go on to have more than 4 cases within a year.

Doctors reach the diagnosis of yeast infection by taking swabs of the vaginal discharge or scrapings of the vaginal sores to examine for yeast under a microscope. Findings of the yeast reproductive forms under the microscope confirms the diagnosis. In some women with prolonged cases, the microscopic examination may be negative, necessitating a culture of the vaginal sores or discharge.

Treatment of yeast infection is with antifungal drugs. These drugs could come in forms of tablets, creams, ointments or suppositories inserted into the vagina. Some forms such as clotrimazole, miconazole, tioconazole and butoconazole creams are available over the counter. Of note is that some of these creams may contain mineral oil, which weakens latex condoms, therefore, making it an unreliable form of contraception during the period of treatment.

Fluconazole is a common oral form of treatment and is often taken as a single dose. Itraconazole is an effective alternative which could also be taken as a single dose. Although, these drugs are available without a doctor's prescription, a pregnant woman with vaginal candidiasis should not use fluconazole as this drug could affect the baby. If one must use this drug, the patient must test negative for pregnancy.

Higher doses of these oral drugs would be required in patients with persistent infection. Treatment of patients' sexual partners is often not necessary. Over-the-counter anti-itch medication may be taken to relieve the itch.

Yeast infection can be prevented by keeping the vaginal area dry. This can be achieved by wearing loose, absorbent and 100% cotton undergarments. Reducing the intake of sugar also reduces the risk of getting the infection, because sugar has been shown to foster overgrowth of yeast in the vagina.

References

Article

  1. Ehrström S, Yu A, Rylander E. Glucose in vaginal secretions before and after oral glucose tolerance testing in women with and without recurrent vulvovaginal candidiasis. Obstet Gynecol. 2006 Dec;108(6):1432-7.
  2. Watson C, Calabretto H. Comprehensive review of conventional and non-conventional methods of management of recurrent vulvovaginal candidiasis. Aust N Z J Obstet Gynaecol. 2007 Aug;47(4):262-72.
  3. Szumigala JA, Alveredo R. Vulvovaginitis. Ferri. Ferri's Clinical Advisor 2009. Mosby; Elsevier; 2009. 155, 1008-1012.
  4. Eckert LO. Clinical practice. Acute vulvovaginitis. N Engl J Med. 2006 Sep 21. 355(12):1244-52.
  5. das Neves J, Pinto E, Teixeira B, et al. Local treatment of vulvovaginal candidosis : general and practical considerations. Drugs. 2008;68(13):1787-802.
  6. Ferrer J. Vaginal candidosis: epidemiological and etiological factors. Int J Gynaecol Obstet. 2000 Dec;71 Suppl 1:S21-7.
  7. Eschenbach DA. Chronic vulvovaginal candidiasis. N Engl J Med. 2004 Aug 26;351(9):851-2.
  8. Sobel JD. Vulvovaginal candidosis. Lancet. 2007 Jun 9;369(9577):1961-71.
  9. Sobel JD, Faro S, Force RW, et al. Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations. Am J Obstet Gynecol. 1998 Feb;178(2):203-11.
  10. Nyirjesy P. Vulvovaginal candidiasis and bacterial vaginosis. Infect Dis Clin North Am. 2008 Dec. 22(4):637-52, vi.
  11. Braverman PK. Urethritis, vulvovaginitis, and cervicitis. Principles and Practice of Pediatric Infectious Diseases. 3rd ed. Churchill Livingstone; Elsevier; 2008. 55.
  12. Biggs WS, Williams RM. Common gynecologic infections. Prim Care. 2009 Mar. 36(1):33-51, viii.
  13. Johnson E, Berwald N. Evidence-based emergency medicine/rational clinical examination abstract. Diagnostic utility of physical examination, history, and laboratory evaluation in emergency department patients with vaginal complaints. Ann Emerg Med. 2008 Sep. 52(3):294-7.
  14. Nyirjesy P, Leigh RD, Mathew L, Lev-Sagie A, Culhane JF. Chronic vulvovaginitis in women older than 50 years: analysis of a prospective database. J Low Genit Tract Dis. 2012 Jan. 16(1):24-9.
  15. Esim Buyukbayrak E, Kars B, Karsidag AY, et al. Diagnosis of vulvovaginitis: comparison of clinical and microbiological diagnosis. Arch Gynecol Obstet. 2010 Nov. 282(5):515-9.
  16. Schwiertz A, Taras D, Rusch K, Rusch V. Throwing the dice for the diagnosis of vaginal complaints?. Ann Clin Microbiol Antimicrob. 2006 Feb 17. 5:4.
  17. Szumigala JA, Alveredo R. Vulvovaginitis. Ferri. Ferri's Clinical Advisor 2009. Mosby; Elsevier; 2009. 155, 1008-1012.
  18. Sobel JD, Wiesenfeld HC, Martens M, et al. Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis. N Engl J Med. 2004 Aug 26. 351(9):876-83.

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Last updated: 2018-06-22 04:33