What is a budding yeast infection. Candidal Vulvovaginitis: Symptoms, Causes, Diagnosis and Treatment

03.04.202214.07.2023 by alexxlab

What are the common symptoms of candidal vulvovaginitis. How is candidal vulvovaginitis diagnosed. What are the most effective treatments for candidal vulvovaginitis. Who is at highest risk for developing candidal vulvovaginitis. How can candidal vulvovaginitis be prevented.

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Understanding Candidal Vulvovaginitis: An Overview

Candidal vulvovaginitis, commonly known as a yeast infection, is a prevalent condition affecting the vulva and vagina. It occurs when there is an overgrowth of Candida species, most often Candida albicans, leading to inflammation and discomfort. This condition accounts for approximately one-third of all vulvovaginitis cases in reproductive-aged women.

The impact of candidal vulvovaginitis is significant, with about 70% of women reporting at least one episode in their lifetime. Moreover, around 8% of women experience recurrent infections, defined as four or more episodes within a year. While Candida albicans is responsible for about 90% of cases, other species like Candida glabrata can also cause infections.

Recognizing the Symptoms of Candidal Vulvovaginitis

Identifying the symptoms of candidal vulvovaginitis is crucial for prompt diagnosis and treatment. The most common signs include:

Intense itching and irritation in the vagina and vulva
Burning sensation, especially during urination or intercourse
Redness and swelling of the vulva
Thick, white, odorless discharge resembling cottage cheese
Soreness and pain in the vaginal area

Do these symptoms always indicate candidal vulvovaginitis? Not necessarily. While these signs are typical, they can also be present in other vaginal infections. Therefore, a proper medical evaluation is essential for an accurate diagnosis.

Exploring the Causes and Risk Factors

Understanding the causes and risk factors associated with candidal vulvovaginitis can help in prevention and management. Several factors can contribute to the development of this condition:

Hormonal changes: Pregnancy, menstruation, or hormone therapy can alter the vaginal environment, promoting yeast growth.
Antibiotics: Broad-spectrum antibiotics can disrupt the normal vaginal flora, allowing Candida to flourish.
Diabetes: Elevated blood sugar levels create an environment conducive to yeast growth.
Weakened immune system: Conditions like HIV or medications that suppress the immune system can increase susceptibility.
Tight-fitting or non-breathable clothing: These can create a warm, moist environment favorable for yeast growth.
Douching or using scented products: These practices can disrupt the natural vaginal balance.

Is candidal vulvovaginitis sexually transmitted? Despite being more common in sexually active women, there is no evidence to suggest that it is a sexually transmitted infection. However, sexual activity can sometimes lead to micro-abrasions that make the vaginal environment more susceptible to yeast overgrowth.

Diagnostic Approaches for Candidal Vulvovaginitis

Accurate diagnosis of candidal vulvovaginitis is crucial for effective treatment. Healthcare providers typically use a combination of clinical assessment and laboratory tests to confirm the diagnosis:

Medical history and physical examination: The doctor will inquire about symptoms and perform a pelvic exam to look for signs of infection.
Microscopic examination: A sample of vaginal discharge is examined under a microscope to identify yeast cells or hyphae.
pH testing: Vaginal pH is usually normal (4.0-4.5) in candidal vulvovaginitis, unlike in bacterial vaginosis or trichomoniasis.
Fungal culture: In recurrent or resistant cases, a culture may be taken to identify the specific Candida species.
Whiff test: Unlike bacterial vaginosis, candidal vulvovaginitis typically does not produce a fishy odor when potassium hydroxide is added to a sample of vaginal discharge.

Can candidal vulvovaginitis be accurately self-diagnosed? While many women attempt self-diagnosis based on previous experiences, studies show that this approach is often inaccurate. Professional medical evaluation is recommended for precise diagnosis and appropriate treatment.

Effective Treatment Strategies for Candidal Vulvovaginitis

Treatment for candidal vulvovaginitis aims to alleviate symptoms and eradicate the infection. The approach may vary depending on the severity and frequency of infections:

Over-the-Counter Treatments

For mild to moderate cases, over-the-counter antifungal medications are often effective. These include:

Miconazole (Monistat)
Clotrimazole (Gyne-Lotrimin)
Tioconazole (Vagistat-1)

These medications are available as creams, ointments, tablets, or suppositories and typically require 1-7 days of treatment.

Prescription Medications

For more severe or recurrent infections, prescription medications may be necessary:

Fluconazole (Diflucan): An oral antifungal medication often prescribed as a single dose
Terconazole: A vaginal cream or suppository used for 3-7 days
Boric acid suppositories: Used for infections caused by non-albicans Candida species

How long does it take for treatment to work? Most women experience relief within a few days of starting treatment, but it’s important to complete the full course as prescribed to prevent recurrence.

Managing Recurrent Candidal Vulvovaginitis

Recurrent candidal vulvovaginitis, defined as four or more episodes within a year, affects about 8% of women. Managing this condition often requires a different approach:

Long-term suppressive therapy: Regular use of antifungal medications for 6 months or more
Maintenance fluconazole: Weekly oral doses for 6 months
Probiotics: To help restore and maintain a healthy vaginal flora
Lifestyle modifications: Including dietary changes and avoiding potential triggers

Why do some women experience recurrent infections? Genetic factors may predispose certain individuals to recurrent candidal vulvovaginitis. These factors can affect the immune response to Candida or cause hypersensitivity to the organism.

Prevention Strategies for Candidal Vulvovaginitis

While not all cases of candidal vulvovaginitis can be prevented, several strategies can reduce the risk of infection:

Maintain good hygiene: Clean the genital area gently with mild, unscented soap and water
Wear breathable underwear: Choose cotton or other natural fibers
Avoid tight-fitting clothing: Especially in the genital area
Practice safe sex: Use condoms to reduce the risk of infection
Manage underlying conditions: Keep diabetes under control
Avoid douching and scented products: These can disrupt the natural vaginal balance
Take probiotics: Especially when on antibiotics

Can diet affect the risk of candidal vulvovaginitis? While scientific evidence is limited, some studies suggest that reducing sugar intake and consuming probiotic-rich foods may help prevent yeast overgrowth.

The Role of the Interprofessional Team in Managing Candidal Vulvovaginitis

Effective management of candidal vulvovaginitis often requires a collaborative approach involving various healthcare professionals:

Primary Care Physicians: Often the first point of contact for diagnosis and treatment
Gynecologists: Provide specialized care for complex or recurrent cases
Pharmacists: Offer guidance on medication use and potential interactions
Nurse Practitioners: Assist in patient education and follow-up care
Nutritionists: Advise on dietary modifications that may help prevent recurrence
Mental Health Professionals: Provide support for patients dealing with chronic or recurrent infections

How does interprofessional collaboration improve patient outcomes? By combining diverse expertise, the team can provide comprehensive care, addressing not only the immediate infection but also underlying factors and potential complications, leading to better long-term management and prevention of recurrence.

Future Directions in Candidal Vulvovaginitis Research

As our understanding of candidal vulvovaginitis continues to evolve, several areas of research show promise for improving diagnosis, treatment, and prevention:

Development of rapid diagnostic tests for point-of-care use
Investigation of novel antifungal agents with broader spectrum activity
Exploration of immunomodulatory therapies for recurrent infections
Studies on the vaginal microbiome and its role in preventing yeast overgrowth
Research into genetic factors that predispose individuals to recurrent infections

What potential breakthroughs might we see in the coming years? Advances in personalized medicine may lead to tailored treatment approaches based on individual genetic profiles and specific Candida strains, potentially improving outcomes for women with recurrent infections.

The Impact of Candidal Vulvovaginitis on Quality of Life

While often considered a minor health issue, candidal vulvovaginitis can significantly impact a woman’s quality of life. The condition can affect various aspects of daily living:

Physical discomfort: Persistent itching and burning can be distressing
Sexual health: Pain during intercourse can strain intimate relationships
Emotional well-being: Recurrent infections may lead to anxiety or depression
Work productivity: Severe symptoms can interfere with daily activities
Social interactions: Discomfort may limit social engagements

How can healthcare providers address the psychological impact of recurrent infections? Incorporating mental health screening and support into the management plan can help patients cope with the emotional burden of chronic or recurrent candidal vulvovaginitis.

Candidal Vulvovaginitis in Special Populations

Certain groups may require special considerations when it comes to diagnosing and treating candidal vulvovaginitis:

Pregnant Women

Pregnancy increases the risk of candidal vulvovaginitis due to hormonal changes. Treatment options may be limited to ensure fetal safety.

Diabetic Patients

Women with diabetes may experience more frequent and severe infections. Strict glycemic control is crucial for management and prevention.

Immunocompromised Individuals

Those with weakened immune systems, such as HIV patients or transplant recipients, may have more challenging infections to treat and may require longer courses of therapy.

Postmenopausal Women

Lower estrogen levels can change the vaginal environment, potentially increasing susceptibility to infections. Topical estrogen therapy may be considered alongside antifungal treatment.

How does the approach to treatment differ in these special populations? Healthcare providers must carefully balance the need for effective treatment with considerations of safety, drug interactions, and underlying health conditions. Tailored approaches often yield the best outcomes for these groups.

Emerging Technologies in Candidal Vulvovaginitis Management

Advancements in technology are opening new avenues for managing candidal vulvovaginitis:

Telemedicine: Allowing for remote consultations and follow-ups
AI-assisted diagnosis: Algorithms analyzing symptoms and test results for faster, more accurate diagnoses
Wearable devices: Monitoring vaginal pH and other parameters to predict and prevent infections
Personalized probiotics: Tailored to individual microbiome profiles
Nanotechnology-based treatments: Potentially offering more targeted and effective drug delivery

How might these technologies transform the management of candidal vulvovaginitis? By enabling earlier detection, more precise treatment, and better prevention strategies, these innovations could significantly reduce the burden of candidal vulvovaginitis and improve women’s health outcomes.

As research continues and our understanding deepens, the management of candidal vulvovaginitis is likely to become increasingly sophisticated and personalized. This progress offers hope for more effective prevention, diagnosis, and treatment strategies, ultimately improving the quality of life for millions of women affected by this common condition.

Vaginal Candidiasis – StatPearls – NCBI Bookshelf

Continuing Education Activity

Vulvovaginitis, or inflammation of the vulva and vagina, most commonly occurs in reproductive-aged women and is usually secondary to infection. Candidal vulvovaginitis is responsible for about one-third of cases. This activity reviews the evaluation and management of candidal vulvovaginitis and highlights the role of interprofessional team members in collaborating to provide well-coordinated care and enhance outcomes for affected patients.

Objectives:

Describe the epidemiology of vulvovaginitis.
Review the presentation of vulvovaginitis
Summarize the treatment options for vulvovaginitis.
Outline interprofessional team strategies for improving care coordination and communication to advance care and outcomes in patients with vulvovaginitis.

Access free multiple choice questions on this topic.

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.

Differential Diagnosis

Allergic reaction

Atopic dermatitis

Lichen sclerosis

Neoplasm

Paget disease

Psoriasis

Sexual abuse

Vulvodynia

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.

Review Questions

Access free multiple choice questions on this topic.
Comment on this article.

References

1.: Buggio L, Somigliana E, Borghi A, Vercellini P. Probiotics and vaginal microecology: fact or fancy? BMC Womens Health. 2019 Jan 31;19(1):25. [PMC free article: PMC6357464] [PubMed: 30704451]
2.: 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. Eur J Clin Microbiol Infect Dis. 2019 May;38(5):877-882. [PubMed: 30685805]
3.: 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. J Obstet Gynaecol Res. 2019 Apr;45(4):897-907. [PubMed: 30663184]
4.: 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. Am J Obstet Gynecol. 2019 Jan;220(1):91.e1-91.e8. [PubMed: 30595144]
5.: Farhan MA, Moharram AM, Salah T, Shaaban OM. Types of yeasts that cause vulvovaginal candidiasis in chronic users of corticosteroids. Med Mycol. 2019 Aug 01;57(6):681-687. [PubMed: 30544194]
6.: 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. Br J Gen Pract. 2017 Dec;67(665):e824-e829. [PMC free article: PMC5697552] [PubMed: 29158246]
7.: 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. Gynecol Obstet Invest. 2017;82(6):607-616. [PubMed: 29017160]
8.: 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. J Eur Acad Dermatol Venereol. 2017 Jun;31(6):925-941. [PubMed: 28164373]
9.: van Schalkwyk J, Yudin MH., INFECTIOUS DISEASE COMMITTEE. Vulvovaginitis: screening for and management of trichomoniasis, vulvovaginal candidiasis, and bacterial vaginosis. J Obstet Gynaecol Can. 2015 Mar;37(3):266-274. [PubMed: 26001874]
10.: 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;58 Suppl 1:1-15. [PubMed: 25711406]
11.: Crouss T, Sobel JD, Smith K, Nyirjesy P. Long-Term Outcomes of Women With Recurrent Vulvovaginal Candidiasis After a Course of Maintenance Antifungal Therapy. J Low Genit Tract Dis. 2018 Oct;22(4):382-386. [PubMed: 29975334]

: Disclosure: Rebecca Jeanmonod declares no relevant financial relationships with ineligible companies.
: Disclosure: Donald Jeanmonod declares no relevant financial relationships with ineligible companies.

Vaginal Candidiasis – StatPearls – NCBI Bookshelf

Continuing Education Activity

Objectives:

Describe the epidemiology of vulvovaginitis.
Review the presentation of vulvovaginitis
Summarize the treatment options for vulvovaginitis.
Outline interprofessional team strategies for improving care coordination and communication to advance care and outcomes in patients with vulvovaginitis.

Access free multiple choice questions on this topic.

Introduction

Etiology

Epidemiology

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

History and Physical

Evaluation

Treatment / Management

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

Differential Diagnosis

Allergic reaction

Atopic dermatitis

Lichen sclerosis

Neoplasm

Paget disease

Psoriasis

Sexual abuse

Vulvodynia

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.

Enhancing Healthcare Team Outcomes

Review Questions

Access free multiple choice questions on this topic.
Comment on this article.

References

1.: Buggio L, Somigliana E, Borghi A, Vercellini P. Probiotics and vaginal microecology: fact or fancy? BMC Womens Health. 2019 Jan 31;19(1):25. [PMC free article: PMC6357464] [PubMed: 30704451]
2.: 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. Eur J Clin Microbiol Infect Dis. 2019 May;38(5):877-882. [PubMed: 30685805]
3.: 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. J Obstet Gynaecol Res. 2019 Apr;45(4):897-907. [PubMed: 30663184]
4.: 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. Am J Obstet Gynecol. 2019 Jan;220(1):91.e1-91.e8. [PubMed: 30595144]
5.: Farhan MA, Moharram AM, Salah T, Shaaban OM. Types of yeasts that cause vulvovaginal candidiasis in chronic users of corticosteroids. Med Mycol. 2019 Aug 01;57(6):681-687. [PubMed: 30544194]
6.: 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. Br J Gen Pract. 2017 Dec;67(665):e824-e829. [PMC free article: PMC5697552] [PubMed: 29158246]
7.: 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. Gynecol Obstet Invest. 2017;82(6):607-616. [PubMed: 29017160]
8.: 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. J Eur Acad Dermatol Venereol. 2017 Jun;31(6):925-941. [PubMed: 28164373]
9.: van Schalkwyk J, Yudin MH., INFECTIOUS DISEASE COMMITTEE. Vulvovaginitis: screening for and management of trichomoniasis, vulvovaginal candidiasis, and bacterial vaginosis. J Obstet Gynaecol Can. 2015 Mar;37(3):266-274. [PubMed: 26001874]
10.: 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;58 Suppl 1:1-15. [PubMed: 25711406]
11.: Crouss T, Sobel JD, Smith K, Nyirjesy P. Long-Term Outcomes of Women With Recurrent Vulvovaginal Candidiasis After a Course of Maintenance Antifungal Therapy. J Low Genit Tract Dis. 2018 Oct;22(4):382-386. [PubMed: 29975334]

: Disclosure: Rebecca Jeanmonod declares no relevant financial relationships with ineligible companies.
: Disclosure: Donald Jeanmonod declares no relevant financial relationships with ineligible companies.

Vaginal candidiasis. What is Vaginal Candidiasis?

IMPORTANT
The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

Vaginal candidiasis is mycosis of the vaginal mucosa that occurs when it is colonized by strains of yeast-like fungi Candida. In the acute stage, redness, swelling and itching of the vulva are noted; soreness, burning and itching in the vagina; abundant, cheesy type of discharge from the genital tract; in chronic – dryness and atrophy of the mucous membrane, excoriation, severe lichenification. The diagnosis of vaginal candidiasis is established according to the clinical picture, microscopic and cultural studies. With vaginal candidiasis, systemic and local antimycotic agents, multivitamins, and immunostimulants are prescribed.

Causes
Symptoms of vaginal candidiasis
Diagnosis of vaginal candidiasis
Treatment and prevention of vaginal candidiasis
Prices for treatment

General

Vaginal candidiasis, or thrush, is a type of vaginal fungal infection caused by microscopic yeast-like fungi of the genus Candida albicans. Candida infection is of great importance in obstetrics and gynecology due to the widespread and increased incidence in recent years. Among vaginal infections, candidiasis is in second place after bacterial vaginosis. Vaginal candidiasis usually affects women of childbearing age (pregnant women – 2-3 times more often), before the onset of menarche and postmenopause is rare. A yeast infection of the vagina can exist in the form of asymptomatic candidiasis and true vaginal candidiasis – acute (lasting up to 2 months) and chronic recurrent (more than 2 months).

Reasons

Vaginal candidiasis is caused by opportunistic yeast-like fungi of the genus Candida, which live on the skin and mucous membranes of the oral cavity, gastrointestinal tract, external genital organs and vagina of healthy women. The change in growth phases (pseudomycelia and blastospores) allows fungi to survive in a wide temperature and acid range. The death of candida causes boiling for 10-30 minutes, treatment with formalin, copper sulphate, carbolic and boric acid. The presence of a mannoprotein shell and enzymes (proteinases and catalases) in mushrooms makes it easier to resist the immune system of the macroorganism.

The dominant pathogens of vaginal candidiasis (in 75-80% of cases) are strains of C. albicans, which have a high pathogenic potential. Vaginal candidiasis caused by other species (C.glabrata, C. tropicalis, C. krusei, C. parapsilosis) is more typical for certain ethnic groups (representatives of the African race) and geographical areas (Mediterranean coast, Middle East), which is associated with specificity microbiocenosis of mucous membranes and skin, nutrition and living conditions.

As a rule, vaginal candidiasis is an endogenous infection that develops in conditions of asymptomatic candidiasis, usually vaginal, less often on the oral mucosa, intestines and skin. For example, the recurrent form of vaginal candidiasis is due to the persistence of candida in the intestine and the periodic entry of the pathogen into the vagina and its colonization. With vaginal candidiasis, pseudomycelium candida usually penetrates only into the superficial layers of the vaginal epithelium, rarely affects deeper tissues, followed by hematogenous spread and damage to various organs.

The appearance of vaginal candidiasis contributes to the insufficiency of the host’s defense system, manifested by a decrease in local immunity of the vagina. Local immunodeficiency in relation to Candida antigens (decrease in the activity of macrophages and lymphocytes) does not allow blocking fungal receptors and enzymes.

Vaginal candidiasis is usually not accompanied by a noticeable decrease in the level of lactobacilli and a change in the normal microflora of the vagina; but with the formation of polymicrobial associations, it can be combined with bacterial vaginosis.

The development of vaginal candidiasis has an imbalance of sex hormones during pregnancy, taking hormonal contraceptives, endocrine pathology. The influence of estrogen and progesterone fluctuations on the vaginal mucosa is manifested by an increase in the concentration of glycogen in epitheliocytes, stimulation of their sensitivity to candida and more effective adhesion of fungi. Vaginal candidiasis much more often accompanies various conditions associated with immunosuppression (HIV infection, diabetes mellitus, tuberculosis, hypovitaminosis, excessive use of antibiotics, corticosteroids, cytostatics, radiation therapy, etc.). Vaginal candidiasis may be associated with atopic manifestations (allergic rhinitis, food allergy).

Nutritional errors, the use of hygiene products (pads, tampons), wearing tight clothing are not considered significant factors in the development of vaginal candidiasis. There is a possibility of transmission of candida infection to a newborn when passing through the birth canal of a sick mother; the sexual way of infection is possible; the risk of infection is higher with frequent oral-genital contact.

Symptoms of vaginal candidiasis

With candidiasis, there are no clinical manifestations, patients, as a rule, do not present complaints. In acute vaginal candidiasis, abundant thick white-gray discharge from the vagina, curdled appearance with a sour smell occurs. The mucous membrane affected by vaginal candidiasis is edematous, hyperemic and prone to bleeding. It shows sharply delimited or merging with each other round and oval foci of cheesy plaque and films, ranging in size from punctate to 5-7 mm in diameter. In the acute phase, the plaques are tightly attached to the mucosa and are difficult to peel off, exposing a shiny, eroded surface with a scalloped edge; later they are easily removed, standing out from the genital tract. Typical for vaginal candidiasis is itching and burning in the vulva, aggravated during menstruation, after physical activity, water procedures. Patients are also concerned about the sharp pain during intercourse.

In chronic vaginal candidiasis, there may be no characteristic secretions, slight hyperemia of the mucous membrane, scanty films and dry erosion, severe lichenization and excoriation are noted. The mucous membrane becomes flabby, atrophic, the entrance to the vagina narrows, hemorrhagic rashes may appear. The chronic form has a long perennial course.

Vaginal candidiasis usually spreads to the external and internal genital organs, the urethra with the development of vulvovaginal candidiasis, cervicitis and urethritis. Vaginal candidiasis can cause abortion (miscarriage, premature birth), development of endometritis in the postpartum period, and infertility.

Diagnosis of vaginal candidiasis

The diagnosis of vaginal candidiasis is confirmed by the presence of clinical signs of infection and the isolation of a culture of fungi from the vaginal mucosa during a microbiological study. Examination of the cervix and vagina with the help of mirrors reveals hyperemia, swelling of the mucosa, gray-white curdled deposits in its folds. When stained with Lugol’s solution, small-dot inclusions and a pronounced vascular pattern appear. Allocations with vaginal candidiasis are found in about 76% of cases, itching – in 32%.

Microscopic examination of the smear reveals round-oval, sometimes budding cells. When bakposev on Sabouraud’s medium, convex shiny white colonies of a rounded shape are found. Species identification of fungi and determination of their sensitivity to drugs, complex PCR diagnostics and ELISA for STI pathogens are carried out. If necessary, the examination is supplemented with a bacteriological examination of urine and a smear of the urethra for microflora, analysis of feces for dysbacteriosis, determination of blood sugar, ultrasound of the pelvic organs, abdominal cavity and bladder.

Treatment and prevention of vaginal candidiasis

Comprehensive treatment of vaginal candidiasis includes exposure to the pathogen – Candida fungi, elimination of provoking factors, and treatment of comorbidities.

In vaginal candidiasis, various groups of antifungal agents are used systemically and locally: polyene antibiotics (nystatin, natamycin), antimycotics of the imidazole and triazole series (clotrimazole, ketoconazole, fluconazole, itraconazole). Good results in the treatment of vaginal candidiasis are shown by fluconazole, which has a wide spectrum of fungistatic action, without side effects on steroid synthesis and metabolism. The efficacy of a single high dose oral dose offers an advantage over other antimycotics.

With a mild course, local preparations (miconazole, clotrimazole) are shown in the form of a cream, vaginal suppositories and tablets. In chronic infection, systemic antifungal drugs are repeated in certain courses. It is preferable to prescribe low-toxic forms of antimycotics to pregnant women (natamycin, nifuratel intravaginally) and in childhood (nifuratel in applications and intravaginally, oral fluconazole).

Therapy of vaginal candidiasis can be supplemented by the local use of disinfectants and anti-inflammatory agents – solutions of borax in glycerin, potassium permanganate and silver nitrate in the form of baths and douches. With vaginal candidiasis of polymicrobial origin, combinations of antimycotics with metronidazole are prescribed. Immunity is corrected with immunostimulating agents, multivitamins are indicated. Cure from vaginal candidiasis is determined by the disappearance of clinical signs and a negative result of microbiological examination.

Prevention of vaginal candidiasis consists in eliminating the conditions for its development: limiting the use of COCs, antibiotics, cytostatics; medical correction of immunodeficiency, endocrinopathies and other comorbidities, preventive examination of women by a gynecologist.

You can get a consultation from a venereologist and a gynecologist in Volgograd, Volzhsky and Mikhailovka at the DIALINE clinics. We offer a wide range of services, including laboratory tests and examinations on advanced equipment. To make an appointment with a specialist, simply call or leave a request on the website.

Sources

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03 IMPORTANT
Information in this section must not be used for self-diagnosis and self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.
Diagnosis and treatment of urogenital candidiasis :: DIFFICULT PATIENT
А.М. Savicheva
GU NIIAG im. BEFORE. Otta RAMS, St. Petersburg
Urogenital candidiasis is a disease of the mucous membranes of the genitals caused by yeast-like fungi of the genus Candida. Candidiasis is common, and about 75% of all women have experienced at least one episode of this disease in their lives. Candidiasis is not an STI, but may indicate changes in immune and/or hormonal status. It should be emphasized that about 20% of healthy women are carriers of yeast-like fungi in the vagina, which does not require treatment.
Etiology
Candida yeast-like fungi belong to the Deuteromycetes imperfect fungi family Cryptococcaceae, as they do not have sexual forms of reproduction and sexual spores. Morphologically, they are unicellular organisms, the cells have a round or oval shape, and also form, with a linear arrangement of budding elements, filamentous forms – hyphae and pseudohyphae. Like all eukaryotes, fungi of the genus Candida have a well-shaped nucleus, sometimes several nuclei. The cell is surrounded by a cell wall containing chitin and cellulose. The size of a yeast cell is 3-4 microns, pseudohyphae – 5-10 microns. In addition to pseudohyphae, candida can form true hyphae, which have parallel walls and septa, while pseudohyphae taper at the ends.
In the study of vaginal discharge, the most commonly isolated species is Candida albicans (about 90%), as well as other species of this genus – C. tropicalis, C. krusei, C. parapsilosis, C. guillermondi and fungi of the genus Torulopsis – Torulopsis glabrata. Currently, T. glabrata is recognized as a normal part of the vaginal biocenosis.
Yeast-like fungi of the genus Candida are opportunistic, sporeless dimorphic fungi that are facultative anaerobes. They tolerate drying and freezing well. They reproduce by multipolar budding. When tissues are invaded by fungi of the genus Candida, they often transform into thin filamentous forms, forming pseudomycelium, which is formed as a result of incomplete budding of elongated yeast cells. At the same time, the formed daughter cell retains its connection with the mother cell due to the narrow isthmus.
Fungi of the genus Candida are found in the air, soil, vegetables, fruits, confectionery. They are representatives of the normal intestinal microflora, oral mucosa, external genitalia and areas adjacent to natural openings, which are associated with natural reservoirs of fungi of the genus Candida. Thus, about 50% of clinically healthy individuals are carriers of fungi of the genus Candida on the oral mucosa. A small number of yeast cells in the stool (from 100 to 1000 per 1 g of feces) are found in clinically healthy individuals. In other areas of the skin and in the bronchial tract in healthy individuals, they are rarely sown and in small quantities. Other representatives of the normal microflora are in a competitive relationship with fungi of the genus Candida.
Pathogenesis
Colonization of the mucous membranes of the genitals by yeast-like fungi of the genus Candida, as well as manifest candidiasis, is a manifestation of the weakening of the “host” defense. It has long been known that the most susceptible to this disease, caused by an opportunistic yeast-like fungus, are very young (infants), very old or very sick people. Candidiasis, first of all, is a “disease of the sick.” Endogenous factors predisposing to this mycosis include endocrine diseases (hypercorticism, diabetes mellitus, obesity, hypothyroidism and hypoparathyroidism), severe general diseases (lymphoma, leukemia, HIV infection, etc.), pathological pregnancy. Currently, the use of antibiotics with a wide spectrum of antibacterial action, glucocorticosteroids, cytostatics, and hormonal contraception most often contributes to the development of candidiasis. A number of exogenous factors also contribute to the development of candidiasis. These include high temperature and excessive humidity, leading to maceration of the skin and mucous membranes, microtrauma, damage to the skin and mucous membranes by chemicals, etc. Exposure to several predisposing factors (endogenous and exogenous) at the same time significantly increases the risk of developing candidiasis.
Infection of the fetus and newborn child usually occurs intranatally when passing through the infected birth canal of the mother, along with this, the possibility of a transplacental and ascending route of infection (congenital candidiasis) has also been proven. It is also possible the development of postnatal candidiasis in newborns. Infection of the fetus and newborn child is facilitated by the presence of vulvovaginal candidiasis in the mother, especially in the third trimester of pregnancy, the presence of concomitant diseases, especially diabetes.
The occurrence of candidiasis in adults most often occurs as a result of autogenous superinfection, although exogenous superinfection (genital, perigenital areas) can also occur. Dysbacteriosis and violation of the protective system of the surface of the mucous membrane and skin facilitates the attachment (adhesion) of the fungus to epitheliocytes and its penetration through the epithelial barrier.
Clinical picture
Vulvovaginal candidiasis is characterized by the formation of a whitish coating on the hyperemic mucous membrane of the vulva and vagina (as with thrush). Characteristic crumbly “curdled” white discharge appears. Patients are disturbed by excruciating itching and burning. Perhaps burning of the vulva during urination and pain during sexual contact. The defeat of the vulva and vagina with yeast-like fungi is characterized by great persistence and a tendency to relapse. In a chronically relapsing disease, an exacerbation is often observed before the onset of menstruation.
Yeast vulvovaginitis usually develops with persistent treatment with antibacterial drugs, in patients with decompensated diabetes mellitus and pregnant women, as well as with prolonged use of hormonal contraceptives. It is possible to transmit the disease from a wife to her husband, who develops yeast balanoposthitis. Candidiasis urethritis is rare.
In newborns, clinical manifestations of the disease develop immediately after birth (with congenital candidiasis) or later in the form of local skin lesions and mucous or severe visceral lesions up to sepsis. However, most often in the presence of vulvovaginal candidiasis in the mother, the child develops candidiasis.
Diagnosis
For the diagnosis of urogenital candida infection, microscopic methods, cultural methods with the isolation of yeast-like fungi, identification of candida species, a test to determine the sensitivity of candida to antimycotic drugs, molecular biological methods (PCR) for the detection of Candida albicans are used.
The material for the study is the discharge of the vagina, cervical canal, urethra, as well as urine. It is necessary to remember the possibility of rapid reproduction of the fungus and start the study as soon as possible after aseptic sampling. To take the material with a vaginal swab or inoculation loop in 10 µl, the discharge is taken from the vaginal fornix and the side wall of the vagina. For microscopic examination, the material is placed on two glass slides, for cultural diagnostics – in a special transport medium.
The microscopic method is preferred for laboratory diagnosis of vulvovaginal candidiasis, since 20% of healthy women have candida in the vagina, which will also grow when cultured, which will give rise to an unreasonable diagnosis of vaginal candidiasis. The cultural method is useful in the chronic relapsing course of the disease, in the study of the action of drugs, in the atypical course of the disease, when other possible pathogens are excluded.
For microscopic examination, the doctor sends to the laboratory a smear preparation from the vaginal discharge and a test tube with a cotton swab, which was used to take the material from the lateral or posterior fornix of the vagina. The middle portion of freely released urine is also sent, taken into a sterile test tube.
For microscopy, unstained preparations are used, as well as preparations treated with KOH, stained according to Gram, Romanovsky-Giemsa, methylene blue.
The diagnosis is based on the detection of elements of the fungus: single budding cells, pseudomycelium, other morphological structures (blastoconidia, pseudohyphae).
Candida grows well on simple nutrient media, including blood agar, wort agar, potato agar, Sabouraud’s medium with glucose or maltose. Candida colonies are moist, cream-colored, raised, shiny or opaque. Candida species are distinguished by the assimilation of carbohydrates as the sole source of nutrition and by the fermentation of carbohydrates with the formation of acid and, in some cases, acid and gas. In table. 1 shows the ability of different types of candida to ferment carbohydrates.
The clinician decides on the significance of the detected yeast-like fungi.
For cultural diagnostics, the clinical material is inoculated on 2-3 media (blood agar, wort agar, liquid and solid Sabouraud media, Vagicult media from Orion Diagnostica (Finland). Incubated at +37 ∞C, as unlike fungi pathogenic to humans, this mode is unfavorable for saprophytes
Assess semi-quantitative growth on agar media and weave pure cultures for subsequent identification. coverslip, leave the culture for 18-48 hours at room temperature, after which they are microscoped in a phase contrast microscope or with the condenser lowered.The shape of the pseudohyphae and the location of the pseudohyphae along the pseudohyphae are assessed.0005 For a quick detection of C. albicans, capillary culture is performed on medium with horse or fetal calf serum. Already after two hours of incubation, this type of candida (the most frequent) gives rise to pseudohyphae.
If further precise identification is required, use carbohydrate kits to check their utilization and fermentation. Currently, diagnostic kits are being produced for both computer and visual recording of the results of carbohydrate fermentation.
It should be emphasized that PCR for the diagnosis of urogenital candidiasis should be used with caution. A positive test result for the presence of C. albicans, obtained by PCR, may only indicate the colonization of the vagina by these fungi and is not evidence of the presence of candidiasis.
Treatment
To prescribe a rational treatment, it is necessary to take into account the clinical form of candidiasis, its prevalence and identified predisposing factors (general and local). With superficial candidiasis of the genitals and the perigenital area, the degree of contamination with yeast of the genus Candida of the gastrointestinal tract should be determined. With massive colonization of the gastrointestinal tract by fungi of the genus Candida, it is advisable to prescribe drugs to suppress their growth (natamycin, levorin, nystatin, etc.).
In acute vulvovaginal candidiasis, lotions and douches with a 0.05% solution of chlorhexidine bigluconate or a 0.01% solution of miramistin have a quick therapeutic effect. Antifungal azole derivatives (isoconazole, econazole, etc.) and polyene antibiotics (natamycin) are also used externally in appropriate forms: suppositories, vaginal balls, vaginal tablets and cream with a special applicator.
With simultaneous damage to the skin folds, external therapy is carried out depending on the severity of inflammation. First, lotions are prescribed (0.05% solution of chlorhexidine bigluconate, or 0.01% solution of miramistin, or 0.04% solution of zinc sulfate), and then lubrication of the foci with 1-2% aqueous or alcoholic solution of aniline dye or 1-2% other anti-candidiasis drug in the form of a paste, gel or hydrophilic cream.
General anti-candidiasis therapy is prescribed for patients with recurrent vulvovaginal candidiasis, as well as for candidiasis that occurs during treatment with antibacterial drugs, glucocorticoids and cytostatics, decompensated diabetes mellitus, cancer, blood diseases, HIV infection, etc. Azole derivatives are recommended, which are well absorbed from the intestine to the systemic circulation. Fluconazole (Mikoflucan) is prescribed 50 mg daily or 150 mg once a week for 2-4 weeks; itraconazole – 100 mg once a day for 15 days; ketoconazole – 200 mg (one tablet) once a day for 2-3 weeks. Known antifungal antibiotics of the polyene series (nystatin, natamycin, levorin) are practically insoluble in water, therefore they are poorly absorbed from the intestine.
In case of recurrent vulvovaginal candidiasis, in addition to identifying contributing factors (diabetes mellitus, abnormal pregnancy, obesity, hormonal contraception, “hidden” infection, etc.), fluconazole (Micoflucan) is prescribed at a dose of 150 mg once a month, and with frequent relapses – itraconazole 200 mg once a day for three days or 200 mg twice a day for one day; Ketoconazole 400 mg once daily for 5 days may also be prescribed. In table. 2 shows the treatment regimen for vulvovaginal candidiasis.
Prevention
It is important to prevent candidiasis in persons with a combination of several predisposing factors: immunodeficiency, blood disease, neoplasm, condition after major operations, as well as after massive treatment with antibiotics, glucocorticoid hormones, cytostatics, who received ionizing radiation.