VULVOVAGINITIS, CANDIDAL

VULVOVAGINITIS, CANDIDAL - Martha H. McLoughlin, MD
BASICS
DESCRIPTION
Vulvar pruritus and/or burning, often with abnormal vaginal discharge
• System(s) Affected: Reproductive; Skin/Exocrine
• Synonym(s): Monilial vulvovaginitis
GENERAL PREVENTION
• Follow instructions under "Patient Teaching".
• For recurrences, consider reinfection from sexual partner(s). Examine and treat the sex partner for Candida balanitis and oral Candida if vaginitis recurs.
• Review "Risk Factors."
EPIDEMIOLOGY
• Predominant age: Menarche to menopause
• Predominant sex: Female only
Prevalence
• 10-20% of nonpregnant premenopausal women are asymptomatic carriers
• Common in pregnancy
ALERT
Pediatric Considerations
Less common before puberty
RISK FACTORS
• Pregnancy
• Diabetes mellitus
• Antibiotic therapy
• Corticosteroid therapy
• Immunosuppressed states
• HIV infection
• Occlusive synthetic underpants and undergarments
• Hypothyroidism
• Oral contraceptive medications (low dose formulations usually not a cause of increased infection risk)
• Anemia
• Zinc deficiency
• Other contraceptives: Sponge, diaphragms, intrauterine devices
ETIOLOGY
• 40% of vulvovaginitis is caused by Candida.
• Overgrowth of Candida species (C. albicans, C. glabrata, C. tropicalis) in vagina
ASSOCIATED CONDITIONS
Sexually transmitted diseases


DIAGNOSIS
SIGNS AND SYMPTOMS
• Intense vulvar pruritis
• Thick curdlike vaginal discharge
• Dyspareunia at times
• Erythema and/or edema of vulva
• Erythema, pain, and pruritus of crural and perineal area
• Thick white patches appear attached to vaginal mucosa.
• Inflamed vulvar skin
TESTS
Lab
• Yeast, spores, and/or pseudohyphae on smear with 10% potassium hydroxide (KOH) solution
• Vaginal pH 4.5
• Culture findings on Nickerson or Sabouraud medium; usually only indicated for recurrent infections
• Pap smear
DIFFERENTIAL DIAGNOSIS
• Trichomonas vaginitis
• Gonorrheal vaginitisin prepubertal girls
• Pinworm vaginitis
• Contact dermatitis/vaginitis
• Allergic vulvitis/hypersensitivity
• Mechanical/chemical irritation
TREATMENT
STABILIZATION
Outpatient treatment
GENERAL MEASURES
• Remove foreign body if one present
• Consider recommending that the patient use a povidone-iodine (Betadine, Operand) douche (15-30 mL/L [2 tbsp/qt] of water) for symptomatic relief until the specific therapy is effective.
• If urination causes burning, have the patient
- Urinate through a tubular device such as a toilet-paper roll or plastic cup with the end cut out
- Pour warm water over vaginal area while urinating
• Insist on strict diabetic control if patient is diabetic.
Diet
Limit sweets (sucrose) and dairy products (lactose for a patient with recurrent infections.
Activity
• Avoid overexertion, heat, and excessive sweating.
• Delay sexual relations until the symptoms clear/discomfort resolves.
MEDICATION (DRUGS)
First Line
• Fluconazole (Diflucan): 150 mg PO once; use with caution in patients with liver disease.
• Miconazole nitrate (Monistat): 1 200 mg suppository at bedtime for 3 days or miconazole vaginal cream at bedtime for 7 days, or
• Butoconazole nitrate (Femstat): 2% vaginal cream at bedtime for 3 days, or
• Terconazole (Terazol): 1 suppository or 0.8% vaginal cream at bedtime for 3 days, or
• Clotrimazole (Gyne-Lotrimin): 2 100 mg tablets intravaginally for 3 days or cream at bedtime for 7-14 days
• Significant possible interactions: Refer to the manufacturer's profile of each drug.
Second Line
• Retreat with different agent, if recurrence
• Course of oral nystatin; 100,000 units t.i.d. for 2 weeks
• Topical gentian violet 1% aqueous solution painted onto vagina weekly until infection resolves (usually 2-3 weeks)
• Boric acid 600 mg in gelatin capsule inserted vaginally daily for 2 weeks
ALERT
Pregnancy Considerations
Oral azoles are contraindicated in pregnancy. A topical azole may be used with no adverse outcomes.
FOLLOW-UP
PROGNOSIS
• Complete cure with vigorous treatment
• Recurrences are common.
COMPLICATIONS
Secondary bacterial infections of the vagina or vulva
PATIENT MONITORING
Generally no specific follow-up is needed. If symptoms persist, repeat pelvic exam and culture.
REFERENCES
1. Fong IW. The value of treating the sexual partners of women with recurrent vaginal candidiasis with ketoconazole. Genitourin Med. 1992;68:174.
2. Jones HW, Wentz-Colston A, eds. Novak's Textbook of Gynecology.11th ed. Baltimore, MD: Williams  Wilkins Co.; 1988.
3. Kaufman RH, Faro S, eds. Benign Diseases of the Vulva and Vagina.4th ed. St. Louis, MO: Mosby-Year Book; 1994.
4. National guideline for the management of vulvovaginal candidiasis. Sex Transm Infect. 1999;75(Suppl 1):S19.
5. Sobel J. Vulvovaginitis, when candida becomes a problem. Clin Dermatol. 1998;16:763-769.
6. Spinillo A, Carratta L, Pizzoli G. Recurrent vaginal candidiasis. J Reprod Med. 1992;37:343.